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23D-165 RC-1- Roofing Date 6 Line St. Estimate Southampton, Ma. 01073 6/10/2015 Phone(413)527-4775 Fax(413)527-8469 Name/Address Job Location Richard Duffney 102 Maplewood Terr. Florence, MA 01062 Terms Rep Estimate valid for 30 days Keith Description Total Remove existing roofs. 5,800.00 Furnish& install aluminum drip edge,pipe flashings, chimney flashings(if needed)and step flashings. Furnish& install CertainTeed Winterguard ice&water barrier along eaves and valleys. Furnish& install synthetic underlayment over existing deck. Furnish& install Lifetime CertainTeed Landmark Series shingle. Furnish&install CertainTeed approved ridge vent. Furnish& install 1/2" fiberboard insulation on flat roof section. Furnish&install.060 re-inforced rubber roof system, mechanically attached on flat roof section. All exterior roofing related debris to be removed by R.C.I. Roofing. All work to be performed according to manufacturers'specifications. Lifetime CertainTeed material warranty included. All related permits will be obtained by R.C.I. Roofing. SPECIAL ITEMS NEEI)ED Add$2.50 per square foot for wood decking replacement if needed. WE LOOK FORWARD TO DOING BUSINESS WITH YOU. Total $5,800.00 TERMS OF PAYMENT 5%Deposit "�:a A Balance upon completion Customer Signature Registration# 126235 e r- Construction License# 074334 Date �y Insured by Banas&.Fickert Ins. — (413)527-2700 The Commonwealth of Massa.ch,usetts Depamnent of Industrial Accidents Office of Investigations 600 Washington Street Boston, M4 02111 wllnv,rnass,gov/dia Workers' Compensation Insurance Affidavit: Bufl ders/1C'o:utl-actors/Electi-ici2ns/Plumbers Applicant Information e_ Please Print Legibly Name (Bu siness/0rgarizationMdividual):_��� ,"� \O, t, ,(o Address: L City/State/Zip;`,S��a-�, ��C M� o o-v3 Phone #; Are you an employer? Clt.eck the-appropriate boxt Type of project (required):^_l 1,E21 am a employer with 2,0 a, �_� 1 any a general contractor and 1 6. [) New construction employees (full andlor part-time),* have hired the sub-contractors 2. [] I am a sole proprietor or partner- listed ou the attached shet,t l 7. ❑ Remodeling I ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity, _ workers' comp, insuranc(:. 9, ❑ Building addition [No workers' comp, insurance 5. We. are a corporation and its required.] officers have exercised their 10.❑ Elect7ical repairs or additions 3. ❑ I am a homeowner doing all work right of exemption per MGL 11.7 Plumbing repairs or additions myself [No workers' comp. a 152, §1(4), and we have no 12, Roof repairs insurance r(:41u.ired,] t employees, [No workers' 1317 Other _ comp insurance required,] 'Any applicant that checks box tl I must also fill out the section below showing their workers'compensation policy information; t Homeowners who suln-0 this affidavit indicating they are doing all work and then hire outside tgntractcrs must submit a new affidavit uidicating such. lContractors that check this box muse auchod an additional sheet showing the name of the suL-contractors and their workers' comp.policy infoi-meiion. I am an employer that Is providing workers' compensation insurance for my employees, Below is the policy and job site (nformatton. Insurance CompanyName,�•- O..c- '��.��...c'�..r�C�r C��-, , ___ Policy#or Self im. L,ia #: S Ulo��,�I O�Z_ _ Expiration Date: ) 0 Job Site Addxess._/d,9 A&&&-,,�� der° __ _ City/State/Zip; to 4�d�3 Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date), Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of crindnal penalties of a fzne up to $1,500,00 and/or one-year imprisonment, as well as civil penalties ill thy; form of a STOP WORK ORDER and a fine of up to $250,00 a day against the violator. .Be advised that a copy of this stat(=nt may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the inforntatlon provided above is true and correct. Sipnat�lre, ,�'�Ciz.--•-''�, 1--- D��te, (�s�'_�_. Phong�—q.- � Off<cial use only, .Do not write In this area, to be completed by city or towns official, City or Town: _ Permit/Licease: Issuing Authority (circle one): 1, Board of Health 2. Building Department 3, City/Tovm Clerk 4,Electrical Inspector 5, Plumbing Inspector 6. Other Contact Persona,_ Phnnp� tr- City of Northampton 212 Main Street, Northampton, MA 01060 Solid Waste Disposal Affidavit In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building permit all debris resulting from the construction activity governed by this Building Permit shall be disposed of in a properly licensed solid waste disposal facility, as defined by MGL c 111 , S 150A. Address of the work: A )- o/ ax,Od, 7,a1-r 15'lorer a , xv+ The debris will be transported by: `A tj le tC- S n O's rc / The debris will be received by: A 54 t Building permit number: Name of Permit Applicant NO rk Date Signature of Permit Applicant SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: Mrk-( V1 �D'1�Q 7 9 9 "Y:11)H License Number `y t V (3 cJ o�, Address Expiration Date Signature Telephone 9. Registered Home Imorovement Contractor: Not Applicable ❑ LclinQ Ili Company Name Registration Number Address Expiration Date r }( 0�m a Telephone L:-qm SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M'.G.L.c. 152, §25C(8)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. _ Signed Affidavit Attached Yes....... d No...... ❑ 11. - Home Owner Exemption The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)families and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor.CMR 780, Sixth Edition Section 108.3.5.1. Definition of Homeowner: Person(s)who own a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two family dwelling,attached or detached structures accessory to such use and/or farm structures.A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. As acting Construction Supervisor your presence on the job site will be required fi•om time to time,during and upon completion of the work for which this permit is issued. Also be advised that with reference to Chapter 152(Workers' Compensation) and Chapter 153 (Liability of Employers to Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,you may be liable for person(s) you hire to perform work for you under this permit. The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of Northampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature �AC.A-Q hA SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [M Siding [0] Other[0] Brief Description of Proposed Work: SF?o Qnr�tP Alteration of existing bedroom Yes No Adding new bedroom___Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet Ba. If New house and or addition to exist!ng housing complete the following: a. Use of building : One Family Two Family Other b. Number of rooms in each family unit: Number of Bathrooms c. Is there a garage attached? d. Proposed Square footage of new construction. Dimensions e. Number of stories? f. Method of heating? Fireplaces or Woodstoves_ Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No j. Depth of basement or cellar floor below finished grade k. Will building conform to the Building and Zoning regulations? Yes No . I. Septic Tank City Sewer Private well City water Supply SECTION 7a -OWNER AUTHORIZATION -TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I Tl , — c o as Owner of the subject property hereby authorize __McLc QPLC,IQ_ (A- R .C . f. IS jqr to act on my behalf, in all matters relative to work authorized by this building permit aR ication. Signature of Owner Date I, 1V oL K as. 0 Ah()Y12_0J Q Qen-} as Owner/Authorized Agent hereby declare that the statements and information on&e foregoing application are true and accurate,to the best of my knowledge and belief. Signed under the pains and penalties of perjury. � ' o� 1` �J�lic1� Print Name Signature of Owner/Agent Date Department use only City of Northampton states of Permit:' ..6 201 Building Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability Room 100 Water{Well Availability Sectric,Plumbing , MA 8 Gas Inspection N orthampton, orthampton, MA 01060 Two Sets of Structural Plans N 3-587-1240 Fax 413-587-1272 Plot/Site Plans Other Specify APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION' 1.1 Property Address: This section to be completed by office / 0.,2— /f44,y. Itwevel Derr. Map Lot Unit /"lerenee, /414 0/0&Z Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) Current Mailing A dress: iP.L Telephone Signature 2.2 Authorized Agent: n/j a Z k I;.�;�P p .C . 7. �o inn L p Name(Print) / Current Mailing Address:' Signature Telephone l 2��S SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant _ 1. Building (a) Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total = 0 +2 +3 +4 +5) Check Number This Section For Official Use Only Building Permit Number:_ Date Issued: Signature: Building Commissioner/Inspector of Buildings Date 102 MAPLEWOOD TER BP-2016-0018 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:23D- 165 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: ROOF BUILDING PERMIT Permit# BP-2016-0018 Project# JS-2016-000030 Est.Cost: $5800.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: RCI ROOFING 74334 Lot Size(sq. ft.): 9104.04 Owner: DUFFNEY REALTY TRUST Zoning:URB(100)/ Applicant: RCI ROOFING AT. 102 MAPLEWOOD TER Applicant Address: Phone: Insurance: 6 LINE ST (413) 527-4775 Workers Compensation SOUTHAMPTONMA01073 ISSUED ON.71712015 0:00:00 TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE ROOF POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Service: Meter: Footings: Rough: Rough: House# Foundation: Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace/Chimney: Rough: Oil: Insulation: Final: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy Siinature: FeeType: Date Paid: Amount: Building 7/7/2015 0:00:00 $35.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner