43-031 456 WESTHAMPTON RD BP-2016-1555
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map-B1ock:43 -031 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-2016-1555
Project 4 JS-2016-002659
Est.Cost:$18600.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
use Group: RCI ROOFING 774334
Lot Size(sq.ft.): 185130.00 Owner: CERNAK KENNETH S TRUSTEE
Zoning: Applicant: RCI ROOFING
AT: 456 WESTHAMPTON RD
Applicant Address: Phone: Insurance:
6 LINE ST (413) 527-4775 Workers Compensation
SOUTHAM PTONMA01073 ISSUED ON:6/29/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:RESHINGLE 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:
FeeTvpe: Date Paid: Amount:
Building 6/29/2016 0:00:00 $40.00
212 Main Street, Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
1 - -- _2_
Dope e£nl use only
City of Northampton SawsofPorssit-
^t] 7 Building Department Curb(uitiOavewau Permit
212 Main Street sewer/SeptlDAvallabitlty. _
1:" .1 Room 1`00 Wa1e`4AVell Availability
i( N 1 Northampton, MA 01060Two Sets oflStruotural Plaits
i on l phone 413-587-1240 Fax 413-587-1272 FISUSIte,Plem I
if
Other Specify
A-1brCATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELL'NG
=CTION 1 -SITE INFORMATION.
1'
p operty Addrr,�ss hla�section to be completed by office
r ylc,/._ Ulesili/sltnv-2,( Map � __ Lot _Unit
SD
t Clcrettee, /J7fi ✓71662- Zone__ ___ _OAerI yDIstmct__
ct
J` �EIin SL District___ CB District_
'AN 2 -PROPERTY OWNERSHIPIAUTHORIZEO AGENT
Winer of Record: --__
Ken etrnGt-.k_ 3'/ i 'P g cn- _ 174,Keno 717/4
_?rn Current Mailing Address, OioE 2
Si Qe 2-1r Gtef-rtd Telephone
=Jew(zed Agent, -_—
"'r' no ri,`J J< 0 . 7 Knn4inq o Liao -i* .s;el $Llvvvnr-�en UVP ()1(;),r7
,Int) /j J Current Mailing Address: I
/.0
• .o(6_ —. .. CLkA'') u5Lar7- Hrf eJ;1 —
!'c Telephone
TON 3ESTIMATED CONSTRUCTION COSTS II
TEstimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1 ) Building Permit Fee
//��
f1Of �l Sr,� Ia LO.
-Ica (p)Estimated Total Cost of
Construction from (6)
Building Permit Fee
__--l--
.,.cPanical (HVAC)
°:re Protect on
=(i + 2 + 3 +4 + b) IA lc, 6.-cc - CheckNumberNumber .2.7 aI
This Section For Official Use Only__
_Ing Permit Number'. isste
ssued.__,__
Curd ng Conml s,o_etYlnepecloe of 9alltlinge Date _ _�
oTiON 5-DESCRIPTION OF PROPOSED WORK (check all an lllcabtgl
"r: House D I Addition ❑ Replacement Windows Alteratlon(s) ❑ Roofing
Or Doors ❑
cossory Bldg. ❑ I Demolition ❑ New Signs (O( Decklt [q Siding (O[ Other[MI
Description of Proposed
s: of existing bedroom Yes No Adding new bedroom_--,_Yes No
d Narrative Renovating unfinished basement Yes __No
iteaned Ro',I -Sheet
If New house and or`.addtklon to existing hawsin.q,rcomplete 8 at,¢llowinc.
Usc of building One Family_ Two Family Other
'iii .per of rooms in each family unit. Number of Bathrooms_—_.__
s .r ere a garage attached?
ased Square footage of new construction. Dimensions
nher of stories?
ne,ncd of neating?_ Fireplaces or Woodstoves_ Number of each
Ecergy Conservation Compliance. Masscheck Energy Compliance form attached?
-.be of construction
s construction within 100 ftof wetlands? Yes _No. Is construction within 100 yr. floodplain _Yes_No
Dep.n of basement or cellar flow below finished grade
; r. oLi oieg conform to the Building and Zoning regulations? Yes No
colic Tank City Sewer Private well Cily water Supply
DmoN 7a • OWNER AUTHORIZATION •TO HE COMPLETED WHEN
1ERS AGENT OR CONTRACTOR/APPLIES FOR BUILDING PERMIT
tittle ,
, as Owner of the sublect
u[no.ze A\Cl fYi C)p Ap. (�+' t1 , C . T.
any behalf in all matters relative to work authorized by this building permit aRllcatlon.
is reofOwner Date ( -23—/(0
f e fl (11)4)()Yt7Pd (k( Pn4- as Owner/Authorised
reify declare that the statements and information ondie foregoing application are true and accurate, to the best of my knowledge
- ec
under the pains and penalties of perjury.
iv, SS
_.,e sf Owner/Agent Date 6i-Lem? /(
T'ON 5 CONSTRUCTION SERVICES
prised Construction Super lr= Not Applicable ❑
or_Idense Nigger V\�,fk �g1ISkP �'� H
License Number
' ry � r be e r4en YID SIC r7 ----- 35 CCS -J6
Expiration Dale
_Z_ 113) b art • LI T1,5
, = Telephone
mpls tared Nome Ininnevernent Ceontradtar - Not Applicable 0
r
^,pznv a e Registration Number
Hit s 4�v _ O5 - 0lo - I9
:,rens Expiration Date
�.).vn(`t )-1(20 120t2L- f1� Telephone (yl'3i),h., LH'1'7) --
T- OW 1C.WORi(ERS'COMPENSATION INSURANCE AFFIDAVIT(fs1,3 c, 1621 26C(11)) `
'vers Compensation Insurance affidavit must be completed and submitted with thie application. Failure to provide this affidavit will result
ae tenial of the issuance of the building permit,
-.ec Afidavl Attached Yes,,..... Er( No..,,,, ❑
11. - Home, Owner Exeznmtion
line current exemption for"homeowners"was extended to include Owner.occupied Dwellings of one(1) or two(2)families
and to slimy such homeowner to engage an individual for hire who does not possess a license,provided that the owner acts
as supervisor. CMR 780,, Sixth Edition Section 108,3,5.1
Definition of Homeowned; 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 detachedstructures accessory to such use and/or farm
structures.A person who constructs more than one home in a two-wear 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 qIl such work performed under the building permit,
As acting Construction Supervisor your presence on the job site will be required nom 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 Co
Gnployees 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 endersigned "homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of
Northampton Ordinances, State and Local ZoninglLaws and State of Massachusetts General Laws Annotated.
homeowner Signature -�{/./P�IA(1 ____
--'�' ,
RC.I. Roofing
6 Line St. Estimate Date
Southampton, Ma,01073 41212016
Phone(413)527-4775
Fax(413)527-8469
Name t Address
Job Location
Ken Cernak
462 Westhampton Rd,
Florence, MA 01062
Terms Rep
Estimate valid for 30 days Chris
Description Total
Remove existing roofs, . v 18,600.00
Furnish& install alurniridihedrip edge, pipe flashings, and step flashings.
Furnish&install new 16 ox. copper chimney flashing.
Furnish& install CertainTeed Winterguard ice&water barrier,6 feet along eaves.
Furnish and install synthetic undedayment over existing deck.
Furnish and install Lifetime CertainTeed Landmark TL 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 52.50 per sq.ft. for wood decking replacement if needed.
pa,,fi CUPoLm
WE LOOK FORWARD TO DOING BUSINESS WITH YOU.
Total $18,600.00
TERMS OE PAYMENT /
5%Deposit Customer Signature. '
Balance upon completion -42 kd 2-'
Registration# 126235pate:
Construction License 4074334 2lz4
Insured by Kanas&Pickett Ins. Shingle Color Selection: 1NDmRRK rt
(413)527.2700 /4l' [6C/ .SlvNdP.;-L 42/
The Commonwealth of Massachusetts
A, s. ( Department of Industrial Accidents
1 m1al- �y I Congress Street, Suite 100
aee .= l
r. = P Boston, MA 02114-2017
..=,...,
www.mass.gov/din
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO NE FILED WITH TIIE PERMITTING AUTHORITY,
Applicant Information �/ Please Print Legibly
Name (Business/Organization/Individual): /' e. 7 R00-A2/0 LL P
Address: (O Lurie_ St.
City/State/Zip: So1mampfrn, M/7 01(173 Phone#: 6%3) rz7 - 4/775
Are you an employer?Cheek the appropriate box:
Typefofproject(rctioned):
I Efrain4,2-0aacmplayer with U employees(full and/or pan-bmeJ7.• New construction
2❑I am a sole proprietor or partnership and have no employees working for me in B. ❑ Remodeling
any capacity. [No workers'compinsurance required]
9. ❑Demolition
3 I am a homeowner doing all work myself No workers'comp insurance required]'
❑I am a homeowner and will he hiring contractors to conduct all work on my property I well 10 ❑ Building addition
ensure that all contractors either have workers compensation insurance or are sole II.❑Electrical repairs or additions
proprietors with no employees.
12.❑Plumbing repairs or additions
5 Ti I am a general contractor and I have htred the sub-contractors listed on the attached sheet
These sub-contractors have employees and have workers'com -insurance13.2-Roof repairs
.
6❑We are a corporation and its of have exercised their right of exemption per MGI,c. 14.0 Other
152,$1(4),and we have no employee.[No workers'comp.insurance required.]
▪Any applicant that checks box 71 must also fill out the section below showing their workers'compensation policy information.
'I lomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit Indicating such.
:Confronters that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entitles 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: �Sfa✓ Jilt 2/9✓O/7✓e5,
Policy p'or Self-ins. Lie. Th /de. Q(cfe3`{015- — Expiration Date /C -,xj- /G.9
Job Site Address: `f/o„Z 4.-)PS /d/a L1/?tt Rd City/State/Zip: rfcrene,,/PA 0/O6 U
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$250.00 a
clay against the violator. A copy of this statement tray be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
Ido hereby certify under gins a d penalties of perjury that the information provided above is true and correct.
Signature, / � . Date: 6 3-- 76.
Phone k: !'y/.) ,J a-7- 2177.-
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License k
Issuing Authority(circle one):
I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person; Phone#:
C_y of Northampton 212 Main Street, Northampton, MA 01060
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c 40, S:54, I acknowledge that as
a condition of the building permit all debris resulting from the construction
activity governed by this Building Permit shall be disposed of in a properly
licensed solid waste disposal facility, as defined by MGL c 111 , S 150k
Address of the work: %.2- zitslhahrick?cf i/orencz,
The debris will be transported by: '' r N{e-4--C.. D Y. LN L
The debris will be received by: Co �vP ���� ��'J��U , , _ 'lt�( 'Gi i
Building permit number: --_
Name of Permit Appljcant ( LT _tl f�r\ cc_p
4.2;,1. ---
Date 3 .ylo Signature of Permit Applicant
2016 10: 20AM Banas & Fickerf insurance Agency No. 7768 P. 1/1
AcoRO CERTIFICATE OF LIABILITY INSURANCE DATE@NINorn-rn
71-15 CERTIFICATE IS ISSUED
T AS A MATTER OF INFORMATION ONAND CONFERS RIGHTS UPON THE CERTIFICATE HOLDER THIS
EICATH DOES NOT AFFIRMATIVELY OR NEGATIVELYAMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
-ELO THS CERTIFICATE INSURANCEDOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
EPRE$EMATIVE ORPRODUCER,MD THE
CERTIFICATE HOLDER.
PO PORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(Ies) must he endorsed. If SUBROGATION IS WAIVED,subject to
:ho terns and condition&of the policy,certain policies may require an endorsement. A aatstnent on this certificate does not confer rights to Ne
:ertiscate holder in lieu of such endorsement(s),
HRrnencT Michael R, Banns
ea..^.a5 6 Flokert PHONE_(*ax Fie. (913) 527-2700 I i6Nd103) SRT-08x9
_Durance Agency .
i air StreetADDRE$Bi mb 0 banaeinsurance cora
Is •
chauoten, MA 01027 ..... wsul£P(s)AFFORDING COMER/ICEBAIge
- INSURER A I AdmCo.Admiral Insurance Co. 124856
ITE° mSUREAa Sa£ety Insurance Co 39459
RCI Roofing, LLP
{23620
oussec Burl innton Insurance Co
6 Line StreetINSURER OI Star Insurance Co _ 1.29562
Southampton, M4 01073 IIsuRO+E.
INSURERF I
9VERAGES CERTIFICATE NUMBER: REVISION NUMBER:
R..__
I,10I ISA TOED CERTIFY Ti LAT TI IN POLICIES UI INSURANCE TE OR BELOW HAVE BEEN IOTHE THE RDO NAMED ABOVE FOR THE POLICY H S
NDICATEO. HMAY EE ssuED D PM' REQUIREMENT, TERM OR EAFFORDED
CONDITION ANY THECONTRACT OR OTHER DOCUMENT SuB Cr 10T TOL WHICH THIS
'ERTrIIC)TS MAY O 0 TIONS OF MAY POLICES TIME INSURANCE VEN ED CEDI BY
ID.3 LAIBED HEREIN IS 9ue.ICr 'IQ ALL .Ht TERMS
X4..LSIOM1S ANDCONDITIONS Of SUCH POLICIES.LfNIT$BHGWN MAY HAVE BEEN REDUCED BY PAID ClAIM6.
AWLiSVBR - e POcoNingCY EU PQIICY En, 1 _-._ r
TYPE OFINSUROIJW 11NSRVNO _ POV C/NVlr2 FJl IMMM19NYYV11(MMlen' LIMiS
I ^ENERALLIa5Iurf • X CA000020963-02 /4/161 S/4/17 EACH OCCURRENCE s 1 000,000
DAMX I. CCWMhxcIL GE NL PA' II MP II ITT pR;MGETOa uccuv IIS 50,000
I PPFIA9E9(L ural
f cwIXTUMAoe i7-1l X�,oa:uR 1� !MED EXP PNDF0 Is 10 000
.._._. i
PERSONALS MV INJURY 1 $ 1,000,CD0�
i CARER/XLL TORRENT(E I2 2,000,000
...CURE/TATE OA T APP HF E PF R I PRODUCTSmM>IOP Ann I s 2,000,000r. :
DPI'CY LIA 2ci 1LOU MI
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▪ 0In0BIL9 LIABILITY X 116207761 9/30/151 9/30/16 fIJtRI1rvtO Slut ful.(ff -
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eC aoMPENSAnON la/4/1B' B/�/17 C , RRcur.r. s 5,000,000
alums_ 'FS1076336 IFAml nnru
EXCESS LAR TOnY LIMIT$ ER , s ._y00..
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OCf LIR
MACE ACCREGATE a 5 000 _
▪ Qu _.._._. 1 10 X A EAMM:LGr=_E s 1 ,000
X REIEN„oNs 10 p00 l _
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aieJviaCi a CA OPE RAToNsealm III, I E.eicemE.POLICY Urnn I $ 1,000,000
I
fon MICR of amPdTON31 LOCATORS l VEHICLES (Mach{4WD 1e1.A W IOOMI ReNBMS SCIACNICI.II Mfg CRCs IR r.q,4,{)
)GPING CONTRACTOR.
i'.RTIFICATE HOLDER CANCELLATION
-__ -- _ _-. .--_— -- --- SHOULD ANY QF THE MOVE DESCRI B ED POLICIES 9E CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DEUVEREO IN
ACCORDANCE WITH THE POLICY PROVISIONS.
*--"r"""**REFERENCE COPY"'"'"*"***” 1
AU1NOR¢ED R6L4£a TATNE ‘ 'M "
619::8010 •triRD CORPORATION. All rights reserved.
ARD 25(2010/06) The AC ORD name and logo are reglstred marks of ACOR•
.r,.. Fax: (413) 534-8344 E-Mail;
-
T Massachusetts Department of Public Safety
ler! Board of Budding Reguiatlons and Standards
e`er oe(/UoiG/Z Aeondh License: C3 Supervisor
n
211HOME IMPROVEMf&ce of Consumer ENT CONTRACTOR
ORI in
„onstr actin& Supervisor
MARKT DELISLE
td ' Ropiraton.n 126235 YPe: 69 BRIGGS STREET
b NNe— Expiration/ 5/8/2098 Pad&erehlp EASTHAMPTON MA 01927
R C . ROOFING L.
MARK DEUSLE T - ,-'7 CA— Exp=raton
Commissioner EINE ST `
u�--- 98ID31201e
SOUTHAM&TON, MA 01073 UnJe secretary
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