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24C-148 .I. Roofing 6 Line St. Esti mate Date Southampton, Ma. 01073 12/28/2011 Phone (413) 527 -4775 Fax (41 3) 527 - 8 4(70 Name / Address Job Location Anna Lee Kantor 19 Arlington St. 19 Arlington St. Northampton, Ma. 01(160 Northampton, Ma. 0I00(1 (413) 586 -6261 Terms Rep Estimate valid for 30 days Dave Description Total Remove existing Garage rooks. 3,000.00 Furnish & install aluminum drip edge. Furnish & install Ccrtain'I'ecd Winterguard ice & water harrier alone eaves. Furnish and install synthetic underlavnient over existing deck. Furnish and install 311 year CertainTeed Woodscape Series shingle. Furnish and install Certain'Feed approved ridge vent. All exterior roofing related debris to he removed by R.CI. Roofing. All work will be performed according to manufacturers' specifications. 30 year CertainTecd material warranty included. All related permits will he obtained by R.C.I. Roofing. Add $2.50 per sq. ft. for wood decking replacement it needed. WE LOOK FORWARD '10 DOING BUSINESS WITII YOU. Total $3,000.00 TERMS OF PAYMENT 5% Deposit Customer Signature Bal upon completion e, I ),_. n lti g -e/... t , Registration N I2b235 Construction License II 074334 Date � � %' �� j')/ ✓ __ Insured by lianas & Fiekert his. (413) 527-2700 The Common wealth of /1Iassaelrusctts _ Department of IrtclustrialAccidents = - Office of Investigations "tW — 600 iI ton Street Ilostun, ; L 1 02111 \sr 3/ tt fit tt. utuss ,vu "ilia Workers' Compensation Insurance .Affidavit: Builders/ Contractors /Electricians /Plumbers Applicant Information Please Print Legibly Name ( Business /Organizationrindividual) =� �. t�, Address: t :, City /State /Lip — Klima _ r C _._ v'�) Phone f +: Are you an employer? Check the appropriate box: 1 Pe of project (required): I. I II 1 am a employer with I :o a genet contractor and i 6 New construction employees (full and /or part titer) ' have lined the sub- contractors 2.1i I aril a sole proprietor or partner- lists d on the aii:rcl■ed sheet. J ivenrodcltnt� ship and have no employees These sub contractors have S. [71 Demolition working for me in any capacity vy-01 kCF:; comp. insurance. r7 ( Building addition [No workers' comp. insurance 5 Li We are a corporation and its 1 . ltcers have exc- versed their o.[, I:iccu-ital repairs or additions required.] of 3.1 1 1 ant a homeowner doing all work right Of exemption p er MCI_ Plumbing repairs or additions myself. [No workers' comp. c. 152. §1(4). and we have no 12. Roof repairs insurance required.1 1 employees No workers' c�tntp insurance n ice rcqun ed.] 1 i 1 ] Other •Any applicant that checks box #t must also till out the section hclow showing their workers' compensation policy infumuttiou t Homeowners who submit this affidavit indicating they tie d■in5 ell work nit then Hire &'inside contractors must suhnrit a ncv■ affidavit wtlicrr' ink suc tContractots that check this box must attached an additional sheet showing the nine oh the suh.conttaetors and their workers' corup, policy intotinot ion . I am an employer that is pr•ovidinl,' workers' compensation in.cureurcc for my employees. Below is the polica' and jab site information. Insurance Company Name:' _ , ,,t Policy # or Self-ins. Lie. ''� c ? �� ' Expiration Date: . f.. ' t 2 Job Site Address: \ asA _nc\ sl �' City /State /Zip: p � i _ vl Ot�,O Attach a copy of the workers' con reus.►tinn policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of M61_ c. I52 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one -year imprisonment, as well as civil penalties in the form of a SPOP 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 certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: ^= Date: 3 Phone #: cc-II 1 ' - t — — Official use only. Do not write in this area, to he completed by city or town official. �) City or Town: Permit /License # Issuing Authority (circle one): 1. Board of health 2. Building Department 3. City /Town Clerk 1. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : M a Y h - De. i i 5+ e, TM 334 1 License Number 5181- oh St. - Easthmpton 1 Ma. n ioail 5 - 03 12 Address Expiration Date ( j3) 527- r775 Signature Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ f 1.26235 Company Name Registration Number 51 a Nolyoke Street - P 0 -'fox 309 5 - ©b -12 Address *�» Expiration Date Easthampton Ma . 010 a4 ( Telephon601 4775 SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(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 EL7 ld No ❑ 11. - Home Owner Exemption The current exemption for "homeowners was extended to include Owner - occupied Dwellings of one (I) 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 he, 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 from time to time. during and upon completion of the work.for which this permit is issued. Also he 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 att — _ , SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) y New House I I Addition I Repl. em- n, l •• s/ Alter. - ./ !�f Roofing Filf i D••r,f .I/ r Accessory Bldg. I I Demolition I I '- . �• 1 s [O] Decks [E] Siding [0] Other [0] Brief Description of Proposed atta h Work: [_ p Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet 6a. If New house and or addition to existing 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, Qt\t> v„ L ex .. K 0—(N. YC C , as Owner of the subject property hereby authorize LP4 ar 1Del L Sl P of R.C.I. . Roof, nei to act on my behalf, in all matters r lative to work authorized by this uilding permit application. attached )_ z -(z Signature of Owner Date I, u . , - . • • • • . A _ as Owner /Authorized Agent hereby declare that the statements and information on the foregoing . • •lication are true and accurate. to the best of my knowledge and belief. Signed under the pains and penalties of perjury. Ma [; s l e, Print Na 3 -4a -1 a, Signature of Owner /Agent Date Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information 1-;xisting Proposed Required by Zoning 'rills column to he Idled in by Uu iId m4 Department lot Site Frontage Setbacks Front Side I.: R: 1,: R: Rear Building Ileight Bldg. Square Footage Open Space Footage `Yo ( Lot area minus hldg & paved parking) or Parking Spaces fill: (volume & location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? , NO 0 DON'T KNOW 0 YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW 0 YES 0 IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO O DON'T KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained O , Date Issued: C. Do any signs exist on the property? YES 0 NO 0 IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO 0 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 V NO 0 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. Li Department use only DEpT. i of Northampton S tatus of Permit: 1 L ,L uilding Department Curb Cut /Driveway Permit 212 Main Street Sewer /Septic Availability � Room 100 Water/Well Availability No PION Northampton, MA 01060 Two Sets of Structural Plans phone 413 - 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 kC+ (l� t \ ��� • Map Lot Unit N C \�rwm'.oi aA Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: \ ` ` +` V-<vv,.. \—Q1? . or ` �} t �r\ \n, ` -o c) S- . A0(�1 hG,,,etn , MG, • OI b(oh Name (Print) Current Mailing Addr•ss: a tta eh e P t - . - 7. Tele 'one Signature 2.2 Authorized Agent: NI Yil 1"08 ' 16 - t .C.I. Roofi nti L Li n_es -E - Soahampton, Nat__ Name (Print) Current Mailing Address: 010 �- ( 113) 527- 4175 .w Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building R ooFir 1 4 3 oC-xi oa (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 = (1 + 2 + 3 + 4 + 5) $ 3 O6O. 00 Check Number / 69 L3- This Section For Official Use Only . Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date A 19 ARLINGTON ST BP- 2012 -0767 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 24C -148 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- 2012 -0767 Project # JS- 2012 - 001349 Est. Cost: $3000.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: RCI ROOFING 74334 Lot Size(sq. ft.): 8015.04 Owner: KANTOR ANNA LEA Zoning: URB(100)/ Applicant: RCI ROOFING AT: 19 ARLINGTON ST Applicant Address: Phone: Insurance: 6 LINE ST (413) 527 -4775 Workers Compensation SOUTHAMPTONMA01073 ISSUED ON:3/7/2012 0:00:00 TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE GARAGE 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 3/7/2012 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner