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24C-105 (5) City of Northampton 212 Main Street, Northampton, MA 01060 Solid Waste Disposal Affidavit In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building permit all debris resulting from the construction activity governed by this Building Permit shall be disposed of in a properly licensed solid waste disposal facility, as defined by MGL c 111 , S 150A. Address of the work: ID3 f ,Ssaso +,--h The debris will be transported b C'RD NqP ( 1--e. 5 The debris will be received by: 0-.0 �-\p�er A_ `--c/C- Building permit number: Name of Permit Applicant 2-6�6 ["/C Date Signature of Permit Applicant • Ro oFin Date 6 Line St. Estimate Southampton, Ma. 01073 5/22/2015 Phone(413)527-4775 Fax(413)527-8469 Name/Address Job Location Nick Fleisher Nick Fleisher 103 Massasoit Street 103 Massasoit Street Northampton, MA 01060 Northampton, MA 01060 Terms Rep Estimate valid for 30 days Description Total Remove existing garage roof. 1,700.00 Furnish& install aluminum drip edge,pipe flashings, chimney flashings(if needed)and step flashings. Furnish& install CertainTeed Winterguard ice&water barrier, 6 feet along eaves and 3 feet in valleys, Furnish and install synthetic underlayment over existing deck. Furnish and install Lifetime CertainTeed Landmark Series shingle. Furnish and install CertainTeed approved ridge vent. MCI ®V 1- All exterior roofing related debris to be removed by R.C.I. Roofing. All work will be performed according to manufacturers'specifications, Lifetime CertainTeed material warranty included. All related permits will be obtained by R.C.I. Roofing. Add$2.50 per sq. ft. for wood decking replacement if needed. Total $1,700.00 TERMS OF PAYMENT 5%Deposit Balance upon completion Customer Signature e, '6 Registration# 126235 Construction License#074334 g Date Insured by Banas&i Pickert Ins. (413)527-2700 AC40R O CERTIFICATE OF LIABILITY INSURANCE °ATE(MM/Dam") 4/2/15 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGI4TS UPON THE CERTIFICATE HOLDER THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER, IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(les) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does;not confer rights to the certificate holder in lieu of such endorsement(s), PRODUCER Z�NTA�-- Banas & Fickert NAME: Michael R. Banas PHONE 413 527_2700 A(X (413) 527-0849 Insurance Agency AoDRESS: 63 Main Street mb @banasinsurance.com --'—�--�-- Easthampton, MA 01027 _. IN4URER(S)AFFORDINGCOVERAGE NAIC# _._......--- _....--..._-._... .... . . ._.... INSURER A:Admiral Insurance Co. 24856__ INSURED INSURERB:Safety Insurance Co. 39454 RCI Roofing, LI,P INSURERC:Eyanstol'n Insurance Co. 35378 6 Line Street INSURER D:Star Insurance Co. 24562 Southampton, MA 01073 INSURER E: INSURER F: COVERAGES CERTIFICATE N UMBER: _ REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. --- -- -- LTSR TYPE OF INSURANCE Ati15L 3U9� --._-.,.-IPdt.li;Y°EYY .. MIOR - POUGY NUMBER MM/DDK MM/DDIYYYY LIMITS A GENERALLIABILITY X CA000020963-01 3/4/15 3/4/16 EACHOCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 5O 000 CLAIMS MADE ©OCCUR ME EXF(Any one e-sm) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GENERALAGGREGATE $ 2,000,000 GEN'LAGGREGATELIMITAPPLIESPER PRODUCTS•COMP/OP AGO $ 2,000,000 POLICY X PRO LOC g JECT F]B AUTOMOBILE LIABIUTY X 6207761 9/30/14 9/30/1!5 N I LIM! Eesccidern $ 1,000,000 ANYAUTO BODILY INJURY(Per poison) $ ALLOWNED X SCHEDULED BODILY INJURY(Per $ AUTOS AUTOS ) X HIREDAUTOS X NO70SWNED PROPERTY DAMAGE $ P ore ccident C UMSRELLALIAB OCCUR X CUBW5757915 3/4/15 3/4/16 EACH OCCURRENCE $ 5,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $ 5,000,000 DED X RETENTION$ 10.000 $ D WORKERS COMPENSATION AND EMPLOYERS'UABIUTY WC0683405 10/5/14 10/5/15 WCSTA7U- O7H- YIN ANY PROPRIETORIPARTNERIEXECU7NE FR OFFICERMEMBER EXCLUDED? NIA E.L.EACH ACCIDENT $ 1,000,000 (Mandatory in NH) f es describe L DISEASE-EA EM LOYE 1,000,000 yy under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY I IMIr $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Renerks Schedule,If more space Is required) ROOFING CONTRACTOR. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABO E B POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE N ICE WILL. BE DELIVERED IN _ ****REFERENCE COPY**** ACCORDANCE WITH THE P I_C ISIO AUTHORIZED REPRESENTATIVE j ©1988.2010 ACORD CORPORATION, All rights reserved, ACORD 25(2910105) The ACORD name and logo are registered marks of ACORD Phone; Fax: E-Mail: SECTION 8-CONSTRUCTION SERVICES —7 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: �lg�;s, P_ 19 9 3 3'1 License Number 0 5 --�� -- I tC Address Expiration Date 61V�) 5 al LIES Signature Telephone 9. Registered Home Improvement Contractor:_ Not Applicable ❑ l Company Name J Registration Number (o L►ne S->✓ _ 0 y l0 Address Expiration Date a N Oq a Telephone 1351 SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(6)) 1� 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....... 9" 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 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 ueriod 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 aA,-,Lc 6A SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House Addition ❑ Replacement Windows Alteration(s) Roofing Or Doors ❑ _ Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [Q Siding [O] Other[Ell Brief Description of Proposed Work: Sep_ (LAaA�A VV Alteration of existing bedroom Yes No Adding new bedroom_ Yes o Attached Narrative Renovating unfinished basement _ Yes No Plans Attached Roll -Sheet 6a. 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 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 I, Lid F]e_t, hh' e_(' as Owner of the subject property hereby authorize .._MCL( Y' QoA kC1(Z (A 6 ,c . I. I�(�(�1�1(' to act on my behalf, in all matters relative to work authorized by this building permit aR ication. (1AA aChed 21:/&1 15 a ure of Owner Date I. M(IvK V)Q,ts (ZC 011 laI12e' d OCI 4- _ as Owner/Authorized Agent hereby declare that the statements and information ondhe foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. Print Name Cy I S Signature of Owner/Agent Date De artment use only p Y �� t! City of Northampton states of Permit: Building Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability' JUN Room 100 WatetNVell Availability Uas inspectl rthampton, MA 01060 Two Sets of Structural Plans 5Eectric,o,,h,mp t n,nn 87-1240 Fax 413-587-1272 Plot/Site Plans Other 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 '©3 �S�-. /rlCt$S Map Lot Unit /Uor+ht>~rnP}an rn Zone _ _Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) Current Mailing dres yi 3� Lee a C kQ Telephone Signature 2.2 Authorized Agent: Al(2 r K 0 0_ C . p -i (o Lin Name(Print) i Current Mailing Address: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only com feted 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 = 0 +2 +3+4+5) Check Number d,5Z 36 AJ5 This Section For Official Use On!y Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date 103 MASSASOIT ST BP-2015-1220 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:24C- 105 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) CaterY. ROOF BUILDING PERMIT Permit# BP-2015-1220 Project# JS-2015-002304 Est. Cost: $1700.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: RCI ROOFING 74334 Lot Size(sq. ft.): 14331.24 Owner: FLEISHER A NICHOLAS&PHOEBE M Zoning URB(100) Applicant. RCI ROOFING AT. 103 MASSASOIT ST Applicant Address: Phone: Insurance: 6 LINE ST (413) 527-4775 Workers Compensation SOUTHAMPTONMA01073 ISSUED ON.61412015 0:00:00 TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE GARAGE 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 6/4/2015 0:00:00 $35.00 212 Main Street,Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner