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15-023 8 SHEPARD'S HOLLOW - 266 CHESTERFIELD RD BP- 2011 -0413 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Bloc 15 - 023 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 -0413 Proiect# 41 JS- 2011 - 000682 Est. Cost: $47800.00 Fee: $286.80 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor. License: Use Group: BOURKE BUILDERS 055137 Lot Size(sq. ft.): 203425.20 Owner KASKEY GARY B Zoning: RR(46)/URA(54)/ Applicant: BOURKE BUILDERS AT. 8 SHEPARD'S HOLLOW - 266 CHESTERFIELD RD Applicant Address: Phone: Insurance: 77 LONG HILL RD (413) 548 -9214 Workers Compensation LEVERETTMA01054 ISSUED ON.11 /10/2010 0:00.00 TO PERFORM THE FOLLOWING WORK.-ADD 1 CAR GARAGE & PORCH ABOVE, MODIFY DECK & ADD LOWER LEVEL 1/2 A - TH POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: / / (S ervice: Meter: , Footings: � � � ` '� � `1 O C ry M ' Rough: - � �� `� Rough2t?' House # Foundation: Driveway Final: Final: 4 Rough Frame: ®k 1 L1) (( C/V^— Gas: Fire Department Fireplace /Chimney: Rough: Oil: Insulation: i Final: Smoke• Final: i THIS PERMIT MAY BE REVOKED BY THE CITY OF RTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND RE Certificate of Occu anc Si nature: �ftitM i�L Feel e: Date Paid: Amount Building 11/10/2010 0:00:00 $286.80 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck - Building Commissioner • T • 266 CjiESTFRFIELD RID BP GIS #: COMMONWEALTH OF MASSACHUSETTS " pl�iCt l (}23 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Cate BUILDING PERMIT Permit # BP- 2011 -0413 Proiect # JS- 2011- 000682 Est. Cost: $47800.00 Fee: $286.80 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: BOURKE BUILDERS 055137 Lot Size(sq. ft.): 203425.20 Owner: KASKEY GARY B & MICHELLE S Zoning: RR(46) /URA(54) Applicant: BOURKE BUILDERS AT: 8 SHEPARD'S HOLLOW - 266 CHESTERFIELD RD Applicant Address: Phone: Insurance: 77 LONG HILL RD (413) 548 -9214 Workers Compensation LEVERETTMA01054 ISSUED ON :11 /10/2010 0:00:00 TO PERFORM THE FOLLOWING WORK .-ADD 1 CAR GARAGE & PORCH ABOVE, MODIFY DECK & ADD LOWER LEVEL 1/2 BATH 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 Si FeeType: Date Paid: Amount: Building 11/10/2010 0:00:00 $286.80 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner File # BP- 2011 -0413 APPLICANT /CONTACT PERSON BOURKE BUILDERS ADDRESS/PHONE 77 LONG HILL RD LEVERETT (413) 548 -9214 PROPERTY LOCATION 8 SHEPARD'S HOLLOW - 266 CHESTERFIELD RD MAP 15 PARCEL 023 001 ZONE RR(46)/URA(54)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildinp Permit Filled out Fee Paid Typeof Construction: ADD 1 CAR GARAGE & PORCH ABOVE MODIFY DECK & ADD LOWER LEVEL 1/2 BATH New Construction Non Structural interior renovations Addition to ExistinK Accessory Structure Buildine Plans Included• Owner/ Statement or License 055137 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO ION PRESENTED: Approved Additional permits required (see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project: Site Plan AND /OR Special Permit With Site Plan Major Project: Site Plan AND /OR Special Permit With Site Plan ZONING BOARD PERMIT REQUIRED UNDER: § Finding Special Permit Variance* Received & Recorded at Registry of Deeds Proof Enclosed Other Permits Required: Curb Cut from DPW Water Availability Sewer Availability Septic Approval Board of Health Well Water Potability Board of Health Permit from Conservation Commission Permit from CB Architecture Committee Permit from Elm Street Commission Permit DPW Storm Water Management ,e elay Signature of Auildi4g 6 ffici Date Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning requirements and obtain all required permits from Board of Health, Conservation Commission, Department of public works and other applicable permit granting authorities. * Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of Planning & Development for more information. File # BP- 2011 -0413 � OK APPLICANT /CONTACT PERSON BOURKE BUILDERS �� A 0 ADDRESS/PHONE 77 LONG HILL RD LEVERETT (413) 548 -9214 PROPERTY LOCATION 8 SHEPARD'S HOLLOW - 266 CHESTERFIELD RD MAP 15 PARCEL 023 001 ZONE RR(46)/URA(54)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out A 15 Fee Paid Typeof Construction: ADD 1 CAR GARAGE & PORCH ABOVE MODIFY DECK & ADD LOWER LEVEL 1/2 BATH New Construction Non Structural interior renovations Addition to Existin Accessory Structure Building Plans Included: Owner/ Statement or License 055137 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFqRMATION PRESENTED: / Approved Additional permits required (see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project: Site Plan AND /OR Special Permit With Site Plan Major Project: Site Plan AND /OR Special Permit With Site Plan ZONING BOARD PERMIT REQUIRED UNDER: § Finding Special Permit Variance* Received & Recorded at Registry of Deeds Proof Enclosed Other Permits Required: Curb Cut from DPW Water Availability Sewer Availability Septic Approval Board of Health Well Water Potability Board of Health Permit from Conservation Commission Permit from CB Architecture Committee Permit from Elm Street Commission Permit DPW Storm Water Management Demolition Delay Signature of Building Official Date Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning requirements and obtain all required permits from Board of Health, Conservation Commission, Department of public works and other applicable permit granting authorities. * Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of Planning & Development for more information. Department use only City of Northampton Status of Permit; Building Department Curb Cut/Driveway hermit 212 Main Street Sewer /SepticAvai►ability Room 100 Water/Well AVal abilltx Northampton, MA 01060 Two Sets ofrStructural Plans phone 413 - 5$1 - 1240 Fax 413 587 - 1272 Plot/S,ite Plans Other Specify','° .. . APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION 1.1 Property Address This section to be completed by office L q ';iA f P Q ( Z 1p Map Lot Unit Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record C R.2 � &A - F S(C8tI-x4S A Name (Print) Current M ' 1' Adss: �I I I _, '• 234 3 Telephone Signature 2.2 Authorized A ent: LA\-k1., A, 7 t c VJ& lk i \k bN- . (.ACAAM IMA Q c54 Na e (Prin Current Mailing Address: Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by ermit applicant 1. Building /1 ? - D O (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from 6 3. Plumbing rf O Building Permit Fee 4. Mechanical (HVAC) �C D 5. Fire Protection 6. Total= (1 +2+3+4+5) C) o Check Number a This Section For Official Use Onl Building Permit Number: Date 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 A", Ac Frontage Setbacks Front j T30z WA Side L: ! R:fur,, L: :... R. i_�. 5 ,1p/..` _... _ i..... Rear Building Height 8 1 ' fX15"T1 N A.. �S� LJpLk- o cc Bldg. Square Footage Open Space Footage % p (Lot area minus bldg & paved _ l t7 FM 3, Z"% p arkin g) # of Parking Spaces ..._... _ _... . ,._..w __ ._. . Fill: volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DON'T KNOW 4%% YES Q IF YES, date issued:" IF YES: Was the permit recorded at the Registry of Deeds? NO Q DON'T KNOW YES 0 IF YES: enter Book , Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO I(& DON'T KNOW Q YES Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained Q , 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 Q NO 0 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 Q 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 6►NvAje Q I? Or Doors E] Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [C] Siding [O] Other [o] Brief Description of Proposed Work: AD.D I - CA1Y (,, iAVj"y- + DDYC4I ikScye Wbt fy t* ik lfit. el e- Lw if-L 71 L TiwpA Alteration of existing bedroom Yes ) ( No Adding new bedroom Yes _ )( No Attached Narrative N f Renovating unfinished basement Yes __No Plans Attached Roll (a Sheets 6a. if New house and or addition to existing housing, complete the following: N J * 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, `- r t:j S (CC ' as Owner of the subject property [� hereby authorize �P/lriL -- +�U(1CVQ�Cj � lrLµ? � trl,(�Ili1Z C� to act on my Jyehalf, in all matter r ive to work authori ed by this building permit application. Signature of Ow r (' Date F v`Y� � t � -y , LLC-- as lama /Authorized Agent hereby declare that the statements and on the foregoing appli ation are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. �1 ALr D-" oin` -I�-�- Print Name � -a- 17- 1 in Signat re of-AQwmor /Agent Dat SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor Not Applicable ❑ Name of License Holder � �- �. G�-- ��!5 13 License Number Addr Expiration n C " 6 L Signature Telephone 9. Registered Home Improvement'' Contractor: Not Applicable ❑ U-C Company Name Registration Number Address Expiration Date Telephone At3`S4`8 - L�a r 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 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street UV Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders /Contractors/Electricians /Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): �la�`. Ll�� - Sw( UW0 _ 5, Address: 77 LOKU., f�J lC_ (Pe &-A City /State /Zip: Phone #: Are you an employer? Check the appropriate box: Type of project (required): 1. Q9 I am a employer with A 4. ❑ I am 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. W Remodeling ship and have no employees These sub - contractors have g. ❑ 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. 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.❑ Roof repairs insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' 13.7 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 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 job site information. Insurance Company Name: Y �, DY &AT c LQrAtO � Policy # or Self -ins. Lic. #: p u3C_ 8 .) -C) Expiration Date: -2- 1 0) Job Site Address: SFF c q 's 60«pw kpg. City /State /Zip: T Ao 0M531 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 forth 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 co v e rif ication. I do hereby c er the pains a d penalties of perjury that the information provided above is true and correct. Sig nature: Date: Phone #_:_ 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 #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes. that apply to your situation and, if necessary, supply sub- contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self- insured companies should enter their self - insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple pernzit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617 -727 -4900 ext 406 or 1- 877- MASSAFE Fax # 617 -727 -7749 Revised 4 -24 -07 www.mass.govfdia GUARD Workers' Compensation and Employer's Liability Policy NorGUARD Insurance Company - A Stock Company INSURANCE Policy Number PAWC118206 Renewal of NEW tGROUP NCCI No.[25844] Policy Information Page [1] Named Insured and Mailing Address Agency Paul Bourke AXIA INSURANCE SERVICES 77 Long Hill Road 73 Marketplace Leverett, MA 01054 P.O. Box 15648 Springfield, MA 01103 Agency Code: MAAXIA10 Federal Employer's ID 04- 3011781 Insured is Individual Risk ID Number 000382174 Additional Names of Insured (N2) Bourke Builders [2] Policy Period From February 01, 2010 to February 01, 2011, 12:01 AM, standard time at the insured's mailing address. [3] Coverage A. Workers' Compensation Insurance - Part One of this policy applies to the Workers' Compensation Law of the following states: Massachusetts B. Employer's Liability Insurance - Part Two of this policy applies to work in each of the states listed in item [3]A. The limits of our liability under Part Two are: Bodily Injury by Accident - each accident $100,000 Bodily Injury by Disease - each employee $100,000 Bodily Injury by Disease - policy limit $500,000 C. Other States Insurance - Part Three of this policy applies to all states, except any state listed in item [3]A. and the states of North Dakota, Ohio, Washington, and Wyoming. D. This policy includes these endorsements and schedules: See Extension of Information Page - Schedule of Forms ............. ................._............. [4] Premium The Premium Basis and, therefore, the premium will be determined by our Manual of Rules, Classifications, Rates, and Rating Plans. All required information is subject to verification and change by audit. (Continued on another page) THE HOUSE AS A SYSTEM Subcontractor List g S'tkr — g + 0 LL0LA:> r2 fl.� �Ir75, 1M�°r Lee Edelberg, Electrician AWC70043540120008 3/9/11 EWS Plumbing and Heating WC8347946 3/21/11 Richard Fay Construction WC2- 315 - 352781 -029 12/7/11 Mark Ricciardone, dba Tile and Stone no employees Richard's Floor Services UB- D41DN457 -10 4/22/11 Peter Waters Painting Services no employees J 77 Long Hill Road /Leverett MA 01054 /Phone - Fax: (413) 548-9214 H I(. H10AAA1 L 1 Fully Inca imel • l i C � 8 SHEPARUS HOLLOW -' 266 CHESTS �` BP-2011-0048 GIS #: COMMONWEALTH OF MASSACHUSETTS a lock: 15 - 023 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 -0048 Project # JS- 2011- 000093 Est. Cost: $14094.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor. License: Use Group: ADAM QUENNEVILLE 070626 Lot Size(sq. ft.): 203425.20 Owner: GIBSON CINDY & GARY KASKEY Zoning: RR(46)/URA(54)/ A ADAM QUENNEVILLE AT. 8 SHEPARDS HOLLOW - 266 CHESTERFIELD RD Applicant Address: Phone: Insurance: 160 OLD LYMAN RD (413) 536 -5955 () Workers Compensation SOUTH HADLEYMA01075 ISSUED ON. 7/20/2010 0:00.00 TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE ROOF 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 7/20/2010 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo Department use only City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit 212 Main Street Sewer /Septic Availability L010 Room 100 Water/Well Availability J�� 9 Northampton, MA 01060 Two Sets of Structural Plans phone 4 -5�7 -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 1.1 Property Address This section to be completed by office U 5h / P,6 el (jGC� Map Lot Unit kec?d s 1'q9 010,53 Zone Overlay District Elm St District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record �Lt1p�v G/ Son w ry K 4, -P_4 i k PAhP --C(S Name (Pr t) U Current Mailing A dress: Y 13- vat - yog Telephone Signature 2.2 Authorized Agent: Adam Quenneville Roofing & Siding, Inc, 160 Old Lyman R Name (Print)�f SoUtj MA 010 �yrrent Mailing Address: Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by ermit applicant 1. Building / // O (a) Building Permit Fee 2. Electrical 7 (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) / y O 9 Check Number D O This Section For Official Use Onl Building Permit Number: Date 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 arking) # of Parking Spaces Fill: (volume & Location A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO Q DONT KNOW YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO ® DON'T KNOW Q YES IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO ® DONT KNOW x9 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 Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding [0] Other [C]] Brief Description of Proposed Work: S� r ' P COyec K czZ 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 existing housing, complete the following: a. Use of building : One Family X 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, �, ( L �i U S 0� `� (�Gt t as Owner of the subject property hereby authorize Adam Quennevb Roofing & Sung. Inc, to act on my behalf, in all matters relative to work authorized by t is building permit application. 7- /S Signature of Owner Date AdM Qn- Rohl Siding,Vc, 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. ,14dl- M a U Print Name Signature of Owner /Agent Date SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor Not Applicable ❑ Name of License Holder r J O Ad am License Number 160 Old Lyman Road K - — Address Son* 11adkyf MA 01015 Expiration Date /,�-- J V1 3 - 5,3G -2n Signature Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ It d 10 nnrwwe.nlle ReAg & WinA he ) D q 9 Company Name �Tm i�wau� Registration Number 160 Old Lyman Road _ Address Son& Hadl MA 01075 Expiration Date Telephone y/ - 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 in the denial of the issuance of the building permit. Signed Affidavit Attached Yes....... Dd- No...... ❑ 11. - Home Owner Exemption The current exemption for "homeowners" was extended to include Owner- occupied Dwellings of one (1) or and to allow such homeowner to engage an individual for hire who does not possess a license, provided that t 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, o is, or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/ structures. A person who constructs more than one home in a two-year period shall not be considered a h Such "homeowner" shall submit to the Building Official, on a form acceptable to the Building Official that he 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 an 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 E Employees for injuries not resulting in Death) of the Massachusetts General Laws Annotated, you may be liabl you hire to perform ork for you under this permit. The undersigned "hocowner" certifies and assumes responsibility for compliance with the State Building Cod Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature �. +'4U-'; r ���ji; .° % .. y r t r �. � for o u1 1rlg eg ula ons are tan �ar s One Ashburton Place - Room 1301 Boston, Massachusetts 02108 Construction'$upervisor License License CS: 70626 Restriction: 00 Birth date: 812'111971. Tr# 3712 Explration: 8/21/2 0 1 AQAM °A QUENNEVILLE - T60.OLD 'LYMAt� RD - -- S L'E '' HAD1�, MA 01075 Office of Consumer Affairs and usiness Regulation 10 Park Plaza - Suite 5170 Boston, Massacusetts 02116 r'? Home Improvement �C „n 4ctor Registration Reqistration: 120982 { Type: DBA t r . . Expiration: 3/25/2012 Tr# 293069 ADAM QUENNEVILLE ROOFIN ADAM QUENNEVILLE �n �= ` -�=� \ 160 OLD LYMAN RD SO. HADLEY, MA 01075 � -��' Update Address and return card. Mark reason for change. - -- Address Renewal Employment Lost Card DPS -CAI 0 50M- 04/04- G101216 STATE OF CONNECTICUT ".rv♦ DEPARTMENT OF CONSUMER PROTECTION ;Be "it known that �UNNE�VILLE ' 160 OLD LL ROAD " I :I SOUTI3, Y; t M OQ75 =2632 ii�1 _ •i 1 �. i i is.certified,by- the DepartxilznCr>atectiozi as a.registered ' < DOME IMPRC�V T. % l7NTRACTOR Re 'fi520 .. i I ADAM ' :UENNEVILLE �RO.OFING { Effective 12/01/2009 . Jerry Farrell,•jf., "Commissioner _ !'. The Commonwealth of Massachusetts - a Department of Industrial Accidents O ffice of Investigations 600 Washington Street Boston, MA 02111 s _ .•r www.mass gov /dia Workers' Compensation Insurance Affidavit: Builders /ContractomAElectricians /Plumbers AyRficant Information Please Print Lelifibly ( )' Name ( B usiness/Organization/individual ): ization/Individual . Address: u City /Statef2ip: `j X10 7 Phone#: l Are you an employer? Check the appropriate box: Type of project (required): 1.M I am a employer with I S7_ 4. E] 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. [] Demolition working for mein any capacity. employees and have workers' 9. Q Building addition [No workers' comp. insurance comp. insurance.: required.] 5. We are a corporation and its 10. El 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 c. 152, 12. Roof airs 1 4 , and we have no .0 TeP insurance required.] t § �) 13.0 Other employees. [No workers' comp. insurance requited.] -Any applicant that checks box #1 must also fill out the section below showing their woken' a mpenss ion policy infamunon" tHomeown= who submit this affidavit indicating they atedoiagiffwen >jcaadthea<hireoutside contrachm moatsubmftanewaffidavitindicatingsuch- ZConuanaathat check this box must munched so addibmal shee tshowhigthe mme ofthemboantractors and sent whether arnot those eaudes have eseployaw. If the sub-contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' conrensadon insurance for my eeiployem Below is the policy and Job site information. Insurance Company Name: 0 Au:: a a � 2:Yx a aR e, Policy # or Self -ins. Lic. U A to [ Expiration Date: c� G 1 I Job Site Address: U ( � L' 9A ( zjCZ 6 U) tee`- City /StateMix Le-e-4 s , /q,4 0105 Attach a copy of the workers' compensation polity declaration page (showing the policy number and expirat iooe 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 51,500.00 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 certrJ'y under the palms and penalties of ptrfury that the lirformation prov& above is true and correct Sig cure Da Phone #: L {l 3 - 5 3 to - , q 4 Of ilcial use only. Do not write in this area, to be conrleted 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 #: RX Date /Time 06/24/2010 10:08 1 413 538 6010 P. 001 Jun -24 -2010 09:45 AM Remillard Insurance 1- 413.538 -6010 1/1 ACORD CERTIFICATE OF LIABILITY INSURANCE OP ID DM DATE(MMIDDNYYY) ADAM -1 06/24/10 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Remillard Insurance Agcy, Inc HOLDER, THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 79 Lyman Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. South Hadley MA 01075 I Phone: 413 - 538 -7862 Fax: 413 -538 -7179 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURER A: AIM Mutual Insurance Company INSURER B: Travelers Ins, Co. Adam Quenneville ersh r INSURER C: Fi rst Speciality Ins Co rp Sidin Inc & Guttershut�er Y 160 Old Lyman Road INSURER 0: Hanover Insurance Company 22292 South Hadley MA 01075 INSURER E: COVERAGES THE 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 CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, INbH LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE MMIDDIYI DATE (MMIDD/YY ) LIMITS GENERAL LIABILITY I I EACH OCCURRENCE $ 1000000 C X COMMERCIAL GENERAL LIABILITY I TBI 06/23/10 06/23/11 PREMISES (Ea occurence) $ 100000 CLAIMS MADE a OCCUR ' MED EX (Any one person) $ 5 000 PERSONAL &ADV INJURY '$1000000 I GENERA A GG R EG A TE s 2000000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS•COMPIOPAGG $ 2000000 POLICY 7 JECT I I PRO• n LOG AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) 5 1000000 B ', `' ANY AUTO BA7450L946 11/01/09 � 11/01/10 I ALL OWNED AUTOS BODILY INJURY S X SCHEDULED AUTOS (Per person) i I 1 I X I HIRED AUTOS BODILY INJURY X NON-OWNED AUTOS (Per accident) I $ )PROPERTY DAMAGE I 1 (Per accident) $ I GARAGE LIABILITY I A ONLY • EA A $ I ANY AUTO OTHER THAN EA ACC i $ I I AUTO ONLY: AGG i S EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE S L OCCUR CLAIMS MADE I AGGREGATE S S DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND TORY LIMITS 1 7 1 ER A EMPLOYERIETORILITY ANY PROPRIETOR/PARTNERJEXECUTIVE AWC701286101 04/29/10 04/29/11 1 E.L. EACH ACCIDENT $ 1000000 OFFICERmnEMBERExCLUDED7 I j E.L. DISEASE - EA EMPLOYEE $ 1000000 If yes, describe under i SPECIAL PROVISIONS below E.L. DISEASE •POLICY LIMIT : $ 10 0 0000 OTHER D Equipment Floater iIHN7140610 02/01/10 02/01/11 Rental E ipment $100,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT f SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SERVMAG SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN ServicaMagic Inc NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL Jill 14 023 Denver West Parkway IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR Golden CO 80401 REPRESENTATIVES. AUTHO ED REPRESENTATIVE ACORD 25 (2001108) © ACORD CORPORATION 1988 V QU EN N EVI LLE www.1800newroof.net ROOFING & SIDING, INC. 160 Old Lyman Road, South Hadley, MA 01075 We Are Licensed 1- 800 - NEW -ROOF • 413. 536.5955 Fully Insured Email: info@1800newroof.net Factory Trained MA Construction Supervisors Lic. #070626 MA Registration #120982 Factory Certified Installers Member of the Home Builder's Association of Western Mass. CT Registration #575920 Member of the Building & Trade Association Member of the Better Business Bureau P.P.C. 38710 Proposal Submitted To: Date one #'s Work: 6, c, o + �i� 7! H: 4 yob ar{pvl Cell: Street f f Email: rt /fw City, Stat , Zip Code Special Requirements / Let /�� /oS W0 E/ /c/ pipe t �i� QCO�` e 6 ef tp wecl— F--i omplete Roof System We shall acquire all appropriate permits for all work Home exterior and landscaping to be protected Entire existing roofing materials to be removed to existing decking 5] Deteriorated existing decking will be replaced at $3.47 per sq.ft. Install Ice & Water Barrier at all eaves, valleys, chimneys, pipes, skylights and sidewalls Install (15 lb. felt Synthe I underlayment over remaining decking area Install Metal drip edge at eaves and rakes 5") (white brown / copper) Install manufacturers starter shingle on all eaves and rake edges l] Install new pipe boot flashing ( tandar copper) Install new step flashing where necessary tandar copper) Install Hand nailed rigid baffled continuous ridge vent ] Install proper soffit ventilation hingles: (6 nails per shingle) f _ / I:- Shingles ❑ 25 year 25 30 year ❑ 50 year Color /` p, � .ry N I Ridge cap shingles Jarranty Options: We guarantee our workmanship for 10 full years (see our warranty coverage) GAF ELK System Plus warranty GAF ELK Golden Pledge warranty himney Options: ,-VV Cl�� 'r I Lead Counter Flashing ❑ Water Seal & Tuckpoint ❑ Rubbe C rown ❑ Metal Chimney Cap 'e Propose hereby to furnish materials and labor - complete in accordance with above specifications for the sum of: )tal Sale Price $ 17.0`2 y Down Payment $ 7JGd Upon Completion $ 5 CCEPTANCE OF PROPOSAL: The above prices, specifications and conditions are satisfactory and are hereby accepted. w are authorized to do work as specified. Payment will be 1/3 down upon signing, and balance due upon completion. npaid balances shall accrue with interest at 18% per annum. P chaser(s) will pay for all costs, expenses and reason - 3le attorney's fees incurred by Adam Quenneville Roofing d Si ng, Inc. to recover any sums due under this contract. ate: -7 rZ I /D Signature: Phone # ate: Estimator's Signature: rTENTION HOMEOWNERS: Please cover all personal belongings in the attic, garage or storage areas due to the )ssibility of roofing debris or dust coming in through cracks of the wood. Adam Quenneville Roofing and Sidings ill not be responsible for debris or dust in the attic or storage areas. vov