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24D-159 RC.I. Roofing Date 6 Line St. Estimate Southampton, Ma. 01073 3/5/2013 Phone (413) 527 -4775 Fax (413) 527 -8469 Name / Address Job Location NICKY D'S China Wok 164 Northampton Street 150 King St. Easthampton, MA 01027 Northampton, MA 01060 Terms Rep Due on receipt Chris Description Total Remove existing roofs. 7,200.00 Furnish and install 1" pressure treated wood nailer. Furnish and install 1" Isocyanurate insulation, mechanically fastened. Furnish and install .060 TPO roof system, mechanically fastened. Furnish and install .032 aluminum edge metal. Furnish and install all related flashings. All work to be performed according to manufacturers' specifications. All exterior roofmg related debris to be removed by R.C.I. Roofing. 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 $7,200.00 TERMS OF PAYMENT 5% Deposit Balance upon completion Customer Signature J 1 J Registration 4 126235 Construction License # 074334 Date Insured by Banas & Fickert Ins. (413) 527-2700 The Commonwealth of Massachusetts Department of Industrial Accidents vim. ( Office of Investigations = '' °e 600 Washington Street e. _� _ Boston, MA 02111 m www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers kpplicant Information Please Print Legibly \lame ( Business /Organization/Individual): R 0_, 9.„ d p ( ', ,nc� U....? kddress: C l-.:, e... 5\-- . J - 2ity /State /Zip:' L , - \ - \ - , 0 , , x , \ , 6 - o - \ 1 C \o . o 0 - 7 3 • Phone #: N /3) 5 .4`1 - 4 (15 .re you an employer? Check the • appropriate box: Type of project (required): ©'I am a employer with 2,0 4• ❑ I am a general contractor and I 6. ❑ New construction employees (full and/or part- time).* have hired the sub - contractors ❑ I am a sole proprietor or partner- listed ou the attached sheet. # n Remodeling ship and have no employees - These sub have 8. n Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. C We are a corporation and its • — required.] officers have exercised their 10. Electrical repairs or additions ❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4), and we have no 12. Rilloof repairs insurance required.] t employees. [No workers' 13. Other comp. insurance required.] ny applicant that checks box i11 must also fill out the section below showing their workers' compensation policy information: omeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. mtraetors that check this box must attached an additional sheet showing the name of the sub - contractors and their workers' comp. policy information. 'm an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site Formation. >urance Company Name: c , M rvL e - , licy # or Self -ins. Lie. #: L Ot 3y 0,5 Expiration Date: i 0 - 5 - 1 3 b Site Address: City /State /Zip: tach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). ilure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a to 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 up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of vestigations of the DIA for insurance coverage verification. to hereby certify under the pains and penalties of perjury that the information provided above is true and correct. gnature: . % -- ° Date: lone #: C�1?) N - 41 `t 5 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 #: Version1.7 Commercial Building Permit I\9ay 15, 2000 SECTION 10- STRUCTURAL PEER REVIEW (780 CMR 110.11) Independent Structural Engineering Structural Peer Review Required Yes O No O SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT l Aj) ' (V `T) LAC , as Owner of the subject property hereby authorize g.000t`t A LU U to act on my behalf, in all matters relative to work authorized by this building permit application. r. `� �,_.. CSA— I• CLcti \v 3-- ' - / Signature of Owner D a1e I O' c \• V■ S\ •.. - S C' . 11CJ(y ∎ c\ C: t--A-A) _ , as Owner /AulhoriZe_d__._ AgeuL,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 p hies of perjury. Print Name 3 -1 -13 Signature of Owner /Agenl Dale SECTION 12 - CONSTRUCTION SERVICES 10.1 Licensed Construction Sup ervisor: Not Applicable O Name of License Holder: f \7'e•-\ \:C - C.. - 3.._ ZG1> '∎ cc L_ f 1 L \22 3 L (� \ License Number 33 ` - _S 9_, C_ - C_�\-'YS ,c.,v O -C7 Cl , C(, .., C.•,■ tJ 2 .5 - 3 - 1 4 _ • Addr __ ' L _ Expiration Dale C i''___ Q*113) ,5"Z1- Lk 5 Signature Telephone SECTION 13 - 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 0 Versiui 1.7 Commercial Building Permit May 15, 2OO(1 SECTION 9- PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES - FOR BUILDINGS AND STRUCTURES SUBJECT TO CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116 (CONTAINING MORE THAN 35,000 C.F. OF ENCLOSED SPACE) 9.1 Registered Architect: Not Applicable ❑ Name (Registrant): Registration Number Address Expiration Dale Signature Telephone 9.2 Registered Professional Engineer(s): Name Area of Responsibility Address Registration Number Signature Telephone Expiration Dale Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Dale Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date 9.3 General Contractor Not Applicable ❑ Company Name: Responsible In Charge of Construction • Address Signature Telephone • Version1.7 Commercial Building Permit May 15, 2001) S. NORTHAMPTON ZONING Existing Proposed Required by Zoning This enlunui lu he filled in b Building I)cpartmem Lot Size Frontage Setbacks front Side L: R: I-.: R: Rear Building Height 131dg. Square Footage Open Space Footage (LA uea minus bldg l paved parking) i� of Parking Spaces (volume ,i l,.unlion) — 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 O DON'T KNOW O YES O IF YES: enter Book Page and /or Document N B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW 0 YES 0 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 0 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 (9 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 0 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. Version 1.7 Commercial 13uilding Permit May 15, 200(1 SECTION 4- CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 CUBIC FEET OF ENCLOSED SPACE Interior Alterations ❑ Existing Wall Signs ❑ Demolition ❑ Repairs ❑ Additions ❑ Accessory Building ❑ Exterior Alteration ❑ Existing Ground Sign ❑ New Signs ❑ Roofing Er Change of Use El Other ❑ Brief Description Enter a brief description here. 01 Proposed Work: 9 (- SECTION 5 - USE GROUP AND CONSTRUCTION TYPE USE GROUP (Check as applicable) CONSTRUCTION TYPE A Assembly ❑ A ❑ A -2 ❑ A -3 MI,.,... A-4 ❑ A -5 ❑ ■ B Business El _ —2A L E Educational ❑ B — 1L I F Factory ❑ F-1 ❑ F -2 ❑ ,J r'e H High Hazard ❑ — L) 1 Institutional ❑ 1-1 ❑ 1 -2 ❑ ■ -- M Mercantile ❑ _ R Residential ❑ R -1 ❑ R -2 ❑ ■ S Storage ❑ S -1 ❑ S -2 ❑ r U Utility ❑ Specify: — M Mixed Use ❑ Specify: S Special Use ❑ Specify: _ COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND /OR CHANGE IN USE Existing Use Group: Proposed Use Group: Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34): SECTION 6 BUILDING HEIGHT AND AREA BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY Floor Area per Floor (sf) 1 s' 1 st nd 2nd 2 d 3 rd 3 4 in 4 • u, Total Area (sf) Total Proposed New Construction (sf) Total Height (fl) Total Height ft 7. Water Supply (M.G.L. c. 40, § 54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System: Public ❑ Private ❑ Zone r .1.1 Itte-disposaLsysten34ji r ''�f "' Version1.7 Commercial Building Permit May 15, 2000 I e� Department useonly kh ki \ 12 City of Northampton Status of=Perrrfit:' �' \o NS Building Department CurbCutJDrivev✓ay Perrnit /c � 212 Main Street Sewer /Septic - Availability o /p 5� FZ�N a�pN Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans phone 413 587 - 1240 Fax 413 - 587 - 1272 Plot/Site Plans Other Specify, APPLICATION TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION 1.1 Property Address: This section to be completed by office ' 5o Kil S ‘-' Map Lot Unit 0.,..e r,,` ; k A Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: � Name (Print)N CV, CV, •b '7t f r Current Mailing Address: kL� irk ,w" 7�t■ '\''' tt E--i--S i V_t1.iw \r-0 " t AAA_ o l O Z l Signature 5 t, cii∎-• ctc\ke ` a Telephone ` Lj ( ..,5 -5�o/ 2.2 Authorized Agent: \ '` C-; t.\ ■ 51 -c, - (kC Ropri ) 1..�..P Co l, . �rc __ 5V' •_`_�c,� .,\city \9\- 011,rock, 01073 Name (Print) Current Mailing Address: Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only • completed by permit applicant 1. ZuiIdiag (1 1 7- 0 00 (a) Building Permit Fee 2. Electrical �J (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 Z O O w 00 Check Number _eS5 — This Section For Official Use Only Building Permit Number Date Issued Signature: Building Commissioner /Inspector of Buildings Date File # BP- 2013 -0813 APPLICANT /CONTACT PERSON RCI ROOFING ADDRESS/PHONE 6 LINE ST SOUTHAMPTON (413) 527 -4775 PROPERTY LOCATION 150 KING ST MAP 24D PARCEL 159 001 ZONE HB(62)/URC(38)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out 6 9/5 0,SS Fee Paid Typeof Construction: NEW ROOF New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 74334 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF ATION PRESENTED: Approved Additional permits required (see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project: Site Plan AND /OR Special Permit With Site Plan Major Project: Site Plan AND /OR Special Permit With Site Plan ZONING BOARD PERMIT REQUIRED UNDER: § Finding Special Permit Variance* Received & Recorded at Registry of Deeds Proof Enclosed Other Permits Required: Curb Cut from DPW Water Availability Sewer Availability Septic Approval Board of Health Well Water Potability Board of Health Permit from Conservation Commission Permit from CB Architecture Committee Permit from Elm Street Commission _ Permit DPW Storm Water Management AO i • • .'on Dela # _...-_...# • . ,5 - V7 - 7,5 re of Buil in: /it ffici. Date Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning requirements and obtain all required permits from Board of Health, Conservation Commission, Department of public works and other applicable permit granting authorities. * Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of Planning & Development for more information. 150 KING ST BP- 2013 -0813 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 24D - 159 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 -0813 Project # JS- 2013- 001393 Est. Cost: $7200.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: RCI ROOFING 74334 Lot Size(sq. ft): 9365.40 Owner: DUPREY NICHOLAS D & BETTY L Zoning: HB(62)/URC(38)/ Applicant: RCI ROOFING AT: 150 KING ST Applicant Address: Phone: Insurance: 6 LINE ST (413) 527 -4775 Workers Compensation SOUTHAMPTONMA01073 ISSUED ON:3/12/2013 0:00:00 TO PERFORM THE FOLLOWING WORK: NEW 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 3/12/2013 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner