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38C-005 The Commonwealth of Massacharettr Department of Industria!Acetdents WT --- '; Office of Investigations t:, �— _ _M _ 600 Washington Street 7 . - " , :.::- -- Boston, n, MA 02111 -- ' '' cur .s I wow tr rassgtn�I Workers' Compeusat'ina. Insurance Affidavit Bwaders/Coafirac ctccians/FIumbers Applicant Information Please Print LeEibiv : A (lit n Q tom► v ;lie Rea l i(1) - r S 1 at 1 ft L N ame �'l Ad: : L/ u (91J 1, m an � i . cit _ L Ja.I ,1 , i /1i 5 o /p7phone tk 1 3 - C Ur -6i S6 Are you an employer? Check the app , , - ha= TYPe of Project reel= with I 4• ❑ I am a general and I 6. ❑ N w l contractor I . I sus a employer s have hired the sub -cot tractors employees (fall and/or part listed am the shed 7_ ❑ Remodeling 2. ❑ I am a alt pJ or P These sub - contractors have S. ❑ Demolition ship and have no employees . an d have workers' wonting for arc in any capacity. 9. ❑ Budding addition [No workers' camp. nnaance Z o. Electrical rrpairs or additions 5. ❑ WC are a corporation and ;In 10.0 3. ❑ I required] t all work olfoeax have their 1lti Pbmnb mpg repairs or additions a�r�. wadi (No workers' comp. �52, § Ina � n�o 12.53. xvof insurance required] t employees. (No ork ras' I110 Other w amp. imams= -] ;Any eepptieem that ebeds Weil c=art also fill out eta seehca below sb their anion' cosapeendea polity intbreation t E( nowaas who =bait this alSl. it m' sung dig me doing all wort BEd Qreu bias amide ataaaa o s must ob=it anew 'Moo* iadiadiat such. Icoatracona dead disc[ ibis ben meet anted ed as addkio a sbor2 :boMa+c too nano ads/ sob000kaolins nod stab wLadmr at monism eodt u b'vo crnplvyees. If doe solo.contradars rare inapinyou, they non prowida tbalr woaiva''comp. policy aenobwar. I arm an employer that is pravia g Workers' mmprnaaivn insurance for my employtQ Blow its the policy and job site infonnation- Inswanc Company dame: 4 AI M mutual - IA SL4 rat n U.. r1 Policy # o r s e l f - i n s . L i e . # : A c r i 0 1 4f 4 /01 �: 1 - a q- a 6 I a fob Site Addtsss: t 0 6� ! L v -e, J� - O r ti al p all Cay gyp: o to (,0 Attach a copy of the workers' compensation policy declaration page (showing the polity unmber and expiration date). Failure to sto Wes coverage as required under Section 25A of MGL a 152 can lead to the imposition of criminal penalties of a fine up to S1,500.00 and/or ohm -year imp:da m ent, as well as civil pe=nnon in the *ma of a STOP WORK ORDER and a frac of up to $250.00 a day against the vitoln or. Be advised that a copy of this statement may be m the Office of Investigations of the DIA for insurance coverage verification. I do hereby ea* tender the pains and pordiicr ofpA7wy that the information provided above it true and correct S guature: v -2L Dane: 0 11 ?hone It 4f 5- . L- 4 1 SS Ci icfar asc oat, .Dv r.ot srr'la ins ibis arm*, 6e hie cossroIded by cit or sown gfeJn City or Town: Permit/License # Issuing Authority (circle one): L Board of Health 2. Budding Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone It: V i iSA j Can DISCOVER D M moms QV EN N E V I L L E www.1800newroof.net ROOFING V SIDING 'V WINDOWS We Are Licensed 160 Old Lyman Road • South Hadley. MA 01075 1.800.NEW ROOF • 413.536.5955 Fully Insured Erna i info # 1800newrooI .net 'Websrte www 18O0newroof net Factory Trained MA r i.oi3truction Seper sors Lr: "070626 MA Registration 0120982 Factory Certified Installers r [•.n0. l a., :,r _ CT Registration v575920 3A7 o Proposal Submitted To Date Phone u s C Francis Remillard 11/25/11 I-1 413- 586 -1329 w 413- 478 -0364 Street Email 160 Grove St. City. State, 7ip Code Special Requirements. Northampton MA 01060 12 month no interest 3% of total Install new plywood on house don't do porch on the left hand Recover x Strip side of the house. Complete Roof System K We 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. Porch on left of X Deteriorated existing decking will be replaced at $3.47 per sq.ft. after full inspection. house . 4 Install Ice & Water Barrier at all eaves. valleys. chimneys. pipes and skylights Install (151b. felt.' Synthetic) underlayment over remaining decking area Install Metal drip edge at eaves and rakes (8 "! 5'1 (whitelbrown /copper) x. Install manufacturer's starter shingle on all eaves and rake edges BBB Install new pipe boot flashing (standard copper) vents --ir— )<Install Snow Country or Cobra rolled vent ridge vent Winner of the 2010 Install proper soffit ventilation TORCH AWARD Shingles: ( 6 nails per shingle) GAF Shingles 25 year ' HD5 0 50 year Color FOXHOLLOW GRAY GAF Ridge cap shingles Warranty Options: 4 We guarantee our workmanship for 10 full years (see our warranty coverage) GAF System Plus warranty GAF Golden Pledge warranty Chimney Options: Lead Counter Flashing Water Seal & Tuckpoint Rubberized Crown Metal Chimney Cap ,r ;1 wJI?1 abnv£ spy Iiatinrl,, '1 ,P sires ai' Total Due ICJ 11 , 13 7 ACCEPTANCE OF PROPOSAL: The above prices, specifications and conditions are Down Payment +5 3 , 800 satisfactory and are hereby accepted. You are authorize. • .0 as specified. Payment will be 1 3 down at start of job. and b. • • d '' • . - Balance Due Upon Completion iS 7 , 3 3 7 11/25/11 S tr,ature +tP 11/25/11 Estimator +Print Name? Dustin Peters (Sign Name) p t n +tcs are nonorrno k r sixty 1601 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 tor debris or dust in the attic or storage areas. SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : '1 , n SW? b i i' J I)1 /b ke 70 .d-(, License Number et I tao 0 Id - J n� c� �� p Lau. i W d £LL a C tb`1 S - a (- d 1 A dress Expiration Date Sign Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ Adam QuenneviUe Roofing& Siding, Inc. Igo Company Name 160 Old Lyman Road Registration Number South Hadley MA 01075 3 Date S D-0 � Address Expiration r Telephone y/3 5- ', - 515 - 5 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 [::1 Addition ❑ Replacement Windows Alteration(s) [J Roofing a Or Doors l] Accessory Bldg. ❑ Demolition El New Signs [D] Decks [p Siding [0] Other [0] Brief Description of Proposed i • Work:, S-rit -'p O a./ .e ! "1 l j f �i1 L f r� ( yee �. f / f '�� `. s ' N, -� Alteration of existing bedroom 'Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No ti 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 , as Owner of the subject property hereby authorize Adam Qrenaevil a Roofing & Siding, In to act on my behalf, in all matters relative to work authorized by this building permit application. 01 - L C - ft( s4,6( i -- l— i J Signature of Owner Date Adam *Revile Roofing & Siding, Inc, 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. Ada- at- (k ) U L,/tJVi - ale Print Name Signatu er /Agent Date Department use only RECEIVED Ci of Northampton Status of Permit: : ui) l ing Department Curb Cut/Driveway Permit _ 62011 2 ' Main Street Sewer /Septic Availability ' oom 100 Water/Well Availability ► • ha pton, MA 01060 Two Sets of Structural Plans .OF ��i��: = ;!' 5: 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 C Cc o G--c � r t ' Map Lot Unit A) C) t /'yl p :f i i m4 Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: / _ Fri) h C 1 S \ n ( RO. i' � / t G (�1 (� 4"-t.. J7" + i V o ( '�' ✓YI p I`� Name (Print) Curre t Mailing Address: ( 3 s& - 13 9 016 66' Telephone Signature 2.2 Authorized Agent: Aci-v i � !(.QVi nk v iL ((a (5l ri blrnavt S©. 46-416 Ltd 1 714(L. Name (Print) Current Mailing Add s: t ire - s3L, Sign Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building 1 0)13'7,06 (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 02026 � � $ ,,� � 6. Total = (1 + 2 + 3 + 4 + 5) 0 II i3'1 Check Number This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date 160 GROVE ST BP- 2012 -0548 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 38C - 005 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 -0548 Project # JS- 2012 - 000919 Est. Cost: $11137.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ADAM QUENNEVILLE 070626 Lot Size(sq. ft.): 41686.92 Owner: REMILLARD FRANCIS J & MARILYN Zoning: URB(100)/ Applicant: ADAM QUENNEVILLE AT: 160 GROVE ST Applicant Address: Phone: Insurance: 160 OLD LYMAN RD (413) 536 -5955 0 Workers Compensation SOUTH HADLEYMA01075 ISSUED ON:12/6/2011 0:00:00 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 12/6/2011 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner