17C-124 (2) . .�. Roofing ______.
Daie
Estimate �___...
A1,11'I-
,)1w,w 1,4 1 ,'7-.t 1.'
1--ax X4 13)
Name, Address Job Location
Cu,,,i Fox
68 Sheffield Ln.
Florence, N/Li. 01062
/3 0 ,
Terms Rep
FS6111MC Valid for 30 days
Description Total
Rcli";vc xist;oo, rok,:s. 12,000. 10
111:11 & 'Sta;1 ALIIIJIMili drip edge, pipe (1ashinos, chillinc\ fk1shillos and step flashillos.
'ccd Winterguaid ice & water harrier alone caves and valleys.
FLI,nish an i ins,-.11 s\•,IlIctiC Undcrlaymcrit over existing deck.
Illol:sh:itw -ista;i >O :u CertainTeed Woodscape Series shingle.
cru ;h a,id -tall *,-crt.�mTced approved ridge vent.
2 L-nts I mpp , d 1)'v owner).
,,\]I •\tcrw� rCi,;:tL'd dchris to he removed by R.C.I. Rooting.
All v, -k wilt he i�c-I'mr-, ,d according to IIIZIII(11'aCI[Urers'specifications.
-Vi ar VA -,,orki,ianship warranty i[ICILICIC(l.
3� Yew Cc naw 1',:cd III;'tCI iid WMTMIlV iIIC1LIdCd.
All' IChk J porn .1' Will he ohtillnCd by R.C.I. Rool,111U.
[()I-wood decking rciflaccnicnt it*needed.
1%1, h 1 50t 1(W I I '1;IiH1CCd Landmark Woodscapc 50 VC;II l)rCII1iUII1 S11111,01C.
r cvt, I I III(is cs te mjcd warv;l III v LI II(-1 I I�lcd it aI o ned I 1,11I.Me is
tL-,'k d wdhh, 7
---,cv-w V\ S�to k e P
,NT- I O()K F(,',WAiM TO t)OJNG BUSINFSS WITH YOU.
Total
,'FIJOIS 'T PAY'ViINT 17
)os
Customer Signature
Oair
hIS111CO ')-\ 1%IUI'� 1 l'ICkL'I1 111S.
1,, 27-271
(lf'Akjssuchuseus
Department u� llirlustrinl.�1 cCirlc,lrt.�
Ofjic'e Uf Ill vesligatlons
000 H"Ushington Street
Boston, ,111A 02111
�� orl.rri' C(11111)cnsa6011 Insurance Built!ers/Conti'rectors/l�:lectriciiins/1'lurubers
1tt1-orlltatiott Nlcuse !'tint Leeibly
\:Ut1C 4�.,nlc:�:-t l• tticutitntliciduall:
,u, c to ,Ikis i I Check tht e
apprnpriute fox:
( + Type of project (required),
� ---
�� ;� . ;,iii ,tntilU ttirl-tlitiCl,• h;ISC hlrCd t)lC G L _jl New constructlon
t lnutnictt>r <tr partner listed on the atusched shc;et. 7. (_J Rculodehng;
:I;t.c no ample>vees These sub-contractors hasc � �. ❑ Denloiition
flit,' in `-1111' LapttClll' clllployee's and have workers'
[J Huilding additiurl
Kcrs �.�t;np. ;nsuranre a0tnp. insurance. �
cd
We arc. a corporation and its Electrical repairs or uddittun;
j to ,, Iler doing ale wilt{ rflicers Iutve exercised their ! i.[� 1,111mbing repairs or additlmis
A'o ct orkers' comp. right ofexerllption per fv1Cil_. 2.2i, repairs
and we have no
u;�„�; I�L• r.luirCd,l c.
152, X1(4), ❑ Other
employees. [No workers' I?, --__-- --
comp. insurance required.]
I must also fill out the SCCl)LM below showing their worker' compensation policy information.
i i ,,,,•,,,,;,,_;, ,, ,uhi„it ���: atti.htvit indicatint;they are doing till work and then hire outside contractors must submit a new al-icidvit indicating such.
ulna douched an mMitiontnl sheet showing the mine tit the soh-cuntructon and.Sidle whether or nol tbosc entities hnvc
cmpjovccs, thc�\ must p)WvIde their worker>' arrnh- h>licy nunnlxt-
'rir, ;irt cr :li,:r i,i providiir worA-ers' enmpensaliort imsiiranc•c/or my empiovees. BeluH' is the pulic. and job sile z
/1I!/rlJlilll U!7.
\;t(UC:_...
_33-.(�. f,.�piratiunOtilt: -I_�._'_Ll_;_ :L_1
vt lit iIt it Collv of the workevs' Coll)pellsation policy declaration Rage (showing the policy, number and expiration date).
Irc 4n, era c as required under Section 25A ol'NIGL c. 152 cull lead to the imposition of'criminal penalties of it
,I till ;t� l �iiU.l>U ;uuilor one-your imprisonment, <ls well as civil penalties in the loran of-a STOP WORK ORDER and it ti
i'tl ;t ;ia� ae ainst the violator. be advised that a cups of this statement tllrty he tarwarded to the Otlice of
cstig;ttiwt; of thr I)1A for insurance coverage verification,
zrrtrler tbt�xin.i ant/penalties o-flierjury that the infrorniation prnvitled above is true and correct.
(�fJiciai u.�r' until, Do tint write in this area, to he con,pleied h.h city o WOwl uJJkiul.
'i
lssu`in :authority (circle one):
11--rrntt,nt J. City/7own Clcrk 4. Electrical Inspector S. Plumbing Inspector
. .
. ,.'ONSTRUCTION SERVICES
N,)me of Lici�n,�o Holder
License Number
Expiration Date
Home Improvement Contractor: Not Applicable 0
Registration Number
Expiration Date
SECTION WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 162, 25C(6))
insurance affidavit must be completed and submitted with this application. Failure to provide this atfidavitvAll result
ier�ia' ,;',Ie issuance of the building permit.
Yes 1-311 No
1-1()riie Owner Exemption
cxncmcxc/npti"v Ior"hopicowners" �as cxIqdcdminclude [oo*(|) or wv<2) 6un |ies
,c ^` .61o°-such homeowner * engage ,n inJi"iduu| k., hire who does not po^scs^ o Ucon^c
�tmcl-visor. CINIR 780, Sixth Edition Section L08.3.5.1,
�),�t-oiition or Homeowner: Person (s)who own a [),ircel ofland on which hc/she rcsldcsor intends to reside,on which there
�—� e'dedm be, u one v, two family dwelling, attached vr detached structures accesso,ymsuch use and/mfarm
person who constructs morc than one home in a two-year criod iholl nQt bc cQnsidcrtd a homimwUcr.
'homro°ncr' oxax ^u»mx m the Building Official,vn o form acceptable to the """"".u°"°^
1-o"ponsible fo.r all such
Cons(ruction Super-visor your presence nuUhoj"h site %YU| be,required kvm time m time, during and upon
vhxe ..urk-k`r which this p^nni/ i` ipvcIJ,
h' ^J,\`odthm with ,c6rc"cxx`Chapter 152 (Worker,;' Comper*aovn) and Chapter \8 (Liability o[Bmpnycmm
:,,, \nu,iu not rcsohio�z i" Death) .,hx' Nunxchumu6cncm| Laws Annotated, fovporswn�o)
x^rk I'(), �^o ondc, thls pern`lt,
'xomco"ncr' uo��� and ^mm`c� n,poodhUity for ovmp|iuouxwith the ';Late Bui��8Cud�City o[
0r�\oxo�c`. �u�cxo� |..,a| l',niu6L^'nxoJSuun[Wun^chuxoosOencm| L*vm �nnu�m�� !
'/.`".,"""o, s.m"wrc ------
. .
SECT�ON_5- DESCRIPTION OF PROPOSED WORK (check all applicable)
e'� H 0 u S Addition 17 Replacement Windows LAlteration(s) F7
Roonng
Or Door-s
New Signs �Elj Decks. IL] Sidling (0) Other[Cl]'
Yes
No Adding new bedroom Yes No
Renovating unfinished basement Yes No
If New �.)Use and or addition to existii holi corTiplete the following:
se of �),, clirij One Family Other
N,j,)but - ooms in each family unit. Number of Bathrooms
P, Dimensions
opost�,� -ire footage of new construction.-
Fireplaces or Woodstoves Number of each
Masscneck Energy Compliance form attached?
is 00 fIL of wetlands' Yes No Is construction within 100 yr. floodplain-Yes 0
or celiar floor below Finished grade
orm lo tne Building and Zoning regulations? Yes No .
Sepi,c City Sewer Private well City water SUPPly
SECTION 7a
0WNERS AGE-NT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Oymer of the subject
diative to work aul prized by this"ouilding permit application.
Date
as Owner/Authortzed
',gen� here' are true and accurate, to the best of my know4edge
Signed under pains and penalties of peoury
Print i
Signatum of��nr,'Agent Date
ri�orrriat ion mus� 5e 'crip�ete�,. Permit ',in Be Denied Due To Incompiete Inlormation
Proposed Required by Zoning
This column to be.fillml in by
Building Department
� Ha� a Special Permit/Variance/Finding ever bcen issued for/on the site?
�� y�
AO \�/ D0�T KNOW \�� YES ��
\-/
/F Y[\, date nsued:� !
IF YES: was the permit recorded at the Registry o( Deeds?
wO `~/~� DONT KNOW /~~\ YES /^-\
i
IF YES� enter Book arid/or Document #/
,he vtccontain a brook' body of water or wetlands? NO 0 D0N7 KNOW /~~\ YES /°~\
IF YES, xasu permit been or need to be obtained from the Conservation Commission?
___
Needs to be obtained \�//~� Obtained y—\ ' Date Issued:
\`�
[
Do any Sigoscxiu on the property? YES 0 NO
\
/F
YES, describe size, ,ypcuoU (ocalmo:
� A,e ',here any proposed changes to or adUibnnso{ signs intended for the pnoper4' 7 YES 0 N 0
! ----- --- ---'--'--�-- � �
IF YES, describe size, type and location:
� v;ix m construction activity is �r�(clearing, grading, cavahon. o, filling)over I acre m is it pa�o(u common plan w
ma�°ood.om/� over Iao�? YES ( \ NO ( )
�� ��
-- ^ w="nemen/ Ponn: hum the DPW iorequired,
6 lot%
�F gd1 PrONN o
"0 04 of Nolhamplon siiidt
Building Department Curb C
212 Main Slreel
Ba~wer
Room 100 vVlrt
Northampton, MA 01060 '''.
pf,nne 413-587-1240 Fax 4 13-587-12 72
CKherrSFwcM' ;,
APP;. CATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
This section to be completed by offlce
1.1 Property —dress.
g S►'lC �\� -- 'tt?. Map Lot Unit
Zone O"riay District,
Elm St. DlstriCt ce Dletrftt
SECTION 2 ,ROPERTY OWNERSHIP/AUTHORIZED AGENT
Owner of record:
-C.0.,- (0% �e_�. `yn �o��nc .�/�a• o�abZ,
;ame Current Matti Address:
Telephone
Signature
2.2 Authorized Agent:
Name (Print) Current Malting Address: O l Q i
signature Telephone _ _J
SECTION 1 ESTIMATED C NQ ,5TRUCTION CQ^,�1TyS
Estimated Cost(Dollars)to be Official Use Only
com feted b rmit applicant
_._ Bu icinyv- I ��I vQV 0 (a) Building Permit Fee
arica; (b) Estimated Total Cost of
ConstrurAlon from 6 _
3. Plumbing ~ Building Permit Fee
4. Mechanic ; "HVAC)
5.,Fire'Protec0,n
5. Total = (l - 2 + 3 +4 + 5) OOU C)r> Check Number
This Section For Of Icisl Use Only J
Date t
Building Pe,rn;! Numbe:. - Issued:
Signature:
BulldIN Commissloner:lnspector of BuAdlnps Deis
68 SHEFFIELD LN BP-2011-0948
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17C- 124 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: roofing BUILDING PERMIT
Permit# BP-2011-0948
Project# JS-2011-001549
Est.Cost: $12000.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RCI ROOFING 74334_
Lot Size(sq. ft.): 25003.44 Owner: FOX COREY A
Zoning:URB(100)/ Applicant: RCI ROOFING
AT. 68 SHEFFIELD LN
Applicant Address: Phone: Insurance:
6 LINE ST (413) 527-4775 Workers Compensation
SOUTHAMPTONMA01073 ISSUED ON.5117120110:00:00
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:
FeeType: Date Paid: Amount:
Building 5/17/20110:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272
Louis Hasbrouck—Building Commissioner