23A-093 (2) RX Date /Time 09/04/2009 12:02 1 413 538 6010 N001
Sep -04 -2009 01:44 PM' Remillard Insurance 1-413-538-6010 1/1
ACORD CERTIFICATE OF LIABILITY INSURANCE OP ID LL DATE(MMIDD/YYYY)
ADAM4 -1 09/04/09
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE -
Remillard Insurance Agcy, Inc HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND QR
79 Lyman Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
South Hadley MA 01075
Phone:413- 538 -7862 Fax INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURER A: Scottsdale Ins Co.
Adam Quenneville Roofing INSURER B: Travelers Ins. Co.
Siding Inc INSURER C: aim Mutual insurance company
160 Old Lyman Road INSURER D:
South Hadley MA 01075
INSURER E:
COVERAGES
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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSRI PO ICY EFFECTIVE POLICY EXPIRATION
LTR )NSRL( TYPE OF INSURANCE POLICY NUMBER DATE (MM /0D/YYI DATE (MMIDD(YY) LIMITS
GENERAL LIABILITY EACH OCCURRENCE $ 1000000
A X COMMERCIAL GENERAL LIABILITY CLS1034980 06/23/09 06/23/10 PREMISES (Ea occurence) s 50000
CLAIMS MADE [] OCCUR MED EXP (Any one person) S 5000
PERSONAL & ADV INJURY $ 1000000
GENERAL AGGREGATE S 2000000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG 5 2000000
7 POLICY 7 JECT n LOC
AUTOMOBILE LIABILITY
B — 1 ANY AUTO BA7450L946 11 /01 /08 11/01/09 COMc SINGLEUMIT 1000000
CO accident)
ALL OWNED AUTOS BODILY INJURY
X SCHEDULED AUTOS (Per person) ")
X HIRED AUTOS
///��� BODILY. INJURY $
X NON -OWNED AUTOS c/ \ (Per accident)
,) PROPERTY DAMAGE S
(Per accident)
GARAGE LIABILITY AUTO ONLY - EA ACCIDENT S
ANY AUTO OTHER THAN EA ACC S
AUTO ONLY: AGG $
EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $
OCCUR n CLAIMS MADE AGGREGATE $
—
DEDUCTIBLE $
RETENTION $ $
WORKERS COMPENSATION AND X ITO Y LIM TS I X I '
EMPLOYERS' LIABILITY
C AWC701286101 04/29/09 04/29/10 E.L. EACH ACCIDENT $` 1000000 .x.
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYEE $ 3.000000
If yes, describe under
_ SPECIAL PROVISIONS below C, E.L. DISEASE- POLICY LIMIT $ 1000000
OTHER 1
0
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES ! EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION ,
PYNCHON SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
/� ^� ` DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS. WRITTEN
1 NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
REPRESENTATIVES.
_. A UTHO ED 4c./744 ACORD 25 (2001!08) m ACORD CORPORATION 1988
/ A l I 'fI
('„.,,,'1`..x ( 0i — i te = = ^ . ui • m /' e l ions an. tans are s
� � oar o g �
q.1 One Ashburton Place - Room 1301
,� Boston, Massachusetts 02108 .
Construction 'Supervisor License •
License CS: 70626
Restriction: 00
Birthdate: 8/2111
Expiration: 8/21/2011
Tr# 3
ADAM A QUENNEVILLE
160 OLD LYMAN RD
S HADLEY, MA 01075 -- •
Update Address and return card. Mark reason for change
' • 0 Address ❑ Renewal ❑ Lost Card
DPS -CA1 CS 50M- 07/07- PC8490 •
j itie - 6 2 , • . #, . , ', , 4 . /4
-,_ Boar. o Building' ' egulat 4ons an. • tan• ar• s
= (= One Ashburton Place - Room 1301
Boston, Massachusetts 02108
Home Improvement: Contractor Registration
Registration: 120982
" Type: DBA
Expiration: 3/25/2010 Tr# 264937
ADAM QUENNEVILLE ROOFING ::::.__:... • •
ADAM QUENNEVILLE -
160 OLD LYMAN RD
SO. HADLEY, MA 01075
- Update Address and return card. Mark reason for change.
DPS -CA1 t5 50M- 07/07- PC8490
El Address E Renewal 0 Employment Li Lost Card
Be it known that 7 , , 1.;-:-,-,- r A QUENNEVILLE r. .
1 160 OI,D L ROAD , igi
?. �nV,wY ' .1 \ t
u ; SO OTI 1, - � -` A U1075 -2632 , l ;
b 1 ` YyrAS F y � l ,
1i
i
E is certifi bythe Dep ie i � f' ti i e 4,___;.3 i . otection as a registered' 1 si .,.. ) ;:::::
-
, ,.1..:.:-:.,-,,, I, HOME IMPRO�lE ONTRA:CTOR
,:„.:::=,_4. i . ,..,..„.:,.....: , Re >� "n' =f .___,,,,,.,..:_.....,:„..„,_._,,, 7.6 ,, t . i gn za ,95920
r ; ..........
I ADAM
QUENNEVILLE ROOFING'
,
« 1
Effe ctive 12/01/2008 T .
' r Exp • ration: •"•,..,-- +,yx. a ryw ' wx :.—t:' 1 . •i i J11/3
0 9
J Farrll, Jr's, Commissroner
4.: •; ._. a - Office of lnvestigatzon1 '
• 600 Washington Stree
.. �` 'B oston, MA 02111
....t,• www. s.gov /dia
Workers' Compensation Insurance Affidavit: Builders/ ontractors /Electricians)Plumbers
Applicant Information Please Punt Legibly
Name ( Business /Organization/Individual) : fl a \ 3..0en r- ,u t� N N^,
Name \C
�J •
Address: t Ola L al-) Rcy:AA
City /State /Zip :_ ' AA • _ hi i Y 1:aU Phone #: -1 ) � L 5955
Are yo an emplo :yerr Check the appropriate box: ' ' ' Type of project (required):
1. FRI am a employer with I S 4. 0 Tam a general contracto and I 6. ❑ New construction
employees (fiill.and/or part- time).* • • have hired the sub -con. ctors
2. n I am a t proprietor or partner listed on the attached sh et. I 7 . 0 Remodeling
ship an have no employees These sub - contractors h: ve 8. [] Demolition
workin for one in any capacity. workers' comp. insuran C. g Y P tY• 9. 0 BuiTding,addition
[No workers' comp. insurance 5. 0 We are a corporation .. d its •
officers have, exercised l,rir 10.0 Electrical repairs or. additions
required.] . . .. .. . .
3. [l I am a homeowner doing all work . right of exemption per . GL 11.0 Plumbing repairs or additions
myself [No workers'' comp. • c. 1'52, §•l (4), and we ' •ve no l2.[ of repairs
insurance required_] t ' employees. [No worke .'
13.0 Other
• ' • comp. insurance requir' d.]
Any applicant dist checks box 41 must also fill out the section below showing their workers' ompcnaation policy information.
t Fiomcowners Igo submit this affidavit indica they r e,doin, g a]) work th hue vtsi. c contractots must submit a new aff indicating sucb.
tCo thaticheck this box must attached an gd'ditiooal sheet showing the m en o
une of the su. .ntractors'sad their workers' comp. policy infomratioq.
I am an ernp /pyer that is providing workers' compensation insurance for y employees: B elow is' policy and job site . . information. I •
Insurance Company Name: j 1 i �0 a v
.•
Policy # or Slf- -ins. Lie. #: kW C. 20 I . Ib'� Ces 'Expiration Date: L i'"' — c 0� 0
_ 7 r c t tag_ (t .' i � vlwe.. Ci /S ate O � ,�
Job Site Addi ess• ty p: t. �. �C Ib! v ITIon , , , 01066
Attach a cop of the workers' compensation policy declaration page (s 1 owing the policy number and expiration date),
Failure to secure coverage as required under Section 25A of MGL c. 152 c:' lead to be imposition of ciirni al penalties of a
fine up to $1; and/or•one -year imprisonment, as well as civil penaiu . in the form of a.STOP ORDER and a fine
of up to 5250.00 a day against the violator. Be advised that a copy of this • tatement may be forwar4ed.to the Office of
Investigationk of fie DIA for insurance coverage verification.
I do hereby le hfy under t pains and penalties of perjury that the info • . provided above is true and' correct
Signature: !! , `
/- .. .. . , Date: 0. i i-t - 0 {j' i . • Phone #: !x( 7rt�(r 3-47S.3 , •
Ofj u se on Do not w ite in this area, to be completed by city, o town ofc:aL
City or Town: • Permit/Li.ense #
Issuing Authority (circle one):
1• Board Health 1 Buil3Sling Departrnept 3. City /Town'Clerk 4 Electrical Inspector 5. Plumbing Inspector
6. Other ;' t •
Contact Person: I. one #:
•
'
D I C5 / 1'' '' ! v� mask. 110.1 DIJCOVER
1r 1r A
QQUENNEVILLE C
ROOFING & SIDING, INC.
160 Old Lyman Road, South Hadley, MA 01075 We Are Licensed
1 -800- NEW -ROOF • 413. 536.5955 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 Association of Western Mass. CT Registration #575920
Member of the Building & Trade Association Member of the Better Business Bureau P.P.C. 38710
Proposal Submitted To: Date Phone #'s Work:
` r74,4, (Q .. 1 r it e iz o 1 H:.` (1 Cell. r
Street; t Mail To:
City, State, \? ~
Code t Special Requirements
p q rements
6 ,4- 1/k 1'06 ` ;YJ l.»,.. k4.:,_ _,f•C,a. € .. C.,F.n,"-. (,. •
Proposal to furnish and install the following
❑ Re -Roof ,, Tear -Off ❑ Gutter
Complete Roof Preparation
all Home exterior and landscaping to be protected
® Entire existing roofing material to be removed to existing decking, including flashing, etc.
0 Site to be cleaned everyday with roll magnet debris removed at project completion
RI Deteriorated existing decking replaced at $2.89 per sq. ft.
r❑ White/ Brown 8 inch metal drip edge installed at eaves and rakes ❑ White/ Brown 5 inch for re -roof only
E] New flashing will be installed where necessary (see Special Requirements)
• Install new pipe boot flashing
JR New lead counterflashing to be cut into chimney
4 We shall acquire all appropriate permits etc. for all roofing work
Complete Roofing System
ID GAF -ELK Leak Barrier installed at all eaves to protect from ice dams (and meet codes in the north)
❑ GAF-ELK Leak Barrier installed in all valleys, around penetrations, and chimneys to protect critical areas
LI GAF-ELK Leak Barrier installed at all Rake Edges
❑ nstall (15 pd. fe Synthetic) underlayment installed over entire decking area
Shingles:
❑ "....,L-k<13 Shingles ❑ 25 year IN 30 year ❑ 50 year Color
EJ Continuous GAF -ELK Snow Country Ridge Vent-will E ehinstalled
❑ GAF-ELK ridge cap shingles
Warranty Options: („
II We guarantee our workmanship for /10 full years (see our warranty cov
We Propose hereby to furnish materials and I labor - complete in accordance with above specifications for the sum of:
(j r' 1') /f u', /
Total Sale Price $ / / -- Down` Payment $ f ,/ ,. .,✓ Upoil Completion $ L , C..
ACCEPTANCE OF PROPOSAL: The above prices, specifications and conditions are satisfactory and are hereby , accepted.
You are authorized to do work as specified. Payment will be 1/3 down upon sighing; and balance due upon completion.
Unpaid balances shall accrue with interest at 18% per annum.' Purchaser(s) will pay for all costs, expenses and reason-
able attorney's fees incurred by Adam Quenneville Roofing and Siding, Inc. to recover any sums due under this contract.
Date: i ' I + '" t Signature: %t Phone #
Date: ° < i ✓ Z�' Estimator's Signature:
Estimates are honored for thirty (30) days from above date
ATTENTION HOMEOWNERS: Please cover all personal belongings in the attic, garage or storage areas due to the
possibility of roofing debris or dust coming in through cracks of the wood. Adam Quenneville Roofing and Sidings
will not be responsible for debris or dust in the attic or storage areas.
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : 0) OU
Adam Ouenneville Roofing & Siding, in{ License Number
160 Old Lyman Road - I
Address South 4fadleu MI l ?lily` Expiration Date
Sig —. Telephone s, 3G '1 S s-
9. Registered Home Improvement Contractor: Not Applicable
Company Name Adam duantoiyille ;R & Sidi i Registration Number
160 Old . Lyman Road 3 - — 10
Address �,�Jti� tf) v o I In z/ Expiration Date
Telephone J J�.eS
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 ❑
11. -Home Owner Exemption
The current exemption for "homeowners" was extended to include Owner - occupied Dwellings of one (I) 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 b e
responsible for all such work performed under the building permit.
As acting °'. Constriction 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
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
5zr New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [Q Siding [0] Other [0]
Brief Description of Proposed
Work: S' . -V t(J 4 ( Nrvel t' � a
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 existin • housin • corn • lete the followin • :
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
as Owner of the subject
property
hereby authorize
to act on my; behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I, /( (AYY1 Qski_!vlr ouu- as Owner orized
Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my kno •gel
and belief.
Signed under the pains and penalties of perjury.
Ck' Umut
Print Name
Signat of er /Agent Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage
Open Space Footage
(L ot area minus bldg & paved
Parking)
of Parking Spaces
sill:
volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO Q DONT KNOW Q YES Q
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW Q 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 Q YES Q'
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained Q , Date Issued:
C. Do any signs exist on the property? YES 0 NO Q
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO Q
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 c plan
otnmbn
that will disturb over 1 acre? YES Q NO 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
-
Department use only
-' , City of Northampton Status of Permit:
`L,_' - Building Department Curb Cut/Driveway Permit
t � � 21 Main Street Se wer /Septic Ava
(i \ Room 100 Water/Well Availability
'' N orthmpton, MA 01060 Two Sets of Structural Plans
phone 413,-,587-1240 Fax 413 - 587 -1272 Plot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION j - SITE INFORMATION
I This section to be completed by office
1.1 PropervAddress:
�� �� Map Lot. Un
17 race ,--e-
Zone Overlay District
1 Elm St. District CB District
SECTION PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner .f Record:
S - , O ft I, . I7 Fat cCl 1 kc.41�e I >lo� "''' J14 U(ot
Name (Print) Current Mailing Address:
Telephone S 8 6 1 J 1
Signature
2.2 Authori ed Agent:
Adam Quenneviiie Hooting & Siding, ini
Name (Print) 160 Old Lyman Road Current Ma Address:
South HAriiPva Mil : 0107t, S S`t 5,� _
Sig r 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
L– I��.06
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) Check Number • // 4" /r' '
This Sect For Official Use Only
,
Building Permit Number: Date
Issued:
Signature: _
Building Commissioner /Inspector of Buildings Date
k
17 FA, ° `� �.: ' BP- 2010 -0601
GIS #: COMMONWEALTH OF MASSACHUSETTS
-CZ CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit # BP- 2010 -0601
Project # JS- 2010 - 000876
Est. Cost: $4775.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ADAM QUENNEVILLE 070626
Lot Size(sci. ft.): 13242.24 Owner: GOTTLIEB SETH G & JENNIFER N
Zoning: URB(100)/ Applicant: ADAM QUENNEVILLE
AT: 17 FAIRFIELD AVE
Applicant Address: Phone: Insurance:
160 OLD LYMAN RD (413) 536 -5955 () Workers
Compensation
SOUTH HADLEYMA01075 ISSUED ON:12/15/2009 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE SOUTH SIDE OF 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 THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
FeeType: Date Paid: Amount:
Building 12/15/2009 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo