Loading...
24D-017 The Conuttonweann of Ma setchusetts i iirit olvir — Department of industrial' Accidents Y — OffiCe OfInVettagatiOn$ c .7111 _,,,, - y 1 Congress Street; Slate 100 Boston, MA 02114 -2017 www. nuass.govfdia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Applicant Information Please Print Leeibly Name (Business/Organisation/individual): �► 0061.1 ".etc L- ,Son - s .. , �•. Address: 151 r�1 . ,_,,, Citjr /StatelZip Sav�l. Et�4 t a S Phone #: 1 /1 3— — p Are you ate employer' Cheek the appropriate box: Type of project (required): 1. ❑ 1 am a employer with _ 4. 0 I am a general contractor and I employees (fitll and/or part- tithe). * have hired the sub-contractors 6 • ❑ New constriction 2. R I am a sole proprietor or partner- listed on the attached sheet 7- ❑ Remodeling ship and have no employees These sub - contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' 0 Building addition [No workers' comp. insurance comp. insurance_ required.] 5 . ❑ We are a corpor ""a ita 10.0 Electrical repairs or additions officers have exercised Their 3. ❑ I am a homeowner doing all work 11 _ ❑ Plumbing repairs of additions myself, [No workers' comp. right of exemption per MCA, 12. Roof re ors insurance required.] t c. 152, § 1(4), and we have no p employees. [No workers' is.❑' Other__,_ comp. insurance required.] "Arty applicant that checks box ti 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 indieare* such. 1 Contractors that check this box must attached =additional sheet showing the name of the sib - contractors and state whether or not those entities have employees. If the Nub - contractors have employees, they trust provide their workers' comp. policy number. I am an ewer that is providing »orkeri' compensation inforram1• my employe-4m Beitme is the pulley end,ktb site information. Insurance Company Nance: Policy # or Self -ins. Lic. #: .. Expiration Date: Job Site Address: as vec tr. , * Ala aw - A City/State/Zip! C)11) Gtr Attach a copy of the workers' compensation policy declaration o�aiat ( showin 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 S1, 500.00 and/or one-year imprisonment, as well as civil penalties in the form of a S'T'OP 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 hereb cent i y ���, t and • r: ; ; that the be oroia tion provided above is true and correct P . ,. : S . • j Official use only. Do not write in this area to be convicted by city or town official City or Town: Permit/License # - _ - + Issuing Authority (circle one): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other ___ Contact Person: _ Phone* , , 4 4 _ — - - ' Office of Consumer Affairs and usiness Regulation 10 Park Plaza - Suite 5170 ;-% Boston, Massachusetts 02116 . . Home Improvement Contractor Registration Registration: 111880 Type: Partnership Expiration: 2/5/2013 Tr# 210289 QUENNEVILLE'S SONS ROOFING KEITH QUENNEVILLE 151 ABBEY ST S. HADLEY, MA 01075 Update Address and return card. Mark reason for change. fl Address HI Renewal Li Employment - Lost Card DPS CAI et 50M-04/04-G101216 Office"fhoiticlellfarsiAldiiiithigadetie License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: • Registration: 111880 Type: Office of Consumer Affairs and Business Regulation ;--) Expiration: 2/5/2013 Partnership 10 Park Plaza - Suite 5170 Boston, MA 02116 OUENNEVILLE'S SONS ROOFING KEITH QUENNEVILLE 151 ABBEY ST S. HADLEY, MA 01075 Undersecretary 'Not valid without signature • Nlaysitchtisetts - Department of Public salet■ Btmrd Ut Buildiott 12c2111:164ms arid `+tari(1.1i License: CS SL 98467 Restricted to: RF KEITH QUENNEVILLE 151 ABBEY STREET S. HADLEY, MA 01075 ExpiratIon: 12/9/2012 98467 Quenneville's Sons Roofing Quotation 151 Abbey Street South Hadley, MA 01075 Quote Number: 472 Quote Date: Mar 25, 2011 Page: Quoted to: 1 MR. ERNEST SENECAL 219 PROSPECT STREET ,. NORTHAMPTON„ MA 01060 1 T - - - - -- -- Customer ID - CidadT iu Payment Terms Sales Rep 00 4/24/11 j Description I Amount Strip off the old shingles down to the plywood, check and replace and soft sheets at $55.00 /sheet, MAIN HOUSE & 3 SMALL ROOFS. Install WATER & ICE BARRIER on all edges, cover the roof with ROOF GUARD jUNDERLAYMENT Install 8" white or brown aluminum drip and rake edge. Install new FLASHING .019 where it is needed Install proper roof ventilation, ridge vents or roof vents. Install GAF -ELK TIMBERLINE Prestique High Defintion Shingles. The shingles are warrenteed for 30 years not to leak under normal weather conditions Clean up and recycle old shingles. The roofers are FULLY INSURED $2,000 deposit at the start and the balance is due upon completion. THANK YOU!! 1 7,695.00 he owners Keith & Gene Quenneville will do the work and have 70 years combined experience. CALL 536 -6630 Owner Keith Quenneville ... _--- stomer Sign... \ , ,, , ,, i ' . ■ 1411 i 1 • , 4 -\., { i 0 / . 9 L., .„.„., \s„ i _ ____, Subtotal 7,695.00 Sales Tax Total ' 1 7,695.00 SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: /) Not Applicable ❑ 1\ Name of License Holder : e a ve." Aiv 4 t i e-- c fg 4 G 7 License Number t5 ( A�‘m, Kadl.e l M4 ©► O 7 Address Expiration Date t i/ 3 — S3G -630 Signature Telephone Registered Home Improvement Contractor: Not Applicable ❑ SOhs �c�o-F:�r, ! I ) 68 Company Name Registration Number t 5 I ` l z e st, So 1-1a a-1-c. � M �-1 D I 0 ' S - 5 - i 3 Address .% Expiration Date APS Telephone 14 - 5- 3G - G G do i A CIA 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 (� }(\A 'S •p 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 wili 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 gi Or Doors El Accessory Bldg. ❑ Demolition ❑ New Signs [El] Decks [0 Siding [ID] Other [0] Brief Description of Proposed Work: S+C ip al- A- NA .c., Stt & & Re Pl wood ( f )c c e • 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, fr(r S r Serl eCG -k , as Owner of the subject property i n hereby authorize Qu \4\ . rttt5 SOYA S 2Oo n to act on my behalf, in all matters relative to work authorized by this buTding permit application. Signature of Owner Date 1, QJe -✓tn -✓ )1 k S S e (.), Op c' Ac-'\ , 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. Si r under the pains and penalties of perjury. et-h.\ QueAvve-vili-e— Print Name GG - o' ti Signatur- .f • . - - d 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 YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW .! YES IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO ® DONT KNOW 11B YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained n , 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 OD 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 ® NO IF YES, then a Northampton Stomi Water Management Permit from the DPW is required. Department use only ity of Northampton Status of Permit Tiding Department Curb Cut/Driveway Permit 2 •12 Main Street Sewer /SepticAvailability Room 100 WaterNVell Availability ampton, MA 01060 Two Sets of Structural Plans t oF,y . ne 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 'd tq Pcospt- Sr Map Lot Unit /vOFl oon.p k p b (O 6 U Zone Overlay District Elm St District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: k f n,es } Scene_ ca. k a l c1 Co P Name (Print) Current Mailing I D 0 GOO Telephone Signature 2.2 Authorized Agent: nr\ j tl SOr% S Is Atob„ St. sou -t4, No.dk -0(04o Name P •' ) Current Mailing Addres3: y13-S'36 -6 6 30 Si. it a Telephone ' ECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building 7� G cJ t S D 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 4 // 6. Total= (1 +2 +3 +4 +5) -t 7(,95 00 Check Number �0G,3V This Section For Official Use Only � // 4/ Issued: s Building Permit Number: / Signature: Building Commissioner /Inspector of Buildings Date 219 PROSPECT ST BP- 2011 -0819 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 24D - 017 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: roofing BUILDING PERMIT Permit # BP- 2011 -0819 Proiect # JS- 2011- 001343 Est. Cost: $7695.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: QUENNEVILLE'S SON'S ROOFING 98467 Lot Size(sq. ft.): 2090.88 Owner: SENECAL ERNEST & BETH A Zoning: URB(100)/ Applicant: QUENNEVILLE'S SON'S ROOFING AT: 219 PROSPECT ST Applicant Address: Phone: Insurance: 151 ABBEY ST (413) 536 -6630 SOUTH HADLEYMA01075 ISSUED ON:4/13/2011 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 4/13/2011 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner