31C-008 (2) 24 WARD AVE BP-2017-1063
GIS k: COMMONWEALTH OF MASSACHUSETTS
Mac:Block:31C-008 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-2017-1063
Project? JS-2017-001821
Est. Cost: $14900.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: RCI ROOFING 126235
Lot Size(so.ft.): 55321.20 Owner: MILLETTE FRANCIS P&BRENDA E
Zoning: WP(68)/RR(64)/URA(42)/FFR(2)/ Applicant: RCI ROOFING
AT: 24 WARD AVE
Applicant Address: Phone: Insurance:
6 LINE ST (413) 527-4775 Workers Compensation
SOUTHAMPTONMA01073 ISSUED ON:3/24/2017 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: OI: 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 Signature:
FeeType: Date Paid: Amount:
Building 3/24/2017 0:00:00 540.00
212 Main Street, Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck- Building Commissioner
09p4nYnt use.00T4
City of Northampton Sts of Pefnrt
' C\ ! ;Hiding Department rvrb ai-tloe'vew6y Ra ma
�`L 212 Main Street SewtpSeptic Avalsbtaty
Re / Room 100 iVeatarMallikariPaRlity
.Northampton, MA 01060 Two Sets of Slruotural.Plans
phone 413587-1240 Fax 413-587-1272 iPle.aeie.P-.Iass
\ ' 'Other S>Calw`
ATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING j
cC-'LN 1 SITE INFORMATION'T a 0- r 7 -- /D9 3
This section to,,be 6ompletedl by office
ronerty A Idr)ss. I
H2N/ /Cd i<L/RI le_ Map_ Lat —_Unit
AtA- 1QY/. Zona_____,___Overlay District
! IElm SL Districtea;District,_,
-"TION 2 .PROPERTY OWNERSHtPIAUTHORIZED.AGENT
I
er ofRe_=4L;
__
�irks Firiae ill9#fo o2`/ U,1&iaa Ave. , /✓erf/aryo n en4 oicOo
e(Prinry Curter,)Melling Address',
//��,, JJ 'Y/3 _337 - 59cC
_ r :r Qr! cl_ _ Telephone
au tori ze d Agee ]
)B.11,112._ " i<. .C . 7' _04-1 r)] In Link.' _ 1. 2Aacr4wuvrrrrlen coo C)IO.:Y7
!Pr,n1) /r J Curren)Mailing Address','
GAY') _ _a9- 1/4-179:; _
Telephone —_� — _I
rICN 3 , ESTIMATED CONSTRUCTION COSTS
ler Esttmeled Cost (Dollars)to be Official Use Only
completed by permit appioant
+ *r9 (a)Euilrling Parma Fee
�nPt -Inot /`/, 9ce. - ----- — —4
peargca, c (b) Estlmatad Total Cost of
Construction from(6)
o,^g Euilcllry Perron Fee.
aics, an,cai(HVAC)
r- F c c'.ion _-
1 =I t2 +3+ 4 `5) /q, 9Cc. - j Check Number , i i;
Thls Section For'OHlclal Use Onlg_
Date
°21-Til Nunter' Issued'__-
r
dOlfer — ==3 a le
BdidirgFomrnh,sneKingpeotor of B.iidln&s
_
---- Dara
_rEGOON e. DEseg2,plo�aoe PROPOGEDWORlj fne1
New Hones Addition Replacement Windows Alteration{s} t Reefing 7/
Or Doors Ci L___
Accessory Bldg. [1 Demolition _ New Signs (ED) Decks f❑ Siding dpi Other lei
Lose-Tenon of Proposed
eisha,. of existing bearenm _Yes No Adding new bedroom Yes No
A caned Narrative Renovating unfinished basement Yes _ No
niers Attached Roll -Sheet
---
ea if New housb end taradai[lan traexislkimp.housillaniabampiety atolloW,rani
Use of building '. One Family Two Family Other—_ __„
%i..meer of xccrs in each family unit: Number o'Bathroom$,
s t!eie z garage attached?_
Proposed Square footage of new construction. Dimensions
Number of stories?
ieelhod of heating? Fireplaces or Woodstoves_, Number of each__
Ene.gy Conservation Compliance._ Messcheok Energy Compliance form attached?
Tarp. of ocostruction
is construction witnin 100 ftof wetlands? Yes No. Is construction within 100 yr, floodplain_Yes_ No
Dept,of easement or cellar floor below finished grade
'.gill ouilreog conform to the Building and Zoning regulations? Yes NO
Sepn.c'ank City Sewer Private well City water Supply
SECTION ea -OWNER AU4'HOR1ZATION TO 8E COMPLETED, WHEN
OWNERS AGENT OR COkeeR*c:. R APPLIES FOR BU1iDiNG PERMIT
.nd&A I/eft& as Owner et the sabiect
;i1✓
ce rty /
f,ef , aubcite ._'Tv&SK r/i2\.iClp. (4Pl C . t firer
to so! on ray b nail in all matters relative to work authorized by this building permit aRllcation.
-::rretcfe of Owner Date _____
q l��
l,C /1l)-4eri-.? CP( Pv1+ as Owner/Authorized
eel hereby declare that the statements and information ongaie foregoing application are true and accurate,to the best of my knowledge
snd begot.
Signed under the pains and penalties of perjury.
f9te r,
3,2 3_.
NNial Iren Owner/Agent ___ Dale ___
!ohs e CONSTRUCTION SERVICES
_"Sy, sou ConstructtonS incere/a'g; Not Applicable
!License b' --"s3yt, �' 0 _--.. 'Mt- 554._
License Number
6 Lilleg ItL&L D ik1 I^(1. fl I Pa-J, _—_—� J M '0 S --(8 ._
Expiration Dale
� Ye
Telephone
iste"eV Wortygdrhenmugnsbit Cilentsaidt* r - - NotApplicable
icer- st _.. tin — Ina:�(y__
I ewicName Registration Number
, — — O 5 "- Ula
Expiration Dale
SS?, car rr18 Or? Telephone ('41")))(I2; "LH5
" ON ties WORk.ERS`COMPENSATION INSURANCE AFFIDAVIT(Nh6.t,c.132,§ 25C.(0))
mess Oompen se'tion Insurance affidavit must be completed and submitted with thin application Failure to provide this a ffidavlt will result l
gorge of the issuance of the building permit
Affidavit Attached Yu .,... No.,_.. ❑
11. - }iolt:e °WriterlEXAMptioni
The cur rent exemption for "homeowners"was extended to include Q Dei.oegtpcled 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-tile owner arty
supervisor.CMR 180, Sixth P,dltion Section 1083.5,1
Del-until) of Homeowner:Person(s)who own a parcel of land on which he/she resides on intends to reside,on which there
is,wr ,a intended to be,a one or two family dwelling,attached or detached etruotures accessory to such use and!or farm
structures. crson who constructs more than one home In a hyo-ysarp mind shall nob be consid eyed a bmnemvne(,
Such "homeowner"shall submit to the Building Official,on a fmm acceptable to the Building Official that ggishe shall be
resoonsfrle for all sttch work performed under the building permit,
As acting Construction Supervisor your presence on the job site will be required from time to time, during and upon
completion of the work for which this permit is issued.
glee be advised that with reference to Chapter 152 (Worker& Compensation) end Chapter ISS (Liability of Employers to
mployees for injuries not resulting in Death)of the Massachusetts General Laws Annotated, you may be Untie for person(s)
you hire to perform work for you under this permit.
The untiei;tgoed"homeowner"certifies and assumes responsibility for compliance with the State Euilding Cede,City of
hiorthampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature— (,Lknt 0 mar•
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 150k
Address of the work: f e er 7/nsc2/mt_
The debris will be transported by: 0-0 Nle E.-1 -_c �� 1S e03),
The debris will be received by: P/e' . 1 j01/Q N A c&-(44-C1! i
Building permit number:
Name of Permit : torcant CLOT Zc)u lj ‘`\
Date Signature of Permit Applicant
3-1 3-/7
Mar. 7. 2017 10: 31AM No. 0868 P.
l"} CAM i DD.,,,1
_RD CERTIFICATE OF LIABILITY INSURANCE _ 3n/1
THS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE. OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND 1110 CERTIFICATE HOLDER.
IMPORTANT; li the certificate holder is an ADDITIONAL INS RED, Ole policylies{ most .e endorsed, If SUMO(• '0 IS W• eD,subject to u
the ferrite and conditions of he policy,certain policies may requIre an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such erdorsemends).
vn°w`En CONTACT
NAME.: Michael A, Danae
Hands 5 Fickest - N
iieN Fery 527-2700 mxmx Net 4413k 527-OO4
.
Insurance Agency Mks; ohesanasinsurance.com
63 Main Street IN9VFER9)ASSOPOIN1 covNIAIE NAIC3
Easthampton, MA 01027 IHsunnn:Adatira1 Insurance Co, 24856
UlStmED /Ns/READ:Safety insurance Co. 39454 v,
ACT Roofing, LLP itauRen(!Admiral Insurance Co, .24856
6 Line Street Iretlnwo:Btac Insurance Co, .._ 24562 .............
Southampton, MA 01073 AIWREt e.
INSURER r:
ss-
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE PCL CES OF INSURANCE USTED BELOW HAVE BEEN ISSUED TO THE MUSED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANT REQUIREMENT,TERM OR CONDITION Cr ANY CONTRACT CR OTHER DOCUMENT WITH RESPECT TO WHCH TH:$
CERTFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY TFE POLICIES DESCRIBED HEREW IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS$}10WN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
BNa TYPE OF INSURANCE � PWCYMIbER Mpp��� �'Nq
♦ OATS
A GENERAL LumuYY X CA000020963-03 3/4/17 3/4/16 EAtHCCCURNENCE 1 .000,000
X co',MEnCwLG ptMLtI ItItt
HOpET
pgFMIaETRENTED u+ure,ccl 50,000
G 4A W&'AIAnE F-1 OCCUR DAPM1LO DIP Wry re seem 10,000.......
PERSON/L0MVINIURY 1,000,000
GENERAL AGGREGATE2,000,000
G9 LAOGREGATeLHITHSPUESPER PRODUCTS,OSMIHOP HOG 2„OO .„6,Q2„,„,
_ room'I Ly2 Pcrr BLOC �[ G1
D NITOMOBILE LIABILITY X 6207761 9/36/16 9/30/1'! gG.,lhnf NLELM,Ir s 1,000,000
MY AIM ODDLY INJURY WOpe/eon) $ _^
AL OWM a v. SCHEDULED eUCILEEYfifiiWRYHINY(Per exIderv) $
PniTOS AUTOS
X He�At40S X AVY09ANEO Fv�reE&k,e LACE 4
3
C WM RELA!.IAN OCCUR X 0X000000305-01 3/d/l7 3/4/13 EACH OCCURRENCE 3 5,000,000
I
is Excess Lino
CLAIM6,IMCE ACC/SEWN 3 5,000,000
DEO X RETENTIONS 19 L000
D I HONKERS COMPENSATOR WC06U3405 to/5/16 10/5/11 NCSTAiL. I OYH- 3
µc EMGmYERV ta9R1TY YIN mnYl W,ve 0-g
-
ANC
EN Y , N/A EL.EACH ACQIE lir_ $ I,000,000
(Mems my In NW HL DISEASE WA HIT/Pe/NEE s 1L000,000
0E8CRIPPil0N 0 mo'gEPATIONs Wlos, EL.OISEAES:POLICY LIMIT 3 1,000,000
I I 1 I
tl1SCRIPTON OCUPERATONB/LOC TONS/VEHICLES IMt,ci ACORD 101,Adlumal R=mM&Ndule,timers we hesurea
ROOFING CONTRACTOR.
CERTIFICATE HOLDER CANCELLATION
5HOULO ANY OF THE ABOVE DESCRIBED PCOQ IES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE OEUVEREO IN
REFERENCE COPY. ACCORDANCE WITH THE POLICY PROVISIONS.
ADMIXUEED PEPRE 6ENThTNE
I
0 19834010 ACORO CORPORATION, All rights reservod,
ACORD25{2010/06} The ACORD name and logo are registeredmarks of ADORE
Phone: FaK E-Mail:
-- _ -
in
Massachusetts Department of Public Safety
3CA I ;5 20M 05,11 Ill Board of Building Regulations and Standards
License. CS-074334
tttl36 -. e„44 fei/ a /uneca Constructon
SupervisorJO
j'Itr;Off of Consumer Affairs&BusinessRegulation
= HOME IMPROVEMENT CONTRACTOR
MARK T DELISLE
,i Registration: 126235 Type: ,
.� 69 BRIGGS STREET t7): I
V rs4 Expiration;l'. 5/6/2018 Partnership EASTHAMPTON MA 01027
R.C.I.ROOFING
MARK DELISLE
6 LINE ST I ^Ax Expiration
c
` ' y- Commissioner 06/03/2018
SOUTHAMPTON,NA 01073 DndmeNetxr -
QII py� �r�. IC r < ' �oa1 oN / GT o : I.t �AaHUs rs
y��s IRNi r x s h71 E�sCi�i. az 5 1104p OF • E ESSIONA
or0h H iP/RR�iV Td� NV)NCON PRAC;TUR / BO$RD Op
4pctntoEtfw2,,:,,,i,P HEE lrifitTAL VOIN;55s
P IN 1 et ISSU7111 E, 'SHE P0'L�OWIN6f LICENSE :
ol,f ' �r`� k oiova kat A' r1‘ksTER 49NdisiR16rso , z
S:
1
� l /MA ,fRii1 oE11sLE �
—,I ,/REaN 1 IEI 11 � EXPIRE6 I " - •tpo ,y,J3;; ,l
PlO OC24747 1 �e 2/Ot/20,I3,1.�tVi� •.B./30/2014 59 BR.16C8° pSII" ' t 3rst' ;F
r ileal! ( �• '
S+N-D l"- -,-" .,, ., IEASaf11 P,7,QN '''MIA 01027"17,15 .'i
—• ty1aG ,. , /z882 (., 2 184
1+.}a,1 NRJOATO 7E41,144 IHillld I
`2°'COMMONWEALTH OF MAS ACHUS TTS: '_
tbIVISION OF.PROFESSIONAL-iL10ENSUREf`''
9HEE1'.MIErAt.vvo8. i,@S ,o',
ISSUES TWE;FOLLOWING L1OET'SE AS A ',
BUINESs
MAR,K7 DELISLE �1 ) `
I" 1
RGIRCOFINgLLP 7dl 1
6 LINE ST $E-t ` r F ` M� ' V
EASTHA,MPTON MA 010, 1 t`�_ ,
601 :0910912a17 2406
L - SENUMA
R :ENPIR 4RIN NSSERIG4NUMREp; -
.St\ The Commonwealth of Massachusetts
i Department ofIndustrial Accidents
�_ i_ "s 1 Congress Street,Suite 100
-#2.9_,=
` TAri € Boston, MA 02114-2017
c + www.mass.gov/die
Workers' Compensation Insurance Affidavit; Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE.PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): y4 e. I Roo4n1 LI_79
Address: 4, .Line., cSt,
City/State/Zip: Souman ipn, 414 0/073,__ Phone #: (9l3) ,1.37 - Li775
Are you an employer?Check the appropriate how:
Type of project(required):
i lleama employer cork o2Q employees troll and+or part-time)* 7. ❑New Construction
a.O I am a sole proprietor or partnership and have no employees working for me in R. fl Remodeling
any capacity.(No workers'comp.Insurance required]
1f.I am a homeowner doing all work myself. No workers'compinsurance required.]t 9. Demolition
4❑1 am a homeowner and will be hiring contractors to conduct all work on my property. 1 will I O Q Building addition
ensure that all cont-ators either have workers'compensation Insurance or am sole I L Q Electrical repairs or edditIons
proprietors with no employees. 12.❑Plumbing repairs or additions
I am a general contractor and I have hied he sub-rontractors listed on the attached sheet. 13.[}'Roof repairs
These sub-contractors have employees and have workers'compinsurance.:
6E We are a corporation and its ejectshave exercised thewright of etempteon per MM.c 14.E Other
152,§I(4),and we have no employees. [No workers'compinsurance required.]
'Any applicant that cheeks box q I must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the name of the suh.contractors and state whether or not those entities have
employees ee. It the subcontractors have employees,they must provide their workers'comp pokey number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name, 8 /- _T.SW-Os pa fie-
Policy#or Self-ins.Tic.ti:_ jIC 0443`./03 Expiration Date: /0 - t'7
lob Site Address: -237/ /124.-G, A/C City/State/Zip:,4/ y//err. r7 /71. 0/c6P
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c.152,625A is a criminal violation punishable by a fine up to$1,500.00
and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a tine of up to$250.00 a
day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certifyunder II mire d penalties of perjury that the information provided above is true and correct
Manature': - Date: 3 -...2 3 - /7
Phone#: (y//.• .) Jae'/- `/7 75—
i
Official use only. Do not write in this area,to be completed by city or town official
City or Town: -Permit/License#
Issuing Authority(circle one):
I. Board of Health 2.Building Department 3.City/Town Clerk 4,Electrical Inspector 5,Plumbing Inspector
6,Other
Contact Person: Phone#:
RC.I.R f$ Estimate Date
6 Line St.
Southampton, Ma.01073 1 10113/2016
Phone(413)527-4775
Fax(413)527-8469
Name 1 Address Job Location
Brenda Millette
24 Ward Ave.
Northampton, MA 01000
Terms Rep
Estimate valid for 30 days Chris
Description Total
Remove existing roofs, 12,500.00
Furnish& install 12"plywood over existing decking,where needed.
Furnish& install aluminum drip edge, pipe flashings,chimney flushings(if needed)and step
(lashings.
Furnish&install CertainTeed Winterguard ice az water barrier along eaves and valleys.
Furnish and install synthetic underlayment.
Furnish and install Lifetime CertainTeed Landmark Series shingle.
Furnish and install CertainTeed approved ridge vent.
All exterior roofing related debris to be removed by R.C.I.Roofing.
All work will be performed according to manufacturers'specifications.
Lifetime CertainTeed material warranty included,
AU related pennits will be obtained by R.C.I. Roofing.
Add for .arage: $2400.00
WE LOOK FORWARD TO DOING BUSINESS WITH YOU.
Total $12,500.00
TERMS OF PAYMENT
5%Deposit Customer Signature: \ C (�
Balance upon completion j ((( t`4'_fY�J7�y.' .._, 5\
Registration# 126235 Date: 3 j Z1 "�}'�
Construction License N 074334 7{ i c.�+(�.IT ///���
(413) d by Banas&Picker(Ins. / 1 �
(413)5272700 Shingle Color Selection: l TT 'volt
�1P110 i 1 35'E.
<4 et_ °Tony)
�y o0. '