Loading...
17C-110 • �..•/RE CERTIFICATE OF LIABILITY INSURANCE OP ID DA DATE(MMIDD /YYYY) ACEFI - 03/25/11 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Haberman Insurance Group Inc HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 95F Ashley Avenue ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. West Springfield MA 01089 I Phone: 413 781 - 7000 Fax: 413 733 - 9545 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURER A: American Safety Insurance INSURER B: Travelers Insurance Company 40282 ACE Fire & Water Restoration INSURER C: Chartis 18 Elizabeth Street INSURER D: West Springfield MA 01089 ( 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 ADD'L POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION I LIMITS LTR INSRC TYPE OF INSURANCE DATE (MMIDDYYY) DATE (MMIDD /YYYY) GENERAL LIABILITY I EACH OCCURRENCE $ 1000000 A X COMMERCIAL GENERAL LIABILITY ENV023710-10-02 09/21/10 09/21/11 PREMISES _ (Ea occurence) $ 50000 CLAIMS MADE X OCCUR MED EXP (Any one person) $ 5000 PERSONAL B ADV INJURY $ 1000000 GENERAL AGGREGATE $ 2000000 GE 'L AGGREGATE LIMIT APPLIES PER. PRODUCTS - COMP /OP AGG $ 2 000000 X POLICY PRO LOC JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1000000 B ANY AUTO HA4168N33610SEL 07/01/10 07/01/11 (Ea accident) ALL OWNED AUTOS BODILY INJURY X I SCHEDULED AUTOS (Per person) X HIRED AUTOS BODILY INJURY $ X NON -OWNED AUTOS (Per accident) PROPERTY DAMAGE (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO EA ACC $ OTHER THAN AUTO ONLY AGG $ EXCESSI UMBRELLA LIABILITY EACH OCCURRENCE $ 1000000 A X OCCUR CLAIMS MADE ENUO23712 -10 -02 09/21/10 09/21/11 AGGREGATE $ 1000000 DEDUCTIBLE $ X RETENTION $ 10000 $ WORKERS COMPENSATION WC S I A I U- OTH AND EMPLOYERS' LIABILITY TORY LIMITS X ER C ANY PROPRIETOR /PARTNER /EXECUTIV I l WC004 - 96 - 3440 07/01/10 07/01/11 E. L. EACH ACCIDENT $ 1000000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ 1000000 If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $ 10 00000 OTHER DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION C ITYN21 DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 2 0 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR City of Northampton REPRESENTATIVES. 212 Main Street AUTHORIZED REPRESENT TIVE Northampton MA 01060 fylrti�.,..• ACORD 25 (2009/01) x ©1988 -2009 RD CORPORATION. All rig is reserved. The ACORD name and logo are registered marks of ACORD . , • L I 4 I 4 ' 14 = 4 Office of Consumer Affairs and usi Regulation -= -- 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration - 71 . 2 Registration: 151246 Type: Ltd Liability Corpor Expiration: 5/23/2012 Tr# 296417 ACE FIRE & WATER RESTORATION=- GARY BRUNELLE 18 ELIZABETH ST. W. SPRINGFIELD, MA 01089 - Update Address and return card. Mark reason for change. - 0 Address Li Renewal ❑ Employment 0 Lost Card UPS -CA1 0 50M- 04/04 - 6101216 giie "ommooutseallg 2 /fSsciackae License or re istration valid for individui use oni Office of Consumer Affairs & B sines Regulation g y ai 0 HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: �� Registration: 151246 Type: Office of Consumer Affairs and Business Regulation : =LI ( Expiration: 5123/2012 Ltd Liability Corpor 10 Park Plaza - Suite 5170 = Boston, MA 02116 AC' IRE & WATERRESTQ1 ATION GARY BRUNELLE -- ' := 18 ELIZABETH ST = W. SPRINGFIELD, MA 010139 • I - Undersecretary ofv. i� ithoutsignature C atet \ lassachu,etts Dep�ttn ttb . s-=• a Rc, u�'nc►�►tiom t f aPund Stlic <<ndxrc►s Board of Build ervisor License Co nstruction Sup t_icense: CS 74416 GARY W BRUN 125 CREST RUN LMA p1034 GRANVIL Expiration : 9/1812012 ��_ �J _ Tr#. 2422 ('ummi•cioncr • SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ 11_ Name of License Holder : C'['PN., W (zv N E;�L. E 1'-N . to License Number t - Cwe-- ca 1►101 . O tb -- e)y' o,t l'Q Address Expiration Date Gu Kl - 3S7 -0 /3 Sig ature Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ Ata k WA-1—ccit- Q s ( a. or-77...D • l 5 / 2 `r c- Company Name Registration Number c C= GvZ.. A f3 rcT S w . S p 5/2.'3 / / Address Expiration Date laJ Telephone fl i SO ^5'2 - 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 ❑ 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, you 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 SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing Or Doors El Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [Q Siding [D] Other [D] Brief Des r iption of Pr posed �1 / Work: Kf pi /J f» fa of f iK �telet G i n.", r I9.w L' kl/ 16 f{ Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet sa. 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 , hel .LA✓ elf , as Owner of the subject property hereby authorize ' `—- t C-e_ yvI" " A-f t'1 ±er to act on my be If, in all matirKs relative to work authorized by this building permit application. Signature of Owner Date I, GR -� (�►� {3 x4 �cIJL�G � � + }�tF(L Res-Res `, asner /Authorized Agent hereby declare that the statements nd 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. Cta Gv 6 tt,A0 t✓LL Print Name Sig :u - of •.,17 -r/Agent Date 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 0 DON'T KNOW 0 YES 0 IF YES, date issued: YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW 0 YES 0 IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW 0 YES 0 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 0 NO 0 IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO Q 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 0 NO 0 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. F f p a t 1101r i Q Department use only City of Northampton Status of Permit: , ,Building Department Curb Cut/Ofiveway Permit `. 212 Main Street Sewer!SepticAvailabil r liefi9 , Room 100 Water/Well Availability orthampton, MA 01060 Two Sets of Structural Plans '': 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 1.1 Property l Address: This section to be completed by office Z I 5 T ; I s 4►e(.- Map Lot Unit Piote.nGG el /9 6 1 0 (. 0 Z- Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: / ✓t / /Gi,.) Qidlwieet Z`i 511S0.-% 4vc R.ttcc ••14Z 0/0 &Z Name (Print) Current Mailing Address: / t-"1 s�3 �� 1 ���� ° l \" Tel phone �r'�5 Signature 2.2 Authorized Agent: /qct. F.t t tJA trr 4 s i is �1 -t. /8 ti, y,-1 t 31 I'Jrsc( rtii A41 itnl, w q' ar l# o1 o� Name (Print) Current Mailing Address: / '1/ 5 . D • 5 Sign i re Telephone SECTION 3 - ESTIMAT CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only co feted by permit applicant 1. Building J 1 z . O v (a) Building Permit Fee (ti ' ! I 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) lit (19 00 Check Number j f $.3 This Section For Official Use Only [` Building Permit Number: Date Issued: Signature: Building Commissioner /Inspector of Buildings Date : File # BP- 2011 -0778 APPLICANT /CONTACT PERSON ACE FIRE & WATER RESTORATION INC ADDRESS /PHONE 18 ELIZABETH ST WEST SPRINGFIELD (413) 750 -5200 PROPERTY LOCATION 24 STILSON AVE MAP 17C PARCEL 110 001 ZONE URB(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out l C ,� Fee Paid ,e1 # / `'J6 � ! r Typeof Construction: REPAIR ROOF & INTERIOR WATER DAMAGE e . ec � �� c( 6, New Construction Y Non Structural interior renovations rL �, f Addition to Existing_ Accessory Structure Building Plans Included: Owner/ Statement or License 074416 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION iciTro Additional permits required (see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project: Site Plan AND /OR Special Permit With Site Plan Major Project: Site Plan AND /OR Special Permit With Site Plan ZONING BOARD PERMIT REQUIRED UNDER: § Finding Special Permit Variance* Received & Recorded at Registry of Deeds Proof Enclosed Other Permits Required: Curb Cut from DPW Water Availability Sewer Availability Septic Approval Board of Health Well Water Potability Board of Health Permit from Conservation Commission Permit from CB Architecture Committee Permit from Elm Street Commission Permit DPW Storm Water Management emo,. :y A 1/7 2- Signa - • Building Official Date Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning requirements and obtain all required permits from Board of Health, Conservation Commission, Department of public works and other applicable permit granting authorities. * Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of Planning & Development for more information. 24 STILSON AVE BP- 2011 -0778 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17C - 110 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: renovation BUILDING PERMIT Permit # BP- 2011 -0778 Project # JS- 2011- 001280 Est. Cost: $6992.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ACE FIRE & WATER RESTORATION INC 074416 Lot Size(sq. ft.): 11456.28 Owner: BARMAN ANDY Zoning: URB(100)/ Applicant: ACE FIRE & WATER RESTORATION INC AT: 24 STILSON AVE Applicant Address: Phone: Insurance: 18 ELIZABETH ST (413) 750 -5200 Workers Compensation WEST SPRINGFIELDMA01089 ISSUED ON:3/29/2011 0:00:00 TO PERFORM THE FOLLOWING WORK: REPAIR ROOF & INTERIOR WATER DAMAGE - NEED TO SEE INTERIOR BEFORE CLOSED IN 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 3/29/2011 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner VISA Proposal Submitted To Date woolm eic.-rd ' 4 A D A Aft r QUENNEVILLE street ROOFING & SIDING, INC. ou0bVER City, State, Zip Code 160 Old Lyman Road, South Hadley, MA 01075 1 -800- NEW -ROOF • 413. 536 -5955 Phone #'s Email: info @l800newroof.net Website: www.1800newroof.net H:.‘ MA Construction Supervisors Lic. #070626 MA Registration #120982 _ "t W Member of the Home Builder's Association of Western Mass. CT Registration #575920 Dumpster Location Member of the Building & Trade Association Member of the Better Business Bureau DH EV CV TW DHP Double Hung 3 -Lite End Vent 3 -Lite Center Vent Twin Double Hung Picture w/2 Double Hung Flankers II. 1i� ., _ ■ '� 111.1111 III 111 IMP- Woodgrain Interiors Vinyl Color Product Code Grid Styles NAT = Natural Oak WH = White BS = Bayshore ST = Standard 5/8" RP 1 = Regal Perimeter GO = Golden Oak CA = Camel SB = Seabrook RC = Regal Colonial RFL = Regal Florentine CC = Colonial Cherry ET = Earthtone NE = Northeast G = Gregorian 1 1/16" RFE = Regal Florentine Elongated WW = White Woodgrain W = Williamsburg 11116" RF4 = Regal Prairie (2 passes) TB = Thin Brass BAY BOW 4 BOW 5 BOW 6 GARDEN 1 <8> ,, 1 ii , 5 ,, L__._ .J WI . Woodgrain Interiors Wood Options Vinyl Color Product Code Grid Styles Glass Options NAT = Natural Oak BIRCH WH = White A = Aurora ST = Standard 5/8" G = Gregorian Stay -Clean Glass GO = Golden Oak OAK CA = Camel RC = Regal Grids W = Williamsburg Regal Glass CO TR 1/3- 1/3 -1/3 TR 1/4- 1/2 -1/4 QUAD Operating Casement Single -Frame Equal -Lite Single -Frame 1/4- 1/2 -1/4 Single -Frame 4 -Lite II - Triple Casement Triple Casement Casement I � I a- ' I I I 1 I mo . a_ 1. 7 ,.n�:,__ Existing Window New Window Existing Window New Window Measurements I Measurements 85 2 O Rough Opening 15 O Rough Opening — W Location Style Metal Style Series W Location Style Metal Style Series V F - (Room /Floor) "Code" Y/N "Code" "Code" -,C1 t. Width Height UI (Room /Floor) "Code" Y/N "Code" "Code" Width Height UI 2 .it + , , /..1 °y (' 14 3 d t , ,. y`.. ,'t 4 15 - — -- 4 16 - 5 17 __ 7 19 8 20 — 10 22 , 11 - J 2 3 12 24 . Color of Color of Window / Door Wrap Window / Door Wrap We Propose hereby to furnish materials and labor - complete in accordance with above specifications for the sum of: Total Sale Price $ / ,), . . „ i Down Payment $ , -'t _., ;' -,' r * Upon Completion $ ACCEPTANCE OF PROPOSAL: The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do work as specified. Payment will be 1/3 down upon signing, and balance due upon completion. Unpaid balances shall accrue with interest at 18% per annum. Purchaser(s) will pay for all costs, expenses and reason- able attorney's fees incurred by Adam Quenneville Roofing and Siding, Inc. to recover any sums due under this contract. Date: r / Signature: ' '* Phone # Date: ' •"/ Salesperson's Signature: /1;' -' ` ' Estimates are honored for sixty (60) days from above date Please remove all breakables from interior wall surfaces during installation. AQR &S will not be responsible for damage. Nov U8 - 2010 06:00 PM Remillard Insurance 1- 413 - 538 -WU10 RO CERTIFICATE OF LIABILITY INSURANCE OP ID LL DATE(MMIDDA'YYY} 11/09/10 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 NAME: I NAME: Remillard Insurance Agcy, Inc (( E " r ,: FAX Nor o � L 79 Lyman Street ADDRESS: South Hadley MA 01075 C U ST OMER ID#: AIIAMQ -1 Phone:413 - 538 -7862 Fax:413- 538 -7179 INSURER(5) AFFORDING COVERAGE I NAICE INSURED - • INSURER A: First Speciality Ins Corp Adam Quenueville Roofing & NSURERB: Travelers Ins. Co. Siding Inc. & Adam Quenneville - INSURE - -- 1-- --- 1 Roofing Inc & GutterShutter INSURER C aI Mut ual inauzwca company Of Western MA —_- -- -._._.----- _ -.._ -- 160 Old Lyman Road INSURERD; Hanover Insurance Company 22292_ South Hadley MA 01075 INSURER E: INSURER F : COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: ?HS IS 70 CERTIF THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD ySIGHTED KDTWITHSTANDING 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, ■ PXC!.USIGN:S AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. I n95R' "ADDpSUB — riag CY�FF'�'POTCYEXP' Lt TR I TYPE OF INSURANCE INSR I WVD� POLICY NUMBER (MM(DDTYYYY) I(MMIDDIYYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE IS 1000000 l ' ~,. -- DAMAGE I U HEN I kU - "' - -" . A X I CCIMMERC :L GENERAL LIABILITY IRG98441 06/23/10 06/23/11 PREMISES (Ea IS 100000 • ' CLAIMS-MADE LX I OCCUR MED EXP (Any one person) $ 2500 5 0 0 PERSONAL d ADV INJURY $ 10 0 0 00 0 GENERAL AGGREGATE $ 2000000 GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS• COMP /OP AGO $ 2000000 I POLICY : I SECOT ' 1 LOC I $ • T ; AUTOMOBILE LIABILTY T COMBINED SINGLE LIMIT —1 $ 10000-0 (Ea accident) B ANYAUiC BA7450L946 11. /ol /lo 11 /01/ z I BODlLY INJURY (Per pc ,on) $ ALL OWNED AUTOS j L_ __ BODILY INJURY (Per accidr_nll X i SCHEDULED AUTOS ~ ' PROPERTY DAMAGE 1{ ' HIRED AUTOS i (Peraccidont) $ X NON-OWNED AUTOS ( $ � UMBRELLA LIAR I $ — `� C h1A0: OCOUR EACH OCCURRENCE EXCESS LIAR AGGREGATE $ L DEDUCTIBLE $ C' WORKERS RETENTION $ 1 $ A - - --- -_ AD PROPHI ERS LIABILITY XECUTIVE I EL EACH ACCIDENT $ 1000000 AWC��O C W TATU 128610 04/29/11, i X TORY LIMITS X L R AND EMPLOYERS' LIABILITY ! _ 1ANY .. I 0 'FICER /MEMBER EXCLUDED? Y N I A ._ _-- -- __ ...., N( ;Mandatory . in NH) - E.L. DISEASE - EA EMPLOYEE $ 1000000 f t s ^s Ccr n n u - --. .- -- -- I • DE SCRIP OF OPERATIONS Aa!aW I 1 E_L DISEASE - POLICY LIMIT $ 1000000 0 0 0 0 0 D I Equipment Floater IHN7140610 02/01/10 102 /0: /11 Rental 1 I Equipment $100,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Addlttooal Remarks Schedule, if more space is required) CERTIFICATE HOLDER CANCELLATION -- I SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE ADAMQUE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Adam Q anue,vi11e Roof & Siding - ._____ - g AUTHORIZED REPRESENTATIVE 160 Old Lyman Rd. South Hadley MA 01075 / 01988 -2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009100) The ACORD name and logo are registered marks of ACORD . . -.,i.N..., g t-2, rI 0 ; u ... 'ing l ' egad dons aril tan. are s NO , One Ashburton Place - Room 1301 If 1 Boston, Massachusetts 02108 Construction :Supervisor License License CS: 70626 . Restriction: 00 Birthdate: 8/211 ' T r# 3712 -- Exp 8 /21/20 11 AQAM A QUENNEVILLE 160 OLD LYMAN RD ---- S''HADLEY, MA 01075 Jl te es • , , • • 4 • / 4 ^- - * ► 17 Office of Consumer Affairs and usiness Regulation �l _ 10 Park Plaza - Suite 5170 + .f Boston, Massa �usetts 02116 Home Improvement / .�2 _ ctor Registration r- -`= .,,,,.,.,,,, Registration: 120982 $"M� .......__... ,---! Type: DBA ��1 / •i Expiration: 3/25/2012 Tr# 293069 v7 r_ ADAM QUENNEVILLE ROOFING:4' is I: "` !,� ' ii i � � - ADAM QUENNEVILLE ,r _ • �i 160 OLD LYMAN RD \ -ti.,� SO. HADLEY, MA 01075 - - -_ , A �- ;,;• Update Address and return card. Mark reason for change. _ Address 7 Renewal Employment - Lost Card DPSCA so 501 64!04- G10 STATE OF CONNECTICUT _-_-_`.._— - ,-- .____. _ + DEPARTMENT OF CONSUMER PROTECTION 1 Be it known that ADAM QUENNEVIT .E tit � ' 160 OLD :' ROAD I SOUTH ', . 51Q75 -2632 i rF %, p. 1 ' . . : :: is certified by the Dep. ao ntd� t ' o a te ction as a registered : { HOME ME ®. N V ONTRACTOR 1 Regis .:� : 0 -„U i <tir i ; ADAM QUENNEVILLE ROOFING 11 Effective :12/01/2009 ` Expiration: 11 /30/2010 1,``",.`1 1---4` . The Commonwealth of Massachusetts Department of Iminstrial Accidents 50— -: O, a ofltry gatlotes = �,,,,� 600 Washington Sterna °':'-` Boston MA 02111 . .p www m gov /tta Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers Annbeaut Information Please Print IeEibiv 1 �- Name ( )� a . . • ea ! . t - ' $ b 1 * " A r1( Address: Ii ()id L rn qy, III City/S 1:. ,'1 am g. _' iii .... i r T . Phone #: ( - • —. Are yore an employer? Clink the appropriate bar. TYPe of Project (required): 1.J I am a employer with i g - 4. ❑ I an a general contractor and I 6. ❑ New construction employees (full and/or part-time).* have hired the sub - contractors 2. ❑ 1 am a sole proprietor or partner- listed on the attached 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. 0 Demolition working for men any capacity. y hive workers' d 9. 0 Building addition [N° workers gyp- insurance required.] 5. ❑ We are a corporation and its 10. ❑ Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have axe rcise d their 11.0 Plumbing repairs or additions right of exemption per MGL _ insurance ] t - c. 152, §1(4), and we have no 13.[} Other employees. [No workers comp. insurance required.] `Any nephew the chocks box #1 mast abo SI out the section below showing their waken' +fie pokey mf rmgim. 1 Homeemees who soling Ibis Akio t rode tisg they ate doings! we& ander* his onside scanner on saint aabmita new wit isdiotiossu b. *cc. , eentYetdeck Ibis balms aeasbe an*Mi-- 'beetiowi erieaeseof,heneb- oeaaoeorsaad *nrwbedrer e employee. If ebe sab.csstackes hue employees, they tot provide their ' comp policy anetbat: I ea as employer dad k ptmvkling workers compemeadom benrraace for sty employers. Below Is the policy sadJob site n A � ll Insurance Company Name: A ! " 1 1..1. Q t /15,i.4 Yet ht VaciAol Policy # or Self -ins Lic. #: W c,, 9 0 Laq, (o 1 C ( Expiration Date: 1 Job Site Address: d t i ST I Sa v / n to r �, M-4 City /St p: 01 c t k Attack a eopy of the workers' oesapeasatisa penny declarsliers page (showing the pommy number and a a:pir atiaa date). Failure to secure coverage as required wider 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 Sarin 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 de hereby coo nectar to oadpensiks o oads:op that the be #rettaa ors provided oh Is true andconect. Signature; Date: i — 4 - 1 ( az= #:_ _ t it -53(a- Sqsc Official we arty. Do sot write la this area, to be completed by dry or tow" official City or Town: Permit/License # basisg Authority (circle one): 1. Board of Balkh 2. Baltfing Department 3. City/ Town Clerk 4. Electrical Inspector 5. Plumbing Impeder 6. Other Contact Person: Phone #: 1444.1f: 10 Oki mi ()lit r, gm/ i iglu! ogsAgstor 14-1;iir 01 'elFnii 14 10 )11 vpt� Artullit.ro! 191d!p- SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: (( Not Applicable ❑ ���® Name of License Holder : ° Quenneville Roofing & Inc. 20 �o 160 Old Lyman Road License Number Soli wry, MA 01075 Address Expiration Date 413 - 53rd -PISS Signature Telephone 9. Registered Ho e Improvement Contractor: Not Applicable ❑ Adam Queo®evilk Roo* & Siding, Inc. �d cji Company Name 1600 1 Lyon Road Registration Number Soli MA 01075 Address Expiration Date Telephone S it �`S3G SRS.S'" — 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 15( 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 be /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, you 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 6.1 ;06tIfif 6"4/1 0/0 14 01101 SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement, Windows Alteration(s) ❑ Roofing El Or Doors [ Accessory Bldg. El Demolition ❑ New Signs [D] Decks [C] Siding [D] Other [D] Brief D cription of Proposed Work: •eo toI- 0 Proposed,„ -C— 3 ilo 1. 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 A t'N RxA(' j 4A , as Owner of the subject property hereby authorize *wilt , g Inc" to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date Ail Qum* Reek & Siding, In , 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. QV e v \LC_. Print Name ■-ac,-t ( Signature of Ow nt Date 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 0 DONT KNOW YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 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 0 Obtained ® , Date Issued: C. Do any signs exist on the property? YES 0 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. pp *WV, Kio.1,4'4', 7 '',.;, • Department use only City of Northampton Status of Permit Building Department Curb Cut/Driveway Permit �✓; 212 Main Street Sewer/Septic Availability 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 1.1 Property Address: This section to be completed by office S.oSon Ave, Map Lot Unit f-' l o QL mp O LOG, Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: AYN,a- Qar cr.a..\ a1 s9"‘tsovt Avie Fno rertct,Mk 6fo42 Name (Prinir Current Mailing Address: S o — SOS- 313 Telephone Signature 2.2 Authorized Agent: Al lQI Rang &Siding,Inc. 14o o 1 May, P. sau4eL.t ftadie i Mft Name (Print) Current Mailing Addict s: p107C 413 - SS S'i SS' Si Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building I ()G (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) I jQ Check Number ((,57 3 This Section For Official Use Only Building Permit Number: I sssuu ed: Signature: Building Commissioner /Inspector of Buildings Date . A ? ` Na; BP- 2011 -0658 • GIS #: COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: windows replaced BUILDING PERMIT Permit # BP- 2011 -0658 Proiect # JS- 2011- 001072 Est. Cost: $1200.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ADAM QUENNEVILLE 120982 Lot Size(sq. ft.): 11456.28 Owner: BARMAN ANDY Zoning: URB(100)/ Applicant: ADAM QUENNEVILLE AT: 24 STILSON AVE Applicant Address: Phone: Insurance: 160 OLD LYMAN RD (413) 536 -5955 0 Workers Compensation SOUTH HADLEYMA01075 ISSUED ON:1/31/2011 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL 3 BASEMENT REPLACEMENT WINDOWS 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 1/31/2011 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner