32C-231 - _ The Commonwealth ofillassachusetts - .,
- Department ofIndustrial Accidents
�' � = = - Office o f Investigations - - •
te . 600 Washington Street
:y Boston; MA 02JJJ
° . "- www.maSs.gov/dia
Workers' Comp Insurance Affidavit: Builders /Contractors/EIectricians /Plumbers
Applicant Information - • PIease Print LeaibIv
Name (B usiness /Organization/Individual): - Adam Quenneville Roofing & @idiag, Inc,
Address: j (t'0 tJ 1cJ Lilt - ko td .
- City /State/Zip: S 31 Mh Na " f /4 ft - jI % Phone #: ii A 656- 6q 5 .5
Are you an employer? Check the-a ate box:- Type of project (required):
- � YP -
P J
1.1g I am a. employer with 15 4- 0 I am a general contractor and I •'
have hired the sub - contractors 6- 0 New construction
employees (full and /or part-time).*
? _ ❑_ i am a sole proprietor or partner listed on the attached sheet 7: 0 Remodeling
These"sub- contractors have
ship and employees _ - 8_ ❑Demolition
working for me in any capacity. ca employees and have workers'
9. 0 Building addition
' insurance - -- comp: msurance.$ .- - - -- -
eq uire workers comp. 10. Electrical repairs reqd] - 5. ❑ We are a corporation and its ❑ p or additions
3. ❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself o workers co right of exemption per MGL
Y [No ' comp. 12
Roof repairs
insurance required.] t - c 152,_§ 1(4),.and we 1iave no
employees. [No workers' 13. E] Other
• - comp. insurance requited]
Any applicant that checks box ;r1 must also fill out the section below showing their workers' compensation policy information.
T Homeowners who submit this affidavit indicating they are doing all work and - then hire outside contractors must submit a new affidavit indicating such.
'Contractors that check this box must attached an additional sheet showing the name of the sub - contractors and state whether or not those entities have
employees. If the sub - contractors have emptoyem, they must provide their workers' comp. policy number.
I am an employer that is providing, workers' compensation insurance for my employees. Below is the policy and job site
information. - -
Insurance Company Name: A .L Pil - M 11 fait 1 J_ il Sara. 11
Policy # or Self -ins. Lie. #: -ui • go, d le I t I Expiration Date: — a q — ti 0 f 3
Job Site Address: iq 4 eye I< c , ih'EQ' City /State /Zip: .)(V4 OM k >'Y Ciao
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 ofMGL c. 152 can lead -to the imposition of criminal penalties of a
fine up to 1,500.00 and/or one-year imprisomuent, 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 DLAfor insurance coverage verification. _
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I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Sisnature: Date: gin271/
- Phone #: 3` . 3 .-` 5 5
�l Lo 5 l
Official use only. Do not write in this area, to be completed by city or town official!
- - -- amity or Town: - _ - - -- -- - - -- - - - -- - Permit/License #
Issuing Authority (circle one):
I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector S_ Plumbing Inspector
6.Other
Contact Person: - - Phone #:
. !i
5Ll D� VISA Maste H _ DISCOVER
QVE N N E V 1 L L E www.1800newroof.net
ROOFING 'V SIDING V' 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 1/ -ehone #'s C:
/ems / Z "`_. , () S A H: 1 `7 1 /3 ' - ..5 - 1 O7tt w: ,
Street Email:
City, State, Zip Code Special Requirements:
_ T A P % � / �. /�� po vpp i d6� ,to; r- RA c 1r firoury
Alo 5 /a' 7 pt,9 144' & J
❑ Recover ❑ Strip ❑ Layers p v o,vs 5'406 G t-" .v1 fru") /2 od
Complete Roof System 0 1, , = /4,4' hose- /f 1a
S Ley--
O VVe shall acquire all appropriate permits for all work .T r r /.A zv ,- it /, AV, v'
K I-lome exterior and landscaping to be protected 124"..i) Pc cf r "
.Strip existing roofing to existing decking and dispose of. Do not Do.
P Deteriorated existing decking will be replaced at $3.47 per sq.ft. after full inspection / d r
Lr stall ., , - - r Barrier at all eaves, valleys, chimneys, pipes and skylights G, Q,
�n . AIn 151b. fel ynthetic) underlayment over remaining decking area g
JInstali Metal drip edge at eaves and rake (8 / 5 ") 4 brown /copp
Install manufacturer's starter shingle on all eaves an. rake edges BBB
c.install new pipe boot flashin • standard /copper) / vents —I_
Install Snow Country or obra rol -d vent ridge vent Winner of the
2010
❑ Install proper soffit ventilation TORCH AWARD
'e j, I i
Shingles: / 1 " ( 6 nails per shingle) K'
64, Shingles ❑ 25 year A30 year ❑ 50 year Color ,Se-rf l
Ridge cap shingles __- --- - --
Warranty Options:
We guarantee our workmanship for 10 full years (see our warren' coverage)
❑ GAF System Plus warranty 3 Da ), O a
❑ GAF Golden Pledge warranty --'i VC1
Chimney Options:
❑ Lead Counter Flashing ❑ Water Seal & Tuckpoint ❑ Rubberized Crown ❑ Metal Cfpney Cap
11'x, 6 ,-------
We propose hereby to furnish materials and labor - complete in accordance with above specifications for the sum of: Total Due ($ "r .r•rr. )
ACCEPTANCE OF PROPOSAL: The above prices, specifications and conditions are Down Payment ($ Ac., •
satisfactory and are hereby accepted. You are author' to do work specified.
Payment will be 113 down at start of job, and balance upon compl o . Balance Due Upon Compl n ( �-_, )
Date: //� 1 r 4 - 8tg �'1 ` �' 0
. ,e n Name
Date: � ; //Z Estimator: (Print Name) ��li� �u,v,✓,�vr. X � rFSig ) �-�
Estimaf s 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.
J
SECTION 8 CONSTRUCTION SERVICES
8.1 Licensed Construction / Supervisor: / Not Applicable 0
Name of License Holder : Ada. yr. £1U ri Ile (/ ,' ` r 6
License Number
Us 0 O ld 1. ( - , � ` rya � ?d . -S c /d , t> -oioi 0- a i- t
Address J - Expiration Date
Sig re Telephone
<9 Registere: ?Ifiom Improvemen :Contractor: - ' J _ -_— - .w a y � ;. ;- Not Applicable ❑
Adam Quenneville Roofing & Siding, Inc. 0-0 q -
Company Name 160 Old Lyman Road Registration Number
South Hadley IAA 9187 2� I
-Address ad"'� - Expiration Date
Telephone 03
�`SECTIOM�.O= WORKERS' COMPENSpr�ION iN`SURANCI,�IFFIDAUIT (M § &)) = s
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 )4 No ❑
1k = -Hate +Ovvier.Exe ption
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-vear period shall not be considered a homeowner.
Such "homeowner" shall submit to Building Official, on a form acceptable to the Building Official, that he/she shall be
responsible for all such work performed under the buiidinp permit. t (
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 0 ( ('YWxre -
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''� 9 - ma y .. -.� -, . -}� �- '-'•' W e^ �:. S � � -i _ i _
ECTION , ZESCRIPTIONDERROPOSED WORItichecitall- applicable)
c r
t' Vi a ..•- 1...�_ .. = :icy- ``'`"�.`i' r _y` ,.} .. -
_ - - .,. t New House ❑ Addition ❑ Replacement Windows Alteration(s) l 1 Roofing p..
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [(l Siding [O] Other [0]
Brief Description of Proposed
Work: yNty lr ; .+ _ 2; � * • un' • 0 l [ 0 L - CCC - i'hc (
of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
7a ew l o nseiac�drtionto :;existing ousfig;xcomp a eteeolloiiinq:
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?
fj Method of heating? Fireplaces or Woodstoves Number of each '
g Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h Type of construction VP
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 .
1.1 Septic Tank City Sewer Private well City water Supply -
*-TION3T INNER kUTHORf2:0ON TO'BA-CONIPAETED VI(FI .
QWNER ENF > GQ�ISRAC AP.,PL -IES. 1011 -10-9 ERMPF _
1, f e;K, Pp ,o C cr , as Owner of the subject
property w' ,
hereby authorize Adam Quenneville Roofing & Siding, Inc.
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signaturd•bf bafirter Date C
-
-- , + Adam Qiiiimedeltoofmg & Siding, Inc, — - - — - as Owner/Authorized
Agent hereby declare that the statements and information o n the foregoing application are true and accurate, to the best of my knowledge
and belief.
_ Signed_under the pains and penalties of perjury.
$ -aoi alai? .e U,z l L2
Print Name
q7)--7(/
Signature of Ownen'Agent Date
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Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by 'Zoning 1 1
This column to be filled in by '
Building Department A
Lot Size I ' 1 ! I t ;f 1
Frontage
i !1. '.
Setbacks Front 1 1 I I i I
r—
Side - R: L: R' I I r "--- 1
Rear 1
Building Height ! ; s 1 I j
Bldg Square Footage 1- °A' t J i i 1
— Open Space Footage
(Lot area minus bldg & paved I I i 1 ! i '_ __.l
parking)
■ # of Parking Spaces ! I 1 {
.
Fill: 11 11 -
(volume & Location) 1 I 1
A. Has a Special Permit /Variance /Finding ever been issued for /on the site? ff
NO 0 DONT KNOW 0 YES 0
IF YES, date issued:1 1
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW i YES 0
IF YES: enter Book Pag I and /or Document #1
B. Does the site contain a brook, body of Water or wetlands? NO Q DONT KNOW 0 ' YES Q
IF YES, has a permit been or need to be-obtained from the Conservation Commission? !!;
- - Needs to be obtained Obtained tem , Date Issued: 1 E
C. Do any signs exist on the property? YES 0 NO Q
IF YES, describe size, type and location: I
— — 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 E. E.. Will the construction activity disturb (Gea grading, excavation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES ® NO 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
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! of Northampton
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Building DepartMent Cdtbs:CiittbnyewayRerrriff
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I SEP 2 7 2012 1.' 212 Main Street .
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Room 100 L ;6:- lj:f
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No . OF BUILD
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NmA S o r.-i2. , 060 (3 Northampton
-N8 , MA 01060 i A
ne 413-587-1240 Fax 413-587-1272 Two Two eTs.: of Structural plans ' ,,--- „.,_-,
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1 APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SkeI3liti
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1.1 Property Address = ' -Ttiissedtiorf.-toltieLtompletedAyOffiCe
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21 Owner of Record:
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Nia+hri mpToni n-yi-
Pe-4-er- ;---a CcCI,
Name (Print) Current Mailing Address:
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3,12 („0" Telephone •?; — 53( -- E, q - ) r- ,) •
Signature • .
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22 Authorized Agent:
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Name (Print) I...i il
Adam Quennevile Roofing & Siding, Inc, ibo Old
Current Mailing Adams:
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19 HANCOCK ST BP- 2013 -0367
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32C - 231 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- 2013 -0367
Project # JS- 2013- 000595
Est. Cost: $10500.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ADAM QUENNEVILLE 070626
Lot Size(sq. ft.): 7187.40 Owner: PACOSA PETER A
Zoning: URC(100)/ Applicant: ADAM QUENNEVILLE
AT: 19 HANCOCK ST
Applicant Address: Phone: Insurance:
160 OLD LYMAN RD (413) 536 -5955 () Workers
Compensation
SOUTH HADLEYMA01075 ISSUED ON:10/1/2012 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP,PLY & SHINGLE ROOF & REMOVE
CHIMNEY
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 10/1/2012 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner