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23A-211 raC 4 Srresk, H: S c o a-cir w: Street Email: 7 0 _Seel c 0 fr, c 't s k (� I ra�F_ c M City, State, Zip Code Special Requirements: 7 / ©G Fal err sS a,� a // beitk /owe- ;"pcichrs G n cx o c 0-f . k. r e [] Recover Strip / / y �:'" f : n c(v��rCT( res +H •z ve_ 4 rl- e j q,ie Is- Gil) ✓F /(e f c n M e., n rtkt, Complete Roof System acquire all appropriate ermits for all work ec d`',s We shall ac ,� crfr�,�c.� sv �ie.�rcwnr q permits ra „ te,, f n�� + ' r?.'i7 ho :JQ- N Home exterior and landscaping to be protected • Strip existing roofing to existing decking and dispose of. Do not Do. pg ., - I - 1 /hr, in coo - o - ,C 1 +(e)/1 S/Ot( C4 !''s4•il) Deteriorated existing decking will be replaced at $3.47 per sq.ft. after full inspecti roe f ® Install Ice & Water Barrier at all eaves, valleys, chimneys, pipes and skylights 6 �•� .��..., r - l , ® Instal (151 ? Synthetic) underlayment over remaining decking area KJ Install Metal drip edge at eaves and rakes (8" 409 (whitz(brown copper) I. Install manufacturer's starter shingle on all eaves and rake edges BBB • Install new pipe boot flashing standar /copper) / vents g Install Snow Country or obra rolled vent ridge ve Winner of the Install proper soffit ventilation TORCH AWARD Shingles: (6 nails per shingle) Cr, /3 F Shingles n 25 year 10 30 year 1 1 50 year Color G - Ridge cap shingles Warranty Options: t We guarantee our workmanship for 10 full years (see our warranty coverage) I GAF System Plus warranty I GAF Golden Pledge warranty Chimney Options: I 1 Lead Counter Flashing Water Seal & Tuckpoint (I Rubberized Crown 11 Metal Chimney Cap We propose hereby to furnish materials and labor - complete in accordance with above specifications for the sum of: Total Due ($ �'f ( ) 23 ) ACCEPTANCE OF PROPOSAL: The above prices, specifications and conditions are Down Payment ($3 O✓-/ / ) satisfactory and are hereby accepted. You are authorized to do work as specified. J Payment will be 1/3 down at start of job, and balance due upon completion. Balance Due Upon Completion ($ 6, O ?" ) Date: L 9 / 9 / L Signature: 1/24-ett-Z Date: °) - / - la-Estimator: (Print Name) 3 ', ;�,-� Sat-Jr ; (Sign Name) - 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 _ The Commonwealth of Massachusetts a Department of Industrial Accidents ` —" - 1 - Of fice of Investigations a,,. " n 600 Washington Street ;re Boston, 1114 02111 • ,, sue.y www.mass.gov/dia " Workers' Compensation Insurance Affidavit: Builders / Contractors /EIectricians/Plumbers Applicant Information " Please Print Legibly Name (Business/Organization/Individual): Adam I uenn Ruofin & Sid Inc. V Address: 1 (' 0 " IL (9 /}iGl n k Oa.d . City /State /Zip: Sale kid l e f M f 6)10 5 Phone #: q J 65L 6'1 5 Are you an employer? Check the ro 1 iate box: PP P Type of project (required): • 1.1K I am a employer with. 15 4- ❑ I aea a general "contractor and I 6- ❑ New construction employees (full and/or part-time).* have hired the sub - contractors 2 = . ❑, I am a sole proprietor or partner- listed on the attached sheet 7: El Remodeling These sub - contractors have ship and have no employees 8. ❑ Demolition working for me in any capacity. employees and have workers' b Y F tY- 9- ❑Building addition [No'wOrkers' comp. insurance - comp: insurance.$ - -- - required -] - 5. ❑ We are a corporation and its • 10.0 Electrical repairs or additions officers have exercised their 11- Plumbing repairs - ❑ I am a homeowner doing all work ❑ or additions Plumbing P. myself. o workers comp. right p Y � ' ht of exemption MGL P 12 V542.00f repairs insurance required.] t • - c- 152, § 1(4),_and we have n o employees. [No workers' 13.0 Other • 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 him 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 insurance for my employee& Below is the policy and job site information. . p " Insurance Company Name: " A N1 I° 1 It 1 1 f S bLi l {r) • Policy # or Self -ins- Lic- # " : W 6" go/ 946 I C 1 Expiration Date: 4 _ at) -,70/ 5 Job Site Address: . 1 0 t? P ( l r .r, n St/TA City /State /Zip: -}-- (0 r e rl " i Y ri4 0 to (..D 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 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to 11,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 1250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DLA -for insurance coverage verification. I do hereby cerrtify under the pains and penalties of perjury that the information provided above is true and correct. Si nature: 740 Date: �?/Z (r' //2.. - Phone #: Z(t 'j- i - ,tSC? .. I Official use Dullt Do n ot wri in this area, to be completed by city or town official - amity or Town: — — Permit/License # Issuing Authority (circ on 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone #: SECTION - CONSTROCTION SERVICES: 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: /11:3( QUI /'7 r'LQ if 1 G 4 License Number / & o d id L fryi g ' d . � c�� - a d j, G oio7s 0- c: /- 9a i 3 Address Expiration Date X13 - 5 3 - 6143' Sig re Telephone j)1 Lt 113 f9 Reaistef ed =Home<I'inOitivemenf`Contractor ' - t - _ Not Applicable ❑ Adam Quenneville Roofing & Siding Inc. ! .46 t k -- Company Name 168 Old Lyman Road Registration Number South 075 3 a i 9- Address . Expi ration Dat Telephone yl3- j3(_ " ?JSS • i - stakIONi:o- WDRKERS' COMPENSATION; IN suRANC AFFIDAVIT (M G L A52; § 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. O a 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 1083.5.1. 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-vear period shall not be considered a homeowner. Such "homeowner" shall submit 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) ofthe Massachusetts General Laws Annotated, von 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 ___fa ( crrt) • J • ue � i r}?' _ _ SECT IONS - iDESCRIP- TION. OFPROPOSED `WORKlcheck-all-appliicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding [p] Other [O] • Brief Description of Proposed ! Wort: . Ii , _ ' ' .. i l I ' ; ' ✓LC f 6470 f - .' Cz.2) Z U 727 / Alteration of existing bed • om Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet I,'��,Lf�I�e«w �iaasezarar��c�t�drtion =to:existnq oh u ,S nq;xcomple #esfhe�ollov,nq: 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 . Li Septic Tank City Sewer Private well City water Supply SECTJON r7a OWNER:AUTHORrziwc N` TO B COMPtE?0 1M=I ST - • QWNE,Eq goalTpR APP LIES FORBTIICDING EEtMI y F I, C W( ' l (l,t ,cL t I , as Owner of the subject property hereby authorize Adam Quenneville Roofing & Siding, Inc. to act on my behalf, in all matters relative to work authorized by this building permit application. UP C C1i'311(i c 1 /2(0 // Signature of Owner Date - i Adam Quennevdle aofin Sidmg, Iac. , 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. •i _ Signed_under the pains and penalties of perjury. 46141/it G tr n n-e t/, IL--e Print Name q 2-((//?___ Signatu'fe of Owner /Agent Date Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information c Existing Proposed Required by'Zoning This column to be filled Building Department ` Lot Size v 1 i I _ i 1 S Frontage Setbacks Front 1 i i ( i i Side L: 1 R:f 1 L:7 R: 1 j I Rear 1 j 1 1 I Building Height i 1 � _ ? 1 Bldg. Square Footage 3 I 1i (Y? I i I 1 1 : — Open Space Footage - - - — {{ (Lot area minus bldg & paved I I _ 1 ( 3 = i______] parking) # of Parking Spaces t I i � Fill: (volume & Location) I f A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DONT KNOW 0 YES 0 IF YES, date issued:] IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW i (3 YES 0 IF YES: enter Book 1 Paged 1 and /or Document it B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW Q YES IF YES, has a permit been or need to be_obtained from the Conservation Commission? -Needs to be obtained - 0 - Obtained rTh , Date Issued: i C. Do any signs exist on the property? YES i0 NO Q IF YES, - describe size, type and location: 1 f ---- - - - - -- D. Are there any proposed changes to or additions of signs - intended for the property ? YES a NO IF YES, describe size, type and location: 1 - I E. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES � ! NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. 70 BEACON ST BP- 2013 -0366 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 23A - 211 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- 2013 -0366 Project # JS- 2013- 000594 Est. Cost: $9123.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ADAM QUENNEVILLE 070626 Lot Size(sq. ft.): 33889.68 Owner: SKROSKI EDWARD B & KAZIMIERA A Zoning: URB(100)/ Applicant: ADAM QUENNEVILLE AT: 70 BEACON ST Applicant Address: Phone: Insurance: 160 OLD LYMAN RD (413) 536 -5955 0 Workers Compensation SOUTH HADLEYMA01075 ISSUED ON:10/1/2012 0:00:00 TO PERFORM THE FOLLOWING WORK: N EW ROLLED ROOFING 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 10/1/2012 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner