10-003 (4) .. Roofing
Date
61_inc Estimate
South,unplun, Ma. 011/7; 3/19/2(112
Phone (413) 527 -4775
Fax (413) 527 - 5460
Name / Address Job Location
Kris Thomson 362 Kennedy Rd.
257 Montague Road Leeds. Ma. (11 (153
Leveret(, MA (1(14 (413) 69-64S7
Terms Rep
blslimate valid for 30 days Dave
Description Total
Remove existing roofs. 5,400.00
Furnish A. install aluminum drip edge, pipe II sltinl,s. cInntne■ flasbing.s and step Ilashings.
Furnish & install new lead counter Ilashings.
Furnish A. install Certain heal Wintergnard ice A. water Hamer along eaves and valleys.
Furnish and install synthetic undcrlavtnenl over existing deck.
Furnish and install 30 year Certainleed Woodseupe Series shingle.
Furnish and install CertainTeed approved ridge \ cot.
All exterior roofing related debris to be removed by R.C.I. liuulin��.
All work will be performed according to inanulaclurers' specifications.
30 year Certain Feed material warranty included.
All related permits will he obtained by R.C.I. Roofing.
Add $2.50 per sq. It. fur wood decking replacement ii needed.
WE LOOK FORWARD TO DOING IiUSINlTSS W I T H YOU.
Total $5,400.00
"PERMS OF I'AYM NT
5'34) Deposit
I3alanec upon completion Customer Signature
Registration (t 126235
Construction License N 071334 I)ate 1. )
Insured by lianas & Flicked Ins.
(413) 527-2700
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The C,ottunottwealth of Massachusetts
...ii Department of Industrial Accidents
ccidents
- �. Office of Investigations
Teti 111
600 Washington Street
€ e � == • �O./ Roston, MA 02111
1/4` - we" tv►v►v.mass. ov /dia
Workers' Compensation insurance Affidavit: Builders /Contractors /Electricians /Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): -' - C x'-, , �. L ,
,
Address: 1,—;\ <_ >\
City /State /Zip .. , ._ ,,,, - ., ` Phone ii: r► = i _ - I':'
Are you an employer? Check the appropriate_ box: Type of project (required):
1. L-"1 am a employer with . -,:
�' 4. [ I am a general contractor and 1
(i. [11 New construction
employees (full and/or part - time).* have hired the sub contractors
2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 1 ❑ Remodeling
ship and have no employees These sub - contractors have S. ❑Demolition
working for me in any capacity. workers' comp. insurance. 9. ] wilding addition
[No workers' com p insurance 5 [11 We are a corporation tint! its • I
required.] officers have exercised their 10.Li Electrical ll repairs or additions
3. ❑ 1 am a homeowner doing all work right of exemption per MGL 11.[_j Plumbing repairs or additions
myself. [No workers' comp. c. 152, § 1(4), and we have no 1 2. [v 1 Roof repairs
insurance required.] t employees. [No workers' i
comp. insurance required.] 13 � — Other
`Any applicant that checks box t/ I must also till out the section below showing their workers compensation policy inti)rmation:
t Homeowners who submit this affidavit indicating they ate doing all work and then hire outside contractors must submit a new affidavit indicrit 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 mt, e nplopees. Below is the policy and job site
information.
Insurance Company Name: , . t...:
• t
:
Policy # or Self -ins. Lic. #: ',,.,,, t' ,:.2 , , *., ,1 :,.:_:1) Expiration Date: 1 ':_ °i 1 3__
Job Site Address:__3-c f � _ p,a City/Stale/Zip : 5� ,_ot 0 21 , 5.1.
Attach a copy of the workers' cornpens:ition 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 $250.00 a day against the violator. 1k advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the in Ormation provided above is true and correct.
Signature: Date: _ - -
Phone #: ,` t Z i f.- t - ' t i:a — -- — -- —
Official use only. Do not write in this area, to be completed by city or town official. II
City or Town: Permit /License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other -
I
Contact Person: - -- Phone #:
` l
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
-Dal ,
Name of License Holder : Mar h v al t it.,___ �] _ — --__ / 4 1334
License Number
516 -tol olie St.- East Ma. n►oaq 5 - 03.42
Address Expiration Date
( i3j 57- X 7'75
Signature Telepho
9. Registered Home Improvement Contractor: Not Applicable ❑
ft 1.I. ' Roofjrici _ _ 12 6235
Company Name Registration Number
51$ Not oke Street - p O. 'Box 309 5-06-1 2
Address ^^ Expiration Date
Eas - npfion M a a 01 0 nt. 1 TelephonEeil 3)527- 4175
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 {3 No ❑
11. - Home Owner Exemption
•fhe current exemption fur "homeowners' was extended to include Owner - occupied Dwellings ofone (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. CM R 780, Sixth Edition Section 108.3.5.1.
Definition of Homeowner: Person (s) who OW 'n a parcel of and 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 !Oral 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 be 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 (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 perform work fur you under this permit.
the undersigned " homeowner" eertities and assumes responsibility liar 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 Addition Replacement Windows Alteration(s) n Roofing 1
Or Doors 0
Accessory Bldg. I 1 Demolition New Signs [D] Decks [E Siding [DJ Other [D]
Brief Description of Proposed �} a h
Work: t t (- er
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 1t{,C S �� ��`)� , ; , as Owner of the subject
property '� Q
hereby authorize JYlar .IJe1 i s l of 1 • l (!
.J. I . Roo n
to act on my behalf, in all matters relative to work authorized by this permit application.
a ttached 3 z
Signature of Owner Date
I, , )' 1aY k UP1 1 S' e, aS aU t 'bQY']xei at , as Owner /Authorized
Agent hereby declare that the statements and information on the foregoing are true and accurate, to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
Print Name
Signature of Owner /Agent Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
h:xislim� Proposed Required by Zoning
This column to he filled in by
Building Department
lot Size
Frontage
Setbacks Front
Side I,: R:
Rear
Building I'eight
Bldg. Square Footage 45.
Open Spaee Footage
(Lot area minus hide & paved
parking)
t,' or Parking Spaces -
Fill:
(volume K Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO Q DONT KNOW Q YES Q
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW Q YES Q
IF YES: enter Book Page and /or Document #:
B. Does the site contain a brook, body of water or wetlands? NO Q DON'T KNOW Q 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 Q
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES O 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 Q NO O
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
- RECEIVED Department use only
City of Northampton Status of Permit:
IN 2 92012 Building Department Curb Cut /Driveway Permit
212 Main Street Sewer /Septic Availability,
Room 100 Water/Well Availability
DEPT OF BUILDING INSPECT10N3
NORTHAMPTON, MA 01060 Northampton, MA 01060 Two Sets of Structural Plans
phone 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
�e vA "c_A Q - Map Lot Unit
t_, ee A
Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
e-. ∎ ( j 1 O crl Sc � t^t1 ehArs . a E . � �,�e,�k no,
Name (Print) Curren Mailing Addres�sj,
2ttacheci Teleph e
Signature
2.2 Authorized Agent:
SaYk le, - � f oof; n Lines -E: SQutl� .arnpton .Ma.
Name (Print) Current Mailing Address: O1A"j�
ei ! 3} 521- 4 ?75 V a..+
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building RoOFt ni 4 f._ o (j)0 la) 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) S' v (' Check Number /9g'sv This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
362 KENNEDY RD BP- 2012 -0839
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 10 - 003 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 -0839
Project # JS- 2012 - 001486
Est. Cost: $5400.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RCI ROOFING 74334
Lot Size(sq. ft.): 128066.40 Owner: BERCUVITZ DEBRA T & KRIS B THOMSON
Zoning: RR(100)/WSP(100)/ Applicant: RCI ROOFING
AT: 362 KENNEDY RD
Applicant Address: Phone: Insurance:
6 LINE ST (413) 527 -4775 Workers Compensation
SOUTHAM PTONMA01073 ISSUED ON :3/29/2012 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 3/29/2012 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner