35-031 (15) BP-2021-2095
782 RYAN RD COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
35-031-001 CITY OF NORTHAMPTON
Permit: Exterior Res
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
Permit # BP-2021-2095 PERMISSION IS HEREBY GRANTED TO:
Project# ROOF Contractor: License:
ADAM QUENNEVILLE ROOFING &
Est. Cost: 13999 SIDING INC 070626
Const.Class: Exp.Date:08/21/2023
Use Group: Owner: KAZAKIEWICH ROGER A&VALERIE J SULLIVAN
Lot Size(sq.ft.)
Zoning: WSP Applicant: ADAM QUENNEVILLE ROOFING &SIDING INC
Applicant Address Phone: Insurance:
1600LD LYMAN RD (413)536-5955 0
SOUTH HADLEY, MA 01075
ISSUED ON:10/27/2021
TO PERFORM THE FOLLOWING WORK:
ROOF
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter: Footings:
Rough: Rough: House # Foundation:
Driveway Final: Final: Final: Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY TIE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Signature:
. >2 . 3,21I
Fees Paid: $40.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
Department use only
g,�rrrsrr City of Northampton �. Status of Permit:
,, � 11 Building Departments' C /-,,curb Cut/Driveway Permit
212 Main Street,/ 0 4i'. r/Septic Availability
, f Room 100�� l �� II Availability
e i -`' Northampton, MA q' I•I (4 Two ets of Structural Plans
phone 413-587-1240 Fax • 1272 �/ PI Site Plans
'�ti�, ther Specify
iyq,,,F
APPLICATION TO CONSTRUCT, ALTER, REPAIR, REN gt** - DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: This section to be completed by office
782 Ryan Rd Florence Ma 01062 Map Lot Unit
Zone Overlay District
Elm St. District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Roger Kazakiewich 782 Ryan Rd
Name(Print) Current Mailing Address: 413-539-0619
see contract
Telephone
Signature
2.2 Authorized Agent:
Adam Quen Seville 160 Old LymanRd South Hadley Ma 01075
Name(Print Current Mailing Address:
413-536-5955
Signatu Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building 13 999 (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from (6) .
3. Plumbing Building Permit Fee ft.Cip
4. Mechanical (HVAC)
5. Fire Protection _6. Total = (1 + 2+ 3 +4 + 5) 13,999 Check Number L 1 G W
This Section For Official Use Only
.,��,� (/ i Date
Building Permit Number: �J5 Issued:
Signature: /7E17
AO 27- ZCZ. )
Building Commissioner/Inspector of Buildings Date
operations.aqrs @ 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 L: R: L: R:
Rear
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 DONT KNOW x YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW x YES
IF YES. enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW x 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? YE5 NO x
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,gradin ex avation, or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YE NO
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 ❑ Replacement Windows Alteration(s) ❑ Roofing )(I
Or Doors El
Accessory Bldg. ❑ Demolition ❑ New Signs [El] Decks [El Siding a71] Other[[1
Brief Description of Proposed New roof, remove&replace existing, install new drip edge, ridge vent, ice&water barrier, pipe boot flashing
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
T Roger Kazakiewich
, 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 10/21/2021
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 cv...1
10/21/2021
Signature of Owner/Agent Date
SECTION 8 -CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: Adam Quennville CS-070626
License Number
160 Old Lyman Rd South Hadley Ma 01075 8/21/2023
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
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 X No 0
City of Northampton
Massachusetts _..
s-q. DEPARTMENT OF BUILDING INSPECTIONS i
JJJttt
1t L
�� �` ; 212 Main Street •Municipal Building �
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:
782 Ryan Rd 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)
Signature of Permit Applicant or Owner4 at
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.
10/21/21, 12:26 PM Roger Kazakiewich-1634742604408.jpg(2550x3549)
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160 Old Lyman Road•South Hadley•MA 01075 We are Licensed
1.800.NEW.ROOF • 413.536.5955 Fully Insured
Email:jnfo(ral$QOnew(44i.0tt Website:www.1800newrootrnt Factory Trained
MA Construction Supervisors Uc.8070626 MA Registration#120982 Factory Certified installers
Member of the Home Builder's Assoc.of Western Man. CT Registration a575920
Member'of the Building a Trade Assocutbn P.r.0 3E710
Proposal Submitted To: Date: Phone 8's: C:
Roger Kazakiewich 9/29/2021 H: w:
Street: Email:
782 Ryan Rd.
City,State,Zip Code: Special Requirements:
Northampton,MA 01060
PROPOSAL FOR'
GARAGE OTHER
RECOVER
Layers: 0 2 3 4 Plywood Included:Yes QC)
Tear off SLATE or SHAKES
COMPLETE ROOF PROTECTION SYSTEM:
ii We shall acquire appropriate permits for all work
it Home exterior and landscaping to be protected
i Strip existing roofing to existing decking with full inspection DO NOT DO:
All project waste shall be removed by dumpster(dumpster for contractor use only)
9 Install Ice&Water Barrier at all eaves 3' f�' ralleys,chimneys,pipes and skylights
4t Install(151b.felt Ar"frESOundertayment over remaining decking area
ii Install Metal drip edge at eaves and rakes B�"/5")enal brown)
it Install manufacturer's starter shingle on all eaves and rake edges
x Install new pipe boot flashing/vent accessories
x Install ridge vent-Snow Country/Cobra rolled/4'Baffled/sJ
Shingles:(standard 6 nails per shingle)
GAF Timbadlne HDZ Shingles Color:To 8e Determined
GAF Tanbedare HOZ Ridge cap shingles
Warranty Options:
>c We guarantee our workmanship for 10 full years
GAF System Plus Warranty
GAF Golden Pledge Warranty
Chimney Options:
El Lead Counter flashing :7 Water Seal&Tuckpoint Li Rubberized Crown L l Cricket
Mason needed(customer provided)
Additional material and labor charges may apply.
S Deteriorated existing decking will be replaced at$5.99 pe tS....and dimensional lumber at$7.00 per linear ft.,
after full inspection. Customer Initials: j`(�
We propose hereby to Furnish masorieh and labor-complete a,aaordnrz with thieve specifications for the sumo( Total Due:IS 13,999.00 )
ACCEPTANCE on PROPOSAL:me above prices,specifications and conditions are Down Payment:($ 4,999.00
sadsfarsory and are hereby accepted.You are authorized to do work as specified. 2"r Payment at Start lob:IS 4,500.00 )
Payment will be 1/3 down at signing,1/3 at start of lob,and balance due Balance Due Upon Completion:($ 4500.00 )
upon oomW0
Date: /0Signatureay�+`x9
Date:9/29/2021 Estimator:(Print Name)-S• Miyi1I8r (Sign Name).:.. 04'at.K./1'rrrrX,��L
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 Quen Roofing will not be
responsible for debris or dust in the attic or storage areas. Customer Initials'
https://www2.marketsharpm.comNF_Attach/850/76050/Roger Kazakiewich-1634742604408.jpg 1/1
A ® DATE(MMfDOIYYYY)
A D CERTIFICATE OF LIABILITY INSURANCE
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 CUMIALT Sarah Pram()
,NAME; •
Clayton Insurance Agency, Inc. PHONE (413)536-0804 •FAX a1n174-N,a
Y INC,No.EA;
(A C,Ng);
1649 Northampton Street AOEPRE33;spremoQalaytoninsurance.net
P. O. Box 9E19 INSURER(S1.AFFORDING COVERAGE NAIL II ,
Holyoke MA 01041-0989 INSURERA:Nautilus_Insurance.Company .
INSURED INSURERB:Arbella Insurance Co.
Adam Quenneville Roofing b Siding Ina. INSURERC:AIM Mutual Insurance Company
160 Old Lyman Road INSURER D,
South Hadley, MA 01075 INSURERE: .
INSURER F
COVERAGES CERTIFICATE NUMBER:2021 MISTER REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE f50UCY PERIOD
INDICATED NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERI/IFICATE MAY SE ISSU50 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 -ADOL-SUER— POLICYEFF POLICY EXP LIMITS
17p ,}TYPE OF INSURANCE INRT am POLICY NUMBER -,JMM(DD/YYYY) IMMIDDh'YYYI
X COMMERCIAL GENERALUABIUTY EACH OCCURRENCE $ 1,000,000
fr�-v�-l� DAMAGE TO RENTED 100,000
A CLAIMS•MADE I C— 1 OCCUR PREMISES lEp oon i no➢) 3
NN1.233313 6/23/2021. 6/23/2022 MED EXP(Any one person) S 5,000
PERSONAL&ACV INJURY S 1,000,000
GEN'L AGGREGATE LIMITAPPUESPER; GENERAL AGOR EGATE S 2,000,000
IOThER:
f?RODUCTS-CAMP/OPAOG S2,000,000
LOC n4 Y
S
AUTOMOBILE LIABILITY .COmeINE0 SfNGLE LIMIT ; 1,000,000
(Ea irptllmt)
ANY AUTO - BODILY INJURY(Per person) i
B
ALL OVVI•!EO %_ SCHEDULED
AUTOS 1020107093 6/23/2021 6/23/2022 BODILY INJURY(Par accident) S
AUTOS
NON•OWNED PROPERTY OAUAGE It
HIRED AUTOS X AUTOS .IP°r alcciding
IJNINSIUNDERINSMOTORI67S $ 100,000/300,000
X UMBRELLA Loa OCCUR EACH OCCURRENCE ,S 5,000,000
A EXCESS LIAR CLAIMS-MADE AGGREGATE 5 5,000,000
DEO RETENTION 5 AN1242102 6/23/2021 6/23/2022 $
WORKERS COMPENSATION X SPAfUTE ER
AND EMPLOYERS'LIABILITY YIN
ANY PROPRIETORIPARTNER/EXECUTIVE El EACH ACCIDENT 4 1,000,000
OFFICER/MEMBER EXCLUDED? I Y I N IA
C (Mandatory in NH) AWC400701266I 4/29/2021 4/29/2022 E.L.DISEASE-EA EMPLOYEE $ 1,000,000
DSsC Pbe OFO ERATIONS below E.L DISEASE POLICY LIMIT S 1.000 000
_
I
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If man space Is required)
Tor informational Purposes Only
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES SE CANCELLED BEFORE
Adam Qnenneville Roofing Siding Ina THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
160 Old Lyman Rd
South Hadley, MA 01075
AUTHORIZED REPRESENTATIVE
Michael Regan/MT 722.4"-/ P
1
ID 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
INS025(201401)
The Commonwealth of n'assacnusecrs
�.. Department of Industrial Accidents
== Office of Investigations
= 600 Washington Street
OM~f r Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information nn Please Print Legibly
Name (Business/Organization/Individual): Mean n 0.0erIeVi t t�t l�Ut l�� tP
Address: (LO 0 A r-7 vv,a,
City/State/Zip: 5001,\ koAlt..d (11A Oio15- Phone#: !3 -53(. 5 q55—
Are you an employer?Check the appropriate box: Type of project(required):
1K[am a employer with 15 4. ❑ I am a general contractor and I 6. New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. employees and have workers' 9 El Building addition
[No workers'comp. insurance comp. insurance.:
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12,_Roof repairs
insurance required.]t c. 152,§1(4),and we have no
employees. [No workers' 13.0 Other
comp. insurance required.]
*Any applicant that checks box It l 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: A 1 M v t vekk J,t15 t9✓.. ' Lip(
if#or Self-ins.Lic.#: A W C�0O-1 0 I ` -31. ( Expiration Date: Li/�1I a
Job Site Address: 1 `1 r(-7 City/State/Zip: rico(eilt-(' 0‘4 O I f.C. 1
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that 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 aim and penalties of perjury that the information provided above is true and correct.
Signature:
Date: /d 3/ )/
Phone#: '1 13 - ✓3c - 59 5
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):
I. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
ViC Division of Professional Licensure
. .- - Board of Building Regulations and Standards
Const.‘mitt$414kIpprvisor
CS-070626 pires:08/21/2023
ADAM A GLIEPAIEV''u 6110;, C''1.• ,-,:
160 OLD LYr4N ,el v::i ,,, f::
• SOUTH HAOLV Mk./..; ,r; " :" •,,
) -, --e. ; , 4 'i A. 3
, ft
Commissioner da.8QA K bjEmti,.....
P52e (620470nowevectid olo//iaddaduaea
Office of Consumer Affairs and Business Regulation
1000 Washington Street- Suite 710 .
Boston, Massachusetts 02118
Home improvement Ccintractor Registration
Type: Corporation
Registration: 191093
ADAM QUENNEVILLE ROOFING AND SIDING,INC. Expiration: 03/22/2022
180 OLD LYMAN RD.
SO.HADLEY,MA 01075
Update Address and Return Card.
SCA i 0 20M-05/17
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1 illik•
CONNECTICUT + DEPAR1'MENT OP CONSUMER PROTECTION
i i ti4);
:Be it known that ,
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ADAM QUENNEVILLE
. 44\
160 OLD LYMAN ROAD " . • 1 9s>.:..A.\I •
SOUTH HADLEY, MA 01075-2632
. ii V•
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,
;
.•• .:-:'
has sanstied the qmtlitications required by law and Is hereby metered as
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HOME IMPROVEMENT CONTRACTOR i L.A..,..,...; '
1.,,,..:
..„;
Registration # HIC.0575920
• I ..:A.
ADAM QUENNEVILLE ROOFING
: -...
Effective: 12/01/2020
. .;
.., 1 14
Expiration: 11/30/2021 it ..g.„‘"
Michelle Seagull.Commissioner
I r .4
•..
, epler411e".•, , 7— - - P.. i 7 P