12C-063 R&AM VISA
Q V E N N E V I L L E www.1800newroof.net
ROOFING VF SIDING ♦ WINDOWS We Are Licensed
160 Old Lyman Road•South Hadley, MA 01075 Fully Insured
1.800.NEW ROOF 413.536.5955
Facto Trained
Email:info@1800newroof.net Website:www.1800newroof,net Factory
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 Phone#'s C:
chi �j. �la�{' �( is 3a, y H:`7i J {- `)`r(,i/ W:
Street Email:
City, State,Zip Code Special Requirements:
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❑ Recover Strip ❑t Layers T,
Complete Roof System
® We shall acquire all appropriate permits for all work
Home exterior and landscaping to be protected Uo:�
Strip existing roofing to existing decking and dispose of. Do not Do. �^r
`b Deteriorated existing decking will be replaced at$3.47 per sq.ft.after full inspection.
[IK] Install Ice&Water Barrier at all eaves,valleys,chimneys, pipes and skylights
Install(151b.felt Sy�at underlayment over remaining decking area
Install Metal drip a ge ves and rake (8 5")(white brown/copper)
.5 Install manufacturer's starter shingle on all eaves an rake edges BBB
Install ne> w • e boot flashing standar /copper)/vents T
Inst Snow Country r Cobra rolled vent ridge vent winner of the
2010
❑ Install proper soffit ventilation TORCH AWARD
Shingles: ( 6 nails per shingle)
' Shingles El 25 year ;t<..30 year El 50 year Color
Ridge cap shingles
Warranty Options:
We guarantee our workmanship for 10 full years(see our warranty coverage)
GAF System Plus warranty
[-] GAF Golden Pledge warranty
Chimney Options:
,A Lead Counter Flashing ❑ Water Seal&Tuckpoint ❑ Rubberized Crown ❑ Metal Chimney Cap
We propose hereby to fumish materials and labor-complete in accordance with above specifications for the sum of:Total Due($ q 3nf7'N )
ACCEPTANCE OF PROPOSAL: The above prices,specifications and conditions are I `w�` y (
P Down Pa ment $ )
satisfactory and are hereby accepted.You are authorized to do work as specified.
Payment will be 1/3 down at start of job,and balance due upon completion. Balance Due Upon Completion($ G Y2 ctl )
Ii
Date:_ Signature:=t "I �>ly,-v f --
Date: 10 -30 P Estimator:(Print Name) 'x-c,11 it � M, (Sign Name)
Estimates 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.
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The Corntnonweulth oj'Mussuc'husetts
Department of industrial Accidents
Office of Investigations
600 Washington Street
UT Boston, Muss. 02111
www,mass.go v/diu
Workers' Compensation Insurance Affidavit: Builders/Con tractors/Electricians/PluInber-s
t ► rlicant tnforntatic jrr Please Print Leeibly
- —
Adam(henneville Roofing 8 Siding Inc
Name Il4usmcs,vUr�;urii.anlmllnii,vi,Ilr;lll _
Address. 160 Old Lyman Road
Oily/tale/Gib: South Hadley MA 01075 PhttnCtl413-536-5955
/ire you an employer^ ( heck (tic apl)roprlate box: 1 e of project (required):
I X I ;air an employer w111, 15 1 am a general contractor and 1 6. 1 Nc%v construction
! employees(full andn,r part lime)_ have hired the suh-contracr<rrs z Rcillodeling
I am a sole proprietor or partner- listed on the attached sheel.
ship and have nu cml)lovees These sub-conlractors have R. Uenu,litinn
cv„rkiii Ibr me in any cap;tcity. employees and have workers' q. 1 Building addition
(No workers' comp. insurance comp. insurance. +
required 5.; We are a corporation and its 10. I�:Iectncal repairs or additions
i ant it horricowner doing all %York officers have exercised their I !_ ! I'lunrhinf repairs Ire ndditi„ns
myself INo workers' comp. right of cxentplion perm M61 i
insurance required] t c_ 152, $ 1(4), and we have nu
m I'_ �ix�l rcintir>
I I �
eployees_[n) workers I Other
C01111). insurance rcquired.I
•,xn) rpplicoont that chicks box pl must also rill our the section bdlow showing their workers'compensation policy information.
tHm
oeownera w'bo submit this affldavlt ladkaling they are doing all work and then hire outside contractors must submit a flew stTdnv'il indicnitut;such.
2Conuetors that check t►6t boa most attach an addilional sheet showing the name of the sub-conirmclors and state whether or not those enlilies have rmplovrr.. If
the xuh-contractors have employees,they must Rrovide their workers'comp,policy number.
l unr tin empto er that is Immiding workers'compensation insurance for nit,empfo►'ees. fletow is the pnlirp acrd ir)h Aire
in/rlrmuliun.
ln,urancc Contpany '4anrc AIM Mutual Insurance
I,ohcv n.,r Sclf-ins. Lic. ;t_ AWS40070126612014A f-:.xiwalion Date. 4/29/2015
106 Site Address. �L)V'ev'c"- � City/Stale/L11):_ C (0f4hCP— Ak
Attach a copy of the workers' compensation policy declaration page (showing (he policy number itnel exl)iralion (date).
I allure 11) secure coverage its required under Section 25a of N161. I>2 can Icad to the inrpusiliun ofcrinunrll pcnallirs 1)fa line
up to .$1.500.00 mend/or one year imprisonment as well as civil penalties in the f0nn of a S 1'01' WORK (M 1)i'R and ;I line of
5250.00 it day against violator. lie advised that a copy of this statement maybe forwarded to the Oflicc of I"vest i,L;at(MIS of[he
DIA for coverage verification.
do herhr certify under the pains and penalties of perjury that the information provided above is true anti correct.
L/ -3-5-3IV.,J
- _ _-..._
Qfjtc•ial use ottlp no not write in this area to he completed by city) or town official
' I
t itv or I awn; I'ermiUlicense N: _.._ .
I
Issuing Authority(circle unc):
t.ltoord of Heath 2. Building t)epartniew 3. ( itvlt'nwn ('jerk 4. h:lectrical Insl►ector 5. 11Iunrbilig Inspector
h. Other
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: i\\ 9 Not Applicable ❑
Name of License Holder: AC �v, �-^�'^'��`i�``^ _ (S- c o
License Number
O\t\, oadl,5
Address Expiration Date
Signature Telephone
9.ReoCstered Home Impmement Contractor: Not Applicable ❑
Company Name Registration Number
Address Expirations bate
J�� Telephone-113 S tS
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 Exewvtion
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 buildine 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
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [0 Siding[[3] Other[0)
Brief Description of Proposed
Work: LJA J
Alteration of existing bedroom Yes No Ad g new bedroom Yes o
Attached Narrative enova ing unfinished basement Yes No
Plans Attached Roll -Sheet
6a.if New (1ouse�and of addition to existing housin�a, complete the follow na:
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
�0�, \ ��C fi�(�w� as Owner of the subject
J
property
hereby authorize
to act on my behalf,in all matters relative to work authorized by this bui4c4hg permit appl' tion.
CC-1c C 11 I�I►`/
Signature of Owner Date
I oX&_, nr�J� , 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.
Sig7 under the pains and penalties of perjury.
Print Name
Signature of Own 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 m .
Frontage
Setbacks Front
Side L: m_ r R: , L:. _. R:11-11-1-111111111-
..
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg&paved ,_
parking)
#of Parking Spaces
Fill:
volume&Location ... ... . ....... ..:a .__
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DON'T KNOW YES
IF YES, date issued:,..
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW fN-7� YES 0
IF YES: enter Book Pager and/or Document#`
B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained , Date Issued
C. Do any signs exist on the property? YES Q NO 0
IF YES, describe size, type and location: _
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. 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 0 NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
lid rise P
City of Northampton Statueerri , �
,'� uilding Departmentr6
NOV -6 � 4 �'-�
212 Main Street SeWpti } flabl► t
�— --` ticri� Room 100 V1e1tMl1� 8�?11
lr-Foec wry,.
0ectrlc Feu ` , �l�o hampton, MA 01060 7 6letsof S' t rafKlan
phone 413-587-1240 Fax 413-587-1272 FIcit!Sftiri
Othet:3pectfy
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
C Si Map Lot Unit
,nn Pi Zone Overlay District
C)�o Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
I k C/ _
�t7�11a�l�y� �uUtr "� t'�1CSZ
Name(Print) J Current Mailing Address:
<('�( �n.nk Telephone
Signature
2.2 Authorized Accent:
Name(Print) Current Mailing Addres .
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building C'3 (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= 0 +2+3+4+5) UV Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
11 CLOVERDALE ST BP-2015-0533
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 12C-063 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-2015-0533
Project# JS-2015-001007
Est. Cost: $9300.00
Fee:$35.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: ADAM QUENNEVILLE 070626
Lot Size(sq. ft.): 7492.32 Owner: DELANEY JOHN B&JUNE L TRUSTEES
Zoning:RI(100)/URA(100)/WSP(l00)/ Applicant: ADAM QUENNEVILLE
AT. 11 CLOVERDALE ST
Applicant Address: Phone: Insurance:
160 OLD LYMAN RD (413) 536-5955 O Workers
Compensation
SOUTH HADLEYMA01075 ISSUED ON.111712014 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 11/7/2014 0:00:00 $35.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner