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32A-218 Nov -08 -2010 06:00 PM Remillard Insurance 1 - 413 - b38 - bull zi( ACORD CERTIFICATE OF LIABILITY INSURANCE OP ID LL DATE 11 ) �09 0 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 LAM iA01 NAME: Remillard Insurance Agcy, Inc -: CI Ext): FAX No): 79 Lyman Street ADDRESS: South Hadley MA 01075 --PRODUCER- CUSTOMER ID ts: ADAMQ -1 _ Phone:413- 538 -7862 Fax:413- 538 -7179 INSURER(S) AFFORDING COVERAGE - NAIC INSURED INSURER A: First Speciality Ins Corp Adam Quenneville Roofing &, 1NSURERO: Travelers Ins. Co. Siding Inc. & Adam Quenneville — — - Roofing Inc & GutterShutter INSURER C: 12T( Mutual Insurance Compaay Of Western an I NSURER D: Ha nover Insurance Com an 22292 16.0 Old Lyman Road t? Y _..__ South Hadley MA 01075 INSURER INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO 11.19 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 - - - -"_ - -- - ADIxsuBF - FULILY POITCYECP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER (MMIDDlYYYY) (MMIDD/YYYY) LIMITS GENERAL LIABILITY I EACH OCCURRENCE ! $ 1000000 DAMAGE 1 U MEN I tU - -" A X COMMERCIAL GENERAL LIABILITY IRG9 8 4 4 1 06/23/10 106/23/11 PREMISES (Ea occurrence) $ 100000 CLAIMS -MADE lXl OCCUR i MED EXP (Any one person) I $ 2500 PERSONAL 8 ADV INJURY $ 10 0 0 0 0 0 GENERAL AGGREGATE $ 2000000 GEML AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $ 2000000 POLICY r PRO- 1 LOC $ JECT AUTOMOBILE LIABILITY COMBINED SINGLE UMIT $ 1000000 I l (Ea accident) B 1 ANY AUTO BA7450L946 11/01/10 11/01/11 BODILY INJURY (Per person) $ ALI.OWNED AUTOS - - - - - - BODILY INJURY (Per accident) $ X SCHEDULED AUTOS PROPERTY DAMAGE 2( HIRED AUTOS (Per accident) i $ X ! NON•OWNED AUTOS $ $ ' UMBRELLA LIAB OCCUR EACH OCCURRENCE S I EXCESS LIAB CLAIMS -MADE AGGREGATE $ - - _ --- DEDUCTIBLE $ RETENTION 5 $ - --- C WORKERS COMPENSATION AWC701286101 04/29/10 04/29/11 X WC$TATU- X OTH- AND EMPLOYERS' LIABILITY YIN TORY LIMITS ER ANY PROPRIETOWPARTNERIEXECUrIV I E.L. EACH ACCIDENT $ 1000000 OFFICER/MEMBER EXCLUDED? N / A - - - -- (Mandatory in NH) E.LDISEASE - EAEMPLOYEE $ 1000000 1/ vyos, curibo nder "— '--- - - - - -- - _ DESCRI u OF OPERATIONS below 1 E.L. DISEASE - POLICY LIMIT $ 100000 0 D Equipment Floater i IHN7140610 02/01/10 1 02/01/11 Rental I Equipment $100,000 DESCRIPTION OF OPERATIONS / LOCATIONS if VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE ADAMQUE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Adam Quenneville Roofing & Siding. AUTHORIZED REPRESENTATIVE 160 Old Lyman Rd. South Hadley MA 01075 O � I a� ©1988 -2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009109) The ACORD name and logo are registered marks of ACORD 7-- % !._� _ - � :Room , � o ars o .u " eguYons and tans are s l ' One Ashburton Place Room 1301 `i + t (e Boston, Massachusetts 02108 Construction' Supervisor License : License CS: 70626 Restriction: 00 • Birthdate: 8/2111 - 971 . Tr�i 3 Expiration: 8/21/20 /2011 ADAM`A, 'QUENNEVILLE 1'60 . OLD LYMAN RD . S;'HADLY MA 01075 — • ?Y - r i - Office of Consumer Affairs and usiness Regulation f 10 Park Plaza - Suite 5170 Boston, Massa' usetts 02116 Home Improvement _,'.),l ctor Registration =---�. ;_,._,.. Registration: 120982 " Type: DBA ( EIz := Expiration: 3/25/2012 Tr# 293069 ADAM QUENNEVILLE ROOFING I m�� \ ';:,\ AAM QUENNEVILLEs = - -- -- 160 OLD LYMAN RD =, �'' SO. HADLEY, MA 01075 = ? - " .., . f Update Address and return card. Mark reason for change. ❑ Address E Renewal E Employment ❑ Lost Card DPS -CA1 ) 50M- 04104- 3101216 S TATE OF CONNECTICUT + DEPARTMENT O . , ' PARTMENT O-F CONSUMER . ri .4 Be it known that j ADAM QUENNEVIT' TT, t. • 160 OLD ROAD SOUTH `.. y 075 -2632 i is certi b y th e D ep " _ n ∎ J i i -i n tect as a registered i HOME IMPRO: , '' l **. • Regi �_ "' l ., .a 0 1 • f rRA,vsr ��''" 4 , ADAM QUENNEVILLE ROOFING ' i Effective:12 /01/2009 Ir... I Exp 11 /30/2010 "` � -c- r - i . • The Commonwealtk of Massachusetts ` Department of Industrial Accidents =:`114 =1 of lavt>gatfotits �' 600 Washington Street �' Boston, MA 02111 www.gnfa/dia Workers' Compensation Insurance Affidavit: BuUders/Contractors/E bens Applicant Infonnatioa Please Print Legibly A • Name ): a i ■■ t ' . t - ' tl • a i ' a (IC Address: t ()id L pa a r, City/State/Zip: SO 6/181,E'.v /�� Q t05 l'hone #:I•1 a 43( S 7 - Are your an employer? Cheek the appropeinte tor: Type of P (required): 1.154 Ism a employer with !'J` 4. 0 I am a general contractor and 1 6. ❑ New construction employees (full and/or part - time).* the Subs 2. ID 1 am a sole proprietor or partner- limbed on the attached sheet. 7. 0 Remodeling ship and have no employees These s � have S. ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building' addition gyp, : required.] comp. insurance 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3. El I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or addllio s [No . comp. right of exemption per MGL 12 ,Roofiepairs insurance required.] t e.1 e es. ' e no - 13 t3 Otter instance] *Any *Oast t t h a t checks box ill mss also sn out the section b e l o w showing their w idoen' eospemetion policy iafoemua s. t Hoimeodraas who sobs* ibis affidavit adman day ate doing all weld and theahies maids c ot:act= nmt sdimitaa aw oddest iosaratiogasca SCoertaamathat cloak dish= oast attaeiedaa addiriomt shoe showiegthe rare ottheaabooatraetera andamtrwheadratsot those entities hese employees. if th sub-conascion huge employees, they mart p ins $her ' comp. policy somber. I art at employer that is providing workers' compensation bargna ce fbr s employee.. Below b the policy sold jab site f Insurance Company Name: f } 1I A /4 u k-u a t J r rut °�. / Policy # or Self -ins. Lic. #: 0 WC, r10 1 ,49, t 1 ©1 Date: / a 9 /, f t lob site Address: ) 6 F1641 Goo A S f 0 t 4 m o-bt\, M City/State/Tap: City /: o n o 60 < Attach a espy of the workers' essapensatism policy declaration page (sly the palfrey amber a■d rapiratise irk Failure to secure coverage as tired under Section 25A of MGL c. 152 can load to the won of criminal penalties of a foe up to S1, 500.00 and/or one-year imprisonnsent, as well as cdvll 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 cm of this stment may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby awe tourer tit amipenalties ,fperfsriy that the Wan nest= provaintabove b Urge s den nw . Signature; , Date: 1 1 aq - ) 0 Phan #: L ela - 53(0 - 3 - 9s-s_ Official toe only. Do not write In Buts area, to be elated by dby or town official City or Town: Permit/License # Labs Authority (circle one): 1. Board of Health 2. Boolding Departa3emt 3. CitylTown Clerk 4. Electrical Inspector 5. Ptmsbing Inspector 6. Other Contact Person: Phone #: A DA Name Cast. # Date GIUENNEVILLE f d (Cf7 c` 1/ 2r)_ _ C) /6 ROOFING & SIDING, INC. Street Address City State Zip 1.800 NEW ROOF /6 / ' ar c Cc k. , SI ' • tt4 413.536.5955 1800NEWROOF.NET Home Phone # Work Phon # " E -mail COMMERCIAL ■ RESIDENTIAL C-6'Y,c' -.Q - i 5'7 ' L — „j'I G�, � 160 Old Lyman Road • South Hadley, MA 01075 L. I hereby authorize you to proceed with the diagnosis fora minimum charge of $ � 5 7i i C k �._ . StraightForward Pricing® Replace 4 SQ of shingles, Stepllash /Counterllaoh -11' n, 50' of wall. Replace 51 I to 7 (15 01 valley, Rehash 10 2s chimney. Construct cricket and hush 3' to 0' wide chimney. Roof Of SIdur CICafIII 2 .001 sq 11. .1.000 011 11 ('I<er fascia or rake w ith Aluminum 51' - 65' Replace 22-30 slates. Quantity x $1637 ea = Replace 3 SQ of shingles. Steptlash /Counterllash 31' to 40' of wall, Replace 41' 111 6 i0' 0f valley. Retlash 16' to 21)' chimney, Install 71' to 110' of ridge vent, Roof or Siding cleaning 1.501 sq. R. - 2.000 sq. R. C fascia or rake with Aluminum 41'- 50 Replace 16 -20 slates. Quantity x $1277 ea = Replace 2 SQ of shingles, SteplLuh /Counterllash 21' of 30' of wall. 111011111 51' to 5 0' or l nt. Replace 31 to 40' of c ttztLoh or repur0c up to 2 Customer Supplied skylight tno interiorulut worn) Install 250 to 350' 01 drip edge, Rehash 13 t0 16' loot chimney, Root or Siding cleaning 1_010 sq. 11. - 1,500 sp. R. Cover fascia or rake w ith Aluminum 31ll-40' Replace 1 ) -15 slates. Quantity x $839 ea = Replace 1 SQ of shingles. Steptlash /Counterflash 1 I'to 20h of wall, Install 31' to 50' 4 of ridge vent, Install 21' to 30' of valley. Clean 251 to 350 of gutter, Retlash q' to 1 chimney (perimeter) or small stone chimney, Replacement or customer supplied skylight (no interior trim work). Tear off and re- shingle 2nd story bay window. Install 101' 10 200 of dripedge, Root int 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 = Relltt0h up to R' perimeter chimney_ Replace 1 Io 2 600(110, of shingles. 3 Stcptlash/('ountcrll;.uh 10 1(1 o1 wall. Install 51' to of cit. edge. 11101011 410 5 hat vents. Dryer hose connections, Replace up 10 15' of valley. )car off and re- shingle 1st story hay window. Install tip lu a0' 01 ridge cent. R1inor tuckpointing and 00 alenealing 01 chinm p t<3' in height). Re-stepping 0nd Icc(uarll 2'04 skylight. installation of curbntomat skylight. ('101111 150' to 250' of gutter, Install 5l' to IO7' of drip edge. Cover fascia or rake with ;Aluminum 11' -20', replace 4 -0 slates. Roof or Siding Cleaning up to 500 sq. R. Quantity x $559 ea = Soil boot replacement, Replace up to 1 bundle of shingles 00 up to 20 shingle tabs, 2 Stepflashing /Counterflashing less than 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, Retlash 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 Gu11er cleaning tup to 30 t Quantity x $159 ea = (Add 30% for roof pitches greater than 6)12) Custom Request Quantity x $ ea: = Quantity x $ ea: = Quantity x $ ea: = Recommendation ' ? t'p k t c-c rto a rxJ J 'co t- --ge,Vr p v i ' .47-rA Wag -- e 1, , ep6 r k !k cr I hereby authorize you to proceed with the above StraightForward Price” of $ /, 5 /, cci X �- _ __ Paid via: Cash, Check (# '192 Credit Card Diagnostic Fee = MC, Visa, AE CC# Exp. Total Due today $523 ,eFo Work performed to my satisfaction Scheduled Arrival Time Actual Arrival Time Thank You! y= P Submitted To / � Date and A D A Alt /.1/r /". C r'f °r, •/ ( ? //242•_ Street mu Q JENNEVILLE ROOFING & SIDING, INC. C= /tNc:"a( ollcSVER City, State, Zip Code 160 Old Lyman Road, South Hadley, MA 01075 1. 800 - NEW -ROOF • 413- 536 -5955 Phone #'s r " ! 10 s 12 - L Email: info@1800newroof.net Website: www.1800newroof.net MA Construction Supervisors Lic. #070626 MA Registration #120982 te' r324.- / 2 7: Member of the Home Builders Association of Western Maas. CT Registration #575920 Dumpster Location Member of the Building & Trade Association Member of the Better Business Bureau DH EV CV TW DHP Double Hung 3-Lite ------- End Vent 3 -Lite Center Vent Twin Double Hung Picture w/2 Double Hung Flankers , , i , ' ,, ,,,. 1 , ,i , in 1,,,,,,. , )<? ,\ ,,, . , ,, , 1, 1 , t f y, t lr t l 1 7 , it . III III Woodgrain Interiors Vinyl Color Product Code Grid Styles NA1 1 = Natural Oak WI-1 1 = White HS 1 H ryshore 51 I = Standard 5r8" RP 1 Regal Peamete' GO -- Golden Oak CA - Camel SB 1 Seab oak. P(; - Regal Colonial RE 3 1 - Regal Florentine CC = Colonial Cherry ET I = Earthtone NE Northeast G = Gregorian 1 1.16" 011- - Hegal Florentine Elongated WW I _ White Woodgrain W - Williamsburg 11 113 R64 i = Regal Prairie i2 passes; i B 1 -Then Brass BAY BOW 4 BOW 5 BOW 6 GARDEN 1 [F, 11. 3 I z 3 d 5 'i ` 4 5 1 I l i I �'`f� 1II ' Woodgrain Interiors Wood Options _ Vinyl Color Product Code Grid S les ' Glass Options NAT 'I = Natural Oak BIRCH WH - -White A - Aurora ST Standard 6/8" ' = G I Gregorian Stay-Clean Glass Cartel GO = Golden Oak OAK • CA , - RC 1 - Regal Gnds - Williamsbur g Regal Glass CO TR 1/3- 1/3 -1/3 TR 1/4- 1/2 -1/4 QUAD Operating Casement Single -Frame Equal -Lite Single -Frame 1/4- 1/2 -1/4 Single -Frame 4 -Lite Triple Casement Triple Casement Casement & I 6� 1 I 11 (I 1 li Existing Window New Window Existing Window New Window ' T ! Measurements 1 Measurements I 1 Room /floor "Code" Metal "Code" l "Code" V Width Her ht Opening I W Location i Style Metal Style Series 1 O Hugh O ht UI pen ng LLI Location I Style Metal Style � le Series - U - o - 1 --- 1 " V Width 'Her 4 t lh f 5 � : H Room /Floor Code Y/N "Code" 1 Code 1 ._, 1 ` "Di! I S` ? 5 - fi _ _ - :,: 'CZ- I_ l 1 — I a 7 , ,D t i- ■ I 1 1 t_ - Color of Color of Window / Door Wrap (AA 1-C_ Window / Door Wrap We Propose hereby to furnish materials and labor complete in accordance with above specifications for the sum of: Total Sale Price $_- . .( ; C !..t , CC: Down Payment $__ /A(/+~ c� Upon Completion $_3 C.0 ACCEPTANCE OF PROPOSAL: The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do work as specified. Payment will be 1/3 down upon signing, and balance due upon completion. Unpaid balances shall accrue with interest at 18% per annum. Purchaser(s) will pay for all costs, expenses and reason- able attorney's fees incurred by Adam Quenneville Roofing and Siding, Inc. to recover any sums due under this contract. / Date ll 4.L . _ Signature �_ j Phone # Date: L --!tit. Salesperson's Sign s are honored fo sixty (60) days from above date Please remove all breakables from interior wall surfaces during installation. AQR &S will not be responsible for damage. ) 9 1 itmig ritia,od 4; 'ppm osno(fr, iptvg Aeo i In !AM! '.fteig 'Ono OnwocI lot lowthir oic. SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: & l Not Applicable ❑ nev Name of License Holder : Adam Qoil& Rook & Inc. 0 G (o 160 OW Lyman Road License Number Address Sod ��' MA 01975 c ' a ∎ - c Expiration Date (13- S3C -s9 Cs Signature Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ Adam Queuevile Roohg & Siding, Inc. i a.o 4 00- a. Company Name 161 Old Lyman Road Registration Number South Hadley, MA 01075 3 - as 1 Address Expiration Date 1 1-- --" Telephone 'Yi 3 S5 - 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 Ica 6 1144 Kotnig ±q(' yptOtaltm ;;!: SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) J Roofing Er Or Doors ®� Accessory Bldg. D Demolition ❑ New Signs [0] Decks [p Siding [0] Other [0] Brief cription of Proposed k V' Work: Loafv. K c Qoo oASe.con Flsoco. kety vektge,v5+; w ^l a. , J Sa ri b - meows 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, (`e� \f.— Z G (' f , as Owner of the subject property Ain Quartile & Siding, Inc, hereby authorize Ain ! bf to act on my behalf, in all matters relative to work authorized by this building permit application. iI - LO Signature of Owner Date Ada Nude R i nIcc. , as Owner /Authorized Agent hereby declare that the stat nts and ormation on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. / aa.wrt Print Name Signature of Owner /A t 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 411. YES IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 111 YES 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 ® 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 IF YES, describe size, type and location: E. Will the construction activity disturb (clearing, grading, e cavation, 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. • Department use only City of Northampton Status of Permit Building Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans phone 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 j G 1- (anco S t Map Lot Unit N o c a.4( O4 , f A 0 t o G o Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: I . occr`cA- Z t' % +o. 14 Nar co 5+. NocArt,awtp}o 04,6% Moan Name (Print) Current Ma slot Addreaq n Telephone Signature 2.2 Authorized Agent: Ail Wag ICo CIA c R. Sou +�,u.,,,a,► ,Ma Blo),s Name (Print) Current Mailing Att?iress: y13 - s36 -Scrs Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building W 1 Q (a) Building Permit Fee I 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) ' 7 1 I7I.Gd Check Number /ftli/97 This Section For Official Use Only Permit Number: Date Building Issued: Signature: Building Commissioner /Inspector of Buildings Date ro c sr BP- 2011 -0513 GIS #: COMMONWEALTH OF MASSACHUSETTS :32A. 218 • 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 -0513 Project # JS- 2011- 000835 Est. Cost: $7171.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ADAM QUENNEVILLE 070626 Lot Size(sq. ft.): 4486.68 Owner: PIETRA LORENA ZURITA DELLA Zoning: URC(100)/ Applicant: ADAM QUENNEVILLE AT: 16 HANCOCK ST Applicant Address: Phone: Insurance: 160 OLD LYMAN RD (413) 536 -5955 () Workers Compensation SOUTH HADLEYMA01075 ISSUED ON:12/2/2010 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT WINDOWS /REAR 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 12/2/2010 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner