24D-327 RC.1. R
6 Line St. Estimate
Southampton,Ma. 01073 5/14/2014
Phone(413)527-4775
Fax(413)527-8469
Name/Address Job Location
Dan Margolis Dan Margolis
264 State Street 264 State Street
Northampton, MA 01060 Northampton, MA 01060
Terms Rep
Estimate valid for 30 days Chris
Description Total
Remove existing roof. 3,000.00
Furnish and install 1/2"fiberboard insulation,mechanically fastened.
Furnish and install.060 reinforced rubber roof system.
Furnish and install all related flashings.
Furnish and install .032 aluminum drip edge.
All exterior roofing 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.
All related permits will be obtained by R.C.I.Roofing.
Customer is responsible for securing interior items and any attic debris from roof removal.
Total $3,000.00
TERMS OF PAYMENT
5%Deposit ,"'j,Balance upon completion Customer Signature �_
Registration#126235 _ f�
Construction License#074334 hh �D J
Date
Insured by Banas&Fickert Ins. 11
(413)527-2700
The Commonwealth of Massachusetts
Department of Industrial'.Accidents
Office of Investigations
d 600 Washington Street
Boston, MA 02111
mirm mass.gov/dia
Workers' Compensation Insurance Affidavit,, Builders/Contractors/Electricians/Plumbers
.pplicant Information Please P11nt Legibly
lame (Business/Organization/Individual): (� ��` dO�� r"o,
i.ddress: C_ t..:,,r\,z_ S 1-
6f0-75 Phone t ( t )
re you an employer? Clteck the appropriate box: Type of project (required):
S I am a employer with 2,0 4. ❑ 1 am a general contractor and I 6, ❑ New construction
employees (full and/or part=time).* have hired the sub-contractors
❑ 1 am a sole proprietor or partner- listed on the attached sheet. $ 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. F7 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 11.7 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,E] 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 indicating such.
ntractors that check this box must attached an additional sheet showing the name of the subcontractors 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.
urance Company Name: '� t.%<-
licy#or Self-ins. Lic, #,�\C ylo�3�t 035 Expiration Date: 10 • $ • d�J
Site Address, 2Zed City/State/Zip, Al(eA",n AA
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 crinunal 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: -'ter
Date
tone#; hs
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. CityaQwn Clerk 4.Electrical Inspector 5, Plumbing Inspector
6. Other
Contact Person: Phone #:
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor-, Not Applicable ❑
Name of License Holder:----.. ice
Sari [i[ ls I e. / j 3.1'j,�
('
License Number
" m %,",zA--o-r . Ma. viola 5 - M - 14,
Address I Expiration Date
0413) 521- N 17175
Signature Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
nQ 126235
Company Name Registration Number
Aoorcaz, Expiration Date
YA� . 10,73 Telephon "1
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......, No...... ❑
11. - Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)families
;ir.d 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 shoU 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
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 [C] Siding [p] Other[71]
Brief Description of Proposed }.
Work. a(��&J-
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 followinq
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
I as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by thislouilding permit application.
c6 c] 5 1�(
Signature of Owner Date `
I' 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.
AAA
Print Name •
22-1
Signature of Owner/Agent Date
Section 4. ZONING Att Information Must Be Completed. Permit Can Be Denied Due To Incomptete Information
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Rear
Building Height
Bldg. Square Footage
Op�n Space Footage %
(Lot area minus bldg&paved
#of Parking Spaces
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
/—\
/—�
NO �_/ DONTKNOVY �_� YES
IF YES, date isaedi |
IF YES: Was the permit recorded at the Registry ofDeeds?
NO - DONTKNOV 'ES
IF YES: enter Book | � Page! | and/or Document #� '
` . ` .
��
B. Does the site contain ubrook, body of water or*ed ��wetlands? NO v�� DON'T KNOW �~� YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs tobeobtained v=� obtained /-� Date Issued:
\_� v�� ' ' �
C. Do any signs exist nn the property? YES 0 NO �.�
— -- ' - -- - --- — — i
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property 7 YES NO
/
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 vi||disturb over 1acre? YES � 0 ND K l
�� ��
|F YES, then a Northampton Storm Water Management Permit from the DPW inrequired.
/7 rF'
Ell I,
V/ IC, Department use only
City of Northampton 'Status of Permit,
MAY 2 3 2014 Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Avail lability
Room 100 Water/Well Availability
Gas inspection
1,AA 1,11060 qorthampton, MA 0 1060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
I z0ther 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
-S\-- Map Lot --Unit—
ANA Zone Ove.Hay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
3,)a C) MGL(-!2�0 20A �Sk"r- S�. A AA A 6 10(,0
Name(Print) Cu rent Mpillng Address:
(ICI I->%I L!j X�, - 9
tu che T e Ie p6 o—n
Signature
2.2 Authorized Agent:
R00fina `6� L ut�;)rn rnn ma.
Name(Print) Current Mailing Address:
( q13) 521- J4715
Signature Telephone
SECTION 3.-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building ROA yl ow, 110 (a) Building Permit Fee
2. Electrical (b) EstimcMed Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6� To t a I =(I +2 + 3 +4 +5) ono C>0 Check Number 75
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/inspector of Buildings Date
264 STATE ST BP-2014-1249
GIs#: COMMONWEALTH OF MASSACHUSETTS
MW:Block:24D-327 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-2014-1249
Project# JS-2014-002104
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.): 8363.52 Owner: MARGOLIS DANIEL&LYNDA
Zoning: URC(100)/ Applicant. RCI ROOFING
AT. 264 STATE ST
Applicant Address: Phone: Insurance:
6 LINE ST (413)527-4775 Workers Compensation
SOUTHAMPTONMA01073 ISSUED ON.512712014 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 5/27/2014 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner