23D-165 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
102 Maplewood Terr.
Florence, MA 01062
Terms Rep
Estimate valid for 30 days Keith
Description Total
Remove existing roofs. 5,800.00
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. Roofing.
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 NEEI)ED
Add$2.50 per square foot for wood decking replacement if needed.
WE LOOK FORWARD TO DOING BUSINESS WITH YOU. Total $5,800.00
TERMS OF PAYMENT
5%Deposit "�:a A
Balance upon completion Customer Signature
Registration# 126235 e r-
Construction License# 074334 Date �y
Insured by Banas&.Fickert Ins. —
(413)527-2700
The Commonwealth of Massa.ch,usetts
Depamnent of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, M4 02111
wllnv,rnass,gov/dia
Workers' Compensation Insurance Affidavit: Bufl ders/1C'o:utl-actors/Electi-ici2ns/Plumbers
Applicant Information e_ Please Print Legibly
Name (Bu siness/0rgarizationMdividual):_��� ,"� \O, t, ,(o
Address: L
City/State/Zip;`,S��a-�, ��C M� o o-v3 Phone #;
Are you an employer? Clt.eck the-appropriate boxt Type of project (required):^_l
1,E21 am a employer with 2,0 a, �_� 1 any a general contractor and 1 6. [) New construction
employees (full andlor part-time),* have hired the sub-contractors
2. [] I am a sole proprietor or partner- listed ou the attached shet,t l 7. ❑ Remodeling I
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity, _ workers' comp, insuranc(:. 9, ❑ Building addition
[No workers' comp, insurance 5. We. are a corporation and its
required.] officers have exercised their 10.❑ Elect7ical repairs or additions
3. ❑ I am a homeowner doing all work right of exemption per MGL 11.7 Plumbing repairs or additions
myself [No workers' comp. a 152, §1(4), and we have no 12, Roof repairs
insurance r(:41u.ired,] t employees, [No workers' 1317 Other
_ comp insurance required,]
'Any applicant that checks box tl I must also fill out the section below showing their workers'compensation policy information;
t Homeowners who suln-0 this affidavit indicating they are doing all work and then hire outside tgntractcrs must submit a new affidavit uidicating such.
lContractors that check this box muse auchod an additional sheet showing the name of the suL-contractors and their workers' comp.policy infoi-meiion.
I am an employer that Is providing workers' compensation insurance for my employees, Below is the policy and job site
(nformatton.
Insurance CompanyName,�•- O..c- '��.��...c'�..r�C�r C��-, , ___
Policy#or Self im. L,ia #: S Ulo��,�I O�Z_ _ Expiration Date: ) 0
Job Site Addxess._/d,9 A&&&-,,�� der° __ _ City/State/Zip; to 4�d�3
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 crindnal penalties of a
fzne up to $1,500,00 and/or one-year imprisonment, as well as civil penalties ill thy; form of a STOP WORK ORDER and a fine
of up to $250,00 a day against the violator. .Be advised that a copy of this stat(=nt 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 inforntatlon provided above is true and correct.
Sipnat�lre, ,�'�Ciz.--•-''�, 1--- D��te, (�s�'_�_.
Phong�—q.- �
Off<cial use only, .Do not write In this area, to be completed by city or towns official,
City or Town: _ Permit/Licease:
Issuing Authority (circle one):
1, Board of Health 2. Building Department 3, City/Tovm Clerk 4,Electrical Inspector 5, Plumbing Inspector
6. Other
Contact Persona,_ Phnnp� tr-
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 )- o/ ax,Od, 7,a1-r 15'lorer a , xv+
The debris will be transported by: `A tj le tC- S n O's
rc /
The debris will be received by: A 54 t
Building permit number:
Name of Permit Applicant NO rk
Date Signature of Permit Applicant
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: Mrk-( V1 �D'1�Q 7 9 9 "Y:11)H
License Number
`y t V (3 cJ o�,
Address Expiration Date
Signature Telephone
9. Registered Home Imorovement Contractor: Not Applicable ❑
LclinQ
Ili
Company Name Registration Number
Address Expiration Date
r }( 0�m a Telephone L:-qm
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M'.G.L.c. 152, §25C(8))
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....... d 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 fi•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 �AC.A-Q hA
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [M Siding [0] Other[0]
Brief Description of Proposed
Work: SF?o Qnr�tP
Alteration of existing bedroom Yes No Adding new bedroom___Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
Ba. If New house and or addition to exist!ng 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 Tl , —
c o as Owner of the subject
property
hereby authorize __McLc QPLC,IQ_ (A- R .C . f. IS jqr
to act on my behalf, in all matters relative to work authorized by this building permit aR ication.
Signature of Owner Date
I, 1V oL K as. 0 Ah()Y12_0J Q Qen-} as Owner/Authorized
Agent hereby declare that the statements and information on&e foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
�
' o� 1` �J�lic1�
Print Name
Signature of Owner/Agent Date
Department use only
City of Northampton states of Permit:'
..6 201 Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
Room 100 Water{Well Availability
Sectric,Plumbing , MA 8
Gas Inspection
N orthampton, orthampton, MA 01060 Two Sets of Structural Plans
N
3-587-1240 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
/ 0.,2— /f44,y. Itwevel Derr. Map Lot Unit
/"lerenee, /414 0/0&Z Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing A dress:
iP.L Telephone
Signature
2.2 Authorized Agent:
n/j a Z k I;.�;�P p .C . 7. �o inn L p
Name(Print) / Current Mailing Address:'
Signature Telephone l 2��S
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
This Section For Official Use Only
Building Permit Number:_ Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
102 MAPLEWOOD TER BP-2016-0018
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:23D- 165 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-2016-0018
Project# JS-2016-000030
Est.Cost: $5800.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RCI ROOFING 74334
Lot Size(sq. ft.): 9104.04 Owner: DUFFNEY REALTY TRUST
Zoning:URB(100)/ Applicant: RCI ROOFING
AT. 102 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 & 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 Siinature:
FeeType: 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