23C-029 RC-1- .Roofing Date
6 Line St. Estimate
Southampton, Ma. 01073 6/10/2015
Phone(413)527-4775
Fax(413)527-8469
Name/Address Job Location
Richard Duffney 96 Maplewood Terr.
102 Maplewood Terr. Florence, MA 01062
Florence, MA 01062
Terms Rep
Estimate valid for 30 days Keith
Description Total
Remove existing roofs. 4,500.00
Furnish& install 1/2" plywood over existing decking.
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 and install synthetic underlayment.
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.
WE LOOK FORWARD TO DOING BUSINESS WITH YOU.
Total $4,500.00
TERMS OF PAYMENT
5%Deposit
Balance upon completion Customer Signature '
Registration# 126235
Construction License#074334 Date
Insured by Banas&Fickext 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: �(a /Q�C� j�rrnyeh� /yr/a
T
The debris will be transported by: 3D OM e�.
The debris will be received by; C� (�1�✓ ( �ti� r/� � G� t-�
Building permit number:
Name of Permit Applicant
Date Signature of Permit Applicant
The Commonwealth of Massachusetts
Depatlrnent of Industrial Accidents
Office of Investigations
a 600 Washington Street
Boston, MA 02111
xmm mass,go v/dia
Workers' Clompensation Insurance Affidavit; Builders/loo:utractors/Electl•icians/Plumbers
Applicant Information Please PI int �eiblY
Name (Business/OrganizationMdividual):_-- � . �d��� ,
Address:�C 1 :�,r\
city/state/zip:``k,���� �.o�� �� m c, o, o-v3 3 Ph one #:Qq/5)
Are you an employer? Check the-appropriate box: Type of project (required): —�
1. I am a employer with ?,O 4. ❑ I am a general contractor and I 6. ❑ New construction
employees (full and/or part-time),* have hired the sub-contractors
2. [] 1 am a sole proprietor or partner- listed on the attached sheet, t 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 10.7 Electrical repairs or additions
required.] officers have exercised their
3. [1 I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions
myself, [No workers' comp. c, 152, §1(4), and we have na 12, Roof repairs
insurance r(Nu.ired.] 1 employees. [No workers' 13,7 Other
comp, insurance required.]
Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information:
t Homeowners who submit this affidzvit indicating they are doing all work and then hire outside contractors must submit a new affidavit bidicating such.
(Contractors that check this box must attached v additional sheet showing the name of the sub-contractors and their workers' comp.policy information.
ram an employer that is providing workers'compensation insurance for my enployees, Below is the policy and job site
informalom
fnsurance Company rdame;�Z'1
Policy#or Self-in,. Li c, #._\,Q �� (D0�?)10� _ Expiration Date: 10^ -45 .� -
Job Site Address- I od er—K• _ City/State/Zip; //, r&ua, /V14 /o/o(o,,2_
Attach a copy of the workers compensation policy declaration page (showin?, 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-yeas imprisonment, as well as civil penalties in the form of a STOP WORK ORDFR and a fine
of up to $250,00 a day against the violator, Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification,
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Phone#; SZ I-141
Official use only, .Do not write lit this area,to be completed by city or town of icial,
City or Town: _ _ PermitfUccuse #_
Issuing Authori.ty (circle one):
1. Board of Health 2. Building Department 3, CitylTown Clerk 4.Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phont! #t
SECTION 8 -CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder r:_Holder: -( V, ��'I�IQ — 79 id�i'1�H
License Number
Address yam/ Expiration Date
;2) 15 al - Ll r 1 11
Signature Telephone
----
9. Registered Home Improvement Contractor: Not Applicable ❑
,,
�� 1�
Company Name J Registration Number
t l, S. O - u O(0 Leo
Address Expiration Date
ot ` r Telephone
SECTION 10-WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152,§28C(0))
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....... R/ No...... ❑
11. - Homle Owner Exemption
The current exemption for"homeowners"was extended to include Owner-oceupied 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, hat 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 fl•om 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 -A A _
SECTION 5-DESCRIPTI(M OF PROPOSED WORK(check all applicable)
New House Addition ❑ Replacement Windows [Alteration(s) ❑ Roofing
Or Doors ❑ _
Accessory Bldg. ❑ Demolition ❑ New Signs [ED] Decks Siding [o] Other[p]
Brief Description of Proposed
Work: _ P
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,o.r addition.to existing housing, complete the foi['owing
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. NumbE:r 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 .
1. 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
-7
I' d o as Owner of the subject
property
hereby authorize �c V, C°1��� � `6�
to act on my behalf, in all matters relative to work authorized by this building permit aR ication.
Signature of Owner --
Date
j L%k as, (14)oyl7 pd_ Q Qp - _ 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 —'
Signature of Owner/Agent _ Date
V, Department use only
City of Northampton Stattus of Permit:
��� � Building Department Curb CuVOriveway'Permit '
62 212 Main Street SewerlSepticAvailability
Room 1
g,Gaspj�0 1O^` hampt n, MA 01060 Twao Set of Structural uctral Plans
«Nor ne 413-587-1240 Fax 413-587-1272 Piot/Site Pans
Other Specify..
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION 7—
1.1 Property Address:
Thls section to be completed by office
,, ( A116"11(a)6(d /erY Map_ Lot _Unit
%%
l' 0K,ev1['C, MA O/O rot. Zone_ Overlay District-
Elm St.District,_ CB District_
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
i
/a.2- /err.
Name(Print) Current(Mailin3g Addres QlG�Cv�-
.L Ha oh,e�1 Telephone
Signature
2.2 Authorized Agent:
Al ',lam _ ._ h .C • 7'. -hoc 415 n
Name(Print) � / Current Mailing Address:
Signature Telephone L!
SECTION 3 -ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be — Official Use Only
completed by permit applicant _
1 Building _ (a) Building Permit Fee
2. Electrical ` (b) Estimated Total Cost of
0onstrLl.OtlOn from 16
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection _ _
6. Total = (1 +2+3 +4 +,15) Check Number. �y e a5
_ This Section For Official Use Only
Building Permit Number:__ Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
96 MAPLEWOOD TER BP-2016-0017
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:23C-029 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-2016-0017
Project# JS-2016-000029
Est. Cost: $4500.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RCI ROOFING 74334
Lot Size(sq.ft.): 39988.08 Owner: DUFFNEY REALTY TRUST
Zoning.URB(100)/ Applicant: RCI ROOFING
AT: 96 MAPLEWOOD TER
Applicant Address: Phone: Insurance:
6 LINE ST (413)527-4775 Workers Compensation
SOUTHAMPTONMA01073 ISSUED ON:71712015 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 Deaartment 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 Sisnature:
FeeTyue• Date Paid: Amount:
Building 7/7/2015 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner