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Department'of Industrial Accidents Office of investigations 600 Washington Street Boston, MA 01111 www.m ass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors icctriciaus/Plumbers _Applicant Information Please: Print Lel'ihiv Name (BasincuA)rganization/Individual): Adarn Quenneville Roofing & Siding Inc Address: 160 Old Lyman Rd __ V City/Stata/Zip: South Hadley MA 01075 Phone.M 111.1-536-5955 Are you an employer? Check the appropriate box: Type of project(required): 1.3 1 am a employer with 15 4. ❑ I am a general contractor and 1 6. ❑ New construction c.mpioyees(full and/or part-time).• have hired the sub-contractors 2.❑ I ant a role proprietor or partner Iisted on the attached sheet. 7. ❑ Retrtodeling ship and have no employees Thtae sub-contractors have 8. ❑Demolition working for the in any capacity. employees and have workers' 9. []Building addition (No workers' comp. insurance GOMP• insuranec.l m9uimd-) 5. ❑ We art a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I I.[]Plumbing repairs or additions mystIL (No work=s'corrip right of exemption per MGL 12.❑Roof repairs it>surattc>r required.) t c. 152, ¢1(4), and we have no 13.[ Otha W^40 5 employ=.[No workers' inntrance required.) 'My arpi ant dot clocks boa AI noel aim fig ow the motion below showing their workers'aompeauatim policy infortratiom t Homdawnare who vAtrit this atrtdavit ioernealing twy am doing all wort and than hin outside contractors rout submit a new adidavir indicating sua. k'vntnetom that check this boa mug attached an additional Oaal showing the name of do sir►sontraaton acct rote w+edw or not these entities have -Vloyam. K the sub-oonvacum have on pioyeea,they meat provide dnafr workers'corrv.policy nurnba. I am an employer than is providing workers'eompensadon insurance for my emptoye= Below is the policy and fob she information. Iruwance Company Name: AIM Mutual Insurance Policy 4 or Self-ins. Lic. M: -AVVC4007)012,86120013A- F_xpiration Date(:,412912014 i `?1 a+'lt� d CirylSntelZip:_ �1c��-e�ace 1A C}1(�b Job Site Add it copy of the workers'compensation policy declaration page(showing the policy number and explradon 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 S 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 5250.00 a day agahurt th4 violator. Be advised that a copy of this statement may be forwarded to the Office of �nvess'al - ng of the DIA for iMurawe covtsnei vtxi8ca6g6 r airaa•+o�rae��nrica I do hereby eert#5p tinder the pains and penalties of perjury thal the information provided above his true and correct sittJUtllm Phone 413-536-5955 1= Official use only. Do not write In Mis area, to be compkteWTy cLFor town official City or Town: Peradt/License p _ Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5]Plunnibb:ing sp ector 6. Other Contact Person: Phone d: - i VVI � = U01P = � proposal Submitted To Date f �, QUENNEVILLE street ROOFING & SIDING, INC. City,State,Zip Code 160 Old Lyman Road, South Hadley, MA 01075 1-800-NEW-ROOF a 413.536-5955 Phone#'s Email:info @1800newroof.net Website:www.1800newroof.net MA Construction Supervisors Lic.#070626 MA Registration#120982 H. 13 ��4� LI I W Member of the Home Builder's Association of Western Mass. CT Registration#575920 Dumpster Location Member of the Building&Trade Association Member of the Better BusmPss Bureau t _ \. 't � H EV CV TW DHP Double Hung ' 3-Lite End Vent 3-Lite Center Vent Twin Double Hung Picture w/2 Double Hung Flanker`s I FE Wood rain Int tors Vinyl olor to uct ode Grid es AT =Natur ak WH =White BS =Bay shore ST =Standard 5/6" RP =Regal Perimeter n Oak CA =Camel SIB =Seabrook RC =Regal Colonial RFL =Regal Florentine CC = olon,al Cherry ET =EartMOne NE =Northeast G =Gregorian 1 1!16" RFE =Regal Florentine elongated WW =White Woodgrain W =Williamsburg 11:16" RF4 =Regal Prairie(2 passes) TB =Thin Brass BAY BOW 4 BOW 5 BOW 6 GARDEN M3 I ) �. , � 3 4 � 2 7 � 5 1 1 2 9 A Wood rain Interiors Wood tic, Vin I o or roduct ode Grid es ass lions NAT =Natural Oak BIRCH WH =White A =Aurora ST -Standard 5/8" G =Gregorian Stay-Clean Glass GO =Golden Oak OAK CA =Came t RC =Regal Grids W =Williamsburg I Regal Glass CO TR 1/3-1/3-1/3 TR 1/4-1/2-1/4 QUAD Operating Casement Single-Frame Equal-Lite Single-Frame 1/4-1/2-1/4 Single-Frame 4-Lite Triple Casement Triple Casement Casement � I I III r � I Existing Window New Window Existing Window _ New Window Measurements Measurements � sc L Rough Opening O Rough Opening O C W Location Style I Metal Style Series C F Location Style Metal Style Series 0 ~ (Room/Floor) Code" Y/N "Code" "Colde" V Width Height UI — (Room/Floor) "Code" Y/N "Code" "Code" Width.Height UI c, l ! (li (,� ) .'3 13 —_ -37 15 ? f 16 7 c1 r is 4 e f e 6 _ 20 ----- — - — — 21 101 t 22,-- — —+-- 3 Color of Color of Window/Door Wrap Window/Door Wrap L,tc1S t *. .a Sh1c C%o'Eh _in We Propose hereby to furnish materials and labor-complete in accordance with above specifications for the sum of: 0-? Total Sate Price$ I i�1 Down Payment$---1,5-,, oo Upon Completion$ /`yC % t ACCEPTANCE OF PROPOSAL:The above prices,specifications and conditions are satisfactory and are hereby accepted. You are authorized to do work as specified.Payment will be 1/3 down upon signing,and balance due upon completioA. Unpaid balances shall accrue with interest at 18%per annum. Purchaser(s)will pay for all costs,expenses and reason- able attorney's fees incurred by Adam Quenneville Roofing and Siding,Inc.to recover any sums due under this contract. F Date:_t 1 11 ( Signature: _ Phone# �t�S�lv L{�S Date:` 1 f Salesperson's Signature: Estimates are honored for sixty(60)days from above date Please remove all breakables from interior wall surfaces during installation. AOR&S will not be responsible for damage. SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder Adam Quenneville CS 070626 License Number 160 Old Lyman Rd South Hadley MA 01075 3/25/16 Address Expiration Date 413-536-5955 t Signature Telephone 9.Renistered Home Improvement Contractor; Not Applicable ❑ Adam Quenneville Roofing 120982 Company Name Registration Number 160 Old Lyman Rd South Hadley MA 01075 3/25/16 Address Expiration Date 413-536-5955 Telephone 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 Officials that he/she shall be responsible for all such work performed under the buildine 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) New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [p] Decks [0 Siding[0y Other[a Brief Description of Proposed Work: 3 replacement windows 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 End or addition W-4iXistinsa 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? I 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 Eric Dibrindisi 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. See Contract y b-.-1 I ignature of Owner Date Adam Quenneville '2ou � SIC I, S � , 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. `) Print Name Signature of Owner/Agent Date 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..._.._.. .. Frontage 4 M_. Setbacks Front Side L.= R.' L:.__... . R: i l 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 Q DON'T KNOW Q YES 0 IF YES, date issued:[ IF YES: Was the permit recorded at the Registry of Deeds? NO Q DONT KNOW Q YES 0 IF YES: enter Book = Page. and/or Document#! B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW Q YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained © , Date Issued:s C. Do any signs exist on the property? YES NO Q IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO e IF YES, describe size, type and location: 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 0 NO e IF YES,then a Northampton Storm Water Management Permit from the DPW is required. City of Northampton #t�it�1 �� '' �t Building Department Y9IY �t ' it u 212 Main Street 132014 Room 100 it"01110 # ; Mu &Gas Inspection orthampton, MA 01060 Trr etttifctifl No�hampton,MA e-#C3-587-1240 Fax 413-587-1272 Plot($ en Other retfy - APPLICATION TO CONSTRUCT,ALTER,REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address;`'�—d rrte, This section to be completed by office � = Map Lot Unit 42 Strong Ridge Rd Florence MA Zone Overlay District 01062 Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Eric Dibrindisi 42 Strong Ridge Rd Florence MA 01062 Name(Print) Current Mailing Address: 413-586-4315 See Conrad Telephone Signature 2.2 Authorized Agent: Adam Quenneville Roofing&Sding Inc 160 Old Lyman Rd South Hadley MA 01075 Name(Print) Current Mailing Address: a' 413-536-5955 Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit 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=0 +2+3+4+5) 2,217 Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date 42 STONE RIDGE DR BP-2014-1099 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 29-599 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Cate oa: windowreplaced BUILDING PERMIT Permit# BP-2014-1099 Project# JS-2014-001875 Est.Cost: $2217.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ADAM QUENNEVILLE 070626 Lot Size(sq. ft.): 81021.60 Owner: DIBRINDISI ERIC P& SUSAN M Zoning: Applicant: ADAM QUENNEVILLE AT. 42 STONE RIDGE DR Applicant Address: Phone: Insurance: 160 OLD LYMAN RD (413) 536-5955 O Workers Compensation SOUTH HADLEYMA01075 ISSUED ON:412312014 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL 3 REPLACEMENT WINDOWS 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 4/23/2014 0:00:00 $35.00 212 Main Street, Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner