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30B-043 (2) 291 RIVERSIDE DR BP-2017-1165 GIS 9: COMMONWEALTH OF MASSACHUSETTS Map:Block:30B-043 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 ti BP-2017-1165 Project it JS-2017-001969 Est.Cost: $3000.00 Fee:$40.00 PERMISSION IS HEREBY GRANTED TO: Const,Class: Contractor: License: Use Group: RCI ROOFING 74334 Lot Size(sq.ft.): 17990.28 Owner: CZARNIECKI ADAM& IRENE Zoning: URB(100)/ Applicant: RCI ROOFING AT: 291 RIVERSIDE DR Applicant Address: Phone: Insurance: 6 LINE ST (413) 527-4775 Workers Compensation SOUTHAM PTON MA01073 ISSUED ON:4/20/2017 0:00:00 TO PERFORM THE FOLLOWING WORK:NEW 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: FeeTvpe: Date Paid: Amount: Building 4/20/2017 0:00:00 $40.00 212 Main Street, Phone(413)587-1240, Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner beloonme t uSesnly City of Northampton .Stanls of RA7mrt Building Department Curb(;utdankrreway Peiimit i 212 Main Street Sewer/septic Avatlabu¢y; i Room 100 Water/Well Ayorablhty Northampton, MA 01060 Two Sets of Structural Plans_ N phone 413.587-1240 Fax 413-587-1272 PfoVSlte wlame. Other SPeolfy. APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING �I LOr.N SITE/INFORMATION 47- / '77// 616 cperty Atldips 6'. ectIon to be completed byoffice „29/ Roecsde- Dr Map- _ Lot C-J-/ l� __Unit F/trent, Al y1 Zone-__ _Overlay D letrict__, Elm St.DIat]ICt.___ CB-District _. _".CN 2 .PROPERTY OWNERSHIPIAUTHORIZED AGENT Croner of Record: Trw. Gza-rnittic r' c29/ M✓er5/C1e., De Florence, ti/A 0/0C".)- Current Magog ing Address: e-4l3 -563 - GOOc Son R'chez rd) See. 4.1-lacked _ Te;ephooe itt_or+.zed Agent -- -__— � . KE)4 Link) �7}- ;'\tur4��ly vnp-!an friA ('lIC7:u"1 r rep . ,�- J Currant Melling Address: _ < — Cc-1V ,;'L=Gr7— L11rifg _ Telephone ?.ON 3 . ESTIMATED CONSTRUCTION COSTS Estimated Cost(Dollars)to be Officio) Ilse Only completed by permit applicant cc('- - (a) Building Permit Foe �. meg rlcar (b) Estimated Total Cost of Construction from (S) ° u rnh'ng B u I I(II og Permit Fee 'cc-a)rcal (HVAC) nroieotion O p - = = 11 + 2 +'3 + el + 5) 3, COO Check Number car5,5- 1 This Section For Officlal Use Only___ Date INC Permit Number.. Issued: �/ Y--/2 Building Comma sionerllnspeolor of Balreings ____ Date i0N 5.DES,CRIPTIOjJ r PROPOSED WORK(check.II applicable) :: House [tel Addition ❑ Replacement Windows Alteration(s) n Roofing f Or Doors ❑ _ snssory Bldg. ❑ Demolition ❑ New Signs (❑] Deoke j=1 Siding (0) Other _ Tescription of Proposed CLAfto.aPA __-- cn of existing bedroom_Yes No Adding new bedroom__ Yes No :pec Narrative Renovating unfinished basement _—Yes No -s A.ached Roll -Sheet if New house and -'.addltlon to=existtipp 11,04inq.cormplettti'Mre followinge Ise oouiiding One Family_ Two Family Other> n be of rooms in each family unit'. Number of Bathrooms__ . ._re a garage attached? c: osed Square footage of new construction. Dimensions' of stories? .!a ihod of heating? Fireplaces or Woodetoves_ Number of each, E rergy Conservation Compliance, Massoheck Energy Compliance form attached? _ /i;e o'construction s construction within 100 ftof wetlands? Yes __No. Is construction within 100 yr. floodplain _Yes___No �eliln of basement or cellar floor below finished grade , d'ng conform to the Building and Zon;ng regulations? Yes No h:,, lc hank City Sewer Private well City water Supply_ 'GN 7a -OWNER AUTHORIZATION .70 BE COMPLETED WHEN +/HERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT -1-r2✓l;, l Zarr1iePk/ as Owner of the subject immense ACAtyaPIUC\(2_ Q4' R ,Cf . Y. F"' iIl( __— f ry banal', in all matters relative to work authorized by this building permit a4�llcation. r.cbtQ� __— -/3 -/7 r,Owner Date __ 9�I -__ _ lfws l)lZ< f.e fkl4)O/oPd Ctc ern,- as Owner/Authorjzed -ereby'feeler's that the statements and information onane foregoing application are true and accurate, to the best of my knowledge cel ef. se unosr the pains and penalties of perjury. - r-o'Owner/Agent Date JTON a CONSTRUCTION SERVICES _ s:eased Construction Suoerylijj : Not Applicable C : ral cc-ans.HQi M: 1)QiiS1" 71L t`_ _ License Number th, :3 socaen ¢n rrti� let'7 o .O ie ^, -- Expiration Dale � - (Ui?,‘) 5 al I'1'15 Telephone ffita Pared HorntgtrmlprovemenCCbntratt*r Not Applicable 0 . "e _ t,CVt Nu b fW n@,UyName � Registration Number 1:esn Expiration Date _ '�L',�'.S�'�rLi-i1=1 ()I Or?'"?• Telephone (`{ ErtJ".+iLHl')c)" I;N*e-WORKERS'COMPENSATION INSURANCE AFFIbAVIT(M,G.L.C.152,§ 2SC(2)) .ars Compensation Insurance affidavit must be Completed and submitted with thle application. Failure to provide this affidavit will result ' conal of the Issuance of the building permitrif , sd A ft idavit Attached Yes....... E, No...... ❑ 1 1. flame wner -ExejnosieR The cur rent exemption for"homeowners"was extended to include Q v�neri occupied Dtyellinas of one(1) or two(2)families and to allow such homeowner to engage an individual for hire who does not possess 2 license,provided that the owner sett ns sups yjsor. CI1VIR 780 Sixth Edition Section 1.08.315,1. DefiniU' of Homeowner:Person(s)who own a parcel of(and on whichhe/she resides or intends to reside,on which there is,or is intended to be, a one or two farnlly dwelling, attached or detached nruetureg accessory to such use and/or farm structures.A person who constructs more than one home In a twory ar period ,alt all not be considered rt homeowner. Such "homeowner"shall atibmit to the Building Official,on a form acceptable to the Building Official,that he/glte shall be responsible for all such work perforated under the building pel'mlp As acting Cotutructlon 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 he advised that with reference to Chapter 152(Workers' Compensation) and Chapter 153 (Liability of Employers to Employees for injuries riot resulting in Death) of the Massachusetts General Laws Annotated, you may be liable for petson(s) you h'ha to perform work for you under this permit, The undersigned"homeowner'certifies and assumes responsibility for compliance with the State Building Code,Cit.,of Norhampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated. fii oneowner Signature azAkfA r k,Pd __ — City of Northampton 212 Main 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 be disposed of in a properly licensed solid waste disposal facility, as defined by MGL c 111 , S 150A. Address of the work: ,297 Mver3/de Di: r/oicncc, 414 The debris will be transported by: Corp/Oct I'uSpoSaj The debris will be received by: / %' . ._ -< r" c. Building permit number: Name of Permit Applicant Rel goo4i• Luc' Date y_ ; _ 7 Signature of Permit Applicant War. 7. 4017 10: 3IAM No. 0868 P. --ti CORJ ° ACERTIFICATE OF LIABILITY INSURANCE i `Aruom°3„ ' 1 THS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFIG TE HOLDER THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES i BELOW, THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), ALRHORI[ED ) REPRESENTATIVE OR PRODUCER,MO THE CERTIFICATE HOLDER. IMPORTANT: if the certificate holder IG on ADDITIONAL INSURED, 670 pollcy(i es) muaf he endorsed. If SUBROGATION IS WAIVED, subject Lc the :Erma and can dlUont of tho policy,pertain policies may requhe an endorsement. A statometlt on this certificate does not confer rights to Mo cmtlntate holder In lay of such endorsenenifs). I pFC WEFA CONTACT NAME; Michael R. lianas Sanas & Fickert P1p usxt+E n Ptp. (413) 527-2700 WY Wc,&E: 1413 527-99§9 Insurance Agency JIq L Opitc,S mb6banasinsuranco,qpm G3 Hain Street INsu- - Easthampton, MA 01027 ._... S Cau a .___... _._ INeURwnl Atimira l Enduranap • . .E ce Co, DOSED IP©URED INwRSAe,Safety Sty9Urance Q. 39454 RCI Roofing, LLP IxwnEnc;ABmiral Insurance OF. 245 . : U Line Street INSURER d;Q tar IOgytir Noe Ca —, 4 •2 Southampton, MA 01073 INSURSs s. _ INSURER rI I ..` COVERAGES CERTIFICATE NUMBER; REVISION NUMBER: MIS tS TO CERTIFY THAT THE FCUCES OF INSURANCE LISTED BELOW NAME BEEN ISSUED TO THE INCWED NAMED AEOVE FOR THE RN_?CY PE"UOD INp,GATS, NOTWITHSTANDNG ANY REQUIREMENT,TERM OR cora/310N OF ANY CONTRACT OR OTHER DOCUMGWT WITH RESPECT TO WHCH THT, CERTtICATE MAY BE ISSUED OR MAY PERTAW,THE INWRANCE AFFORDED BY TEE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL TH5 'MERMS, EXOLJ90 9 AND CONOTI' YSOF SUCH POLICIES.LIMITS SHOWN MAY SASE SEEN REDUCED {BY PAID(C.IAIVS. ILTR• TY PE OFINSURNIC4 ..... ISM a Ca SU POUCINUK5F21 .-.�0/P.Ip PODGY OW'..1i- WITS .--. I rte i G545FR5411celum X CA000020963-93 3/4/17 3/4/10 atom OGCu4RENC£ I4 1,000 0,Q. CAVAE RESTTE0 sn XIOC+MVALGONeMuk3IOTY 50 00 I r i CLALsu. elnoR �}� s OCCUR ne o ra [A� ore m I.Pr. .0,000 PERSOTAL aEnv IruuRY f 1 1 r 0 000 i_., GENERALA90REQATE t3 2,C00„000 j CrEkLAOCR£_TE5551T XMASPER _PROOUVI'Rs oatRVP me 13 2,c FI.QQQ fomiovi XI PA' r ILO 3 D I N)TOMOCIL4 LIAENU 1 X 6207761 r 9/90/18 9/90/17 Seamen L 3 1,000,000 ANY ACM cooly IOIJU RY PBI p rem) $ ALL OWNeaSCHEDULED 800ILY INJURY P AUKS X TOay�. - jlSAVAGE((Per e:aidemI 3 X HAW AUTOS X ADIOS a� -Wet e.ELrk1EPrii $ Lc C II u,Yaffun LnAa OCCUR X GX000000305-01 3/4/17 3/4/10 EACH OCCURRENCE 3 5 0002 100 i ExcelSIND OLAINS.MAPS message 3 5 000 000 DC X RETarOCNI COMM . 3 D :I: aECcsccasENSATION 400E03405 10/3/15 10/5/11 1 wOSIAM-I off.. ”' 410 FM#tOYERS'u eIurY y1N urcPROFRIErONPARTNERk>EWINE n)n - E.L.EACHACOCEM „„„ 3 1,000„_(`00 F aCERUCIADER EXCLUDE)? Y , I If a stRyIicn,i under . o .A.e.EA 'L Y:: 1 000 .00 D BcwPnyTN Cr ODE PATIQND oemw _ a-.rgnu'.P.USYL,I 3 1 000 000 I 1 :P SCPIPTION OF OPERAnoUS I LOCATIONS)VEMa69 IM dh AGORD 3%,AaSEM.I Re FM N+SCMEuln,HEW.Spate It r.GU.Nf ^....... ROOFING CONTRACTOR. • • CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE MOVE DESCRIBED POLICES BE CANCEL LED E[FORE THE EXPIRATION DATE THEREOF, NOTICE Wlll BE DCUITREO IN REFERENCD COPY. ACCOROPNCE WITH THE POLICY PROVISIONS. AUTHORS°REPAEGENTATiVE 1 © 1988-2010 ACORD CORPORATION All rlghls reserved ACORD 2912010/05) The AC ORD name and logo are registered marks of ADORE, PtIc 1e: Fax: Sartain -, cps,p Massachusetts Department of Public Safety — 34Bi Ni 20M.::5II "Vi Board of Building Regulations and Standards �P & nfeea/G%F t �� dilrf License: CS-074334uperys fw, office of Consumer Affairs&Rnsmess R cgufatmn - :-onstr[iotkon Supervisor �. r HOME IMPROVEMENT CONTRACTOR x� MARK T OESTRE ats(4) Registration, 126235 TYPO' 69 BRIGGS STREET 1.;,;21. I n Exp 2Cdn, 516124-ae PatYneesh p EASIMAMPTON MA 01623 fl.go, R.C.i ROOFING MARK DELISLE / (� k 6 LINE 5r I C ^mi `-n`^ 05i031tlon. - Commissioner f6103t2058 SOUTFIAMPTON, MA 0103 Undersecretary 's'.:R- 9 � "Ys to `O_N��h10N i f• 4YH1 OP';. 9!14 °,- 3 �'yd;' ' $ sane.R �4 q#_ A P'm+4,Li OF O ESSIONA c� as HOME iM"RS3i ,sei�p,N7�NCONfr&ACTOR � nS T .1tCtreabtittGy44'.P SN E,, 114E AIRI{NRS ° 1N4j1 '10 - ,i, , i ISSEl119,THE POILLOW-IW ER 1 j, _ ,Li A #,�iASR5F NMRSS1 Ri ofh� ,;� t )NA`Rtf� 1 6EI ISLE I q E thvE4 - WINE$ a q< RIC 06241241 Z 1. , $rd !LSO,22 yl� ^11111/30/2014 59 SH10.4'ur �'�' ,9 ",f 2 s�;,so i ., .. A' F� 2M s-',, O (/ Or'Ji7 17.E"9 i ,46111116NBMBEB <P CO ' MONWEALTH OF MASS GFIUSET ':S DIVISION CiF PRi3PESSIONAL,ICENSORE' . ,'EQA33)T GF SM E't metAi WOA24,CERs , .. ISSu s t 1E FOLLOWING LICENSE AS A SU> iNgas,, W MARKT DELIoLE 'ROI ROOFI(4QLLAt. Idlitil I it t ) , t EASTHAMPTON MA0107u tl I 3\5� s �• . 601 e,i x9/09/2047 .; (sl 2406 '61 LI NSE:NBAW it -._ENPIR TION)A1 T .SERIAL NUMBER I The Commonwealth of Massachusetts pl 6 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 RE FILED WITH THE PERMITTING AUTHORITY. Applicant Information �} Please Print Legibly Name(Business/Organization/Individual): R c I Rao-4n9 f_L/ Address: 6Lint St. / City/State/Zip: Soumar`npftin, MAI 0/O73 _ Phone #:1111 (ht/3) .„5a7 - Are you an employer?Check the appropriate hax: Type of project(required)', i.F�nn,a employer with atQ employees CMI and/or pan-Mme)" 7. 0 New construction 2..❑lam a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.(No workers'camp.insurance required.) 3.7 l am a homeowner doing all work myself.INo workers'comp. insurance required]' 9. ❑Demolition 4.❑t am a homeowner and ll be hiring contractors to conduct all work on my property. I will 1p ❑Building addition ensure that all contra-mom either have workers'compensation ineurmnoe or are sole 111.7 Electrical repairs or additions proprietors with no employees. 12.7 Plumbing repairs or additions 5.❑I am a general contractor and I have hired the subcontractors listed on the attached slice:. 13.EfRoof repairs These sub-contractors have employees and have workers'compinsurance.: 67 ik'e are a ter C d ms offices have exercised thea right oio.an ti24GL . 14.0 Other pma ur_nn g pion per 152,21(4),and we haverm employees.(No workers comp_Insurance required.] *Any applicant that checks box 01 must also fill out section below showing their workers'compensation policy information. t I Icmeowners 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 employeesif the subcontractors 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 ssite information. ( / Insurance Company Name: ' r �i Si fa 7PP... Policy#or Self-ins.Lie.#r: pp {IG L2 68 rf3"D Expiration Date: /0 " - /7 Job Site Address: .29/ (,'Z/5/vied O/. City/State/Zip /'7/OI'F£7/z, AM O/06,2 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 Itenahies 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 certff under t aftstyrd penalties ofperjury that the information provided above is true and correct 51nature: ' Date: 4— /3 "/7 .. Phone#. (''//3) .5;27 ' y7AS— 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 tete): 1. Board of Health 2.Building Department A City/Town Clerk 4.Electrical Inspector 5.Plunthing Inspector 6.Other Contact Person: Phone#: R.C.I. Roofing 6 Line Sl. Estimate Date Southampton,Ma.01073 4/6/2017 Phone(413)5274775 Fax(413)527-8469 Name r Address Job Location Irene Czarnieeki 291 Riverside Dr. Florence, Ma. 01062 Terms Rep Estimate valid for 30 days Chris Description Total Furnish and install 1/2"pressure treated wood nailer over existing roof 3,000.00 Furnish and install I/2"fiberboard insulation,mechanically fastened. Furnish and install ,060 EPDM roof system,mechanically fastened, Furnish and install 032 aluminum edge metal. Furnish and install all related flashings. All work to be performed according to manufacturers'specifications. All exterior rooting related debris to be removed by R.C.1. Roofing. 5-year R.C.T. workmanship warranty included. All related permits will be obtained by R.C. Roofing. WE LOOK FORWARD TO DOINO BOSINESS WITH YOU. Total s3,000.00 TERMS OF PAYMENT 5%Deposit Customer Signator ; (� Balance upon completion �Qft1Q' M\AQ(Jcl Registration p 126235 Date: Construction License#074334 Insured by Banos&Fickert Ins. (413)527-2700 Shingle Color Selection', 04�„et ibn4r