35-163 (4) p � VISA
QVENNEVILLE
ROOFING 'W SIDING 'V WINDOWS
160 Old Lyman Road•South Hadley, MA 01075 B
1.800.NEW ROOF 413.536.5955
Email:info@ 1 800newroof.net Website:www.1800newroof.net Winaer of the
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&TrIade Association
iProposal Submitted To: ---. Date ----' PhoT nP e#'s --- C:<t''
PJns,–, (Z.c,i�e7C,o� �j '��j�(�H:`rt; �;4`� IQ v) W:
Street -- — —�-+ Email: ---
cS C1,no,,
City,State,Zip Cobe i Job Name/Location:
Proposal to furnish and inste it 11hr. #ssVo,.vinr
COCO
C40
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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($ K)1Z)0 }
Pr, !.k-Yt soy
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.
Payment will be 1/3 down at start of job,and balance due upo"omplet+on I Balance Due Upon Completion($ ?'000 D�'• )
Da:e:._. I Signature: ----
�., Lf c"7P tJ 1(��,�
Date: � 3 I _Estimator:(Print.Name).._)cti _____(Sign Name)
Estimates are honored for sixty(60)days from above date
ATTENTION HOMEOWNERS:Please cover all personal belongings in the attic,garage ar storage areas due to the
possibility of roofing debris or dust coming in through cracks of the wood.Adam Quenneville Rooting will not be
responsible for debris or dust in the attic or storage areas.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of In vestigations
1 Congress Street,Suite 100
Boston,MA 02114-2017
www mass gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information a Q Please Print Legibly
Name (Business/Organization/Individual): AM Quenney kRoofing&Siding,Inc.
Address: /6 4 Old Wrno-o I�Oa C,Q.
City/State/Zip: A 1075 Phone#: 913-S3(" 59 55
Are you an employer?Check the appropriate box: Type of project(required):
1.RI am a employer with J6 4. FI I am a general contractor and 1 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. []Remodeling
ship and have no employees These sub-contractors have g. r_j Demolition
working for me in any capacity. employees and have workers' 9. F-1 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.[]plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.[f Roof repairs
insurance required.] t a 152, §1(4),and we have no
employees. [No workers' 131-1 Other
comp.insurance required.]
*Any applicant that checks box 41 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.
tContractors 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. Be1mv is thepolicy and jab site
information.
Insurance Company Name: J S)Sur-aou,..-
Policy#or Self-ins. Lic.#: t 1 I,UG' da'(pI a d'(o 10� J-I A Expiration Date: fg t
Job Site Address: k) a. az� City/State/Zip::41U!,Q,
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.
f do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature: Date: 1 tq
Phone#: 413-53!,SgsS
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: Adam QnenneVllle Roofing&Sid%Inc. o l o
160 Old Lyman Road License Numb9er�
Address f W 0075
Expiration Date
Signature Telephone
9 ReuisteredHome;Improverrient'Contractor _ ,_A LL Not Applicable £
no &Qedons COmpahU'R'ah> "°"�'u'v Ralimb w LYM M69!na Registration Number
160 Old Lyman Road
Address South 3
s I i�
aey, Expiration Date
Telephoneq)3ri b"S l
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...k £ No...... £
Y1 s �o-ma Qwner Egemy i
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 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 F-1 Replacement Wir�iowsl Alteration(s); ❑ , Roofing
Or Doors �T
Accessory Bldg. ❑ Demolition ❑ New Signs [O) r,. Dirks`�ff; Siding(0] Other[[3]
Brief Desc. ion of Proposed
Work: LS40LLL4 /UA)� AD- 4LL& �C
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa If New-house°aznd or additio exfsting.Ii ouslnq,=:compfete.:>the
n>to followlnQ:
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.
1. 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 �/�` Aa(y\ ►�
to act on my behai ,in ail matters relative to work authorized by thig building per ' application.
Signature of Owner Date
I �Adom -e t7 'Q0 !_'4 aQtr� , _xn C ^ as Owner/Authorized
Agent hereby declare that the statements alntdi i ormation on tFe foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the p s and penalties of perjury.
r, L(Z-
P—ri ni 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
---p Building Department
Lot Size
Frontage
Setbacks Front
Side L:= R:= L:= R:1_...r---�
Rear
Building Height 1�
Bldg.Square Footage % i-
Open Space Footage %
(Lot area minus bldg&paved
-kin
#of Parking Spaces
Fill:
(volume&Location) I
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO � DONT KNOW 0 YES Q
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES
IF YES: enter Book Page and/or Document#F
B. Does the site contain a brook, body of water or wetlands? NO M 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 0 , Date Issued: _
C. Do any signs exist on the property? YES Q NO
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
IF YES, describe size, type and location: J�
x
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 Q NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
City of Northampton atus a1u ;;
U Building Department rtl ufae
- 6 014 ail2 I � ��
SAY z � 212 Main Street
Room 100tee( 3a� 111
Gas Inspection
Northampton, MA 01060 tS tom ,.
EI ctric.FI<<mc
_ 4n of 13-587-1240 Fax 413-587-1272 1 P(o tf P RM r
t '.�-. 6 Aga w l�4'�'T-• r� v _{
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH ON O TWO F MILY DWELLING
SECTION 1-SITE INFORMATION
( �ThlsIsectlo aitie'tcoplefedboff�ce
IF
1.1 Property Address: F
-Map �5_ � h5trp
(� U i CJ(PV r�ZOII� tl is 'y�IStrli;t e s y a
�` R Z F 1'�`•� 1 'v' _ y � c r 1 � F i� tlta+ s1 - f .ti 1
l V f tc -
EImStDistncfGB�DIst�cfii .x
SECTION 2.=PROPERTY OWNERSHIPIAUTHORIZED AGENT'
2.1 Owner of Record: r
Name(Print),J Current M llihc
YAddress:
s D C4--TN�n� Telephone
Signature
2.2 Authorized Agent:
IL.Q ; �� Ito& Ulf, �ma� Kd � ��Q�� , kW 6
Na a(Print) Current Mailing Address:
_ y13�S3� �5"
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=(1 +2+3+4+5) Check Number
This-Section For OfficiM Use Onl
Date .
Building Permit Number. Issued:
Signature:
Building CommissiarlerAnspectorlof Buildings Date
807 RYAN RD BP-2014-1162
GIs#: COMMONWEALTH OF MASSACHUSETTS
MU:Block: 35 - 163 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-2014-1162
Project# JS-2014-001969
Est. Cost: $7000.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ADAM QUENNEVILLE 070626
Lot Size(sa. frt.): 46173.60 Owner: ROBERTSON NANCY
Zonin : Applicant: ADAM QUENNEVILLE
AT. 807 RYAN RD
Applicant Address: Phone: Insurance:
160 OLD LYMAN RD (413) 536-5955 O Workers
Compensation
SOUTH HADLEYMA01075 ISSUED ON.51612014 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPLACE RUBBER 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 Occupant' signature:
FeeType• Date Paid: Amount:
Building 5/6/2014 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner