29-183 (3) 111111 1
R C. Ro ofin Date
6 Line St. Estimate
Southampton,Ma. 01073 5/20/2014
Phone(413)527-4775
Fax(413)527-8469
Name/Address Job Location
Peter Jones 105 Briarwood Dr,
105 Briarwood Dr. Florence, MA 01062
Florence, Ma. 01062 (413) 548-0371
Terms Rep
Estimate valid for 30 days Chris
Description Total
Furnish&install aluminum drip edge on Garage only. 3,600.00
Furnish&install Lifetime CertainTeed Landscape Series shingles over existing Garage roof.
Furnish&install ridge vent.
Furnish& install pipe vent flashings and all other related flashings.
All exterior roofing related debris to be removed by R.C.I. Roofing.
All work to be perfonned according to manufacturers' specifications.
Lifetime CertainTeed material warranty included.
]-year R.C.I, workmanship warranty included.
All related permits will be obtained by R.C.I. Roofing.
Customer is responsible for securing interior items and any attic debris from roof removal.
Total $3,600.00
TERMS OF PAYMENT
5%Deposit
Balance upon completion Customer Signature W-. L
Registration# 126235
Construction License#074334 6
Date
Insured by Banas&Fickert Ins.
(413)527-2700
The Commonwealth of Massachusetts
Department of Industrial',Accidents
Office of Investigations
d 600 Washington Street
.` Boston, MA 02111
www,mass.gov/dia
Workers' Compensation Insurance Affidavlt: Builders/Contractors/Electi•icians/Plunabers
pplicant Information Please Print Legibly
aerie (Business/Organization/]ndividual): -
.ddress: C.o
o-? 3 ' Phone #: (y13)
-e you an employer? Check the appropriate box: Type of project (required):
I am a employer with Z U 4, ❑ I am a general contractor and I 6. ❑ New construction
employees (full and/or part=time).* have hired the sub-contractors
❑ I am a sole proprietor or partner- listed on the attached sheet. t 7. Remodeling
ship and have no employees These subcontractors 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 MOL 11.❑ Plumbing repairs or additions
myself [No workers' comp, a 152, §1(4),'and we.have no 12. Roof repairs
insurance required.] t employees. [No workers' 13.❑ Other
comp, insurance required,]
iy applicant that checks box tf 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 utdicating such.
ntractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers' comp.policy information.
man employer that Is providing workers'compensation insurance for my employees. Below is the policy and job site
ormation.
urance Comp any Name: -
licy# or Self-ins. Lia #:-W 0 ', Expiration Date: 10 - $ - 14
Site Address: 10�5 66cl-c-W(--t f City/State/Zip; )ccV\i-e ,ZA 4 Cpl GIoZ
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 MOL 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 $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
Date: (�n
t one
#
S
OfcW use only. Do not write in this area, to be completed by city or tolvn official.
City or Town: Permit/License #
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: z h is l 177 q s3,1
License Number
Address �r Expiration Date
1413) 5 21 N 17 75
Signature Telephone
9, Registered Home Improvement Contractor: Not Applicable ❑
• _ 'Roo 6 nQ
(;ompany Registration Number
CIL-
Aoart:" Expiration Date
%, QL !`L aynotn 1 a. t)1 0-7 Telephon
SECTION 10•WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§26C(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....... 4Z No...... 0
11. - Home Owner Exemption
The current exemption for"horpeowners"was extended to include Owner-occupied Dwellinss-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
ns 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 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
.,\Iso 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,States and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
f
I.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House [7 Addition [] Replacement Windows Alt ra n(s) Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ Signs 16 ec s [❑ Siding ❑] Other[177]
Brief Description of Proposed Wf
Work: at
VV
Alteration of existing bedroom Yes No Add g n r m Ye No
Attached Narrative Renov i h dd basem nt Yes No
Plans Attached Roll -Sheet
6a. If New house and or addition to existing housing, cUplete the followin, :
a. Use of building : Ore 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, Z�' J G"A as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this uilding permit application.
y
Signature of Owner Date
I' as Owner/Authorized
Agent hereby declare that the statements and information on the foregoing aQplication 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
Frontage
Setbacks Front
Rear
Building Height
Bldg. Square Footage
Op:en Spate Footage %
(Lot area rninus bldg&paved
of Parking Spaces
A. Has o Special. Permit/Vohance/Finding ever been issued for/on the site? `
NO DON'T \_��_�
v_� 7 KNKNOW YES
\ '
|F YES, date issuod] | '
IF YES: Was the permit recorded ut the Registry ofDeeds?
NO �-� DON'T KNOW �-L�'� YES /r�_��
»^�
IF YES: enter 8nnk Page! | and/or Document # �
'
B. Does the site contain abrook, body of water orwetiunds? NO 0 DON'T 0 YES 0
IF YES, has permit been or need to be obtained from the Conservation Commission?
Needstnbeobtained ^
-
� Ob��ned /~� , Date Issued:
^-~ |
C. Do any signs exist on the property? YES 0 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: |
' .
E. Will the construction activity disturb(clearing, gradingexcavation, or filling)over 1 acre nrisd part ofa common plan
that will disturb over 1acre? YEGK � NO �"_��
�-^
IF YES,then a Northampton Storm Water Management Permit from the DPW ia required,
V
Department use only
City of Northampton Status of Permit:
F0 Building Department Curb C.ut/Drive.way Permit
212 Main Street Sewer/Septic Availability
& N Room 100 Water=ell Availability
S\e tk o Northampton, MA 01060 Two Sets of 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 I -SITE INFORMATION I
1.1 Property Address: This section to be completed by office
� 05 6 C, P.Ir(.Aj C Map Lot Unit-
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
�)e—Vc—r n 105 IS(--:,ck-c w c, f k b cezycs— AA A C)i o(,,?,
Name(Print) Current Mailing
( LI 11) 03'31
49 tt-a che,A Telephone
SignaCure
2.2 Authorized Agent:
M;ayh I RwFina LL'-O-g'siz slaulllamotm Mi.
Name-(Print) Current Mailing Address: 0101, 3-
H 13) 5 21 115
Signature felephone'
SECTION 3.-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building 'n 0(D (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=0 +2+3 +4 + 5) 0 Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
105 BRIERWOOD DR BP-2014-1303
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 29- 183 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-2014-1303
Project# JS-2014-002191
Est. Cost: $3600.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO
Const. Class: Contractor: License:
Use Group: RCI ROOFING 74334
Lot Size(sa. ft.): 10367.28 Owner: JONES PETER A&ELEANOR B
Zoning: Applicant: RCI ROOFING
AT. 105 BRIERWOOD DR
Applicant Address: Phone: Insurance:
6 LINE ST (413) 527-4775 Workers Compensation
SOUTHAMPTON MAO 1073 ISSUED ON.6/612014 0:00:00
TO PERFORM THE FOLLOWING WORK.-strip & SHINGLE GARAGE 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 6/6/2014 0:00:00 $35.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner