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17A-273 (2) *Z* � RC-1- REstimate Date 6 Line St. Southampton,Ma. 01073 4/10/2015 Phone(413)521-4775 Fax(413)527-8469 Name/Address Job Location Alison Lucy 34 Fern Street Florence, MA 01062 Terms Rep Estimate valid for 30 days Chris Description Total Remove existing roofs. 10,400.00 Furnish&install aluminum drip edge,pipe flashings, chimney flashings(if needed)and step flashings. Furnish& install CertainTeed Winterguard ice&water barrier along eaves and valleys. Furnish& install synthetic underlayment over existing deck. Furnish&install Lifetime CertainTeed Landmark Series shingle. Furnish& install CertainTeed approved ridge vent. Furnish& install 1/2" fiberboard insulation on flat roof section. Furnish &install .060 re-inforced rubber roof system,mechanically attached on flat roof section. All exterior roofing related debris to be removed by R.C.I.Rooi:mg. All work to be performed according to manufacturers'specifications. Lifetime CertainTeed material warranty included. All related permits will be obtained by R.C.I.Roofing. SPECIAL ITEMS NEEDED Add$2.50 per square foot for wood decking replacement if needed. WE LOOK FORWARD TO DOING BUSINESS WITH YOU. Total $10,400.00 TERMS OF PAYMENT 5%Deposit -` Balance upon completion Customer Signature x Registration# 126235 Construction License#074334 Date Insured by Banas&Fickert Ins. (413)527-2700 The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations 600 Washington Street Boston, MA 02111 Q mires.mass.gov/dia Workers' Compensation Insurance Affidavit: Build ers/Contract ors/El e ctricians/Plumbers ,pplicant Information Please Punt Legibly lame (Business/Organization/Individual): (� L k c,p P, "-"g� �d.dress: �, ;ity/State/Zip:' mo' o�o'V Phone #:Sy1.3) re you an employer? Check the-appropriate box: Type of project (required): �-rl am a employer with Z O 4. ❑ I am a general contractor and I 6. ❑ New construction _ employees (full and/or part=time).* have hired the sub-contractors _) I am a sole proprietor or partner- listed on the attached sheet. $ E] Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance, 9. ❑ Building addition [No workers' comp, insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10,❑ Electrical repairs or additions ❑ I am a homeowner doing all work right of exemption per MGL 11.71 Plumbing repairs or additions myself. [No workers' comp, c. 152, §1(4),'and we have no 12. Roof repairs insurance required.] t employees. [No workers' 13.❑ Other comp, insurance.required,] iy applicant that checks box#I must also fill out the section below showing their workers'compensation policy information, mmeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit aidicating such. ntractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information, m an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site 'ormatiom l u:rance Company Name: li(,y#or Self-ins. Lie, #:_W C C Expiration Date:_ ) 0 Site Address: City/State/Zip: tach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date), inure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of crm-dnal penalties of a ,e up to $1,500,00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine up to $250,00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of vestigations of the DIA for insurance coverage verification. to hereby certify under the pains and penalties of perjury that the information provided above is true and correct: Date: — Official use only. Do not write In this area, to be completed by city or town official. City or Town: Permit/License # 1[ssuiug Authority (circle one): :l. Board of Health 2.Building Department 3, City/Town Clerk 4.Electrical Inspector 5, Plumbing Inspector 6. Other ,Contact Person: Phone#: SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: p Not Applicable j ❑0 Name of License Holder: Ar � h r-1 (� I e� � ! "7 �l 3 4 License Number 518_1{� �o� St Eastbzm� Ma 01=1 - t�3 - t Address Expiration Date Signature Telephone 1 9.Roistered Home Improvement Contractor: Not Applicable ❑ • . "Roo 6. nQ 1262.3-5 Comb pQany Name ) Registration Number sol 5-Address J ti Expiration Date , t A. 010� Telephon • 7 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....... ` j No...... ❑ 11. - Home Owner Exemption The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)families and to allow such homeowner to engage an individual fir 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(s) 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 �1 1 Work: aC'h.Pl� Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet .sa. 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 I. 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 L v as Owner of the subject property hereby authorize ' to act on my behalf, in all matters relative to work authorized by this uilding permit pplication. 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 q' 2- Signature of Owner/Agent Date D _ Department use only ity of Northampton Status of Permit: MAY jilding Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability Electric, Plumbing&Gas inspeckns Room 100 Water/Well Availability Northampton. nor,010160 I 0 hampton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans ©ther 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 l.� Map Lot Zone Overlay District Unit- MAElm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) Current Mailing Address: a tta ehe A Telephone Signature 2.2 Authorized Agent: M • f � .hton JJ_a Name(Print) Current Mailing Address: rn ��Ola X13 527- X75 V Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building rr� o (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=0 +2+3 +4+5) V Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date 34 FERN ST BP-2015-1059 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17A-273 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: ROOF BUILDING PERMIT Permit# BP-2015-1059 Project# JS-2015-002012 Est.Cost: $10400.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: RCI ROOFING 74334 Lot Size(sq. 1): 8755.56 Owner: LUCEY ALISON J TRUSTEE Zoning. URB(100) Applicant: RCI ROOFING AT. 34 FERN ST Applicant Address: Phone: Insurance: 6 LINE ST (413;) 527-4775 Workers Compensation SOUTHAMPTONMA01073 ISSUED ON:51412015 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: FeeType: Date Paid: Amount: Building 5/4/2015 0:00:00 $35.00 212 Main Street, Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner