32C-225 (2) R.C.I ROOFING
40 MAINE AVENUE
P.O. Box 309 FCESI MA TE
EASTHAMPTON, MA 01027-0309
PHONE (413) 527- 4775
FAX (413) 527-8469
Date: JUNE 30, 2003
Estimate To:
LARRY WEST Estimated By: MARK DELISLE
95 MAIN ROAD Start Date:
H!. YDENVILLE, MA 01_1035 Job Location: FLAT ROOF SECTION ONLY @
75 HAWLEY STREET
NORTHAMPTON, MA
Job Phone: (413) 268-3315
JOB DESCRIPTION
F'URNTSH AND TA1,'3TAfF, Mnl)TFTED BITUMEN ROOF SYSTEM OVER EXTSTIIVG ROOF,
AND INSTATT
r
S TO BE REMOVED BY R.C.I. RCOFING.
r T v F
SHTP WARRANTY INCLUDED,
:1 RTAT_Pr) aFl_M r'P,,7 W7-f7 Rr ORTA IN .D BY R C.
SPECIAL ITEMS NEEDED
dditional information pertaining to this Job Estimate
TERMS OF PAYMENT
30% UPON DELIVERY OF MATERIALS Total Estimated
70% UPON COMPLETION Job Cost $2,400.00
REGISTRATION#126235
FED.ID#04 3418839 Authorized
CONSTRUCTION LICENCE#074334 Signature
NSURED BY HACKWORTH INSURANCE(413)527-9907
DUPLICATE-CLIENT COPY
ttP2
=04�'Oy
#(jamptoIl
9 d �asaacflnsctta
m DEPARTMENT OF BUILDrNG INSPECTIONS
212 Main Street 2 Municipal Building '
Northampton, Mass. 01060
WORI{ER'S COMTENSATION INSURANCE AFFIDAVIT
SN
(1i0CnSec/permittee)
with a principal place of business/residence at:
L10 'AA.0-( k 0.Q V N'\Aa, Io? 7 (P11000)V1"3 -7 IS
(street/ci ty/skate/ri P)
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:
(Ins-uran Conl"q_ny) (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 Contactor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Compauy/Policy Number) (Expiration Date)
(Name of Contractor) (Insumace Compauy/PoLcy Number) (E.\-pirabon Date)
(Name of Contractor) (Innsurance Cowpany/Policy Number) (Expiration Date)
(atlaclr additicnil s!kct if nc�:ru;�to L'zd tic iafonrutioa pertaiaing to all cccr:racton)
( ) I am a sole proprietor and have no one working for Ine.
( ) I am a home owner performing all the work myself.
NOTE:please be aware that wtrilo homco«ucra 1�bo crn}play pczocu w ci)=intcnxr c com rucLiai or repair work on a d%%tlling of
not meet than throo units is 1ci id1 the resides or cc the vourxis apmtzr=a tharto arc not r,•cnerally oonriclatd to be
cmploym under the wort u's ccrnpc«.tioo Act(GL152-a 1(5)),application by a 110mco%Nwx for a license cc permit may cvidc=the
legal ctatua of am ozr ployx uo or tfu W«<o<<CompOnxtion Ad
I unde:sund this a copy of this rzatancrt ar,y bo fouwnrdoci to tiro Dcpartnxcxi oFindtirstrinl Arx-ilasrf Offioo of Itr�u�n�for tho
coverage va-if catioa and ttut failure to accttre covtrnbo urxicr section 25A of hiGL 152 can icad to tbd imposition of criminal penalties
ooaustxn of a rme'of up to S 1,500.00`WOc unprisoamcat of up to one year and civil penalties in the foam of a Stop Work OrdG and a
fino of 5100.00&.&y against tnc.
For dcp-ta—If 1120 caly
permit Ntunber
MaPlf hot#
y Sigzlature of Lioczse&permittce e
SECTION 8 kPO`NSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
L(L (V'KO .tip J ' ,
Address Expiration Date
Signature 1 / Telephone
r �f
rwmnvr 3 ry nun se-�<.�ew� s�'"59�*"� ',�'rFJ � E u r� w 5
Ree"i's e,e ' ' Me.imBrovement,Contractor ,,I t" � " w � f Not Applicable ❑
.5
Registration Company Name Registration Number
Address
Expiration Date
�0 AkzL v
Q., "�x Telephone Clt.3 SZ7 Z(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....... Q, No...... ❑
- � ,o1ne�0,wne> .Exem.pfi
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 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
SE071014; DES�R�IPTION OF PROPOSED WORKlcheck,aIVappIicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding [ ] Other [ ]
Brief Description of Proposed Work: rlrl
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
s hf New ho""""es afid on'tddition to'existing=tiousing,:'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. 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 .
1. Septic Tank City Sewer Private well City water Supply
SECTION 7a OWNER,AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS'AGENT""ORACONTRACTOR APPLIES FOR BUILDING PERMIT
I, W e as Owner of the subject property
hereby authorize V"twL 'De lis)-e, _ OT DD 1 nQ to act or
my behalf, in all matters relative to work authorized by this building perrnit applic on.
Signature of Owner Date
I, "N\, as Owner/Authorized Agent
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 penalties of perjury.
�
Print N le f
Signature of Owner/Agent Date
a
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:
•
f Northampton 5 o
I ing Department e
2 Main Street
oom
AUG 1 1 2003 R 100 e
e ..
N rtha pton, MA 01060
DEPT OF BUILD -587.1240 Fax 413.587.1272
NORTNAm?TON,MA 01060
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION.1 SITE JNFORMATION
1.1 Property Address: aThis section to'pbecomplet d1kio" �c �s
Y ;T� , `
Lot t-
ki
Elm St.'Distnct' CB District
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
" '\� q_ 5 Xi n 'Rd - .Nau&nyi&
Name(Printy Current Mailing Address:
ab4 - 3315
Telephone
Signature
2.2 Authorized Agent:
1 QX
Name(Print) Current Mailing Address:
Signature Telephone
SECT ION3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars) to be Official Use Only
completed by ermit applicant
1. Building QOa('�n oo,00 (a) Building Permit Fee
2. Electrical 11�� 11 (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) a 400 ,(D Check Number
.This Section For Official Use Only
Building Permit Number: Date Issued:
S,ignat
pre:
'
Building'Commissioner/Inspector of Buildings Date
7 BP-2004-0159
G1S#: COMMONWEALTH OF MASSACHUSETTS
R•? - CITY OF NORTHAMPTON
Lot:-001
Permit: Buildina
Category: BUILDING PERMIT
Permit# BP-2004-0159
Project# JS-2004-0238
Est.Cost: $2400.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: RCI ROOFING 126235
Lot Size(sq.ft.): 7797.24 Owner: WEST LAWRENCE E&LINDA A&
Zoning:URC Applicant: RCI ROOFING
AT. 75 HAWLEY ST
Applicant Address: Phone: Insurance:
P 0 BOX 309 (413) 527-4775 Workers
Compensation
EASTHAMPTONMA01027-0309 ISSUED ON.8112103 0.00.00
TO PERFORM THE FOLLOWING WORK.INSTALL MODIFIED BITITUMEN FLAT 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 Sienature:
FeeType: Receipt No: Date Paid: Check No: Amount:
Building 8/12/03 0:00:00 4345 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo