30A-003 6 Line St. Estimate Lou Date
Southampton,Ma.01073 5/7/2013
Phone(413)527-4775
Fax(413)527-8469
Name/Address ._._ Job Location
Amanda Anderson 280 Florence Rd.
280 Florence Rd. Northampton, MA 01060
Northampton, MA 01060 (413) 320-8300
Terms Rep
Estimate valid for 30 days Chris
Description Total
Remove existing roofs. 7,500.00
Furnish&install aluminum drip edge,pipe flashings,chimney flashings and step flashings.
Furnish&install CertainTeed Winterguard ice&water barrier along eaves and valleys.
Furnish and install synthetic underlayment over existing deck.
Furnish and install Lifetime CertainTeed Landscape 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.
Lifetime CertainTeed material warranty included.
All related permits will be obtained by R.C.I.Roofing.
Add$2,50 per sq.ft,for wood decking replacement if needed.
A Certainteed Surestart plus warranty will be included with a fee of$500.00 absorbed by RCI
Roofing if signed within 7 days.This extended warranty means that 25 years of the Lifetime
warranty is covered for labor and materials. The remaining years of the Certainteed warranty
would be covered for material only.
WE LOOK FORWARD TO DOING BUSINESS WITH YOU.
Total $7,500.00
TERMS OF PAYMENT
5%Deposit
Signature n ,
Balance upon completion Customer Si g '
Registration it 126235 r
Construction License 1l 074334 J 102 Lf !?f
Insured by Balms&Fickert Ins. Date
(413)527-2700
CD b n r vTl f- .� e v) n 01
The Commonwealth of Massachusetts
Department of Industrial Accidents
_A►, Office of Investigations
°�� 600 Washington Street
4 Boston, MA 02111
`terIle' www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
.pplicant Information Please Print Legibly
Tame (Business/Organization/Individual): R Q...,-L- Q.,qg,c', , ■o L,L.C'
iddress:_ Lo L.j •e.. .
;ity/State/:Zip:a,,,&- \ikt, t(moo., o f 0-7 5 • Phone #: (y 13) 52,1 -Y1'15 .
re you an employer? Check the appropriate box: Type of project (required):
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 on the attached sheet. t 7, E Remodeling
ship and have no employees - These sub-contractors have 8. ❑ Demolition
working for me in any capacity. — workers' comp. insurance, 9, E] Building addition
[No workers' comp. insurance 5. _ 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.❑ 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'
comp, insurance required.] 13.❑ Other
comp,
applicant that checks box//l must also fill out the section below showing their workers'compensation policy information:
Jmeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
ntractors 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
brma!ion.
urance Company Name: 5 , cc- �`,r\.,.,._(-0_,_\L r_: ,
licy# or Self-ins. Lie, #: (DlA?)<( O 5 Expiration Date: 10 • .5 . 1 3
3 Site Address: 2.`V 4 c‘Oc-ehLt, ?,a . City/State/Zip:A)ctr ,o.ry of
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
.e 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,
is hereby certify under the pains and penalties of perjury that the information provided above is true and correct:
�-2--
mature: /� " Date: Z8 1.3
tone#: -t-(1_ 52,-1'x(`1 `( 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 T
Contact Person: Phone #:
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑ •
Name of License Holder: ark 1 (�, 1 7)4 334
License Number
51B HOIT4;e,Ho1uoe. St.- 2astk �i . • s U . . • .. 5 - 03 -1_
Address Expiration Date
(4 13) 527. 1}7?5
Signature Telephone
99.Registered Home Improvement Contractor: Not Applicable ❑
Ji. . I. /RaOfin9 .26235
Company Name 1 Registration Number
.18 NoIyoke Street - P. D. $ox 30cf 571 b 1.y
Address r1 Expiration Date
.E st i mpron/ Ma. oioe2 ( Telephon€0i3 5Z7• 77~
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152, §25C(6)) 1
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 'g No ❑
11.. - 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,at ovided 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(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 tt.ad
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House E Addition [] Replacement Windows Alteration(s) E Roofing Y
Or Doors it
Accessory Bldg. E Demolition New Signs [0] Decks [C7 Siding [El Other(oj
Brief Description of Proposed a tacbed
Work: (.L
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 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. _`nl.�M c.t1__ _ CL, 1—S , as Owner of the subject
property Mar hereby authorize t 1'tar 1JL°,`;j ,[�Roo 1 1 n
to act on my behalf, in all matters relative to work authorized by this uilding permit application.
',attaielleZ1 )3
Signature of Owner Date
I, J' ZY 1 TI L S,e -as au L 1'1)Y•t xe4 a w!, ,as Owner/Authorized
Agent hereby declare that the statements and information on the foregoing Rjolication are true and accurate, to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
•
Print Name / p
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 1 1 ' f
Frontage ;
Setbacks Front F
Side L:I R: L: R:1 ' 1
Rear
Building Height
e
Bldg. Square Footage % i
i
Open Spade Footage
(Lot area minus bldg&paved 1
parking)
#of Parking Spaces
Fill: 1'
(volume&Lpcation) '
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 0 YES 0
IF YES: enter Book Page; and/or Document #i
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 0 Obtained 0 , 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 0 NO t
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 01 NO 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Rcf� N 1 department use only
City •of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
212 Main Street `Sewer/Septic Availability
y?EC1■ct4s Room 100 Water/Well Availability
5\j;_001..,\ 0°6°MA orthampton, MA 01060 Two Sets of Structural Plans
NoRSN • phone 413-587-1240 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 _1
1.1 Property Address: QQ This section to be completed by office
?.10 O -eirN ,j, Cl(� Map_ Lot
Unit..
jUoCk\r\cialf4(--t Zone
Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: \r-.
15 fj(- . • S• 5 A ikA .U 12._.1
Name(Print) Current Mailin•, ,• ress:
_a tta eked Q-10) 20 330C Telephone
Signature
2.2 Authorized Agent:
113 - t�.C. - w - • _. .r . . g L
Name(Print) Current Mailing Address: 01013_
('II 3) 521- 4?75
Signature Telephone
SECTION 3 -ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
com.letecl by permit applicant
1. Building Roof..�n, 4 (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) '—1 5 w. G() Check Number i 9z64 *35
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
280 FLORENCE RD BP-2013-1161
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 30A-003 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-2013-1161
Project# JS-2013-001904
Est. Cost: $7500.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RCI ROOFING 74334
Lot Size(sq. ft.): 2461 1.40 Owner: ANDERSON AMANDA
Zoning:URA(100)/WSP(100)/ Applicant: RCI ROOFING
AT: 280 FLORENCE RD
Applicant Address: Phone: Insurance:
6 LINE ST (413) 527-4775 Workers Compensation
SOUTHAMPTONMA01073 ISSUED ON:6/5/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:STRI 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:
FeeType: Date Paid: Amount:
Building 6/5/2013 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner