42-141 (2) A6LI DDLA
\1r51C'; DISCOVER
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QUENNEVILLE
ROOFING 'V SIDING ■ WINDOWS 6
160 Old Lyman Road•South Hadley, MA 01075 BBB
1.800.NEW ROOF • 413.536.5955
Winner of the
Email:info @1800newroof.net Website:www.1800newroof.net 2010
MA Construction Supervisors Lic.#070626 MA Registration#120982 TORCH AWARD
Member of the Home Builder's Association of Western Mass. CT Registration#575920
Member of the Building■tTrade Association
Proposal Submitted To: Date Phone It's C: •
PA\o')D (3L155 f 7b60 8u3:1ei /0//11/3 H: V/3-516-?22/ w:'/13 -S, -.2 :01)4v/6
Street Email:
7( 3 WESTN,4MPTmPJ At)
City, State,Zip Code Job Name/Location:
c OAcNCE , MA 0/06 Z
Proposal to furnish and install the following
Cot.& Nfl(;ge w/ TIM.A.142 L'I-K4c 5/0/06-
CUT IN) 5ac-c/T /p.1 c PM OP /40Q *_ /r A,-F -0
/v ,W o 4%5E Fps 9o017 J a T5 41. i
C o Lo c& 5-iv/fa: K /'4 I ?.5'
TR I w) L;044.) u,r-J/1(..- .tI 10
wR/�P
S0fr
Ask us about
affordable bank
financing
We propose hereby to furnish materials and labor-complete in accordance with above specifications for the sum of:Total Due($ •v/ 915
ACCEPTANCE OF PROPOSAL: The above prices,specifications and conditions are Down Payment($ - )
satisfactory and are hereby accepted.You are authorized to do work as specified. c►QS
Payment will be 1/3 down at start of job,and balance due upon completion. Balance Due Upon Completion($ ( / !/• )
Date:_ld(//// --Signature: _ JLd
Date: I 0/0 3 Estimator:(Print Name) _ _5 !e-- ---(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 Quenneville Roofing will not be
responsible for debris or dust in the attic or storage areas.
<\ The Commonwealth of Massachusetts
Department of Industrial Accidents
---_�1 Office of Investigations
fit,=-
— s l Congress Street, Suite 100
- ;s :
Boston, MA 02114-2017
•
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (B usiness/Organization/Individual): Adam Quenneville Roofing&Siding,Inc,
Address: I Co 0 QI Lm4.n —Road,
Ci /State/Zi.: .LM-.. • ,11. 41 1 /, A I0 5 Phone#: 013-53(0- 59S-5
Are you an employer?Check the appropriate box: Type of project(required):
1.ai am a employer with )S 4. ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub-contractors 6. New construction
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. employees and have workers' 9. ❑Building addition
[No workers' comp. insurance comp.insurance.#
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.[: Roof repairs
insurance required.] t c. 152, §1(4),and we have no
employees. [No workers' 13.[ Other Si
comp. insurance required.]
Any applicant that checks box I must also till 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.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and joh site
information.
Insurance Company Name: A
Al NV VILA 5L71r0.nC k.—
Policy#or Self-ins. Lic. #: P}OG LtDO9 DI a sL 1 a 01 3 A Expiration Date: (1) -c) ) 14
Job Site Address: (P. U)J s'rCtr City/State/Zip: "Rots-Lk/Lei , O(Cka"
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$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. 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 under the pai s and penalties of perjury that the information provided above is true and correct.
Signature: Date: 1 0 1 1 LO )3
Phone#: 413-53(o- Sass
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#:
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable £
Name of License Holder: j.\AUI1\ ,io i/1(D 1`'`,f ' / C �0 License Number
1C0o Old Lekal, ?al, 3604 46066 , 0..,14 b/C7S ?)al))S.
Address Expiration Date
,j/k_____ Li lb-531o�-55S�
Signature Telephone
9 ,Registered-Home-lmprovement Contractor; _.._ G. ._.. .,. : '-',.:-.1'_.. ....._ Not Applicable £
A-dam a)ve.nnQ %l i ---P-cc C -4-SiottYli, 1(. , )a-09 8a-
Company Name Registration Number
Yoo Oldlect,nd, 661-1-1 . L, nca olo7S" 3lasl►i}
Address Expiration Date
tt
Telephone L11. --c.9111-59Sc
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. I3ame (Jwner Egemiptoln
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,
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
r
New House ❑ Addition CD Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [Q Siding Of Other[0]
Brief De cription of Propos
Work: nwtt Olaf 43 ,/L 1Oh LiM-'i kit/Ai Ull, Sid-di
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
Ba:tf Newhouse'and.or addition to»eidet ng-housing,_complete tfleloilowinq:
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 Ta-OWNER AUTHORIZATION-TO BE COMPLETED WHEN .
OWNERS AGENT OR CONTRACTOR APPLIES FOR.BUILDING PERMIT
I ;t''A °I:160 oe ?)07-700, ,as Owner of the subject
property ee ,,, .� �"
hereby authorize 40�'h 0,0-PJ211�✓i 11-4 �blar�Q -G A"; —Pic--
to act on my behalf,in all matters relative to work authorized by-this building p�miit application.
Pi eThkellAP A- l0//bf13 .
Signature of Owner Date
I fl1 AP.Vi(6 OUkk'ne " S"cu'`S ,. c.._ ,as Owner/Authorized
Ag nt hereby declare that the statements and intemation on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the pai s and penalties of perjury.
Pr nt Name
��
� `-- - ,D),b J) . ..
Signature of Owner/Agent Date
i
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Section 4. ZONING All Information Must Be Completed.Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size I I 1 l 1
i
Frontage
L _....1;_.__._ 1 ._,.._...__.___.._
Setbacks Front L_J I I I I
Side L:! I R:'._._...._! L:I. t R:i l______S
Rear 1_.____i F i i
Building Height [ i L J
Bldg.Square Footage
1-1 I f % r---1 I �-i
Open Space Footage
(Lot area minus bldg&paved ,-____I {J L__, J L_.1
parking)
#of Parking Spaces I _— Icy i
Fill: L_..�_�.�,. .....,<�_,........p..,_ i' ..�,._ ......_.-.,,,.........�. kwµ..,,��_.._._...._....�,.._. ..__._...-t
(volume&Location) t I
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW ef YES 0
IF YES, date issued:[Y
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES Q
IF YES: enter Book I
i Page] •~ W and/or Document#[ i
B. Does the site contain a brook, body of water or wetlands? NO el, DONT KNOW 0 YES 0
1F YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained
0 1
, Date Issued:
jj
C. Do any signs exist on the property? YES Q NO a
IF YES, describe size, type and location: t
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO 0"
IF YES, describe size, type and location: 11'
E. Will the construction activity disturb(clearing, grading,exca tion, or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
•
•
•
r : 3De @.{� k ett�e ony � '
�� City of Northampton i�'� t. , � `,
ty p = fa usabpPAer a 4 R z� 7
\u) ! Building Department ,i titIDY&a+a� e is iz v.p.G.Im .h �; ��, .
l 212 Main Street csew S ptic Ava ta�`iiilt� e. �g �y"R gi „ `i ,:
4'lA�' r rF } ,w'.- s� a ti
V ZJi 1 7 LU73 ..✓ @� F�i"W � � �,s�' !,�' r'�'7x4 �( N�%y N'�' rci°�_�d� ��d� 1���.
Room 100 AFat'er {I+Avat1abi tl tit klr,.��' . ; ,� �q' �' a
rta.�, .P.,fi'&.e`.,�r' m'� x.,. Grp +,,6. 9?, �' +�., re, �`N,,kt t I
orthampton, MA 01060 ;rtes�ltr� i+xalapla � ���xf ai= ��r a
tectric,Plumbirtg t Gas Inc•ections
b.;.\ n, :��ne 4 3-587-1240 Fax 413-587-1272 'PIo IBM's, ,.1 #;t-1 } '� "' 4ry� a34"
Northampton,MA op pl p,}�f�' n 'a i It a-- ..1!:'4 m �i r'��',,,,a*"� 'a0�',a,i.'��l 400,
i.4..,..fi.�� Tx$cu._...n-. "ati-
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH ;'ONOO- TWO F,MILY DWELLING
SECTION 1 -SITE INFORMATION
g" i Ttiis, econ o be mpeedy ffie 1.1 Property Address:
MaP a I"YLoi; ,3 F ,rj Unit
`"�'� vt''z' 9 zw3. aC'# '� 'a'r �';i'ra F i'` ,�$ --'` ._-4,,,,- ¢ -s 's=
a '?oC( iii-r a��. _ �F t s ig- l Dz x.�i. �,� .A.. ,i
%%wine i r F .., lOveriayrDistrtct'u :.... ._.
.sElmrSt District.., '�ileirt�.,il7htF fi�::�a CS District ,sca Ar,.� .._
. SECTION 2.-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record; ti.
P. . ', L `l �- i' A 3)2 2.Q - —1L,' L).sq n ) Outmci , /lug 101.)-
Name(Print) Current Mailing Address:
k� �13M 5flo"7.1 i
Telephone
Signature
2.2 Authorized Agent:
•u A-•J ,11. _ h∎0al" • 4-- � 1 A.i. 160 oI li n td -� �. /144. 01073
Name(Print) Current Mailin(/Address:•
jk___ 413--53/e-SgrrS"
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS.
Item Estimated Cost(Dollars)to be • : . . Official Use Only
completed by permit applicant - .
1. Building
/ a Buildin Permit Fee
G
g /LP I s'Uf� � ) 9•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) 1 /lp p'99S Uv Check Number 0?‘10 e 3 i.
This Section For Offlcial Use Only
Building Permit Number. Date
issued:
Signature: - .
Building Commissionerlirtspector.'of Buildings. bate ,
763 WESTHAMPTON RD BP-2014-0484
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:42- 141 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:vinyl siding BUILDING PERMIT
Permit# BP-2014-0484
Project# JS-2014-000733
Est. Cost: $16995.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ADAM QUENNEVILLE 070626
Lot Size(sq. ft.): 17946.72 Owner: BLISS DAVID K&TODD H BUZZEE
Zoning: Applicant: ADAM QUENNEVILLE
AT: 763 WESTHAMPTON RD
Applicant Address: Phone: Insurance:
160 OLD LYMAN RD (413) 536-5955 () Workers
Compensation
SOUTH HADLEYMA01075 ISSUED ON:10/18/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:REPLACE VINYL SIDING
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 10/18/2013 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner