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18C-087 RC.1- Roofilt o Date 6 Line St. Estimate Southampton, Ma. 01073 10/7/2015 Phone(413)527-4775 Fax(413)527-8469 Name/Address Job Location Steve Zuechino 70 Gleason Rd. Northampton, MA 01060 Terms Rep Estimate valid for 30 days Chris Description Total Remove existing roofs. 13,000.00 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 and 3 feet in valleys. 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 $13,000.00 TERMS OF PAYMENT 5%Deposit Balance upon completion Customer Signature Registration# 126235 Construction License#074334 c Date InSUred by Banas&Fickert Ins. (413)527-2700 City of Northampton 212 Main Street, Northampton, MA 01060 Solid Waste Disposal Affidavit In accordance of the provisions of MGL c 40, S54, 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 licensed solid waste disposal facility, as defined by MGL c 111 , S 150A, Address of the work: 7i) � 4��,114401. "" o/�- The; debris will be transported by, The debris will be received by: �V\'r� ��ti��e/(� 6�-cl `�Ui r Building permit number: Name, of Permit Ap Hcant p ._ Date �� 3 -iS Signature of Permit Applicant The Commonwealth of Massachusetts Department of Industrial Accidents - o I Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): -A L L P Address: L16& f City/State/Zip: ,S ufh�tr�� ftir� /UXI 01 17:3 Phone#: (-//3) ,5"x'7 - Are you an employer?Check the appropriate box: Type of project(required): I. r tam a employer with c:,2-0 employees(full and/or part-time).* 7. ❑New construction 2.F-]I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp,insurance required.] 9. ❑ Demolition 3.F-1 I am a homeowner doing all work myself. [No workers'comp.insurance required.]r 4.F-]I am a homeowner and will be hiring contractors to conduct all work on my property. I will 100 Building addition ensure that all contractors either have workers'compensation insurance or are sole I LE Electrical repairs or additions proprietors with no employees. 12,Q Plumbing repairs or additions 5.E]I am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers'comp.insurance.; 13.E2-Roof repairs 6.F-1 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. f Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors 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: /slat PU✓�i J/�p Policy#or Self-ins. Lic, #: t'1JG D(� `/Q�' Expiration Date: /O Job Site Address: 70 G/OD tan �L! City/State/Zip: , f��f/��2jx ivy, M/1 t 106-0) Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c, 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under t ains a d penalties of perjury that the information provided above is true and correct. Signature: /" � Date: 11-12 -IS- Phone#: ! /3 ) 5:2-7- -'/726— Official use only. 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 Person: Phone#: SECTION 8 -CONSTRUCTION SERVICES rY 3-a1 Licensed Construction Supervisor; Not Applicable ❑ Jame of License Holder; � t�Ip —__ r ,– _H q License Number Low �f Ac I—) 1y)Qi 01 cn 3 Xddress /.- Expiration Date )ignalure Telephone t_Re.gistere:d Ho:me•Impro.ve:rnentG'ontnac'tor Not Applicable ❑ :grnpany Name J Registration Number \ddress J Expiration Date - r Telephone SL ` SECTION 10.WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M;G,L, c. 1 62, § 250((7 Norkers Compensation Insurance affidavit must be completed and submitted with thi:c application. f=ailure to provide this affidavit will result n the denial of the issuance of the building permit. ;Igned Affidavit Attached Yes,,,,,.. Cf No...... ❑ The current exemption for"homeowners"was extended to include Owner.-oceitpled Dwellings of one(i) 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. C114R?80, 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 c>tructures accessory to such use and/or farm structures, A person who constructs more than one home In a two-near oeri,od 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 fi am 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_-Anco LA __— SECTION 5•DES.CRIPTO%OF PRiDPOSED WOR4(check all anallcahle) New House ❑ Addition ❑ Replacement Windows TAlteration(s) F7 Roofing Or Doors ❑ L_ Accessory Bldg. ❑ Demolition ❑ New Signs (❑] Decks Siding (❑] Other(❑j Brief Description of Proposed Work: c 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 hour( and=car add'i�kion t'-dg}xrstill hoaastna; c My1.6t0 the 0iio.wlhq 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? Proposed Square footage of new construction. Dimensiomi C. Number of stories? it Method of heating?` Fireplaces or Woodstoves_ Number of each g. Energy Conservation Compliance, Masscheck Energy Compliance form attached? h. Type of construction . is construction within 100 ft, of wetlands? Yes No. Is construction within 100 yr• floodpiain Yes No Depth of basement or cellar floor below finished grade 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.B.E COMPLETED! WHEN OWNERS AGENT OR C.ON,rRACTO.R APPLIES FOR BUILDING PERMIT I .SIC tie- Z" C e/I p �_— as Owner of the subject I_,roperty hereby authorize )(2_1\.C'u.. o4 r)(' to act on my behalf, in all matters relative to work authorized by this building permit aR lication _ J�Jed Signature of Owner Date ___ as Owner/Authorized ;gent hereby declare that the statements and information on 6e foregoing application are true and accurate, to the best of my knowledge snd belief. Signed under the pains and penalties of perjury. _ 'Name _ print Name 'ignalure of Owner/Agent Date 77777 tr.d nt us'e only City of Northampton Staters of Permrt Building Department wrb C,ut/©;IW-6i y,Permft ~ 115 212 Main Street Sewr3rJSe.paicAuailabil(ty,.: Room 100 waterMGeli!Avarlabilrty T orthampton, MA 01060 Two Sets.pf StructuraLPians . ne 413.587-1240 Fax 413-587-1272 Plat/Site Mans Other S je6.0, y. APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION. 1,1 Property Addreas; l hNv.s'ectlon to be compleae:d by office 7C C'I" arm "U Map _-- Lot —Unit A'(✓f1-)d i) J TY1 Q Zone--- - _Ouer.Iay District__. Elm 81,Distdot;_ C:B D:Is.trlct;T SECTION 2 • PROPERTY OWN ER>'HIPYAUTHO.RIZED AGENT 2.1 Owner of Record: Name(Print) Curren Malting Address: Telephone Signature 2,2 Authorized Agent: --1_rI�� I i,l I.P �1.�_ L. Yl _s� 1L1LC�11 C I L> l 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 1, Building (a)Building:P.ormit Fee 3, Cot). - 2 Electrical (b):Estimated Total Cost of Construction from.6 13 Plumbing Builzlin:g Perrrilt Fee 4. Mechanical (HVAC) 5. Fire Protection 6 Total = (1 + 2 +3 + + 5) J 3 0 0��. Check Number This Section For Official:Use Only_ Building Permit Number: Date Issued: Signature: —_ — Building Comm issionerllns.pector of Buildings Date 70 GLEASON RD BP-2016-0706 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 18C-087 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-2016-0706 Project# JS-2016-001180 Est. Cost: $13000.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: RCI ROOFING 74334 Lot Size(sq. ft.): 14941.08 Owner: ZUCCHINO STEVEN M&LYNNE A BLAISDELL Zoning URB(100)/ Applicant. RCI ROOFING AT: 70 GLEASON RD Applicant Address: Phone: Insurance: 6 LINE ST (413) 527-4775 Workers Compensation SOUTHAMPTONMA01073 ISSUED ON.11119/2015 0:00:00 TO PERFORM THE FOLLOWING WORK.•STRI P & 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 11/19/2015 0:00:00 $40.00 212 Main Street,Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner