12-012 RC.1. R m � Date
6 Line St. E s t' m a to
Southampton,Ma. 01073 9/4/2014
Phone(413)527-4775
Fax(413)527-8469
Name/Address Job Location
John Ziegler 20 Country Way
20 Country Way Florence, MA 01062
Florence,MA 01062 (413) 320-9438
Terms Rep
Estimate valid for 30 days Chris
Description Total
Remove existing main roofs only. 5,100.00
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.1.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.
Customer is responsible for costs associated with collections including attorney fees.
Total $5,100.00
TERMS OF PAYMENT
5%Deposit / L
Balance upon completion Customer Signature
Registration 4 126235
Construction License 4 074334 Date �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
miw.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
.pplicant Information Please M t Lepzibly
came (Business/Orgarization/Individual);
.ddress; �, 1_:,,r\-e-- -
;ity/State/Zip; Phone #: Z �5�?.'l - -
re you an employer? Check the appropriate box: Type of project (required):,
�- 1 am a employer with Z U 4. ❑ I am a general contractor and I 6, ❑ New construction
employees (full and/or part=time),* have hired the sub-contractors
❑ I am a sole proprietor or pam>.er- listed on the attached sheet. # 7. ❑ 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.Er'Roo'
oof repairs
insurance required.] t employees, [No workers' 13.7 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 aff1davit indicating such,
ntractors that check this box must attached an additional sheet showing the name of the subcontractors and their workers' comp.policy infornation,
in an employer that Is providing workers'compensation insurance for my employees. Below is the policy and.job site
'ormatiotL 1
urance Company Name: \ tz%<- —C` r\��
licy#or Self-ins, Lic, 0_5 Expiration Date: 10 $ - d
Site Address: 7.0 WQ, City/State/Zip: „rp-A lard Q10(,?_
tack a copy of the workers' compensation policy declaration page (shoMng 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.
io hereby certify under the pains and penalties of perjury that the information:provided above is true and correct:
Date:
tone
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
f
Name of License Holder: aY� ,1 .Z�Lf / 7 q ,5 3
License Number
LL
Address 4 Expiration Date
Signature Telephone
9, Registered Home Improvement Contractor: Not Applicable ❑
Company Name Registration Number
H�O`'oreaa Expiration Date
x,70 ltL OTC)n Telephon
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 Wil result
in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... 4Z No-- ❑
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
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 buildin¢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 L�.�S?�C(4
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [❑] Decks [❑ Siding [[3] Other[❑]
Brief Description of Proposed }-
Work: La� �
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. Messcheck 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, J� () v c�
as Owner of the subject
property
hereby authorize ,
to act on my behalf, in all matters relative to work authorized by this uilding permit application.
ae P ILI
Signature of Owner Date
I, 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.
Print Name
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 Deparhnent
Lot Size
Frontage
Setbacks Front
Rear
Building Height
Bldg, Square Footage %
Op�n Space Footage %
(Lot area rninus bldg&paved
4 of Parking Spaces
A. Hasa 3pedoi Permit/Variance/Finding ever been isouedfor/on the site? ,
NO 0 DON'T KNOW 0 YES 0
|
|F YES, date isaued:| / '
IF YES: Was the permit recorded at the Registry of Deeds
NO �`� DONTKNOY� »r� YES
�� ��
IF YES: enter Book Page: ( and/or Document �
'
B. Does the site contain a brook, body of water orwetlands? NO 0 DDNT KNOW 0 YES 0
IF YES, has permit been or need tobe obtained from the Conservation Commission?
Needstnbeobtained ^_'�-� Obtained y—v��� Date |�sued' | /
' ' �
C. Do any signs exist on the property? YES L�
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 /—���
IF YES, describe size' type and location: \
|
E. Will the construction activity disturb(clearing, grading, excavation, or filling)over 1 acre orisit part ofo common plan
that will disturb over 1 acre? YES 0 NO 0
IF YES, then a Northampton Storm Water Management Permit from the DPVV is required,
L1 p 2 Department use only
DW �C ity of Northampton status of permit:
U uilding Department Curb Cut/Driveway Permit
SEP 18 2014 212 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability
Electric,Plumbing&Gas I hampton, MA 01060 Two Sets of Structural Plans
Northampton, 87-1240 Fax 413-587-1272 Plot/Site Plan
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
Map Lot Unit
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
r, 7L'eA\ r .c 2—Q C k nkr,-k t - �V„ n - Md, o i0'(,
Name(Print) `� Current Mailing Addr s: 1-
a tfi.a ehe C 1 Telephone
Signature
2.2 Authorized Agent:
•0'.T. ntl &Q )m ut'o V1 Ka.
Name(Print) Current Mailing Address: 010_1e
�-�-- 013 52#1- J4 775
Signature Telephone
SECTION 3 -ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
}
completed by ermit applicant
1. Building Roo Fi n '+' 00 (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) O . Check Number
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
20 COUNTRY WAY BP-2015-0321
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 12-012 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-2015-0321
Project# JS-2015-000598
Est.Cost: $5100.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RCI ROOFING 74334
Lot Size(sq. ft.): 24393.60 Owner: ZIEGLER JOHN F&CHRISTINE WHITE-ZIEGLER
Zoning-: Applicant: RCI ROOFING
AT. 20 COUNTRY WAY
Applicant Address: Phone: Insurance:
6 LINE ST (413) 527-4775 Workers Compensation
SOUTHAMPTONMA01073 ISSUED ON.911812014 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 Siznature:
FeeType: Date Paid: Amount:
Building 9/18/2014 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner