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29-602 (3) 70 STONE RIDGE DR BP-2016-1075 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block:29-602 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) cate,ory: ROOF BUILDING PERMIT Permit# BP-2016-1075 Project# JS-2016-001831 Est. Cost: $10900.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: RCI ROOFING 74334 Lot Size(sq. ft.): 139827.60 Owner: HAYSSEN VIRGINIA DOUGLASS Zoning: Applicant: RCI ROOFING AT. 70 STONE RIDGE DR Applicant Address: Phone: Insurance: 6 LINE ST (413) 527-4775 Workers Compensation SOUTHAMPTONMA01073 ISSUED ON.3/7/2016;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 3/7/2016 0:00:00 $40.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner Department use only City of Northampton -Statvs of:PeeIn!t: t(t� B ilding Department curb c;utl©rl�eway Perm lt 12 Main Streetewei/ pticykuatlabilty`. r N rssrrcnr.r�s Room 100 UUatE r/V!/ell AvAi[abtlity DEN.OroFj PTOv'MAotioSU ampton, MA 01060 Two S'et's.of Structural,Plans phone 413-587-1240 Fax 413-587-1272 rio'/tite Pians Qther S'hecify. APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION'—� 1.1 Property Address: 171111"y vectl.oln to be completed by office Stzne. Ady& Map.= --- Lot _—Unit Zone —_ _ _Overlay District__ I _ Eli..SA, District,_—_ CB District — SECTION 2 •PROPERTY OWN ER,rHIPIAUTHORIZED AGENT 2.1 Owner of Record: _ ' _� i)"-1 Cclle,�, Name(Prirat Current Mailing dress: �-yl 3,�:��"- 3 e Ce U (C� Telephone Signature 2.2 Authorized Aoent: — Ind/ _ I "'� f•.1—')v—W.11.3G��. 4. tl —S� r\, r) ' 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 (c)(o? _ (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of onStrUctl0fl frorr.(U.) 3. Plumbing Building Perrnit Fee 4. Mechanical (HVAC) _ 5. Fire Protection _ 6. Total = (1 + 2 + 3 +4 + 5) �� - — Check Number This Section For Officli.al Use OnlL_ Building Permit Number:_ Date Issued Signature: Building Commissioner/Inspector of Buildings Date i SECTION 5-DE8C IPTCO OF PR(?POSg,D WORK(ch.eck aII apW ab:Isy New House Addition Replacement Windows Alterations) ❑ Roofing Or Doors ❑ -- _ Accessory Bldg, ❑ Demolition ❑ New Signs [i=) Decks [[Z] Siding (tI] Other 101 Brief Description of Proposed Work: _ _—' CL (1<1c' d Alteration of existing bedroom Yes, No Adding new bedroom_ —__Yes No Attached Narrative Renovating unfinished basement _ Yes _No Plans Attached Roll -Sheet sa, If New h:a.use and.ot a.d'diti.an to ex'rs illon,hou inq, comi�.Sete'thr��lIpwima: a. Use of building : One Family i 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. Dimensions e. Number of stories? f. Method of heating? _ Fireplaces.or Woodstoves_ Number of each g. Energy Conservation Compliance. Masschedk Energy Compliance form attached?�Y 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 CONTRACTOR APPLIES FOR BUILDING PERMIT I, I r` ;a� >SC11 __. as Owner of the subject Property y hereby authorize _. ��11�1� t�'_ �j , �t . T. ��'�tr) to act on my behalf, in all matters relative to work authorized by this building permit aR ication. Signature of Owner Date I, (wy''t1 \,)l)i ��1}4im"10d (h()L yl _, as OwnerlAuthorized Agent hereby declare that the statements and information omthe 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 SECTION 8 -CONSTRUCTION SERVICES 8.1 Licensed Construction Su,pervtasor: Not Applicable El oldt, Name of License Holder; r -1 �i�P ( } License Number Andress Expiration Date �"`. Ll`I1 ; Signature Telephone 9, Ractis.tere.d Home:Improvement C'o.ntraetor Not Applicable ❑ Company Name Registration Number Address -r— Expiration Date `O'� 'c� TelephoneL4-JAL.' t �- SECTION 10-WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L,c.162, §26C(6)) 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....... IV( No...... ❑ f 1. 11bimne Owxlier ft mot 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.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 structures accessory to such use and/or farm structures.Aperson who constructs more than one home in a jwo-dear pewiod 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 rerformed under the building pLimit. 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 Laws Annotated,you may be liablg 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 The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 www,mass.govldia Workers' Compensation Insurance Affidavit-, Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Apolicant Information Please Print Legibly Name (Business/Organization/Individual):—/� � 1 A119 a-, L L P Address: L/t")61 (9/-. City/State/Zip: Sou#qdn �n 94 01073 Phone #: 64113) 6�'7 - 1-177 — FAre you an employer?Check the appropriate box: Type of project(required): 1.[��arn a employer with 114) employees(full and/or part-time).* 7, New construction 2.O 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 4.7 1 am a homeowner and will be hiring contractors to conduct 811 work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.7 Electrical repairs or additions proprietors with no employees. 12,7 Plumbing repairs or additions 5.7 1 am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13,[2-Roof repairs 'Fhese subcontractors have employees and have workers'comp.insurance.1 6.7 we are a corporation and its officers have exercised their right of exemption per MGL C. 14,❑Other 152,61(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 insuranceformy employees. Below is the policy and job site information, Insurance Company Name: Ail- J-L�erlll-7,ee- Policy#or Self-ins. Lic, #: ILI(f, 1 13 41-06- Expiration Elate,, Job Site Address: 71' 37�n� Ri Z/'�& 6 City/State/Zip: f-IcKe.-IGe, -I.T7A 0/ 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 d fit dpenalties of perjury that the information provided above is true and correct. ,y under Signature: Date: 3 - Phone#: 7 - 4 V7 75 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 Marin Street, Northampton, NIA 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; 7c x,,d, e ,- - , The debris will be transported by; 3D The debris will be received by; C' rv\P Building permit number; Name of Permit Appl'cant Date Signature of Permit Applicant R.C.I. Roofing Date 6 Line St. Estimate Southampton,Ma.01073 2/23/2016 Phone(413)527-4775 Fax(413)527-8469 Name I Address Job Location Virginia I layssen 70 Stone Ridge Dr. Smith College Florence, MA 01062 44 College Lane Northampton, MA 01063 Terms Rep Estimate valid for 30 days Chris Description Total Remove existing roofs, 10,900.00 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 underlayrnent 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. Price does not include the new addition. WE LOOK FORWARD TO DOING BUSINESS WITH YOU. Total $10,900.00 TERMS OF PAYMENT 5%Deposit Customer Signature: Balance Upon completion Registration# 126235 Construction License 9 074334 1 Date: M-cjA 16 Insured by Banas&Fickert Ins, Shingle Color Selection, (4 13) 527-2700 1 CAI—