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35-051 (2) r yam' - - Proposal Submitted To Date iQ U E N N EV I L L E Street ROOFING & SIDING, INC. ` , City,State,,Zip Code 160 Old Lyman Road, South Hadley, MA 01075 ,,4A c iG'E 1-800-NEW-ROOF • 413.536-5955 Phone#'s Email:info @1800newroof.net Website:www.1800newroot.net MA Construction Supervisors Lic.#070626 MA Registration#120982 H:tY+51 Sri. Y3 E SJ 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 AREAS to be SIDED PRODUCT PROFILE CORNERS *COLOR* Front Solid Core Clapboard Standard �i ] Siding Left Premium Pointe Dutcnclap ® Outside Corners f Back Market Square Designer' 0 _ Right Shakes/Rounds Roughsawn INSULATION Qc c`4�✓ Hand A Split C 4® � i^ 13�kCK Other Other i� C k :zLTlth Rounds White Only 3/8"[:] or Tyvek Q AREAS TO BE COVERED New Gutters&Down Spouts' Front Left Back Right 'COLOR* Other Area Soffit&Fascia -. �k,i e Yes No Frieze Board: 1=N Soffit Only — Fascia Only —_ Tuck Fascia Color:__ 3 New Gutters&Down Spouts to be installed in existing locations,unless Cover Frieze board with: PVC Alum.Coil® or Vert.Soffit 0 noted below. Qty *COLOR* Qty Qty Windows/Doors j. Storm Windows ® Awnings up to 8' Garage/Patio Door Storm Doors Awnings Over 8' Double Garage Door -- Burglar Bars* Existing Shutters Build Out Frame —_ In certain markets,Burglar Bars can be removed,but no reinstalled. Yes No Q If Yes: Vinyl/Wood® Aluminum 0 Only where new sidings is to be installed. Adam Ouenneville Roofing&Siding,Inc.will NOT remove asbestos material. Y/N Double 5"Soffit a Color: GABLE VENTS Front Beaded Soffit 5 Location: Qty *COLOR* Left 5 W;)it,?or Canyon Tan ONLY. Rectangle Back Y/N *COLOR* Octagon Right Wrap Porch Beams Wrap Porch Posts a NEW SHUTTERS Y/N *COLOR* If of Pairs *COLOR* Knee Braces Louvred Triangular Gable Vents e Raised Panel Specify the locations: — _ 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 of$4.00 per Sq.Ft.for Plywood and$5.00 per Lin.Ft.for Dimensional Lumber. Customer Signature: Date: We Propose hereby to furnish materials and labor-complete in accordance with above specifications for the sum of: Total Sale Price$ !G� Down Payment Upon Completion $ 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. C, Dat&� ��. / Signature: � b� Phone# Date: 3 f f/1 y Salesperson's Signature._ _Z' i 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. Department of Industrial Accidents Office of Investigations 600 Washington Street wi Boston, MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Adam Quenneville Roofing & Siding Inc. Address: 160 Old Lyman Rd City/State/Zip: South Hadley MAO 1075 Phone.#: 413-536-5955 Are you an employer?Check the appropriate box: Type of project(required): 1.3 I am a employer with 15 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-timer) • have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for ire in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp.insurance comp.insurance.i n ] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself[No workers'comp right of exemption per MGL 12.❑Roof repair insuz==n9Wred.]t c.152,§1(4),and we have no 13.[ 'Other J i cLtr C employees.[No workers' comp.insurance required.] Any applicant that checks box 01 must ako fin out the section blow showing their workers'compauation policy information. t Hotndowners who submit this affidavit indicating they am doing all work and then hire outside contractors mutt submit a new affidavit indicating such. 3f-onnaetors that check this box must at- ad an addidenal sheet showing the name of the sub-contractm and suit whether or not those entities have errrployea. if the sub-contractors have employers,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees Below is the polity and Job site information. Insurance Company Name: AIM Mutual Insurance Policy#or Self-ins.Lic.#: AWC40070128612013A Expiration Date: 4/29/2014 Job Site Address: i too �a.m �0,R") City/StatcMp:�f U4\r-Ct 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 e. 152 can lead to the imposition of criminal penalties of a fire 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 orup to$250.00 a day against thtr violator. Be advised that a copy of this statement may be forwarded to the Office of Investistations of the DIA for insurance coverage verification. I do hereby certify under the Wins and penalties of perjury that the information provided above is true,,and correct. Sixnaturc• Date• — Phone#• 413-536-5955 Of ri al use only. Do not write in this area,to be compkied 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#• SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: Adam Quenneville CS-070626 License Num er 160 Old Lyman Rd South Hadley MA 01075 �ai 1� Address Expiration Date 413-536-5955 Signature Telephone 9.Ri64t61*d Home tmbiVyement Contractor: Not Applicable ❑ Adam Quenneville Roofing 120982 Company Name Registration Number 160 Old Lyman Rd South Hadley MA 3/25/16 Address Expiration Date Telephone 4135365955 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 - dome CJw>rer 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 SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House El Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors E] Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [0 Siding[If] Other[a Brief Description of Proposed Work: -1ZMh --_ Srrlahc /_what W'�� .S MLpi �Jhj� OUL'-P Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet sa.J '`N h& n` ,ad i ' 't© xis in h i! i e the f ]i win `: 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 Kenneth Dziuba as Owner of the subject property hereby authorize Adam Quenneville Roofing&Siding Inc. to act on my behalf, in all matters relative to work authorized by this building permit application. See Contmct aS I►�i Signature of Owner Date lYl GQJS �l C r 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. vti(.m Q C.il!ne.v , J�. Print Name as l Signature o Owner/Agent 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 Q DONT KNOW YES 0 IF YES, date issued:', IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW Q YES 0 IF YES: enter Book Page, and/or Document# B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained i Obtained 0 , Date Issued: C. Do any signs exist on the property? YES 0 NO 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 (D 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 G) IF YES,then a Northampton Storm Water Management Permit from the DPW is required. ii a i1 �-i 6 - City of Northampton > �� 3 �r 1 - Building Department 212 Main Street ` MR 6 ,. '! Room 100 r � a Northampton, MA 01060 � i �"4�w Al Elect p1 w4, -587-1240 Fax 413-587-1272 t ib l8lt aI It 'h ' ° ` " Il�gii('.a 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 9 0 �j„ � Q�� Map Lot Unit Zone Overlay District Elm St.Wstrict CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Kenneth Dziuba 960 Ryan Rd Florence MA 01062 Name(Print) Current Mailing Address: 4135864365 t✓t}h C-(-/ Telephone Signature 2.2 Authorized Anent: Ckin—(�en/u.tJ' .iU -1zo 4i"Q I-��G�p� , �lr . I(Po C, 61 hth Name(Print) / Current Mailing(Address: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by rmit applicant 1. Building 1.101 D 0U (a)Building Permit Fee 2. Electrical Q (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total=0 +2+3+4+5) 10,785 1 Check Number This Section For Official Use Only Building ermit Number: Date g Issued: Signature: Building Commissioner/Inspector of Buildings Date 960 RYAN RD BP-2014-0987 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 35 -051 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-2014-0987 Project# JS-2014-001709 Est. Cost: $10785.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use GroM: ADAM QUENNEVILLE 070626 Lot Size(sq. ft.): 14941.08 Owner: DZIUBA KENNETH Zoning: Applicant: ADAM QUENNEVILLE AT. 960 RYAN RD Applicant Address: Phone: Insurance: 160 OLD LYMAN RD (413) 536-5955 O Workers Compensation SOUTH HADLEYMA01075 ISSUED ON:312712014 0:00:00 TO PERFORM THE FOLLOWING WORK.-install 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 3/27/2014 0:00:00 $35.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner