25C-172 (2) RC.10 R 11 o o fin Date
6 Line St. Estimate
Southampton,Ma. 01073 10/28/2014
Phone(413)527-4775
Fax(413)527-8469
Name/Address Job Location
Betty McDonald 129 North St.
129 North St. Northampton, MA 01060
Northampton, MA 01060 (413) 584-0416
Terms Rep
Estimate valid for 30 days Chris
Description Total
Remove existing barn and flat roofs. 7,400.00
Furnish& install 1/2" plywood over the existing decking.
Furnish& install aluminum drip edge,pipe flashings,chimney flashings(if needed)and step
flashings.
Furnish& install CertainTeed Winterguard ice and water barrier along eaves.
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.
Customer is responsible for securing interior items and any attic debris from roof removal.
Total $7,400.00
TERMS OF PAYMENT
5%Deposityl'���''"
Balance upon completion Customer Signatur
Registration# 126235 `L� /
Construction License#074334 Date J/ ael J 7
Insured by Banas&Fickert Ins.
(413)527-2700
The Commonwealth of Massachusetts
Department of Industrial`Mceidents
Office of Investigations
d 600 Washington Street
Boston, MM 02111
miiv.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electl•icians/Plumbers
applicant Information Please Print Legibly
lame (Business/Organization/Individual):
address: �,
;ity/State/Zip: of o-v3 Phone #; (x{13) `0 15
re you an employer? Check the-appropriate box: Type of project (required):,
S 1 am a employer with 2,0 4. ❑ I am a general contractor and I 6. ❑ New construction i
employees (full and/or part=time).* have hired the sub-contractors
7. Remodeling
J I am a sole proprietor or partner- listed on the attached sheet. t
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 1o,❑ 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 ill 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 utdicating 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 lily employees. Below is the policy and.job site
ormation.
urance Company Name: -
licy#or Self-ins, Lic, #: \,k) (Q(oS31q 0-15 Expiration Date:_ 10 • 5 • E -
Site Address:_ 2,y ,ti)oCA-�h ,S"t - AAA Q to G.o
tach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date),
ilre to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties or 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,
io hereby certify under the pains andpenalties ofperjury that the information provided above is true and correct.
gnaturc•
Date•
tone# -
Ojf<cW 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 C]
Name of License Holder: M? 1{ �P, `ef f 714��*'(
License Number
Address Expiration Date Ar 141"1
Signature Telephone
9. Registered Home Improvement Contractor: Not Applicable 0
1.W 35
Companv•Name Registration Number
Aooreaa Expiration Date
n —7 3 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....... ie No...... O
11. - Home Owner Exemption
The current exemption for"horpeowners"was extended to include Owner-occupied Dweliin¢s of one(1) or two(2)families
and to allow such homeowner td engage an individual for hire who does not possess a license,provided that the owner acts
as supervisor.CMR 780, Sixth Edition Section 108.3.5,11.
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 shallil 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 mwn(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'
\orthampton 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 ❑ Addition ❑ Replacement Windows Alteration(s) Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [1711] Deck Q Siding [C7] Other[0]
Brief Description of Proposed
Work: 144/�J �, 4y, i �l V V
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 t0 gusting 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� as Owner of the subject
property
hereby authorize PLY I S1 e d R Soof;nei
to act on my behalf, in all matters relative to work authorized by this uilding permit application.
at t o she i 1 I I
Signature of Owner Date
I, ,.Maxk 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
I —
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 %
.Qppn Space Footage %
(Lot area minus bldg&paved
of Parking Spaces
Fri.]11
A. Has a Special Pennit/Vadance/Finding ever been issued for/on the site? `
f-� y—�
NO �_/ DON'T KNOW �_� YES
|F YES, date ioupd; /
IF YES: Was the permit recorded at the Registry of Deeds?
NO � DONTKNOV � YES
0
/ !
IF YES: enter Book ! � Poge| ! and/or Document #! �
��
B. Does the site contain a brook, body ofvvutprnrvvetiands7 NO ��/ DON'T KNOW v�� YES
IF YES, has permit been or need to be obtained from the Conservation Commission?
Needs �-t Obtained v-� Date Issued:
\
!
.`-`.^ ^. ~` .~`...^. ~~^...^. �_� . ~.^= .,,"=". |
��
C. Do any signs exist on the property? YES x^� NO k1i
IF YES, describe size, type and location: | |
D. Are there any proposed changes to or additions of signs intended for the property ? YES NO 0
. /
IF YES, describe size, type and location: | |
'
E. Will the construction activity disturb(clearing, grading, excavation, nr filling)over 1 acre misd part ofa common plan
that will disturb over 1acre? YES C � NO
��
|F YES,then o Northampton Storm Water Management Permit from the DPW io required.
Department use only
City of Northampton Status of Permit:
Building Department Curb:CutlDrivevvayPermit
212 Main Street se er/Septic Availability
- 4 Room 100 WaterNvell Availability _
Novi 2 � orthampton, MA 01060 Two Sets of Structural Plans _
_ .41 -587-1240 Fax 413-587-1272 Plot/Site Plans
Electric. 1 r <: ton:
r4ther 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:
(?�q ti)' r <F , Map Lot Unite
/j 0 C kNNt.- y\9V0 ()1 AAA Zone Overlay District _
Elm St.District CB-District _
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
i ✓y�C��or 125 j0 �Y� �� �C�r\c rv.D�oA /,1A O 1 b G
Name(Print}-1 C rrent cling Addr ss:
ta Ch Telephone
Signature
2.2 Authorized Aaent:
..
Name(Print) Current Mailing Address: 010-18T
o I!) 5 pr7- J4 175
Signature Telephone
SECTION 3.-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building o0f.1 h ( t
'C 0 (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) Q(� , CSU Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued: —
Signature:
Building Commissioner/Inspector of Buildings Date
129 NORTH ST BP-2015-0550
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:25C- 172 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-2015-0550
Project# JS-2015-001054
Est. Cost: $7400.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RCI ROOFING 74334
Lot Size(sq_ft.): 10541.52 Owner: MCDONALD ELIZABETH A&MELISSA A HAYES&MARTHA J BOYER
Zoning URC(100)/ Applicant. RCI ROOFING
AT. 129 NORTH ST
Applicant Address: Phone: Insurance:
6 LINE ST (413) 527-4775 Workers Compensation
SOUTHAMPTONMA01073 ISSUED ON:11/13/2014 0:00:00
TO PERFORM THE FOLLOWING WORK.STRIP & SHINGLE BARN & FLAT ROOFS
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 11/13/2014 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner