11-018 RC.1- RDate
6 Line St. Estimate
Southampton, Ma. 01073 11/2/2015
Phone(413)527-4775
Fax(413)527-8469
Name/Address Job Location
Bonnie Carhart
31 Rustlewood Ridge
Florence, MA 01062
Terms Rep
Estimate valid for 30 days Chris
Description Total
Remove existing roofs. 5,000.00
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 IKO shingles. CNvr.bnti Fo,,tst Cy---
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.
All related permits will be obtained by R.C.I. Roofing.
Add$2,50 per sq. ft. for wood decking replacement if needed.
Estimate pricing is for the two sections of restoration needed and two 14'ridge caps.
WE LOOK FORWARD TO DOING BUSINESS WITH YOU.
Total $s,000.00
TERMS OF PAYMENT
5%Deposit Customer Signature:
Balance upon completion
Registration# 126235 Date:
Construction License#074334
Insured by Banas&Fickert Ins. Shingle Color Selection: 0 C
(413)527-2700 ���
City of Northampton 212 Main Street, Northampton, MA 01060
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as
a condition of the building permit all debris resulting from the construction
activity governed by this Building Permit shall bE; disposed of in a properly
licensed solid waste disposal facility, as defined by MGL c 111 , S 150A,
Address of the work;
The debris will be transported by, � Nv� 5�1 S
The debris will be received by; � ��C� ����.� �.�� U r��h.i�e/(
Building permit number;
Name of Permit Appl'cant z�' �C.,��� ��✓� l �✓l�.
r
Date Signature of Permit Applicant
The Commonwealth of Massachusetts ��, rrtntt or,rn
Department of Industrial Accidents
Office of Investigations
I Congress Street, Suite 100
Boston MA 02114-2017
www,mass.gov/dia
Workers' Compensation Insurance Affidavit; Builders/Cc)ntractors/Electricians/Plumbers
Applicant Information _ !! Please Print Legibly
Name (Bus iness/Organization/Individual):_
Address:
City/State/Zip: �cc. `iQ.rati l� , / � eyo,73 Phone #:
kre you an employer? Check the appropriate box: Type of project (required):
[2,I am a employer with x,2.0 - 4, ❑ I am a general contractor and I
— * have hired the sub-contractors 6, ❑ New construction
employees (full and/or part-time).
❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g, ❑ Demolition
working for me in any capacity. employees and have workers' 9, ❑ Building addition
[No workers' comp. insurance comp, insurance,$
required.] 5. ❑ We are a corporation and its 10.7 Electrical repairs or additions
❑ 1 am a homeowner doing all work officers have exercised their 11.7 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 112—Moof repairs
insurance required.] ' 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.
10111eowners who submit 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
iployees, If the sub-contractors have employees,they must provide their workers' comp,policy number,
am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
formation.
('71
tsurance Company Name:
clicy 4 or Self-ins. Lic, 4: 4 ( Expiration Date; /D
City/State/Zip:
)b Site Address: 1u sf/�I '�1�lC•� ��+t��� ��eYl cx, MA
ttach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
aiIure to secure coverage as requited under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
ne 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,
do hereby certify under the a�ins and enalties o ejur that the information provided above is true and correct.
mature: Date; ___
// y /S�
I one #, 0113) 1-7 `7'7S-
Official use only. Do not write in this area, to be completed by city or town offcciat
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#:
>E:CTION 8 •CONSTRUCTION SERVICES
._1 Licensed Construction Supervlsor: Not Applicableu ❑
Lame of License Holder:-- --- r �' y�11)
License Number
4_�1C�V. �4o n . I 01('t�7'3 _ 0 Cj chJ -° I ld
_�
,ddress \ 7 Expiration Date
gnature Telephone
Registered Hio:m:e::Impro:Ve:ment C,'o•ntna;ctar;; Not Applicable ❑
ompany Name Registration Number
ddress �-- —�-
Expiration Date
Telephone � L '
E:CTION 10•WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.,G,L, c,162, § 260(Ei))
Jorkers Compensation Insurance affidavit must be completed and submitted with this application. failure to provide this affidavit will result
the denial of the issuance of the building permit,
Igned Affidavit Attached Ye:s....... C( No.,..,. ❑
11. ��;orniF Owz�:er ��xnt�`taio>l
The current exemption for"homeowners"was extended to include Owner-oceupied 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
RS supervisor, CIgR 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:>tructures accessory to such use and/or farm
structures.A person who constructs more than one home in a two-vgaLnerl,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 ftom 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— 0
ii
i
°E_CTION 5-DESCRIPTIOtJOF PRi0POSED WORK�hec_k al)annaicabiej
New House Addition [] Replacement Windows Alteration(s) F7 Roofing
Or Doors ❑ T_— _
4ccessory Bldg. ❑ Demolition ❑ New Signs (oj Decks Siding (oj Other(ID)
3rief Description of Proposed 1\
!York:
Iteration of existing bedroom Yes No Adding new bedroom __Yes No
attached Narrative Renovating unfinished bas0n ertt Yes No
'fans Attached Roll -Sheet —' �—
>a, If New,housEaand cDr ad.d'lion.toexsting ho;using;;comp.let� fii fiollo_ wina:;
Use of building : One Family Two Family_ Other__,___.
Number of rooms in each family unit: Number of Bathrooms
Is there a garage attached?
i Proposed Square footage of new construction, Dimensions
Number of stories?
Method of heating?_ Fireplaces or Woodstoves_ Number of each
Energy Conservation Compliance, Masscheck Energy Compliance form attached?
Type of construction
Is construction within 100 ft. of wetlands? Yes _`No, Is construction within 100 yr, floodplain Yes No
Depth of basement or cellar floor below finished grade
Will building conform to the Building and Zoning regulations? Yes No
Septic Tank___ City Sewer Private well City water Supply
3 E.CTION 7a -OWNER AUTHORIZATION -TO B.E.C.OMPI.ETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR B.MIDIN.G PERMIT
1
C'YIn l e CCU Q✓f
,r�oper}y as Owner of the subject
I --�
ereby authorize _� ( S'IZ. (L-t_ t o �1(, ir)(I
D act on my behalf, in all matters relative to work authorized by this building permit aR ligation,
ignature of Owner Date _
f �-K LlL �5--� ��f?�'I �r'� n-� _ as Owner/Authorized
,gent hereby declare that the statements and information on de foregoing application are true and accurate, to the best of my knowledge
nd belief,
igned under the pains and penalties of perjury,
ri nt Name
gnature of Owner/Agent Date —
,.�rt
i��
f
I
� .��� ,r,.,...� Oepartmefit use orrfy
B C � I clt of Northampton Staters of p6rmntt:
Bull ing Department Curb Cut%1J;riveway Permit
2u�� jNorthhmpton,2 2 Main Street Sewer/ eptacAvatlabrlity
J Room 100 w'axernn�airAvariab�iiit-y
MA 01060 Two Sets of StructuraLPlans
DFr't araurc+ 'rl s %,-517-1240 Fax 413-587-1272 P1ot%Slte Plans
NOR7TiAMP7
Other SI�effy
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Addross: 1 hhr s;ectl.0n to:be c:omple.te:d by offiee
31 Ua`f/e Wood 42,dye Map_`___ Got unit
Zone
_OverlayDlstrict__.
Eiin 81. District;___ C13 1stdot-
SECTION 2 -PROPERTY OWN:ERS'HIR/AUTHORIZED AGENT
2.1 Owner of Record; !�
PCtw.Sileie-1e )d i�id ��eare r7ihG�;,1_
Name Print -
( ) Current aHn Address:
S 0— _ Telephone
Signature
2.2 Authorized Agent:: \ ` '
Name (Print) ,r Current Mailing Address:
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars)to be Official Use.Only
completed by permit applicant
1 Building - L (a:)Building.Permit:Fee
2 Electrical (;b):Estlmate.d Total Cost of
Construetion from.(6) _
3. Plunbing Building Perrnit:Fee
4. Mechanical (HVAC)
5. Fire Protection
_6. Total = (1 + 2 +3 +4 + 5) 1 CPO. Check Number
This SeOon For-Off Ictal:Use Only_
Building Permit Number:. Date
Issued
Signature:
Building Commissioner/Inspector of Buildings Date
31 RUSTLEWOOD RDG BP-2016-0653
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 11 -018 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-2016-0653
Project# JS-2016-001097
Est.Cost: $5000.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RCI ROOFING 74334
Lot Size(sq. 1): 80368.20 Owner: SCHMIDT BONNIE S C/O BONNIE S CARHART
Zoning-: Applicant: RCI ROOFING
AT. 31 RUSTLEWOOD RDG
Applicant Address: Phone: Insurance:
6 LINE ST (413)527-4775 Workers Compensation
SOUTHAMPTON MAO 1073 ISSUED ON.11110/2015 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 11/10/2015 0:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner