17A-160 (2) A . The Commonwealth ofMassachusetfs
---- Department of Industrial Accidents
t'IS.. _- -'. Office of Investigations
=�4
—� 600 Washington Street •
;� Boston, M.A. 02111
`' -, _?"'' www.tnass.gov /din
Workers' Compensation Insurance Affidavit guilders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly •
Name {B : A Ad. Olt Oak,/ , -ll : l L2 oa l eti fi S i a i Y15 , ..t yl a
Address: Rep ( 11 i 41
Cit /state/Zip: 6ewai art t lY1 A- OIb7Phone lk t 3= ve -5i s C
Are you an employer? Check the appro to bo= Type of project (required):
1. VI I am a employer with 157 4. D I am a general contractor and I 6_ El New construction
employees (full and/or part-time).* have hired the sub - contractors
2.0 I am a sole proprietor or partner- listed on the attached sheet 7- 0 Ming
ship and have no employees . These sub -contractors have g- ❑ Demolition
working for me in any capacity. employees and have workers' 9.
[No workers' comp_ comp- .. addition
S. 0 We are a corporation and its 10.0 Electrical repairs or additions
3. ❑ I am a homeowner doing all work officers have exercised their ILO Plumbing repairs or additions
myself Ni) workers' comp. right of exemption per IV/GL 170 Roof reps
insurinsurance -1 t c. 152, §1(4), and we have no
employ.. [No workers' I3_0 Other
comp- insurance rN-]
#Any applicant that checks box 11 mud also fill out the =dim below showing their workers' coropcnsatitan poly i -
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must admit anew affidavit mdir•e:.g such.
ICoatraatone that check this box and attached an additional shad showing the mane of the sob- eonnactors and stile whether or not those entities have
employees. If the sub- contractors have employees, they roust provide their worlaas' comp. policy number.
I am an employer that is providing workers' compensation insurance for nzy employees. Below is the policy and job site
infornmthr .
Insurance Company Name: A t M )11 U Ll L t T j1 si t rA h e_c_ q
Policy # or Self -ins. Lie. #: /1- to � "1V 12 ( �a /01 Expiration Pate: Li- a q 'I'2 6 1 a
Job Site Address: ?)'S T 0 X Pa rims led P 6 {--e t7 k Cit (IAA O r o t 9--
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 cziunnal 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 5250.00 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 certify under the pains tad penalties of perjury that the information provided above is hue and correct
Signatnue: . Date:
r0 —►I
Phone it: Z. {( 3— 6, - 6a.6"'S
Official rose only_ Do not wile in this area, to be completed by city or town official
City or Town: Permit/License #
Issuing Authority (circle one):
L Board of Health 2. Building Department 3. City/Town Clerk 4. EIectrical Inspector 5. PIumbing Inspector
6. Other
Contact Person: Phone #:
' ' • ;? •
7 ;411i1cf',
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction ii'1 Supervisor:: Not Applicable ❑ /.
Name of License Holder : 4Ci '7D6
Old L � f f �} License Number
Address o Old L-J YY1u1 Pp( J &. t 1Qdtc, (' \/ �, 8 01 I- UI
ddress l 616 (1S Expiration Date
Sign e Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
Adam Quenneville Roofing & Siding, Inc. Id-) 9 X
Company Name 160 Old Lyman Road Registration Number
Address Suuth Hadley, A 01075 3 / y� Expiration Date
Telephone q (3-536-0
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 X 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
D Name Date
3,4 r ,l 0 (A. -� ./ - -/,) /'
QUENNEVILLE StreetAddres ` City State Zip
ROOFING ■ SIDING ■ WINDOWS
3 S _ Fc — - a5 ..s A UiCt;
1.800. .NEW ROOF 5955 413 0 .NEW ROOF Home Phone # _ Work Phone # Cell # -
1800NEWROOF.NET FoS) 5-70
RESIDENTIAL v COMMERCIAL E mail:
160 Old Lyman Road • South Hadley, MA 01075 —. ___— _ _.___ —_ _ StraightForward Pricing®
1 Story 6/2 Story 3 Story
Replace 4 SQ of Shingles, Stepfiash/Counterflash 41' to 50' of Wall or Chimney,
7
Replace 51' to 65' of Valley, Lead 17' to 25' Chimney, Construct Cricket and Flash
3' to 6' wide Chimney, Roof or Siding Cleaning 2,001 sq ft - 3,000 sq ft, Cover
Fascia or Rake with Aluminum 51' - 65', Replace 22 -30 Slates, Remove and
Replace 1 SQ of Dormer Siding Quantity x $1787 ea = $
Replace 3 SQ of Shingles, Stepflash/Counterflash 31' to 40' of Wall or Chimney,
6
Replace 41' to 50' of Valley, Lead 16' to 20' Chimney, Install 71' to 110' of Ridge Vent,
Roof or Siding Cleaning 1,501 sq ft- 2,000 sq ft, Cover Fascia or Rake with Aluminum
41' - 50', Replace 16-20 Slates, Remove and Replace I SQ of Wall Siding Quantity x $1392 ea = $
5 Replace 2 SQ of Shingles, Stepfash/Counterflash 21' to 30' of Wall or Chimney,
Install 51' to 70' of Ridge Vent, Replace 31' to 40' of Valley, Re -Flash or Replace
up to 2 Customer Supplied Skylights (no interior trim work), Install 250' to 350' of
Drip Edge, Lead 13' to 16' Chimney, Roof or Siding Cleaning 1,001 sq ft - 1,500 sq
ft, Cover Fascia or Rake with Aluminum 31'- 40', Replace 11 -15 Slates Quantity x $922 ea = $
Replace 1 SQ of Shingles, Stepflash /Counterflash 11' to 20' of Wall or Chimney,
4
Install 31' to 50' of Ridge Vent, Install 21' to 30' of Valley, Clean 251' to 350' of
Gutter, Lead 9' to 12' Chimney (perimeter) or Small Stone Chimney, Replacement
of Customer Supplied Skylight (no interior trim work), Strip-off and Re- Shingle 2nd
story Bay Window, Install 101' to 200' of Drip Edge, Roof or Siding Cleaning 501 sq
ft - 1,000 sq ft, Cover Fascia or Rake with Aluminum 21' -30', Replace 7 - 10 slates Quantity x $763 ea = $
Lead up to 8' • - nm It ' eplace 1 to 2 bundles of Shingles, Stepflash/
3 Counterfiash 6 to r o ". or Chimney, Install 31' to 100' of Drip Edge, Install
4 to 8 Hat Vents, Dryer Hose Connections, Replace 15' to 20' of Valley, Strip -
off and Re- Shingle 1st story Bay Window, Install up to 30' of Ridge Vent, Minor
Tuckpointing and Watersealing of chimney (<3' in height), Re- Stepping and
IceGuard 2'x 4' Skylight, Installation of Curbmount Skylight, Clean 150' to 250' of
Gutter, Install 51' to 100' of Drip Edge, Cover Fascia or Rake with Aluminum 11'-
20', Replace 4 -6 Slates, Roof or Siding Cleaning up to 500 sq ft Quantity x $612 ea = $ t7 la
Soil Boot Replacement, Replace up to 1 bundle of Shingles or up to 20 Shingle Tabs,
2 Stepflashing /Counterflashing less than 5' of Wall, Installation of up to 50' of Drip
Edge, Installation of up to 3 Hat Vents, 10' or less of Gutter/Fascia Replacement,
Clean 31' to 150' of gutter, Reflash electric pole/heat stack, Crop up to 30' of
valley. Replace 1 -3 slates, Cover Fascia or Rake with Aluminum 10' or less, Install
Rubberized Crown on Chimney Cap, Install Stainless Steel Cover on Chimney Flue Quantity x $427 ea = $
1 Roof Certifications, Gutter Cleaning (up to 30') Quantity x $179 ea = $
Replace Rotted 'Damaged Decking, as needed, at $3.47 /sq ft Quantity x $3.47 = $
Roof Pitches greater than 6/12 Add 30% = $
Shingle Color: Excess Build -Up of Moss & Mold Add 30% = $
3rd Story Roofs Add 20% = $
Ice /Snow Removal $
Other Requests: TA d g .�..14 e,t 4F( e s r.e, / 5s .J .4.- (4 $ a
$
Notes:
Sub -Total $
BBB Diagnostic Fee $ - 997a6"-
—17 I hereby aut - Iz=��Q to proceed with the above Straightforward Price" of: Total Due $ ,
Winner of the �( Sj . r g '
2010 ,
TORCH AWARD Down Payment Due Today $ /000
�
/ / Balance Due Upon Completion of Job $ 33 I
/4
Specialist Print Name: ,e / ` //A I,• Thank You!
1;4 y , -r,
„
4=
I
rr! V ,10 Department use only
Q1GV City of Northampton Status of Permit:
g 2��' , uilding Department Curb Cut/Driveway Permit
2 '212 Main Street Sewer /Septic Availability
o Room 100 Water/Well Availability
aF Nort MA 01060 Two Sets of Structural Plans
phone 413 - 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: A This section to be completed by office
3c 4-o T G� (VY1 U (�'�` Map Lot Unit
IN VA- A 6 ( 0 6 Zone Overlay District
r Y Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
c oh + E m lc ko sLc- c 3 S F G x Far rn 5 /it 1/4-
Name (Print) Current Mailing Address:
e-e c.O ,1 TCzc fi -e v y(� '7(� D I )-• C/( /o
`J 1 Te lephone
Signature
2.2 Authorized Aaent:
Ada *I Reds: & Side, Inc, /tic Cid LI Plait fed -
Name (Print) Current Mailing Add or e7 s
� 3 -- 6'3ra._cei SS
Signa Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building . 3 (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) 3 j a ale Check Number ] S _ �/`
This Section For Official Use Only
Permit Number: Date
Building Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
w +
35 FOX FARMS RD BP- 2012 -0217
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17A - 160 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 -0217
Project # JS- 2012- 000324
Est. Cost: $3312.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ADAM QUENNEVILLE 070626
Lot Size(sq. ft.): 17990.28 Owner: DITKOUSKI JACOB & EMILY
Zoning: URA(100)/ Applicant: ADAM QUENNEVILLE
AT: 35 FOX FARMS RD
Applicant Address: Phone: Insurance:
160 OLD LYMAN RD (413) 536 -5955 () Workers
Compensation
SOUTH HADLEYMA01075 ISSUED ON: 8/31/2011 0:00:00
TO PERFORM THE FOLLOWING WORK: INSTALL RUBBER ROOF ON DORMER
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 8/31/2011 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner