Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
23D-036
nn lid LC/ IIIIIC uD /u3/4u1u 1 LS 1 413 538 61.110 P. 001 May - 03.2010 02:22 pm Remillard Insurance 1 -413 -538 -6010 1/1 ACORD CERTIFICATE OF LIABILITY I D M DATE(MMIDO/YYYY) I A , 1 05 03/10 PRODUCER I THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONL' AND CONFERS NO RIGHTS UPON THE CERTIFICATE Remillard Insurance Agcy, Inc HOLDER, THIS CERTIFICATE. DOES NOT AI N END, EXTEND OR 79 Lyman Street I ALTO THE COVERAGE AFFORDED BYITH POLICIES BELOW. South Hadley MA 01075 Phone : 413-538-7862 Fax ;;913 -538 -7179 INSURERS AFFORDING COVERAGE i NAIC# INSURED INSURER ASE Butnal Inatae:nos Comm r z _L. INSURERS: Travelers Ins . Co. . Adam Quenneville,Roofing S ding Inc INSURER C: Scottsdale Ins Co 160 O .Ld L n Road INSURER : 13: South Hadley ILL 01075 INSURER ' ,E: COVERAGES- THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWRHBTANDI ■1C ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POUCIES DESCRIBED HEREIN IS SUBJECT T ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUC -I POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. I NSI< UU'L POLICY EFFECTIVE LILY EXPIRATION LIMITS LTR NSRC TYPE OF INSURANCE POLICY NUMBER DATE (MMIDD/YY) [ P DATE IMM /DOIYYI — GENERAL LIABILITY EACH OCCU CI: 81000000 , uANtru;t w tNr•1 T C � X COMMERCIAL GENERAL UABILrrY CP81034980 06/23/09 06/23/10 PREMI3E8(Edoccularuel' 5100000 CLAIMS MADE I " i OCCUR MED EXP (An pe 3 5000 PERSONALII ADVIIiJURY 31000000 — GENERAL AGGRE s 2000000 GENt AGGREGATE LIMIT APPLIES PER: PRODUCTS • COMP(OPAGO B 2000000 r I fl POLICY i --- JE8 Flux _ - AUTOMOBILE LIABILITY COMBINEDSINGUELIMIT $ 1000000 B ANY AUTO BA7450L946 11/01/09 11/01/10 (Ea occident) ALL OWNED AUTOS BODILY INJURY X SCHEDULED AUTOS (Per person) S X HIRED AUTOS- BODILY INJURY • X NON -OWNED AUTOS (Per accident) § • PROPERTY DAMAG E $ (Pee accident) GARAGE LIABILITY AUTOONLY -EA ACe)DENT S H ANY AUTO OERTNAµ — EA ACC S F AI AUTO ONLY: AGG S EXCESS/UMBRELLA LIABILITY J EACH OCCURPEN $ OCCUR n CLAIMS MADE AGGREGATE $ $ _~ DEDUCTIBLE -1 s � RETENTION $ ! $ — WORKERS COMPENSATION AND X ITORYLI 8 ER EMPLOYERS LIABILITY AWC701286101 04/29/10 04/29/11. E.LEACHACCIDEN A 31000000 ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBEREXCLUDED? E.L DISEASE •EA PLOYEE S 1000000 ; SPEC AL PROVISIONS below _ El. DISEASE • POKY LIMIT 3 1000000 OTHER • DCSCRIPTION OF OPERATIONS/ LOCATIONS / VeHICLGB/ EXCLUSIONS ADDED BY ENDORSEMENT:/ SPECIAL PROVISIONS 1 CERTIFICATE HOLDER CANCELLATION , '—ii"--- _ AD QU SHOULD'ANY OF THE ABOVE DESCRIBED POLICIES BE CAN j I p'.OLLED BEFORE THE EXPIRATION Adam Quenneviile Roofing - DATE T NE ISSUING INSURER WILL ENDEAVOR T MAIL 30 CAVE WRITTEN Brian NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO CO SO SHALL fax #536 ^1446 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON T INSURER, ITS AGENTS OR PO Box 612 South Hadley MA 01075 REPRESENTATIVES, AUTOO ED REPRESENTATIVE . 4 814)1 . _ L ACORD 25 (2001108) SD ACORD CORPORATION 1988 The Cimmbioveaffh. of Ma stichasetts . . Dparmanent ofIn; , !rind Accidents , t -.Wee zth ,p-- 600 Washington Street 0.::; BegtOnr44 On/ www.inass_govldia Workers' Cnmpens ttwn Insurance Affidavi ' Bnit}ersiContr ,actors eetri:cians/Piunkbers. Applicant Information Pease Print L Name (}3wsiness/Orga ): blAchniN C antw&li cy c t Address: / C O ma Ron.. Ci1y /S e ip: `01 it MRS Plioe #. 1 -113 5 3(5 — Are you an employer? Check the appropriate box: Type of project (required): 1. I am a employer with 4.101 am a. gel contractor will - 6. 0 New ct on employees (full and/or part- time).* have hired the sub - contractors 2. El l arn a sole proprietor or partner- listed on the attached sheet. t 7 . 0 Remodeling ship and have no employees ao boutts have 8. [] Demolition for me in any ca aa�city. workers' comp. in surance. 9.0 I g addition [No workers' comp. insurance 5. 0 We are a corporation and its • realtaired.j officers have exercised rcised their 10. ❑ Electrical repairs or addition 3, 0 1 am a ho xe .r g all work - right ofexempti per MGL 11.0 P1¢an�g repairs or additcrarr. myself. [No workers' comp. c. 152, §1(4), and we have no l2 f repay j _nnsu ante a ] t employees.. [No Workers' 13 . . , Other comp. i mcanceirequire�d.j *.Any applicant that checks box #1 must also fill out the section below showing their i' orkeis' em®�pebsation policy infonnalion. t Honieowners who-submit this affidavit indicating they arc doing all work and then hire outside contractors must submit a new affidavit indicating such. teenttaetoes that checkeibia box mass¢ attached aim addiii onal sheet showing the name 4f the sub - contractors and their emrkers' comp. policy information. - I am. an. e lo er. that - -_ workers! co ensue ire vn o p e r - ! L the and jt1 site rrap y p • ading � , .� my policy � information. Insurance Company Name: 1:)) /1 AAA O taikae Policy # or. Self- -ins. Lie. #: f] C,OC 7Q } Expiration Date: 4't - oaci - ,f t L _ Job Site Address: '�i'- Cit " /ore4 t, AA .0010a Attach a copy of the workers' compensation policy declaration Rage (showing 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. $1,50.0:0.0 anttior. one imprisonment, as..we ..as.CiVil Ones ba. be foran.df a :STOR WORICORDER and_ a.finir 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 1nvestisak n of the DIA for fustlfetlagg Virevase ,roz: etion. I do hereby certify under the pains and penalties of perjuly that the information provided above is true and correct Signature Date: .S1/ y// U Phone .5 C S95 ##. s3 ---- -= rafficud ore o Do not this , to opted by, city or town official q C ity or Town: Permit/License # _ Ong Authori y (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector ;F,, numbing I e .t" .. JS "6.," Other Poax , • .. . _ . _ • - - -.-- -• • —• . „ . . • . , : , • .., i ; ' . . . . • . . , • — . ,..., ip - . . ; 1 A ' i d • _ , .. . ,, . 0 ar . . ..:Iui sing 6 eguirtions an: 44 tan f I ar ' ,.___7.1„ -e6 .. . • -,-._., ••-------, , . • ,‘ f . - • • _ . „____ . One Ashburton Place -:Roorn 1301 • --- --ilyi • Boston, Massachusetts 02108 , . .. . • • , - Construction Supervisor License License CS: 70626 ' . . • . . . . .: - •1., ''..•:•.* ".'.. •:-. :::"....• Restriction: 00 i • :.. ........:'''- ' .. . .:.: '''' ' • . - • 'Birthdate: 8/21/1971 Tr# 3712 Expiration: 8/21/2011 • . ,. . .. ." • ' ":,:, . • -i- • - , ..... .... . . ... .- mk .QUENNEVILLE : . ,...,............. ,..... : .' '' '.''' • •1 0 OLD 'LYMAN RE .: • • • .. _ .,•• •,,,.,..,...:. .:....• .... i ',,.'•• : §•'HADLEY, MA 01075 . • .-- • • • • , - • • . . . . -- • : . : . . . • . :..• ... .,"....... . ..... . Update Addrss and return r M on • a C g a e rd . t - 6 2 0~tozitevecra . P 4 A 1 - ---ffiriiim_r -2--rag of Consumer Affairs and usiness Regulation 10 Park Plaza - Suite 5170 - si _--.-- f.. Boston, Massat11.isetts 02116 Home Improvement.;..q tctor Registration .......__— ,...=,: ----,------ RegistrTaytipoen:: DBA . 120982 Expiration: 3/25/2012 Tr# 293069 "' — - ,.. ADAM QUENNEVILLE ROOFIN a-z,- --, Mi i ISM 0 , , ADAM QUENNEVILLE - 4 , 160 OLD LYMAN RD . , „ . • .,„ , . - s w. . . t . - - - SO. HADLEY, MA 01075 - Ira k Q \-- : - ., -_- / __,./;\,/,,,,, o Upd A a d te dr A e d ss dre L r_ ss a n o card E . M DPS-CA1 0 50M-04/04-G101216 , _ ..,, 7 ,„___.,„, :. , 7 _ ,--,,, ,, r..13 6.: kiti ... ... :..:.,,,,.....7......,......,...,..,,....... ..;.......!:::,,...: .,;,,.:, r...,:i.........i...,.,...:..,:,...,...,..,... ..., . ........ , ...„,-- ,,77--:r".F.5,7..:;':.:!:;.!...:§:".'..::'7,.','•".'-',:V .. '..:•.::\'' (- .:::.•!..','..', . :.......• •: ••:-.......:.•;..'..;:1::::___ :;:;,;:-'...'...-j.%:::',..•• e ', 3 .':-:;:"...,.';'3,...::': , :::'' . ' - • ' ' ' ''''1 .s.f.'':':".• ;..,!'::''':?,.'',..:.!",;.`:,:' ....i.,..,,•:.:,..:....;:::•;;',.....;..20:.'.:;:,"p7'.7'.-t.V.:v1,ME*.i;s3!'.1". '''.,....,;.'''.;';.;./C• .....q • • - ' . - i• :'; lat..;'. ::: •- ' ...:"'..,..."..3;;':'... ......."•'':;;.',:,:'::'.';';`:.;.;;;3......',;.;:i'-:...;',? .: clii.1• „ • ,..,,.....„ .,,,.., •:;.::::...-.......%,,,,....,;•: ••• .........:v..„. •:...? - • • • . •• .: • • • i 't .:: -' '-".' ••••••::;••••'.'•: ..4 ' •••;.•;;....:::.',n....**•..:.:.;', •.,..':•• ., ,W-'1..4, 5. ; 1,, ; ,, ek•?:•; ,, .....wik:z••••• , 0,4.:4:3s , . , !:•;•,:.,.. :-......,-..,:.•,.....,::‘ .:.;....,...,..: .....,•:,...: „:i!....,::::•;; • ., . • - .., - : • • • . i , ,t '''.. l'''' : ''..;':::,:::::?;:......-:',..'.'1.-::...::,'::i:.:..N`,.?.....C:....:1;., - : ` .:t.11 ' .:, :'•': 7 4iftitiK4f1 7 ,7'.'": : . ''.... : i ';.. • i t : ::: .6q-it.,., ,.;...:..; ..• ,.....1::ii:1'.:,'1:•.:.:1'..f.';;:t.i..;-:!..4.-...::;,:.',•::;::::...ii:•.;?•!-:•;.•;.",:::•.46.0.:01);14....7.'‘.7'-../.' . ,. ,..'...'' :::: :: ::. ; :. 1' , ........."..:!... :••:: .: • .. . '1 14 ,-9..gt',:i....:..:..........::-...:.::;,,,,,...,,:i.l..::.;.,-..:.,..:-..,,:.....•.....;:i,..:....,i.,,„111,is4.6.12;,:..;::...:-.:,..",.......:,:,:::::.,......... :;:;;.. 7 . : : ' • . • i: 1 : ?6:: '.".'.....) ' '''' ' ''. ..' '-' '''''.' 4 .. ' . ".' 2 • • •:•-. i, ' '1 , ,..,..-::•.., . .../.:,•: ;. . ; -.... ,,•-:. . . „ t . .. '::::it., ,. ;':..... :::.: : :.• .. .;' :'•„;.... .1' ..: :i,•;...rt;:y.,..7,-,,,fg,:.`. . • •,,,:•.:.,,,,,.,..k,s-4.::•,:::....,Lii.:....,....•._.......,../......',.......,::.;,.....:.::•....::z.,i..!•;:'......i..:„...•••,:,....... •:. ,..• . . . i - AK . , ..-}ar ,...:::::::-.:,........,,.,•.::1..... • •:,. • ; . 7 •"•.•••:. '.:',:':V...-.........!..i? :*?,44.■•....•,•,•:).:;;;;;•.'.1.''..,•?...1,'•••:•;•:••,.1.,•:•*\'....1:.b.1.'••.ilf•J• .-',• •'•.•:: i• .1:"...q;:!•,::•:.::.:•...i.:.,....•••'..',...::::;!.......,.f • . •- .1: : : . • •: : :.:::: : •:.•••• .''''':"' i .• :..:' :::::.......:.; .:!... '•-•,. ' ....• . • • .., • ..!i •It I': :•'•••:.• .: ..•': 1 ....': •••:.:.•.:••, .. •1:;7:-i••••;'*:::'‘,W.•:•..7•'..ft7.:.• '!{N:•••••':*...."•■••1W.. 4 • S.: L :{44 : . ;.‘.1 ,.....;,•„... :: : * ; : i. • *,,, g*•'...tkr;i:d;••• :••••••••••.',•••••••;:..*:: ••••;'.:••••• '•:.:*:.''..... • . • . . . :i7.- 7.-Fial,,,•" :I • •••• * *.::••••,./ • ...,1;, .... 'i' '"."•*:,••• .'• •• •2;;;.:.•••,;,•.f.-7,(••:..• : i:; ' 4*-;••7! ;, ••• • • r:. = ',4•/-4 * •.r • • ••• ... •••• - 11!;• ' 4 • 1 9: - ; •Cft.e ilal?:'•••'4'....4 ?t:'•-•*147"-('7: :i %-:*'‘/•'-'.. ••* • .• ' * • • 'ga*: -"Zi:..., 4 ; "..; :•.• . ' .: . • . ' • '' • •/..:..; •:), • . , . ,e: .. e. ' • ' ..!,,,..• : .:: !.,, , i..:.; '.. ,• ,,: ;.••••• '• c '' • ';':.: . ...F . -........: •*.'...•:•••::'•••••••••'.•:+;•''..:'.' '•" •.**• •-•?' * • Sf; • •,, -• 4:• •••• . • • • • 1 • •I'i :*•'• • l• • • . :•• •.• •• •'• ••••'... 'i '• " , ••• .•• '•.-. • ' . • •• :",`:•,•,;(••'•,.c.. :*:...../•,:::,;-:;."'" "•:•:•!:,"'•••,''. ,A. '''• • '''' ' ''' "•* •.*:.'' ..:0N.T0A :•GTOR. L......:ii:-.).; . • c•-,': • . , ,... 1 -,.:40 ":-.'o..::::,i,_•.., :i..........: , ....:!...• ::.•:: :..." ....:.1.,".,,, .... ,,,.._‘ ,..... ,-, 4 ••: i ti.... 02. -../....,..-. ....: .....;,. -,.....,....• . . • . •- .,•41.:.... : ,:10.'4r: :t.:-.?"..i:.,"' ...';• i::::::::::::,,.,..1Kegf 4N,..,.....,:-..:-....,... ...‘. 4-. . ,=- ......; ,. .::).‘;= , : , ..;::,..:"..,!::::...: , ......;;::::...,...'::•'.':.;..:''...............::..,..: .: ..: .. 1: ' .4 : ...''':•'5.• :•::;i' '.;.:.'::::. ...-.':-'...1..:;W...T.:-.14,...„.,5•1,..._"'N-g.tz-ii-itt:i...;'-''':•!.'•.:-:;.....;i:::.•',...: . ...., ..:.• .... • - ... i . i, '''' .1. .'...!-'•:..;::..::.''%.''.1'''..:.::•:.:•.';•,:-...H....;:'.•;,•,,•.(•`.:':...:..,...:;.. ......:' ''' : ; , : : : : : " .":'2 7 . ': ....... ;•.' ' ' '' ' '. ...:::31i :1: ,;: :: : .:.•,;."..;:::::::,,"":"? ' ' - : ,.' ; ''..) .....;• :: ;.,4 ; .. " ;.,. :1 ; : , ;,:::;i:?.:::::•::.,:f.7 :;:'.....,::..::.:;:?:';',1":",;.:%.:::1:,.."1;i::..1:.:"......!,,:l:.;•:,:..-4'.:::f,;'..;;,'";.::::•••:;1:''::1•31::., .. :'..'..:-... . .: •• 1: ' . i . :! ' 11. : ' !'!:;; ; ; g 7;;. II I. ,, : ,: ...., ' ' ' ', r '' ..., '',,: ',....; ' ..,,,• ' • . ,,•';', •', ,.:'....,/, 1 ,•,;:,,.' ..,',..; t:;, ' :,.::,-..;..1,.. :,, '',.:',. , ...4, ;,-;::::r 7 :..., ::',,-;,*•::',...,...........; ::::,7..',.':.:, ...' ,13 • .." ... : ,.:. ' -:, . , "!..., „•, r .-'. :4,,:;',,, :;:::::.n...,:,.% ;. ,.F.4.;'1.;,N''': .4,:;e.6;,K1474'WV,V,14)40.." ; ;.„q '. :.. ..,..."....• .': ..,.. -...,,-, „ , ;:!...,;.,,:,....,,,,,,,,t..41.,,,,,,,,..f..1,...:,.......,:1,;.i.i...:.:,,:r......n....,,.. .. . :. :.. I , ...x. .4...':; ' ': -.....' .',......1..:41:17A145.N.112M-k,'•"•". ... '''"'" ' ',. .;,.,:.;,.. :., ' .::: '' : . • '. '" .; i.....' , ....: • ;.....;:,..:'•.:...*:.:,.,i.f.....,...'"?.';;;;:7:..y.j.115,.,.,..i...,;:.:i...::,.„..*..1..,.,:,,.• —„,:,...,.. c-„,..,..i:::....:: „..1Aii::::, : ' ' • ' 1 ' . "' 1• : • : ':: • • ■ ,••+ ''''''•" • ••' - ' •1 '''•• ' ... • ",) • • ••• ''•'•r• • • ' • • •• • •••• •: ' - • -• - •• ;'•• • * •,"' :' •:•••;‘; ' * ••• *, li_. ' "461rolithilYleNtbdtArt....r_.f.....1tX „ - .• ••• ••.;;':••',•IL.„4.+....,..16.7....6.1,"„r7r!..'•47.44,: '• H ... :.. ....,. .-..-:*:: :.:• . ' - , • • . .._... .. ,.....•.-- ..- ....4 , -,--.. 1 '.: •1•••;f*;•••;:::!•1• 41.'",,,;•':;: ,ZW.;.•:• .; ' e '.• ',Lir •• ".:•/'..0.4/n•A'III5 • ' . ■••- • •• ' --•": . • • . . � mask: % DffcsVER CCU EN N EVI LLE www.1800newroof.net ROOFING & SIDING, INC. 160 Old Lyman Road, South Hadley, MA 01075 We Are Licensed 1-800-NEW-ROOF • 413-536-5955 Fully Insured Email: info@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 Member of the Better Business Bureau P.P.C. 38710 Proposal Submitted To: Date Phone #'s Work: .. ... ,‘) 40. ^1 ,S~(lo) /o H: ( S& Q 015 Cell: Street Email: is ©K�„,./ 0,, „, Cit y, State, Zip Code Special Requirements 1:f / a:' t PAY e /A 0 /0C oZ ‘P.1f1 1, C. ei n re,v” e.4i Complete Roof System Ga ^05 e / <n0"1 ° (g) We shall acquire all appropriate permits for all work Ki Home exterior and landscaping to be protected vP j 6, ti (Sm j' Entire existing roofing materials to be removed to existing decking IS Deteriorated existing decking will be replaced at $3.47 per sq.ft. E' Install Ice & Water Barrier at all eaves, valleys, chimneys, pipes, skylights and sidewalls ▪ Instal 15 lb. felt Synthetic) underlayment over remaining decking area g Install Metal drip edge at eaves and rakes (8" 5/� white brown / copper) 1' Install manufacturers starter shingle on all eaves and rake edges N' Install new pipe boot flashing( standar. co Install new step flashing where necessary standar copper) N Install Hand nailed rigid baffled continuous ridge vent ❑ Install proper soffit ventilation Shingles: (6 nails per shingle) .) CA - f - Shingles ❑ 25 year 153[ 30 year ❑ 50 year Color Ili •c Cep/ 6 F Ridge cap shingles Warranty Options: YWe guarantee our workmanship for 10 full years (see our warranty coverage) ❑ GAF ELK System Plus warranty L' —( U ❑ GAF ELK Golden Pledge warranty �( y J ga� j (. %'�1A 10 `DKi �v � n ' Chimney Options: ( 'Do I Ib 6 : - (#1 wee is- � ' 7 0_ i - , g,. Lead Counter Flashing ❑ Water S al & Tuckpoint ❑ Rubberized Crown ❑ Metal Cjhlmney Cap We Propose hereby to furnish materialsd,labo - complete in accordance with above specifications for he sum of: Total Sale Price $ / Y 7b N Down Payment $ /S O Upon Completion $ C ACCEPTANCE OF PROPOSAL: The 'above prices, specifiZations and conditions are satisfactory and are hereby accepted. You are authorized to do work as specified. Payment will be 173-down_upon-signing, and balance due upon completion. Unpaid balances shall accrue with interest at 18% per annum. Purchaser(s) will pay for all costs, expenses and reason- able attorney's fees incurred by Adam Quenneville Roofing and Siding, Inc. to recover any sums due under this contract. Date: 4�A a 0 Signature: , / j :• Phone # Date: /.)// Estimator's Signature: 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 and Sidings will not be responsible for debris or dust in the attic or storage areas. t/09 42' �� �- e o ry a 8.1 Licensed Construction Supervisor: ���� Mot Applicab e ❑ m ( n W Name of License Holder : 6 lll� /`,� °_ 1^( 1 . t' / n ao263, License Number Itoo Old rmn W. . �dkq, 4 0149. Volt ht Address Expiration Dat. X13. 53 6, -- 57 SS Sign u Telephone °.lac' , ' e° e,as'' 1 &v :roe . :,ntra"; r- Yt`r,l---,s"r A. T $, 7e `k, s ', 4 rr,..'5 Not Applicab e 0 Company Name Registration Number I (oc) 04 mail k.4 -,So. �, AA_ 0 /07J ...? / . Address Expiration Date Telephoneli /3 - 1',S'S" js Y' la r 7- , X I "�p�;;, ", W, , r nS x 4y ki !' Y • I � .. "� y ce. �c� # fir•. �i ' i mjr T d4. J4 L '.. jr6� ,,, it i �r i 4 , a „,, J:' " 2 'a, ' 7 . , 4 '.i M a 0 ° ■ ^ 0 ylU. , I a �ViT. , , 04-. i ,c: iii :z_ ,, : § �I ): -� �t '� a .. • s _ � � ` .�iX � i .�A� ^d9�9 - ! � :r•�. �' ' fir � ���."." " .II Y7i � , ' � Workers Compensation Insurance affidavit must be completed and submitted with this application. Failu to provide this affidavit will result in the denial of the issuance of the building permit. _ Signed Affidavit Attached Yes No ❑. _. • i -, _ ; , �� f fi r., i s 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. Definitioii-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 perfonn.work for you under this permit. . The undersigned "homeowner" certifies and assumes; responsibility for compliance with the State Bu lding Code,. City, of ..;` Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature • • • Y nn�"'r " � 1:1 F ' " pl AI A� 1 4Q T .�^�"`�r� .: aZ �� � r�- ���-.,�y� ���I d� �., •� � I .h • �' �i , b i�� 1 i t4� ���,,,ccc i _ • �J D d D 0 © C o a o r � ,�I'' , � �• ,,,, _at^+ ,.de'£ - �.a . t:. .. .x4„u�-v n�.�, �.a , r C:47MI 1i.,rGI.LEt� s • "''=- I� `. rl�Jl&.%..L v3,t lre .,ir:..:.. Pl.i.s.: - tL' - Ci WVIITt { J'JIIIga:ut;L't.p bi ,lta ,'ft' ' :.-,,_ R§.x .:�„ - '�a�R New House ❑ Addition 0 Replacement Windows Alteration(s) ❑ Roofing y, • Or Doors ❑ I Accessory Bldg. ❑ Demolition❑ New Signs [ 1. Decks [ ] Siding [ ] Other [ ] Brief Description of P - roposed Work: 'f1 O0 C--- ' �vo -Z7lS ti i `,20 ,. Alteration of existing bedroom Yes . No Adding new bedroom Yes No Attached Narrative 0 Renovating unfinished basement Yes No Plans Attached Roll 0 - Sheet 0 • ;,smIT N °Who ;fit 0 a atiiitite ar 0,,„e„ !f ,ti�nn h,au fir g+. Garinl .I 1, LI ;t5 : 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. Mascheck Energy Compliance form attached? .r. h. Type of construction ::....... i. Is construction within 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 g and Zoning regulations ?. • Yes No':. I. Septic Tank City Sewer • • Private well _ City water Supply t G• fr I.r '' f4 4 H.� '* Q Y'�i 111 . 31 . � 1 " - i d m �n . ; ,,:, t ' 1 ,,,,` " 17 " , . . "'_.,a t 'Ew- !* 1.,, , , '� . „ s? . ,: .�Jk an M' . 'd ■ ” 411,0111f , ;4.:�Ia'. x ik.' d kola1i; �� F ' a m. I. 6O t,<.1Q r t bon e''''1 , as Owner of the subject property hereby authorize A . �e AA r , l . , . A 1if &CIZ ) 1C_ _ to act on o» my behalf, in all matters relative to work authorized by this ding permit ai plication. S e(2. r t-e) SCI 0/0 Signature of Owner Date . t l N 7 . L . I. ;/ 140 44 4 i dih . _, as Owner /Authorized Agent hereby declare that the statements and information non the foregoing application are true and accurate to the best of my knowledge and belief. Signed under the pains and penalties of perjury. +4GLC1 f nne ); CCU__, . _ Print Name G2.__ • - . • C ) ybc, Signature of Owner/Agent Date 1 y • h City of Northampton � . ,: ,e� �- L . • 7w y , ♦ ,w , Building Department FW ' �� 3� ?ti '" 5 -� � a ,•: ; � • 010 212 Main Street mu if� ; : ,,. � rL., R w� , .rG` • 2 , Room 100 `� 0 � aF 0 i�, ° #:" P� _ • M ' mpton, MA 01060 t �-4 c� -41 at . .t; y6. _, - . phone 4- 3-587-1240 Fax 413 587 1272 a � T , ' -_, 5: 1` "-" ? .�? 7.,— ,-.�.•,...�. "' t o ' T ,.APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWu FAMILY DWELLING • • .... ._ , trJ W n y r 0 a 4 . p a r+. sM " evt �. �J i y t, , , °f J 1 tai o o plea b rim,i,.iooto,'S " s x 1.1 Property Address: � � R * 1 i � * },.. r ' v ed l g, h r u J � , Y L' ' y '1 + �' f ; a °�' r ,44.4.4- 1 c ' r� Ornio y� ,{//� 4 xc l 1 _ y `44'1 �+ 'S '. 1 'a ' � z ''f C -;-M fs , i " . rl . h '�9• 40 . .�.e, . v, ' - 5 }�}ti � `� ����t 1sa•3` �"'+', -�� � �s ' '" G t rio ' w w � ; /t t� • o/J� a ¢ ✓ J ,!1 V ,cl? 1 1�.i 7 . '''P 1 ,I?i _ ' -� ,. , C' . r t tr c , y ._.. ., y :. r f'4vr ._[: 'rri -'v t�fl�'ILi a ',a ' -k•.S ,' 2 .t • V +N. r x t_. 61,x EGTgo 1 N =''P ; Q;P,E ," Yd% •:, . 11:/ �� U�„'' t p> , N ^'T . Ir ,l F � :•.!.•. ia.albv-- _ - F' ' .,- ,.:I 4r.':d hdl ,�`.: • � L vt • 1 " Fi ;i .:' "" :.i ;'''•! I. " hT "T,,. '', f, , , .. . ,, , . , T: .., r. l h $ru°i �ya:n � •�.d �" :k' iS�ri�l� .,, a• : °r 2.1 Owner of Record: Er��r ird Ai ba 11 es f /4 � rrlond ' rr /ors, 41i p t, /46,..1 Name (Print) Curre2i Mailing Address: • Contrad- �` C . Telephone Signature 2.2 Authorized Agent: Name (Print) Current Mailing A..re55: 413 _ 5i - ____—.-- Sig ature Telephone -0i:Y7u',Ita, -, K h I Y' YI"n'1rS'IM I 4 :. 1 bfp r 1 '•gt`s"Tj -0E n F I A t'E''Da 9 Q N A a'.�I�� ., ErS. ..., Fill Ju -' .•`-' te r,, ; :,•I'. {N '. Item Estimated Cost (Dollars) to be .' ' ;L ff(era`I � n - com•leted b permit a•ollcant .; . •• :.. ..` ., „_..._, _ .�•-:"� ` ' 1. Building [[ / (a) Building P-errnt,,trfleer i 2. Electrical - . (t ),Estirnated Tot 'I G Constructiori;fr;0;n .fJ 1 .... 3. Plumbing Building Permit F i ' 2 • • 4. Mechanical (HVAC) • 11,... 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) # � . • / Check Number ,i� ►'�� �'-- • This Sect'ionr : ;Use`,O ;nl _ • , , g r „ � : r , .� ,• .. i . 8ui1'd:>ngPe'rni`TNur> e � •DatdI's•su'edc,.,. .y _ , a4;�' ` .iM1tw::� �'�'I r ..'!!"•, 1 ry • F •Y "• l L !'a! 9x`.•9 J 1 :* • • �'•- 1 ;�' ; "(a�! }r ?.- :,L.'h1 !' r', • r�; .r:�y•1 a;: _ ::',,1'.„t.. .. ' .: _._ • ,�' 11 jr • 1 y 1 i• t "�F +1 r • - . Bailor! &,haem ssion's{T I.i':e'ctor,ot,B}Iid Cig ,.!, . -.,. . �� e, . • 12 ORMOND DR I BP- 2010 -1051 GIs #: COMMONWEALTH OF MASSACHUSETTS clan :Block: 23D - 036 ' CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: BUILDING PERMIT Permit # BP- 2010 -1051 Project # JS- 2010- 001548 Est. Cost: $7476.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ADAM QUENNEVILLE 070626 Lot Size(sq. ft.): 7666.56 Owner: ALBONESI EDWARD J Zoning: URB(100)/ Applicant: ADAM QUENNEVILLE AT: 12 ORMOND DR Applicant Address: Phone: Insurance: 160 OLD LYMAN RD (413) 536 -5955 () Workers Compensation SOUTH HADLEYMA01075 ISSUED ON:5/21/2010 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 Occupancy Signature: FeeType: Date Paid: Amount: Building 5/21/2010 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo