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23A-168 (2) i 57 PINE ST BP-2020-0413 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block:23A- 168 j CITY OF NORTI3AMPTON . Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY jFUND (MGL c.142A) Category: ROOF BUILDING PERMIT Permit# BP-2020-0413 Proiect# JS-2020-000700 Est. Cost: $10800.00 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 () Workers Compensation SOUTH HADLEYMA01075 ISSUED ON.101112019 0:00:00 TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE 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: I 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. I Certificate of Occupancy Signature: FeeType: Date Paid: Amount: Building 10/1/2019 0:00:00 $40.00 212 Main Street, Phone(413)587-1240, Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner E C E_I >° µ City of Northam ton r Pe_Y It - .� �. Building Depart ent. Cuct�C Dnv(way Permit , 212 Main Stre t OCT - 1 � verl apt c vaifability Room 100 3ilability ?� Northampton, MA 10 T o cturl Plans' _ K ,� �� P :• phone 413-587-1240 Fax 413°5q�?frnr�c iretv I,TON 'N��an F/ M 77 APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONEiOR TWO FAMILY DWELLING SECTION 1 `SITE INFORMATION 1.1 Property Address: �� T.his section to be completed by office Map ' Lots Umt �1 Gf emGcl 0 10 GZone `�° Overlay District �. Elm St.Dlstrlct ' ' �� CB;�Dlstrict� � ' SECTION 2 PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: /In,) 5.1 P?ne St I F1,,(ee1cc 0).g 0/6 L Name(Print) Current Mailing Address: I� ��_ Sad L� 5e C Coy.,\Cc�c K Telephone Signature 2.2 Authorized A-gent: A c)c^, Queoineut Ile Qe, ;�, / 'o Old 2 d ja 140 cIe,� Name(Pri ) Current Mailing Address: l3 - 53L -59 Signatu a Telephone SECTION 3-ESTIMATED.CONSTRUCTION=COSTS. Item Estimated Cost Dollars to be ;r i (Dollars) Offcial Use Only completed by permit applicant 1. Building ,U FOO . 00 (a)Building'.Permit Fee 0 , 2. Electrical (b),_Estimated Total`Cost of` 'Construction from 6 , 3. Plumbing Building Permit Fee ; r 4. Mechanical(HVAC) 5. Fire Protection 3 6. Total=0 +2+3+4+5) /(d $Qa. ev Cfieck•Nuinber ,.t. 'This"Section For OfficiallJse_Onl Bwldirig Permit Numb r ;f �:, Date k ,{Issued 721 Signafure Building Commissioner/Inspector of Buildings :Date.•. r 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 Frontage I F Setbacks Front Side L:= R:= L:= R:= Rear s Building Height Bldg. Square Footage % �--] Open Space Footage l % (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 YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW tich YES IF YES: enter Book Pagel and/or Document#�� B. Does the site contain a brook, body of water or wetlands? NO k_.,j DON'T KNOW YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained , Date Issued: —� C. Do any signs exist on the property? YES NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES 0 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 NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. SECTION 5-DESCRIPTION OF PROPOSED WORKr(check,all aoalicatile) r-n F New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [0 Siding[0] Other[ED] Brief Description of Proposed 1 / n Work:_ i2emovr Qa,� f ePlar-C S��n�JQ �rke le ��t Ur4le0'k1rer\ JQ« , ICe fiW�ier � t&'0,nr/fidje Vtr. I / Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement I Yes X No Plans Attached Roll -Sheet sa If Neviri o6i'Wand;or atlditi ex�'�� i'a' d irla;t�"compli teal"Kill iwo n : I a. Use of building:One Family Two Family Other j b. Number of rooms in each family unit: Number of Bathrooms I 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 l Number of each i 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 - OWNER$-AGENT OR CONTRACTOR APPLIES FOR BUILDING /�, 1 '10Lr Act /soy) 0y)1 t e 2h ,as Owner of the subject property n) + hereby authorize //�V Jot 0,1 ( Cuf_' _Ncul 1�C to act on my behalf, in all matters relative to work authorized by this building permit application. Se e. CG n cae'C 9130119 Signature of Owner Date OEM— J ,as Owner/Authorized Agefit hereby declare Mat the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed under the pains and penalties of perjury. A&a4, Q�,INAIA r Print Name 'Lu-_ q JSD1 �5 Signature of Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES., 8.1 Licensed Construction Supervisor: Not Appicable ❑ Name of License Holder: A je-as l 1�yC� ne-U9 1I C C3 G")`0 G DC License Number l.,0 Q L,►�.�,.. 2 �o N OLJIeA (bA 010-7ry),b I Address U Expirati n D e dl�, yi3 -53(-, - 51 Signature Telephone 1ReuistereCVR06 a lmbrov®ment=GontractoE� , . ,,rye.. ., . < � Not Applicable ❑ 4OAV, IQUCY)MV11l6 toof,,)kL4 St /q /®q] Company Name Registration Number I l.G 4i Lr Q S� ala�I� �,A ®1o� j 2a/�� Address A U Expiration Date Telephone'913 S3(,55 0' SECTION 1O WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M G:L 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 :7 DEPARTMENT OF BUILDING INSPECTIONS yi F A i pia 212 blain Street • Municipal Building Jy1A tb Northampton, MA 01060 i AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application The Office of Consumer Affairs and Business Regulation("OCABR")regulates theiregistration 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: (ZUCr(n . . Est. Cost: 1 /® F00 . Go Address of Work: 5 P I r)C. 5'T t i c)t C rbc c 0-)13 a lG L p I Date of Permit Application: 913011 I i 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: .1130[17 A C2 rauenrle,V1111, k0t /,'1 7 J C 0 � � ( / 02-7 Ddte Contractor Name MC Registration No. I OR: :. Notwithstanding the above notice,I hereby apply for a building permit as the owner of the above property: Date Owner Name and Signature I City of Northampton Massachusetts DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • municipal Building yJk, a P 4 ." Northampton, MA 01060 . ss •�,,ti 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 �Q?S x • s��r<< ,� G DEPARTIWNT 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: 57 P i n c '51 Tlow)u_ rnA OfOG)_ (Please print house number and street name) Is;to be disposed of at: i i (Please print name and location of facility) a Or will be disposed of in a dumpster onsite rented or leased from: USA IgOyI14 C C(i� �hC 5 t'?')U (cn � Z �nk ie � Z � G�0o y (Company Nbtne and Address)- Signature dress)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. j The Commonwealth of Massachusetts Department of IndustrialAccidents_ 1 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 (Business/Organization/Individual): Address: City/State/Zip: Phone M Are you an employer?Check the appropriate box: Type of project(required): 1.[]I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.❑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. El Demolition 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 E]Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.E]Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.E]Roof repairs These sub-contractors have employees and have workers'comp.insurance.: 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 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 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: Policy#or Self-ins.Lic.M Expiration Date: 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. 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#: I a ® r �AA &M BBB QU E N N E V 1 L L E Winner of the TORCH AWARD ROOFING 'W SIDING W WINDOWS 160 Old Lyman Road•South Hadley•MA 01075 We arelLicensed 1.800.NEW.ROOF • 413.536.5955. Fully Insured Email:InfoC►1800newroof.net Website:www.1800newrooEnet Factory Tralned MA Construction Supervisors Lic.M070626 MA Registration#120982 Factory Certified Installers Member ofthe Home Builder's Assoc.of Western Mass. CT Registration#575920 i Member of the Building&Trade Association PAC 38710 Proposal Submitted To: Date: I/t{e/jef Phone#'s: C: H l + vv- Street. : Stree_t: vk Email: City,State,Zip Code: 2 Proposal to furnish and install the following: EYQ� ate, I 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 focdebris or dust in the attic or storage areas. Customer Initials: I Additional materials and labor charges.may apply. Deteriorated existing decks g will be replaced at$3.77 per sq..ft.after full inspection Ask us about Customer Initials affordable bank Deteriorated existing dimensional lumber to be replaced at$5.00 per linear ft.after full inspection r '.(� financing! Customer Initials , f �Year WarrantY OPtions: 1 Year ^-1 5 Year 1� 0 i We propose hereby to furnish materials and labor—complete in accordance with above speclrications for the sum of: Total Due: ACCEPTANCE OF PROPOSAL-The above prices,specifications and conditions are Down Payment:($J,$5^6G U satisfactory and are hereby accepted.You are authorized to do work as specified. I Balance Due Upon Completion:($'l,qf 'Q 't Payment will be 1/3 down at signing and balance due upon completion. Date: Signature: Date: Estimator:(Print Name) ! Sign Name) ` Estimates are honored for sixty(60)days from above date. i ACOORID00 CERTIFICATE OF LIABILITY INSURANCE DTE x4/20 9 D/YYYY) 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.- RODUCER;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 CONTA NAME: Sarah Premo Martin J Clayton Insurance Agency, Inc. PHONE —0804 FA1X (413)534-7874ECAIC No =,t,: No 1649 Northampton Street A�E SS:spremo(imjclayton:com P. O. Box 989 INSURERIS)AFFORDING COVERAGE NAIC 4 Holyoke MA 01041-0989 INSURER A:Nautilus Insurance Company INSURED INSURERS:Green Mountain Insurance Company Adam Quenneville Roofing 6 Siding Inc. INSURERC:AIM Mutual Insurance Company 160 Old Lyman Road INSURER D: INSURER E: South Radley MA 01075 INSURER F: COVERAGES CERTIFICATE NUMBER:2019 MASTER PREVISION 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 WITH 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. INSRR ADDLISUTYPE OF INSURANCE IVSD W D POLICYNUMBER MMfDDYIYYYY EFF MMIDD EXP I LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE FOOCCUR DAMA GE T O RENTED 100,000 PREMISES Ea occurrence) $ X Y NN1000129 6/23/2019 6/23/2020 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENIAGGREGATELIMITAPPUESPER: GENERALAGGREGATE $ 2,000,000 POLICY JECT RI- FLOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT g 1,000,000 Ea accident B ANY AUTO BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED 20030465 6/23/2019 6/23/20201 BODILY INJURY Per accident $ AUTOS AUTOS X Y ( ) X HIREDAUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident $ X UMBRELLA LIAO OCCUR EACH OCCURRENCE $ 5,000,000 A EXCESSLUAB HCLAIMS-MADE AGGREGATE $ 5,000,000 DED RETENTION S AN069764 6/23/2019 6/23/2020 $ WORKERS COMPENSATIONx PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETORIPARTNERIEXECUTIVE AWC4007012861 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 S 1,000 000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES(ACORD 101,Additional Remarks Schedule,maybe attached I more space 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 Michael Regan/FMT ©1988-2014 AICORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD INS025(201401) I I { The Commonwealth of Massachusetts - Department=of lndustrialAccidents ' 1 Congress Street,Suite 100 3 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 (Business/Organization/Individual): Adam Quenneville Roofing & Siding InIc 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 o project(required): l.NdI am a employer with__15employees(full and/or part-time).* 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working forme in $. ❑Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition In I am a homeowner doing all work myself.[No workers'comp.insurance required.]+ 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10❑Building additi.on ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with'no employees. 12.❑Plumbing repairs or additions 5.F1 I am a general contractor and I have hited the sub-contractors listed on the attached sheet. 13.[�RoOf repairs. These sub-contractors have employees and have workers'comp,insurance.t 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.E]Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] 't { *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. tContractors 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 ant an ensployer that is providing workers'compensation insurance for my employees Below is the policy and job site information. q p AIM Mutual I Insurance Company Name: I t AWC40070128612019A ' 4/29/2020 Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address:. 'P11AA City/State/Zip: h�A Attach a copy of the workers'compensation policy declaration page(showing the policy nuifiber 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. I do hereby certify under ttheePains andpenaldes ofperjury that the information providd�edf above is true and correct Signature: Date: Phone#: 413-536-5955 Official use only. Do not write its 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#: Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Construef6ln'S pervisor CS-070626 ram j E ires:08/21/2021 " ADAM A QUENNEVILLE'Ae, 160 OLD LYMAN RC SOUTH HADLEY MAWJ075� Commissioner «cZClr% f1 Office of Consumer Affairs and Business Regulation One Ashburton Place - Suite 1301 Boston, Massachusetts 02108 Home Improvement_Cbntractor Registration Type: Corporation Registration: 191093 ADAM QUENNEVILLE ROOFING AND SIDING _INC-i Expiration: 03/22/2020 r� . << 160 OLD LYMAN RD. SO.HADLEY,MA 01075 IT- Update Address and Return Card. SCA 1 d 2pM•05117 villZ STATE OF CONNECTICUT' + DEPARTMENT OF CONS'01VIER PROTECTION Tae it known that` ADAM QUENNEVILLE 160 OLD LYMAN ROAD SOUTH HADLEY, MA 01075-26,32 . I has satisfied the qualificafions reclui'rcd by lav and is hercby registered as a HOME IMPROVEMENT CONTRACTOR Registration.# HYC:0575920 ADAM QUENNEVILLE ROOFING t v Effective: 12/01/2018 I Expiration: 11/30/2019 j Michelle Seagull,Commissioner �7 r � T W cry.__ —_~ _ ..tJ♦"r _..-�� L_ A'�G'�" "L`�'�'�'s I1" L'� I