49-025 (3) i
RC.1. Roofing Date
6 Line St, Estimate
Southampton,Ma. 01073 10/20/2015
Phone(4 13)527-4775
Fax(413)527-8469
Name/Address Job Location
Tim O'Brien
688 Park Hill Rd.
Northampton, MA 01060
Terms Rep
Estimate valid for 30 days Chris
Description Total
Remove existing roofs. 16,900.00
Furnish& install aluminum drip edge,pipe flashings, chimney flashings(if needed) and step
flashings.
Furnish& install CertainTeed Winterguard ice&water barrier along entire north side of house
with 6 feet along eaves, 3 feet in valleys on the rest of the house.
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.
Sani-can will be provided on the job site.
Loam will be provided for restoration of lawn, if needed,
Add$48.00 per sheet for wood decking replacement if needed.
WE LOOK FORWARD TO DOING BUSINESS WITH YOU.
Total $16,900.00
TERMS OF PAYMENT
5%Deposit Customer Signature:
Balance upon completion '
Registration# 126235
Construction License#074334 Date: fl,
Insured by Banas&Fickert Ins. Shingle Color Selection-
(413)
527-2700 rz t
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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
IICEmsed solid waste disposal facility, as defined by MGL c 111 , S 150A.
Address of the work; 6yf zrk//i/ 12�hdil'ejIr;v /2 1
The, debris will be transported by:
The debris will be received by; e"O l�v\P iV4L. •
Building
g permit number:
Name; of Permit Applicant c
Date �, / S Signature of Permit Applicant
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The Commonwealth of Massachusetts
Department of Industrial Accidents
-- d 1 Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.gov/dia
NVorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Leeibl
n y
Name (Business/Organization/Individual): C 7 /'�paWL I L L P
Address:
City/State/Zip: ,S ylkd ,r7 7�" 01073 Phone #: (J-113) 5�7 - -11'77f
Are you an employer?Check the appropriate box: Type of project(required):
1.[ am a employer with c)_U employees(full and/or part-time).* 7. ❑New construction
2.❑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
3.7 I am a homeowner doing all work myself.[No workers'comp.insurance required.]T
4.F'�1 am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 ❑Building addition
ensure that all contractors either have workers'compensation insurance or are sole 11,F-1 Electrical repairs or additions
proprietors with no employees.
12.[:]Plumbing repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. Roof repairs
These sub-contractors have employees and have workers'comp.insurance.'
6.❑we are a corporation and its officers have exercised their right of exemption per MGL a 14.❑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.
t 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 insurancefor my employees. Below is the policy andjob site
information.
Insurance Company Name; �TQ�' �hs� t✓/! ��
Policy#or Self-ins.Lic. C3-626J Expiration Date: /0 J /w
Job Site Address: !fi City/State/Zip; Aler-INLxpfDl,, fi�1- C`/e G-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.
Sienature: `- "`' Date: //-/7 -/S_
Phone#: ('�/_� � �"�_-7 7S—
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#:
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SECTION 8 -CONSTRUCTION SERVICES
1.1 Licensed Construction Supervl§or; � Not Applicable ❑
game of License Ho der
License Number
r C on ►Y C� I Ct�7'� _—___ n G; �J'� �° I ld
ddress '��,/.-r✓��_ Expiration Date
15 ail LI`I'1
Signature Telephone
1_Re;giste:re:d Ho:mejrhore.vemant.C,onttna�c'tar Not Applicable ❑
-ompany Name Registration Number
s? L.t()c)_ U 5 - U(_0 to
address — Expiration Date
Telephoned L ` -
SECTION 10•WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M;G,L, c,162, § 26C.(Ei).) --
Workers Compensation Insurance affidavit must be completed and submitted with this application, f=ailure to provide this affidavit will result
n the denial of the issuance of the building permit,
Signed Affidavit Attached Yea....... Cf No......
I L llornF OW!!t r EXexnt�t o_r
The current exemption for"homeowners"was extended to include Owner°occgyied Dwellings of one(1) or two(2) families
and to allow such homeowner to engage an individual for hire who does not po:,sess a license, provided that the owner acts
as supervisor, ClgR 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:;tructures accessory to such use anti/or farm
structures. A person who constructs more than one home in a two-near mod 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_ � 0 LA __--
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;SECTION 5-DESCRIPTI211 O�,F P: PQSRD WORtSJcheg:k aII antallcable)
New House [� Addition ❑ Replacement Windows Alteration(s)
Or Doors Roofing�—
❑ �_—
Accessory Bldg, ❑ Demolition ❑ New Signs (p] Decks [[� Siding (0) Other(CO)
Brief Description of Proposed
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet —' --
sa. If New h.ouSe>and:;oI ad daion.to:exis.tiin.g ho:ustng;.:compaetahghio.wlnai:
a. Use of building : One Family _ Two Family Other__---„
b. Number of rooms in each family unit: Nurnber of Bathrooms
c. Is there a garage attached?
cl Proposed Square footage of new construction. Dimensions
E!, Number of stories?
f Method of heating?_ Fireplaces or Woodstoves_ Number of each
c. Energy Conservation Compliance, Masscheck Energy Compliance form attached?_—
P. 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 callar 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 M
OWNERS AGENT OR CONTRACTOR AP.PI:,IES FOR R.U.ILpLN.G PERMIT
--1 -- as Owner of the subject
,property '— —
hereby authorize -T- d- (I
to act on my behalf,,yilfn all matters relative to work authorized by this building permit aR licration.
Signature of Owner Date
as Owner/Authorized
,gent hereby declare that tho statements and information on 6e foregoing application are true and accurate, to the best of my knowledge
and belief.
Sig`n/\ed, under the pains and penalties of perjury.
�rinf Name
>ignature of Owner/Agent Date -
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r e_ xP De) artmefit use arrly
- "Ity of Northampton 5tatirs of:Rermrt
3uil ing Department 004rb Cuflflnruew y Peonit
NOV 19 2015 2 2 Main Street sewer/ septic Awa'ilability,'.
Room 100 W�ter(We l Avaifabrlrty
DEPT.OP I ;n.;r _
- "r rth mpton, MA 01060 Two Sets of StructurahPlans
'° -1240 Fax 413-587-1272 Piot/S te s.
Other Slaelfy
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEM01.I>H A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1A Property Address. 1 hl:raectiun to:be c:ompI6.ted by office
�b'� rrlC l ill � Ma;p`. .___ Lot _Unit
Zone —_ _Overlay Dis.trl t_—.
Elm S.t, DGatrfet CB D1su'laf,_
SECTION 2 -PROPERTY OWNERSHIPYAUTHO:RIZED AGENT
2.1 Owner of Record;
Name(Print) Cur r nt Mai ing Address;
�e —E 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 ___ _
1. Building (a)Building Permit Fee
2 Electrical (b):Estlmat..d Total Cost of
Construction from.(6)
3. Plumbing Quildin.g Per:rnit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Tctal = (1 + 2 + 3 + 4 + 5) qpo. - Check Number d
This Seetion For Offl:ctal:Use Only
Building Permit Rumber::_ Date
I:ssued;�`--
Signature;
BuIlding Commissioner/Inspector of Ruildings Date
688 PARK HILL RD BP-2016-0705
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:49-025 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-2016-0705
Project# JS-2016-001179
Est. Cost: $16900.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: RCI ROOFING 74334
Lot Size(sq. ft.l: 79714.80 Owner: O'BRIEN TIMOTHY J&MAUREEN A
Zoning-: Applicant: RCI ROOFING
AT. 688 PARK HILL RD
Applicant Address: Phone: Insurance:
6 LINE ST (413) 527-4775 Workers Compensation
SOUTHAMPTON MAO 1073 ISSUED ON:11/19/2015 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 11/19/2015 0:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner