24D-233 (7) RC-1:00 o0fing Estimate Date
6 Line St.
Southampton,Ma. 01073 6/10/2015
Phone(413)527-4775
Fax(413)527-8469
Name/Address Job Location
Jennifer Levi 212 Prospect St.
11 Bryan Ave. Northampton, MA 01060
Easthampton, MA 01027
Terms Rep
Estimate valid for 30 days Keith
Description Total
Remove existing roofs. 11,900.00
Furnish & install 1/2"plywood over existing decking.
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.
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$2500.00 for garage roof.
Add$1200.00 to replace skylight.
WE LOOK FORWARD TO DOING BUSINESS WITH YOU.
Total $11,900.00
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
licensed solid waste disposal facility, as defined by MGL c '111 , S 150A.
Address of the work: 412 1ro c'f SfA
The debris will be transported by: OM'e" --e. 11S'
The debris will be received by: y\,\(J ���- ' � ��ti� ��(� ✓�� GI ��
4
Building permit number:
Name of Permit Appl'cant ZCT &(y6
Date Signature of Permit Applicant
The Commonwealth of Massachusetts
Depar-tinent of Industrial Accidents
Office of Investigations
600 Washington Street
Boston AM 02111
W}m tnass,g ov1dia
Workers' Compensation Insurance Aff"idaAtl Bullders/lam o:iltl,actors(Electricinns/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual); �j ���, S ��, l,L•C�
Address;- �4L C""-
City/State/Zi)r,; k o' �) Phone
Are you an employer? Check the appropriate,box: Type of project (required):`~_}
1. [ am a employer with U 4• [� I am a general contractor and. I 6. ❑ New construction
employees (full and/or part-time),* have hired the sub-contractors
2. [1 I am a sole praprietor or partner- listed on the attached sheet, t F7 Remodeling I
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity, workers' comp, insuranct:. 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. [l I am a homeowner doing all work right of exemption per MGL 11.7 Plwnbing repairs or additions
myself [No workers' comp. c, 152, §1(4), and we have no 12. Roof repairs
insurance r(�qu.ired,) t employees, [No workers' 1317 Other
COMP, insurance required.)
'Any applicant that checks box tt 1 must also fill out the section below showing their workers'cotrq)ensation policy information.
l Homeowners who sutnnit this affidavit indicating they are doing all work and then hire outside aontrectors must subnit a new affidavit u,dicatinp such.
(Contractors that check thin box must attached an additional sheet showing the name of the subcontractors and their workers'comp,policy information,
I am an employer that is providing workers' compensation insurance for my employees, Below is the policy and job site
information.
tnsw•anee Company Name; �'� l7 (I
Policy #or Self-in; Lie, #;�� go, ?)y O;"� _ Ex-piration Date: /)Q (v
Job kite Address,_ � y ? J City/State/Zip; IVCr✓ dry /7J71q oyo6•o
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 MOL c, 152 can lead to the imposition of criminal penalties of a
rme up to $1,500.00 andlor one-year imprisonment, as well as civil penalties ut the form of a STOP WORK ORDER and a fmc
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 certify under the pains and penalties of perjure that the information provided above is true and correct.
__Date:
Phone#; � j . _141L T
Official use only, .Do not write In this area, to be completed by city or covert of fccial•
City or Town: Permit[License:
Issuing Authority (circle one):
LBoaxd He0th 2. Building Depa rtment 3, City/Town Clerk 4,Electrical Inspector 5, Plumbing Inspector L son: PhnnF, a,
SECTION 8 -CONSTRUCTION SERVICES —�
8.1 Licensed Construction Supervisor: Not Applicable C3(�I ,
Name of License Holder 2�gI I S16 —_ lii y 9 q '52A.-
License Number
`;-i Ln�'hrtrnrdon 1 Yl 01 c a 3 0`> °y� ° Ito
Address / y �`` — Expiration Date
Signature Telephone 1
9. Registered Home.Improvement'Contractor: Not Applicable ❑
Company Name Registration Number
Address T— Expiration Date
09 Telephone L ."
SECTION 10-WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L,c. 152, §25C(ti))
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....... I,-.( 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 peri,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 haws 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_ lAe)-c 6PA __—
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House Addition Replacement Windows [Alteration(s) Roofing El
Or Doors 71
Accessory Bldg. ❑ Demolition ❑ New Signs (0;1 Decks Siding (711 Other 101
Brief Description of Proposed `�
Work: _ S �OL(IQ � ---
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 housinct, complet e tho following:
a. Use of building : One Family—, Two Family Other—__--._
b Number of roorns 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
as Owner of the subject
property
hereby authorize _ +� (�1 C'1Z ` , , I
to act on my behalf, in all matters relative to work authorized by this building permit as Allication.
--
aA�a c n P
Signature of Owner Date
I, [AUk K 1_)c?�1,S�Q CSC (�h l(]1't7F��� aQen+ as Owner/Authorized
Agent hereby declare that the statements and information on 4e 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
1 City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
j/ Room 100 WaterMJe l Availability
`f' f Northampton, MA 01060 Two Sets of Structural,Plans
phone 413-587-1240 Fax 413-587-1272 Plot/Ste Piai s
Other Specify
APPLI ATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEM01_IS1-1 A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION —�
1.1 Property Address: This;section to be completed by office
o�
/,z 101'es fecf 3/ Map— _-- Lot —Unit
//Iaib h n, Zone Overlay District_,–_--
Elm St.District District
SECTION 2 -PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
lt6 YT 14, zz4f611&-,k&"
Name(Print) Current Mailing Address:
Sel- a/71d-Me, — Telephone
Signature
2.2 Authorized Agent: I 7
6 _ _c2`1� _� 'C , 7' r i rt n ^urrent Mailing Address:
' ' r 1 A ��`C}�-�'
Name(Print) r i
Signature \_ Telephone
SECTION 3 -ESTIMATED CONSTRUCTION COSTS ( —
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building t / (a)Building Permit fee
2 Electrical (b)Estimated Total Cost of
Construction from (o) _
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 +2+3+4 + 5) j j q- 00' ' Check Number b
This Section For Official Use Only__
Building Permit Number:_ Date
Issued:
Signature:
Building Commissioner/inspector of Buildings Date
212 PROSPECT ST BP-2016-0441
G1S#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:24D-233 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-2016-0441
Project# JS-2016-000730
Est.Cost: $11900.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RCI ROOFING 74334
Lot Size(sq.ft.): 10802.88 Owner: DONNELLY SUSAN&JENNIFER LEVI
Zoning.URB(100)/ Applicant: RCI ROOFING
AT. 212 PROSPECT ST
Applicant Address: Phone: Insurance:
6 LINE ST (413) 527-4775 Workers Compensation
SOUTHAMPTONMA01073 ISSUED ON:101212015 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP, PLY & 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 10/2/2015 0:00:00 $40.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner