24D-322 r
BP- 2011 -0331
GIs #: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit # BP- 2011 -0331
Project # JS- 2011- 000542
Est. Cost: $3000.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RCI ROOFING 74334
Lot Size(sg. ft.): 4268.88 Owner: GARDENER PHOEBE SHELDON AKA PHOEBE SHELDON
Zoning: URC(100)/ Applicant: RCI ROOFING
AT. 245 STATE ST
Applicant Address: Phone: Insurance:
6 LINE ST (413) 527 -4775 Workers Compensation
SOUTHAMPTONMA01073 ISSUED ON:1011212010 0:00:00
TO PERFORM THE FOLLOWING WORK.- INSTALL NEW 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 10/12/2010 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
City of Northampton Sta }
Building Department curb`C �
212 Main Street Serlrer 7``. •.
0 CT 2010
at
- $
R oom 100 Wit
Northampton, MA 01060 T
phoAe 413 587 -1240 Fax 413 -587 -1272 Plot%$Ite`f l
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address
This section to be completed by office
Map Lot U n+t
Zone Oveday District
Elm 5t. District CB Die tiict
SECTION 2 - aROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record
ac A .`z) ye0A In_ r fv\,O- . Ol 0L. .
Name (Print) Current Mailing Address:
e. Tele p�io
Signature
2.2 Authorized Agent:
ne
i Name (Print) Current Malting Address:
- 13� 527. 1 4 ' 75
T '
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
f Item Estimated Cost (Dollars) to be Of6dal Use Only
i
completed by permit applicant
1. Building oo C) U O , Ca 0 (a) Building Permit Fee
i
2. Electrical (b) Estimated Total Cost of
Construction from 6
3. Plumbing _ Building Permit Fee
4. Mechanical (HVAC)
5 Fire Protection
6. Total = (1 -2+3+4+5) G O G . 0 O Check Number ci2
This Section F or Official Use Onl
BotleingPermit Number. Date
Issued:
Signature:
Building Commissionerllnspector of Buildings Dala
R
' Y .• } �.S .. ...
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by "Zoning
This column to be filled in by
Building Department
L" )t Size
F 1 onta gc I I
Setbacks Front
Side L:' R: - - -- L: _ R: - --
Rear
B gilding Height {_ -
B dg. Square Footage %
i
0 �cn Space Footage %
(L)t area minus bldg & pave I
a kin )
L
0 )f Parking Spaces
FI1:
um c.Lly�calion)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO O DONT KNOW Q YES O
IF YES, date issued:,
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW O YES 0
IF YES: enter Book Page! and /or Document #�
B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW O YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained Date Issued:
C Do any signs exist on the property? YES O NO O
IF YES, describe size, type and location I
�1
D. Are there any proposed changes to or additions of signs intended for the property ? YES O NO O
IF YES, describe size, type and location:
E Vlll the construction activity disturb (Gearing, grading, excavation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES Q NO V
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
SE 'TION 5- DESCRIPTION OF PROPOSED WORK (check all applicable
New House r'] I I Addition �] Replacement Windows Alteration(s) Roofing
Or Doors C-1
Accessory 51dg — L] i Demolition New Signs [tom] Decks,([] Siding
Bnei Descript ,)n of Proposed a�tat^� t
/Vcrt: 1
i Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plan Attached Roll - Sh
sa. If New house and or addition to existing housing, complete the following:
a. Use of bu iding One Family Two Family Other
b. Number c - rooms in each family unit: _ Number of Bathrooms
I c. Is there a garage attached?
d. ProposeC Square footage of new construction. Dimensions
i
e. Numbe c! stories?
Method of heating? Fireplaces or Woodstoves Number of each
c Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. - 1 ype of construction
Is cons;ru.,tion within 100 ft of wetlands? Yes No. Is construction within 100 yr. ftoodplain Yes No
;depth of b 3sement or cellar floor below finished grade
I
k. Will buildir,g conform to the Building and Zoning regulations? Yes No.
j I. Septic Tark _,__ City Sewer _� Private well City water Supply
I
SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
jl OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
C) b c as Owner of the subject
property
hereby authorize _ • • •
to act on my behalf, in all matters r alive to work authorized by this uilding permit application.
Sig'natur'of Owner Date
i
I, _ y 2Y '�� �� p_ 25 aU Y i:J ?1Qent _ as OwnertAuthorized
Agent hereby d eclare that the statements and information on the foregoing lication are true and accurate, to the beat of my knowbdp
and ':relief.
Signed under tr,e pains and penalties of perjury.
MAY
Print Name
Signature of Own, :r/Agent Date
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed C onstruction Supervisor Not Applicable O
Name of Liconr'c Holder
License Number
Address Expiration Date
Signature Telephone
i
i
9. Registered Home Improvement Contractor: Not Applicable O
I / Roo nQ i �bZ_35
Company Name Registration Number
i HaarC�� Expiration Date
M 21 , L TeIephon. 1 3) 5,2 4 LL
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 162, § 26C(6))
Workers Comoensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in th denial o f the issuance o the building permit.
I Signed Affic,svit Attached Yes...... � No ...... 0
1 1. - Home Owner Exemption
ThC current exemption for "homeowners" was extended to include Owner - occupied Dwellings of one (1) or two(2) families
:rr.' to allow such homeowner to engage an individual for hire who does not possess a license, provided that the owner acts
,ts supervisor. CMR 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
s..)r s intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/ or farm
„ „ctures. A p erson who constructs more than one home in a two -year period shall not be considered a homeowner
!t "homeowner” shall suhmit lo. the Building Official, on a form acceptable to the Building Official that he/she shall be
res ponsible for all such work performed under the building permit.
A� acting, Construction Supervisor your presence on the Job site will be required from time to time, during and upon
rxnnpletion of the work•f'or which this permit is issued.
�Iso be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to
!n ployecs for injuries not resulting in Death) of the Massachusetts General Laws Annotated, you may be liabk for persons)
\-ou hire to perform work for you under this permit.
Th:, 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 _ attac
The Common wealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
boo Washington Street
i Boston, MA 02111
w w w. trtass. g o v1d iu
�Vor•hcl•s' C:ontpensation Insurance Affidavit: Builders /Contractors /Electricians /Plumbers
Applicant Infornuition Q Please Print Legibly
I� (E?'Eainess /l?rs;aniuttian /individual): � �_�- � \Q Q�_Z ��.�
I sta tc, '11): Phone
Are you an employer'. Check the appropriate box: Type of project (required):
I am ;E cntplc�} er with 20 _ 4 • ❑ I am a general contractor and
cn,plo.�ccs (full and/or part- time)."
have hired the sub - contractors 6. [❑ New construction
�. ❑
listed on the attached sheet. 7. ❑ Remodeling am a sole proprietor or partner-
;hip <uui have no employees These sub- contractors have H. ❑ Demolition
workin" for me in any capacity. employees and have workers' t
I ). ❑ Building addition
(No ,v,)rkers' comp. insurance comp. insurance.%
requircd.1 5• ❑ We are a corporation and its 10.❑ Electrical repairs or additions
❑ 1 anf o homeowner doing; all work officers have exercised their I i .❑ Plumbing repairs or additions
ntvscl:" JNo workers' comp. right of exemption per MGI. 12 [�T`Roofrepairs
nsurtncc rcyuirccl.� i c. 152. §1(4), and we have no
employees, (No workers' 13.0 Uther�_
comp, insurance required.)
All ;,p hr afu +n.rt checks box Nl must also till out the section below showing their workers' compensation policy infonnation.
I loMc„wucrs "ho submit this affidavit indicating they are doing all work and then hire: outside contractors must submit a new affidavit indicating such,
: Contractors tl:at check this bos nwst attached an additional sheet showing the name of the sub - contractors and state whether or riot those zntitics have
cmplo ±Ccs. I( dl,: pub contractors have employees, they must provide their workers' cornp. policy nurnber.
I um an enip;oYer that is providing workers' compensation insurance for n!v emplovees. Below is the policy and job site
in jormution.
Insurance Co:rtpan} Namc: 4 > �o.J�a -� r\ _
or ti if -ins. Lie. tt: 3 S t Expiration Date: O L ,Q LO
Jot) Site Address: City /State /Zip: - ,.,,o o o
Attach it copN of the workers' compensation policy declaration page (showing the policy number and expiration date).
t :rilurc to se"ue ccwc;rage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
i trp to Sl ,�w,00 and/or one -year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
ot up to 5250 00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Invu-stigations of - the D I A for insurance coverage verification.
I do herehl• r::rrdJy under thelpains and penalties ofperjury that the information provided above is true and correct.
s . late: I V Y_ L o l (5
Phone 4. 1 41' 1 S
Ojjiciu/ u.se only. Do not write in this area, to be completed by city or town official
City °or Town: Permit/License #
Tssdig Authority (circle one):
4 -i
1 $Oard of Health 2. Building Department 3. City/Town Clerk d. Electrical Inspector S. Plumbing Inspector
6:0`ther
Goitatact Person: Phone #;
11 ,,.n im, ;1!
33.f
le: tit!ri_ftiJ t� 00
MARK i DELISLE
33 FIRST AV
EAS THAMPTON, MA 0102,
U h,c d l un"ninri Aflair> Ifuiinr.> kr;;u6rtinn
Ti ROME IMPROVEMENT CONTRACTOR
r;f: Rcyistrition: 1 sr,?3`;
?> Expiration: 5/6/ 12 Ira
Type: Partnership
k C I ROOr ING
MARK DELISLE
C LINE S I _
SUU HAMPTON, MA 01073 ( u�lrr.crrrt;iI --
R.c i. Roofing
6 1 il�(' St. _
Si:)utr., 01073 Estimaltv Date —
PlOnc (4 1413)13) 57527-4775 -- - � -
Fax (413) 527 -8469 9/29/2010
Name / Address Job Location
Phoebe Sheldon 245 State Street
245 State Street Northampton, MA
Northampton, MA 01060 586 -7932
Terms Rep
Estimate valid for 30 days Dave
Job Description Total
Remove existing roof. 3,000.00
Fu nish and install 1/2" fiberboard insulation, mechanically fastened.
Furnish and install 60mil Versico roof system.
Fi4rnish any; inst,)II all related (lashings.
I ui dish and instoli .032 alun.inlm) drip edge.
All , xterior roofing related debris to be removed by R.C.I. Roofing.
AP vyork to be performed accor to Wanufacturers' specifications.
5 y nor R.0 I. workmanship warranty included.
All re;ate.d permits will be obtained by R.C.I. Roofing.
VVF LOOK FORWARD TO DOING BUSINESS WITH YOU. Total $3,000.00
'I1 :I:N1S OF 1
Ih•I'OSil
fla!ancc ul�,n cnnplcliun �C` ,
a
Ilr�nu .,r;,,n # It,?3S Customer Signature . �Z�--
CMISI vrli0u1 I.iCcn>c # 07433ti
Imurcd by lianas & Fickurl Ins. Date
41 's- 527 - 17(111