38B-108 (5) R.C.I ROOFING
40 MAINE AVE.
P.O. BOX 309 .,� ES Tl ATE
EASTHAMPTON, MA 01027-0309
PHONE (413)527- 4775 �� MA
FAX (413)527-8469
Date: JULY 15, 2002
Estimate Tot
MARY COLEMAN Estimated By: MARK DELISLE
190 EAST ST. Start Date: ;.
WILLIAMSBURG, MA. 01096 Job Location: 25 MONROE ST.
NORTHAMPTON, MA. 01060
Job Phone: (413)296-4787
JOB DESCRIPTION
FETRNISH AND rATS TA T.r, n PLYWOOD OVER EXISTING DECKING,
FTMA7T.qW A ND INSTALL TCR AND WATER RARRTFR ALONG EAVES AND VALLEYS.
-ALL ROOFING RELATED DEBRIS TO BE REMOVED BY R.C.I. ROOFING.
SPECIAL ITEMS NEEDED
SHINGLE ROOF - $8,640.00
FLAT SECTION - $1,200.00
Additional information partaining to this Job Estimate
TERMS OF PAYMENT
30%PRIOR TO START Total Estimated
70%UPON COMPLETION Job Cost $9,840.00
REGISTRATION alt 126235
FED.IDO 04 3418839 Autholized
CONSTRUCTION LICENSE*074334 Signature
INSURED$YiXACKWORTH/LAPLANTE INS.(413)527-9907
ORIGINAL-ESTIMATOR COPY
• • •o4.tttAMP�O
9 d Grit of 'Warf4alll f on z
�airrarlla:rtt:'
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street a Municipal Building '
Northampton, Mass. 01060
WORICEWS COMPENSATION INSURANCE AFFIDAVIT
(l►censee/permittee)
with a principal place of business/residence at:
t
40 Y�o-%�ti Qy E. tE h Wlnr 010ahone#) Zll3 •SZ7-i/77 S
(street/city/stawap)
do hereby certify, under the pains and penalties of perjury, that:
"I an employer providing the following worker's compensation coverage for my
employees working on this job:
am�—Company) (Polity 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 Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiradon Date)
(attach additional sheet if nooc nuy to incaude inforuutioa pertaining wall coahacwn)
( ) I am a sole proprietor and have no one worEng for me.
( ) I am a home owner pelfonuing all the work myself.
NOTE:please be awue that whilo bomeowncta who employ pcnom to do main]awxc' consmictioo or repair work ao a dwmWng of
not mcce thsn tbrco unity in which the bomoowncr r esida cr oa the grounds apparLnant thacto arc Dot Cc=-Lay ono kkrtd to be
employers undo the worker's ocmpcnua oa Act(GL152,=1(5)),appUca6oa by a homcowDir for a liccase or perm may evidence tho
legal status of an employee coder tho Workoes Compoosation AcL
t understand that a copy of thin sfatesneo!maybe forwarded to the Deputmcot of lndztstrid Accideo&OS$oo of rrrrrrancn for the
coverage verificstioa turd that failure to aoatrc ooverago trOdGZ socdon 25A of MOL 152 an lead to tb.impos oa of criminal pwalt3es
oomistwg of a•fine of up to S1.500.00 and/or imps isotmxcd of up to one year and Civil pernweg in the foie of a Stop Wo&Order and a
limo of 5100.00 a day agsia4 tt>G
For dal uao Only
permit Number
Lot#
SignaWre of LicenseeJPermittee
��C,Q,N S`Ef2VICES���'°
8.1 Licensed Construction nSSu erq visor: c` Not Applicable ❑ LA
Name of License Holder: � ' ar`y" `C.d k SA� 0_1 'A 33
License Number
Address Expiration Date
Signature 00, Telephone
SIM MM, Not Applicable ❑
ompany me Registration Number
R Z 9N Cade CIA _l ' 1 - 044
Address 1J Expiration Date
•�[� you .n Q\/F. Y% Telephone
SECTION 10 r (OSR ERS';C,OMPENSAT ON 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.......45 No...... ❑
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 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(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
ft
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work:
Alteration of existing bedroom Yes No Adding new bedroom es No
Attached Narrative 0 Renovating unfinished basement Yes No
Plans Attached Roll 0•Sheet 0
MM
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?
In. 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 lax 0WNE3R�AUIH0RIZATI0N; WT�O BECOMPLETED WHEN
OWNERS,AGENMOR C0N7R/�CTOR APPI IES FAR BUILDING PERMIT
. :.:.z '
1, Co—l t `��-`t1 f^ , as Owner of the subject property
hereby authorize Mo_E I=V\.'S� to act on
my behalf, in all matters relative to work authorized by this building.permit application.
Signature of Owner Date
CL 9\rn, ' r\rk , as Groner/Authorized Agent
hereby declare that the statements and information on the foregoing ap i tion are true and accurate, to the best of my
knowledge and belief.
Signed under the pains and penalties of perjury.
Print Name
;e5�rll
-Z� -ems
Signature of Gamer/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:
City of Northampton
Building Department
i' (l- (� €A ,y, ( ; I 2 Main Street
s
Foom 100
' North4m pton, MA 01060
j CC' lh'bnb"-413 58 ' 240 Fax 413-587.1272
I A��L�C�T'ION"1`� CON9TRUC ,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR 7W0 FAMILY DWELLING
SECTION 1-SITE INOIRMAT�UN=
Esec c{> t krri
1.1 Property Address:
D
,: .�,
' CBtD„ Vft�Y -
SECTION 2- PROPERTY'OWN ERSHIP'LAUTHORIZEDsgGENT
2.1 Owner of Record:
OS
Name(Print) -,.� Current Mailing Address;
C'• - 2_c/to - 4
° Telephone '
Signature -
f
2.2 Authorized Agent:
� l9 C tnn 04,ca.oral
Name(Print) Qurrent Mailing Address:
S gnature Te phone
SECTION 3 -.EST I I"MATE,Q CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use-Only
completed by ermit applicant
1. Building L10 , (a) Building Permit Fee
4
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 Onl
Building Permit Number: Date Issued;
Signature:
Building Commissioner%Lnspector of Buildings Date,;
s �
BP-2003.0434
GIS#: COMMONWEALTH OF MASSACHUSETTS
k i CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2003-0434
Project# JS-2003-0733
Est. Cost: $9840.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RCI ROOFING 074334
Lot Size(ss . ft.): 14810.40 Owner: COLEMAN MARY ANN&ZUCHOWSKI
Zoning:URB Applicant: RCI ROOFING
AT. 25 MUNROE ST
Applicant Address: Phone: Insurance:
P O BOX 309 (413) 527-4775 Workers
Compensation
EASTHAMPTONMA01027-0309 ISSUED ON:10129102 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP, PLY & 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 10/29/02 0:00:00 636 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo