36-016 ZAH_2)5t\CAn, A DISCO/ER
QUENNEVILLE
ROOFING ♦ SIDING 'V WINDOWS
160 Old Lyman Road • South Hadley, MA 01075 BB B
1.800.NEW ROOF • 413.536.5955
Winner of the
Email: info@1800newroof.net Website: www.1800newroof.net 2010
MA Construction Supervisors Lic. #070626 MA Registration #120982 TORCH AWARD
Member of the Home Builder's Association of Western Mass. CT Registration #575920
Member of the Building & Trade Association
1 Proposal Submitted To: Date Phone #'s C:
I
- 3C Nnt, g MA T\fJEZ /4/1. [11 H: W:
Street Email:
3. r�.S �- / ti'
City, State, Zip Code Job Name /Location:
Proposal to furnish and install the following
• Res? lr —e, ► :Sbi -S - A N1 . S, STE ::s0 ,.s
3 00
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Ask us about
affordable bank
financing
We propose hereby to furnish materials and labor - complete in accordance with above specifications for the sum of: Total Due ($ ZC, ( S )
ACCEPTANCE OF PROPOSAL: The above prices, specifications and conditions are Down Payment '50 )
satisfactory and are hereby accepted. You are authorized to do work as specified.
Payment will be 1/3 down at start of job, and balance due upon completion. Balance Due Upon Completion ($ 1 � s 1 5 9 — )
Date:X/,h,' -- r'"-, / /Signature: �{ v '' .�.�.- - ' � �r- i /�
Date: 1 `I Zi i( Estimator: (Print Name) ` � ='Z . (' I (Sign Name) _ — a_rrz_ _1�/ 1- _
Estimates / / / are honored for sixty (60) 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 for debris or dust in the attic or storage areas.
The Commonwealth of Massachusetts
----- Department of Industrial Accidents
is� " ;" Office of Investigations
6 =z;i 600 Washington Street
`• r ? Boston, MA 02111
,- www mass.gcWdia
Workers' Compensation Insurance Affidavit Builders/ Contractors lElecfiricians/PIwmbers
Applicant Information Legibly / Please Print Legibly
Names : A C16t VYl 0um rve..I ! Le koo 4fl) fi S t I; ei5 f J- via
Address: f L o (21J i j ai 0. .
City /Stalmzi.:_ 6,. + A k f ' a d 1 1 4 A- 0 k n 4 b o n e i i : 1 3 - . c 5 6 - 6 1 5 - S
Axe you an employer? Check the approp . to box Type of project
4. ❑ l a m a general c coder and I (required):
1. I am a employer with ( 6. 0 New cooshuction
employees (full and/or part-time).* have hired the sub�corarectars
listed on the attached shed 7. ❑ Remodeling
2.0 I am a sole proprietor or partner-
ship and have tro employees .. Tbcse sub-contractors have S. ❑ Deeunlit
working for me in any capacity. employees and have workers' 9. ❑Building addihion
[No workers' comp. insurance - insurance t
} 5. ❑ We are a corporation ms
and its 10 -0 Electrical s or additions
officers have exercised their
3. ❑ lam a homeowner doing all watt. 1 Plumbing repairs or additions
myself [No workers' comp. rig rt of exemption ption per MGL ., tp3
] t r 152, §l(4), and wehaven° 23_0 Other
employes- [No wows'
_ comp. insumnce -]
'Awry applicant that checks box t I mast also 51, oat the section below showing flair wwloxs' map on policy infaavation.
t Eiomeowoess who submit this affidavit ink they son doing all wok sod (Imo him outside mmuada s roost submit manor affidavit indicating such
le-outrun= le-outrun= that check this box nowt snitched sec additions, shod showing the roma ads, and moo whctrr at aortas* catkins lava
employaxs. lithe wb•attacto:s tone c a aloyoes, limy must provide their wok camp. policy manta
I am an employer that isproviding workers' con ea:sufion insurance for my employees. $dew is the policy and job site
uzfornnaaion.
I n s u r a n c e C o m p a n y Name_ 141 M m Wilt ej I n Sk ra l 1 a -
Policy # o r S e l f - i n s . Lin #: A W C ' I 01 2 4 [ o /O 1 Expitation Date: LI - '9 ii —) ) o
Job Sits Address: 3 ``i LeSf fr_/,01 - !- I& fi tie . = � G i 6 (e "D
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secwe coverage as =Fired under Section 25A of MGL a. 152 cart 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 fmc
of up to $250.00 a day against the violator. Be advised that a copy of this stat nacnt may be laded to the Office of
Investigations of the DIA for insurance coverage ve=ig action.
I do hereby catify under the pains and pent lties of perjury that the informndion provided above is true and correct
S' {' afire: / / Da>z: )-`- O - I I
Phone #: 'i 1 5-1.5 -6 SS
off r rrsc wily_ .De Rot write ii. this =raw, m be cosnptatad by city or tows official
City o r Town: Permit /License ense #
Issuing Authority (circle one):
1. Board of Health L Bardding Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing inspector
6.Otber
Contact Person: Phone
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : AA&gin 0/A1 4 I/ 70e, ;?-6
License Number
Add V /c y r�a s( ' 5•
0 . 41 ,4A )Id I "?i'L O( 1S -off (- c - / 3
/ U Expiration Date
� �le Zz �l 'S -S9SS
Sign j Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
Adam QaennevilkRoo li : & Siding, Inc,
Company Name 160 Old Lyman Road Registration Number
Address South Hadley, MA 01075 Expiratio -- e s- as 1
( — Telephone ( f/3 - „-S 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 D Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ! 2
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [0 Siding [D] Other [0]
Brief Descripti of Proposed _ t
Work: i- _
p -0 L tP .f f el. `t' - L / /L4
Alteration of existing bedroom Yes No Addin 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, . n n I Lk r 4a r , as Owner of the subject
property
hereby authorize Adam Qaenneviile Roofing & Inc.
Siding,
to act on my behalf, in all matters relative to work authorized by this building permit application.
642t I c) - e - t l
Signature of Owner Date
I, Adam Qnenno&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.
»c a 6 '1 4 47 a Ze
Print Name
/
Signatu r /Agent Date
RECEIVED Department use only
City of Northampton Status of Permit
JAN 4 2012 Building Department Curb Cut/Driveway Permit
212 Main Street Sewer /Septic Availability
Room 100 Water/Well Availability
DEPT. of BUILDING INSPECTIONS MA 01060 Two Sets of Structural Plans
wosnianePro " orthampton,
phone 3- 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
35 9-00 s - DI I i r k Map Lot Unit
Zone Overlay District
Elm St District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
nrl `cr Ma r Nr - Lz) :35 lJ ,,7 ,- -- Le — (- fcf- e0e_
Name (Print) Current Mailing Address: V y A /
Telephone t 1 .- t it 1 3 -
Signature
2.2 Authorized Auent: /
Ac1t2vn Olken vt�e>/i ( � ((c (.�(ci 1- rntc.N a. 50. 4l- 66-c c1 7`11.;;.
Name (Print) Current Mailing Address:
ne--k___ G r � - s3 -sa ss
Sign ' Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building 6 66. u V (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) cY l t' 0 j , 0 U Check Number 0d ef 9' 3 cli (jLS '
This Section For Official Use Only
Date
Building Permit Number Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2012 -0625
APPLICANT /CONTACT PERSON ADAM QUENNEVILLE
ADDRESS/PHONE 160 OLD LYMAN RD SOUTH HADLEY (413) 536 -5955 Q
PROPERTY LOCATION 35 FOREST GLEN DR
MAP 36 PARCEL 016 001 ZONE URA(100) //WSP II
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out qq
Fee Paid a7 O g
q5
Typeof Construction: REPLACE 1 JOIST & SISTER JOIST & 1 SQ ROOF
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 070626
3 sets of Plans / Plot Plan
THE FOL ING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION PRESENTED:
Approved Additional permits required (see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND /OR Special Permit With Site Plan
Major Project: Site Plan AND /OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received & Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission Permit DPW Storm Water Management
—
, 111 r . -
/-
ature of Building fficial Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health, Conservation Commission, Department
of public works and other applicable permit granting authorities.
* Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning & Development for more information.
35 FOREST GLEN DR BP- 2012 -0625
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 36 - 016 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 -0625
Project # JS- 2012 - 001077
Est. Cost: $2605.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ADAM QUENNEVILLE 070626
Lot Size(sq. ft.): 14157.00 Owner: MARTINEZ WILLIAM J & JENNIFER M
Zoning: URA(100) //WSP II Applicant: ADAM QUENNEVILLE
AT: 35 FOREST GLEN DR
Applicant Address: Phone: Insurance:
160 OLD LYMAN RD (413) 536 -5955 0 Workers
Compensation
SOUTH HADLEYMA01075 ISSUED ON:1/5/2012 0:00:00
TO PERFORM THE FOLLOWING WORK: REPLACE 1 JOIST & SISTER JOIST & 1 SQ
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 1/5/2012 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner