25-068 (3) AGORA, CERTIFICATE OF LIABILITY INSURANCE OP ID DM DATE(MWOONYYY)
ADAMQ -1 06/24/10
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Remillard Insurance Agcy, Inc HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
79 Lyman Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
South Hadley MA 01075 •
Phone : 413--538 -78 62 Fax :413- 538 -7179 INSURERS AFFORDING COVERAGE I NAIL #
INSURED INSURER A: AIM Mutual Insurance Company
INSURER B: Travelers Ins . Co .
Adam Quenneville Roofing & I NSURER C: First Speciality Ins Co rp
Siding Inc & Guttershutter P y
160 Old Lyman Road INSURERD: Hanover Insurance Company 22292
South Hadley MA 01075
INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LTR ?NSR• rips OF INSURANCE POLICY NUMBER - DATE (MM(DO/YY) DATE(MMIDD/VY) LIMITS
GENERAL LIABILITY I EACH OCCURRENCE $ 1000000
AMAC,t,'
C X COMMERCIAL GENERAL LIABILITY ; TBI 06/23/10 0 6/ 23 / 11 I u PREMISES Ea 1itN occurence) 1EU 5100 0 0 0
1 CLAIMS MADE X OCCUR ' MED EXP (Any one person) 55000
PERSONAL &ADV INJURY ' $ 1000000
I �
GENERAL AGGREGATE $ 2000000
GENT_ AGGREGATE LIMIT APPLIES PER PRODUCTS - COMP/OP AGG $ 2000 0 00
POLICY PRO• n LOG
JECT
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT 51000000
ANY AUTO BA7450L946 11/01/09 11/01/10 (Ea accident)
ALL OWNED AUTOS BODILY INJURY
'
X. SCHEDULED AUTOS (Per person) 1
X I HIRED AUTOS BODILY INJURY
X NON -OWNED AUTOS (Per accident) I $
PROPERTY DAMAGE
(Per accident) 1$
•
•
GARAGE LIABILITY I I AUTO ONLY • EA ACCIDENT $
•
I I
ANY AUTO OTHER THAN EA ACC 5
AUTO ONLY: AGG 5
EXCESS /UMBRELLA LIABILITY EACH OCCURRENCE S
I-1 OCCUR ( ICLAIMS MADE 1 AGGREGATE S
DEDUCTIBLE _ $
RETENTION $ $
WORKERS COMPENSATION AND OR LIMITS 07
TORY LIMITS � E -
R
EMPLOYERS' LIABILITY
A AWC701286101 04/29/10 04/29/11 I E. L. EACH ACCIDENT 51000000
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBEREXCLUDED') j E.L. DISEASE - EA EMPLOYEE 51000000
If yes, describe under
SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT i $ 1000000
OTHER
D Equipment Floater IHN7140610 02/01/10 02/01/11 Rental
1 I Equipment $100,000
DESCRIPTION OF OPERATIONS 1 LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT ! SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
SERVMAG SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
REPRESENTATIVES.
AUTHO ED REPRESENTATIVE
ACORD 25 (2001108) 0 ACORD CORPORATION 1988
i
3• Ori ' I ' . 0 , 0,
- y _ � o ar. o . u1 . ing egul ions ane tan are s
t ll One Ashburton Place - Room 1301
Boston, Massachusetts 02108
Construction'Supervisor License
• .. License
70626
.. Restriction: 00
. . . •Birthdate: 8/21/1
Expiration: 8/21/2011 Tr# 3
A AM •A QUENNEVILLE -:
1'60 OLD 'LYMAN RD . . -
S HAD1^EY, MA 01075 ., --
_.;___,_-.7.w.---,=_:: t Office of Consumer Affairs and usiness Regulation
11= 10 Park Plaza - Suite 5170
• .. Boston, Massa„c, usetts 02116
Home Improvement Q actor Registration
Registration: 120982
\� � . Type: DBA
-, = r Expiration: 3/25/2012 Tr# 293069
ADAM QUENNEVILLE ROOFIN 4 , - \..
ADAM QUENNEVILLE —`
160 OLD LYMAN RD (.,..:\5 - ;: 1; 1
SO. HADLEY, MA 01075 \ '',,-0 - -
"`� "^r��'Y� !,;,� Update Address and return card. Mark reason for change.
_
—)'- El Address Renewal 0 Employment Lost Card
DPS -CA1 is 50M- 04/04- G101216
,"_..._— _._._, --- -- -..— _ _ ----- ._.._....___---- .�..*--- "._. -._ _._.._" _....._._- .J... . f s .
«° STATE OF CONNECTICUT ♦ DEPARTMENT OF CONSUMER PROTECTION 1
5 ( Be it known that
I A.'YVJ[ QUENNEVIT I F l
' AD
AIM NNE�I . .
160 OLD I,� ROAD
/ �, , t , ,
a SOUTH, 9. -,' 4 - 1 Q75 -2632
1 (c•r�, 7 } s
is certified by the De ar ri A } � " i
«�� � Y P � t.. ��� $tectton as a registered 1
1 HOME IMPRCa 0 y' 'ONTRACTOR , A ' .1.:1"::-.1--:
Re gis - r 7 5920
j ADAM QUENNEVILLE ROOFING ,
( Effective: 12 /01/2009 Ill
I ! "'
Ex .. i /30/2010 -
Jerry Farrell, J r., Commissioner
Et 1- = -
= The Commonwealth of Massachusetts
` _. _ Department of Industrial Accidents
_, � , Office of Investigations
Vaal— II Z , 600 Washington Street
- = : Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders /Contractors/Electricians /Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/In A a _ u e. ' . 1 - Y - 1 * \ . " } a ✓tC
.
Address: 161) ()t A �.y PA an I� e-
City /State/Zip: ', his, a • i SIT Phone #: I - _3 . --• .
Are you an employer? Check the appropriate box: - --
Type of project (required): 1.M I am a employer with 4. ❑ I am a general contractor and 1
employees (full and/or part-time).*
have hired the sub - contractors 6. 0 New construction
2.0 I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling
ship and have no employees These sub - contractors have 8. 0 Demolition
working for me in any capacity. employees and have workers' 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.:
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3. ❑ I am a homeowner doing all work officers have exercised their ri of exemption MGL 11.0 Plumbing repairs or additions
myself. [No workers' comp. right P 12BLRooftepairs
insurance required.] t c. 152, § 1(4), and we have no
employees. [No workers' 13.0 Other
comp. insurance required.]
Any applicant that checks box d1 must also fill out the section below showing them workers' compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and them hire outside maraca= must anbutha new affidavit such.
:Contractors that check this boatmen* attached an additional sheet showing the mmeuftbesub-ooatracsors and sate whether aunt those entities have
employees. If the sub•contaetors have employees, they must provide their workers' comp. policy number.
I am an employer that is providing workers' compensation insurance for my employers. Below is the policy and Job site
information.
Insurance Company Name: (4- /A 1t4 u. a . )isurci i1 t +P,
Policy # or Self -ins. Lic. #: 0 WC, 1 1 0 (eg9, to 1 0 1 Expiration Date: Va q/ i 1
Job Site Address: ( ? R Ve C' (J b. „i/L, Np c 0.. ,,. ti AAA City /State/Zip: 010 (ecQ
Attach a copy of the workers' compensation policy deelaradon page (showing the pokey number and expira dea fie).
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 carte wnder� andp afpM� t the information prov a above is true and correct
Signature: Date: - (q -1O
Phone #: 'fl 3 -53 to - 5 S
Official use only. Do not write in this area, to be completed by city or town Vidal
City or Town: Pernrit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. Cityfi'own Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
A Dm N Gust. # ate QUENNEVILLE 4,1r kCI kv
ROOFING & SIDING, INC. Street Address
City tote � Zip
■
1-800-NEW ROOF (,` V ft 1,... — _ n �f 1 O b O(
413.536.5955 `�'
1800NEWROOF.NET Home Phone # Work Phone # ail (��nn/�
COMMERCIAL .. RESIDENTIAL \,i,& f 0 ( Lk ( (-1 f .l 1' (_e@ lr e S
160 Old Lyman Road • South Hadley. MA 01075 o 6
AI
I hereby authorize you to proceed with the diagnosis for a minimum charge of $ /a X 4 ,... , r •� /, / -
StraightForward Pricing® N;c 5
K -e, 3a -q/A2-
g g
Replace 4 SQ of shingles, Stepflash/Countertlash 41' to 50' of wall, Replace 51' to
7 65' of valley, Reflash 17' to 25' chimney, Construct cricket and flash 3' to 6' wide
chimney, Roof or Siding cleaning 2,001 sq. ft. - 3,000 sq. ft. Cover fascia or rake with
Aluminum 51' - 65' Replace 22 -30 slates. Quantity x $1637 ea =
Replace 3 SQ of shingles, Stepflash/Counterflash 31' to 40' of wall, Replace 41' to
6 50' of valley, Reflash 16' to 20' chimney, Install 71' to 110' of ridge vent, Roof or
Siding clean' . • II s.. ft. - 2,000 sq. ft. Cover fascia or rake with Aluminum 41'-
51 • e. ace 16 -20 slates. Quantity x $1277 ea = i.2. v?
Replace 2 SQ of shingles, Stepflash/Counterflash 21' of 30' of wall, Install 51' to
5 70' of ridge vent, Replace 31' to 40' of valley, Retlash or replace up to 2 Customer
Supplied skylight (no interior trim work), Install 250' to 350' of drip edge, Reflash
13' to 16' foot chimney, Roof or Siding cleaning 1,001 sq. ft. - 1,500 sq. ft. Cover
fascia or rake with Aluminum 3I' -40' Replace 11 -15 slates. Quantity x $839 ea =
Replace 1 SQ of shingles, Stepflash/Counterflash 11' to 20' of wall, Install 31' to 50'
4 of ridge vent, Install 21' to 30' of valley, Clean 251' to 350' of gutter, Reflash 9' to
12' chimney (perimeter) or small stone chimney, Replacement of customer supplied
skylight (no interior trim work). Tear off and re- shingle 2nd story bay window.
Install 101' to 200' of dripedge, Roof or Siding cleaning 501 sq. ft. - 1,000 sq. ft.
Cover fascia or rake with Aluminum 21' -30' Replace 7 -10 slates. Quantity x $694 ea =
Reflash up to 8' perimeter chimney, Replace 1 to 2 bundles of shingles,
3 Stepflash/Counterflash 6' to 10' of wall, Install 51' to 100' of drip edge, Install 4 to
8 hat vents, Dryer hose connections, Replace up to 15' of valley, Tear off and re-
shingle 1st story bay window, Install up to 30' of ridge vent. Minor tuckpointing
and watersealing of chimney (<3' in height), Re- stepping and IceGuard 2'x4'
skylight, Installation of curbmount skylight, Clean 150' to 250' of gutter, Install
51' to 100' of drip edge. Cover fascia or rake with Aluminum 11' -20', replace
4 -6 slates. Roof or Siding cleaning up to 500 sq. ft. Quantity x $559 ea =
Soil boot replacement, Replace up to I bundle of shingles or up to 20 shingle tabs,
2 Stepflashing /Counterflashing less than 5' of wall, Installation of up to 50' of drip
edge, Installation of up to 3 hat vents, 10' or less of gutter /fascia replacement, Clean
31' to 150' of gutter, Reflash electric pole/heat stack, Crop up to 30' of valley. Replace
1 -3 slates. Cover fascia or rake with Aluminum 10' or less. Install rubberized crown
. on chimney cap. Install stainless steel cover on chimney flue. Quantity x $387 ea =
1 Roof certifications of Gutter cleaning (up to 30') Quantity x $159 ea =
(Add 30% for roof pitches greater than 6/12)
Custom �..e 4- -
Request �nr1T - - 1 �' Quantity x $ ea: =
6 t;SflC K r' (4 S Quantity x $ ea: =
Quantity x $ ea: =
Recommendation
I hereby authorize you to proceed with the above StraightForward Pricee of $ / Z) X = ` =a
9 4> a
Paid via: Cash, Check (# 2") ) Credit Care Diagnostic - - : `Z 7
MC, Visa, AE CC# Exp. Total Due today $ ' > t4) Pe
Work performed to my satisfaction L
Scheduled Arrival Time Actual Arrival Time
Thank You!
miii■ in F
D VISA naas07 -r" ' MOWER AZZ____/_ZarAV:A\
QUENNEVILLE 000i 2 . 'L
ROOFING & SIDING, INC. ���
160 Old Lyman Road, South Hadley, MA 01075 (AO)
1.800- NEW -ROOF • 413-536-5955
Email: info @1800newroof.net Website: www.180onewroof.net
MA Construction Supervisors Lic. #070626 MA Registration #120982 -
Member of the Home Builder's Association of Western Mass. CT Registration #575920
Member of the Building & Trade Association Member of the Better Business Bureau
Proposal Submitted To: Date Phone #'s
D E S e , keLit H: L 1 9 9417 W:
Street Jabber
City, State, Zip Code Job Loca '. n:
46a tt a tc\ MA ClUriC
Proposal to furni h and install the following
❑ Re - Roof ❑ Tear -Off ❑ Gutter
5+ -le�- Ir y 5 c tlw_t_cS.c pti_
. % NP
Ask us abo , t
a f ordable ba r k
fl,nnci g
\ VIZ'?
We Propose hereby to furnish materials and labor - complete in accordance with above specifications for' •• .f:
dollars ($ C() j O - 3434;c>
ACCEPTANCE OF PROPOSAL: The above prices, specifications and conditions are satisfactory and a : • - - by accepted.
You are authorized to do work a Ipecified. Pa - ent will be 1/3 down at start of job, and balance due upon completion.
Date: lb(ID Signature: .- - C . Phone #
Datee - IOC fO Estimator' ' ign ture: , i t 111110P - ' ' _ 1 s-ex
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.
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : Adam Quenneville Roofing & Siding, Inc. 7 c, a �,
160 Old Lyman Road License Number
South Hadley, MA 01075 -al- t
Address Yf Expiration Date
Signature Telephone '11.3 — 3c. _ s_S
9. Reaistered Home Improvement Contractor: Not Applicable ❑
Adam ucnnevilk Roofing & Siding, Inc. « c r 0 1% . /.
Company Name Q Registration Number
160 Old Lyman Road - as a,
Address v a,lc,(416; ‘137.5- Expiration Date
Telephone 4(3 ' S3G 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
. r 0.•
'itr4111 ftilt,PT 7 r itqf s .Jr 4 i;ii;
;11it ;" 'llii 4 ,4.," • , —
,4 ,• • $ • : r • -
• ,
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding [0] Other [0]
Brief Description of Proposed ,
Work: (Leplo.c.e. I LcC� Ate 5oreor - 8.e«.rn O-r&- s4- - n .g (?4iict -S alajoi;
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
I, 3e, Sst LO..o , as Owner of the subject
property J fi & Q
Ada
hereby authorize * Reefing & S�0 In
to act on my behalf, in all matters relative to work authorized by this building permit application.
-(q -10
S ignature of Owner Date
Ail *rude Rein & Sag, liG
, 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.
AaO V Qu crneu A
Print Name
q - 19 -1 v
Signature of Owner /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
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 ® DONT KNOW • YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO ® 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 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained ® , Date Issued:
C. Do any signs exist on the property? YES Q NO Q
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES ® NO
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 Storm Water Management Permit from the DPW is required.
Department use only
City of Northampton Status of Permit:
PLOI s -' \Building Department Curb Cut/Driveway Permit
2 212 Main Street Sewer /Septic Availability d?� a Room 100 Water/Well Availability
__�Noi thampton, MA 01060 Two Sets of Structural Plans
- .1. pho 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
G � R `V trj0.tiv� �� Map Lot Unit
k ) f 5 c A N A . c . r + n koc.01\ I l� H 0 0 6 0 Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
S_SSC LouN-% Wodecya■W Noc}ho,wp4on,MA 0 Go
Name (Print) Current Mailing Address:
1- 5 “ - 9g1 7
Telephone
Signature
2.2 Authorized Agent: p tt
Ada i Qum* A & , � inG , co o to LC,1Ma in S(yu V\0 cl1e� 4P. C.,103 Name (Print) Current Mailing Addres J
4 1 1 3 5 - 59SS -
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building 4, N 77 (a) Building Permit Fee
.�U
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) 1 11147 o Check Number ji'a0to _
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
n
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File # BP- 2011 -0162
APPLICANT /CONTACT PERSON ADAM QUENNEVILLE
ADDRESS/PHONE 160 OLD LYMAN RD SOUTH HADLEY (413) 536 -5955 Q
PROPERTY LOCATION 67 RIVERBANK RD
MAP 25 PARCEL 068 001 ZONE SC(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out } of n --j- i t 3 c
Fee Paid id O
Typeof Construction: REPLACE SUPPORT & BEAM & SISTER IN 5 RAFTERS
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 FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
Il 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
De •• • ' ' • • Dela
(
Si: • i ilding i fic r 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.
67 RIVERBANK RD BP- 2011 -0162
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 25 - 068 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit # BP-2011-0162
Project # JS- 2011- 000268
Est. Cost: $4477.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ADAM QUENNEVILLE 070626
Lot Size(sq. ft.): 13372.92 Owner: LANG JESSE L
Zoning: SC(100)/ Applicant: ADAM QUENNEVILLE
AT: 67 RIVERBANK RD
Applicant Address: Phone: Insurance:
160 OLD LYMAN RD (413) 536 -5955 0 Workers
Compensation
SOUTH HADLEYMA01075 ISSUED ON:9/28/2010 0:00:00
TO PERFORM THE FOLLOWING WORK: REPLACE SUPPORT & BEAM & SISTER IN 5
RAFTERS
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 9/28/2010 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner