23A-125 (7) BP-2022-0489
24 MIDDLE ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
23A-125-001 CITY OF NORTHAMPT N
Permit: Exterior Res
PERSONS CONTRACTING WITH UNREGISTERE CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY F ND (MGL c.142A)
BUILDING PE MIT
Permit# BP-2022-0489 PERMISSIONISH REBYGRANTED TO:
Project# 2022 ROOF Contractor: License:
ADAM QUENNEVILLE R••FING &
Est. Cost: SIDING 070626
Const.Class: Exp.Date:08/21/2023
Use Group: Owner: SEILER M ' ARET L& LEONARD MELNICK
Lot Size (sq.ft.)
Zoning: URB Applicant: ADAM QUE VILLE ROOFING & SIDING
Applicant Address Phone: Insurance:
160 OLD LYMAN RD (413)536-5955 AWC4007012861
SOUTH HADLEY, MA 01075
ISSUED ON:05/10/2022
TO PERFORM THE FOLLOWING WORK:
NEW ROOF ON LEFT UPPER MAIN SECTION &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:
Final: Final: Final: Rough Frame:
Gas: Fire Department Driveway Final: Fireplace/Chimney:
Rough: Oil: Insulation:
Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHA TON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Signature:
)11
Fees Paid: S80.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
ia i
, - .- Department use only
Aciftr.:,W,� City of Northampton �qY Status'Df Permit:
f S .4
Building Department ' �! /u�r�b,,CuUQtiveway Permit
�!, y� ; 212 Main Street o����� g er/Septic Availability
..,. Room 100` N;oPBU�� WaternN,,ll Availability
Northampton, MA 01060-- T,�r -,��6''tv,TytoSe1s of Structural Plans
phone 413-587-1240 Fax 413-587-1272 Pl'ot sit4 Plans
Other Specify
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: This section to be completed by office
24 Middle St Florence Ma 01062 Map 34- Lot !26-- Unit
Zone Overlay District
Elm St.District_ CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Len&Meg Melnic&Seiler 24 Middle St Florence Ma 01062
Name(Print) Current Mailing Address: 413-584-2670
see contract
Telephone
Signature
2.2 Authorized Agent:
Adam Quenneville 160 Old LymanRd South Hadley Ma 01075
Name(Prirlf r1fed by pdfFi ler Current Mailing Address:
1 11,1a4 auennel/lle / 413-536-5955
Signature 0171o22 Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building 8,327.00 (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from(6) J/
3. Plumbing Building Permit Fee J�LC�
isk/O 4- ' 6
4. Mechanical (HVAC) I. '
5. Fire Protection
6. Total =(1 +2+3+4+5) 8,327.00 Check Number (?i
u„
l,� This Section For Official Use Only 1
Building Permit Number: eP�J J _oi.r I f 9 Date
Issued: U
igSignature:
- 5-IO-ZOZZ
Building Commissioner/Inspector of Buildings Date
operations.aqrs @ gmail.com
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) n Roofing n
Or Doors El
Accessory Bldg. ❑ Demolition ❑ New Signs [El] Decks [p Siding ED] Other[El]
Brief Description of Proposed new roof on left upper main section&new sventing skylight replacment w/ice&water barrier.
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
Len& Meg Melnick&Seiler
I, , 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 05/02/2022
....._..__.__........
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.
Adam Quenne ille
Print Name
05/02/2022
Signature of Owner/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: Adam Quennville CS-070626
License Number
160 Old Lyman Rd South Hadley Ma 01075 8/21/2023
Address Expiration Date
J 413-536-5955
Signat a Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
Adam Quenneville Roofing&Siding Inc 191093
Company Name Registration Number
160 Old Lyman Rd South Hadley Ma 01075 3/22/2024
Address Expiration Date
Telephone 413-5 36-5955
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
Massachusetts
A ,;
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:
24 Middle St 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)
Verified by pdfFiller •
Hdar//QuenneVae
�ie �o�z
Signature eofermit Applicant or Owner Date
If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the
Building Department as to the location where the debris will be disposed.
111
IEli lEN,111il11.11LIE AW R V/SA, DISC VER ':
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: 4/26/22 Phone#'s: Len C: 413 530-9876
Meg Seiler & Len Melnick H: W:
Street: Email: lenme156@juno.com
24 Middle St —
City,State,Zip Code: Special Require nts: Shingle only left side
Florence MA 01062 Small 6 ft gu er Front porch
PROPOSAL FOR: stairway included.
H• SE GARAGE OTHER
RECOVER Gutter from Wood stove to the
41110 street with downspout included.
. s: 1 2 3 4 Plywood Included: Yes r No
cI ear off SLATE or SHAKES venting sky=_ght replacement
included.
COMPLETE ROOF PROTECTION SYSTEM:
Z We shall acquire appropriate permits for all work
id Home exterior and landscaping to be protected
1t1 Strip existing roofing to existing decking with full inspection DO NOT DO: Rest of the house
l All project waste shall be removed by dumpster(dumpster for contractor use onl Only left side upper
LR Install Ice&Water Barrier at all eaves 3'/t`,valleys,chimneys,pipes and skyligh s
main section of the
HInstall(151b.fe' nderlayment over remaining decking area house to be installed.
'E I Install Metal drip edge at eaves and rake/5"iglIr brown)
(X Install manufacturer's starter shingle on all eaves and rake edges
)El Install new pipe boot flashing/ve ccesso 'es
Li Install ridge vent-Snow Count /Cobra rolled/ Baffled/Roll
Shingles: 1
GAF Shingles Color: Weathered wood
GAF Ridge cap shingles
Warranty Options:
K We guarantee our workmanship for 10 full years
J GAF System Plus Warranty
! GAF Golden Pledge Warranty
Chimney Options:
® Lead Counter Flashing O Water Seal&Tuckpoint O Rubberized Crown Cricket
O Mason needed(customer provided)
Additional material and labor charges may apply. $5.19
x Deteriorated existing decking will be replaced at II* r sq.ft.and dimensional lumber at $15 per linear ft.,
after full inspection. Customer Initials:
We propose hereby to furnish materials and labor—complete in accordance with above specifications for the sum of: Total Due:($ 8,327 )
ACCEPTANCE OF PROPOSAL:The above prices,specifications and conditions are Down Payment:($ 2,500 )
satisfactory and are hereby accepted.You are authorized to do work as specified. Balance Due Upon Completion:($ 5,827 )
Payment will be 1/3 down at start of job,and balance completio
Date:4/26/22 Signature:
/ (:_//E7/
/1
Date: 4/26/22 Estimator:(Print Name) James BOnavita (Sign Name) l'/1u<
ATTENTION HOMEOWNERS:Please cover all personal belongings in the attic,garag r storage areas due to the
possibility of roofing debris or dust coming in through cracks of the wood.Adam Quennev'le Roofing will not be
responsible for debris or dust in the attic or storage areas. Customer Initials:
ACO CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY)
‘i..../ 4/15/2022
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(les)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
NAME: Sarah Premo
Clayton Inaurance Agency, Inc. INC.No,EX11: (413)536-0804 FAX
P INC.No): (413)334-7B74
1649 Northampton Street E-MAIL spremo@claytoninsurance.net toninsurance.net
ADDRESS: Y
P. 0. Box 989 INSURER(S)AFFORDING COVERAGE NAIC B
Holyoke MA 01041-0989 INSURER A:Nautilus Insurance Company
INSURED INSURER e:Arbella Insurance Company
Adam Quenneville Roofing & Siding Inc. INsuRERc:AIM Mutual Insurance Company
160 Old Lyman Road INSURERD:
South Hadley, MA 01075 INSURERE:
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 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 INSn Jilin POLICY NUMBER (MMIDD/YYYY) IMMIDDIYYYYI LIMITS
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 5 1,000,000
DAMAGE
A CLAIMS-MADE X OCCUR PREMSESOTE(Ea ooccurrence) 5 100,000
NN1283315 6/23/2021 6/23/2022 MED EXP(Any one person) 5 5,000
PERSONAL 8 ADV INJURY 5 1,000,000
GENT-AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE 5 2,000,000
X POLICY n JECT PRO- LOC PRODUCTS-COMP/OP AGG 5 2,000,000
$
OTHER: _
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000
(Ea accident)
B -ANY AUTO BODILY INJURY(Per person) S
ALL OWNED SCHEDULED 1020107895 6/23/2021 6/23/2022 BODILY INJURY(Per accident) 5
AUTOS ^ AUTOS
NON-OWNED PROPERTY DAMAGE
X HIRED AUTOS X AUTOS (Per accident) 5
UNINS/UNDERINS MOTORISTS 5 100,000/900,000
X UMBRELLA LIAR OCCUR EACH OCCURRENCE 5 5,000,000
A EXCESS LIAB CLAIMS-MADE AGGREGATE $ 5,000,000
DED RETENTION$ AN1242102 6/23/2021 6/23/2022 5
WORKERS COMPENSATION X PER OTH-
AND EMPLOYERS'LIABILITY Y I N STATUTE ER
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT S 1,000,000
OFFICER/MEMBER EXCLUDED? Y N/A
C
(Mandatory In NH) AWC4007012861 4/29/2022 4/29/2023 E.L.DISEASE-EA EMPLOYEE 5 1,000,000
II 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 apace 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 �7
Michael Regan/FMT ✓7 / p atQ4.,,
@ 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
INS025(201401)
Commonwealth of Massachusetts
it Division of Professional Licensure
Board of Building Regulations and Standards
Constv4AP iSlpfkrvisor
CS-070626 y ,icfpires:08121/2 23
ADAM A QUENNEVILLE`t 4160 OLD LYMAN RD _t,
SOUTH HADLEY MA O 10:• �?
`1`0/.S\11.t0-
Commissioner da�a 1C. J&nL
dlA€ Wo4n/rito4tweaa'A, aiCY1( dad,taem
Office of Consumer Affairs and Business Regulation
1000 Washington Street- Suite 71 0
Boston, Massachusetts 0211 E
Home Improvement Contractor Registration
Type: Corporation
Registration: 191093
ADAM OUENNEVILLE ROOFING AND SIDING,INC. Expiration: 03/22/2022
160 OLD LYMAN RD.
SO.HADLEY,MA 01075
Update Address and Return Card.
SCA I CS 2OM.O5r17
,�'�i7+ 'f:4` rYJ>t r"''`�•ht f,tnr';;,f i VT..t, r s�,t ;+� t •^� f -�,•f ,�^ t•; •t
. r � i� le3 C} t t"t t 1•F 1, r
• _
Aft,' � W , f zr l44"MI . GC i VY t ia s r a � t •,
—�, nJ
STATE OF CONNECTICUT + DEPARTMENT OF C NSUMER PROTECTION
Be it known that r'
ADAM QUENNEVILLE
160 OLD LYMAN ROAD I
SOUTH HADLEY, MA 0107t2632 I >
f t ls,
". has satisfied they qualifications required by law and is hereby registered as a
HOME IMPROVEMENT CONTRACTOR r'
Registration # HIC.0575920 '
( ice,
ADAM QUENNEVILLE ROOFING I ;"
rfi. Effective: 12/01/2021
03/31/2023 /1Z � � I 1 ,
Expiration: f
Michelle Seagull,Commissioner
'�� -s•�� � r s r n s n � f U t f, r s � ���������� a Li « �
,t '' :"2 : t lsh ,f.s.rr ai �.J�•..,f 'ttiEY•1�r. ` :t., A ,�7 t r.
� v a, 3; � .tea ,� i \hc ��
The Commonwealth of Massachusetts
� Department of Industrial Accidents
! ;
_ la• Office of Investigations
600 Washington Street
—=5 = Boston,MA 02111
•A�
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): ACleir' Gbverv-a)t l c- Q io t1X
Address: (LO O l A L ►�„�, C L �J
City/State/Zip: SovW 1\10,Atc,6 G] Phone#: `t 13 -53C-5'155
Are you an employer?Check the appropriate box: Type of project(required):
1.4K 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' 9 [7] Building addition
[No workers' comp. insurance comp.insurance.:
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 11.0 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
employees.[No workers' 13.0 Other
comp. insurance required.]
"Any applicant that checks box#I 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.
Insurance Company Name: A M v T vek\ i/1S U ic.\t.C-+
Policy#or Self-ins.Lic.#: A W C`10 o10 i a' 'C G( Expiration Date: I�� 1/a 3
Job Site Address: 24 MiddleSt City/State/Zip: Florence Ma 01067.
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.
1 do hereby certify under th ains and penalties of perjury that the information provided above is true and correct.
Signature: / Date: CI`)-1,}Dc)"
Phone#: 'l!3 ` 53C — 5959-
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#: