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17A-083 (9) 19 CAROLYN ST BP-2020-0359 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17A- 083 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-2020-0359 Project# JS-2020-000602 Est. Cost: $13200.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: ADAM QUENNEVILLE 070626 Lot Size(sq. ft.): 10846.44 Owner: LIBBY JONATHAN Zoning: RI(100)/URA(100)/WSP(100)/ Applicant: ADAM QUENNEVILLE AT. 19 CAROLYN ST Applicant Address: Phone: Insurance: 160 OLD LYMAN RD (413) 536-5955 O Workers Compensation SOUTH HADLEYMA01075 ISSUED ON.9/18/2019 0:00:00 TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE ROOF & REPLACE SKYLIGHTS 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 9/18/2019 0:00:00 $40.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner .- P 9D iDepartment use only �t� «rl City of NorthamIlton Status of ermit: V Building Department gurb,Cut/ rive jay Permit 212 Main Stree SE� $ewer/Setic Avpilability l Room 100 Water/W�eJ�Avail6bility Northampton, MA 01060r�Ir�c5bt $�Strucjtural Plans phone 413-587-1240 Fax 413-5"MU AVVII Pis 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 60 Unit T (pf E'r1CC m N 0 1 bG a Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: L 1 Co"Ca\Iyer. . rn0n,\Ck Lt201 Co,roIn 5-1 FIC,r0rI (z CnA 0/()G1 Name(Print) Current Mailing Address: � -,71 LY - c�y tiers Q Telephone Signature 2.2 Authorized Agent: n 'v1 cl01 Q QrnncV ��C P'oot tr+ f �1 chin 'fn,c )�►U O!� �I►�a� �� 50 N4��'1 n',� Oloi) - Name(PdCurrent Mailing Addre s: �;j 5 3 G 5?S�S� SignatLfre Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only --completedby ernnitapplicant 1. Building 1 3 200 • co (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 0 5. Fire Protection 6. Total = (1 +2 +3+4 +5) 3 zco . c,, Check Number D 77 This Section For Official Use Only Building Permit Number: Date Issued: Signature: V0 Building Commissioner/Inspector of Buildings Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) 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 �� t Building Height Bldg. Square Footage 010 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 © DONT KNOW YES Q IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW 13� YES IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW 0 YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained © , Date Issued: C. Do any signs exist on the property? YES © NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES © NO 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 IF YES,then a Northampton Storm Water Management Permit from the DPW is required. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) —7 New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing Or Doors ❑ I E X Accessory Bldg. ❑ Demolition ❑ New Signs [t7] Decks [❑ Siding[0] Other[E] Brief Description of Proposed n Work: (L�rnv;R Sk �+ CeD�CGCC (-GQ� Qnd 5 Alteration of existing bedroom Yes X_No Adding new bedroom Yes �_No Attached Narrative Renovating unfinished basement YesNo Plans Attached Roll -Sheet ea. If New house and or addition to existing housing, complete the foliowina: a. Use of building : One Family 'X- 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, as Owner of the subject property �/'� hereby authorize 4 6 eve QUChr1yL 11C, to act on my behalf, in all matters relative to work authorized by this building permit application. ec Coy iQ4c( m--7/11 Signature of Owner Date 1, 4 (�G" Q)C n'c-w 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 p ' and penalties of perjury. A&k eA i P A Name Signature of Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: A OC^ V«'1r\CV 1` (- Ccj 0 II '' II License Number �0 O i L7 mc,-. �� S0,.I h NrJjC-,1 m✓J C)B/)I' aI0� I Address Expirati n Date ~-- "113 5 3 C 59S� Signature Telephone 9. Registered Home Improvement Contractor. Not Applicable ❑ Company Name Registration Number Addres Expirat on D e Telephone4t/3 51,57D 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...... ❑ City of Northampton r , Massachusetts } DEPARTMENT OF BUILDING INSPECTIONS ( � 212 Main Street •Municipal Building Northampton, MA 01060 rih Y- \V Debris 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. The debris from construction work being performed at: I � Co ro l�n 5-1 T Infcncc Mro 00ca (Please print house number and street name) Is to be disposed of at: 15 Mille•, �� Cn��el Z C i o aG - (Please print name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: X5#4 14aulin , 4- Z�C (Company N61ne and Add ss) IJ k --- q b, 1,7 Signature of Permit Applicant or Owner Date If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the Building Department as to the location where the debris will be disposed. The Commonwealth of Massachusetts Department of Industrial Accidents a 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): Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.❑I am a employer with employees(full and/or part-time).' 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 3.❑1 am a homeowner doing all work myself.[No workers'comp.insurance required.] 4.f_1I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 E]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.M I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.: 6.[:]We are a corporation and its officers have exercised their right of exemption per MGL c. 14.[:]Other 152,§1(4),and we have no employees.[No 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 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: Policy#or Self-ins.Lic.#: Expiration Date: 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$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains andpenalties ofperjury that the information provided above is true and correct Signature: Date: Phone#: 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#: City of Northampton •�` Massachusetts DEPARTMENT OF BUILDING INSPECTIONS y 212 Main Strout • Municipal Building E, i Northampton, MA 01060 AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and subcontractors performing improvements or renovations on detached one to four family homes.Prior to performing work on such homes,a contractor must be registered as a Home Improvement Contractor("RIC"). M.G.L.Chapter 142A requires that the"reconstruction, alteration, renovation, repair, modernization, conversion, improvement, removal, demolition, or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units....or to structures which are adjacent to such residence or building"be done by registered contractors. Note:If the homeowner has contracted with a corporation or LLC,that entity must be registered Type of Work: 200 � Est. Cost: I /3i d oo AddressofWork: � � Ce"rv, 711 710(cnct Mw MOO- Date of Permit Application: I hereby certify that: Registration is not required for the following reason(s): _Work excluded by law(explain): Job under$1,000.00 Owner obtaining own permit(explain): Building not owner-occupied Other(specify): OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION. Signed under the penalties of perjury: I hereby apply for a building permit as the agent of the owner: . 911-Al AACW &n7 uul 1%13 Date Contractor Name HIC Registration No. OR: Notwithstanding the above notice,I hereby apply for a building permit as the owner of the above property: Date Owner Name and Signature City of Northampton Massachusetts DEPARTMENT OF BUILDING INSPECTIONS ij 212 Main Street • Municipal Building Northampton, MA 01060 Massachusetts Residential Building Code Section 110.R5.1.2 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. Section 110.R5.1.3.1 Any homeowner performing work for which a building permit is required shall be exempt from the licensing provisions of 780 CMR 110.R5, provided that if a homeowner engages a person(s) for hire to do such work, then such homeowner shall act as supervisor. 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. �usMM�w�� w<x»rr.ae. senarws wa.�oc>w♦ ®� VISA= DISCOVER ,J'0 160 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 Builders Assoc.of Western Mass. CT Registration#575920 Member of the Building&Trade Association P.P.0 38710 Proposal Submitted To: Date: Phone#'s: C: 774-644-4451 Jonathan + Monica Libby 8/29/19 H: W: Street: Email: 19 Carolyn St City,State,Zip Code: Special Requirements: Florence MA 01062 EPDM rubber roof on backside upper PROPOSAL FOR. low pitch with 1" ISO insulation board. HOUSE GARAGE OTHER replace back right skylight with STRIP RECOVER velux VS-1404. Layers: 01 2 3 4 Plywood Included: Yes or� remove + dispose of satellite. Tear off SLATE or SHAKES customer is responsible for any COMPLETE ROOF PROTECTION SYSTEM: interior work A We shall acquire appropriate permits for all work do not touch gutter covers Ap Home exterior and landscaping to be protected * Strip existing roofing to existing decking with full inspection DO NOT DO: lower right side and 3 All project waste shall be removed by dumpster(dumpster for contractor use only) garage 4 Install Ice&Water Barrier at all eaves� 6',valleys,chimneys,pipes and skylights Install(151b.felt/ yntheti nderlayment over rem Ing decking area IV Install Metal drip edge at eaves and rakes/5") White brown) At Install manufacturer's starter shingle on all eaves and rake edges Install new pipe boot flashing/vent accessories Install ridge vent-Snow Country/Cobra rolled/4'Baffled As Shingles:(standard 6 nails per shingle) Tamko Heritage Shingles Color: Rustic Redwood Tamko Ridge cap shingles Warranty Options: V We guarantee our workmanship for 10 full years GAF System Plus Warranty GAF Golden Pledge Warranty Chimney Options: F-1 Lead Counter Flashing n Water Seal&Tuckpoint f-1 Rubberized Crown f—I Cricket Mason needed(customer provided) Additional material and labor charges may apply. p Deteriorated existing decking will be replaced at$3.77 per sq.ft.and dimensional lumber at$7.00 per linear ft., after full inspection. Customer Initials:�4 Y We propose hereby to furnish materials and labor—complete in accordance with above specifications for the sum of: Total Due:($132 0 0 ) ACCEPTANCE OF PROPOSAL:The above prices,specifications and conditions areDown Payment:($4 0 0 0 ) satisfactory and are hereby accepted.You are authorized to do work as specified. I 2nd Payment at Start Job:($4 0 0 0 ) Payment will be 1/3 down at signing,1/3 at start of job,and balance due Balance Due Upon Completion:($5200 ) upon completion. Date: S 4. )A Signature: Date: 8/29/19 Estimator:(Print Name)Robert Croteau (Sign Name) 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: NOTICE OF SCHEDULE CHANGES The contractor agrees that when delays become known to the Contractor,the Contractor will advise the Owner as soon as reasonable. DELAYS IN THE COMPLETION SURE TO HIDDEN CONDITIONS The Owner hereby acknowledges and agrees that in certain remodeling work,the demolition of portions of the pre-existing structure may reveal additional defects, conditions or the need for additional work,which must be repaired,altered or carried out in order to commence or complete the work described under the contract. In such case(s),the Owner agrees that the duration of the work and the scheduled date of completion may differ from the date on the front,and that such variation which is not avoidable by the Contractor shall not be considered to be a violation of the contract. ADDITIONAL WARRANTY INFORMATION All warranties for equipment supplied by the Contract under the Agreement shall be those given by the manufacturers of such equipment,which shall be and are hereby passed through directly to the Owner.Under such manufacturer's warranties,the Owner may be required to register or mail in a warranty card or other evidence of ownership and use of such equipment in order to activate such warranties.The warranty gives the Owner specific legal rights,and Owner may also have other rights which vary from state to state.Under Massachusetts law,sale of goods carry an implied warranty of merchantability and fitness for a certain purpose.All material is guaranteed to be as specified.All work shall be completed in a workmanlike manner,according to standard practices.Any alteration or deviation from above specifications involving extra costs will be executed only upon written orders and will become an extra charge over estimate.All agreements are contingent upon strikes,accidents or delays beyond control. SUBCONTRACTING Contractor agrees that,notwithstanding any agreement for materials and/or labor between Contractor and third party,Contractor is responsible to Owner for completion of all work described in a timely and workmanlike manner. NO ACCELERATION OF PAYMENTS BUT ESCROWING ALLOWED The Contractor may not require payments to be made in advance of the times specified in the Payment Section(front)for the reasons the he deems himself or the payments to be insecure.If,however,he deems himself to be insecure,he may require,as a prerequisite to continuing the work described herein,that the balance of the payments under this contract that are in control of the Owner,shall be placed in a joint escrow that requires the signature of both the Contractor and the Owner for withdrawal.You agree to pay cash according to the terms shown above or,if we approve your credit,to sign a note provided by us for payment of the amount due. You also agree to sign a completion certificate upon completion of the work.If you fail to pay according to the above terms and have not signed our note,the entire unpaid amount becomes immediately due,and you must pay a collection cost equal to our actual collection costs up to 15%of the total amount you owe,plus attorney's fees and court costs.In addition,you understand that by failing to pay according to the above terms,the Contractor may have a claim against you which may be enforced against your property in accordance with the applicable lien-laws. INSURANCE Contractor will be responsible to Owner or any third party for any property damage or bodily injury caused by himself,his employees or his subcontractors in the performance of,or as a result of,the work under this Agreement.Contractor agrees to carry insurance to cover such damage or injury.The Contractor recognizes his obligation to maintain a workers'compensation Insurance policy to cover his employees.Contractor further recognizes the obligation of any,and all subcontractor to maintain a workers compensation policy to cover their employees. Contractor maintains a liability insurance policy with minimum coverage limits of one million dollars($1,000,000.00) CONSTRUCTION RELATED PERMIT ACQUISITION The Contractor under provisions of Chapter 142A of the General Laws is required to apply for and obtain all construction-related permits.The Contractor shall not be deemed responsible for delays in the work described in this Agreement caused by regulatory permit granting or Inspectional agencies,authorities or individuals. COMPLETENESS OF AGREEMENT FOR EXECUTION The Owner is hereby advised that he should not sign this Agreement unless and until all blank sections have been filled in or marked as void,deleted or not applicable, and until all exhibits and related or referenced documents that are incorporated herein are attached hereto. COPY OF AGREEMENT TO BE GIVEN TO OWNER The Laws of Massachusetts shall govern this Agreement.It must be executed in duplicate,and an original,signed copy hereof shall be given to the Owner at time of execution.No work under the Agreement shall begin prior to the signing of the Agreement and transmittal to the Owner a copy thereof. LIABILITY Company is not responsible for damage or loss caused in whole or In part by:the acts or omissions of other parties,trades or contractors;lightening,gale force winds (+110 mph),hailstorms,ice damage,ice damns(caused by thawing and freezing of Ice,water or snow)hurricanes,tornados,floods,earthquakes or other unusual phenomena of the elements;structural settlement;failure,movement,cracking or excess deflection of the roof deck;defects or failure of materials used as a roof substrate over which Company's roofing material is applied;faulty condition of parapet walls,copings,chimneys,skylights,vents,supports or other parts of the building; vapor condensation beneath the roof,penetrations for pitch boxes;erosion,cracking and porosity of mortar and brick;dry rot;stoppage of roof drains and gutters; penetration of the roof from beneath by rising fasteners of any type;inadequate drainage,slope or other conditions beyond the control of Company which cause ponding or standing water;termites or other insects;rodents or other animals;fire;or harmful chemicals,oils,acids and the like that come into contact with Customer's roof and cause a leak or otherwise damage Customers roof.If Customer's roof fails to maintain a watertight condition because of damage,by reason,of any of the foregoing,any applicable written limited warranty shall immediately become null and void forthe balance of its term.Company accepts no liability to indemnify or hold Customer harmless for claims or damages to persons or property,except to the extent that such damage occurs during performance of Company's work and are the direct result of Company's error or omission.Notwithstanding the foregoing,Company shall not be responsible for damages to any area of the property upon which Company's work has not been completed nor is Company responsible for slight scratching or denting of gutters,oil droplets in driveways,hairline fractures in concrete, damage to flowers or landscaping,or minor broken branches on trees,plants or shrubbery.In no event shall Company be responsible for any type of damage resulting from vibrations,including,but not limited to,interior drywall damage,nail pops or disconnection of chimneys,flues,air ducts,ventilation shafts,exhaust vents,furnace vents or sewer vents.Customer understands and agrees that Company shall have no responsibility for damages of any kind to persons or property occurring after job completion. CANCELLATION Owner may cancel this contractwithin three business days of executing this document.Such cancellation must be in writing and delivered to the Contractor.Contractor reserves the right to cancel this contract at any time within thirty days of the date of this contract.If we cancel you will be promptly notified in writing by an authorized officer Of Adam Quenneville Roofing&Siding Inc.If we cancel,we will promptly return any down payment(s)you have made. AC" CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 1111a— � 1 6/24/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLYAND 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 NT NAME: Sarah Premo Martin J Clayton Insurance Agency, Inc. AICNNo Ext: (413)536-0804 FAX,Ne: (413)534-7874 1649 Northampton Street E-MAIL SS, spremo@mjclayton.com ADDRE P. O. Box 989 INSURERS AFFORDING COVERAGE NAIC III Holyoke MA 01041-0989 INSURER A:Nautilus Insurance Company INSURED INSURER B:Green Mountain Insurance Company Adam Quenneville Roofing & Siding Inc. INSURERC:AIM Mutual Insurance Company 160 Old Lyman Road INSURER D: INSURER E: _ South Hadley MA 01075 INSURER F: COVERAGES CERTIFICATE NUMBER:2019 MASTER 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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 ADDLSUBRTYPE OF INSURANCE IVSD WVD POLICY NUMBER POLICY POLICY EFF EXP LTR MM DDIYYYY MMIDDIYYYY LIMITS X COMMERCIALGENERALLIABILITY EACH OCCURRENCE $ 1,000,000 DA A A I CLAIMS-MADE MX OCCUR PREMISES Ea occ(x . 100,000 X Y UN1000129 6/23/2019 6/23/2020 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENLAGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,000 POLICY [fl PRI- MJECT LOC PRODUCTS-COM AGG $ 2,000,000 OTHER' $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ 1,000,000 B ANY AUTO BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED X Y 20030465 6/23/2019 6/23/2020 BODILY INJURY(Per accident) $ AUTOS AUTOS X HIREDAUTOS X NON-OWNED PPReOPPERdTYIDAMAGE $ AUTOS X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 5,000,000 A EXCESS LIAB HCLAIMS-MADE AGGREGATE $ 5,000,000 DED I I RETENTION$ AN069764 6/23/2019 6/23/2020 $ WORKERS COMPENSATION - PER TH- ANDEMPLOYERS'LIABILITY xYSTATUTE OR ANY PROPRIETOR/PARTNERIEXECUTIVE ❑NIA AWC4007012861 4/29/2019 4/29/2020 E.L.EACH ACCIDENT $ 1,000,000 C (Mandatory In NH)EXCLUDED? 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 I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Workers' Compensation benefits will be paid to Massachusetts employees only. Pursuant to Endorsement WC 20 03 06 B, no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires, or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued (unless the expiration date on the above policy precedes the issue date of this certificate of insurance) . The status of this coverage can be monitored daily by accessing the Proof of Coverage - Coverage Verification Search tool at www.mass.gov/lwd/workers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE FOR PERMITS ONLY THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Michael Regan/FMT ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD INS025(201401) The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street,Sttite 100 Boston,MA 02114-2017 w s' www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED NN7TH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organi2ation/individual): Adam Quenneville Roofing & Siding Inc Address: 160 Old Lyman Rd City/State/Zip: South Hadley, MA 01075 phone k 413-536-5955 Are you an employer?Check the appropriate box: hype Of project(required): i.V/ [a n a employer with 15 _employees(full and/or part-time).* 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. [:J Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 3.0 1 am a homeowner doing all work myself.[No workers'comp.insurance required.]' 10 Q Building addition 4.❑1 am a homeowner and will be hiring contractors to conduct all work on my property. [will ensure that all contractors either have workers'compensation insurance or are sole I LE]Electrical repairs or additions ro rietors with no employees. p p12.E]Plumbing repairs or additions 5.❑I ant a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.Q'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.F1 Other 152,$1(4),and we have no employees.[No workers'comp insurance required.] *Any applicant that checks box#1 must also fill out the section below showing(heir 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 nine 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 a»r an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: AIM Mutual AWC40070128612019A 4/29/2020 Policy#or Self-ins.Lic.#: _ Expiration Date: Job Site Address:_ n `- O City/State/Zip: �— Attach a copy of the workers'compeYisation policy declaration page(showing the policy number and ex iration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby certify under the ins and penalties of perjury that the information provided above is true and correct. Signature Date: 911) 111 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#: I Conunonwealth of Massachusetts ' i`ls��flj Division of Professional Licensure Board of Building Regulations and Standards Construction Supgrvisor CS-070626 �f. Expires:08/21/2021 ADAM A QUEJUNEVILLE l X 160 OLD LYMAN RD SOUTH HADLEY MA 01076 f '�Y► 1tt14t,}1t' `� Commissioner A,j,,,,c7i/�. . e_//C�� Yl�/J l��•�/l'//r/'//Gt<J/ �� ��1/Jr�t/1'/%///rJ���/rJ Office of Consumer Affairs and Business Regulation One Ashburton Place - Suite 1301 Boston, Massachusetts 02108 Home Improvement Contractor Registration Type: Corporation ADAM QUENNEVILLE ROOFING AND SIDING, INC. Registration: 191093 160 OLD LYMAN RD. Expiration: 03/22/2020 SO. HADLEY,MA 01075 Update Address and Return Card. SCA, a 20WOS t 7 ;.��:•1* ':?:+. N'r?.1':: ;�.Yi,,C•.'.:, +::iir+„ �:'1`::n r�'�'h;.. (!r':�•tr,,, .r ''�. .t~t'•`i,,. .:H.;.�t4 .,{.t„� .r•.yam .11, v N. ::,,�,f .^,1;.. �: ,.'r f •ir. ,;,x M, �%';�^, �:'�', fr7•,t''Syfr ••t j'itif,__.. STATE, OE,CONNECTICUT ♦ DEPARTMENT OF CONSUMER PROTECTION Be it known that �j ADAM QUENNEVILLE - 160 OLD LYMAN ROAD F F{ SOUTH HADLEY, MA 01075-2632 i has satisfied the qualifications required by law and is hereby registered as a y' .: HOME IMPROVEMENT CONTRACTOR - 3 Registration # HIC.0575920 ADAM QUENNEVILLE ROOFING Effective: 12/01/2018 Expiration: 11/30/2019 s Michelle Seagull,Comminioner at 1 'WANWAM'"A”, ,l "1 "T W x L A" w -A-�IA-MM-A-IMP A W A-+rr-�-.