32A-219 MAY -27 -2010 04:07 F+.rom:RCI Roofing 4135278469 To :5871272 Page : 2-'2
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R .C.I. Roofing
6 Line St.
Southampton, Ma_ 41073 Estirriate Date
Phone (413) 527 -4775 1115/2009
Fax (413) 527 -8469
Name / Address Job Location .___.__. J
Jerome Szawlowski Garage Only
56 Westwood Terr. 18 Hancock Street
Florence, Ma. 01062 Northampton, MA
584 -4668
.
Terms ! Rep
. L
Estimate valid for 20 clays , Rich
I Job Description Tot>31
Remove existing roofs. 2,500.00
Furnish & install 1/2" plywood ove existing decking.
Furnish & install aluminum drip ed e, pipe fleshings, chimney Fleshings and step
fleshings. I
Furnish & install new lead counter ashings. 1
Furnish & install CertainTeed Wint rguard ice & water barrier along eaves and
valleys.
Furnish and install 15 lb. felt.
Furnish and Install 30 year CertainTeed Woodscape Series shingle.
Furnish and install CertainTeed approved ridge vent.
All exterior roofing related debris to be removed by R.C.I. Roofing.
All work will be performed according to manufacturers' specifications.
5 -year R.C.I. Roofing workmanship warranty included.
30 year CertainTeed meter's) warranty included. t
All related permits will be obtained by R.C.T. Roofing. I
*NOTE* Work to be done: Spring 2010
THE OWNER HAS THE RGHT TO NM. THE
THREE BUSINESS DAYS DATE . F SIGNINGCONTRpCT WITHIN (3) Total $2,500.007
i
TERMS OF PAYMENT /
5% Deposit i -
Balance upon completion Customer Signatu - , i i; % .,, _ `",!, -. - Jr __ ' Y '-6-
Registration # 126235 '
Construction License # 074334 Date - 44 5 '° /0
Insured by Reynolds, Barnes & Hebb, Inc. 413 - 447 -7376
.1.-- NI,Iss,tchliscits - Nci),ir !merit 4 i'tillh, , ..,Itcts
k i... lilf,trd 4 R1111(111'2 R..',..:111,41wn, An d s..,.
C..:')I1StrUCtiUt SuO ',V;...■ ':.:^
License CS 74334
Restricted to: 00
,...
MARK T DELISLE
33 FIRST AVE
EASTHAMPTON, MA 01027
Expiiation. 5/3/2012
t ,11.114ssiom.e Tr#: 26357
. .. 4 7te ( MO frt.( 1 / eat" // CI 14 (1.1e16
• ' - 7: - Office 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
E.-:' ,. ? - Office of Investigations
ik
600 Washington Street
Boston, MA 02111
" � \‘ '" , i
.... • 4
r,s.. www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians /Plumbers
Applicant Information Please Print Lezibly
Name (13usiness /Oreanirzu __
ion /Individual): La Q
(\ Q 1 f\ \--R
J
Address: / — `n Q.. _ ,
Y—
City/State/Zip: � � �„ (V� o►o`[� Phone #: C ( � t-kii j
Are you an employer? Check the appropriate box: Type of project (required):
1 . 1 am a employer with 20 4. [] 1 am a general contractor and I
employees (gull and /or part - time).'
have hired the sub contractors 6. ❑ New construction
2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. [] Remodeling
ship and have no employees These sub - contractors have 8. [J Demolition
working, for me in any capacity. employees and have workers'
[No workers' comp. insurance comp. insurance.:
9. ❑ Building addition
required 5. ❑ We are a corporation and its 10,0 Electrical repairs or additions
3. ) I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
mysel t ' . [No workers' comp. right of exemption per MGL 12 Ealioof repairs
insurance, required.) t c. 152, §1(4), and we have no
employees. [No workers' 13.0 Other
_ comp. insurance required.]
*Any applicant that checks box #1 must also till out the section below showing their workers' compensation policy Information.
r Ifomeowners who submit this affidavit indicating they arc doing all work and then hire outside contractors must submit a new affidavit indicating such.
'Contractors that check this box must attached an additional sheet showing the name of the sub - contractors and state whether or not those entities have
employees. If the sub - contractors have employees, they must provide their workers' comp. policy number.
1 am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
in f nrmation.
insurance Company Name: a..e. Qx-OQt.r\--. it Cr,.S . n .
Policy 4 or Self-ins. Lic. 4:MAK. C Lk _5$ 0'i 3S t - Expiration Date: 1 0 - 5 - 2, Q I 0
Job Site Address: 1 C'ieLA(;c -g . s\-- C ity /State /Zip: .]„_M \.r , f1Ar 0 10(00
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
line up to S1,300.00 and /or one -year imprisonment, as well as civil penalties in the form ofa STOP WORK ORDER and a fine
of up to S25400 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.
/ do hereby ' rtifG' under the ins and penalties of perjury that the information provided above is true and correct.
Signature: _ Date: ,5- an I d
Phone #: LLIA 3 ,5".. " Ll`l.`1 S
Official u.,c only. Do not write in this area, to be completed by city or town official.
Ctt 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 __
Contact Person: Phone #:
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SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Appl' ble 0
Name of License Holder
NIZY l ei 33
License Number
5+ O , . • • • 5-03-10
Address Expiration Date
0413) 52?- x /75
Signature Telephone
9. Registered Home Improvement Contractor: Not Applicable 0
L.I 126235
Company Name • Registration Number
Ob -10
Aoareaa Expiration Date
• w . 01 • • • u - • • $ TelephonfO1 4/75
/5
SECTION 10 - WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6))
Workers Ccmoensation 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 No ❑
11. — Home Owner Exemption
The current exemption for "homeowners" was extended to include Owner- occupied Dwellinrts of one (1) or two(2) families
and to allow such homeowner to engage an individual for hire who docs not possess a license, provided that the owner sett
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
strictures. A p erson who constructs more than one home in a two -veer 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 Chaptcr 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to
En 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.
Th. 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 att.ao,ked •
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• • ••,36
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SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House F Addition ❑ Replacement Windows Alteration(s) ED Roofing
Or Doors El .
Accessory Bldg. ❑ Demolition n . New Signs [p] Decks ,[l=] Siding [p] Other [p]'
Brief Description of Proposed attar�h.e�
Work:
j 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
'
b. Number c' rooms in each family unit: Number of Bathrooms .
I c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
1
e. Number cr stories?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Ccnservation 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. floodpiain Yes No
. 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 A YS, l e, "0, r). ;.::y 0\ � c , as Owner of the subject
property
. Q
hereby authorize L. MAY M l AY 11 1 S, P oT r 1 , • c. I . R&
to act on my behalf, in all matters r ative to work authorized by this uilding permit application. 9 .
Att. 0hpd • te0
Sig'nttture of Owner Date
I, y . : II- - , e ' • . I , i , 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.
l Print Name
..___,4
S2,c - / 0
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 filkd in by
Building Department
__ ' -
ux8izc � i i| '- -----
__ ,
Ronta8o ' `, 1 ` 1 - -�-- \
Setbacks Front /
■ ^
. � `
r
Side L R: ' L` | K: . � � -J
Rear /'_ |
. ^
Bui\din8Bd&h � |--)
` i . '
B dg. Squar Footage | % [ ' i \ '
— - —
O -)enSpaeeFootage %
(L^x�um=�umumnm� � � . | . |
pa:king) .
: ' \
#,fPad�ngSpucc '— '
r-- ' - _
-- U � | - � -�
' � ! ! \
(°�"mo»4 _
A. Has a Special Permit/Variance/Finding ever been issued forion the sfte?
0 ��
NO 0 �� � DONT KNOW �_� YES x+~�
. ' � '
|F YES, date ieued: /
IF YES: Was the permit recorded at the Registry of Deeds
�� 0 YES 0
NO DONT �~/ ` �~� �~� | --- ---
IF YES: enter Book i Pug� > and/or Document #1
|
` ___'___ _
-__
�� 0
D. Does the site contain a brook, body of water orwetlands? NO �~ �� KNOW �~� � DONT KNO YES «��
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained �~� Obtained �~� Date Issued: |
�~� «�� ' 'L_____-_____(
C. �� �� Do any the property? YES �~/ NO «��
i '- - - ------------
IF YES, describe size, type and location: i (
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO 0
--- ---------'--------`--
IF YES, describe size, type and location: i
E. WiII the construction activity disturb ring, gradingexcavation, nr filling) over 1 acre nrish part nf common plan
that will disturb over 1 acre? YES 0 l N{} � l
�� ��
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
1 City of Northampton Slat o a �'
I Building Department .. Curb C ; i f
<, `j`l 212 Main Street R
� A , R J .. _ I��tir 4 4.1•‘7 . � .
Room 100 Wet -: ( ' . r
Northampton, MA 01060 TO? 4; ,.. ;,
phone 41 Fax 413 587 - 1272 plotld'ite I l~ " ;4 :ti4 ,-rr . T
,mss•., f
Other S • - 4-+iF4 s -.:,. , 1.,
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 .? I�c .r1Cs.x.Y S`r
Map ' Lot Unit
C, r - La_rh -Q t , Zone Overlay District
Elm St. District C8 District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Name (Print) Cu ent M Bin Address:
Te pho
Signature
2.2 Authorized Agent:
Maak - De le - F .C.I. oofi ' ,, _ -. • _ ..
Name (Print) Current Mailing . dress: O ■ 613
- .-- (113) 521- 4115
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Offidal Use Only
completed by permit applicant
1. Building 00 , Ft 4 2 500 , � (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5.-Fire Protect ion
6. Total =(1 +2 +3 +4 + $ o , 60 Check Number /600 2.'3s
This Section For Official Use Only
Date
Bgt Permit Number. Issued:
Signature:
i Building Commissioner/Inspector of Buildings Date
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1
:I BP- 2010 -1070
GIS #: COMMONWEALTH OF MASSACHUSETTS
'p :B1ock: 32A - 219 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- 2010 -1070
Project # JS- 2010- 001571
Est. Cost: $2500.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RCI ROOFING 126235
Lot Size(sq. ft.): 5270.76 Owner: SZAWLOWSKI JEROME J
Zoning: URC(100)/ Applicant: RCI ROOFING
AT: 18 HANCOCK ST
Applicant Address: Phone: Insurance:
6 LINE ST (413) 527 -4775 Workers Compensation
SOUTHAMPTONMA01073 ISSUED ON:5/26/2010 0:00:00
TO PERFORM THE FOLLOWING WORK: STRIP & SHINGLE GARAGE 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 5/26/2010 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo