35-030 R.C.I ROOFING
40 MAINE AVE.
P.O. BOX 309 y
EASTHAMPTON, MA 01027-0309 "V ESTIMATE
PHONE (413)527 4775
FAX (413)527-8469 p
Date: SEPTEMBER 9, 2002
Estimate To:
SANDY OSTROWSKI Estimated By: MARK DELISLE
11 SUMMERFIELD RD. Start Date:
NORTHAMPTON, MA. 01060 Job Location: 11 SUMMERFIELD RD.
NORTHAMPTON, MA. 01060
Job Phone: (413)586-6238
JOB DESCRIPTION
FURNISH & INSTALL 151b.FELT OVER EXISTING DECK.
FURNISH & TUaTALL 30 YEAR TAMK0 SHINGLE.
ALL ROOFING RELATED DEBRIS TO BE REMOVED RY_RrT ROOFING,
ALL W01ZK WILL PERFORMED ACCORDING TO MANUFACTURERS SPECIFICATIONS,
5 YEAR R.C.T. WORKMANSHIP WARRANTY TATrrr7nFQ-
30 YEAR TAMK0 MATERIAL WARRANTY INCLUDED.
SPECIAL ITEMS NEEDED
ADD 2.00 PER SQ. FT. FOR WOOD REPLACEMENT IF NEEDED.
Additional information pertaining to this Job Estimate
TERMS OF PAYMENT
30%PRIOR TO START Total Estimated
70%UPON COMPLETION JobCoSt $4,000.00
REGISTRATION 0126235
FEDERAL I.D.*04 3418839 Autholized
CONSTRUCTION LICENSE i 074334 Signature ( l X (l -/ J
INSURED BY HACKWORTH INSURANCE(413)527-9907
ORIGINAL-ESTIMATOR COPY
4-.�tUNP�O
s=e 'g CCx�J LY� �D����llt}7�Btt
9 6 �aasttcpnsctts
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street a Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFMAVIT
9x 00 ct
with a principal place of business/residence at:
4 O YY 00 CkV � Yea _ Ol oL�phone#) �l l3 •SZ7-�(?7 S
(streedcity/statrlal))
do hereby certify, under the pains and penalties of perjury, that:
"I an employer providing the following worker's compensation coverage for my
employees working on this job:
aasurAce� �.� 1 '�JCZ-315.3i� �zy•oii �o - 5-0�
Company) (Policy Number) T-xpiration 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)
(Name of Contractor) (Insurance Company/Policy Number) (Expiratoa Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additional shccc if neocuuy to ii d information pertaining to all ooatr.d r3)
( ) I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE:pleau be awue thu vAdlo homeowocra wbo employ pc=m to do maiatc�urns ruction or rcpa r work on a dwelling of
not mono than throe units in which the homoowocr midea oc on the grouods appurtenant thereto arc not geocrally oomkic cd to be
employers undo the worker's oomp=sation Ad(GLI 52.=1(5)),application by a homoowou for a UCC=a PWmif may evideow tho
legal stuua of an employee uoderthe Workeet compamatioa Act
I und==id dul a copy of tbia a&umcat may be forwarded to tho Dcp xw..r of ladrutrid A'D6&a&OfSoo of Laurance for the
coverago venficsiioo and that failure to wore covert p trader soctioa 25A of MOL 152 can kid to tbo'imposition of eriminsl pcmltid
oomisting of a fine of up to S 1,500.00 aadlor impeiso=3=A of up to one year ad civil pmaltics in the form of a Stop Work Orda and a
fwo of S 100.00 a day against ma
For use only
permit Number
Mall f' J/�_Lot rr
Signawre of Licansec/petmitfce
SERII,ICES'
8 1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: ' lO���1 �L1 S\ - 01 Lk 3—5 LA
License Number
440 YC ,
Address Expiration Date
Signature Telephone
M- 0 COMM= Not Applicable O
Company-Name Registration Number
`Ql 0- � \ + 0
Address �� �� Expiration Date
y6 M<' ^f., Q_\J F. C I VoY\ Telephone�����7-�17
SECT ON l0GYOR�ERSCpMPENSATION INSURANCE�A..FFIDAVIT'(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....... O No...... O
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
e ,
.402 a k
4 i .
... rroetrky
T
rw
New House ❑ Addition ❑ Replacement Windows Alteration(s)❑ Roofing JK
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 J
Attached Narrative 0 Renovating unfinished basement Yes No
Plans Attached Roll 0• Sheet 0
;a l`f Nero Nh"^oMMOMT"d`18MUM t IBM n �. c"�M IMefth" 851`1 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 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 ;;OWNEQUT�H�ORIZ� N TO B5fCOMPLETED WHEN
OWNERS,AC�EN7�?jCQRi4CTORAPPLIES FOR BUILDING:PERMIT
_ 4
as Owner of the subject property
hereby authorize ( 0.t ������ R T �QQ�� to act on
my behalf, in all matters relative to work authorized by this building.permit application.
Signature of Owner Date
�\rinwy' r\ as Owner/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.
vy c_� Z o
Print Name
/0 - / Z - (
Signature of Gwfter/Agent Date
i
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:
t
n Uji8;f Northampton
B iiAg Department
r¢"
rain Street
' Rom 100
�. Northaympton, MAO 1060
phone 413.587=1240 Fax 413-587.1272
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION-1-S:ITE INf O�[VIA71oN,
1.1 Property Address:
k Zo D Is w ,ate
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZMAGENT
2.10 ner of Record:
b 1 SC,xyl TVA 4XI A
Name(Print) Cur entMaing Address:�O` 2li
n MXD�il1 .
Telephone
Signature y -
2.2 Authorized Agent: I
Name(Print) Qurrent Mailing Address: _
Signature Te Nph one
SECTION 3 ESTIMATED CONSTR IOC TfON COSTS
Item Estimated Cost(Dollars)to be Official Use•Only
com leted b ermit applicant
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) C/C>C�C� Check Number
This Section For Official Use Onl
Building Permit Number: Date Issued:.
Signature:
Building'.Comm ssioner ln�pi r of tidings Date;,.
l
BP-2003-0514
CIS#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2003-0514
Project# JS-2003-0856
Est. Cost: $4000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RCI ROOFING 126235
Lot Size(sq. ft.): 13808.52 Owner: OSTROWSKI SANDRA A
Zoning: URA Applicant: RCI ROOFING
AT. 11 SUMMERFIELD ST
Applicant Address: Phone: Insurance:
P O BOX 309 (413) 527-4775 Workers
Compensation
EASTHAMPTONMA01027-0309 ISSUED ON:11119102 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP & 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 11/19/02 0:00:00 646 $25.00
212 Main Street,Phone(413) 587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo