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38C-039
.. Roofing ( Line st. Esti Date Southampton. Ma. (1107; 3/10/2012 Phone (413) 5 27 - 17 75 1:;t5 (4 I3) 5z 7 -1(,n) Name / Address Job Location Debra W ijnhoven ;(i :) ; r_:- .. 354 South SI. 354 South SI. Northampton, Ma. (II060 Northampton, Mgt. 01060 (413) 53I -3 4 eons Rep Estimate valid for 30 days Dave Description Total Remove existim4 roofs. 9,200.00 Furnish & install I;2" plywood over decking. Furnish & install aluminum drip edge. pipe !lashings. chimney !lashings and step !lashings. Furnish install new lead counter !lashings. Furnish & install CertainTeed Winterguard ice & water Farrier along eaves and valleys. Furnish and install synthetic underlayment. Furnish and install 30 year CertainTeed Woodscapc Sc; ies shingle. Furnish and install Certain heed approved ridge vent. All exterior rooting related debris to be removed by 1/ (.I. Roofing. All work will be performed according to manufacturers' speeilications. 30 year CertainTeed material warranty included. All related permits will be obtained by R.C.I. Rootium. Add: 5750.011 fur Certainteed landmark 50 year premium shingle. A Certainleed 5urestart plus extended warranty will he included with a tee of $300.00 absorbed by RCI Roofing if signed within 7 days. This extended warrntty means that 20 of the all year warranty is covered for labor and material [he last I0 ve;w., the 3U year Certainteed warranty would be covered for material unly Note* If no plywood needed: So.1,((1 .0(1 WE LOOK FORW /A1:1) TO DOING 13USIN1?SS W11 1' ((14 Total $9,200.00 TERMS OF I /\1'fv9t:Ni' 5 Deposit Balance upon completion Customer Signature Registration t( 120235 Construction License N (174334 Z. Dale 3 /16/11 Insured by t3anas & Fickcrt Ins. - 013)527;27M The Commonwealth of Massachusetts 11 / Department of Industrial Accidents ._� � . ! 1 Office of Investigations =3 = 600 Washington Street f 3 ::= Boston, MA 02111 www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): "` Q ic`Z c; r ; t l.,, \... t' Address: i._ L,,\... .\--. City /State /Zip: ,,,_\-\ -,,-„-,,\ •, , t'vvo, c t o 7 : Phone #: '. / 3) .:5 =: -_1 - fi 7 `_(`: Are you an employer? Check the appropriate box: Type of project (required): 1. (Ri am a employer with 2, 0 4. I I I am a general contractor and 1 6 [ I New construction employees (full and/or part - time).* have hired the sub - contractors 2. ❑ I am a sole proprietor or partner- listed on the aiutcheu sheet. t 7 Remodeling ship and have no employees These sub - contractors have 8. Demolition working for me in any capacity. workers' comp. insurance. 9 g Y P� Y� i Building addition [No workers' comp. insurance 5. I I We are a corporation and its • required.] officers have exercised their 10 Electrical repairs or additions 3. E I am a homeowner doing all work right of exemption per MGL 11. Plumbing repairs or additions myself. [No workers' comp. c. 152, § 1(4), and we have no 12. V' „ Roo f repairs insurance required.] t employees. [No workers' 13.1 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: >\ C,_ ” , ;,, .. , rtu.c._.. (1",= Policy # or Self - ins. Lic. #: '1,,a e L% :'T:i . m4 `a — Expiration Date: I C% j . t 2, Job Site Address: 3,S4 Sr ._(,, `s\ City /State /Zip k ? A 1 V v k - p \ ck, O 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 of perjury that the information provided above is true and correct. - Signature: c L Date: . 2L 1 Phone #: 013 ` .` 1 L1.1 7 Official use only. Do not write in this area, to be completed by city or town official. Il 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 : arkl)P S '_e, - 7 li 334 License Number 516 gokyole. St. Easthmpton 1 Ma. oio ii 5 - 03 -42 Address Expiration Date ( � 3) 57- Lj r775 Signature T ..i 9. Registered Home Improvement Contractor: Not Applicable ❑ i• el .I. /ROO 126235 Company Name Registration Number 51 Hol Street - P 0. 6,0x 309 5- Ob - i 2 t1 Expiration Date Eastha npton, Ma. 010217 Telephon il 3)52? "T rfn ! 