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23D-008 (2) 54 NONOTUCK ST BP-2017-0560 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:23D-008 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-2017-0560 Proiect# JS-2017-000907 Est. Cost:$4400.00 Fee:$40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: ADAM QUENNEVILLE 070626 Lot Size(sa.ft.): 10018.80 Owner: DEIHL DOUGLAS&JANE NIEJADLIK Zoning: URB(100)% Applicant: ADAM QUENNEVILLE AT: 54 NONOTUCK ST Applicant Address: Phone: Insurance: 160 OLD LYMAN RD (413) 536-5955 0 Workers Compensation SOUTH HADLEYMA01075 ISSUED ON:10/25/2016 0:00:00 TO PERFORM THE FOLLOWING WORK:STRIP & INSTALL NEW ASPHALT ROOF ON UPPER MAIN ROOF 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 Si,nature: FeeTvpe: Date Paid: Amount: Building 10/25/2016 0:00:00 $40.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner Department use only if y City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit O _ 212 Main Street Sewer/Septic Availability 44f `ti Room 100 Water/Well Availability vNorthampton, MA 01060 Two Sets of Structural Plans o°Q phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans Other Specify •P CATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 8`" , iJ 600 1.4 Property Address: This section to be completed by office 54 Nonotuck St 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: Douglas &Jane Deihl 54 NonotuckSt Florence, MA 01062 Name(Print) Current Mailing Address: See (413)586-5322 Contract Telephone Signature 2.2 Authorized Agent: Adam Quenneville 160 Old Lyman Rd South Hadley MA 01075 Name(Print) 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 4,400.00 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) 4,400.00 Check Number This Section For Official Use Only t�GG Building Permit Number: Date / ,, Issued: Signature: AleA"1" �� Buildi Commissioner/Inspector of Buildings Date immoommon 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 °lo (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 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW O YES Q IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO Q DON'T KNOW © YES Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained 0 , 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 O NO I& 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 Q IF YES,then a Northampton Storm Water Management Permit from the DPW is required. vimmerimmmon SECTION 5-DESCRIPTION OF PROPOSED WORKJcheck all applicable) J New House D Addition [l Replacement Windows Alteration(s) ❑ Roofing 2 Or Doors 0 Accessory Bldg. D Demolition El New Signs [0] Decks [El Siding[D] Other[p] J Brief Description of Proposed Work: Strip and install new asphalt roll roof on upper main roof only 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 Ic. 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 Douglas&Jane Deihl I, g , as Owner of the subject property hereby authorize Adam Quenneville Roofing & Siding Inc. to act on my behalf,in all matters relative to work authorized by this building permit application. See Contract (b19 E1 e Signature of Owner Date I Adam Quenneville ,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 A1/4......_____ 1DI (R (r . Signature of Owner/Agent Date immunimEMMI SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable 0 Name of License Holder: Adam Quenneville CS070626 License Number 160 Old Lyman Rd South Hadley MA 01075 8/21/2016 Address /2Expiration Date k./ 413-536-5955 Signature Telephone 9. Registered Home Improvement Contractor: Not Applicable 0 Adam Quennevilie Roofing &Siding inc. HIC 120982 Company Name Registration Number 160 Old Lyman Rd South Hadley MA 01075 3/25/2018 AddressExpiration Date ��L� Telephone 413-536-5955 SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.t_.c.152,§25C(65) 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 ¢ii 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 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 City of Northampton 212 Main Street, Northampton, MA 01060 Solid Waste Disposal Affidavit In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building permit all debris resulting from the construction activity governed by this Building Permit shall be disposed of in a properly licensed solid waste disposal facility, as defined by MGL c 111 , S 150A. Address of the work: 54 Nonotuck St Florence, MA 01062 The debris will be transported by: USA Hauling & Recycling Inc. The debris will be received by: USA Hauling & Recycling Inc. 15 Mullen Rd Enfield, CT Building permit number: Name of Permit Applicant Adam Quenneville IQ\kck ikfo Date Signature of Permit Applicant L _—J BBB Q U E N N V i L L Enr- Winner at Ow TORCH AWARD ROOFING N. SIDING'r WINDOWS 160 Old Lyman Road•South Hadley•MA 01075 We are licensed 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 Assoc.of Western Mass. CT Registration#575920 Member al the Quilding&Trade Assotiatlon P.P.0 38710 Proposal Submitted To: , Phone#'s: C: �uS141 A-3-0,,,c_ �e.t4 \1 i( 11 1(.r +t:<f13-5%.k 531 W: StreetEntail: jt1 k.)Ono I t_ 54 City,State,Zip Code: r(er«c. er) 010(.,2 Proposal to furnish and Install the following: Qt:Movc c.,a cCQle c roil rc;at o.\ r, t cI.t f'r _ tri 6 ,+',C Ca^ STvr6) (iJiNtZC �cAt' e 4yc. Ful( sa5e 51xc\ loc ,. c.,(tcoot (oior C1ciSeSi To 1,1ortec (fee^ NJ(c,1 5C0.<" VC n. (SC cCAccgil\ of ? c'15 C..cvu- knot, USC g`k k.)0(.,31,6-t_ Cor tiumc11er ATTENTION H MEOWt4ERS: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: Additional materials and labor charges may apply. Deteriorated existing decking will be replaced at 53.77 per sq.ft.after full inspection Ask us about 1 Customer Initials affordable bank ,, Deteriorated existin Imensional lumber to be replaced at$5.00 per linear ft.after full inspection financing! Customer Initials Warranty Options: 3 1.Year i 5 Year )<1,0 Year We propose hereby to furnish materials and labor—complete in accordance with above sgedtkSbons fur the sum of Total Due:($4/'f Q4•C'0 ) ACCEPTANCE OF PROPOSAL:The above prices,specifications and conditions are ()tic L is 6.58/ Down Payment:($ ri 5(Z'co) satisfactory and are hereby accepted.You are authorized to do work as specified Balance Due Upon Completion:($ v g00'C)) Payment will be 1/3 down at signing and balance due upon completion. Date:/0'/9— /6 Signature:- ��„7.,_,,.�,�a1(�e'.----' Date:_I V (41 (l.' _Estimator(Print Name) 5r(AI Sc c(..(c . (Sign Kama)A.../- Z'" Estimates a e h ored for sixty(60)days from above date. A`�o® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYI 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 poticy(ies)must be endorsed. It SUBROGATION IS WAIVED,subject to 7 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 I CONTACT Melinda Rarakula NAME: Goss & McLain Insurance Agency :PHONE (413)534-7355 to).(413)536-9286 1767 Northampton Street ss.mkarakula@gossmclain.com 0 Box 1128 INSURER(S)AFFORDING COVERAGE NAIC# _ Holyoke MA 01041-1128 INSURER ANauti1us_ILLS Company INSURED INSURER B AIM Mutual Ins Co Adam Quenneville Roofing 4 Siding Inc INSURER C: 160 Old Lyman Road INSURER D: _ 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 INSR TYPE OF INSURANCE stip;yVn I POLICY NUMBER I(MOM CDDIYYYYYI IMMJDDNEFF POLICY Y EXP LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 DAGE TO A - , CLAIMS-MADE X1 OCCUR PREMISES(EaENTED t currence) $ 100,000 NN685342 , 6/23/2016 6/23/2017 MED EXP(Any one person) $ 15,000 PERSONAL&ADV INJURY S 1,000,000 GEM AGGREGATE LIMIT APrPLIES PER: 'GENERAL AGGREGATES 2,000,000 X POLICY JCC ( I LOC 1 PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: Emp'oyeeBenefits $ 1,000,000 AUTOMOBILE LIABILITY COMBINED SINJLE LIM,T $ Ea accident ANY AUTO BODILY INJURY(Per person) S ALLOVRdED —'SCHEDULED BODILY INJURY(Per accident) S AUTOS AUTOS NON-OWNED PROPERTY DAMAGE S HIRED AUTOS AUTOS (Per accident) Underinsured motorist BI split I$ UMBRELLA LIAB _ OCCUR EACH OCCURRENCE S 1,000,000 C x I EXCESS UAB X CLAIMS-MADE AGGREGATE $ DED XI RETENTIONS 10,000 A2t030622 8/13/2016 8/13/2017 •$ I WORKERS COMPENSATION I X PER CTI-1- AND EMPLOYERS'LIABILITY Y IN � STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVEE.L.EACH ACCIDENT 5 1,000,000 /M OFFICEREMBER EXCLUDED? Y 1 N/A D (Mandatory In NH) AWC4007012861-2016A 4/29/2016 4/29/2017 E.L.DISEASE-EA EMPLOYE: S 1,000,000 III yyes.descnbe under DESCRIPTION OF OPERATIONS below I E.L.DISEASE-POLICY LIMIT S 1 000 000 DESCRIPTION OF OPERATIONS/LOCATIONS!VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached H more space Is required) Certificate holders are additonal insured on the above captioned GL policy; subject to policy forms, conditions, and exclusions. Adam Quenneville, as an officer, is excluded from the Workers Comp policy. Pt' 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 /�v/ C/ Y.-L� ®1588-2014 AGGRO CORPORATION. Alt rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD INS025'701a711 The Commonwealth of Massachusetts !l. Department of Industrial Accidents 1 Congress Street, Suite 100 7.174:= $$ Boston, MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. .2. w+licant Information Please Print Legibly Name (Business/Organization Individual): Adam Quenneville Roofing & Siding Inc. Address: 160 Old Lyman Rd. City/State./Zip: South Hadley, MA 01075 Phone #: 413.536.5955 Are you an employer?Check the appropriate box: Type of project(required): 1.131 I am a employer with 15 employees(full and/or part-time).* 7. 0 New construction 2.0I am a sole proprietor or partnership and have no employees working for me in 8. El Remodeling any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]' 9. ID Demolition 4.01 am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 D Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.[]Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.fl I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.IN Roof repairs These sub-contractors have employees and have workers'comp.insurance.: 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§l(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box 01 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are 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.#: AWC4007012861-2016A Expiration Date: 4/29/2017 Job Site Address: City/State/Zip: Attach a copy of the workers' 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 5250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DR for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Signature: Date: L i' 1 Q '((p 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#: - P Massachusetts Department of Public Safety ®' Board of Building Regulations and Standards License: CS-070626 Construction Supervisor 11 ADAM A QUENNEVILLE r 160 OLD LYMAN RD.. ,t 4i«.: SOUTH HADLEY MA .7 - N' CA__:... Expiration: Commissioner 08;21!2017 Vis.\ he V� p 'm mm 'nwea&A o(Q/ a saa �i &eiis 57--='--9%.„, 4] Office of Consumer Affairs and Business Regulation %--&.. -ml" 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 120982 Type: DBA Expiration: 3/25/2018 Tr# 419291 ADAM QUENNEVILLE ROOFING _ ADAM QUENNEVILLE — 160 OLD LYMAN RD — SO. HADLEY, MA 01075 — — — - Update Address and return card.Mark reason for change, sca+ Cr 20re-e511uAddress fl Renewal Employment i_ I Lost Card q = �•.t. ' .1,i.-:S,yS• :I•��i ' "�; '1'' y•.1'r.�'1♦ '. �,•i.a'-•F``7:tiff.,s,1 4Y'. •1^L 1Y a -t'. ; ia' ,',Y;n i4 . --;,'::(',.`.q-'''' ,.`T-'• ''< .AP •5'''-'i''''.... ...',"6," :'8:.. ` '7: , �!'' ` • '',k" '` :41,0-4',0;c"....::1.4.:',''51:,40::. `' • - a ,4A< '4 \ . ? t. 'w `� ` 'i..- .51"� 2!1.11' i41L ._ *" !�,r- tel' .....4 -,,,f________ _ G — r1' . ,. STATE OF CONNECTICUT + DEPARTMENT OF CONSUMER PROTECTION - , ,r.',...: Be it known that ' I ' '- ;A ADAM QUENNEVILLE ; 160 OLD LYMAN ROAD rii ,-j: e. ,, SOUTH HADLEY, MA 01075-2632 v.„.: �,Vii . i' is certified by the Department of Consumer Protection as a registered 'R Ali ( HOME IMPROVEMENT CONTRACTOR 1 . :;C; Registration # HIC.0575920 ;�! I ADAM QUENNEVILLE ROOFING Effective: 12/01/2015 ;;: Expiration: 11130/2016 /If�114 t... +7< !•• A h in A,[Luck,Cnmm+ssianec vt '`_ ,or* '� . �' 4► W'`^ l iK�N i-'- .Y.- • ,i�,yI�" - ` F 4.� .:1;.*"7,. 1 t '`ti. .17� `;K y..t>1 ";• 3Y's Firs .••%v}.. 1 a�q.. •.1,: !....•.-,44,,,.,4 .z . '-1. .7z,:.. _ .;,;e,.t '".A'd5.`,A_ .�aA . ,E. ..r ��. _,., ..