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24D-121 Mar 26 2014 7:20PM Realty Rate/VBC 4138250219 page 2 „ QUENNEVILLE WOOPwrs.Sol".WHIC aims i eD Oid lyirw Road•SoA Hafty.W 01(n 11 JM.NEw NOW 413436MS5 � enwr tnip�1100rw+ROannq M bm.l, 140000ma nn MA CWMftOffl Np&VOM L a..eMW VA 010MON N1200ft to ossfll+ue» bhweuar.MWMWNWSAW rdWrmah"L CTRrplserWwf6"M powtf„brnNirr-W._._� .Oshk _3126114 POW GOW vaby&**,g C-"V,I— M W. arse 20D KkV Et gib,2 Cosa.._.....� .--.. --f-awf ea"$n NOOMMAM M OIDW 'Wo 1MVr bkm NM�aoM else orN�opvpwri Proposal to furnlah mta InstaN do fo o to r adNk4W n par ahsar Iromrad tr N�9 nrwsd srd nR Indudso a poor. Valey Bukkig Company,Inc.wU supply inawims. Dwnpaler&pwmN ;1600.00 Roo!LMcr $4243.60 Price MCiudea permit,040 AM,fuN stop and re-roof,droppi g one chimney on Cads secdw and removing any old ardennas. Ask us about afforrkrbte bank fiosctreci>rg xlpeNarr.,anrra�mrana�rranfma-carpsin.ooaafwwrase.Yr dpsYor+wn...ea:AgiDw17�_57438D ) momw OF PrAPON NL:Vs aban Rte. 0 0aw yard artaert ar Down Pp*-%$$_I-WAD d ) rrrdseaq ant aro Muett aerstaa M an&*Av *d Om qw NM I tanraat re!br to eow q s1r1 alta,a+ aprr cusp **upon Oear PW-m M-M 20 oat:- �r DIWb21E 1 nr: 1111 "tNOW AOM0fiwrrw r (MPHare) Caaptwm w nrnand f or riaq%M drys ham stow doh ATI MnON NONNO NWL,rlao.cwmr rN p.rarert 6rlanaAgr ti rn.�asosw•n a release•raw ew m edr P�+Nr•�rmaww da6rtr s auu oaekg N tlroush rtr�doa rl ti�a Moo.MaiN GoasttoNNs rMrdlnO,��bo P, VA' br erYAr or dart to**serge or acsea4p seem The Commonwealth of Massachusetts a � Department of Industrial Accidents =' Office of Investigations 1 1 Congress Street, Suite 100 jj Boston. MA 02114-2017 www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/lndividual): Adam Qnennede Rooh Q lot ill Siding,lot Address: f 4a 0 00� City/State/Zip: /0'75 Phone#: 43-53L,- SyS5 Are you an employer?Check the appropriate box: Type of project(required) 1 al am a employer with 1S _ 4. ❑ 1 am a general contractor and 1 employees (full and/or part-time). have hired the sub-contractors 6. New construction 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g. ❑Demolition wonting for me in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp. insurance comp.insurancel required] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions F1 I am a homeowner doing all work officers have exercised their 11.❑ umbing repairs or additions + myself. [No workers' comp. right of exemption per MGL 12. 00f repairs insurance required.] c. 152, {+1(4),and we have no employees. [No workers' 13.❑Other comp. insurance required.] •font applicant that chet:ks box WI mustalso till out the section below showing them workers'c�mpensati�n p ,icy inlonnation. t Homeowners who submit this affida,6t indicating they are doing all wo;k and then hire outside contractors must submit anew affidavit indicating such !Contractors that check this box must attached an additional shoe(showing the name ol'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 employee.-- Belmr is the policy and joh site information. Insurance Company Name:��ill #(,l_Ct, SL?►�Cl���+2... ___ �f a9 j 1 4 Policy#or Self-ins. Lie. #;_�}-(,)G qOC)`7 OJa�JaD1.3 A Expiration Date:_______ Job Site Address: ,�D© hg _City/State/Zip:4 0& / mp .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 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 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 und�the pains and penalties of perjury that the information provided above is true and correct. i afore: �/' D to 3 a`7�l y Phone# 4/3'53-k- A,5_5 tlficiai uce only. Do not write in thiv 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#: SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable £ Name of License Holder: Adam Quenneville Roofing&Siding,Inc. W 160 Old Lyman Road License NumIV Address f Expiration Date Signature Telephone 9 Re4isteredHomeamp ravemenfContractor ' Not Applicable £ —Ad2 ennnolla Radm ' ' l�n R�a- Compan a f Registration Number 160 Old Lyman Road _3 Jas-1) W Address South Hadley,NA 01075 Expiration Date Telephone N 13^S3 b S9 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 bu' ing permit. Signed Affidavit Attached Yes....... £ No...... £ Y l '.Nome U�ner sEzempt><on 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 ❑ Addition F Replacement Windows Alteration(s) ❑ Roofing Or Doors E2 Accessory Bldg. El Demolition ED New Signs [Clj Detcs "[C] Siding[C!] Other[o] Brief Descnfqion of Proposed Work: * �l.Qr 01YtD+ C .,LjCt PP i ► l` ?-a Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet sa If>Nevl `lio�lse and%or addition=t6 existing,4, umng, comple a the followlna: 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 C as Owner of the subject property r hereby authorize � V' to act on my behalf,in all matters relative to work authorized by this buildirt§permit application. Signature of Owner Date I. C • as Owner/Authorized Agdnt 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 nd penalties of perjury. Aarr, eri as 1, lls�- Prini Name Li .. 3 hQ)r y Signature of Owner/Agent Date Section 4. ZONING Alt Informatian Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning Tliis column to be filled in by Building Department Lot Size r t Frontage �- Setbacks Front ��� Side L:= R:!__._l r--� L:t_..._��� R:= Rear Building Height Bldg.Square Footage % Open Space Footage (Lot area minus bldg&paved azkin ) #of Parking Spaces Fill: -- volume&Location)1 A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DONT KNOW YES 0 IF YES, date issued:, I IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW Q YES 0 IF YES: enter Book [ I Pag and/or Document# B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained Q , Date Issued: ; C. Do any signs exist on the property? YES Q NO C( 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 IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading,excavaton,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. _ City of Northampton atusQ ,e Building Department @ �. 212 Main StreetY,rer/se R Room 100 Wi3ter�`life -A" a hampton, MA 01060 TwtxrS {s€ P 4 phS �o41 - 87-1240 Fax 413-587-1272 P[a/SitFlaxts APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH ON O TWO F MILY DWELLING L SECTION 1 -SITE INFORMATION jvv * Tfiis secfior�tQ b{etcorttpled�bj/�office� 1.1 Property Address: h � � �{ }� F ' '° ¢r r ` IUIB�� 5�� n� i>Qt 7M. t� r si1n)trt rh Distn�t� t SECTION 2.-PROPERTY OWNERSHIP/AUTHORIZED AGENT::. 2.1 Owner of Record: r. t/Q A'i ricl 00M42anq ,bf &'1CaylOt 1�I lw . fLA Djd3S Name(Prinu Current Mailing Address: qj Telephone Signature 2.2 Authorized Agent: Name(Print) Current Mailing Address: Signature Telephone SECTION 3 ESTIMATED CONSTRUCTION COSTS. . Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building (a)Building P.emmit Fee 7 43 &'Q 2. Electrical (b)Estimated Total Cost of Constructioh`from 6 3. Plumbing Building Permit Fee T 4. Mechanical(HVAC) 5. Fire Protection 6. Total=0 +2+3+4+5) 5 3 Check Number This-Sect ion For Official Use Only Building ermit Number Date g Issued: Signature: Building Commissioner/inspector'o#Buik))ngs Date 200 KING ST BP-2014-1011 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 24D- 121 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-2014-1011 Project# JS-2014-001742 Est. Cost: $5744.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Groin ADAM QUENNEVILLE 070626 Lot Size(sq. ft.): 11586.96 Owner: VALLEY BUILDING COMPANY INC Zoning: HB(100)/ Applicant: ADAM QUENNEVILLE AT: 200 KING ST Applicant Address: Phone: Insurance: 160 OLD LYMAN RD (413) 536-5955 O Workers Compensation SOUTH HADLEYMA01075 ISSUED ON:41412014 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 Occmancv Signature: FeeType• Date Paid: Amount: Building 4/4/2014 0:00:00 $55.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner