17C-277 4/17/2014 Roofing agreement.jpg
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6 Line 5t.
Estimate Date
Southarttpton,Ma.01073 d/17I207A
Phone(413)5274775
Fax(413)527-8469
Name(Address Job Location
Susan Bourque 13 Lilly St.
13.Lilly St. Florence,MA 01.062
Florence,MA 01062
Terms Rep
1?st9mate valid for 30 days Chris
Description Total
Remove existing roots. 9,900.00
Furnish&install aluminum drip edge,pipe flashings,chinxney flashings and step flashings.
Furnish&install 6'CortainTeed Winterguard ice&water barrier along eaves and valleys.
Furnish and install synthetic underlayment over existing deck.
Furnish and install Lifetime CertainTeed Landmark Series shingle.
Furnish and install Ceriain`I'eed approved ridge vent.
All exterior roofing related debris to be removed by R.C.I.Roofing.
All Nvork will be performed according to manufacturers'specifications.
Lifethne CertainTeed material warranty included.
All related permits will be obtained by R.C1#tooling:
Add$2.50 per sq.t2.for wood decking replacement if needed.
A Certainteed Stueslart phis wavramy will be included wvith a fee of$380:00 absorbed by RCl
Rooting if signed within 7 days.'Phis extended warranty means that 25 years of the Lifetime
warranty is covered for labor and materials.The remaining years of the Certahtfeed warranty
would be covered for material only.
Customer is responsible for securing utterior items and any attic debris from roof removal.
Tot.! $9,900.00
TERMS OF PAYMENT' �
5%Deposit
Balance upon completion Customer Signature
Registration b'126235 ) L(
Constmction License#074334 mate
insured by 138nas Fickrri Ins. _
(413)527-2700
https://mail.google.cont/mail/?riz=lR6GGLE en US435#into xl14570cd8c8330212?proiector=1 1/1
The Commonwealth of Massachusetts
Department of Industrial-Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
msrw.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
.pplicant Information _ Please Print Legibly
lame (Business/Organization/Individual): �tip�-�`, ,\.I.L.?
address:_(.,
0�0-7 3 Phone #: 13) — 5
re you an employer? Check the-appropriate box: Type of project (required):
am a employer with Z 0 4. ❑ I am a general contractor and 1 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, # 7. ❑ Remodeling
ship and 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
❑ I am a homeowner doing all work right of exemption per MGL 11.❑ 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,❑ 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 afridavit utdicating 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 policyand job site
ormatiom
uranee Company Name:
licy#or Self-ins, Lia #: \Lp" (3 QIs 114 O 5 Expiration Date: I V - j - 4 !4
) Site Address: 1_� \ "i\\_ City/State/Zip: t,;�r��C�M,,k cluc,2.
tack a copy of the workers' c . pensation 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 ORDFR 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,
io hereby certify under the pains and penalties of perjury that the information provided above is true and correct;
Date. . y
tone#; (�i 3 `�2. 1~�(`1 `( ts
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 1
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of license Holder:-- ]` k 1717 q s3 4
License Number r
Address Expiration Date I/
527- N775
Signature Telephone
9, Registered Home Improvement Contractor: Not Applicable ❑
6-- R- 1 126235
Company Name Registration Number4yj,
HcorCa� Expiration Date
T Qr ' , � Telephone���,���
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.—... 4e No...... ❑
11. - Mine Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellln¢s 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 108.3.5,11.
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. Ajierson 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 fbr 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 mw 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_ 1Ll.dC,�ied
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House Addition [] Replacement Windows Alteration(s) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [p] Decks (❑ Siding [p] Other[01
Brief Description of Proposed }�
Work: —
Alteration of existing bE!droom Yes _No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
8a.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
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building perm//it application.
Qy��-� �
Signature of Owner Date _
I'—'May -,• 1� jY lI t as Owner/Authorized
Agent hereby declare that the statements and information on the foregoing a4lication are true and accurate, to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
Ise l�-
Print Name
Signature of Owner/Agent Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Propose�- Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Rear
Building Height
Bldg. Square Footage %
Op:en Space Footage %
(Lot area minus bldg&paved
of Parkin S aces
A. Has a Special Permit/Variance/Finding ever been issued for/on the site? `
NO ���-� DON'T /r�KNO� �_/ YE
|FYES
�
duteioued'
' '| .
IF YES: Was the permit recorded at the Registry of Deeds?
NO »�/�-\ DON'T KNOW y-�_�� YES /-�
�~�
IF YES: enter Book ! | Page| ! and/or Document #�
B' Does the site contain abrook, body of water nrwetlands? NO 0 DON'T 0 YES 0
IF YES, has a permit been or need to beobtained from the Conservation Commission?
Needs tnbeobtained �-� Obtained /=� Date | '
Y~� ' ' |
[' Dn any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location: |
D. Are there any proposed changes toor additions nf signs intended for the property 7 YES ��'~� NO �~��t
/
IF YES, describe size, type and location: | |
E. Will the construction activity disturb(clearing, gradingexcavation, orfiUing)over 1 acre oris it part ofo common plan
that v�||di�urbover 1 acre? YES K � NO � �
�� ��
IF YES, then a Northampton Storm Water Management Permit from the DPW ix required.
Department use only
City of Northampton 'Status of Permit,
Building Department Curb Cut/Driveway Permit
D
212 Main Street 'Sewer/Septic Avallabilit,
Room 100 WaterMell Availabilit,
2 4 2014 Northampton, MA 01060 Two Sets of Structural Plans
onE 413-587-1240 Fax 413-587-1272 'Plot/Site Plans
Elec ric, Plumbing&Gas Insp ctions
No Other Specify
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: This section to be completed by office
Map Lot Unit
Zone Ove rlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
(-C-yX cr_ /vA a- c'k -z—
Name(Print) c�trent�Iling dress:
t_t yl 151 -12-4 2-
--a 'a C be. Telephone-
Signature
2.2 Authorized A-cient:
M, Rodi na rnyl ma
Name--(Print) Current Mailing Address: 0 107,13,
��< 013) .5207- 417!5
Signature Telephone
SECTION 3.-ESTIMATED CONSTRUCTION CO
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building q0OF1 In C) 0 . C)c (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 co 44
6. Total=(1 +2+3+4+ Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/inspector of Buildings Date
13 LILLY ST BP-2014-1114
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17C-277 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ROOF BUILDING PERMIT
Permit# BP-2014-1114
Project# JS-2014-001893
Est.Cost: $9900.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RCI ROOFING 74334
Lot Size(sq. ft.): 4704.48 Owner: BOURQUE SUSAN C
Zoning: URB(100)/ Applicant: RCI ROOFING
AT. 13 LILLY ST
Applicant Address: Phone: Insurance:
6 LINE ST (413) 527-4775 Workers Compensation
SOUTHAMPTONMA01073 ISSUED ON:412412014 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:
FeeType: Date Paid: Amount:
Building 4/24/2014 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner