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 ;. {
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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