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32A-122 (7) 67 KING ST BP-2021-1298 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 32A- 122 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-2021-1298 Project# JS-2021-002144 Est.Cost: $114800.00 Fee: $805.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: ADAM QUENNEVILLE 070626 Lot Size(sq.ft.): 28880.28 Owner: BAKER ADAM Zoning:CB(100)/ Applicant: ADAM QUENNEVILLE AT: 67 KING ST Applicant Address: Phone: Insurance: 160 OLD LYMAN RD (413) 536-5955 O _ Workers Compensation SOUTH HADLEYMA01075 ISSUED ON:5/7/2021 0:00:00 TO PERFORM THE FOLLOWING WORK:NEW 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 Framc: 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. 4 • • y9 . 3215, Certificate of Occupancy Signature, FeeType: Date Paid: Amount: Building 5/7/20210:00:00 $805.00 212 Main Street, Phone(413)587-1240, Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner / . Versionl.7 Commercial Buildingfermit May 15, 2000 Department use only 7' ., ;., City of Northampton Status of Permit: I' # `:��4, Building Department Curb Cut/Driveway Permit - ).,, qt ''./ , 212 Main Street Sewer/Septic Availability t,� ,:?" 6' t\, Room 100 Water/Well Availability %'= c�� Northampton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans j '� Other Specify APPLICATION TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION This section to be completed by office 1.1 Property Address: 67 King St Northampton Ma 01060 Map W} Lot I ZZ Unit Zone Overlay District Elm St. District CB District SECTION 2 -PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Adam Baker 67 King St Northampton Ma Name(Print) Current Mailing Address: 413-570-1130 Signature See contract Telephone 2.2 Authorized Agent: Adam Quenneville Roofing & Siding 160 Old Lyman Rd South Hadley Ma Name(Print) Current Mailing Address: / 413-536-5955 Signature /I Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building 114,800.00 (a) Building Permit Fee 2. Electrical i (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) fib A A i 5. Fire Protection 6. Total = (1 + 2 + 3 +4 + 5) Check Number / 0/0a This Section For Official Use Only Building Permit Number Date 69 ,a/ ,./L4( Issued Signature: & 5-7 2Dz1 Building Commissioner/Inspector of Buildings Date Versionl.7 Commercial Building Permit May 15,2000 SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 CUBIC FEET OF ENCLOSED SPACE Interior Alterations ❑ Existing Wall Signs ❑ Demolition❑ Repairs Additions ❑ Accessory Building❑ Exterior Alteration ❑ Existing Ground Sign El New Signs❑ Roofing® Change of Use❑ Other❑ Brief Description New roof,install duro last roofing system,per duro last scope of work. -- ; Of Proposed Work: SECTION 5-USE GROUP AND CONSTRUCTION TYPE USE GROUP (Check as applicable) CONSTRUCTION TYPE A Assembly ❑ A-1 CIA-2 CIA-3 CI1A CI A-4 ❑ A-5 ❑ 1 B ❑ B Business ❑ 2A ❑ E Educational ❑ 2B F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ I Institutional ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ 3B ❑ M Mercantile ❑ 4 ❑ R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑ S Storage ❑ S-1 ❑ S-2 ❑ 5B ❑ U Utility ❑ Specify: M Mixed Use ❑ Specify: S Special Use El Specify: COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND/OR CHANGE IN USE Existing Use Group: (.__ _ _ ___._.._�. Proposed Use Group: ._ ..._... ._._....__ __„......_. Existing Hazard Index 780 CMR 34):' Proposed Hazard Index 780 CMR 34) ,,, SECTION 6 BUILDING HEIGHT AND AREA BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY Floor Area per Floor(sf) 15t 151 0 2nd 0 2�e 0 - 3rd 0 3 d ___ .. _. . .__. .__.. 0 4th 0 4th 0 ...., __. Total Area (sf) Total Proposed New Constru,ction,(sf�._. Total Height(ft) 0 Total Height ft _ __ ___ 0 7. Water Supply(M.G.L. c. 40, § 54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone❑ Municipal El On site disposal system❑ Versionl.7 Commercial Building Permit May 15,2000 8. NORTHAMPTON ZONING 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 DON'T KNOW x YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO DON'T KNOW YES IF YES: enter Book Page and/or Document # B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 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 NO IF YES, describe size, type and location: E. Will the construction activity disturb clearin ,gradin 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. Versionl.7 Commercial Building Permit May 15,2000 SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES- FOR BUILDINGS AND STRUCTURES SUBJECT TO CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116 (CONTAINING MORE THAN 35,000 C.F. OF ENCLOSED SPACE) 9.1 Registered Architect: Not Applicable Name(Registrant): Registration Number Address Expiration Date Signature Telephone 9.2 Registered Professional Engineer(s): Name Area of Responsibility Address Registration Number j Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date 9.3 General Contractor Not Applicable Company Name: Responsible In Charge of Construction Address Signature Telephone City of Northampton 212 Main Street, Northampton, MA 01060 Solid Waste Disposal Affidavit In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building permit all debris resulting from the construction activity governed by this Building Permit shall be disposed of in a properly licensed solid waste disposal facility, as defined by MGL c 111 , S 150A. Address of the work: 67 King St Northampton Ma The debris will be transported by: Adam Quenneville Roofing & Siding The debris will be received by: Adam Quenneville Roofing&Siding Building permit number: Name of Permit Applicant Adam Quenneville Roofing & Siding Date Signature of Permit Applicant Versionl.7 Commercial Building Permit May 15, 2000 SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11) Independent Structural Engineering Structural Peer Review Required Yes - No lZ... SECTION 11 -OWNER AUTHORIZATION -TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1 Adam Baker , as Owner of the subject property hereby authorize Adam Quennevilee to act on my behalf, in all matters relative to work authorized by this building permit application. See contract 04/30/2021 Signature of Owner Date _ •-• 4 1 Adam Quen•nevill , 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. p g jiz Print Name 04/30/2021 Signature of Owner/Agent Date SECTION 12 -CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable 0 Name of License Holder: Adam Quenneville CS 070626 License Number 160 Old Lyman Rd South Hadley Ma 08/21/2021 Address Expiration Date 413-536-5955 Signature Telephone SECTION 13-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 )C No From: Adam Quenneville Roofing & Siding Inc. To: Jonathan Flagg Building Commissioner City of Northampton 212 Main Street Northampton, MA 01060 The Massachusetts Building Code, section 107.1 allows for an exclusion from requirements for construction control in certain situations. In accordance with code section 104.10, I request that you grant a modification to waive the requirement for construction control of the project at 67 King St. Northampton, MA 01060 _ because the work is of a minor nature, will not affect structural elements, health, accessibility, life or fire safety, and will be done in accordance with the prescriptive requirements of the code. Thank you for your consideration. - Respectfully, • / Vice President of Commercial Operations r� ry Q imms 4. * st AWARD VISAS O::R t) 0 k N ,. an+o W:.NER 160 Old Lyman Road•South Hadley•MA 01075 We are Licensed 1.800.NEW.ROOF • 413.536.5955 Fully Insured Email:irrt .$„0 t nwroe f. of Website:www.1800newroof.net Factory Trained MA Construction Supervisors Lic.#070626 MA Registration#120982 Factory Certified Installers Member of the Horne Builder's Asset.of Western Meta. CT Re:g!stratinn#475920 Member of the Building&Trade A•si•cladon p..P.0 3871.0 Proposal Submitted To: Date: Phone#'s: C: Greenfield Cooperative 4/23/2021 H: W: Street: Email: 67 King St. _— City,State,Zip Code: Northampton,MA 01060 . Proposal to furnish and install the following: Install Duro-last roofing system.' Install per Duro-last scope of work. See attached example specifications Section 9 - Bank 83,900.00, Section 2-Pure Bar!Sutter-34,900.00 If done at once Total- 114,800.00 Mk 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 u itfr Ftoiing will not be responsible for debris or dust in the attic or storage areas. Customer tMit! We propose hereby to furnish materials and labor—complete In accordance with above specifications for the sum of: Total Due:($114,800.00 l ACCEPTANCE OF PROPOSAL The above prices,specifications and conditions are Down Payment:($ 38,600.00 satisfactory and are hereby accepted.You are authorized to do work as specified. 2nd Payment at Start Job:($ 36,600.00 ) Payment will down at signing,1/3 at s and lance due Balance Due Upon Completion:($ 37,600.00 l upon co p Date: Signatur • + Date: 4123/2021 Estimator:(Print Name)S. Mir'iI! r (Sign Name) 624,41.0., s; 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 lierelaws. 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($1,000,000,0e) CONSTRUCTION RELATED PERMIT ACf1UtSfON 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 priee 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 riot 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 snail he 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 i ependent arbitrator assigned by the American Arbitration Association to resolve their dispute.Owners acknowledgement of arbitration 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.It we cancel you will be promptly notified in writing by an authorized officer of Adam Quenncviiie Roofing&Siding inc.If we cancel,we will promptly return any down payment(s)you have made. AC L® CERTIFICATE OF LIABILITY INSURANCE DATE THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Sarah Premo NAME: Clayton Insurance Agency, Inc. PHONE (413)536-0804 FAX 413l530-7814 (A/C,No,Eat): (A/C,No): 1649 Northampton Street E-MAIL ADDRESS: spremo@claytoninsurance.net P. O. BOX 989 INSURER(S)AFFORDING COVERAGE NAIC S Holyoke MA 01041-0989 INSURER A:Nautilus Insurance Company INSURED INSURER B:Green Mountain Insurance Company Adam Quenneville Roofing & Siding Inc. INSURER C:AIM Mutual Insurance Company 160 Old Lyman Road INSURER D: South Hadley, MA 01075 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:2020 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 r INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD� POLICY NUMBER IMM/DD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY _EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED A CLAIMS-MADE X OCCUR PREMISES (Ea occurrence) $ 100,000 NN1143748 6/23/2020 6/23/2021 MED EXP(Any one person) $ 5,000 PERSONAL 8ADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY JECT PRO- X PRODUCTS-COMP/OPAGG $ 2,000,000 X OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 - (Ea accident) B ANY AUTO BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED 20035707 6/23/2020 6/23/2021 BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE X AUTOS (Per accident) $ X HIRED AUTOS UNINS/UNDERINS MOTORISTS $ 100,000/300,000 X UMBRELLALIAB _ OCCUR EACH OCCURRENCE $ 5,000,000 EXCESS LIAR A CLAIMS-MADE AGGREGATE $ 5,000,000 DED RETENTION$ AN0B8790 6/23/2020 6/23/2021 $ WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000, OFFICER/MEMBER EXCLUDED? Y N/A C (Mandatory in NH) AWC4007012861 4/29/2021 4/29/2022 E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) For Informational Purposes Only CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Adam Quenneville Roofing & Siding Inc THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN 160 Old Lyman Rd ACCORDANCE WITH THE POLICY PROVISIONS. South Hadley, MA 01075 AUTHORIZED REPRESENTATIVE Michael Regan/FMT / Sri&c-r P ' "` ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025(201401) The Commonwealth ofM ssacI setts ig 4' Departmerzt-of Industrial Aeeidents I Congress Street,Suite d a Boston,ALI 02111-2017 - nrfirmnrassgov/dia Workers'Compensation Insurance Affidavit:BuiiIders/Con€ractors/Elecfiricians/Plumbers_ TO BE FILED MTH rak,PERMITTI&G AUTHORITY. Applicant Information Please Print Legibly Name Es itressrorganization/rrtdividual): 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): I.J 'r am a employer with 15 employees(full andfor part-time).* 7. El New construction2.❑Ian a sole proprietor or partnership andhaveno employees working forme in & []Remodeling any capacity.[No workers'camp_insurance required./ 3.0 I an w a horneaner doing all work myself[No workers'comp.insurance requircd.j t g_ 0 Demolition 10 0 Building addition ,4_ID I am a homeowner and will hehiring contractors td conduct all work as my property_ I will _ ensure that all cantractorseither have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.El Planzcirtg repairs or additions5.fl I ama general contractorand I have hired the sub-contractors listed on the attached sheet. 13 Roof repairs These sub-contractors have employees and have workers'cramp.insuntnce_t 6.I t We am a corporation and its officers have exercised their right of exemption per#lGL n. 14.Q Other 152, I{4},and we have no employees.[No workers'comp_insurance requircd.j *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 arc doing alt work and then hire outside contractors mast submit a new affidavit indicating such_ Contractors that check this hex must attached air 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 isprovidarg workers'conTerrsation insurance for my employees. Below is the policy and fob site tPtform¢tion. Insurance Company Name: AIM Mutual Policy#osSeEf-ins_Lie_ - AWC40070128612019A Expiration Date: it//9 ; '� , fob Site Address: C,1 K t� )+ City/State/Zip: N0 f I I\0-p fh O 1C C Attach a copy of the workers'corWpensation policy declaration page(showing the policy number and aspiration date). Failure to secure coverage as required underMGL c.152,§25A is a criminal violation punishable by a flue up to SI,500.00 and/or one-year imprisonment,as well as civil penalties in the forms of a STOP WORK ORDER and a ffne 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 verifcatiort. I ea hereby certify carder pairs axd penalties of perfuly that the information provided alcove is liac and correct Signature: Date: 5 13/?) Phone#: 413-536-5 5 Official use only. Da not write in this area,to be completed by city or town official. City or Town: Permit/License€t Issuing Authority(circle one): i_Board of Health 2.Building Department 3.City/Town CIerk 4.Electrical inspector 5.Plumbing Inspector b_Other Contact Person: Phone l'#: w` Board of Building Regulations and Standards . Constri.t'itSact%t p rvisor CS-070626 LApires:08/21/2021 ADAM A CUV1NEif G-_ 160 OLD LYMAN R 40 SOUTH HADL Y MA" j. ;VP • /, {iFsS Iv Commissioner ! r A (652 /e 04.W nwea&A i P. (kJa le e1i Office of Consumer Affairs and Business Regulation 1000 Washington Street- Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Corporation ADAM QUENNEVILLE ROOFING AND SIDING INC. Re xpiration: 191093 Expaation: 03/22/2022 160 OLD LYMAN RD. SO.HADLEY,MA 01075 Update Address and Return Card. sca f et zoixesrn Ar w a w . a .:: fib_: a m a a 4 a ` wJi,. w i a r a dr r,,_fy o f mar: a �' a Ar a Ir STATE OF CONNECt'ICUT + DEPARTMENT OF CONSUMER PROTECTION ! Be it known that ADAM QUENNEVIJ.i.F, 160 OLD LYMANROAD ;II SOUTH HADLEY, MA. 01075-2632 has satisfied the qualifications requited by tasv and is hereby registered as a HOME IMPROVEMENT CONTRACTOR Registration # HIC.0575920 • j ADAM QLJENNFVILLE ROOFING Ex! Effective: 12/01/2(20XI& ,jg.,,AVA07 ) ; a011/30/202l fific a to&aka%Commtruoeer • p