23A-184 R . I. Roofing
6 Line St.
Southampton, Ma. 01073 Estimate Date
Phone (413) 527 -4775
Fax (413) 527 -8469 5/28/2010
Name I Address Job Location
Diane Fedorchak
166 South Main 166 South Main
Florence, Ma. 01062 Florence, Ma. 01062
(413) 374-9416
Terms Rep
Estimate valid for 30 days Dave
Job Description Total
Remove existing porch roof. 1,500.00
Furnish & install new lead counter flashings.
Furnish & install CertainTeed Winterguard ice & water barrier along eaves.
Furnish and install synthetic underlayment over existing deck.
Furnish and install 30 year CettainTeed Woodscape Series shingle.
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.
All related permits will be obtained by R.C.I. Roofing.
Add $2.50 per sq. ft. for wood decking replacement if needed.
WE LOOK FORWARD TO DOING BUSINESS WITH YOU.
Total $1,500.00
TERMS OF PAYMENT —` /
5% Deposit ) /
Balance upon �__ • /
• I xmcom I Cu stomer Signature ��--- "`
Registration N 1262 e,'
Construction License # 074334
Insured by lianas & Fickert Ins. Date 611c//‘
).57/o
413 -527 -2700
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License CS 74334
Restricted to: 00
MARK T DELISLE ., -qt.:. 4, . 4,
33 FIRST AVE
EASTHAMPTON, MA 01027 ..
........--„,
c-_- ----- ---'. Expiration. 5/3/2012
t ”iiimissimier
Tr: 26357
:lire (oonthq,o/taw.://f/; H/ 71
Ofticc of Consumer Affairs & Business Regulation
HOME IMPROVEMENT CONTRACTOR
Registration: 126235
Expiration: 5/6/2012 Tr# 293949
Type: Partnership
R.C.I. ROOFING
MARK DELISLE
6 LINE ST
SOUTHAMPTON, MA 01073 Undersecretary
The Commonwealth of Massachusetts
Department of Industrial Accidents
,ter,' " Office of Intvestigations
IMO"! , 1"` 600 Washington Street
h'%LL,,��'f' Boston, itlrt 02111
. � -.:) ` w ww. ►tuts.gov /diu
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Q Please Print Legibly
Name (li,.,n,ess: )ruanirationiindividuaf}: . � _.._._ QQ _ \_?
ti Slit 1 c, / i l) : ______ t i o`t 3 Phone #: - Li `I — 1
y r re you an employer? Check the a ppropriate box: Type of project (required):
i and a employer with 2.0 - [ ) I am a general contractor and I
employees (mull and /or part - tinsel.' have hired the sub-contractors
1
y 6. [l New cr_>nstntction
J i and a sole proprietor or partner- listed on the attached sheet. 7. h_J Remodeling
ship have no employees gees These sub - contractors have
E E } S. y
❑ Demolition
work iii ;,: for me in any capacity. employees and have workers'
P 9. [J Building addition
No v■,arkersl Cofllp. insurance comp. insurance.'
rquir�.1. j i. _-__ We are a corporation and its 10.F Electrical repairs or additions
t. Li 1 and a homeowner doing all work officers have exercised their I I .0 Plumbing repairs or additions
,,I sel :. i No workers' comp. right of exemption per fv1GL
I 2
E Roof repairs
insurance required.) ' c. 152, §1(4), and we have no
employees. [No workers' 13.LJ Other _______
--- .___--- _- _- -_ -_ -_
comp. insurance required.)
' .0l. .,ppiicant u,,,t .alecks tux a I must also fill out the section below showing their workers' compensation policy information.
ihrrneo.vncrs „ho submit this affidavit indicating they arc doing all work and then hire outside contractors must submit a new affidavit indicating such.
'( on+raetors tha+ .:heck this lxrx must attachetl an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. !I'M,: sub- contractors have employees, they must provide their workers' comp. policy number.
I am utt employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
inW rination.
!nsurunce l.o:+;Psnv Nante:_Q„(„e. _ T'fDQG".i iy - Cc,..s.0..1 ��-�- __ -- --- - - - -- --
Expiration liration Date: 0 r r +" :. ,,r ,, ;-rt„. i . +c.':, c B _ �S - 1 l • 5 - a 0 iS?
doh Site :\eldt::ss --� ` c .` !\_ _______ City /State /Zip: Q t - �.. tO 2..
at tach a cup} of the workers' compensation policy declaration page (showing the policy number A nd expiration date).
I -;,i litre to sec arc coverage as required under Section 25:A of MGL c. 152 can lead to the imposition of criminal penalties of a
+,+e up to S 1 .'W.00 and /or one -year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fin
up to 520 Oh) a dov against the violator. Be advised that a copy of this statement may he forwarded to the Office of
investigations of the DIA for insurance coverage verification.
/ Flo /rereh■• certify under the ins and penalties of perjury that the information provider/ above Lc true and correct.
Phon it cy,.t3 5 - — t 5
li
OJjicia/ u. only. 1)o not write in this area, w he completed by city or town official.
ta l ` o r "Iow Permit/License q
a + art
�t3fit ti p; authority (circle one):
t` =$02rd of Health 2. Budding Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing inspector
G,.r i(t7 r
Phone fl:
SECTION 8 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor: Not Applicable 0
Name of Licen;ie Holder -__ - aY ■ 1 T 1 1 S i_ ( 7( 1 1 3 3 +
License Number
ln e_ • 0_ .- ill. • it S -03-ha
Address _ Expiration Data
Signature Telephone
.....ie 9. Registered Home Improvement Contractor: Not Applicable 0
,. 'Re f� 112 ^
Comp e Q � Re islra`tO
Registration Number
..„re + -� L� ^ 11/� Expiration Date
& ±i m pto -, Ma. 01 6 7 3 ___ Telephont6i ?.7 - ?(75
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 162, § 25C(6))
Workers Ccmaensation 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 ce No 0
11. - Home Owner Exemption
the current exemption for "homeowners" was extended to include ()weer- occupied Aweilinei of one (1) or two(2) families
a nd to allow such homeowner to engage an individual for hire who does not possess a license, provided that the owner acts
is ;Lunt 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. ar is intended to he, a one or two family dwelling, attached or detached structures accessory to such use and / or farm
.:• octures. A Berson who constructs more than one home in a two - year period shall not be considered a honteowraer.
5;;,:h "homeowner" shall submit to the Building Official, on a form acceptable to the Building Official, that he/she ihatl be
responsible for all such work performed under the buildinE permit,
.\> acting Construction Supervisor your presence on the job site will he required from time to time, during and upon
completion of the work.tbr which this permit is issued.
•\I,o he advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to
!.mplovccs for injuries not resulting in Death) of the Massachusetts General Laws Annotated, You may be habit for person(s)
vcu hire to perform work for you under this permit. .
ill.: undersigned "homeowner" certifies and assumes responsibility for compliance with the State Building Code, City of
\c rthampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature 3t1.aCI ed --------------------
4
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SECTION 5 - DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ( Addition Replacement Windows Alterations) n Roofing Ed
Or Doors • •
Accessory Bldg. l I Demolition . New Signs [DI Decks iQ Siding [DI Other [CJ
5net Descr ht ,gin of Proposed a ty.��1 �1
York L h
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 budding One Family Two Family Other
Number c rooms in each family unit: Number of Bathrooms
c. Is there a ]arage attached?
d. Proposes Square footage of new construction. Dimensions
e. Numbe• c stories?
f Method of heating? Fireplaces or Woodstoves Number of each
Energy Conservation Compliance Masscheck Energy Compliance.form attached?
Type of construction
Is cons ruo.tion within 100 h. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No
j . Depth cif Casement or cellar floor below finished grade
k. Will bui:dir,g 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
�,�da <� , as Owner of the subject
property r Q "� ^
hereby authori:_e JAY -- 04 1 Si e Ql 1 j• c. -+... RQQ F } i n9
to act on my behalf, in all matters r ative to work authorized by this uilding permit application.
I arhe.d u
Sigf Owner Date
iA • • • • de . • .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.
, r1R
1
Print Name
Signattire ° ot Owner/Agent Date
Section 4. ZONING Alt 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
I. SiLe I I
F; untage I I I
Scthacks Front
Side I.: R: l.:' R: i
Rear I 1
B_ gilding Height
. I
B dg. Square footage I % I
0 e)cn Space Footage
(Lit arca minus blur .& paved . I i
pa.king)
t, )f Parking Spaces
Fu. ,
Flume L heatign)
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 O
IF YES: enter Book Page and /or Document tit
B. Does the site contain a brook, body of water or wetlands? NO o DONT KNOW O YES o
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained , Date Issued:
0 0 I
C Do any signs exist on the property? YES O NO o
IF YES, describe size, type and location: ; j
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 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
City of Northampton Statulr
•
Building Department CurbC , ;;;
21.2 Main Street 1''' � � ,�
Room 100 Wa
Northampton, MA 01060 T }' °+ �'
phone 413 -587 -1240 Fax 413- 587 -1272 Plot$`s - +"51F °y ~ , ;', °•
r t
Other`S• t•, ^t!.
1 ;1: r
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
i Co Co ,5 ,k. Map ' Lot Unit
Zone Owriay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Name (Print) Current Mailing Address:
0413)314-1
a t ache Telephone
Signature
2.2 Authoriz Agent: r
M pvk lP. ° led � i. i�11 ~ s • ate 9 #11 • •
Name (Print) J Current Mailing .dress: O ■ 6
( 52'1- 4715
Signature Telephone
SECTION 3 - ESTIMATED CON$TRUCj3ON COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building qo oft .11 �� b O � G (a) Building Permit Fee
2. Electrical J (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
: 3 + + 5) (-) . 00 Check Number /4e; . fit 3C
This Section For Official Use Only
Date
•
Bonding Permit Number. Issued:
Signature:
Building Commissioner/Inspector of Bulidings Dele
F.1 „ ilSkd '
tiVIIIMAIN ST: BP- 2011 -0038
GIS #: COMMONWEALTH OF MASSACHUSETTS
°lock 23A 184' 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-2011-0038
Project # JS- 2011- 000066
Est. Cost: $1500.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RCI ROOFING 74334
Lot Size(sq. ft.): 8276.40 Owner: FEDORCHAK DIANE
Zoning: URB(100)/ Applicant: RCI ROOFING
AT: 166 SOUTH MAIN ST
Applicant Address: Phone: Insurance:
6 LINE ST (413) 527 - 4775 Workers Compensation
SOUTHAMPTONMA01073 ISSUED ON: 7/14/2010 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 7/14/2010 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo