17A-290 • Roofing Date
() Line St. E
Southampton. Ma. 01073 10/10/2011
Phone (413)52.7-4775
Fax (413) 527 - 54(,9
Name / Address Job Location
Joseph & Lydia Bartolomeo 68 I- lillcrest Dr.
68 Hillcrest Dr. Florence, Ma. 01062
Florence, Ma. 01002 (413) 320 -74(7
Terms Rep
Fstinutte valid for 30 days Dave
Description Total
Remove existing cools. 12.400.00
Furnish & install aluminum drip edge, pipe Iltishings. chimney {lashings and step {lashings.
Furnish & install new lead counter {lashings.
Furnish & install ('ertainTeed \VinterLtuard ice & wale: harrier along eaves and valleys.
Furnish and install synthetic underlayntent Oyer existing deck.
Furnish and install 311 year Certain Teed eed Woodscapc Series shingle.
Furnish and install Certainhecd approved ridge vent.
All exterior roofing related debris to he removed by R.C.I. Rooting.
All work will he performed according to manufacturers' specifications.
30 year Certain heed material warranty included.
All related permits will he obtained by R.C.1. Roofing.
Add $2.5)) per sq. fl. for wood decking replaccinent if needed.
Add: $1,450.00 for Certainteed Landmark \Voodseape SU ycair pentium shingle.
A Certainteed Surestart Plus extended warranty will be included with a fee k 4 `S580.00 absorbed
be ROI Roofing ir sic_ned within 7 days. this extended w:ur;ac_. ,mteim:, that 20 of the 30 year
warranty is covered ror labor and material. The Iasi II) vears or the 311 year Certai warranty
would he covered ror material only.
WI: LOOK FORWARD PD DOING ItUSINI:SS WIt)) YOU.
Total $12,400.00
1 FRms OF I'AYN :NT
%o Deposit
13,danre upon completion Customer Signature
Registration rt 126235
Construction License tl 117;133 -1
Insured by Balms & r ickert Ins. I)IL l /0// 1 1/
(413)527-2700
The Commonwealth ofIllussuchusetts
— Department of Industrial ,Accidents
Office oflnvestigatiotts
.
z — 600 II'ushin, ton Street
•
�a .� Boston, 111 /1 02111
►vWyv.m« ss.gu
Workers' Compensation Insurance Af'fidavit: Builders /Contractors /Electricians /Plumbers
Applicant Information Please Print Legibly
Name (BusinessiOr /Individual): " � '`L ` •
Address:
City /State /Lip - • w�. > Phone V: �
Are you an employer? Check the appropriate bus: Type of project (required):
1. Lal am a employer with 'i [_j 1 am :t gencntl contractor and I
:New constnutiou
employees (full an(llor p a 1 hit ed
r
2. .1 1 am a sole proprietor or partner - listedonthe hedttsheet.ocs _ j yetttodeItne
ship and have no employees These sub - contractors have 8- [_] Demolition
working for me in any capacity. wot kcrs' comp In0 11 Inc c q
!; y Pt 5 n Building dddtnon
corporation i insurance 5. \Vc. rrc .i rtion and its
[ No workers' comp. Li officers have cxcicued their 0 [ _1 Electrical repairs or additions
required.]
3. [ I am a homeowner doing all work right of exemption pet MOO. 11 [_] Plumbing repairs or additions
myself. [No workers' comp. c 152, ' 1( =I). and we have no 12.[y[ Roof repairs
insurance required.] 1 employees. [No workers'
13.__1 Other
c'.11n mnolr UK( required.
Any applicant that checks box it l must also till out the section below showing their winters' compensation policy inhumation
Homeowners who submit this affidavit avit indicating they itie doing all woo: and then lute outside contaactors must su a new altiiinvit Indien: rug such -
t Uontractors that check this box mast attached an additional sheet showing the name of the sub - contractors and then comp . policy intorrnutiou.
I am an employer that is providing; ty'orkers' compensation insurance 'Or my employees. Below is the policy and job site
information.
Insurance Company Narnc: `;� _�_
Policy or Sc f ins. I I #
y '",]_L` t_�r�� !��:� - - -- -- — - - -- — Explrruon Date: - --
Job Site Address: - _ - 4 i_\\ �� e � QC City /Statci /i is
Attach a copy of the workers' compensation policy declaration page (showing the police number and expirat ion date).
Failure to secure coverage as required under Section 25A of tMGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one -year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a clay 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.
I do hereby certify under the pains and penalties offperjury that the information provided above is true and correct_
Signature_ - Date: 3 -�.-
Phone #: �H1 ; (
Official use only. Do not write in this area, to be completed by city or town official. (j
City or Town: Permit/License #
issuing Authority (circle one):
1. Board of health 2. Building Department 3. Cityllown Clerk 4. Electrical Inspector 5. Plumbing Inspector -
6. Other -- - -- _
Contact Person: !'hone Cl: ��
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: m, } 1 o Not Applicable El
of License Holder : M aY k L e, I � s 16
License Number
516 got St. - Easthampton Ma. oioa.7 5 - 03 - . 2
Address Expiration Date
..i
( �3) 52?- X775
Signature Telepho� ne
9. Registered Home Improvement Contractor: Not Applicable ❑
ft.i ' Roofnq • 126235
Company Name Registration Number
5 i B Holyoke Street _ - P.O. .3
0- Boy ___ 5 - db -1 z
Address Expiration Date
Eastharnpl'on a+ 0102/1 Telephon{iI3)527'l"?5
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 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 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 he, 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 lhrm acceptable to the Building Official, that he /she shall he
responsible for all such work performed under the building permit.
As acting Construction Supervisor your presence on the job site will he required from time to time, during and upon
completion of the work.b r which this permit is issued.
Also be advised that with reference to Chapter 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 Ibr 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 attached
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House I Addition n Replacement Windows Alteration(s) El Roofing
Or Doors L�
Accessory Bldg. I 1 Demolition 1 1 New Signs [Oj P -cks [Q Siding [0] Other [O]
Brief Description of Proposed
Work: attachprl
Alteration of existing bedroom Yes No ddin e .edroo Yes __ No
Attached Narrative novating unfinished b. ment Yes No
Plans Attached Roll - Sheet
6a. If New house and or addition to existing housing, complete the following:
a. Use of building : One Family Two Family Other _
b. Number of 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
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 1 CONTRACTOR APPLIES FOR BUILDING PERMIT
I,
e--,.o f Lyci. +c. R \ "A-X-e , as Owner of the subject
property
hereby authorize Mar L i s1 e o f Fi I . Roof rl l
to act on my behalf, in all matters r lative to work authorized by this uilding permit application. 9
ate 2chec1
Signature of Owner Date
I, ,,May LJIP' as a�a 1, , 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.
,Mark li
Print Name
3 - I a---
Si of Owner /Agent Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
f:xisting Proposed Required by toning
I his column to be filled in by
Building Department
Lot Sc' iz.
Frontage
Setbacks Front
Side
Rear
Building I leight
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg & paved
parking)
l of Parking Spaces
Fill:
(volume & Ipcation)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DON'T KNOW O YES Q
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW 0 YES O
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 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained O , 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 Q NO Q
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.
, RECEIVED Department use only
► City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
MAR w 7 20IZ 212 Main Street Sewer /Septic Availability
Room 100 WaterfWell Availability
DEPT OF BUILDING INSPECTIONS Northampton, MA 01060 Two Sets of Structural Plans
NORTHAMPTON, "" tiff: "' C 413 587 -1240 Fax 413- 587 -1272 Plot /Site Plans
Other Specify
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Addre s:
This section to be completed by office
i Map Lot Unit
Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
ToS� � e, \---.1.1“.\_ \---.1.1“.\_ OXVe. \olvv --0 (0 k ,-t\\Cxcs\- N C\oc-r .A , `Ao, . oiow,
Name (Print) Current Mailing Address:
a tta die d Q-k∎3) 32_0 1 L%;1
Telephone
Signature
2.2 Authorized Agent:
IAaYk - De ' 1e - t .C.i. roof; n9 _6 L ; -E. ,SQ N.
Name (Print) Current Mailing Address: 0101
.- __ (x{13) 527- 4 175 .�
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building R 0 1 .� 4 C)v (a) Building Permit Fee
2. Electrical 'j (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) kZ,y00 00 Check Number /
This Section For Official Use Only �'
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
68 HILLCREST DR BP- 2012 -0770
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17A - 290 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 -0770
Project # JS- 2012- 001352
Est. Cost: $12400.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RCI ROOFING 74334
Lot Size(sq. ft.): 31929.48 Owner: SARRO LYDIA & JOSEPH F BARTOLOMEO
Zoning: URA(100)/ Applicant: RCI ROOFING
AT: 68 HILLCREST DR
Applicant Address: Phone: Insurance:
6 LINE ST (413) 527 -4775 Workers Compensation
SOUTHAMPTONMA01073 ISSUED ON:3/7/2012 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 3/7/2012 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner