30C-059 (2) BP-2022-0012
369FLORENCE RD COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
30,C-059-001 CITY OF NORTHAMPTON
Permit: Exterior Res
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
Permit# BP-2022-0012 PERMISSIONISHERLBYGRANTED TO:
Project# ROOF Contractor: License:
ADAM QUENNEVILLE ROOFING &
Est. Cost: 2175 SIDING 070626
Const.Class: Exp.Date:08/21/2023
Use Group: Owner: CONZ ERIC BOGGIO ROTHENBERG NANCY ANNE
Lot Size (sq.ft.)
Zoning: WSP Applicant: ADAM QUENNEVILLE ROOFING & SIDING
Applicant Address Phone: Insurance:
160 OLD LYMAN RD (413)536-5955 AWC4007012861
SOUTH HADLEY, MA 01075
ISSUED ON:01/04/2022
TO PERFORM THE FOLLOWING WORK:
CAP&VENT REPAIR, REPLACE SKYLIGHT
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:
I� •
2_ .
Ary
Fees Paid: $40.00
•
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
Department use only
„AVJ r City of Northampton Status of Permit:
t. Building Department Curb Cut/Driveway Permitft
212 Main Street Sewer/Septic Availability
t,. 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
This section to be completed by office
1.1 Property Address:
369 Florence Rd Florence Ma 01062 Map Lot Unit
Zone Overlay District
Elm St. District CB District
I
SECTION 2 -PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Nancy Rothenburg 369 Florence Rd Florence Ma
Name(Print) Current Mailing Address: 413-585-1661
see contract
Telephone
Signature
2.2 Authorized Agent:
Adam Quenneville 160 Old LymanRd South Hadley Ma 01075
Name(Pr' ) 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 2,175.00 (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 = (1 + 2 + 3+4 + 5) 2,175.00 Check Number
This Section For Official Use Only
Building Permit Number: 6,:- " I sssuu
ed:
Signature: / //' /- 3- 7L)2
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 X YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW X YE4--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 I 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 ? YEF-1 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 jI 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) n Roofing X
Or Doors E
Accessory Bldg. ❑ Demolition ❑ New Signs [El] Decks [E] Siding D] Other[al]
Brief Description of Proposed Small repair of cap and vent, and remove and replace skylight with a new vented skylight.
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, Nancy Rothenberg , 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 12/28/2021
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
12/28/2021
Signature Owner/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Adam Quennville CS-070626
Name of License Holder:
License Number
160 Old Lyman Rd South Hadley Ma 01075 8/21/2023
Addre Expiration Date
X,, 413-536-5955
Signature Telephone
9. Registered Home Improvement Contractor: Not Applicable 0
Adam Quenneville Roofing & Siding Inc 191093
Company Name Registration Number
160 Old Lyman Rd South Hadley Ma 01075 3/22/2022
Addre �e✓, Expiration Date
Telephone 413-536-5955_
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 0
City of Northampton
.ai-ter, no,.:c.,..1't.,,,,i94Massachusetts wi
! ki->,
DEPARTMENT OF BUILDING INSPECTIONS' 212 Main Street •Municipal Building� Northampton, MA 01060
Debris Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building
permit all debris resulting from the construction activity governed by this Building Permit shall be disposed
of in a properly licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
The debris from construction work being performed at:
369 Florence Rd Florence Ma 01062
(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 Roofing & Siding 160 Old Lyman Rd South Hadley Ma
(Company Name and Address)
1 �-t
Signatur � of Permit Applicant or Owner bate
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.
D AAA ROOF MAX r Get a
QUENNEVILLE 00F. HAMPOO
ROOFINGw SIDING w WINDOWS More Life. Less Money. Guaranteed. = - ---� ,•.• �.M._ -
160 Old Lyman Rd • South Hadley, MA 01075
1.800.NEW.ROOF • 413.536.5955
Email: roofshampoo@l800newroof.net
Website: www.l800NEWROOF.net
MA Construction Supervisors Lic.#070626 MA Registration#191093
Member of the Home Builder's Assiociation of Western Mass. CT Registration#575920
Member of the Building and Trade Association
Customer Nancy & Eric Rothenberg Address: 369 Florence Rd.
City: Florence State: MA ZIP: 01062 Email: nancy@spiritoftheheart . org
Home: 413—5 8 5—16 61 Office: Cell:
NO BILL WILL BE SENT -- PAYMENT DUE UPON COMPLETION OF WORK.
Roof Shampoo® is the eco-friendly roof cleaning solution that does NOT contain chlorine bleach. The
proprietary Roof Shampoo® product is safe for your landscaping. Our state-of-the-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.
Roof MaxxTM is an all-natural plant based treatment that's 100% safe for people, pets, property, and the
environment.A renewably sourced, bio-based alternative, Roof Maxx's scientific formulation uses the
latest green technology offering benefits to worker and consumer health,the environment, America's
economy and energy security. 100% SAFE BIO-BASED... GREEN AND CLEAN!
—� — • s • �
Adam Quenneville R•• g hereby offers to perform the work listed below for the amount shown.
replace cap + vent (weatherwood)
DESCRIPTION OF WORK AREAS cap+vent $ 1100
Clean alg.;.,fungus,and/or moss related stains by treating areas(s)indicated Roof Shampoo $ 999
be •w. Roof Tune Up $ 495
Roof in Front of House Only Roof in Back of House skylight $ 1800
Entire Roof Other Affected Areas Coupon Discount $ 1099 2 5 0
Total All Services $ 3295
*5Deposit Received $ 1100
Year Transferable Roof Maxx TM Warranty
*1 Year Roof Shampoo® Guarantee of 6 re-growth* Balance Due $ 2195
12/2 3 / \J\At,
DATE: /IOMER SIGNATURE:
ACCEPTANCE OF PROPOSAL:The above prices,specifications and c itions are satisfactory and are hereb cepted. ou are aut rized to do work
as specified.Payment,will be 1/3 down at time of signing,and balance due upon completion.
DATE: 12/23 'A�ESPERSON:(Print Name) Nate Flachs
__- (Sign Name)
ACO 4 CERTIFICATE OF LIABILITY INSURANCE DATE(MM100/YYYY)
‘i.------' 6/2 4/20 21
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 en ADDITIONAL INSURED,the pollcy(Ios)must be endorsed. If SUBROGATION IS WAIVED,subject to
the terms and conditions of the poilcy,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 Ci1NTRirr
Sarah Brame
Clayton Insurance Agency, Inc. PHONE
CAL (423)536-0804 {wc,No1: (41n934-114
Itv1.649 Northampton Street Iao0H55$,apremo@olaytoninsurance.net
R. 0. Box 989 INSURER{S1 AFFORDING COVERAGE NAIC Y
Holyoke MA 01041-0989 INSURER A:Nautilus Insurance Company
INSURED
INSURERe:Arbella Insurance Co.
Adam Quenraville Rooting b Siding inc. INSURERc:AIM Mutual Insurance Company
160 Old Lyman Road INSURER 0
`-
South Hadley, MA 01075 INSURER e:
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 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 9Y THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL NE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS
iNSR TYPE OF INSURANCES POLICY 6FF POLICY EXP "--
-074 F(SD,)LID. POI,icY NUMBER IMM(0ONYYYI (My1In(fYYYI LIMITS
X COMMERCIAL GENERALUA8JUTY EACH OCCURRENCE S 1,000,000
A _CLAIMS-MADE OCCUR OA14AfiiSnSRENTEO $
100,000
�iEM54E8 1E�x a�r nml
..._ NN1prows))933:5 6/23/2021 6/23/2022 MEU EXP(Any one prows)) S 5,000
,-�
_ _ RERSONAI.A A0V INJURY S 1,000,000
GEN'LAGORCGATEL'MIrAPPUESPER; GENERAL AGGREGATE S 2,000,000
X POLICY I j PR
JECTO• LOC PRODUCTS-COMPOPAGO S 2,000,000
OTHER` 5
AUTOMo9ILE UATTIUTY 4 E + SINGLE UA4T s 1,000,000
B ANY AUTO BODILY INJURY(Per person) S
AU.OYITIEO X SCHEDULED /020107095 G/23/2021 6/21/2022 BODILY INJURY(Per accident) 3
AUTOS AUTOS .�
X f11R2D AUTOS $ NON-OWNED PROPERTY DAMAGE a
AUTOS L-112.r.-.5a5aLl
UNINSAJNOERINS MOTORISTS 5 100,000/300,000
X UMBRELLA UAS -_ OCCUR EACH OCCURRENCE ,$ 5,000,000
A 4 EXCESS LIAR CLAIMS-MADE AOOREMATE $ 5.000.000
0E0 RETENTON 4 AN1242102 6/23/2021 6/23/2022 5
WORKERS COMPENSATION PER T O1N-
ANDEMPLOYERS'UA9ILITY V/N X,�°,I,AfUTE I ER
ANY PROPRIETORIPARTNER/EXECUTIVE Et EACH ACCIDENT 4 1,000,000
OFFICERIM EMBER EXCLUDED? I Y I N/A C
(Mandatory in NH) APC4007012861. 4/29/2021 4/29/2022 E.L. 018EASE•EA EMPLOYEE $ 1,000.000
If yyea,dascnbd under
DESCRIPTION OF OPERATIONS be,.ow El:DISEASE POLICY OMIT t 1,000,000
_
DESCRIPTION OF OPERATIONS/LOCATIONS i VEHICLES(ACORD 101,Addition-al Ranurks Schedule,may to attach.d If mon apaoe 4a requlnd)
Por Irnforrnational Purposes Only
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OR THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Adam Quenneville Roofing Siding Inc THE EXPIRATION DATE T}IEREOP,NOTICE WILL BE DELIVERED IN
160 Old Lyman Rd ACCOROANCE WITH THE POLICY PROVISIONS.
South Hadley, MA. 01075
AUTHORIZED RePRESENTATVE
I Michael Regan/UHT /r P A?,,,,,,,.
a)1988-2014 ACORD CORPORATION. All rights roservod.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
INS025(2014011
The C'ommonweattn of Iv[assacnuaeus r ,
jl ;. . Department of Industrial Accidents
, Office of Investigations
t"�13� 600 Washington Street
—I4
Boston,MA 02111
, !.
www mnss.gav/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information /� Please Print Legibly
Name (Business/Organization/Individual): A QtGw O 1 .oCr'1+'-U d��t- 0-CIn 71�t 7 ei c
Address: (LO 01 A Li►'v.,e,,, Q.
City/State/Zip: 5ou11- kok.ge.4 nllo Oto )c Phone #: 1113 —53C 5C 5T
Are you an employer?Check the appropriate box: Type of project(required):
I.81 1 am a employer with 15 4. ❑ I am a general contractor and t 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ II am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
workingfor me in anycapacity. employees and have workers'
P tY 9. ❑ Building addition
[No workers'comp. insurance comp. insurance.:
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.C I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL l 2.1 Roof repairs
insurance required.]t c. 152, §1(4), and we have no
employees. [No workers' l3.❑ Other_ .
comp.insurance required.]
*Any applicant that checks box#f must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. Q— _
Insurance Company Name: r' L. (v f ves\ i/1S U(c-(C-
Policy 4 or Self-ins. Lic. II: / wG cio010 1 a'A. i Expiration Date: I�� +/9
369 Flornece Rd Florence Ma 01062
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 Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of
investigations of the DIA for insurance coverage verification.
I do hereby certify�uadurthe pains and pens es of p jury that the information provided above is true and correct.
4,:iae OuenneViiie 12/28/2021
Signature: Date:
1,,L131LUZ_
Phone#: 1113 - 5 3c - 5` 5 s
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. Budding Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone#:
Commonwealth of Massachusetts
10/1 Division of Professional Licensure
Board of Building Regulations end Standards
Conslr ti tli tlpprvisor
CS-070826 ,� ,, Metres:08/21/2023
ADAM A QUENNEH f4.
180 OLD LYMAN R' 0
SOUTH HADLQ,Y MIA ' "4*
Np
t r 4f ,i iol. a..
Commissioner egeept K &n,,hh&.
Ile (60ilf/rtiuf'rrrl<'a`i l,r�L (`,•, , ' (1, .,T(IC 4 -
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. Regis 13
160 OLD LYMAN RD. Expi ration:ration: 03/22/2/2022
SO.HADLEY,MA 01075
Update Address and Return Card.
SCA I t7 20M-05117
STATE OF CONNECTICUT + DEPARTMENT OF CONSUMER PROTECTION I j'k , ,
fBe it known that l' "7,�
I j .
°` i' ADAM QUENNEVILLE j ,' a
f 'i 160 OLD LYMAN ROAD l'�'
V. « I i
SOUTH HADLEY, M.A. 01075-2632
«, i i '..
1
has satisfied the qualifications required by law and is hereby registered as a �
4 ' HOME IMPROVEMENT CONTRACTOR ,.:
YYRY
iY.
,'r Registration # HIC.05759201 lip.,,,,,-.?
11
0 ,f
l
f
,4 i ADAM QUENN :VI.I.I_, ; ROOFING
i
4.
4 `..; ,,,:i3 Effective: 12/01/2021 l �` y:
f,. Expiration: 1��,y"�on: 03/31/2023 ,_'
4
Michelle Seagull,Commissioner .
ry ,/I �=+tea �'�, ,Y y+� �'(. ^�,
g 4g 1;i + P M.: ,� t Y4t qF .y i q /7,i 'i ."- 47. �v,. ..... 4 F 'R 0 4 :4_. J ...Y
•
5 ssv t API X d a fJ �g,' t` 1 �y, ,ii,*e,„, ! ' '''
-S,'>l.? i..' t 1'.W `,;''',V `;1' s, 14 �gp 1 t , K � . ` '� •:: , , r' ,...;,. '�-�tV'''.A/I••s 2 "tT^ 'a'^ '.'''' ` �,�1;.4i K, t: