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17A-160 (3) .,. _ The Commonwealth of Massachusetts *1 . 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 Quennevilte Roofing&Siding,Inc' — -------------- ----------- — --- -- Address:_ i IP 0 0 �j ,YIC0/1 �C a cl c \ , T Phone#: i j F �q4-;‘)C t � [ 2 � [ %tiJ / — -- L')iD' -s� — j Are you an employer?Check the appropriate box: Type of project(required): II. 'j I am an employer with � 4. _ I am a general contractor and I 6. New construction employees(full and/or part time).* have hired the sub-contractors 7. , Remodeling 2. I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub-contractors have f 8. Demolition working for me in any capacity. employees and have workers' q Building addition [No workers'comp. insurance comp. insurance.+ required] 5. We are a corporation and its 10. Electrical repairs or additions 3. i am a homeowner doing all work officers have exercised their 1 1. Plumbing repairs or additions myself [No workers' comp. right of exemption perm MGL insurance required] t c. 152, § 1(4),and we have no 12. Roof repairs employees. [no workers' comp. insurance required.) 1 13. -- Other 1 — � *Any applicant that checks box#1 must also rill out the section below showing their workers'compensation policy information. llomeowners 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 em to ees,the must 9 rovide their workers'corn . ion(( number. I ant an employer that is providing workers'compensation insurance for my employees. Helms,is the policy and job site information. Insurance Company Name:__A rIn_ i�tit`4...1 .1.n5tt rC411 e _._._._ -- ------- -- I Policy #or Self-ins. Lic. ti; ! 90 i Ab lo 1 Expiration Date: '•f`;9161—4716 Job Site Address:) ._FOX_ _'( ___k —.---- City/State/Zip: Fio?e., _1110_ 010663- 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 tine 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 $250.00 a day against violator. Be advised that a copy of this statement maybe forwarded to the Office of investigations of the DIA for coverage verification. 1 do herby certify and the pains and penalties of perjury that the information provided above is true and correct. �Sif Signature: �� Date /T �Lyi 0La E1 f1L V i him Name: Ili /'hone i# / 3_�� ( 6--c-16)-`� Ofcial use only Do not write in this area to be completed by city or town official City or Town: _ _---� ---_� Permit/license#:� _! ._.— Issuing Authority(circle one): I.Board of Heath 2. Building Department 3. City/Town Clerk 4. Electrical Inspector S. Plumbing inspector 6.Other Contact person: Phone#: L \1 DJ t_ me..4 DISCOVER QUENNEVILLE ' ROOFING ■ SIDING ■ WINDOWS 6 A 160 Old Lyman Road•South Hadley, MA 01075 BB B 1.800.NEW ROOF • 413.536.5955 Winner of the Email: info @1800newroof.net Website:www.1800newroof.net 2010 MA Construction Supervisors Lic.#070626 MA Registration#120982 TORCH AWARD Member of the Home Builder's Association of Western Mass. CT Registration#575920 Member of the Building&Tiede Association Proposal Submitted To: y Date S- 17-/3 Phone#'s C: C cGk� -�l /�'ovs) / H:9/3 S-70 0a /:� W: Street Email: _�$ /-- c X FIG r�S �A G City, State,Zip Code Job Name/Location: _7—/N1(f) c f' /2 t2 CI 0 6,2- Proposal to furnish and install the following ( E, v c. -s 1, riei 5 /' -s a h _6 t, J <-) s/de s E,_(` -1 h % f- C C V r--1 e! S fA 4 .5 JI 1 cy i+c� e i5f S-t' 6 1 4(,'-),,-) /,7 0J 9�e�/�'r'/ /4>/1 ell t // f �4 " ' CO v a.1 r ,,CA i .%-s /S'/ /2t'Gu _i© /. L t / cD4 S' h i A S-/r S 4), �-J, _3C ` 0 _I ✓(�,f- ei �.( �� f i C— / f" r,J e r k 6',r s h ,n C✓4>%/1-3 /? . t A ,. Ask us about affordable bank financing We propose hereby to furnish materials and labor-complete in accordance with above specifications for the sum of:Total Due($ f, 8'0 c2 ) ACCEPTANCE OF PROPOSAL: The above prices,specifications and conditions are Down Payment($ E,00. ) satisfactory and are hereby accepted.You are authorized to do work as specified. Payment will be 1/3 down at start of job,and balance dueApon co on. Balance Due Upon Completion($ /9 ©0 ) r 1 !. 1 + > 'z; . Date:Date Signature:__ / Date:S a/7 ./-3 Estimator: Print ame -ft:-, P/ " f ( ) .� �j sc,v'ry (Sign N.••_ _� 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: License Number Address Expiration Date Signature Telephone 9.Registered Home Improvement-Contractor Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone 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 ❑ 1 Home Owile Exem ption 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 applicable) ,. .x New House n Addition [1 Replacement Windows Alteration(s) n Roofing J Or Doors D Accessory Bldg. Ti Demolition 1 I New Signs [D] Decks [I-t Siding[DI Other[D] Brief De : iptiop of Proposed C-1' • Work: Jobe; t', /_lL ! . ' " '' _ .1. o`�� w 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, b i-T v S K--{' , as Owner of the subject property hereby authorize 'wki re\ ., / 0 i t .� , q_. .... is % . to act on my behalf, in all matters relative to work authorized by t • building permi application. 6/5/l3 Signature of Owner Date Ana.e,.�"c �" .. a . "+�°. 7. _ e •-:i r° - , `0 a s fit..�`�' V9! i ueno id TO1rs z�--: ct.0i'� t ,p?C- , as Owner/Authorized A /tAaJYi b declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge 9 hereby and belief. Sign d under the pain nd penalties of perjury. rint Name �L,- 1,0 JcJi 3 Signature of Owner/Agent Date Section 4. ZONING AU Information Must Be Completed.Permit Can Be Denied Due To Incomplete Information Existing . Proposed Required by'ioning 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) i #of Parking Spaces ----- — — Fill: (volume&Location) — -- • -------' — -`-°--` A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO Q DONT KNOW 0 YES 0 IF YES, date issued:. IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW Q YES Q IF YES: enter Book ` Page i and/or Document#' • B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW Q YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained 0 , Date Issued: C. Do any signs exist on the property? YES 0 NO i • IF YES, describe size, type and location: 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: 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 0 IF YES,then a Northampton Storm Water Management Permit from the DPW is required. . 0 CD Department use only "i City of Northampton Status of Permit: RECEIVED Building Department Curb Cut/Driveway Permit ie. 212 Main Street - Sewer/Septic Availability JUN I +.. 20(3 Room 100 WaterllNel!Availability Northampton, MA 01060 Two Sets of Structural Plans DEPT.OF BUILDING IN,`:,PECTi one 413-587-1 240 Fax 413-587-1272 Plot/Site Plans • NORTHAMPTON,MA 01060 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 JS- x -2-rir-s 1QQd-- Map Lot Unit Zone Overlay District Efm St.District CB District -SECTION 2 PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record. 14 5 i CO b � sics 6x ray-01_ 7c4, Flo kcL, nuci ?Now- Name Print) Current lvtAlipg Address: L-A 6\` jo. Telephone Signature 2.2 Authorize Agent: Ca /al); ryl-Sicj.g ;..>c, )loo bid itii 12 ,-&.- �. , iliA cic7 Name(Print) Current Mail&Address: i% (----- 4/3 `:-36 -5,7-C- Signature Telephone SECTION 3--ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant - 1. Building p• ,k0L) 6th (a)Building Permit Fee ji 2. Electrical (b)Estimated total Cost of Construction from(6) 3. Plumbing Building Permit Fee - - 4. Mechanical (HVAC) - 5. Fire Protection _ � _CV 17 6. Total=(1 +2+3+4+5) ��d�� Check Number .� 9J 3 - - - This Section For Official Use Only — Date Building Permit Number: Issued: Signature: Building Commissioner/Inspector of Buildings Date 35 FOX FARMS RD BP-2013-1181 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17A- 160 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: ROOF BUILDING PERMIT Permit# BP-2013-1181 Project# JS-2013-001941 Est.Cost: $1800.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ADAM QUENNEVILLE 070626 Lot Size(sq. ft.): 17990.28 Owner: DITKOVSKI JACOB&EMILY B Zoning:URA(l00)/ Applicant: ADAM QUENNEVILLE AT: 35 FOX FARMS RD Applicant Address: Phone: Insurance: 160 OLD LYMAN RD (413) 536-5955 () Workers Compensation SOUTH HADLEYMA01 075 ISSUED ON:6/11/2013 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 6/11/2013 0:00:00 $35.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner