23D-085 (8) 41 WARNER ST BP-2001-1065
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:23D-085 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category:roofing BUILDING PERMIT
Permit# BP-2001-1065
Project# JS-2001-1886
Est.Cost: $4350.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: RCI ROOFING 126235
Lot Size(sq. ft.): 24524.28 Owner: EVANS JOHN M JR&HELEN L
Zoning: URB Applicant: RCI ROOFING
AT: 41 WARNER ST
Applicant Address: Phone: Insurance:
P 0 BOX 309 (413) 527-4775 Workers
Compensation
EASTHAMPTONMA01027-0309 ISSUED ON:6/19/01 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP,PLY & SHINGLE ROOF
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Inspector of Buildings
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
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:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 6/19/01 0:00:00 381 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
r.
C -,
Department use only
City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 Plot/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
r h Q; 5 t' Map Lot Unit
Zone Overlay District
/` Elm St. District CB District_
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
HO le A /�v4 s / 9 r h er ) /
Name(Print) Current Mailing Address:
Telephone 5 , L j
Signature b �c7
2.2 Authorized Agent:
Ai ch.rI( pQ (o'slc ? 6c4 ,t / 5 f /�
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. Building • (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total =(1 + 2 + 3 +4 + 5) L./ 3 Sc' Check Number
/This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
e •
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE
DENIED DUE TO LACK OF INFORMATION
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW YES
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW
YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained , Date Issued:
C. Do any signs exist on the property? YES NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ?YES
No
IF YES, describe size, type and location:
SECTION 5- DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing k
Or Doors 0
Accessory Bldg. 0 Demolition❑ New Signs [ ] Decks [/] Siding[ ] Other cJ
[ ]
Brief Description of Proposed Work: ,fr,/- Shy iy/ '3 4e e(,/�ovd/ c yr $hihciQ
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 alridtior ed litiort.ttl xit'ilt-teheing complete the folk wih _
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
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Mascheck 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 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
, as Owner of the subject property
hereby authorize to act on
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
, as Owner/Authorized Agent
hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my
knowledge and belief.
Signed under the pains and penalties of perjury.
(ter/( Del;s/
Print Name
G / /C-,
Signature of Owner/Agent ate
•
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: l y , q (t �C (e `15 /"‹ C7 79 33 c
License Num er
3 G k fey. 5 3 c �
Address Expiratio Dat
Signature Telephone
egisfe om notik ma' iC (fibt " ` . 'l " Not Applicable ❑
✓
CompanyName A/eRegistration Number
ei d �G/ h .5 Co�0�
Addres Expi ation Date
e."ko
Telephone 52 7 - C` 7 7 5
SECTION 10-WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152,§25C(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 Yes ❑ No ❑
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 two-year period 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 performed under the building permit.
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 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
O�gttAMpiO
Bow f 11±ti1 af NL1 'illM11Ypt1IIt4 ea6a::, %
___
tMIIIIIM
�ti•s�sl
}:..ram
-m- DEPARTMENT OP BUILDING INSPECTIONS =_
212 Main Street ' Municipal Building '
Northampton, Mass. 01060 e," um'
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
I, OAaCK. \ 0 (., 5Ie
clipermittee)
with a principal place of business/residence at:
3 C c--;n-1.-- s 4- lc- 74 < 0/v.2 ? (phone#) 52 7 - 777S—
(6ttt&city/state/Ilp)
do hereby certify, under the pains and penalties of perjury, that:
( I am an employer providing the following worker's compensation coverage for my
employees working on this job:
L, 6er 7 4//Vq/ Gr/c/ - 3/.r-3/ 7/a c/ -%
(Insurance Company) (Policy Number) (Expiration Date)
( ) I am a sole proprietor, general contractor or homeowner (circle one) and have hired
the contractors listed below who have the following worker's compensation policies:
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
If
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additional sheet ifneri-e.ry to include information pertaining to all contractors)
( ) I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself
NOTE:please be aware that while homeowners who employ persons to do tn■irstenarare,construction or repair work on a dwelling of
not more than throe units in Which the homeowner resides or on the grounds appurtenant thereto are not generally considered to be
employers under the worker's rompe t ation Act(GL152,ss 1(5)),application by a homeowner for a license or permit may evidence the
legal statue of an employer under the Worker's Compensation Act.
I understand that a copy of this et atcmeni may be forwarded to the Department of Industrial Accident?Of oe of 11:19urwoe for the
coverage verification and that failure to secure coverage under section 25A of MC1L 152 can lead to the imposition of criminal penalties
consisting of a fine of up to S 1,500.00 and/or imprisonment of up to one year and civil penalties in the form of a Stop Work Order and a
find of 5100.00 a day against me.
For departmental ues only
I ... 7.‘, _. e' (------- Permit Number map# Lot#
Signature of Licensee/Permitfee ate
R.C.I ROOFING
40 MAIN AVE.
P.O. BOX 309 ESTIMATE
EASTHAMPTON, MA 01027
(413)527- 4775
FAX (413)527-8469 Date: 5/31/01
,Estimate To:
HELEN EVANS Estimated By: MARK DELISLE
Start Date:
Job Location: 41 WARNER ST.
NORTHAMPTON
Job Phone: (413)584-3649
JOB DESCRIPTION
REMOVE EXISTING ROOFS
FURNISH & INSTALL 1/2" PLYWOOD OVER EXISTING DECKING
FURNISH & INSTALL ALUMINUM DRIPEDGE AND ALL OTHER RELATED FLASHINGS
FURNISH & INSTALL ICE & WATER BARRIER ALONG EAVES
FURNISH & INSTALL 151b.FELT
FURNISH & INSTALL 25 YEAR TAMKO SHINGLE.
FURNISH & INSTALL RIDGE VENT
FURNISH & INSTALL RUBBER ROOF ON FLAT SECTIONS
ALL ROOFING RELATED DEBRIS TO BE REMOVED BY RCI ROOFING.
5 YR. R.C.I. WORKMANSHIP WARRANTY INCLUDED
25 YR. TAMKO MATERIAL WARRANTY INCLUDED
SPECIAL ITEMS NEEDED
Additional information pertaining to this Job Estimate
TERMS OF PAYMENT
30%PRIOR TO START Total Estimated
70%UPON COMPLETION Job Cost $4,350.00
REGISTRATION#126235
FEDERAL I.D.#04 3418839 Authorized
CONSTRUCTION LICENSE#074334 Signature
INSURED BY IiACKWORTH INSURANCE(413)527-9907
ORIGINAL-ESTIMATOR COPY
I