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17A-010 50 HASTINGS HGTS BP- 2012 -0098 GIs #: COMMONWEALTH OF MASSACHUSETTS Map :Bloc 17A - 010 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: roofing BUILDING PERMIT Permit # BP- 2012 -0098 Project # JS- 2012- 000153 Est. Cost: $10838.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ADAM QUENNEVILLE 070626 Lot Size(sq. ft.): 13503.60 Owner: SKIBISKI JOHN F JR & ANN H zoning: URA(100) //RI/WSP Applicant: ADAM QUENNEVILLE AT. 50 HASTINGS HGTS Applicant Address: Phone: Insurance: 160 OLD LYMAN RD (413) 536 -5955 O Workers Compensation SOUTH HADLEYMA01075 ISSUED ON. 7129120110:00:00 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 7/29/20110:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner Department use only ity of Northampton Status of Permit: uilding Department Curb Cut/Driveway Permit G 212 Main Street Sewer /Septic Availability �UL 2 J � Room 100 Water/Well Availability, ort ampton, MA 01060 Two Sets of Structural Plans 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 This section to be completed by office 1.1 Property Address 5 o ST' Yl S P i�,hf Map Lot Unit Zone Overlay District Elm St. District_ CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record S �- i 15o OsS i (195 4t("i 4 - F1 o r -e o c.e / AAA o It* Name (Print) Current Mailing Address: .5- 6-o Pra o f n coo 3 LAS 7 Telephone Signature 2.2 Authorized Agent: «0 Dld G m `z o Name (Print) Current Mailing Ad ess: Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by ermit applicant 1. Building ' D G 3 o C (a) Building Permit Fee 2. Electrical 0 (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) r C Co Check Number This Section For Official Use Onl Permit Number: Date Building Issued: Signature: Building Commissioner /Inspector of Buildings Date SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable New House ❑ Addition ❑ Replacement Windows Alterations) T ofing Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [M Siding [O] Other [a Brief Description of Proposed ii n Work: 'Sir) n 11 A ( fi✓1 9 4 [airs Ux fad 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 and or addition to existina 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? 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 as Owner of the subject property hereby authorize A" AL to act on my behalf, in all matters laworkau orized b his building permit application. Sign re of Owner ct4-kK A-et/. Date I, A& Qw a 0, as Owner /Au1bD1=d 4Wt 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. 4d& '-) 7 & PrPr ntNarne 42L'It- g -a -6- / Signat of Owner/Agent Date mat Afw* Not, SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor Not Applicable ❑ Name of License Holder CY , G� f (I) ��(�/ l qa C0 License Number Address j Expiration Date '/l3-�'�� - 5`15S o�Q' S � tur Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ IAa few Company Name 168 (did Lysu ReW Registration Number Address t MA 91175 Expiration Date 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 Official that he /she shall be responsible for all such work perfo 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 *4 #"1 bli, The Covwwnweidth of Maysachuseffs Depm-tment of .Industrial Accidents O )Twe of Investigations 600 Washington Y&eet Boston, MA 021I1 www masxgov /dia Workers Compensation Insurance Affidavit: Builders /ContractorMecfiriciau- gPlumbers Applicant Informtation Please Print x,egibly j _ Name (B . A dt1 OUMVV -V� �U 60 t� t S d itq 1� Address: Le U Yn q n C itylstatelZi : d lK A D 167�Phane Are you an employer? Check the mpprop to box: Type of project (required): 1. [ am a employer with 16: _ 4. E] 1 anz a gcucral contractor and I employees (fitll and/or part time).* have hired thr, sub -caws 6_ [1 New construction 2. El I am a cola proprietor or partner Iishcd on the attached shit 7 E] deli ship and have no employees .'x sttb�ntractors have g. ❑ Denoolition working fior me in any capacity. employees and have workers' [No work=s' comp_ instance �- -# 9- Q Btuldmg addition l 5. ❑ We are a corporation and its 10_❑ Electrical rcpanrs or additions 3. ❑ I am a homeov na' doing all work officers have tstcetcised &cw I1.[] Phtmbimg repairs or additions Myself [No workers' comp. right of cxemption Per MGL 12:N Roof repairs ittsara requira-1 t r 152, §1(4X and we haven 13.❑ Od r cauployem [No workers gyp- required.] *Any applicant that checks box 91 mast alm fill ad rho mcfxm bdow showing their wo i=e mmp -snewn policy itt wwatbo. I Homeowners who submit this a$d" inficWog d-y+ are doing all work and th. hire osiride matrartarrs =at subtoit anew+ affidavit iadiaadiuug such Icontracw= that check this box amst attached an addi - W shoot A wing Bic — . of the wb-contraetors d sbta vvh� or not ♦boss entities havo anployoes. If rho Mb—contractors hewn empbyoes, they mast provide /heir woticets' comp policy ammba. lam an employer that is providvig worltm' compensation irrsurartce for my employe= Below is the po licy turd job sire infornudioa. Insurance Company Name: 1 a hAOLI i n Ski Y'll YI (—'L Policy # or Self -ins. Lit:, #: C r i !) E)CPhation Job Site Address: S 4,2 f 4 fS " R 6 ( Yl t t C tfylSlait/Zp: t V V1 0 l0 6 ,9 Attach a copy of the workers' compensation policy dechration page (showing the policy number and expiration date). Failure to soave coverage as requited Section 25A of MGL c- 152 can lead to the nmPossiit of carnmiaal 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 tiie Office of Investigations of ft MA, for mstuzmce coverage verificat ion - I do hereby cr * gn&tr fhe pa &a and penalties ofpeijky that the info rmadan provided abow is true and correct Siieuai: / Dom r j a D — l C Phone #: Officied use only. Do not wrike in this area to be conWkfzd by city or hnm ortiat City or Town- Permiuuceuse # Issuing Authority (circle one)_ L Board of Health 2- Building Department I Cityfrown Clerk 4- Electrical Inspector 5. Plumbing Inspector 6- Other Contact Person- Phone #� Jun -23 -2011 09:43 AM Remillard Insurance 1- 413 - 538 -bury ...�..�. OP ID: LL A�RQ' CERTIFICATE OF LIABILITY C OMM I THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO ROM UPON THE CERTIFICATE HOLDW THIS CERTIFICATE DOES MOT AFRIRIIAATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED 13Y THE POLICIES BELOW. THIS CER71FICATE OF INSU11MMCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING MBURERM AUT•HORMED REPRES WATNE OR PRODUCER AND THE CERTIFICATE HOLDER. IMPORTANT: if the cw'tECate holder is an ADDITIONAL INSURED, the poky0n) must be endorsed. N $UBROOATION IS WANED, subject to the temat and conditions of the policy, certain POU des may require an endoraemenR A statement on Ws ow fidarte doss net confer rights to the cer0ame holder In Neu of such e . PRDOUCQR 413436 -7892 RemOlard Insurance Agcy, Inc 4113- 338 -7178 79 Lyman Street South Hadley, MA 01078 ADAMQ -1 Stephen E. Radon ArFOROSto am r MUM Adam Quennevilie'Rodfng & raM #6 .AIM Mutual Insurance Com pn Siding Inc m@IM B:Travelera Ins. Co. ISO Old Lyman Road c South Hadley, MA 01076 easura!xe: F: COVERAGES 2LRTMATE NUMBER: REVISION NWR: THIS 18 TO CERTIFY THAT THE POLICIES OF blStMNCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED FOR THE POLICY PERIOD INDILATED NOT"THSTANDW ANY REQUIREMENT, TEw OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WICH THIS CERnmATE MA7 BE ISSUED OR MAY PERTAIN, THIS INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIII IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LETS SHOWN MAY HAVE BM REDUCE BY PAID CLAM& r1k CIF MURANCE Lear$ SENSE t. uADe.IT1' EACH OCcUriftel E COMMOC111l.t ALLMBdrry oe f y f CLA N-MADE F-1 OCCUR MIw FxP ma !non : PERSOWV & MM I iAM t GENHLALAGOREGATE $ 00M AGGROG ATE UWF APPLES PER PRODUCTS - CDM1P1bP AQG j pmw LOC i Aurorroea.a MOWN oowm e m x uw t 1,000 8 ANYAUrD 7 f50t.948 11/0190 11101/11 BODLY WAXf MW pmop) s AL OV*= AV. 03 BODILY INJLNtY(PV �addmr) X 6CiDfR�AUTO$ t PRDPERTYDWM X HFM AUT08 W X NON- OMMEDA MOS i e ff " OCCUR EACH OC CUR�MGE S CLANrS."we AGORMM $ v NR11tlfmISCONPWe1►TIDN X ATU- X A ( y 1" —i p/A 1AIC70121910i 04 /11 W29M2 EL SACHA:CLDENr a Y de�c,buwidr � i _! E1 018EA8E -EA 8 1.0 00 1. 1 D TIOa OF oNft7tCM / U=TrOHR / YBECLFa UtEFa01t ACORD 141, AdMft d s mft $*Aftl% a ■rom ewe Is CERTIFICATE C SNDULD AMY OF THE ABOVE DOSCRIM POLICIRS M CANCECL w BEFORE THE E%PIRATION DATE WEREOF, NOTICE WILL 66 06UV9M IN ACCORDANCE %M TOE POLICY PROVIS100. AUT"OR M FAWRISSMATN 0 lMS -2009 ACORD CORPORATION. AN rights reserved. ACORD 25 (2009106) The ACORD narne and logo are registered marks of ACORD A� 6 CERTIFICATE OF LIABILITY INSURANCE DATE 201 IDDIY1 /23/1 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. 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, AN THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WANED, 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 endomerment(s). PRODUCER NA TE C Lynne Methot, Ext. 102 PHONE Foley Insurance Group Inc. (N6 W F r , (413) 214 -7474 FAX (413)214 -7447 37 Elm Street . lmethot @foleyinsurancegroup.com INS S AFFORDING COVERAGE NAIC 0 West Springfield MA 01089 -2703 INSURERA :Peerless Insurance INSURED INSURER B : Adam Quenneville Roofing & Siding Inc. INSURER C: 160 Old Lyman Road INSURERD: INSURER E: South Hadley MA 01075 -2632 INSURERF: COVERAGES CERTIFICATE NUMBER CLI162305763 REVISION NUMBER: THIS IS TO CERTIFY THAT 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE POLICY NUMBER M/DD YYYY � LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES a occurrence) $ 100,000 A CLAIMS-MADE XI OCCUR 4006912267 /23/2011 /23/2012 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $ 2, POLICY X PRO LOC $ AUTOMOBILE LIABILITY L LI accident ANY AUTO BODILY INJURY (Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ NON -OWNED PROPERTY DAMAG $ HIRED AUTOS AUTOS (Par accide S UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS L1AB CLAIMS -MADE AGGREGATE $ DED RETENTION $ WORKERS COMPENSATION I WC STATU- OTH- AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? ❑ NIA (Mandatory in NH) E.L. DISEASE - EA EMPLOYE9 $ If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT 1 $ DESCRIPTION OF OPERATIONS /LOCATIONS /VEHICLES (Attach ACORD 1(1, Additional Remarks Schedule, if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Brian Foley /LYNNE ACORD 25 (2010/05) ©1988 -2010 ACORD CORPORATION. All rights reserved. ".-1 "" -1 -11 — Ti.n Af'f1Rn name anti Inn^ aria raniettartaA marire ^f ar`rwn Massachusetts - Department of Public Safets .Board (9f Building Regulations and Standards Construction Servisor License License: CS 70626 ADAM A QUENNEVILLE 160 OLD LYMAN RD S HADLEY, MA 01075 Expiration: 8121/2013 ( .nnni..ioner Tr#: 21002 Office of Consumer Affairs and usiness Regulation >r' 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 120982 Type: DBA Expiration: 3/25/2012 Tr# 293069 ADAM QUENNEVILLE ROOFING ADAM QUENNEVILLE 160 OLD LYMAN RD SO. HADLEY, MA 01075 _— - - Update Address and return card. Mark reason for change. �- Address Renewal Employment I ost Card �r ii,3 y''� �A 'r� h ..tea' {.rs Y d • STATE OF CONNECTICUT + DEPARTMENT OF CONSUMER PROTECTION Be it known that ADAM QUENNEVILLE t> 160 OLD LYMAN ROAD SOUTH HADLEY, MA 01075 -2632 ' is certified by the Department of Consumer Protection as a registered HOME IMPROVEMENT CONTRACTOR Registration # HT C.0575920 ADAM QUENNEVILLE ROOFING - Effective: 12 /01/2010 Expiration: 11 /30/2011 �- ems` e Fa J r., J erry ll, J ., ommissioner 1 Q U E N N E V I L L E www.1800newroof.net ROOFING ♦ SIDING 'W WINDOWS We Are Licensed 160 Old Lyman Road • South Hadley, MA 01075 1.800.NEW ROOF 413.536.5955 Fully Insured Email: info @1800newroof.net Website: www.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 P.P.C. 38710 Proposal Submitted To: Date Phone #'s C: hi S 1 1 H: W: Stree �( Email: y City, State, Zip Code Q Special Requirements: El Recover Wstrip a L,. r - 0 j Complete Roof System '12 shall acquire all appropriate permits for all work Home exterior and landscaping to be protected Strip existing roofing to existing decking and dispose of. Do not Do. Deteriorated existing decking will be replaced at $3.47 per sq.ft. after full inspection. Install Ice & Water Barrier at all eaves, valleys, chimneys, pipes and skylights Install (151b. felt /Synthetic underlayment over remaining decking area Install Metal dri ed a ai eaves and rakes 8" / 5" white brow /copper �j Install manufacturer's starter shingle on all eaves and rake edges BBB Install new pipe boot flashing (standard�pper) / vents — r -q Instal Snow Countryor Cobra rolled vent ridge vent Winner of the 2010 ❑ Install proper soff it ventilation TORCH AWARD Shingles: ( 6 nails per shingle) Li�,4%w Z Shingles ❑ 25 year ❑ 30 year ❑ 50 year Color nc 4 73- 1, L�q ( � C , < ("C' ' Ridge cap shingles Warranty Options: We guarantee our workmanship for 10 full years (see our warranty coverage) ✓mil GAF System Plus warranty ❑ GAF Golden Pledge warranty Chimney Options: Lead Counter Flashing ❑ Water Seal & Tuckpoint ❑ Rubberized Crown ❑ Metal Chimney Cap We propose hereby to fumish materials and labor - complete in accordance with above specifications for the sum of: Total Due ACCEPTANCE OF PROPOSAL: The above prices, specifications and conditions are ki Down Payment ($ J nU 0 0 ) satisfactory and are hereby accepted. You are authorized to do work as specified. I ) 3 "( Payment will be 113 down at start of job, and balance due upon completion. Balance Due Upon Completion ($ � 7 5 - - -00 ) Date: l Signature: Date: ) 11 Estimator: t Name) Sr ofi 5(4-4 (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.