25C-182 (4) R.C.1 ROOFING o�
40 MAINE AVE. �v
P.O. BOX 309 v
EASTHAMPTON, MA 01027-0309 ESTIMATE
PHONE (413)527- 4775
FAX (413)527-$469
Date: AUGUST 5, 2002
Estimate To:
NANCY CHAMBERLIN Estimated By: MARK DELISLE
83 NORTH ST. start Date:
NORTHAMPTON, MA. 01060 Job Location: 83 NORTH ST.
NORTHAMPTON, MA. 01060
Job Phone: (413)584-7982
JOB DESCRIPTION
-REMOVE EXISTING FLAT ROOF ALOMG PERIMETER OF MAIN RQQF,
REPLACE ROTTED WOOD 9 �52,00 PER 20. FT.
17TIRAITSH AND IMSTALL 112" FTBERBOARD ROOF INSULATION.
FURNISH AND INSTALL .045 REINFORCED RTIRRFR KFKRRANE,
FURNISH AND INSTALL .032 ALUMINUM DRIP EDGE.
ALL ROOFTNG RELATFQ QFRR TS TO BE REMOVED BY R.C.I. ROOF1JVG.
SPECIAL ITEMS NEEDED
PRICE FOR ALL NEW PLYWOOD - ADD $1,200.00 TO TOTAL JOB COST (_ $3,500.00)
Additional information pertaining to this Job Estimate
TERMS OF PAYMENT
30%PRIOR TO START Total Esstimated
70%UPON COMPLETION Job Cost $2,300.00
REGISTRATION#126235
FED.ID#04 3418839 Authorized
CONSTRUCTION LICENCE#074334 Signature
INSURED BY HACKWORTH INSURANCE(413)527-9907
ORIGINAL-ESTIMATOR COPY
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-
Bd l�:ssachasrttts
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060 '
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
4, /' s
ly
(IicenserJpermittee)
with a principal place of business/residence at:
4-7 r, ./1-7G� � /� '/� y���. C'lr--),> (phone#)
(street/city/state zip)
do hereby certify, under the pains and penalties of pegury, that:
( ) I am an employer providing the following worker's compensation coverage for my
employees working on this job:
f �rr /V
(Insurance Company) (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 Conrpany/Policy Number) (Expiration Date)
r.
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Compauy/Poiicy Number) (Expiration Dale)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additiccil sScct if ntccniry to inc]ude information pertaining to all contractors)
( ) 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 aware that while homcownen who emplay persoas to do ma�omst=on or repair work on a dwelling of
not more than carne units is which the homoowncr resides or oa the grounds appurtenant thereto arc DO(gcncralty ooasidurd to be
employtin under the worker`s zatioa Act(GL152,ss 1(5)),application by a homeowner for a license cc permit may cvidcnoc the
legal astir of an employer under the Workceg C.ompanation Ad.
I uadens d that a copy of this s tatemcut may be forwarded to the DeQartmmG of Ind atrial Accidea&of5oo of Isrsrcwoa for the
coverage verification and that failure to soa=oovaago under scctioa 25A of MOL 152 can lead to the impos¢ion of criminal penAWCS
ooasisti c of a fine'of up to S1,500.00 aadlor kVriso� of tip to ow year and eiVII penalties in the form of a Stop Work Order and a
fins of 5100.00 a day against mc.
For dgmtn�uao only
Permit Number
W Lot#
•Signature of Liccnseelpermittee
SECTION 8=:CONSTRUCTION SERVICES!
8.1 Licensed Construction
S�ju ervisor: i Not Applicable ❑ !
Name of License Holder: /� ` l l e 3 C/
License Number
Addres Expiratio Da
C 77.E
Signature Telephone
M_ Not Applicable ❑
7 !,,)& .2--3 .a---
Company Name J ,L Registration Number
Address Expira on ate
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....... ❑ No...... ❑
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
SECT'ON�5'DESCRIPTIONOF PROPOSED WORKS ch ckall a ` licable
.,r
1 d
New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet❑
6aIfi�N who se�ancl oratlditio"Ii�to�eicisting"lioustr � corn°ple�e° :thefollowinlr:
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
SECTION Za OWNERiAUTHORIZATION'-TO BE COMPLETED WHEN
OWNERS AGENT"OR°'CON TRACTOR,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 permit application.
Signature of Owner Date
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 and r the pains and penalties of perjury.
Print Name
Signature of Owner/Agent Date
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
-
I IF YES, describe size, type and location:
{
l•n
Northampton
Bij d Department
�'.'..'G 1 0
60 C2 ain Street
R om 100
CEp Of 13[_,ILDING-jySpFA
Wham ton, MA 01060
240 Fax 413-587-1272
.p
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1- SITE INFORMATION,
This section#o°bezcdrii'p ed.by of rce
1.1 Property Address:
Ma Lots �g �t1
Zone Overlay Dis#rtct '
Elrri St. District CBD►str ct
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent: .-.
Name(Print) y� Current Mailing Address:
Signature Telephone
SECTION 3'- ESTIMATED?CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building (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
6. Total = (1 + 2 + 3 + 4 + 5) Check Number
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
r
BP-2003-0175
GIS#: COMMONWEALTH OF MASSACHUSETTS
; CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Cate og ry: BUILDING PERMIT
Permit# BP-2003-0175
Project# JS-2003.0327
Est.Cost: $2300.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RCI ROOFING 126235
Lot Size(sq. ft.): 14113.44 Owner: CHAMBERLIN NANCY C
Zoning.URC Applicant: RCI ROOFING
AT. 83 NORTH ST
Applicant Address: Phone: Insurance:
P O BOX 309 (413) 527-4775 Workers
Compensation
EASTHAMPTON MAO 1027-0309 ISSUED ON.8116102 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPLACE RUBBER MEMBRANE 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:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 8/16/02 0:00:00 601 $25.00
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo