32C-176 (5) 10/23/2014 8;48AM FAX 14135278468 RCI ROOFING 00001/0001
RC 01. 00ru Dafe
e6 Line St.
Southampton,Ma.01073 t0/1�zd14
Phone(413)527-4775
rA%(413)$27.8469
Name/Address Jab Location
Holyoke St,LLC. 19 Holyoke St,
Attn:Harold Willard N.arthampton,MA 01060
19 Holyoke St. (413) 584-7344
Northampton,MA 01060
'Terms Rep
F.sthnate valid for 30 dttya Keith
Description Total
Removt existing roofs on 2 stall garage. 4,300.00
Ful-nish&install ill"plywood over existing docking.
1?urni$h&install aluminum drip edge.
Furnish&Install CerteinTeed Winterguard ice&water barrier on entires reot
Furnish and install Liflatirne Cortalnreod Landmark Sorles shingle.
All exterior roofing related debris to be removed by R-C.1.Roofing,
All work w.lil be performed accordlrtg.to.titanufisciurer8'...spaaiflctltlotls.
L•ifvtfine CcrtettiTeed material wattittty Included.
All related pormits will be obtained by R.C.I.Rooting.
FLO W
Customer Is responsible for 84onring interior itoms and any anlc deltrls from roof removal.
T- 70t
TERMS OF PAYMUNT
5%Deposit Customer Signature
Baltmce upon completion
Roglstratiorn M 126235
ConstnictiOn License#074334 bate
insured by Bans&fickert Ins.
(413)527.2700
1 /T HOFId 09CZb6S£Tb S ,C70UVH WV 17Z TT bTOZ "6T "AOR
The Commonwealth of Massachusetts
Department of Industrial-Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electi-icians/Plunnbers
.pplicant Information Please Print Legibly
lame (Business/Organization/Individual): (� ( kdp
address;
;ity/State/Zip; r\ mo_ o�o°7 3 Phone #; (q13) 5 a`l -V1,15 -
re you an employer? Check the appropriate box: Type of project (required):_
g'I am a employer with 2 U 4. ❑ I am a general contractor and I 6, ❑ New construction i
employees full and/or .* have hued the sub-contractors
(fall p art=time) 7. Remodeling
i
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' 13.0 Other
comp, insurance required]
iy applicant that checks box N 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 utdicating such,
ntractors that check this box must attached an additional sheet showing the name of the subcontractors and their workers' comp.policy information,
in an employer that Is providing workers'compensation insurance for my employees. Below is the policy and.job site
'ormatiom
urance Company Name: 5�0-<- -
licy#or Self-ins. Lic, #: W � . Expiration Date: 10 • 5 . J.!4
Site Address: i q A-Q�uC �a City/State/Zip:�4lor l�,aw�D n�, 1r� O)oi�o
tach a copy of the workersT 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 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 andpenalties ofperjury that the information provided above is true and correct
gnature: .�
/ Date: I1-1�1- 1y
tone# C�i ..-(`4`1 `( -'s
Ofjt*cW use only. Do not write lit 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. CitylTown Clerk 4.Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone#:
SECTION 8 -CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor; Not Applicable 0 Q
Name of License Holder:
License Number
Address Expiration Date
5 2q- 175
Signature Telephone
9. Registered Home improvement Contractor: Not Applicable O
Company Name Registration Number
I (n 6n
AoorUba Expiration Date
aha. Q 1 ON3 Tetephon
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 Wit result
in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... iz No...... O
11. - Home Owner Exemption
'The current exemption for"horpeowncrs"was extended to include Owner-occupied Dwelllnes 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 shag be
responsible for all such work performed under the building permit.
,�s 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
Hmployees 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
\orthampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated,
Homeowner Signature att.a�,,�e(4
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House Addition ❑ Replacement Windows Alterati n ) Roofing
Or Doors ❑ fl
Accessory Bldg. ❑ Demolition ❑ New Signs [171] c Siding [0] Other[0]
Brief Description of Proposed
Work:
Alteration of existing bedroom Yes No Adding n w edroom Yes No
Attached Narrative Renovating u,fi fished basement Yes No
Plans Attached Roll -Sheet
,6a. If New house and or addition to existing housing, comp'l'ete 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, r A ctr- as Owner of the subject
property
hereby authorize ' R.C. T.
to act on my behalf, in all matters relative to work authorized by this building permit application.
at,t a ehe d 1 \- 19 - '4
Signature of Owner Date
'hA MeIiSlle- -aS _aLJt6y'17.eJ aQent 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,
Signature of Owner/Agent Date
Section 4, ZONING Att 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 Deparh-nent
Lot Size
Frontage
Setbacks Front
Rear
Building Height
Bldg. Square Footage
(Lot area rninus bldg&paved
of Parking Spaces
A. Has a Special Pennit/Yariance/Finding ever been issued for/on the site?
NO �_y_�� DONT KNOW �_�~�� YES
!
IF YES, dote issued; | '
IF YES: Was the permit recorded ut the Registry ofDeeds?
NO 0 DONTKNOY 0 YES ~
IF YES: enter Book ! | Page! | and/or Document #� �
B. Does the site contain n brook' body of water orwetlands? NO �^ DON'T KNOW 0 � 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needatnbeobtained �
-
� Obt�ned /,�' Date
\
v.� ' ! /
C. Do any signs exist on the property? YES 0 NO
' - �- -- - - -` -- - ---- - — i
IF YES, describe size, typo and location' |
|
D. Are there any proposed changes tonr additions ofsigns intended for the property 7 YES \~�/�� NO �~~��
�
IF YES, describe size, type and location: � !
E Will the construction activity disturb(clearing, gradingexcavation, nr filling)over 1 acre nrioit part ofa common plan
that will disturb over 1acre? YEGK � NO � �
`�/ ^�v
IF YES,{hen o Northampton Storm Water Management Permit from the DPW io required.
Department use only
j City of Northampton Status of Permit:
I jv�� I' Building Department Curb Cut/Driveway Permit
212 Maln Street "Sewer/Septic Availability
2 I ROOM 100 Water/Well Availability orthampton, MA 01060 Two Sets of Structural Plans
I, 3-587-1240 Fax 413-587-1272 PiotlSite Plan's
A i'
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
C rlly1o,rt'1�\ Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
.a,k.("Vye S} U-t - (6Lrdl lua\'\�r.� 1c, a lw6l - S� - kc�r4 w lon /A4 o)OCC
Name( rint) Current Mailing-Address:
-attiche.(A Telephone
Signature
2.2 Authorized Agent:
MIA I 0.1�AJ6 ?(Xfinn
Name(Print) Current Mailing Address: T0 0-
13) 5:21- J4 175 V
Signature Telephone
SECTION 3.-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
{ completed b permit applicant
1. Building o0fi h '`�' C'L (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from (6)
3. Flumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total = (1 +2+3+4+5) C C Check Number
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
19 HOLYOKE ST BP-2015-0596
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32C- 176 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-2015-0596
Project# JS-2015-001128
Est. Cost: $4300.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RCI ROOFING 74334
Lot Size(sc. ft.): 33105.60 Owner: HOLYOKE STREET LLC
zoning: GB(100)/ Applicant: RCI ROOFING
AT. 19 HOLYOKE ST
Applicant Address: Phone: Insurance:
6 LINE ST (413) 527-4775 Workers Compensation
SOUTHAMPTON MAO 1073 ISSUED ON.11/2112014 0:00:00
TO PERFORM THE FOLLOWING WORK.STRIP & SHINGLE GARAGE 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 11/21/2014 0:00:00 $35.00
212 Main Street,Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner