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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. _ • 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 - • ''� 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 • 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. { . , .., ., ...„ IRECEIVE _ ,,,F. ,_:,-, ',.'-'' :'.-: '..• *,-'--",?, :. -,. : : , ' „, ': ,1 ::::./ . . ,, ,.:::,?4.7s ,,, : , -.--&-. "':;:,'::;.-----; i'f.. - ,..17 - , -:',---.-.,-..: :6''6fileof-P,..PETP. ! of Northampton CitY ' ‘,..,,,,:„..„,„„..._,., „4:-.,,--,,,,,:g-,.,,,-,-„,.;,;::::3,-,„;„„.::„.....-„:,..:::;-;;„:„::::::;7---„„,„::::,7,v,-'::i_2:-:flf„,„1„-„,„:„:-„-;7„.:•-,'.... -_„...„.„i Building DepartMent Cdtbs:CiittbnyewayRerrriff o S I SEP 2 7 2012 1.' 212 Main Street . i Room 100 L ;6:- lj:f ,.. ,*,-.- ,-,-----i,, .:4F...:7„-:•,Zs.:',If.':.,t--_-:,---.:7,;,..4.,:::-.‘5::,,,-,, No . OF BUILD ;rr . j GKeT 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 ' ,,--- „.,_-, ..!. ',P113f(siteL ,!- „ - -- 74 i .7. , ..:. ',,...': ..,--_,:, - -, i . :: -,:_=,-,,,,-::,,-- „•-:::'.;,,.. 1 i 1 APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SkeI3liti - 1.1 Property Address = ' -Ttiissedtiorf.-toltieLtompletedAyOffiCe : h' .7„._,::c-;::-:-„:;_--1.:ii.--,7 - -f-:!7:'7-. ,, , ,„, - -..„.;:„.„ - „i. , ..,, ,„ _,„..i.-„g„ ; ..z- . .., : -, ; ,-_ § ,-,._-,.. ; --;s=4„-t65t - : ". -. '' . n- . :" . .11 - i' . .. 7- e -, =-x-7...YF.:=:=7z 1 Map : , , 1 r= ''' Lot -.._ ... _-_. -_-.,,,—,.--,,,,,-.7-tr_i--„i„..,_.:-,,,,,,,,,,,„: I I Ck 1(cAn c o ck:, Stfee- • 11.:47-",,-.,..'57i1:,:f"."!.:•;A';' ..,;:-4..-Ty."'"::::';5:.=t''''''-itl,',1.it_. :A1-717f;pf:1-,'-'..:7-":;'.7::,-•:-0:: eiliii'E'-ria:,--• •'.-'0 . : -:'. '7 - ,:r.r .: : - . 4 1 1.4.:-''''''''..."-t" -;*..'1*"..-4*-1.7:"..*::.n.',.:4.-:'-....iT;-'IV= r; 7.--; 74C151"aitnAa.`7.-;'-‘,";_=.,411,:.,.:4.'11...Z-4:: 1 '- ._____;_-_-_, , : _,.rAw r =7,?Are.y z z , : : .: 7,x , -;:ft.g : -....-:_ 21 Owner of Record: . _ l q .--i-ln( .1:)C _I( ) i Nia+hri mpToni n-yi- Pe-4-er- ;---a CcCI, Name (Print) Current Mailing Address: 1 3,12 („0" Telephone •?; — 53( -- E, q - ) r- ,) • Signature • . i 22 Authorized Agent: e . Name (Print) I...i il Adam Quennevile Roofing & Siding, Inc, ibo Old Current Mailing Adams: .- I:// -6u,-6 fiVi- 0 0/76 e.) ,VA „ ,..f.L.- • Signature Telephone It i em Estimated Cost (Dollars) to be Building .'fr=:'.;:::1i-r..Tf:'T1'..Z:?:C1:±:..i.z,'-'5T_9.th,---.„9.1°::!.:°:e-::;-.CP;IY completed by permit applicant - :-,::.?;-z,.. L_ - ... 1 (ay,ifiiiildifig71?„0!711-ff eF.,-.'...4::-'...-E 1. 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''':: -: '--,!-' 7•. :74::a..:%::•:,__.„ .i7..7:74...R-i.:;;r5-L7,-- 42 2;trT:"..T#::e.-...f.i..:1'T..:„g;...ctls,,..,L.:--:j;:..:,-::.t-::::3?,-.,,..-: ifl::.,.1:::.:".t..-:,.i::.F.,:::„-Date---,,,,,-;:,-„:„„,,„ , 0 6- 4 11 . 4 _ , ..91,9.: 11 !_,TP- 9 P 1 :=. 7 n; - "Fa.,;.c-: , .:=== , - , ‘ , '------ :----:,---,-------'—:- 7 '.--- :' - E.r.k.:::2:;..:..:::::.;47,:ai...--;-:.;:..,-.t..--- ..- - - - . - . . 1 1 • : . 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