23A-091 (4) Kc.l. Roofing Date
6 Line St. Estimate
Southampton,Ma. 01073 1/24/2014
Phone(4l 3)527-4775
Fax(413)527-8469
Name/Address Job Location
Kim Rescia 311 Locust St.
311 Locust St. Florence,MA 01062
Florence,Ma. 01062
Terms Rep
Estimate valid for 30 days Chris
Description Total
Remove existing roofs. 13,300.00
Furnish&install 1 1/2"nail board.
Furnish&install aluminum drip edge,pipe flashings,chimney flashings and step flashings.
Furnish&install CertainTeed Winterguard ice&water barrier along eaves.
Furnish and install synthetic underlayment.
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.
Customer is responsible for costs associated with collections including attorney fees.
Total $13,300.00
TERMS OF PAYMENT
Deposit
Customer Signature
Balance upon completion
Registration# 126235
Construction License#074334
Insured by Banas&Fickert Ins. Dater:,".�
(413)527-2700 t"J
z'
The Commonwealth of Massachusetts
Department of Industrial',Accidents
Office of Investigations
600 Washington Street
.` Boston, MA 02111
° miw.mass.gov/dia
Workers' Compensafion Insurance Affidavit, Builders/Contractors/Electi•icians/Plumbers
,pplicant Information Please PHIlt Legibly
lame (Business/Organizationflndividual): p , C\-0.
address: �,
c) o-i 3 Phone #; (y1.3) 15 '1 -QF" -(5
re you an employer? Check the appropriate box: Type of project (required): 1
�, am a employer with 2 0 4. ❑ I am a general contractor and 1 6, ❑ New construction
employees full and/or art=tune .* have hired the sub-contractors
( p ) 7, Remodeling
�
❑ I am a sole proprietor or partner- listed ou the attached sheet, I ❑ g
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp , insurance. 9, ❑ 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, 1.52, §1(4),'and we have no 12. Roof repairs
insurance required.] t employees. [No workers' 13.7 Other
cornp, insurance required,]
iy applicant that checks box#I 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,
ntracton 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
'ormatiort.
urance Company Name: -
licy#or Self-ins. Lic. #:-W ylo'?)3 y 05 Expiration Date: I 0 • S • d q
Site Address:,_S I( LOC—Slt City/State/Zip:cl("�-tin "'"ikA 010L-,2,
tack 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 crinunal penalties of a
,e up to $1,500,00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
up to 5250.00 a day against the violator, Be advised that a copy of this statement may be forwarded to the Office of
vestigations of the DIA for insurance coverage verification,
fo hereby certify under the pains andpenalties ofperjury that the information provided above is true and correct
mature:
.�'Cir ,- Date: '
tone
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: Per #
Issuing Authority (circle one):
1. Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5, Plumbing Inspector
6. Other
Contact Person: Phone#:
SECTION 8 -CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: MaYh Mel(5 ,e. J ( q,3 3 T
License Number
Address 'T Expiration Date
0441 .5 ?- ??5
Signature Telephone
9. Registered Home Improvement Contractor: Not Applicable O
Companv Name Registration Number
Haoreaa Expiration Date, i ynplbn . Ma. O I C ,•�-�
3 Telephon •..4fq
SECTION 10-WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L,c.162,§211
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... No...... ❑
1 . - Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)families
;ind to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner_Let$
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 ty
responsible for all such wort;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. I
.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 pem)n(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,Clty of
Northampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature , �-
i
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House [ Addition [] Replacement Windows Alteration(s) Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [❑] Decks [❑ Siding [❑J Other[r7]
Brief Description of Proposed
Work: a t a� 1�
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 followincl:
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
�C t 01 as Owner of the subject
property
hereby authorize Po- 71, 860Fj*nei
to act on my behalf, in all matters relative to work authorized by this"building permit application.
ae P_ �
Signature of Owner Date
I ,M'AV k Me-I W e- a5 -aL] aQent as Owner/Authorized
Agent hereby declare that the statements and information on the foregoing aablication 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 DepaMnent
Lot Size
Frontage
Setbacks Front
Rear
Building Height
Bldg. Square Footage %
.Open Spate Footage %
(Lot area ininus bldg&paved
4 of Parking Spaces
A. Has a Special Pemht/Ynriune/Finding ever been issued for/on the site? `
NO 0 DONTKNDW 0 YES
\ ' �
|F YES, date ioue& ( '
IF YES: Was the permit recorded at the Registry of Deeds
NO ~ DONTKNOY — YES 0
IF YES: enter Book | ' Page! | and/or Document �� �
/
B. Does the site contain a brook, body of water orwetlands? NO � � DONT KNOW �-� YES
�� ��
IF YES, has permit been or need to be obtained from the Conservation Commission?
Needstnbpobtained /—
� Obtained �-^ Date |xoued' i '
v�/ �-� ' . �
C. Do any signs exist on the property? YES 0 NO 0
- - -- ' - i
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES ���~\ NO y~~
IF YES, describe size, type and location:
� |
E Will the construction activity disturb(clearing,gradingexcavation, nr filling)over 1 acre nrisit part ofa common plan
that will disturb over 1acre? YES � � NO
~^�
IF YES,then a Northampton G1nnn Water Management Permit from the DPW ia required.
Department use only
j City of Northampton Status of Permit:
/ Building Department Curb Cut/DriuewayPermit
212 Main Street Sewer/Septic Availability
Room 100 Water/1Neli Availability
Northampton, MA 01060 Two Sets cf 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
311 LJQC-5t` '�)V Map Lot Unit. _
Y�o e—'n(–'C' Zone Overlay District_
Elm St.District C13 District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
T1�M j5A>'r nc t M A 01 0(62 _
Name(Print) Current Mailing Address:
a tta eh d �'�'-� -
Telephone
Signature
2..22 A,,.�ut��horized Agent: �
Name(Print) � Current Mailing g Address:
13 527- Al 115 _
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building 3 3��� (a) Building Permit Fee
. c,�a _
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) s 0 C, Check Number
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
311 LOCUST ST BP-2014-0921
GIs#: COMMONWEALTH OF MASSACHUSETTS
MU:Block: 23A-091 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-2014-0921
Project# JS-2014-001590
Est. Cost: $13300.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Groin RCI ROOFING 74334
Lot Size(sq. ft.): 11891.88 Owner: RESCIA KIM STUART&NANCY DONATO
Zoning_URB(100)/ Applicant: RCI ROOFING
AT. 311 LOCUST ST
Applicant Address: Phone: Insurance:
6 LINE ST (413) 527-4775 Workers Compensation
SOUTHAMPTONMA01073 ISSUED ON:31312014 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 3/3/2014 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272
Louis Hasbrouck—Building Commissioner