16B-037 GIS #:
Lot: -001
Permit: Bu
Categoa:
Permit # BP
Project # JS-
Est. Cost: $3940.00
Fee: $35.00
Const. Class:
Use Group:
Lot Size(sq. ft.): 13 1 %
Zoning: URB(100)/
Applicant Address
160 OLD LYMA
Compensation
SOUTH HADLE'
TO PERFOR
POST THIS CAI
Inspector of Plumbir.
Underground:
Rough:
Final:
Gas:
Rough:
Final:
THIS PERMIT IM
ANY OF ITS RUI
Certificate of Occ
FeeType•
Building
-- �fC�PLICAl
SECTION 1 - SITE
1.1 Property Addre
) 10 Peen
SECTION 2 - PROF
2.1 Owner of Recoi
Name (Print)
Signature
2.2 Authorized Age
Name (Print)
Si
SECTION 3 - ESTIN
Item
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVA
5. Fire Protection
6. Total =(1 +2 +3
Building Permit Num
Signature:
Section
Lot Size
Fronta e
Setback:
Building
Bldg. Sq
Open Sp
(Lot area n
p arking)
# of Part
Fill:
volume &
A. I
N
IF YES
IF YE
IF
B. Doe.
IF
N1
C. Do
IF
D. Are
IF
E. Will
that
IF YI
SECTION 5- DESC
New House [
Accessory Bldg. [
Brief Description of
Work:
Alteration of existinc
Attached Narrative
Plans Attached Roll
6a. If New house
a. Use of building
b. Number of roor
c. Is there a garac
d. Proposed Squa
e. Number of stori
f. Method of heati
g. Energy Consen
h. Type of constru
i. Is construction i
j. Depth of basem
k. Will building cor
I. Septic Tank _
SECTION 7a - OWN
OWNERS AGENT C
I
I,
property
hereby authorize
to act on my behalf, i
i gnature of Owner
I, 4
Agent hereby declarf
and belief.
Signed under the pai
Print Name
Sign at ner /Age
SECTION 8 - CON
8.1 Licensed Con
Name of License Ho
Address
Signature
9. Regis red Ho
Company Name
Address
SECTION 10- WO
Workers Compens
in the denial of the i
Signed Affidavit Att
The curr
and to al
as su e
Deriniti
is, orisi
structure
Such "ho
res onsi
As actin
completi
Also be
Employe
you hire
The and
Northam
Homeow
Ema
MA(
Mem'
Mem'
Prop(
Stree
City,
Flo c
Comp
We
[ Hot
Ent
Det
Insl
[ Inst
[gInsl
M Inst
Rinst
Inst
[� Inst
❑ Inst
Shingl
4
t9
Warm
�We
S GAI
❑ GAI
Chimn
[� L ea
We Prop
Total Sa
ACCEPT
You are
Unpaid I
able attc
Dater
Date
ATTENTI
possibili
will not t
W?`t kerg'
A.nal In]
Name (Bu
Addr-ess:
city /Sip
Are you an empl
l.. I am a =ph
employees (
2 1 amasole
ship and hai
working fol
(No worker
reTiTed_j
3. 1 am a home
myself. (No
insmmn= ae
*Any applicant that cho
t Hoideowners who- sub
If:onttac4o[s tit cinecic
:I am are. ernrpioyer. a
in, formation.
fnaumiee Commpal�
Policy # or. Self - ins.
3ah Site Address:,...
Attach a copy of t)
Failure to secure co
'fine up. to.1,5441)t
of up to $250.00 a c
Invesfxgalions of Ott
I do hereby certify
S�natnre:
Phone #:
Offici rd rise o nb
City or Town. _
Issuing Author
1. Board of Heal
AC�?R CERTIFICATE OF LIABILITY INSURANCE OP D DM DATE(MW0D/YYYY)
-1 1 05/03/10
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONL) AND CONFERS NO RIGHTS UPOij rIE CERTIFICATE
Remillard Insurance Agcy, Inc HOLDER. THIS CERTIFICATE. DOES NOT AMEND, EXTEND OR
79 Lyman Street ALTS, THE COVERAGE AFFORDED BYITHE POLICIES BELOW.
South Hadley MA 01075
Phone: 413 -538 -7862 Fax:,913 -538 -7179 INSURERBAFFORDINGCOVERA>;E _ NAIC#
INSURED' 14URER'A: mm Llntna] Inana9p�ca ny
INSURERS Travelers Ins. Co.
Adam Quenneville Roofing & INSURER C Scottsdale Ins Co.
$idin Inc
160 0 d Lyman Road INSURER b:
South Hadley M 01075
INSURER 9:
COVERAGES
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 Td. WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IB SUBJECT Td ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LTR NSA TYPE OF INSURANCE POLICY NUMBER DATE MM OWN ATE MWDDIYY LIMITS
GENERAL LIABILITY EACH OCCU CE $1000000
C X COMMERCIAL GENERAL LIABILITY CPS1034980 06123109 06123110 PREMISES o 6100000
CLAIMS MADE Q OCCUR MED EXP ft one pwow) 95000
PERSONAL 6ADVINJURY $1000000
QZNKRAL AG6aso.T6 *2000000
GEML AGGREGATE LIMIT APPLIES PER. PRODUCTS•COMPWAGO 52000000
POLICY F T F LOC
AUTOMOBILE LIABILITY COMBINED SINGLE. LIMIT
B ANYAUTC BA745OL946 11/01/09 21/01/10 (Es a�n da" 91000000
ALL OWNED AUTOS BODILY INJURY
X SCHEDULED AUTOS (Peromml S
X HIREDAUTOS BODILY INJURY
X NON•OWNEDAUTOS (Peracelderd) S
PROPERTY OHMAGE S
(Per eeofdenl)
GARAGE LIABILITY AUTO ONLY- EAACCIOENT 6
ANY AUTO OTkiERTHAN EA ACC 6
AUTOONLY. AGO S
EXCUSIUM13RELLA LIABILITY EACH OCCUR S
OCCUR n CLAIMS MADE AGGREGATE S
E
DEDUCTIBLE i
RETENTION 6 t
WORKERS COMPENSATION AND X IT80M 8 1 X
A EMPLOYERS' LIABILITY AWC701286101 04/29/10 04/29/11 E.L EACH ACCIDENT ( S1 00 0 000
ANY PROPRIETORIPARTNERIEXECUTNE
OFFICERIMEMBEREXCLUDED? E.L DI SEASE .EA EMPLOYE $1000000
SPE�IALPROVISIONS below E.L DISEASE .POLICY LIMIT 1 S 1000000
OTHER
DESCRIPTION Of OPERATIONS I LOCATIONS 1 VSHICLGS / UXCLUPAONS ADDQO SY 9NOORSEMENT1 SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
pXLV QUE SHOULDjANYOF THE ASCVE DESCRIBED POLICIES ¢E CANCELLED BEFORE THE EXPIRATION
Adam Quennevil le Roofing DATE THgREDF, 7NE ISSUING INSUABR WILL LIMDBAVOR TO MAIL 30 DAYS W AIrMN
Brian NOTCH TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO 00 SO SHALL
f ax # 53 6 -144 8 IMPOSE NO 0e1410ATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AOENTS OR
Po Box 612
South Hadley MA 01075 REPRESENTATIVES.
AUTHO ED REPRESENTATVfi
ACORD 26 (2001108) ® ACORD CORPORATION 1988
oar o ul Mg egul
moans an tan ar s
One Ashburton Place - Room 13 01
~ Boston, Massachusetts 02108
Consttruction License
,:. , ...•,:: ...
.. License CS: 7 0626
Restriction: 00 r
Birthdate: 8121 f1971
Expiration: 8!21 /2011
Tr# 3712
AQACV6`A- 4 00F,NNEVIL:LE -
4-60 OLD �LYM 'N RD : •°
..5;`HAhLEY, MA 01075. ':
Update Address and return card. Mark reason for change
O Address Renewai El Lost Card
76 e siness
Office of Consumer Affairs and Regulation
10 Park Plaza - Suite 5170
Boston, Massa usetts 02116
Home Improvement r tractor Registration
Registration: 120982
Type: DBA
z Expiration: 3/25/2012' Tr# 293069
ADAM QUENNEVILLE ROOFIN b
ADAM QUENNEVILLE
160 OLD LYMAN RD w
SO. HADLEY, MA 01075 q
Update Address and return card. Mark reason for change.
Address Renewal Employment E] Lost Card
DPS -CAI is 5OM- 04/04- G101216
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