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13-101 (10) 120 COLES MEADOW RD BP-2021-1415 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 13 - 101 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-2021-1415 Project# JS-2021-002353 Est.Cost: $11880.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: ADAM QUENNEVILLE 070626 Lot Size(sq. ft.): 71177.04 Owner: BALL EILEEN Zoning: Applicant: ADAM QUENNEVILLE AT: 120 COLES MEADOW RD Applicant Address: Phone: Insurance: 160 OL_,D LYMAN RD (413) 536-5955 O Workers Compensation SOUTH HADLEYMA01075 ISSUED ON:6/1/2021 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: 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. yo • Certificate of Occupancy si;,matnrc:j • • • ! I FeeType: Date Paid: Amount: Building 6/1/2021 0:00:00 $40.00 212 Main Street, Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner r Y Department use only c1444; City of Northampton Status of Permit: Building Departme)hi � Curb Cut/Driveway Permit 212 Main Stre 4/0 Sewer/Septic Availability �F Room 100 ar Water/Well Availability Northampton, M4 060 � Tyvo Sets of Structural Plans phone 413-587-1240 Faxt-4 3- -1272 Plot/Site Plans yn;`^r> Other Specify q r4r APPLICATION TO CONSTRUCT,ALTER, REPAIR, REN �P DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION This section to be completed by office 1.1 Property Address: 120 Coles Meadow Rd Northampton Ma 01060 Map Lot 1 D / Unit Zone Overlay District Elm St. District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Eileen Ball 120 Coles Meadow Rd Northampton Ma Name(Print) Current Mailing Address: 617-335-6699 see contract Telephone Signature 2.2 Authorized Agent: Adam Quenneville 160 Old LymanRd South Hadley Ma 01075 Name(Prin Current Mailing Address: 413-536-5955 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 11,880.00 2. Electrical (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee 42-K 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 +4 +5) 11,880.00 Check Number / 0 2/ 2 This Section For Official Use Only Building Permit Number: ba - ),i 14(6 I sssuu ed: ///// Z- /- ZOZ Signature: Building Commissioner/Inspector of Buildings Date operations.aqrs @ gmail.com 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 DON'T KNOW )( YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO DON'T KNOW x YEC-1 IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW x 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? YE5 NO x IF YES, describe size, type and location: E. Will the construction activity disturb clearing,gradin excavation, or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YE 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 [ I Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [E] Decks [❑ Siding [0] Other[0] Brief Description of Proposed New roof on specified sections on house, remove and replace existing roofing, install drip edge ridge vent Work: 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 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, Eileen Bali , as Owner of the subject property Adam Quenneville hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. see contract 05/20/2021 Signature of Owner Date I, Adam Quenneville , 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. Adam Quenneville Print Name )61/1/4.......„,..„ 05/20/2021 Signature of Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable D Name of License Holder: Adam Quennville CS-070626 License Number 160 Old Lyman Rd South Hadley Ma 01075 8/21/2021 Address, Expiration Date �� 413-536-5955 Signature Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ Adam Quenneville Roofing & Siding Inc 191 093 Company Name Registration Number 160 Old Lyman Rd South Hadley Ma 01075 3/22/2022 Address 'V Expiration Date Telephone_`13-536-5955 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 X No ❑ City of Northampton g rl,, �s_,�"� ' . sp�' Massachusetts ���5 % b } ig DEPARTMENT OF BUILDING INSPECTIONS ;' War ,fxo 1- 212 Main Street •Municipal Building �y� 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: 120 Coles Meadow Rd Northampton Ma (Please print house number and street name) Is to be disposed of at: Adam Quenneville Roofing&Siding 160 Old Lyman RD South Hadley Ma (Please print name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: Adam Quenneville Rooting & Siding 160 Old Lyman Rd South Hadley Ma (Company Name and Address) (AA.,/ s aCIA Si nature Permit Applicant or Owner Date 9 Pp 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. Ct�ItM lV[ �1I'i ILA �0✓7,;tiAuu(4,Y( A V/SA= olscv 160 Old Lyman Road•South Hadley•MA 01075 We are Licensed 1.800.NEW.ROOF • 413.536.5955 Fully Insured Email:info@l800newroof.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: 5/3/21 Phone#'s: C: 617-335-6699 Eileen Ball H: W: Street: 120 Coles Meadow Rd Email: eileenwynneball@gmail.com City,State,Zip Code: Special Requirements: Northampton, MA 01060 Main house front slope only PROPOSAL FOR: with doghouse dormers on it HO SE GARAGE OTHER and front porch attached to it STRIP RECOVER Layers 3 4 Plywood Included: Yes .r No ❑ off SLATE or SHAKES COMPLETE ROOF PROTECTION SYSTEM: . We shall acquire appropriate permits for all work ,2' Home exterior and landscaping to be protected .d--Strip existing roofing to existing decking with full inspection DO NOT DO: ;r- All project waste shall be removed by du er(dumpster for contractor use only) Y_ Install Ice&Water B. '- at all eaves 3' 6',v Ileys,chimneys,pipes and skylights ,Et--"Install(151b.feldW derlaymen ever remaining d ' area ,---- Install Metal drip e••- . eaves and rak:c 5")(whit rown) JT Install manufacturer's starter shingle on all eaves and rake e ges k-Install new pipe boo - •'.• vent accessories V Install ridge yen -Snow Count obra rolled/4'Baffled/Roll Shingles:(standard 6 nails per shingle) Hickery GAF Shingles Color: GAF Ridge cap shingles Warranty Options: We guarantee our workmanship for 10 full years ❑ GAF System Plus Warranty ❑ GAF Golden Pledge Warranty Chimney Options: 0 Lead Counter Flashing 0 Water Seal&Tuckpoint 0 Rubberized Crown 0 Cricket 0 Mason needed(customer provided) Additional material and labor charges may apply. $155 Per Sheet kl Deteriorated existing decking will be replaced at eft.and dimensional lumber at$7.00 per linear ft., after full inspection. Customer Initials: We propose hereby to furnish materials and labor—complete in accordance with above specifications for the sum of: Total Due:($ 11, 880 ) ACCEPTANCE OF PROPOSAL:The above prices,specifications and conditions are Down Payment:($ 4000 ) Pd CC satisfactory and are hereby accepted.You are authorized to do work as specified. 2nd Payment at Start Job:($ 4000 ) Payment will be 1/3 down at signing,1/3 at start of job,and balance due Balance Due Upon Completion:($ 3880 ) upon compll ti n, /21 Date: Signature: Date: 5/3/21 Estimator:(Print Name) Joe Snopek k Th P (Sign Name) 413-221-4329 ATTENTION HOMEOWNERS:Please cover all personal belongings in the attic,garag 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 for debris or dust in the attic or storage areas. Customer Initials: 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 gives 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. 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. LIABIUTY Company is not responsible for damage or loss caused in whole or in part by:the acts or omissions of other parties,trades or contractors;lightening,gale force winds (+110 mph),hailstorms,ice damage,ice damns(caused by thawing and freezing of ice,water or snow)hurricanes,tornados,floods,earthquakes or other unusual phenomena of the elements;structural settlement;failure,movement,cracking or excess deflection of the roof deck;defects or failure of materials used as a roof substrate over which Company's roofing material is applied;faulty condition of parapet walls,copings,chimneys,skylights,vents,supports or other parts of the building; vapor condensation beneath the roof;penetrations for pitch boxes;erosion,cracking and porosity of mortar and brick;dry rot;stoppage of roof drains and gutters; penetration of the roof from beneath by rising fasteners of any type;inadequate drainage,slope or other conditions beyond the control of Company which cause ponding or standing water;termites or other insects;rodents or other animals;fire;or harmful chemicals,oils,acids and the like that come into contact with Customer's roof and cause a leak or otherwise damage Customer's roof.If Customer's roof fails to maintain a watertight condition because of damage,by reason,of any of the foregoing,any applicable written limited warranty shall immediately become null and void for the balance of its term.Company accepts no liability to indemnify or hold Customer harmless for claims or damages to persons or property,except to the extent that such damage occurs during performance of Company's work and are the direct result of Company's error or omission.Notwithstanding the foregoing,Company shall not be responsible for damages to any area of the property upon which Company's work has not been completed nor is Company responsible for slight scratching or denting of gutters,oil droplets in driveways,hairline fractures in concrete, damage to flowers or landscaping,or minor broken branches on trees,plants or shrubbery.In no event shall Company be responsible for any type of damage resulting from vibrations,including,but not limited to,interior drywall damage,nail pops or disconnection of chimneys,flues,air ducts,ventilation shafts,exhaust vents,furnace vents or sewer vents.Customer understands and agrees that Company shall have no responsibility for damages of any kind to persons or property occurring after job completion. 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. A�oREP CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDO/YYYY) 4/19/2021 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 Prem0 NAME: Clayton Insurance Agency, Inc- PHONE FAX (A/C,No.Eat): (413)536 0804 (A/C No): 1413)534-7874 1649 Northampton Street E-MAIL ADDRESS: sp y remo@cla toninsurance.net P. O. Box 989 INSURER(S)AFFORDING COVERAGE NAIC B Holyoke MA 01041-0989 INSURER A:Nautilus Insurance Company INSURED INSURER B:Green Mountain Insurance Company Adam Quenneville Roofing 6 Siding Inc. INSURER C AIM Mutual Insurance Company 160 Old Lyman Road INSURER D South Hadley, MA 01075 INSURERS 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 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 LTR TYPE OF INSURANCE thjSD <NV11 POLICY NUMBER POLICY EFF POLICY EXP LIMITS (MM/DD/VYYY) (MMIDDIYYYY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE X OCCUR DAMAGE TO RENTED 100,000 PREMISES (Ea occurrence) $ NN1143748 6/23/2020 6/23/2021 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY PRO- JECT LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: AUTOMOBILE LIABILITY (COM EaaBI EDtSINGLE LIMIT $ 1,000,000 H ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS x AUTOS 20035707 6/23/2020 6/23/2021 BODILY INJURY(Per accident) $ X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS (Per accident) UNINS/UNOERINS MOTORISTS S 100,000/300,000 X UMBRELLA LIAR OCCUR EACH OCCURRENCE $ 5,000,000 A EXCESS LIAB CLAIMS-MADE AGGREGATE $ 5,000,000 DED RETENTION$ AN088790 6/23/2020 6/23/2021 $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N X 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 I LOCATIONS I 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/EMT 772,/-74,7 ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025(201401) t. —t Tire Cortrmcnwealth of Massachusetts _ Department,of Industrial Accidents —Ef1i=74 1 Congress Street,Suite 100 ': ice ii' .gt Boston,MA 02114 20d 7 - ' wwfrssgovldiu � w.rn Workers'Compensation Insurance Affidavit:Bu$ders/Contractors!Electricians/Plumbers_ TO BE FILED SITITH rah.PER1iUTTII`G AUTHORITY. Applicant Information Please Print Leaibly N?me(B ness/org izatioritrrtdividual): Adam Quennevilie Roofing & Siding Inc Address: 160 Old Lyman Rd City/state/Zip: South Hadley, MA 01075 phone#: 413-536-5955 Are you an emglayer?Check the appropriate boa: Type of project(required): I. am a employer with 155 employees(full artdfarparttime)_* 7. Q New construction. 2.❑I am a sole proprietor or partnership and have no employees working forme in 8. D Remodeling any capacity.(Nu workers'camp_insurance required.? 3.0 I air a homeowner doing all nark mysek£[No workers'camp.insurance requucd.l f 9_ Q Demolition 10 Q Building addition 4_11 faro a lorrnecrvaer and will hehiring=tractors td conduct aiI work on ray property_ I will ensure that all contractors either have workers'compensation insurance or ue sale I I.❑Elec n ical repairs or additions proprietors with no employees. I2.0 2lumomg repairs or additions ! 5.fl lain a general contractor and I have hand the sub-contractors listed art the attached sheet I3_ Qof repairsThese sub-contractors have employees and have workers'comp.insurances 6.i I We are a corporation and its officers have exercised their right ofezeniption per bfGL e_ 14.U Other I52,1 t(44,and we have no employees.[No workers'comp_insurance required.] *Arty applicant that checks box 141 must alsa fill out the section below showing their workers'compensation policy information. t Horneowners who submit this affidavit indicating they are doing all work arra then hire outside contractors must submit a new affidavit indicating such_ tCoatractnrs that check this hex must attached arc ed anal sheet thawing 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 motor I stir an employer that ispravidiug workers'corrzperrsatiorz insurance far trim employees_ B.elaw is the policy arrd job site information. Insurance Company Name: AIM Mutual Policy#or Self-ins.Lic.#:- A►/VC40070128612019A Expiration Date: i/3.41/, a' fob Site Address: I DO __o (') 0-ec,Ac a1 LA City/StatefZip: N'o f ,r,p I c ra PrIA 010C o Attach a copy of the workers'compensation policy declaration page(showing the policy number and laipiratiou date). Failure to secure coverage as required under N/FGL c.I52,§25A is a criminal violation punishable by a fine up to Sl,5QQ.O0 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 3250.00 a day against the violator.A copy of this statement may lee forwarded to the Office of Investigations of the DIA for insurance Coverage verif!cation. 1 da hereby certify raider the p ar rdperralties ofperfua:y t(ratthe urforrrratranprovided above is true oriel correct. Signature: Date: 5]a o a I Phone Al: 413-536-5955 1 Official use only. Do Rat write in this area,to be completed fry city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1..Board of Health 2_Building Department 3.City/Town CIerk 4.Electrical Inspector 5.Plumbing Inspector 6_Other Contact Person: Phone#: Constru.Ctibri ut peMsfar V vy -' CS-070626 - Eapires:06/21/2021 ADAM A QU N 4- _ 160 OLD LYE R 1fAv SOUTH HADL Y MA t� ` t f PM i'.410* Commissioner ^ / / C/X e Cea r an ettea&A tIPAMdaCkidela Office of Consumer Affairs and Business Regulation 1000 Washington Street- Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Corporation Reg ADAM QUENNEVILLE ROOFING AND SIDING.INC. r�on: 031 Expiration: Q3/22/22/2022 160 OLD LYMAN RD. SO.HADLEY.MA 01 075 Update Address and Return Card. sc.;I * 201,445117 +14g4k' ,,` .. is qi:> 7.q; _';.\�;/i:%•�' '..Za :�i..;\'Fr.::�t� r:a:i• ::'.•:'�\ fiv':... '/ate•.• `.,•'�s. ',�. !r1.,:.�:, .:✓ ':. J .K..,.1.�f ../ ..II �^•` ..IL' :�I::�'.i .,.n,.l..t�':;.i'tSjl:. t.'.i.4.. ,. •.:(:Y.�• ':l' • r i ajar ,��'•` �J°' ` f ` b :. awe' a.,e . � s . i A s + i. . .� ., , *... 4y •. i .. * r- +► STATE OF CONNECTICUT + DEPARTMENT OF CONSUMER PROTECTION Jr Ile it known that • ADAM QUENNEVII.r.F: . 160 OLD UMW ROAD SOUTH HADLEY, MA. 01075-2632 i has satis6ed the quali&catitms required by taw and is hereby registered as a i HOME IMPROVEMENT CONTRACTOR Registration # HIC.0575920 I. `• ADAM.QVENNEVILLE ROOFING` f r 11 Effective: 12/01/202fl JEx;zratwn: f/ /2021 R IMichelle Seagull,Comml siumer z T