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13-006 25 MARIAN ST BP-2017-1077 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 13 -006 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-2017-1077 Project II JS-2017-001846 Est.Cost: $3000.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ADAM QUENNEVILLE 070626 Lot Size(so. ft.): 24132.24 Owner: EVANS JAMES A JR&GAIL R&MICHELLE PEREZ&K EVANS-PEREZ Zoning: Applicant: ADAM QUENNEVILLE AT: 25 MARIAN ST Applicant Address: Phone: Insurance: 160 OLD LYMAN RD (413) 536-5955 1) Workers Compensation SOUTH HADLEYMA01075 ISSUED ON:3/29/2017 0:00:00 TO PERFORM THE FOLLOWING WORK:STRIP ONE LOW SLOPE SHINGLE SECTION & INSTALL NEW EPDM RUBBER 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: FeeType: Date Paid: Amount: Building 3/29/2017 0:00:00 $40.00 212 Main Street,Phone(413)587-1240, Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner DeparMent use only City of Northampton status of Permit: Building Department Curb Cut/Driveway Permit MAR2 9 2011 212 Main Street Sewer/Septic Availability • Room 100 Water/Well Availability -- . 'I Northampton, 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 1 -SITE INFORMATION Bp- /7 /O 77 1.1 Property Address: This section to be completed by office 25 Marian St Map Lot Unit Northampton, MA Zone Overlay District 01060 Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: James Evans 25 Marian St Northampton, MA 01060 Name(Print) Current Mailing Address: See Contract 413-586-1605 Telephone Signature 2.2 Authorized Agent: Adam Quenneville Roofing&Siding Inc. 160 Old Lyman Rd South Hadley MA 01075 Name(Print) /7 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 3000.00 2. Electrical (b)Estimated Total Cost of Construction from(6) 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5.Fire Protection gicyte 6. Total=(1 +2+3+4+5) 3000.00 Check Number y73j7 This Section For Official Use Only Building Permit Number: Date ssuetl: Signature: - 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 Depamneat 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 0 DONT KNOW O YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW O 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 0 , 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 0 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 0 NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required, pECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing 71 Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [O) Decks [O Siding[DJ Other Id] Brief Description of Proposed Work: Strip one law slope shingle section end install new EPDM rubber system. 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 WoadstovesNumber 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 low 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 la-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, James Evans ,as Owner of the subject Property 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 3kfr)t) Signature at Owner Date t" 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. Sign d under the pains and penalties of perjury. in friatukfi (-A Print Name 3 ) h? Signature of Clymer/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: Adam Quenneville CS 070626 U License Number 160 Old Lyman Rd South Hadley MA 01075 8/21/2017 Address Expiration Date 413-536-5955 Signature Telephone 9.Registered Home Improvement Contractor: Not Applicable 0 Adam Quenneville Roofing 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.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 0 11. - Home Owner Exemption 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 1083.5.1. 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: 25 Marian St 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 kik ap niudit ICC Date Signature of Permit Applicant �I ) BSB QUENNEVILLE Winner of the nw&ne "Id _IP ROOFING V' SIDING II WINDOWS 160 Old Lyman Road•South Hadley•MA 01075 We are Licensed 1.800.NEW.ROOF - 413.536.5955 Fully Insured Email:-mew18 inti[ Website:www.laoonewroofnet Factory Trained MA Construction Supervisors Lit#070626 MA Registration#120982 Factory Certified Installers ember tithe biome Buuilden Assoc.or Wester Mass. CT Registration i/575910 Member of the Building&Trade Mmnaoon Pe.c 311710 Proposal Submitted To: Dale: // Phone Ms: C:ph)s3/-3503 31»�7 H_ (90/\56614or W_ Street: Email: =e nr=•✓ V @ „ iieof8roeaie -refc_� City,State,Zip Code: F„f 234, C._ tic( twtmf-4.. /,tom Ole&6 Proposal to furnish and install the following: Ere J/ / e,// ��,fe,.� ru...(a /.. ..w.�. tie ..J( tencvz r ✓SCS. B/' z l.t e..// n.T.a. . .I, ... ,C .r4'' . .4,7„; c, 4 .../� r.r4/� FS:. /.e..../ sse ^ll ri uf M✓ a 54. d Rep a.(4C n✓ /'tniw./ea sia ...IY g^S II ,w? v 3/.ch M4. .nr.. re Naci •,SL.. d� �� . �.�G. d. _,l/ ,acedy _44 „et/ SF 5,J Aa, �)a5 ✓s Pna.� 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 will not be responsible for debris or dust in the attic or storage areas. Customer Initials: Additional materials and labor charges may apply. x Deteriorated existing decking will be replaced at$3.77 per sq.ft.after full inspection Ask us about Customer Initials 2542 affordable bank `6 Deteriorated existing dimensional lumber to be replaced at$5.00 per linear ft.after full inspection financing! Customer Initials (le Warranty Options: 1 Year 5 Year — 10 Year 12, / YY^” We propose ereonm.ah mama.an labor-complete in accordance babove specifications for the sum of. Total Due3CCO ACCEPTANCE OF PROPOSAL:The above prices.specifications and conditions are Down Payment:1$ /CVO I satisfactory and are hereby accepted.You are authorized to do work as specified Balance Due Upon Completion:l5 ) Payment will be 1/3 down at Signing and balance due upon completion. aC(D Date: 33(/77/17 Signature: rr (•) s.— '/- of Date: �Mt 4'7 Estimator Print Name) Ff II' `•••'c'' (Sign Name) /r/ Estimatesarehonoredfor sixry(6D/days from above date. " ACOR CERTIFICATE OF LIABILITY INSURANCE DATEIMWDD""') `---- 6/24/2016 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 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 CONTACT Melinda Karakuls NAME. Goes & McLain Insurance Agency .uPHC No,Eql:.1413)539-7355 Fja NO:{413)41444246 1767 Northampton Street fib% ss:Itcarakula®gossmclain.com P 0 Box 1128 INSURER(S)AFFORDING COVERAGE I_ NAIOp Holyoke MA 0104 1-112 8 INSURER A Nautilus Ins CO pony • INSURED INSURER B AIM Mutual In¢ Co Adam Qu¢nn¢Ville Roofing a Siding Inc INSURER C: 160 Old Lyman Road INSURER D: 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 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 SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. .__ — ISUBR' ._ ILTR TYPE OF INSURANCE D Iµypl I POLICY EFF POLICY EXP I LTR POLICY NUMBER IMWODP(YYYl1M WDDMYYY LIMITS R '.COMMERCIAL GENERAL LIABILITY EACH OCCURRENCI E DAMAGE TORENIEO S L 000,000 A I I OIAIMSMADE .I OCCUR 0 PREM$ESI€@ cel I S 100,000 1{{116e5342 6/23/2016 6/23/2017 MED EXP(Any One permn) 5 15,000 I__. 1 iPERSONAL SADV INJURY l5— 1,000,000 rENL AGGREGATE LIMIT APLIES PER IGENERAL AGGREGATE S 2,000,000 -K ?WHY�I PRO. r -... JECT ` LOC PRODUCTS-COMP/OP AGG S 2,000,000 � OTHER rErnployee Benefits I$ 1,000,000 AUTOMOBILE LIABILITY I I COMBINED SINGLE LIMIT $ (Ea a¢Ieentt) iANT AUTO BOD!LY INJURY{Per person) I5 ' ALL DINNED I SCHEDULED I -- ,_�A UT' AUTOS BODILY INJURY(PereodoeM) 5 I—111 AUTOS EO PROPERTY DAMAGE HIRED AUTOS 44 (AUTOS i� 0 5 I I—T I I' Undennsuredmomnldel wit i$ UMBRELLA LIAB I I _— OCCUR EACHOCCURRENCE •5 1,000,0.00 L. IX EXCESS UAB X CLAIMS-MADE I AGGREGATEEGATE DED X 'RETENTIONS 10,000 IANO 30622 8/13/2016 8/13/2017 I 6 (WORKERS COMPENSATION I PER 0TH, I AND EMPLOYERS'LIABILJTY T.tNI I 'I EL EACHUTE IER , PROPREEOR/EXCLUDR EOUTVE EL ACCIDENT S 1,000,000 D OFFICER/MEMBER EXCLUDED' YI'NIAI yesdxtarylnNH) ANC9007012861-2016A . 4/29/2016 4/29/2017 II EL.DISEASE-EA EMPLOYE� 5 1,000,000 'IDfy enbe under I DESCRIPTION OF OPERATIONS below !E L DISEASE.POLICY LIMIT 5 1,000,000 I I . I DESCRIPTION or OPERAI1ONSI LOCATIONS t VEHICLES (ACORD 101,Aaaltonal Remarks schedule,may be Marred If more space Is required) Certificate holders are additonal insured on the above captioned GL policy; subject to policy forms, conditions, and exclusions. Adam puenneville, 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. AIIIROWEED REPRESENTATIVE /�//� f M Karakul a/MIND? /// -r.L-- ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INSD26 Omenn The Commonwealth of Massachusetts g•I =' ' _�+i Department of Industrial Accidents 1 _ I— 1 Congress Street,Suite 100 R . Boston,MA 02114-2017 r 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(Business/Orgameation/lndividua0: Adam Quenneville Roofing & Siding Inc. Address: 160 Old Lyman Rd. City/State/Zip: South Hadley, MA 01075 phone#: 413.5363955 Are you an employer?Check the appropriate box: Type of project(required): LEI 11111 SI employer with 15 employees(full and/or parttime)^ 7. [3 New construction l am a sole proprietor or partnership and have no employer's working for me in 4. ❑Remodeling any.capacity.[No workers'comp.insurance required] 1—ry 301 am a homeowner doing all work myself.[No workers'comp.insurance required]' 9, llr^�qJl Demolition401 am a homeowner and will be hiring contractors to conduct all work on my property. s will 10 lJ Building addition ensure that all contractors either have workers'compensation insurance or are sole l Lp Electrical repairs or additions proprietors with no employees. 12,E Plumbing repairs or additions 5I am a generalcontractor and I havehired the sub-contractors listed the attachedh on sheet ❑ 13.®Roof repairs These sub-contactors hate employees and have workers'comp.insurance.' 6.0 We arc a corporation and its officers Mac exercised their right of exemption per MGL c. 14.❑Other 152,41(4),and we have no employees.(No workers'comp.insurance required] ^Any applicant that checks box 01 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidasit indicating they are doing all work and then biro 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,conhactors and state whether or not those entities have employees. If the subcontractors have employees,they must protide their workers"comp_policy number. I am an employer that is providing workers'compensation insurance for m}'employees. Below is the policy and job site information. Insurance Company Name: AIM Mutual Insurance Policy#or self-ins:Lie.#; AWC4007012861-2016A Expiration Date: 4129/2017 Job Site Address:, City/State/Zip: 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 S1,500.00 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 cernfy under the pains and enalties of perjury that the information provided above is true and correct Signature: Date: 3/11-Ci) ? Phone#: 413.536.5955 j 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#: „� ,�. Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CS-070626 Construction Supervisor ADAM A QUENNEVILLE .-. 11 180 OLD LYMAN RD • - SOUTH HADLEY MA !t' n f LJ..- Expiration'. // � Commissioner / 08121/2017 1e. hie it liime lltelectflll' C �f(,i.iCtC'�tl.lr//i Office of Consumer Affairs and Business Regulation 10 Park Plaza- Suite 5170 Boston, Massachusetts 02116 home Improvement Contractor Registration Registration: 120982 Type: ODA Expiration' 3/25!2018 Tref 419291 ADAM QUENNEVILLE ROOFING ADAM QUENNEVILLE 160 OLD LYMAN RD -- -- ---- -.- - --- SO. HADLEY, MA 01075 - - --- --- --- ----- Update Address and return card,Mark reason for change. SO4a0 2OY tiny J Address U Renewal ❑ Employment fl Lost Card � � r +ti >C1 ` t° ±,w ter_ +r �,c. �,r_ �r ,r .nr" *.r �,etet_ -r� �r �_.u� i STATE OF CONNECTICUT 4. +DEPARTMENT OF CONSUMER PROTECTION tkt jl ! Be it known that-141 b,.. ADAM QUENNEVILLE• "bi 160 OLD LYMAN ROAD SOUTH HADLEY, MA 01075-2632 is certified by the Department of Consumer Protection as a registered Avi HOME IMPROVEMENT CONTRACTOR .) Registration # HIC,0575920 fr. A4 rADAM QUENNEVILLE ROOFING 4. Effective: 12/01/2015 } 4, Expiration: 11/30/2016 • yIjo AthanA.11 nic,ernitzniezioner b _ ` .:9".711"1‘ try A ' .T"a ;I"L 171 ♦ :in': ."* i1 RL i* iTi