75 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 J°` No ❑ 11. - Home Owner Exemption The current exemption for "homeowners" was extended to include Owner - occupied Dwellings of one ( I) 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. CM R 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 lOrm 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 joh site will he required from time to time, during and upon completion of the work•lor which this permit is issued. Also he advised that with reference to Chapter 152 l Workers' Compensation) and Chapter 153 (Liability of Employers to Employees li)r injuries not resulting in Death) of the Massachusetts General Laws Annotated. you may be liable for person(s) you hire to perform work fir you under this permit. The undersigned "homeowner certilies and assumes responsibility ti►r compliance with the State Building Code, City of Northampton Ordinances. State and Local toning haws and Stale of Massachusetts General Laws Annotated. H omeowner Signature at.aakea_ SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ( I Addition I Replacement Windows Alteration(s) I Roofing Or Doors ❑ Accessory Bldg. I I Demolition I 1 New Signs [El] Decks [Q Siding [Elj Other [0] Brief Description of Proposed } - ao�P� Work: [_ Alteration of existing bedroom Yes No Adding new 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, t°bns( @t'•-\ � nkeV© , as Owner of the subject property hereby authorize V ' ► ar "De, i s Q o f f j • C, I . Roof; n9 to act on my behalf, in all matters r4.1ative to work authorized by thislouilding permit application. attache.c1 3 ,c Signature of Owner Date I , M k "Mel S , e, -as au t1oY`[ L&l aQ nt , as Owner /Authorized Agent hereby declare that the statements and information on the foregoing adolication are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. SvlaY li sle, Print Name 3 -2o -1a Signature of Owner /Agent Date Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Ilxisting Proposed Required by "Zoning This column to he filled in by building Department Lot Size Frontage Setbacks Front Side l.: R: Rear Building I leight Bldg. Square Footage Open Space Footage (/i (Lot arch minus bldg Paved parking) // of Parking Spaces Fill: plume .'` I4)cat1o11) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DON'T KNOW O 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 (3 DONT KNOW 0 YES Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O 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 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 0 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. Department use only r RECEIVEI City of Northampton Status of Permit: Z Building Department Curb Cut /Driveway Permit 212 Main Street Sewer /Septic Availability Room 100 Water/Well Availability r.0 F ir ° Northampton, MA 01060 Two Sets of Structural Plans " T p hut e 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 Address: This section to be completed by office 35(g 0LA ,5\r'. Map Lot Unit /L rt 4 \a R (\, j . Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: -- __\nora_krk W■_ V \7-1. 35'4 ,c,t,13-k- .‘ - ko(4- 0,q\- Pk Name (Print) Cur n t Mailing Address: 1 0,0,0 t a eh e Telep one • Signature 2.2 Authorized Agent: d ark 'De . le, - •C.s. oofi nr • _ - . if • d ( Iv . Name (Print) Current Mailing Address: 01013... --- ___ ( — 13) 521- 4115 Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building R oo f in . ` , C w U O , 0 0 � (a) Building Permit Fee _ 2. Elec'rical `+ tb) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 2 6. Total = (1 + 2 + 3 + 4 + 5) $ C Un ,C) 0 Check Number / t 2 / ? i .? S This Section For Official Use Only JJ Date Building Permit Number. Issued: Signature' Building Commissioner /Inspector of Buildings Date 354 SOUTH ST BP- 2012 -0819 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 38C - 039 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 -0819 Project # JS- 2012- 001431 Est. Cost: $9200.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: RCI ROOFING 74334 Lot Size(sq. ft.): 4791.60 Owner: WIJNHOVEN DEBORAH K Zoning: URB(100)/ Applicant: RCI ROOFING AT: 354 SOUTH ST Applicant Address: Phone: Insurance: 6 LINE ST (413) 527 -4775 Workers Compensation SOUTHAMPTONMA01073 ISSUED ON:3/22/2012 0:00:00 TO PERFORM THE FOLLOWING WORK:STRIP, PLY & 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 3/22/2012 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner