25C-013 CONTRACT
R & 11 ROOFING, LLP
59 South Street
Easthampton MA 01027
(413) 527 -9378 — Ph
(413) 527 -8244 - Fx
TO: JOB N ►ME:
EVELYN SANTON
16 DAY AVENUE 16 DAY; AVENUE
NORTHAMPTON MA 01060 NORThAMPTON MA 01060
DESCRIPTION OF PROIECT:NEW SHINGLE ROOF — APPROXIMATELY 2,300 SQUARE FEET
1. REMOVAL AND DISPOSAL OF EXISITNG ROOF.
2. INSTALL ICE AND WATER BARRIER ON EAVES AND VALLEYS.
3. INSTALL ON PLY OF 15LB BASE FELT ON REMAINDER OF EXPOSED DECK.
4. INSTALL DRIP EDGE AND RAKE EDGE METAL.
5. INSTALL 30 -YEAR ARCHITECTURAL SHINGLE ROOF SYSTEM.
6. INSTALL ALL REQUIRED FLASHINGS.
7. ALL RELATED DEBRIS ID BE REMOVED BY R & H ROOIFING, LLP.
LABOR + MATERIAL$ = $147794.:86 — - d'
ItPror
* ** ADD $1.75 /SQUARE FOOT FOR DECI< REPLACEMENT * **
PAYMENT SCHEDULE:
50% DUE UPON DELIVERY Of MA $5.867.Q .fi, L ? 0Cl
100% DUE UPON 100 910 COMP . N =444674* + Co 1I
R & H ROOFING, LLP Y TON
DATE DATE
'
10 390d dTl BNId00d - > taVZsLZSEtb tt :tit 0ToZ /6Z/V0
The Commonwealth of Massachusetts
F _—_,=-7== .,department of industrial Accidents
, � , Office of Investigations
1= 600 Washington Street
£ �. Boston, MA 02111 •
www mass.gov/dia
Workers' Compettsation Insurance Affidavit: Pnilders /ContracCarsiElectric, ans. lunribers
Apxrlicant information .,,�,,,._, .. ��"q �� ) � ,. / . Please Print L
Name (Business tgnizationtIndividuall:___� N zz ��C 1/� `CL � ._ __ _______._.
A d d r e s s :, __--- -__.._ __ _.-__. ___ __ _. - -- __
Cit /state/Z.�r: L _ +� 6/6_,Z2._ Phone #.` _ L i /3 : 5 -Z 7_ 7 ( ___•__._.__
Are you an employer? Check theeappropriate box: _- .. ___._.._ _�__� Ty
of project (required):
1. 'it"1 am a employes with __ 4. appropriate. I am a general contrac.iar and 1
r * have hired the stth ontractors New construction
(full and or part••titnw }.
2 I am a sole proprietor or partner- listed ou the attached sheet $ ' L Remodeling
and have no employees
These sub - contractors have 8. 0 Demolition
working for me in any capacity. workers' comp. insurance. , 9. 0 Build :6g addition
[No workers' comp. insurance 5. 0 We area corporation and its •
required.] otrcers have exercised their 1 s.L Electrical repairs or additions 3, L) I am a homeowner doing all work right of exemption per MCI, 11.x] Plumbing repairs or additions
myself. [No workers' comp, C. 152, §1(4), and we have no 12.0 Roof repairs
insurance required.) t employees. [No workers' 13. Other
comp. insurance; required.] !`"�
� 'Any nppiicttnt that chs eck bot #1 must also fill out the section below allowing their workers' compe- osati: tt policy information' — ^ – ' � .__
t Iioni o wmen; who submit this affidavit indicating they are doing all work end then hire outside contractors thust submit a new affidavit indicating such.
'Contractors that check this box must attached an additional sheet showing the name of the suh- eontrrretlm and their workers' comp. policy information.
f am an employer that is providing wor hers' cornperrsatiora insurance for try employees Below it the policy and job site
information. y�
insurance Company Name:_l� I /�____ UIT , � L25L r -
Policy # or Self -ins. Lic. #: 'WC7Q I Z L L2i 2 9 Expiratior Date /c)---,2c1 -10
lob Site Address: /__, �/ / �i J '- /' /�/�
s� L 5 . �2 EI._....— ._._.— Fits /.�.,tateJL ;r...�l 1 v L� CLOt.L�'1..�'
kttach 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 MOL 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 tic Office of
Investigations of the DIA for insurance coverage verification.
,do hereby certi 7 under the ins d penalties of perjury that the information provided above k true and correct
S_ *ran.. C: � _ -- - _------ --_.— _.__.._..— _..�,-. __-_r_ _...__ _ / 6
Phonc#: 2 -
Official use only. Da not write In this area, to be completed by city or town official.
City or Town; _ Permit/License # .__._. _.._..___..._. 1,,
Issuing Authority (circle one):
—_ _._. _ _ I
I. Board of Health 2. Building Department :4. City/Town Clerk 41_ Electrical Inspector 5. Plumbing 1nFpecfor
}
6. Other
Contact Person:_______ _ ._ _ _ Phone #:
•
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: , ,� 1• Not Applicable ( j
Name of License Holder : I4� (G... 1 I L,� 1�. / S C3 c5 y aZ7 f/
License Number
59 Lo L5i. �1i mf - l��
Address Expiration Date
LJ13- -- ) - 37e
Signature Telephone
9. Registered Home Improvement Contractor Not Applicable El
(Z , Lt r / b5
Compan4 Name Registration Number
Uc l Sr t 1 11'1 r) 0/ -7 7 -( / -`
Address' (q13) Expiration Date
4.01 f"
Telephone, ? 7' s)r
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 build'ng permit.
Signed Affidavit Attached Yes No ❑
11. - Home Owner Exemption
The current exemption for "homeowners" was extended to include Owner occupied Dwellings of one (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. 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 form 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 will be required from time to time, during and upon
completion of the work for 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 perform work for you under this permit.
The undersigned "homeowner" certifies and assumes responsibility for compliance with the State Building Code, City of
Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing jAt
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [p Siding [D] Other [D]
Brief Work: M r E c5
LI) 1�1� - /Za
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, , as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
2y P
I, -�' , as Owner /Authorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
/
Print Na
Sig t e of Ownelgent 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
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:.
Rear
Building Height
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg & paved
parking)
# of Parking Spaces
Fill:
(volume & Location)
A. Has a Special Permit /Variance /Findin ever been issued for /on the site?
NO 0 DONT KNOW YES
IF YES, date issued:!
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW YES
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained
, Date Issued:
C. Do any signs exist on the property? YES 0 NO
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
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 0 NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Department use only'
City of Northampton Status of Permit;
Building Department Curb Cut/Driveway Permit
212 Main Street Sewer /Septic Availability
Room 100 wateriWell Aya lability,
Northanfpton, MA 01060 Twos 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
DA) Map Lot Unit
� C--I1- 1-E/],r) p T7 /` / I �/„/� Zone Overlay District
r I�r ► / (. ( 1� Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Name (Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent: 5 �, 1 ` '
1 t l�l_ I 1 1�'A -(Y1 M c 10t9-7
Name rint) Current Mailing Address:
r
S gnature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. (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) 1 a y . (Y) Check Number
This Section For Official Use Only
Building Permit Number: I sssuu
ed:
Signature:
Building Commissioner /Inspector of Buildings Date
Y AvE " `. BP- 2010 -0972
GIS #: COMMONWEALTH OF MASSACHUSETTS
: 25C o 3; : 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 # B P- 2010 -0972
Project # JS- 2010- 001434
Est. Cost: $11234.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: R & H ROOFING 042781
Lot Size(sq. ft.): 6229.08 Owner: SANTON EVELYN ALICE
Zoning: URB(100)/ Applicant: R & H ROOFING
AT: 16 DAY AVE
Applicant Address: Phone: Insurance:
59 SOUTH ST (413) 527 -9378 Workers
Compensation
EASTHAMPTONMAO1027 ISSUED ON:4/29/2010 0:00:00
TO PERFORM THE FOLLOWING WORK: STRI P & 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 4/29/2010 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo