23D-160 (4) The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
k1V 600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Aoalicant Information Please Print Legibly
Name(Business/Organization/Individual): Adam Quenneville Roofing&Siding Inc
Address: 160 Old Lyman Rd
City/State/Zip: South Hadley MA01075 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. F1 New construction
employees(full and/or part-time).* have hired the sub-contractors
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 insurance.$ 9. ❑ Building addition
[No workers' comp.comp.insurance p" (0.❑ Electrical repairs or additions
required.] 5. ❑ We are a corporation and its
3.❑ 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 [�Roof repairs
insurance required.]t c. 152, §1(4),and we have no
employees. [No workers' 13.❑Other ,
comp. insurance required.]
'An'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.
*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 aip an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
inf#rmation.
Insttrarice Company Name: AIM Mutual Insurance
Policy#or Self-ins. Lic.#: AWC4007012861-2015A Expiration Date: ,4/29/16
Job Site Address: f q JWri.� City/State/Zip:_ aq_,
Attach a copy of the workers'compensatio% 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
Fine;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 fine
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 d®hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Si 'j ature: Date: I�
Phone#:
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Fssuing 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#:
Q V E N N E V I L L E www.1800newroof.net
ROOFING W SIDING 'V 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.1800newroot.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 R.P.C.38710
Proposal Submitted To: Date Phone#'s C: 51 Irsaf-06 7d
1+'V^f e P.✓+ It? H: ��/13�70�7- °�Y _W:
Street Email:
City,State,Zip Code I Special Requirements:
WU 6` rcr���a. o, �a..�s /
,1 d R-PnC r A 106 � J
6 Aw
Moat FA.-4, acct eye 5 0y
SC X055 ni9- �'� aXC �nrPLC�o�/ II
E] Recover [9 Strip UT:Layers "�'4
/
Complete Roof System
9 We shall acquire all appropriate permits for all work
a Home exterior and landscaping to be protected sued
[� Strip existing roofing to existing decking and dispose of. Do not Do.
Deteriorated existing decking will be replaced at$3.47 per sq.ft.after full inspection.
Install Ice&Water Barrier at all eaves,valleys,chimneys,pipes and skylights 7
Install(151b.felt/ nt etic underlayment over remaining decking area
7 Install Metal drip edge at eaves and rakes/5")4a rown/copper)
C
5 -Install manufacturer's starter shingle on all eaves and rake edges BBB
❑ Install new pipe boot flashing(standard/copper)/vents _r
❑ Install Snow Country or Cobra rolled vent ridge vent Winner of the
2010
❑ Install proper soffit ventilation TORCH AWARD
Shingles: (6 nails per shingle)
6,+F Shingles [:125 year �4 30 year [:150 year Color
G,+F Ridge cap shingles
Warranty Options:
We guarantee our workmanship for 10 full years(see our warranty coverage)
❑ GAF System Plus warranty
❑ GAF Golden Pledge warranty
Chimney Options:
❑ Lead Counter Flashing ❑ Water Seal&Tuckpoint ❑ Rubberized Crown ❑ Metal Chimney Cap
We propose hereby to furnish materials and labor-complete in accordance with above specifications for the st..n of:Total Due($ S-7,50 )
ACCEPTANCE OF PROPOSAL: The above prices,specifications and conditions are I Down Payment($ Moe) )
satisfactory and are hereby accepted.You are authorized to do work as specified.
Payment will be 1/3 down at start of job,and balance due upon completion. Balance Due Upon Completion($
Date: �(�°/<�Signature:
Dater Estimator:(Print Name)�� (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.
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 8121115 8/21/2017
Address Y e — 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 3/25/16
Address Expiration Date
Telephone413-536-5955
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 buildi g permit.
Signed Affidavit Attached Yes....... d 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 bome 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 [O] Decks [M Siding [01 Other[CI]
Brief Description of Proposed
Work: Strip dormer and install new asphalt rollroofing Strip existing roofing and install new asphalt shingle system on main house only
Alteration of existing bedroom Yes X No Adding new bedroom Yes X No
Attached Narrative Renovating unfinished basement Yes X No
Plans Attached Roll -Sheet
sa. 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
Naomi Tannen 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
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
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: 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 Q YES Q
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO ® DON'T KNOW YES
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO ® DON'T KNOW ® YES 0
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 ® NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES ® 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
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Department use only
City of Northampton Status of Permit:
' Building Department Curb Cut/Driveway Permit
$r 212 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
Z phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
Q Other Specify
LICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This section to be completed by office
1.1 Property Address:
Map Lot Unit
147 Maplewood Ter
Florence, MA 01062 Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Naomi Tannen 147 Maplewood Ter Florence, MA 01062
Name(Print) Current Mailing Address:
413-727-3948
Telephone
Signature
2.2 Authorized Aaent:
ei►i � Igo �;� �- i �cx. �� t�lc� y-rte,,. �� t>LA plan
Name(Print) Current Mailing Addr s:
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
5,750.00
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) 5,750.00 Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
147 MAPLEWOOD TER BP-2016-0311
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:23D- 160 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-2016-0311
Project# JS-2016-000499
Est.Cost: $5750.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ADAM QUENNEVILLE 070626
Lot Size(sq. ft.): 20952.36 Owner: TANNEN NAOMI
Zoning: URB(100)/ Applicant: ADAM QUENNEVILLE
AT: 147 MAPLEWOOD TER
Applicant Address: Phone: Insurance:
160 OLD LYMAN RD (413) 536-5955 O Workers
Compensation
SOUTH HADLEYMA01075 ISSUED ON.911012015 0:00:00
TO PERFORM THE FOLLOWING WORK.STRIP & SH I NGLE 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 Siznature:
FeeType: Date Paid: Amount:
Building 9/10/2015 0:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner