35-219 (8) ............
RC-1. ........g-'-ft oofin Date
6 Line St. Estimate
e
Southampton,Ma. 01073 5/6/2015
Phone(413)527-4775
Fax(413)527-8469
Name/Address Job Location
kmte Caplan
26 Ladyslipper Lane
Florence, MA 01062
Terms Rep
Estimate valid for 30 days Chris
Description Total
Remove existing roofs. 13,600.00
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.
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.
WE LOOK FORWARD TO DOING BUSINESS WITH YOU,
Total $13,600.00
TERMS OF PAYMENT r 5%Deposit
Balance upon completion Customer Signature
Registration# 126235
Construction License#074334 ate �J
Insured by Banas&Fickert Ins. —
(413)527-2700
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: �� Lr �►�t, �rip� � Q F(����1ce ���"�
The debris will be transported by: CK) OPle. 1—
The debris will be received by: C'U o 1e, /f
Building permit number:
Name of Permit Applicant
Date Signature of Permit Applicant
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
mm inass.gov/dia
Workers' Compensation Insurance Affidavit,, Build ers/loontractors/El ectricians/Plurabers
Applicant Information Please Pi!Dt Legibly
Name (Business/Organ ization/Individual):
Address:�t
City/State/Zjp:`,:ac,����o,,,�.o�_a �.ma of o-,7 3 Phone 54-1 �l yl 15
Are you an employer? Check the appropriate box: Type of project (required):
1, I am a employer with Z U 4. ❑ I am a general contractor and.I 6. ❑ New construction
employees (full andlorgart-tune),* have hired the sub-contractors
2.[] 1 am a sale proprietor or partner- listed on the attached sheet. $ 7. ❑ 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 10.❑ Electrical repairs or additions
required.] officers have exercised their
3. [] 1 am a homeowner doing all work right of exemption per MGL 1 l,❑ Plumbing repairs or additions
myself [No workers' comp. c. 152, §1(4), and we have no 12, Roof repairs
insurance rNuired,] t employees, [No workers' 13.[:] Other
comp, insurance required.)
'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information:
I Homeowners who submit this affidavit indicating they are doing;all work and then hire outside mniractors must submit a new aFlidavil indicating such
tContractors that check thi>box must attached an additional sheet showing the name of the subcontractors and their workers' comp.policy information.
1 am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
fnformaiiom
[ustwanee Company Name;
Policy #or Self-in,, Lie. #; e : C�ID`a�,<I 0�_ _ Expiration Date; I U .�-
Job Site Address;__ _ City/State/Zip; _
Attach a copy of the workers' compensation policy declaration page (showing,the policy number and expiration date),
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500,00 and/or one-year imprisonment, as well as civil penalties u1 the form of a STOP WORK ORDER and a fine
of up to $250.00 a dad, against the violator, Be advised that a copy of this smMme:nt may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification,
I do hereby certify under the pains andpenalties ofperjury that the information provided above is true and correct.
Signature: ��C�-z-� Date; lau
Phone
Ofclal use only. .Do not write In this area, to be completed by city or town official,
City or Town; Permit[License #_
Issuing Authority (circle one):
L16, Board of HeOth 2. Building Department 3, City/Towu Clerk 4.Electrical Inspector 5, Plumbing Inspector
Other
ontact Person: Phone! #;
SECTION 8-CONSTRUCTION SERVICES 7
8.1 Licensed Construction Supervisor: ++ li7
Not Applicable ❑
Name of License Holder: ma.( y, J 1:,1 P_ 1 9 4 3 .)'I
License Number
Address Expiration Date
C�I1 � 5a9 - 8795
Signature Telephone
9.Registered Home Improvement Contractor: Not Applicable ❑
fP .C . Z. V)W ing I :aLDQ S
Company Name Registration Number
(a 1-to St ys-- 0(,o I�p
Address Expiration Date
/�
l)`Q9 _Telephone&J3) -9 ` c
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152,§26C(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....... 15�1 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 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�wwa 699
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 [M Siding [❑] Other[❑]
Brief Description of Proposed
Work: 'R P'P- C..L O'C_ke
Alteration of existing bedroom Yes No Adding new bedroom Yes No
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, , as Owner of the subject
property t r
hereby authorize me c V, C . I. �� Itt In C4
to act on my behalf, in all matters relative to work authorized by this building permit aP0 ication.
a:y- aCbod 5)acclls
Signature of Owner P Date
I,M Ct.(k' Wk' as'n uN'"oya 1pd Gt 0 n+- 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 and penalties of perjury.
Print Name
acp I
Signature of Owner/Agent Date
Department use only
C" City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
�A �� 212 Main Street Sewer/Septic Availability
Room 100 WatedWell Availability
rN1P� 2 No hampton, MA 01060 Two Sets of Structural Plans
11 U s 87-1240 Fax 413-587-1272 Plot/Site Plans'
pwrr bm oO N oto6o
i1G� Other Specify
PLICATION 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''
<,�U Ln. Map Lot Unit
F li6rence, MIA Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
-TO-MY Q- �fltl��l4Jtl ��0 Lli t ��i12th%( �C1YIP
Name(Print) Current Mai
lin
Telephone
lS4?P 0.+lrxC�le�l W1.
hone
Signature
2.2 Authorized Agent:
MQLZk 0011"Je q Line Suk clynn4i-q-yY 1a -)10Q ]
Name(Print) Current Mailing Address:
Li
Signature Telephone
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=0 +2+3+4+5) Check Number a,
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
26 LADYSLIPPER LN BP-2015-1187
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map-Block: 35 -219 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-2015-1187
Project# JS-2015-002226
Est.Cost: $13600.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: RCI ROOFING 74334
Lot Size(sq.ft.): 57499.20 Owner: CAPLAN JAMIE ANN
Zoning. Applicant. RCI ROOFING
AT. 26 LADYSLIPPER LN
Applicant Address: Phone: Insurance:
6 LINE ST (413) 527-4775 Workers Compensation
SOUTHAMPTONMA01073 ISSUED ON.512812015 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:
FeeTvpe: Date Paid: Amount:
Building 5/28/2015 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner