31B-102 .. Roofing
hIincSI Es Date
Smilltamltton. t;i.()II)7 8;311 /20I I
5 '_7 -4775
1: t-11_i) 5'7 -1(0)
Name / Address Job Location
\Vcss'Falhot 67 Prospect St.
07 Prospect St. Northampton. Ma. 01060
Northampton. Ma. 010611 (41 3) 522- 145))
Terms Rep
Uistitnatc valid fin 30 Jay, Dave
Description Total
Remove existing rOO(. 13,010.00
Furnish and install 1/2" fiberboard insulation, mechanically fastened.
Furnish and install .1143 reinforced rubber root system.
Furnish and install all related ['lashings.
Furnish and install .1132 aluminum drill edge.
All exterior roolinz related debris to be removed by R.( I. Rooting.
All work to he pertorined according to manufacturers' speeilicatinns.
year IU( .t. workmanship warranty included.
All related permits will he obtained by Cr). I'. Rooting.
WI; LOOK FORWARD TO DOING BUSINESS WITH YOU.
Total S13,0011.00
TER—IS Or PAYMENT —
Balance upon eomplctiuu Customer Signature
Registration 4 126235
Construction ruction I icense 4 1)74334 );itc
Insured by Kinds d'c I:ickcrl Ins.
(;1 3) .527-2710
The Commonwealth of Massachusetts
Department of Indt,<strial A ccidents
1 1,.....r.-...... , :-----:-V
it ....
f
Office of Investigations
= , 600 Washington Street
'.- .•' ti Boston, MA 02111
:: ^v w w W. mass. go ►' /d is
\Vor'hers' Compensation Insurance Affidavit: Builders /Contractors /Electricians /Plumbers
Applicant Information Please Print LeEibly
N 03us ul e s5/C)roani7ttion!tndividtx 1 _ f �\—.?
LItliState Li p: (ti Uto` Phone #:(y( _.._ 4 'L-1`fiS
Are you an employer? Check the appropriate box:
Type of project (required):
LYJ i am a employer ■vuh 2,0 4 . p I am a general contractor and 1
etnplu, ees (lull and/or part-time).*
have hired the sub- contractors f' New constriction
Li I am a sole proprietor or partner- listed on the attached sheet. 7. [1 Remodeling
ship anti have no employees These sub- contractors have
I f i�. � Demolition
work:1qt for me in any capacity. employees and have workers'
p` t 9. Li Building addition
No cc ,Irkers' comp. insurance comp. insurance.:
requirL-c1.I 5. ( I We are a corporation and its loll Electrical repairs or additions
i__] I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
titvscll. 1No workers' comp. right of per MGL 12.2"koofrepairs
insurance required.] ' c. 152, §1(4), and we have no
employees. [No workers' 13. Other
comp. insurance required.] __ _
'.n� apl>licani IRa1 checks box u 1 must also nil out the section below showing their workers' compensation policy information. ����� ���
-�
I i,inicownets , submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
-t_ ontractors 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. li t sub- contractors have employees, they must provide their workers' comp. policy number.
I rmt an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
in/ornration.
I tsurai ,:e Company Name: a e. Q'2 C�c C o. \ ),- n
i'ohe ; or Sept -ins. I.Ic. 4: ikjU)C 5i 0"2_, 35 io , Expiration Date: I O Th5 -- a 0 1 0
Job Site Add, ess: (pl_ �ct, .\- Cit /State /Zip: , n.-,_+ a .0i 73
At tach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
:ailirc to sec.tre coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
I'mc up to �i.:;i)U.00 and /or one -year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
oi to IS2j0 iN) a day against the violator. Be advised that a copy of this statement may he forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
i do hereby c'ortifi' under the ins and penalties of perjury that the information provided p abov _
true _ late: J
Shone.#:' `-i.13 .'t. ":- _L -l __ ____ --
(i
-
I` Official use onli'. Do not write in this area, to he completed by city or town official.
C'ity' 'Fowl!: Permit/License $
Xssu' lg Authority (circle one):
j,» Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6 ;Oilier
.riiiitaci Person: Phone 1t:
SECTION 8 - CONSTRUCTION SERVICES
.1 Licensed Construction Supervisor: �l1�\ Not Applicable ❑
Name _o f L i G r ., r Holder . _ 4✓-4.._i i
License Number
%.d.lress _ Expiration Date - --
-- ------ -_______ ( 13)_5 2 - ' 7
;signature Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
• 126235
Company Name J Registration Number
5 I La
•■ccrr,,, Expiration Date —
��.� rn tQ_n_ Jam_• L� -__ y13)5,27 _yi7
i c ;lephonc� 1
SECTION 0- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6))
'SN- 3rkers Ccndensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
the denial of the issuance of the building permit.
Signed Affinz,vit Attached Yes ir7 No ❑
- Home Owner Exemption
current exemption !Or "homeowners" was extended to include Owner occupied Dweilints of one (I) or two(2) families
to allow such homeowner to engage an individual for hire who does not possess a license, provided that the ma Acta
;r\ supervisor. CMR 780, Sixth Edition Section i08.3.5.I.
Definition of Homeowner: Person Is) who own a parcel o land on which he.%she resides or intends to reside, on which there
�r is intended to he, a one or two family dwelling, attached or detached structures accessory to such use and / or farm
,:Mures. A Lerson constructs more than one home in a two - year period shall not be considered a home4R'per•
'homeowner" shall submit to the Building Official, on a form acceptable to the Building Official, that he/she shall be
ree ponsible for all such work performed under the buiidine, permit.
:acting Construction Supervisor your presence on the job site will be required from time to time, during and upon
co,npletion of the work.for which this permit is issued.
;:,0 be advised that with reference to Chapter 152 ( Workers' Compensation) and Chapter 153 (Liability of Employers to
o:.ployccs for injuries not resulting in Death) of the Massachusetts General Laws Annotated, YQU m be Ilbif, for person(s)
.,ol hire to perform work for you under this permit.
l 1, 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
. ,t
,
.
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House Addition Replacement Windows Alteration(s) n Roofing 71
Or Doors El •
Accessory Bldg. i 1 Demolition I . New Signs [p] Decks [Q Siding [CO Other [OF '
Work: Descr,l: -on of Proposed attanheozi
Iteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
sa. If New house and or addition to existing housing, complete the following:
a. Use of bu;iding One Family Two Family _ Other
•
Number c rooms in each family unit — Number of Bathrooms
c. Is there a garage attached? - -
I
d. Proposec Square footage of new construction. Dimensions
e. Number ci stories?
. Method of heating? Fireplaces or Woodstoves Number of each
9. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
o Type of construction
Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No
Depth of basement or cellar floor below finished grade
Will building conform to the Building and Zoning regulations? Yes No .
Septic Tank City Sewer Private well City water Supply
SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
NHS _ \ ex\ mss' . as Owner of the subject
property ►� Q (7 �(�
hereby authorize l aY e\ l S e. c j U• +� • Ro'in
to act on my behalf, in all matters r lative to work authorized by this ui ding permit application. 9
a Ohed q - /
Signatirkief Owner Date
I .
. ? ' / 0 ' 4 • / , • , as Owner /Authorized
Agent hereby declare that the statements and information on the foregoing . ••lication are true and accurate, to the best of my knowledge
and belief.
I .
Signed under the pains and penalties of perjury.
N yDe. 1s 1 e
Print N9ma
°!
I Signature of Ownt:r /Agent Data
- .
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
, . .
1..)t Sue
,
Hontile,t:
Sclbacks Front
Side 1: Rs 1,,:'
R:
, 1
Rear
B Jilding I ieight
r if , Jg„ Square Footage
0 )en Space Footage
(1.. q area minus hIdg & paved
pa king)
if Parking Spaces
- t
i 1 i
.ocalion)
A Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW 0 YES 0
. .
IF YES, date issued::
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 ,. DONT KNOW 0 YES 0
, . . . ..... .....
, 1
IF YES: enter Book . Page
i i and/or Document #1
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained
0 Obtained
0 , Date Issued: I 1
C. Do any signs exist on the property? YES CD NO 0 .
IF YES, describe size, type and location: 1
J
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO 0
!'
IF YES, describe size, type and location: ,
E Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
�`� �;.'e, -; r a., . , I
City of Northampton Siio! iq ` •
Building Department Cur b`C _Akio A # °" ', ;' ' ;I.' t` ' . • .
212 Main Street Se a. 1t' � ''` 1,1 . '
Room 100 W stepW'` °i .q . ",.....• ... .
Northampton, MA 01060 Twq44, , . • , 4 , r •, .',4,, y ^ . �
phone 413- 587 -1240 Fax 413- 587 -1272 PlotiS`ffe Pis• , 4:+ »x�
x, �,r + able r � r ,. R-
r�+rc'rfrtiA "�* 'R'Q� L t 1 ! d . , l +
Other S ped } 't .t:TMa !,e4^ta.'.w � �" 1 i.' a.. ..A
APPLCATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION •
1.1 Property ddress This section to be completed by office
j �� C) � SQ ,� L� S r Map ■ Lot Unit
+V Q'r"' G-vv Vet. 'l , w,, Zone Overlay District
Elm St. District CB District
i
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
W SS 1 c. \ba le Qco.lt��� S� - iVer t .otobo
Name (Print) Cu (eft Malting A dress:
at
tZC ai phl.) ,,, - 1
Teleone
Signature
2,2 Authorized Agent:
.viaYK . le, - .e.z. codf ...•. •
Name (Print) i n c J Current Mailing • ddress: O 1 Ca`l
� - 2 ---+-- (i1 13) 521' 4115
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
t. Building 12 C. (a) Building Permit Fee
3 , 000 0 0
2 Electrical J (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Protect ion ,
6. Total = (1-2+3+4+5) $ I ., OOO , °O Check Number /1 1 3�
i This Section For Official Use Only
Date
Bonding Permit Number. Issued:
}
Signature: ____
Building Commissioner/Inspector of Buildings Dots
•
',' Yr .„,,
rss.
• •
•
• 67 PROSPECT ST BP- 2012 -0268
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 31B - 102 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- 2012 -0268
Project # JS- 2012- 000432
Est. Cost: $13000.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RCI ROOFING 74334
Lot Size(sq. ft.): 18251.64 Owner: TALBOT WESS
Zoning: URC(100)/ Applicant: RCI ROOFING
AT: 67 PROSPECT ST
Applicant Address: Phone: Insurance:
6 LINE ST (413) 527 -4775 Workers Compensation
SOUTHAMPTONMAO1073 ISSUED ON:9/16/2011 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 9/16/2011 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner