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17C-191 (3) The Commonwealth of Massachusetts li*Iii. Department of Industrial Accidents Office of Investigations 600 Washington Street Boston; Mass. 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Siding, Please Print Legibly Name (Business/Organization/Individual) : Adam Quenneville Roofing& Inc' Address: I (PO 0 t(I r? l )y1Ctr[ F R Oa d - City/State/Zip: 0 ' f11 - C`il t_e t. V Phone/4: LI 1 " h -6(z 6'7/65 ) "- 5 Are you an employer?Check the appropriate box: Type of project(required): I.>( I am an employer with I 4. . I am a general contractor and I 6. New construction employees(full and/or part time).* have hired the sub-contractors Remodeling 2. I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub-contractors have 8. Demolition working for me in any capacity. employees and have workers' 9 i Building addition [No workers' comp. insurance comp. insurance. required] 5.1 We are a corporation and its 10. ' Electrical repairs or additions 3. I am a homeowner doing all work officers have exercised their 1 I. Plumbing repairs or additions myself [No workers' comp. right of exemption perm MOL insurance required]t c. 152, § 1(4),and we have no 12.y Roof repairs employees. [no workers' 13. comp. insurance required.] — — "Any applicant that checks box#1 must also 611 out the section below showing their workers'compensation policy information. 'Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. ;Contactors that check this box must attach an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. II the sub-contractors have em o ces,the must .rovide their workers'corn . o olio number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job she information. hA Insurance Company Name:_r 11 k- r 4 I ._115(k f t1 Y1 e E�_ I/ r `h)I A S /0 i. Expiration Date:`t�,)cL- 6,/1 Policy #or Self-ins. Lic. f#: _�_� en, � lob Site Address: I -_-1'3 I r ilLftJL - _.--- City/State/Lip: (}ZQace_ _ _� U ---- 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 of MGl_ i 52 can lead to the imposition of criminal penalties of a tine up to$1,500.00 and/or one year imprisonment as well as civil penalties in the term of a STOP WORK ORDER and a fine of $250.00 a day against violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA far coverafe verification- — -- s 1 do herby certify under t e pains and penalties of perjury that the information provided above is true and correct. Signature: _"L —__ ._ Date 5-jib 3-__ ___.._ ' r Phone ii• ti 1 , - ` j(�: <--, c j!�5 Print Name: Ait IrYI l t.Z 1111 ✓i l L --- —- Official use only Do not write in this area to be completed by city or town official 1 City Permit/license#: _.._-----_..__ Clty or Town: -----. Issuing Authority(circle one): I.Board of Heath 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact person: Phone#. x_j '4`°R°® CERTIFICATE OF LIABILITY INSURANCE 4/24/2013 ) 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 CONTACT Lynne Methot, Ext. 102 Foley Insurance Group Inc. PactON F:t)• (413)214-7474 (ac.No);(413)214-7aa7 37 Elm Street E-MAIL rou 1methot @foie insurance com ADDRESS: y g p INSURER(S)AFFORDING COVERAGE NAIC# West Springfield MA 01089-2703 INSURERA:Peerless Insurance Company 24198 INSURED INSURER B:Safety Indemnity 33618 Adam Quenneville Roofing & Siding Inc. INSURER C:Scottsdale Insurance Co. 160 Old Lyman Road INSURER D AIM AIR INSURER E: South Hadley MA 01075-2632 INSURERF: COVERAGES CERTIFICATE NUMBER:CL1342406968 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES Or INSURANCE LIS1ED 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. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER 4MM/DDIYYYY) (MM/DDIYYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE PREMISES 100,000(Ea occurrence) $ A CLAIMS-MADE [X OCCUR GL6912267 6/23/2012 6/23/2013 MED EXP(Any one person) _ $ 5,000 PERSONAL&ADV INJURY $ 1,000,000, GENERAL AGGREGATE _ $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 —1 POLICY X PRO-T LOC $ JEC: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 B X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED i SCHEDULED 6215480 11/1/2012 11/1/2013 BODILY INJURY(Per accident) $ AUTOS AUTOS _ HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS (Per accident) PIP-Basic $ 8,000 UMBRELLA LIAB X OCCUR EACH OCCURRENCE _ $ 5,000,000 c X EXCESS LIAB CLAIMS-MADE AGGREGATE $ 5,000,000 DED RETENTION$ XLS0082909 6/23/2012 6/23/2013 $ D WORKERS COMPENSATION X WC STATU- OTH- AND EMPLOYERS'LIABILITY TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE Y N E.L.EACH ACCIDENT $ 1,000,000 (Mandatory OFFICER/MEMBER EXCLUDED? Y NIA AWC7012861012013 /29/2013 4/29/2014 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) Proprietor/Partner/Executive Officer/Member exclusion applies on Workers Compensation. The certificate holder named below is included as an additional insured for general liability coverage for ongoing operations if required by written contract, permit, or agreement executed prior to a loss. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. FOR PERMITTING PURPOSES AUTHORIZED REPRESENTATIVE Brian Foley/LYNNE --_-_:-. E > --2j.;%, ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INSA'S miring)nt This ArARf nnmo and Innn ern roniefororl rnerfe of ACl1Rrl tIassachusetts-Department of Public Snfetl ri it Board of Buildin s Re_odariun' and Standards License: CS 70626 ADAM A QUENNEVII I E • 160 OLD LYMAN RD S HADLEY, MA 01075 Expiration: 8/21!2013 " nlnci•Chater Tr#: 27Q02 i Office of Consumer Affairs and yt_Amoadee4elek ness Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 120982 Type: DBA Expiration: 3/25/2014 Tr# 222024 ADAM QUENNEVILLE ROOFING ADAM QUENNEVILLE 160 OLD LYMAN RD SO. HADLEY, MA 01075 Update Address and return card.Mark reason for change. Address Renewal Employment Lost Card DPS-CA1 a,r 50M-04/04-G101216 --- - - 1:1;, } t 2< 1 V t I V 1 t +';dt fr,' aVi f .i \ t ay l i11: 1 ti t t'r. .1: 't {1) Yi14- 1 ,� 3}�1 t 4f,r i �,,,df4,1 �" :4 ail r. l),+�.tp'7}�,, tp:..�i r.'4!)..1,, ..1 i 6 Efr+; .+'+\1,. ,� ':ti,1., l�.: 1„ i X41,... ]t,�,SI,. ,.::7\ .�'d�,',y,m ,t�,�a {n}li� ,F, .?1lf+�r I ,�.a:,�., �, .1��1� y't y,�i� iy�j:;` t.�11,+`,m'VbU,�, y t:• 4' 1l �, :.n ,� iM : M� „' ,4".' / kc t : �'� , �;: '�, }':: 11411', 8;,. STATE OF CONNECTICUT' 4 DEPARTMENT OF' CONSUMER PROTECTION ,:.., Be it known that ADAM QUENNEVILLE 160 OLD LYMAN ROAD SOUTH HADLEY, MA 01075-2632 is (C t t((1 by the Department of Consumer Protection as a registered HOME IMPROVEMENT CONTRACTOR \.r,K Registration # HIC.0575920 t, ADAM QUENNEVILLE ROOFING rte '. `f't Effective: 12/01/2012 Expiration: 11/30/2013 , - William M.Rubenstein,Commissioner ,.mil. �I D vi i c_ DISCOVER Q U E N N E V I L L E www.1800newroof.net ROOFING ■ 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: Dat i Phone#'s C: H2)1 Street \ ' ,� Email:, '`' ��`l ,\.-_, ae. a t, , 2,,i,-",v--“,4\„ . (.- ( \;?c V .\k(,ut`-1 City, State,Zip Code Special Requirements: i 1t e v t f? i' ' }�C 1 ,rf !, Recover ,` Strip LL Layers • ' �'C Complete Roof System L We shall acquire all appropriate permits for all work f tLkome exterior and landscaping to be protected i kr Strip existing roofing to existing decking and dispose of Do not Do. j 1.-,f ,,,. J___ -t Deteriorated existing decking will be replaced at$3.47 p sq_ft.after full inspection. :ii Install Ice&Water 'er at•[I ewes,valleys,chirtiineys es find skylights l?»nstall (151b.felt(S nhetic u derTa ment over rem n decking g area l Install Metal drip edge at eaves and rakes(8" 5) ite rown/copper) a t'"!-'Install manufacturer's starter shingle on a ves p nd rake edges BBB `_-=.5<install new pipe boot flashing ' tattdard/hopper)/vents —T- yfnstall Snow Country or etar rolled veniTiid e vent) Winner of the ._.- 2010 Install proper soffit ventilation TORCH AWARD Shingles: ( 6 nails per shingle) Cr'''') . �� - Shingles ] 25 year 30 year J 50 year Color \'''`" _ ,'fit Ridge cap shingles Warranty Options: We guarantee our workmanship for 10 full years(see our warranty coverage) I GAF System Plus warranty _ GAF Golden Pledge warranty Chimney Options: 1: -lead Counter Flashing Li Water Seal&Tuckpoint ❑ Rubberized Crown H Metal Chimney Cap We propose hereby to furnish materials and labor-complete in accordance with above specifications for the sum of:Total Due($ C C-t)0 ) ACCEPTANCE OF PROPOSAL: The above riees,specifications and conditions are I Down Payment($_ ;(;)(;,{ ) satisfactory and are hereby accepted ou are authoriied to do work as specified. 1 - Payment willlbe 1/3 down at start of and alance Qpe upon completion„ _ _.Balance-Due-Upon Completion($ 3000 _rt_._) will)be ? � 1 Date Slgnatu Date t i`/ 1•3 Estimator:(Print N e) ..A !h_ M1,1. (Sign Name)__,[ —i� Estimates are honored for sixty(60)days f m 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: Inc. ot Applicable ❑ Name of License Holder: Adam Quenneville Roofing&Siding, nc. iiNa a 1c. 160 Old Lyman Road License Number South Hadley,MA 01075 8 41 113 Address /� Expiration Date V13.s3�-mss Signature Telephone 9.Registered Home improvement Contractor. Not Applicable ❑ ennevilk Roofing&Siding,Inc. l a 9 `c Company am g •� f Registration Number 160 Old Lyman Road Address South Hadky,MA 01075 I Expiration Date Telephone 03--36:-5 S— - .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 ®wvler Exe r� tion 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,von 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 J SECTION 5 DESCRIPTION OF PROPOSED WORK(check all applicable) } , New House ❑ Addition I 1 Replacement Windows „ Afteration(s) n Roofing rx Or Doors D 'i• Accessory Bldg. ED Demolition El New Signs [o] ' '[decks x[Q,i j; , ' "Siding[CII Other[DI Brief D= cription of Proposed , Work: a'L/u'Y K' i ti 1 4^7.+ ' 0 "ION et-3 '4410'PA 1. • L 0 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 complete following: I a. Use of building: One Family Two Family Other b. Number of rooms in each family unit: Number of Bathrooms d° frii ,i , : 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 1, S ON eaC}YL•% ,as Owner of the subject property hereby authorize Adam Quenneville Roofing&Sidin2,Jnc, to act on my behalf, in all matters relative to work auth rized by This building permit application. C. - 11/ l/3 Signature of Owner Date x I, Adam Quennevilleloofing& lindg, ii , as Owner/Authorized Agent hereby declare that the state ents an information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the p ' s and penalties of perjury. Adam ( ef_____2/212:,/2/(sz Print Name s-h J'3 Signature of Owner/Agent Date Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information y, Existing Proposed Required byioning This colu„„``,,gg��,''to be filled in by Building D partmeat t Lot Size .� _ - -- a A Frontage --- - _____ Setbacks Front _— Side L: R:___—. L:.____:__ R:_.___.: .—� Rear Building Height _ Bldg.Square Footage % ^tl— Open Space Footage ___-__ ____ % __ s —, (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 03) YES 0 IF YES, date issued:, IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO 0 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 i0 , Date Issued: C. Do any signs exist on the property? YES 0 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 0 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. eCC'`fb-_. Department use only C —� I ity of Northampton Status of Permit uilding Department Curb Cut/Driveway Permit ' MAY w it ! 212 Main Street Sewer/SepticAvaiiability Room 100 Water/Well Availability o�euuoweiNSPecrao� N• hampton, MA 01060 Two Sets of Structural Plans NOAflWiPTON .',.. - ■1 . 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 This section to be completed by office 1.1 Property Address: j� II t l e it f�ac�.� Map Lot Unit. i F"1 p-- Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: G 1.-1-e S l e c y\on S f 11A)t I afj' ?J aLe, rI D z'h , 1!tP-61061 Name(Print) Current Mailing Address: C--tn-ka t!1.3— -.kci-09/V . e ,(•A" Telephone Signature 2.2 Authorized Agent: Adam Quenneville Roofing&Siding,Inc. /coo old no n , _ /ladiey, YX -au7c Name(Print) Current Mailing dress: '21------------- —,S-9 "--S Signature Telephone SECTION 3--ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building eon OD (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction fromi6)- - 3. Plumbing Building Permit Fee- 4. Mechanical(HVAC) , 5. Fire Protection 6. Total=(1 +2+3+4+5) tt. &, DOC co Check Number. 1�. - This Section For:Official-Use.Only. - - Date Building Permit Number: - Issued: Signature: Building Commissioner/Inspector of Buildings • Date • 11 WILDER PL BP-2013-1073 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17C- 191 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-2013-1073 Project# JS-2013-001770 Est. Cost: $6000.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ADAM QUENNEVILLE 070626 Lot Size(sq. ft.): 5096.52 Owner: SIMMONS KATHLEEN E Zoning:URB(100)/ Applicant: ADAM QUENNEVILLE AT: 11 WILDER PL Applicant Address: Phone: Insurance: 160 OLD LYMAN RD (413) 536-5955 0 Workers Compensation SOUTH HADLEYMA01075 ISSUED ON:5/8/2013 0:00:00 TO PERFORM THE FOLLOWING WORK:STRI P & 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 5/8/2013 0:00:00 $35.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner