23C-059 (2) RC,1:0-
-O Ofn g Date
6 Line St. E s t mae
Southampton, Ma.01073 3/31/2015
Phone(413)527-4775
Fax(413)527-8469
Name/Address Job Location
Robin Silva
181 Willow St.
Florence, Ma. 01062
Terms Rep
Estimate valid for 30 days Chris
Description Total
Remove existing roofs from back section of house and detached garage. 8,700.00
Furnish&install aluminum drip edge, pipe flashings, chimney fleshings(if needed)and step
flashings. Z ;n c- uv',OS 4w G o.,N a 4L goof
Furnish &install CertainTeed Winterguard ice&water barrier along eaves and 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.
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Total $8,700.00
TERMS OF PAYMENT
5%Deposit
Balance upon completion Customer Signature
Registration# 126235
Construction License#074334 Date �O
Insured by Banas&.Fickert Ins.
(413)527-2700
City of Northampton 212 Main Street, Northampton, MA 01060
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as
a condition of the building permit all debris resulting from the construction
activity governed by this Building Permit shall be disposed of in a properly
licensed solid waste disposal facility, as defined by MGL c 111 , S 150A.
Address of the work: IC; Z�/j,rel2 �
The debris will be transported by: 3-) r pl'e,1-- .. cc)
The; debris will be received by: �\'\p If���Je/� �
1
Building permit number:
Name of Permit Applicant
Date Signature of Permit Applicant
The Commonwealth of Massachusetts PrintForr
Department of Industrial Accidents
Office of Investigations
I Congress Sheet, Suite 100
Boston
, MA 02114.2017
www.mass.gov/c(ia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/P'lumbers
Aj2plicant Information _ _ Please Print Legibly
Name (Business/Organization/Individual):
Address:
City/State/Lip:__; r u.fh «�yJ fn1� , ��1/� eo/U73 Phone #: l3) V 77'x_ _
Are you an employer? Check the appropriate box: Type of project (required):
l I am a employer with x,2.11 4. ❑ I am a general contractor and I
6. ❑ New construction
employees (full and/or part-time).* have hired the sub-contractors
?.❑ I am a sole proprietor or partner- listed on theiattached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g, ❑ Demolition
working or me in an capacity. employees and have workers'
g Y p Y� 9. ❑ Building addition
[No workers' comp, insurance comp, insurance.$
required.] 5. ❑ We are a corporation and its 10.7 Electrical repairs or additions
?. ❑ I am a homeowner doing all work officers have exercised their 11,El Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.0'T6f repairs
insurance required.] c. 152, §1(4), and we have no
employees. [No workers' 13.7 Other_
comp, insurance requited.]
4ny applicant that checks box 91 must also fill out the section below showing their workers'compensation policy information,
Homeowners who subinit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such,
_'ontractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
nhloyees. if the sub-contractors have employees,they must provide their workers'comp,policy number,
ain an employer that is providing workers' compensation insurance j'or my employees. Below is the policy and job site
if ormation.
isurance Company Name: aSr'
olicy 4 or Self-ins. Lie. 9: _ �, '�, o$ —_ Expiration Date:- /D . _:i I!!�,
b Site Address:_%�'/ Id,llcut, ,�r —_City/State/Zip: i Zot eli T LY,11,1 Cio,��,;2
,ttach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
,ti I ure to secure; coverage as required under Section 25A of MG'L c. 152 can lead to the imposition of criminal penalties of a
nc 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
f up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
ivestigations of the DIA for insurance coverage verification,
cer ti 0 under the awns and enalties of per*ur that the information provided above is true and correct,
do laeaeGy y
mature =
]Date:F.-
hone #: l
Official use only. Do not write in this area, to be complete&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 Pet-soil: Phone#.:
SECTION 8 -CONSTRUCTION SERVICES
8.1 Licensed Construction SugerVolor: Not Applicable ❑
Name of License Holder: Jam'► 'p r7� H 12)H
License Number
C_' `
Address r/r Expiration Date
Signature Telephone
9. Registered Home Improvement Contractor:; Not Applicable ❑
Company Name Registration Number
Address T— Expiration Date
'� c r N 09 a Telephone 191
SECTION 10-WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L,c. 162, §25C(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....... Ed No...... ❑
11. - Dome Owner Exemption
The current exemption for"homeowners"was extended to include Ownei-ocegDied Dwellinjis 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-oeri,od 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 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 i (��(,x LA
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House Addition ❑ Replacement Windows [Alteration(s) Roofing
Or Doors ❑ -- _
Accessory Bldg. ❑ Demolition ❑ New Signs [ Dec: s [Q Sid ng [0] Other ]
Brief Description of Proposed S c� ---
Work:
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 t:o existina housing, complete the fol;lowin :
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 CON'rRACT'OR APPLIES FOR BUILDING PERMIT
1, C��J i n �V4L, --, as Owner of the subject
property 1
hereby authorize �[�_V1�j� (,1 B . C . T. �(o tc c' _
to act on my behalf, in all matters relative to work authorized by this building permit aR ication,
Signature of Owner Date
as Owner/Authorized
Agent hereby declare that the statements and information ondfie 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
-- 5=Q City of Northampton States of Permit:
G ----"'1 Building Department Curb Cut/Driueway Permit
,ctC 212 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability
�oNS orthampton, MA 01060 Two Sets of Structural,Plans
3-587-1240 Fax 413-587-1272 Piot/Site Plans
µoast r 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
Si- Map_ Lot _Unit
NI A
Zone^ _ _Overlay District
Elm St.Distrlct _ CS District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
See - aeh?__ d Telephone
Signature
2,2 Authorized Agent:
Name(Print) ,� Current Mailing Address:
r
Signature Telephone
SECTION 3 -ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building -b (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 = (1 +2+3 +4 + 5) ??w - Check Number
This Section For Official Use Only _
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
181 WILLOW ST BP-2016-0502
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:23C-059 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:ROOF BUILDING PERMIT
Permit# BP-2016-0502
Project# JS-2016-000840
Est.Cost: $8700.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Groin RCI ROOFING 74334
Lot Size(sq. ft.): Owner: SILVA ROBIN B TRUSTEE
Zoning:URA(103)/WSP(l01 /WP(25)/SR(0)/ Applicant: RCI ROOFING
AT. 181 WILLOW ST
Applicant Address: Phone: Insurance:
6 LINE ST (413) 527-4775 Workers Compensation
SOUTHAMPTONMA01073 ISSUED ON.1011412015 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE HOUSE & GARAGE 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 10/14/2015 0:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner