24C-088 Jan 30 14 1O: 42a Mrw 4132821099
P . 1
RCI Roarmg , •
6 Line St.
Estimate
Date
Southampton, iota. 01073 9/18/2013
Phone(413)527-4775
Fax(413)527-8469
Name/Address Job Location
Tom Willits 39 Massasoit St
39 Massasoit St Northampton, MA 01060
Northampton, MA 01060 (413) 538-1744
Terms Rep
Estimatc valid for 30 days Chris
Description Total
Furnish and install 1/2" Fiberboard insulation,mechanically fastened over existing root'. 1000.00
rurnish and install .060 reinforced rubber roof system.
Furnish and inst^.il all related fleshings.
Furnish and install .032 aluminum drip edge.
All exterior rooting related debris to be removed by R.C.I.Roofing.
All work to be performed according to manufacturers'specifications.
5 year R.C.I.workmanship warranty included.
Ail related permits will be obtained by R.C.I. Rooting,
WE LOOK FORWARD TO DOING BUSINESS WITH YOU
Total $3,Y0.00
TERMS OF PAYMENT
5°/ Deposit
Balance upon completion Customer Signature
Registration# 1262;5
Construction License 4 074334
Insured by Ranas&Fickcrt ins. Date 0
(413)527-2700
The Commonwealth of Massachusetts
Department of IndustrialAccidents
Office of Investigations
600 Washington Street
Boston, MA 02111
miw.mass.gov/dia
Workers' Compensation Insurance Aff"ldaAt. Builders/Conti-actors/Electricians/Plumbers
applicant Information Please P11nt Legibly
lame (Business/Organization/Individual); L, �dp� „nq l_L
.ddress: p�
;ity/State/Zip; ��-�, �� � M0., o�« 7 3 Phone #: 1"(5
re you an employer? Check the appropriate box: Type of project (required):
❑'I am a employer with Z 0 4. ❑ 1 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. # Remodeling
ship an'd have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp, insurance. 9. ❑ Building addition
[No workers' comp. insurance 5, ❑ We are a corporation and its
required,] officers have exercised their 10.❑ Electrical repairs or additions
r7 I am a',homeowner doing all work right of exemption per MGL 11.7 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' 13.7 Other
comp, insurance required.]
iy applicant that checks box#I must also fill out the section below showing their workers' compensation policy information:
:)meowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit uidicating 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
ormation.
uranee Company Name:
licy#or Self-ins, Lia #;��. c�b�33y O 5 Expiration Date: 10 S - d (_4
Site Address: -72 (tea SS&S�+ V -�k. City/State/Zip:A/ov-.,,,mp�W , kr A oko(,u
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,
to hereby certify under the pains and penalties of perjury that the information provided above is true and correct:
Mature:
Date:
tone#: l
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
Contact Person:_ Phone#:
SECTION 8 •CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable O
� n
Name of License Holder;— M Ay k S P, � / ,q,33
License Number
LL'ane- Si.� -OL Vj: M a. n i to 21 29 - ,03 - 14
Addrgss - t Expiration Date
_ AP.1 �J413) 5,21- � 72 5 _ -
Sign�ture Telephone
9,Registered Home Imorovement Contractor: Not Applicable ❑
• "I" .a �., _ 126235
m
Copan' y Name Registration Number
Hoo�C�� Expiration Date
� le�>►.11s�J1� A, o10,73 TelephonA[&.5,��
SECTION 10-WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c„ 152,§26C(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....... 4z No...... ❑
11. - Horne Owner Exemption
The current exemption for"hoMeowners"was extended to include Owner-oceunied Dwellings of one(1) or two(2)families
,md to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner aetg
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. AA person who constructs more than one home in a two-year veriod 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;
�s acting Construction Supervisor your presence on thejob site will be,required from time to time,during and upon
completion of the work.for which this permit is issued.
.,,Iso 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
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House Addition ❑ Replacement Windows Alteration(s) El Roofing
Or Doors O
Accessory Bldg. ❑ Demolition ❑ New Signs [CI] Decks Siding [0] Other[M]
E orl Description of Proposed
Work. 1
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
as Owner of the subject
property N ^�
hereby authorize l�'t��1_ el(S1e Q .C. T. Boofi*nq _
to act on my behalf, in all matters relat- ive to work authorized by this uilding permit application,
Signature of Owner Date
I'. . M sl e_ a5au t Y 1 aQex � , as Owner/Authorized
Agent hereby declare that the statements and information on the foregoing lication are true and accurate, to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
MAY �
i
51 -
Print Nam _
Signature of Owner/Agent Date
— , —
�
�
�
|
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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 Departrnent
Lot Size
Frontage
Setbacks Front
Side U!
Rear
Building Height
'
Bldg. Square Footage %
-Oppn Space Footage %
(Lot area rninus bldg&paved
of Parking Spaces
A. Has u Special Permit/Variance/FindinQ ever been issued for/on the site?
/��
�~�
NO Y�� DON7KNOYY �_� YES
| '
IF YES, date issued; |
IF YES: Was the permit recorded at the Registry of Deeds
NO \_��� DONTKNOVV �_��� YES �_��
�
IF YES: enter Bonk Pa8e! | and/or Document #i �
. ` . .
�� �� ��
B. Does the site contain o brook, body of water orwetlands? NO �_� DON'T KNOW v�/ YES �~�
IF YES, has a permit been or need tobeobtained from the Conservation Commission?
Needs tobeobtained �`� 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 0 NO 0
/
IF YES, describe size, type and location: ' <
'
E. Will the construction activity disturb(clearing, grading, excavation, or filling)over 1 acre orisd part ofa common plan
that will disturb over 1acre? YES � � N0 C l
��
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Department use only
0 City of Northampton '.Status of Permit:
Building Department Curb Cut/DrIveway Permit
as Ions 212 Main Street 'Sewer/Septic Availability
P,
Room 100 Water/Well,Availability�___
Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 �Plot/Site Plans
I other Specify_
.ICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION —7
1,11 Property Address: This section to be completed by office
t<x C>,� -S c, --s Map Lot Unit
Aj 0 V-A V0i,-qV\0-IC71 4"\ Zone Overlay District
Elm St,District-- CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
31 Ma- (,p
Name(Print) i�Address:
-at t Telephone t4
Signature
2.2 Authorized A-ge t:
Mayk af.
Name(Print) Current Mailing Address: -
U 0107,13
tJfi� 5 21- 4 115
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTa
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building ROD Fi Ina 3 000� 5-0 (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing BuIldino Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total=(1 +2+3 +4 +5) iber .1213Y
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
39 MASSASOIT ST BP-2014-1066
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24C-088 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ROOF BUILDING PERMIT
Permit# BP-2014-1066
Project# JS-2014-001831
Est. Cost: $3000.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RCI ROOFING 74334
Lot Size(sq. ft.): 5619.24 Owner: WILLITS THOMAS R&NANCY J WHEELER
Zoning: URB(100)// Applicant: RCI ROOFING
AT: 39 MASSASOIT ST
Applicant Address: Phone: Insurance:
6 LINE ST (413) 527-4775 Workers Compensation
SOUTHAMPTONMA01073 ISSUED ON:411612014 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL NEW RUBBER ROOF SYSTEM
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 4/16/2014 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner