41-026 . .. Roofin
g Estimate
Date
6 Line St. t
Southampton,Ma. 01073 9/23/2015
Phone(413)527-4775
Fax(413)527-8469
Name/Address Job Location ``��,h
Mike Baffaro t K-fzisrF�1 'Fz,� h�i We 0ja 01Z lmb a
1163 Westhampton Rd. LT3 6acf-zw 40 u �E'Q tntk� lb-"r
Northampton, MA 01060 rb � 5vadu p-.-- I S S cc Jtc=4-.
Terms Rep
Estimate valid for 30 days Chris
Description Total
Remove existing roofs. 7,600.00
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.
(Z Chou
WE LOOK FORWARD TO DOING BUSINESS WITH YOU.
Total $7,600.00
TERMS OF PAYMENT ----
5%Deposit
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, 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
IicE:nsed solid waste disposal facility, as defined by MGL c 111 , S 150A.
Address of the work: ll&,3 - Ill-tie,
The; debris will be transported by: O W 'e .
The, debris will be received by
Building permit number:
Cr /
Applicant
( '
Name of Permit .__
Date Signature of Permit Applicant
The Commonwealth of Massachusetts 1'ri'nt Forrn,
Department of Industrial Accidents
Office of Investigations
!: y' I Congress Street, Suite 100
;t Boston, MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information _ Please Print Legibly
Name (Business/Organization/Individual):_ R L.T R 04rlt;
Address:
City/State/Zip: ,S�u. ��;� ., / /� jwy73 Phone 4: ( l3) 5-,;,2-7— 4775
Are you an employer? Check the appropriate box: Type of project(required):
1.['1 am a employer with c,2.0 4. ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub-contractors 6. ❑ New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g, ❑ Demolition
working or me in an capacity. employees and have workers'
g Y 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.
required.] 5. F1 We are a corporation and its 10.7 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.[-hoof repairs
insurance required.] t c. 152, §1(4), and we have no
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,
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
$Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. if the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that isproviding workers'compensation insurance for my employees. Below is thepolicy and job site
information. LL
Insurance Company Name: - --
Policy 4 or Self-ins. Lie. 9:w;76R31-10T Expiration Date: /D
Job Site Address: Slam City/State/Zip: /L'OYfh��t� � ��� ���' k9
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Fai lure 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 in 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 statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certif� under the ains rmd enalties o feeduu that the in ormation provided above is true and correct.
Dater -_/v
Signature: ; �... _ _ __ __ __ _. _
Phone 4: 5-1.7 'Y 2 7S
Official use only. Do not write in this area, to be completer)by city or town official
City or Town: Permit/License #
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: Phone#:
SECTION 8 -CONSTRUCTION SERVICES
8_1_ Licensed Construction Supervisor: _ — Not Applicable ❑ y
Name of License Holdor;_____M�df,� Is
License Number
Address Expiration(Date
ri Lill'J'S
Signature Telephone
9. Registered Home lrngrovemen C_ontr 'ctor_, Not Applicable ❑
Company Name --^ Registration Number
ire ���,--- —�— S— ()(.0 — I l0
Address Expiration Date
r
Telephoner
SECTION 10-WORKERS' COMP:ENS ATION INSURANCE AFFIDAVIT(M.G.L.c. 152, §25C:(0))
workers Compensation Compensation Insurance affidavit must be completed and submitted with thie; application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit —
L Signed Affidavit Attached Ye:s....,,, Cr No...... ❑
11. - ome O:wri;erx ems-tior
The current exemption for"homeowners"was extended to include Owner-occi,tpied 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. CIVIR 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-Y-ear period shall not be considered a homeowner,
Such"horneowner"shall submit to the Building Official,on a form acceptable to the Building Official,that he/she shall be
res onsible 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_�� (,t0 hpd _4_
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicab ej
New House [_] Addition Replacement Windows Alteration(s) F7 Roofing
Or Doors 1771 T ,
Accessory Bldg, [_] Demolition New Signs Decks [❑] Siding (❑) Other(❑)
Brief Description of Proposed —
Work:
Alteration of existing bedroom Yes.--No Adding new edroom_--,_Yes --No
Attached Narrative Renovating unfinished basement _ Yes _No
Plans Attached Roll -Sheet
6a, If New housq and or add i.on<to E.xisting h.owSin, complete thta feffowin
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
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 CON'rRACTOR APPLIES FOR BUILDING PERMIT
M i k& 411/0 Z k Sf .f '/,�St��r, �_— as Owners-of the subject
property -s-
hereby authorize Q( ?. C , 1 ��1fin ' _
to act on my behalf, in all matters relative to work authorized by this building permit aplication.
Signature of Owner Date
I, p (1 o_yt �- as Owner/Authorized
Agent hereby declar;that the statements and information on a foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury,
Print Blame
Signature of Owner/Agent Date __—
�-� -- — -- bepartrnertt use only
E City of Northampton S:tatos of Permit:
Building Department Curb�0uVDrbveway Permit
212 Main Street SewerlSepticAvailabilit=y_ _
Room 100 WeterMWell Avail.ability
N rthampton, MA 01060 Two Sets;of Structural:Plans
a� Msp 587-1240 Fax 413-587-1272 PiotiSite-Pians.
Other Specify
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
r — —
1,1 Property Addrfas: This section to be completed by office
i
�j�, �l_,�c�S`f�tQ r►t � rTc Map— --- Lot _Unit
I r
t"Y fhi[i')u7 fZ'ii, ��1� Zone„_____-__Overlay District,—T_
Elm St,Distrl'ct___ CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT�
2.1 Owner of Record;
bf _+.,- 'st91 �1)i3ion,
Name(Print) Current M,11'ng Address: Ole C
36,1 c ��1 Telephone
Signature
2.2 Authorized Agant:
Name(Print) ✓ ` Current Mailing Address;
Signature Telephone
SECTION 3 -_E_STIMATED CONSTRUCTION COSTS —^
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1 Z49444� d (a) 8uilding.Permit Fee
2 Electrical (b) Estimated Total Cost of
Construrtio_n from (6)
3 Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection _ --
6 Total = (1 + 2+ 3+4 +5) r �;Z"L; Check Number �p
f This Section For'Offictal UseseOniv _ —
Building Permit Number:. Date
Issued,
Signature: _
Building Commissioner/Ins.pector of Buildings Date
1163 WESTHAMPTON RD BP-2016-0531
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:41 -026 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-2016-0531
Project# JS-2016-000887
Est. Cost: $7600.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RCI ROOFING 74334
Lot Size(sq.1): 20603.88 Owner: BAFFARO MICHAEL&KRISTEN FOSSUM
Zoning-: Applicant: RCI ROOFING
AT. 1163 WESTHAMPTON RD
Applicant Address: Phone: Insurance:
6 LINE ST (413) 527-4775 Workers Compensation
SOUTHAMPTON MA01 073 ISSUED ON.1012012015 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 10/20/2015 0:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner