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48-015 ' gti BP- 2011 -0545 110 GIS #: COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category BUILDING PERMIT Permit # BP- 2011 -0545 Proiect # JS- 2011- 000897 Est. Cost: $3525.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor. License: Use Group: ADAM QUENNEVILLE 070626 Lot Size(sq. 1): 217800.00 Owner: NOYES BRIAN K & STEPHANIE K DOUGLASS Zoning: RR(100) //WP Applicant. ADAM QUENNEVILLE AT. 150 DRURY LN Applicant Address: Phone: Insurance: 160 OLD LYMAN RD (413) 536 -5955 () Workers Compensation SOUTH HADLEYMA01075 ISSUED ON :1211412010 0.00:00 TO PERFORM THE FOLLOWING WORK.- REPLACE 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 Sisnature• FeeType: Date Paid: Amount: Building 12/14/2010 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner Department use only City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit Uti 212 Main Street Sewer /Septic Availability Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans phone 413 - 5,87 :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 This section to be completed by office 1.1 Property Address ( u r L C VN e— Map Lot Unit FlecencC j µA 01 00:91. Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record 51}cphck��� Oaua►InSS ISO Drur!j Loge Floccnce- 1AAA 01062 Name (Print) Current Mailing Address: Telephone Signature 2.2 Authorized Agent: A6, am 160 CSI C L L uMC y\ Rd Sov-1,6. Ho4leg MA Name (Print) Current Mailing Address: 01 s 't S - 3G - s5 >;s Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only com leted by ermit applicant 1. Building 3 S_ (a) Building Permit Fee .vv 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) 3 5,1 Check Number This Section For Official Use Onl Permit Number: Date Building Issued: Signature: Building Commissioner /Inspector of Buildings 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 Frontage Setbacks Front Side L: R: L: R: Rear Building Height Bldg. Square Footage % Open Space Footage % (Lot area minus bldg & paved p arkin g) # of Parking Spaces Fill: volume & Location A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO ® DONT KNOW ® YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW • YES IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO © DONT KNOW If YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained ® Obtained ® , Date Issued: C. Do any signs exist on the property? YES © NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES © NO 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 ® NO • IF YES, then a Northampton Storm Water Management Permit from the DPW is required. SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Or Doors 171 Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [M Siding [0] Other [C7] Brief De cnptio of Proposed Work: Kd , i-' cc.P�CCe_ w ��-� ro ltc� CGoT; rx 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 and or addition to existina housing, complete the followina: 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, as Owner of the subject property i hereby authorize , • 61 I� to act on my behalf, in all matters relative to work authorized by this building permit application. Ia-6 - ly Signature of Owner Date I, Ma *" If If lot 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. Iyck Qve.y\(1eyMe— Print Name Signature of Owner /Agent Date ���� �� �� SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor Not Applicable ❑ Name of License Holder : AdA® Qn n e v i fl e Rook & Sft Inc. ' ? A G a � IN IW Lyw Rad License Number Address f Expiration Date 4 /3-514 -5455 Signature Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ Arm m vi1 00 &i�a rte-_ t acaq � 2 Company Name ry , ��� H � _ � Registration Number VNt fiwwu Address mwk MA IN Expiration Date Telephone 413-6M, 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 lot The Conumnweda of Manwhirseft emw qfhdMIWdAcddex& h office oflnvend9adons tM Wtzd*W" Sbed Boston, MA 02111 www.resass g0V1&% workers' Compea ftm bmira ce Affidavit: DuAders/ContracWWE bers w,.,.t:xet lfefnr+uwtgp Pteaw Print Name( �; �. �t��y�tn� \�� " i \nr,� 1 - ✓IC, Address: J D( A R. l r" City/S '� An rw sa mployer? Cbeek tied appropriate bw.. Type of projed (required): I.X I am a employer with , 4. Q I am a general cm acw and I 6 Q New construction employees (full and/or part —W have hhvd the sub-coubactors 2. Q 1 am a sole proprietor or po tM listed on the attached sheet. 7. ❑ Remodeling ship and have no employees Thee sub-contractors have & ❑ Demolition employees and have workers' worldrtg for are in any deity. 9. Q Building addition (No wodcas' comp. ftwxance; 0om insuranco mq�) 5. Q We are a corporation and its 10.❑ Electrical repairs or additions 3. Q I am a homeowner doing all wade officers have exercised their 1 I.Q Phunbing repairs or additions mywW IN* wokess' coop. right of exemptiou per MGL 1 t c. 152, §1(4� and we have no 13 0 empbyees. (No wo&M comp• kwu ance required.] •Any apptic� art ahecb bac it mmt aUo � ant the so�tioa bolo�r �io+ris6lbeir wodmts' oos�pem�tioa policy infoemNioe. � Homeonaes. rho �aii.efiee►itareg as doineal rnadcaedehoshimaWida aontntsoa meta�hmitaoeoxa8riag adiramg,aa< sGamr�taoRe. tale +�ar.boo«tattaeiedtna3gtiiaatl tioetahowinglieareol waaasao. traoloisad� +arahararsot eaiptoyees. if ine aaboaetsetaa hwe employaea, 6ry eeoK provide thei wiodmes' comp. >� aoe�er. IM are a pieya && is pMjj&V nesr*m" el Sawmaw for aey a Bd Pw is dw poHc, f mi fi►b sft Insurance Company Name: rt u � � :Krrs ,t u iui e _ Policy # or Self -ins. Lic. #: a W ry O ja il( 10 ( Expiration Date: �oT I Job Site Address: ISO bru Lane, F(osoncc. 0%o(,1 City/StateiZip: Atb & a ew oftbe verb m$ eoespeaaNise< Pe ft acct ara 1 . Pace (As" k g 60 Pe ft nw bw SW isf date Faflm+e to swm eovvrrage as ruined tinder &w6m 25A of MGL a 152 can lead to the you of aimind patalties of s fine up to S1, 500.00 and/or one - year imprison mead, as well as civil pmalties in the form of a MP WORK ORDER and a fine of up to 5250.00 a defy qpind the violdar. Be advised that a copy of this statement mar be forwarded to the Office of lavestigstions of dbe DIA for irzm=ee covuW verifloadon. I & haeby coo water the aa�lpa S efPff*7 Bert dte � PV bf & balm o�edco MM 1 Pbone # 'f(3- - S.3 (a- 59 S5, OffIr d are Orly. Duo neat wt* ix dws wv4 to be cetntpkW by d& or >mm offlcW City or Town: Perret /Lioease # Ming Authority (eirele one). 1. Board ofBadth 2. Bu§ftg Sepaxrte►ent 3. City/Tmm Clerk 4. iEt tricai Uspeaw S. PI ®bicg kaspectur 6.Otber Contact Persos: Pboae #: Nov -08 -2010 06:00 PM Remillard Insurance 1- 413- b38 - 601U c�c ® CERTIFICATE OF LIABILITY INSURANCE OP ID LL L i 1E /09/ 10 ACORD o9 /la THIS • CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE BOLDER. 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 policy(les) 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(s). PRODUCER NAME: AX PHONE Remillard Insurance Agcy, Inc �Ext: (Al Nc): 79 Lyman Street ADDRESS: _ South Hadley MA 01075 CU ADAMQ -1 _ Phone:4 -538 - 7862 Fax:413- 538 -7179 INSURER(S) AFFORDING COVERAGE NAIL# INSURED _ INSURER A: First Speciality Ins Corp Adam Quenneville Roofing & INSURER B: Travelers Ins. Co. Siding Inc. & Adam Quenneville - - - -- - Roofing Inc & GutterShutter INSURER C: AXX Mutual Zasuzaaca company Of Western MA 160 Old Lyman Road INSURER O: Hanover Insurance Company 22292 South Hadley MA 01075 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERT)FY THATTHE 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY SE ;SSUEO OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. _ LTR TYPE OF INSURANCE IN SR WV POLICY NUMBER (MMIDDIYYYY�MIDDIYYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE ! $ 10 00000 A X COMMERCIAL GENERAL LIABILITY IRG98441 06/23/10 06/23/11 PREMSES(E� $1 0000D CLAIMS -MADE 1 `• I OCCUR MEDEXP(Anyoneperson) $ 2$ PERSONAL BADVINJURY 1 3100 0000 G ENERAL AGGR EGATE $ 2000000 _ G AGGREGATE LIMIT APPLIES PER: PRODUCTS - CO MP /QP AGG $ 2000000 POLICY PECOT- u LOC $ — AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 100 (Ea accidmi) B IX ANY AUTO BA745OL946 11/01/10 11/01/11 BODILY INJURY (Per person) $ ALL OWNED AUTOS BODILY INJURY (Par accident) $ SCHEDULED AUTOS PROPERTY DAMAGE X HIRED AUTOS (Peraccidont) $ X NON-OWNED AUTOS - $ UMBRELLA LIAB OCCUR I EACH OCCURRENCE 5 EXCESS LIAB CLAIMS -MADE I AGGREGATE S DEDUCTIBLE - - -- RETENTION $ $ C WORKERS COMPENSATION AWC701286101 04/29/1D 04/29/11 X W TATU- X AND EMPLOYERS' LIABILITY TO LIMITS ER . _ ANY PROPRIETORIPARTNERJEXECUTIV -VIN /A E.L. EACH ACCIDENT $1000000 OFFICERIMEMBER EXCLUDED? -''- -- (Mandatory in NH) E.L. DIS - E A EMPLOYEE $100000 - 0. I( yyes, desaiba under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 10 0 0 0 0 0 D Equipment Floater IHN7140610 02 02/01/11 Rental Equipment $100,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) CERTIFICATE H OLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE ADAMQUE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Adam Quenneville Roofing & Siding AUTHORIZED REPRESENTATIVE 160 Old Lyman Rd, South Hadley MA 01075 ©1988 -2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD A DA _ &ard) QUENNEVILLE ROOFING & SIDING, INC. 160 Old Lyman Road, South Hadley, MA 01075 1. 800 - NEW -ROOF • 413- 536 -5955 Email: info @1800newroof.net Website: www.1800newroof.net MA Construction Supervisors Lic. #070626 MA Registration #120982 Member of the Home Builder's Association of Western Mass. CT Registration #575920 Member of the Building 8 Trade Association Member of the Better Business Bureau Proposal Submitted To: Date Phone #'s r tit / H ; r- f , 'f� �W Street ' Job Name: r City, State, Zip Code Job Location: Proposal to furnish and install the following ❑ Re -Roof ❑ Tear -Off ❑ Gutter , ✓ J. 1, � p l _ Ask us about affordable bank financing We Propose hereby to furnish materials and labor - complete in accordance with above specifications for the sum of: -- — - — — dollars ($ 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 at start of job, and balance due upon completion. Date: Signature: Phone #_ _TT - -- — — Date: _ _ Estimator's Signature: 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.