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ZZ, D A. , VISA Mc.) DISCOVER
Q U E N N E V I L L E www.1800newroof.net
ROOFING ■ SIDING ■ WINDOWS We Are Licensed
160 Old Lyman Road • South Hadley, MA 01075
1.800.NEW ROOF • 413.536.5955 Fully Insured '
Email: info@1800newroof.net Website: www.1800newroof.net Factory Trained
MA Construction Supervisors Lic. #070626 MA Registration #120982 Factory Certified Installers
Member of the Home Builder's Association of Western Mass. CT Registration #575920
Member of the Building &, trade Association P.P.C. 38710 .
Pr 0 posal Submitted To: ate Phone #'s C: LA I -JO ._ `1 $
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Street Email: '
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City, Sta e, Zip Code Special Requirements:
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❑ Recover _rip L_; Layers
Complete Roof System _ ^\
We shall acquire all appropriate permits for all work \-r \`_% )\�\\
• Home exterior and landscaping to be protected c
e Strip existing roofing to existing decking and dispose of. Do not Do. (trc--\'` cv61S
rE Deteriorated existing decking will be replaced at $3.47 per sq.ft. after full inspection.
Li Install Ice & Water Barrier at . d,' " alleys,40. , f 'pes } d skylights
Z Install (151b. felt / ynthetic nderlayi ten Over remaining decking area
• Install Metal drip edge at eaves and rake (8" 5 ") (white /brown /copper)
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N-Install manufacturer's starter shingle on all eaves and rake edges BBB
K Install new pipe boot flashing (standard /copper) / vents •-
.-N Install Snow Country or Copra rolled vent ridge venter Winner of the
2010
❑ Install proper soffit ventilation TORCH AWARD
Shingles: ( 6 nails per shingle)
L :A \ Shingles 1] 25 year ] 30 year E] 50 year Color (-- h (C e cn \
C; A\ Ridge cap shingles
Warranty Options:
,<We guarantee our workmanship for 10 full years (see our warranty coverage)
❑ GAF System Plus warranty `
❑ GAF Golden Pledge warranty
Chimney Options: ' OA milt -.)
• Lead Counter Flashing ❑ Water Seal & Tuckpoint ❑ Rubberized Crown ❑ Metal Chimney Cap
We propose hereby to furnish materials and labor - complete in accordance with above specifications for the sum of: Total Due ($ 1 / 7 (
� l./ )
ACCEPTANCE OF PROPOSAL: The above prices, specifications and conditions are Down Payment ($ )
satisfactory and are hereby accepted. You are authorized to do work as specified. - v ��
Payment will be 1/3 down at start of job, and balance due upon completion. Balance Due Upon Completion ($ / 7 )
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Date: I `t' 1 3 7 Signatt 22,— ) ' �",
Date: ? / / I Estimator: (Print Name) �Cj`31-\anc ' e Jtt Ile (Sign Name)
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.
s_, _ The Commonwealth of Massachusetts
Le . Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston; Mass. 02111
www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians /Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual) : Adam Qnennevile Roofing & Siding, Inc,
Address: i & O 0 ! ci �� illa vl f Oa cI
City /State /Zip: �j()L( i 147161 !—e i f I N'�, fr Phone #: i-I-13 - ,�'� 3 (.; - .. q65
J c) / 015
Are you an employer? Check the appropriate box: Type of project (required):
I . X 1 am an employer with 1 4. I am a general contractor and 1 6. Li New construction
employees (full and /or part time).* have hired the sub - contractors
2. I .I 1 am a sole proprietor or partner- listed on the attached sheet. 7• Li Remodeling
ship and have no employees These sub - contractors have 8. ' ! Demolition
working for me in any capacity, employees and have workers'
o workers' comp. 9. "i Building addition
[N p. insurance comp. insurance. +
required] 5.11 We are a corporation and its 10. Lt Electrical repairs or additions
3. til I am a homeowner doing all work officers have exercised their
m myself 1 1. i1 Plumbing repairs or additions
y [No workers comp. right of exemption perm MGL
insurance required] t c. 152, § 1(4), and we have no 12. i Roof repairs
employees. [no workers' 13. LI Other
comp. insurance required.]
*Any applicant that checks box NI must also fill out the section below showing their workers' compensation policy information.
+Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:Contactors that check this box must attach an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If
the sub - contractors have employees, themust provide their workers' comp. potty number.
1 tart an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information. _
Insurance Company Name:A riM Pi uti_&, 1. rI5 Li. ee Li-AR-010
Policy # or Self -ins. Lie. #: A U1 C, '7O / A-�� /0 1 Expiration Date: /:
Job Site Address: t- 0 k) 1 I WAS A City /State/Zip: N of '1(1 .4"1,I(j• ` K - (
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration (date).
Failure to secure coverage as required under Section 25a of MGL 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
$250.00 a day against violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the
DIA for coverage verification.
I do herby certify under the pains and penalties of perjury that the information provided above is true and correct.
t
Si nature: Date: / L i 13
Print Name: MAW! O LLD "i nt ✓ ► I L
I kL Phone #: i 3- 536- , Cf S
Official use only Do not write in this area to be completed by city or town official
City or Town: Permit/license #:
Issuing Authority (circle one):
1.Board of Heath 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 Applicable ❑
Name of License Holder : Adam Quenneville Hoofing & Siding, Inc.
License Number
160 Old Lyman Road
� p ,3
Address !'
South Hadky, MA 01015 Expiration Date
Signature Telephone
9.4kegistered Home ImorovementContractor . Not Applicable ❑
Adam (*aeevill. Roofing & Sidi:, lit /0q
Company Name 160 Old Lyman Road Registration Number
South Hadley, MA 01075 + ` 3) V) /4
Address l/ Expiration Date
Telephone /I3 -536 "-
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 A No ❑
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 1083.5.1.
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 \ (' 1 -
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House n Addition n Replacement Windows Alteratiarl(s� I t Roofing
Or Doors D
Accessory Bldg. ❑ Demolition n New Signs [D] Decks [d= , '' Siding [O) Other [D]
•
Brief Description of Proposed , f � �Q�,
Work: mwG� 0 — [ P, �' d-C- a r /Lep 1/� o W K O _
Alteration of existing bedroom U 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 lousing, 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, Cl/1 'bQY)Ot.k2f , as Owner of the subject
property f ^ _ e ;� (?
hereby authorize ln J , nria4, /L IOC'
to act cn my behalf, in all matters relative to work authorized by thi uilding permit Akplication.
‘.5,(Le CO-A4-1a,ut- qi4b
Signature of Owner Date
I, nt i 0,01 ( e i CCI; 14 1 J5{�r 1 I C , as Owner /Authorized
Ag hereby declare that the statements and inforftfation on the fore6joing application are true and accurate, to the best of my knowledge
and belief.
Signed under the p ns and penalties of perjury.
u I (Q
Print Name
4)4 /13
, Signature of Owner /Agent Date