29-041 RC.1. Roofing Date
6 Line St.
Estim
Southampton, Ma. 01073 5/24/2012
Phone (413) 527 -4775
Fax (413) 527 -8469
Name / Address Job Location
Pat Kapitsky 59 Pioneer Knoll
59 Pioneer Knoll Florence, Ma. 01062
Florence, Ma. 01062 (413) 586 -7753
Terms Rep
Estimate valid for 30 days Dave
Description Total
Remove existing roofs. 4,900.00
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 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.
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.
Add: $550.00 for Certainteed Landmark 50 year premium shingle.
A Certainteed Surestart Plus extended warranty will be included with a fee of $220.00 absorbed
by RCI Roofing if signed within 7 days. This extended warranty means that 20 of the 30 year
warranty is covered for labor and material. The last 10 years of the 30 year Certainteed warranty
would be covered for material only.
WE LOOK FORWARD TO DOING BUSINESS WITH YOU.
Total $4,900.00
TERMS OF PAYMENT
5% Deposit 1 1
Balance upon completion Customer Signature r 0 1 l �$ ' - �_
Registration # 126235 40
Construction License
# 074334 Date ,� / I
Insured by Banas & Fickert Ins. -
(413) 527 -2700
The Commonwealth ofAlassachusetts
Department of Industrial Accidents
11 ' Office Of Investigations
MINIM -
g • 600 Washington Street
vat Roston, i''L'1 02111
rrt,'w.nrass.aou /din
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print .Legibly
Name (Businessiorg,anization /Individual) :
- --- - - - - -- - --
Address: c
City/State/Zip:'-.. )\–, � �' 1 — Phone It: (-03
Are you an employer? Check the appropriate box: hype of project (required):
4 . [— I ant a general contractor and 1
am a employer with 6. j New construction
employees (full and/or part - time).* have hired the sub - contractors
2. fl I am a sole proprietor or partner- listed on the attadieu sheet. t Li Remodeling
ship and have no employees "These sub - contractors have S. r] Demolition
working for me in any capacity. workers' comp. insurance. `). Building Addition
[No workers' comp. insurance 5. Li We are a corporation and its •
required.] officers have exercised their 10.H Electrical repairs or additions
3.1 1 I am a homeowner doing all work right of exemption per MCI., 11.Li Plumbing repairs or additions
myself. [No workers' comp. c. 152. §1(4), and we have no 'v Roo f repairs
insurance required.] t employees. [No workers'
13.1 1 Other
comp insurance required.]
'Any applicant that checks box PI must also till out the section below showing their workers compensation lxalicy information.
Homeowners who submit this affidavit indicating they ate doing all work and then hire outside contractors H submit a new aflitlavit indices'" ing such.
tContractors that check this box must attached an additional sheet showing the name of the sub - cntractors and their workers' comp. policy inlormation.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: , •• a ^ v ;.
Policy # or Self -ins. Lic. #: Expiration Date: I r 4?
Job Site Address: �q \arv-cc - -- v.o \\ C ity /Slate /Zit): e a rt . O \bl
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expirarion date).
Failure to secure coverage as required under Section 25A of MG L c. 152 can lead to the imposition of criminal per ofa
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 fine
of up to $250.00 a day against the violator. 13e advised that a copy of this statement may be forwarded to the Office of
Investigations of the D1A 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� t Z--
Phone #: i•; 1 a ', t - LC( 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):
L Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector
6. Other
Contact Person: Phone #:
Ameminov
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : M' h T i ____ '77
License Number
516 -tol St.- Easthampton Ma. otoaf/ 5 -03 4
Address Expiration Date
�Lf 57 - Li ?'75
Signature /� Telephone ►3)
9. Registered Home Improvement Contractor: Not Applicable ❑
fte.i.'Roo 126235
Company Name Registration Number
51 e Aol Street, - P. O. Box 301 5 - I �#
Address Expiration Date
Eas than ptorv, M. n47 Telephon0 13)52q -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 K 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 Ilomeowner•: Person Is) 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 dwellin <u, 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 -lhr which this permit is issued.
Also he advised that with reference to Chapter 152 ( Workers' Compensation) and Chapter 153 (Liability of Employers to
Employees !Or 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 fir compliance with the State Building Code, City of
Northampton Ordinances. State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature _ atta Chad
_.___..
Awrw
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House [i Addition ( Replacement Windows Alteration(s) f Roofing ryi
Or Doors ❑
Accessory Bldg. [ Demolition I I New Signs [O] Decks [El Siding [t]] Other [o]
Brief Description of Proposed
Work attachPli
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, PONse, (. � kok �� Z , as Owner of the subject
property
hereby authorize t aY "D V t i s e R. CP I . Roof; n9
to act on my behalf, in all matters relative to work authorized by this uilding permit application. 9
attached )Z
Signature of Owner Date
I, _Nark LJel i � e, OU j or zr" a !. , as Owner /Authorized
Agent hereby declare that the statements and information on the foregoing auDlication are true and accurate, to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
Mar lisle
Print Name
Signature of Owner /Agent Date
k,-
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to he filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side 1.: R: 1,: R:
Rear
Building Height
Bldg. Square Footage
Open Space Footage
(I of area minus bldg & paved
parking)
4 of Parking Spaces
Fill:
(volume d Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site? .
NO Q DON'T KNOW Q YES Q
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW Q YES Q
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO Q DON'T KNOW Q YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained Q , Date Issued:
C. Do any signs exist on the property? YES Q 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 Q NO Q
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 Q
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
r
�N:vrLt .ioN Department use only
IS. sNOii�ds City of Northampton Status of Permit:
au Building Department Curb Cut/Driveway Permit
5 I 1 212 Main Street Sewer /Septic Availability
Room 100 Water/Weil Availability
N MA 01060 Two Sets of Structural Plans
a� 41 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
I
1.1 Property Address: This section to be completed by office
59 p ► z,n e_t-C' Y tl a‘ ` Map Lot Unit
- c\oe.e_Y \(_•Z Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
9Q tlP (o c. V c.4, Z K V, pi +,h tx_t' 1'', clrM - coy- cvlcse t wo, o\otoe_
Name (Print) C re Mailin Address:
attaehed (4,nt 3 , - v ts
Telephon
Signature
2.2 Authorized Agent:
V4 : - ... — . • I ., It r I _ e . - • _ . • '. III • • • il '. .
Name (Print) 7 7 . Current Mailing Address: 01013_
(3)521-
ww
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building P,00fi h `�P 00 (a) Building Permit Fee
2. Electrical 9 et` 00 . (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) $ t 1 00 OQ Check Number Qj Qo 0 Lit 3f -
This This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
59 PIONEER KNLS BP- 2012 -1128
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 29 - 041 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 -1128
Project # JS- 2012- 001928
Est. Cost: $4900.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RCI ROOFING 74334
Lot Size(sq. ft.): 11979.00 Owner: KAPITZKY JOHN E & PATRICIA R
Zoning: Applicant: RCI ROOFING
AT: 59 PIONEER KNLS
Applicant Address: Phone: Insurance:
6 LINE ST (413) 527 -4775 Workers Compensation
SOUTHAM PTON MA01073 ISSUED ON: 6/15/2012 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 Signature:
FeeType: Date Paid: Amount:
Building 6/15/2012 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner