17A-163 (5) Name Date
QUENNEVILLE « Street Address
ROOFING'W SIDING '►WINDOWS B3313J/ 1 c� fa"'S i?d
1.800.NEW ROOF --- ---- City State Zip
f-/,,'1C /4A GI GGA'
413.536.5955 Winner of the Home Phone# Work#
1800NEWROOF.NET TORCH AWARD (}) ,3-`ki
RESIDENTIAL - COMMERCIAL Cell# Email
160 Old Lyman Road•South Hadley,MA 01075
StraightForward FricingO
i Story y2 Story �:.,_3 Story
7 Removc&Replace 3 SQ of Shingles,Stepftash/Counterflash 41'to 50'of Wall or Chimney, _
Remove&Replace 41'to 50'of Valley,Install 121'to 160'of Drip Edge.Install 71'to 10(1'
of Ridge Vent&Ridge Cap Shingles(Baffled or Rolled),Lead Flash Chimney 24'to 28'
perimeter,CLEANING Roof or Siding2,001 sq ft-3,000 sq ft,Construct Cricketand-PWA
3'to 6'wide Chimney,Cover 51'-65'of Fascia or Rake with Aluminum.Remove&
Replace 1 SQ of Dormer Siding Qty_„_x$1787 ea=$
6 Remove&Replace 2 SQ of Shingles,Stepflash/Counterflash 31'to 40'of Wall or Chimney,
Remove&Replace 31'to 40'of Valley,Install 91'to 120'of Drip Edge,Install 51'to 70'
of Ridge Vent&Ridge Cap Shingles(Baffled or Rolled),Lead Flash Chimney 19'to 2.3'
perimeter,CLEANING Roofor Siding I 5 I sq It to 20)0 sq ft,Cover 41'to 50'of Fascia
or Rake with Aluminum,Remove and Rcplace 1 SQ of Wall Siding Qty-x$1392 ea e$
Remove&Replace 1 SQ of Shingles,Stepllash/Counternash 21'm 30'of Wall or Chimney,
Remove&Replace 21'to 30'of Valley,Install 71'to 90-of Drip Edge,Install 31'to 50'
of Ridge Vent&Ridge Cap Shingles(Bafftcd or Rolled),Lead Flash Chimney 14'to 18'
perimeter,CLEANING Roof or Siding 1,001 sq ft to 1,500 sq ft,Cover 31'to 40'of Fascia or
Rake with Aluminum,Minor Tuckpointing and Water sealing of Chimney 5'to 9'm height Qty-x $922 as=$
Remove&Replace 2 Bundles of Shingles,StepOash/Counterflash I I'to 20'of Wall or
Chimney,Remove&Replace i V to 20'of Valley,Install 51'to 70'of Drip Edge,Install 21'
to 30'of Ridge Vent&Ridge Cap Shingles(Baffled or Rolled),Lead Flash Chimney 9'to 13'
perimeter,CLEANING Roof or Siding 501 sq ft to 1,000 sq ft,Cover 21'to 30'of Fascia or
Rake with Aluminum,Clean 25 I'm 3550'of Gutter,Minor Tuckpoiming and Watersealing of
Chimney less than 5'in height.Strip-off and Re-Shingle 2nd Story Bay Window Qty_X $763 ea=$
3 Remove&Replace up to 1 Bundle of Shingles,Stepflash/Counterflash 6'm 10'of Wall or
Chimney,Remove&Replace up to 10'of Valley,Install 31'to 50'of Drip Edge,Install up to 20'
of Ridge Vent&Ridge Cap Shingle.(Raffled or Rollo),Lead Flash Chimney up to 8'perimeter,
CLEANING Roof or Siding up to 500 sq ft,Cover 11'to 20'of Fascia or Rake with Aluminum,
Install Dryer Bose Connection&Flash through Roof,Strip-off and Re-Shingle 1st story Bay
Window,Clean 101'to 250'of Gutter.Install 5I'to 100'of Ice&Water Barrier, Qty._-.,,.X $612 ea=$
2`Removc&Replace un to 1 bundle of Shingles StepBash/Counterflash<5'of Wall or Chimney,
his a upl"t1 to'IO'of Dnp Edge,10'or Icss oFGuttcr or Fascia Replacement,Clean 31'to IW,
of Gutter,Cover IW or less of Fascia or Rake with Aluminum,Install Rubberized Crown on
Chimney Cap,install Stainless Steel Cover on Chimney Flue,Install 21'to 50'of ice&Water tt
Barrier.Remove&Reinstall I Soil Boot Qty t x $427 ea=$ yv2
1 Rcxtf C'ertificaticros,Gutter Cleaning up to 30',Install up to 20'of Ice&WaW Bamer (qty-x $179 ea=$
n Rcplace Rotted/Damaged Reeking,as needed,at$3.47/sq ft Qty�x$3.47 =$
�` Shingle-CLOSEST MATCH: Root Pitches greater than 6/12 Add 30%_$
Brand: Excess Build-Up of Moss&Mold Add 30%=$
Color: (inti) 3rd Story Roofs Add 20%=$
Other Services: $
$
$
Notes: , ..k, lc�r r 1W4</
t',- t J ,.t� rwv etre Sub-Total$ y�
Diagnostic Fee$
Total Due$ _ii,l
Down Payment Due Today$ `, ✓
Balance Due Upon Completion of Job$ `
I hereby quthorix aim proceed with the above StraightForward Pricee
� n
IA`!
Specialist Print Name:
Thank You!
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02114-2017
www mass.gov/dia
Workers' Compensation Insurance Affidavit:General Businesses.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Auulicant Information Please Print Legibly
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):
1.® I am a employer with 15 employees(full and/ 5. ❑Retail
or part-time).* 6. RRestaurant/Bar/Eating Establishment
2.❑ I am a sole proprietor or partnership and have no 7, M Office and/or Sales(incl.real estate,auto,etc.)
employees working for me in any capacity.
[No workers' comp.insurance required] 8• ❑Non-profit
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]* 11.0 Health Care
4.❑ We are a non-profit organization,staffed by volunteers,
with no employees. [No workers' comp. insurance req.] 12.to Other Roof repairs
*Any applicant that checks box#I 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 Ava- Suite 730
City/State/Zip: Holyoke, MA 01040
Policy#or Self-ins.Lic. # AWC4007012861-2015A Expiration Date: 4/29/16
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 andpenalties of perjury that the information provided above is true and correct.
Simature• U'�� Date: �1 I t"
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
A� 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 Q
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Dec s [ Siding[[3) Other[a
Brief Description of Proposed
Work: Replace rotted decking and fascia on shed and install new asphalt shingles.
Alteration of existing bedroom Yes 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 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, Julie R'4J1aA'G)\&Julie Reiss as Owner of the subject
property
hereby authorize Adam Quenneville
to act on my behalf, in all matters relative to work authorized by this building permit application.
See Contract `� 1
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 ® DON'T KNOW Q YES
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 O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained ® Obtained Q , 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
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 I(&
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
.1 Department use only
ity of Northampton Status of Permit:
uilding Department Curb Cut/Driveway Permit
`". + 212 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability
D> �,FJ, r,; r"":. : No hampton, MA 01060 Two Sets of Structural Plans
"0 '`'A` ,'..,t `'3 - 87-1240 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
11 Fox Farms Rd.
Map Lot Unit
Florence, MA 01062 Zone Overlay District
Elm St.District CIS District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Julie R; & Julie Reiss 11 Fox Farms Rd. Florence, MA 01062
Name(Print) Current Mailing Address:
413-218-9089
See Contract Telephone
Signature
2.2 Authorized Agent:
Adam Quenneville Roofing 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 permit applicant
1. Building (a) Building Permit Fee
497.00
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) $497.00 Check Number
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/inspector of Buildings Date
11 FOX FARMS RD BP-2016-0997
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17A- 163 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-2016-0997
Project# JS-2016-001685
Est. Cost: $497.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ADAM QUENNEVILLE 070626
Lot Size(sq. ft.): 9975.24 Owner: RICHARDSON JULIE
zoning: URA(100)/ Applicant: ADAM QUENNEVILLE
AT: 11 FOX FARMS RD
Applicant Address: Phone: Insurance:
160 OLD LYMAN RD (413) 536-5955 O Workers
Compensation
SOUTH HADLEYMA01075 ISSUED ON:2/8/2016 0:00:00
TO PERFORM THE FOLLOWING WORK.STRIP & SHINGLE SHED 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 2/8/2016 0:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner