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42-085 RC.I. Roofing Date 6 Line St. Estimate Southampton, Ma. 01073 7/17/2013 Phone(413)527-4775 Fax(413)527-8469 Name/Address Job Location John Bowler 165 Glendale Rd. 152 Main Rd. Northampton, MA 01060 Westhampton, MA 01027 (61'7) 828-7710 Terms Rep Estimate valid for 30 days Chris Description Total Remove existing roofs. 6,800.00 Furnish& install aluminum drip edge, pipe flashings,chimney flashings and step flashings. Furnish&install CertainTeed Winterguard ice&water barrier along eaves and valleys. Furnish and install synthetic underlayment over existing deck. 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. All related permits will be obtained by R.C.I. Roofing. Add$2.50 per sq. ft. for wood decking replacement if needed. A Certainteed Surestart plus warranty will be included with a fee of$280.00 absorbed by RCI Roofing if signed within 7 days. This extended warranty means that 25 years of the Lifetime warranty is covered for labor and materials. The remaining years of the Certainteed warranty would be covered for material only. WE LOOK FORWARD TO DOING BUSINESS WITH YOU. Total $6,800.00 TERMS OF PAYMENT�' 5%Deposit Balance upon completion f a Customer Signature .'J Registration# 126235 �" - de Construction License#074334 Date Insured by Banas&Fickert Ins. (413)527-2700 61/4841 c9 The Commonwealth of Massachusetts _* Department of Industrial`Accidents -vim;4 Office of Investigations mss" rs °e� 600 Washington Street Boston, MA 02111 Nevi wnnv.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Lpplicant Information Please Print Legibly lame (Business/Organization/Individual): Cl (1_,' , Q.,,p c:\ ,\o U,.? .ddress:___C4 L., e. 5\-- . ;ity/State/Zip:S z A. , -\ \i∎,z) 1 C"\o . of o-7? ' Phone #: Ni3) 5& 1 -L(-('15 . re you an employer? Check the:appropriate box: Type of project (required): I T- I am a employer with 2 U 4. ❑ I am a general contractor and I 6, E New construction employees (fiill and/or part-time),* have hired the sub-contractors ❑ I am a sole proprietor or partner- listed on the attached sheet. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity, _ workers' comp, insurance. 9, 1:1] Building addition [No workers' comp. insurance 5, We are a corporation and its _ required.] officers have exercised their 10. Electrical repairs or additions I am a homeowner doing all work right of exemption per MGL 11.— Plumbing repairs or additions myself [No workers' comp. c. 152, §1(4), and we have no 12.21<of repairs insurance required.] t employees. [No workers' comp, insurance required.] 13.❑ Other ,y applicant that checks box 01 must also fill out the section below showing their workers' compensation policy information.' Dmeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such, ntractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers' comp.policy information. m an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site brmation. urance Company Name: 5., C' c `-s`,h`� ..-r ry .. , licy#or Self-ins. Lie, #: W (' _ (Duo&?)L1 0,5 Expiration Date: I U • 5 • 1 3 Site Address: i(DS CA \.�f\.Ac e , '()NA, City/State/Zip:)3 ,Lcuy\R';ntAka. 0iOQO •tach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). ilure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a .e 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 up to $250.00 a day against the violator, Be advised that a copy of this statement may be forwarded to the Office of vestigations of the DIA for insurance coverage verification, to hereby certify under the pains and penalties of perjury that the information provided above is true and correct. mature: .•�� '°� Date: tone#: Cpl3 52. (`L.(`1C Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License ii Issuing Authority (circle one): 1, Board of Health 2.Building Department 3, City/Town Clerk 4.Electrical Inspector 5, Plumbing Inspector 6. Other Contact Person: Phone:#: SECTION 8 •CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: 1 1e1 Not Applicable 0 Name of License Holder: Mar -e\i s ( J-1 3 3'+ License Number L '3_ _ m _ Nl o / '. , 5 _ 03 - 16. Address Expiration Date (Li J 3) 52?- 11 175 Signature Telephone 9. Registered Home improvement Contractor: Not Applicable 0 ftC . L '?tôofinc . 1262.55 Company Name Registration Number • Hcaore» } �► n Expiration Date k �O 4�t an iFtCa �1r Ma, 0 1 G 3 Telephon��I 3)I.21 7'5 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 ce No 0 . 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 tä 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 perimit. 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 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 a .t.aehed • ■ • SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House Addition Replacement Windows Alteration(s) Roofing I-' Or Doors El C — Accessory Bldg. Demolition C New Signs [D] Decks [Q Siding [DJ Other[DJ Brief Description of Proposed �y,y.ac�� Work: L L Alteration of existing bedroom Yes- No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet -- ,sa. 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,r OY\ A.`)\ as Owner of the subject property hereby authorize t at/ T i 1 Si e O(' .C. I I. Roofl Yl to act on my behalf, in all matters relative to work authorized by this uilding permit application. Ott ached Signature of Owner minommminamosimmuate I, „lay Deli Ste, aS_ aLI tlior'ae.d acriant as Owner/Authorized Agent hereby declare that the statements and information on the foregoing aptiolication are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. Print Name Signature of Owner/Agent Date 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 Lot Size ? I Frontage € ` i ' Setbacks Front , I Side L:' R:` L: R:1 , I j Rear , Building Height Bldg. Square Footage i f .Open Spade Footage % (Lot area minus bldg&paved I parking) #of Parking Spaces ' Fill: (volume&Lpcation) 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 0 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 ) , 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 O NO 0 IF YES,then a Northampton Storm Water Management Permit from the DPW is required. --J Department use only RcE1VED City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit AUG - 2 20i� 212 Main Street Sewer/Septic Availability Room 100 Water/Well Availability PEP,.of G;o ,o sPecT:oNS Northampton, MA 01060 Two Sets of Structural Plans NORTHAMPTON,MA 01.060,Ph vile 13-587-1240 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 (Co S ( (\-e_Y\c L Q.+ e•A_ . Map_ Lot Unit ,&J c? ' cL \Q1--v'1 Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: ---- 6 q\ bo ,>;,\ ISM-, mo;..-. etc\ - eS‘\,r,ry,ck,Ai Nip. 0IcZ-7 Name(Print) Curren Address: _attaah d Tt M,ailin z� „t© e Telephone Signature 2.2 Authorized Agent: MaYk 'DP le, q.C.z. n9 46 1, ' 4 - • _. t II Name(Print) Current Mailing Address: 01013_ • - _--`-- ('4 15)) 521- 4175 Signature Telephone SECTION 3.-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building Quu In/ 4 / oc) (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) if, 6_,ca (0C1 00 Check Number ,,,21111•=1/ rio This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date 165 GLENDALE RD BP-2014-0121 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:42-085 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-2014-0121 Project# JS-2014-000234 Est.Cost: $6800.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: RCI ROOFING 74334 Lot Size(sq.ft.): 41774.04 Owner: BOWLER RICHARD&JOAN F TRUSTEES Zoning: Applicant: RCI ROOFING AT: 165 GLENDALE RD Applicant Address: Phone: Insurance: 6 LINE ST (413) 527-4775 Workers Compensation SOUTHAMPTONMA01073 ISSUED ON:8/5/2013 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 8/5/2013 0:00:00 $35.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner