32A-088 (13) 25 GRAVES AVE COMMONWEALTH OF MASSACHUSETTS BP-2021-1956
Map:Block:Lot:32A-088-
001 CITY OF NORTHAMPTON
Permit: Alts Renovations
Repair
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
Permit# BP-2021-1956 PERMISSIONISHEREBYGRANTED TO:
Project# ROOF AND SIDING Contractor: License:
ADAM QUENNEVILLE ROOFING &
Est. Cost: 61497 SIDING 070626
Const.Class: Exp.Date:08/21/2023
Use Group: Owner: GANDARA MENTAL HEALTH CTR INC
Lot Size (sq.ft.)
Zoning: URC Applicant: ADAM QUENNEVILLE ROOFING & SIDING
Applicant Address Phone: Insurance:
160 OLD LYMAN RD (413)536-5955 AWC4007012861
SOUTH HADLEY, MA 01075
ISSUED ON:09/28/2021
TO PERFORM THE FOLLOWING WORK:
ROOF & SIDING
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.
Signature:
� ).9 13.7)
I
Fees Paid: $406.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
r-- Versiont.7 Commercial Building Permit May 15, 2000
Department use only
., /{jam— City of Northampton Status of Permit:
+� / Building Department Curb Cut/Driveway Permit
SEP 2 212 Main Street Sewer/Septic Availability
7 202/ Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
'p
Nofirki coIND�NSP one-413-587-1240 Fax 413-587-1272 Plot/Site Plans
oyosoo S / Other Specify
APPLICATION T CO CO ONSTRUCT, 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:
25 Graves Ave Northampton Ma 01060 Map Lot Unit
Zone Overlay District
Elm St. District CB District
SECTION 2 -PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Joe Martins 25 Graves Ave Northampton Ma
Name(Print) Current Mailing Address:
413-214-5442
Signature See contract Telephone
2.2 Authorized Agent:
Adam Quenneville Roofing & Siding 160 Old Lyman Rd South Hadley Ma
Name(Print) Current Mailing Address:
1413-536-5955
Signature Telephone
SECTION 3 -ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building 61497 (a) Building Peirnii Fee
2. Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee �)r
4. Mechanical (HVAC) --4) 11061
5. Fire Protection
6. Total = (1 + 2 + 3 +4 + 5) Check Number I Dqv
This Section For Official Use Only
Building Permit Number 64,4,1K0
Date
Issued
Signature:
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❑ New Signs❑ Roofing® Change of Use❑ Other❑
Brief Description New roof,remove and replace existing roofing,install new drip edge and ridge vent,pipe boot flashing and ice and water barrier on eves
valleys pipes and chimneys. New siding,we will go over existing siding,install 3/8 fanfold insuation board,bent metal wrap on all doors,
Of Proposed Work: windows and fascia,vinyl soffit,then new vinyl clapblard siding.
i
SECTION 5-USE GROUP AND CONSTRUCTION TYPE
USE GROUP (Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A-1 ❑ A-2 ❑ A-3 ❑ 1A I ❑
A-4 ❑ A-5 ❑ 1 B ❑
B Business ❑ 2A ❑
E Educational ❑ 2B 12
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 0 R-3 ❑ 5A ❑
S Storage ❑ S-1 ❑ S-2 0 5B J ❑
U Utility ❑ Specify:
M Mixed Use ❑ Specify
S Special Use ❑ 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)
1st 01st 0 �.�.. m.
0
... _. _.�. ... d 3rd
3rd 0
.. 4th
4th 1 0:
_..� 0
Total Area (sf) i I Total Proposed New Construction (sf) __.
i
ii—
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 0 Private 0 Zone Outside Flood Zone❑ Municipal ❑ On site disposal systems
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 )( YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW YE1-1
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW 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
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 12
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: 25 Graves Ave 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
09/22/2021
iik)
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
SECTION 11 -OWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
Joe Martins , as Owner of the subject property
hereby authorize Adam Quenneville to
act on my behalf, in all matters relative to work authorized by this building permit application.
See contract 09/22/2021
Signature of Owner Date
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.
AA-Ctiv - an 1441 14hz.
Print Name
09/22/2021
Signature of Owner/Agent Date
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: Adam Quenneville CS 070626
License Number
160 Old Lyman Rd South Hadley Ma 08/21/2023
Address /� Expiration Date
V�'l1 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 I? I No n
L 1
41�6NN�VILLit f 4" •Ti I AWARD VISA at
4ai
ROOFING 'w SIDING 2010 WINNER
160 Old Lyman Road•South Hadley•MA 01075 We are Licensed
1.800.NEW.ROOF • 413.536.5955 Fully Insured
Email:)nfo@1800newroof,net Website:www.1800newroof,net Factory Trained
MA Construction Supervisors Llc.#070626 MA Registration#120982 Factory Certified installers
Member of the Home Builder's Assoc.of Western Mass. CT Registration#575920
Member of the Building&Trade Association P.P.0 38710
Proposal Submitted To: Date: Phone#'s: C:
Gandara Center 9/942021 H: W:
Street: e ks Email:
251Graves i$ve
City,State,Zip Code:
Northampton, MA 01060
Proposal to furnish and install the following:
We will pull all appropriate permits associated with the following siding installation
We will remove exising siding and dispose of/Go-over Existing
We will install House Wrap/3/8"fanfold Insulation board
We will Install custom bent metal wrap on all windows,door,fascia,Smooth I Pvc coated aluminum
Coil stock color; White
We will install vinyl soffitt on all overhangs vented soffit as required&solid where not required
Soffit color; White
We will Install new vinyl siding system manufactured by; Kaycan ( t"(97
Siding style;Clapboard/Dutchlap/Shakes �o
Siding;tier; Timberlake
Siding width; Q4
Siding color; Standard colors
Corner color; White
Light block color; White
Splitblocks,j-blocks,&dryer vent hood color; White
J-channel around'windows,doors,rootiines,color; White
We will remove and install Pairs of shutters color; Style;Louvered/Raised panel
We will install gable vents Color;
Any deteriorated wall sheathing will be replaced at 5.99 Sq Ft Customer Initials;
Ask us about
affordable bank
financing!
ATTENTION HOMEOWNERS:Please cover all personal belongings in the attic,garage or storage areas due to the
possibility of roofing debris or dust coming In through cracks of the wood.Please remove any lawn ornaments or yard
furniture.Adam Quenneville Roofing will not be responsible for debris or dust in the attic or storage areas.
Customer Initials:
We propose hereby to furnish materials and labor—complete In accordance with above specifications for the sum of: Total Due:($ 39,999.00 )
ACCEPTANCE OF PROPOSAL:The above prices,specifications and conditions are Down Payment:($ 13,333.00 )
satisfactory and are hereby accepted.You are authorized to do work as specified. 2nd Payment at Start lob:($ 13,333.00 )
Payment will be i/3 down at signing,1/3 at art of lob,and balance due Balance Due Upon Completion:($ 13,333.00 )
upon cocrilletlo n Date: 1— -�/ Signature:
Date: 9/9/2021 Estimator:(P nt Name) S. 'lit Kla(Sign Name)5'7 1.-v-a-+L 711,4;1
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.
DELA,ifS 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.ownershlp 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 fora 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,oT 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(51,000,000.00)
CONSTRUCTION RELATED PERMIT ACQUISITION
The Contractor under provisions of Chapter 142A of the General Laws is required to apply for and obtain all construction-related permits.The Contractor shall
not be deemed responsible for delays in the work described in this Agreement caused by regulatory permit granting or Inspectional agencies,authorities or
individuals.
MODIFICATION
This Agreement Including the provisions relating to price and payment schedule cannot be changed except by a written statement signed by both the
Contractor and the Owner.However,cancellation by Owner Is allowed In accordance with the Notice of Cancellation.
COMPLETENESS OF AGREEMENT FOR EXECUTION
The Ownier 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
sppliable,and until ill exhibits and related or referenced documents that are incorporated herein are attached hereto.
COPY OF(AGREEMENT TO BE GIVEN TO OWNER
The Lawsof Massachusetts shall govern this Agreement.It must be executed In duplicate,and an original,signed copy hereof shall be given to the Owner at
time of execution.No work under the Agreement shall begin prior to the signing of the Agreement and transmittal to the Owner a copy thereof.
ARBITRATION
In the event the Owner and Contractor have a dispute regarding any of the terms,conditions,provisions or performance of this contract,the parties agree to
place the matter into arbitration before an Independent arbitrator assigned by the American Arbitration Association to resolve their dispute, Owners
acknowledgement of arbitration clause
CANCELLATION
Owner may cancel this contract within three business days of executing this document,Such cancellation must be In writing and delivered to the Contractor.
Contractor reserves the right to cancel this contract at any time within thirty days of the date of this contract.If we cancel you will be promptly notified In
writing by an authorized officer of Adam Quennevllie Roofing&Siding Inc.If we cancel,we will promptly return any down payment(s)you have made,
i�N OWN LAM oo—o AWAR
l0st DtScc,VEP ,.
• h:c,.•.4,04•_bK411..:s_w,n.M7W'. VISA CC:'
t _.,.,,.,p.."�,..,y...,«,.i......_.«»....,.. 2010 WINNER
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: Phone#'s: C:
Gandara Center 9/9/2021 H: W:
Street: Email:
25 Graves Ave
City,State,Zip Code: Special Requirements:
Northampton, MA 01060
PROPOSAL FOR:
HOUSE GARAGE OTHER Optional Gutters add- 3,499.00
STRIP RECOVER
Layers: 1:) 2 3 4 Plywood Included: Yes.' E.
Tear off SLATE or SHAKES
COMPLETE ROOF PROTECTION SYSTEM:
)4 We shall acquire appropriate permits for all work
6C Home exterior and landscaping to be protected
X Strip existing roofing to existing decking with full Inspection DO NOT DO:
X All project waste shall be removed by dumpster(dumpster for contractor use only)
FC} Install Ice&Water Barrier at all eaves 3' 6, alleys,chimneys,pipes and skylights p ���l�
kll Install(151b.felt vn eis underlayment over remaining decking area
X Install Metal drip edge at eaves and rakes Oil 5" EIED brown)
X, Install manufacturer's starter shingle on all eaves and rake edges
t Install new pipe boot flashing/vent accessories
X Install ridge vent-Snow Country/Cobra rolled/4'Baffled us
Shingles:(standard 6 nails per shingle)
GAF Timberline HOZ Shingles Color: To Be Determined
GAF Timberline HDZ Ridge cap shingles
Warranty Options:
n We guarantee our workmanship for 10 full years
GAF System Plus Warranty
i GAF Golden Pledge Warranty
Chimney Options:
El Lead Counter Flashing Cl Water Seal&Tuckpoint L 7 Rubberized Crown O Cricket
0 Mason needed(customer provided)
Additional material and labor charges may apply.
X Deteriorated existing decking will be replaced at$5.99 per sq.ft.and dimensional lumber at$7.00 per linear ft.,
after full inspection. Customer Initials:
We propose hereby to furnish materials and labor—complete In accordance with above specifications for the sum of: Total Due:($ 17,999.00 )
ACCEPTANCE OF PROPOSAL:The above prices,specifications and conditions are D wn Payment:($ 5,999.00 )
satisfactory and are hereby accepted.You are authorized to do work as specified. 2nd P ent at Start Job:($ 6,000.00 )
Payment will be 1/3 down at signing,1/3 at start of b,and balance due Baian ue Upon Completion:($ 6,000.00 )
upon completion.
Date: Signature:✓
Date: 9%9/2021 Estimator:(Print Na S. Min ler (Sign Name)ae..L`Q..+1'
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 Quenneviile Roofing will not be
responsible for debris or dust in the attic or storage areas. Customer Initials:
NOTICE OF SCHEDULE CHANGES
The cohtractor 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 workdescribed 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 fall to pay according to the above terms end 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 attorneys
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,ores 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 ell exhibits and related or referenced documents that are Incorporated herein are attached hereto,
COPYOFAGREEMENT 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 shell begin prior to the signing of the Agreement and transmittal to the Owner a copy thereof.
LIABILITY
Company's 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 materiel Is applied;faulty condition of parapetwalls,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 end 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 falls 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 ere 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 Quennevlile Roofing&Siding Inc.If we cancel,we will promptly return any down payment(s)you have made.
op
th, ACC CERTIFICATE OF LIABILITY INSURANCE DATE(MMrDOIYYYY)
‘......'ff 6/24/2021
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 Premo
NAME;
Clayton Insurance Agency, Inc. PNONE (413)536-0804 FAx ui�r v<-,a,a
INC.Na.EMU 1 IA/G No):
1649 Northampton Street E-MAIL AODRE", Yzemo@cla toninsurance-net
P. 0. Box 989
INSURER(S1 AFFORDING COVERAGE NAIC Y
Holyoke MA 01041-0989 INSURER A:Nautilus Insurance Company
INSURED INSURER B:Arbella Insurance Co.
Adam Quenneville Roofing 6 Siding 111C. INSURER C AIM Mutual Insurance Company
160 Old Lyman Road INSURER 0:
South Hadley, MA 01075 INSURERS;
1 INSURER F:
COVERAGES CERTIFICATE NUMBER:2021 MASTER REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POUCY PERIOD I
INDICATED NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS t
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 RECUCED BY PAID CLAIMS
INSR T AOOL tiT1OR' POLICY EFF POLICY EXP
LTR I TYPE OF INSURANCE I INSD„WVO POLICY NUMBER (MMIDWYVYV) (MM(DD2YYYYI LIMITS
1 X COMMERCIAL GENERALUABIUTY
EACH.OCCURRENCE S 1,000,000
DAMAGE TO RENTED
A I CLAIMS-MADE 1 X OCCUR PREMISES IEP a al _ 100,000
Km 2933:5 5/23/2021 6/23/2022 MED EX?(Any one Cersnn'r 3. 5,000
PERSONA:_.ACV INJURY S 1,000,000
GEN-AGGREGATE UMITAPPUESPER. GENERAL AGGREGATE S 2,000,000
A POLICY l I IECT 7 LOC PRODUCrS-COMP,OP AGG S 2,000,000
OTHER: S
r 1 S 1,000,000
AUTOMOBILE LIABILITY 'COf tSInEO SINGLE OMIT
(Er aepaam) _
B I ANY AUTO BODILY INJURY;Per person) S
ALL OWNED 8 SCHEDULED
AUTOS AUTOS 5/29/2021 6/23/2022 (Per/020107993 BODILY INJURYaccident)
S
X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE S
AUTOS (Per sz60900
_ UNINSUNCERINS MOTORISTS $ 100,000/300,000
X UMBRELLA UAB I ' r
1 .� OCCUR EACH OCCURRENCE S 5.000,000
A EXCESS LIAR CLAIMS-MACE AGGREGATE S 5.000,000
CEO RETENTION a A231242102 6/23/2021 6/23/2022 3
WORKERS COMPENSATION X PER OTH-
AND EMPLOYERS'LIABILITY YIN $TA(UTE ER
ANY PROPRIETORIPA:RTNER/EXECUTIVE E.L EACH ACCICENT S 1,000,000
OFFICERIMEMEER EXCLUDED', Y I N IA C
(Mandatory in NH) AWC4007012861 4/29/2021 4/29/2022 EL DISEASE-EA EMPLOYEE S 1,000,000
It yes,descnbe under
DESCRIPTION OF OPERATORS baow _ E.L.DISEASE POLICY LMIT S 1,000,000
J
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schaduls,may be attached If more space is required}
For Informational Purposes Only
I
I
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Adam Queluleville Roofing & Siding Inc THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
160 Old Lyman Rd ACCORDANCE WITH THE POLICY PROVISIONS.
South Hadley, MA 01075
AUTHORIZED REPRESENTATIVE
I1LCHAel Regan/EMT ,n$" )
1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD
INS025(2a14011
The Commonwealtn of wIassacnuseus i t
Department of Industrial Accidents
i' i Office of Investigations
600 Washington Street
� � Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information /� f� n/ Please Print Legibly
Name(Business/Organization/Individual): Aker VL Oer�A)t��t- 9---00*ti6 3'tciply 4i^fitr
Address: 1 GO 0 k A L�b.1..,„, C L
City/State/Zip: 5°t - 14 kto (IIK) Cato )c Phone #: 1113 -53(.-5(155—
Are you an employer?Check the appropriate box: Type of project(required):
1.45K I am a employer with 15 4. ❑ I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. [] Demolition
working for me in any capacity. employees and have workers'
[No workers'comp. insurance comp. insurance.t 9. ❑ Building addition
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 1 1.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12 Roof repairs
insurance required.]t c. 152,§1(4),and we have no 13.®C Other �j I l�
employees. [No workers'
comp. insurance required.] J
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
*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. Q _
Insurance Company Name: r 7 �' t 01�1 ��0 f�
Policy#or Self-ins. Lic.#: A(G C(U O10 ' ''' C ( Expiration Date: VaCtf 9
llr
Job Site Address: V D (AUK 3 l� i C. City/State/Zip: No fill a—p1 o i /a^A 01 QG 0
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
tine 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. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DR for insurance coverage verification.
I do hereby certify under the pains and penalties ofperjury that the information provided above is true and correct
Signature: N.--./ Date: 7i/))
Phone#: 11 13 ` ✓3L 5 9 5 5'
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):
I. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
Vi Division of Professional Licensure
j y Board of Building Regulations and Standards
•
Constf4 ttIlij upervisor
�r
CS-070626 * Kr.,pires:08/21/2023
ADAM A QUVQN li
160 OLD LYM N
• SOUTH HADL4,Y
, d' •
Commissioner ,,iw e a< �bC 5(.La.-
di-4e ce
of Idea
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. Registration: 3
1093 160 OLD LYMAN RD. Expiration: 03/22/22/2022
SO.HADLEY,MA 01075
Update Address and Return Card.
.ICA 4 0 20M-05/17
v ._ •ilk a', •, '_ ` Jr. 'sYr. ,'*- 1,'r Ir- .4„.* ' A.a� _�r_-.._�-r•_• w fir_ 'wJ:`'- II4_ *w_ *>!". ,..t_♦ *..". •a.,"_ ':-
i STATE OF CONNECTICUT + DEP.ARTMENT OF' CONSUMER PROTECTION it• {I
• l: Be it known that II
6 ,
I i ADAM QUENNEYILLE i
160 OLD LYMAN ROAD
SOUTH HADLEY, MA 01075-2632 'i
f
I`
has satisfied the quahtieauons required by taw and is hereby registered as a i
HOME IMPROVEMENT CONTRACTOR
Registration # HIC.0575920
ADAM QUENNEVILLE ROOFING
F ` Effective: 12/01/2020 i j
Expiration: 11/30/2021 /L.& r Gi y'
Michelle Seagull,Commisaioeer
Epp F Y �•