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32A-006
A I D A Nat }ie Date V n Sov�a f - — I QUENNEVILLE Street Addr s� f City State Zip Li ROOFING∎ SIDING WINDOWS 1 4 5 j . N it t a /tl'I9/ {tt ' ' A a V t i.800.NEW ROOF Home Phone Work / Work Phone t Cell ;# / 18 ` 1 3 - .sv it - v � +,/✓C(' �./ L 13 -2;2. -6359 H_b -DEt T+At - (D.tMEPC; AL Emaii. StraightForward Pricing�R 1 Story A 2 Story 3 Story R, i lan- 4 St) Stint Ie,. 4tepil t h Cour rtl,t,it 41 t , iu , f 11 t ( tIntttet 7 R } lacc St , I A ;tllc,. I cod I to 1S. Chunn , (n n,tru.1 Cricket and Rosh to In ,, t (umite,, Rnnt ut SnIur: ( tc.mnt) ' still v1 tt .,1 It. ( .1, 1.1 tt R:d,c liunnnau. S 1 h5 Rehl«:r 1 ti Slatc Retti, cud Rcpl,t.r I SO n i 1)„rn;cr Sv,hig Quantity x 51787 ea = $ k �It S( I 1i t o 1, , qVV �i i u R - t n, t A ,I I, tt I ititit , In I t t!t1 R lent R t , ,, S ',III ,1 ten ,t( } t t h.,!r cl 110muuus I1 ,I) R,Li.,. 1• ) a t ,t AS ti,,11;1. Quantity — x S1392 ea = S _. R t , l.,rc 'Il SI t t u . qty tl :.1 „ ui tct l.,,h 21 t , 1)Y , AV 1. of (land));.). 5 Install Si to II • ni Rid! V'cnt Raj ltic I in It) t V`dl,.',_ R 11unit nt k I la,x' up to C1,nnrner StIpplted Sh lt_Ith ■n„ micr■r (tins „ark t. lit tall _' ^U Io :51t of Drip Edon -, I -e ;td 1?' to It ( harne))) - Root Cle mint I tht l , y It - I Stu) .y it (+ „cr Fa,n is , : , r Rakc ,n all Aluminum ;1 441 Rcptscc 11 - S Slats Quantity x S922 ea = $ tint is Sti1 (,t t ,r(.((:( tt ,i At nil (.I0 s, ( u.n,:t. I t., + ,r I 2 . Cu,t,a -n' Supl I S III stop, II,i, N t ;,l 111 -1(11 itri , 'nr, ; It , I_,i_. R, ,n } 'i _ l i::n to -!) "l I!uht „11'. i = „tcr I .n.t,, R 'n. „ til: \I,tt (tut., ' - .;u lo `si.n)..” Quantity x 5763 ea = S I n, ni up n C peruncter I ens Reple en I to _' hundle„tf Shingles. Strpfl,t 3 ,,ninterIIJ,lt In to nt will n( hur,nc, hitch ' 1 w Itht of Dui 1 dl.. Imiail 1 to n Flat \cnt, Instil Drier ti „ r C Repine I> It III of A',(Ile■ . titnp t,it .md Re Shingle I ,t ,,r\ ISas V\indots. Install up t„ 3(t. nt Rldee Acut. \Idiot I uckpotntitsc and A\,hens, Zinc of Chaises t <3' m hctehl >. Re - Stepping and 1 :Guard v 1 SF, It>,ht. In dlaut tt nnl ( urhnnunt Inkiutht ( ISn t .Sn 0! t 1 1 1 , 1 „ ( 1 1 t i t . ] . ht l i s t ni Urt1 1.4e ( , t I 1 t 14 Rakc' „ iilt:Alununum I I - - )l'_ Rcpl t a 1 -6 SI tic . Root 44 ~tout_ (I .aunt` up t StIn .y it Quantity_ x $612 ea = $ hcl,i...- it T:� - c Ii,n \cn,- kepi „p n 1 2 nh u, I i n,:pll ti n C t t ,. t Vl II In t ti a ar It li I lz,.- , t I of mutts r., n.i Root.), 1 t `I.Hus ( .,, I.:.. n R.,i.r :,u.t \Inn,, un i 'n- .! Rt)!)),) ,l ( :. , ,. (' rni ( its t.il St ani, � V,, i (,,S. ( ttrnn, , i ltn: Quantity x 5427 ea = $ 1 Rout Ccii is.drm,. ()utter Ck.uunc 'up to :It Quantity x $179 ea = $ neck,) e1 ) it Quantity x S3.47 = S Roof Pitches greater than 6/12 Add 30% _ $ Shingle Color. Excess Build -Up of Moss & Mold Add 30 °0 = S 1 ti - �i`w - 3rd Story Roofs Add 20% _ $ Ice /Snow Removal (Minimum $400) S _ Tarp (Minimum $500) j� S Other Requests: t� i'' 1 0 t/ '+= C L l i vl. y B �. � d t/4../ 1� 00] $ I anR Gov O'z» Jf r ? 1- 161 $ Notes: r, yeti / ! G je_G____) / 9i' /4 / ✓� S] f/ Sub -Total $ / 3 y 3 BBB Diagnostic Fee S *01.e49•• — "j' -- I her authorize you to proceed with the above StraightForward Price of: Total Due $ 1 , 3 ✓ Winner of the x 2010 'J TORCH AWARD Down Payment Due Today S 1 p y P 1 Balance Due Upon Completion of Job S / 3 Specialist Print Name: 1 3 J ✓J i fil cV, $ � Thank You! •, „ . arraim D VISA w DISCOVER jut QUENNEVILLE ROOFING V SIDING • WINDOWS 160 Old Lyman Road • South Hadley. MA 01075 BBB 1.800.NEW ROOF • 413.536.5955 r rnail into4 1800newroof net Website. www 1800newroof.net Winner of the 2010 1A Construction Supervisors Lic 4070626 MA Registration 4120982 TORCH AWARD tn, Home Butldef r.7t Western Ma &A CT Registration 45 75920 Mernba; o! tine Building & Trade Assoc+atron Proposal Submitted To Date Phone 4's C: 1) 0h h 3 ©vz a °l- 2,, - 11 H:gr,-58g-6 '1S5w 'V3 Street Email 4 1 wq f,, v t f. City. State. Zip Code q Job Name,Location. h/ar i-h40 0 fyy MA 0(010(! Proposal to furnish and install the following 1 et 7 II r v b6 L ✓` r ep e/ 0 "1 h >°¢ 5 {eft r ©d7 . vh b i✓ ae 10 v f a "°� v h el S a f" 47 e-- �/ro u h F7 r co . ,nle l� Ask us ciboiit affordable bank financing uropu e t'e,( :) '; in furnish matertals aaru labor • complete in accordance with above specrfrsatrons tut the sum of Total Due (S ACCEPTANCE OF PROPOSAL: The above prices, specifications and conditions are Down Payment (5 f 3 o satisfactory and are hereby accepted. You re authorized to do work as specified. J .7 -7 0 Payment will be 1 3 down at start of job, a alance due upon completion. Balance Due Upon Completion ($ __ - Date. Si Date q — ). 7.11 Estimator: (Print Name) 17 v5 K rtf`C~s Si n Name) s/ Estimates are honored for sixty (60) days from above date ATTENTION HOMEOWNERS: Please cover all personal belongings in the attic, garage or storage areas due to the possibility of roofing debris or dust coming in through cracks of the wood. Adam Ouenneville Roofing will not be responsible for debris or dust in the attic or storage areas. • ACORD CERTIFICATE OF LIABILITY INSURANCE 6/23/2011 rr' THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the pol must be endorsed. if SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(sj. PRODUCER NAME Lynne Methot, Ext. 102 Foley Insurance Group Inc. PHO exit ( 214 -7474 I f Not (413)214 -7947 37 Elm StreetDO�ss lmethot @foleyinsurancegroup.com INSURERS) AFFORDING COVERAGE NAIC C _ West Springfield MA 01089 -2703 INsuRERA:Peerless Insurance INSURED INSURER B : Adam Quenneville Roofing & Siding Inc. INSURERC: 160 Old Lyman Road INSURERD INSURER E : South Hadley MA 01075 -2632 _ INSURER F : COVERAGES CERTIFICATE NUMBER:CL1162305763 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 15 SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE INSR NNQ . POLICY NUMBER , I 1 • • 1 ) LIMITS GENERAL. LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE 10 RENTED PREMISES 100 PREMISES (Ea occurrence) $ 100,000 A - J CLAIMS -MADE X + OCCUR 4006912267 6/23/2011 6/23/2012 MEDEXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GENL AGGREGATE UMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,000 POUCY [ ,I T 7 LOC $ AUTOMOBILE LIABIUTY (Ea accident) $ ANY AUTO =" $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY $ HIRED AUTOS AUTOS NON-OVVNED ( *cadent) G _ $ UMBRELLA UAB OCCUR EACH OCCURRENCE S EXCESS UAB CLAIMS -MADE AGGREGATE � $ DEO I RETENTION $ $ WORKERS COMPENSATION [ WC STATU• 10TH - AND EMPLOYERS' UABILITY Y / N TORY LIMITS I ER ANY PROPRIETOR/PARTNER/EXECUTIVE N / A E.L. EACH ACCIDENT OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ Y yes desc ribe u nder DESCRIPTION OF OPERATIONS below E.L. DISEASE - POUCY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Brian Foley /LYNNE ACORD 25 (2010/06) 1 1988 -2010 ACORD CORPORATION. All rights reserved. - - -- --- -•--,�.....�. s w�nean Jun-23-2011 09:43 AM Remillard Insurance 1- 413. 538 - bulu -,•••. OP ID: LL ACRD CERTIFICATE OF LIABILITY INSURANCE DATE THIS CERTIFICATE 18 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POUCmm8 BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTiTITfE A CONTRACT SEiWEER THE ISSUING INSURERS), AUTHORIZED REPRESENTATIVE OR PRODUCER AND THE CERTIFICATE HOLDER. IMPORTANT: if the carttflcate holder is an ADDITIONAL INSURED, the policy(lee) must be endorsed. If SUBROGATION IS WANED, subject to the terms and conditions of the pocky, certain policies may require an endorsement. A obtained on this certificate doss not corker rights to the certificate holder to lieu cinch endorssrame s). raooucm 413- 538 -7882 RemWard ineurence Agcy Inc 413- 53841 79 Lyman Street South Hadley, MA 01075 Stephen E. Radon cuEroreeso +�ADAIIiQ -i MOM Adam QuennevMe•RotAEmg & AMMER A I AIM Mutual Insurance a Compelty Siding Inc esBIJRIN s : Travelers Ina. Co. 160 Old Lyman Road u C: South Hadley, MA 01075 afeUMD t$SURER 5: tNBURQtF: COVERAGES CEETIFICATE NUMBER: REVISION MASER: This I8 TO CERTIFY THAT TIM POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY RAT, TERM OR CONOMON OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR tiAY PERTAEN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS Of SUCH POLICES. WITS SHO■*4 MAY HAVE BEEN REDUCED BY PAID C1AIM& L TYPEOrBsWntANCa • Dart Waif POLICY MIME t :38 • , '+�l LMe1s SOISRA . UAEeJTY SAM OCIXII� ` IAli1� COMMERCIAL GENERAL LIABILITY PRIIINSES fir arm nsmos , $ 1 CLANAWAOE ❑ occuR EEO erP tRMPsremt _ PeRSOWL ADYIJURY e GENERAL MAIREGATE $ — GB � dL AGGRO 1 la AP Pet PRODUCTS - CO*IIOP AOG $ I POLICY I t Mtt!t i t L.oc At/TOWELS LL#eLITY a TINGLE ulriT 1 plaimossnO 8 ANY AUra SA7450L948 11101110 1111)1111 eOOLLY sum mar pima ALL OtN(EC AUTOS BODILY INJURY Ss eoobet) $ X sanouLso.urros PROPERTY !MEMOS X HIRED Aurae • X riori.cmaeo AUTOS r UNINSIL .A LIAO ^ OCCUR EACH OCCURRENCE 8 _._ ICCONA Luse CLAMS-MAW N30REDATE LEDUCTSLE • ll tt!u 5 WORMS AND SrLOYesP UAL RJTY X ' ' ' . ;4 41 1 4 X I' A ' AormomormaipAsmamosctmui AWC701288101 04'29! ! 04/28/12 O,1,. motAccioarrr a 1,000,000 r�"�O`Yat.orlrls 1 1 E.L. oIes ee- SASAPLOYEE a 1,000,000 1 7: _ 145. •.a f.4..' ..... • •1 1 , I • ,Q00 DtlCAFISON OF OPERATIONS! LOCATIOIS! VSIC .ae Mao ACORD 111. MNIN GE Itsansts SEMENN, R fore spars b required) 9ERTiFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESDRIBED PCLICRIS BI! CANCELLED BEFORE THE ta:MATSON DATE TNdttAF, NOTICE WILL BE DBLNRRED IN ACCORD/JACK MAIN 111a POLICY PROVISIONS. AUTHOR REPREININTATIVE P 01988 -2008 ACORD CORPORATION. All rights reserved. ACORD 25 (2008106) The ACORD name and logo are registered marks of ACORD A t The Commonwealth of&iassachusettr -- --- Department of Industrial Accidents t i:.... i., W..= _ Office of Investigations 6 — 1/4 b110 Washington Street ` .: s Boston, NIA 02111 a . www zzwss.gov /die. Workers' Compensation Insurance Affidavit Builders! ContractorslElecbricianslPlumbers Applicant Information Please Print Le ibis Name {s A $(1 t wl 0lck.jvl -V Z l Le kOO An t S (‘ I i n) ilk!- Address: i€ 0 V 1 J 1 10 1 a n 41 ' cityIStatelzip: f , A kfrad 14 it 0 /o7‘hone #: j1 _ -5q SS Are you an employer? Check the approp , to bozo Type of project 4. 0 I am a general contractor and I YP� re P j (n9n )' I . I am a employer with tj 6. ❑ New cooshuction employees (bull and/or part - time).' have hired the sub - contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet 7. ❑ Remodeling ship and have no employees These sub - contractors have g- ❑ Demolition working for me in any capacity- employees and have workers' 9. ❑ Building additiOn No workers' comp. insurance - T suran•e # required.) 5_ ❑ We are a corporation and its 10.0 Electrical repairs or additions 3. CI Ism a bomeawrxer doing all work have exercised their 11 -[] Plumbing =pairs additions myself o workers' comp. right of exemption per MGL insurance ] i c_ 152, §1(4), and we have no 12.�' repairs employees. [No, 13.❑ Other gyp- insurance -] 'Any applicant that chocks box NI runt also fin out d►e section below showing their workers' compensation policy iabnadioo. t Homeowners who suborn this affidavit inificating they arc doing all work and then hire outside matradoss must =bait anew slisdavk indicating such. 1 Contractws that check this box amt attached an additional shed showing the none of the sub-ranttadors and rata whether or mot thos* entities have employers. If the sub - contractors have employees, they most !Fide their workers' comp, policy norther. I am an employer that is provding workers' compensation insurance for my employees. Bdow is the policy acrd job site War :v gan- Insurance Company Narne: A � l W T � M in t tIA of n su ra et e.L policy # or Self -ins. Lie. #: Pi C. � 01 2k 6 ID ( Expiration pate: q - g q - ,h t , Job Site Address: , I i I Dr — ilk f T/ .- jj`1p tD 11 City p: 1)14 01 U 66 Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 2SA of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $ 1,500.00 and/or one-year imprisonment, as well as civil penalties in the Soren of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify carder the pains and penalties of pedury that the information provided above is true and correct Signature: / :22L Date: q — 1 ti 11 Phone, it; 4 13" z6 -51 ‘c r Official use only- Do not write in this ram, s , be completed by city or toter: 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 #: ii....i. • litIVW V7.1 ppm Oututimit Iff4114:1* Mgt VW SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : 11 LJ a till ti tie e o g License Number Pd . S . � C� �, �'1�4 0 �� 7�" I i (w /*3 Address Expiration Date - -515 Sig Telephone 9. Registered Home Improvement Contractor. Not Applicable ❑ Adam Qmuamcy Roafmg& Sidamg, Lc, 1)0 Company Name 160 Old Lyman Rood Registration Number South Ilodk MA 01075 ; S - ` / Address Y1 / / h� Expiration Date � Telephone sy SS 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 ❑ 11. - Home Owner Exemption 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 .•0. ,.,. ppti! (ri.et,51, Kiwis lit (4. ..":..flug' illc , , SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) Q Roofing Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [p] Decks [p Siding [0] Other [0] Brief Description of Proposed Work: .5tzt 1 r4 q u<Yllb lid r'- eX1SI Nit rDU 64216_ I Iry -44 jaeL e l, �, - , he r i L' eii me-4 /, Alteration of existing bedroom Yes No Adding new bedroom Yes No G' V Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet 6a. If New house and or addition to existing housing, complete 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 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 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 I, /i /'� !) <5 6 a Z e-- , as Owner of the subject property ., Qum* r� hereby authorize Ads Qum* Roofing Siding, & ►7ing, In to act on my behalf, in all matters relative to work authorizecr by this building permit application. - e-It 067( hat f/iClCs4 q- (II- // Signature of Owner Date I, Adam OlelieVile Rat& Sid lic , as Owner /Authorized Agent hereby declare gnat the statements in o bon on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. . ii C.' ll ill A r as 0 ii,, 11,‘ Hi Print Name 2 Signature of O►vnerlAgent Date i v� f� } �� f. � . 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 <)111 &Jed Srr t Map Lot Unit � e. vn011 I in -- Zone Overlay District Elm St District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: g i/Ul h n 5 u (-Pi /Da (if St- ot k 4 ; rim- Name (Print) / Current Mailing Address: C 1D e' 6 1 .7 L± D n I e 't Z°/2 c Lose ( Telephone / �/ J ' � .� 6 I T 5S signature 2.2 Authorized Anent: Adam Quennevil a Roofing & Siding, Inc, /6 o a/d tifin n . u i& Name (Print) Current Mailing Adds: �� Signa Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building .5 6 y 3 . a (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) � 5 3. 0 C Check Number c)` ) d j a 4,3s This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner /Inspector of Buildings Date 24 WALNUT ST BP- 2012 -0269 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 32A - 006 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- 2012 -0269 Project # JS- 2012- 000433 Est. Cost: $3543.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ADAM QUENNEVILLE 070626 Lot Size(sci. ft.): 1 1499.84 Owner: NIXON JOHN L III & PETER E SOUZA JR Zoning: URC(100)/ Applicant: ADAM QUENNEVILLE AT: 24 WALNUT ST Applicant Address: Phone: Insurance: 160 OLD LYMAN RD (413) 536 -5955 0 Workers Compensation SOUTH HADLEYMA01075 ISSUED ON: 9/16/2011 0:00:00 TO PERFORM THE FOLLOWING WORK: INSTALL RUBBER ROOF, REMOVE CHIMNEY TO ROOFLINE & 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: 9 / /4q /' sue 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner