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31A-100 • ' . . • . . . =' =_ °_ � o ar • o u • Ing ' egu ions an. tan • ar • s l One Ashburton Place - Room 1301 • Boston, Massachusetts 02108 Construction'Supervisor License • License CS: 70626 Restriction: 00 • Birthdate: 8/2111 • Expiration: 8/21/2011 Tr# 3712 ADAM A QUENNEVILLE 160 OLD LYMAN RD S HADLEY, MA 01075 . Update Address and return card. Mark reason for change Address Renewal Lost Card DPS -CAI ca 50M- 07/07- PC8490 -6 . * _ ►,__ : Boar. o Bui Re lat �ons an. ' tandar. s " One Ashburton Place - Room 1301 • ' • _� Boston. Massachusetts 02108 ••. Home Improvement - Contractor Registration Registration: 120982 • Type: DBA Expiration: 3125/2010 Tr# 264937 • ADAM QUENNEVILLE R00FING:„ .`..::_:::. ADAM QUENNEVILLE 160 OLD LYMAN RD SO. HADLEY, MA 01075 . -- - Update Address and n card. Mark reason for chang • (� Address ' 0 Renewal retur Employment Lost C ard DPS -CAI Cr 50M -07/07- PC8490 t Be it known that i n 'ADAM QUENl EVTLLE� ; I 1 OT�D ROAD SOtJT 7 t '` ' 107 5 26 2 • z • r ' " v,Y 1 rr ::,_ i.,. . ,,.. ,. ,. :,,...,. 1 s • c ert ied by th I� ep , t et { �' f� ' i i'i e otectio a registered ' ...,s:s!_.% ..t I------ f H O M E I MPRC�E C ONTRACTOR ;. { «� } �r r f Lt 1 � 7 R ego at �ti.A ' 5920 f k rR�ary sr -- .. 'IV ADAM QUENNEVILLE ROOFI I Effective+ 12/.01/2008 z t .. , • 1 " E p.i ra'tt o n � ; 11/30/2009 !; ; r �, _ _`'o i n e , s Jcf carrell, Jr ; Com 1• RX Date /Time 07/09/2009 14:55 1 413 538 6010 P.UU1 Jul - 09 02:38 PM' Remillard Insurance 1-413-538-6010 1/1 ACORD CERTIFICATE OF LIABILITY INSURANCE . OP ID LL DATE(MMIDDIYYYY) ADAMQ -1 07/09/09 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Remillard Insurance Agcy, Inc HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 79 Lyman Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. South Hadley MA 01075 Phone:413 -538 -7862 Fax:413- 538 -7179 INSURERS AFFORDING COVERAGE NA(C# INSURED INSURER A: arx Mutual mourance company Adam Quenneville Roofing & INSURER B: Travelers Ins. Co. Siding Inc INSURER C: Scottsdale Ins Co. 160 Old Lyman Road INSURER D: South Hadley MA 01075 INSURER E: COVERAGES 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSH AULJT - POLILYEFFEECTIVE POLICY EXPti>? TrOA LTR INSRC TYPE OF INSURANCE POLICY NUMBER DATE (MM /DDIW) DATE (MM /ODNY) LIMITS GENERAL LIABILITY EACH OCCURRENCE 51000000 C X COMMERCIAL GENERAL LIABILITY CLS1034980 06/23/09 06/23/10 PREMISES(Eaoc wrens) 550000 I CLAIMS MADE l i t OCCUR MED EXP (Any one person) 55000 t PERSONAL8ADVINJURY 51000000 GENERAL AGGREGATE $ 2 0 0 0 0 0 0 OEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG 52000000 n POLICY n PE n LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 51000000 B ANY AUTO BA7450L946 /01/08 11/01/09 (Ea accident) ALL OWNED AUTOS BODILY INJURY 5 X SCHEDULED AUTOS , ` (Per person) X HIRED AUTOS \ BODILY INJURY X NON -OWNED AUTOS (Par accident) 5 --� PROPERTY DAMAGE 5 (Per accident) 1 GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY AGG $ EXCESS/UMBRELLA LIABIUTY / \ EACH OCCURRENCE $ OCCUR n CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE 5 RETENTION 5 \ $ WORKERS COMPENSATION AND \ X I WC STATU- X I Dl H- TORY LIMITS ER A EMPLOYERS' LIABILITY AWC701286101 04/29/09 04/29/10 E.LEACHACCIDENT 5 1000000 ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYEES 10 00 0 0 0 If es. describe under SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT 3 10 00 0 0 0 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS 1 VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT 1 SPECIAL PROVISIONS P y CI' CERTIFICATE HOLDER CANCELLATION AD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN Adam Quenneville Roofing Inc. NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL fax #53 6 -144 8 IMPOSE NO OBLIGATION OR UABILITY OF ANY KING UPON THE INSURER, ITS AGENTS OR PO Box 612 South Hadley MA 01075 REPRESENTATIVES. AUTHO ED REPR SENTATIVE_ / ACORD 25 (2001108) �Sy L~ / 0 ACORD CORPORATION 1988 i,: (1 tea. U ` ` UJJtLe uj .114,,, Le . . .„ . + 600 Washington Street • � = . . s 'Boston, MA 02111 .11,1„ w iv mass.gov /dia • Workers' Compensation Insurance Affidavit: Builders /Contrac ors/Electricians/Plumbers Applicant.Information • Please Print Lezibly . • Name ( Business /Organization/Individual): ' .. di , ,,,A t1 1 •tt1 : ' Address: l s>a � l0 ( - O'ftYXrl R c)k( . - } M 1 :Q�J ^ Phone #: L City /State /Zip:_ f, 53 CL 5956 o ,�._� . _ M Are yo an employer? Check the approp b ;l to ox: ' ' Type of project (required): 1. I 1 air a employer with 1. 4. ❑ Tam a general contracto and I 6. ❑New construction employees (flail .and/or part- time).* • • have hired the sub -con.1 ctors 2. ❑ I am a ole proprietor or partner- listed on the attached sh et. t ❑Remodeling • ship and have: no employees These sub- contractors h: ve 8. 0 Demolition working for in any capacity. workers' comp. ins C. Y P �' � 9. ❑ BuiTding,addition [No workers' comp. insurance 5. ❑ 'We are a corporation . a its • required_] . officers have exercised it 10.❑ Electrical repairs or. additions 3. ❑ I am a homeowner doing all work . right of exemption per : GL 1 i .❑ Plumbing repairs or additions myself [No workers' comp. • c. 1'5 §' l (4), and we h. ve no 12.2 Lopf repairs insura>ce required.] t " employees. [No worke .' • <' comp. insurance requir d.] 13.0 Oth ;? Any applicant tat checks box #1 must also fill out the section below showing their workers' ompenaation ..liey information., . t Homeowners o submit this affidavit indicating t are doing all work then hire ou .. tsi.c contractors ust gn ff`r,'d bprit a new aavit indicating such: • 1 Coatraetors that�c this box must attached an ad ditional sheet showing tb .n of the sit. .nttactoii'.. d their workers' comp. policy informatioq. I am: an employer that is providing work compensation ins urance for y employ: es.' Below is the policy and job site information. i j Insurance Company Name: n 1 i l t a • • Policy # or Self -ins. Lic. #: ACS) C. - 2013,5031MR • Exp' :non Date' L 'f, - —a�� • Job Site' Address : _4 1 ,rig): <� r City /S . te/Zip: N i 1 1tet 1140,1 . Attach a cop 1 of the workers' compensation policy declarati p age (slowing t li :. policy number and expiration date). Failure to se �� coverage as required under Section 25A ofMGL t. 152 c: a lead to a• imposition of cr'irnilialpenalties of a fine up to Sl 50o.00 and/or•onc -year imprisonment, as.well as civil ptnalti . in the ft!, .. 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_ - • tatement ;lay be forwarded.to the Office of Investigatio4 oftlic DIA for insurance coverage•verification. • • II Ida hereby eeti under tom : pants and penalties of p that tyre info • n pr. '• ed above is tru and 'correct: Signature: ' ---- - - • _ • ' ' * Date: - l' - 7-o I • • • Phone #: i��I?► iS L5 • ' . 1 Officio/ u se ony. Do not write in this area, to be completed by city o town offic • L ' ' City or Town: Permit/Li.ense # • Issuing Authority (circle oe): .. ' .. • • 1. Boardof Health 2.1iuilding Departmept 3. City/Town'Clerk 4 Electric. Inspector 5. Plumbing Inspector b. Other I' . , Contact P'.erso•n a 'h one #: i r t l � — � • • immmi VISA Masi "gym + e DISCOVER o AAA 111••111= QU ENNEVILLE ROOFING & SIDING, INC. 160 Old Lyman Road, South Hadley, MA 01075 1- 800 -NEW -ROOF • 413- 536 -5955 Email: info @l800newroof.net Website: www.1800newroof.net MA Construction Supervisors Lic. #070626 MA Registration #120982 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 Proposal Submitted To: Date Phone #'s (ece / ,�, �� gi3 ; � 1-1:64 w: Street / Job Name: Q N�� I City, State, Zip Code Job Location: Ua >L , . fen 1 ^ 4 (J /o . Proposal o furnish and install the following ❑ Re -Roof Tear -Off ❑ Gutter /e / ge /l /`-.d: ;.. ',^ tC „ C `. ' 1 ) A3 41 c.rc/ 0.. / c c • ! G � /OeL, . a tti k /tert. C A, (C 4C,A t /H c iP/l rA ( 1 .- -e r/c , •• • ��d ri�11 A` Ask us about y tr� affordable bank yvo 7 u � , t .� ; 7 , N. financing We Propose hereby to furnish materials and labor - complete in accordance with above specificationn�for �th sum of: dollars ($ /�t9C ' fie90 ACCEPTANCE OF PROPOSAL: The above prices, specifications and conditions are 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. Date: c Z I / $ Signature:cc-A.4('A \Ct-l.' Phone# Date: • 3 ■ Estimator's Signature: d ,fl l / 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. SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : 0 7 C U -A `r Adam Qd flineVille Roofing & Siding, Inc, License Number 160 Old ?elan Road Smith Hadley MA 01075 Address Expiration Date // Signature Telephone 9. Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Adam Quenneville Roofing & Siding, Ifrli0„0 - 1 G 160 Old I_ man Road Address S Outh i1adlev MA Expiration Date 01075 Telephone _") 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 SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) l l Roofing Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [C] Siding [D] Other [D] Brief Description of Proposed �� Work: Jn %!kin 1. 51,.. " n 4 pvkc rl` 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 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 1, , as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date I, (\ (7 (l tkv∎e ,L (`. ("N ��% � , 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. C UL L Print Name 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 m 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 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES Q W YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO Q DON'T KNOW 0 YES Q 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 Q NO Q 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 Q 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 Q NO 0 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. Department use only City of Northampton Status of Permit: Btrildinc,\Department Curb Cut/Driveway Permit 212 Main Street Sewer /Septic Availability Aoom 100 Water/VVell Availability Northampton, MA 01060 Two Sets of Structural Plans phone.413 -587 -1240 Fax 413 - 587 -1272 Piot/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 Map Lot Unit .,, ��. Zone Overlay District Elm St. District ' CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: C -e t I Het)17 Name (Print) Current Mailing Address: Telephone 7 4 Signature 2.2 Authorized Agent: Adam Quenneville Roofing it Siding In Name (Print) 160 Old Lyman Road C urrent Mailing Address: . , South Hadley. MA 01075 (, S`f,S ;3i ature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only _completed by permit applicant 1. Building (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) 1I')k OC' Check Number /557 lit 3 5— This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner /Inspector of Buildings Date • 9 r BP- 2010 -0288 GIS #: COMMONWEALTH OF MASSACHUSETTS ock: 31A - 100 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 -0288 Project # JS- 2010 - 000373 Est. Cost: $1120.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ADAM QUENNEVILLE 070626 Lot Size(sq. ft.): 13721.40 Owner: MARTYN CECILIA G Zoning: URB(100)/ Applicant: ADAM QUENNEVILLE AT: 9 FEDERAL ST Applicant Address: Phone: Insurance: 160 OLD LYMAN RD (413) 536 -5955 () Workers Compensation SOUTH HADLEYMA01075 ISSUED ON:9/15/2009 0:00:00 TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE PORCH 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 9/15/2009 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo