10B-074 RC.I. Roofing Date
6 Line St. E
Southampton, Ma. 01073 7/25/2011
Phone (413) 527 -4775
lax (41 3) 527 - 5409
Name / Address Job Location
Donna Larson 32 Water St.
32 Water St. Leeds, Ma. O I (153
Leeds, Ma. ()I053
Terms Rep
Estimate valid for 311 days Dave
Description Total
Remove existing porch rook. 7.000.00
Furnish & install aluminum drip edge.
Furnish & install CertainTeed Winterguard ice & water harrier along eaves and valleys.
Furnish & install synthetic underlayment over existing deck.
Furnish & install 30 year CertainTeed Woodscape Series shingle.
Furnish & install 1/2" fiberboard insulation on Hat root section.
Furnish & install .045 re- inforced rubber roof system_ mechanically attached on flat roof section.
All exterior roofing related debris to he removed by R.C.I. Rooting.
All work to be performed according to manufacturers' specifications.
All work will he performed according to new OSIIA 0/I5/201 1 standards.
5 -vcar RCI Roofing workmanship warranty included.
All related permits will he obtained by R.C.I. Roofing.
Add $2.50 per square foot for wood decking replacement if needed.
WI: LOOK FOIZWi \Rl) TO DOING UUSINNSS WITH YOU.
Total $7,000.00
TERMS OF PAYMENT
5(7 Deposit 1
Balance upon completion Customer Si nature
Registration # 12(1235
construction License N 074334 i ,
D
Insured by lianas & Fickert Ins. _
(413) 527 -2700
,f The Commonwealth of Massachusetts
a of industrial A ccidents
4 r. �'' Office of Investigations
�'� 600 Washington Street
�•. > 4,,i Boston, ,14 02111
rr s�L' www.m ass,govitliu
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians /Plumbers
Applicant In torination Please Print Legibly
Nun tI . iicss Or anir.(iun /lndivitfuai }: _ .
_A c.)__Q ,_._ - -\,-\,-.
\ddress: 1 v Y1
ltv t<tt�il.i�t .. , _ .>. � 1 Q'Z3��.___ Phone 4 : _. �_ ``�.. ... __._ _. _ __. _ .___.
Are ) ou an employer:' Check the appropriate boa: type of project ( required): 1
1 1 am a employer with _2.0 4 . ❑ I am a general contractor and l !
ti
have hired the sub-contractors . Li N ew constntction i
=ployce:; (tali and /or part- tinsel." _
i I am a sole proprietor or partner listed on the attached sheet. 7. ( 7 R emodeling
ship ; These sub - contractors have
and have no employees H. ( 1 Demolition 1
‘yorking for r tte in any capacity. employees and have workers' q Building addition
iNo tt .irkcrs' comp. insurance comp. insurance.:
5. We are a corporation and its 1 f).[1 E lectrical repairs or additions
required. 1 ❑ p
1 1 am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
nr,sell. No workers' comp. right of� exemption per MGL 12.'oofrepairs
insurance required.1 r c. 152. §1(4), and we have no
employees. [No workers' 1 3•❑ {):her
comp. insurance required.] . ____________ -______ __ -.
• Any applicant iaai checks box 41 must also till out the section below showing their workers' compensation 1xrlicy inlorntation .
l some 'woer „f submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such
t'unlractors thin check this box Hurst attached an additional sheet showing the name of the sub - contractors and state whether or not those entities have
cmplovccs. If Ow sub - contractors have employees, they must provide their workers' comp. policy number.
/ r art crrrp/oi•er that is providing workers' compensation insurance for ni' employees. Below is the policy and job site
in /orntation.
Insurance (.'t ,tpany Nat,te: � _ . �-\ \- T - --
Policy , . or tiulf -ins. Lie. fa:
AL\X.0 CA_ _553_0'1 3S (., - - - -- - Expiration Date: 0 _ - , Q1___
Job Site Add: ess:32..�lk e ( --SV - City /State/Zip: Le_r_. S 4 in_a_ . 01OS3
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
F;tilurc to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
Line up to SI.�0O OO and /or one -year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
oI to S250 II) a day against the violator. Be advised that a copy of this statement may he forwarded to the Office of
Investigatiotrs of the DIA for insurance coverage verification.
1 do hereby c•c•rti r u nder the ins and penalties of perjury that the information provided above is true and correct.
Date; - Z5 -- l 1
I
Official lie only. Do not write in this area, to he completed by city or town official.
Permit/License #
r ^;t
1 s uS Au thorn (circle one):
11. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector
6Other
riry tt et Person: Phone #:
,
SECTION 8 CONSTRUCTION SERVICES l
_ Licensed Construction Supervisor: Not Applicable 0
M pp
rvamo ct Llcr .,e Noider M_aY - e l is l - — — _____. 1 4-- - --
License Number
,,,J,1,,,,,,, Expiration Date
I:;nat,.re Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
FLE ' 1211z_215
Company Name ` Registration Number
't
5 - }
ii
`` � n �� c rr . ,,, ry - - Expiration Date R- ` - -`
,.5 . 7.r1171p {- ola r._ Mar CO3 - -- -- 1eiephont4'.JJ 3)527. I75 I
SECTION 1C- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6))
'.Vorkers Ccn,;,ensation 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 Affic it Attached Yes _ _ r� No . ❑
11. - Home Owner Exemption
n: current exemption for "homeowners" was extended to include Owner-occupied 1.)wellints of one (1) or two(2) families
ar,'. ,n allow such homeowner to engage an individual for hire who does not possess a license, provided thitt the owner tact:
:r, supervisor. CMR 780, Sixth Edition Section 108.3.5.1.
f)e linition of Homeowner: Person (s) who own a parcel of land on which he /she resides or intends to reside, on which there
it is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and! or farm
:.:cluires. A person who constructs more than one home in a two -year period $hail net be considered A humeowoer•
,:ch homeowner" shall submit to the Building Official, on a form acceptable to the Building Official, that hNshe Mall be
responsible for all such work performed under the building, permit.
\,,, acting Construction Supervisor your presence on the job site will he required from time to time, during and upon
c ocopletion of the work.for which this permit is issued.
\.,o be advised that with reference to Chapter 152 ( Workers' Compensation) and Chapter 153 (Liability of Employers to
Cu.ployces for injuries not resulting in Death) of the Massachusetts General Laws Annotated, you inty be liable for persons)
ou hire to perform work for you under this permit.
Tit.: undersigned "homeowner" certifies and assumes responsibility for compliance with the State Building Cock, City of
Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated. .
Homeowner Signature _ . _3_ .t_ac,hed_
IA.
„.„.., .
...,
, . .
•
...
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House 1 Addition ( Replacement Windows Alteration(s) E Roofing r
Or Doors
Accessory Bldg. Demolition 1 . New Signs [D] Decks [Q Siding [DI Other [01' -
Brief Descnt)t of Proposed � /
'work: 1
rdteration of existing bedroom Yes No , dding 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 (ding One Family Two Family Other
o Number r rooms in each family unit. Number of Bathrooms
,.;�.
,,. Is there a garage attached? _
d. Proposed Square footage of new construction. Dimensions
e. Numbe- c stories?
• Method of heating? _ Fireplaces or Woodstoves Number of each
p. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
Type of construction
is construction within 100 ft of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No
, Depth of Casement or cellar floor below finished grade
K . 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
��h•2c?� ,0.0
C)‘(\ , as Owner of the subject
property
hereby authori e Aar ar .1J e, sl e QT 1 j • C , �-1.. Rco
to act on my behalf, in all matters rdlative to work authorized by this building permit application.
atta ched -2.5 —
Sig'in2ti1[ey,of Owner Date
. rG
WI • ' • • I .0 , 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.
Signed under the pains and penalties of perjury.
M D 1;s 1 e
Print Name
Signature of Owner /Agent Date
,
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 , 1 7
Fr onlac c .
Setbacks Front t
Side I.: R: L:' l(
Rear I
Building Height
13 Jg,. Square Footage °
I
C) 3en Space Footage
(L a area minus bldg & paved ,
•
_
I
I uf Parking Spaces
FiIl. 1 ( . l ,
! i
(volume & 14)ca11GnL
a Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW O YES O
IF YES, date issued:!
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW O YES O
IF YES: enter Book Pagel i and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW O YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained q Obtained O , Date Issued:
C. Do any signs exist on the property? YES O NO O
IF YES, describe size, type and location
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO C
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 a NO 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Int!
Y *
e City of Northampton Stlrtlr'> kl � : ` '
r"
�r M ,
�eCe Building Department C X )- ,
0 .6 D250 212 Main Street . ' 41 , ; � . ,'' � `!
•
Room 100 , yek n. �, 1 s
Northampton, MA 01060 Two ;', ,, r ; . •
c i ,; W
`' '. one 413 - 587 - 1240 Fax 413 587 - 1272 Plot/Stte f rt "s 'a; r,. Air, ..A;3, :..
Other Spoor/ . _ `' .•
' , x sei'
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
arc', tI,) O` \'fit ,S\ . Map . Lot Unit
L._. <_eA- . Zone O ertay District
Elm SL District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: \ \._.e.2e_AN i • A -- Z ` CYCVC\ 00. .-- _0.-C- 0 Y'1 3 a W 0 t r - Yv � • 01053
Name (Print) Cutr Address: ��� 9
e Tel /1 it
Signature
2.2 Authorized Aqent:
MaYk_ - q.c,i. confinfl .
. _ . . ... ..• SI 6 • —
Name (Print) Current Mailing • ddress: O t di.3
1'�' 4 --- (4i3) 52 - 4115
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant ,
j 1. Building 1 0ofi .4 `1 0 0 , 0 0 (a) Building Permit Fee
2. Electrica', J i (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) ,'$N-1 000 . 00 Check Number /go-7o 035°- ,
This Section For Official Use Only
t - -
Date
Bbilding Number. Issued:
Signature:
Building Commissioner/inspector of Buildings Date
32 WATER ST BP- 2012 -0215
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 10B - 074 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 -0215
Project # JS- 2012- 000322
Est. Cost: $7000.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RCI ROOFING 74334
Lot Size(sq. ft.): 15333.12 Owner: LARSON DONNA M
Zoning: URB(100) //WP Applicant: RCI ROOFING
AT: 32 WATER ST
Applicant Address: Phone: Insurance:
6 LINE ST (413) 527 -4775 Workers Compensation
SOUTHAM PTONMA01073 ISSUED ON :8/31/2011 0:00:00
TO PERFORM THE FOLLOWING WORK :STRIP & SHINGLE PORCH ROOFS
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 8/31/2011 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner