29-477 (3) R.C.1 ROOFING
40 MAINE AVE.
P.O. BOX 309 -
EASTHAMPTON, MA 01027-0309 ESTIMATE
PHONE (413)527- 4775
FAX (413)527-8469
Date: SEPTEMBER 26, 2002
Estimate To:
MIKE BRIN Estimated B : CHRIS THOMPSON
601 BURTS PIT RD. Start Date:
FLORENCE, MA. 01062 Job Location: 601 BURTS PIT RD.
FLORENCE, MA. 01062
Job Phone: (413)585-8753
JOB DESCRIPTION
REMOVE EXISTING ROOFS.
FURNISH & INSTALL 30 YEAR TAMKQ -17HINGLF,.
ALL ROOFING RELATRn QRRRT-'7 TO RR REMOVED BY RCT R00FTnr-
5 YEAR R.C.T. WORKMANSHIP WARRANTY TNCTMED,
30 YEAR TAMK0 MATERIAL WARRANTY 1MrTrff)FQ.
ALL RELATED PERMITS WTrT, FIR OBTAINED RY R.C.T. ROOFING,
SPECIAL ITEMS NEEDED
ADD $2.00 PER S . FT. FOR WOOD REPLACEMENT IF NEEDED.
Additional information pertaining to this Job Estimate
TERMS OF PAYMENT
30%PRIOR TO START Total Estlmated
70%UPON COMPLETION Job Cost $3,570.00
REGISTRATION#126235
FEDERAL I.D.#04 3418839 Authorized �^
CONSTRUCTION LICENSE#074334 Signature
INSURED BY HACKWORTH INSURANCE(413)527-9907
ORIGINAL-ESTIMATOR COPY
9 fl QxtR 1rf 'Warf4aill flan
6 �;sa+tcgttsctta'
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
with a principal place of business/residence at:
1
L10 YY)a%'mti QVE_ h Yylu O)oL�phone#) Zll3 -SZ7-�(77S
(streWcity/staldrip)
do hereby certify, under the pains and penalties of perjury, that:
am an employer providing the following worker's compensation coverage for my
employees working on this job:
r u,L-�_� '�CZ-315•�IllZy•011 �O - 5'O�
Company) (Polity Number) (Expiration Date)
O I am a sole proprietor, general contractor or homeowner (circle one) and have hued
the contractors listed below who have the following worker's compensation policies:
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (F-xpi.ration Dale)
(Name of Contractor) (Insurance Company/Policy Number) (Bx-piration Date)
(attach addition!sheet Tncceuary to include information pertaining to.11 ooatrn )
O I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE:please be aware that white bomeowa=who employ persona to do m& •1•,,•,,cr,cons:, t oa or repair work on a dwW108 of
not more than throe units is which the bomoowner rexidc3 cc on the grounds appurtenant tb=w an not gcow4y cons;d«cd to be
cmployaa under the work-e-ooagxa Won Act(GL152,ss 1(S)),applicatioa by a homcow=for a licca=a permit may evidence tho
legal status of an employer under the Wockoes Compensation Act.
I uadastand that a copy of thin sibtcmcot may be forwarded to the Dcpartmm2 of T—h, ial Aaidm Oflioo of lasuranw for the
ooveraao wrificatioa nad that failure to secure covaago treader soetioa 25A of MGL 152 as lead to the'imposition of criminal penalties
g of a fine of up to S 1,500.!00 and/or imp<isaamo of up to one ysar and civil pcaaltia is the form of a Stop W ads Order and a
line 0175100.00 a day against M
ga. al uao caly
permit Number
��
Signahsr�e of LiccnseeJPermittx
y... :
.. .�
or
��EC m �'�1,O,N SERVICES'
8 1 Licensed-Construction Supervisor: Not Applicable ❑
Name of License Holder: ` '' ox-y1 �L1 k SA�_ 01 ( ` 3-3 LA
License Number
Address Expiration Date
y �S.7,-J - 14-x-7
Signature Telephone
Not Applicable ❑
35
Company-Nam Registration Number
_11- _,C5 - � - �y
Address Expiration Date
f— GLV F. t VIZYl Telephoned/1-. -�4
S MPENSATION R.I..RANC,EwAFFID,AVIT.(M G.L. c 152,§25,(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...... ❑
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-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 Surervisor 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
SE YadDlIf i
P av�u!t!0!R1fRlf!14X -
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other[ )
Brief Description of Proposed Work: -
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
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 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
SECTION7aOWNER�AU11O IZ' TIONT�OnBECOMPLETED' WHEN
OWN RSgACENT O C F�C7 R�PI?LIESfI~QR`8. ('DI,, PERMIT
Y'\ , as Owner of the subject property
hereby authorize MO..� -I- (Z100 F YI\A to act on
my behalf, in all matters relative to work authorized by this building.permit application.
/0 07,
Signature of Owner Date
I, MG-10L tsl '� �„� 9\rr�� r\ , as Gwmr/Authorized Agent
hereby declare that the statements and information on the foregoing ap i tion are true and accurate, to the-best of my
knowledge and belief.
Signed under the pains and penalties of perjury.
'tom (3-c- Z o o ►�
Print Name
Signature of 4wker/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:
City of Northampton
ILI
Building Department
212 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
SECTION l-SITE IN.. MA
�TION:
1.1 Property Address: �'
o. 0 D
YEIm St 1 D'i' Dt.
SECTION 2-PROPERTYiOWNERSk IP/AUTHORIZED-AGENT °
2.1 Owner of Record:
Name(Print) —,� Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
- gnk 309 h "016v
Name(Print) .Qurrerit Mailing Address:
Signature Te phone
SECTION 3 ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use'Only
completed by ermit applicant
1. Building (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from-i 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total =0 + 2 + 3 + 4 + 5)T 70 Check Number
This Section For Official Use;Onl
Building Permit Number:< Date Issued:
Ik
Signature:,
Building Co"rrimissionerllnspector of Buildings Date':_
41116
LUIS PIT RD, BP-2003-0423
GIs#: COMMONWEALTH OF MASSACHUSETTS
: 10 477 CITY OF NORTHAMPTON
`Lot: - W.
PermifR" Building
Category: BUILDING PERMIT
Permit# BP-2003.0423
Project# JS-2003-0721
Est. Cost: $3570.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RCI ROOFING 126235
Lot Size(sg.ft.): 79714.80 Owner: BRIM MICHAEL F
Zoning: SR Applicant: RCI ROOFING
AT: 601 BURTS PIT RD
Applicant Address: Phone: Insurance:
P O BOX 309 (413) 527-4775 Workers
Compensation
EASTHAMPTONMA01027-0309 ISSUED ON:10125102 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP & S H I N G L E 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 10/25/02 0:00:00 3121 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo