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25C-141
. . Roofin ()Lines,. Est I mat e Date Southampton. Ma. 1111173 I0/12 /20I I Phone (413) 527 - 477 fax (413) 527 - 546 0 ) Name / Address Job Location Barbara Eaton & Ed Salners 47 -49 Orchard St. 212 Loudvillc Rd. Northampton, Ma. (11(16(1 Easthampton. Ma. 01027 (267) 980-3357 � I i orals Rep Estimate valid for 3(1 days Dave Description Total Remove existing rut's. 23900.00 Furnish & install 1/2" plywood over existing decking. Furnish & install aluminum drip edge, pipe Ilashings. chimney !lashings and step )lashings. Furnish & install new lead counter !lashings. Furnish & install Certain'I'eed W intergu,ird ice &water harrier along eaves and valleys. Furnish and install synthetic underlavntent. Furnish and install 30 year Certain heed \\ oodseape Series shingle. Furnish and install ('ertain'Iced approved ridge vent. All exterior roofing related debris to he removed hr I:.CI. Rooting. All work will he perforated according to manufacturers' speei 30 year Certain Teed material warrant included. All related permits will he obtained he R.C.I. Roofing. Add: $1,250.1)1) for Certai eed Landmark Woodscape 5)I year premium shingle. A Certainteed Surestart Plus extended warranty will he included with as ice of 5501(011 absorbed by RCI Roofing if signed within 7 days. I'Itis extended warranty means that 20 of the 30 Year warranty is covered for labor and material. [he last 10 years of the 31! rear Certainteed warranty wotdd _''yered for mat:irk:I rI WI'. LOOK FORWARD TO DOING I(USINfSS \VI7l1 YOU. Total $23,900.00 I CRMS OF I'iAYMt.;N'I' 5' Deposit I3 glance upon completion ( 3 ignature zet t , —,� Registrtui,an N 126235 Construetion License 41174334 Date Insured by lianas \ I�ickcri Ins. _ Z D 1 (413) 527 -27011 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations =wan 600 Washington Street -IA mom • % • = Boston, MA 02111 ,� • v www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): CL , Q0 ( , Address: C, ,\\-- City / State /Zip: o 7 3 Phone #: c9/ 3) -- ( r{ ( _ . 1' Are you an employer? Check the appropriate box: Type of project (required): 1. PI am a employer with 2 O 4. [1 1 am a general contractor and 1 6. 1 New construction employees (full and/or part-time).* have hired the sub - contractors 2. I am a sole proprietor or partner- listed ou the attached sheet. t 7. ( Remodeling ship and have no employees These sub - contractors have 8. I I Demolition working for me in any capacity. workers' comp. insurance. 9. I Building addition [No workers' comp. insurance 5. n We are a corporation and its • required.] officers have exercised their 10.1 Electrical repairs or additions 3. ❑ I am a homeowner doing all work right of exemption per MGL 11.1 Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4), and we have no 12. (j ioof repairs insurance required.] t employees. [No workers' 13.1 I Other comp. insurance required.] Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information: t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub - contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self-ins. Lic. #: is vL;'A Expiration Date: ! 0 j t Z Job Site Address: r - `1 c l Or t.. \,cvc -c3 City /State /Zip: ko n No b Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL 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 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. I do hereby certify under the pains and penalties ofperjury that the information provided above is true and correct. Signature: Date: j -2.- 12, Phone #: ( y t % Z, l 41 T Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : Near Il T e l (J' e. j L1 3 3 4 License Number 5) B Holyoke St.- Easthmpton Ma. o io !1 5 - 03 -') 2 Address Expiration Date t1 � '75 Signature Telephone ►3) 527 - .... 9. Registered Home Improvement Contractor: Not Applicable ❑ ft. e. I. 'Roofi n9 126235 Company Name Registration Number 5 18 Holyoke Street - P. 0. Box 301 5 - Ob - 12 Address �1n Expiration Date Eastharnpfion Ma. 010.? Telephonee413)52 - 4115 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 Q No ❑ 11. - Home Owner Exemption The current exemption b r "homeowners' was extended to include Owner - occupied Dwellings of one (I) or two(2) families and to alloy 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 tbrm 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 vwill be required from time to time. during and upon completion of the work.lbr 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 for person(s) you hire to per.lorm work for you under this permit. The undersigned "homeowner" certifies and assumes responsibility tier compliance with the State Building Code, City of Northampton Ordinances. State and Local Zoning haws and State of Massachusetts General Laws Annotated. Homeowner Signature attached SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House Addition I I Replacement Windo s Alteration(s) [ 1 Roofing FY Or Doors CI Accessory Bldg. I ( Demolition I I New Signs [❑] 'Decks [lJ Siding [❑] Other [❑) Brief Description of Proposed }}--a lZe Ylk• Work: L (�' 1 Alteration of existing bedroom Yes No Adding rtew bedroom Yes No Attached Narrative Renovating unfinished basement 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 CONTRACTOR APPLIES FOR BUILDING PERMIT I, C_c'i..>v' , as Owner of the subject property hereby authorize a Y h - Dell sl e of • C. I . Roo f) ri to act on my behalf, in all matters relative to work authorized by this uilding permit application. 9 t,t a ehed 3 - 2 -1 2_ Signature of Owner Date I, J1Y de I S'' e, -as aU thoY`LLe4 aj�t�t , 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. MaY1� l sl es Print Name Signature of Owner /Agent Date Section 4. ZONING AR Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information 1?xisting Proposed Required by toning 'th is column to be filled in by Building Department Lot Size Frontage Setbacks Front Side I.: R: 1,: R: Rear Building I !eight Bldg. Square Footage Open Space Footage (Lot area minus bldg & paved parking) # or Parking Spaces Fill: (volume & I pcation) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DON'T KNOW 0 YES 0 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 O 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 O 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 O 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 Q NO O IF YES, then a Northampton Storm Water Management Permit from the DPW is required. Department use only RECE EVED City of Northampton Status of Permit: Bu lding Department Curb Cut/Driveway Permit WA 9 212 Main Street Sewer /Septic Availability ' °t 7 1 G Room 100 WaterNVell Availability ortt.ampton, MA 01060 Two Sets of Structural Plans DEPT. OFBUILDINGI S 3 -5d7 -1240 Fax 413 - 587 -1272 Plot /Site Plans NORTHA Other Specify 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 — y9 © • Map Lot Unit ®C,�\-CA-\ Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: 63-c\cic r<\. 01/4\ ?-1?, e_ -%a �� -6(1 kck okll Name (Print) Currpnr Mailing Address: + �2 �� 98n - 3 5`'1 t Che Telephon6 Signature 2.2 Authorized Agent: 3 Y I) e. - r�. Foof i n �- i. e 5t:.'S,a. a mp ro r1 a Name (Print) 9 . a Current Mailing Address: O1O+ 3. (qI3) 521- 4T15 Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building R 2? J f 00 . G0 (a) Building Permit Fee 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) $ 23 9 00 Check Number / 03 906 This Section For Official Use Only Date Building Permit Number: Issued. Signature: Building Commissioner /Inspector of Buildings Date 47 ORCHARD ST BP- 2012 -0771 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 25C - 141 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 -0771 Project # JS- 2012 - 001353 Est. Cost: $23900.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: RCI ROOFING 74334 Lot Size(sq. ft.): 10018.80 Owner: EATON BARBRA L & EDWARD A SALNERS JR Zoning: URB(100)/ Applicant: RCI ROOFING AT: 47 ORCHARD ST 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