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38B-023 Recover existing modified roof on Widow's Walk with rubber. Flash existing chimney with 60 mil rubber and terminate. Note: All existing debris to be removed by R C I Roofing. All work to be performed according to manufacturing specifications. 2 year R. C. I. workmanship warranty included. All related permits will be obtained by R.C. I. Price: $4,200.00 Terms of Payment: 5% Deposit down upon signing contract. Balance upon completion of job. To accept the contract, please siana.Ind return to R.C.I. Roofing along with the 5% Deposit. Signature Sincerely David Brown Residential Estimator Roofin 6 Line Street, Southampton, MA 01073 Phone: 413 -527 -4775 Fax: 413-527-84 Date: 4/24/2012 To: Mr. & Mrs. Frederick Busi 111 South Street Northampton, MA01060 RE: Estimates for repairs to 3 flat roof areas Northampton, Massachusetts Attn: Mr. Frederick Busi Dear Fred; Thank you for the opportunity to bid the flat roof sections at the above address in Northampton, MA. The scope of work would be as follows: Roof #1 Recover existing modified roof on left side of home Furnish and Install 1 /2" fiberboard insulation, mechanically attached. Furnish and Install 60 mil black rubber, fully adhered to insulation. Furnish and Install all related flashing. Furnish and install .032 aluminum drip edge to area. Repair existing drain pipe Roof #2 Recover existing modified roof on back of home Application is the same as above without drain pipe. Roof #3 Widow's Walk The Commonwealth of /Massachusetts * -- Department of Industrial Accidents 16E61 h ���►� � O f� �i ce of Investigations �W r.= 600 fi'ashiitgton Street y , � Boston, MA 02111 )t')1'}t'. mass.g ov /dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name usiness/Or ganization/1ndividual): , "y„. ; a :' Address: &„ L,,,, k_. ° ; City /State /Zip fit'; -;_k j ^V' �i`�_x, �.�J` , s w - t- ` • t ' Phone tIV: rl/ ' I l -f ' i - — Are you an employer? Check the appropriate box: Type of project (required): i. FTI am a employer with _ 1. 1 am a cnet al contractor and 1 New construction ernployees (full and/or part - time).* have hired the sub -contr actors 2.1 1 I am a sole proprietor or partner- listed on the aita�.hed sheet. 7 F Remodeling ship and have no ernployees "These sub - contractors have S. n Demolition working for me in any capacity. wor kers' comp- insurance. 9, n Build addition [No workers' comp. insurance 5. ❑ We are a corporation and its • r 1 O. [_J Electrical repairs or additions required.] officers have exercised their 3. (- I am a homeowner doing all work right of exemption per MGL 11.1 1 Plumbing repairs or additions myself. [No workers' comp. c. 152, § 1(4), and we have no 12. 's. / Roof repairs insurance required.] 1. employees- [No workers' 13 1 Other comp. insurance required.] `Any applicant that checks box tt 1 must also till out the section below showing their workers' compensation policy infunnation. t Homeowners who submit this affidavit indicating they are doing all wor and then Hire outside contractors must submit a new aflidevit indica'iiig such. tContractors that check this box trust attached an additional sheet showing the name of the sub - contractors and their workers' comp. policy information. 1 am an employer that is providing workers' compensation insurance fin my employees. Below is the polio' and job site information. Insurance Company Name: -,1 •v : c Policy # or Self -ins. Lie, #. ',, !, , I L ? _ 'P, ' ' -i �r Expiration Date: l (., i Z' Job Site Address: k\ Sh Ic-� — — City `State /Zip:Mr- c. vvv0 -t, 'Aka .typt c. 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 he 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: -- - Date 1 - 7 - Z — t z, `t `5r,_i (-1`t . Phone #: � l , } - Official use only. Do not write in this area, to be completed by city or town official. 1 ii City or Town: _ Permit /License # — Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. Citvf Clerk 4. Electrical Ltspector 5. Plumbing Inspector 6. Other Contact Person: — Phone #: 1 SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : Kay X "D __ 17 3 3 Al. License Number 516 Rolyo St.- Earthmp1on Ma, o Ioafl 5 Address Expiration Date ( 5 f7. 7 75 Signature Telephone i e 9. Registered Home Improvement Contractor: Not Applicable ❑ ft.I. — 126235 Company Name Registration Number 5i 13, Nolyoke Street - P. 0. 'Box 361 5-06- i t Address Expiration Date Eas tharn piton / Ma . 010 W7 _ Telephon €013)527 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 V No ❑ 11. - Home Owner Exemption The current exemption for - homeowners - was extended to include Owner - occupied Dwellings ()lone (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 or land on which he /she resides or intends to reside, on which there is. or is intended to be. a one or two family dtvell1 in. 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 liirm 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 oldie y,vork.lor which this permit is issued. Also be advised that with reference to Chapter 152 ( Workers' Compensation) and Chapter 153 (Liability of Employers to Employees lin injuries not resulting in Death) of the Massachusetts General Laws Annotated. you may be liable for person(s) ■ou hire to perlorm work for you under this permit. The undersigned - homeowner - certifies and assumes responsibility lbr compliance with the State Building Code, City of Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature _— tt' ckeci__ SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House [7 Addition [1 Replacement Windows Alteration(s) [ Roofing rif Or Doors ❑ Accessory Bldg. I 1 Demolition [ 1 New Signs [❑] Decks [❑] Siding [❑] Other [❑] Brief Description of Proposed ;1� /� Work: . � / � La � Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes o 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,( 'C. et, LY-. 'w—�' , as Owner of the subject property j� -('' hereby authorize t a Y h .i1e� t Si +D Q r l R n �1• R. ` . T. Roof) n to act on my behalf, in all matters relative to work authorized by this uilding permit application. 9 Att. adie.d 6 4 7- 12. Signature of Owner Date I, L ►ay k Teh 5' l e, as aL1 t r 1(1/170 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. Vert sl ed Print Name `� 1 - 1- Z. 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 he filled in by Building Department Lot Size Frontage Setbacks Front Side 1.: R: L: R: Rear 13uildinu IIeighl Bldg. Square Footage Open Space Footage "4. (Lot ;ilea minus hldg & pav park ing) # of Parking Spaces Fill: (volume & location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DON'T KNOW 0 YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW Q YES 0 IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO 0 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 0 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 Q 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 O 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 MAY 2 2 212 Main Street Sewer /Septic Availability Room 100 Water/Well Availability L SPECTIONS • rthampton, MA 01060 Two Sets of Structural Plans DEPT. GF BW 0 ; 1 1 6 : , 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 This section to be completed by office 1.1 Property Address: t Map Lot Unit A , Zone Overlay District (5CL'M Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: Name (Print) Curr t Mailing Address : at,.aehe� .s Telep one Signature 2.2 Authorized Agent: Nark Roofi n L LL„nest, &tali mpron, ,Ma. Name (Print) Current Mailing Address: 010 717 ( 521- 4/15 Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building Q oo }� a 0©, 0 �- (a) Building Permit Fee 2. Electrical !! �` l (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection � - L 6. Total = (1 + 2 + 3 + 4 + 5) $ ( -Loot:). , Check Number (>loi¥ 3 This Section For Official Use Only Building ermit Number: Date g Issued: Signature: Building Commissioner /Inspector of Buildings Date 111 SOUTH ST BP- 2012 -1031 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 38B - 023 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 -1031 Project # JS- 2012 - 001769 Est. Cost: $4200.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: RCI ROOFING Lot Size(sq. ft.): 11630.52 Owner: BUSI FREDERICK A & ESTA S Zoning: URC(100)/ Applicant: RCI ROOFING AT: 111 SOUTH ST Applicant Address: Phone: Insurance: 6 LINE ST (413) 527 -4775 SOUTHAMPTONMAO1073 ISSUED ON:5/22/2012 0:00:00 TO PERFORM THE FOLLOWING WORK: REPAIR 3 FLAT ROOF AREAS 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 5/22/2012 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner