38A-070 RC.1.Line � Date
E t� mate
6 Le St.
Southampton,Ma. 01073 8/25/2014
Phone(413)527-4775
Fax(413)527-8469
Name/A dress Job Location
Gabriel Peeples 163 Grove St.
163 Grove St. Northampton, MA 01060
Northampton, MA 01060 (508) 523-4368
Terms Rep
Estimate valid for 30 days Chris
Description Total
Remove existing roofs. 13,800.00
Furnish& install aluminum drip edge,pipe flashings, chimney flashings and step flashings.
Furnish&install CertainTeed Winterguard ice&water barrier along eaves and valleys.
Furnish& install synthetic underlayment over existing deck.
Furnish& install Lifetime CertainTeed Landmark Series shingle.
Furnish& install CertainTeed approved ridge vent.
Furnish & install 1/2" fiberboard insulation on flat roof section.
Furnish &install .060 re-inforced rubber roof system,mechanically attached on flat roof section.
All exterior roofing related debris to be removed by R.C.I. Roofing.
All work to be performed according to manufacturers' specifications.
Lifetime CertainTeed material warranty included.
All related permits will be obtained by R.C.I. Roofing.
SPECIAL ITEMS NEEDED
Add$2.50 per square foot for wood decking replacement if needed.
A Certainteed Surestart plus warranty will be included with a fee of$540.00 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 $13,800.00
TERMS OF PAYMENT
r)
5%Deposit f�
Balance upon completion Customer Signaturey 41 >
y
Registration# 126235
Construction License# 074334 Date
Insured by Banas&Fickert Ins.
(413)527-2700
The Commonwealth of Massachusetts
Department of Industria[Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
mm.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electi`icians/Plumbers
.pplicant Information Please Pd t Legibly
7aMe (Bu sines s/Orgarizationllndividual): C"g
address: (4
of o-7 3 ' Phone #:(y13)
re you an employer? Check the-appropriate box: Type of project (required):
�1 am a employer with ?,0 4. ❑ I am a general contractor and I 6. ❑ New construction i
employees full and/or art=time .* have hired the sub-conuactors
( p ) 7. Remodeling
�
❑ I am a sole proprietor or partner- listed ou the attached sheet. t 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 10.7 Electrical repairs or additions
required,] officers have exercised their
❑ 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 urdieating such.
ntractors that check this box must attached an additional sheet showing the name of the subcontractors and their workers comp.policy information,
man employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
'ormatiom
trance Company Name:
licy#or Self-ins. Lic, #: W �� Expiration Date: I 0
Site Address: 1(03 C`1(bJe. City/State/zip;bjer4 ,iyiD AA bAC30)
tack 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 penalties of a
,e up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the fonn of a STOP WORK ORDER and a fine
up to S250.00 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.
gnattre: Date:
tone# --
OjTtcW 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 ❑
Name of License Holder: )•l�r� �l L.ZI e� '71q334
License Number
Address Expiration Date
Signature Telephone
9, Registered Home Improvement Contractor: Not Applicable ❑
• • ran _ 1262-4.5
CompanvName Registration Number
_, C-e- S-Ob- 1 �n
.H°°rC" - Expiration Date
arn010 n 2. � /'-7 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 Afficlavit Attached Yes....... No...... ❑
11. - Home Owner Exemption
The current exemption for"horpeowners"was extended to include Owner-oeeunied 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.
.,\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 pemn(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
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House F7 Addition F7 Replacement Windows Alteration(s) Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [C] Siding [0] Other[0]
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
i
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
I, C`I(71 6 r.\ ` _ as Owner of the subject
property hereby authorize ' R.C. T.L •
to act on my behalf, in all matters relative to work authorized by this building permit application.
at,taeh'PA 9-I,9 -14
Signature of Owner Date
I, Azyk Me-lisle- t, , as Owner/Authorized
Agent hereby declare that the statements and information on the foregoing RJblication 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 Departrnent
Lot Size
Frontage
Setbacks Front
Rear
Building Height
Bldg. Square Footage V)
Open Spate Footage %
(Lot area ininus bldg&paved
of Parking Spaces
A. Has a Special. Permit/Yahance/Finding ever been issued for/on the site? `
NO 0 DON'T KNOW _ YES 0
)
|F YES, date isoue& | '
IF YES: Was the permit recorded at the Registry of Deeds?
NO � DUN7KNOY � YES
0
IF YES: enter Book | . Pago! � and/or Document
/
��
B. Does the site contain a brook, body ofvvaterorwet�nds7 NO v�� DON'T KNOW \_/ YES
IF YES, has permit been or need tobe obtained from the Conservation Commission?
Needs tnbeobtained �-� Obtained /—� Date |ssued' | !
�~/ ' ' |
� �
C. Do any signs exist nn the property? YES n~-�� NO �__�
�
-- - — — - - |
IF YES, describe size, type and location: / |
D. Are there any proposed changes tooradditions of signs intended for the property 7 YES NO 0
IF YES, describe size, type and location: ) !
E. Will the construction activity disturb(clearing,gradingexcavation, or filling)over 1 acre nrind part ofo common plan
that will disturb over 1acre? YEGK��� NO ���l
|F YES,then o Northampton Storm Water Management Permit from the DPVVinrequired.
-- City of Northampton Status of Permit: Department use only
SEP Building Department Curb Cut/Driveway Permit
2 2014 212 Main Street Sewer/Septic Availability
Room 100 WaterMell Availability
Ehkftc, Plumbing&Gas Inspeeti orthampton, MA 01060 Two Sets of Structural Plans
tul
Northampton, q Oi
13-587-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: This section to be completed by office
�?) C-1 1 _�,� Map Lot Unit
�j�rC�ME7t���1 Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: `` q
On",-i e- � 4 'l_�Q\Z S'+ � r zA�/C yY> �IC':��nctv�nivv�c.c1�M
Name(Print) C r f ailing Address:
Telephone
ho
hone
Signature
2.2 Authorized Agent: -L Luo'esizSaLl�arn rnrI4 Na.
W-nT
Name(Print) Current Mailing Address: 010113-
_
( 13) 521- J4 775
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 ((3)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 +2+ 3 +4 +5) C Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
163 GROVE ST BP-2015-0338
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 38A-070 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-2015-0338
Project# JS-2015-000622
Est.Cost: $13800.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: RCI ROOFING 74334
Lot Size(sq. ft.): 15507.36 Owner: PEEPLES GABRIEL
Zoning: URB(100)/ Applicant: RCI ROOFING
AT. 163 GROVE ST
Applicant Address: Phone: Insurance:
6 LINE ST (413) 527-4775 Workers Compensation
SOUTHAMPTONMA01073 ISSUED ON.912212014 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:
FeeTyne• Date Paid: Amount:
Building 9/22/2014 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner