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42-032 • BP- 2011 -0530 GIS #:' ' COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: BUILDING PERMIT Permit# BP- 2011 -0530 Project# JS- 2011 - 000870 Est. Cost: $6500.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: RCI ROOFING 74334 Lot Size(sq. ft.): 75794.40 Owner: JOHNSON WARREN G & VICTORIA E CO- TRUSTEES OF THE KOLCZ NOMIN Zoning: SR(100,//WSP II Applicant: RCI ROOFING AT: 755 WESTHAMPTON RD Applicant Address: Phone: Insurance: 6 LINE ST (413) 527 -4775 Workers Compensation SOUTHAMPTONMA01073 ISSUED ON :121812010 0:00:00 TO PERFORM THE FOLLOWING WORK.- & 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 Signature: FeeType: Date Paid: Amount: Building 12/8/2010 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner City of Northampton Ski 3 p j Building Department CtirO`C" 212 Main Street ` Room 100 Northampton, MA 01060 phone 413 - 587 -1244 Fax 413 - 587 -1272 t�iotl►' Other�S j 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 — 1 L i �,S� rv��� Map Lot U nit uc Zone _ Overlay District__ ­ Elm St. District CB DM SECTION 2 PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record 15 U3 Name (Print) Cu nt Mail Address: —T 1 Telep ne Signature 2 .2 Authoriz Agent: Jae uLr Name (Print) Current Mailing Add ress: Q 1 O `-l• 527- 1I5 Signature Telephone SECT10N 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by rmit applicant �-1. Building © C�C� (a) Building Permit Fee 2. Electrical (b) Estimated Total Cont of . Construction from r 3. Plumbing Building Permit Fee L- 4. Mechanical (HVAC) 5 Flre 6. Total = (1 + 2 + 3 + 4 + 5) Check Number This Section For Official Use On ltAlirt'gPermit i,Jumber. Date Issued: i Sigirratiure: +1 "` Building Commlaalonsr/lnspector of Buildings Dels Section 4, ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be filled in by Building Department Lo Siz _ Fronta e Sctbacks Front _ Side L: R: R: i Rear Building Height B'dg. Square Footage 0-,)en Space Footage (Lx area minus bldg & paved akin # :)f Parking Spaces Fill: L , volume & f Kation A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO O DONT KNOW O YES Q IF YES, date issued:! I IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW O YES O IF YES: enter Book Page; and /or Document #� B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW O YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained O , Date Issued: C. Do any signs exist on the property? YES O NO O IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES O NO O IF YES, describe size, type and location: E. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of 'a common plan that will disturb over 1 acre? YES O NO O IF YES, then a Northampton Storm Water Management Permit from the DPW is required. SECTION 5- DESCRIPTION OF PROPOSED WORK (,check all applicable) New house ❑ Addition Replacement Windows Alteration(*) Roofing Or Doors ❑ 1 Accessory Sidg. ❑ Demolition ❑ New Signs 10] Decks [M Siding (01 Other 101 ' Brief Descript on of Proposed Work: I i Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet l i sa. If New house and or addition to existing housing complete the follo a. Use of budding : One Family Two Family Other b Number of rooms in each family unit: Number of Bathrooms I 1 c. Is there a garage attached? %r d. Proposed Square footage of new construction. Dimensions e. Number of stories? '. Method of heating? Fireplaces or Woodstoves Number of each g. ;energy Ccnservation Compliance. Masscheck Energy Complianee.form attached? h. Type of , onstruction Is construction within 100 ft. of wetlands? _^ Yes No. is construction within 100 yr. floodplain ,__Yes No ;. Depth of casement or cellar floor below finished grade 1 k. Will building conform to the Building and Zoning regulations? Yes No. { f. Septic Tar:x City Sewer Private well City water Supply I - SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT f i, &V\ �� Q� „1, , as Owner of the subject property ^� Q n hereby authorize _S aY I�L S,� Q� fl • l t. • na to act on my behaif, in all matters relative to work authorized by thislouifding permit application. _ a, ► -3 �� Sigh} Kt&' df Owner Date i, , as Owner /Authorised Agent hereby declare that the statements and information on the foregoing lication are true and accurate, to the beat of my krtowlsdge i and belief. Signed under the pains and penalties of perjury. Print Name 1-340 Signature of Owner /Agent Date r SECTION 8 - CONSTRUCTION SERVICES 8.1 1 : icensed Construction Snervisor Not Applicable ❑ M Na me of Lice Holder : ,' `aY -T P, s le - 17 ?'7 1. J'] License Number t Address a Expiration Dale Signature Telephone 9. Registered Home Improvement Contractor Not Applicable R oo fi na 12 b 23� Company Name Registration Number Expiration Date arn_Y1 MA- ( lU3 Teiephon SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 162, § 26C(6)) 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....... �e No...... ❑ 11 - - Home Owner Exemntion The current exemption for "homeowners" was extended to include Owner - occupied Dwellin s of one (1) or two(2) families ar.d to al low such homeowner to engage an individual for hire who does not possess a license, Drovlded 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 or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/ or farm q;- octures. A person who constructs more than one home in a two -year period shall not be considead a homeowner Su,:h - homeowner - shall submit to the Building Official, on a form acceptable to the Building Official that htJshe shall be responsible for all such work performed under the building permit As acting Construction Sunervisor 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. :\!so be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to Em,ployces for injuries not resulting in Death) of the Massachusetts General Laws Annotated, you may be liable for person(s) .1rn, 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 t • 1, � „y i`„N.: _.� � •, �•�- t'he Commonwealth of Massachusetts 7 Department of Industrial Accidents Office of Investigations 600 Washington Street 7 . Boston, MA 02111 www.tnass.gov /dia Workers' Conipensation Insurance Affidavit: Builders/ Contractors /Electricians /Plumbers Applicant Information Please Print Legibly Name ( Business /Organim6on/lndividual) : City /Stat c!Zi Phone #: - L1 Are you an employer? Check the appropriate box: Type of project (required): `J� ( atn a employer with _ `l• F t am a general contractor and f emplovc,s (full and/or part - time). have hired the sub - contractors 6. [] New construction j �. ❑ h I am a sole proprietor or partner- mid have listed on the attached sheet. ?. ❑ Remodeling ship ui have no employees These 8. F1 Demolition working for me in an capacity. employees and have workers' S y 9. ❑ Building addition [No �korkers' comp. insurance comp. insurance.• required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions I 1 . ❑ I am it homeowner doing all work officers have exercised their 1 I.[] Plumbing repairs or additions yselt'. ,Jo workers COtn right of exemption per MGL ,n y [' p. 12. Y_ Roof repairs insurance required.]' c. 152, §1(4), and we have no employees. [No workers' 13.❑ Other _ comp. insurance required.] ';try appiicaru that cheeks box #1 must also fill out the section below showing their workers' compensation paliey information. I iumeo%vncrs \ + ho sutm,it this affidavit indicating they we doing all work and then hire outside con tractors must submit a new affidavit indicating such. 'Contractors that check this box must attached an additional sheet showing the name of the sub - contractors and state whether or not those entities have employees. If the sub - contractors have employees, they must provide their workers' comp. policy number. I am an empioYer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Cutnparty Name: �� Q'�DQtGC'"�_= CwS�.w.�`• -�,, '� n S _ i'oltcy € or 5<<it =ins. L_ic. ;tSI�IS..._. ^ q 5? 0'1 S_( Expiration Date: / 4 - L S' - O Job Site Address: Ctty /State/Zip: 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 criminal penalties of a tine up to $' ,00.00 and/or one -year imprisonment, as well as civil penalties in the 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 statement may be forwarded to the Office of investigations of the DIA for insurance coverage verification. I do hereby c•.rrtify under the ins and penalties of perjury that the information provided above Is true and correct. ate • 12 .1 Pilo — A ' — ± - Ufl fcial use only. Igo not write in this area, to be completed by city or town offlciaL a Ipr Town: Permit/License # g Authority (circle one): rd of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector ter n..... a rt. Id 4 !r'I; lint III Ij 11, '1), j I S t L 7,43,34 Resffa:led 00 MARK T DELISLE 33 FIRST AVE EASTHAMPTON, MA 01027 ....... r(4 26357 ZME IMPROVEMENT CONTRACTOR Sys Registration: 126235 Expiration: 5/6/2012 Tra 29J949 Type: partnership R,C 1. ROOFING MARK DELISLE 6 LINE ST SOUTHAMPTON, MA 01073 R,0C roofin LLP 6 Line St. Southampton, Ma. 01073 E st i m ate Date Phone(413)527 -4775 Fax(413)527 -8469 5/28/2010 Name / Address Job Location Alicia Ralph 755 Westhampton Rd. 755 Westhampton Rd. Florence, Ma. 01062 Florence, Ma. 01062 (413) 584 -3824 Terms Rep Estimate valid for 30 days Dave Job Description Total Remove existing roofs. 6,500.00 Furnish & install aluminum drip edge, pipe flashings, chimney flashings and step flashings. Furnish & install new lead counter flashings. Furnish & install CertainTeed Winterguard ice & water barrier along eaves and valleys. Furnish and install synthetic underlayment over existing deck. Furnish and install 30 year CertainTeed Woodscape 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. 5 -year RCI Roofing workmanship warranty included. 30 year CertainTeed material warranty included. All related permits will be obtained by R.C.I. Roofing. Add $2.50 per sq. ft. for wood decking replacement if needed. , A�$'F�SA a� L�RdiF4E- A n y n� Cei:win e warra a . I Iona years, wl e include in seven s. F vE LOOK FORWARD TO DOING BUSINESS WITH YOU. i Total $6,500.00 5% Dcp OF PAYMENT Balance upon completion / Registration # 126235 Customer Signature Construction License # 074334 Insured by lianas & Fickcrt Ins. Da 413 -527 -2700 15 "'d