17D-027 (3) •6 Line St.
• • Estimate Date
Southampton,Ma. 01073 8/19/2015
Phone(413)527-4775
Fax(413)527-8469
Name/Address Job Location
Carmen Junno
73 Straw Ave.
Florence, MA 01062
Terms
ERe.p Estimate valid for 30 days
Description Total
Remove existing roofs. 7,200.00
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.
Add$2400.00 for garage.
WE LOOK FORWARD TO DOING BUSINESS WITH YOU.
Total $7,200.00
TERMS OF PAYMENT
5%Deposit
Balance upon completion Customer Signature /��'"�^-•-
Registration# 126235 l �
Construction License#074334 Date cl "'
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: —Z3 S, VZ) AV&
The debris will be transported by: L. D Mp f.-�--e.
The debris will be received by: 0"0 �-\p 1er4.-Ab(qUIk-e �'�ti� c/( a-CI
4
Building permit number:
Name of Permit Applicant ZCT �.t}�K, f"-/�" (1-L.-
Date Signature of Permit Applicant
The Commonwealth of Massachusetts
Departinent of Industrial Accidents
Office of.investigations
600 Washington Street
Boston, MA 02111
mirm in ass,gov/dia
Workers' Compensation Insurance Affidavit. Build ers/Co ntractors/Electricians/Plumbers
Applicant Information Please Piint LeE�iblY
Nme (Business/organization/Individual), —(�," �-�, C\0, a,�'_
Address: ,L L:;
Phone #; (��1_ ���'1 141-75
Are you an employer? Check the'approprlate box; Type of project (required):
1, Ell am a employer with Z 0 4, �_I I am a general contractor and. 1 6, ❑ New construction
employees (full and/or part-time),", have hired the sub-contractors
2, ❑ l am a sole proprietor or partner- listed ou the attached she-,t, 1 7. ❑ Remodeling I
ship and have no employees These sub-contractors have; 8. ❑ Demolition
working for me in any capacity, _ workers' comp, insurance, g, ❑ Building addition
[No workers' comp, insurance 5. We are a corporation and its
required,) officers have exercised their 10.❑ Electrical repairs or additions
3. ❑ 1 am a homeowner doing all work right of exemption per MGL 11,0 Plumbing repairs or addidous
myself. [No workers' comp. c. 152, §I(4), 'and we have no 12, Roof repairs
insurance r(Nju.ired.) t employees, [No workers'
13•❑ Other
_ comp, insurance required.)
Any applicant that checks box ill must also fill out the section below showing their workers'compensation policy information;
Homeowners who sulnnit this affidavit indicating they are doing all work and then hire outside aontraotors must submit a new affidavit uidicating such.
Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers' comp,policy inforrnation.
ram an employer that is providing workers' compensation insurance for my employees, Below is the policy and job site
tnfortnation.
[nsw ance Company/dame, ' �Y�`.sv-r2ar�Lx
Policy#or Self ins, Lia, #:�}S C�lv ?,�I O�i_ - Expiradon Date; 10_L5 l
Job Site Address;_ - City/State/Zip: l f1/Olo1
Attach a copy of the workers' compensation policy declaration page(shoKdng the policy number and expiration date),
Failure to secure coverage as required under Section 25A of MGL a 152 can lead to the imposition of crinunal penalties of a
fine tip to $1,500,00 and/or one-year imprisonment, as well as civil penalties ur thr, 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:rne:ot may be forwarded to the Office of
Investgadons of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties ofperjury that the information provided above is true and correct;
Okla/ use only, Do not write lit this area, to be completed by clty or towrt of l&al.
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;_ Phnne, tt
SECTION 8-CONSTRUCTION SERVICES 7
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: MCLC Y., 012 LL,_ _ r7 9 y S--,Sy
License Number
fn n d nlor73 05 ®(D:�, -- �(c
Address Expiration Date
Signature Telephone
9. Registered Home improvement Contractor: Not Applicable ❑
y.C , -f. �int^� IaUQ3s
Company Name Registration Number
(? Li ()5- y(0
Address Expiration Date
N 09 3 Telephone
SECTION 10-WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.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....... R" 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 joh 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_ IA CCLC 6A
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House Addition ❑ Replacement Windows Alteration(s) ❑ JRoofing
Or Doors 1771
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [[Z] Siding [0] Other[❑]
Brief Description of Proposed +�
Work: Sep- a-C
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?
In. 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 ca,rw" V u;hn D as Owner of the subject
property
hereby authorize --MCL 1 k QP C1 tZ ( R .C . i9-'(YY'X10('
to act on my behalf, in all matters relative to work authorized by this building permit aR ication.
Signature of Owner Date
I, Mai (ik*i Ls n e (hr1-I Qvi?M O Qe k
i1 , 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
Department use only
OCT A S 2�1 I f Northampton Status of Permit:
d ng Department Curb Cut/Driveway Permit
i9tiotric,Plumbing&Gas lnapsotlgij Main Street Sewer/Septic Availability
Northam ton.MA 01060 oom 100 Water/Well Availability
Nort ampton, MA 01060 Two'-Sets of Structural Plans
phone 413-587-1240 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
7/
/3 Ave- Map Lot Unit
r1Or°GvtC,o/ Nt Zone _Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Jn v i car m.cr) Jurin o 73 E-izuj Avg- PA o i
Name(Print) Current Mailing Address:
See Telephone �
Signature
2.2 Authorized Agent: n r p
Al 11 r K D I i. I .' & ,C 7. K G OL 1 Yl C1 rl
Name(Print) /.� Current Mailing Address:'
Signature Telephone I) ✓ H9 15
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) X10 0. Check Number Q
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
73 STRAW AVE BP-2016-0462
GIS#: COMMONWEALTH OF MASSACHUSETTS
MW:Block: 17D-027 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-2016-0462
Project# JS-2016-000761
Est. Cost: $7200.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RCI ROOFING 74334
Lot Size(sq. ft.): 16335.00 Owner: JUNNO DAVID&CARMEN
Zoning:URB(100)/ Applicant: RCI ROOFING
AT: 73 STRAW AVE
Applicant Address: Phone: Insurance:
6 LINE ST (413) 527-4775 Workers Compensation
SOUTHAMPTONMA01073 ISSUED ON.101612015 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 Siiznature:
FeeTyue: Date Paid: Amount:
Building 10/6/2015 0:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner