25C-156 rc c V R r i� v i
30 HIGH ST
EASTHAMPTON MA 01027 �ST� ATE
(413)527 4775
FAX (413)527 8469 Date: MAY 19 2000
Estimate To:
JOHN DELJU;EY
Estimated By: CHRIS THOMPSON
08 BRIDGE ST Start Date:
NORTFMPTON,MA 01060 Job Location: NORTHAMPTON
I � I
Job Phone: 582 1877
JOB DESCRIPTION
REMOVE 3 LAYERS OF ASPHALT SHIA7(-,T,FS
FURNISH AND INSTALL 151b FELT,
FURNT.SH AND TN.STAT,T, T(-F, ti WATFR RARRTFR AT,ONC; F,AVF,.S ANT) VATT,FY.S.
r.
L FURNISH AND TN TAT, , C013RA RaGE VENT,
ALL gOoFr&iG pEBgIS TO RR F. nVF.n RY A T R nPTN_
ALL WORK WILL BE PERFORMED IN ACCORDANCE WITH MANUFACTURERS SPECIFICATIONS.
SPECIAL ITEMS NEEDED
I
I I
Additional information f attaining to thi's Job cstimat2
TERMS OF PAYMENT
30%PRIOR TO START Total Estimated
70%UPON COMPLETION JOJ COS $8,700.00
CONSTRUCTION LICENSE#074334
FEDERAL 1.D#341883.9 r"iUtiiO/iZ8f1
REGISTRATION►!126235 Signature - k
INSURED BY BANAS INSURANCE(413)527 0288
ORIGINAL-ESTIMATOR COP
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DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
K e
(licellseeJpermittee)
with a principal place of business/residence at:
- -3o 49 _(phonC4
(Street/ci ty/statr/a p)
do hereby certify, under the pains and penalties of penury, that
I am an employer providing the following worker's compensation coverage for my
employees working on this job:
k L
Re S
(Ins Iran mpany) (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) (Insurance Cornparry/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Coarpany/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/PoLicy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additional sheet ifntocnmy to include informaIIoa pertaining to all contra )
O I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE:please be awam that whilo homcoveom who employ persons to do maiatena__:�oomtrtretioeor repair work ou a desalting of
not mote than thine units in which the homeowner resides or on the Vein appurtenant thereto arc not generally oomidemd to be
employers under the worker's compcau4oa Act(GL152,ts 1(5))�,application by a homeowner for a license cc permd tray evidenoa tho
legal status of an employer under the Worlcoes Compoosatim Act.
I underhand that a oopy of this statcmecd may be forwarded to the Departznont of Industrial Ao idea&Oboe of Irrsruaace for the
coverage verification and that failure to secure coverage under section 25A of MGL 152 can lead to the imposition of criminal penalties
ooasisting of a fine of up to 51,500.00 and/or imprisonmwi of up to one year and civil penalties in the form of a Stop Work Order and a
fine of S 100.00 a day against ttx
For igMtnCC al user only
Permit Number
Cl u Map# Lot#
Siv&vi re of I icensee permit tee e
c�rio>N�-coNSTRUCrlonl SERVICES
o.1 Licensed Construction Supervisor: / Not Applicable ❑
Name of License Holder : f' ' ` ` 7 41 3 �
License N tu
.-> f t i73
Address Expiration Da e
7 7
Signature Telephone
N,.
Not Applicable ❑
Company Name Registrati n Nu ber
Address r✓ Expirgftion Date
S.)- 7Telephone L J.)- 7
SEC71QN.10,INQRKERS'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.
igned Affidavit Attached Yes....... ❑ No...... ❑
i
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
TIQ 5- S P 5 c I' i able
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: �� S ) 5 �' G f
S k i fi 5 r s 1,.-k"
Alteration of existing bedroom Yes No Adding new e ,�
droom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet❑
offlodft:
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
Energy Conservation Compliance. Mascheck Energy Compliance form attached?
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
SEC71aN 7a=d NER Al3THQf l�I TIQN, T±f3 I31E'dOMPL&TED ,WHEN
�}WNRSAGN7 f)R f~Cfl+II7IATR AI�F�LI1=SfMII ': U1�:DtN'G F' tM11"
as Owner of the subject property
hereby authorize to act on
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date as and accura
te, to the best of my
hereby declare that the statements and information on the foregoing application are true a y
knowledge and belief.
-.,igned under the pains and penal 'es of perjury. '
Print Name
C
Signature of Owner/Agent Date
e
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:
1 '
City of Northampton
Building Department
212 Main Street
Room 100
Northampton, MA 01060
phone 413-587-1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SEC fitlN `SATE INF'QRMAT ON°
1.1 Property Address: his s�cti4 A 0
s K i s
b
x
y A
SECTI#,2-PROP RIYOWN0$141,PIAUTHORtZEp AGENT
2.1 Owner of Record:
ak✓i iJG� �Gne�/ "—C)
ame(Print) Current Mailing Addres
Telephone
Signature
2.2 Authorized Aeent:
Name(Print) Current M ing Address:
ci o
.Z -7 7�
� S"
Signature Telephone
SECTIbN, Tl $`tED Cflt+f5TftiCIT16N.COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building (a) Building Permitfee ;
2. Electrical (b)Estimated Total Cast of
Construction from. 5
3. Plumbing Buildingfermit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total =0 + 2 + 3 +4+ 5) 7 U U Chegfc t umber '-x--
t'hls Section,for'Official Use=Oi l
Buifidirig"Pei,mi Numkaer date Issued:"
Signature:
'Building Commissioner/inspector of Buildings Date,
208 BRIDGE ST BP-2001-0210
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map.-Block:25C- 156 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category:roofing BUILDING PERMIT
Permit# BP-2001-0210
Project# JS-2001-0338
Est.Cost: $8700.00
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: RCI ROOFING 126235
Lot Size(sq.ft.): 3397.68 Owner: DELANEY JOHN B&LORRAINE
Zoning-:URB Applicant: RCI ROOFING
AT. 208 BRIDGE ST
Applicant Address: Phone: Insurance:
30 HIGH ST (413) 527-4775 Workers
Compensation
EASTHAMPTONMA01027 ISSUED ON:8124100 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. Inspector of Buildings
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
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 8/24/00 0:00:00 MO $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo