35-027 (7) Jam,`� ISA v
QUENNEVILLE
ROOFING 'V SIDING Vr WINDOWS B88
160 Old Lyman Road•South Hadley, MA 01075 �.-_
1.800.NEW ROOF • 413.536.5955
Email:info 0 1 800newroof.net Website:www.I 800newroof.nat Winner of the
MA Construction Supervisors Lic.#070626 MA Registration#120982 2010
TORCH AWARD
Member of the Home Builders Association of Western Mass. CT Registration#575920
Member of the Building&Trade Association
Proposal Submitted To: Date Phone#'s C:
k t/ I/ t o� H:(,(/<� S 7U-0&y^ W:
Street / Email:
U yR /� �,. �G�1
City,State,Zrp Code
F6 rF /fI A
Proposal to furnish and install the following
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.S`Pe�
C, $1e/
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P117sir
Ask us about
affordable bank
financing
We propose hereby to furnish materials and labor-complete in accordance with above specifications for the sum of:Total Due($ 1"S7,01
)
ACCEPTANCE OF PROPOSAL: The above prices,specifications and conditions are Down Payment($ Vp.0 `c )
satisfactory and are hereby accepted.You are authorized to do work as specified.
Payment will be 113 down at start of job,and balance ue u n completion. Balance-Due Upon Completion($ 71 )
Date: II I j Signature:
Date:__ ( ) (Sign Name)
Estimator: Print Name �t
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
possibllky of roofing debris or dust coming in through cracks of the wood.Adam Quennevllle Roofing will not be
responsible for debris or dust In the attic or storage areas.
1ta- The Contnuni wealth of lti/u.oi'.,iuc•hu.+ett.r
Department o f Induslriul:t c'ciderrl.�
Offi(,.e of/it vea•tilratiort.c
00 fi'ushingtotr .S'treet
Boston, Mass. 02111
uv w w,tna,s,s.go v/diu
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A t blican( Ill forfrlatioti Please I'r inl Legibly
Adam uuennevlle Roofing Si(Jinq Inc
11!i11111' 111u�inc»I(br�;un Ldlnni/InJn ulu,ill -
Address, 160 Old Lyman Road
( ilk/Slalc/GiI): Souln Hadley MA 01075 413-536-5955
l llllnL'Il:
Arc you All employer' (.heck (he appropriate box: � f hype or-project(required):
x I ,1111 an employer with 15 A , I ;tin t�cnertl cruurtciur :ctrl I � I t: Nck� :(insloiitiurt
enytloyecs(lull andim earl 111110 ' have hired (he soh-CO+IUae7fars
7 RCI11l NJell11�'
I ;1111 a sole proprietor or parLtcr listed on the attached shed.
.hip and have art employees I hcsc sub-c mtrac(ors have ?. L>enurhiiuii
%—rking tar file iii am Capacity employces and have workers'
* '). i I3ufldut�;addition
jNo workers' cmiy. insurance comp. insurance. ,
rcqutrcdj S.i We are a corporation and its 10. I-aec(ncal rcpafrs('I addaltons
t I >im a homeowicr doing gill work oflicers have exercised their
� I I 1'lunthin� repair.r1f addlin)n>
nnsell' [No workers comp right o(exemplitm pens M(il,
iflcurance rcquiredj f c 1S2, II 1). ant) we havc n1t I.'. lfvul repatr>
employees- ono workcr:s-
I + (hhcr
cort(p. tnsurancc required.
s nv applicant that checks box 11'1 must also rill fill(the section below showing their workers'compensation policy Isformalioo.
tllotsreowaers who aobmll Ihb&Mdavit ladkating they are doing all work and then hire outside contractors must submit a new affidavit intlicatitig.uct1.
;e.nataetors that cheek Ihb box moat anaeh an additional sheet showing the name of the sub-cnntrarturs and slate whether or Wert those entities have rmpimer.. II
the soh-contractors have employees they must provide their workers'comp,O!Ucy aamber.
I ant an enrplorer that is providing workers'compensation irl.s'trrcrnce fir nnv emp/rrree.8. tlehrn,is the pulie'I'and joh site
ter fivrrrtution.
nvlrtnrc( f>tnpan Nance AIM Mutual Insurance
or Scll-n1s I�ic ;; A WS4007012861201 aA i 4/29/201,5
I:x trrtt(it]n Gale:
Inh\ucAJJress.
Attach a copy of the workers' compensation policy declaration pagie (showing; the policy number sand expiraIion (Ilale
I ,nlurc ill ,ecorc covcrnL;e ;ta rcrluired under SCltloll Zia of'M(d. 1�2 r:.ut lead to the nnpo�ition 1fl criulinal pC11� 11C> abet line
q, it, S1.500,00 and/ormlc %car imprisonmenl as well as civil pelialticti in the Karat o(a S 1'()I' WORK OIMI"N :(nil ;t line (it
,;2SU.00 it day against violator. Be advised thal it copy of chi's stalelllcnt milybe (orwvarded to the Ot'ficc of Invc;digallons of Ilie
Oli1 lur Coverage verilication.
I eta herhr cerfifr under the pours ar►cl penalties of perjury that the infirrmution provided above is true refire/cwrrect.
sr4nruru -...Ufrr`- �' I ll �.I
P/m/ �(illw ) Phone 'f c
Official use o►tlp Do not write in this area to he completed by city or town olficiul
( ilv or I 41w41: l'crntiUliccnse p:
Issuing;Authoritc (circle one); _ -
I.Itoard of[lentil 2. Ifuikling I)epurUnenl 3. C ity(fntvn ('leek a, Electrical tnsltertor S. I'lullthing Inspeelm
h. (ether i
( on(tact persort: I'hone b:
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Adam Quenneville CS070626
Name of License Holder:
License Number
160 Old Lyman Rd South Hadley MA 01075 8/21/15
Address Expiration Date
413-536-5955
Signature Telephone
9,Rea stired-Ham&lrhiiioirement Contractor;, Not Applicable ❑
Adam Quenneville Roofing 120982
Company Name Registration Number
160 Old Lyman Rd South Hadley MA 01075 3125/16
Address Expiration Date V4�� Telep hone413-536-5955
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...... ❑
IL -Home Owner 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 ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑✓
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [M Siding[❑] Other[❑]
Brief Description of Proposed AE M� n
Work: Strip dormer and install new asphalt roll roofing
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,exis066 hb6sinm complete the followina:
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
Michael Klatsky
1, , 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 Contract I(.
_ 11 1 t
Signature of Owner Date
Adam Quenneville 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.
Adam Quenneville
Print Name q
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 Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
of Parking Spaces
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DON'T KNOW G YES 0
IF YES, dateimsue& |
IF YES: Was the permit recorded at the Registry ofDeeds?
NO K � D
�� [—
IF YES: enter Book Page, and/or Document# /
��
B. Does the site contain abrook, body of water orwetlands? NO �J� DON'T KNOW �_� YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs tobeobtained ��� Obta�ned �~� Date \
�_� �_� ' . [__________]
C. Do any signs exist on the propert ��y� YES «�� 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,gradingexcavation, ur filling)over 1 acre nrinit part ofa common plan
that will disturb over 1acre? YESK��� NO
|F YES,then o Northampton Storm Water Management Permit from the DPW iorequired.
City of Northamptona
Building Department �
212 Main Streetr1
NOV 1 4 2GW Room 100 -�, � m
Northampton, MA 01060 � � � y � � �I� s�� �
lectric, f'iumbin &Gas I "
Northampton, MA oy�so 13-587-1240 Fax 413-587-1272 Of ile Pid,
I k r,
4tfteri�
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
1040 Ryan Rd Map Lot Unit
Florence MA Zone Overlay District
01062
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Michael Klatsky 1040 Ryan Rd Florence MA 01062
Name(Print) Current Mailing Address:
413-570-0842
Telephone
Signature
2.2 Authorized A/a'ent:
f—I rn �.X�-4Y1r�rtJ�1� ��pCj C��c L ��..�.✓� �� �t,`1. ttt �wtt�\�7
Name(Print) Current Mailing Addre :
I.5-S36 -515`�
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building 1,379 (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=0 +2+3+4+5) 1,379 1 Check Number (v
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
1040 RYAN RD BP-2015-0560
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 35-027 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-2015-0560
Proiect# JS-2015-001074
Est. Cost: $1379.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: ADAM QUENNEVILLE 070626
Lot Size(sq. ft.): 10890.00 Owner: KLATSKY MICHAEL
Zoning: Applicant: ADAM QUENNEVILLE
AT. 1040 RYAN RD
Applicant Address: Phone: Insurance:
160 OLD LYMAN RD (413) 536-5955 O Workers
Compensation
SOUTH HADLEYMA01075 ISSUED ON.1111412014 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL NEW ROLL ROOF ON DORMER
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 11/14/2014 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner