25C-233 C • . Roofing
6 Line St. Est' mate Date
Southampton, Ma. 01073 9/27/2012
Phone (413) 527 -4775
Fax (413) 527 - 8469
Name / Address Job Location
Ian Milsark 167 -169 Bridge St.
PO Box 592 Northampton, Ma. 01060
Northampton, Ma. 01061 (413) 374 -4616
Terms Rep
Estimate valid for 30 days Dave
Description Total
Remove existing roof. 6,900.00
Furnish and install 1/2" fiberboard insulation, mechanically fastened.
Furnish and install .060 reinforced rubber roof system.
Furnish and install all related flashings.
Furnish and install .032 aluminum drip edge.
All exterior roofing related debris to be removed by R.C.I. Roofing.
All work to be performed according to manufacturers' specifications.
5 year R.C.I. workmanship warranty included.
All related permits will be obtained by R.C.I. Roofing.
WE LOOK FORWARD TO DOING BUSINESS WITH YOU.
Total $6,900.00
TERMS OF PAYMENT > /
5% Deposit
Balance upon completion Customer Signature G(s
Registration # 126235
Construction License # 074334
Insured by Banas & Fickert lns. Date
(413) 527-2700
The Commonwealth of Massachusetts
a �
— *_;,, Department of Industrial Accidents
I
Office of Investigations
/1°
_... ,. 600 Washington Street
C = ' Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plunnbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual): R (� `� bO �-'',
Address:
City /State /Zip: ,��a�,��,,,,��, c� �0 , o•7 3 • Phone #: ( "115
Are you an employer? Check the appropriate box: Type of project (required):
1. D I am a employer with Z U 4. ❑ I am a general contractor and I
6. E New construction
employees (full and/or part - time).* have hired the sub -con tractors
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. ❑ Demolition
working for me in any capacity. — workers' comp. insurance. 9. ❑ Building addition
[No workers' comp. insurance 5. We are a corporation and its
requ ired.] officers have exercised their 10._ Electrical repairs or additions
3. I am a homeowner doing all work right of exemption per MGL 11._ Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4), and we have no 12. Roof repairs
insurance required.] t employees. [No workers' 13, Other
comp. insurance required.]
'Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information:
r Homeowners who 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 box must attached an additional sheet showing the name of the sub - contractors and their workers' comp. policy information.
r am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: ,> c , <, ,,_i•-�,.an C` R ,
Policy # or Self -ins. Lie. #: V.) . O(e'i3 <I 05 Expiration Date: 10 • 5 _ 2,
Job Site Address: /0 - IV/ City /State /Zip:
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 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 information provided above is true and correct
Signature: Date: / 0 - 2/-/Z_
Phone #: ( �1 � S" "41
Official use only. Do not write in this area, to be completed by city or town official.
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
Contact Person: Phone #:
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : M ZY I °DPI ( S e, (77 3 3
C M lo License Number I�
51 Hoe. j St.++ .` Easthm f tort Ma, nar/ 5- a3 Address
�J Expiration Date
Signature Telephone
9.. Registered Horne ,improvernent Contractor.:; Not Applicable ❑
Q.L.I. 11 9 of;n 1 235
Company Name Registration Number
5 1 i3 Kolyake Street - P. 0. Box 309
Address Expiration Date
Eastbarn pto n Ma . rO 1 o f? TelephonEen 3)5.27-'7' �1 775
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 No ❑
1 1. — Rome 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 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 attan ' d
•
•
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
•
New House E Addition E Replacement Windows Alteration(s) C Roofing
Or Doors ❑
Accessory Bldg. Demolition — New Signs [E] Decks [E] Siding [E) Other [p)
Brief Description of Proposed ��
Work: '. t ,"Li L_ A ∎a,
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 foll.owing'
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
CLAN ` n s S ( a r \\ , as Owner of the subject
property
hereby authorize 3Y Eli Si e Q T ?• e. I I . Roofi'n9
to act on my behalf, in all matters relative to work authorized by th uilding permit application.
t,t aehe.d to -zci-tz
Signature of Owner Date
May 1ay El i 5' `P. a S aU L 1 JQY1 x ao °[.h l , 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.
MaYk I
Print Name
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
Lot Size i ` 4 1 I I
Frontage I ' I 1 I
Setbacks Front 1 i
Side L:` ' R: I L: I R:1 I ' I
E i
Rear l t
Building Height # # i t
Bldg. Square Footage i I % I F
Open Space Footage
(Lot area minus bldg & paved I ' I I
parking)
# of Parking Spaces '
I
Fill: ! l l
((volume & Lpcation) ?
3
i
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:j
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW t YES 0
IF YES: enter Book i Page I and /or Document #I
B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW 0 YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location: , 1
D. Are there any proposed changes to or additions of signs intended for the property ? YES l NO l
IF YES, describe size, type and location: i j
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 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
A
^� 4 Department use only
City of Northampton Status of Permit:
Building Department Curb Cut /Driveway Permit
• ' 2012 212 Main Street Sewer /Septic Availability
Room 100 Water/Well Availability
orthampton, MA 01060 Two Sets of Structural Plans
DEPT. NORTHAMPTONIMAO`TIONS p
3- 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 , I q) rtc f_ S Map Lot Unit
Zone _ Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
foes cc, ? y _ > x 5 c i l _ IlseA1.,, k , NVa . O cab
Name (Print) Cul Maihn Address:
attaChe hone y "`+`Q��►
Tele hone
Signature
2.2 Authorized Agent:
Name ( Print) 9 Current Mailing Address: 010:13_
1 0_. .+
�
-�-- (4 13) 521 - 47 ?5
Signature Telephone
SECTION 3.• ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building f ,00fi n J G+ f 4 9 0 Cy (a) Building Permit Fee
2. Electrical J l (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) $ ( 900. n C: Check Number 0209Y( 6:55
This Section For Official Use Only
Date
Building Permit Number: Issued:
•
Signature:
Building Commissioner /Inspector of Buildings Date
169 BRIDGE ST BP- 2013 -0518
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 25C - 233 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- 2013 -0518
Project # JS- 2013- 000831
Est. Cost: $6900.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: _ RCI ROOFING 74334
Lot Size(sq. ft.): 19906.92 Owner: GOLOB BERNARD M C/O M H & B LLC
Zoning: URC(52) /SC(48)/ Applicant: RCI ROOFING
AT: 169 BRIDGE ST
Applicant Address: Phone: Insurance:
6 LINE ST (413) 527 -4775 Workers Compensation
SOUTHAMPTONMA01073 ISSUED ON:11/2/2012 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL SINGLE PLY ROOF SYS
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 11/2/2012 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner