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18C-050 (2) Department use only J 'j.. City of Northampton Status of Permit: '. rl ,'' Building Department Curb Cut/Driveway Permit IL f 212 Main Street �p Sewer/Septic Availability Room 100 �� Water/Well Availability '. 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 1.1 PropAddress: This section to be completed by office !{erty J1 (� (a5 J NOI.�'l\C Map-- � Lot I Unit ",Tc� -Tu, A O( c) 3 Zone Overlay District Elm St. District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) Current Mailing Addres yZ 3 A - 3? 2 Telephone Signature 2.2 Authorized Agent: Name7L--- Current Mailing Address: y/353(- 51 Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building 1 3LIO 00 (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = 0 +2 + 3 +4 + 5) 1 ")CIC- , w' Check Number Q y This Section For Official Use Only (� Building Permit Number: cam)" M Date Issued: Signature: 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 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 O DONT KNOW YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO Q DON'T KNOW J YES O IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO Q DON'T KNOW --(R� YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained V Obtained O , Date Issued: C. Do any signs exist on the property? YESO NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO IF YES, describe size, type and location: E. Will the construction activity disturb (clearing, grading, excavation, or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES O NO 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) Q Roofing Pq Or Doors E] Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [[] Siding [O] Other[U Brief Descriptof Proposed i n Work: t_ L Crin Gn �_ C I U; Alteration of existing bedroom Yes No Adding new bedroom Yes �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 new construction. Dimensions e. Number of stories? f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction i. Is construction within 100 ft.of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No j. Depth of basement or cellar floor below finished grade k. Will building conform to the Building and Zoning regulations? Yes No . I. Septic Tank City Sewer Private well City water Supply SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,- S J/)m ckr _ as Owner of the subject property n - I hereby authorize A jan, QVrnnCU11\U to act on my behalf, in all matters relative to work authorized by this building permit application. Se e con 1l 170Z� `f_/JL2a a6, Signature of Owner Date I, A(AcAm Qvennc'ud(C 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 penalties of perjury. ucnnG�i��� Print Nam All,1 ear) Signatu a of Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction/Supervisor: Not Applicable ❑ Name of License Holder: Acs AM i�tI1ISCU►II( C-5 0-10(3(0 License N tuber ILO O I L Ma., (LSo(1 I�a le (Y1 o lot 5 �' a I c3 i Ad drEx iratio Date Z-- /-, gnature Telephone 9. Registered Home Improvement Contractor: 11 Not A(�pplicable ❑ 4Q1Ot , Q.UPnrr.u,hL &JI"r 4 �1C'IrC �i7C. 191oq� Company Name 0 0 Reg'stratio Number 0 14 00� L � o- ie MA o,o� ' 3 as a Addres ^ �^ Expi ation Date Telephone ,J/3 51,59)t' 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 W. � Massachusetts ��' '•;;. DEPARTMENT OF BUILDING INSPECTIONS r 212 Main Street •Municipal Building "E 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: (Please print house number and street name) Is to be disposed of at: A&V' Qvcnncul lk zc,al in.c / (.,0 01j l-,rnG h Q-A 14CLAC6 MIA 0/0-'C- (Please print name and ibcation of facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) k q I, 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. The Commonwealth of Massachusetts r Department of Industrial Accidents A = 1 Congress Street, Suite 100 Boston, MA 02114-2017 N �* www mass.gov/dia NVorkers' 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 #: Are you an employer?Check the appropriate box: Type of project(required): I.❑1 am a employer with employees(full and/or part-time).* 7. ❑ New construction 2.❑1 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 10 ❑ Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 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.❑1 am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers'comp.insurance.t 13.❑Roof repairs 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. /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.#: 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. /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#: a r. Get a JD0 QUENNEViLLE vv� (") (7� It4 SI INCA 160 Old Lyman Rd • South Hadley,MA 01075 1.800.NEW.ROOF • 413.536.5955 www.RoofNhampoo.com Email: roofshampoo.agrs@gmail.com Website:www.1801)newroof.coni MA Construction Supervisors Lic.#070626 MA Registration#120982 Member of the Home Builder's Assiociation of Western Mass. CT Registration#575920 Member of the Building and Trade Association Customer Sharon Inman Address: 65 B Hatfield St City: Northampton State: MA ZIP: 01053 Email: Home: Office: Cell: 413-822-0397 NO BILL WILL BE SENT -- PAYMENT DUE UPON COMPLETION OF WORK. Roof Shampoo@ is the eco-friendly • • • solution that does NOT • chlorine • • • • ' • • • • •O . • • . • landscaping. • of :art equipment delivers a soft, gentle low pressure water rinse. Absolutely NO damaging high pressure and NO scrubbing. The Customer agrees that Adam Quenneville Roofing has the right,at its sole discretion,not to proceed with the job if working conditions are deemed unsafe. In addition to algae growth,which is characterized by dark,streaking stains,some roofs also have lichen colonies,fungus,and moss. Lichen colonies,moss,and thick algae sometimes eat through the granules on the shingles into the roof deck. Removing these may reveal granule loss caused by the lichens,moss,or thick algae growth.Adam Quenneville Roofing is not responsible for granule loss due to the damage caused by lichen colonies,moss,and thick algae. The Customer affirms that there are no existing roof leaks,failed flashing,leaky vent pipes,or other opportunities for water intrusion into the home or basement through windows,foundation cracks,etc. Adam Quenneville Roofing hereby offers to perform the work listed below for the amount shown. Description of Work ROOF CLEANING $ 1, 787 Clean algae,fungus,and/or moss related stains by treating areas(s)indicated Roof Shampoo $ 3, 100 below. Roof Tune Up $ 495 Roof in Front of House Only Roof in Back of House Roof—Maxx $ 2, 945 Coupon Discount $ 2, 082 (25%) Entire Roof Other Affected Areas Total All Services $ 6, 245 Notes Replace all ridge cap and ridgevent 2, 000 Deposit Received $ Balance Due $ 4, 245 Best time of the day for project: morning afternoon anytim Is there a preferred day of the week? 4/11/2020 DATE: SIGNATURE: ACCEPTANCE OF PROPOSAL:The above prices,specifications and conditions are satisfactory and are hereby a epted.You are authorize to do w as specified.Payment will be 1/3 down at time of signing,and balance due upon completion. 4/11/2020 DATE: SALESPERSON:(Print Name) Dustin Peters (Sign Name) ACO CERTIFICATE OF LIABILITY INSURANCE FDATE 6/224/2019412019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLYAND 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 ICDE: Sarah Premo Martin J Cla ton Insurance en Inc. NE (413)536-0804 AC No: 1�13)s3�-)e 0 y Ag cl'r NoExt1649 Northampton Street AIL spremo@mjclayton.comRESS: P. O. Box 989 INSURER 5 AFFORDING COVERAGE NAIC tl Holyoke MA 01041-0989 INSURER A:Nautilus Insurance Company INSURED INSURER B:Green Mountain Insurance Com an Adam Quenneville Roofing & Siding Inc. INSURERC:AIM Mutual Insurance Company 160 Old Lyman Road INSURER D: INSURER E South Hadley NIA 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 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. ADDL SUER PODCY EFF POLICY EXP rALTR TYPE OF INSURANCE POLICY NUMBER MMIDD/YYYY MM/DD/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMA R NT ❑ 5 100,000 CLAIMS-MADE X❑OCCUR PREMISES Ea occurrence X Y NN1000129 6/23/2019 6/23/2020 MED EXP(Any one person) 5 5,000 PERSONAL 8 ADV INJURY 5 1,000,000 GEN'LAGGREGATE LIMITAPPLIES PER'. GENERAL AGGREGATE $ 2,000,000 JECT F LOC PRODUCTS-COMPIOPAGG 5 2,000,000 POLICY � 5 OTHER: AUTOMOBILE LIABILITY Ea accidentSINGLE LIMIT S 1,000,000 BODILY INJURY(Per person) 5 ANYAUTO B ALL OWNED X SCHEDULED X Y 20030465 6/23/2019 6/23/2020 BODILY INJURY(Per accident) S AUTOS AUTOS ED PROPERTY DAMAGE S X HIREDAUTOS X AUTOS Per accident 5 X UMBRELLURETENTI OCCUR EACH OCCURRENCE 5 5,000,000 A EXCESS LIASCLAMS-MADE AGGREGATE $ 5,000,000 DEO 115706976? 6/23/2019 6/23/2020 5 WORKERS COMPENSATION x STATUTE OERH AND EMPLOYERS'LIABILITY YIN E.L.EACH ACCIDENT 5 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE Ai7C4007012861 4/29/2019 4/29/2020 OFFICERIMEMBER EXCLUDED? ❑ NIA E.L.DISEASE-EA EMPLOYEE 5 1,000,000 C (Mandatory In NH) If yes,describe under DESCRIPTION OF OPERATIONS bete. E.L DISEASE-POLICY LIMIT S 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may 6e attached if more space Is requlmd) 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 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD INS025(201401) Commonwealth of Massachusetts ® Division of Professional Licensure Board of Building Regulations and Standards Construction Su"rvisor it CS-070626 Uires: 08121/2021 ADAM A QUENNEVILLE ` 160 OLD LYMAN RD SOUTH HADLEY MA 01 y ff OISNIAO-Is' Commissioner ,�1/ �--- Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Corporation _A r „ Registration: 191093 ADAM QUENNEVILLE ROOFING AND SIDING, INCii I� 160 OLD LYMAN RD. Expiration: 03/22/2022 �� SO.HADLEY,MA 01075 Update Address and Return Card. STATE OF CONNECTICUT ♦ DEPARTMENT OF CONSUMER PROTECTION i Be it knovm that I }; I ADAM QUENNEVILLE 160 OLD LYMAN ROAD t, `;�'€ ti . .IJT . „ SOUTH HADLEY, MA 01075-2632 I1Wh has satisfied the qualifications required by law and is hereby registered as a ° HOME IMPROVEMENT CONTRACTOR t 'I Registration # HIC.0575920 I' ADAM QUENNEVILLE ROOFING i Effective: 12/01/2019 Expiration: 11/30/2020 r Miebelle Seagull,Cammissiuner j ---- �� ♦ ♦ ♦ 1 wY The Conlnlotnvealth of Massachusetts Depa1•tment.of Industrial Accidents I Congress Street,Sitite 100 Boston,,UA 02114-2017 M 1v1vw.lnass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FiLED N1•'iTH THE PERI�4ITTI1\C AUTHORITY. Applicant Information Please Print LeQibiv 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 boa: Type of project(required): 1.VI an a employer with___1_5 _employees(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. E]Remodeling any capacity.[No workers'comp.insurance required.] 9_ ❑Demolition 3.Q i am a homeowner doing all work myself[No workers'comp.insurance required.]t 10E]Building addition 4.Q I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.Q I am a general contractorand I have hired the sub-contractors listed on the attached sheet. 13-eRoof repairs These sub-contractors have employees and have workers'comp.insurance.t 14.E]Other 6.Q We are a corporation and its officers have exercised their right of exemption per 1rfGL C. I53, §1(4).and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. t Hmneowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Contractors that checkthis box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their «workers'comp.policy number. I avi an employer t/rat isprovi(lirtg workers'contperrsatioat irtsurance for my employees. Below is the policy and job site information. AIM Mutual Insurance Company Name: — AWC40070128612019A4/29/2020 Policy#or Self-ins.Lic.#: Expiration Date: �^ Job Site Address: G53 N dk�,C Q <Jt City/State/Zip: �Orl (/"t MA 0/0 J Attach a copy of the workers'compensation policy declaration page 01101ving the policy number and exp ration 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 DTA for insurance coverage verification. I7Si hereby certify urld the pains acrd penalties of perjury that the information provided above is true attd correct. ature: Date: Phone#: 413-536-5955 EN: only. Do Trot write in this area,to be completert by city or town offrcial. n: Permit/License# hority(circle one):Health 2.Building Department 3.City/Torn Clerk 4.Electrical Inspector 5.Plumbing Inspector rson: Phone#: