17C-023 (3) X1/16/2002 10:35 413-527--8469 RCI RODFI1*3 FAGiE 0:3
R.C.1 ROOFING
40 MAINE AVE.
309
'14�to - D A 01027-0309 C(=ES TZMA TE-)
7 1�5
7Y �$27- 4775
NOW
FA�� 4 13 f-0469
Dabs: 2-i6-n
T irm ESHMOW RX: MARK DEL ISLE
Fik– w-'P-plc PE RT i F S stad Date:
7:3 MAIN ST. Job Lomition: 1-3 KENG ST.
AMHERST, MA. 01002 F,1,0RFNCP, 14A. 01060
I Job Phone: (413)2F6-3442 (VAX 253-0799)
JOB MCRIPYTON
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25 AR "R=—
SPECIAL ITEMS NEEDED
XF NEW 5HF.4rHDV6 tS AIZEDEC, - ADD J4,000,00 TO XTAL $12,000.00)
TOTAL J0B C�fl' KOT TO ZKC:EZL1 12,0,99.GC.
Addtionat iffwmatian peda"to this Jc6 Ebfirrate
Job Cost jtL000.q.0
TERMS OF PAYMENT :7mEj�oj I
3C%PRIOR TO STAFtT Total Estimated
70%UPON COMPLETION
REGISTRATION#126235
FEDERAL I.D.4104 3418639 AEA'hofizod
CONSTRUCT!ON LICENCE#074334 Signaftm
INSURED BY HACKWORTH iNSURAWCZ(413)5274*07 1
ORIGINAL--ES71MATOR COPY
o4�liMfPTO '
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DEPARTMENT OF BUIIZFNG INSPECTIONS '
212 Main Street ' Municipal Building '
Northampton, Mass. 01000
WORKER'S COMPENSATTON INSURANCE AFFIDAVIT
(1i=se&permittee)
with a principal place of business/residence at:
(phone#)
(street/city/statr/ap)
do hereby certify, under the pains and penalties of perjury, that.
( ) I am an employer providing the following workers compensation coverage for my
employees working on this job:
(Insurance Company) (Policy Number) (Expiration Date)
( ) I am a sole proprietor, general contractor or homeowner (circle one) and have hired
the contractors listed below who have the following worker's compensation policies:
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) Gnsurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurmce Company/policy Number) (Expiration Date)
(Name of Contractor) (Insurance, Company/Policy Number) (Expiration Date)
(stiff additioml shoot ifnvorsury to include information pertaining to all ooabm ors)
( ) I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE:please be awuc that whim homcowmn who employ pc==to do mxadcmnc�mruuucrioa or repair work on a dwelling of
not more than three units is which the hotnoowncr midcs or oa the grounds appurtenant iherdo arc not gco=11y oowidered to be
emtploycn under the worker`s ration Act(GL152,ss 1(5)) application by a homcownu for a license oe permit may evidcaoe the
legal atatua of an omployar under the Wocicces C.ompeosation Act
I undcruaad that a copy of this uatemcut may be forwarded to the Dcputasccd of Indzuhial Aoeid,=b Offioo of Insuranoa for the
oovmgc verification and that failure to secure covmago under suction 25A of MQL 152 can lead to tba imposition of criminal pcnaltics
ooh of a fmc of up to S 1,500.00 and/or impris�of tip to one ytar and civil pcoame,in the form of a Stop Work Order and a
find of 5100.00 a day against tae.
For dq=tmoatal use ontY
/ Permit Number
' p2 f lirlz gyp# Lot#
:=lr& Signature of L- ermittee
r.
s
8 1 Licensed Construction Supervisor: / Not Applicable ❑
Name of License Holder: ' ,l�rf 1` [
License Number
Address Expiration Date
;>-
Signature Telephone
Not Applicable ❑
l � l
Age o-),2-
Company Name Registration Number
. G 309 -r ;V7
Address Expiration Date
Telephone S) 2- /�7Jr
'S
ECTIQN 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 affida
will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... No...... ❑
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)familie
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 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(,
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
�i' ddo'
�ECTION��DESCRIPTI�ON�O� PROPOSED�IVOR�`���he�k�all�a licable '"'�
dar: & :: s a
New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: Ve kuav-c CA6,j A 117 J
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet❑
'tfi New house nd 6a orO'd'tl gidk :cofi0, tie
46116w nr
/
a. Use of building : One Family Two Family y 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. Mascheck 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
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 . E1 COMPLETED WHEN
OWNERS AGENT"OR CONTRACTOR.APPLIE$F'OR8-BU1l:DING PERMIT
as Owner of the subject prope
hereby authorize ( to a(
my behalf, in all matters relative to work authorized by this building p rmit applica ion.
Signature of Owner Date
C _S o� as Owner/Authorized Agent
hereby declare that the statements and inf mation on the foregoing application are true and accurate, to the best of my
knowledge and belief.
�Pr ned under the pains and penalties o perjury.
int Name
Signature of Owner gent Date
4
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE
DENIED DUE TO LACK OF INFORMATION
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
volume&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW YES
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW
YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained Date Issued:
C. Do any signs exist on the property? YES 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:
-
- ---- ---- Northampton
u t! ��B i ig Department
I L;i Main Street ;S ►'
i I oom 100
FEB - 7 "02No pton, MA 01060
f phone 413-587- 1240 Fax 413.587-1272 PI�o /Si ePl s, 1 ,
-�`APPLTCaTf6N'f 0 CONSTRUC , ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This section to be'compI etl by off ce
1.1 Property Address: t''f *��
[[
3 Map Lot ' Uni '.
J �1� lL l m F k 3 4X sCA
Zone Overlay Distrct�
Elm St. District CW, I' I
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT>
2.1 Owner of Record:
73 'rnA,h 5 N ersT
Name(Print) Current Mailing Add ess
iEi&- 3 4-2
Telephone
.w
Signature
2.2 Authorized Agent:
/?C 1 o 64rx 3a f
Name(Print) `�� Current Mailing Address:
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building 06)C3 (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) Check Number
This Section'For Official Use Only
Building Permit Number: Date Issued:
Signature:`
Date
Building Commissioner/Inspector of Ruflding�
`7$J&wELL ST(1-3 KING AVE) BP-2002-0702
GIST#: COMMONWEALTH OF MASSACHUSETTS
1Cj1ap.Block- 17C-023` CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category:roofing BUILDING PERMIT
Permit# BP-2002-0702
Project# JS-2002-1128
Est.Cost: $8000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RCI ROOFING 126235
Lot Size(sq. ft.): 171 19.08 Owner: SHEBEK PETER M JR
Zoning:URB Applicant: RCI ROOFING
AT. 7 BARDWELL ST (1-3 KING AVE)
Applicant Address: Phone: Insurance:
P O BOX 309 (413) 527-4775 Workers
Compensation
EASTHAMPTON MAO 1027-0309 ISSUED ON:217102 0:00:00
TO PERFORM THE FOLLOWING WORK.-ST R I P & S H I N G L E ROO F
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/ Sienature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 2/7/02 0:00:00 25 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo