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17C-057 r The Commonwealth oj'Mussuehusetts Department of/ndustriul Accidents Office of Investigations lull 600 N/ashingunt .Street Hovott, Mass. 02111 w w w.rnass.go v/d iu Workers' Compensation Insurance Affidavit: Builders/Contr-,ictors/Fleclricians/Nlutttbers ,\pplicant hlformatioti Please Print L. ibl� Ad'arm Quenoevllle Rootin g & Siding Inc. Address. 160 Old Lyman Road CiIV/Sidle/%Ip: South Hadley MA 01075 Phunell: 413-536-5955 It re slou, areml)lo er with k the - h +e of ,ro eel (rec aired): r. Check the appropriate box: YI I .I 1 X l 15 4, 1 I ant a general contractor and 1 0. ! New construclum entplovees(full and/or part time)_" have hired the sub-contractors 7_ IZenxxlelind I tut, it sale proprietor or partner- listed on the attached shee,. ship and have no employees I-here sub-contractors have K. I)entoluion k%orking litr me in any capacity employees and have workers q. i Building addition No workers' comp, insurance comp. insurance. + reguiredl 5.1 We are a corporation and its 10. I Iaectrical repairs or additions I ;tilt it horncowner doing all work officers have exercised their i I I- P unahirtg repairs or additions na)sell (No workers' comp. right of exentpuon perm MGI, insurance required) t c_ 152. § I(4), and we have no 12. Kuofrepairs employees. (no worker,"I Olhcr C01111). insurance required.) ------------ ----- --- —--- --- - - - _ •\nv applicant that checks box#1 must also rill out the section btlow showing their workers'eomptassUion polity Information. Momtowntrs who submit this affidavit Indicating they are doing all work and then hire outside contractors most sohmit a new affidavit indicating.orb. tCosuetors that check this box most attach an additional sheet showing the name of the xub-contractors and slate whether or not those entities have rmplurees. It she sub-c nsraelors have employees Ihty must provide their workers'comp.polty isamber. I um an employer that is providing workers'compensation insurance fur my emptuYeex. Below is the policy rand lob site in fivmution. nsuruuc Company Nantr AIM Mutual Insurance I'rolicv n or Sell-ins. L.ic. i/ AWS40070128612014A f:xpiration Dale. 4/29/2015 )oh life Address V�) C �� l f brr Attach a copy of the workers' compensation policy declaration page (showitIg the policy nulnber alld ezpiralic,n (date). 1 ;ailtirc• to secure coverage as required under Section 25a of M(il. 152 can lead to the imposition ()l cnntinal pcnallirs ul ;t line u(o to $1.500.00 and/or one year imprisonment as well as civil penalties M the form of a STOP WORK OROI-:R and ;i tine of '5250.00 it day against violator lac advised that a copy of this statement maybe litnvarded to the OfIICC of InvcsligationS of the UI/\ I'orCoverage verilicatiun. l du herhy certi/j,under the prrirls and pertallies of perjar{,that the in Irmntiott provider)ohnve is true and cwt-rect. 1',tnt \aria. 1 I III i hung' 1; Official use o►►lt= Do not write in this area to be eoatpleted by c'ifl, or town official I t i1v nr town: Pcrntil/license li: � Issuirig Authority(circle tine): I.1loord of heath 2. Building Uepr+rintew 3. OtylVown Clerk 4. Electrical lospeclor 5. 1'IunlhinR lospeclor h. thher 1 onlacr person: 1'11unc tJ: _ QUENNEVILLE ROOFING 'W SIDING W WINDOWS 160 Old Lyman Road•South Hadley,MA 01075 1.800.NEW ROOF 413.535.5955 Email:infoG1800newroof.net Website:www.1800newroof.ret Winner of the 2010 MA Construction Supervisors Lie.#070626 MA Registration#120982 TORCH AW.kF'� Member of the Horne Builder's Association of Western Mass. CT Registration#575920 Member of the Building&Trade Association Proposal Submitted To: Date Phone#'s C: yi3- fit-�CGSr i sC f'YIC�CCt 1i 11 )y H: ihJ: Street Email: i-ra ckts�w� 5� City,State,Zip Code * Iocc ncc- (11 A Proposal to furnish and install the following &D Ovr., C'x limes r'o71 ,NJ cLJ toll rootir�e �cti4.�o1 � AjeLd �u II ice C.V. t1 1 f i d rUcr�i �Cr , Cali �'dc'i /"j t'jt,.s C� 7s k-,, 1�) a� 5 W C (' I 40—X, a/ Pno-i�CtclS v-fi� ,- P�tCt., �LI✓ cS C-x� � 1 Ct ►Vn c �11c� (,1doe� (.,)III b� CcPl�ctcl �� 3,`?� Ask as about affordable bank financing We propose hereby to furnish materials and labor-complete in accordance with above specffi=jc^.s for the sum of:Totai Due($ } +t �• ) ACCEPTANCE OF PROPOSAL: The above prices,specifications and conditions are Down Payment satisfactory and are hereby accepted.You are authorized to do work as specified. Payment will be 113 down at start of lob,and balance due u on completion. Balance Due Upon Completion($ j Date If o I _Signature: go f Date: �I 11 Estimator:(Print Name) C� �I SC�,�� (S g Name) Estimates ar honored for sixty(60)days from above date ATTENTION HOMEOWNERS:Please cover all personal belongings In the at ic,garage or storage areas due to the possibility of roofing debris or dust coming in through cracks of the wood-Adam Ouennevllle Roofing will not be responsible for debris or dust in the attic or storage areas. A SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Adam Quenneville CS 070626 Name of License Holder: License Number 160 Old Lyman Rd South Hadley MA 01075 8121/15 Address Expiration Date 413-536-5955 Signatur Telephone 9.Registered Home Improvement Contractor: Not Applicable ❑ Adam Quenneville Roofing 120982 Company Name Registration Number 160 Old Lyman Rd South Hadley MA 01075 3/25/16 Address Expiration Date Telephone 413-536-5955 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....... K No...... ❑ 11'. -''Home ©wrier 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 0 Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding[O] Other[l�j Brief Description of Proposed Work: replace roll roofing on 2 sections 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 existing housing. complete the following: 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 Harry Petrucci l , 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 II XS I Signature of Owner Date ill Adam Quenneve I , 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. Signe under the paigp and penalties of perjury. Moux wu i I Lk- Prird Name 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 €.... m....,_. ,_. �.. m.a _ n., Frontage L-- Setbacks Front Side L: _s R L. ' R: J Rear Building Height .w Bldg. Square Footage Open Space Footage % _ w (Lot area minus bldg&paved mE _ ,,, parking) # of Parking Spaces Fill: volume&Location i_,, A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DON'T KNOW Q YES Q IF YES, date issued: 1 .,m IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW YES Q IF YES: enter Book Pagel and/or Document# B. Does the site contain a brook, body of water or wetlands? NO Q DON'T KNOW Q YES Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained , Date Issued I C. Do any signs exist on the property? YES NO r� 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 Q 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 Q IF YES,then a Northampton Storm Water Management Permit from the DPW is required. City of Northamptont #us saf Perms Building Department OurlbZ00rl4eW6 Pbilit az 212 Main Streetewrteptt Aueilaktr) t Room 100 WeterllNvetlab-lyi_� Northampton, MA 01060 TyioSettrucur has ' �NOT�� phone 413-587-1240 Fax 413-587-1272 PloUltets f�tttei'Specify '° � 0 kM k � � 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 182 Chestnut St 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: Harry Petrucci 182 Chestnut St Florence MA 01062 Name(Print) Current 41 Mailin Address: Telephone Signature 2.2 Authorized A ent: &-i °F -' S j&Did Wyno 11 tP- , Sp RA 1)will ame(Print) Current Mailing A ress: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building 1,787 (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) 1,787 Check Number 3�9'J�'j 35. OD This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date 182 CHESTNUT ST BP-2015-0609 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17C-057 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-2015-0609 Project# JS-2015-001177 Est. Cost: $1787.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ADAM QUENNEVILLE 070626 Lot Size(sq. ft.): 23086.80 Owner: PETRUCCI HARRY Zoning: URA(100)/ Applicant: ADAM QUENNEVILLE AT. 182 CHESTNUT ST Applicant Address: Phone: Insurance: 160 OLD LYMAN RD (413) 536-5955 O Workers Compensation SOUTH HADLEYMA01075 ISSUED ON.121212014 0:00:00 TO PERFORM THE FOLLOWING WORK:REPLACE ROLL ROOFING ON 2 SECTIONS 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: FeeTy e: Date Paid: Amount: Building 12/2/2014 0:00:00 $35.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner