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32C-031 21 BREWSTER CT BP-2016-1128 GIs #: COMMONWEALTH OF MASSACHUSETTS Map Block: 32C-031 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A) Category: ROOF BUILDING PERMIT Permit# BP-2016-1128 Project# JS-2016-001929 Est. Cost: $22000.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: RCI ROOFING 74334 Lot Size(sq. ft.): 4225.32 Owner: RESCIA RICHARD R& S ZEWSKI TRUSTEES OF THE STANDICK TRUST Zoning: CB(lOo)/ Applicant: RCI ROOFING AT. 21 BREWSTER CT Applicant Address: Phone: Insurance: 6 LINE ST (413)527-4775 Workers Compensation SOUTHAMPTONMA01073 ISSUED ON.•3/23/2016 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 3/23/2016 0:00:00 $40.00 212 Main Street,Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner — - ? Department use only A` (amity of Northampton Statvs of'Per rriit:- Building Department Curb cut ortJeway Perm It 212 Main Street Sower/ Optic Availability` - t Room 100 ')Neter/Well Auaifability Northampton, MA 01060 Two Setssof Structural,Plans: oEr"Nc;j;N,' , h;one 41.6 587-1240 Fax 413-587-1272 PioV&' * 1'iar<s Q:ther Specify APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOI-I:>H A ONE OR TWO FAMILY DWELLING ( SECTION 1 •SITE INFORMATION' 1.1 Property Address: 1 hla section to be completed by office 3 Map: cJ Loa 63 �. --Unit N0f_1hd Win, /Yll� � Zone.__ _Overlay Distraetr�, Elm St.Distrlot CB Distrlct SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: �f CIu t- PC, 3n�c _ 797 A1i9rthQrnfi1vn, MH 1�lc i-oma Name(Print) Current Mailing Address: `a3- 3�0 /83i 5t_< _. Telephone Signature 2.2 Authorized Agent: (L� Name(Print), ✓ Current Mailing Address:' 1 � l �I Signature _ Telephone --_ SECTION 3 -ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be �^ Official Use Only completed by permit applicant ___ 1, Building (a)Building Permit fee 2. Electrical (b) Estimated Total Cost of _ Construntion from.(6) _ 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5, Fire Protection 6. Total = (1 +2 +3 +4 + 5) % ate. Check Number This Section For Official Use Only Building Permit Number: Dater Issued: Signature: Building Commissioner/Inspector of Buildings Date SECTION 5-DESCKPTEOj'3 O:F PROPOSED WORE.(fleck a';i,(�apalicable) New House Addition [❑ Replacement windows Aiteration(s) ❑ RoofingT Or Doors 17711 Accessory Bldg. ❑ Demolition ❑ New Signs (tom] Deeks Siding [C]] Other[©j Brief Description of Proposed 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 howsgv andor.a,dditi;on a ex'ts.tinn houim;g, com .let 'fih fi61:10win a. Use of building ; One Family Two Family Other I 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 900 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 , 1. Septic Tank___, City Sewer Private well City water Supply SECTION 7a -OWNER AUTHORIZATION -TO BE COMPLETED WHEN OWNERS AGENT OR CON'rRACTO.R APPLIES FOR BUILDING PERMIT !r6 tSC_r' �'fF-rl(6 c L /YuS —_. as Owner of the subject property t t �j hereby authorize � (�1 i C�—(a t' ,t//_� , T. 6 -( -- to act on my behalf; in all matters relative to work authorized by this building permit aR lication, (IA- a('hP.d - /(0 Signature of Owner Date I, �E�C,'� ) �}�(1 t�4)oy'"?_ d a QcC nY llr ___— —_, as Owner/Authorized Agent hereby declare that the statements and information onset 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 c f, Signature of Owner/Agent Date SECTION 8 -CONSTRUCTION SERVICES 8.1 Licensed Construction Supervi:3orr: ( { Not Applicable ❑ 2 t! Name of License Holder:_ -! x.11 IP_ r r7 1-1 21� l License �Number Address Expiration Date Signature Telephone 9. Registered I tome:Improvement CContract6r:. Not Applicable ❑ Company Name Registration Number ( () U oc�- ()11--) d C)In i l i Address -�-- Expiration Date m(Lk.W._rM.LA ��`� TelephoneL„ SECTION 10•WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G,L, c, 162, §26C(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 Yea,....,. C( No.,.... ❑ 11. Home, Owl"Iler. Exe, on 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 t~wo-year period shall not be considered a homeowner. Such"homeowner"shall sLibmit to the Building Official,on a form acceptable to the Building Official,that he/she shall be responsible for all such work nerformed under the buildin permit. As acting Construetion 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_ Q -LL_ _ ___ The Commonwealth;of Massachusetts Department of Industrial Accidents I 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 Leeibiv Name (Business/Organization/Individual): �f, 1 lqoo r7q LP Address: Ll n' e..- f City/State/Zip: MI-1 0/073 Phone 9: 6L113 '7 - I-f`775_ Are you an employer?Check the appropriate box: Type of project(required): 1.❑r !am a employer with c4-0 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 $, ❑Remodeling any capacity.(No workers'comp.insurance required.] 9. ❑ Demolition 3.7 1 am a homeowner doing all work myself. (No workers'comp.insurance required.]t 107 Building addition 4❑1 am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole i 1,❑ Electrical repairs or additions proprietors with no employees. 12.[]Plumbing repairs or additions 5.17 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'camp.insurance.t b.❑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. 1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: �ta/l l- Policy#or Self-ins, Lic, #;� 2(n d33'7(697 Expiration Date: Job Site Address: Jl-.23 City/State/Zip: for hQr l71/� oio� 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 WORT{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. do hereby certify under ti gins a d penalties of perjury that the information provided above is true and correct. Signature: " �J \_ Date: Phone#• J1:17 775— 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#: 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 licensed solid waste disposal facility, as defined by MGL c 111 , S 150A, Address of the work: /-,;z3 1"1l The, debris will be transported by: Cl�✓ll ,�-- 1 , i�� ,r� The debris will be received by: 0"0 �\'\p �( :�( �,(�r�ti; �j(v /� -Gl, li-6 Building permit number: Name of Permit A I'cant z� Date 14,, Signature of Permit Applicant RC-1- Roofin_ g Date 6 Line St. Esti m ate Southampton, Ma. 01073 2/23/2016 Phone(413)527-4775 Fax(413)527-8469 Name/Address Job Location STANDICK TRUST 21-23 Brewster Ct. P.O. Box 797 Northampton, MA Northampton, MA 01061-0797 Terms Rep Estimate valid for 30 days Chris Description Total Remove existing roofs. 22,000.00 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, 6 feet 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. WE LOOK FORWARD TO DOING BUSINESS WITH YOU. Total $22,000.00 TERMS OF PAYMENT 5%Deposit C:;ustomer Signature: Balance upon completion Registration# 126235 ' Construction License#074334 Date: 2� lu Insured by Banas&Fickert Ins. (413)527-2700 Shingle Color Selection: