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23A-168 57 PINE ST BP-2020-0310 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 23A- 168 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-2020-0310 Project# JS-2020-000526 Est. Cost: $1670.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor. License: Use Group: ADAM QUENNEVILLE 070626 Lot Size(sq. ft.): 15986.52 Owner: KONIECZNY ANN MARIE Zoning: URB(100)/ Applicant: ADAM QUENNEVILLE AT. 57 PINE ST Applicant Address: Phone: Insurance: 160 OLD LYMAN RD (413) 536-5955 0 Workers Compensation SOUTH HADLEYMA01075 ISSUED ON.9/10/2019 0:00:00 TO PERFORM THE FOLLOWING WORK.-REMOVE AND REPLACE RIDGEVENT AND CAP SHINGLES 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 9/10/2019 0:00:00 $40.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner -it &0lun TPC yi 5Department use only City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit t , 212 Main Street Sewer/Septic Availability Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 Fax 41pgi TMY Site Plans 6 r Spe ify APPLICATION TO CONSTRUCT,ALTER` REPAIR, RENOVATE OR DEM LISH A ONE OR TWO FAMILY DWELLING i SECTION 1 -SITE INFORMATION j nFPT OF rUIu)INc,INSPECTION g his ection to be completed by office 1.1 Property Address. L. NORTHAMPTON.PAA01pro 3 �} /0 Lot (,,�L// Unit f Zone Overlay District Elm St. District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: AJ)r, 0^,ar� r_ �L'��t' ctr , �1 P..,C_ S� f IorcrlCt � A oi�i � C Name(Print) Current Mailing Address: Telephone Signature 2.2 Authorized Agent: Name(Print) Current Mailing Address: 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 2. Electrical (b) Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee (� 4. Mechanical (HVAC) R 5. Fire Protection 6. Total = 0 +2+ 3 +4 + 5) V �('� ��' Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: ('� q} Building Commissioner/Inspector of Buildings Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) 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 _ _... Fronta e Setbacks Front Side L:= R:= L:= R: Rear - Q Building Height t--t Bldg. Square Footage % 3 Open Space Footage % (Lot area minus bldg&paved parking) #of Parking Spaces t Fill: 1 (volume&Location) A. Has a Special Permit/Variance/Finding ever ben issued for/on the site? NO © DON'T KNOW 0 YES IF YES, date issued: IF YES: Was the permit recorded at the Regist of Deeds? NO ® DONT KNOW 0 YES 0 IF YES: enter Book Page and/or Document # r B. Does the site contain a brook, body of water,or wetlands? NO 0 DON'T KNOW () YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained ® Otjtained Q , Date Issued: C. Do any signs exist on the property? YES ® NO IF YES, describe size, type and locatio D. Are there any proposed changes to or additions of signs intended for the property? YES ® NO Q 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. SECTION 5- DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Or Doors 71 0 Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [Q Siding[O] Other[0] Brief Description of Proposed Work: Ceo-o ve act- c iaec ue nk an 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 k 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 X 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, , 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 � � l !`J C}C�.-� v c t (� Q u cff1 1 n Q A J► I r t Ise) C.- as Owner/Authorized Agent hereby declare that the statements and information-tin the foregoing applicakion are true and accurate,to the best of my knowledge and belief. Signed under the pains and penalties of perjury. Sc-TI Print Na Sig ture of Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: rNot Applicable ❑ Name of License Holder: .n1 LJ t,r� y�►ln� U� L QyU ` ^( �n SI d11^1 Irlc- C S— 0-10 U7C, License Number uo of L (2, rh'A oto-K-. -jai I -)-1 Address Expiration bate 5qS"�� Sigr Telephone 9. Registered Home Improvement Contractor: I Not Applicable ❑ �c►Qrh �V< rintUi �1� +c ovt i�� l�+r� Ji 05-15 ( 5 ao Company Name Registration Number Ic,o old 0_4 so,A� Naj((L r'),% 010-7� 11 /30111 Address U Expirattion bate Telephone-4113 rJ3� _.SSn 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...... ❑ City of Northampton Massachusetts DEPARTMENT OF BUILDING INSPECTIONS rrJ ti� 212 Main Street • Municipal Building Northampton, MA 0106011a 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.G.L.Chapter 142A requires that the"reconstruction, alteration, renovation,repair, modernization, conversion, improvement, removal, demolition, or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units....or to structures which are adjacent to such residence or building"be done by registered contractors. Note:If the homeowner has contracted with a corporation or LLC,that entity must be registered Type of Work: "e-Nu wt. a,,. ( t'plaCc. Cc,p 4n�. uta\ Est. Cost: -7 G ,co Address of Work: rJ P o n c 5 1 I o t P nc L n"1 t4 0 O G Date of Permit Application: � 110' 1 g 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.G.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: 911010 /J clarr, Quenneu,IJC, eoXn a•►d 51 dm i /nc- 05`151x0 Date Contractor Name 141C 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 iG DEPARTMENT OF BUILDING INSPECTIONS , 212 Main Street • Municipal Building 5Jy3� 0Ch4 Northampton, MA 01060 Massachusetts Residential Building Code Section 110.R5.1.2 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. Section 110.R5.1.3.1 Any homeowner performing work for which a building permit is required shall be exempt from the licensing provisions of 780 CMR 110.R5, provided that if a homeowner engages a person(s) for hire to do such work, then such homeowner shall act as supervisor. 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. City of Northampton Massachusetts �� �.- '< DEPARTMENT OF BUILDING INSPECTIONS � 212 Main Street •Municipal Building Northampton, 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 properly licensed solid waste disposal facility, as defined by MGL c 111, S 150A. The debris from construction work being performed at: 5-� PI r,C- 5 t TIo(en( C. 0)b" O (Please print house number and street name) Is to be disposed of at: ��Gm Q�C►1+1CUr1�� C..crat jrl 1 (,o d� � Yhur, IL� SVUTI Natj(c, ! 'gel 0/0-?C (Please print name and locatioTI of facility) U Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) Si nature 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. The Commonwealth of Massachusetts Department of Industrial Accidents v; 0 1 Congress Street,Suite 100 < Boston,MA 02114-2017 www mass.gov/dia NVorkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Aoolicant Information Please Print Leeibly Name(Business/Organization/Individual): Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with employees(full and/or part-time).' 7. ❑New construction 2.rl I am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance requir�/d 10 ❑ Building addition 4.�[am a homeowner and will be hiring contractors to conduct all work on my prol ensure that all contractors either have workers'compensation insurance or are s 11.[]Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.M I am a general contractor and I have hired the sub-contractors listed on the attac13.❑Roof re airs These sub-contractors have employees and have workers'comp.insurance? p6.a We area corporation and its officers have exercised their right of exemption per 14.❑Other 152,§1(4),and we have no employees.[No workers'comp.insurance required. *Any applicant that checks box#1 must also fill out the section below showing their w rkers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then outside contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name f the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their worke comp.policy number. I am an employer that is providing workers'compensation insur nce for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy decla ation page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, 5A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in he 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 rwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Signature: Date: Phone#: 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#: r Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states."Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. #617-727-4900 ext.7406 or 1-877-NIASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia AC RV CERTIFICATE OF LIABILITY INSURANCE ° 6/2 ) 4/20 9 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 CUNTA T NAME: Sarah Premo Martin J Clayton Insurance Agency, Inc. Pcv°N Ext: (413)536-0804- ac No: (413)534-7874 1649 Northampton Street E-MAIL ADDRESS: spremoQmjclayton.com P. O. Box 989 INSURERS AFFORDING COVERAGE NAIC M Holyoke MA 01041-0989 INSURER A:Nautilus Insurance Company INSURED INSURER B:Green Mountain Insurance Company Adam Quenneville Roofing S Siding Inc. INSURER C:AIM Mutual Insurance Company 160 Old Lyman Road INSURER D INSURER E: South Hadley MA 01075 INSURER F: COVERAGES CERTIFICATE NUMBER:2019 MASTER 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 CONTRACTOR OTHER DOCUMENT VVITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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. INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER MM DDY EFF POLICY EXP RIYYYY MMIDDfYYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE X�OCCUR DAMA D 100,000 PREMISES Ea occurrence) $ X Y NN1000129 6/23/2019 6/23/2020 MED EXP(Any one person) $ 5,000 PERSONAL 6 ADV INJURY $ 1,000,000 GENIAGGREGATELIMITAPPLIESPER- GENERAL AGGREGATE $ 2,000,000 POLICY PRO- I LOC PRODUCTS-COMPIOPAGG $ 2,000,000 OTHER $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 Ea accident ANY AUTO BODILY INJURY(Per person) $ B X ALL OWNED SCHEDULED AUTOS X AUTOS X Y 20030/65 6/23/2019 6/23/2020 BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE $ HIREDAUTOS X AUTOS Per accident $ X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 5,000,000 A EXCESS LIAB HCLAIMS-MADE AGGREGATE $ 5,000,000 DED I I RETENTION$ AN069764 6/23/2019 6/23/2020 $ WORKERS COMPENSATION x PER TH- AND EMPLOYERS'LIABILITY YIN STATUTE I I ER ANY PROPRIETOR/PARTNER/EXECUTIVE AWC4001012861 4/29/2019 4/29/2020 E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? ❑ NIA C (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT 1$ 1 00,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached B more apace Is required) Workers' Compensation benefits will be paid to Massachusetts employees only. Pursuant to Endorsement WC 20 03 06 B, no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires, or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued (unless the expiration date on the above policy precedes the issue date of this certificate of insurance) . The status of this coverage can be monitored daily by accessing the Proof of Coverage - Coverage Verification Search tool at www.mass.gov/lwd/workers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE FOR PERMITS ONLY THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ,�y7 Michael Regan/FMT ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD INS025(201401) f The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street, Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED wTTH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/individual): 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.V1 an a employer with 15 inployees(full and/or part-tune).* 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. F-1 Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.] 10 Q Building addition 4.❑1 am a homeowner and will be hiring contractors to conduct all work on my property. [will ensure that all contractors either have workers'compensation insurance or are sole I L❑Electrical repairs or additions proprietors with no employees. 12.L]Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These subcontractors have employees and have workers'comp.insurance.* 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.0 Other 152,§1(4),and we have no employees.[No workers'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 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 have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I 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 — Policy#or Self-ins.Lic.#: AWC40070128612019A Expiration Date: 4/29/2020 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$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. do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Signature: Date: 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): 1. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: r Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Constructi6ri�§Upervisor CS-070626 Expires. 08/21/2021 ADAM A QUENNEVILLE 160 OLD LYMAN RD SOUTH HADLEY MA 01075 to r Commissioner %�� (.Jlr�7'?..a/Yl-ly/T�/.11t°(?.•J`,>�?-' 4�_/l�llc�rlll�CCC�1{,/*i��/ri 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: 191093 160 OLD LYMAN RD. Expiration: 03/22/2020 SO. HADLEY,MA 01075 Update Address and Return Card. SCA 1 A 20M.W17 :!}l. .+�'.vh�! ^y3 �+�..i•.L;�,. 'n� "l�%;r rc•>};� ::�,y..* r..Ry^ '•.p.• .:r.;�� -y^r..� i•i>,;,� -.;of C,rr r `�X .X 1�1;. •;k-} -:;>.,, r STATE OF CONNECTICUT ♦ DEPARTMENT OF CONSUMER PROTECTION T Be it known that r ADAM QUENNEVILLE f rs. 160 OLD LYMAN ROAD f` SOUTH HADLEY, MA 01075-2632 j l i s r r ! ; r has satisfied the qualifications required by law and is hereby registered as a ��" HOME IMPROVEMENT CONTRACTOR Registration # HIC.0575920 ADAM QUENNEVILLE ROOFING �r Effective: 12/01/2018 _ Expiration: 11/30/2019 1Tich•tlr Seagull.[rrtnmiwiuner r ��-- � 20 ROOOFNG w SIDING AWARD VISA GVDISCOVER J 160 Old Lyman Road•South Hadley•MA 01075 We are Licensed 1.800.NEW.ROOF • 413.536.5955 Fully 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 Assoc.of Western Mass. CT Registration#575920 Member of the Building&Trade Association P.P.0 38710 Proposal Submitted To: Date: Phone#'s: C: Ann Marie Konieczny 6/14/19 H: 413-584-3284 W: Street: Email: 57 Pine St City,State,Zip Code: Florence MA 01062 Proposal to furnish and install the following: Remove and replace cap on entire house and porches Cut in ridge vent on house where possible IKO Dual Black Be extremely careful of the flower and garden beds around house Ask us about affordable bank financing! 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.Please remove any lawn ornaments or yard furniture.Adam Quenneville Roofing will not be responsible for debris or dust in the attic or storage areas. Customer Initials: We propose hereby to furnish materials and labor—complete in accordance with above specifications for the sum of: Total Due:(S 1,670.09 ACCEPTANCE OF PROPOSAL:The above prices,specifications and conditions are Pdck# Down Payment:($ 750.00) satisfactory and are hereby accepted.You are authorized to do work as specified. I 2nd Payment at Start Job:($ ) Payment will be 1/3 down at signing,1/3 at start of job,and balance due Balance Due Upon Completion:($ 920.00 ) upon completion. Date: Signature: Date: 6/14/19 Estimator:(Print Name) Scott Sedlak (Sign Name) Estimates are honored for sixty(60)days from above date. NOTICE OF SCHEDULE CHANGES The contractor agrees that when delays become known to the Contractor,the Contractor will advise the Owner as soon as reasonable. DELAYS IN THE COMPLETION SURE TO HIDDEN CONDITIONS The Owner hereby acknowledges and agrees that in certain remodeling work,the demolition of portions of the pre-existing structure may reveal additional defects,conditions or the need for additional work,which must be repaired,altered or carried out in order to commence or complete the work described under the contract.In such case(s),the Owner agrees that the duration of the work and the scheduled date of completion may differ from the date on the front,and that such variation which is not avoidable by the Contractor shall not be considered to be a violation of the contract. ADDITIONAL WARRANTY INFORMATION All warranties for equipment supplied by the Contract under the Agreement shall be those given by the manufacturers of such equipment,which shall be and are hereby passed through directly to the Owner.Under such manufacturer's warranties,the Owner may be required to register or mail in a warranty card or other evidence of ownership and use of such equipment in order to activate such warranties. The warranty give the Owner specific legal rights,and Owner may also have other rights which vary from state to state.Under Massachusetts law,sale of goods carry an implied warranty of merchantability and fitness for a certain purpose.All material is guaranteed to be as specified.All work shall be completed in a workmanlike manner,according to standard practices.Any alteration or deviation from above specifications involving extra costs will be executed only upon written orders and will become an extra charge over estimate.All agreements are contingent upon strikes,accidents or delays beyond control. SUBCONTRACTING Contractor agrees that,notwithstanding any agreement for materials and/or labor between Contractor and third party,Contractor is responsible to Owner for completion of all work described in a timely and workmanlike manner. NO ACCELERATION OF PAYMENTS BUT ESCROWING ALLOWED The Contractor may not require payments to be made in advance of the times specified in the Payment Section(front)for the reasons the he deems himself or the payments to be insecure.If,however,he deems himself to be insecure,he may require,as a prerequisite to continuing the work described herein,that the balance of the payments under this contract that are in control of the Owner,shall be placed in a joint escrow that requires the signature of both the Contractor and the Owner for withdrawal. You agree to pay cash according to the terms shown above or,if we approve your credit,to sign a note provided by us for payment of the amount due.You also agree to sign a completion certificate upon completion of the work.If you fail to pay according to the above terms and have not signed our note,the entire unpaid amount becomes immediately due,and you must pay a collection cost equal to our actual collection costs up to 15%of the total amount you owe,plus attorney's fees and court costs.In addition,you understand that by failing to pay according to the above terms,the Contractor may have a claim against you which may be enforced against your property in accordance with the applicable lien-laws. INSURANCE Contractor will be responsible to Owner or any third party for any property damage or bodily injury caused by himself,his employees or his subcontractors in the performance of,or as a result of,the work under this Agreement.Contractor agrees to carry insurance to cover such damage or injury. The Contractor recognizes his obligation to maintain a workers'compensation insurance policy to cover his employees.Contractor further recognizes the obligation of any and all subcontractor to maintain a workers'compensation policy to cover their employees. Contractor maintains a liability insurance policy with minimum coverage limits of one million dollars($1,000,000.00) CONSTRUCTION RELATED PERMIT ACQUISITION The Contractor under provisions of Chapter 142A of the General Laws is required to apply for and obtain all construction-related permits.The Contractor shall not be deemed responsible for delays in the work described in this Agreement caused by regulatory permit granting or inspectional agencies,authorities or individuals. MODIFICATION This Agreement including the provisions relating to price and payment schedule cannot be changed except by a written statement signed by both the Contractor and the Owner.However,cancellation by Owner is allowed in accordance with the Notice of Cancellation. COMPLETENESS OF AGREEMENT FOR EXECUTION The Owner is hereby advised that he should not sign this Agreement unless and until all blank sections have been filled in or marked as void,deleted or not applicable,and until all exhibits and related or referenced documents that are incorporated herein are attached hereto. COPY OF AGREEMENT TO BE GIVEN TO OWNER The Laws of Massachusetts shall govern this Agreement.It must be executed in duplicate,and an original,signed copy hereof shall be given to the Owner at time of execution.No work under the Agreement shall begin prior to the signing of the Agreement and transmittal to the Owner a copy thereof. ARBITRATION In the event the Owner and Contractor have a dispute regarding any of the terms,conditions,provisions or performance of this contract,the parties agree to place the matter into arbitration before an independent arbitrator assigned by the American Arbitration Association to resolve their dispute.Owners acknowledgement of arbitration clause CANCELLATION Owner may cancel this contract within three business days of executing this document.Such cancellation must be in writing and delivered to the Contractor. Contractor reserves the right to cancel this contract at any time within thirty days of the date of this contract.If we cancel you will be promptly notified in writing by an authorized officer of Adam Quenneville Roofing&Siding Inc.If we cancel,we will promptly return any down payment(s)you have made.