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29-455 (10) Apr;g4-PUd U[:U3 VM KelflI I ICIVU 1101,1I ally 1--tJ.J JJV vviv AC CERTIFICATE OF LIA 1LITY INSURANCE CSR ail DATE(MMMOIYY)rYJ • ADAM -1 1 04108108 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Ramiila=a 2naurance Agcy, Inc HOLDER THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 79 Lyman Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. South Hadley MA 01075 Phone:413-538-7862 Pax:413-538-7179 INSUR ERS AFFORDING COVERAGE NAIC# INSURED INSURERA: AIR annual xna ranee emapaay INSURERB: 65t Paul /Tzaselere inaursaee Siding Ina®villa Roofing & INSURERC: Scottsdale.Ins Co. P O BOX 612 INSURER D: South Hadley MA 01075 INSURER E COVERAGES THE POLICIES OF INSURANCE,LISTED BELOW..1AVE BEEN ISSUED 10 THE INSUR NAMED ABOVE FOR THE POLICY PERIOD INDICATED,NOTWITHSTANDING ANY REQUIREMENT,TERM 08 CONDITION Of ANY CbrYTTt:4'7TOR OTHeKDOCUM NT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN S SUBJECT TO ALL THE TERMS,E(CLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY-HAVE BEEN REDUCED BY PAID CIA) POLICY EXPIRATION LTR NSR TYPE OP INSURANCE POLICY-NUMBER GATE MM100 DATE MMMDIYI. LIMITS GENERALLIAHIIJTY - EACH OCCURRENCE $1000000 C I X COMMERCIAL GENERAL LIABILITY CLS1384198 06/23/07 06123108 PL'R E.1 Eao«,rence) $50000 CLAIMS MADE XX OCCUR MED EXP(Any one person) $5000 PERSONAL BADVINJURY $1000000 GENERAL AGGREGATE $2000000 GEWL AGGREGATE LIMIT APPLIES PER: w \\ PRODUCTS-COMPIOP AGG S 2 0 00 0 0 0 POLICY M JECT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $1000000 B ANYAUTO BA745OL94607 11/01/07 11/01/08 (Ensoddent) ALL OWNED AUTOS BODILY INJURY $ X SCHEDULED AUTOS (Per person) X HIRED AUTOS 1 l BODILY INJURY g X NON-OWNED AUTOS _ I I (Per accident) PROPERTY DAMAGE $ (Par accident) GARAGE LIABILITY - AUTO ONLY•FA ACCIDENT- S ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG S EXCESSNMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR ❑CLAIMS MADE ` AGGREGATE S DEDUCTIBLE g RETENTION S g WORKERS COMPENSATION AND TORY LIMITS X ER EMPLOYERS'LIABILITY A ANY PROPRIETORIPART NER/EIfECUi1VE AWC01286101200 7 04/29/07 04/29/08 E.L.EACHACGDENT $1000000 OFFiCEWMEMBEREXCLUDED? AWC701286101200 04/29/08 04/29/09 F-.L.DISEASE-EAEMPLOYEE 51000000 Ups ,describe under SCIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $1000000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED.BY E IDORSEMENT ISPECIAL.PROVISIONS CERTIFICATE HOLDER CANCELLATION -'_- SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATETHEREOF;THE ISSUING WSURERIMLLENDEAVORTO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO 00 SO SHALL \ IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR \\\ REPRESENTATIVES - AUTHORI@ED REP TIVE. ACORD 25(2001108) RD CORPORATION 1988 3 } foaTrWoufflmg egul ions an tan ar s One Ashburton Place - Room 1301 Boston, Mass.p.chusetts 02108 Construction`Supervisor License : :..-... License CS: 70626 Restriction: 00 'Birthdate: 8/21/1971 Expiration: 8/21/2009 Tr# 3712 ADAM A QUENNEVILLE 160 OLD LYMAN RD 5 HADLEY, MA 01075 - Update Address and return car4.Magk reason for change Address. Relnewal Lost Card 'S-CAI as 5OM-07/07-PC8490 L Boar o Buildin e l g gu a ons an =andars One Ashburton Place - Room 1301 Boston. Massachusetts 02108 Home Improvement-Contractor Registration Registration: 120982 , Type: DBA Expiration: 3/25/2010 Tr# 264937 ADAM QUENNEVILLE ROOFING`', ADAM QUENNEVILLE 160 OLD LYMAN RD - SO, HADLEY, MA 01075 Update Address and return card.Mark reason for change. IS-CAI Co SOM-07/07-PC8490 E] Address 0 Renewal Employlment Lost Card +JaV�s.° .w's th',�s.yewms:w�•.s.wwrw�rre.ryrw rw=asr� awc,es +r9•• .,.f., ..:;+,....,.__�:�:>,-�.-,.•(��.�..,.`°n l,�.�,,?: ,;;,.�r:a,''6 i:r->t:.fe X-'+;T.>I r .r:,:,fi�n5.}.;`rr�,.''� "y•.?i l�,tB^,:•w.r L P�'}n=A:•� ^''Y'r 4`.I� t Q^r.1:` CC) ^:y'.�'. -^�ti;u:F:++^'+`F.?7'�''....Hr,?"'`;:r.rr.�S ^ V. -, �•� ak t ws tM t 3f i .r,f .l y S �h i ! f � f4� � .(' 't 'S .i. tt„ •, y'UcJpTirw aS ib 4 i 4++A'3 , ttd kigy'�4��,h�•S y�2b��ry£!!ir M r.t df$Y{y`2l�f S!t f L x ,4 �;'T�,]F`1 U,l�O77ha 5r2 2 x' - �t x6.,... „'• Wv1b �- M ,.h,:y•,:H.••;x4.,rJ- y.^ s 1& efrri#ef�}� ' �tii .' � Ytectlorr as'a r� iSered r 5 d i 1 .�wI.SyV;�CFE.,: yyi"'A 1. 3u- r Cr � L' �.1. a� " '6'1j' F+ :�r rye ty.,r 'r �7t'e:.,•.'r.�;,,. -1 �. .J 7rr Jk r Jf `/ � ✓ E 1 I : , s . Effe�ctjt e. 12/a'i 26 7 L� , l 1 r v �r �ratlbn.t1� 020`0 t `3 AA w V i ne uummunweutin uI 1r1 uJJUl�c t[Jecca Department of Industrial Accidents Z Office of Investigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LeLribly Name(Business/Organization/Individual):. Address: l(,,D W Lw frn RCKA City/State/Zip: LC`)S Phone#: S95+ Are an employer?Check the appropriate box: Type of project(required): I. I am a employer with j 5 4. ❑ I am a general contractor and 1 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.$ ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL I I.El Plumbing repairs or additions myself.[No workers'comp. c. 152,§I(4),and we have no 12. Zoof repairs insurance required.]t employees.[No workers' I3.❑Other 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 hue outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name: ) Policy#or Self-ins.Lic.#: W �l�J I � Expiration Date: t✓�r / f� Job Site Address: td C I~E'' s V te-1i✓ (/r, City/State/Zip: rhir f-n C e= MA©/06,. 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 t pains and penalties of perjury that the information provided above is true and correct: Signature:_ Date: Phone#: (r 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#: WA%, �AA�AW QUENNEV1111LLE ELK4 ROOFING & SIDING, INC. The Premium Choice- 160 Old Lyman Road, South Hadley, MA 01075 We Are Licensed 1-800-NEW-ROOF * 413-536-5955 Insured Email:info @1800newroof.net Website:www.1800newroof.net Factory Trained MA Construction Supervisors Lic.#070626 MA Registration#120982 Factory Certified Installers Member of the Home Builder's 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 r'lrs��, Cam. V? a 61 Cell: 61'13) ac' Street Mail To: City,State,Zip Code^ Special Requirements Proposal to furnish and install the following (110) ❑ Re-Roof [R Tear-Off ❑ Gutter / /Pi�N� Complete Roof Preparation /fit/ Home exterior to be protected by tarps and plywood , �If"�'� `^ �,�PG��nF.c c.cv�t� Shrubs, landscaping,trees to be protected f(,,�/r ® Entire existing roofing material to be removed to existing decking, including flashing, etc. [�Site to be cleaned everyday with roll magnet debris removed at project completion [� Deteriorated existing decking replaced at$2.50 per sq.ft. White rown inch metal drip edge installed at eaves and rakes ❑ White/Brown 5 inch for re-roof only ® New flashing will be installed where necessary (see Special Requirements) M Install new pipe boot flashing N We shall acquire all appropriate permits etc.for all roofing work Complete Roofing System 0 ELK Leak Barrier installed at all eaves to protect from ice dams (and meet codes in the north) ❑ ELK Leak Barrier installed in all valleys, around penetrations, and chimneys to protect critical areas P 15 pd. reinforced underlayment installed over entire decking Shingles: c- a ELK Prestique°Series a 30 year ❑ 50 year Color J��� l✓�rc� ❑ Nailable ridge vent will be installed [� ELK ridge cap shingles Warranty Options: [& We guarantee our workmanship forl9 full years ❑ ELK10-Year Umbrella Coverage Limited Warranty upgrade. ❑ ELK15-Year Umbrella Coverage Limited Warranty upgrade. VISA We Propose hereby to furnish materials and labor-com9ldie in accordance with abbve specifications for the sum of: Total Sale Price $ LYK 2__ 0 Down Pay dent$ /S Uon Completion $ 3 70 ACCEPTANCE OF PROPOSAL:The above prices,sp cifications and conditions fe satisfactory and are hereby accepted. You are authorized to do work as specified.Payment 'will be 1/3 down upon,si ning,and balance due upon completion. Unpaid balances shall accrue with interest at 18%per anrium`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: C 4s Signature: % Phone# %/3 5-K(' _. C 7.3 Date: (/ �U Estimator's Signature: ��-�/ Estimates are honored for sixty(60)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. E., 7; -....: :N�IITr v rry':fit i'R*-rF k5�� flNB ( � T4U ;TI�OM SURr1lICfS� ^. 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder Adam Quennevi♦le Roofing&Siding, Inc. License Number 160 Old Lyman Road cy Address Expiration Date Signature Telephone Re ste FIEND!Wn ov me"n"'fonfr5a +^ Not App�lircable�y❑ Company Name Adam uennevr oo ng g. Inc. Registration Number c 160 OW Lyman Rroad 3—.,�•Jr"'' Lo Igh Address �,eyrli�A _ Expiration Date Telephone 524 :17 7: Cp ..�. ......_..._........._ _ ........0 r..-::_ .,•-v.:.•n ..err. r.'r:-. rv!??_:Yx:r _'3':::v.:i! k:ii ;r..; -'£ir5.. liy..iir5i:ir - ._��... �c�t�� �€�"�� :��P�� -�''•��,�ad�p�l?�jk .:r G.r.r:a,,,.:;i'rr�x wis :.-t;i;r•t >,i a• , i f SEC10'F� O=W,�R ES' 011PEISAI,O;N1SURtC�EFFIDAI/fTti(Mh1L c 152, 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...... ❑. The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or:two(2)families and to allow such homeowner to engage an individual for hire who does not-possess a license,provided that the owner acts as supervisor. CMR 780, Sixth Edition Section 108.3.5.1. Definition of Homeowner:Person(s).who own a parcel of land on which he/she resides or intends to reside,on which there is, or is intended to be, a one or two family dwelling,attached or detached structures accessory to such use and/or farm structures.A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner" shall submit to the Building Official,on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed .under the building permit. As acting Construction Supervisor your presence on the job site will be required from time to time,during and upon completion of the work for which this permit is issued. Also be advised that with reference to Chapter 152(Workers' Compensation) and Chapter 153 (Liability of Employers to Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated, you may be liable for person(s) you hire to perform work for you under this permit. The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City.of. Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature y; r �,'r I1 n�n - v a t;�ulll jn�,e k2s -v 1 r� ;LSCyG. I:OIa" V9 $ ..r R Ucs{(„ #.1'Fe .:. rdlPtka+ 2,. ' . .. ..: Nk9f"�5ja;"-' ..... w.�wvsdl;l.;lr- New louse ❑ Addition ❑ Replacement Windows Iteration(s) ❑ Roofing 1. Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ] Brief Description of Proposed Work: !'1 e-kn O v B ®© 0*16y Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative 0 Renovating unfinished basement Yes No Plans Attached Roll 0 - Sheet 0 tip, a d 01,MHOM t ex+9-ti g r rn-�" ramp ye e "e 11o< n .. 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. Masch,eck 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 1. 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, ® / �'� as Owner/Authorized Agent hereby declare that the statements and information on the foregoing appileation are true and accurate, to the best of my knowledge and belief. Signed u der the pains and penalties of-perjury. J/ Print Name w 6 - 1 Signature of Owner/Agent Date y'of Northampton $uil ' 'ng Department 21Main Street Rborn 100 , a' ampton, MA 01060 phoy>-e"413.587.1240 Fax 413-587.1272 PLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING a SECTION � - SITE�,17�FO�IYI�TIAN� . . , �,M 'compF"ete'"d;�b.s;offrce. �,�1 1.1 Property Address: rs 1 ' Zon ,a v i;1 "' Dist .!•ct ,,�� � ��'� t ,�EIrr�St-District �" ; V �• C$�D:rsjr cf �.���^� ,�r a SECTION2:T PROA,ERT�Yti rOi} ftVES1r�tPIAUTHQIZED`r� Ef+IT 2.1 Owner of Record: Name(Print) Curren Mail'ng.Ad mess: r C n�� A. yl � 8 - v 735° �lo Telephone Signature 2.2 Authorized Agent: Name(Print) current Mailing Address: Signature Telephone ' i. '5- wPw� iaiRt�•�jXY :!�y!,w i n n'o43I.+A!' • Sfi rid 5 r+ 5>= ioN 3 rE�aT,lllA'15ED C:ON�f �CSY;r Item Estimated Cost(Dollars) to be3Fffreial Use dn{y completed b ermit app licant 1. Building Q' 7C� (a') Building Permrt Feed r 2. Electrical (b) F:r- ated,Totah'Oost:of Censtructiorr;from�:�6 .. _ 3. Plumbing building Permit-Fe'e 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 +4 + 5) � .Check,Number fL This Section;For Offi:Jbi l Use;Only. Bulldng'Perrr�rt Number Date Issued: f - � i :•: -- 1 r� r Building.Cofrimissronsr/In,SPector„oi Biildmgs; Daze: 4 i. VR BP-2008-1166 GIs#: COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category:roofing BUILDING PERMIT Permit# BP-2008-1166 Project# JS-2008-001717 Est. Cost: $4870.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Adam Quenneville 120982 Lot Size(sq. ft.): 10018.80 Owner: ZANVETTOR MELISSA Zoning: URA Applicant: Adam Quenneville AT. 64 CRESTVIEW DR Applicant Address: Phone: Insurance: 160 OLD LYMAN RD (413) 536-5955 () Workers Compensation SOUTH HADLEYMA01075 ISSUED ON.6/24/2008 0:00:00 TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE 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 6/24/2008 0:00:00 $25.0012665 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo