29-086 (3) M
R.C.I ROOFING
40 MAINE AVE.
P.O. BOX 309
EASTHAMPTON, MA 01027-0309 ESTIMATE
PHONE (413)527-4775
FAX (413)527-8469
jof" Date: SEPTEMBER 9,2002
Estimate To:
GREG KRAUSE Estimated B : MARK DELISLE
410 RYAN RD. Start Date:
NORTHAMPTON, MA. 01060 Job Location: 410 RYAN RD.
NORTHAMPTON, MA. 01060
Job Phone; (413)586-3413
JOB DESCRIPTION
REMOVE RXrSTING ROOFS,
ALL ROOFING RELATED DEBRIR TO BE REMOVED BY RCI ROOFING.
ALL WORK WILL PFRFQPMED ACCORDING To AfAAfrjFACTUgEgS SpFrTFICATIONS,
5 YEAR R.C.T. WORKMANSHIP WARRANTY TATrrrff)RD.
ALL RELATED PFRMT'Pq WILL BE ORTAINED BY R.C.I. ROOFING.
SPECIAL ITEMS NEEDED
ADD $2.00 PER S . 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 $3,300.00
REGISTRATION 0126235
FEDERAL I.D.#04 3418839 Authorized
CONSTRUCTION LICENSE#074334 $19natu . G��
A „
(V,V,V
INSURED BY HACKWORTH INSURANCE(413)527-9907 _
ORIGINAL-ESTIMATOR COPY
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DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORICER'S COMPENSATION INSURANCE AFFIDAVIT
1, r � ',s�� - s X00 Y�
with a principal place of business/residence at:
t .
Z4 YnCL%-f\ti wy F- Yea _ OIoZ'�phone#) �l13 -SZ7-k?7 S
(6trcvcity/stawxip)
do hereby certify, under the pains and penalties of perjury, that:
WI am an employer providing the following worker's compensation coverage for my
employees worming on this job:
��tAdt,c XA- � ti�c-s, 31s•3iiizy o� ra - s-o�
Company) (Polity Number) (Facpirat on Date)
( ) I am a sole proprietor, general contractor or homeowner(circle one) and have hired
the contractors listed below who have the following worker's compensation policies:
(Name of Contractor) (Insurance Company/Polity Ntunbcr) (Expiration Date)
(Name of Contractor) (Insurance Company/Poky Number) (Expiration Date)
(Name of Contractor) (Insurance Compauy/PoUcy Number) (Etphdon Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additional sheet if neoeaary to include information patainius to all ooatmd r3)
( ) I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE:please be aware that while homeowners who employ pczsom to do maiutmancc,oom:ructioa or repair work on a dwelling of
not more thsn throe uEuu is which the boamownce raids oc oa the Qoundt appurt=n therdo an oot ecomally oowWcred to be
cmploy=undo the vodka's coavcnsatroa Act(GL152,a 1(S)),application by a homeowner for a license or permit may evil tho
legal dates of as employee uudec tho Wockoe's C.000pamation Act.
I understand that a copy of this ssa cmmi may be foewnrded to tho Depn u=d of Iod.rstrid Accident,'OtHoo of fww+noe for the
coverage vaifiicadoo and that failum to secure ooverag*under soctioa 25A of MOL 152 an lead to tb0 impositioa of mimhW Pea tWcs
oomistm&of a fie of up to S 1,300.00=N-ixnpr6o�of up to one year and civil pc n46c3 is the form of a Stop W sic Order cad a
fum of 3100.00.day apnina toe
Foe d 1110 oozy
permit Number
Maps Lot#
y�.ss Signahtre of Licauseetpermittee
,
8.1 Licensed Constructions Supervisor: Not Applicable ❑
Name of License Holder: �O�C �i�► S\ 0-1 ` 33 LA
License Number
Address Expiration Date
Signature Telephone
Not Applicable ❑
� zL 2, 35
Com Ps Y n ame \ Registration Number
R 0 (�o(Y;:� 01A ,14:�-lo " 0 L
Address Expiration Date
A CXQ F_ Y1 Telephone
SECTIQN 10 WO E,RS'COMPENSAT10N INS�URANEI=AFFID"AVIT'V.G . 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...... ❑
The current exemption for"homeowners"was extended to include Owner-occupied Dwellines 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 buildine 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
fy '
� I
, k k
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other[ ]
Brief Description of Proposed Work: VN E R coo
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative 0 Renovating unfinished basement Yes No
Plans Attached Roll 0•Sheet 0
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
I. 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 !OWNERAUH,ORIZATION TO BE:COMPLETED WHEN
OWNERS Adtf4TrOR!CO ITRACTOR�APPLIES FOR BUILDING PERMIT
ru , as Owner of the subject property
hereby authorize UO —'N to act on
my behalf, in all matters relative to work authorized by this building.permit application.
9
Signature of Owner Date
CL '\rrl " ,rip , as Owrter/Authorized Agent
hereby declare that the statements and information on the foregoing ap i tion are true and accurate, to the-best of my
knowledge and belief.
Signed under the pains and penalties of perjury.
M GLic Z p
Print Name
Signature of Owner/Agent Date
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
puking)
#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
IF YES, describe size, type and location:
r
City of Northampton
Building Department
212 Main Street
Room 100
Northampton, MA 01060
phone 413.587.1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE IIFO2M/1TION.
1.1 Property Address: c
O1 .
� 10 V\ a
VP
. EIIn.St.piS$r•►�,t" �.. . .. C�B�p�!���!.ct. .. � a,.`�' $,
SECTION - PROPERTY OWN ERS;H,IP/AUTHORIZEDAGENT
2.10 ner of Record:
Name(Print)-AJ Current Mailin Address.
�/�_ •�a�-�.moo.�P�-tb ✓l.�r.
Telephone
Signature
2.2 Authorized Agent:
Mal
I
Name(Print) Qurrent Mailing Address:
Signature TTee'ephone
SECTION 3 ESTIMATED CONSTRUCTION CO, tS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building 3 3 (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee a�
4. Mechanical(HVAC)
5. Fire Protection
6. Total =(1 + 2 + 3 +4 + 5) Check Number
This Section For Official Use Onl
Building Permit Number:, idp o 13--3 Q� Date Issued:
Signature:
Building Commissioner/Jnspector of i Buildings Date;
1 � x RD. BP-2003-0362
GIS#: COMMONWEALTH OF MASSACHUSETTS
:29-086 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2003-0362
Project# JS-2003-0601
Est. Cost: $3300.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RCI ROOFING 074334
Lot Size(sq. ft.): 12501.72 Owner: KRAUSE GREGORY J&SUSAN B
Zoning: URA Applicant: RCI ROOFING
AT: 410 RYAN RD
Applicant Address: Phone: Insurance:
P O BOX 309 (413) 527-4775 Workers
Compensation
EASTHAMPTONMA01027-0309 ISSUED ON.1017102 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP AND 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:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 10/7/02 0:00:00 3124 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo