23C-080 QUENNEVILLE
ROOFING 'V SIDING 'V WINDOWS
160 Old Lyman Road•South Hadley,MA 01075
1.800.NEW ROOF 413.536.5955
Email:info@ 1800newroof.net Website:www.1800newroof.net Winner if the
MA Construction Supervisors Lic.#070626 MA Registration#120982
Member of the Home Builder's Association of Western Mass. CT Registration#575920 TORCH H AWARD
Member of the Building&Trade Association
Proposal Submitted To: Date Phone#'s C;Cyr,3 3�d_373°2
H Yt3 586- `5n W:
Street Email:
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City,State,Zip Code
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Proposal to furnish and install the following
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We propose hereby to furnish materials and labor-complete in accordance with above specifications for the sum of:Total Due($
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 job,and balance due upon completion. Balance Due Upon Completion($ )
Date: Le 1 hi 15 Signature:
Date: /3113 Estimator:(Print Name) ..i1*ti (Sign Name)
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
possibility of roofing debris or dust coming in through cracks of the wood.Adam Quenneville Roofing will not be
responsible for debris or dust in the attic or storage areas.
The Commonwealth of Massachusetts
Department of Industrial Accidents
r� Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.go v/d is
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):-_ Adam Quenneville Roofing& Sidinq Inc.
Address: 160 Old Lyman Rd
City/State/Zip: MA 01075 Phone #: 413-536-5955
Are you an employer?Check the appropriate box: Type of project (required):
112 t am a employer with 15 — 4. ❑ I am a general contractor and 1 6. ❑ New construction
employees (fu?l and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g. ❑ Demolition
working for me in any capacity. employees and have workers' q E] Building addition
[No workers' comp. insurance comp. insurance.t
required.] 5. F1 We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 1 I.❑ Plumbing repairs or additions
myself. [No workers' comp. tight of exemption per MGL 12 M 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 N 1 must also 1111 out the section below showing their workers'compensation policy information.
Ilomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such
Contractors that check this box must attached an additional sheet showing the name of 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 ernplq yer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: AIM Mutual Insurance
Policv #or Self-ins. Lic. #: A(WC4007012861-2015A Expiration Date: 4/29/16
Job Site Address: e1- V��tSS � City/St ate/Zip:
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`.61,500.00 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.
Signature: Date:
Cobio//s-
Phone#: 1-2,—S3 — --- — — —
Official use only. Do not write in this 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 ❑
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 Home Improvement 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
a---- 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....... V, No...... ❑
11. - 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 M
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks Siding [o] Other[a
Brief Description of Proposed
Work: Strip existing ri..:
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
I, Diane Johnson 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 ( ho )
Signature of Owner Date
Adam Quenneville as Owner/Authorized
I,
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 pain nd penalties of perjury.
Pmt 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 tilled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R L: R:
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DON'T KNOW YES 0
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 , Date Issued:
C. Do any signs exist on the property? 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, grading, excavation, or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Department use only
D ? ity of Northampton Status of Permit:
uilding Department Curb Cut/Driveway Permit
JUN 19 `x015 212 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability
Electric,piu�,Lincl & .;Inspe hampton, MA 01060 Two Sets of Structural Plans
North , { 0 - 87-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
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
Map Lot Unit
42 Bliss St
Florenece MA 01062 Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Diane Johnson 42 Bliss St Florenece MA 01062
Name(Print) Current Mailing Address:
413-586-6569
See Contract Telephone
Signature
2.2 Authorized AcIent:
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
com leled by ermit applicant
1. Building (a) Building Permit Fee
2600.00
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) 2600.00 Check Number b
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
42 BLISS ST BP-2015-1338
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 23C-080 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-2015-1338
Project# JS-2015-002440
Est. Cost: $2600.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Groin: ADAM QUENNEVILLE 070626
Lot Size(sq. ft.): 17685.36 Owner: JOHNSON DIANE
Zoning URA(100)/WSP(100)/ Applicant: ADAM QUENNEVILLE
AT. 42 BLISS ST
Applicant Address: Phone: Insurance:
160 OLD LYMAN RD (413) 536-5955 O Workers
Compensation
SOUTH HADLEYMA01075 ISSUED ON:612212015 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL NEW FLAT ROOF 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:
FeeType: Date Paid: Amount:
Building 6/22/2015 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner