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17A-052 (5) 158 OAK ST BP-2022-0012 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17A-052 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL. c.142A) Category: Siding BUILDING PERMIT Permit# BP-2022-0012 Project# JS-2022-000015 Est.Cost:$5400.00 Fee: $60.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: ADAM QUENNEVILLE 070626 Lot Size(sq.ft.): 6229.08 Owner: WOLOSENKO SANDRA L Zoning: URB(100)/ Applicant: ADAM QUENNEVILLE AT: 158 OAK ST Applicant Address: Phone: Insurance: 160 OLD LYMAN RD (413) 536-5955 O Workers Compensation SOUTH HADLEYMA01075 ISSUED ON:7/6/2021 0:00:00 TO PERFORM THE FOLLOWING WORK:NEW SIDING ON NORTH SIDE OF HOUSE 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 signarurc:� a i FeeType: Date Paid: Amount: Building 7/6/2021 0:00:00 $60.00 212 Main Street,Phone(413)587-1240, Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner ` .)N Department use only n.al City of Northampton �` Status of Permit: `.� Building Department `�C Curb Cut/Driveway Permit . , ► 212 Main Street / er/Septic Availability_. Room 100p, �l ‹_IN ell Availability Northampton, MAQ0 1 co 2 ets Structural Plans phone 413-587-1240 Fax -1272 �c�j PI Site P,IJns they S,pieecify APPLICATION TO CONSTRUCT, ALTER, REPAIR, RE Vitk'w^' DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION This section to be completed by office 1.1 Property Address:158 Oak St Florence Ma 01062 Map OOA Lot_ J.!14 Unit Zone Overlay District Elm St. District CB District SECTION 2 -PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Sandra Wolosenko 158 Oak St Florence Ma 01062 Name(Print) Current Mailing Address: 413-586-9461 see contract Telephone Signature 2.2 Authorized Agent: Adam Quenneville 160 Old LymanRd South Hadley Ma 01075 Name rint) 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 5,400.00 (a) Building Permit Fee 2. Electrical (b) Estimated Totai Cost of Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) Ob° 5. Fire Protection 6. Total = (1 + 2 + 3 +4 + 5) 5,400.00 Check Number f O 1 10 L n This Section For Official Use Only f Building Permit Number: 6i -- p7 Date Issued: Signature: 7 2-Zez Building Commissioner/Inspector of Buildings Date operations.agrs @ gmail.com 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 Rear C . Building Height Bldg. Square Footage Open Space Footage (Lot area minus bldg&paved parking) #of Parking Spaces ~- Fill: (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO DON'T KNOW I)( YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO DON'T KNOW )( YE�1 IF YES: enter Book Page and/or Document # B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW YES IF YES has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 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 x IF YES, describe size, type and location: l E. Will the construction activity disturb clearing, gradin excavation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YE jJ NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable C] Name of License Holder: Adam Quennville CS-070626 License Number 160 Old Lyman Rd South Hadley Ma 01075 8/21/2021 Address Expiration Date 413-536-5955 Signature Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ Adam Quenneville Roofing&Siding Inc 191093 Company Name Registration Number 160 Old Lyman Rd South Hadley Ma 01075 3/22/2022 Address Expiration Date Telephone413-536-5955 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 X No ❑ SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing n Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [E] Decks [❑ Siding [M] Other[El] Brief Description of Proposed New siding on North side 158 only, remove and replace existing siding and insulation with new. Work: Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 6a. If New house and or addition to existing housing, complete the following: a. Use of building : One Family Two Family Other b. Number of rooms in each family unit: Number of Bathrooms c. Is there a garage attached? d. Proposed Square footage of new construction. Dimensions e. Number of stories? f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction 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 I, Sandra Wolosenko as Owner of the subject property Adam Quenneville hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. see contract 06/29/2021 Signature of Owner Date 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 06/29/2021 Signature o wner/Agent Date City of Northampton a"AMero, /A 't`ti Massachusetts ' (; lt ;* . . f ' ', DEPARTMENT OF BUILDING INSPECTIONS I `' 212 Main Street •Municipal Building t. Northampton, MA 01060 -;, 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: 158 Oak St Florence Ma (Please print house number and street name) Is to be disposed of at: Adam Quenneville Roofing&Siding 160 Old Lyman RD South Hadley Ma (Please print name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: Adam Quenneville Roofing & Siding 160 Old Lyman Rd South Hadley Ma (Company Name and Address) )1&___. I 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. ALL VISLOUN'1'6 AVeLlEL) 12 rla QUENNEVILLEela AWARD VISAS Disc VER 2010 WINNER 160 Old Lyman Road•South Hadley•MA 01075 We are Licensed 1.800.NEW.ROOF • 413.536.5955 Fully Insured Email:info@l800newroof.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: Phone#'s: C: SANDRA WOLOSENKO 6/25/21 H: 413-586-9461 w: Street: Email: 156-158 OAK ST City,State,Zip Code: FLORENCE MA 01062 Proposal to furnish and install the following: 1) OBTAIN ALL PERMITS NEEDED TO DO WORK 2) DELIVER DUMPSTER TO DISPOSE OF DEBRIS 3) STRIP OFF SIDING .AND INSULATION ON 158 SIDE (NORTH SIDE) 4) REPLACE ANY ROTTED WOOD NEEDED TO DO WORK 5) SUPPLY AND INSTALL NEW VINYL SIDING AND .INSU.LAT•ION ON THAT WALL DO NOT REPLACE,ANY EXISTING TRIM ON THAT GALL ' 6) SIDING IS KAYCAN WHITE 4 INCH LIFETIME WARRENTEE 7) PRICE INCLUDES ALL MATERIALS,LABOR,DISPOSAL OF DEBRIS Ask us about affordable bank financing! 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.Please remove any lawn ornaments or yard furniture.Adam Quenneville Roofing will not be responsible for debris or dust in the attic or storage areas, Customer Initials: We propose hereby to furnish materials and labor—complete in accordance with above specifications for the sum of: Total Due:($ 5, 4 0 0 ) ACCEPTANCE OF PROPOSAL:The above prices,specifications and conditions are Down Payment:($ 1, 8 0 0 ) satisfactory and are hereby accepted.You are authorized to do work as specified. 2nd Payment at Start Job:($ Payment will be 1/3 down at signing,1/3 at tart of job,and balance due Balance Due Upon Completion:($ 3, 600 ) upon completion. ✓� / Date: 6/25/21 Signature: vv 6/25/21 � ziQDate: Estimator:(Print Name) DAVE AREL (Sign Name) /Estimates are honored for sixty(60)days from above date. 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 give 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. MODIFICATION This Agreement including the provisions relating to price and payment schedule cannot be changed except by a written statement signed by both the Contractor and the Owner.However,cancellation by Owner is allowed in accordance with the Notice of Cancellation. 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. ARBITRATION In the event the Owner and Contractor have a dispute regarding any of the terms,conditions,provisions or performance of this contract,the parties agree to place the matter into arbitration before an independent arbitrator assigned by the American Arbitration Association to resolve their dispute.Owners acknowledgement of arbitration clause CANCELLATION Owner may cancel this contract within 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. 1 U ACORL CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/VYYV) 6/24/2021 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 CONTACF Sarah Premo NAME: Clayton Insurance Agency, Inc. (A/C, Ext): (413)536-0804 FAX No): 413)534-7074 1649 Northampton Street ADDRESS: spremo@claytoninsurance.net P. O. Box 989 INSURER(S)AFFORDING COVERAGE NAIC# Holyoke MA 01041-0989 INSURERA:Nautilus Insurance Company INSURED INSURER B:Arbella Insurance Co. Adam Quenneville Roofing & Siding Inc. INSURERC AIM Mutual Insurance Company 160 Old Lyman Road INSURER D South Hadley, MA 01075 INSURERE: INSURER F COVERAGES CERTIFICATE NUMBER:2021 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 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 W ADDL SUBR POLICY EFF POLICY EXP LIMITS LTRINSR VD POLICY NUMBER (MMIDD/YYYY) (MM/DDIYYYY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED A CLAIMS-MADE X OCCUR PREMISES (Ea occurrence) 100,000 NN1283315 6/23/2021 6/23/2022 MED EXP(Any one person) $ 5,000 PERSONAL 3,ADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $ 2,000,000 X POLICY PRO- JECT LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS X AUTOS 1020107895 6/23/2021 6/23/2022 BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE X HIRED AUTOS X AUTOS (Per accident) UNINS/UNDERINS MOTORISTS $ 100,000/300,000 X UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ 5,000,000 EXCESS LIAB A CLAIMS-MADE AGGREGATE $ 5,000,000 DED RETENTIONS AN1242102 6/23/2021 6/23/2022 S WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITY Y I N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? Y N/A C (Mandatory in NH) AWC4007012861 4/29/2021 4/29/2022 E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) For Informational Purposes Only CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Adam Quenneville Roofing & Siding Inc THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN 160 Old Lyman Rd ACCORDANCE WITH THE POLICY PROVISIONS. South Hadley, MA 01075 AUTHORIZED REPRESENTATIVE ( Michael Regan/FMT ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025(201401) ADDITIONAL COVERAGES Ref# Description Coverage Code , Form No. Edition Date Blanket Al Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Included Ref# Description Coverage Code Form No. Edition Date First Party Data Breach Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Included Ref# Description Coverage Code Form No. Edition Date Additional Insured ADDIN Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium $25.00 Ref# Description Coverage Code Form No. Edition Date BEXCR BEXCR I Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref# Description Coverage Code Form No. Edition Date Medical payments MEDPM Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium 5,000 Ref# Description Coverage Code Form No. Edition Date Uninsured Motorist Liab/BI UM Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium 100,000 300,000 Ref# Description Coverage Code Form No. Edition Date Underinsured Motorist Liab/BI UNDUM Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium 100,000 300,000 Ref# Description Coverage Code Form No. Edition Date PIP-Basic PIP Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium 8,000 Ref# Description Coverage Code Form No. Edition Date Experience Mod Factor 1 EXPO1 Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium -$8,606.00 Ref# Description Coverage Code Form No. Edition Date Increased employer's liability INEL Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium $963.00 Ref# Description Coverage Code Form No. Edition Date Expense constant EXCNT Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium $338.00 OFADTLCV Copyright 2001,AMS Services,Inc. - - s..�..,u•..a:-vas++� rr�acrR.su a.u.�rsza.cuwcw .° t p CongressStree4 State d00 '�� Boston;MI 20d 7 - ' _< nninvmzssaovldi.'¢ Workers'Compensation Ensurazzee Affidavit:133ndders/ContractarslIIecrriciansfPlana5ers_ TO BE FILED MTTH'Lan.PERM11T1 G A ntmarrY. Applicant Information PIease Print Leahfv Name(Badnessforgartizatiotr(Individual}: Adam Quenneville Roofing& Siding Inc Address: 160 Old Lyman Rd City/State%Zip: South Hadley, MA 01075 phQIIe#: 413-536 5955 .re yea an employer?Check the appropriate ha;: Type of project(regaired): E.f f lava a emproyerwith 15 employees(full andforpart-time)." 7. Q Nor construction 2.0 I aaa a safe proprietor or vartaership andhaveno employees wnrlang forme is g. Q Remodeling any capacity.thin workers'camp.insurance regaired.1 9. 0 Demolition 3.—1 t aria hamenc ter doing all Wart myself[Na workers'camp_insurance required._t 4.0Iara a icraammerand wlTT hen-ring contractors to conduct aft work art nay property_ twill lfi Q Building addition - 1 maze lac all contractors either have workers'campeut rtiaa insurance or are sole 11_Q Electrical repairs or adthUa s a pmt7LTeto6 wit rxo employees. - . r 12.0 P lUmbIltg repairs or additions ` 5.El l aai a genetef contactor and Ihave hir�.d due sub-contractors listed oa the attached sheet Q These subcontractors have employees and have workers'camp.lnsu aace fi 13_ P oafrepair's s 5.0 We are a ecrmored=and its.a€Fm=have exercised the'dem afexeuiptfmr per BMOC f ezA I152,i t(44,and we have ad employees.[No c3-arkers'comp_iasmauce required-1 4A.ity applicant that checks Box II most also Fill atm the section helot./showing.Qieir workers'compensation policy iothm atran. FKaine awaers who submit this atlidavitindicating they arc doing all 000rlc and hea hire outside contractors must submit a new afldavr2 indicating such_ *Contractors that eheckthhis hex most attached as cud,rionalsiteetshawing the name of the sofa-caattacrars aruistate whether er or oat those entities have employees if the suhc-comractoss have employees,they must provide their rorkers'tvrriv policy nmsher_ l am art vi pio7er tftatis-provirrrg Fuarkcrs'eorrrperrsatiore iersrcmnce for my empfayees: Berm i is Eire policy cardjef site irrforrtrsiiorr.. Insurance Company Name: AIM alfUtlfal Policy g or Sett ins Lic.#:- AAWC40070-123612019A E-piratiaa Date: l rots Site Address: 1 9,-153- Oak- S City/state/Zip: c ►ricrtc mA 61 o(, )- Attach a copy of the workers'compensation policy declarat ioa page(sh.owing the policy number and erp ra€iaa date). Failure to secure coverage as required.underiVIGL c.15,§25A is a criminal violation-punishable by a fine up to SI,5Qa.O0 anddfor one-year imprisonment,as well as civil penalties ia.to farm of a STOP WORK ORDER and a free of up to 3251OO a day against the violator A.copy of this statement t may be forwarded to the Office of Investigations_of the DI'A far insurance coverage veri.fcatio n. 1 der ker eby cerirfp tinder tfie Fins arrd penalties of perjury th tttfte ilrf rntatian provided¢bone is true eFrrI corm Signature: t Date: t Phone* 413.-536 59 5 Official tese orxllr. Do not unite in this na-ea to be completed ay thy or town o}fieiaL City or To : Permit/License# Fssunag Authority(elide Dire): 1_Board et Heath 2.Budding Department 3.City/Town Cleric 4.Electrical Cnspector T.Plumbing Inspector 6_Other ContactPersou_ Phone f : ' CS-070626 Spires:08/21/2021 ADAM A Q MO OLD LYMAN"- r I ", SOUTH HAALTY MA: ;tJ. ,/, s Commissioltet f — C9L nweA(1,1 / I400acAusee.a Office of Consumer Affairs and Business Regulation 1000 Washington Street-Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Coon ADAM QUENNEVILLE ROOFING AND SIDING INC. 03/22/2022 1.80 OLD LYMAN RD. SO.HADLEY.MA 01075 Update address.and Return Card. 8CA t is 20M.415[Y7 Ja. - 4} a`F • i . 1 .. aYi,. -II,. a at • 4. a * -w it a r 40._ ♦ ! a * 441r a .►t'.: , * 4 0. . .* y - A. i' !t :: STATE OF:CONNECTICUT.+ DEP RTME.NT OF:CONSUMER PROTECTION . ttfznown that' . ._ / ADAM Q�N Vl f..f.�"'_ ������iiiiii - 160 OLD IX/ie AN ROA D ,;: ` "SOUTH HA:ILEY MA. 01075-2632 r `„ t 4' has satisfied the qualifications required by taw and is hereby registered as a j `: 1. 4 .1 - -�HOM-IMPROVE �CONTRACTOR f' 1 Ir Registration # HTC.0575920 • i I ADAM Q fENNE'VILLE ROOFING' 1 \ * t Fti'eet re: 12/0+1/2020 I , 11 Expiiratian: It/30/2021 IR . ', Michas SegoU,Commissioner I i \ * ) 4' 4 .s 4 9 4 4 4 4y' w '4 4 19- -.41-r .."V. .,r'VI. 47, _,Z 4 4 -r'4 .4 ,4* 4 4 4► .9'* .t 4' -