24A-114 (4) RC-1. Roofing Date
6 Line St. Estimate
Southampton, Ma. 01073 11/10/2015
Phone(413)527-4775
Fax(413)527-8469
Name/Address Job Location
Steve Gusan
78 Prospect St.
Northampton, MA 01060 , G�t
Terms Rep
Estimate valid for 30 days Chris
Description Total
Remove existing roofs. 6,800.00
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.
WE LOOK FORWARD TO DOING BUSINESS WITH YOU.
Total $6,800.00
TERMS OF PAYMENT l
5%Deposit Customer Signature:
Balance upon completion )/ � C
Registration# 126235 Date:
Construction License#074334
Insured by Banas&Fickert Ins.
(413)527-2700 Shingle Color Selection:
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: 7X A A% 7 /T= n
The debris will be transported by.
The debris will be received by: 0'0 �\'\p l erf�� L;�(`���J�e/(`"t't�
Building permit number: I
Name of Permit Applicant � �C'T 6 ( LL
Date �� _ is Signature of Permit Applicant
\ The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): 1 Rp��r��l LL P
Address: (o Ll rj e-
�lf.
City/State/Zip: S ufhdrn frn A14 01073 Phone #: (,�'/3) If'775_
Are you an employer?Check the appropriate box: Type of project(required):
l.�am a employer with 19-6) employees(full and/or part-time).* 7. ❑New construction
2.❑I am a sole proprietor or partnership and have no employees working for me in 8. []Remodeling
any capacity. [No workers'comp.insurance required.]
9. El Demolition
3.F—]1 am a homeowner doing all work myself.[No workers'comp.insurance required.]+
4.7 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 E] Building addition
ensure that all contractors either have workers'compensation insurance or are sole 1 1.Q Electrical repairs or additions
proprietors with no employees.
12.F�Plumbing repairs or additions
5.7 1 am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. Roof repairs
These sub-contractors have employees and have workers'comp.insurance.:
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14,❑Other
152,§1(4),and we have no employees.[No workers'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 is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: �TQy �h S� ✓� �Q
Policy#or Self-ins.Lic.�#: AI C- Q(ooP 3�/O5J Expiration Date: /O
Job Site Address: w1h,-1X mpq rv6� �,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 MGL c. 152,§25A is a criminal violation punishable by 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. 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 rains a d penalties of perjury that the information provided above is true and correct.
Si nature: C' Date:
g S� S
Phone#: LI-1-12 J��-7 7276-
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 SERVICES
81 Licensed Construction Supervisor: Not Applicable ❑
Name of License
License Number
ice, S.Y 1l Y1�4 Yl LT�fli 1 �)CIr�
of) - �0
Address Expiration Date
Signature Telephone
9, Ragis.teire:d Wo meArnpro.veme.nt?C.nn:tractdr: Not Applicable ❑
E1. C , t1RC1 ► Il "A 1 DU21t
Company Name �J Registration Number
c t oL
Address T— --'— `
Expiration Date
COE rk�� ()`��r7 Telephone�� � ` :
SECTION 10-WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M;G.L,c. 152, § 25C:(Ei))
✓Yorkers 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 Ye:s....... 12 No...... ❑ +
11. , 1 omEe Ow;rier xexnt��>!On
The current exemption for"homeowners"was extended to include Owner-oceimied 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 Homeownei;; 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- em-�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/sire shall be
responsible for all such work performed under the buildine permit.
As acting Construction Supervisor your presence on the job site will be required fi•om 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_ (�- � chod --_
SECTION 5-DESCRIPTION{O.F PROPOSED WORK,( heek a11,AWL1Lcab1e)
New House [7 Addition F] Replacement Windows Alterations) Roofing
i Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [CM] Decks (❑ Siding 10] Other 11711
Brief Description of Proposed ``11
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 Nauss) and or ad`d,Wo.n o extsting hogs hnn complete fihe f0 owing;
a. Use of building : One Family_ Two Family Other
b. Number 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 collar 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 TRACTOR APPLIES FOR BUILDING PERMIT —
SyYeI6 6-('s e / _— as Owner of the subject
property
hereby authorize _ n 2.1 Q C)-t �1�
to act on my behalf, in all matters relative to work authorized by this building permit aR lication
Signature of Owner Date
1=1� -_•
I, v Iti n C10-_Vt E' 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 us"e o.n(y
City of Northampton Status of Permit:-
Building Department Curb cut rtV.eway Permlt
1 212 Main Street SewerhSepticAvailabillty
Nov Z 3 ?(MI5 ! Room 100 Water/,Well Aytaif2bility_
I Northampton, MA 01060 Two Set's.o`Structural_Plans
ce r cs e: _ ., one 13 587-1240 Fax 413-587-1272 Piot/Slte Pians.
Other Sleclfy
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOI.I:iH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION —�
1.1 PropertyLAddress: / 1,111's section to m
he copleaed by office
i
79 P-c S �[' A V r:5: Map— _-- Cot —Unit
/t14 Zone _ _ _Overlay District,_•
_ Elm St.District._ CB'Dls.trict�
SECTION 2 -PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
,SfeC&
Name(Print) Curren Mailing Address:
#a Mvd Telephone
Signature
2.2 Authorized Agent:r ' ` ` , —
�. Lin p_ Yl >
Name(Print) �,r � Current Mailing Addressr-;�
Signature _ Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be �^ Official Use Only
com leted by ermit applicant
1 Building (a) Building Permit Fee
2. Electrical (b) Estlmate.d Total Cost of
Construction from.(6)
3. Plumbing Building Perrnit Fee
4. Mechanical(HVAC)
5. Fire Protection �--
6 Total = (1 + 2 +3+4 +5) Check Number y
This Section For O.fficlal:Use Only. _
Building Permit Rumber:_ Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
78 PROSPECT AVE BP-2016-0721
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24A- 114 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-2016-0721
Project# JS-2016-001208
Est. Cost: $6800.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RCI ROOFING 74334
Lot Size(sq. ft.): 20995.92 Owner: GUSAN STEPHEN
Zoning:URA(100)/ Applicant: RCI ROOFING
AT. 78 PROSPECT AVE
Applicant Address: Phone: Insurance:
6 LINE ST (413) 527-4775 Workers Compensation
SOUTHAMPTON MAO 1073 ISSUED ON.1112412015 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:
FeeTyne: Date Paid: Amount:
Building 11/24/2015 0:00:00 $40.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner