29-113 The Commonwealth of Massachusetts
Department of Industrial Accidents
!� : �
--.� �—.-. Office of Investigations
•1
4 4.1301===..... 1 Congress Street, Suite 100
Boston,MA 02114-2017
°f : 4' www.mass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Annlicant Information Please Print Legibly
Name (Business/Organization/Individual): Adam QIIeiinevl le Roofing&Siding,Inc,
Address: //PO OW ea cJ
City/State/Zip: OI0-75 Phone#: 531 C9SS-
Are you an employer?Check the app priate box: Type of project(required):
1.MI am a employer with Is" 4. 0 I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
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. 0 Building addition
[No workers' comp. insurance comp.insurance.:
required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.] t c. 152,§1(4),and we have no n
employees. [No workers' 13.®Other S 5 KtpailS
comp.insurance required.]
"Any applicant that checks box k 1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
Contractors that check this box must attached 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,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. _
Insurance Company Name: A M U-ki.a‘ .1-�loran co--
Policy#or Self-ins. Lic. #:/1U)C.Lice/0118w-0I?)A Expiration Date: 4 '"aZ9r���
Job Site Address: Ia c S)rn r►e>z A e J d 'lye,. City/State/Zip: F L C _ fitA 0It-n
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 c. 152 car 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 certify under the pains and pena ties of perjury that the information provided above is true and correct
Signature: (� � Date: 1 S1 i3
Phone#: LJ�3r 531,0"6`1-5-c
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 Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
yam Proposal Submitted To Date dab
Ma ter anti ��G.�G.rC .w SSt+.ry �'i�r(ifi�r 1
I� Street
ICI QUENNEVILLE uMmr� 'H�
, r
ROOFING & SIDING, INC.
DUK•VER City,State,Zip Code
' 160 Old Lyman Road, South Hadley, MA 01075 -� ����� r� ��
1-800-NEW-ROOF • 413-536-5955 Phone#'s * r - 3ar - (,3 n,r,:
Email:info @1800newroof.net Website:www.1800newroof.net
MA Construction Supervisors Lic.#070626 MA Registration#120982 H'�f f r SVLH 4_f I X30 W.
Member of the Home Builder's Association of Western Mass. CT Registration#575920 Dumpster Location
Member of the Building&Trade Association Member of the Better Business Bureau �C i uCw�
✓ .-. er. w s !�' „y z ^a _yam' ,""4yy 5 ,�^1. a
s
�s...,n*�,.,... .-,w� ,"��.,."�` =t'�cw� ?'er�.�'+,,az»,«a�..�,n.,.'�ikro�.d ���*,n�. "�n. �+ '';� .ir�Mrrul+ ... e�..<s%w .r�a�r m„xx�'��'��;
AREAS to be SIDED PRODUCT PROFILE CORNERS *COLOR*
-f-('r`6f AL A rc E
Front&1 Solid Core Clapboard ® Standard EXI Siding Ldf l'c';. CG`?en
Left Premium Pointe Dutchclap Outside Corners w fl r..l G`'`'.1
Back Market Square Designer” n
Right Shakes/Rounds Roughsawn INSULATION
NvT 3r'«' (X-rek Hand Split
Other Other-3 r l" '"" Rounds — 'White Only 3/8"1 I or Tyvek Ka
.,. t ddw a .»
«,,,. ....a ., ., 7:2;;Z:laMarItILIT:: 7,.w..,..,'Y' '
AREAS TO BE COVERED New Gutters&Down Spouts 3
Front Left Back Right *COLOR* (� Other Area
Soffit&Fascia -a h. h `,f e,�-,e d 0 k v,-, Yes No
Frieze Board' Q
Soffit Only
— — —. —
!ti!h 1�t
Fascia Only f
Tuck Fascia Color:
'New Gutters&Down Spouts to be
installed in existing locations,unless
'Cover Frieze board with: PVC Alum.Coil jai or Vert.Soffit Q noted below.
- -,.,.. t> I7177,. .ht- ,,.,,+.,.»x' ,. k`<o. «,�.. .. .... ..... ..w.. ..R,,..._s .727277,4"-
n*,etw*x._.
Qty ,� *COLOR* Qty Qty
/W
Windows/Doors h,,-T, Storm Windows Awnings up to 8'
Garage/Patio Door Storm Doors Awnings Over 8'
Double Garage Door -- Burglar Bars* Existing Shutters -7-
Build Out Frame
*In certain markets,Burglar Bars can be removed,but no reinstalled.
Yes No Q If Yes: Vinyl/Wood tt, Aluminum
°Only where new sidings is to be installed. Adam Quennevi e Roofing&Siding,Inc.will NOT femove asbestos material.
Y/N Double 5"Soffit H Color: GABLE VENTS
Front Beaded Soffit 5 Location:_— Qty *COLOR*
Left 5 White or Canyon Tan ONLY. Rectangle I oL
Back Y/N *COLOR* Octagon �
Right
Wrap Porch Beams
Wrap Porch Posts NEW SHUTTERS
IIIIIIIIMEK Y/N *COLOR* #of Pairs *COLOR"
Knee Braces H Louvred
Triangular Gable Vents Raised Panel
,, . ,„ Specify the locations: e r'«f- ,v-;r,-. 4,,,o,_..-- «,,1 r- r�r" (y,nc?uv Cranr_}
N a 7 r
C G c,x.„.,t'. , -,,,�ir.'�c_ e',r:.t n � rle:: i r-. �h `'- � :M r
W,e,dadd r,:-A,,, <7 " i\c,f, ---
I have reviewed and agree with the job specifications described above.
If rotted wood is discovered AFTER removing the existing siding,or if it could not be identified at the time of sale,
there will be an additional charge o $4.00 per Sq.Ft.for Plywoo nd$5.00 per Lin.Ft.for Dimensional Lumber.
ce �� r
Customer Signature: '� Date: Q 4 f f 7j
We Propose hereby t furnish materials and labor-complete in accordance with above specifications for the sum of:
1 .a C3. -3-1'?.)
Total Sale Price $ I, ■��� Cm Down Payment$ -3000 (00 Upon Completion$ Lo I 5(7) ('
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 inter t at 18%per annum. Purchasertsywill pay for all costs,expenses and reason-
able attorney's fees incurred by Adam uenneville ooffing and s,,nc.to recover any sums due under this contract.
/44, i-y... /ii, el. cl -iii, /
Date: ?i �( I 2) Signature: A� �-�., vv e# `=lt f. �)� /_t f! -
Date: 7"/d �1 " Salesperson's Signature. .r:t A ,.„,_,f ,/& -
Estimates are honored for sixty(60)days from above date
Please remove all breakables from interior wall surfaces during installation. AQR&S will not be responsible for damage.
Versionl.7 Commercial Building Permit May 15,2000
^
`.
SECTION 1 � � � � •
�- �.
. - „e�,
Independent Structural Engineering Structural Peer Review Required • Yes 0 No 0
SECTION !'`'
OWNERS AGENT OR CONTRACTOR APPLIES FOR.BUILDINGPERMIT :
/
, __________.aoDwmerof�eou�n�pmpo�'
�
_ .`
_ _ � _ __ __
/ to
hoebyau�o�e-____ -------------------'------ -------
act on my behalf,in all matters relative to work authorized by this building permit
application.[ --7
St-t_. | /
-~��� _
Signature of Owne � ` Date
_
__ __ ____
-� '
_____ 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_pequa,_._ .
����
/ |
As_____—
. ��/ 5�//3 ________'_—_--_-____-__-__
:Signature m Owner/Agent Date
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable []
Adailifeineville Ro41114 Siding-4 c.
'L .. (� ----- -----^
License Number
-__-� ^�
--- � --,r-- -~-'- Expiration Date
Address
q/
Z.:4 __�-_-_____--__
Signature Telephone
' , - / '
SECTION 13 §-25C(6))
Workers Compensation Insurance affidavit must be complete and submitte with this application. Failure to provide this affidavit will result
in the-denial of the issuance of the building permit.
�� K
_S�nedAffidovdAuachsd Yes �� No l
~_/
__'~^_ '-_-___-_--
'
Version1.7 Commercial Building Permit May 15,2000
SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTION,SERVICES-FOR BUILDINGS AND STRUCTURES SUBJECT TO
CONSTRUCTION CONTROL PURSUANT TO 780 CMR:116(CONTAINING. MORE THAN-35,000 C.F.OF'EILOSEO SPACE)
9.1 Registered Architect:
-- Not Applicable ❑
Name(Registrant): 9 _,.M.-u...�._._...�._ .._.___...._,.
Registration Number
•Address _.__.__.__. . .,_.._...m_._..._.__.___..__..._....
• """— Expiration Date
Signature Telephone
9.2 Registered Professional Engineer(s):
Name Area of Responsibility
Address Registration Number
_ �~
Signature Telephone Expiration Date �
_. f
Name Area of Responsibility
•
Address -- ,_
Registration Number ,___ Y _.
_.__._
Signature Telephone Expiration Date
Name Area of Responsibility
i
Address Registration Number
Signature Telephone Expiration Date
•
Name Area of Responsibility
Address _.___._._—_—_._._ --------_---- — Registration Number _.�__� _ .1~._
i
Signature Telephone Expiration Date
9.3 General Contractor
_ -.. ._,..__.-.--.-.-.__._-.—` Not Applicable ❑
: ..Adam Quean�vi�eoo do Sd . .._.
Company Name: �((�(�_ _ D,,a,__ ___
Responsible In Charge of Cons i
` Hadley;MA 01035u _._. .A _..__,.._._...._._._�..�__._.w.._
_Actoseas_ 4/„..._, 3 .sib SSSr__!
1 Signature Telephone - l
•
Version 1.7 Commercial Building Permit May 15,2000
S. NORTHAMPTON•ZONING ,
. Existing Proposed Required by Zoning .
. This column tote filled in by
Building Department
Lot Size __ ___.
Frontage
Setbacks Front —"
Side L:`,.... . R:..—.....: L::......._...._' R: __._.._._i .__ _.
Rear
Building Height _ :
Bldg.Square Footage ---- _--- % --_—
Open Space Footage ---- % . ____
—— (Lot area minus bldg&paved _____-j _-- ,_,,.
parking)
#of Parking Spaces
Fill:
(volume&Location) Lill-
_ ....__. ..._.._._-. ..,.._.....___._..__-______,_..,__..
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
- NO S 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
IF YES: enter Book ` Page; , and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO GI 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:
C. Do any signs exist on the property? YES 0 NO ED
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 Q NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
_
Version1.7 Commercial Building Permit May b,2000
SECTION 4-CONSTRUCTION.SERVICES FOR PROJECTS LESS THAN 35,000 4
CUBIC FEET OF ENCLOSED SPACE- .
Interior Alterations ❑ Existing Wall Signs ❑ Demolition❑ Repairs❑ Additions ❑ Accessory Building 0
Exterior Alteration ❑ Existing Ground Sign 0 New Signs❑ Roofing❑ Change of Use❑ Other I§ _516 ,��,�,
Brief Description 'Enter a brief description here. lZi2-tA evc old Si dzci g /LLp tet,t? to iv. tutu t'1yt-,
Of Proposed Work:E SRS ,
SECTION 5-USE GROUP AND CONSTRUCTION TYPE'
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A-1 ❑ A-2 ❑ A-3 ❑ 1A 1 ❑
A-4 ❑ A-5 ❑ 1B ❑
B Business ❑ 2A ❑
E Educational ❑ 28 - r ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C 0
N High Hazard ❑ -- - 3A ❑
I Institutional ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ 38 ❑
M Mercantile ❑ 4 0
R Residential ❑ R-1 ❑ R-2 0 R-3 0 5A ❑
S Storage 0 S-1 ❑ 5-2 ❑ 58 ❑
U Utility
El Specify:'
M Mixed Use ❑ Specify:
S Special Use ❑ Specify:
COMPLETETHIS SECTION IF EXISTING UNDERGOING_RENOVATIONS,ADDITIONS AND/OR CHANGE-1N USE
Existing Use Group: ___ __..__ _____...___._.,._.. Proposed Use Group: _ _..__._....__,.......______•_.___,_ _.
Existing Hazard Index 780 CMR 34): _
� _.._ __, Proposed Hazard Index 780 CMR 34):,?._M_.._..__._. __
SECTION.6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY
Floor Area per Floor(sf)
�� —
2nd .
3b • __ ._.,. 3b .
•
41h — 4 . ___ ...,._. ._ -.
Total Area(sf) ___ Total Proposed New Construction(sf) -
Total Height(ft)
•
_ .._ _ Total Height ft
7.Water Supply(M.G.L.c.40,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
Public ❑ Private ❑ Zone . __w_.,_ Outside Flood Zone Municipal ❑ On site disposal system
Version1.7 Commercial Building Permit May 15,2000
Department use,only
City of Northampton Status of Permit:
. _
\----, c t--, Building Department
r-':-=3---- 2013 ort212RoMoarnin iSotoreet 060
,,..•p — 6
1
1 , -
&Gas 1 sPe
leic"ic'Plumbing. MA 01060
g-14 3-587-1240 Fax 413-587-1272 Curb Out/Driveway Perrnit-L.-' . H :
_.
Sewer/SeptidAvailability . .
_ .
VVaterAiVell Availability , "
Two Sets of Shicturaf Plans
Plot/Site Plans
Other Spetify, - .
- CATION TO CONSTRUCT,REPAIR,RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address:
. This section to be completed by office
)X aPriknAtr-C;eick . s.■. Map Lot Unit
it&t2ILf—e— . MA 631()(° Zone Overlay District
CB District
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
_
:1)•:1101A.CA ---- q.-0 .a4-4
-.N—Cr-e-LL' '
13-Stl 0042-r-Qtle--1 — _r_t9,.1044
Name(Print) Current Mailing Address:
(413--54- q)CO
Signature - e...t. Telephone
2.2 Authorized A.ent:
ePir
Name(Print) Current Mailing Address:
4,(____
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building q I .0 OC ' (a)Building Permit Fee
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) 15.6 c)° , Check Number c?9030 41,5-5-
This Section For Official Use Only
Building Permit Number Date
• Issued
Signature:
Building Commissioner/Inspector of Buildings Date
12 SUMMERFIELD ST BP-2014-0297
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 29- 113 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: vinyl siding BUILDING PERMIT
Permit# BP-2014-0297
Project# JS-2014-000494
Est. Cost: $9150.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ADAM QUENNEVILLE 070626
Lot Size(sq. ft.): 12501.72 Owner: MARTINDELL RICHARD C& SUSAN TRUSTEES
Zoning: Applicant: ADAM QUENNEVILLE
AT: 12 SUMMERFIELD ST
Applicant Address: Phone: Insurance:
160 OLD LYMAN RD (413) 536-5955 () Workers
Compensation
SOUTH HADLEYMA01075 ISSUED ON:9/10/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:REPLACE VINYL SIDING
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 9/10/2013 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner