17C-050 ��
RC.1. RDate
6 Line St. Estimate
Southampton, Ma. 01073 6/18/2014
Phone(413)527-4775
Fax(413)527-8469
Name/Address Job Location
Steven Hinks 35 Strawberry Hill
35 Strawberry Hill Florence, MA 01062
Florence, MA 01062 (413) 427-5838
Terms Rep
Estimate valid for 30 days Chris
Description Total
Remove existing roofs. 17,600.00
Furnish& install aluminum drip edge, pipe flashings, chimney flashings and step flashings.
Furnish &install CertainTeed Winterguard ice&water barrier along eaves and valleys.
Furnish and install synthetic underlayment over existing deck.
Furnish and install Lifetime CertainTeed TL Series shingle.
Furnish and install CertainTeed approved ridge vent.
All exterior roofing related debris to be removed by R.C.I. Roofing.
All work will be performed according to manufacturers'specifications.
Lifetime CertainTeed material warranty included.
All related permits will be obtained by R.C.I. Roofing.
Add $2.50 per sq. ft. for wood decking replacement if needed,
A Certainteed Surestart plus warranty will be included with a fee of$620.00 absorbed by RCI
Roofing if signed within 7 days, This extended warranty means that 25 years of the Lifetime
warranty is covered for labor and materials. The remaining years of the Certainteed warranty
would be covered for material only.
Customer is responsible for securing interior items and any attic debris from roof removal.
Total $17,600.00
TERMS OF PAYMENT
o Deposit L
5/o
Balance upon completion Customer Signatur
Registration# 126235
Construction License#074334
Date
Insured by Banas&Fickert Ins. AZAZZ
(413)527-2700
The Commonwealth of Massachusetts
Department of Industrial'Accidents
Office of Investigations
600 Washington Street
.�` Boston, MA 02111
iQ 'v r
www,mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
.-pphcant Information Please PiZnt Legibly
lame (Business/Orgarization/Individual): _ P\ L m �\dp P' C\., W,
address: L� 5�
;ity/State/Zip: Phone
re you an employer? Clleck the-appropriate box: Type of project (required):
9'11 am a employer with ?,U 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. 1 7. ❑ Remodeling I
ship and have no employees These sub-contractors have 8. [] Demolition
working for me in any capacity. workers' comp , insurance. 9. 7 Building addition
[No workers' comp, insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10,7 Electrical repairs or additions
❑ I am a homeowner doing all work right of exemption per MGL 11.[1 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' 13,7 Other
comp, insurance required.]
iy applicant rhat checks box#1 must also fill out the section below showing their workers'compensation policy information:
)mcowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavil indicating such,
ntractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers' comp,policy information,
in an employer that Is providing workers'compensation insurance for my employees. Below is the policy and.job site
'ormatiom
uranee Company Name:_ 0
licy#or Self-ins, Lic, #: 0(.o'8 o,5 Expiration Date: I U
Site Address; City/State/Zip: or,k. n 4AA okQ'li
tack a copy of the workers' compens on 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 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 certlfy under the pains and penalties of perjury that the Information provided above is true and correct.
Date:
tone 1)
Official use only. Do not write Irr 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
8.1 Licensed Construction Supervisor-, Not Applicable O
Name of License Holder:—M AA 4.P-l t S Ito, '77 q,33'!
License Number
Address Expiration Date
52q- Nq'75
Signature Telephone
9, Registered Home Improvement Contractor: Not Applicable 13
ion f;na 1 b 235
Company Name Registration Number
HOOreaa } Expiration Date
Telephon
SECTION 10-WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L,c.152,§26C(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...... 0
11. - Home Owner Exemption
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
m 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 shag be
responsible for all such work performed under the building permit.
,as acting Construction Supervisor your presence on thejob 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 a .ta�,hed
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing lyJ
Or Doors []
Accessory Bldg. ❑ Demolition ❑ New Signs [❑] Decks [Q Siding [❑] Other[[D]
Brief Description of Proposed
Work: (��y,}.�C����
L
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 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 uiiding permit application.
;_ )
Signature of Owner Date
I. ,1ay h 1)el i sl e_ aSau t6Y,i 7, A aQ -ri 1. as Owner/Authorized
Agent hereby declare that the statements and information on the foregoing apblication are true and accurate, to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
MAY Ile,
Print Name
Signature of Owner/Agent Date
Section 4. ZONING AU 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 %
.Oppn Space Footage %
4 of Parking Spaces
A. Has aSpecaiPermit/Yahonce/Finding ever been issued for/on the site?
NO 0 DON'T KNOW 0 Y[5 0 — '
IF YES, date isaue&, /
IF YES: Was the permit recorded at the Registry ofDeeds?
�
-\ �-�
NO \�� DONTKNOYV \_/ YES
IF YES: enter 800k ! � Page! | and/or Document #� '
. . . .
�� �� ��
B. Does the site contain a brook' body ofv/ater or wetlands? NO �_� DON7 KNOW �_� YES �_�
IF YES, has a permit been or need tobe obtained from the Conservation Commission?
Needs tnbeobtained �`� Obtainod /�� Date
\�� \�� ' ' �
C. Do any signs exist on the property? YES NO
0
IF YES, describe size' type and tocabon: | {
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO 0
|
IF YES, describe size, type and location: | .
E Will the construction activity disturb(clearing, grading, excavation, or filling)over 1 acre oris it part ofo common plan
that will disturb over 1acre? YES NO K D
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Department use only
'Status of Permit:
City of Northampton
ji,' Building Department 'Curb Cut/Driveway Permit
JUN 2 6 2014 i 212 Main Street Sewer/Septic Availabilit
L:� Room 100 WfaterNVell.Availability
Electric, F,,Ut'nbing as ns Northampton, MA 01060 'Two Sets of Structural Plans
fon, MA -10 one 13-587-1240 Fax 413-587-1272 Plot/Site Plans
Northa�rf!Pfon, M Inspectio
Other Specify
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This section to be completed by office
1.1 Property Address:
Map Lot Unit_
clf-r--Acc Zone Overlay District__
Elm St.District CS District-
SECTION 2-PROPERTY OWNERSHIP/AUTHCRIZED AGENT
2,1 Owner of Record:
-35 �S��ilipe CrIA ace Y\,C-r , A A, 6W(62
e-n
Name(Print Cu rent Malling.Addres
ajt-�� q2O-A39
C�? Tel'e-phone-
Signature
2.2 Authorized Agent OnFina LL-is�gsiz armn rnn Ma.
Aly h Current Mailing Address:
Name(Print)
H13) 521- J411-9
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
connDleted ---`--k-ant
1. Building Ro o F,y1a li-A 0100 (a) Building Permit Fee
2� Electrical (t,) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (I +2+ 3 +4 +5) o 0-- 0 0 Check N
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building commissioner/Inspector of Buildings Date
35 STRAWBERRY HILL BP-2014-1399
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17C-050 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-2014-1399
Project# JS-2014-002370
Est.Cost: $17600.00
Fee:$35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RCI ROOFING 74334
Lot Size(sq. ft.): 19645.56 Owner: HINKS STEVEN L&MARY LEBEAU
Zoning: URA(100)/ Applicant. RCI ROOFING
AT. 35 STRAWBERRY HILL
Applicant Address: Phone: Insurance:
6 LINE ST (413) 527-4775 Workers Compensation
SOUTHAMPTONMA01073 ISSUED ON:612 712 01 4 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 6/27/2014 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner