06-062 (3) .t.
The Commonwealth of Massachusetts
Department of Industrial Accidents
z, Office of Investigations
3 600 Washington Street
Boston,MA 02111
www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print.Leeibly
Xame(Business/Organizaiion/Individual): Adam Quenneville Roofing&Siding Inc.
Address: 160 Old Lyman Rd
City/State/Zip: South Hadley MA01075 Phone #: 41 6_595.5
Are you an employer?Check the appropriate box: Type of project(required);
1.[2 1 am a employer with 15 4. ❑ 1.am a general contractor and 1
employees(full and/or part-time):" ave hired the sub-contractors 6. New construction
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. ❑'Demolition
working or me in an capacity. employees and have workers'
g Y P �'• 9. [] Building,addition
[No workers'comp.insurance 'comp. insurance.:
required.] 5. ❑ We are a corporation and its 10 ❑ Electrical repairs or additions
3.0 1 am a homeowner doing all work officers have exercised their 11:❑ Plumbing repairs or additions
myself. [No workers'comp. . right of exemption per MGL 12[Q�Roof repairs
insurance required.]t c. 152,§1(4),and we have no
employees.[No workers' 13.0 Other
comp. insurance required.]
•Any' applicant that checks box#1 must also rill out the section below showing their workers'compensation policy information.
t Ho;rneowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:Coiractors 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 a#an employer that is providing workers'compensation insurmece for my employees. Below it the policy and job site
infsrmadon. _
Instltrartce Company Name,,, AIM Mutual Insurance
Policy#or Self-ins. Lic.#: AWC4007012861-2015A Expiration Date: ,4/29/16
Job:Site Address: V 1-61 - City/State/Zip: roS3
Attoch a copy of the workers.'compensation,policy declaration page(showln :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
fine up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of alSTOP!WORK�ORDER and a fine,
of to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to,.the,Office of
Jnvestigations of the DIA for insurance coverage verification.
I di hereby certify underake pains an4penafties of perjury that the information provided above is true and correct.
Si oattue: Date: 17
Phdne#: 113 -S3lo-o.�5
Official use only. Do not write in this area,to be completed by city or town offtciaL
10ty 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
f.Other _
Contact Person: Phone#:
t "U :NN"Q E V I'L L E www.1800newroof.net
ROOFING IV SIDING 7W WINDOWS We Are Licensed
160 Old Lyman,Road•South Hadley,MA 01075
1.800.NEW ROOF 413.536.5955 Fully Insured
Email:info @1800newroof.net : ' website:www.1800newroof.net Factory Trained
MA Construction Supervisors Lic.'#070626 MA Registration#120982 Factory Certified Installers
Member of the Home Builder's Association of Western Mass. CT Registration#575920
Member of the Building&Trade Association P.P.C.38710
Proposal Submitted To: Date Phpn e#'s// p �/ F-?
y&. �d #�/ /S H: W:
Street.
3a
City,State,Zip,"Code
S�c��o�5 �E cccl�c5 A-�
ecover ❑ Strip ❑Layers < <,
3 S�SIi �QPP�`t .6(, GJ�►� rCtFJe�
Complete Roof System
® We shall acquire alFappnopriate permits for all work `�,
® Home exterior and landscaping to be protected
❑ Strip existing roofing3o existing decking and dispose of. 044M Do. (Y)1( _Ik�
❑ Deteriorated existing decking will be replaced at$3.47 per sq.ft.after full inspection.
❑ Install Ice&Water Barrier at all eaves,valleys,chimneys,pipes and skylights
❑ Install(151b.felt/Synthetic)undeffayment over remaining decking area
] Install Metal drip edge at eaves and rakes(9' o"" "/brown/copper) C(�
❑ Install manufacturer's starter shingle on all eaves and rake edges B$$
'K Install new pipe boot flashing(tandar /copper)/vents
❑ Install Snow Country or Cobra rolled vent ridge vent winner of the
2010
❑ Install proper soffit ventilation TORCH AWARD
r�sils�ef-s rr19 ) f}i
SWH494ee.96 � � hingles ❑ 25 year ❑ 30 year ❑ 50 year Color
Ridge cap shingles
Warranty Options:
J"We guarantee our workmanship r 10 full year (see our warranty coverage)
❑ GAF System Plus warranty
❑ GAF Golden Pledge warranty
Chimney Options:
❑ Lead Counter Flashing ❑ Water Seal&Tuckpoint ❑ Rubberized Crown ❑ Metal Chimney Cap r
2 G�
We propose hereby to furnish materials and labor-complete in accordance with above specificationis�f9r the sum of: .,ial Due($ (J 7 )
ACCEPTANCE OF PROPOSAL: The above prices,specifications and conditions are I ` ,tr+ +Down Payment($A 66C
satisfactory and are hereby accepted.You are authorized to do work as specified. C �t c1
Payment will be 1/3 down at start of job,and b nce due upon mpleti n. Balance X�Upon Completion($ 11'2 )
Date: Signature:
Date: " ?J'�� Estimator:(Prin am 1G K Pe 2tT (Sign Name)
Estimates are honored for sixty(60)days from above date
W/3 -X35 88 q5 W,,rK CC1
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 Ouenneville Roofing will not be
responsible for debris or dust In the attic or storage areas.
Versionl.7 Commercial Building Permit May 15,2000
SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes 0 No 0
SECTION 11 -OWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, Beaver Brook Condominium Association &Jody_Gerbasi 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. f
Signature of Owner Date
I, 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 periury.
Adam Quenneville
Print Name
Signature of Owner/Agent Date
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: Adam Quenneville CS 070626 U
License Number
_ 160 Old Lyman Rd South Hadley MA 01075 8/21/2015
Address Expiration Date
413-536-5955
Signature Telephone
SECTION 13-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,6L No 0
Versionl.7 Commercial Building Permit May 15,2000
SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES-FOR BUILDINGS AND STRUCTURES SUBJECT TO
CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116(CONTAINING MORE THAN 35,000 C.F.OF ENCLOSED SPACE)
9.1 Registered Architect:
Not Applicable ❑
Name(Registrant):
Registration Number
Address
Expiration Date
Signature Telephone
9.2 Registered Professional Engineer(s):
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
9.3 General Contractor
Adam Quenneville Roofing & Siding Inc. Not Applicable ❑
Company Name:
Adam Quenneville
Responsible In Charge of Construction
160 Old Lyman Rd South Hadley MA 01075
Address
413-536-5955
Signature Telephone
Version 1.7 Commercial Building Permit May 15,2000
8. NORTHAMPTON ZONING
Existing Proposed Required by Zoning
This column to be filled 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 0 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 4) DON'T KNOW O YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained Q , Date Issued:
C. Do any signs exist on the property? YES 0 NO O
IF YES, describe size, type and location: Entrance sign
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.
Versionl.7 Commercial Building Permit May 15,2000
SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations ❑ Existing Wall Signs ❑ Demolition❑ Repairs❑ Additions ❑ Accessory Building❑
Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing 0 Change of Use❑ Other ❑
Brief Description Enter a brief description here.
Of Proposed Work:
Recover EPDM rubber over existing 1 laver on 4 sections of condo units A-F
SECTION 5-USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A-1 ❑ A-2 ❑ A-3 ❑ 1A ❑
A-4 ❑ A-5 ❑ 1B ❑
B Business ❑ 2A ❑
E Educational ❑ 2B I ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
I Institutional ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ 3B ❑
M Mercantile ❑ 4 ❑
R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑
S Storage ❑ S-1 ❑ S-2 ❑ 5B ❑
U Utility ❑ Specify:
M Mixed Use ❑ Specify:
S Special Use ❑ Specify:
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND/OR CHANGE IN USE
Existing Use Group: Proposed Use Group:
Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34):
SECTION 6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY
Floor Area per Floor(so
1 St 1st
2nd 2nd
3rd 3rd
4th
4th
Total Area (so Total Proposed New Construction (so
Total Height(ft)
Total Height ft
7.Water Supply(M.G.L. c.40, §54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
Public ❑ Private ❑ Zone Outside Flood Zone❑ Municipal ❑ On site disposal system❑
Versionl.7 Commercial Building Permit May 15,2000
— - \ Department use only
',City of Northampton Status of Permit:
' uilding Department Curb Cut/Driveway Permit
�.J w
212 Main Street Sewer/Septic Availability
Water/Well Availability
�. ns Room 100
ae`'I�o hampton, MA 01060 Two Sets of Structural Plans
Elects lull,fiJ A 01050
e 13-587-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: This section to be completed by office
330 Haydenville Rd i — J Map Lot Unit
Leeds, MA 01053 Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Beaver Brook Condominium Association 330 Haydenville Rd Leeds, MA 01053
Name(Print) Current Mailing Address:
413-586-7958
Signature Telephone
2.2 Authorized Agent:
Adam Quenneville Roofing &Siding Inc. 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 13,750.00 (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) 13,750.00 Check Number
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner/Inspector of Buildings Date
330 HAYDENVILLE RD BP-2016-0226
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 06-062 CITY OF NORTHAMPTON
Lot: -000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cate ory: ROOF BUILDING PERMIT
Permit# BP-2016-0226
Project# JS-2016-000382
Est. Cost: $13750.00
Fee: $80.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ADAM QUENNEVILLE 070626
Lot Size(sq. ft.): Owner: Beaver Brook Nominee Trust
Zoning: SR(100) Applicant: ADAM QUENNEVILLE
AT. 330 HAYDENVILLE RD
Applicant Address: Phone: Insurance:
160 OLD LYMAN RD (413) 536-5955 O Workers
Compensation
SOUTH HADLEYMA01075 ISSUED ON.812512015 0:00:00
TO PERFORM THE FOLLOWING WORK.-RECOVER RUBBER ROOF ON 4 SECTIONS OF
UNITS A-F
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 8/25/2015 0:00:00 $80.00
212 Main Street, Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner