11C-034 (4) R.C.1 ROOFING
P O Box 3 9 RO-222 001 =TIMA TE
EASTHAMPTON, MA 0(413)527- 4775PO 060NS FAX (413)527-8469 Date: 6/19/01
Estimate To:
JOE ASHTON Estimated By: MARK DELISLE
n Start Date:
Job Location: LEEDS PACKAGE STORE
AJ
a 1 *4
"JobPhone: 586-0663 FAX 584-3295
JOB DESCRIPTION
NEW ROOF TO RE TMSTALLED OVER EXISTING ROOF
FURNISH & TMSTALL 112" FTRERBOARD RECOVER INSULATIOAl MECHAN-TCALLY FASTENED
PTIRNT.<:�R r 1jVSTALr, 1K0 TORCH APPLIED MOnTFTFD BITUMEN FLAT ROOF SYSTEM
FURNISH & INSTALL .032 GAUGE COPING METAL ON FRONT OF BU1LDING
FURNTSH & INSTALL .032 GAUGE ALUMINUM EDGE METAL ON BACK OF RUTLDlAfG
ALL ROOFING RELATED DEBRIS TO RE REMOVED BY R.C.I. ROOF11vG
ALL WQR.K WTT,T, RE PERFORMED IN ACCORDANCE WITH MANUFACTURERS SPECIFTCATIONS
12 YEAR MANUFACTURERS LABOR & MATERIAL WARRANTY -TIVCLUDED
ALL PFT,ATED FLASHIAIGS INCLUDED
SPECIAL ITEMS NEEDED
Additional information pertaining to this Job Estimate
TERMS OF PAYMENT
30%PRIOR TO START 70°%UPON COMPLETION Total Estimated
MA.REGISTRATION#126235 Job Cost $6,000.00
FEDERALI.D#3418839
CS LICENSEM074334 Authorized
INSURED BY HACKWORTH INSURANCE(413)527-9907 Signature ( )��
ORIGINAL-ESTIMATOR COPY
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B �lasa Atl(ttartta'
DEPARTMENT OF BUILDITNG INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
with a principal place of business/residence at:
_t
1/0 /�� `,� � ✓� fns'• 0�.1�7(Phone#} �.Z �- q 77S
(street/city/staf elnp)
do hereby certify, under the pains and penalties of pegury, that.
W, am an employer providing the following workers compensation coverage for my
employees working on this job:
vv4 i Svc, 3 /ST 3l 1/ 2y o
(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) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Compaay/PoGcy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additioml shed if necessary to kwlude information pertaining to aII ooa rectors)
( ) 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 aurae that whilo homeowners who employ persons to do main __ate eoreniction or repair work on a dwelling of
not more than throe units in which the homeowner mides oc on the grounds gTurteav t thereto art not geneally Considered to be
employers under the wvrice"s compensation Ad(GL152,ss 1(5))�application try a homeowner for a l oc=or permit may evidence the
legal rtanrs of an employee under the Worlds Compomation Act.
1 understand that a oopy of this ctatcmmi may be forwarded to tbo Dopwtmmt oflndu3tiel Aoddca&Offioc of Insurance for the
coverage verification and that failure to secure coverago under section 25A of MOL 152 can lead to the imposition Of Mmimal Pemlties
consisting of a fine of up to S 1,500.00 and/or im prisot #of up to one ytar and civil penalties is the form of a StCP Work Order and a
fine of S 100.00 a day against tae.
gPermit —only
Number
.� Lot#
`i Signature of Licensee/Permittee
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable 0
Name of License Holder
/9 X9
Signature Telephone
Not Applicable 0
4 () m I', Ce",-lee ��/C/ 2
Address Expir4ion/6ate
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152,§2SC(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.
WiM
The current exemption for'hooeonmem~was extended toinclude one(1) orowo(2)families
and to allow such homeowner to engage ao individual for hire who does not possess alicense,provided that the owner acts
as supervisor.CMR 780, Sixth Edition Section 108.3.5.1.
Definition of :Berson(s)who own apmreln[���x��b��r�i�am����/�i�.�n����
is,o/iu�t ndcdk`bc'uooeo«t*o�odly6woOi ,uttucbedordcom6cdxkocUuroxaccemorytouuubuoeuod/ortarm
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 Superviso your presence on the job site will be required from time to time,during and upon
completion of the work for which this pen-nit is issued.
Also he advised that with reference to Chapter l52(VVockom` Conpoomuduu) and Chapter |53 (Liability o[Employers to
Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,you may be liable bnrperauu(x)
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
SECTION 5 DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] / Siding[ ] Other [ ]
Brief Description of Proposed Work:—VI,
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes __No
Plans Attached Roll ❑ - Sheet❑
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. 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 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
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.
"Signature of Owner Date
as Owner/Authorized Agent
hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my
knowledge and belief.
Signed under the pains a d penalties of perjury.
Print Name
i
Signature of Owner/Agent Date
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:
4
p C� L ampton
0 Ffl g
artmentt
212 i Street
JUN 2 6 2M1 R 00 I
Northam ton, MA 01060
DE N 40 Fax 413.587-1272
Q ,,z
HAMPTON MA 01060 y 'mom
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 b ,completed,by gf �ce
d,,;, Map'! Lod;: Unit
kY"
Zone Overlay District-
Efrh St. District" GB Restrict
SECTION 2 -PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
-j 0 e- �h 1�c�►r1
Name(Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone Cl 7 7-5—
SECTION 3 • ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building (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 =(I +2 + 3 +4 + 5) c> O Check Number
This Section For Official Use Only
Building Permit Number: Date Issued;
:Signature:
Building Commissioner/Inspector iof Buildings gate
=� 'Y'DENVILLE kv' BP-2001-1105
GIS#: COMMONWEALTH OF MASSACHUSETTS
:Block: 11C 434' CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Categor :roofin BUILDING PERMIT
Permit# BP-2001-1105
Project# JS-2001-1944
Est.Cost:$6000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO.
Const.Class: Contractor: License:
Use Groin RCI ROOFING
Lot Size(sq.ft.): 18730.80 Owner: ASHTON JOSEPH D
Zoning:HB Applicant: RCI ROOFING
AT.• 24 HAYDENVILLE RD
Applicant Address: Phone: Insurance:
P O BOX 309 (413)527-4775 Workers
Compensation
EASTHAMPTONMA01027-0309 ISSUED ON:61261010:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL NEW FLAT ROOF SYSTME OVER
EXISTING
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Inspector of Buildings
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
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:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 6/26/010:00:00 387&388 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo