24D-131 (3) Mar 26 2014 7:20RM Realty Rate/VBC 4138250219 page 1
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The Commonwealth of Massachusetts
Department of Industrial Accidents
a OJf1ce of Investigations
1 Congress Street, Suite 100
Boston, MA 02114-2017
�l www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print LeBibl
Name(Business/Organizaton/ndividual): Adam Qede1e ROOg ng&Sidiog11nc. �
Address: f 4P 0 QI Jmc�
City/State/Zi JC75 Phone#: y13'S3(,- S9S5
Are you an employer?Check the appropriate box: Type of project(required)
I al am a with employer 5 4. 1 am a general contractor and I
�— 6. New construction
employees(full and/or part-time).* have hired the sub-contractors
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, F] Demolition
employees and have workers'
working for me in any capacity. 9. �Building addition
[No workers' comp. insurance comp.insurance.
required] 5. We are a corporation and its 10.❑Electrical repairs or additions
ED am a homeowner doing all work officers have exercised their IL[] lumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12 oof repairs
insurance required.) c. 152, §l(4),and we have no �
employees. [No workers' I3.[] Other
comp. insurance required.)
°An% applicant that checks bos#I must also till out the socuon below showing their workers'comix-nsation policy in onnation.
t liomeowmrs who submit this affidavit indicating the% are doing all wc.;k and then hire outside contractors mast submit a new affidavit indicating such
:Contractors that check this bos trust attached an additional sheet showing the name o1'thc sub-contracture and state whether or not those entities have
cntployees. If the suh-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees )3elme is the policy and joh site
information. 1 t _
Insurance Company Name: 11 #�1Ct 1 :L)S iran u.Expiration Date: 4 aq .114
Policy#or Self-ins. Lic. #:_4I,UG'�OD�1 01-1(�'(c I o�1.D1,3�_-_________ P
' r '/ � 1`
Job Site Address— kqo r— ��' _City/State/Zip:)0)4}ao,AA 3�,Mo-
attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as regtrired 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 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 andpenalties ofperjury that the information provided above is true and correct.
Si, afore A—, Date
Phone#: J413-53 Sq, �
t)fficial use only. Do not write in this area, to he 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 Quene-d"Ii RUd1mart A Cidinrt I e 10
6 License Number
160 Old Lyman Road 11a)-
Address on a y, Expiration Date
q 13 - rSyS
Signature Telephone
9 ment Coritractr
.Rgiserd i Not Applicable £
Adam 0-1000149:110 2fififing& la-OCIS
lit
Com a Registration Number
160 Old Lyman Road 3�a-s- 11(0
Address South Hadley,IWA 01075 Expiration Date
Telephone `i 13 -�b"�`1��
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 uilding permit.
Signed Affidavit Attached Yes....... £ No...... £
ll: .�Iame Owner Fgempton<
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 pen-nit.
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 [] Replacement Windows Alteration(s) Roofing
Or Doors
Accessory Bldg. ❑ Demolition New Signs (C311 Siding(0] Other[0]
Brief Des tion of Proposed ,� 1
Work: Lpmt)v< d- /LQ_!')I�-�2 rT�'�Q Q - SjU►1�1D
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa-tf.Neuv house anti or a ddition fo exisfinc :h"ouslng .complete the fol[owma:
.._... j: .;fish+ « . • .
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. floodpiain 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, as Owner of the subject
property
hereby authorize W_ .n n _U'f j IV- rRoC) Yl�i `��t`c�0►�4 -7�1C
to act on my behalf,in all matters relative to work authorized by this Wilding permit application.
Se P Ccrn47&'C-� -3 �1q
Signature of Owner Date
1, 11t i
Tt* as Owner/Authorized
Age hereby declare that the statements and infornration on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Sig d under the p*s and penalties of perjury.
i'tin#Narne v41 — . ...
31)-7) q
Signature of 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:I_.�:j R:L.
Rear
Building Height C�
Bldg.Square Footage
Open Space Footage %
(Lot area minus bldg&paved
parking)
[� 1
#of Parking Spaces
Fill: -
(volume&Location)
A. Has a Special Permit/Variance/Finding ver been issued for/on the site?
NO 0 DONT KNOW YES 0
IF YES, date issued: 1
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW Q (YES 0
IF YES: enter Book L Pagel_ _ i and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW e YES Q
IF YES, has a permit been ar 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
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,excay don,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES Q NO 'e-11001
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
City of Northampton s�afilrmtr i -
Building Department
212 Main Street vererl5plcrar
Room 100ate ¢e �atla loll y �
Z ,•,� ampton, MA 01060wS st�v qtr `a P. _�
- 81-1240 Fax 413-587-1272 `Pt0 t15�[a.
PRO
��ecAP � ATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH ON20, TWO F MILY DWELLING
SECTION 1-SITE INFORMATION =
E This sectJ o taYbTe co plefedb`officer
1.1 Property Address: -
s`"' -a ?-' F' dam" + , +
Maps 3 ��� Lo� -�-�3��t ��1rIi1�
c LEO one
4Y
SECTION SECTION 2.-PROPERTY OWNERSHIP/AUTHORIZED AGENT:
2.1 Owner of Record:
�Q.11e � '� 1c9.�►�► �rn�-r�u L 0 �c4 d q& lAadW . j'k A G103S
Name(Pri _j ng Adl�dlress:
Telephone
Signature
2.2 Authorized Anent,
,its IIZ06 4 S dj , mow- )Lt) old Wman 0, .& Aeot" . �h�1 vlut�
ame'(Print) Current Mailing Ad ess:
Signature Telephone
.SECTION 3-ESTIMATED CONSTRUCTION COSTS.
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building (a)Building Permit Fee
oa
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection At 0M
6. Total=0 +2+3+4+5) 9 ao Check Number
This Pot Official Use Only
Building ermit Number. [late
g Issued:
Signature:
Building Commissloner/inspector.'of Buildings Date
22 HOOKER AVE BP-2014-1006
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24D- 131 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Categorv:ROOF BUILDING PERMIT
Permit# BP-2014-1006
Project# JS-2014-001259
Est.Cost: $4399.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ADAM QUENNEVILLE 070626
Lot Size(sq. ft.): 10541.52 Owner: VALLEY BUILDING COMPANY INC
Zoning: URC(100) Applicant: ADAM QUENNEVILLE
AT: 22 HOOKER AVE
Applicant Address: Phone: Insurance:
160 OLD LYMAN RD (413) 536-5955 Workers
Compensation
SOUTH HADLEYMA01075 ISSUED ON:41312014 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 4/3/2014 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner