18C-113 186 JACKSON ST BP-2017-0350
GIS#: COMMONWEALTH OF MASSACHUSETTS
Man:Block: I8C- 113 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-2017-0350
Project# JS-2017-000577
Est. Cost: $14943.86
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ADAM QUENNEVILLE 070626
Lot Size(sq.ft.): 34412.40 Owner: JOHNSTON KATHRYN L
zoning: URB(99)/ Applicant: ADAM QUENNEVILLE
AT: 186 JACKSON ST
Applicant Address: Phone: Insurance:
160 OLD LYMAN RD (413) 536-5955 O Workers
Compensation
SOUTH HADLEYMA01075 ISSUED ON:9/74/2076 0:00:00
TO PERFORM THE FOLLOWING WORK:REMOVE EXISTING ROOF MATERIAL AND
INSTALL NEW ASPHALT SHINGLE SYSTEM
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:
FeeTvpe: Date Paid: Amount:
Building 9/14/20160:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
De agemtus***
City of Northampton StatusofpemNt.
Ft) Building Department
44-: =-- 212 Main Street
Room 100 WW1
14 2016 Northampton, MA 01060 Tw Sets
on 413-587-1240 Fax 413-587-1272 Ptat ite
r. c9L1 VG NS O81ei Sptaty
. _ MAG1.Sb
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
186 Jackson St Map Lot Unit
Northampton, MA 01060 Zone Overlay District
Elm St.Madet CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Kathryn Johnston 186 Jackson St Northampton, MA 01060
Name(Print) Current Mailing Address:
See Contract 413-695-1157
Telephone
Signature
2.2 Authorized Agent:
Adam Quenneville 160 Old Lyman Rd. South Hadley, MA 01075
Name(Print) 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 (a)Building Permit Fee
$ 14,943.86
2. Electrical (b)Estimated Total Cost of
Construction from(6)
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection '/ ,/.p/
6. Total=(1 +2+3+4+5) $ 14,943.86 Check Number 3) g5lett 7
This Section For Official Use Only
Building Permit Number. — Date
Issued:
Signatur- %,c/
Building Commissioner/Inspector of Buildings
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
(Lot area mmus bldg&paved
parking)
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW O YES O
IF YES, date issued:.
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW ® YES O
IF YES: enter Book Page: and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW O YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained O , Date Issued:
C. Do any signs exist on the property? YES O NO O
.. ......... ..... .
IF YES, describe size, type and Location:
D. Are there any proposed changes to or additions of signs intended for the property? YES O 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 O NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION S-DESCRIPTION OF PROPOSED WORK(check all applicable}
New House ❑ Addition ❑ Replacement Windows Alteration(s) D Roofing
Or Doors ❑
Accessory Bid?? 0 Demolition ❑ New Signs i0} Decks [O Siding[❑j Other[CI)
Brief Description of Proposed
Work: Remove existing roof material and install new asphalt shingle system.
Alteration of existing bedroom Yes X No Adding new bedroom Yes X No
Attached Narrative Renovating unfinished basement Yes _ X No
Plans Attached Roil -Sheet
5a.N 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?a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I Kathryn Johnston as Owner of the subject
property
hereby authorize Adam Quenneville
to act on my behalf, in all matters relative to work authorized by this building permit application.
See Contract 9(1 IRA
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 �y
rrrnvv'" „ 9 /9h 1p
Signature of Owner/Agent Date
SECTION B•CONSTRUCTION SERVICES
0.1 Licensed Construction Supervisor Not Applicable 0
Nesta o1 License Holder
Adam Quenneville CS 070626
License Number
160 Old Lyman Rd. South Hadley, MA 01075 8/21/2017
Address „ Expiration Date
413-536-5955
Signature Telephone
0,Registered Herne Improvement Contactor: Not Applicable ❑
Adam Quenneville 120982
Cempanv Name Registration Number
160 Old Lyman Rd. South Hadley,MA 01075 3/25/2018
Address Expiration Date
Telephone 413-536-5955
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.a. 152,§25C(6l)
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 ❑
11. - Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwettines 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
a supervisor.CMR 7110, 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 Al 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(%)
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
l�_ � �' .AVM\ T
QUENNEVILLEWilmer of eheeata
ROOFING Nr SIDING Iv WINDOWS TORCH AWARD
160 Old Lyman Road • South Hadley, MA 01075
1.600.NEWROOF 413.536.5955 Clalms.AQRS@gmall.com
MA Construction Supervisors Uc.#070626 MA Registration#120982 CT Registration#575920
HOME EXTERIOR AGREEMENTl
t +
Name k r k 0 k Date G" a 1, Ins. co w'cc 7 1+ t Iairn# 00S aggt7k71
Add s r Ph Fx
a iS• xa Staff Adj. ) ,
Phone #'s H _. c Lin .
-- S' l Ind. Adj. �/i)r %cLA Pelb
Email
Proceeds l/ Roo "n• M. e '.Is
Roofing ._... $ iy( t �,D — Brand of Shingles - ;.or .. e -,....
Siding $ Syle of Shingles warn! r
Gutters _ $ Sq.of Shingles• 4: MOP Ridge Cap _. .�'fs
_ $ Tear Off: yes a no• O 3
' rI 1, Undedayment,. is rS Ridge Vent al J
TOTAL $ f i ) Leak Barriern.,/ ..•
y t�
Drip Edge, nci_Alumi itiitltn-•rown LF u+
Ati supplements approved by the homeowners insurance company are to be
thea
Included into the Total of the contract agreement and must be paid to Adam Fleshings r
Quenneville Roofing&Siding,Inc. Permits Furnished ]j6 nails per shingle)Decking$ C3, /sheet
Homeowner's Mrdata:__
ALL Checks Payable to Adam Quenneville Roofing&Siding,Inc. We will pick up all debris Throughout the building process.We
We will roll your yard with a magnetic roller.All debris will be
+e $ s removed, hauled away.and recycled whenever possible.
Deductible Chock: t
IIrnom Client) dare I Chock ft g gAmountSld/ln() Materials
First Insurance Draft 0107/16 (111150%c-
i 1 j5$ 1 Z 5( Brand of Siding i//// '�: ._.....
{cmCeaa) Oho*it a5,wm Style of Siding Dutch Laps Clapboard❑
�t (d1 / Color / ,d
Supplement Draft: $ 7! -6`5.S Amount of Siding a
(Iron'ceom) Dare Check*ex �nnwum House Wrap yes❑ gu(2tel Report yes l7 no
Fascia LF .7/312 Color:_
Upgrade Payment: Col
Soft SF_....._ _ or
(hoTCPomi Oats • Checks Amount Eaves %Vented %Solid lla Rakes Solid
Gutters & DoSnspouts
Aluminum,,lLF a - n e ede
Company's Limited Warranty:2 years on full replacement contracts and Color Lill ' Downspouts r x 3',3"x 4'0
repair contracts.No warranty exists until this contract Is paid in full. Leaf Protection .4/24-
contract is contingent upon insurance company approval and limited to the Job Details
mount and scope of that approval.Customer agrees that Adam Quenneville v
goofing e Siding,mpInc.will perform all horns of exterior ete approved the O Chi- v � s
upon
eane above.Any additional out of pocket expenses must be O
igreed upon before work begins. Homeowner's MA �. -
leneral Contractor:Homeowner acknowledges Adam C en vflle yi a
-
ioefin4&Siding,Inc.as a general contractor and as sue k�III be entitled fa A\ i s
0%overhead and 10%profit, as allowed by Insurance standards. iffi lC !l MiltST,
twice of Cancellation:You the customer,may cancel this agreement at any
me prior to midnight of the third business day of this agreement.
sea reverse side for Notice of Cancellation and Explanation of this right.)
Homeowner's krit�
. WAMPUM 0yl7lrb Q liir
� 0747
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c sim7emfoagreemern —..—..... Dore , m.xc.....rewamo-m o.a
— da., .- Iaaamememiir Management Appocrat Cats
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This contract is subject to final approval from authorized management of Adam Quenneville Roofing &Siding, Inc.
Adam Quenneville Rooting&Siding, Inc. reserves the right to deny any contract within 48 hours of the date on this contract.
If contract is denied all monies paid by customer shall be returned within 48 hours of the date on this contract.
This contract consist of this page and the reverse side of this pages and Shall be considered the entire contraci by the panes Involved
ACO o® CERTIFICATE OF LIABILITY INSURANCE 6TEeffeZo to
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
SELOW. 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(les)must be endorsed. N 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 CONTACT Melinda Raraknla
NAME:
DOSS & McLain Insurance Agency PHONE fttY. (413)534-7355 FAX
JtiL t+a3I.53e-a2aa
1767 Northampton Street g s,InkartektantOae9mC lain.CoA
P 0 Box 1128 INSURER(S)AFFORDING COVERAGE _ NAIC p___
HolyokeMA 01041.1128
INSURER Nautilus Ins Company
INSURED
INSURERBl IM MULn81 Z96 CoL' _
Adam Quenneville Roofing & Siding Inc INSURER C:
160 Old Lyman Road INSURER O:
INSURER E: __ _
South Hadley MA 01075 INSURER F: !
COVERAGES CERTIFICATE NUMBER:CL1662403220 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 WIICH 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.
)NRR - ADDLIBUSR - • PoIICY FF I POLICY EXP r"
LW
EW
E OF INSURANCE me)l yry0I POLICY NUMBER IMM'DO((WY) (MWDDAYYY11 LIMITS
X COMMERCIAL GENERAL LIAOILITY I [ I j EACH OCCURRENCE - 1,000,000
—- rbAM E TO ReNTLD
A ( iCtAIMSMADE X OCCUR ) 1 199,000
:,ME SESSEeor*pe! cel IE
I NN665342 Ill 6/23/2016 6/23/2017 MED EXP(Any one person) S 15,000
I _..
r _ PERSONAL S AGV INJURY 'E 1,000,000
•GENL AGGRLCATE LIMIT APPLIES PER GENERAL AGGREGATE !.S 2,000,000
PoLN'T,...--1,,,_ L_IOC PRn 1 IS COMP1OPAGO $ 2.000,000
__._.
11 I
OTHER. Employee Bene6IS 5 ;.,800 000
I AUTOMOBILE LIABILITY , 'COMBINED SINGLE LIMIT $
LER accident)
ANY AUTO 9001 YINJUR (Per person) 5
— ALL OWNED , SCHEDULED ' BODILY INJURY(Per occident) S
'�_ AUTOS AUTOS
- HIRED AUTOS NOM-0WNW 'PROPERTY DAMAGE 5
AUTOSI :(Ce:acC
j I j I UMednsured m610tt161 split S
I UMBRELLA LIAR I_ OCCUR EACH OCCURRENCE: $ 1.000,000
c X.EXCESS LIAe_ X i MA
CLAIM& DE' 'AGGREGATE $
DED 1$ RETENTIONS LD,OOB 61ID3062R I S/13/2016 8/13/2017
WORKERS COMPENSATION 1 I X PER ^
AND EMPLOYERS'LIABK51' ._STATUTE ERE
ANY PROPRIETOR/PARTNER/EXECUTIVE , - 7• (I EL EACH ACCCENI S 1,000,000
OPFlCER,MEMBER EXCLUDED, YJ NIA',
D - - - —
iMeMetorylnNm • AWC400701,2S61-2016A .. 4/29/2036 I 4/29/2011 1 Ey.DISEASE EA EMPLOYEE S 1,000,000
I9 pIPTION PO
IOESLRIPTIONQFUPERATIONS Deipw ' '!EL 05EASE.POLICY LIMIT 1,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES(AGGRO 101,AEGBioeal Remarkk SebeiAe,may be attached If more space N r quinas
Certificate holders axe additonal insured OA the above captioned GL policy) subject to policy forms,
conditions, and exclusions. Adam Quenneville, as an officer, is excluded from the Workers Comp policy.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTRRVE �J�/ ✓._</ +T,� /
M Karakula/MINDY / e ' t_
m 1888-2014ACORD CORPORATION. All rights reserved,
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
INS025.tr;4 n
The Commonwealth of Massachusetts
l� r6�1 Department of industrial Accidents
- el' I Congress Street, Suite 100
217/ Boston,MA 02114-2017
.%/5
2114-2017
nwww.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/OrganizatiorJmdividual): Adam Quenneville Roofing &Siding Inc.
Address: 160 Old Lyman Rd.
City/State/Zip: South Hadley, MA 01075 Phone#: 413.536.5955
Are you an employer?Check the appropriate box:
Type of project(required):
1.®I am a employer with 15 employees(full and/or pan-time).'
7. ❑New construction
ED I am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling
any capacity_(No workers'compinsurance required.]
3 l am a homeowner doing ll work mselt[No workers'compinsurance re9. ❑Demolition
4.0 1 am a homeowner and will be hinn contractors to conduct all work on my10❑ Building addition
gpmperty. Iwill
ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions
proprietors with no employees. 12.0 Plumbing repairs or additions
5.n 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:
6.0We are a co oration and its officers have exercised their right of exemption 14.❑Other
T € P Oer MGL e.
152,41(4),and we have no employees.[No workers'comp_insurance required]
*Any applicant that checks box al must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they arc 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 halo
employees. lithe subcontractors have employees,they must pros ide their workers'comp.policy number.
lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: AIM Mutual Insurance
Policy#or Self-ins.Lic.#: AWC4007012861-2016A Expiration Date:te4/29/2017
lob Site Address: I, Sift r ) not sty-1 - City/State/Zip:1�\QY an.expiration date). a(CUL)
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 and nalties of perjury that the information providedt
above is true and correct.
9 Signature: ( r'� Date: 19
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):
I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
am Massachusetts Department of Public Safety
Board of Building Regulations and Standards
License: CS-070626
Construction Supervisor yy"
ADAM AQUENNEYILLE <"'y
ISO OLD LYMANRD
SOUTH HADLEY MA
N1.z CA_. Expiration:
1/ �L Commissioner / / 08/41([017
em` H�Jle (./rib,7>ioi/torn/a r jn iltia.i,irerl/rr.1r'//i
Office of Consumer Affairs and Business Regulation
e 10 Park Plaza - Suite 51.70
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration 120982
Type: OSA
Expiration' 3/25/2018 Era 419291
ADAM QUENNEVILLE ROOFING
ADAM QUENNEVILLE
160 OLD LYMAN RD
SO. HADLEY, MA 01075 _—_... —_ _ _
Update Address and return card.Mark reason for change.
SCA0 zwno u+i Address f-.. Renewal i� Employment `,1 Last Card
�.' ,' x ::, °«' x Por/ S ' R1 it s •Cit u i ,.,
,""a..s
STATE OF CONNECTICUT + DEPARTMENT OF CONSUMER PROTECTION
Re it known that M
ADAM QUENNEVILLE
160 OLD LYMAN ROAD r '
SOUTH HADLEY, MA 01075-2632
is certified by the Department of Consumer Protection as a registered
411
HOME IMPROVEMENT CONTRACTOR
Registration # HIC.0575920
itt
- 'i _ ADAM QUENNEVILLE ROOFING
d �
Effective: 12/01/2015
Expiration: 11/30/2016
Jn ❑ C 4 ¢
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