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17C-084 e llippoi terr DISCOVER • . A D A Gila EN! NEVILL t!YicK .j 53 - r {Z4 z ROOFING & SIDING, INC. 160 Old Lyman Road, South Hadley, MA 01075 1. 800 - NEW -ROOF • 413- 536 -5955 Email: info @1800newroof.net Website: www.1800newroof.net MA Construction Supervisors Lic. #070626 MA Registration #120982 Member of the Home Builder's Association of Western Mass. CT Registration #575920 Member of the Building & Trade Association Member of the Better Business Bureau Pr UL al Submitted To: Dat Phone #'s 5 _ d$3 3 A EL/j1so 8 Ia3 /icy H:� -(I3 -' W: i ll 334 - 1J I Street Job Name: g± et ES � City, State, Zip Code Job Location: LoRn)cE /vA 0 I D(c.2 Proposal to furnish and install the following ❑ Re -Roof gl Tear -Off ❑ Gutter 1 o R. C3(b .-z y \ b J Vu R.. wczoD ZJ Iti4A t Y c-bcpyzi 4 /tvSr-ftq o.hd t eock R.,c3,(36 ,it..041o4Pi --i '• W ,ire V 60 Ask us about CO — (0OO Z C 2 60 affordable bank `� financing We Propose hereby to furnish materials and labor - complete in accordance with above specifications for the sum of: dollars ($ Yo00 m ) ACCEPTANCE OF PROPOSAL: The ove prices, p ' 'cations and conditions are satisfactory and are hereby accepted. You are uthorized to do wor s ecifi. ui ..�j�' b1 1/3 down at start of job, and balance due upon completion. Date: " /�-3/ © Signatur —" • - / Phone # ` 2 –5 b 326 Date: B -`- 3 " ICI Estimator's Signature'L.., Estimates are honored for sixty (60) days from above date 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 Quenneville Roofing will not be responsible for debris or dust in the attic or storage areas. ACORD CERTIFICATE OF LIABILITY INSURANCE OP ID DM DATE(MMIDOIYYYY) ADAMQ -1 06/24/10 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONIFERS NO RIGHTS UPON THE CERTIFICATE Remillard Insurance Agcy, Inc HOLDER, THIS CERTfFICATE DOES NOT AMEND, EXTEND OR 79 Lyman Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. South Hadley MA 01075 Phone : 413 - 538 -78 62 Fax :413- 538-7179 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURER A; AIM Mutual Insurance Company INSURER B: Travelers Ins . Co . Adam Quenneville Roofing & I NSURERC: First Speciality Ins Corp Siding Inc & Guttershutter P y , 160 Old Lyman Road INSURER D: Hanover Insurance Company 22292 South Hadley MA 01075 INSURER E: 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 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR DD' POLICY EFFECTIVE POLICY EXPIRATION L TR iNSR TYPE OF INSURANCE POLICY NUMBER DATE (MMIDD!YY) DATE (MMIDDIYY) I LIMITS GENERAL LIABILITY 1 l EACH OCCURRENCE 51000000 UAIVAC,e IUKhNItU X COMMERCIAL GENERAL LIABILITY THI 06/23/10 06/23/11 1 PREMISES (Eaoccurence) 5 100000 ■. CLAIMS MADE X OCCUR ' I MED EXP (Any one person) $ 5000 ■ I PERSONAL & ADVINJURY ! $ 1000000 i ■ GENERAL AGGREGATE $ 2000000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS • COMP /OP AGG j $ 2000000 POLICY fPR f I f JECT LDC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 5 1000000 $ : A NY AUTO BA7450L946 i 11/01/09 11/01/10 (Eaaccidenl) ALL OWNED AUTOS BODILY INJURY S • X : SCHEDULED AUTOS (Per person) X I HIRED AUTOS BODILY INJURY X NON•OWNED AUTOS (Per accident) I $ PROPERTY DAMAGE (Per accident) I � GARAGE LIABILITY I i f AUTO ONLY - EA ACCIDENT $ ANY AUTO • 1 OTHER THAN EA ACC I $ • AUTO ONLY: AGG S EXCESS /UMBRELLA LIABILITY EACH OCCURRENCE 5 n OCCUR CLAIMS MADE AGGREGATE S • 5 DEDUCTIBLE $ RETENTION $ $ WCSIATU- UiH- WORKERS COMPENSATION AND TORY LIMITS I ER EMPLOYERS' LIABILITY A AWC701286101 04/29/10 04/29/11 I E.L.EACHACCIDENT 51000000 ANY PROPRIETOR/PARTNERIEXECUTIVE OFFICER/MEMBEREXCLUDED7 j E.L. DISEASE - EA EMPLOYEE $ 1000000 if yea, describe under SPECIAL PROVISIONS below j E.L. DISEASE • POLICY LIMIT i $ 1000000 OTHER D Equipment Floater iIHN7140610 02/01/10 02/01/11 Rental Equipment $100,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SERVMAG SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 3 0 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO 50 SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTOO ED REPRESENTATIVE ACORD 25 (2001108) © ACORD CORPORATION 1988 • 1"...\_ v! �G� 0 • . . . A ° # A ,. s , * - oar • o : u1 • ing ' egul sans an tan ar s One Ashburton Place - Room 1301 -411 Boston, Massachusetts 02108 Construction License . License CS: 70626 , :'... Restriction: 00 , •8irthdate: 8/2111971 ,.. • • • Expiration: 8/21/2011 Tr# 3712 ADAM A QUENNEVILLE 160 OLD LYMAN RD S` HADLEY, MA 01075 , _ .._ sm_ , ..-_,__ .Liotte -67„...., I , 4 ' /4 r =---,_7titif -- --_ r 111 Office of Consumer Affairs and usiness Regulation 10 Park Plaza - Suite 5170 �_� Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 120982 Type: DBA Expiration: 3/25/2012 Tr# 293069 ADAM QUENNEVILLE ROOFING ADAM QUENNEVILLE 160 OLD LYMAN RD SO. HADLEY, MA 01075 . •P1. i` ..:.i•Y,•. �{/. W i'i 5i'iti M1 ,/.:,•:7�•,S. �V r W 1 W, W Y W ! V/ Y W ti� .rr W y ti W ? W Ol � l• t'r• A•.. rh i ' l.t ,Syb;• 455A; ., r:r: SrS, ,5r':, @'F•t, 'tai: ; , ;y s;• •tlY , �, r. ,t.;• ;; +i. ,.,M , 4 is . r..1dY' % -: i, rJf %i il,, / , . , .tp�,,� 5 r 1. 4 f 4: / F g1 �� 7! \ R 1 f "' F F\ \ f �\ A. f F f li ; \ >; f "7 f \ f A` R !All •.:. ,., 1R 441A% .. F,,. r fF ,. ,R..,, �..,. F,.;.. > , .. .�' .. Fl F R ,'c F .r 5u' STATE OF CONNECTICUT + DEPARTMENT OF CONSUMER PROTECTION r, i nown Be it known that .„ y ADAM QUENNEVILLE 1 60 OLD LYMAN ROAD l SOUTH,I-- IA.D-1. Y, MA 01075 -2632 , r l •R4t ' i 9 191 \ ` i y P- S, 1 :' / r f is certified by the Deparnt cif (Ao�sLler Ijx©tection as a registered / t' HOME IMPROVEMENT CONTRACTOR Regist Eton -I ;-0575920 y ADAM QUENNEVILLE ROOFING , �u • Effective: 12/01/2009 K . Expiration: 11/30/2010 ___�_ Jerry Farrell, J r., Commissione The Commonwealth of Massachusetts • Department of Industrial Accidents k . > � t Office of Investigations ` 600 Wad Street Boston, MA 02111 MEMO ± www mass.gov /dia Workers' Compensation Insurance ABidavlt: Builders/ Contractors /Electricians/Plumbers Annlicant Information Please Print Letlibly • . ' \ 9 Name (Business/ ): s ■! .. e., ' . , • - a # s 4 A r1C Address: ILO n t A L 4h d. City/State/ • , : , ,u. a : eta phone #: [ - ' .- --' — Are you an employer? Check the appropriate boa: TYPe of Project (required): 1.121 I am a employer with l 5 4. 0 1 am a general contractor and 1 employees (full and/or part-time).* have hired the sub - contractors 6. ❑ New construction 2. ❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees T sub-contractors have 8. 0 Demolition working or me i employees and have workers' y ' t 9. ❑ &Wing addition [No workers' comp. insurance COmp. insurance. required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their 11. Plumbing mbPlumbing repairs or additions myself workers right t of ex emption per MGL 12 ,Roofrepairs insurance reguired.1 t c. 152, § 1(4), and we have no employees. [No workers' 13.0 Other comp. insurance required.] Any applicant that darks box Al most also fill out the section below showing their wodoms' compensation pricy information. t Homeowners who submit this affidavit indicating tiny INC doingas wok 1h i a outside cortcarson mast snbmiti affidavit indir asch. /Caahsct=1hm checked" boxmet aaachedin additional sheet iowingthe name of helee- coatractors sod state whethcarnot these entities Owe employees. If he sub-contractors brae employees, they most provide their wailers' gyp. policy number. I am an employer that is providing wakes' cow insurance for my employers Below is the policy and job site info Insurance Company Name: A- VA A u c l Jyl� u rA n t P, / Policy # or Self -ins. Lic. #: A WC . 9 O le (c� [ ©L Expiration Date: / 02 q /�G 1 1 Job Site Address: ?7 C h e5 +n o S +. F(oc ca 14 A COQ. City/State/Zip: !// d Attach a copy of the workers' eantpensaton policy t page (showing the policy number and expiration- dates Failure to secure oovaage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to S1, 500.00 and/or one -year invrisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification , I do hereby cam► under the and penalties ofperjury that the infonnatton pre viledmbove 1s true and Signature: Date: /aG1 [ 0 ne #: lit 3"5.3(0"a 5 Ojjidal use only. Do not write In this area, to be completed by dty or town oilidal City or Town: Permit/License # Issuing Authority (circle one) 1. Board of Beahb 2. BuBding Department 3. City/ own Clerk 4. Electrical inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: f if(1 6 ifi*Ual V tut !k)11 H .4 70;1, SECTION 8 - CONSTRUCTION SERVICES Adam & ',1 8.1 Licensed Construction Supervisor: Adam Quenneville Roofing & Siding, Inc, Not Applicable ❑ Name of License Holder : 160 Old Lyman Road 7Q(, of Lyman Number South Hadley, MA 01075 _9( Address Expiration Date q13- 53` - Signatu Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ Ada Qmnevi&e Roofing& Siding, Inc. as-) Company Name 160 Old Lyman Road Registration Number South Hadley, MA 01075 - 2 s- i Address Expiration Date Telephone L( 13 'CSC "$RSS SECTION 10 WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 162, § 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 No ❑ 11. - Home Owner Exemption The current exemption for "homeowners" was extended to include Owner- occupied Dwellings of one (1) or two(2) families and to allow such homeowner to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor. CMR 780, Sixth Edition Section 108.3.5.1. Definition of Homeowner: Person (s) who own a parcel of land on which he /she resides or intends to reside, on which there is, or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/ or farm structures. A person who constructs more than one home in a two -year period shall not be considered a homeowner. Such "homeowner" shall submit to the Building Official, on a form acceptable to the Building Official, that he /she shall be responsible for all such work performed under the building permit. As acting Construction Supervisor your presence,on the job site will be required from time to time, during and upon completion of the work for which this permit is issued. Also be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to Employees for injuries not resulting in Death) of the Massachusetts General Laws Annotated, von may be liable for person(s) you hire to perform work for you under this permit. The undersigned "homeowner" certifies and assumes responsibility for compliance with the State Building Code, City of Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature 6° 6111141 1F KNI *Fit PC A O Mit Pr SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [E] Siding [0] Other [0] Brief Description of Proposed n Work: ee'Ov n , I 1 - oo�'�ns+o world t TR 5, 36-1 'RI TA- R ltin3 oarL kubrf'`e^` 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 budding : 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 1, PGVAck_ - ( ) So4 , as Owner of the subject property Qum* look It k hereby authorize Atlas to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date Adas Q�R&S'Iit 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. Adams Q eAnevd \ Print Name Signature of Owner /Agent Date Section 4. ZONING Alt 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 0 • • DONT KNOW ® YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW 0 YES IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO ® DONT KNOW YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q 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 (clearing, grading, 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. " 4401:,i* 10* I mit Department use only City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit ►AUG 3 1 2010 212 Main Street Sewer /Septic Availability Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans phone 413487 - 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 1.1 Properly Address: This section to be completed by office o1G54-nuk S'f'- Map Lot Unit Floce.i ce 00 Co a Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: B .v`a\ Et %%Orl $7 Ike-$ #n A- S+ Fl cc - / Mk otoG Name (Print) Current Mailing Address: k /3 SAS —Of 33 Telephone Signature 2.2 Authorized A ent: bag& ► it 160 Old L tr►okA R.& . Soup" Ho�1a� Name (Print) Current Mailing Address: 41'; - 6 Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building 3 f 40 0 (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) 9 3 Check Number /r33/ n5 This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner /Inspector of Buildings Date • q 87 CHESTNUT ST : • BP- 2011 -0183 GIS #: COMMONWEALTH OF MASSACHUSETTS 'Map:Block: 17C - 084 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: BUILDING PERMIT Permit# BP- 2011 -0183 Project # JS- 2011- 000308 Est. Cost: $3600.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ADAM QUENNEVILLE 070626 Lot Size(sq. ft.): 10890.00 Owner: ELLISON PAULA K Zoning: URB(100)/ Applicant: ADAM QUENNEVILLE AT: 87 CHESTNUT ST Applicant Address: Phone: Insurance: 160 OLD LYMAN RD (413) 536 -5955 0 Workers Compensation SOUTH HADLEYMA01 075 ISSUED ON:8/31/2010 0:00:00 TO PERFORM THE FOLLOWING WORK:STRIP & INSTALL NEW RUBBER MEMBRANE ROOF 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. Certificate of Occupancy Signature: FeeType: Date Paid: Amount: Building 8/31/2010 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner