18C-066 (2) RC.j. Roofing
Date
6 Line St. Estimate
Southampton,Ma, 01073 10/27/2015
Phone(413)527-4775
Fax(413)527-8469
Name/Address Job Location
George Houck
6 Allison St.
Northampton, MA 01060
Terms Rep
Estimate valid for 30 days Chris
Description Total
Remove existing roofs. 10,300.00
Furnish& install aluminum drip edge,pipe flashings, chimney flashings(if needed)and step
flashings.
Furnish& install CertainTeed Winterguard ice&water barrier, 6 feet along eaves,
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.
WE LOOK FORWARD TO DOING BUSINESS WITH YOU.
Total $10,300.00
TERMS OF PAYMENT
5%Deposit Customer Signatur
Balance upon completion
Registration# 126235
Construction License#074334 Date:
Insured by Banas&Fickert Ins.
(413)527-2700 [Shingle Color Selection:
City of Northampton 212 Main Street, Northampton, MA 01060
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c 40, S:54, I acknowledge that as
a condition of the building permit all debris resulting from the construction
activity governed by this Building Permit shall bE, disposed of in a properly
IicE:nsed solid waste disposal facility, as defined by MGL c 111 , S 150A.
Address of the work: 6 Albs.2—) di rt//, �E—O
The, debris will be transported by: co ('v 'r—',1--e. l� S
The debris will be received by: (2,si V\,\p
Building permit number:
Name of Permit Applicant C
¢ ,e
Date _ Signature of Permit Applicant
The Commonwealth of Massachusetts Prjnt Eorrn
Department of Industrial Accidents
31' ( Office of Investigations
I Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information / Please Print Legibly
Name (Business/Organization/individual): h L Lw _
Address:
City/State/Zip: } cc. �i ., IVIJ 0/073 Phone #: (0 3 '��� - 47'75
Are you an employer? Check the appropriate box: Type of project(required):
1. E2'I am a employer with 40 - 4. ❑ I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g• ❑ Demolition
working or me in an capacity. employees and have workers'
g Y 9. ❑ Building addition
[No workers' comp. insurance comp, insurance.$
required.] 5. ❑ We are a corporation and its 10.7 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.E] Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.2-Moof repairs
insurance required.] c. 152, §1(4), and we have no
employees. [No workers' 13.❑ Other
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners Who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such,
tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. if the sub-contractors have employees,they must provide their workers'comp,policy number,
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy# or Self-ins. Lie. #:_ �_ 3�/U 5 Expiration Date: /D - :i
Job Site Address: A/bson Ste• City/State/Zip: AiA G/o6 n
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine 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
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certij auuler the gins and enalties o er'ur that the in ormatlon provided above is true and correct.
Signature: ; _-. _ Date:
Phone#: -Y`7`7,5—
Official use qtly. Do not write in this area, to be completed by city or town 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 Pei-son: Phone#:
SECTION 8 -CONSTRUCTION SERVICES: _-
8.1 Licensed Construction Supervisor: II Not Applicable ❑
Name of License Holder: Y-, !
License Number
Address ��— r Expiration Date
Signature Telephone
9, Ragistere.d Rom e.lm r:,ovement Contractors Not Applicable ❑
, C , I _�?S1Ct.�i "A1D�2)-
C )—
ompany Name — Registration Number
(1 try �! 'T-- --- U 5 n(n__
Address Expiration Date
Telephone� ��`
SECTION 10-WORKERS' COMPENSATION INSURANCE AFFIDAVIT (MIG.L. c. 152, § 250(G))
Workers Compensation Insurance affidavit must be completed and submitted with thiE; application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed Affidavit Attached YE:s....... Cf No,..... ❑
11. - Ho-Mie O:wi-fer Exemptlon
The current exemption for"homeowners"was extended to include Owner-occi,r ied Dwellings 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
2L& CZAR 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 donstructs 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,
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-Ac LA _—__
SECTION 5-DESCRIPTION OF PROPOSED 1N0RK(check al(applicable)
New House Addition ❑ Replacement Windows Alteration(s) Roofing�—
Or Doors !] T_—
Accessory Bldg. ❑ Demolition ❑ New Signs (M] Decks [Q Siding (0) Other[=[
Brief Description of Proposed 11
Work: _ ---
Alteration of existing bedroom Yes. No Adding new bedroom_--_Yes No
Attached Narrative Renovating unfinished basE;merit Yes No
Plans Attached Roll -Sheet —
6a. If New house and oI add t]on to exis.tlng,housing;; cdmPl.ete t,.ht2'ol:Lowina!:
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, floodpiain 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, 6eora e. ilcu Ck— -- as Owner of the subject
property I
hereby authorize I V\CAC n(2-. �.C'P-- c4- mo`
to act on my behalf, in all matters relative to work authorized by this building permit aR Iication.
Signature of Owner Date
as Owner/Authorized
Agent hereby declare that the statements and information ondhe foregoing application 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
Department use only
City of Northampton status of-Permlt:
Building Department Curb Cut ariueway Permit
NOV _ 4 c 212 Main Street SewerGSaptic Auailabintyr
U -°- � Room 100 CNaterMt II AuAi(abiltty_
orthampton, MA 01060 Two Sets°of"Structural Plans-
DEPT. RTHA
NOFiTHASiP r;;r4u C, f� nrp - e 4 3.587-1240 Fax 413-587-1272 Pi'otdSite Plans
-, LIA 0-0co
Other Specify
L APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
'1.1 Property Addrf;ss; 1'htc;section to.be compie.ted by office
(o
Sr Sr Map_ . _-- Lot _Unit
I
�ts'rl�r�.rn� n X94 Zone _Overlay District_
Elm St,Distri'ot;_—_ CB DlstYict�
SECTION 2 -PROPERTY OWNERS HIPIAUTHORIZED AGENT
2.1 Owner of Record;
Ceo� g ouc (o Allmon,t ZVl rfhQ, i fof ,M-11
Dame(Print Current Mailing Address;
S_C e a A�aC/ �� _ Telephone
Signature
2.2 Authorized Agent:
Name(Print) �� Current Mailing Address;
Signature _ Telephone --_
SECTION 3 -ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be �^ Official Use Only
completed by permit applicant
(a) Building^Permit Fee
�2 Electrical Q (b) Estimat(ad Total Cost of
Construction from.(6)
3. Plumbing Building Permit Fee
j 4 Mechanical(HVAC)
5. Fire Protection
6. Total = (1 +2 + 3+4 + 5) /0, 3o0. _ Check Number
This Section For Official.Use Only
Building Permit Number:. Date
Issued:
Signature:
Building Commissioner/Inspector of B.uiidings Date
6 ALLISON ST BP-2016-0629
GIs#: COMMONWEALTH OF MASSACHUSETTS
MV.-Block: 18C-066 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-2016-0629
Project# JS-2016-001049
Est. Cost: $10300.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO
Const.Class: Contractor: License:
Use Group: RCI ROOFING 74334
Lot Size(sq. ft.): 6882.48 Owner: HOUCK GEORGE F
Zoning:URB(,100)/ Applicant: RCI ROOFING
AT: 6 ALLISON ST
Applicant Address: Phone: Insurance:
6 LINE ST (413) 527-4775 Workers Compensation
SOUTHAMPTONMA01073 ISSUED ON.111412015 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 11/4/2015 0:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner