17C-251 Jan 10 2012 12:23PM HPMG 413 - 582 -9973 page 2
r / n \
.QUENNEVILLE
ROOFING V SIDING V WINDOWS tit
160 Old Lyman (load • South Hadley, MA 01075 Mr •
1.800.NEW ROOF • Winner cot the
Email info° tactonawroof. net Webslte: www.1800nevecof.net 1810
MA Construction Supervisors t.ic *O70026 MA Registration #920982 TORCH AWARD
Member el Me Home guiders Aseodelon of Weown moo. CT Registration *575920
Member site auuderte & 1d, Ass t on
-ter .
Proposal Submitted To: a 4, Date /0 .1 7 - I Phone V's C:
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Street Email:
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City, State, Zip Code Job Nama /Location;
E/a re n c . r'+7
Proposal to furnish and Install the fallowing
0 70 /).f 4- Ca?fn -rrs (,move.. des JL G nat ra . . b•.g3 ana r
ti Gns( rre roof -For i.is7', /l or' side. ell re'LI we to; I);
Pr er,d -t and , 's // a /1ru 770 X00 - Sr' ysite
on x;e1t p•rc 1 onok -Play 11 F' o.ln1<s 40 r AeL—)
dec.king -f- A r..is -fa Pro/ by e 4 r d prn -ircg.
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__ rc It � • ' o 7 , 700 Ask us about
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financing
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Ws prepo0e hereby to W'Nfh matutios are tabor • complete in ecowdante wan above sPod§tmliens 101 the Cm of: Total Due (S // A 00
ACCEPTANCE Or PROPOSAL; The above prices. epeeillmttobs and aondhloes Ire Down Pa nt O C t
satisfactory snO era hereby accepted. You an authorized to do walk se spedllsd. 3 a )
Payment *NI be t 3 down at start el lob, and balance due upon completion. .„r Balance Due Upon Completion ($,. , Y a 0 _ )
Date- { t[ ) ... If .�ioe.. f •' .11101 4/ _ #' a ,a, , r ... - -
Date: / 0 Estimator Men: Name) r' Mil' N. , ,0
Estknates are bor ored for sbay (60) days from above date
ArrENTION HOMEOWNERS: Mesas cover ell personal belongings In the attic, gangs or storage aasas duo to the
posalbtlity of roofing debris or dust coming In through croaks of the wood. Adam Qusnnetrille Rooting will not be
responsible for debris or dust In the ciao or atoreye areas.
A. The Commonwealth of Mtrssach isetfs
Deptulinent of Industrial Accidents
l� ==.-- _ l : office of Investigations
e .° , 600 Washington Street
4 . _ Bostan, MA owl
im wtvw:rrhas By d n slEle�ct�ricia�zs /PIumbets
Workers' Compensation. Insurance Affidavit rs1 o � P rint bi blY
Applicant Information
Name (A - — _.hoH .n: A Cl i 141. d „.1 U ; 1 LL t, i di 1 L C
Address:J Le a 01 J Giv ria n 41.
cityist .: 60... _ _ 'Q _ d P 4 M olD hone #: 13
Are you an cmpkiyoi? Cheek the approp , to bor Type of project (required):
4. 0 I aru a genial contra to and I
I . I am a employer with 6_ ❑ N GVV raonsttvct
employees (fall and/or part-time).* have hind the sub ors
listed on the attached shoat 7 Q Remodeling
2. ❑ I amt a sole proprietor ,xpartner-
These sub- contractors have R. [] Demolition
ship and have no employees caps t-
working fix me in emtploye es and have workers' 9. omittin 2ddituozi any cep
t
[No vNOr3oers' cowls. 5 0
comp. re corporation dad ill 10.0 Electrical repairs or additions
3. ❑ l h aacoworr d wait officers have cxaciSed their 11.E Plumbing repairs or additions
myself. [14o '�.
right of §I (4 have I Rnofre
insurance rc,ltur+zl.1 t employees. [No mss I3_Q Other
gyp- insurance �ed.]
4 ,ey applieamt that clued= box. #1 roust also fa[ oat the section below g their workere anapeuession worker policy informatiov.
f Homeowners who saber+& this *ffi6arii ink they vs doing all ..odr and then hire: outside meVatinie mint submit anew affidavit indicating stock
:Comrades that check this heoc mist attic ad NA .ddi"io.nt sheet: showing to nano at this and state whether ar not those entities Iowa
eveptoyxt. If dee mb rs lave =pierce, that rant provide thhei . workers comp. policy aermba:
I ant are employer that irprnvidng worms' compensation insurance for my employes. Eduw is the policy and job rite
bnforractsort
Insurance Company Name_ rml utuQ.l - I nSk.ran —
Policy # o r Self-ins. L i e . #: frW C r i o t 2k6 lot pate: L - & q 6 /1
Job Site Address: T i /1/a id Mart 1 art A S7 - n 0 (..G +'t te- (atyIS1i : " 0 i 0 6 �--
Attach a copy of the workers' compeosaitioa policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as requited under Section 25A of MGL c. 152 can load to the iwpositiuu of cranium' I penalties of a
fine up to S 1,500.00 and/or out, -yeti imprisorment, as well as civil penalties in the form. of a STOP WORK ORDER iced a f a
o f up to S250.00 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
tion
I do hereby certif r under the pairs and penalties of perjury that the information don prmdded above is true and correct
L Date: / " // — / ?■
Phonic # _ I ` 6 bt, - , i �
()frt ., rue way- Do net .mile iaa Alois =raw. Jo b• consploterir by city or tow= ofciol
City or Town: Permit/Liceusc #
Issuing Authority (circle one):
1_ Board of Health 2 - Buiktiug Department 3. City/Town Clerk 4. Electric* al Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
j�
x 70 u a-6
Name of License Holder : ar iYl /.0 G I it, (11 it
License Number
j (o n ld Lj n' 0- ga ` 3OVL1 d £ l l�t- oo, - c A ress Expiration Date
� ��z "�
Sign j Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
Adam QnennevilleRoofmg& Siding, Inc. d-o
Company Name 160 Old Lyman Road Registration Number
Address South Hadley MA 010T5 3 a s- °
Expiration Date
Telephone tf / 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 jK No ❑
11. - Rome 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 ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing W'
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [E] Siding [0] Other [0]
Brief D - scription of Proposed - 1 /
Work: r_ Iu. • ! 'r h d4u) v'. • r 't' lib 1 0 004 S ti S n - '-
ff re-h- roe
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
1, _ ' "1 , as Owner of the subject
property `J
hereby authorize Adam Qum* Roofing & Siding, In
to act on my behalf, in all matters relative to work authorized by this building permit application_
Sip- urk t a- dos-e& 1 - 1- (X
Signature of Owner Date
I Adam QnenevilleRoofng & 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.
�d 14'L f >f' ti 19 h7.e V i /(�f'
Print Name
Signatu er /Agent Date
RECE V P Department use only
City of Northampton Status of Permit.
Building Department Curb Cut/Driveway Permit
JAN 1 3 012
212 Main Street Sewer /Septic Availability
Room 100 Water/Well Availability
.of euu moo Northampton, MA 01060 Two Sets of Structural Plans
p one 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
`�- This section to be completed by office
1.1 Pro a Address:
( 114
AA) PL J. Map Lot Unit
e 1 b h e M 14- 6 I D (D- Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
�; '^ mph' r e ero1e (.11 fah et amitt e0 . x t Fs4 - Nor t aMt p 1 f�4 lO
Na a (Print J Current Mailing Address:
to L r f S-(4 Telephone Li 13 - t 8 a Ctq 6
Signature
2.2 Authorized A /
Tk �t vn CX 1,cre n v V i ILL t Co U t Ic Lf-( main • .4tul� 1 - 71/tr�
::: e (Print) Current Mailing Add s: U
S36-SISS
atu re Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building ceQ O , (1c) (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) 6 BUG , 00 Check Number a Q cit. / ,. o r 3 5
This Section For Official Use Only ��GG
Date
Building Permit Number. Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
41 NORTH MAIN ST BP- 2012 -0661
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17C - 251 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 -0661
Project # JS- 2012- 001140
Est. Cost: $5800.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ADAM QUENNEVILLE 070626
Lot Size(sq. ft.): 29969.28 Owner: VITOLS ELSA C C/O HPMG
Zoning: SI/URB(100)/ Applicant: ADAM QUENNEVILLE
AT: 41 NORTH MAIN ST
Applicant Address: Phone: Insurance:
160 OLD LYMAN RD (413) 536 -5955 () Workers
Compensation
SOUTH HADLEYMA01075 ISSUED ON:1/18/2012 0:00:00
TO PERFORM THE FOLLOWING WORK: REPLACE PORCH 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 1/18/2012 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner