35-056 (2) R.C.1 ROOFING
40 MAINE AVE.
P.O. BOX 309
EASTHAMPTON, MA 01027-0309 C(C;E;ST;l M A TE
PHONE (413)527- 4775
FAX (413)527-8469 wolf
Date: SEPTEMBER 23,2002
Estimate To:
MAURICE SCOTT Estimated By: MARK DELISLE
944 RYAN RD. Start Date:
FLORENCE, MA. 01062 Job Location: 944 RYAN RD.
FLORENCE, MA. 01062
Job Phone: (413)584-4707
JOB DESCRIPTION
MANUFACTURERS REMOVP AND TNSTALL PLYWOOD SUPPTTFD BY OWNER,
FURNISH AND INSTALL RIDGE VENT.
ALL ROOFING RELATED DEBRIS TO BE REMOVED RY R.C.I. ROOFING.
SPECIAL ITEMS NEEDED
REPLACE 2X6 RAFTER AND HEADER.
FURNISH AND INSTALL CRICKET AND NEW FLASHING ON CHIMNEY AND VENT PIPE.
Additional information pertaining to this Job Estimate
TERMS OF PAYMENT Total Estimated
30%PRIOR TO START
70%UPON COMPLETION Job Cost $2,700.00
REGISTRATION#126235
FED.ID#04 3418839 Authorized
CONSTRUCTION LICENSE#074334 Signature
INSURED BY HACKWORTRILAPLANTE INS.(413)527-9907
ORIGINAL-ESTIMATOR COPY
oft tiAM PLO
g� � -
9 6 �assarflrt,:rtta'
DEPARTMENT OF BUILDrNG INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060 y
WOM CER'S COMPENSATION INSURANCE AF + AAVTT
with a principal place of business/residence at:
40 r%f7 , /f-�C' � h 0/0.) 7 -(phone#) j,►l - Y 77r
(stre_-Ucity/.5 afrhip)
do hereby certify, under the pains and penalties of perjury, that.
O I am an employer providing the following workers compensation coverage for my
employees working on this job:
(Insurance Company) (Polity Number) (Expiration DaLe)
O 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) (Insrtrant c Company/PoLicy Number) (Expiration Date)
f
(Name of Contractor) Unsu ,3ncz Compam/Policy Number) (Expiration Date)
(Name of Contractor) (Intutrancz- Compa_oy/Pohcy Number) (Expiration Date)
(Name of Contractor) (Insurance Compan iPolicy Number)— (Expiration Date)
(attach a6dm60 1 tboct if noon- Ty to inc}udc infocmxtioo pat m=4&to all ooatma r})
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 while homcovrrxra who cr;pl cry parans to cio ma utcu=cr,cors�t:r ca cr rcpaa work ou a d N+c g of
not atoec than three uaita in which the Iwmoonvet rrsida«oa the grounch zprrarrteautt lhaeto arc oot goner+lly oo¢iidcrcd to be
cmploycr3 under the workes ampamttioa Act application by a homcowoa for a 6cca5t tic permit may cvidcnoc the
Icg21 ctahrs of an omployx under tho Wort t Compeaseion AcL
I un&rsund that a copy of this ctatec m may ho forwarded to tbo Departnxnt of Indushial Aeci&-&offioo of Iu:iuinoo for the
coverage vuific3lion and that failure to sxurc covango undx soetion 25A of WIL 152 can lad to tho imposition of airmail pcnallics
oomittiag of a flue of up to S 1,500.00 and/or imprisoauxat of up to orx year and civil pcssaltia in dI form of a Stop Work OrdG and a
f=of 5100.00 t day tgnimt tie
only
Permit Number Lot#
Signature of License crmittcc e
SECTION,8 :CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor, Not Applicable ❑
Name of License Holder : " ` G f � ' 1 S ' �— 7 Ll
License Number
Address Expiration Date
Z - 9�
Signature Telephone
Re inter'dr} bm 1mverrienCo rn actor wa � ,
a..�M� fika � Not Applicable ❑
2, 37r
Company Name Registration Number
40
Address Expiration Date
Telephone-Vi? G�5
SECTION-10-VIIO.RKERS'.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...... ❑
�. 60"O ®�x�O� Iemp�tion
_
The current exemption for"homeowners"was extended to include Owner-occupied Dwellinjzs 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 tinder 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 —
SECTIONS yDESCRIPTION OF.PROPOSED WORK(checkall aaalicable)
,,,., ,
K
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] 1 Siding[ ] Other [ ]
Brief Description of Proposed Work: �(+! '� (�S �� 7/( S [� 1-k[ Q
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative ❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet❑
sa_ IfgNewsh�ouse an�d�oraddition°toexistin tiousin;�;�comgCete�thefol<L°o'win'i�:
g,.
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
SECTION 7a=`OWNER AUTHORIZATION -TO BE COMPLETED WHEN
01WNERS,.AGENT'OR CONTRACTOR,APPLIES FOR BUILDING PERMIT«
l as Owner of the subject property
hereby authorize to act on
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
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 Name
Date
Signa[[[[ture of Owner/Agent
,
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 S atus ;f r r
Build Department CbCii
1' ic,�1 .. in Street SewerlSe tc
_ _ I m 100 W9'er"I va
f.
Northa r
n, MA 01060 T o Sets
phone 413 58V'-' 0 Fax 413-587-1272 Pio/Site�Pans
Other Spec IT, 04 `
L::LA RPLICATION TO'CO1CT, TER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
This section to be completed by office
1.1 Property Address:
Map_ Lot } Unit
Zone_ Oierlay D�str�ct
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
r
Name(Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
Name(Print) Cur ent Mailing Address:
Signature Telephone
SECTION 3 - ESTIMATED;,CONSTRUCTION COSTS
tem 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 r 6
3. Plumbing Building Permit Fee
4_ Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) VC,� Check Number
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature: —
Building Commissioner/Inspector of Buildings Date
944 RYAN BP-2003-0378
GIs#: COMMONWEALTH OF MASSACHUSETTS
1 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2003-0378
Project# JS-2003.0638
Est.Cost: $2700.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: RCI ROOFING 126235
Lot Size(sg. ft.): 15376.68 Owner: SCOTT MAURICE E&DONNA M
Zoning: SR Applicant: RCI ROOFING
AT. 944 RYAN RD
Applicant Address: Phone: Insurance:
P O BOX 309 (41 1) 527-4775 Workers
Compensation
EASTHAMPTONMA01027-0309 ISSUED ON:10 110102 0:00:00
TO PERFORM THE FOLLOWING WORK:ST R I P & S H I N G LE 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 10/10/02 0:00:00 624 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo