25A-059 (2) R.C.I ROOFING
40 MAINE AVE.
P.O. BOX 309
EASTHAMPTON, MA 01027 -0309 ESTIMATE
PHONE (413)527- 4775
FAX (413)527 -8469
Date: 3 \1 \02
Estimate To:
MR MRS BOURKE Estimated By: MARK DELISLE
12 CROSBY ST Start Date:
NORTHAMPTON, MA 01060 Job Location: 17 HUBBARD ST
NORTHAMPTON, MA 01060
Job Phone: 413 297 0970
JOB DESCRIPTION
REMOVE FxTSTTNG SHTNGT,F,s.
FURNTSH & TNSTAr,T, A T UMTNUM DRTPEDGE ANn Ar,L OTHER RET,ATET) FT,ASHTNGS.
FTTRNTSH & TNSTAr,T, TCF, & WATER RARRTER ALONG EAVES.
FURNTSH & TNSTATj 75 #. FELT OVER EXTSTTN; DECK.
FURNTSH & TNSTAr,T, 30 YEAR T,AMKO SHTNC,T,E.
FURNTSH & INSTAr,r, CoRA RIflGE VENT.
ALT, ROOFTNG RET,ATF,n DFRRTS TO RE REMOVED BY RCT ROOFTNG.
AT,T, WORK WTT,T, PERFORMED AC,CORDTNG To MANUFACTURERS SPECTFTCATTONS.
5 YEAR R.C. T. WORKMANSHTP WARRANTY TNLCrJDED.
30 YR TAMKO MA TER TA T, WARRANTY TNCT,TJfED.
PERMTT INCLUDED.
SPECIAL ITEMS NEEDED
ADD TO CONTRACT AS /IF NEEDED,DECK REPLACEMENT $1.50 PER SQUARE FT.
Additional infonnation • ainin. to this Job Estimate
TERMS OF PAYMENT
30% PRIOR TO START Total Estimated
70% UPON COMPLETION Job Cost $2,640.00
REGISTRATION #126235
FEDERAL I.D. #04 3418839 Authorized
CONSTRUCTION LICENSE # 074334 Signature " l /
ORIGINAL - ESTIMATOR COPY
i
scotAMOP�D --
B 8 Gx ? II �aIIY� IIYT I — L.=
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..i's :_ —= DEPARTMENT OF BUILDITNG INSPECTIONS
' , 212 Main Street • Municipal Building
Northampton, Mass. 01060 ..• s'
WORKER'S COMPENSATION INSURANCE AF11J)AVIT
(licenste/permittee)
with a principal place of business/residence at:
yd mt3., 115 n.S.)t . s\ rap \CA i {a. O1021 (phone #)(g! �) 5' Z ) CIS
(street/city /states p)
do hereby certify, under the pains and penalties of perjury, that
(v)am an employer providing the following worker's compensation coverage for my
employees working on this job:
1.-,%\li �(Vtk e�ak k, c\ 3(S- 3it1t4•o�t /v-5 -OZ,
&ce Company) (Policy Number) (Expiration Date)
( ) I am a sole proprietor, general contractor or homeowner (circle one) and have hired
the contractors listed below who have the following worker's compensation policies:
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
4 r
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Comparry/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additional sbeci if necessary to include information pertaining to all coat:radors)
( ) 1 am a sole proprietor and have no one w orking for me.
( ) 1 am a home owner performing all the work myself.
NOTE: please be ague thud while bomeowsxn who employ pezzoas to do maintenance, construction or repair work on a dwelling of
not morn than throe units in wbids the homeowner resides or on the grounds appurtenant thereto arc not generally coosidacd to be
employer, under the worker's compensation Ad (GL152,ss 1(5)), application by a homeowner for a license oc permit may evidence the
lc ctatua of an employer under the Worker's Campomation Act
1 understand that a copy of this statement may bo forwarded to the Department of Ind.utrial Aozidents' Oflloo of Imur+nee for the
coverage vaificatioe and that failure to accuse covmtgo under section 25A of MOL 152 an lead to the imposition of Criminal penalties . .
oomisting of a fine of up to S1,500.00 mdfor insp isoament of up to one year and civil pcmaltia in the form of a Stop Work Order and a
find of 5100.00 a day against me.
For del ttae poly
Permit Number
m Lot #
Signature of Liacncer/Permitfcc Late
a
Y
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : VCA CI ,'C` ` 2 \ , , LA �� d1 '-1 33`4
License Number
'- (..: ._ .: - - -- - -•n .� . o 6Z -7 5 ' 3 -aZ
Address Expiration Date
�
U 3) 677 -(-1
Signature Te ephone
1431 Sgt i tt4.i el i` i i 111 ilt l to Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
C ® '1 O ! KERS ;COMPENSATION INSURANQE AFFIDAVITI (MSG L. c: 152, § 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affida
will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes ❑ No ❑
The current exemption for "homeowners" was extended to include Owner - occupied Dwellings of one (1) or two(2) familie
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(.
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
a 57�'4r7 a 5 r� z ,: w: 1 w5 4 77: 3qM.
Tyr^^ 7 a -, }_ . .—^— --,- 7717 ^^ ..... < .... ., .. .,:: , 7
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing V
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [) Siding [ ) Other [ ]
Brief Description of Proposed Work: I s -viio;;Tc 3 1' % es 0 r ,re r r ...e.
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative 0 Renovating unfinished basement Yes No
Plans Attached Roll 0 • Sheet 0
if N.e'""" lw h o '' i o. n i t on' t Igtin _?h in'_ • CO ° , _ a i ttellffih f l l i ;
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. Mascheck 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
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
ig�'ON � ® 5 ® Z ® :' <:1 9,p ,, PEED tWH,Ik
OA R �. te. ®" . C ®V 0 0#9 II
i , a...A ,c--ti ,,, :_).01/4.)._(-- �.:_... , as Owner of the subject proper
hereby authorize ( 'L • Cka0C ` \- • to act
my behalf, in all matters relative to work authorized b his building permit application.
Signature of Owner Date
1 O C12 F \* , S \ L. - . (&00ck , as. Owner /Authorized Agent
hereby declare that the statements and information on the foregoing applicat re true and accurate, to the best of my
knowledge and belief.
Signed under the pains and penalties of perjury.
Print . �
CJ
Signature of Owner /Agent Date
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE
DENIED DUE TO LACK OF 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 /Finding ever been issued for /on the site?
NO DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW YES
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW
YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained , Date Issued:
C. Do any signs exist on the property? YES NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ?YES _
No
IF YES, describe size, type and location:
^ 1
IV r1; ■ xFs
ity ,, f Northampton {��k�ft
g Departmentc�r�
ccn C� . uq 01060
,rION. , ,
�anR1N!` .s. 12 Main Street
Room 100
Northampton, MA 01060
phone 413.587 -1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SEC�7lON 1 SIT NFORfIIIAPIQN
S tO be � C 7cl Ce y4
1.1 Property Address: - ,u
--y asp • e • '� � ° '` � �
No `(V\ ra 41 bloC> �
SECTIOf)1 'f2 PROPERTY O /AUTHQ IZEDtAGENT
.,. ., .. .
2.1 Owner of Record:
/ ,2. t_'Fb S\,o S V • yUo &f rb n , MO,
Name (Print) Current Mailin Address:
(I )7-9,- 0
Telephone
Signature
2.2 Authorized Agent:
\ t ��� S\ . Q O y ak. 30c1 yx,x. ciaz7
Name Current Mailing Address:
u 1 s 7 - y 77S
Signature lephone
SEC1 L3�' E ffrl`IVIAttI*D ®NSA' ® ®' r ,�
Item Estimated Cost (Dollars) to be Official •Use Only
completed by permit applicant g.
1. Building (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) Check Number
Thts S,wecttbn Fir Official Use;.O,nly:
r
!IdgPermr �umle�
w �
•
Sgrtature� h
3.. Bu1f?gy °llerllape,tor >gf,l�8 >'', �,' ��e
to
5 '
IIHUBBARD AVE BP- 2002 -0761
Gls #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 25A - 059 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: roofing BUILDING PERMIT
Permit # BP- 2002 -0761
Project # JS-2002-1265
Est. Cost: $2640.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RCI ROOFING 126235
Lot Size(sq. ft.): 5227.20 Owner: BOURKE ANDREW
Zoning: URB Applicant: RCI ROOFING
AT: 17 HUBBARD AVE
Applicant Address: Phone: Insurance:
P O BOX 309 (413) 527 -4775 Workers
Compensation
EASTHAMPTONMA01027 - 0309 ISSUED ON:3/11/02 0:00:00
TO PERFORM THE FOLLOWING WORK: ST R I 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:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 3/11/02 0:00:00 2476 $25.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo