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17A-221 � ��- Name Date �.� l�ob�r'�'t/�Hr k /a l ate ,ZS - // QUENNEVILLE Street Address C City State /I ��yy Zip /�Vl ROOFING V SIDING V WINDOWS / Q�lr� S'�' /� ✓'�HC A V /e, . 1.800.NEW ROOF Home Phone # Work Phone # Cell # 1800NEWROOSNET sf� -G,Z L-1 , 1 DEr� t IA firer i N �4L E mail: K i� G I 2& C o �t c Q�S /( . 4/ StraightForward Pricing® 1 Story 2 Story 3 Story 7 R place a S() 'shingle Stcpi1 „h Cnunterlla,h 41 I sit „t Wall 11 Chinmr�. R plure 1 1„ 1, ` ■1 A I caJ I" t,. ' ('lumne■ (r 1 Crnket and Fluah dd F' a Ide ('hlmnri. R,, „t C c,tntn,d 2101 11 _ Crtct ha,: la or Ka Vlumlr :um ', I . 6 R'4,),' 21 +I) ',Lite RS nu. e and Repiaee 11Q „t Uonttrr tii I ne Quantity x $1787 ea = $ 6 I I r soa r11w , rin 1trh hiun I, It r -+ n i A Ihc I . 1 4 " (lutt�ncc I t! s n I E<t is A,nl h„ 1 A,gut.. (l; uun_ 1 ' t ' 1 ' M y t 1' 1 ., : ie I R. k L. ' +nh Vlu„nuh; I �n Krri.,c r 'u yI,iL` r ,:m "-, ;hi Rcl ti, - ) �,� V\eli 'L6t,: Quantity x $1392 ea = S 5 Replace 2 SQ of Shtugles. ssicii11.011 Auntei flash _ \‘411 Cl nntr . In,tu11'1't:' "t)','4RideVent Replace ^ 1„10' \4lc). Flt,h„r pla.e up u, 2 ('u.n Supplied S4 l ht, In„ tntrrtc Iran m.04,4 Imtall 2;4 n 3 >0 o f I)np 1 e I t:n1 1 to 14 Ciumnr }. Ko „I 1 Sxhrl (leaning I,(Mil ,y It - 1 500 sq Cmu Fr ci.t tit Rake N11111 .11umiu e f um rl all . R pl,,. 11 lc Slate, Quantity ` x $922 ea = $ ?OZ. 4 1(1 lion yI ii I I t „ti 1 N t hit n In IC I �,i R I _ ^ni lnRall 21 !■ ) Vatt (1...0 io 0i (_ t - Y vet /fm- 5/5 V' ; 4 . u , , . I .t . 1 t h I nee ,-1 ,11,,,11 Ilk 1 c4)1)'f11 S G G t" Rorg ) �ofM I lu,h m 1upl 114 o.�l t n0.: I I , , , r ( � i -„tl n � K - thi n I :1411 � �� A11. I,,1c 114 1 1 III A r [hip 1 .1 h I , I .'i ! C :.0 vi 11 �el , JA n, ■1 n C„ .I I , .:,, , { .,ee iii V,iuununi ■U'. I p,.ce 11 11 !c Quantity ! x $763 ea = $ ■ up to p'rnmoter ( Repla.e 1 to 2 hun S dr „d iinple,. Stzt�tla 3 ('nuntcrtla,h n I„ iii' „t 11`all 1 'hininct Imtall '1 tr I'44 ni Ili ip 1 II).lail t a, ti Hut A cnt , , In )r It ,r Conno Hon. RcpI I ( 'il n( Valleg. `Anti and Re- Shingic 1A ,unc tint \\ induct lnstail up to ?n 01 Ridge 'rot. \lu1 „r Tukkllutnurti and A\1,k'r.',41n4.d Chmwet I<3 of Re Stepping .11111 I, J11101,12 .4' SkV 11,114. In,talian,at„1 (.Lrhrnuunt Skv light. ('lean I ?ti' to 250' 1 ' 1 4' 111 -14 SLuc R„ I „111111 i 1 114, ( ' leaning ur n,_ 111 1 It ItVI Minimum I! Quantity x $612 ea = $ p,„ 1,: }u„t „i 113'x kc :+1 „pn ,� ,tlhmel 2 11 ur41r I,1 1 ep11 Inn, ut 1 t .l \\ op s Itr14 1.141,' lu t.,lla 1 ^ al [Li \e =I ,I+ , 1 1C ot 01111,1 1 Rip I, menu ('Ie. tl sh ,4 1.11,1 R. i. n Ltr,;rr. 1 1, 11,...,1 Cr, i up t, ,u „1 A allrc kri 1 : 11.,44^ , .4 ' 4 111 -, R. tkc 4 V1.111,11,411 1 , ,r lr , ,. ln.t.tllRuhhe: tr 1n 1 Ifni, S L. ci , r ( Iun,itc ,lure Quantity x $427 ea = S 1 RI C'ertilil Gunter Cleaning 1 up t„ 311'; Quantity x $179 ea = $ Rcplarr ,l 1).ck ne, dcd .0 1 • -l' .,1 tl Quantity x $3.47 = $ Roof Pitches greater than 6/12 Add 30% = $ Shingle Color: Excess Build -Up of Moss & Mold Add 30% = S \/S /l G C �C ✓ 3rd Story Roofs Add 20% = $ 3— T.? b Ice /Snow Removal (Minimum $400) S qz'2 Tarp (Minimum 8500) $ 7 l0 3 Other Requests: $ Notes: Sub -Total $ / BBB Diagnostic Fee $ee' "fi' I hereby authorize you to proceed with the above StraightForward Price of: Total Due $ , r `S Winner of the X --1� 2010 -- — — -- TORCH AWARD Down Payment Due Today $ 5 ' 5 Balance Due Upon Completion of Job $ 1) 0 Specialist Print Name: 2//5 -1 yl / ��v"s �' Thank You! A . The Commonwealth of Massackitsetts ----.— Department of Industrial Accidents ! sr_ j'' Office of Investigations 6 Et �s = 600 Washington Street � ,''" '' Boston, MA 02111 . ..,s www ma. s.gmVV'i n Workers' Compensation Insurance Affidavit Baders/Contractors/Electriciansinumbers Applicant information PIease Print Legibly ll Name (B A O1 Wl Qbt yinAI l t-2 ©0l il) t Si' i n 1 C Address: i Le 0 U 1 J 1ji 41 . Cit /stateizir: 6,'. K !"0 Ii'l 016 o e#: t 3 - 6 Vr -61 SC Are you au employer? Check the avi ro . to bore Type of project (required): 1. (24 I an a employe with 1 4. f il I am a general contractor and I 6- C] New acsostnution employees (full and/or pithier).* have hind the: sub-contractors 2. ❑ I am a sole proprietor or partner listed on the af3ached duct L [] Remodeling ship and have no employees TFicse sib- coneizartots have S. [] Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition No workers' comp- insurance comp. insurance.: required 5. El We are a corporation and its 100 Electrical repairs or additions 3.0 1 tom a homeowner doing all work officers have exercised their 1 LEI Plumbing repairs or additions myself No wodcers' comp. right of per 143L L repairs insurance I t c. 152, §l(4), and we have no I3_0 Other employes (No workers comp- immix= required.] cAny applic:et that Checks box t I mug also fiat oat den section blow showing their workers' wmp or policy mfOrawtioo_ t Homeowners who submit this 'Stint indading they ran doing all wort and doer 1»:e outside contractors must =beat :new athdavit indicating loch. !Contractors that check this box oast attached an additional shoat allowing the oar= of the and stab: *bather or nor those entities have employees. if the rob -Era tars have employees, they must provide their withers' comp. policy l con an employer that zr providing workers' compensation insurance for my =Aye= Below is the policy acrd job site infra-audio' c. Insurance Company Name: AT M m 4th( a j "1n Su r a ef , • Policy # or Self -ins. Lic. #: A C r i () I LH, 101 Evin Eioti Pate: q -- 9@-)6 i a L A Job Site Address: 0(9- in or t i p P St. "! 1CI' ?Vj L.e__ Qty : olpo <T Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to scan coverage as rcquirnd unekr Section 25A of MGL c. 152 can lead to the of crkuinal penalties of a fine up to $1,500.00 and/or one -year imprisonment, as well as civil pez a1ties in the form of a STOP WORK ORDER and a fine of up to $250.00 a clay against the violator. Be advised that a copy of this staberneat may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby reritifi pains turd penalties of per jury that the information provided above is true and correct 5 • ature: Date: I 1 1 Phone #: L f l 3 6 bG - S S vfiri .r rcvc risky_ Do "rot write is: this. cons, to ba corsgsletazf Ey cite) or tows* officio' t City or Town: Permit/License # Issuing Authority (circle one): 1 - Board of Health 2. Budding Department 3. City/Town Clerk 4. Electrical luspectot 5. Pltutzbing Inspector 6.Other Contact Person: Phone #: SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed ConstructionSupervisor: Not Applicable ❑ Name of License Holder : r� a 0662 G I t, I); 1( 49 706?-6, License Number (4 C 104 [ n t� v 2(' ljoudi Wn d (.t-i i L& O!( e- a (- do l 3 Address Expiration Date Sign Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ Adam Quenneville Roofing & Skiing, Inc. 0-e ?d Company Name 160 OW Lyman Road Registration Number Address South Hadley MA 01075 Expiratio - e 5 ao I Telephone V/ - 9453 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 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, von 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) [J Roofing Or Doors CI Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [CJ Siding [CO Other [d[ Brief Description of Proposed ,9 Work: '1 it 49 ,V111.1 d ! J l� i/!� ,�i 1/ ✓J G6 i 2 get 2 / uctj' c'- t ht- 51 1a/ Alteration of existing bed om 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 stones? 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 . 1. 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 1, �Gf / , as Owner of the subject property hereby authorize Adam Qnemmev Roofing & Siding, Inc. to act on my behalf, in all matters relative to work authorized by this building permit application. .5 . . COX- frg of (-6-2 0-10 'di j /— / CI - f Signature of Owner Date I, Adam Quenmevilie Roofing & Siding, inG 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. A Cia -14L 4 3 LU b7ILiV i I� Print Name Signatu er /Agent Date y � Department use only RE EIVED ity of Northampton Status of Permit : uilding Department Curb Cut/Driveway Permit NOV I 212 Main Street Sewer /Septic Availability 5 r Room 100 Water/Wen Availability . rthampton, MA 01060 Two Sets of Structural Plans DEn of sun.biNG ws • ": - 41:-587-1240 Fax 413- 587 -1272 PIot/Site Plans NOAMPTON 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 1,g3- i f 1 Maple_ ii 1 J Map Lot Unit it,(' f t! ( r /1 0 10 6 d- Zone Overlay District an St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: Ph-er � 'u i t . k I Q - 5 liM fi le. 5 r. Fo r.-e ki C f( v1 — Name (Print) Current Mailing ti ' Address; ,� _ s 1ais a io6 G ar k k L / �i, Vl '-!' ---c i Telephone Signature 2.2 Authorized Agent: �p1 I / j Ac- tin Oit_ ri rrt!/ >l i IL_ i ce a 613 Ll-1 mci✓t ( • Sc. 41 Name (Print) Current Mailing Add s: G��-- `i( c3G -51S Sign Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building j''/ _ c4' 0 6 (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 = (1 + 2 + 3 + 4 + 5) g6 66 _Check Number is This Section For Official Use Only Permit Number: Date Building Issued: Signature: Building Commissioner /Inspector of Buildings Date 182 NORTH MAPLE ST BP- 2012 -0489 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17A - 221 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- 2012 -0489 Project # JS- 2012 - 000820 Est. Cost: $1685.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ADAM QUENNEVILLE 070626 Lot Size(sq. ft.): 18730.80 Owner: KLAES ROBERT & JUNE Zoning: URB(100)/ Applicant: ADAM QUENNEVILLE AT: 182 NORTH MAPLE ST Applicant Address: Phone: Insurance: 160 OLD LYMAN RD (413) 536 -5955 () Workers Compensation SOUTH HADLEYMA01075 ISSUED ON:11/17/2011 0:00:00 TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE 2 SQ ROOF & VALLEYS 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 11/17/2011 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner