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18D-026 (3) Department use only City of Northampton Status of Permit Building Department Curb Cut/Driveway Permit 212 Main Street Sewer /Septic Availability Room 100 Water/Well Availability Northampton, 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: This section to be completed by office S� 0 c e• � Map Lot Unit ,t' � I MA Ot0(oO N o c ..\\, a P Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: SA.CL Sck -Ccx -A S$ Dame /UOV aw.P-V0(‘ o1OGP0 Name (Print) Current Mailing Address: q/3 1 7 1 Telephone Signature 2.2 Authorized Agent: jj.�. Ail Q • , 1EG J Co Old L toh avl S 00 "tAn ■ke.3, MA Name (Print) Current Mailing Address: 010 )- Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building ' 3cs 1/6-0 (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 r9 6. Total= (1 +2 +3 +4 +5) # I ti $ - 0 �,�, Check Number /794( > °13� c) This Section For Official Use Only Building Permit Number: Issued: s g I 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 parking) # of Parking Spaces Fill: (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 . DONT KNOW IP YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO © DONT KNOW j YES IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO ® DONT KNOW ® 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 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) ' I Roofing Or Doors O Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [[] Siding [0] Other [0] Brief D scription of Proposed p 4j Work: en-A6 re i5� C IC!∎aer -- n Sotaki0 -IC V OC 4 - oo- , \ - R L,.� p 'et 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 I, 5 S a C■- , as Owner of the subject property Q t � hereby authorize ` & hit to act on my behalf, in all matters relative to work authorized by this building permit application. IQ Signature of Owner Date & reg loc, , 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. �1&0.M QVQ ,n,e-Vt \ Print Name la- ,s- -10 Signature of Owner /Agent Date SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not ApplicabApplicable ❑ Name of License Holder : • • . � G aG License Number 161 Old Lyau Road g -a 1 — Address Sad Hadk , MA 01075 Expiration Date /3- - sts Signature �► Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ Ado Querelle Wag & Sidag, Iec, ►2©a i Company Name 160Old Lyme Read Registration Number Soot Hadley, MA 01075 3 -as- ID Address Expiration Date _Telephone �fl 3 -S3G-59SS 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 -- i.=. ...-1.------ krtrt F.F.71111 7 :.:-AtE i t, 5s / Office ofinvestigations 606 Washington Street Boston, 111A 02111 www.mass.govkfia Workers' Compensation Insurance Affidavit: Ituilders/Contractors/Electricians/Plumbers Please Print Legibly Annlicutt Infonnation Name musinessiorganhationib4rvidualy A Ail $1 RtjtY1 kr v I , sl:' Address: 1 1,2 fl NA L ,. City/State/Zip: &i) . • • a i tib7 Phone #: • Are you an empkryer? Check the appitimriate box: Type of Project (required): . 0 I am a general connnctor and 1 1.154 I am a employer with j S 4 " 6. 0 New construction have hired the sub-contractors employees (full and/or part-time).* listed on the attached sheet. 7• 0 Remodeling 2. 1:1 1 am a sole proprieb3r or parmer- These sub-contractors have & 0 Demolition ship and have no employees employees and have workers' working for me in any capacity. 9. 0 Building adcfrtion comp. insurance.: [No workers' comp. insurance 5. 0 We are a corporation and its 10.0 Electrical repairs or additions required.] officers have exercised their 11.0 Plumbing repairs or additions 3. 0 I am a homeowner doing all woric . right of exemption per MGL myself. [No workers' comp. 12ARoofrepairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13.0 Other com p. insurance required.] _ •Aey applicant tint drecks ban #1 moat also tith out the section below :bowing thew' workers' cosprantion policy information. I Hotueoween WE sobrat dr affidavit isetheeting day ara doing all wok aedtbeabire arraide coonectera rant anbratha new affidavit ladicatintancit ;Coneramerstlen clunk*, box son anadroden additiond duet elmoingthe ore oftbealb-ethentioes end mate-vthether erect those entities ben employees. If the sub-contracten bare ampler**, they mot provide their satakes' comp. policy emmgr. I at IN employer diet is providing workers' compessetiox Jasmine e for or employees. Below it the policy aid job she leformetioss. Insurance Company Name: Pt k PA A U. 4 CI ■lc...,(A t^4 ilt e....- Policy # or Self-ins. Lic. #: 0 Loc. ri O Lag., 4 I t 0 1 &oration Date: q /49 / i Job Site Address: 55 Diavvl. A el c Por4-1 vx 1 0 0 C 0 Attach a espy of the workers' eempensation policy declaration pap (skewing the policy number and 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 S1,500.00 sod/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 ate:anent may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. !j, hereby certip seoferth tebss esdpeaeldes ofperjory that the provided alias e I s true4prd %gnome: Date: i a_71 .S: - I 0 Pbone it: l it3-5310-5 6 15" (Veld use only. Do not write In this area, to be completed by city or town eideL City or Tow.: Perssit/Lieease # Issuing Authority (circle este): 1. Board of Haft 2. Bairn% Department 3. City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector " - 6. Other Contact Person: Phone 0: . , is* • 0 1 si " egul Ions aril "tn. ' ) One Ashburton Place - Room 1 301 :: ./ Boston, Mas 02108 • Construction •Supervisor License License CS: 70626 Restriction: 00 Birthdate: 8211 Expiration: 8/212011 Trit 3712 ADAM A QUENNEVILLE - 160 OLD LYMAN RD -- S;'HADLEY, MA 01075 ,_/ ei 0 0 I T 1, ` _` y ___ `j Office of Consumer Affairs and usiness Regulation �- i 10 Park Plaza - Suite 5170 ..- Boston, Massa.Iusetts 02116 Home Improvement ' _9 t_ • ctor Registration `-� — Registration: 120982 `T` '= 7 Type: DBA 1 A ^ — ( f Expiration: 3/25/2012 Tr# 293069 ADAM QUENNEVILLE ROOFING4 --w �, 7= � ,,',, ADAM QUENNEVILLE 'b -=_ - _w- ,--- n • 160 OLD LYMAN RD `: _w �— SO. HADLEY, MA 01075 ''_. _ ��) — - -- ,,! ,- -�,, ' Update Address and return card. Mark reason for change. - -'"— J Address ❑ Renewal C Employment 7 Lost Card OPS -CA1 is 50M-04/04•G101216 { STATE OF CONNECTICUT + DEPARTMENT OF CONSUMER. PROTECTION ! ,.. Be it known that t f. 1I • ADAM QUENNEVIT:I .F r* 160 OLD T_ ROAD � SOUTH , a -; ' i -175 -2632 .' /7 r ` ,! is certified the De - fied by it y pa c . , tectton as a registered I HOME IMPR .0 4 CONTRACTOR ! Reg -- 4 a y 0 j : 1 T RANST U y - -- i � r` ilk i ADAM QUENNEVILLE ROOFING = i Effective: 12 /01/2009 Expiration: 11 30 2010 i Nov-08-2010 06:00 PM Remi l lard Insurance 1 - 413 - 538 - hUlU (ic • e DATE (MMIDDIYYYY) 1217 o CERTIFICATE OF LIABILITY INSURANCE OP ID LL 11/09/10 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, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, 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 endorsement(s). (-UN 1AuI PRODUCER NAME: Remillard Insurance Agcy, Inc _ PHONE co I• (PJC ,No): ___ 79 Lyman Street ADDRESS: South Hadley MA 01075 CU A11Q - 1 Phone:413- 538 -7862 Fax:413- 538 -7179 INSURER(S) AFFORDING COVERAGE NAIL# INSURED INSURER A: First Speciality Ins Corp Adam Quenneville Roofing & INSURERS: Travelers Ins. Co. Siding Inc. & Adam Quenneville — — -- - Roofing Inc & GutterShutter INSURER C: Amt mutual Insurance company Of Western , ern MA "'- 160 Old Lyman Road INSURER D: Hanover Insurance Company 22292 South Hadley MA 01075 INSURER E: _ INSURER F : COVERAGES CERTIFICATE NUMBER: 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 COMPACT 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, _ r'XC!. USIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. I mbir — - _- - - -- -- - - - - -- OU SU - _ ._ - POLiCYEFF''7�'p "OL(CYEJiP - ' -. TR I TYPE OF INSURANCE L INSR WV101 POLICY NUMBER (MMIDD/YYYY) I(MMIDDIYYYY) LIMITS 1' GENERAL LIABILITY EACH OCCURRENCE j 1000000 DAMAGE IU KEN IEU A - -- COMMERCIAL GENERAL LIABILITY IRG98441 06/23/10 106/23/11 PREMISES(Eaoccurrence I $ 100000 X I CLAIMS -MADE LX OCCUR MED EXP (Any one person) S 2500 I_ PERSONAL &AOVINJURY $ 1000000 _ GENERAL AGGREGATE $ 2000000 I GENT AGGREGATE LIMIT APPLIES PER PRODUCTS - COMP /OP AGG $ 2000000 POLICY [ PRO � -� LOC $ 1 JECT AUTOMOBILE LIABILITY I COMBINED SINGLE LIMIT ^ (Es acaidenl) $ 1000000 13 I I ANY BA7450L946 11/01/10 11 /01 /11 BODILY INJURY (Per persan) $ I ALI. OWNED AUTOS X ■ SCHEDULED AUTOS BODILY INJURY (Pe accident) $ PROPERTY DAMAGE $ X I HIRED AUTOS (Per accident) X I NON•OWNED AUTOS $ - -- -- - - - - -~ _.._ $ _� '-' -'--- UMBRELLA LIAR I OCCUR i EACH OCCURRENCE S EXCESS LIAB CLAIMS -MADE i AGGREGATE S DEDUCTIBLE S 1 RETENTION $ I $ C WORKERS COMPENSATION I AWC701286101 04/29/10 04/29/11 X TORY x 0TH AND EMPLOYERS' LIABILITY Y / N - - - - -- ANY PROPRIETOR/PARTNERIECECUfIV� - j� I E.L. EACH ACCIDENT $ 1000000 OFFICER/MEMBER EXCLUDED? ' J N /A i - - -- (Mandatory in NH) I E.L. DISEASE - EA EMPLOYEE $ 1000000 deeibn Linde, lf _ DESCRIPT OF OPERATIONS below --- I E . DISEASE - POLICY LIMIT $ 1000000 D Equipment Floater Im97140610 02/01/10 02/01/11 Rental I I Equipment $100,000 DESCRIPTION OF OPERATIONS I LOCATIONS i VEHICLES (Attach ACORD got, AddItIonal Remarks Schedule, if mare space is required) CERTIFICATE HOLDER CANCELLATION — — SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE ADAMQUE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Adam Quenneville Roofing & Siding AUTHORIZED REPRESENTATIVE 160 Old Lyman Rd. South Hadley MA 01075 © 1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009109) The ACORD name and logo are registered marks of ACORD ..A D : M VISA ard, ' L c�a OI%COVER QUENNEVILL -E ROOFING & SIDING, INC. 160 Old Lyman Road, South Hadley, MA 01075 1- 800 - NEW -ROOF • 413- 536 -5955 Email. info @l800newroof. net Website: www.1800newroof.net MA Construction Supervisors Lic. #070626 MA Registration #120982 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 Proposal Submitted To: Date 0 -6 l c Phone #'' 1 / 3,-4 4" , e 1 e , t j ' .1,� .,I ,, L t H: -/6 t</ /'/ W:,2':r. E.'u1L Street Job Name: / 1 { / City. State, Zip Code / 0 /y [ n Job Location: Proposal to furnish and install the following ❑ Re -Roof © Tear -Off fl Gutter /I ,'P_ ex /3 �, ^5 rdi, b ra' r- /"S der ,, -0 C ( ✓•'i _(' ( Pi) i 5 /.7 f /., f ' /n'� >C�I 1, %/ f ' 4 de , I - „1Sfr,// niwt / ./ 5U ,rir eb. ri. c r 1�•, 1 �� fc c��G�� F f.,, ; <-(-t ci , 0 S'tt // e, I' - I ti JGroC S s7 /7r,hs / ,, I t V V /< <j C// e ,Jt. /S, r ,p.. „S `. ,.' <./ l /- „ . . c'f "ir 1 . f ( ' ( J v i; e - L { 1. , / ) ' 1 1 / /7 r cJ O`/ L ' / / / ' 1 . ' , 7 c'CI J r' rz) r' Tci / 4 / i o fro y C --c, 0 ( n r , (S c •/ 4 c,• f j r ,4./ At 4 y'<'� M., r; / Jr ,ee tr 1,, 46„),.. r /k .'' .1 ' S /, „e'' i ;/ri r' / -, r . -' Ask us about affordable bank financing We Propose hereby to furnish materials and labor - complete in accordance with above specifications for the sum of: (h,� - Y y : 4 . - - - ; ; ; A t i P I , - . - 0 - y _ dollars ($ r YS C_ f'LD ) ACCEPTANCE OF PROPOSAL: h:. e prices, specifications and conditions are satisfactory and are hereby accepted. You are th rized to do work a ,. fled. Pay pf�ent will be 1/3 down at start of job, and balance due l u .. •p�o ( n comp / t(.�, on Date: f ! C Signal r /` ' ' �1 �r Phone #_ I 7 1 'L C ^ JJ - .i Date /0” -Z (G/ Estimator's ' ignat -: ----- ^�t ,_r. _n .✓ r .� 1 ', , /S J' - E• . _ Estimates are honored for sixty (60) d. s from abo ..-)#' � / 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.