24C-017 RC-1-0*10Roolf-m
Date
6 Line St. Estimate
Southampton,Ma. 01073 4/16/2014
Phone(413)527-4775
Fax(413)527-8469
Name/Address Job Location
Patrick Fleming 274 Prospect St.
Janet Kelly Northampton, MA 01060
274 Prospect St. (413) 586-8142
Northampton,MA 01060
Terms Rep
Estimate valid for 30 days Chris
Description Total
Remove existing roofs. 13,900.00
Furnish&install 1/2" plywood over the existing decking.
Furnish&install aluminum drip edge,pipe flashings, chimney flashings and step flashings.
Furnish&install CertainTeed Winterguard ice and water barrier along eaves and valleys.
Furnish&install synthetic underlayment.
Furnish&install Lifetime CertainTeed Landmark Series shingle.
Furnish&install CertainTeed approved ridge vent.
Furnish&install .045 re-inforced rubber roof system on flat roof section.
All exterior roofing related debris to be removed by R.C.I.Roofing.
Lifetime CertainTeed material warranty included.
All related permits will be obtained by R.C.I.Roofing.
A Certainteed Surestart plus warranty will be included with a fee of$400.00 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 $13,900.00
TERMS OF PAYMENT
5%Deposit
Balance upon completion Customer Signature
Registration# 126235 ////
Construction License#074334 Date OWoS ,2
Insured by Banas&Fickert Ins.
(413)527-2700
The Commonwealth of Massachusetts
Department of Industrial',Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
wnnv,mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/El ectricians/Plumbers
,ppllcant Information Please Punt Ley
ib1Y
lame (Business/Organization/Individual): P\
.ddress: �,
;ity/State/Zip: mo_ oto-7 3 Phone #: (u13)
re you an employer? Check the appropriate box; Type of project (required):
S I am a employer with Z 0 4, ❑ I am a general contractor and I 6. ❑ New construction
employees (full and/or part-time),* have hired the sub-con72ctors
❑ I am a sole proprietor or partner-
listed on the attached sheet. # �� Remodeling
ship and have no employees These sub-contractors have 8. ❑ 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.❑ 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.❑ Other
comp, insurance required,]
iy applicant that checks box#1 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 uidicating such,
ntractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers' comp,policy information.
man employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
ormation.
urance Company Name: -
licy#or Self-ins, Lie. #; W C � (DQ;,S 14 o 5 Expiration Date;_ 10 - S . 4
Site Address; 2.14 PrpSA+e_CAe S�- . City/State/Zip:& _ s,fl p, A 010(-0
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 criminal per>alties 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
ve.stigations of the DIA for insurance coverage verification,
(o hereby certify under the pains and penalties of perjury that the inform aflat;provide//d above is true and correct.
gnature: .�
'F Date:
tone#: --=S�.-f
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, 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 E3
Name of License Holder: aY� i.J_�..�t S 'Q� 171—q -334
License Number
LL`, 0 Ma. n►Q`► 5 - ( l _
Address �— Expiration Date
Q413) 521 N125
Signature Telephone
9. Registered Home Improvement Contractor: Not Applicable O
12b23,5
Company Name \. �]— Registration Number
Hoorba, Expiration Date
Q I a-7 3 Teiephon
SECTION 10-WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.162,§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....... �e No...... ❑
11. - Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellin¢s of one(1) or two(2)families
and to allow such homeowner tb 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 workserform,ed 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
Tmployees 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,States 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 F7 Replacement Windows Alterations) Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [p] Decks Siding [L7] Other[M]
Brief Description of Proposed }
Work: at L 0- 1]
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 housin-g, 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
,r\Q as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by thislouirding permit application.
2t.taehPc1 �0 -q -�
Signature of Owner Date
I� as Owner/Authorized
Agent hereby declare that the statements and information on the foregoing 4lication are true and accurate, to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
Print Name
-- 6 - 9 - ► �
Signature of Owner/Agent Date
Section 4, ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete 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 %
Olipen Spate Footage %
(Lot area minus bldg&paved
9 of Parking Spaces
A. Has aSpecial Pennit/Vahance/Finding ever been issuodfor/on the site? `
~�
� �
NO v�-�/ 03N7KNOV� \�� YES \~�~�� '
\
|F YES, date ioupdl / '
IF YES: Was the permit recorded at the Registry of Deeds?
NO *~/�-� DONT KNOW �-� YES
x��
IF YES: enter Book | | Page, | and/or Document
�
.
B. Does the site contain o brook' body of water or weUands? NO 0 DON'T KNOW 0 YES 0
IF YES, has permit been or need to be obtained from the Conservation Commission?
Needs tobeobtained �`� 0btained /`� Date |�aued' i !
�-/ �-� ' ' !
C. Do any signs exist on the property? YES �-� NO
-' -- - - — - --- -- - |
IF YES, describe size' type and location: |
O. Are there any proposed changes to or additions of signs intended for the property ? YES ���-� NO y-���
/
IF YES, describe size, type and location: ' |
.
E. Will the construction activity disturb(clearing, grading, excavation, orfiU|ng)over 1 acre oris it part ofo common plan
that will disturb over 1 oona? YES ��� � NO ����
IF YES,then o Northampton Storm Water Management Permit from the DPW io required.
Department use only
City of Northampton Status of Permit:
JUN 1 1 2014 Building Department �Curb Cutf/Driveway Permit
212 Main Street Sewer/Septic Avallabilit,
Room 100 '�Waterfflell Availabilit
pectio
ric Plurniolng&Gal I'E; rthampton, MA 01060 Two Sets of Structural Plans
Elect A 01060
NortlnE',M002,V'. p one 413-587-1240 Fax 413-587-1272 PIat/Site Plans
'Other Specify_
APPLICATION TO CONSTRUCT,ALTER, REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
11 Property Address: This section to be completed by office
1--k Map Lot Unit
�J. Zone Ove Hay District
Elryi St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
T\�'X f-\�0� 2-7 q ALrA ia m nVo-n AA. o i w o
Name(Print) Current Mailing Address:
L4 It--2
- 3) 1--V
--attache-(A Telephone
Signature
2.2 Authorized Agent:
rn MA
na LL.Q-�-Siz am
Name(Print) Current Mailing Address: 0 10173-
Signature Telephone
SECTION 3.-ESTIMATED CONSTRUCTION COSTS I
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building R00fin 11 (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Ccnstruction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total =0 +2+3 +4 +5) -2 ()o
Check Number f4
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
274 PROSPECT ST BP-2014-1336
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24C-017 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cateeory: ROOF BUILDING PERMIT
Permit# BP-2014-1336
Project# JS-2014-002235
Est. Cost: $13900.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RCI ROOFING 74334
Lot Size(sg. ft.): 7056.72 Owner: FLEMING PATRICK&JANET KELLY
Zoning: URB(100)/ Applicant: RCI ROOFING
AT. 274 PROSPECT ST
Applicant Address: Phone: Insurance:
6 LINE ST (413) 527-4775
SOUTHAMPTON MAO 1073 ISSUED ON:611212014 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 6/12/2014 0:00:00 $35.00
212 Main Street, Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner