29-572 KC.I. Roofing Date
6 Line St.
Southampton, Ma. 01073 10/7/2015
Phone(413)527-4775
Fax(413)527-8469
Name/Address Job Location
Bruce Gilbert
172 Overlook Dr. 7 oL
Florence, MA 01062
Terms Rep
Estimate valid for 30 days Chris
Description Total
Remove existing roots. 8,700.00
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.
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.
WE LOOK FORWARD TO DOING BUSINESS WITH YOU.
Total $8,700,00
TERMS OF PAYMENT 2
Customer Signature /
5%Deposit �� 1i07
Balance upon completion
Registration# 126235
Construction License#074334 Date odo)a Or 201 S
Insured by Banas&Fickert Ins. '
(413)527-2700
City of Northampton 212 Main Street, Northampton, MA 01060
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c 40, S:54, I acknowledge that as
a condition of the building permit all debris resulting from the construction
activity governed by this Building Permit shall bE� disposed of in a properly
IicE�nsed solid waste disposal facility, as defined by MGL c 111 , S 150A,
Address of the work: I7j I �_Y_/cr���cr,
The, debris will be transported by: CO 0
The; debris will be received by: 0-'�j V,\p ler
Buildin
g permit number:
Name of Permit Applicant � � �. o /11'/6
Date fir_ �� Signature of Permit Applicant
L _ The Commonwealth of Massachusetts Print Form.
Department of Industrial Accidents
Office of Investigations
I Congress Street, Suite 100
Boston, MA 02114-2017
A: www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information _ Please Print Ledbly
Name (Bus iness/Organization/Individual):_ R L-T J'`C p0� rl'e L _
Address:
City/State/Zip: ? cc. � ;� i., P/1 0/y`73 Phone #: 3 7 /V 775
Are you an employer? Check the appropriate box: Type of project(required):
1.[}`I am a employer with oU) 4. [] I am a general contractor and 1 6. ❑New construction
employees (full and/or part-time).* have hired the sub-contractors
2.7 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g, 7 Demolition
working for me in any capacity. employees and have workers' 9 0 Building addition
[No workers' comp. insurance comp. insurance.$
required.] 5. F-1 We are a corporation and its 10.0 Electrical repairs or additions
3,❑ I am a homeowner doing all work officers have exercised their 1 l.❑ Plumbing repairs or additions
myself, [No workers' comp. right of exemption per MGL 12.2<oof repairs
insurance required.] C. 152, §1(4), and we have no
employees. [No workers' 13.E] Other
comp. insurance required.]
'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
.'Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such,
tContractors 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 is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Compary Name:
Policy # or Self-ins, Lic. We 6)6Y3,-10S-
I Y 3,-f 0 S Expiration Date:
Job Site Address: 1 ✓IyIcpLr. City/State/Zip: /ova, /7�f� D/h�
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Fai I ure 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 certify under the ains and enalties o er'ur that the in ormativn provided above is true and correct,
Sig ature: Date
.L
Phone#: (`1/3) .5� 7 - 'y`775—
Official use only. Do not write in this area, to be completed 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 SERV:IGES
8.1 Licensed Construction Supervi:�o Not Applicable ❑
Name of LicenseHolder;���-, ��Ijsip
License Number
In n 0 5 .-CJ -° I In
Address ✓�� Expiration Date
15 an - Ll`1'15 _
Signature Telephone �-
9. Registered Home:lmpro.veme.nt C:o.n.tra�ctor•, Not Applicable ❑
Company Name Registration Number
(-% t o' ` 0"S • 0 lo
Address T— —�-
Expiration Date
TelephoneL ,ZL
SECTION 10-WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M'.G.L,c. 152, § 2SC(G))
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 perm_ it.
Signed Affidavit Attached Ye:s..... . rd No...... ❑
11. - Hamm, Owls er E�ernAt�or<
The current exemption for"homeowners"was extended to include Owner-ocegyled 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. ClgR 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-Ye.ar 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 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
SECTION 5-QE$_CRIP.TIOJJ OF PR0POSE,D WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing EZ
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [M} Decks [Q Siding [0) Other[01
Brief Description of Proposed 11 I
Work:^ — k P- tC( `X1 P ---
Alteration of existing bedroom—.–Yes. No Adding new bedroom--_,_Yes No
Attached Narrative Renovating unfinished basement --Yes —No
Plans Plans Attached Roll -Sheet
6a. If iNew h:ousE and;ca:I add+ IOn to-exlsting.housi.n%-j.corn;plefi fi, -�01`1.owinn
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, Dimen;ions
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
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 tt ee 61 Al2erk ____ as Owner of the subject
property t
hereby authorize �� P �C��. CA--i l_i . �7( rte(
to act or my behalf, in all matters relative to work authorized by this building permit aR lication.
.I C'd
Signature of Owner Date
C-I<C1P_Y1-� _— as Owner/Authorized
Agent hereby declare that the statements and information one e foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury,
Print Name
...rte'' .•/��
Signature of Owner/Agent Date
Department use.Qn[y
BE , = City of Northampton status of Permit:
— Building Department Cur=b OutrtartVeway`Per=rnit�
MIS 212 Main Street SeweriSept .Avauabilltty
��Room 100 WaterNVel►Auaifafilit,
rthampton, MA 01060 Two Sets:ofStructural.Plans
It1Sr' TONS
•587-1240 Fax 413-587-1272 PioUSIte.Ptans
c,w,n1n
Otter Specify
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION —�
1.1 Property Address; 117 section to be completed by offl.ce
17,�2, C1m-1 vLb• Map Lot Unit
F1 or-ev1Ce, MA Zone _Overlay District___
Elm St,District;___ CB Dlstrict�T
SECTION 2 -PROPERTY OWNERSHIP/AUTHO.RIZED AGENT
2.1 Owner of Record:
6rw ' brill o & I . tt 17J_ Cede✓Le) br. FCCr .,ice.
Name(Print) /��— Current Mailiing�Address;
5e� c�rice _ _ Telephoned X93 9
Signature
2.2 Authorized)Age�'nt�� �'�, �, ,\' 7
Name(Print) Current Mailing Address,
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be w^ Official Use Only
completed by permit applicant ___
1 Building ' p 7 C�. (a)Building Permit Fee
--- —
2. Electrical (b) Estlmate.d Total Cost of
Construction from.(6) _
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total = (1 +2 + 3 +h +5) x700, Check Nurriber
This Section For Official:Use Only_
Building Permit Number::_ Date
Issued
Signature:
Building Commissioner/Inspector of Buildings Date
172 OVERLOOK DR BP-2016-0638
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:29-572 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-2016-0638
Project# JS-2016-001059
Est.Cost: $8700.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: RCI ROOFING 74334
Lot Size(sq_ft.): 26745.84 Owner: BRADLEY-GILBERT BRUCE G&MARYELLEN F BRADLEY-GILBERT
Zoning: Applicant: RCI ROOFING
AT. 172 OVERLOOK DR
Applicant Address: Phone: Insurance:
6 LINE ST (413) 527-4775 Workers Compensation
SOUTHAMPTON MA01 073 ISSUED ON:11 1512015 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 11/5/2015 0:00:00 $40.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner