17C-119 (8) �r
Estimate
6 RC.1ate
Line St.
Southampton, Ma. 01073 3/17/2015
Phone(413)527-4775
Fax(413)527-8469
Name/Address Job Location
Star Drooker Star Drooker
24 Sheffield Lane 24 Sheffield Lane
Florence, MA 01062 Florence, MA 01062
Terms Rep
Estimate valid for 30 days Chi-is
Description Total
Remove existing roofs. 13,400.00
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 and install synthetic underlayment over existing deck.
Furnish and install Lifetime Certain'reed 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 $13,400.00
TERMS OF PAYMENT
5%Deposit �r�4
Balance upon completion Customer Signature
Registration# 126235
Construction License#074334 Date .�
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, IS54, 1 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 150&
Address of the work: _ �-/ 1266!2 ., RY
The debris will be transported by: C-) 0--r.. C)
The debris will be received by: �\'\p
1
Building permit number:
Name of Permit Applicant CLT 6 / LL�P
2 7- /S
Date Signature of Permit Applicant
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
'd 600 Washington Street
Boston, MA 02111
miw mass.gov/dia
Workers' Compensation Insurance. Affidavit, Builders/1Co;utl-actors/Electricians/Plurabers
Applicant Information e_ Please Plant Legibly'
Name (Business/Organization/Individual):
Address: C L L:;
g, o°y 3 Phone
Are you an employer? Check the appropriate boxt Type of project (required):^ _l
1. [D-1 am a employer with U 4, f_l 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 paer- listed on the attached shci�t. t Remodeling
rtn I
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity, _ workers' comp. insurances, 9, ❑ Building addition
[No workers' comp, insurance 5. �_) We. are a corporation and its
required,] officers have exercised theix 10.❑ Electrical repairs or additions
3, [❑ I am a homeowner doing all work right of exemption per MGL I l,❑ Plumbing repairs or additions
myself [No workers' comp, c. 152, §1(4), and we have no 12. Roof repairs
insurance r(Nu.ired,] t employees, [No workers'
13.❑ Other
comp insurance required.]
Any applicant that checks box 91 must also fill out the section below showing their workers'coi q)ensation policy information,
r Homeowners who sulnnit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
iContractors that check thi;>box muse attached an additional sheet showing the name of the sub-contractors and their workers' comp,policy infoi-Mation,
r am an employer that is providing workers' compensation insurance for my employees, Below is the policy and.job site
information.
Insurance Company Name; /�`
Policy #or Self ins, Lie, #: �,l r U(01 '?)Q1 Expirabon Date: ) 0 45 . 116,________
Job Site Address._ ss`iP iP�i_��.� _ Ci.ty/State/Zip; 10 /'f ,Q1 .2
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 per>.alties 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 day against the violator, Be advised that a copy of this state:meut may be forwarded to the Office of
[nvestigadons of the DIA for insurance coverage verification,
t do hereby certify under the pains and penaltles of perjury that the information:provided above 1s true and correct.
7_/S
Phone#
Officlal use only, .Do not write In this area, to be completed by city or towri of ficial,
City or Town; Permit/Licease: #_
Issuing Authority (circle one);
1, Board of Health 2. Building Department 3. City/Town. Clerk 4,Electrical Inspector 5, Plumbing Inspector
6, Other
Contact Person:.— __ _T___ Phnnp, a,
SECTION 8 -CONSTRUCTION SERVICES ---
8.1 Licensed Construction Suoerv''iisor: '' Not Applicable Cl
Name of License Holder: MrI r i, 11SL _ — r7� H ":.s'M
License Number
Address /' �i Expiration Date
Signature Telephone
9. Registered Home Imai�ovement Contractor:, Not Applicable ❑
Company Name Registration Number
1 c�—Lir— >�,--- --- __ _ O ly lfl
Address Expiration Date
,j u �����f7 Telephone1�j
SECTION 10-WORKERS' COMPENSATION INSURANCE AFFIDAVIT(MIG.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....... 2/ No...... ❑
11. - Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellinfis 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 Officiall,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 ckc 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 [❑ Siding [i Other[r7]
Brief Description of Proposed ,-�.-
Work:_
Alteration of existing bedroom Yes No Adding new bedroom _Yes No
Attached Narrative Renovating unfinished basement _ Yes No
Plans Attached Roll -Sheet --
Sa. 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, Daniel S&1- _bryokey- as Owner of the subject
property
hereby authorizeG
to act on my behalf, in all matters relative to work authorized by this building permit aR ication.
(a,-'A a c h CL__ 7- -�_'7-/S'
Signature of Owner Date
�ENNr
C1 C n U4)o't?od n Qen4- 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.
a.0 ss
Print Name
Signature of Owner/Agent Date
- Department use only'
Cit of Northampton Status of Permit::
Bp ding Department Curb CuVDriveway Permit
I jul 2 ��� 1, 212 Main Street
Sewer/Septic pticAvaaability
" - Room 100 Water/Well Availability
_ G mpton, MA 01060 Two Sets of Structural Plans
Eteciri Fur;rir g .�a !O
Northar"p'° - -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
j q sht Map. —.— Lot _Unit
F/Q/ln L c, MA ��� � Zone Overlay District
Elm St.District;_ CB District,
SECTION 2-PROPERTY OWNERS HIPIAUTHORIZED AGENT
2.1 Owner of Record:
atild (Wr bl-04.e/' _ ��� /ore�c 11711 eve&z-
Name(Print) g/ Current/Mailing 1Address:
3� aty'd 71e/ Telephoner,
Signature
2.2/�/Authorized Agent: T p
Name(Print) "f �� Current Mailing Address: r�
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 4.5) 00, Check Number
This Section For Official Use Only
Building Permit Number:.
Issued:
Signature:
Building Commissioner/inspector of Buildings Date
24 SHEFFIELD LN BP-2016-0120
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17C- 119 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-2016-0120
Project# JS-2016-000209
Est. Cost: $13400.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RCI ROOFING 74334
Lot Size(sg. ft.): 20778.12 Owner: DROOKER HAROLD&NINA
Zoning. URB(100)/ Applicant: RCI ROOFING
AT: 24 SHEFFIELD LN
Applicant Address: Phone: Insurance:
6 LINE ST (413) 527-4775 Workers Compensation
SOUTHAMPTON MAO 1073 ISSUED ON.713012015 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:
FeeType: Date Paid: Amount:
Building 7/30/2015 0:00:00 $40.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner