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eammaouvealig oPlitzactoalsiA Board of Building Regulations and Standards , Construction Supervisor License Licenset CS 74334 1")11,41 -90)10 Tr# 23520 \ 4 ! MARK T DELISLE ' 33 FIRST AVE EASTHAMPTON, MA 01027 Commissioner gize eammoitamera ar,ilawackaata Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR al t Registration: 126235 *.1 Expiration: 516/2010 Tr# 266063 1 • Type: Partnership R.C.I. ROOFING MARK DELISLE 51 B HOLYOKE ST. EASTHAMPTON, MA 01027 Administrator w t• n V.xt o f Northampton la 3 ��+` j,~:: �� Jilassscaosctb' II ail ,ice" j 1 D EPARTMENT OP BUILDING INSPECTIONS 212 Main Street ' Municipal Building a Northampton, Mass. 01060 �` oie " s~ WORKER'S COMPENSATION INSURANCE AFFIDAVIT • • I, • 9 1 o0 I,• (license&permittite) with a principal place of business/residence at: • - t - • • 4 _1A ...e % 0101,3 (phone #k413) 54 - AP715 - . • . city /statrinp) do aercby certify' under the pains and penalties of penury, that: (4cI am an employer providing the following worker's compensation coverage for my employees working on this job: Ne... e) coo.\ %A"; OA ■ re.. mss. CO. 0C c 4S‘ClUaNlk 1 Qet \A)c3L3rlO8 so - (Insurance Company) (Policy Number) (Expiation Date) () 1 am a sole proprietor, general contractor or homeowner (circle one) and have hired the contractors listed below who have the following worker's compensation policies: (Name of Contractor) (Insuuancc Company/Policy Number) (Expiration Date) (Name of Contractor) ' (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (,11,4:13 addition i Mote it to include beer:() ion permitting to all ooatrectoes) of ( ) 1 am a sole proprietor and have no one w orking for me. ( ) 1 atn a home owner performing all the work myself. . 1 NOTE: plc= be slam that vale bome>,vcaesa vebo employ persona to do maintainer, cconnetiboae stink watk no a dry of . o; morn than throo units in *Mite bomnowoer resides or on the moods smartened *ado ere not geaas14l► conside+edte be =ploy= uadcr the wocioets oompcasstioo Ad (Man.:al (5)). appllatioa by a boneowoa for t &epee or permit may evidencethe c 1.1 stsru: of an omploya under he Wocicoes Compensation Ad. . I understand that a copy otthis:Salem i may be forrrstded to the Depestmood otlodttsj 4 Maitkiii Moe erimon*Nbtiet oo`reragc vait'ustioa sad that tailors to sealre coverage wider seeded. 25A (M k Wades 0I, I5 asedto aliksi i�ttilo , . ocaustin o f a foe bf up to S1,500.00 a n d / o r k g : r i s c o : s a t ( ) C l i p to one y e w sod civil penalties in lbe *mots Stop Vat On* d a '' . finer 0( 5100.00 ashy agsiust mc. ' .5 F Pcmitl • ,3 Mips i� ' SiguattrYt: ofLiccaxclPortnittte Cate , • r . SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ • M y� � Name of License Holder : PA 1 l i s le , TM 334 License Number kL:te 5+ 4, o i. z.(\ i . • I' 5 -a3 -I0 Address - Expiration Date Signature ' /.0 Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ ft(?. I. r Roo f; 119 126235 Company Name Registration Number —r L .. T _ S _:.....��_ _ 5 —0L-10 1 Aaareaa Expiration Date IxS uillaYnp1 n , Ma . 0 ∎073 Telephonee4131i2 7• 4/15 SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 26C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached Yes No ❑ 11. – Home Owner Exemption The current exemption for "homeowners" was extended to include Owner- occupied Dwellings of one (1) or two(2) families and to allow 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 Homeowner: 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 detached structures accessory to such use and /or farm structures. A person who constructs more than one home in a two -year 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 all such work performed under the building permit. As acting Construction Supervisor your presence on the job site will be required from time to time, during and upon completion of the work.for which this permit is issued. Also be advised that with reference to Chaptcr 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to Employees 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 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 a ,ta( M t S. ■ SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House El Addition Replacement Windows Alteration(s) Roofing C Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks ,[p • Siding [o) Other [Dj' Brief Work: Descript on of Proposed aaCL �1J (1 Alteration 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 building : One Family Two Family Other b. Number or rooms in each family unit: Number of Bathrooms c. Is there a garage attached? d. Proposed Square footage of new construction. Dimensions e. Number of stories? f. Method of heating? Fireplaces or Woodstoves Number of each I g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No j. Depth of basement or cellar floor below finished grade k. Will building conform to the Building and Zoning regulations? Yes No . I. 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 I, l v �C. , as Omer of the subject � I property Q hereby authorize t I • M Lan �el I S� t Q � I (• 1j• I • ROO -) n9 to act on my behalf, in all matters r lative to work authorized by this uilding permit application. a tt.A Glee `'"1 - Signattfreof Owner Date I, 11. ' i • / " 1 , as Owner /Authorized Agent hereby declare that the statements and information on the foregoing . •'Iication are true and accurate, to the best of my knowledge and belief. • Signed under the pains and penalties of perjury. =aYk 1I sly, • 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 Lot Size Frontage Setbacks Front Side L R: L: R: Rear Building Height Bldg. Square Footage Onen Space Footage (Lot area minus bldg & paved parking) # of Parking Spaces Fill: (volume & Location) 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 IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW Q YES Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained ,Date Issued: C. Do any signs exist on the property? YES 0 NO 0 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 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 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. d p _ of Northampton „ Stlli L � �' , p fue of r� � Department Curb C • 212 Main Street ■ t `S eyV,r , d -1 a L.: J((2 k 0 200 9 Room 100 Water7W b o `5efe d" Northampton, MA 01060 Tw } I --� DE �`` phone 413 -557 -1240 Fax 413- 587 -1272 Plot/Site pie � � "t a" ( OF E , k:. � t�� r'f1� Other Specify 't'�, {' q tr • s 2 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 (O t44 \\ C C Map I Lot Unit 4 `p Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: V\o. 1 5 ∎ 'C -C\ C. W C-Z-. \\ Name (Print) - Current Mailing Addresso X31 5 r 05 30 a tt a C C- c Telephone � Signature 2.2 Authorized Agent: Marik 1)e.. 1 - .C.r. Roofi _ 5,9v.-1/4 _ Name (Print) Current Mailing dress: Q 013 ( 521- 4115 Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building ftOQf 4 ` t \ ,5a©. 00 (a) Building Permit Fee 2. Electrical 1 (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) $ , , 500 00 Check Number This Section For Official Use Only • Boilding' Permit Number. Date Issued: Signature: Building Commissioner /Inspector of Buildings Date t4 , , File # BP- 2010 -0075 APPLICANT /CONTACT PERSON RCI ROOFING ADDRESS /PHONE P 0 BOX 309 EASTHAMPTON (413) 527 -4775 PROPERTY LOCATION 110 HILLCREST DR MAP 17A PARCEL 294 001 ZONE URA(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT - - Paid t/Buildin Permit Filled out ee Paid • T eof Construction: Roofin New Construction Non Structural interior renovations Addition to Existing Accesso Structure Buildin• Plans Included: Owner/ Statement or License 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO IATION PRESENTED: Approved Additional permits required (see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project: Site Plan AND /OR Special Permit With Site Plan Major Project: Site Plan AND /OR Special Permit With Site Plan ZONING BOARD PERMIT REQUIRED UNDER: § Finding Special Permit Variance* Received & Recorded at Registry of Deeds Proof Enclosed Other Permits Required: Curb Cut from DPW Water Availability Sewer Availability Septic Approval Board of Health Well Water Potability Board of Health Permit from Conservation Commission Permit from CB Architecture Committee Permit from Elm Street Commission L37/a-/O9 Signature of Building Official Date Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning requirements and obtain all required permits from Board of Health, Conservation Commission, Department of public works and other applicable permit granting authorities. * Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of Planning & Development for more information. • • 110 HILLCREST DR BP- 2010 -0075 GIS #: COMMONWEALTH OF MASSACHUSETTS ;.t - CITY OF NORTHAMPTON Lot: -001 Permit: Building Category: BUILDING PERMIT Permit # BP- 2010 -0075 Project # JS- 2010- 000081 Est. Cost: $0.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: RCI ROOFING Lot Size(sq. ft.): 20386.08 Owner: KSIENIEWICZ MARY H & CHARLES F & JOHN W Zoning: URA(100)/ Applicant: RCI ROOFING AT: 110 HILLCREST DR Applicant Address: Phone: Insurance: P 0 BOX 309 (413) 527 -4775 EASTHAMPTONMA01027 - 0309 ISSUED ON: 7/22/2009 0:00:00 TO PERFORM THE FOLLOWING WORK: Roofing 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 7/22/2009 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo