11A-008 R.C. I. Roofing ,,A,
51B Holyoke Street
P.O. Box 309
Easthamptcn cn, MA 01027 Estimate Date
Phone (413) 527-4775 1/13/2009
Fax (413) 527-8469
Name/Address Job Location
George Kohout Back Addition (Partial)
37 Evergreen Road 37 Evergreen Road
Leeds, MA 01053 Leeds, MA
586-3759
Terms Rep
Estimate valid for 20 days Rich
Job Description Total
Remove existing roofs. 1,200.00
Furnish & install aluminum drip edge and step flashings.
Furnish & install CertainTeed Winterguard ice &water barrier on entire portion.
Furnish and install 15 lb. felt over existing deck.
Furnish and install 30 year CertainTeed Woodscape Series shingle.
All exterior roofing related debris to be removed by R.C.I. Roofing.
All work will be performed according to manufacturers' specifications.
5-year R.C.I. Roofing workmanship warranty included.
30 year CertainTeed material warranty included.
All related permits will be obtained by R.C.I. Roofing.
SPECIAL ITEMS NEEDED
Add $2.50 per sq. ft. for wood decking replacement if needed.
1
l
THE OWNER HAS THE RIGHT TO CANCEL THE CONTRACT WITHIN (3)
THREE BUSINESS DAYS OF DATE OF SIGNING. Total $1 ,200.00
TERMS OF PAYMENT
5°ra Deposit
Balance upon completion Customer Signature
Registration# 126235
Construction License#074334 Date / Z/4(1
U
Insured by Reynolds, Barnes&Hebb, Inc. 413-447-7376 -"y
ZG4� ��
Gi
t� Of 'Nar#IIa11lptell
3d �l:saachnsciti'
a � n
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060 ,
WORKER'S COMTENSATION INSURANCE AFMi AVTT
i,
Mly h
(licxnscrJpermiticc)
vvs-lh a principal place of busines Sires idence at:
513- (phone# -.1??5
r;trcct/ ty/stalrJaP)
c�,, he:Eby ce-ti>y, under the pains and penalties of perjury, that:
/
�v I as employer providing the following worker's compensation coverage for my
emnlovices working on this job:
Nati 6aal U nib n F`i Ye.
Tres• Co. of i 'ttsbuyq PA WC3b31'T69 10/05/09
('nsluanec Company) Y (Policy Number) (Expiation Date)
I «Z a sole proprietor, general contractor or homeowner (circle one) and have hired
tl:c contractors listed below who have the following worker's compensation policies:
(I'arze of Contactor) (Laurance ComparryiPolicy Number) (Expiration Date)
- (Diane of Contractor) (Insurance Comparry/Policy Number) (Expiration Date)
(Name of Contractor) (Laurance ComparrylPoGcy Number) (Expiration Date)
R,:amc of Contractor) (Lnstuame Company/PoUcy Number) (Expiration Date)
,,'-UACL a4AitiOQ21 Sheri if neceiury to iach3de infoemstion pertaining to all ooatmcton)
I am a sole proprietor and have no one worldng for me.
I am a home owner performing all the work myself.
r
NOTE:plc sc be awuc that H trio homcowvcrs who employ pertons to do m+ird'. _.,rr construction or repair work ao a dwelling of
:.o(more than throe units in wlbch the homeowner rrsida of oa the pounds appurtewu32 thwdo an not generally ooaruiacd to be
c..a*Y 3 under the woci %a a;,cx ioa Act(GL152,ss 1(5)),application by a homoowncr for a license or permit may evideooe tho
:tsx;C.suit of an employer under the WocS z cocepoeattion Art-
1 uz-�-icrrtand that a copy of this cr.atcmast may Ue focvrardod to tho Deputy ce2 of Industrial A.ocidea&OISoo of tuwticm fir the
--X&t va-ific aion acid that failure to roatrc t ovaragv uodar soetion 25A of MOL 1 S1 an lad to tk*osWoa of aimW P=Wet
;.octsisiiag of t"x'of up to S 1,500.00 wad"i c p Mi of up to owe year and avr7 pcmwcs in the form of a Stop Work Older trod t .
of�-104.00 Idly agniwt me.
For depsutmmtal wo only
Permit Number
-2 o?7 09 Map# Lot# z'
>: s; Signature of LiccnserRrrmittee -
SECTION 8 -CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: ` Not Applicable ❑
Name of License Holder: KAY k I)e1 i S 1 op, 7?q ,3 3 4
License Number
.18, o u o • Ea3l�zmn n a. 01oal - 10
Address —T Expiration Date
1
527- q 1 175
Signature Telephone
9.Registered Home Improvement Contractor: Not Applicable ❑
M. L' . I, lemon f;na 12 b 235
Conri j Registration Number
5 19 Make-Sire t 0• ��y- 5-�b- 10
Address i {� .�� )ms Expiration Date
Easthamp finry J"►a+ Q�Q2-q TelephonEMA52 -
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 will result
in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... ❑ No...... ❑
11. - Home Owner Exemption
The current exemption for"homeowners"\ras 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
st:'uctures. 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 joh site will be required from time to time,during and upon
completion of the work-Ibr which this permit is issued.
Also he advised that with reference to Chapter 152(Workers' Compensation) and Chapter 153(Liability of Employers to
I';<nployecs Jor injuries not resulting in Death)ofthc Massachusetts General Laws Annotated,you may be liable for person(s)
you hire to perlorm work ft01-you under this permit.
l-hc undersigned "homeom\ner"ccrti lies and assumes responsibility liar 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 ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [[—] Siding [p] Other[O]
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
,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
1, C PS n 0 n ! as Owner of the subject
property
hereby authorize LN air '
to act on my behalf, in all matters relative to work authorized by this uilding permit application.
attached a/'V l09
Signature of Owner Date—�
I' 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
V a7�o9
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
Scthacks Front
Side I.:
Rear
Building I(eight
Bldg. Squarc Footage °/,
Open Spacc Footage `N,
(Lot area minus hide&paecd
pa-kinc)
ol'Parkino,Spaces
I iii:
('111111C&l pcation)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW 0 YES Q
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW O YES 0
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO Q DON'T KNOW 0 YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained Q , Date Issued:
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location:
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, grading, excavation, or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO O
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Department use only
City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability,
_ q r, Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 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
.3'1 Evergreen Road, Map Lot Unit
L `1 Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Poehx�, �hnlli- 3 n lnad_/ Feeds njo53
Name(Print) Curr nt actin ddre s:
A tta eke Telephone
� - X375
ephone
Signature
2.2 Authorized Agent:
Eas..t. ameto�n a.
Name(Print) Current Mailing Address: —T X01021
( 113 527- -41 15 f
Signature Telephone
SECTION 3 -ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building Roo F1 YIQ um.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) ,bb Check Number
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
BP-2009-0714
GIS#: COMMONWEALTH OF MASSACHUSETTS
Allykil f. CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category BUILDING PERMIT
Permit# BP-2009-0714
Project# JS-2009-001058
Est.Cost: $1200.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Groin RCI ROOFING 126235
Lot Size(sg. ft.): 22956.12 Owner: KOHOUT GEORGE&DEBRA ORGERA
Zoning:URA(100)/ Applicant: RCI ROOFING
AT: 37 EVERGREEN RD
Applicant Address: Phone: Insurance:
P O BOX 309 (413) 527-4775 Workers
Compensation
EASTHAMPTONMA01027-0309 ISSUED ON:31312009 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 Si nature:
FeeType• Date Paid: Amount:
Building 3/3/2009 0:00:00 $35.0013664
212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272
Building Commissioner-Anthony Patillo