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29-163 (4) BP-2023-0912 48 HICKORY DR COMMONWEALTH OF M SSACHUSETTS Map:Block:Lot: 29-163-001 CITY OF NORTHA PTON Permit: Exterior Res PERSONS CONTRACTING WITH UNREGI TERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARA TY FUND (MGL c.142A) BUILDING PERMIT Permit # BP-2023-0912 PERMISSION IS HEREBY GRANTED TO: Project# ROOF 2023 Contractor: License: ADAM QUENNEVIL E ROOFING & Est. Cost: 28673 SIDING 070626 Const.Class: Exp.Date: 08/21/202 Use Group: Owner: L DE CK HENRY M& BETTY Lot Size (sq.ft.) Zoning: WSP Applicant: ADAM UENNEVILLE ROOFING & SIDING Applicant Address Phone: Insurance: 160 OLD LYMAN RD (413)536-5955 AWC4007012861 SOUTH HADLEY, MA 01075 ISSUED ON: 07/13/2023 TO PERFORM THE FOLLOWING WORK: STRIP AND REROOF 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 NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: IA• Fees Paid: $40.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner ,�_ Department use only ":,- �� City of Northampt,6�T'---- �E V ,s of P rmit:Building De artm nt Cur Cut/ riveway Permit - ,,. 212 Main tre t JVL12 Se er/Se tic Availability � ``� °� 2023 Room 00 W er/W II Availability �� e�` Northampton MP�E T Set of Structural Plans sw phone 413 587 124 ax PP 4� �� SoEcr USite Plans Other S ecify 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 48 Hickory Dr Florence Ma 01062 Map Lot Unit Zone Overlay District i Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Linda Dupont 48 Hickory Dr (Florence Ma 01062 Name(Print) Current Mailing Address: 413-237-0002 see contract Telephone Signature 2.2 Authorized Agent: Adam Quenneviile 160 Old LymanRd South Hadley Ma 01075 Name(Prirlt) Current Mailing Address: 4da4 Quennedie 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 28673.00 (a)Building Permit Fee 2. Electrical 0 (b)Estimated Total Cost of Construction from(6) 3. Plumbing 0 Building Permit Fee 4. Mechanical(HVAC) 040 5. Fire Protection 0 6. Total=(1 +2+3+4+5) 28673.00 Check Number ILO}7 This Section For Official Use Only Building Permit Number: J'7-'e'., 3 4/1,? Date Issued: Signature: /�1 7-- 15- ZOZ3 Building Commissioner/Inspector of Buildings Date kaylee.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 DONT KNOW X YEF7 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? YEF1 NO X IF YES, describe size, type and location: E. Will the construction activity disturb clearing,gradin x avation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YE II 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 7 Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [ice Siding[] Other[El] Brief Description of Proposed new roof, remove&replace existing roof, new underlayment,drip edge, ridge vent, ice and water, pipe boot 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 Wooftoves Number of each g. Energy Conservation Compliance. Masscheck Energ 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 Linda Dupont , 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 06/26/2023 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 ' y. Adam Quenneville Print Name 06/26/2023 Signature of Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable 0 Name of License Holder: Adam Quennville CS-070626 License Number 160 Old Lyman Rd South Hadley Ma 01075 8/21/2023 Address Expiration Date 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 3/22/2024 Address 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 % Massachusetts '� DEPARTMENT OF BUILDING INSPECTIONS s% ' ,s..7' 212 Main Street •Municipal Building v 1, -- Northampton, MA 01060 rtiy r,- "' 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: 48 Hickory Dr Florence 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 Roofing&Siding 160 Old Lyman Rd South Hadley Ma (Company Name and Address) IPV.:d:adby ptl!piMer /-tla�/C�uennel/((e 06/26/2021 Signature of Permit 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. A�D CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 4/12/2023 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. lac No.Est); (413)536-0804 (AAic,No): (4131534-,9,4 1649 Northampton Street E.MML Ss: spremo@claytoninsurance.net ADDRE P. 0. Box 989 INSURER(S) AFFORDING COVERAGE NAIC 8 Holyoke MA 01041-0989 INSURER A:Nautilus Insurance Company INSURED INSURER B Green Mountain insurance Company Adam Quenneville Roofing & Siding Inc. INSURER c:Gray Surplus Lines Insurance Company 160 Old Lyman Road INSURERD:AIM Mutual Insurance Company South Hadley, MA 01075 INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER:2022 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP W M/ LIMITS LTR INSD VD POLICY NUMBER (MDDIYYYY) (MM/DD/YYYY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE A CLAIMS-MADE X OCCUR PREMISESO(EaENTE occurrence) $ 100,000 X BI & PD DED $2,500 NN1423290 6/23/2022 6/23/2023 MED EXP(Any one person) $ 5,000 PERSONAL &ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY JECT PRO- LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ B ALL OWNED SCHEDULED _ AUTOS AUTOS 20047429 6/23/2022 6/23/2023 BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE $ X HIRED AUTOS AUTOS (Per accident) UNINS/UNDERINS MOTORISTS $ 100,000/300,000 X UMBRELLALIAB _ OCCUR EACH OCCURRENCE $ 5,000,000 C EXCESS LIAR CLAIMS-MADE AGGREGATE $ 5,000,000 DED RETENTION$ GSL100712 6/23/2022 6/23/2023 $ WORKERS COMPENSATION X PER ERH- AND EMPLOYERS'LIABILITY STATUTE ER YIN ANY PROPRIETOR/PARTNER/EXECUTIVE NIA D (mandatory in NH)NH) E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBEREXCLUDED? y AWC4007012861 4/29/2023 4/29/2024 E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) For Informational Purposes Only. Workers' Compensation benefits will be paid to Massachusetts employees only. Pursuant to Endorsement WC 20 03 06 B, no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires, or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued (unless the expiration date on the above policy precedes the issue date of this certificate of insurance) . The status of this coverage can be monitored daily by accessing the Proof of Coverage - Coverage Verification Search tool at www.mass.gov/lwd/workers-compensation/investigations/. 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 ACCORDANCE WITH THE POLICY PROVISIONS. 160 Old Lyman Rd South Hadley, MA 01075 AUTHORIZED REPRESENTATIVE Michael Regah/FMT /92 ,,r P' ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025(201401) The Commonwealth of Massachusetts ,=. Department of Industrial Accidents Office of Investigations — 600 Washington Street �� Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information /� /� n _. �) +Please Print Legibly Name(Business/Organization/Individual): A�e�r, t,.lLve'r1v`(U t tlt' `�Ot 116. C� J 4l r Y (r✓)c Address: 1 GO 01 L�v City/State/Zip: 5°v% 1•141Art_ (I'ln 01057 Phone#: 1113 —53C'5 R55 Are you an employer?Check the appropriate box: • Type of project(required): 1.4K1 am a employer with 15 4. ElI am a general contractor and C 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 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. rj Demolition working for me in any capacity. employees and have workers' 9 Building addition [No workers'comp. insurance comp.insurance.t required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their ILO Plumbing repairs or additions myself.[No workers'comp. right of exemption per MGL 12.E1 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. l am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: i.r u 1 ucx nS 0 Vacy Policy#or Self-ins.Lic.#: AWC 4Oo10 ge'( Expiration Date: a 3 Florence Ma 01062 Job Site Address: 48 Hickory or 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 eeirtifounderte pains and penalties of perjury orlon provided above Is true and correct. Qda�/C2uennetrle -_. 06/20/2023 Signature:_ Date: Phone#: 41 3 ` 5 3c - 59 5 c 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#: Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Consk * ilii'pervisor CS-070626 * ,, Expires:08/2112023 .......... ADAM A QUE NN ., r 160 OLD LYMAN R 0 SOUTH HADLEY MA 41015 '" "' Commissioner 'r'!• K. l C i THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Corporation Registration: 191093 ADAM QUENNEVILLE ROOFING AND SIDING, INC. Expiration: 03/22/2024 160 OLD LYMAN RD. SO. HADLEY, MA 01075 Update Address and Return Card. o't : '11,his ?,t -,,k,k?2 �ye''.�1„ • �'�F�'st o , ;.,,, S,� I �s' t bb,°s' .fit,,7N.7*,` . t ki.r+rr,4 4 .a7.') #., tyyrlk} f' . i;,1 4.1 1 t!7'Z,/' v ,�i"i'.+t.a..�:..i. r,,< f 7 ':„cyS 3'},'�' Y',�, ,r. -� ^vS'�a.t F �' t� '4ks d �y,..2r `v , �z, � +«7. ry•'lg- '� ri ,� h �i , 1 S 1 ''ia, - '' .�„ 'T 3 ; ' •s k t' ,pt 0 ;y am 4 le f �;, ` STATE OF CONNECTICUT + DEPARTMENT OF CONSUMER PROTECTION 7,, Be it known that , ADAM QUENNEVILLE ``:v`. :- i 160 OLD LYMAN ROAD i '; � i r _ SOUTH HADLEY, MA 01075-2632 -u.-4 1 ti . has satisfied the qualifications required by litw an is hereby registered as a { fir. HOME IMPROVEMENT CONTRACTOR { k-.. p. ; ASg. ADAM QI ENNFVILI,I ROOFING ; Registration #: HIC.0575920 x, l�lF `,` , Effective: 04/01/2023 ! tJ I d �l : Expiration: 0.3/31 j2024 � , i Michelle Seagull,Commissioner i T.4'. ` 1•'. ;t 't, ti;.'41.,.r4.',"4t;/�° I. s. 1''i 4v1s 4t '>'' ' tv ''",rf.^.r ' l• '�..''1,`'''i' �‘ '1•` ...-.''t. 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