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31A-170 60 MAYNARD RD BP-2016-1308 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 3 1 A- 170 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-2016-1308 Project# JS-2016-002255 Est. Cost: $9800.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: RCI ROOFING 74334 Lot Size(sq. ft.): 7492.32 Owner: POMEROY RUSSELL I&BARBARA K C/O MICHAEL ROGERS Zoning:URB(100)/ Applicant: RCI ROOFING AT. 60 MAYNARD RD Applicant Address: Phone: Insurance: 6 LINE ST (413) 527-4775 Workers Compensation SOUTHAMPTONMA01073 ISSUED ON.5/10/201,6 0:00:00 TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE ROOF POST THIS CARD SO IT IS VISIBLE FROM THE NTREET 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 5/10/2016 0:00:00 $40.00 212 Main Street,Phone(413)537-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner Q E '. Department use only [�AY '' ( fty of Northampton Status of Permit: E3 ilding Department Curb-Gut/Driveway Permit DEPT.OEC ;sr r;ovs 212 Main Street Sewer/SepticAvailability MA N:; 'tiAti/F.OiV, A 01060 Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural,Plans phone 413-587-1240 Fax 413-587-127 Piot/Site Plans Other Specify. APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION'—� 1.1 Property Address: This section to be completed'by office n6 0 l��Ct�nCLYC� �C� ap— _-- Lot _Unit v l (✓ Q rn� one _ _Overlay District EIm St.District._ CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: lolMatL e rS Name(Print) Current Mailing Address: _ 3U a-ff e/0eC� '-//3 - ��/ - lU7 T9� Signature IIOlephone I 2.2 Authorized Agent: L 10:�7 � Name(Print) ,. Current Mailing Address:' Signature _ Telephone SECTION 3 •ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant ___ 1 8�uldang (a)Building Permit Fee 2 Electrical (b) Estimated Total Cost of Construction from (6) 6. Plumbing Building Permit Fee I _ 4 Mechanical(HVAC) 5. Fire Protection 6. Total = 0 +2 + 3+4 + 5) �l Fri) - Check Number This Section For Official Use Oniy__ Building Permit Number:_ Date Issued: Signature: Building Commissioner/Inspector of Buildings Date SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House Addition Replacement Windows Alterations) Roofing Or Doors © Accessory Bldg, Demolition ❑ New Signs [01 Deeks Siding[0] Other[COj 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 house and or addition to existing co plete the following 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. Dimensions T _ e. Number of stories? f. Method of heating? Firepla es or Woodstoves_ Number of each g. Energy Conservation Compliance. Mass eck 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 cellar floor below finished grade k, Will 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 CONTRACTOR APPLIES FOR BUILDING PERMIT l as Owner of the subject property hereby authorize _no- V14er �}(to act on my behalf, in all matters relative to work authorized by this buildingt a� ication. Signature of Owner Date I,_ "�f>�; (D.� (1 Q-4i 91'1'7Pd aQC�n-4 —_ as Owner/Authorized Agent hereby declare that the statements and information onde foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. Lw �� 0e r Print Name �. -3 162 Signature of Owner/Agent bate SECTION 8 -CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Vame of License Holder: —Mrk License Number address Expiration Date 15 al Ll 11115 Signature Telephone I 3, Re.ais:tere.l Home.lm rovement C ontractdr: —L Not Applicable ❑ Z;ompany Name Registration Number -- —�— a S-- y la 4ddress Expiration Date Telephone �� SECTION 10-WORKERS' COMPENSATION INSURANCE AFFIDAVIT( G.L.c. 152, § 25C'(0)) Workers Compensation Insurance affidavit must be completed and submitt d with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached YEa....... No...... ❑ i 11. 11"o;MT, Owlier Exem;p Mt The current exemption for"homeowners"was extended to include Owner-occripied 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.E 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 ponstructs more than one home in a*two-Year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official, on a foam acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building 4ermit. 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 liable for person(s) you hire to perform work for you under this permit. The undersigned"homeowner"certifies and assumes responsibil'''ty 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 -- a I Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia «'orkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Leeibly Name (Business/Organization/Individual): Rp,VWL L P Address: City/State/Zip; ,S, of/�Qr�i ih AV/ Ole)73Phone � #: �-//3) � '7 - I-/'775_ Are you an employer?Check the appropriate box: Type of project(required); 1.E311am a employer with aU) 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.] 3.7 1 am a homeowner doing all work myself. [No workers'comp.insurance required.]' 9. ❑ Demolition 4. I am a homeowner and will be hiring contractors to conduct all work on! 10 ❑ Building addition ❑ g � y property. I will ensure that all contractors either have workers'compensation insurance,or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.7 1 am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers'comp. insurance.t 13.❑Roof repairs 6.❑We are a corporation and its officers have exercised their right of exemption per MGL a 14.[:]Other 152,§1(4),and we have no employees. [No workers'comp.insurance rrOquired.] *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:__ S/ lay- h Soli✓�n/�� Policy#or Self-ins. Lic. #: LUG Q&f 3`�'T Expiration Date:_ /O Job Site Address: 1,;e fid)1I/J<!-d Jed City/State/Zip:��rf�j�in�/Z r� �?� 0/0�•Gj Attach a copy of the workerV policy declaration page(showing the policy number and expirat nog 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 certityunder t ains a d penalties of perjury that the information provided above is true and correct. Si nature: e Date: 1!5 .� Al Phone#: �/3,) x"027 — y775— 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, 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 bei 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: C�) lywk—.�--rz. l l The debris will be received by: ►�,(� ��� ��_ (�� ���`Je/C -C/� /�� BuildingI permit number: j Name of Permit A I'cant Date J �� Signature of Permit Applicant I Roo . Date' Mg RCi� # SEstimate Scat:thantpton. Ma. 01073 12 1 201; I o' )4 13)527-1:169 Name/Address Job Location Michael RoLyers a_ 60 Maynard Rd. Northampton. MA 01060 J Terms Rep F stimme. w-alid for 30 days Chr' Description Total Remove existinu roofs- 9,800.01) I"'Lli-HiSh&' install alnnainunt imp ed-e. Dille t1ashings,chimnew fla4hings(ifneeded)and step fl<ashitags. Furnish& install Certain teed Winterwrd ice£t.water barrier.6 }'i:et along eaves. Ftuni,h and install',%'ntlte.tir tinder la yment owc.r existing deck. i Furnish and install lil`etime C'ertain't'crit landmark Series shim4— Ftarnish and install C MLitt F ed approved ridge vent, All exterior roofin.; related debris to be removed by R.C.I. Roofing. All \vork will be pertormed according to manufacturers'specifications. Lifetime C'erttai fFeed material warrants' inclUded. All relaatcd permits will be obtained by R.C.I. Roofing. Add S-2,50 per sq, ft. Ior vv od decking+,replacement ifneeded. i 1vI-. LOOK ht)RW ARD TO DOING IWSINI"'SS WI"I I YOU, �} Total S9,800,00 hl It t1S of t';11`v11:N.) �" 1)c•I�c� it t:t:5tt7ttl•r`i�nitcar4� 1111aatcc upon rorr:pletion Rca:stradon t 12623 , -+ C'o:3,truc6011 I icensc =07,4334 �+ hisuru3 bBwiu is& Fickert Ins. l(4l3)52-7'-2, 0() tittin le Color Selection: