23B-016 (3) / JUN -09 -2010 23:02 Frorn:RCI 'Roo fin9 4135278469 To:14135275424 Pa9e:2'2
RC 1.
Roofing
6 Line St.
Southampton, Ma. 01073 Estimate Date
Phone (413) 527 -4775
Fax (413) 527 -8469 6/9/2010
Name / Address Job Location
7. 1
Charles T. Conner
C/O Taylor Agency 14 Hatfield St.
87 Main Street Northampton, Ma. 01060
Easthampton, MA 01027 (413)
Terms Rep
•
Estimate valid for 20 days Chris
Job Description Total
Remove existing roofs on garage and lower porches on house 15,000.00
Furnish & install 1" insulation mechanically attached.
Furnish & install wood nailer to match height of insulation.
Furnish & install .045 re- inforced rubber roof system, mechanically attached .
All exterior roofing related debris to be removed by R.C.I. Roofing.
All work to be performed according to manufacturers' specifications.
5 -year RCI Roofing workmanship warranty included.
All related permits will be obtained by R.CJ. Roofing.
SPECIAL ITEMS NEEDED
1 /3ox 42‘
y.1 3
i (VYi le.
WE LOOK FORWARD TO DOING BUSINESS WITH YOU.
Total $1 5,000.00
TERMS OF PAYMENT
5% Deposit
Balance upon completion
Registration # 126235 Customer Signature
Construction License # 074334
Insured by Banas & Fickert Ins. Date
413- 527.2700
*.. AI,I tills II. ilt p .ir',11, 11∎ I I'ilhli, •i, •
pa H.∎.tr,f , ,I I{uildin iv :ul.ili..■ iu■l , i.tii,l,
Ln:rn‘c , ,;5 74334
Rest! it toil Iii 00
MARK T DELISLE k ,;
33 FIRS AVE
4,„-,%t ° �`
EASTHAMPTON MA 0!02 , - . ;
, ,,i III.yiyI. , T 1 , :'6357
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(llticr ul l uu.unrcr : lila:is .G ltu.iue ' Regulation
- HOME IMPROVEMENT CONTRACTOR
•, Registration: 126235
j Expiration. 536/2012 1 rt7 20304y
Type: Partnership
R t; I ROOFING
MARK DELSLE
6 LINE ST _
,3 1)W HAMPTOPJ . MA 01073 �I 'idyl ‘et
The Commonwealth of Massachusetts
4 Department of Industrial Accidents
4 Office of Investigations
�w -- 600 Washington Street
we rim
•• ∎• ° Boston, MA 02111
4 - f /
r,Y�' www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians /Plumbers
:Applicant Information Please Print Legibly
Name ( Business lOrganization /lndividual):A OQ , ri \...x.....? —_ -
Address: A e:.. ,\\-- .
C'irv'StGtt� lip: �`� P hone #: - �-1�
Are y-ou an employer? Check the appropriate box: Type of project (required):
` I . 1 1 am a empl with _'O 4 . ❑ 1 am a general contractor and t
emplo (full and /or part - time)."
have hired the sub contractors 6 . ❑ New construction
2. ( 1 1 am a sole proprietor or partner- listed on the attached sheet. 7. L] Remodeling
ship and have no employees These sub - contractors have g, ❑ Demolition
working far me in any capacity. employees and have workers' 11 Building addition
[No workers' comp. insurance comp. insurance.:
require f,!
5 __.. P
We are a corporation and its 10.0 Electrical repairs or additions
3. P1 I an a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
riivsel:. [No workers' comp. right of exemption per MGL
12.2 repairs
insurance required.] t c. 152, § 1(4), and we have no
employees. [No workers' 13.11 Other
comp. insurance required.]
'Any applicant that checks box is l must also till out the section below showing their workers' compensation policy information.
liotneownens ■\
No submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
'Contractors that check this fox 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.
/ ant an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: Q.Q.'.. Q' C..><' , C_r. S■,.w.A — 1.- n S .
Poke) r or Sc It-ins. Lie. #: Ajty.A_ CL 58 0'i 2 5 tor _ Expiration Date: f 0 - 5' 2.Q 1 0
Job Site Address: IM i� t t'I A. ,\� City /State/Zip: pc'' n ° S)Iot0
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secare coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
line up w 41.00.00 and/or one -year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
()Cup to 5250.00 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 ccrrtify under the ins and penalties of perjury that the information provided above is true and correct.
S ignattire __ Date: 1 -13-10
Phone #: c 3) , ? 1 — L V 15
1
Official use only. Do not write in this area, to be completed by city or town official
City'or 'Town: Permit/License #
TSS # rig Authority (circle one):
1 "06ard of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6 F Other _
C ot'tict Person: Phone #:
•
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder :_ Otiellale, T? X1334
License Number
,
ta'" O Aa∎ a.% • . • g' 5 -03 -l 2..
Address - Expiration Date
. ( 13) 52 ?- 111
Signature / Telephone
l
9. Registered Home Improvement Contractor: Not Applicable ❑
F . 126235
Company Name Registration Number
— - ►11 '.:.�....;.- 5 -Ob -12
1-1001 Expiration Date •
• :AI . tit 0 • • V - . 0 $ Telephon • 4_.!__[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 resutt
in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes {if" No _ ❑
1I. - Home Owner Exemption
Th.:. current exemption for "homeowners "' was extended to include Owner- occupied Dwellings of one (1) or two(2) families
and to al low 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. .)r is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/ or farm
sr. ,ctures. 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 form acceptable to the Building Official, that he/she shall be
resp rk onsible for all such wo performed under the building permit.
.' \: 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.
Also he advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to
I n for injuries not resulting in Death) of the Massachusetts General Laws Annotated, YOU afar be Iiabk for pet'sor
vnu hire to perform work for you under this permit.
Thy undersigned "homeowner" certifies and assumes responsibility for compliance with the State Building Code, City of
\orthampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature ____atCI
. ■ YM ±yt.,1 ,. i
•
O WN. Ill I 1°Will.
a
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition n Replacement Windows Alterations) ❑ Roofing Eyf
Or Doors CI • •
Accessory Bldg. 1 1 Demolition ❑ New Signs [0] Decks [Q_ Siding ICI) other([)'
Brief Description of Proposed
Work: -- 2ttaehe4i
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 bu'iding : One Family Two Family Other
b. 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. Number of stories?
f. Method 01 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
Depth cf 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, 1 . C 42) , as Owner of the subject
property fit)
hereby authori: e tiny L e. 1 S, e. c:€ • ej. I . Roof
to act on my behalf, in all matters r ative to work authorized by thisuilding permit application
attached m fo
Sig'natClre'Of Owner Date
I, V • r - - a - 1 • , ' • • I .0 , as Owner /Authorized
I Agent hereby declare that the statements and information on the foregoing _ . •iication are true and accurate, to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
aYk In
Print Name
-f3 6
Signature of Owner/Agent Date
Section 4. ZONING All 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 1( )
L, }t Size .
Ft ontage i i i
Setbacks Front i
Side L:' R:
Rear. I L_ __
13.tilding Height . ___ _ -,
I I
B :fig. Square Footage %
O en Space Footage
(l. ,t arca minus bldg & paved I
pa king)
# )f Parking Spaces
Fi I I: ; 1 _
(v„lume & l. ' ' I )
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 0 DONT KNOW 0 YES 0
IF YES: enter Book ' ; Page I and /or Document #1 1
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 (D Obtained O , Date Issued: ('
C. Do any signs exist on the property? YES O NO O
IF YES, describe size, type and location: 1 1
I
D. Are there any proposed changes to or additions of signs intended for the property ? YES O 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 wit disturb over 1 acre? YES O NO 0 •
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
4 M 1e c
City of Northampton Sta at ,,
Building Department Curb C x ! , „ i ;,-;, ,
; 212 Main Street
\ J Room 100 Wat • t ' ` ,, •
°' ° J r
Northampton, MA 01060 !� •; ,. •
phone 413 587 - 1240 Fax 413 587 - 1272 F�lo`
t 1 {ii � :‘%,;,,:f, , i
,•,. sr•rr v,.. Ira r - i j
Other'S • • - 4ro: , ,,
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
' 4 i t;...l.1 ,\- Map . Lot Unit
o . r0■ , No. ,*A- ( " Zone Overlay District
1 Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner i of Record: \ r \ \
Name (Print) Cur• nt Mailing Address: '
`if3) 5
attached Telephone
Signature
2.2 Authorize :1 Agent:
Ma e. led — .c.z. ofi - .. .. • .t, ..
Name (Print) Current Mailing • .dress: 01 0'13
■;-. -- (x}13) 52'7- Af?75
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building 1i00P! 4150 ID OCR (a) Building Permit Fee
2. Electrical J (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fes
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 - 2 + 3 + 4 + 5) $ 1 5 0 00. a -° Check Number / 9 7( i -1�'
This Section For Official Use Only
Bofdirig Permit Number.
Date
Signature:
Building Commissioner/Inspector of Buildings Date
•
'-k;',1.,`
•
»f 1'2 ..
14 ST A BP- 2011 -0147
GIS #: COMMONWEALTH OF MASSACHUSETTS
viap :Block: 23B - 016 ' 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 -0147
Project # JS- 2011- 000242
Est. Cost: $15000.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RCI ROOFING 74334
Lot Size(sq. ft.): 25743.96 Owner: CONNOR CHARLES T
Zoning: SI(100)/ Applicant: RCI ROOFING
AT: 14 HATFIELD ST
Applicant Address: Phone: Insurance:
6 LINE ST (413) 527 -4775 Workers Compensation
SOUTHAMPTONMAO1073 ISSUED ON :8 /20/2010 0 :00 :00
TO PERFORM THE FOLLOWING WORK :STRIP & SHINGLE GARAGE & PORCH ROOFS
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 8/20/2010 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner