17C-110 (8) ,,Y M visa Q
QVENNEVILLE
ROOFING ♦ SIDING W WINDOWS 131313
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160 Old Lyman Road•South Hadley,MA 01075
1.$OO.NEW ROOF • 413.536.5955 Winner of the
=mail:info a 1800newroof.net website:www.1800newroof.net 2010
NA Construction Supervisors Lic.#070626 MA Registration#120982 TORCH AWARD
dember of the Home Builder's Association of Western Mass. CT Registration#575920
vtember of the Building 8 Trade Association
Proposal Submitted To Date Phone#'s C:
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City, State,Zip Code
Proposal to furnish and install the following
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The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
(_ 600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (13usiness/Organization/indivi(ival):_ Adam Quenneville Roofing & Siding Inc.
Address: 160 Old Lyman Rd
City/State/Zip: South Hadley MA 01Q75 Phone #: 413-536-5955
Are you an employer? Check the appropriate box: Type of project (required):
1. 1 am a employer with 15 4. ❑ I am a general contractor and 1 6 ❑ New construction
have hired the sub-contractors
employees(full and)or part-time}.*
❑
listed on the attached sheet. 7. F-1 Remodeling 2. 1 am a sole proprietor or partner-
ship and have no employees These sub-contractors have g, ❑ Demolition
working for me in any capacity. employees and have workers' 9. ❑ Building addition
insurance workers' comp. insance comp. insurance.t
5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
required.]
3.❑ 1 am a homeowner doing all work officers have exercised their I I.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.[�Roof repairs
insurance required.]t c. 152, §1(4), and we have no
employees. [No workers' 13.❑ Other
comp. insurance required.]
*Any applicant that checks box#I must also till out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
1(ontractors that check this box must attached an additional sheet showing the name of the sub-contractors and slate whether or not those entities have
employees. I f 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 employees. Below is the policy and job site
information.
Insurance Company Name: AIM Mutual
Policy €t or Self-ins. Lic. #:- AWC4007012861-2015A Expiration Date: 4/29/16
j- ---
Job Site Address: A50V, /'IV Z City/State/Zip: 'l'�ort e Q !v d(V(0-j
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
tine 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 tine
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 and penalties of perjury that the information provided above is true and correct.
Sus nature: %c Date•
Phone#: �13 °.1310" �_ ---- —
Official use only. Do not write in this area, to be completed by city or town official
City or Town: Permit/License i#
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 ❑
Adam Quenneville CS 070626
Name of License Holder:
License Number
160 Old Lyman Rd South Hadley MA 01075 8/21/2015
Address Expiration Date
413-536-5955
Signature Telephone
9 Registered iftme lmprovement Contractor' Not Applicable ❑
Adam Quenneville Roofing 120982
Company Name Registration Number
160 Old Lyman Rd South Hadley MA 01075 3/25/2016 _
Address Expiration Date
Telephone 413-536-5955
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.162,§26C(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. - Ha►me 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 D
Accessory Bldg. ❑ Demolition ❑ New Signs [[3] Decks [p Siding[[3] Other[❑]
Brief Description of Proposed
Work: Strip existing roofing and install new asphalt shingi. Strip existing roofing on back dormer and install EPDM Rubber
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa. Ifi New house and ar-4ddition to existlnn ho.U.s n6. complete the,follow na:
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, Andrew& Leida Barman 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 ' /-113 1
Signature of Owner Date
Adam Quenneville
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.
Signed nder the pains and penalties of perjury.
2
Printhl
ame
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.1... L.., .m... R.i...m. j i
....,
Rear 4
Building Height ?
Bldg. Square Footage % _
Open Space Footage %
(Lot area minus bldg&paved
arkin
#of Parking Spaces
Fill:
volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DON'T KNOW � YES
IF YES, date issued ` 1
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW YES Q
IF YES: enter Book ; Paged and/or Document#I
B. Does the site contain a brook, body of water or wetlands? NO G) DON'T KNOW Q YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained , Date Issued:
C. Do any signs exist on the property? YES Q NO Q
IF YES, describe size, type and location: r
D. Are there any proposed changes to or additions of signs intended for the property? YES NO
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 Q NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
�� l epartmenf se p l r a
City of Northampton Status of permit:
Building Department Curb utlC�rivewqiy i erint
1-3 t ,
212 Main Street Sawerd eptioA iiiAbill
Room 100 WatarNUatt�l�ratlabtli r!
Northampton, MA 01060 ,acr Sets ofri Ihans Y r.
phone 413-587-1240 Fax 413-587-1272 rl #l» itePlr�s
rw 0-5toecify
ICATION 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
24 Stilson Ave Map Lot Unit
Florence MA 01062
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Andrew& Leida Barman 24 Stilson Ave Florence MA 01062
Name(Print) Current Mailing Address:
617-894-4503
See Contract Telephone
Signature
2.2 Authorized Agent:
Adam Quenneville 160 Old Lyman Rd South Hadley MA 01075
Name(Print) Current Mailing Address:
413-536-5955
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
2,250.00
2. Electrical (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) 2,250.00 Check Number /
This Section For Official Use Only
Building ermit Number: Date
g Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
24 STILSON AVE BP-2015-1127
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17C- 110 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-2015-1127
Project# JS-2015-002123
Est. Cost: $2250.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ADAM QUENNEVILLE 070626
Lot Size(sq. ft.): 11456.28 Owner: BARMAN ANDREW T&LEIDA
Zoning. URB(100)/ Applicant: ADAM QUENNEVILLE
AT. 24 STILSON AVE
Applicant Address: Phone: Insurance:
160 OLD LYMAN RD (413) 536-5955 O Workers
Compensation
SOUTH HADLEYMA01075 ISSUED ON.•511812015 0:00:00
TO PERFORM THE FOLLOWING WORK.REPLACE BACK DORMER 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 5/18/2015 0:00:00 $35.00
212 Main Street,Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner