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28-006 (3) gw401 SYLVESTER RD BP-2017-0268 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:28 -006 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 PERNIIT Permit# BP-2017-0268 Project# JS-2017-000458 Est.Cost: $8900.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ADAM QUENNEVILLE Lot Size(sq.ft.): 58370.40 Owner: REUTENER DONALD B JR Zoning: Applicant: ADAM QUENNEVILLE AT: 401 SYLVESTER RD Applicant Address: Phone: Insurance: 160 OLD LYMAN RD (413) 536-5955 () SOUTH HADLEYMA01075 ISSUED ON:8/31/2016 0:00:00 TO PERFORM THE FOLLOWING WORK:ROOFING MAIN HOUSE ONLY 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: FeeTvpe: Date Paid: Amount: Building 8131/2016 0:00:00 $40.00 212 Main Street,Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner • Department use only RECEVED City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit AUG2 9 2016 212 Main Street Sewer/Septic Availability Room 100 Water/Well Availability DEP of BUIW NG INS' TIGNS orthampton, MA 01060 Two Sets of Structural Plans NOR7}+AMPTON,J',.>;: �e 4 3-587-1240 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 401 Sylvester Rd Map Lot Unit Florence, MA 01062 Zone Overlay District Elm St District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Donald & Mary Reutener 401 Sylvester Rd. Florence, MA 01062 Name(Print) Current Mailing Address: 413-5844376 Telephone Signature 2.2 Authorized Agent: Adam Quenneville 160 Old Lyman Rd.South Hadley, MA 01075 Name(Print) A Current Mailing Address: 413-536-5955 Signature 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 ga ,a - $8,900.00 2. Electrical (b)Estimated Total Cost of Construction from (6) _ 3. Plumbing Building Permit Fee a9 /fa ---- 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+3+4+5) $8.900.00 Check Number j'‘5 ` 5._ This Section For Official Use Only Date Building Permit Number: Issued: Signature: 41111rOF., .77--,,--Z"' Building Commissioner/Inspector of Buildings 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 a o 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 O YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 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 O DONT KNOW Q YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained O , Date Issued: C. Do any signs exist on the property? YES O NO O IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES ® NO O 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 O NO lip IF YES,then a Northampton Storm Water Management Permit from the DPW is required. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition D Replacement Windows Alteration(s) ❑ Roofing IA Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [Q] Decks [Q Siding [O] Other[EH Brief Description of Proposed Work: Remove existing roof material and install new asphalt shingle system. Alteration of existing bedroom Yes_ X No Adding new bedroom Yes _ X Nq , Attached Narrative Renovating unfinished basement Yes X 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 1, Donald&Mary Reutener , as Owner of the subject property hereby authorize Adam Quenneville to act on my behalf, in all matters relative to work authorized by this building permit ap lication. See Contract f •Z-4 le Signature of Owner Date 1, Adam Quennevirie , 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. Adam Quenneville Print Name _____ gAH1lb Signature of Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: Adam Quenneville CS 070626 License Number 160 Old Lyman Rd.South Hadley,MA 01075 8/21/2017 Address Expiration Date 413-536-5955 • Signature Telephone 9.Registered Home Improvement Contractor: Not Applicable 0 Adam Quenneville 120982 Company Name Registration Number 160 Old Lyman Rd.South Hadley.MA 01075 3/25/2018 Address Expiration Date Telephone 413-536-5955 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 la' No 0 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 'eriod 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 BBB QV EN N E V I L L E Winner of the TORCH AWARD U 5"�r2 ROOFING V SIDING V WINDOWS 160 Old Lyman Road•South Hadley•MA 01075 We are Licensed 1.800.NEW.ROOF • 413.536.5955 Fully Insured Email:info Cai1800newroof.net Website:www.1800newroof.net Factory Trained MA Construction Supervisors Lic.#070626 MA Registration#120982 Factory Certified Installers Member of the Home Builder's Assoc.of Western Mass. CT Registration#575920 Member of the Building&Trade Association P.P.0 38710 Proposal Submitted To: Date: /3/ Phone 4's: c(iur3' r,?Su 3tsc3 AA., 4- N / � ' /� /eu, ✓e.t , 58V NJ] 1( H:(f/ 13xW: Street: / Email: Yu, 5,,/,e54,4. ?al City,State,Zip Code: Special Requirements: F(r,L+.,ce AA C/clic. l..s41/ zoic sl..rs S.kcI sto�.� PROPOSAL FOR: HOUS3 GARAGE OTHER TRIP RECOVER NEW GUTTERS Layers: Q 2 3 4 Plywood Included: Yes orNo L Tear off SLATE or SHAKES COMPLETE ROOF PROTECTION SYSTEM: g We shall acquire appropriate permits for all work )( Home exterior and landscaping to be protected Strip existing roofing to existing decking with full inspection DO NOT DO: e 54) )C All project waste shall be removed by dumpster(dumpsterfor contractor use only) ��ff X Deteriorated existing decking will be replaced at$3.77 per sq.ft.after full inspection Customerinitial) ('4(D Install Ice&Water Barrier at all eaves 3', 36 valleys,chimneys,pipes and skylights • Install(151b.felt'Iltrab underlayment over remaining decking area $ Install Metal drip edge at eaves and rakes®/5") lat5 brown) Install manufacturer's starter shingle on all eaves and rake edges k Install new pipe boot flashing/vent accessories Install ridge vent-Snow Country/Cobra rolled/4'Baffled/Roll Shingles:(standard 6 nails per shingle) 6A t' Shingles -I 25 year k 30 Year L 50 Year Color: }-vir GAF' cap shingles Warranty Options: • We guarantee our workmanship for 10 full years(see our warranty coverage page) GAF System Plus Warranty GAF Golden Pledge Warranty AQRS Recommendations: • Lead Counter Flashing Water Seal&Tuckpoint -Rubberized Crown _ Metal Chimney Cap CG Replacing old skylights(or waiver must be signed) __ Mason work(or waiver must be signed) I I Heated panel roof system L Insulation J]Ventilation Opted out of AQRS recommendations Customer Initials: XX We propose hereby to furnish materials and labor—complete In accordance with above specifications for the sum of: Total Due:(S U�GQ ) ACCEPTANCE OF PROPOSAL The above ices,specifications3c c 0 ec prandconditionsare Down Payment:($ ) satisfactory and are hereby accepted.You authorized to do work as specified. Balance Due Upon Completion:(S . 60 ) Payment will be 1/3 down at start of job,and '!nce due upon ompletion. 71-3/76' f A '/ Date: )) Signature: Date: iS/.73//G Estimator:(Print Na rn Al C•ia (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. Customer Initials: O® ACDATE(MWDO/YYYY) A� CERTIFICATE OF LIABILITY INSURANCE 6/24/2016 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 NAME: Melinda Rarakula Goss & McLain Insurance Agency p N ,NatL (413)534-7355 IAlc,No),(413)536-9286 1767 Northampton Street A DRESS:mkarakula®gosamclain.com P 0 Box 1128 INSURER(S)AFFORDING COVERAGE f MAIC# Holyoke _ MA 01041-1128 INSURER A:Nautilus Ins Company INSURED INSURER B AIM Mutual Ins Co Adam Quenaeville Roofing & Siding Inc INSURER C: 160 Old Lyman RoadINSURER D: I ' INSURER E: _ South Hadley MA 01075 INSURERF: COVERAGES CERTIFICATE NUMBER•CL1662403220 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._ INNSSR_ AWL SUBR POLICY EFF POLICY EXP TYPE OF INSURANCE INSD WVD POUCY NUMBER (MM'DDIYYYY) IMMYDD/YYYYI UNITS X I COMMERCIAL GENERALL4AB%UTY EACH OCCURRENCE S 1,000,000 -DAMAGE TO RNTED A 1 CLAIMS-MADE I X OCCUR _PREM SES(EaEoccurrence) $ 100,000 a1W685342 16/23/2016 6/23/2017 MEDEJ(P(Anyoneperson) $ 15,000 PERSONAL&ADV INJURY $ 1,000,000 GEN1 AGGREGATE LINT APPLIES PER: GENERAL AGGREGATE S 2,000,000 X POLICY f }JECT i LOC1 1PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: Employee Benefits $ 1,000,000 'AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ,_,(Ea accident) _ ANY AUTO ' BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS I HIRED AUTOS AUTOS ;PoOaE entDAMAGE $ r acci_Underinsured motorist BI split S UMBRELLA LIAB OCCUR _EACH OCCURRENCE 5 1,000,000 C x EXCESS LAB X CLAIMS-MADE _AGGREGATE 5 CED I X RETENTION$ 10,000 - AN030622 8/13/2016 8/13/2017 S WORKERS COMPENSATION , PER OTH- AND EMPLOYERS'UABILITY Y f N ;STATUTE ER ANY PROPRIETOR/PARTNER'EXECUTIVEE.L.EACH ACCIDENT $ 1,000,000 OFFICER,'MEMBER EXCLUDED? Y N/A — D (Mandatory In NH) AWC4007012861-2016A 4/29/2016 4/29/2017 E.L.DISEASE-EA EMPLOYEE S 1,000,000 If Xes,describe under DcSCRIPTION OF OPERATIONS below ' E.L DISEASE-POLICY LIMIT $ 1,000,000 I DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Certificate holders are additonal insured on the above captioned GL policy; subject to policy forms, conditions, and exclusions. Adam Quenaeville, as an officer, is excluded from the Workers Comp policy. 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. AUTHORIZED REPRESENTATIVE M Karakula/MINDY 7/44...4._ 62,-Ii-4___ ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The&CORD name and logo are registered marks of ACORD NS025 OOn14(ITi The Commonwealth of Massachusetts Department of Industrial Accidents • alk- = orc, 1 Congress Street, Suite 100 _ Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/organization/individual): Adam Quenneville Roofing & Siding Inc. Address: 160 Old Lyman Rd. CityiStateiZip: South Hadley, MA 01075 Phone#: 413536.5955 Are you an employer?Check the appropriate box: Type of project(required): 1.E1 1 am a employer with 15 employees(full and/or part-time).* 7. 0 New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in g. [] Remodeling any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]i 9. 0 Demolition 10 [] Building addition 4.01 am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or arc sole 11.0 Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.[E1 Roof repairs These sub-contractors have employees and have workers'comp.insurance.% 6.0 We arc a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§t(4),and we have no employees.['.4o workers'comp.insurance required.! *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they arc doing all work and then hire outside contractors must submit a new affidavit indicating such. 'Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: AIM Mutual Insurance Policy#or Self-ins.Lic.h: AWC4007012861-2016A Expiration Date: 412912017 Job Site Address: 140 'lit S r Cack • City/State/Zip:Ft 01 Qv\C eJ V'V' O 1 Olow Attach a copy of the worker compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to 51,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DLA for insurance coverage verification. I do hereby certify under the pains an penalties of perjury that the information provided ahoy is true and correct Signature: Date: 6 � 11t4, Phone#: 413.536.5955 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: w Massachusetts Department of Public Safety Board of Building Regulations and Standards License:CS-070826 Construction Superviso- Wt. ADAM A QUENNEVILLE , - e, 160 OLD LYMAN RD. '1Y -4 • SOUTH HADLEY MA t, f NI.� C..A._._.- Expiration: Commissioner 08/21/2017 .r{te t -- L no rninnuoecA oigl a.14 eh coeti P V.4-7.;. Office of Consumer Affairs and Business Regulation ,, 10 Park Plaza - Suite 5170 '` Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 120982 Type: DBA Expiration: 312512018 T># 419291 ADAM QUENNEVILLE ROOFING ADAM QUENNEVILLE ^_ 160 OLD LYMAN RD —" SO. HADLEY, MA 01075 Update Address and return card.Mark reason for change. --_ Address 0 Renewal Li Employment I Lost Card SCA 1 0 20M-05111 .,.. . h.—.'tl"_ 'I ' -�� 11.,* '-' `-'-�~- L"'- '-,^4 - 'tip- 4r 11'w: '4'.16' 1,,1r1 Iff..'+- - # -IQ'''.( -' -' - - I — - - ---- -- -_ ,� j , STATE OF CONNECTICUT + DEPARTMENT OF CONSUMER PROTECTION I . = 4,, Be it known that : i ' ADAM QUENNEVILLE �. . i ( 4. 160 OLD LYMAN ROAD :` ',) SOUTII HADLEY, MA 01075-2632 \- i is certified by the Department of Consumer Protection as a registered f it HOME IMPROVEMENT CONTRACTOR `; Registration # HIC.0575920 .K;) /` ',, ,, ADAM QUENNEVILLE ROOFINGsv t Effective: 12/01/2015 • t. 4git :. : i Expiration: 11/30/2016 iv"abc:8-- ,,,.. .,:i, p �,;.. � J.•a1hon A.I Lurk,Connnisxionct -./ 4.F "4.s.- -41„t _ 41 * 441"11, 47ra 4r* q ti q-'a 4f,'* q.a 4trF- 41;* _4,A, v q''W 'a a 1i V -1"..i 4 4,.>n.4, .. d`.. .I, .i•V .i,`A..�''•d �4..:•%11Z �.w. i31.' .l1. A )0 ...