17A-119 v
R.C.1 ROOFING
40 MAINE AVE.
P.O. Box 309 FESMATE
EASTHAMPTON, MA 01027-0309
PHONE (413)527- 4775
FAX (413)527-8469
Date: APRIL 22, 2002
Estimate To:
ELZBETH GREGORSKI Estimated By: MARK DELISLE
46 CLAIRE AVE. Start Date:
FLORENCE, MA. 01060 Job Location: 46 CLAIRE AVE.
FLORENCE, MA. 01060
Job Phone: (413)584-3742
JOB DESCRIPTION
REMOVE EXTSTING ROOFS,
5 YEAR R.C.T. WORKMANSHIP WARRANTY rMCLUDED.
SPECIAL ITEMS NEEDED
ADD $2.00 PER SQUARE FOOT FOR WOOD REPLACEMENT IF NEEDED.
Additional information pertaining to this Job Estimate
TERMS OF PAYMENT
30%PRIOR TO START Total Estimated
7096 UPON COMPLETION
Job Cost9-eeese9
REGISTRATION#128235 TOO. Ca
FEDERAL I.D.004 3418839 Authorized
CONSTRUCTION LICENSE t 074334 Signature �"k 1
INSURED BY HACKWORTH INSURANCE(413)527-9907
DUPLICATE-CLIENT COPY
a.
• 4•�1iMiP�0 ..
B �aSfACt(t[ftllf•
e �
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
with a principal place of business/residence at:
yo ma►�n� �j.v \�•ny..,p n �Ma OIbG'XPhone#�y�3�,'
(strce(/city/statrlap)
do hereby certify, under the pains and penalties of perjury, that:
(v�'I am an employer providing the following worker's compensation coverage for my
employees working on this job:
6)C x-31 S.31117,q-011 10-5-02
ansur-Ace 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:
...t
r (Name of Contractor) (Insurance Company/Policy Number) (Expirntion Date)
(Name of Contractor) (Insurance Company/PoLicy Number) (Expiration Date)
(Name of Contractor) (Insurance Compauy/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(nand,additioml sheet ifneccusry to isrclude infonnstioa pertaining to.il ooatn d )
( ) 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 aware that while homeownm who employ per om to do„n„.tcu ner,comuuction'or repair work on a duelling of
not more than throe unite is which the bomwwocr resides or on the grounds appurtenant thereto arc not geoeralty 000saknd to be
employers under the wwkcex compensation Ad(GL152.fs 1(5)1 application by a homeowner for a license a permit may evidence tho
legal status of as employs under tho Woricoes Campoau6oa Ad.
I unde:suad that a copy of this rutrmccd may bo faewarded to tho Dtpwtmca2 of Iodwtriah Aocideadf O$oo of lnwc+noe for the
ooverage verification and that failure to seam covarago under soodoa 25A of MOL 152 an lead to tba imposition of criminal penalties
oonsisting of a fine of up to S1,500.00 and/or imprisonment of tip to one year and civil pcn&Mcs in the form of a Stop Work Order and a
fine of 5100.00 a day against tvc
For depatmeaw use ody
permit Number
Map# Lot#
Timiature of T Date
Version 1.7 Commercial Building Permit May 15,2000
4
Independent Structural Engineering Structural Peer Review Required Yes......❑ No......❑
SSE
Q
1, �Z �—:S
as Owner of the subject property
hereby authorize C to act on
my behalf, in all matters relative to work authorized by tbi&uilding permit application.
Signature of Owner Date
I, ma—rAet', O W as Owner/Authorized Agent
hereby declare that the statements and information on the foregoing applicati re true and accurate, to the best of my
knowledge and belief.
signed under the pains and penalties of perjury.
r
Print Name
Signature of Owner/Agent Date
''4
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:no—no :K!)E \\S��. b - LA
1
License Number
4
Address I Expiration Date
C— S21 qM11 S 4-3) ,
Signature Telephone
SEGTION�3 NS7�011 RA fr�b�iVlT�f+llG 52 C(. '
y.
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...... ❑
Version 1.7 Commercial Building Permit May 15,2000
9.1 Registered Architect:
Not Applicable ❑
Name(Registrant):
Registration Number
Address
Expiration Date
Signature Telephone
92 Registered Professional Engineer(s):
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
9.3 General Contractor
Not Applicable ❑
Company Name:
Responsible In Charge of Construction
Address
Signature Telephone
Version 1.7 Commercial Building Permit May 15,2000
7. Water Supply(M.G.L.c.40,§54) 17.1 Flood Zone Information: 17.3 Sewage Disposal System:
Public ❑ Private ❑ Zone: Outside Flood Zone ❑ Municipal ❑On site disposal system ❑
8. NORTHAMPTON ZONING
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:
' Version 1.7 Commercial Building Permit May 15,2000
' .4
Interior Alterations Existing Wall Signs Existing Ground Signs Additions ❑ Roofing �(
❑ ❑
Exterior Alterations Demolition❑ New Signs [ ] Change of Use ( ] Other [ ]
❑ Accessory Building[ ] Repairs [ J
�ESC2�P7�'
� 4
USE GROUP(Check as applicable) CONSTRUCTION TYPE _
A Assembly 10 A•1 ❑ A-2 ❑ A-3 ❑ 1A ❑
A•4 ❑ A•5 ❑ 1B ❑
B Business ❑ 2A ❑
E Educational ❑ 2B I ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
Institutional ❑ 1.1 ❑ 1.2 ❑ 1.3 ❑ 3B ❑
M Mercantile ❑ 4 ❑
R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑
S Storage ❑ S•1 ❑ S-2 ❑ 5B ❑
U Utility ❑ Specify:
M Mixed Use ❑ Specify:
S Special Use ❑ Specify:
s COMPtE�T H15 $, y nRGO1N�REN S ' , f1O S DD1TI D,-WGENUSE x`
Existing Use Group: Proposed Use Group:
Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34):
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION
I
Floor Area per Floor(sf) 15t
1st 2nd
2"d 3'd
3`d 4th
4th
V
Total Area (sf) Total Proposed New Construction (sf)
_................................... I
Total Height(ft)
Total Height ft••--•--•---•--------
t - _
Version 1.7 Commercial Building Permit May 15,2000
City of Northampton
--Building Department
212 Main Street
Room 100
Northampton, MA 01060
phone 41 587:•1240 Fax 413.587.1272
APPLICATION TO CONSTRUCT, RE R OCCUPANCY OF, OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY ING
1.1 Property Address:
F
Ll t CU" `'� QV�
p s
��
2.1 Owner of Record:
G I -
Name(Print) Current Mailing Address:
1
Signature Tele hone
2.2 Authorized Agent:
P fox 30� - , ns c\. rte.
Name(Print Current Mailing Address:
`G j `
Signature Terephone
EQT N a
.,—u NKNt,*@�ff3`t:Y uh„ va?S,k6„Xpb .,,M N,3b 4 i
Item Estimated Cost(Dollars)to be 4w
completed by ermit appl icant ..<..,
1. Building
2. Electrical ed Totat I n
t .. .
3on
_struct ,
lon fro
3. Plumbing
: R
PermitFe
! IVY "�,�1'�� -�'� f �'4�
4. Mechanical (HVAC) Y, '
5. Fire Protection
6. Total = 1 +2 +3 +4+5 'eccf � �
IN! 1111 i
s
,
Y,
y .,
3 %
v �, y BP-2002-0965
GIS#: COMMONWEALTH OF MASSACHUSETTS
. ' t?A_119 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Cate o : BUILDING PERMIT
Permit# BP-2002-0965
Project# JS-2002-1564
Est.Cost: $4800.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: RCI ROOFING 126235
Lot Size(sq.ft.): 7753.68 Owner: GREGORSKI ELIZABETH&
Zoning:URA Applicant: RCI ROOFING
AT. 46 CLAIRE AVE
Applicant Address: Phone: Insurance:
P O BOX 309 (413) 527-4775 Workers
Compensation
EASTHAMPTONMA01027-0309 ISSUED ON:518102 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:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 5/8/02 0:00:00 2632 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo