16C-015 AUAAIL
VISA �
QVENNEVILLE
ROOFING W SIDING W WINDOWS
160 Old Lyman Road•South Hadley, MA 01075 131333
1.800.NEW ROOF • 413.536.5955 Winner of the
Email:info01800newroof.net Website:www.180onewroof.net 2010
MA Construction Supervisors Lic.#070626 MA Registration#120982 TORCH AWARD
Member of the Home Builder's Association of Western Mass. CT Registration#575920
Member of the Building&Trade Association
Proposal Submitted To: Dattee, Phone#'s C:el _ 24+4 -4p%Af
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City,State,Zip Code
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We propose hereby to furnish materials and labor-complete in accordance with above specification�fpr thgsum colf:Total Due($ 32,50 )
ACCEPTANCE OF PROPOSAL: The above prices,specifications and conditions are � N C Vf Do(vn 1yment($ 12,90 )
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 upon completion. as ahcethk Completion($
Date: " ��' Signature:- 'k ') ?5 �{
Date: Estimator:(Print Name)A/.Gk l RS4, -5 —(Sign Name
Estimates are honored for sixty(60)days from above date 535— t 5l 01 �P,
ATTENTION HOMEOWNERS:Please cover all personal belongings in the attic,garage or store e a as 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 ?,
Mpar ltwnt of Industrial Accidents '
Offke of Investigations
600 Washington Street
Boston,MA 02111
www.massgov/dia -
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
k)Vlicant Information 'P-iease Print Legibly
r
11ame(Business/organizaiion/lndividual): Adam Quenneville Roofigg&Siding Inc
Address: 160 Old Lyman Rd
City/State/Zip: South Hadla bdA 01OZ5 Phone#:
Ate 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 cgnstruction
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 for me in any capacity. employees and have workers' 9 ❑ Building-addition
[No workers'comp.instumme tCOmp. insurance.1
required.] 5. ❑ We area corporation and its 10:❑ Electrical repairs or additions
3.13 1 am a homeowner doing ail work officers have exercised their I P[3 Plumbing repairs or additions
myself[No workers'camp right of exemption per MGL 12:[5 Roof repairs
insurance required.]t" c. 152,§1(4),and we have no
employees.[No workers' i 3.❑(?ther
comp. insurance required.]
'AnJ applicant that checks box#I must also rill out the section below showing their workers'compensation policy information
t Haaneowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:Cotinactors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have f
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
1 a#an employer dw is providing workers'no on�for my employees. Blow is Ae pol�i y and fob site
inj'Finadan'
i
lnst)rartce Company Name:. AIM Mutual Insurance
Policy#or Self-ins.Lic.#: AWC4007012861-2015A Expiration Date: ,.4/29/16-
Job Site Address: 1 Y 1 City/State/Zip:'�"1 0 Y•,Q n C J,M VA C)l OL02.
Att ch a copy of the workers'compensation, licy declaration page(showing'the policy isnmber and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the impositiort of criminal penalties of a
finti tip to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOPtIVORK'•ORDER and a fine':
of u to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to.thesOffice of
_Javfstigations of the DIA for insurance coverage verification.
I de hereby certify un der._:th'_ trs a n d penalties of perjury tkot the information provided above is true and correc Lt,
Si o?3 f�
Phdne#: Lf J(O- Sq SE
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OffWal use only. Do not write t'n this area,to be co by city or town oJJ°uiai
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
fi.Other
Contact Person: .r Phone#:
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: Adam Quenneville CS 070626
License Number
160 Old Lyman Rd South Hadley MA 01075 8/21/2017
Address Expiration Date A---- 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
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 13
Accessory Bldg. ❑ Demolition ❑ New Signs [o] Decks [M Siding [0] Other[d]
Brief Description of Proposed
Work: Remove existing roof material and install new asphalt shingle system on garage roof only.
Alteration of existing bedroom Yes V No Adding new bedroom Yes V 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 V 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, Susan Crimmins 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 ��a �►
Signature of Owner Date
I, Adam Quenneville Roofing & Siding Inc. 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 () DON'T KNOW ® YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO ® 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 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 0 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 NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Department use only
�n City of Northampton Status of Permit:
V Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
SEP 2 5 2015 Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
0*ctric,Plumbing a Gas t 13-587-1240 Fax 413-587-1272 Plot/Site Plans
Northam ton,MA D1060 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
254 Spring St
Florence, MA 01062 Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Susan Crimmins 254 Spring St Florence, MA 01062
Name(Print) Current Mailing Address:
413-296-4420
See contract Telephone
Signature
2.2 Authorized Aaent:
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 (a) Building Permit Fee
$ 3,250.00
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total= 0 +2+3+4+ 5) $3,250.00 Check Number
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
254 SPRING ST BP-2016-0417
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 16C-015 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-2016-0417
Project# JS-2016-000655
Est.Cost: $3250.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Groin ADAM QUENNEVILLE 070626
Lot Size(sq. ft.): 124146.00 Owner: CRIMMINS SUSAN B
zoning: URA(100)/WSP(100)/ Applicant: ADAM QUENNEVILLE
AT. 254 SPRING ST
Applicant Address: Phone: Insurance:
160 OLD LYMAN RD (413) 536-5955 O Workers
Compensation
SOUTH HADLEYMA01075 ISSUED ON.912512015 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE GARAGE 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 9/25/2015 0:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner