35-242 Name Date
(ob 7)ekc e_A e� IUjaF - f ti
QUENNEVILLE Street Address City State Zip
ROOFING V SIDING V WINDOWS - �I �� P
1.800.NEW ROOF Lc�A. Lr --- - - - - -- fhA _ -- 0101. )
1.8
4 . NEW ROOF Home Phone # i Work Phone # Cell #
1800NEWROOF.NET 911 311-331)- _ (,Oq- i33 y-flI
RESIDENTIAL ■ COMMERCIAL E mail:
160 Old Lyman Road • South Hadley, MA 01075 _._
StraightForward Pricing®
1 Story 2 Story 3 Story
Replace 4 SQ of Shingles, Stepflash/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 Donner 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 1 SQ of Wall Siding Quantity x $1392 ea = $
5 Replace 2 SQ of Shingles, Stepflash/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 Cus i. � y . � .. ' ,. Sk li • hts (no interior trim work), Install 250' to 350' of
Drip Edg .:
��t t� try } 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 1 x $922 ea = $ q , 0 0
4 Install • of Shingles, tepflash /Counterflash 11' to 20' of Wall or Chimney,
stall 31' to 50' o e 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 = $ 70. oo
Lead up to 8' perimeter Chimney, Replace 1 to 2 bundles of Shingles, Stepflash/
Counterflash 6' to 10' of Wall 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 = $
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 = $
L I Replace Rotted/ Damaged Decking, as needed, at 53.47/sq ft Quantity x $3.47 = $
Roof Pitches greater than 6/12 Add 30% = $
//��
Shingle Color: Excess Build -Up of Moss & Mold Add 30% = $
4 31 t, n„,„ `,c n w'` 3rd Story Roofs Add 20% = $
Ice /Snow Removal $
Other Requests: 1 5. $ J. 5• o0
$
$
Notes: P� )eec� av�. C st•+�e -fu Scn-'o.K- n.0lt-11 tout,2
Sub -Total $
B B B Diagnostic Fee $ 99660
I hereby authorize you to . • eed ith the above StralghtForward Price• of: Total Due $ /810 .0o
Winner of the X • 4 _ 4
2010 (,f)0 -00 -
TORCH AWARD � CK /.)U 5 Down Payment Due Today $
Balance Due Upon Completion of Job $ I)10 u o
Specialist Print Name: 5c15 Se c It c hank You!
A k The Commvniveadth of Massachusetts
Department of Industrial Accidents
- - 3} =- - � : Office of Investigations
i �.
6
=Pit= ` 600 Washington Street W;:�:..� ' Boston, MA 02111
.� }r www trrrrss:govldia
Workers' Compensation Insurance Affidavit Bw" Iders/ Contractors /Eleefricians/PIumbers
Applicant Information j� / Please Print Legibly
Name /� "
A Cid vYl OtAiiini -1l � {1L kOO lia) t' S t li 1�'! L ,�-YIC
A d d r e s s : / L I U ( 1 J 1- 'n a n Ad
C i t y / S c a t e l T • :_ 5,.. - i l l & 1 1 4 i t 0 /07 Phone #: (3 - Cie---51S‘
Are you an rmpleyer? Chuck the approp . , box Type of project (required):
I. t21 I a am anplorx with i . 4. Q I am a general and I
6. ❑New construction
employees ani a (fu11 and/or part-time).* have hired the sub-contractors
2.0 I am a sole proprietor or partner-
listed on the alert 7. 0 Remodeling
ship and have no employees These sub -contractors have S. Demolition
wading for mein any capacity. emPioyees and have workers'
9- Q Braiding addition
[No wcrdce s' romp_ insurance nastn t
l 5. 0 We are a corporation and its 100 Electrical repairs or additions
officers have c ao�ised thei 11.
3. ❑ I am a homeowner doing all work repairs or additions
insurance right of exemption per MIL fi ) t c. 152, §1(4), and we haven°
13.0 Other
employees` No waakas'
c ) _
' Any wilt:mt that cheeks box III aunt also lilt out the section bcluw shoving their workers' compensation policy intonation.
t Komoowxes who sabmit this aMuM ieurnatbg they are doing all work and then tae outside sentiments roost submit anew affidavit indicating such.
rcontimum that shirr this book urea attached an Wiliam) short stowing the name of the wbsomtradaas ma sums wLetber a not those entities loom
employes. 'flaw solacontraeors have employees, Say oust provide their workers" conhp, policy rmnhhm
ram an employe that irprovidrng workers' com passed° n inset -wTce for my employees. Jdow is thepofty and job site
aSurancc C o m p a n y Name: ATM m u t t - 1 1 4 - inSU ra n LL
Polic # o r S e l f - i n s . Lic. # : we- r 701 I R, 101 EViraliaa P a l e : 4 - -j a
Job Site Addis: 3 LLI t% 1 t f p.tr LAri_g ' C' l G f -d 6'( CSL My/State/Ty: ! m- 0 l 6 6 ' t?
Attach: a copy of the workers' Lompensatioa policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as =piked under Section 2SA of MGL c. 152 can lead to the impoeitinn of criminal penalties of a
the up to S1,500.00 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 this 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 herby cat& router lire pains andpendtks of perjury that the irrform:dor: provided above is true and correct
S•_ , Ai / G Dal: I— Pt-- 1
Phone if: ' ( . 5 - 5 (t - ' �S
Offi t here way- Do rwt strife in. this area, !o bet roossipletod by tit or talon 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
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: I I Not Applicable ❑
/
Name of License Holder : / Ji en tut 1 v_P 111 i(i 70 le ?
License Number
620 n 1d t4j Otto 2c W d ai s e -a r - do
A dress U Expiration Date
Si Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
Adam Queaueville Roofing& Siding, Inc. o-e ?63
company Name 160 Ohl Lyman Road Registration Number
South Hadky,MA 01075 3- a5-
Address Expiration Date
Telephone ( //3 ?,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 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
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House [J Addition ❑ Replacement Windows Alteration(s) [J Roofing
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [p Siding [0] Other [d)
Brief Deteri C t i o rop d
Work: pI Q S 4
c S/ z rt rtu- 610 l
/ ,Q _ ti �, rYl l'l.U- r l�-2 l C,� � L tt_ i +~ t? � 41.t,t�l
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
ROI) ( 1 ro't ` as Owner of the subject
property
hereby authorize Adam Quenon* Roofing & Siding, Inc,
to act on my behalf, in all matters relative to work authorized by this building permit application.
5-€- e -0 iix 1 OS� c� /(- Pi
1(
Signature of Owner Date
Ads Qaennevile Roofing & Siding, I nc, 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.
A d1LU 1 6 V JL
Print Name
Signatu er /Agent Date
..
Department use only
RE CEIVED of Northampton Status of Permit:
B u ding Department Curb Cut/Driveway Permit
NOV '12 Main Street Sewer /Septic Availability
N 1 5 200 Room 100 Water/Well Availability
o ampton, MA 01060 Two Sets of Structural Plans
°FBuILDINO 13- .87 -1240 Fax 413 - 587 -1272 Plot/Site Plans
worm 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
3q Map Lot Unit
Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
2vb �c dt r v -d e 1-14 51 i r �-ct `l - X10 r-e �,
Name (Print) Current Mailin Addre s:
Telephone Li l7) •• ,3C� - 3:47
Signature
2.2 Authorized Agent:,
Ac- 01,41 -11 me d i l k. 1(o v blcl L mavk fZ� • So. t d(.ec
Name (Print) Current Mailing Add s: V
( • S36 -ss
1 s
Sign Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building ' Pip £. (a) Budding 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) C �rJU t co Check Number v�r 5
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
39 LADYSLIPPER LN BP- 2012 -0493
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 35 - 242 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 -0493
Project # JS- 2012- 000824
Est. Cost: $1870.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ADAM QUENNEVILLE 070626
Lot Size(sq. ft.): 60984.00 Owner: SCHROEDER CAROL R & ROBERT A
Zoning: SR(100) //WSP II Applicant: ADAM QUENNEVILLE
AT: 39 LADYSLIPPER LN
Applicant Address: Phone: Insurance:
160 OLD LYMAN RD (413) 536 -5955 () Workers
Compensation
SOUTH HADLEYMA01075 ISSUED ON:11/17/2011 0:00:00
TO PERFORM THE FOLLOWING WORK:RELEAD CHIMNEY & REPLACE 1 SQ AROUND
CHIMNEY
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 11/17/2011 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner