38b-261 52 REVELL AVE BP-2017-0497
GIS COMMONWEALTH OF MASSACHUSETTS
Map:Black:38B-261 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-2017-0497
Project# JS-2017-000818
Est.Cost: $3250.00
Fee: S40.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ADAM QUENNEVILLE 070626
Lot Size(sq. R.): 7927.92 Owner: NOVAK ANTHONY SCOTT&PAMELA CLARK NOVAK
Zoning: URB(100)1 Applicant: ADAM QUENNEVILLE
AT: 52 REVELL AVE
Applicant Address: Phone: Insurance:
160 OLD LYMAN RD (413) 536-5955 0 Workers
Compensation
SOUTH HADLEYMA01075 ISSUED ON:10/17/2016 0:00:00
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 THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
FeeTvpe: Date Paid: Amount:
Building 10/17/2016 0:00:00 $40.00
212 Main Street, Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
•
-/\ Department use only
City of Northampton Status of Permit:
' - Building Department Curb CuUDriveway Permit
/ . \� / 212 Main Street Sewer/Septlp gvallabilily
� Room 100 Water/Well AvailabilityN\p\
Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 PloUSite Plans
" /
�.. Other Specify
LICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION BP- / 7-L I
1.1 Property Address: This section to be completed by office
52 Revell Ave Map Lot Unit
Northampton, MA 01060
Zone Overlay District
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Scott Novak 52 Revell Ave Northampton, MA 01060
Name(Print) Current Mailing Address:
See Contract (413)559-9465
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
3,250.00
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) 3,250.00 Check Number,/ Q�j $4d
This Section For Official Use Only
Building Permit Number: Date
de
//�/Jj� Issued:
!!
signature i�% /Dj(r
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 aream inus bldg&paved
parking)
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW O YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW al 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 O 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 O
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) 1 1 Roofing I7 I
Or Doors D
Accessory Bldg. ❑ Demolition El New Signs ID] Decks ID Siding ID] Other]CI]
Brief Description of Proposed
Work: See Contract
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
Scott Novak
property ,as Owner of the subject
hereby authorize Adam Quenneville Roofing&Siding Inc.
to act on my behalf,in all matters relative to work authorized by this building permit application.
See Contract IL ) to
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.
Sig d ntlpains((an�d� penalties of perjury.
Ulv.'(°(btu; I�
riot Name
Glc- (VLH II>0
Signature of Owner/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable 0
Name of License Holder: Adam Quenneville CS 070626 U
License Number
160 Old Lyman Rd South Hadley MA 01075 8/21/2017
Address /'1 Expiration Date
111 n� 413-536-5955
Signature Telephone
9.Registered Home Improvement Contractor: Not Applicable 0
Adam Quenneville Roofing HIC 120982
Company 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.e.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 M' No 0
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 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
City of Northampton 212 Main Street, Northampton, MA 01060
Solid Waste 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.
Address of the work: 52 Revell Ave Northampton, MA 01060
The debris will be transported by: USA Hauling&Recycling Inc.
The debris will be received by: USA Hauling&Recycling Inc. 15 Mullen Rd Enfield, CT
Building permit number:
Name of Permit Applicant Adam Quenneville Roofing &Siding Inc.
1D\11 \ 14' '✓r ��
Date Signature of Permit Applicant
/mac° BBB
QUENNEVILLE
Winner u the TORCHAWARD =MEI
IIILMISA WinI=e• R
ROOFING V' SIDING V WINDOWS
160 Old Lyman Road•South Hadley•MA 01075 We are Licensed
1.800.NEW.ROOF • 413.536.5955 Fully Insured
Email:info6B1800newroofnet Website:www.1800newroof.net Factory Trained
MA Construction Supervisors Liz.#070626 MA Registration#120982 Factory Certified installers
Member of the Home Builders Assoc.of Western Mass. CT Registration#575920
Member of the Building&Trade Association P.P.0 38710 11
Proposal Submitted To: Date: Phone Ws: C('/O/ 55//-`1 YG>
SO # l< 5/x 6 H: W:
Street: Email:
S R'w.// ,Ave
City,State,Zip Code:
N.l47l,r MA 0/060
Proposal to furnish and install the following:
at
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n/G<a ek.7 / �.<.> 441 .3 .,,«.,k1 , czderl 4' A147e. N.<..F.
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ATTENTION HOMEOWNERS:Please cover all personal belongings in the attic,garage or storage areas due to the D`
possibility of roofing debris or dust coming in through cracks of the wood.Adam Quenneville Roofing will not be AF
responsible for debris or dust in the attic or storage areas. Customer Initials: 17-,A1 R4t4.n21
Additional materials and labor charges may apply.
C. Deteriorated existing de king will be replaced at$3,77 per sq.ft.after full inspection
Ask us out
Customer Initials 1946 affordable
ban
IC Deteriorated existing dimen nal lumberto be replaced at$5.00 per linear ft,after full affordable bank
inspection 1 �p financing!
Customer Initials -M!� 1
Warranty Options: - 1Year •I- 5 Year — 10 Year Ice f7 ye`A
We propose hereby to furnish materials and labor-complete in accordance with above specifications for the sum of Total Due:($ 3aSD )
ACCEPTANCE OF PROPOSAL:The above prices,specifications and conditions are Down Payment:($I,Pub - '1)
satisfactory and are hereby accepted.You are authorized to do work as specified. Balance Due Upon Completion:(5 S, sic-cr
Payment will be 1/3 down at signing and bal e due upon complti�on.
Date: Cul-3CIle signature: �� / 'n�/�
Date: et(3c1r4, Estimator:(Print steel f,4 emir (rife (sign Name)
Estimates are honored for sixty(601 days from above date.
a�log `M•AI
CERTIFICATE OF LIABILITY INSURANCE OATCOnNYY)
6/2_4/2016
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 policyfes)must be endorsed. if SUBROGATION IS WAIVED,subject to
the terns 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 endorsementjs).
PRODUCER C2NTAci Melinda Xarakula
RAM_E:
Gose & McLain Insurance Agency PMT {413)534-7355 FAX Not (413 "4'92"
1761 Northampton Street Ampss mharakulallgos emclain.corn
p 0 Box 1128 INSURER(S)AFFORDING COVERAGE NAICX
Holyoke MA 01041-1128 INsuRERA Nautilus Ins Company
INSURED INSURER IITH Mutual Ins CO
Adam Quenneville Roof ing R Siding Inc INSURER
160 Old Lyman Road INSURER O: ''
_INSURER E:
South Hadley MA 01075 INSURERF:
COVERAGES CERTIFICATE NUMBERS1,1662403220 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. NOTWTHSTANDING ANY REQUIREMENT TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT VATH RESPECT 1'O 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 SHOPM MAY HAVE BEEN REDUCED BY PAID CLAIMS.
v - - -� POLICYWTp6cICYEXP - - - - _--
I INSO s m'
LTR TYPEOFGINERALUE INSO Wm' PO4CY NUMBER IMMIDO/YYYYI IIM WDOIYYI'TI' LIMITS
X COMMERCIAL GENERAL MAeIUTY 1 ' I ' ;EACNOCCURREMCE 5 1,000.009
A '.CLAIMS.MADE I OAMXSE 6RENYCO 100,000
A_UfXUR MED SE$lE f£4u.LnR1 $
I_ _. _ __. _ NN6B5312 6/23/2014 6/23/2011 MED EXP(Anyperson) 5 15,000
PERSONAL e AIN INJURY 5 1,000,000
N'L AGGREGATE LIMIT APPLIES PER II GENERAL AGGREGATE I5 2_000,000
X�POLICY i_, LOC `PRODUCTS,GOMP ,AG 5 2,000,009
9 I OTHER I .2mpioyee Benefiti 6 1,000,000
I iI COMBINED 61NdLE LIMIT $
I AUTOMOBILR LIABILITY
ZANY AUTO I
I 4
I BODILY50DILY INJURY(Per person. $ -
A
r -
T ALL OWNED SCHEDULED I BODILY INJURY IP eco sen) 5
�._AUTOS ANTO .DVAJEO PROPERTY WMAU ___--
E
C- HIRED gVR15 ' . _rales - ) 5
! Underinsured mmmal Si w!n L.5
UMBRELLA WAR ! OCCUR
— EACH OCCURRENCE _ _ S 1,000,000
c I X I EXCESS LIAR X GLAIMS.MADE 'AGGREGATE 5
1DED 'X i RETENTIONS 10,coo /.24039622 Si13/2026 18/L312017 ; p 5
'WORKERS COMPENSATION X ISiATJTE �EflN
'APO EMPLOYERS UABILRY 1 --- '
(!ANY PROPRIETOIR'PARTNEWEY£CUiVE YIN( E.1-EACH ACCIDENT 5 1,000,000
OFFICER/Mmaseatry IliN.R E%CLV0E0? y 'IINIA I AWC4001012861-2016/. 4/29/2016 ' 4/2 9/2 011 1 EL DISEASE EA S _ 1,000,000
D If es de M lMBER
ITyes bN Oder
DE6GPIPTION OFOPERATION50eMw1E.L.TDISEASE-PO4Qv LIMIT 3 1.000,000
I
� 1 I
I
I
DESCRIPTION OF OPERATIONS I LOCATIONS?VEHICLES (ACORD In AddIUonel Remarks Schedule,may be attached II more apace Is rsquwR0)
Certificate holders are additonal insured on the above captioned GL policy; subject to policy forms,
conditions, and exclusions. Adam Ouenneville, as an officer, is excluded from the Workers Camp 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,
AUTHORIZEO REPRESENTATIVE
I M Karakula/MTNDY
®1088-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD
INS026,26eenn
The Commonwealth of Massachusetts
'
1i3s"� Department of Industrial Accidents
=:= nn
1
I Congress Street,Suite 100
_,� Boston, MA 02114-2017
' www.mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (suslness/organiration/Individnab: 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..l I am a employer with 15 employees(Poll andfor cart-time).' 7. 0 New con5twclion
2.01 am a sole pmpriewr or partnership and have no employees working for me in $, ❑ Remodeling
any capacity.[No workers'comp_insurance required] El
3.0 I am a homeowner doing all work myself[No workers'comp.insurance required.]' 9. LTJ Demolition
3 p l am e homeowner and will be blimp contractors to conduct all work on my property. 1 with O O Building addition
cramp that all contractors either have workers compensation insurance or arc sole I [j Electrical repairs or additions
proprietors with no employees.
12.0 Plumbing repairs or additions
50 Tarn a general contractor and I have hired the sub-contractors lisled on the attached sheel13.®Roof repairs
These sub-contractors have employees mid have workers'romp.insurancet
6.0We are a corporation and its officers have exercised their right of exemption per MGL c. 14.DOther
152,§U4),and we have no employees,[No workers compinsurance required}
-----
"Any applicant that chocks bre#1 must also fill out the section below showing their workers'compensation policy information.
r Homeowners who submit this affidavit indicating they arc doing all work and then hire outside contractors must submit a new affidavit indicating such,
rContractors that check this box must attached an additional sheet showing the name of the sub-contractors and sato whether or not those entities have
employees. If the rubcontractors have raw/pyres,they must provide their workers'comp policy number.
7 am 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
AWC4007012861-2016A . 4129/2017
Policy#or Self-ins.Lie, #: Expiration Date:
Job Site Address: 9-) I? evv t..j A- Q . City/State/Zip:NO(i-4v,Cf.ri•-oYC1-1.MN OIClH°
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
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.
7 do hereby certify under the pains and penalties of perjury that the information provided above is true and correct
/y
Signature: "/ - Date: /O/)t II p
Phone#: 413.536.5955
Official use only. Do not write in this area,to be completed by city or town official A
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#:
Massachusetts Department of Public Safety
Board of Building Regulations and Standards
License:CS-070826
Construction Superviso,
ADAM AQUENN€V&LE
180 OLD LYMAN RD f j ,�
SOUTH HADLEY MA "
pp Y
f' 'ZX Expiration.
_ Commissioner 08/21/2017
r%Ir' o»,mo ,raert/a r. r` '47.L;aae/triol7i
Office of Consumer Affairs and Business Regulation
10 Park Plaza- Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 120982
Type: DBA
Expiration 3/25/2018 Tr/ 418291
ADAM QUENNEVILLE ROOFING
ADAM QUENNEVILLE
160OLD LYMAN RD
SO. HADLEY, MA 01075
update Address and return card.Mark reason for change.
AddressL Renewal Employment El LostC.ard
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2 nro .:a1 a"kids C1.
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STATE OF CONNECTICUT 4+ DEPARTMENT OF CONSUMER PROTEC 17ON it ,
1j
Belt known drat
"01 ADAM QUENNEVILLE I
+
4 160 OLD LYMAN ROAD r
,: SOUTH HADLEY, MA 01075-2632
is certi tied by the Department of Consumer Protection as a registered
HOME IMPROVEMENT CONTRACTOR I
Registration # HIC.0575920
it f
r
ADAM QUENNEVILLE ROOFING
Effective: 12/01/2015
Expiration: 11/30/2016Pla„
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