35-120 D
VISA Master► • ® DISCOVER
QUENNEVILLE
ROOFING ■ SIDING WINDOWS 6
160 Old Lyman Road • South Hadley, MA 01075 BBB
1.800.NEW ROOF • 413.536.5955
Winner of the
Email: info@ 1800newroof.net Website: www.1800newroof.net 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 & Trade Association
Proposal Submitted To: Date Phone #'s C:
Street Email:
City, State, Zip Code Job Name /Location:
r
Proposal to furnish and install the following
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We propose hereby to furnish materials and labor - complete in accordance with above specification or the s rn of: Total Due ($ L l 7)(.,.1 )
ACCEPTANCE OF PROPOSAL: The above prices, specifications and conditions are ' ` "'
satisfactory and are hereby accepted. You are authorized to do work as specified. ‘,
13 Payment ($ C )
Payment will be 1/3 down at start of job, and balance due upon completion. Balance Due Upon Completion ($ 1 )- ' .y )
Date: Signature: 1.
Date: ! Estimator: (Print Name) .," : , f a tr (Sign Name) .277
-
Estimates are honored for sixty (60) days from above date 4,,.0 ` s> - ; „ti„( z, ("
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.
The Commonwealth of Massachusetfr
— Depalnent of Industrial Accidents
}==` t -
Office of Irtvesfigafions
Y1i+. -• , 600 Washington Street
1/4416. '�'� Boston, M4 02111
a• mil, -, ■Iwfir.mas .govidi
Workers' Compensation Insurance Affidavit= Bwtiders/ Contractors /Fdec rician,s/P1umbers
Applicant Information Please Prhit Legibly
Name : A ci d; 14( Oltittve - tt.2 tSoolt1) t Si r : i 05 , .1.06=
Address: e y V 1 J t-I ✓ n a 1 41. '
R
cit :_ __ -•...A teal fVlit oro74hone #: t 3 - C 6—q SC
Are you an employer? Check the ap . , • ' to box: Type of project (required):
1. Vi I am a employer with 16-- 4. [1 I am a general contractor and I 6. ❑ New construction
employees (full and/or part-timer have hired die sub oao3rec�ars
listed on the attached sheet 7. ❑ Remodeling
2. ❑ I amt a sole proprietor or partner
ship and have no employees . These sub - contractors have g ❑ Demolition
working for me in any rapacity employees and have workers' 9. 0 Building additiOn
[No workers' comp- insurance p_ insurance.*
t
5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3. ❑ 1 am a homeowner doing all officers have eaoetrcted ILO Phanbmg errs or additions
right of exemption perMGL
myself [No workers' comp.
] f C. 152, §1(4), and we have no insurance 12. Roof =pails employ - [No workers' 13. Other
caw. irearrance -]
`Any applieeat that attics boa ill ,mut also 511 out the section below shaving their workers' compensation policy id>Soneetioo.
t Homeowners vrlm submit this alSdmrit intimating they are doing all wale and dna lire outside =stream unlit submit :new d'6davk indicating awl.
:Contras= that cheat[ this bane mast attached an additional sheet showing the noose of the sob- tmetraoas and aloe whether or not those entities haves
employees. lithe sub etas lave mph/res. they mast provide the waters' comp- policy mamba.
I aim an employer that isprnviing workers' compensation insurance for my employees. Below is the policy and job site
ihforrittrisort.
Insurance Company Name: R T M m Lt tit 0,-( -1 n ClA ra 11
Polity # or Self -ins. Lie '1..� . Pr r1/ 2,f o� I 1011 Expiration Pate: q - q —,76 1 a
lob Site Adrir s: ? w 5 4)_ t d F'[OT-P it ee (stye / n4 a /)i /0
Attach a copy of the workers' compensation polity declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 2SA of h4GL c 152 can lead to the imposition of aimi coal penalties of a
fine up to $1,500.00 and/or one -year imprisonment, ent , as well as civil penalties in the fxm 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 In the OtEtCe of
Investigations of the DIA for insurance coverage verification_
I do hereby cextif, under the pains and penalties of perjury that the information provided above is true and correct
Signature: , A Date: if —' i
Phone it L i 13 6G --q 6"
pffir - ft.r rcrc nasty_ Do reor write =not; this m^s to eosr d he by a j' f or lawn offfri f t
City or Town: PermitlLicease #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. PIuznbing Inspector
6. Other
Contact Person: Phone fit
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisorr�,�� Not Applicable ❑
Name of License Holder : / 9 C i ( L b 4 2 6 /7 rt j/
License Number
ad Old G ins i� /�d . 50.1 d(t 0/0/7
Address y Expiration Date
Si to a Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
Adam QuennPailIe Roofing & Siding, Inc. / T ? JZ
Company Name Registration Number
South 0kl Lyman Road pRoad 3 �-
Address South Hadk MA Hadley VlM V r5 Expiration Date
Telephone 1/0
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 ❑
11. - Home Owner Exemption
The current exemption for "homeowners" was extended to include Owner- occupied Dwellints 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 ❑ Replacement Windows Alteration(s) ❑ Roofing 1Z1
Or Doors ID
Accessory Bldg. ❑ Demolition El New Signs [0] Decks [C7 Siding [O] Other [dl
Brief Description of Proposed . 7 M 5 k /i' a erep t &t4-t-4.- --- "d
Work: � 1l /1 4 0
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 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
, S c Lez(.r-er' , 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.
3‘6/- 7 C -e /1 ? IO L 11- 4— it
Signature of Owner Date
Adam Quenneville Roofing & Siding, In , 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.
Artix itt
Print Name
Signa re of Owner /Agent Date
•
Department use only
RECEIVED amity of Northampton Status of Permit
3uilding Department Curb Cut/Driveway Permit
212 Main Street Sewer /Septic Availability
- 9 MI Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
DEPT. NO RT?iAMPTO N, of BUILD NG 01080 c 41.: - 587 -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
n � &o.i� O1 1 Map Lot Unit
I 6 (-e t i , Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Name (Print) i Current Mailing Address:
T C G -e a Telephone 15 !' � 7 _ 6,a I
Signature
2.2 Authorized Agent:
Adam Quenneville Roofing & Siding, Inc. !l o 6 ail Lt/ met . Zc — PA C C
Name (Print) Current Mailing ss:
'/7 0 075
Sign ait e` r `4cLa. k '. Qta 0 rt P Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building 750 o (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 5) 1011.5Z0
6. Total = 1 + 2 + 3 + 4 + 5 � Sd , 00 Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
37 DREWSEN DR BP- 2012 -0470
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 35 - 120 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- 2012 -0470
Project # JS- 2012- 000775
Est. Cost: $2750.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ADAM QUENNEVILLE 070626
Lot Size(sq. ft.): 15507.36 Owner: SCHEURER GEORGE B & CAROL A
Zoning: SR(100) //WSP II Applicant: ADAM QUENNEVILLE
AT: 37 DREWSEN DR
Applicant Address: Phone: Insurance:
160 OLD LYMAN RD (413) 536 -5955 () Workers
Compensation
SOUTH HADLEYMA01075 ISSUED ON:11/9/2011 0:00:00
TO PERFORM THE FOLLOWING WORK: NEW RUBBER 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 11/9/2011 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
37 DREWSEN DR BP- 2012 -0470
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 35 - 120 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- 2012 -0470
Project # JS- 2012- 000775
Est. Cost: $2750.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ADAM QUENNEVILLE 070626
Lot Size(sq. ft.): 15507 Owner: SCHEURER GEORGE B & CAROL A
Zoning: SR(100) //WSP II Applicant: ADAM QUENNEVILLE
AT: 37 DREWSEN DR
Applicant Address: Phone: Insurance:
160 OLD LYMAN RD (413) 536 -5955 () Workers
Compensation
SOUTH HADLEYMA01075 ISSUED ON:11/9/2011 0:00:00
TO PERFORM THE FOLLOWING WORK: NEW RUBBER 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 11/9/2011 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner