13-034 (2) 400 NORTH KING ST BP-2019-1464
GIS#: COMMONWEALTH OF MASSACHUSETTS
MamBlock: 13-034 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 k BP-2019-1464
Pmiect# JS-2019-002376
Est.Cost:$5000.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const.class: Contractor: License:
Use Group: ADAM QUENNEVILLE 070626
Lot Size(sp.R.): 31188.96 Owner: CAMP ANGEL LAURA
zoning: Applicant: ADAM QUENNEVILLE
AT: 400 NORTH KING ST
Applicant Address: Phone: Insurance:
160 OLD LYMAN RD (413) 536-5955 () Workers
Compensation
SOUTH HADLEYMA01075 ISSUED ON.N24120190.00.00
TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE ROOF WITH EPDM RUBBER
ROOFING
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 Occugancv Signature:
FeeTvoe: Date Paid: Amount:
Building 6/24/20190:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
i
(Z-�
Department use only
City of Northampton Status of Permit:
Building Department Curb cuVDriveivay Permit
212 Main Street SevredSeptic Availability
Room 100 WaierM+ell Availability_. :.;
Northampton, MA 01060 Two Sets of Structural Plans"!
phone 413-587-1240 Fax 413-587-1272 PIoVSite P acre
10 Other Spa 'fy
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLIS AOI E OR TWO FAMLI
ILY DYYE NG
f LAT 11111
2019
SECTION 1 -SITE INFORMATION
1.1 Property Address. This p TIONS
NORTHgMP? 1Ot oso
Map�- Lot
400 N King St Northampton, MA 01060 Zone Overlay District
Elm SL District CS Dlebkl
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
Laura Camp Angel 400 N King St Northampto , MA 01060
Name(Print) Current Mailing Address: 928-600-6706
Telephone
Signature
2.2 Authorized Anent:
11 vi Qoofi l00 Old QJ .
Name(PM1It) Current Mailing Add ss: QI •S
UI3�531p-S9SS
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit ap licant
1. Building 5,000.00 (a)Building Permit Fee
2. Elecaiwl (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fite
4. Mecheniwl(HVAC) VV11Y�
5. Fire Protection
6. Total=(1 +2+3+4+5) 5.000.00 1 Check Number
This Section For Official Use Only
Building PeDaftmit Nun De
ssued:
Signature: 11L,
Building Commissionedmapector of Buildings Date
production @ 1800newroof.net
EMAIL ADDRESS(REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
Section,4. ZONING All Information Must se Completed. Permit Can so,bemed pue To Incomplete Information
Existing Proposed Required by Zoning
This column to M filled in by
Building Depadmmt
Lot Sin L -------
Frontage Fron e � t
Setbacks Front C C_:. 1
Side L:O R:O L=7 R:[--] [__] I ...I
Rear
Building Height O O
Bldg.Square Footage
Open Space Footage O % O O O
ares minus bNg@ pinnedpaA
rkin
k of Parking Spaces C� O
Fill:
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 O YES 0
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: _ I
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 O
IF YES, describe stze, 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 Pennit from the DPW is required.
SECTION 6-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing O
Or Doors O
Accessory Bldg. ❑ Demolition ❑ New Signs [01 Decks (M Siding[0] Other IO]
Brief Description of Proposed Rcmme exinin6 roormaieriel vM iruull new EQDM Q"bkae., ra-fl ry 8tj`$lA'/1.
Work:
Alteration of wasting bedroom_Yes x No Adding new bedroom_Yes x No
Attached Narrative Renovating unfinished basement Yes x 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 navy constiunbon. Dimensions
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance tone 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
I, Laura CQrV)�I ,as Omer of the subject
property
Adam Cluenneville Roofing&Siding Inc
hereby authorize
to act on my con
behalf, in all matters relative to work authorized by this building permit application.
Sk_e-. 6n-t vC-t- toJ-6IIi
signature a' owner /� Dab
I. Mang CUL(. nen ud u— ,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 penaMes of perjury.
VIICC
Print Name
/
Signature o Owner/Agem Dab
SECTION B-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: Adam QUenneVllle
License Number
160 Old Lyman Rd South Hadley, MA 01075 CS 070626
Address Expiration Dale
6/21/2019
Signatilre Telephone
413-536-5955
9./1Reaietered Home lmpmwment Comn(c�tor: C Not Applicable 0
t\c11m l 11 to 11'�V1f 11111L. ROO�hq -� h1C�t rin
Company Name Regisal Number
go 1 n �- So� �W ryll4 L 7S 191093
Addre u Telephone E�iretbn Date
u�3-S�oS�/ 3/22/2020
SECTION 10.WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.O.L.e.182,§2SC(8))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit vnll result
in the denial of the issuance of theDuiltling permit.
Signed Affidavit Attached Ves....... No...... 0
City of Northampton
:.5
.w Massachusetts
c
�I DEPARTeNT OF BUILDING INSPECTIONS
212 Nain Street • Nunicipel Building N p�
Nortasmpton, IBI 01060
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and
subcontractors performing improvements or renovations on detached one to four family homes. Prior to
performing work on such homes,a contractor must be registered as a Home Improvement Contractor("HIC").
M.C.L.Chapter 142A requires that the"reconstmction, alteration, renovation, repair, modernization, conversion,
improvement,removal, demolition, or constriction of an addition to any pm-existlng owmwr upiad building containing
at least one but not more than four dwelling units...."to structures which am adjacent to such residence or building'be
done by registered contractors.
Note:If the homeowner has contracted with a corporation or LLC,that entity most be registered
1� V
Type of Work:^ OOT q It r_ Est.Cost: '5007.Ilv
Addressof Work: C0 !V �1 . /WI'�-'�'lQ IvrA o1(yb0
Date of Permit Application: (O w1(9
I hereby certify,that:
Registration is not required for the following reason(s):
_Work excluded by law(explain):
_Job under$1,000.00
_Owner obtaining own permit(explain):
Building not owner-occupied
Other(specify):
OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED
CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT
ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND
UNDER M.C.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK
PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION.
Signed under the penalties of perjury:
I hereby apply for a building permit as the agent of the owner:
le6`tot Nam �V�hV1EVil (t KDf71lli1 J 11093
Date Contractor Name IC Registration No.
OR:
Notwithstanding the above notice,I hereby apply for a building permit as the owner of the above property:
Date Owner Name and Signature
City of Northampton
Massachusetts
ff c
DEPARZNENZ OF NDZLOZND ZNSPEC?IONS
212 Main Street •16nici,al Building T
-. NortBevpton, MA 01060
Debris 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 property licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
The debris from construction work being performed at:
L{oo A/ nq S4.
(Please print house numb and street name)
Is to be disposed of at:
USS Hak. + P� J
/s, Mullen 2d En{ic rd CT apOz
(Please prim name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:n
1S MUIIXk " . ESA -1 C18too82
(Company Name and Address)
k 1, I. I , s
Signature of Permit Applicant or Owner Date
If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the
Building Department as to the location where the debris will be disposed.
oYWM ®VnwA a'b� V/ ('� J /ate
160 old Lyman Road"South Hadley•Rall $\\ a///e-x❑mnsed
LeDO.NEW.ROOF a /13536.5955 Fully Insured
Email:info61400neermcf.net Waimea www.voNNwroof.net Factory Trained
MA Construction Supemisors❑c.W70636 MA Registration 613098E Factory Certified Installers
Mwro.rddw xwm auMNaaw[.NNVnemasau CT Registration#575920
Mmibv W Ne BWdreaTraee/,u¢btlm PlLNa10
Proposal Submitted To: Date: Phone Ifs: [:
uVA N H. W.
street n/, s Emall: LACfl UPSi MS 14. C011
Fret 14 LzOal (Fin+
CRY,state,nn Apl / dMQ O1G(o Spedal Pe uire n %I �I
PROPOSAL FOR: SICA� Ip k ' rsa4A a.6c EPbIAr.
HOOSE GAPIIGE OT��HEP,
STR s\-`^E�NCOO EER— s1W\ lU�t RTu 13CgI �r
layers:of E 3 • ywoodlnduded: Yesor No aX im JTI411 66 ��TP
❑ TearaN5lATEorSHAKES9�R r. crvec S+r[P
COMPIEIE HOOF PR01ECilON gYgyEM: GVt
We shall acquire appropriate permits for all work 'r4&styI R� ,PA/J`
X Nome exterior and landscaping to be protected *uR PipirRJ eve—Ma I.eAQYI
❑ Strip existing ro ifing to existing dockingwith full Inspection DO NOT DO:
)3 All project waste shall be removed by dumpster(durysterfor contractor use OnW
❑ Install Ice&Water Baffler at all eaves Y/6',valleys,chimneys,pipes and skylights
❑ Instill(151b.felt/Synthetic)underlaymentoverr deckingarea
)< Install Metal drip edge ateaves and rakes l8"/5"I white brown)
L Install manufacturer's starter shingle an all eaves aedges
L Install new pipe boot Noshing/vent accessories
❑ Install ddgs vent-Show Country/Cobra rolled/4'Bafged/Roll �y� �/s}
ShIngIM:(stanAs'yMa,6 nails per shl le) I�QW1�. UIg'1[y
Shingles color. ZIA K
u�Idge cep shingles
c le vjN Roo F 4R ^^ e
C rte.cy' g
/t Weguaranteeour workmanship for full years {�� J1 ��IA o-,
J GMSptem Plus Warranty
❑ GAF Golden Pledge Warranty
Chimney Options:
O lead Counter Flashing 7Water Seal&Tuckpo8d ORubbedted Crown flCricket
fJ Mason needed Icusromer provided)
Additional material and labor charges may apply.
❑ Deteriorated existing decking will W replaced at$3.P Per sq.ft.and dimensional lumber at$7.00 per linear f[,
after full inspection. OaepmerinMbk:
we wwaw rwwwraamax maan.e..el.bar-.anPl[umao-aanu.ivam.[rPmn w/:� Total Due:(55)�G60
�/{ ) �II�
ACCEPTANCE Of PROPO9aL Ti.above pNey ape[Matlm[aM[wNRbm ax C�\.)town Paymem:l$ Irlp-.[a )� J
vtblaCery eM an M1erebyewpnd.YaumautaM[adtotlo wort asape[Mad. l Balance DOFUpon Completloml$'4,4o I—I
Panamint WNW 113dix,mA Wn of job,and Man.Me upon oxinnbn �j V VV
Wfe:� F a Signature: ` /////�
Date:(0 Estimator:(Print Name)krk (Sign Name) f+1
ATTENTION HOMEOWNERS:Please cover all personal belongings In the attic,garage m storage areas due to the
Possibility of roofing debris or dust coming in through cracks of the wood.Adam Ouennevllle Roofing will not be
responsible for debris or dust in the attic or storage areas. Cusurnerinildols:
AC bB CERTIFICATE OF LIABILITY INSURANCE
05102201g
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATWELY 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: N the cerii8ats holder IS an ADDITIONAL INSURED,the policy110s)..at have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED,subject W me terms and conditions of the policy,certain Policies may rectulm an endorsement. A statement on
this caHlflcate does not confer rights to the certificate holder In lieu of such endorsement(.).
PROoucEq xAME.PONT—
Me1irwJ.Ka.W.
Gose B McLain Insurance Agency . (413)530.7355 Ne: (413)5368286
1767 Northampton Street laiAB mkemhuletipgmsmNaln sum
PO Box 1128 INSURENSI APFORMNG CWNU°E MMCI
Holyoke MA 01031-1128 esusEAA. Nautlla Insumna Comprry
MNIe[O qua; NaWlus lnsurena ConlpelM
Adam Ouernmilla RoOMg 6 Siding Inc Mouses, TNO Bond Excranpa,Inc
ISD Od Hyman Road INSURER°:
PNRERE:
SoAN Hall, MA 01075 INSURER F'
COVERAGES CERTIFICATE NUMBER: CL185104976 REWSION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAYS BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITIISTMIDINGANY REQUIREMENT.TERM OR CONDITION OF WIYCONTRACT OR OTHER DOCUMENTWITH RESPECTTO WHICHTHIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN.THE INSURANCEAFFORDED BYTHE POLICIES DESCRIBED HEREIN Is SUBIECITOALLTHE TERMS,
EXCLUSIONSAND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLUM9.
lues LT0. IVR OFeMURaMOE FDMCYIMBIR UCY angs
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CelYE111MMfiBIrIKLWAIIY Escrocc MOlLE S 7.000.000
CIANIHA DE ®CIX:UR S
Mm. s 15,000
A Y NNBSZ218 ONZY2018 0823/2019 PErMOrIALaAw NeNY S IAW,000
GENLN1aRE0ATELMRAWLIEB FEq: GENERKMOIEGATE $ 2'000'000
POLICY®Jf:CT ❑LOC PROIXICTB.COMPFPAOG S 2.000.000
pay. Emplom BrMeb E 1,000,000
AUTOMOBILE LUAlsom CGN s
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DED NETENTICM S 'UUAU p
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C 9363881 01/192019 044191
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Cedmate holders are adtllional insured on me shove captioned GL p011ry; ubpd W policy forts,condilios,and estlueions.Atlas Quenne fifla es an
oMar.Is excluded M1°m the Workers Como Ig14y
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THEABOYE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOR NOTICE WILL BE DELIVERED IN
Adam Ouennwllle Rooting 6 Siding Inc. ACCORDANCE WTIN ME POLICY PROASIONS.
AUIM°RIFFO NPREBEMNIr�M�v/n
a 195"01SACORD CORPOftAnom. All lights rsterYed.
ACORD 25(2 01610 3) TM ACORD name and logo aro registered marks of ACORD
AV Oa CERTIFICATE OF LIABILITY INSURANCE
04
0412N 9
THIS CERTIFICATE 15 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 arms and conditions W the policy,certain policies may require an endorsement. A statement on this certhilci a does not confer rights to the
certi8ute holder In lieu o1 such endorsement(s).
PROWL[R CONTACT Fe TNdell
MARTIN J CLAYTON INSURANCE AGENCY INC
E♦
1649 NORTHAMPTON ST RTE 5 UIMRER(l) FORDINGCOVERAGE _ Ki
HOLYONE MA 01041 WMm1 A: AIM MUTUAL INS CO _ 33758
IXEURM VIAMERS: __
ADAM QUENNEVILLE ROOFING&SIDING INC Ixsuxaac:
INSURO
160 OLD LYMAN ROAD samara E:
SOUTH HADLEY MA 01076 1 IwuREA F:
COVERAGES CERTIFICATE NUMBER: 393099 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,
FXUMMS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, _
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MBCMPTMINOFoPFIU 3ILCCATDNSIVEHICLES(ACORD 101.AMiBene Rrrnm.5eardWgM,iWMNadNmws WwMrpWMI
Workers Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 S.no authorization Is given TO pay
claims for Done%t0 employees in slates other than Massachusetts If the Insured hires,or has hired those employees outside of Massachuse0s.
This certificate of insurance shows me pou4 h force on the data that this certificate was issued(unless the expiration date On the above policy precedes the
Issue date of W s cedificale of insurance). The status of this coverage Can W monBored deny by accohniN me Proof Df Covarege-Comepe Verification
Search tool at www.mass.gov/IwdN em-canpwmti°Mmest'gationW.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Adam Quenneville Roofing & Siding Inc ACCORDANCE WITH THE POLICY PROVISIONS.
160 Do Lyman Road MTxon¢EDREPR SMATNE
South Hadley MA 01075 terie
Daniel M.Cr y,CPW,Vice President-Residual Merkat-WCRIBMA
O 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD
The Commmnlaealth ofMassaehuselis
Department of IndustriatiAccidearis
1 Congress Street,Suite 100
Boston,MA 02114-2017
avwwmoss.gov/dier
W11mrivers'Compensation Insurance Affidavit:Builders/Contractors/EimriciansNtumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Aoolicanl Information Please Print Legibly
Name(BmincenrOrgannatinnntMividual): Adam Quenneville Roofing & Siding Inc
Address: 160 Old Lyman Rd
City/StateJZip: South Hadley, MA01075 phone#: 413-536-5955
Are you an empWyer?Clock the Wropme,hoe:
Type of project(required):
L�Ian.aoobve, ((ult aMwmpai-mi 7. E]New Construction
2.❑l am a rule pmpriewmprerchip and leve no employem wotrag for me in 8. E]Remodeling
my,u,,v ,,IN.workers'comp.in nowere required)
3.❑1sahomcm ,doin8 all wakmyself IN.woreo'compimmenarermirMll q. El Demolition
n
4.❑1emab,nm =endwllbehiringmnuecwmwmMncaallwwkunmyproperty. [will
IB❑Bilding addition
.mum thauuconuumrs eidmrmve wwkera'mmpmamian imummepnreaoie II.❑Electrical repairs or additions
pmprWmn win na enpWyou. 12.❑Plumbing repairs or additions
5.❑1 m•BermimnhanoraM 1 baro hued nesub-cavuaclorslinrA m the uoacid tlren. 13.m Roof repairs
These aubmsimmusslmveereployece aM have wo,kcri comp.iovvamet
6.❑We mc.empomdonaM iu.facers ho,commisd their right afesern t on per Mal,c. 14.❑Other
152,f t(4k roti we here rucepbyees.IN.workers'comp.immax,ax,uircA.)
'Any ii,a cam that chmksloa gl mun Oro fell rut the eetion below 4ioei ig theuwarken'mmpcnsetion policy information.
I flmmmwners who Submit nim.mdevit indicating thry,are doing all wnrkaor nen him outside conaecton must submit a new affidavit indkating much.
lCmannurs thercheeknis hos connamched madditional sheetshowing the vs,re of theortcmo ratnmsand cote whmbmmmm thou Curios have
anployarworkersrump.poli<Y number.
I am an employer tkatisproviding workers'rompeneation insuranceformy employees. Befowisfhepolleymdjobsin
information.
Insurance Company Name: AIM Mutual
Policy sorSeif-ins..Lie.u: A�W�C4'0/0701286121019A Expiration Date:
lk I-4129/2020
Job Site Address, `"rOO / rs . F-t Y1 f- Citylsla lzip: I jQ �f'1 A4 D
Attach a copy of the work..'compensation olicy declaration page(showing the policy number and eaptra on date). OIOLo 1
Failure to secure coverage as required under MGL c. 152,p25A is a criminal violation punishable by a fine up to 51,500.00
and/or one-year imprisonment,a 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 I`
coverage verification. 1
l do hereby certify ander the ins mrd penalties ofpuhi that the information provided above is nue and eorrect.
Signature' V Dal `w IrW
Phones• 413-536-5955
OJrdal use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/Licenses
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 s:
ilk Conxnonereaah of Massachusetts
DWHoon of Professional Lkensure
Board or Building Regulations and Standards
COnstrUetlan Supervisor
CSW0626 Expires:OB/212019
VILLE
ROAM A
HADLEY MA01 7
160 OLD LYMAN ROAD
SOUTH HADLEY CL
JX, Commissioner ✓""�
J �atrziizoiar�rPez oj�,�%cc a iJn s
Office of Consumer Affairs and Business Regulation
One Ashburton Place- Suite 1301
Boston, Massachusetts 02108
Home Improvement Contractor Registration
Type: Corporation
ADAM QUENNEVILLE ROOFING AND SIDING,INC. Registration: 191083
160 OLD LYMAN RD. Expiration: 03/22/2020
90.HADLEY,MA 01075
Update Address and Rehm Card.
STATE OF CONNECTICUT ♦ DEPARTMENT OF CONSUMER PROTECTION
Be it knonan'that
ADAM QUENNEVILLE
160 OLD LYMAN ROAD
SOUTH HADLEY, MA 01075-2632 ;
ISI
has satisfied the qualifications required by law and is hereby registered as a
HOME IMPROVEMENT CONTRACTOR
I
Registration # HIC.0575920
ADAM QUENNEVILLE ROOFING
Effective: 12/01/2018
Expiration: 11/30/2019 xe,k r ,, omm;y;o ,r