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29-182 (2) R.C.I ROOFING 40 MAINE AVE. P.O. BOX 309 o ESTIMATE EASTHAMPTON, MA 01027-0309 '� PHONE (413)527- 4775 FAX (413)527-8469 Date: JULY 15, 2002 Estimate To: KEN POMP$LL4 Estimated By: MARK DELISLE 82 BRIARWOOD DR. Start Date: FLORENCE, MA. 01060 Job Location: 82 BRIJ�RWOOD DR. FLORENCE, MA. Qr�� Job Phone: (413)584-5088 JOB DESCRIPTION FURNISH & INSTALL 151b.PELT OVER EXISTING DECK, FURNISH & INSTALL 30 YFAR TAKK0 SHINGLE. ALL WORK W.TTT, PRRFORMED ACCORDING TO M"UPACTURERS SPECIFICATIONS. SPECIAL ITEMS NEEDED ADD $2.00 PER FT. FOR WOOD REPLACEMENT IF NEEDED. Additional information pertaining to this Job Estimate TERMS OF PAYMENT 30%PRIOR TO START Total Estimated 70%UPON COMPLETION Job Cost $5 so)" REGISTRATION 5126235 FEDERAL I.D.504 3418839 Authorize/ l CONSTRUCTION LICENSE 5 074334 Signature l /Z)� INSURED BY HACKWORTH INSURANCE(413)527-9907 I ORIGINAL-ESTIMATOR COPY 4S1iAMP�0 A d �27 x1t71 �11I�TIItt a6Icssxrhttsrtta' m DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street ' Municipal Building Northampton, Mass. 01060 WORKER'S COMPENSATION INSURANCE Ali iAVIT (licens�Jpel-mitcer) -- with a principal place of businesslresidence at: t1 40 YY)M% �� O-V f. Vy\ 010Znph0 ne#) 913 -S-Z7-y77 S (st=Ucity/Aatdzip) do hereby certify, under the pains and penalties of pefjury, that: ( I am an employer providing the following worker's compensation coverage for my employees worEng on this job: a� Compmy) (Policy Number) (Expiration Dale) O I am a sole proprietor, general contractor or homeowner (circle one) and have hued the contractors listed below who have the following worker's compensation policies: (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiation Date) (Name of Contractor) (Lris ranfti Company/Policy Number) (Hxpirabon Date) (Name of Contactor) (Insurance Compny/Policy Numb-er) (Expiration Date) (auadi a6liticcil zrxct if ntcc_ .Fy to include infocinatiou pertaining to ell oatmcton) O I nun a sole proprietor and have no one working for me. ( ) I am a home owner performing all the work myself. NOTE:pteaae lx aware that whilo homcotii-icrs who cmpIay pa o=to&D a ainI-„nc,oc--.- loo or rcpau wuck on a dwelling of not rue"than throe units in NvEc t the homoonvcr resides or on the graurls appurtcnani tlrcio art no(wally coasidmd to be employes under the works c(xt�p . ticn Act(GL152,sa 1(5)),application by a homeowner far a ticaise oc permit may evidcnoe the legal ax"of an employer under tho Workcez Compomation Ask- I undcr t d dmi a copy of this ctatcmcni may be forwarded to the Dq'xi Ir rol of j d ruin!Aoci&riy Offioe of ra3. oo for the coverage vaif cation and that failure to accure oovzigo under section 25A of MOL 152 can acad to tho imposition of criminal pcnalLca ooasistiag of a f nc of up to S 1,500.00 andtor impris�of up to one year ad civil panitics in the form of a stop Work Order and a fum of S 100.00 1 day against mc_ Fa&T-trrr'tal trso only permit Number < � Lot# Y S29iahue of Liccnsee/Perm-ittee te R SECTION 8'-C 0 1 NSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : ' l O.'-lt�s ©I A 33 LA License Number Address Expiration Date q13 5Z-1 w 44`7`15 Signature Telephone �-... �;� .'.��.. . ��rx rte= �:Re r 1IN rn- m r.'��emen n ra > y„ �.�a .�_, Not Applicable ❑ �- / zL z35 Company Name v Registration Number Address Expiration Date QV C t VQYl Telephone yI3°�27�� 7 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....... ❑ No...... ❑ ,omen 1 ner The current exemption for"homeowners"was extended to include Owner-occupied Dwellinp_s 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 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 buildinna 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 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 SECTION 5= DESC14IPTI3ONOF PROPOSEDVORK(ch'eck all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding [ ] Other [ ] Brief Description of Proposed Work: Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative❑ Renovating unfinished basement Yes No Plans Attached Roll ❑ - Sheet o 6 If N6 house �n IM dditi'MA611e misting;°t'oirs�ing complete the fo1'I"owing: 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. Mascheck 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 as Owner of the subject property hereby authorize 0.�C' ��"� —�� 1 (00 Y-\A to act on my behalf, in all matters relative to work authorized by this building permit application. 0 -�'10 -02 Signature of Owner Date M�Y!� ��t �, �Z')[j�� rN as Gwmr/Authorized Agent hereby declare that the statements and information on the foregoing app tion are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. Print Name V -,o -O2, Signature of Q;w4 r/Agent Date t r Section 4. ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED DUE TO LACK OF INFORMATION Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size Frontage Setbacks Front Side L: R: L: R: Rear Building Height Bldg. Square Footage % Open Space Footage % (Lot area minus bldg&paved parking) #of Parking Spaces Fill: volume&Location A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO DON'T KNOW YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO DON'T KNOW YES IF YES: enter Book Page _ and/or Document # B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW YES 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 _ NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ?YES _ No i IF YES, describe size, type and location: .ffi City of Northampton Building Department C:txr 212 Main Street Room 100 a Northampton, MA 01060 e s a phone 413-587-1240 Fax 413-587-1272 Po7Slte a t�rSpe�l APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION This sectionA bekcomp eted by office, 1.1 Property Address: V � Ma Zon �str e Ouertay Dict � bn cct- � Elm St. District CB District -` SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) Curre& ng - OXY Telephone ` Signature 2.2 Authorized Agent: I Name(Print) Current Mailing Address: Signature Te ephone SECTION 3 ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars) to be Official Use Only _ completed� ermit a licant 1. Building ,/ f) (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) Check Number _ This Section For Official Use Only Building Permit Number: Date Issued; Signature: Building Commissioner/inspector of Buildings Date W-4.. BP-2003-0192 GIS#: COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON Lot: -001 Permit: Building Category: BUILDING PERMIT Permit# BP-2003-0192 Project# JS-2003-0353 Est. Cost: $5500.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: RCI ROOFING 126235 Lot Size(sg. ft.): 10018.80 Owner: POMPILLI KENNETH S Zoning:.URA Applicant: RCI ROOFING AT: 82 BRIERWOOD DR Applicant Address: Phone: Insurance: P O BOX 309 (413)527-4775 Workers Compensation EASTHAMPTONMA01027-0309 ISSUED ON.8/27/02 0:00:00 TO PERFORM THE FOLLOWING WORK:ST R I P & S H I N G L E 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: Fee Type: Receipt No: Date Paid: Check No: Amount: Building 8/27/02 0:00:00 2959 $25.00 212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo