24C-152 � 6 1(
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QU E N N E V I L L E Winner of the TORCH AWARD V
ROOFING W SIDING W WINDOWS
160 Old Lyman Road•South Hadley•MA 01075 We are Licensed
1.800.NEW.ROOF • 413.536.5955 Fully Insured
Email:infoCED 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 Assoc.of Western Mass. CT Registration#575920
Member of the Building&Trade Association P.P.0 38710
Pro o al Submitted To: Date: Phone#'s: C:
1,,,// 0/ 3//fir H:�Y,3) ''y W:
Street: Email:
City,State,//Zip Code: Special Requirements:
PROPOSALFOR:
HQUSE GARAGE OTHER
RECOVER NEW GUTTERS
Layers: (21) 2 3 4 Ply_ ood Included: Yes r No
K Tear o SLAT SHAKE
COMPLETE ROOF PROTECTION SYSTEM:
We shall acquire appropriate permits for all work
Home exterior and landscaping to be protected )) /
Strip existing roofing to existing decking with full inspection DO NOT DO:
All project waste shall be removed by dumpster(dumpsterfor contractor use only)
Deteriorated existing decking will be replaced at$3.77 per sq.ft.after full inspection Customerinitials:
Install Ice&Water Barrier at all eaves 3'/0 valleys,chimneys,pipes and skylights
Install(151b.felt Synthetic underlayment over remaining decking area
Install Metal drip edge at eaves and rakes 888:)5") white brown)
Install manufacturer's starter shingle on all eaves and rake edges
Install new pipe boot flashing/vent accessories
+ Install ridge vent now Countr Cobra roiled/4'Baffled/Roll
Shingles:(standard 6 nails per shingle)
T A,1 t Shingles = 25 year N 30 Year 50 Year Color: 4J,
TArtK"c Ridge cap shingles
Warranty Options:
We guarantee our workmanship for 10 full years(see our warranty coverage page)
GAF System Plus Warranty
GAF Golden Pledge Warranty
AQRS Recommendations:
Lead Counter Flashing _ Water Seal&Tuckpoint Rubberized Crown a Metal Chimney Cap
7 Replacing old skylights(or waiver must be signed) _= Mason work (or waiver must be signed)
I" Heated panel roof system Insulation Ventilation
Opted out of ACIRS recommendations Customer Initials: G�
we propose hereby to furnish materials and labor—complete in accordance with above specifications for the sum of: Total Due:($
ACCEPTANCE OF PROPOSAL:The above prices,specifications and conditions are Down Payment:($ 3"0 `� )
satisfactory and are hereby accepted.You are authorized to do work as specified. I Balance Due Upon Completion:($ 657( )
Payment will be 1/3 down at start ofjob,and.galance due upon completion.
Date: ) r Signature:
./
Date: f//�3//> Estimator:(Print Name) �S'/ ��•�r 1 (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 Quenn ville Roofing will not be
responsible for debris or dust in the attic or storage areas. Customer Initials:
The Commonwealth of Massachusetts
Department of Industrial Accidents
e 1 Congress Street,Suite 100
7 Boston,MA 02114-2017
www mass.gov/dia
Workers'Compensation Insurance Affidavit:General Businesses.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Leeibly
Business/Organization Name:_Adam Quenneville Roofing &Siding Inc.
Address: 160 Old Lyman Rd
City/State/Zip: South Hadley. MA 01075 Phone#:_ 413-536-5955
Are you an employer?Check the appropriate box: Business Type(required):
112 I am a employer with 15 employees(full and/ 5. ❑Retail
or part-time).* 6. []Restaurant/Bar/Eating Establishment
1❑ I am a sole proprietor or partnership and have no 7. []Office and/or Sales(incl.real estate,auto,etc.)
employees working for me in any capacity. g, Non- rofit
[No workers' comp.insurance required] p
3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment
their right of exemption per c. 152, §1(4),and we have 10.[]Manufacturing
no employees. [No workers' comp, insurance required]* I L Health Care
4.❑ We are a non-profit organization,staffed by volunteers,
with no employees. [No workers' comp.insurance req.] 12.M Other Roof repairs
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
**If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
organization should check box#1.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information.
Insurance Company Name: AIM Mutual Insurance
Insurer's Address: 330 Whitney Ave_ Suite 730
City/State/Zip: Holyoke, MA 01040
Policy#or Self-ins.Lic.# AWC4007012861-2015A Expiration Date: 4129/16
Attach a copy of the workers'compensation 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 do hereby certify, under the/pains and penalties of perjury that the information provided above is true and correct
Signature: i%/ Date: -if 136
Phone#: 413-536-5955
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office
6.Other
Contact Person: Phone#:
www.mass.gov/dia .
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. 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
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....... R 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 [M Siding[p] Other[p]
Brief Description of Proposed
Work: Remove existing roof material and install new asphalt shingle system.
Alteration of existing bedroom Yes_ X No Adding new bedroom Yes .No
Attached Narrative Renovating unfinished basement Yes _X_No
Plans Attached Roll -Sheet
6a. If New house and or addition to existing housing, complete the followina:
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
I, Patricia Russell 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 it �30I AI
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 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 O DON'T 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 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 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.
g ty of Northampton Status of Permit: Department use only
B ilding Department Curb Cut/Driveway Permit
i 212 Main Street Sewer/Septic Availability
DEG + ( 2015 Room 100 Water/Well Availability
Lt ampton, MA 01060 Two Sets of Structural Plans
oEr r c "" ��M 3- 87-1240 Fax 413-587-1272 Plot/Site Plans
NQ,4..ITif,+ice�U:
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
39 Arlington St.
Northampton, MA 01060 Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Patricia Russell 39 Arlington St. Northampton, MA 01060
Name(Print) Current Mailing Address:
413-584-2074
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 (a) Building Permit Fee
$ 9,500.00
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) $9,500.00 Check Number 3
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
nR1,1NGTON ST BP-2016-0742
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24C- 152 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
c i tcLu \: IzOOI. BUILDING PERMIT
Permit# BP-2016-0742
Project# JS-2016-001243
Est.Cost: $9500.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
use_cro"I1 ADAM QUENNEVILLE 070626
l_,ot simsd It.): 9583.20 Owner: RUSSELL PATRICIA LEE
zonima: URB(100)/ Applicant: ADAM QUENNEVILLE
AT. 39 ARLINGTON ST
Applicant Address: Phone: Insurance:
160 OLD LYMAN RD (413) 536-5955 O Workers
Compensation
SOUTH HADLEYMA01075 ISSUED ON.121212015 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:
Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
TI-IIS 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 12/2/2015 0:00:00 $40.00
212 Main Street, Phone(413)587-1240, Fax: (413) 587-1272
Louis Hasbrouck—Building Commissioner