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25C-120 (5)
The Commonwea"of Massackstsetts , DVaot,jnt of Indw&W Accidents 1 - - Office of Inveskgadons 600 Washington Street Roston,MA 02111 www.Mass gov/diet Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers ADD11C8at Information ?lease Print Legibly Dame(Business organiisuon/individual): Adam Quenneville RoofiM&Siding Inc Address: 160 Old Lyman Rd 1 City/State/Zip: 52 A 04075 Phone#: Ate you an employer?Check thesppsopriate box: Type of project(required):. 1. I am a employer with 15 4. ® I am a general contractor and 1 6 ❑New cgnstruction Have hired the sub-cor>tractors employees(full and/or part-time).'*-.. 7.. Remodeling.. 2© I am a sole proprietor orpartner- listed on the attached sheet ❑ �. have no employees These sub-contractors have 8. E]'Demolition slap and working for e in any capacity. employees and have workers' th 9. ❑Building-addition [No workers'comp.ittsluanee comp.insurance= required.] ''�-� ' S. [] ;e are a i_rporation and its I0:•❑Electrical repairs or additions 3.❑ I required.] a homeowner doing all work officers have exercised their I 1:r❑J Plumbing repairs or additions MGL myself.[No workers'camp. . §I �d we have no 12:u�f trans insurance required.]t,-. 13. G1tlter employees.[No workers' "= comp.insurance required.] a • applicant that checks box#I must also fill out the section below showing their workers'aompensadau policy ikon• t Hwwwners who submit this afTifvit indicating they are doing all work and dw hire outside contractors must submit anew affidavit indicating sttch.; tCo tractors that check this box must attached an additional sbeet showing the row of the sttb•eontractors and state whetter or not those entities have emphoyees if the sub-comaetors have emeployees,they must provide their woriters'00004•policy mmober. 1 an eFvloyer that is pr+vt+rd g wontm, hwwmcefor aty Rdew as the policy and job srte Insurance Company Naaze eta tu..; Inca — Policy#or Self-ins.Lic.#: AWC4007012861 2015A Expiration Date: -4!29/16 Job:Site Address:23– 25 E 1 Z0.0 QtAA�� - City/Stawzip:T�O r+-�i nnnarn ,MIS! O 10 Attu s copy of the workers'. 4ouipolicy declaration page(sieowtng the policy pt tber aid expiration date): Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of driminal penalties of a find tip to.51,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOBWORKORDER and a fine: Of t4ot$ 00 a day against the violator. Be advised that a copy of this statement May be forwarded to theOffice of in of the D IA fag~insurance coverage verification. 1 Z hereby cerlejy,undetrA pairs andpwaltls of pwjrtry Mare the WennaWn provided -is true and con-con-ca y s Date: / bf Vffx al use only. Do not wr,to jn this are%to be cot by city or town orklal �ity or Town: Permit/License# l suing Authority(circle one): $.Board of Health 2.Buiki n;Department 3.City/Town Clerk 4.Electrical Inspector.5,Plumbing Inspector i.Other Contact Person: rr Phone#: T /A � A VISA i fl Q V E N N E V I L L E www.1800newroof.no ROOFING 'V SIDING W 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 8/25/15 Phone#'s C: Joan Hart _ H: 413-253-7436 W: Street Email: JDOY4 Foq.4t'7—cp &)—n4t • am 23-25 Elizabeth Street _ ibo lehart mail.com City,State,Zip Code Special Requirements: Northampton,MA 01060 *2/3 of Roof Only, 1/3 section is recent. *New OSB Sheathing included on roof sections to be F-1 Recover 2 Strip M Layers stripped. Complete Roof System WJ We shall acquire all appropriate permits for all work ® Home exterior and landscaping to be protected ® Strip existing roofing to existing decking and dispose of. Do not Do. 1/3 recent section 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 21 Install(151b.felt/Synthetic)underlayment over remaining decking area Install Metal drip edge at eaves and rakes 8@ 5") white rown/copper) c Install manufacturer's starter shingle on all eaves and rake edges B$$ V1 Install new pipe boot flashing EE)copper)/vents ❑ Install Snow Country or Cobra rolled vent ridge vent winner of the 2010 ❑ Install TORCH AWARD Shingles: (6 nails per shingle) GAF Timberline Lifetime Shingles ❑ 25 year ❑ 30 year ❑ 50 year Color Closest Match GAF Ridge cap shingles Warranty Options: V We guarantee our workmanship for 10 full years(see our warranty coverage) F1 Chimney Options: ® Lead Counter Flashing ❑ Water Seal&Tuckpoint ❑ Rubberized Crown ❑ Metal Chimney Cap We propose hereby to fumish materials and labor,complete in accordance with above specifications for the sum of:Total Due($ 13;689.00 ACCEPTANCE OF PROPOSAL: The above prices,specifications and conditions are I Down Payment($ 4,500:00 satisfactory and are hereby accepted.You are authorized to do work as specified. Payment will be 113 down at start of job,and lance due upon comp tian. Balance Due Upon Completion($ 9�A0 ) d, ,j d v i Date: / Signature: Date: 8/25/15 Estimator: Tint Name) Adam Quenneville (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. NNW I yC� i 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 413-536-5955 Signature Telephone 9. Reallstered 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 k:� 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 0 Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding [0] Other[Cl) Brief Description of Proposed Work: Remove existing roof material and install new asphalt shingle system. 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, Joan Hart 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 appllcatl n. See contract 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 � b31�5 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 O 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 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 Q Obtained 0 , 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 ity of Northampton Status of Permit: Duilding Department Curb Cut/Driveway Permit S�� 2 5 L015 212 Main Street Sewer/Septic Availability Room 100 Water/Well Availability � plumbs^on Gas%ns ampton, MA 01060 Two Sets of Structural Plans Nortnam ne 413-587-1240 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 23-25 Elizabeth St Northampton, MA 01060 Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT 2.1 Owner of Record: Joan Hart 23-25 Elizabeth St Northampton, MA 01060 Name(Print) Current Mailing Address: 413-253-7436 See contract Telephone Signature 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 $ 12,500.00 (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) $ 12,500.00 Check Number This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner/Inspector of Buildings Date 25 ELIZABETH ST BP-2016-0416 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block:25C- 120 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-2016-0416 Project# JS-2016-000653 Est. Cost: $12500.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ADAM QUENNEVILLE 070626 Lot Size(sq. ft.): 3267.00 Owner: HART JOAN TRUSTEE Zoning: URB(99)/ Applicant: ADAM QUENNEVILLE AT. 25 ELIZABETH 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 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 Occupant 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