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35-132 (9) The Commonwealth of Massachusea Departra'ent of Industrial Accidents ' Office of Invatigadons ' 600 Washington Street Boston,MA 42111 www.nmagov/dia Workers' Compensation Insurauee Affidavit: Builders/Contractors/Electricians/Plumbers Iotilicant Information Resse,Print Legibly Dame(Business/organizationnndividual): Adam Quenneyille ftall M&Sidin4 Inc. Address: 160 Old Lyman Rd City/State/Zip: Phone#: Ate you an employer?Check the-appropriate box: Type of project(required).. 1. lain a employer vra`th 15 4. ❑ 1 am a general contractor and I employees(fall and/or part time): . Have hired the sub-contractors 6. (_0 New cpnstruction 2© 1 am a sole proprietor or pairtrterL listed on the attached sheet. 7..❑Bemodeling. ship and have no employees These sub-contractors have 8. 0`bemolition working for me in any capacity. employees and have workers' comp.insuranceJ - 9. ❑Buildiog addition [No workers cx>nnp.in6lttaaee '• �:. ,� required.] 5. ❑ We are a corporation and its 10:-❑Electrical repairs or additions of5cers have exercised Their 1!: 3.� !am a homeowner doing ail work - ❑Plumbing repairs or additions myself o workers' of exemption per MGL y �P• . 12:[ Roof repairs insurance required.]t c. 15 §1(4�and we have no employees.[No workers' 13.❑t3fier comp insurance required.] s appliaat that checks box Ml must also fill out the section below stowing their workers'aompen"=policy ipfotrmstim t H(imeowners who sutmtit this affiftvit indicating they are doing all work sod then hire outside contractors must submit a new affidavit indicating such. ;Co�drat check this box must attached an additiornl street showing the tame of the sub-oo avAors and state whether or not those entities have etnpEoyees. if the subcontractors have employees,they crust provide their workers'camp.policy somber. I aft a�a employer tkat is Frm'ad�g!vonl�s' _. �al�s jor eg'e�oJoyara. 1leLvw is ltrepoltcy arod�rb rise inrrmatwiOL lr4rance,Company Naar . AIMJSAutiral.lt�surance Policy#or Self-ins.Lic.0: AWC4007012861-2015A Expiration Date*-_.A29/16` Jobi Site Address:! CO City/State/Zip: V- , Q Y Q.V 1 CO .►�/1 14 (�1 C)Lo Z Attach a copy of the workers'¢omtpeasatio"liFy declaratlon pale(sho'?VM9 the pt,!i - .dtnber slid expiration dad): Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of tHminal penalties of a fN up to 51,500.00 and/or one-year imprisonment,as well as civil penalties in the fo-M of a STOP;-WORKORDER and a fine*: - of to 5250.00 a day against the violator. Be advised that a copy of this statement May be forwarded to died3ffice of _l:l ons of the DIA for insurance coverage verification. !ds kprby cell wader tke pains mod penaUies 000*J'dw the byormaden prnvided a4m is Pue and correct.y t413- 53(D - Vffxsal use only Do not ry;(te n skis area to be cnarob vrd,by city or town o,�`u iaL Pity or Town: Permit/License# Psuing Authority(circle one): a .Board of Health Z.BtrBdin9 Department 3.City/Town Clerk 4.Electrical Inspector.5.-PiumMug Inspector 6.Other Contact Person: Phone#• QUENNEVILLE ROOFING 'W SIDING 'W WINDOWS 160 Old Lyman Road•South Hadley, MA 01075 BT 1.800.NEW ROOF 473.536.5955 Email:info 0 1 800newroof.net Website:www.1800newroof.net Winner of the MA Construction Supervisors Lic.#070626 MA Registration#120982 TORCH H AWARD Member of the Home Builder's Association of Western Mass. CT Registration#575920 Member of the Building&Trade Association Proposal Submitted To: Date Phone#'s C: 7` H: W: Street Email: City,State,Zip Code Proposal to furnish and install the following i � 1 Y 3. 5' �1 f^ C Ask us about affordable bank financing We propose hereby to furnish materials and labor-complete in accordance with above specifications for the sum of:Total Due($ 1 4;. ACCEPTANCE OF PROPOSAL: The above prices,specifications and conditions are Down Payment{$ t ) satisfactory and are hereby accepted.You are authorized to do work as specified. I{ Payment will be 113 down at start of job,and balance due upon,completion. Balance Due Upon Completion($ ) Date: Signature: Date: "? Estimator:(Print Name) (Sign Name), .r 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 Cluennevllle 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 ❑ 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 Ez Or Doors El Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding [O] Other[p] Brief Description of Proposed Work: Install fiberboard over entire flat roof. Alteration of existing bedroom Yes V 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 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, Pamela &Thomas Williams 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 9 4-S J I'( 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 0 DON'T KNOW ® YES Q 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 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained Q , Date Issued: C. Do any signs exist on the property? YES O 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 r� I"� I j E ity of Northampton Status of Permit: ;�„i�--V uilding Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability P 2 5 2015 11 ROOM 100 Water/Well Availability N rthampton, MA 01060 Two Sets of Structural Plans Electric,Plumbing&G -587-1240 Fax 413-587-1272 Plot/Site Plans Northampton,mA 01060 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 716 Ryan Rd Florence, MA 01062 Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Pamela &Thomas Williams 716 Ryan Rd Florence, MA 01062 Name(Print) Current Mailing Address: 41-4-585-0678 See contract Telephone Signature 2.2 Authorized Agent: Adam Quenneville Roofing & Siding Inc. 160 Old Lyman Rd South Hadley MA 01075 Name(Print) &77� 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 $ 5,435.00 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) $5,435.00 Check Number 3 This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date 716 RYAN RD BP-2016-0418 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 35- 132 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-2016-0418 Project# JS-2016-000656 Est. Cost: $6435.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ADAM QUENNEVILLE 070626 Lot Size(sa. ft.): 11412.72 Owner: WILLIAMS PAMELA B zonine: Applicant: ADAM QUENNEVILLE AT. 716 RYAN RD Applicant Address: Phone: Insurance: 160 OLD LYMAN RD (413) 536-5955 () Workers Compensation SOUTH HADLEYMA01075 ISSUED ON.912512015 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL FIBERBOARD ON FLAT 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 Simature: 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