28-054 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(so. 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: ®J 12 4 /( Cr
THIS PERMIT MAY BE REVO 1 B THE C TY 0 ' ' ORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND ' ." "f ►'� . f
„ta is !T°4"' tze
Certificate of Occupan ignature:
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
, e.„-„-(5',...dex ty#,,,,,,,,,duizea
7_.
; I� Office of Consumer Affairs and usiness Regulation
'' =}£f ! f 10 Park Plaza - Suite 5170
-=may' Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 105948
Type: Partnership
Expiration: 7/21/2012 Tr# 297732
R & H ROOFING
Henry Hopkins
59 SOUTH STREET —
Easthampton, MA 01027
Update Address and return card. Mark reason for change.
I- I Address I 1 Renewal [ 1 Employment HI Lost Card
'S -CA1 it 50M- 04/04- G101216
.aa, ( 2 - / - %e lJo4TY/ico -c Ueat O (a cu-Aciae License or registration valid for individul use only
\ Office of Consumer Affairs & Business Regulation g y
7t HOME IMPROVEMENT CONTRACTOR before the expiration date. if found return to:
r,4 Registration: 105948 Type:
Partnership Office of Consumer Affairs and Business Regulation
,_ 10 Park Plaza - Suite 5170
: Expiration: 7/21/2012
Boston, MA 02116
R & " H ROOFING
Henry Hopkins
59 SOUTH STREET 4 _ A�
Easthampton, MA 01027 - - - -_ - - -- --
Undersecretary N alid without si nature
Massachusetts - Department of Public Safcth
to Board of Building Regulations and Standards
Construction Supervisor License
License: Cs 42781
Restricted to: 00 tat
HENRY E HOPKINS .
59 SOUTH ST
EASTHAMPTON, MA 01027 r
-�'-- -'� Expiration: 6/2/2012
( nnniii, iuocr Tr #: 27089
1)/18!20i1 TOE 12: 13 FAX 4135336010 Remillard ins. Agency iZiC 0 1 10 C 1
-----•""' RHRO-1 OP ID:. DM
A,c.-.c.R.,/, CERTIFICATE OF LIABILITY INSURANCE , DATE OM MI/DEO I" Y; I
10/1 tkil 1
. ------
' 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
l BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURERISI, AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
r IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policyliesi must be endorsed. If SUBROGATION IS WAIVED. subject to
the terms and conditions of the policy, certain policies may require an endorsemertt. A statement on this certificate does not confer r!gfIts to the
certificate holder in lieu of such endorsements).
ORCULICER
413-53B-7862 CONTACT owE. Debora Mello
;Remillard insurance Agcy, Inc i FiU{
179 Lyman Street 413-5394179 Zat .. L i f y‘ c, N , ) , 413-5384010_
!South Hadley, MA 01075 E.MAII.
ADDRESS: deboramello
Stephen E. Radon
7 ---------
1 I INSURER'S) AFFORDING COVERAGE ! NA■C *
INSURER A : AIM Mutual Insurance Company i
INSURED R & H Roofing, LLP INSURER 0 : Safety insurance Company
39454
1 Henry Hopkins/Charles
Robertsn INSURER C : First S_peciarty Ins Co .
l 59 South St. _ 1-
! Easthampton, MA 01027 INSURER D ! Associated Internitional
INSURER E . North American Specialty
I f
INSURER F :
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
r T HIS ;TS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE. FOR THE FOUCY RERIOE
INUCATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT \,%1TH RESPECT TD WHICH THIS
I CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJEC TL AJ.. 1HE TERms,
1 EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID Ci.AIMS
; VS'Fii - br.msoiti' POLICY EFF 1 POLICf EXP ' !--i
J___, TYPE OF INSURANCE ! 1, . POLICY RIMER .,11ANUDDITYYY) , IMM/DDITY1Y) r --- i GENERAL LIARIUTY , ' ..
EACH OCCURRENCE ! a 1,00000
1 C X ./ 4 4 1 ,,,,,,,,,,,, , OttACC. ft,';' ■
' V A ' COMMERCIAL G E NE RA E LIABILITY ! X ! i IRG98367-2 0510,,, ,,,,,,,,. ), PREVISES ;Ea cc.E.,, ! $ 50.00
.._.... ..... . .
1 ut.tvs..vAvE )(I OCCUR i MED EXP /Any c! )7e../;,0A/ : $ ezc!udeci
1
! 1 I
, 1 .
1 [ 1 I 1 Apy iNLIorTY 11,. 1,000,00
, GENERA AGGREGATE $ 3,000,00
. ' GENII- AGGREGATE LIMIT APPLIES PER : • ! PRODUCTS . COMPADP AGG . I 3,000,00
X POLIO) !NA LOC I
. I 1
-!-- -1- I SI !
! AUTOMOBILE. immu COMBINED "CL LIME re i
[ 1,000,091
IN a acciatell 4.
A 1 ANY AUTO 2433476 06126111 - 00/26/12 soots( INJURY ;)rs,:nI $
: ! ALL OWNED i 'xi SCHEDULED , I BODILY IN I
_ J AUTOS
! ,,U RY• P
(kr a $ i
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1-- =NNED ' PROPERTY O'djabE I
X I HIRED AUTOS ^ '
J. AUTOS
,
--4- (1accidenS
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LIMBREi.LA LIAB 1
I I I OCCUR
I , EACH OCCURRENCE ! $ 5,000,0o
i
1 X 1 EXCESS LIAR 11 j CLAkVIS IXORW3607811 06,1vii 1 05117/12 AGGREGATE .I. 5 5 00C „ COOJ
i I OF,r L _ 'RETENTION $ J 1 1
'COMPENSTION
- I
AND EMPLOYER LIABIL)T . V& aTATJ• • MA-
I ....LIDNY...7.,AITS_!. X _FR 1
S' Y /
A I ANY' PROPRIE-OR/PARTNER/SXECUTIVE Y N lAWC7011424012010 10/24/10 10/24/11 r.,1.. EACEI ACCIDENT $ 1,0D0,0001
R E X EX.CLUDEC? {Id
10/24/11 10/24412 : EL DISEASE • EA EMPLOYEE $
(Iliandalcri In NH) , lAWC701742401201 1 I ,00O,a000l I i l descAbe urder I
_ I DESCRIPTION Or OPERATIONS bekm i_ ' — _LE '_. DISEASE • FOLIC/ LIMIT : $___ 1,000,00
E ;Installation float
1 I 1 06/17111 ! 06/17/12 floater 55303F
1
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0Escs.pTiON OF OPERATIONS / LOCATIONS t VEHICLF-S .4AttionAcoan ff1, Adettlonel Remarks Schedule, If (Inure space is required)
. -
, .., ,__,......_
CERTIFICATE HOLDER CANCELLATION _
ra-- -
RELAMAN
SH0110 ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 1
THE EXPIRATION BATE THEREOF. NOTICE WILL BE DELIVEFEC IN
ACCORDAKE WITH l'hE POLICY PRd\ftSIONS,
AIITRORIZED REPRESENTAT'ff,
4 •Ci4NTALM.-- a.... 4$41
_
------
1....f 19E35.2010 ACORD CORPORATION. All rights reserved.
ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD
.._..
The Commonwealth of Massachusetts
Department of Industrial Accidents
= h E '
? Office of Investigations
, � p
: 1 -
= § 600 Washington Street
; — c Boston, MA 02111
;l www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization /Individual): goo-/0- L P
Address:5q S 7 7/ .___s7
City /State /Zip:e ' �6 J, /04 616g 7 Phone #: 1 /433 — 2 2 £ 9328"
Are
4. ❑ I am a contractor and I ou an employer? Check the appropriate box: Type of project (required):
1. I am a employer with /3 general 6. Ill New construction
employees (full and /or part- time).* have hired the sub - contractors
2. ❑ I am a sole proprietor or partner- listed on the attached sheet. t 7 ❑ Remodeling
ship and have no employees These sub - contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
officers have exercised their 10. ❑ Electrical repairs or additions
required.]
3. ❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself. [No workers' comp. c. 152, § 1(4), and we have no 12. ❑ Roof repairs
insurance required.] t employees. [No workers'
comp, insurance required.] 13. Other.A.) -eU a-06
)
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
$Contractors that check this box must attached an additional sheet showing the name of the sub - contractors and their workers' comp. policy information.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information. / f
Insurance Company Name: /11-4 1) -tui . / f JSI I WAI C — 66,
Policy # or Self -ins. Lic. #: / 70/ 2' / / Cl {Y/ Ex iration Date: / 1/1,7
Job Site Address: City /State /Zip :FC.er(;rtA - /T e / (4.
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 criminal 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 $250.00 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 certi i nder the p' 'ns and is enalties of perjuty that the information provided above i true , nd correct.
Al Si. ature: %�(hr - � .. /, Date:
/ �/
Phone #: L A 3 0/- /3 7 er
Official use only. Do not write in this area, to be completed by city or town 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: Not l � / Not Applicable ❑
'ri
Name of License Holder : / v � l / /I /t! ff3 C SO / ' I
License Numlper
5c1 LSO(fl1 sJ E- MA/ m1 01 07 C2 d- 1 P--
Address Expiration Date
r 4 ---- -- q/3.50 "7 73 7 f '
Signa ure ( Telephone
6. Registered Home Ilnlbroveinent Contractor. , ' Not Applicable ❑
( 14 (MP 1 LLP /a (1ff
Company Name Registration Number
ST a" a , �� %61 -7 7 /d.j / i -
ddress (1436-42`7C4:3 � /7 g Expiration Date
0 l Telephone
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 ❑
1 tiA3ox>r a (wafer Eeimption
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 ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors I]
Accessory Bldg. ❑ Demolition ❑ New Signs [El] Decks [Q Siding [O] Other [0]
Brief Descri tion of . Proposed W 0' 1 _ _ --1117-1\f')
Work: CIE 13 (1 r �i" � �(
Alteration of existing bedroom Yes No Adding new bedroom Yes y No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
6a. If New hot1se and br addition to existing housing, complete the followed:
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
, as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I i / `% )4Oef6/Af'S , 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.
g ii
Print Name
■49/8
Signature of wner /Agent 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 1 - '
Setbacks Front
Side L: R: L: R:C. I 1
Rear
Building Height
4
I
Bldg. Square Footage
Open Space Footage %
(Lot area minus bldg & paved I i
parking)
# of Parking Spaces -- °-TM
Fill: �.., .. ,.�
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DON'T KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW 0 YES 0
IF YES: enter Book 1 Page and /or Document # G
B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained
, Date Issued:
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO Q
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 0 NO 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
.,..^""1 '
ao- ._ r
L :
1
gr
_ . Dep `�trn r► IUe osnly h �N
City of Northampton S #a #us of Permit
ECEI
El : it i Department .4'�, H
ul d ng �b CU� � y � � l �'y Pe�rmit� � 1 �, _, �
�� I�y� II € ,
212 Main Street Sever /'p 1 tlf�.v ' 111 - �
t r ,I r t x s u:1 l,I a „IIII, rc
_; 8 2()11 Room 100 1l�ett yai la i,�9 :, r 11 l
#� 1 1 1, € ti, I P ��i ' IIIIl1,111 ( Il I I I, +i IIII € r r , ' F I
ortham ton MA 01060 `I� Ic� J �$ ip �I
p € ✓d” R I �' Il l l kt - �, l I,",7: ":�r h 4 m ? w E' Ifl '� 11 IJI11
- , I r i hn3 t I, 1 h I I,P, u1 1 IIII N N I
OF • • • • e 4 3- 587 -1240 Fax 413- 587 -1272 Pier �t u'�a X 1,1 , „I,I Il t m r,'hu
� }1 _ � wr l'„ I I II, I � I � tl tl N 1 1 iIB I, ' yil h N I Ij I,�ll li illl „Id1� I , NI I, 1
'- �lL��.... . 01 & 4 N s „ i t l,lh , h,rv,� €f „NuI, „I � i y1 �7I dl I! 4111 V' w V „I r
$t1e 3'{' " ,I f r 111, a I, 11 I IIII I 19r , 11a i�' 1 @ 'I 1U N, I
, 1 . ,„ . �i,, x , „I r i fh:' 4i �,hi11NSp € l'..s .,
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address: /J. h 'rJ �� (I This section to be completed by office
a r - 9 -- t Cr __ Map Lot Unit
Cam, / - 'L ” t
• Zone Overlay District
"(-_0 Z 7V J 41 a- C)l ��
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
- - ; S o k . t ° 2 , / / I / 6) / •/ ' ) ' c J i r e , L � / ,1
•� (��� Current Mailing Address:
- '► `i' Shy - O rd'
_ -s°'' Telephone
_-Signature
2.2 Authorized Agent:
5 cse)u ,c7 c T Rift
1z i-f iftro-- J LI P ; J
Name ( int) I Current Mailing Address:
r q/3-5(2-7 — 937 (F
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. - BtriirttrI (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)� �f - Check Number J ?&'f 1 '7c
This Section For Official Use Only
Building Permit Number: IIsssued:
Signature:
Building Commissioner /Inspector of Buildings Date
616 RYAN RD BP- 2012 -0560
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 28 - 054 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 -0560
Project # JS- 2012- 000940
Est. Cost: $8792.00
Fee: $70.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: R & H ROOFING 042781
Lot Size(sq. ft.): 12066.12 Owner: KMETZ JEFFREY L & LISA D
Zoning: SR(29)/URA(71) //WSP II Applicant: R & H ROOFING
AT: 616 RYAN RD
Applicant Address: Phone: Insurance:
59 SOUTH ST (413) 527 -9378 Workers Compensation
EASTHAMPTONMAO1027 ISSUED ON:12/8/2011 0:00:00
TO PERFORM THE FOLLOWING WORK: SH I NGLE 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 12/8/2011 0:00:00 $70.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner