31A-214 53 HARRISON AVE BP-2016-1034
GIs#: COMMONWEALTH OF MASSACHUSETTS
MV.-Block: 3 1 A-214 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 4 BP-2016-1034
Project# JS-2016-001747
Est. Cost: $2400.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RCI ROOFING 74334
Lot Size(sq.111 8537.76 Owner: SHULMAN SETH M&LAURA REED
Zoning: URB(I00)/ Applicant: RCI ROOFING
AT. 53 HARRISON AVE
Applicant Address: Phone: Insurance:
6 LINE ST (413527-4775 Workers Compensation
SOUTHAMPTONMA01073 ISSUED ON.-211912016 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 2/19/2016 0:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
T-- pepartmefi�t'use orrfiy _
'aity of Northampton status of Permit:
.I 3uilding Department Curb tiDriv ,y P6.r,mit.
212 Main Street Swectept�cuatlabilty � ,
FEB 19 20116 Room 100 Watem6ii 4v ilab'pity,
N rthampton, MA 01060 Two Sets.of'Structural,Plans
nEE r OF eur yr .n floc;, ��rt� 418-587-1240 Fax 413-587-1272 =Pi ovsite Plans.
aor�rttan5,���; re
Other Specify,
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOi_l;>H A ONE OR TWO FAMILY DWELLING
SECTION 1 •SITE INFORMATION
1.1 Property Address: 1'hi.;sectioi3 to he completed.by office
- Map Lot Unit
iti^✓ 11L2�� r- sn t 1 iT Zone _Overlay District,_-
Eire St.District.--_ CS District,_„
SECTION 2-PROPERTY OWNERS)HIP/AUTHORIZED AGENT
2.1 Owner of Record: l ��
Zz�OGk e eel _ �_ L� G�CL'"1 T I VL
Name(Print) Current Mailing Address:
�( f (/z? _ (A e,� Telephone
Signature
2.2 Authorized Aaent:
Name(Print) ter" ti Current Mailing Address:'
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed b permit applicant
1. Building - (a)Building~Permit'Fee
2. Electrical (b)Estimated Total Cost of
Co:nstr.Lrction from 6_
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
�-5. Fire Protection �11 � f
6. Total=0 +.2+3+4+5) ,z q0 t. - Check Number
This Section For'Offlclal Use OniL_
Building Permit Number: _ Date
Issued:
Signature: � —_
Building Commissioner/ins,peetor of Buildings Date
SECTION 5-DESC IPTIO OF PROPOSED WORK,(check all annllcahle}
New House Addition ❑ Replacement WindowsTAlterations) Roofing —
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs (711 Decks (M Siding (oj Other(Ell
Brief Description of Proposed 51
Work: _ R
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a, If Ne.WhousE;an'd t>:s! addli.or� 10 eX'IStitlq �20L151't1q,, Go:rnlet th+ ferl:lo, wig:
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, Dimension;,
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
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 -OWNER AUTHORIZATION .TO RE COMPLETED WHEN
OWNERS AGENT OR CON'r ACTOR APPLIES FOR BUILDING PERMIT
I, as Owner of the subject
property
hereby authorize _�� � l t C��_ 01 (I �lttL(' —_
to act on my behalf, in all matters relative to work authorized by this building permit aR lication.
Signature of Owner Date
I. ma`' � (1'� .61(1t"o od n C1PY1± ___ as Owner/Authorized
tio
Agent hereby declare that the statements and information onde foregoing applican 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 8 -CONSTRUCTION SERVICES
8A Licensed Construction Supervl:sory: Not Applicable ❑ t7
Name of License Holder: `
—, , t.� �t _ �7 r)�� L
License Number
Address zr, 7 Expiration Date
Signature Telephone
9_. Registered Home lmt)roverrie.nt C'bntra�ctdr.: Not Applicable ❑
Company Name Registration Number
( Q �. mfk1 _ _ br-i— off — Ito
Address —r— f,} �� Expiration Date
Telephone,t�L
SECTION 10-WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M,G.L, c. 162, §25C(0))
Workers Compensation Insurance affidavit must be completed and submitted with this application, f=ailure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... Lc( No...... ❑
11. , 11omx-e Owtte>r Ex:empt on
The current exemption for"homeowners"was extended to include Owner-ocei:11A2d 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
as supervisor.CIV_IR 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.Akerson who donstructs more than one home in a two-Rear 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_ ��Lp " �y_
The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street, Suite 100
Boston, MA 02114-2017
www,mass,govldia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers,
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organizatiott/Individual): ( 1q,90 i4 ,LL/0
Address: L/6 e- �1 7
City/State/Zip: , lu idL-n -1Pn IVI--1 Oleo 7.:3 Phone #: (//3) 5" '7
Are you an employer?Check the appropriate box:
�i Type of project(required);
1.Q 1 am a employer with c�—U employees(full and/or part-time).* 7, 7 New construction
2.7 1 am a sole proprietor or partnership and have no employees working for re in $, Remodeling
any capacity,[No workers'comp,insurance required.}
9. Demolition
3,❑1 am a homeowner doing all work myself[No workers'comp,insurance required.]t
❑
107 Building addition
4.❑1 am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.7 Electrical repairs or additions
proprietors with no employees, 12.❑Plumbing repairs or additions
5.7 1 am a general contractor and I have hired the sub-contractors listed on the attached sheet. j [I�ROof repairs
These sub-contractors have employees and have workers'comp.insurance.t
6.❑We are a corporation and its officers have exercised their right of exemption per MGL a 14.0 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.
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: T ?Yh j�LrYi/
Policy#or Self-ins. Lie, #; lCI C /2 `7`Q 7 Expiration Date: /0 j-
Job Site Address: 5� >Ilarp 1St ,, AVe
City/State/Zip:NJJI'YfAd,0,1121VP I7214 0IDjcC
Attach a copy of the workers' compensation policy declaration page(showing the policy number an 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 farm of a STOP WORK ORDER and a fine of up t0$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 tlt ains and penalties of perjury that the information provided above is true and correct.
0
Signature: Date:
Phone#; ( l_ } X02.`� — '�-7:Z5—
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#:
City of Northampton 212 Marin .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. -If-2
The debris will be transported by; 3-)
The debris will be received by; � V\I\P
Building permit number;
Narne of Permit App
l'cant ��u,�i �`/�
Date Signature of Permit Applicant
�2 /6
RC.1. Roofinor •
6 Line St. Estimate Date
Southampton, Ma. 01073 11/19/2015
Phone(413)527-4775
Fax(413)527-8469
Name/Address Job Location
Laura Reed
53 Harrison Ave.
Northampton, MA 01060
Terms Rep
Estimate valid for 30 days Chris
Description Total
Remove existing roofs. 2,400.00
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.
1 30bs' : r,.,o rV--0'-V- 4,1,4-,
WE 1-00K FORWARD TO DOING BUSINESS WITH YOU.
Total $2,400.00
TERMS OF PAYMENT
5%Deposit Customer Signature: ��
Balance upon completion
Registration#
Construction License
#074334 Date:
Insured by Banas&Fickert ins.
(4 13)527-2700 Shingle Color Selection: