17D-023 . • - '.
.-ls., \lass,ichtisciis Dup.ilfmclIt H hililit.
Board 4 BwIrliti2 Rc2til,itit and s
i,::crmstructcor,
Ltcense.. CS 74334
Restricted to: 00
MARK T DELISLE
,.. _..
33 FIRST AVE - ''-' I • it: ' I
EASTHAMPTON, MA 01027
..........._.- _----.._---3,.,,
Expiratror). 5/3/2012
c .windssi.,ner Tr#: 26357
fro,,, 11 741....lel
Office of Consumer Affairs & Business Regulation
- e4.-E.;:i , ,=F HOME IMPROVEMENT CONTRACTOR
rl V,- l ---. , ,') Registration: 126235
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t
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\-- Expiration: 5/6/2012 Tr# 293949
Type: Partnership
R.C.I. ROOFING
MARK DELISLE
6 LINE ST
SOUTHAMPTON, MA 01073 Undersecretary
--.......1.1111MINNEIMINIMMUINNIMMONIMIINI
.
■
RC . Roofing
6 Line St.
Phone (413) n, 52 7- 47 77073 5 Esti m Date
Phone (413) 7 -7 4/26/2010
Fax (413) 527 -8469
Name / Address Job Location
Edy Ambroz
125 Straw Ave. 95 Straw Ave.
Florence, Ma. 01062 Florence, Ma. 01062
(413) 586 -1806
Terms Rep
Estimate valid for 30 days Dave
Job Description Total
Remove existing roofs. 8,600.00
Furnish & install aluminum drip edge, pipe flashings, chimney flashings and step
flashings.
Furnish & install new lead counter flashings.
Furnish & install CertainTeed Winterguard ice & water barrier along eaves and
valleys.
Furnish and install synthetic underlayment over existing deck.
Furnish and install 30 year CertainTeed Woodscape Series shingle.
Furnish and install CertainTeed approved ridge vent.
All exterior roofing related debris to be removed by R.C.I. Roofing.
All work will be performed according to manufacturers' specifications.
5 -year RCI Roofing workmanship warranty included.
30 year CertainTeed material warranty included.
All related permits will be obtained by R.C.I. Roofing.
Add $2.50 per square foot for wood decking replacement if needed.
Add: $1,050.00 for Certainteed Landmark Woodscape 50 year premium shingle.
A Certainteed Surestart Plus extended warranty (additional 5 years) will be included
with fee ($420.00) absorbed by RCI Roofing if signed within 7 days.
WE LOOK FORWARD TO DOING BUSINESS WITH YOU.
Total $8,600.00
TERMS OF PAYMENT
5% Deposit
Balance upon completion Customer Signature /
Registration # 126235 /�
Construction License # 074334 Date r (�` -
Insured by Reynolds, Barnes & Hebb, Inc. 413- 447 -7376 4 —�
The Commonwealth of Massachusetts
Department of Industrial Accidents
......,Ar Office of Investigations
OM
600 Washington Street
"" � l Boston, MA 02111
l_:�� .
r - www.ntuss.guv /dia
\VorLers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians /Plumbers
Applicant information Please Print Legibly
Nutne (Basinessiorganitittion /Individual): c, \,.,A„ , )____
,-Address: e._ �� .
Cityiistatc /r j� A1on {tea. o a`t P hone #: y( 5 ,`(- Lt�1`15
Are you an employer," Check the appropriate box: Type of project (required):
i . r I am a employer with 2.0 _ 4 . 71 1 am a general contractor and I
employees (full and /or part - time)."
have hired the sub contractors 6. fl New construction
2.1 I am a sole proprietor or partner- listed on the attached sheet. 7. I I Remodeling
ship and have no employees These sub - contractors have 8. [ Demolition
working for me in any capacity. employees and have workers'
9. [ Building addition
1 No c■ irkcrs' comp. insurance comp. insurance.:
reciuircd.1
5. C r-� We are a corporation and its 10.0 Electrical repairs or additions
I I am a homeowner doing all work officers have exercised their I 1.0 Plumbing repairs or additions
m yseli - � No workers' comp. right of exemption per MGL 12 [yRoofrepairs
insurance required. 1' c. 152, §1(4), and we have no
employees. [No workers' 13.0 Other
`y` comp. insurance required.]
':1ny applicant that checks box 4 l must also fill out the section below showing their workers' compensation policy information.
I torneowners a ho submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
'Cururretors 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. lithe sub- contractors have employees, they must provide their workers' comp. policy number.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
in/Or/nation.
insurance Co:npanv Name: I e.. R - • C.c- Qt.. - y,a_A \-._ ..a,.. n S .
Policy t, or Salt' -ins. Lic. #.2)‘t] �4 5 Q'■ 3. ( _ - —` Expiration Date: 1 0 t j - aQ 1 0
Job Site Address: 95 5Vre j, e. City /State /Zip:rk cc t 014x.. O(064
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
:;tilure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
not.: up to 51.500.00 and /or one -year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
or up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
1 do hereby certify under the ins and penalties ofperjury that the information provided above is true and correct.
S ii gn'ature: _— Date: 5 --- (O
s'hone # :' (�l 3) 5 ?_,. - LA, VI 5
Official use only. Do not write in this area, to he completed by city or town official.
City *or 'Town: Permit/License #
Wang Authority (circle one):
1 Board of Health 2. Building Department 3. City/ Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6 Q 'thcr
Contact Person: Phone #:
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction S p Not Applicable ❑
:;
Name of Licene Holder J' 1 aY k T e s le w / c I" I 3 '3
License Number
LL :asigc.i ii.
Address Expiration Date
J4
Signature Telepho(ne j3) -Lj775
,...00:
,
9. Registered Home Improvement Contractor: Not Applicable ❑
fi. E . I. 1�oo 1217235
Company Name Registration Number
Aooreaa Expiration Date
SO titlarriptaq, Ma. 0! Telephon(6i3)527. 15
SECTION 10 WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 162, § 25C(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 act'
as s upervisor. 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. .ir is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/ or farm
su Jerson who constructs more than one home in a two -year period shall not be considered a homeowner.
Su, :h "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 buildinE 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.
A!so he advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to
Ea for injuries not resulting in Death) of the Massachusetts General Laws Annotated, you May be lia¢le for person(s)
you 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 a.taChed .
•
• t .• ^',•,. ,, ' l'.../‘,,,,'
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SECTION 5 - DESCRIPTION OF PROPOSED WORK (check all applicable)
New House n Addition l l Replacement Windows Alteration(s) Roofing LJ
Or Doors .
Accessory Bldg. Demolition L I • New Signs (ID] Decks (CJ Siding [DI Other (Dl•
Brief Descript )n of Proposed ^�taCh.
I Work: attach
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
o. Number c` rooms in each family unit: Number of Bathrooms
c. Is there a garage attached? •
d. Proposed Square footage of new construction. Dimensions
e. Numbe- ct stories?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance.form attached?
h. 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
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, Q \ci c , as Owner of the subject
property Q
hereby authorize �aY T \ t S1 P Q` I ] • Y I . Ro
;o act on my behalf, in all matters r ative to work authorized by this ui ding permit application. 9
'tt chP,d .5-- 1/4 1
Sig ,'",',t,,, ',of Owner Date
.
1 . May k - Melt si P _ a s au thoY I7PJ as t , as Owner /Authorized
Agent hereby declare that the statements and information on the foregoing aWication are true and accurate, to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
MAYS II 5 1.0
Print Name
Signature of Owner /Agent Date
Section 4. ZONING AU 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
Li( Size j 1 1
FHontagc I
Setbacks Front
Side I.:_ R:_.�. - L:— K. _I
Rear 1 _i
B -gilding I leight
B dg. Square Footage % 1
O )en Space Footage
(t.,i arca minus hldg & paved ,
pa:kin0
# )f Parking Spaces 1
HI: ,
1
j
0 & Locations
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 O DONT KNOW 0 YES
i
IF YES: enter Book Page I and /or Document #1
B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW O YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained , 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 O 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 O NO a
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
,
City of Northampton Stsltrof .
j Building Department Curb C 'W .
212 Main Street
i k t * ' 1
4''` ` '
Room 100 Wat ' '' i ;,a` .,.
Northampton, MA 01060
Tr!'", -a.�.ti, • phone 413 -587 -1240 Fax 413 -587 -1272 Ploti it '°`,43 xr =, 4 ` ' ate.
/yam tber
1 O` 1y `e+�l °L 'A , ''..:Ti l t." , : '' , i
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
q 5 S \ (b .-v.3 (N,) C + t, m 1 i L ' Lot Unit
■ \ U vk-L-� , Zone ; i Overlay District
EinySt1 Qlttdct -_- CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
` 2.1 Owner of Record:
Qrn b Z— i ZS , S w t C\ d c- .vLc.c. , wko- .0t ot, Z.
Name (Print )-- Current Mailing Address:
taehed ire SA
) S -1806
Te
Telephone
Signature
2..22 Authorized �Agent:
J "t L�Y� - i It°r•e.1.. fQnT
I
4. -~ a ' . , • _ w • *• •
Name ( Print) Current Mating ' .dress: p, 0 , ..13
---'---• (i413) 521. 41T5
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building 13,00f, yul 8 ( 00 . Q (a) Building Permit Fee
\p
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) $ (c, 0 b , 06 , Check Number /516 f 5C -
This Section For Official Use Only
• Date
Bolding Permit Number. Issued:
Signature.
j Building Commissioner/Inspector of Buildings Da
1
BP -2010 -1032
GIS #: COMMONWEALTH OF MASSACHUSETTS
Block r7D = h` 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- 2010 -1032
Project # JS -2010- 001523
Est. Cost: $8600.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RCI ROOFING 74334
Lot Size(sq. ft.): 9583.20 Owner: AMBROZ EDYTHE M & BARBARA W GRAVES
Zoning: URB(100)/ Applicant: RCI ROOFING
AT: 95 STRAW AVE
Applicant Address: Phone: Insurance:
6 LINE ST (413) 527 -4775 Workers Compensation
SOUTHAMPTONMA01073 ISSUED ON:5/19/2010 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 5/19/2010 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo