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28-030 �i Name pnz�,vr Date tO! \` ,1 QUENNEVILLE "" Stree Address ROOFING SIDING W' WINDOWS BBB 1O g ` v °n �d � City 1.800.NEW ROOF . State Zip F o t en d e ( State Oho G �. 413.536.5955 Winner of the Home Phone # Work # 1800NEWROOF.NET TORCH AWARD RESIDENTIAL ■ COMMERCIAL r Cell # ` Email 160 Old Lyman Road • South Hadley, MA 01075 `� S C S S C g 7 3 StraightForward Pricing® V1 Story 2 Story 3 Story 7 Remove & Replace 3 SQ of Shingles, Stepflash /Counterflash 41' to 50' of Wall or Chimney, Remove & Replace 41' to 50' of Valley, Install 121' to 160' of Drip Edge, Install 71' to 100' of Ridge Vent & Ridge Cap Shingles (Baffled or Rolled), Lead Flash Chimney 24' to 28' perimeter, CLEANING Roof or Siding 2,001 sq ft - 3,000 sq ft, Construct Cricket and Flash 3' to 6' wide Chimney, Cover 51' - 65' of Fascia or Rake with Aluminum, Remove & Replace 1 SQ of Dormer Siding Qty x $1787 ea = $ 6 Remove & Replace 2 SQ of Shingles, Stepflash/Counterflash 31' to 40' of Wall or Chimney, Remove & Replace 31' to 40' of Valley, Install 91' to 120' of Drip Edge, Install 51' to 70' of Ridge Vent & Ridge Cap Shingles (Baffled or Rolled), Lead Flash Chimney 19' to 23' • perimeter, CLEANING Roof or Siding 1,501 sq ft to 2,000 sq ft, Cover 41' to 50' of Fascia or Rake with Aluminum, Remove and Replace 1 SQ of Wall Siding Qty x $1392 ea = $ 5 Remove & r Replac`e r of Shingles tepflash/Counterflash 21' to 30' of Wall or Chimney, emove Rep ace Ito of Valley, Install 71' to 90' of Drip Edge, Install 31' to 50' of Ridge Vent & Ridge Cap Shingles (Baffled or Rolled), Lead Flash Chimney 14' to 18' perimeter, CLEANING Roof or Siding 1,001 sq ft to 1,500 sq ft, Cover 31' to 40' of Fascia or Rake with Aluminum, Minor Tuckpointing and Watersealing of Chimney 5' to 9' in height Qty X $922 ea = $ 4 Remove & Replace 2 Bundles of Shingles, Stepflash/Counterflash 11' to 20' of Wall or Chimney, Remove & Replace 11' to 20' of Valley, Install 51' to 70' of Drip Edge, Install 21' to 30' of Ridge Vent & Ridge Cap Shingles (Baffled or Rolled), Lead Flash Chimney 9' to 13' perimeter, CLEANING Roof or Siding 501 sq ft to 1,000 sq ft, Cover 21' to 30' of Fascia or Rake with Aluminum, Clean 251' to 350' of Gutter, Minor Tuckpointing and Watersealing of Chimney less than 5' in height, Strip -off and Re- Shingle 2nd Story Bay Window Qty x $763 ea = $ 3 Remove & Replace up to 1 Bundle of Shingles, Stepllash/Counterflash 6' to 10' of Wall or Chimney, Remove & Replace up to 10' of Valley, Install 31' to 50' of Drip Edge, Install up to 20' of Ridge Vent & Ridge Cap Shingles (Baffled or Rolled), Lead Flash Chimney up to 8' perimeter, CLEANING Roof or Siding up to 500 sq ft, Cover 11' to 20' of Fascia or Rake with Aluminum, Install Dryer Hose Connection & Flash through Roof, Strip -off and Re- Shingle 1st story Bay Window, Clean 101' to 250' of Gutter, Install 51' to 100' of Ice & Water Barrier Qty x $612 ea = $ 2 Remove & Replace up to 1 bundle of Shingles, Stepflash/Counterflash <5' of Wall or Chimney, Install up to 30' of Drip Edge, 10' or less of Gutter or Fascia Replacement, Clean 31' to 100' of Gutter, Cover 10' or less of Fascia or Rake with Aluminum, Install Rubberized Crown on Chimney Cap, Install Stainless Steel Cover on Chimney Flue, Install 21' to 50' of Ice & Water Ranier, Remove & Reinstall 1 Soil Boot Qty x $427 ea = $ 1 < • •f Certifications, Gutter Cleaning up to 30', Install up to 20' of Ice & Water Barrier Qty x $179 ea = $ M, Replace Rotted /Damaged Decking, as needed, at $3.47 / sq ft Qty x $3.47 = $ Shingle - CLOSEST MATCH: Roof Pitches greater than 6/12 Add 30% = $ Brand: �? n Excess Build -Up of Moss & Mold Add 30% = $ 'O / Color: T HoIIh I./ (intl) 3rd Story Roofs Add 20% = $ Other Services: - (t0 Y - - • L° w _ ' 1 5 $ ;,70 7b 3 o � k � • _ . 1 a .ee. •■ ,_ • $ Notes: ' yt a/ aS Sub -Total $ 1V� Diagnostic Fee S 99.00 Total Due $ 1 4,7 ) y Down Payment Due Today $ f ° 1) L- Balance Due Upon Completion of Job $ .>"00 I hereb auuthhorize you to proceed with the above StraightForward Price X Specialist Print Name: 1,f 4 r(11 C Thank You! - Massachusetts - Department of Public Safety 9 Board of Buiidiu Regulations and Standards License: CS 70626 AL ADAM A QUENNEVILLE y 160 OLD LYMAN RD _ S HADLEY, MA 01075 �-'G-- y'- Expiration: 8/21/2013 ( onnni Try: 21002 =�1 Office of Consumer Affairs and usiness Regulation -- _ 10 Park Plaza -Suite 5170 " _.. Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 120982 Type: DBA Expiration: 3/25/2014 Tr# 222024 ADAM QUENNEVILLE ROOFING ADAM QUENNEVILLE 160 OLD LYMAN RD SO. HADLEY, MA 01075 - - Update Address and return card. Mark reason for change_ DPS-CA1 0 50M- 04/04- G101216 ❑ Address 0 Renewal 0 Employment 0 Lost Card r 1` r %- " ." r =mow , . - � v ,-- . ;' k i " = = i' ` i i .' - rt ! ,� 1 � . , � `E� /+�v � � ,fir ) ., � 4` {{. s r.� `^ f'�L-:�,. , 4t r D z �5 � (: ..: :: ryr � : \ s .£ --, .r} 4 -ef ea•..'.. r� - : •y l �• : ' ! ' tc Ar - f * ry c a �i '�i�F °tr t r - yt t � C ' _ � + t S TATE OP CONNECTICUT 4- DEPARTMENT OF CONSUMER PROTECTION Be it known that I - . 1 1 --5 ' ADA QUENNEVILLE 1,-->- _ 160 OLD L1 AN O.AO _ == 1 K r� _ , S OUTH. - F1 Y t?fFA 01075 2632 c a j J T is certified by the De arri�ient f Co I rptection as a registered i. HOME ®' IEN" CONTR ACTOR , Eti.,,..._ i Regis aG0575920 r � • -- _ E"°C r - - .ADAM QUENNEVILLE ROOFING 'th 1l - +- , Effective_ 12/01/2011 � _ 1 Expiration: 11 /30 /2012 . , ., , William M. Rubenstein, Commissioner - - A' '',& .,' s r -^r *'-../01)- k. r-1� 44 - - 3 N k Ll K �,,' - '' ' `' }t~ y r 1r'. r l'''• "K :F. £ F Ii ' ; jr K r jr . - , ,r'`'S :` c ` ;' 9 . S „,,,&”, ' ., . tom. �' iii 9f ;-'."-,'"-i's � . 'Ca ig2.�v `a `A .. ��_.s, fl�e= ' 'ti J \ • /.9� . s 1 �� L. l `ti _i ����i _r� ■ U:. VS :-=UL.: WED 14: .:h FAX 4L351boUiU Rem11tar0 Ins. Agency I jUkJ''I)U. • ----"No ADAMQ -1 OP ID: LL A CORD DATE (MM/DINYYYY) C CERTIFICATE OF LIABILITY INSURANCE 02/08/12 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 BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: if the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in Lieu of such endorsement(s). PRODUCER CONT 413- 538 -7862 _ NAME Linda Landry FieldEddy Insurance 413- 538 -7179 PHONE 413-63 8 -7862 a , Ne 413- 538 -6010 79 Lyman Street _IALC lo, E> ( ) ;South Hadley, MA 01075 ADDR linda fieidedd .com RIA Agency Financed Account . — • INSURER INSURERA AFFORDING COVERAGE , NAIC N INSURER A• AIM Mutual Insurance Company INSURED Adam Quennevllle Roofing g INSURER a :Hanover Insurance Company - 22292 Siding Inc 1 60 Old Lyman Road INSURER C: • South Hadley, MA 01075 INSURER D : INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: - REVISION NUMBER: THIS IS TO CERTIFY THAT 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ,'INSR jADDL %IBM ! POLICY EFF POLICY EXP LTR TYPE OF INSURANCE i_INSR YYVD 1 POLICY NUMBER l (MMIOD/YYYY)1(MWDDIYYVYI LIMITS GENERAL LIABILITY I j EACH OCCURRENCE I S i COMMERCIAL GENERAL , PREMI E $ aocc occurrence. - i I PREMISES�aoccurrenco) ; $ - ■ I CLAIMS -MADE ! OCCUR I MED EXP (Any one person) I $. I ! , . . PERSONAL B ADV INJURY I $ i j GENERALAGGREGATE $ GEM . AGGREGATE LIMIT APPLIES PER I PRODUCTS COMP /OP AGG a $ POLICY . '��' JECT LOC f --- --- ----- ' - - - -' ( I $ AUTOMOBILE LIABILITY I COMBINED SINGLE LIMIT ,._ -- . I (Ea accdent) $ ANY AUTO ! BODILY INJURY (Per person) t $ . - ALL OWNED j ) SCHEDULED I BODILY INJURY (Per accident) $ AUTOS - AUTOS NON - OWNED I PROPERTY DAMAGE -- - - _ -- - - -- -- HIREI)AUI OS AUTOS ! , accident) _ $ i I$ I UMBRELLA LIAR 1 ' OCCUR 1 I EACH OCCURRENCE $ EXCESS UAB I 1_ ! CLAIMS-MADE _ _ ! I AGGREGATE $ . OED I I RETENTION$ j I I S A • 1 I B 'Equipment Floater f !IHN7140610 01/01/12 01/01/13 'Rental 100,000 Ded 500 DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule. 11 more space Is required) CERTIFICATE HOLDER CANCELLATION WINRESI SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ' ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE G a / ; o��.� � I © 1988 -2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD • A i p CERTIFICATE OF LIABILITY INSURANCE DATE(MM(DD/YYYY) 4i27i2012 TIIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS C RTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT cT Lynne Methot, Ext. 102 NAmE, Foley Insurance Group Inc. (A/C. ), (413) 214 -7474 I FA No): (413) 219 -7447 37 ;Elm Street ADDRESS: ( lmethot @foleyinsurancegroup . com INSURERS) AFFORDING COVERAGE NAIL # West Springfield MA. 01089 -2703 INsui A:Peerless Insurance Company 24198 INSURED INSURER :Safety Indemnity 33618 Adam Quenneville Roofing & Siding Inc. INsuRERc:Scottsdale Insurance Co. 160 Old Lyman Road INSURER D Associated Industries of MA INSURER E : South Hadley MA 01075 -2632 INSURER F: COVERAGES CERTIFICATE NUMBER:CL1222306204 REVISION NUMBER: ' THIS IS TO CERTIFY THAT 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDLSUBR POLICY EFF POLICY EXP LIMITS ,QTR RisILAYD YW POUCY NUMBER (MM(DDIYYYY) (MWDD/Y1 GENERAL LABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES ((Ea enaai) $ . 100;000 A 1 C(AiMS -MADE I X I OCCUR ;7, 6912267 6/23/2011 6/23/2012 MED EXP (Any one person) $ 5,000 — PERSONAL&ADVINJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEM AGGREGATE LIMIT APPUES PER: PRODUCTS - COMP /OP AGG $ 2,000,000 7 POLICY 1 1 JFCOT- 1 1 LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 B X ANY AUTO BODILY INJURY (Per person) $ — ALL OWNED SCHEDULED 6215480 11/1/2011 11/1/2012 BODILY INJURY (Per accident) $ _ AUTOS _ AUTOS HIRED AUTOS AUTOS ED PROPERTY DAMAGE $ AUTOS (Per accident) — PIP - Basic $ UMBRELLA LAB X OCCUR EACH OCCURRENCE $ 5,000,000 C x EXCESS L AB CLAIMS -MADE AGGREGATE $ 5,000,000 I DEB I X RETENTION$ 10,000 X1,80080268 2/22/2012 6/23/2012 $ D WORKERS COMPENSATION X I WC STATU- f -IOTH- AND EMPLOYERS' LIABILITY TORY LIMITS l ER , ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N AWC7012861012012 0 4/29/2012 04/29/2013 E EACH ACCIDENT _$ 1,000,000 OFFICER/MEMBER EXCLUDED? I N I N/ A .L. (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POUCY UMIT $ 1,000,000 DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (Attach ACORD 101, Additional, Remarks Schedule, 5 more space's required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE , Brian Foley /LYNNE 1`'"^ �j�s ACORD 25 (2010/05) © 1988 2010 ACORD CORPORATION. All rights reserved. INS025 nnlnfl5)ni Th. A(:npn nmmo.nrl Innn =ram rnnietornrlmnrlrc of A(_nPf • The Commonwealth of Massachttsear Department of Inclustrial Accidents 's1= `"=-"` `� Office of Investig ations s 71e i 600 Washington Street `• "'., . — ` Boston, 02111 www mass.govfdia Workers' Compensation Insurance Affidavit Builders / Contractors /Elecfxicians/Plumbers Applicant Information Please Print Leeibly Name (B : A tit vik OttlA rl,t1/ 1 g kOO All t S (V61, . L rl C Address: i a O1 c it t i ( n a M/. city/statem : 64.1 ,4 k nV A- O/ 74hone l 3 - C54 - 61 ss A.re you an employer? Check the tr te bor Type of 1. I: ant _It r . with ■ if general _ contractor .N.. project Il f 1 _ and/or part-time).* X1_1 . attached sub-contractors 6_ 1:3 New constructio . 2. ■ .Ili - .1^ proprietor 1 : r or partner- t J hie ■ Remodeling These sub-contractors bave g- Cl Dclapiiii° ship and have no employees . worting for me in any capacity. ! 0 Buikiing . Id t 1 . comp_ insurance,: (No worlass' comp_ insmance 5_ 0 We are a corporation and its 10-0 Electrical tepairs or additions _. )1 _I 3. ■ am 11 I• �/ •' .,.• doing r officers have .. e i _1 their ■ ll/ r 11 - repairs 1' additions right accomplice' per IviCiL myself [No wrakers' (=DP- 12. 21 Roof repairs , and von have no yl camp_ 13_0 Other 5k employees. [No workeas' insurance / `Any applicant that checks box 11 meat also fill out the section bclvw showing their worksrs♦ annixosaLOI policy infirm. f Homeowners who submit this tnlbdavit indenting they as doing all work asd that hire outside contractors omit submit a new affidavit iodiartiag arch LContractas that check this boat mast atbehed an additional shed showing the name of the sabosedractoss wad state whetter or not those entities have c m p i o y e s. I f t h e sub - contractors have e a o p l o y e r s t h e y m a t t provide t h e i r wvrlrere c o m p . po t r I am an employer that isprotn g workers' compensation insarartce for ray employees. Below is the policy and job site information_ insurance Company Name: fir M m u to &I I / I ca r an cfh_ Policy # or Self -ins. Lic //�� #: !"l U) C 1 O 1 , i (p 101 Expsaion Pte: ' - a 9 13 Job Site A d d r e s s : _' 6 ► , ► / i , — . Flo r n 1 '' t y s t a t /Zip :. 6 /O 4 Attach a copy of the wo •1 -' peotsation 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 mapasit m of criminal penalties of a fine up to 51, 500.00 and/or one-year imprisonment, as well as civil penalties in the form ofa 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 Ofie1 of Investigations oldie DIA for insurance coverage verification. Ida hereby catijt under the paints and' penalties of perjury that the inform :lion provided above is titre mid correct Signature: 7A--.1.- Datue: 6— /L / 6 Pte, it: q 1 5- 6 S Cfficinf rise only_ Do not write in this aver;, to be compliers,' by criy or tams: o tai d 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 Applliiccable ❑ Name of License Holder : Ada yr !� 1/1-e / l,Q jj + d - ` L License Number 16o did 1, ia ?d, Sau4 -/i :�, ��o�� s -aI -, 1 Address Expiration Date Sig re Telephone .9 Regis eredn . omexiriiprovemen ` ontractor.. Not Applicable ❑ Adam Quennevilk Roofing & Siding, Inc. 0-6 c Company Name 160 Old Lyman Road Registration Number South Hadley, MA 01075 3 — �S— r Address Expiration Date Telephone 03- C-6 DJ5 SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M G 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 ❑ ® o ea- x Winer j ti 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 imilicable) = New House ❑ Addition ❑ Replacement Windows Alteration(s) I I Roofing n Or Doors D Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [(_] Siding [0] Other [[] 5//i c;1 } r Brief D-.cription of Proposed /1 < 1 J J Work: f IA /. l A.' -e / %l. / /' a i� d / /, %. £ / f / CQ [ $ J Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet 6a l y[ ew h "ouse4al d.orvaddition to°.existinq housing, court ete t. a #or owtnq: 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 7 = OWNER AUTHORIZATION . T O BECO ED MPLET WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR B UILDING PERMIT I, �r�� fin as Owner of the subject property hereby authorize Adam Quennevdle Roofing & Siding, Inc, to ac on my behalf, in all matters relative to work authorized by this building permit application. 6 - 16 -13 - ignature • Owner Date Adam Quenneville 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. /ida ata V i t Print Name / Signature of Owner /Agent Date • ., Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information b Existing Proposed Required by'Zoning This column to be filled fa by Building Department ° ' Lot Size I H 1 Frontage ; ? € , Setbacks Front i t 1 Side L: t� -�i R:` $ L I R:' ! Rear Building Height i Bldg. Square Footage 1 t l Open Space Footage % (Lot area minus bldg & paved S i parking) # of Parking Spaces Fill:_ i I ._ ______ _ _______ (volume & Location) l I A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DONT KNOW 0 YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 IF YES: enter Book ( I Page! and /or Document # B. Does the site contain a brook, body of water or wetlands? NO 0 DONT 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: i C. Do any signs exist on the property? YES 0 NO 0 IF YES, describe size, type and location: P D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO 0 IF YES, describe size, type and location: 1 i 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 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. �., . R �_ -__,_ Dep a us only 'VED itv of Northampton S.ta us`` `fPemi m w � uilding Department C rr y a P rmit - > / 1 '‚ 2012 / 212 Main Street Se` rl ehe =vatlabl I � w Room 100Ia er e a fabiii SF � N rthampton, MA 01060 °- R =" M inn 4i1 - 587 -1240 Fax 413 - 587 -1272 + i - s Other Specl 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 f r� Q h i Map Lot Unit 1 ( "x k ' �n 0 1 V ll /1 Q < +a '''" c+ `-'ti , one Ert =*: 'k + Qverlay Distric Ffm St Dstrict CB District -° SECTION .2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: Coro le, Anzo i ! f?�h d. r/C f- �nee 1 oio� Name (Print) Current MaiIir4 Address: 13' , S�'� ..i). /.. _ 'd Telephone . ��. � � /_ G�7 ?2 , / Signatur 2-W . 4f /3 -- &L / — ✓ 7 q 2.2 Authorized Aqent: Adam Quenneville Roofing & Siding, Inc, j /p o (j/ d t a A ,x. z �( Name (Print) Current Mailing Addss: Signature d/� 9 Telephone SECTION 3 .-ESTIMATED CONSTRUCTION COSTS`-' Item Estimated Cost (Dollars) to be OfficaI Use.OnIy completed by permit applicant 1. Building /7 (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construct on froir. (6) . 3. Plumbing Building Permit Fee 1 � 4 4. Mechanical (HVAC) 5. Fire Protection 6. Total= (1 +2 +3 +4 +5) (S Check Number'> This Section For Official Use Only Building Permit!Numb- Date Issued Signatue Building Commissioner /inspector of Buildings Date 668 RYAN RD BP- 2012 -1135 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 28 - 030 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- 2012 -1135 Project # JS- 2012 - 001942 Est. Cost: $4724.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ADAM QUENNEVILLE 070626 Lot Size(sq. ft.): 41991.84 Owner: Anzovin Carole Zoning: Applicant: ADAM QUENNEVILLE AT: 668 RYAN RD Applicant Address: Phone: Insurance: 160 OLD LYMAN RD (413) 536 -5955 0 SOUTH HADLEYMA01075 ISSUED ON:6/19/2012 0:00:00 TO PERFORM THE FOLLOWING WORK: remove & replace 1 sq shingles /remove 2 skylights 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 6/19/2012 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner