25C-146 R.C.I ROOFING
40 MAINE AVE.
P.O. BOX 309 FDD IMA
EASTHAMPTON, MA 01027-0309
PHONE (413)527- 4775
FAX (413)527-8469
`1N Date: OCTOBER 15, 2002
Estimate To:
ZETTA McCORMICK Estimated By: CHRIS THOMPSON
29 ORCHARD ST. Start Date:
NORTHAMPTON, MA. 01060 Job Location: 29 ORCHARD ST.
NORTHAMPTON, MA. 01060
Job Phone: 413 586-1262
JOB DESCRIPTION
ALT, ROOFTNG RFTATFn DEBR TS TQ RE REMOVED BY R.( - T. ROOFING.
SPECIAL ITEMS NEEDED
Additional information pertaining to this Job Estimate
TERMS OF PAYMENT
30%PRIOR TO START Total E=stimated
70%UPON COMPLETION Job Cost $9,000.00
REGISTRATION N 126235
FED.ID#04 3418839 Authorized } `
CONSTRUCTION LICENSE#074334 Signature
INSURED BY FiACKWORTFVLAPLANTE INS.(413)527-9907
DUPLICATE-
CLINT OPY
g ,'e Cr►zf�• laf ��I�#[�ttnt�r�ntt
s .< ': �t+catsr>lasrtts
DEPARTMENT OF BUILDIT(O INSPECTIONS
212 Main Street Municipal Building
Northampton, Maas. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVrr
(Iicensecliamittee)
with a principal place of business/residence at: ;
40 aL� OLV>✓ F 1 �" YvIA olOL7bhone#) t1/3~SZ7-q*77_7
(6tnct/citY,(5U rinp)
do hereby certify, under the pains and penalties of perjury, that:
am as employer providing the following worker's compensation coverage for my
employees worlang on this job:
�• �_ 1�C'S-.315•�IltZy•oll 10- 5-OZ .
• (Lam-Ace CPmpany) (Policy.Number) (Expiration 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) (Iasi mcx Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Inwranc a Company/PoUcy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach addwooal Sled if nooeauy to ioctude in(ocrnLdoa pertaining,to all coatra )
O I am a sole proprietor and have no one working for me.
O I am a home owner performing all the work myself.
NOTE-pleaao be aware tbst whilo bomeow D=wbo employ perscata to do m- -^•^comuuwoa or repair work ou a dwelling of
W morn ttun tbroa uaiu in w"the homoowaa reridef or oa the grwa ds appurtenant thumto are not gcoemily comidcrod to be
aaployera uadct the WMkes po¢>p=W*M Act(GL152.x2 1(5)).appliestioe by•hoauowaa for a llama cc peraa may evidence tbo
Iegal striae of an employer coder the Wo icoes Compomatioo Act
I uoduu*m1d tbat s copy ofthta saatcmml may be forwarded to the Depumxct of Lukutrid Aoddedy OlSoe of Iaauwoa,ra the
eovaago vuiacatioa aad thu failure to&=m covaago trader swdoa,23A of MOL 152 an tad a the imposition of tariminsl peaaltdes
oomiat=9 of a•rma ttf Up to SI.5W-00 aa&or kq isoameat OUP to one year and civil pe W cs is the form of a stop Work order acid a
rue of S1oO.00 a day against tae
For d use ooty
Permit Number
p;E Lot#
i;
;90fuccnscclpermittce a —�
•..W�QAe.5da7JcJea):w.,,..•:.�jy...• ............. ........ -
f
min
l *Y. r
Q, Licensed Construction Supervise Not Applicable ❑
Name of l.tcense Holder•`
Ucense r
Numbe
440 rya-.<, rC- OW ��,_ '• 3 'y
Address Expiration Date
�-I 13 ` ,'S z ' LITIS
Signature Telephone
am, 1114MOMM Mil Not Applicable 0 C pany-Name T— Registration Number
_ - tray
•Address �^ t Expiration Date
GLV F- C t-k-O)n Telephone ►/3-501 Al
CcQ 1?. SAY� I r.. FF �gV1T(I�I�G�L,G'
Am XN 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...... ❑ z.
I IN
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 bey 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
r
j
ww
i
New House O Addition O Replacement Windows Alteration(s)O Roofing
Or Doors O
Accessory Bldg. O Demolition0 New Signs [ ] Decks [ ] Siding[ ] Other( ]
Brief Description of Proposed Work:gf- QAA C%5--Q V\S4 wotA O k'
Alteration of existing bedroom Yes No Adding;new bedroom Yes No
Attached Narrative 0 Renovating unfinished basement Yes No
Plans Attached Roll 0•Sheet 0
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
U W, �GiPI RMIT
k
V\\c as Owner of the subject property
hereby authorize m0.r ��\���- � 1\00 � �l to act on
my behalf, in all matters relative to work authorized by,this building.permit application.
/6
Signature of Owner Date
I, m �� 1�� �S� �. �..�- �T'r , as Owner/Authorized Agent
hereby declare that the statements and information on the foregoing applbtion are true and accurate, to the-best of my
knowledge and belief.
Signed under the pains and penalties of perjury.
q\o o� � ►�a
Print Name
/0 - � ) -C
Signature of Oww/Agent Date
Section 4.
tLt`INFORMATION MUST BE COMPLETED, or PERMIT CAN BE
DENIED DUE TO LACK OF INFORMATION
Existing Proposed Required 0 Zoning
This column o be filled in by
Building Deomeat,
Lot Size
Frontage
Setbacks
s .. ... L: R: L: R
Building Height
Bldg.Square Footage %
Open Space Footage %
(Lot uea minus bldg do paved
parking)
#of Parking Spaces
�c
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'TXNOW
YES
IF YES, has a'permit been or need to be obtained from the Conservatioa_Commission?
Needs to be obtained Obtained , Date Issued:
Co- 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
.-Puilding Department
. .212 Main Street
Room 100
p L C h'6"6 413 587-1240 Fax 413-587-11272
F_I
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVA�E OR DEMOLISH A ONE OR TWO FAMILY DWELLING
,SE6'.T1ON4
1.1 Property Address: x" ec e o
QY
SECTION 2 P.�iOP �fif��QYIINI~�I $ P AUTHOF �Z.ED!gG NT
2.1 Owner of Record:
Name(Print) y — Current Mailing Address:
• ('� �� .�) X�� ��.{�L �1.3 r��rQ.1l1f� I,JC�, l r �`�. .
_ Telephone
Signature
2.2 Authorized Agent:
I
Name(Print) Qurredt Mailing Address: „ _
Signature Telephone
SECTION:3 'ESW T;ED CONSTRUCT ON COUTS
Item Estimated Cost(Dollars)to be Official lJse'On�y`
completed by ermit applicant
1. Building I a (a)Building Perrlit 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) Check Number
Th'i"s Section;Far.Official Us Obly
Building Permit Nu .h r^ Date Issued k`
04;4t.'
Signature J+ «, F v 4J a � '�►� x ,
¢u'.ildi�g G4fC►►nlsslonW .'ilp for
BP-2003.0593
GIs#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category_ BUILDING PERMIT
Permit it BP-2003.0593
Project# JS-2003-0981
Est. Cost: $9000.00
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Gr1pp:. RCI ROOFING 074334
Lot Siz Asa. ft.): 4791.60 Owner: MCCORMICK JOHN F JR&DARLEEN
Zoning URB Applicant: RCI ROOFING
AT: 29 ORCHARD ST
Applicant Address: Phone: Insurance:
P O BOX 309 (413) 527-4775 Workers
Compensation
EASTHAMPTONMA01027-0309 ISSUED ON:12123102 0:00:00
TO PERFORM THE FOLLOWING WORK: )TRIP, PLY & 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 11 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 Sienature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 12/23/02 0:00:00 1835 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo