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17C-048 RC.1.107rollofing Estimate Date 6 Line St. Southampton,Ma. 01073 8/19/2014 Phone(413)527-4775 Fax(413)527-8469 Name/Address Job Location Larry Yentsch Glafyra Ennis PO Box 120 80 Fox Farms Rd. Leeds, MA 01053 Florence, MA 01062 (413) 695-1452 Terms Rep Estimate valid for 30 days Chris Description Total Remove existing roofs. 13,400.00 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 Landmark 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$600.00 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 $13,400.00 TERMS OF PAYMENT 5%Deposit Balance upon completion Customer Signature Registration# 126235 Construction License#074334 Date 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 miw.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers .pplicant Information Please Print Leeibl_y lame (Business/Organization/Individual): Q'm QC)�� Clq� U C� ti ,ddress; S�- ;ity/State/Zip;1'),t,&- ,o., o l Phone re you an employer? Check the-appropriate box: Type of project (required): I am a employer with Z 0 4. ❑ I am a general contractor and I 6, ❑ New construction employees full M1,10r art=time . have hired the sub-contractors (fall ) 7. Remodelin � ❑ I am a sole proprietor or partner- listed on the attached sheet. $ ❑ g 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' 13.7 Other comp, insurance required.] ny applicant that checks box#1 must also fill out the section below showing their workers' compensation policy information: ameowners 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. m an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site 'ormwiott. urance Company Name: � r licy#or Self-ins. I,ic, #; ` C�1o53?,y o5 __ Expiration Date: 10 - d Site Address: 1ya 1 c0,x �OT hd _ City/State/Zip: Q, �nL AAA OIOt�,Z� 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 crinunal 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 5250,00 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 certify under the pains and penalties of perjury that the information provided above is true and correct gnatul•e; .� Date: Lone 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 O Name of License Holder: M zy h M.,1 S 1 e, — c7 7 q,3`!� 1 4 License Number '. � Ma, ►off 5 - ( - :� Address Expiration Date Signature Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ . b�T'1YlU Company Name J Registration Number HOOreaa Expiration Date r,da 1�;4sf 1�r11 �'Q a, t)11),l ,3 Telephon 37L 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 Wil result in the denial of the issuance of the building permit. Signed Affidavit Attached Yes.....,. No...... ❑ 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 gets 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. \Iso 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 2ttan``YlP SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alterations) Roofing Or Doors F Accessory Bldg. ❑ Demolition ❑ New Signs [ "r Decks [[� iding [L7] Other[ -] Brief Description of Proposed Work: attachevi /I rkXY'A rY V) Alteration of existing bedroom Yes No Adding new bedroo Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet -- .6a. If New house and or addition to existina 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 I-) .lS - • hereby authorize to act on my behalf, in all matters relative to work authorized by this uilding permit application. -�t.d 0�e S.J Signature of Owner Date I, AW k M A i Sl e- 'a, aU 6y'gi�A aQent as Owner/Authorized Agent hereby declare that the statements and information on the foregoing lication are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. Print Name ' Signature of Owner/Agent Date Section 4. ZONING Alt 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 Open Space Footage % (Lot area ininus bldg&paved 4 of Parking Spaces A. Has a Special Permit/Variance/Finding ever been issued for/on the site? , /-� � NO v�-1/ DON'T KNOV� t�� YES | IF YES, duteiesued:| / ' IF YES: Was the permit recorded at the Registry of Deeds? NO �-� DON'T �-\—�\ YES �-� IF YES: enter Bnok | Pa � ! and/or Document #� ' / - . ^ B. Does the site contain abrook, body of water orwettands? NO 0 DON'T 0 YES 0 IF YES, has u permit been or need to be obtained from the Conservation Commission? Needs to be obtained �~� Obtained y-� Date |��ued' \ �-� �-� ' . ! . C. Do any signs exist on the property? YES 0 NO 0 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: � | ` E. Will the construction activity disturb(clearing, grading n. nrfiUing) over 1 acre orioit part nfa common plan that*iUdisturb over 1acre? YES NO 0 IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Department use only 7 City of Northampton Status of Permit: 7 Building Department ?Curb Cut/Drive.way Permit 14 212 Main Street Sewer/Septic Availability_ AUG 2 Zo Room 100 WaterW ell Availability as s ecfons rthampton, MA 01060 Two Sets of Structural Plans FjaetriC,plumbing& oe 41 -587-1240 Fax 413-587-1272 Plot/Site Plans Northam ton, A I Other Specify APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWEL SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be completed by office -90 ��-C-A^- C—A Map Lot Unit Zone Ove May District Elm St.District C13 District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: C-1�0�(�k<-c,,- C-VNV� --s Vo lk C1.11 64 �Ao(XVticjr--. 106 Name(Print) -J Current Mailing Address: att'ache-C] Telephone Signature 2.2 Authorized Agent: .M;1 v�k R00fil ncl L ings+.- am a. Name(Print) Current Mailing Address: 010173- 4A 13) 5 21 Signature Telephone SECTION 3.-ESTIMATED CONSTRUCTION CO LT-S Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building f (a) Building Permit Fee k0fi 13 .(4 bo . c)() 2. Electrical (b) Estimated Total Cost of ConStrUction from (6) 3. Plumbing Building Permit Fee 4, Mecharical(HVAC) 5. Fire Protection OC 6. TotaI =0 +2+3 +4 +5) 00 Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: I Building Commissioner/Inspector of Buildings Date 80 FOX FARMS RD BP-2015-0211 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17C-048 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-2015-0211 Project# JS-2015-000397 Est. Cost: $13400.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: RCI ROOFING 74334 Lot Size(sq. ft.): 19994.04 Owner: ENNIS GLAFYRA R Zoning: URA(100)/ Applicant: RCI ROOFING AT. 80 FOX FARMS RD Applicant Address: Phone: Insurance: 6 LINE ST (413)527-4775 Workers Compensation SOUTHAMPTONMA01073 ISSUED ON.812112014 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 Sitinature: FeeTvpe: Date Paid: Amount: Building 8/21/2014 0:00:00 $35.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner