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24D-108 D A Name Cust. # Date i( CAIJENNEVILI_E ROOFING & SIDING, INC. Street Address City State Zip 1.800 NEW ROOF Home Phone # Work Phone I . r 413.536.5955 Y.. # � E E mall - 1800NEWROOF.NET i �� :... COMMERCIAL RESIDENTIAL 1 `' d ISO Old Lyman Road • South Hadley. MA 01075 hereby authorize you to proceed with the diagnosis Sr a inn charge of $ X StraightForward Pricing° ,�, t � � - 2 6 ( � _ Replace 4 SQ of shingles Stepllash /Cnunlerf lath -1 1 ' to 50• of w all. Replace 51' to 7 65' of valley. Rcll I lu ehimne■ Construct cricket and flash 3' to 6' wide chimney. Roof or Siding cleaning 2.001 sq ft. - 3.000 sq. It Cover fascia or rake with Aluminum 51 65' Replace 22 -30 slates. Quantity x $1637 ea = Replace 3 SQ of shingles. Stepflash /Counterflash 31' to 40' of wall, Replace 41' to 6 50' of valley, Reflash 16' to 20' chimney, Install 71 to 110' of ridge vent. Roof or Siding cleaning 1,501 sq. ft - 2.000 sq. ft. Cover fascia or rake with Aluminum 41•-• 50' Replace 16-20 slates. Quantity x $1277 ea = Replace 2 SQ of shingles, Stcpflash /Counte(lash 2I' of 30 of wal). Install 51' to 5 •dge vent Replace 3I' to 40' valley Reflash or replace up to 2 Customer Suppled skylight (no mlcrur assn 1101 k). Install 250' to 350• of drip edge, Rehash 13' to 16' foot chimney. Roof or Siding cleaning I UI0I sq. It 1.50(1 sq. ft. Cover fascia or rake with Alumintnn 31 ' -40' Replace I I 15 slates. Quantity x $839 ea = Replace 1 SQ of shingles, Stepflash /Countertlash 1 1'to 20' of wall, Install 31' to 50' 4 of ridge vent, Instal) 2I ' to 30' of valley, Clean 251 to 350' of gutter. Reflash 9' to 12' chimney (perimeter) or small stone chimney. Replacement of customer supplied skylight (no interior trim vvurk). Tear off and re-shingle 2nd story bay window. Install 101' to 200' of dripedge, Roof or Siding cleaning 501 sq. ft. - 1.000 sq. ft. Cover fascia or rake with Aluminum 21'-30' Replace 7 -10 slates. Quantity x $694 ea = Reflash up to S' perimeter chimney_ Replace I to 2 bundles of shingles. 3 Stepl lash /Cuunter(lash to I (t• of wall. Install 51 100' of drip edge. Install 4 to S hat v ents, Dryer hose connections. Replace up to 15 of valley fear off and re- shingle Ist story hay viindnty, Install up to 30' of ridge vent. Minor tuckpointing red vsatersealing of chimney ( <3' in height ). Re- stepping and IceGuard 2'r4' skylight. Installation of vurhmount skylight. Clean I50' to 25(1' of cutter, Install 5r toIO0' of drip edge. Cover fascia in rake uith Aluminum II'-20'.replace 4 -6 slates. Roof or Siding cleaning up to 5(1(1 sq. It. Quantity x $559 ea = Soil hoot replacement, Replace up to I bundle of shingles or up to 20 shingle tabs, Z Stepflashing/Counterflashin less than 5' of wall Installation of up to 50' of drip edge. Installation of up to 3 hat vents, 10' or less of utter /fascia replacement, Clean 31' to 150' of gutter, Reflash electric pole /heat stack, Crop up to 30' of valley. Replace I -3 slates. Cover fascia or rake with Aluminum 10' or less. Install rubberized crown on chimney cap. Install stainless steel cover on chimney flue. Quantity x $387 ea = 1 Runt eertilicatinns of Gutter cleaning kip to 30 1 Quantity x $159 ea = (Add 30% for roof pitches greater than 6112) Custom Request kuo (' t t& s 4K Quantity x $ ea: _ Quantity x $ ea: _ ITJRt"•e t (3 ') Rc,a &x :F Quantity x$ ea: _ Recommendatiol (1) ,p, YtS Frt+l i', i t k S le f' ' e ,a T} i m44it. ti S f h; I hereby authorize you to proceed with the above StraightForward Price' of $ J Paid via: Cash, Check (# ) Credit Card Dia sttc - F 1 L ko MC, Visa, AE CC# Exp. ottal Due today $ t 1 Z - ') Work performed to my satisfaction `2 " Scheduled Arrival Time Actual Arrival Time Thank You! Nov -08 -2010 06:00 PM Remillard Insurance 1 - 413 b38 - bulu cfc ® CERTIFICATE OF LIABILITY INSURANCE DATE(MMJDD/YYYY) fC�RD OP ID LL 11/09/10 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER GUN i AL.I NAME: PHONE Remillard Insurance Agcy, Inc e, Eat): - INC, No): 79 Lyman Street ADDRESS: _ y South Hadley A 01075 - PRODUCER' y CUSTOMER ID #: ADAMQ - Phone:413- 538 -7862 Fax:413- 538 -7179 INSURER(S) AFFORDING COVERAGE NAIL INSURED INSURER A: First Speciality Ins Corp Adam Quenneville Roofing & INSURER B: Travelers Ins. Co. Siding Inc. & Adam Quenneville Roofing Inc & GutterShutter INSURER C: ASN Mutual Insurance Company Of Western MA 160 Old Lyman Road INSURER D: Hanover Insurance Company 22292 South Hadley MA 01075 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING 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 POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. L� TYPE OF INSURANCE AWL SUBR' -'- PULILY tl-F UCTe P'" LIMITS INSR WVD POLICY NUMBER (MM(DDIYYYY) (MMIDD/YYYY) GENERAL LIABILITY EACH OCCURRENCE $ 1000000 - DAMAGE 1 O KEN I tU A X COMMERCIAL GENERAL LIABILITY IRG98441 06/23/10 06/23/11 PREMISES (Ea occurrence) $ 100000 CLAIMS -MADE [ ° I OCCUR MED EXP (Any one person) r$ 250 0 PERSONAL B ADV INJURY $ 10 0 0 0 0 0 _ ( GENERAL AGGREGATE $ 2000000 GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $ 2 0 0 0 00 0 POLICY r !p (--] LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1000000 (Ea accident) $ ANY AUTO BA7450L946 11/01/10 11/01/11 ---- _ -_ BODILY INJURY (Per person) $ ALL OWNED AUTOS BODILY INJURY (Per accident) $ X SCHEDULED AUTOS PROPERTY DAMAGE X HIRED AUTOS (Per accident) X NON-OWNED AUTOS $ � UMBRELLA LIAB — OCCUR EACH OCCURRENCE S 11 EXCESS LIAR CLAIMS -MADE AGGREGATE Y $ DEDUCTIBLE 5 RETENTION $ $ C WORKERS COMPENSATION AWC701286101 04/29/10 04/29/11 X WCST X 01N AND EMPLOYERS' LIABILITY TORY L IMITS ER N ANY PROPRIETORJPARTNER /EXECU(IVEr E.L.EACHACCIDENT $ 1000000 OFFICER'MEMBER EXCLUDED? I ) NIA - --" -- '- - (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ 10 0 0 0 0 0 If yes, describe under - - - - -- - DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 10 0 0 0 0 0 D Equipment Floater 1IHN7140610 02 /al /lo 02/01/11 Rental Equipment $100,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE ADAMQUE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Adam Quenneville Roofing & Siding AUTHORIZED REPRESENTATIVE 160 Old Lyman Rd. South Hadley MA 01075 �J ` I G7� �c rraG ©1988 -2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009109) The ACORD name and logo are registered marks of ACORD * �ie f r p lns ari • tan • ar • s � = . � +t o • u s ing egu • a' One Ashburton Place - 'Room 1301 if � Boston, Massachusetts 02108 Construction License • License CS. 70626 . ' Restriction: 00 . Birthdate: 8/21/1971 Expiration: 8/21/2011 Tr# 3 AQAM QUENNEVILLE 1'60 OLD; 'LYMAN RD - ` S`HADLEY, MA 01075 .... .: -- _ — EL , , , - /4 p = ` Office of Consumer Affairs and usiness Regulation 4f 10 Park Plaza - Suite 5170 •.F Boston, Massa:' usetts 02116 Home Improvement �.� it .. ctor Registration =— Registration: 120982 _ 6 *Mt --- Type: DBA r ? Expiration: 3/25/2012 Tr# 293069 ADAM QUENNEVILLE ROOFIN ^ --- '';' -=- w DA Q N _= ADAM QUENNEVILLE M. "_ 160 OLD LYMAN RD =,'= ` SO. HADLEY, MA 01075 _ /� \ C > :' t` ' - S � ",/ Update Address and return card. Mark reason for change Address 11 Renewal 0 Employment E Lost Card DPS-CA1 C) 50M-04/04- G101216 STATE OF CONNECTI +" DEPARTMENT OF CONSUMER; PROTECTION : ,,,. Be itlnownthat - ADA114 QUENNEVIT :T ,F. i 160 OLD o;r ROAD SOUTH . .9.: i i17 2 >R /,H• 5 -263 1 1' M1 ` i. �P :II/ � �Gr i s certified by the Dep _ n t h' ' - wi tection as a registered I HOME I IMPRt A i'. f �•NTRACTOR �. -, I Regis ~i '''''''''-'''' , - e ::- '020 ' lecH' I TRANS i -5 1 I. ADAM QUENNEVILLE ROOFING Effective: 12/01/2009 Expiration: i - 1\. The Commonwealth of Massachusetts ,� Dot of Accidents 74. , Office ce of Investigations + 600 Washington Street Boston, MA 02111 , ' , wwwanass.govhfia Workers' Compensation Insurance Affidavit: Buitders/Contractors/E Annlica nt Information Please Print Legibly ' \ 1 Name ): a .. e. ' 4 1 - • s • s 4, A ✓IC. Address: I tan (NA Li/ n d. City C .:,,. • „: ; ) s i • a ■ 1 f i7 Phone It: ( - ,- --• Are yaw an employer? Cheek the appropriate bar: Type of P (required): LI% I am a employer with IS. 4. 0 I am a general contractor and I and/or ll part-time).* have hired the sub-contractors construction 1 6. ❑ New oY ( fu listed on the attached sheet. 7. 0 Remodeling 2. ❑ 1 am a sole proprietor or partner- These sub-contractors have ave ship and have no employees S. 0 Demolition working for me in any capacity. employees and have workers' 9. Q. BuIldn>g addition [No workers' camp. insurance comp. e.: required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions right of per MGL myself. [[No i 120.1tooft+eparrs insurance ) t c. 152, §I(4), and we have no 13.Q Other employees. [No workers' • comp. insurance required.] *Any applicant that checks boat it most also fill out the section below sbowiag theme oedema' compensation policy information. t Hemeawna sites able* tibia sildly& iodating they am doingall wadsandhatldm amide oommetosa mot admits. es w affidavit indicts' Saiomanosstds dads t is boot apt attacied ae mlationsl them thowingthe new ofthcaols•ooauamus anlsets kecac sot those entice lame e■ployee& Ifthe tsb-eoanaaora hero employees, they seat povide their wodaere Comp- policy number. I are an employer that is providing workers' coaapaemdo a Iaswursoe for my employees. Below is the policy and fob she informstion Insurance Company Name: 4 t /i t / l r ret 11 t P P o l i c y # o r S e t t - i n s . Lic. #: P WC . 1 1 o 1,19,10 [ a 1 Expiration Dab: /c2 9 I Job Site A d d r e s s : 7-7 S S-I-. N askp r M 4 City/State/Zip: O1o o Attu a dopy abbe workers' compensation policy Matson page (showing the policy nsember sad Failure to same coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to S1, 500.00 and/or one-year imprisosuneni, 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 DIA for insurance coverage verification. I do hereby cell► woofer the modpenolttes efper�y that the Wonnation pr+ovWidabove is bar antconact Signature: Date: 1a. i -1 v #: Yt 3- .531- , -9�c glair use only. Do not write ht this ma, to be completed by city or bar Odd City or Town: Permit/License # Waft Authority (circle one): 1. Board Oneida 2. Belding Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: 1#t) tig4 '1 0Ni" 6 ■:!clr tilfT•* A lq0;:e 14 goiti ltiarm (Uittpir#; 1100,:initi 7 • SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : 76 G a License Number NO Old Lynn Road -a I - Address South Hadley, MA 11575 Expiration Date Signature � Telephone 4 t - 53 5ct s'� 9. Registered Home Improvement Contractor: Not Applicable ❑ 2 Company Name - Registration Number 166 Old Lyman Road 3 - Address South Hadley, MA 01075 Expiration Date Telephone 1f 3 - S36-SRSS 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, 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 IPS OM* KAYlt 6 Ktoi* di SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition El Replacement Windows Alteration(s) I I Roofing X Or Doors 0 Accessory Bldg. ❑ Demolition El New Signs [O] Decks [0 Siding [0] Other [0] Brief Description of Proposed Work: Si-cop an Qtpct C Qata - xt area. -4l¢y� (� 61/t r Alteration of existing bedroom 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 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 I, DP. CIOCU -V G.. V bzC , as Owner of the subject property Siding, authorize Q & SidInc, to act on my behalf, in all matters relative to work authorized by this I uilding permit application. 1 -ic-1( Signature of Owner Date Air QUIlltille R & gI In , 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 &.w e- Print Name 5 /(5 Signature of Owner /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 Frontage Setbacks Front Side L: R: L: R: Rear Building Height Bldg. Square Footage Open Space Footage (Lot area minus bldg & paved parking) # of Parking Spaces Fill: (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DONT KNOW YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO ® DON'T KNOW YES IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO ® DONT KNOW YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained ® Obtained 0 , Date Issued: C. Do any signs exist on the property? YES ® NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES ® 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 ® NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. Department use only City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit , 212 Main Street Sewer /Septic Availability Room 100 WaterNVell Availability Northampton, MA 01060 Two Sets of Structural Plans phone 413 587 -1240 Fax 413 - 587 - 1272 Plot/Site Plans 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 a? 7 Sicyke. $-f • Map Lot Unit NO c4lA.v$ on 1 mA O 1p c2 O Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: ©l O U Debdea‘4 awibec4 ? ?7 S-1a4 54, Mo t'��.aw�pi�vn,/' 1 A Name (Print) Current Mailing Address: y/3 ro S 3 Telephone Signature 2.2 Authorized Agent: Adam Quayle Rook &t ' Iic, 14o Old Lt. Alan R Name (Print) Current Mailing Addres Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building 3,1 a S, o o (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) x' 3 1 I1S.00 Check Number This Section For Official Use Only Building Permit Number: I sssuu ed: Signature ,046 /' . ' / ? Building Commissioner /Inspector of Buildings Date • BP- 2011 -0537 GIS #: COMMONWEALTH OF MASSACHUSETTS b y; 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- 2011 -0537 Project # JS- 2011- 000881 Est. Cost: $3125.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ADAM QUENNEVILLE 070626 Lot Size(sq. ft.): 4617.36 Owner: FEDORCHAK DIANE & E BRIGHAM C/O DEBORAH LAMBERT -HUBER Zoning: URB(100)/ Applicant: ADAM QUENNEVILLE AT: 277 STATE ST Applicant Address: Phone: Insurance: 160 OLD LYMAN RD (413) 536 -5955 0 Workers Compensation SOUTH HADLEYMA01075 ISSUED ON:12/9/2010 0:00:00 TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE DAMAGED AREA 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 12/9/2010 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner