36-207 (6) Roofin
6 Line St.
g Estimate Date
Southampton,Ma.01073 11/3/2014
Phone(413)5274775
Fax(413)527-8469
Name/Address Job Location
Dennis Heberet 5 Birch Lane
5 Birch Lane Florence,MA 01062
Florence,MA 01062 (413)246-0474
Terms Rep
Estimate valid for 30 days Chris
Description Total
Remove existing roofs. 22,600.00
Remove existing rear gutters.
Remove existing fascia on rear.
Furnish&install cedar fascia& 1"x2"shingle strip.
Furnish&install aluminum drip edge,pipe flashings,chimney flashings(if needed)and step
flashings.
Furnish&install CertainTeed Winterguard ice&water barrier on entire roof.
Furnish and install synthetic underlayment over entire existing deck.
Furnish and install Lifetime CertainTeed*Pro Landmark Series shingle.
Furnish and install CertainTeed approved ridge vent.
Re install gutters.
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.
Finishing of cedar products to be done by others.
Add$2.50 per sq.ft.for wood decking replacement if needed.
A Certainteed Surestart plus warranty will be included with a fee of$760.00 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 $22,600.00
TERMS OF PAYMENT
5%Deposit
Balance upon completion Customer Signature
Registration#126235
Construction License#074334 Date—, �
Insured by Banas&Fickert Ins.
(413)527-2700
/ VIM S �)1 p-o LC cC)L �n,oz 12c (3t�,c k
The Commonwealth of Massachusetts
Department of Industrial-Accidents
Office of Investigations
600 Washington Street
t` Boston, MM 02111
miw.mass.gov/dia
Workers' Compensation Insurance Affidavit: Build ers/Contract ors/El ecti-icians/Plumbers
applicant Information Please PriDt Legibly
1 ame (Business/Orgaruzation/Individual): Lt,' op
,.ddress: �,
;ity/State/Zip: ,���-�, �o� cT of o-13 Phone #: (x Q) 5�1,1 -� -1 25
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 art
ees full and/or =time .* have hired the sub-contractors
y ( riet p or or partner-
) listed on the attached sheet, t 7• ❑ Remodeling
I am a sole prop
]
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 lo.❑ 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' 13.0 Other
comp, insurance required,]
iy applicant that checks box fl l 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 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
'ormatlon.
urance Company Name:
licy#or Self-ins. Lic. #; W �7(A_ 1 O 5 Expiration Date,_ 10 • 5 - J.!4
Site Address; -5 i�), noe . City/State/ZiP; �rY �,_ �_�• n►oc�L
tach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date),
iluse to secure coverage as required under Section 25A of MGL c, 152 can lead to the imposition of criminal 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 $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,
(o hereby certify under the pains andpenalties ofperjury that the Information provided above is true and correct.
matu Date:
tone#: 5?,1 -1 `ihs -
Official use only. Do not write in this area, to be completed by city or toim official.
City or Town; Permit/License #
Issuing Authority (circle one):
1. Board of Health 2.Building Department 3. Cityrrown Clerk 4.Electrical Inspector LPlumblng pec tor
6. Other
Contact Person: Phone#:
SECTION 8 -CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
�01 ,�c I� J
Name of License Holder; M aY�—�.t �� ��q `.1 4
License Number
Address - Expiration Date
(1413) 521- qq5
Signature Telephone
9, Registered Home Improvement Contractor: Not Applicable ❑
1.26235
CompanvName Registration Number
-
(-� s� , 5-0�- ►;
/Aoorea� Expiration Date
01'1 Telephon
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 will 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"horpeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)families
,ind 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.
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, Statc and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
i •
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ff- Roofing FYI
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [o] Decks [[Z] Siding [❑] Other[0]
Brief Description of Proposed
Work: ttaC!
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., comolete the followincl:
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, ` ) _ VNV �S \ �Y� t" `� as Owner of the subject
property
hereby authorize ' •
to act on my behalf, in all matters relative to work authorized by this building permit application.
at,tachpad i t - 111-1-\,-k
Signature of Owner Date
I, Aly h Me,i Sl e. aS au t6)Y17.gA apent 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 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
Olpen Space Footage %
(Lot area ininus bldg&paved
of Parking Spaces
A. Has o Special Permit/Yariance/Finding ever been issued for/on the site?
~��
NO �_/�-\ DONT KNOW �~� YE3
|F YES, date issued; | '
IF YES: Was the permit recorded at the Registry of Deeds?
NO �� DON'T KNOW �� YES
x�/ \~� \~�
IF YES: enter Book | � Page! | and/or Document #� �
/
�� ��
B. Does the site contain a brook` body nfvvaterorwetlands? NO v���� DONT KNOW \~� YES «+�
IF YES, has permit been or need to be obtained from the Conservation Commission?
Needs tobeobtained |�sued'
/~~� Obtained /—� Date | |
v^� ' (
�-�
C. Do any signs exist on the property? YES NO
0 l~�
IF YES, describe size, type and location: i |
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO
0
/
IF YES, describe size, type and location: |
|
E Will the construction activity disturb(clearing, gradingexcavation, or filling)over 1 acre orioit part ofa common plan
that will disturb over 1acre? YES K ) NO � ]
�� I�
|F YES,then a Northampton Storm Water Management Permit from the DPW io required,
Department use only
NOV 20 2014 City of Northampton Status of Permit:
Building Department 'Curb Cut/Driveway Permit
L7
C-
!,*.�, � 212 Main Street 'Sewer/Septic Availability.
C- Room 100 ,W'ater1W'elI Amailabilit
Northampton, MA 01060 Two Sets of Stru ctural Pians
phone 413-587-1240 Fax 413-587-1272 ePlot/Silte PIans
I�Olher Specify_
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION I -SITE INFORMATION
1.1 Property Address: This section to be completed by office
P-- Map Lot Unit
-D �6�(-C-\-",
Zone Overlay District
AA A Elm St.District CIB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
CkQY-C A-C e— AAA L 0
Name(Print) CZent Mailing Address:
4 1 U 7-q G - 0(4-1 S
Tel�jphon6
Signature
2.2 Authorized Agent:
M
h -1) e, Rod i na ScalaM ton ma
Name(Print) Current Mailing Address: 0 107,13.
( �13) 52#1-
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building Ro 0 Fi (Poo� (Doi (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= 0 +2+3 +4+5) 00 Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
5 BIRCH LN BP-2015-0587
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 36-207 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-2015-0587
Project# JS-2015-001119
Est. Cost: $22600.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RCI ROOFING 74334
Lot Size(sa. ft.): 81457.20 Owner: HEBERT DENNIS P&DONNA G
Zoning: Applicant: RCI ROOFING
AT. 5 BIRCH LN
Applicant Address: Phone: Insurance:
6 LINE ST (413) 527-4775 Workers Compensation
SOUTHAMPTONMA01073 ISSUED ON.•1112012014 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 11/20/2014 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner