17A-160 Roofing
6 Line St.
Southampton, Ma. 01073 Estimate Date
Phone (413) 527 -4775
Fax (413) 527 -8469 7/1/2010
Name / Address Job Location
35 Fox Farm Rd. 35 Fox Farm Rd
Florence, Ma. 01062 < !
Florence, Ma. 01062
(413)320 -2543
Terms Rep
Estimate valid for 30 days Dave
Job Description Total
Recover back dormer with 1/2" plywood and EPDM rubber. 3,900.00
All work to be performed according to manufacturers' specifications.
All exterior roofing related debris to be removed by R.C.I. Roofing.
5 -year R.C.I. workmanship warranty included.
All related permits will be obtained by R.C.I. Roofing.
WE LOOK FORWARD TO DOING BUSINESS WITH YOU.
Total $3,900.00
TERMS OF PAYMENT
5% Deposit
Balance upon completion 4 r y
Registration q 126235 Customer Signature - , - / t
Construction License # 074334
Insured by Bans & Fickert Ins. Date " ;,` /
413 - 527 -2700
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U ittl ■1 Iiuilrlin Nk- 21i1.1i .inrl ii.
Ln:enstt. CS 74334
Betas, ted it). 00
MARK T DELISLE
33 FIRST AVE
EASTHAMPTON, MA 01027
Exlnrati n 5/3/2012
Tr »: 26357
.' %Ilr (, n 'i a.r.nn,. /�t...;���-1�r�arl��1
Office ul Consumer Jttairs 13usincss 1lckulari�w
HOME IMPROVEMENT CONTRACTOR
p 4 Registration: 126235
Expiration: 5/6/2012 Ti 293949
Type: Partnership
R C ROOFING
MARK DELISLE
6 LINE ST
SOU i HAMPTON, MA 01073 lindersccretar)
01.
:: � 1 h Cnmptionl alih iy i�Iassachus
Department of ln(iu.slri i/,•iccidenls
-f' OJce Of l tt ve.sllit,'atiutt.s
i' • ' � � 600 H''(1sltinl'lun Street
, t '�� i_4 i Boston, ;I1/1 02111
\\ milers Compensation Insurance Affidavit: Ii( ilt Jers/ C:( tntr ;tctr
u 4 / /Pluutbers
.\l,ulicaut Information Please Print Legibly
N:1111:: (ili.,,nr:;:,t)1 ti 7,aln?n lndit id . -_ 1- — . __ QO _ _1 -LM___ _\,
t.titk•.;%ili: i ? ' - / t ff (>lttteti:( 41:.m`-i`l-15 __
arc ■t,u an rinployer:' Check the appropriate box: — Type of project (required):
!_`! 1 Mil ;1 CiiitliO er with 20 7 p I am a n cticrai contractor and I
1 New construction
enapi, (lull <tndior itnrt•tinle).' have hired the sub- contractors -
_ , I ,tin ;t sole proprietor or partner_ listed on the attached sheet. Li Remodeling
;Hp ,wJ ii,o. e no ctia) 1'I oyees l he:ie sub-contractors have
1 'i. iii D emolition
vvork;nh.; ;tar me in a11v capacity employees and have Worker*' 1
`:0 1,.irr.c•rs' comp. insurance comp. insurance..
l [l Liuilding addition
We are a corporation and its II l l).1 j Electrical repairs or additions
i ant 1 homeowner doing till work oflieers have e.vereised their I I ;I P lumbing, repairs or additions
tosel; jNo workers' comp. right of exemption per iM61. 1 I',[ y Roof repairs
nsur no c retuired. I ' e- 1 52, 1(a), and we have no
employees. No workers' '.❑ O ihet
comp. insurance required.)
• tn. i,, lir,n .o ,:heck, hu.c a l 111101 rtlSi rill out the section below showing their workers' compensation policy information.
i tonnc.ncrtc/> ,. h,, .u■nut this arlida,'it indicating they ;arc doing all work and then hire outside contractors must .submit a new atlidavit indicating suc
•t ‘uuipcuxs ih:,i check ibis box OWN( attached an additional sheet showing the name or the sub - contractors and state whether or not those entities have
cinp!„vec .s. II th<_ soh contract have employees, they must provide their workers' con ip. policy number.
/ ,;ter an empiorer that is providing workers' compensation insurance for rn.a' employees. Below is the polio' and job site
in /ur(rtatiu,t.
1
urttnei ' n' C ! c. oLA r y .
' .. w � , ■: - I,n <. he f'. ,.c_W5. _ CL_ 5` 02 __3. Cs.__... _ kxptration Dat
' P __' _ o LQ-
It,;, bite Ac }� NA __` 1��____�__ -- (2itviStrat /ip _'Q(ryt(r� _OJO(a.�.
Attach :, col„ u1 the workers' compensation policy declaration page (showing the policy number and expiration date).
,,lure to seC_:re coverage its reL inred under Section 2ViiA of MOL c. 1:S2 can lead to the imposition of criminal penalties of ra
I1 ;1,2 up to S; , '00.1.)t) and /or one -, ear iinprisonr)tent, as well as civil penalties in the form of a S'l'OP WORK ORDER and n CI
,i1 up to M_'10 titJ ii day against the violator. Fie advised that a copy of' Ins statement may he forwarded to the Office of
! ivesugatiu,a:. of the DlA for insurance coverage verification.
/ Jo hereht t2rr4/i' under the ins and penalties of perjury that the information provided above is true and correct.
_
he ne'ii _(;:i l��J.--� -- .1_.: LA, ��
O uIL.' ,, /t /a'. /)r, lr(r( h'rlte in MIS ()tell, 10 he completed by city of 1014'11 official.
' IC r C uIts ' it — __— ____ -- Permit/License _,______ —_ — --
1n : authority (circle one):
IA 3'6 ,if Health 2. Building Deportment J. L.'itvi Town Clerk 4. Electrical inspector S. Plumbing Inspector
6,„ff,thcr - — --
Phone p:_ __ _
i
•
SECTION 8 - CONSTRUCTION SERVICES
• 3 1 Licensed Construction Supervisor: Not Applicable 0
Name of Liu.n:,e Holder -- +-_W h. 11-Ll_t..]_1 ed — — _ 7 g 1 1,3 3 4
License Number
L L + 5Q_ -4...... a► .. 14 . • 11 __ -Q 3 -IR
A Expiration Date
_ — C !3) 5�7- ��? - -____
Sygnature Telephone
3. Registered Home Improvement Contractor: Not Applicable O
_� Gx�_tf' 1 2 6235 •
company Name Registration Number
1/400rc„ E xpiration Date
& �1_�,G. . _1J..1 J.
_ 1
SECTION 70 WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 162, § 25C(6))
Workers CcmJensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will mutt
,n the denial c,i the issuance of the building permit.
Signed Attic:3,, it Attached Yes. _ No. . 0
1 1. – Home Owner Exemption
i h,, current exemption for "homeowners" was extended to include Owner-occupied Dwdllrtu of one ( I) or two(2) families
_,r,, to allow such homeowner to engage an individual for hire who does not possess a license, proyldcd (h&j tbtowncr act,
;IS ,upervisgr. ChM 780, Sixth Edition Section 108,3.5.1.
(pc (wit ion of Homeowner: Person (s) who own a parcel of land on which he/she resides or intends to reside, on which there
.ir is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and / or farm
..,,:.,ore A person who constructs more than one home in a twee -rear period }ti+rll not be considered a homeowner.
;,;:,:h `homeowner" shall submit to the Building Official, on a form acceptable to the Building Official, That heishc shall In
rc,ponsiblc for all such work performed under the building Permit.
acting Construction Supervisor your presence on the lob site will be required from lime to time, during and upon
:,,;npletinn of the work•for which this permit is issued.
A:so be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to
L: :plovices for injuries not resulting in Death) of the Massachusetts General Laws Annotated, yqg may In Habit for peraon(s)
, hire to perform work for you under this permit.
(he undersigned "homeowner" certifies and assumes responsibility for compliance with the Stale Building Code, City of
v', Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated. •
Homeowner Signature -, _ taoile�d
"1;'i !r
.'r.,. i r.,r.
4, ,.t
.
~ '
— - - _____--
. SECTION 5 DESCRIPTION OF PROPOSED WORK (chec all applIcable)
---_'—____- —___ __ ' � ___-
w e` House \ / Replacement Windows Alteration(s) / | Roofing r�
Or Doors �
El ' `''
� y New |c]} Decks ([] — Siding ^
Accessory (
., `_� , nu��) Other •
___ __-__-_- '-_____- _-_~�=_ ______ -__ -_-
�"c! Scsc:',; on o/ Proposed _ |
/vo �________.____�_ ��Ltc�(��l�i�_' --_---- ---_ --
;.xc/000n w ousting bedroom Yc^ No Adding new bedroom __ Yes __ No
. Attached wr,'ixvc Renovating unfinished basement ______Y�a No
=w:s Attache:: Ron Sheet
a^ If New house and or addtion to existing housinq complete the foUcvv|ng:
.i Use a/x"/*nn One mm,lv ________ �wo F"m,/y Other __ . _ _ .
z :umuc'r'oum,.: each family unit _ __ w:m*o,o|8am,00mu __
. '
: :: Is there a �^,ngc attached? . ^�
u Propose:: Square footage of new constr Dimensions
e wvm�«' n• stories?
�
• metnoc ot ncwng7 Fireplaces or Woodstoves Number of each
5 E oc,g? C,nocrv^tmn Compliance _ _____ masscnocx Energy Compliance form attached?
| � Type u/:_onsovum"
Is cons;",wn =m.: mo t of wetlands Yes No Is construction within 100 v, floodplain Yes No
Depth ''1ummcmn, cellar floor below finished grade
' ^ Will ou/ld`,,g conform to the Building and Zoning regulations? Yes No
' Septic Ta:^__ City Sewer Private well _ City water Supply
__ __
SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
______________ __
'
. J _____ _________ . as Owner of the subject ' ~~
7,opo ,
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ne,ub'aum �
n,', �� • • ' . a I. U& • a
oa� nnmyb^ ha --' oom,na� , ' at�o\ownm avdnohzoobvmia "vUuingpuvnk°ppUca
ay. \ J ^- | \
________ __
______________
i -T��� ' -- «� ' � ' _--� _ . . mwO,~`w� *w�o�eu
Agent
� -- ' _
� ^ - ^ c/a,c t the om nnrnm anu i�"rm"�v�on txe 6o,egoing ac�|ic"Vnn are t,uo vnu accurate, \othw wwmt f myxno°i�
hereby - o
noC belief
Signed doro.e pains and penalties of pequry
•
`0���4 �
` • l� ~
'4 • �•
Print Name
—i '- /`�
, ``.�
S�^u���f C�o*xpont _ Dale _
,. ---
. ,
Section 4. ZONING I Ail information must Be Completed. Peimit Can Be Denied Due To Incomptete Information
F.xisting Prorio.sci.1 Required by Zoning •
rho column to bc filial
holding Drpoutment
■
1....2. ;,iiiiiiti.,:c ,
_ - — . i
ti ;hacks Lroni
,Site I R: I.;'
,
,
. .
Rear
— .
II iilding ifeight
II tis,. Square Footage I
:
0 ctil SpilCC I n
41rca 111,,,,,,,N■li: .1.: P.1,-,7,1
Spaec:i
-- —
-:— , —
I : :
, , 1
— "
,
, Has a Special Permit/Variance/Finding ever been issued for/on the site?
N O 0 DONT KNOW 0 YES 0
IF YES, date issued:t
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book Page ' and/or Document iti
1 Does he 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?
, I
Needs to be obtained 0 Obtained
0 , Date Issued:
C Do any signs exist on the property? YES 0 NO 0
!
IF YES, describe size, type and location: ; ,1
D Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO 0
- - - 1
IF YES, describe size, type and location:
Will the construction activity dist,irb (clearing, grading, excavation, or nliing) over I acre or is it part of a common plan
that will disturb over I acre? YES Q NO 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
. ,
3*14 ' , "I'.V . i ' 4 , - 1 - 7; y:7 - 7 - . 7 . ... , , , .....• . . ... .
City of Northampton Statilsof ,I, : - . • .. .
"•', ''' V..t.",:, ''i' : le
Building Department curb o
.. . ...,.-' ,;,\,4% .., .).: -r%
1 1 21\? Main Street — ".6, 4 .? ' '" '
..
s 1 100 ''' 4.. , „i . ,,,, •
W,It • • !' i'' l . .1:..l' ' . '
NaFtn MA 01060 -r:,,q t.;. '', -..;. - , .• :;.. .. . .
*.' ; , -,,-. .,, •,.1...,,,..r.„,t,,,,,,,i, ,,,,,, ,,,.: _ _
,.„..., phone'413-587-1240 f:ax 413-587-1272 PIO4 • "a:„.,,:, . <4 el. ".., ;;;, :
....„,„ ,._lir - 4,.,-
Oth er opea
_______
APP..:CATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
I Propert ddress This section to be completed by office
1 y •:.
35 EX (-0.-C 9,a Map ' Lot Unit
- C - \.0•C'e.)(1.Cr_. Zone — Overlay Ds District
Elm St. District Cli [Aetna;
SECTION 2 - ,, 'ROPERTY OWNERSHIP/AUTHORIZED AGENT
.______ • — ______.
2.1 Owner of Record:
--e_c(v. ...A .■ct....„,(
Name (Print) Current , ailing Address: 606"
_attaCbe.C. Telephone 2...1 Z
- Signature
2.2 Authorizes Agent*,
- . _
•
Name (P
q.e.,L..tthirk . ...* a ' . .• .... a. 146 .
rint) Current Mailing • +rest: 0 ■ fS
..e .,••-• r'_....-e. "
- ..---.....,_____ ('i.13) 521- 4115
Signature • Telephone
SECTION 3 - ESTIMAT CONSTRLICTJON COSTS
; !tern Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1 Building I ot:) F. 1 n9 4 31 00 . 00 (a) Building Permit Fee
— .
, 2. Electrical (b) Estimated Total Cost of
3. Plumbing -- Building from (6)
lding Permit Fee
4, mechanic.a: HVAC)
5: Fit ,
5. Total = (1 - 2 + 3 + 4 + 5) iit 39 oo. ob , Check Number iat 35
This Section For Official Use Only
Date
Building Penn: Number. Issued:
Siin'ature:
Building Commisalonertinspecto( of Suildtrup Oats
_
•
• •
vp BP- 2011 -0039
GIS #: COMMONWEALTH OF MASSACHUSETTS
tift:Block: ,.160 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 -0039
Protect # JS- 2011- 000067
Est. Cost: $3900.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RCI ROOFING 74334
Lot Size(sq. ft.): 17990.28 Owner: DITKOVSKI JACOB
Zoning: URA(100)/ Applicant: RCI ROOFING
AT: 35 FOX FARMS RD
Applicant Address: Phone: Insurance:
6 LINE ST (413) 527 -4775 Workers Compensation
SOUTHAMPTONMA01073 ISSUED ON:7/14/2010 0:00:00
TO PERFORM THE FOLLOWING WORK: RECOVER REAR DORMER , PLY,RUBBER
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 7/14/2010 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo