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23B-070 ACORD CERTIFICATE OF LIABILITY INSURANCE OF ID DM DATE (MM /O0 W(Y) ADAMQ -1 06/24/10 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Remillard Insurance Agcy, Inc HOLDER, THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 79 Lyman Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. South Hadley MA 01075 i Phone: 413 -538 -7862 Fax :413-538 -7179 INSURERS AFFORDING COVERAGE 1 NAIC # INSURED INSURER A. AIM Hutua1 Ineu:ence Company INSURER B: Travelers Ins. Co . Adam Quenneville Roofing & I NSURER C: F irst Speciality Ins Corp Siding Inc & Guttershutter P y 160 Old Lyman Road INSURER C: 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. cc I LTR NS Ryy O TYPE OF INSURANCE POLICY NUMBER DAT E Y MMIDD✓ri E P DATE (MM /D TION I LIMITS I GENERAL LIABILITY , EACH OCCURRENCE S 1000000 � uAMAUt r u xtH s to C rX COMMERCIAL GENERAL LIABILITY J TB 06/23/10 06/23/11 i PREMI$ES(Eaoccurence) $ 100000 CLAIMS MADE X OCCUR ; MED EXP (Any one Person) $ 5000 PERSONAL BADVINJURY $1000000 GENERAL AGGREGATE $ 2000000 GENt AGGREGATE LIMIT APPLIES PER: PRODUCTS • COMP /OP AGO S 2000000 POLICY JECT PRO LOC t AUTOMOBILE LIABILITY I ! COMBINED SINGLE LIMIT 51000000 $ ANY AUTO BA7450L946 11/01/09 11/01/10 ; (Ea accident) ALL OWNED AUTOS BODILY INJURY ' X SCHEDULED AUTOS ! (Per Person) I S X I HIRED AUTOS BODILY INJURY I $ X NON -OWNED AUTOS (PEI accident) PROPERTY i (Per aent) AMAGE • txld i $ I GARAGE LIABILITY • I AUTO ONLY • EA ACCIDENT ' $ • I ANY AUTO OTHER THAN EA ACC i $ AUTO ONLY: AGO I S EXCESS /UMBRELLA LIABILITY EACH OCCURRENCE S n OCCUR CLAIMS MADE I AGGREGATE 5 5 ~_ DEDUCTIBLE S RETENTION $ J $ WORKERS COMPENSATION AND TORY L l 1%2 EMPLOYERS' LIABILITY A AWC701286101 04/29/10 04/29/11 I E.L. EACH ACCIDENT 51000000 ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? j E.L. DISEASE - EA EMPLOYEE $ 1000000 If yes, describe under SPECIAL PROVISIONS below j E.L. DISEASE • POLICY LIMIT i $ 1000000 OTHER D Equipment Floater IHN7140610 02/01/10 02/01/11 Rental Equipment $100,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES ! EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SERVMAG SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER. ITS AGENTS OR REPRESENTATIVES. AUTOO ['REPRESENTATIVE ACORD 25 (2001/08) © ACORD CORPORATION 1988 _ Je ions a n, tan• ar• s !--- � , 0 .0 sing egu I __ f One Ashburton Place - Room 1301 Boston, Mas>.achusetts 02108 • ConstructionSupervis License S' 70626 .. License C 7 Restriction: 00 1 .. Birthdate: 8/21 Expiration: 8/21/2011 Tr# 3712 ADAM'A QUENNEVILLE 1'60 01:1$ 'LYMAN RD _____ S'HADLLY, MA 01075 -_ _ gite / 4 ' / 4 17i401-n-, c Office of Consumer Affairs and usiness Regulation e 1I . 10 Park Plaza - Suite 5170 x= Boston, Mass, usetts 02116 Home Improvement :. .2).s •ctor Registration Registration: 120982 ._._, _ Type: DBA > Expiration: 3/25/2012 Tr# 293069 - ADAM QUENNEVILLE ROOFIN M --� -- . .r ADAM QUENNEVILLE m .. > J ,1 wwr 160 OLD LYMAN RD '-� — SO. HADLEY, MA 01075 'F.-1=4.3 _ w li 7r' \ /�, ti 7 , ' _ so ,,, 4 Update Address and return card. Mark reason for change. '---- Address 0 Renewal E] Employment fl Lost Card DPS -CA1 0 50M- 04/04- G101216 I STATE OF CONNECTICUT +" DEPARTMENT OF CO NSUMER: PROTECTION , Be it known that ADAM •' QUE1 \NEVI aI' F, • :, 160 OLD .4 ,04.,0.-.. ROAD SOUTH „ .14...; . • NI , - 4075-2632 i is certified by the Dep n ” f .,:.'. ',.., tection as a registered I III ' PR I A � � ►: 9 • N � TRACTOR I HOME IM PR I � 1 ' _ RegY °' J 5920 . ?,...? NSt ?; r :i ,c a r . - i ADAM QUENNEVILLE ROOFING Effective: 12/01/2009 : _ .. , I t Expiration: 11/30/2010 'm.'^.�.4,c- - - The Commonwealth of Massachusetts Department °Material A =q,` f Office of Inver lgallons krt t) , 600 Wa hington Street = hr I Boston, MA 02111 www gov/dra Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Annlicant Information Please Print Legibly 1 Name( Y i A u es ' .c • ' a • \ a& a ✓1C., Address: ILo ()I L e. City/State/Zip: .,-) kris a ' iii ► I hi Phone #: ( 11 3 - 53 (o` 55< • Are you an employer? Check the appropriate box: T ype o f (required): 1.114 I am a employer with Is- 4. al am a general conbaator and 1 6. ❑ employees (full and/or part-time).* have hired the sub-contractors 6 New constriction 2. 1 am a sole proprietor or partner- listed on the attached shoot. 7. 0 Remodeling ship and have no employees These sub - contractors have S. ❑ Demolition working for me at any deity. employes and have workers' 9. ❑ Building [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 11.0 Plumbing repairs or additions myself. [No 'gyp. right of exemption per MGL 12 ,Roofrepairs insurance required.] t c. 152, §1(4), and we have no 13.[} Other employees. [No workers' _ insurance required.] *Any applieast that cbedos box it mast also la out the section below showing their wedgies' caspeasmat policy information 1 Hommaiaaus Mao sob nil this a ei& indioaoagthey nee doing ax wont'adthnitiee outside c nnesom most solso tavow die indintiogach. . sOm amondst clon*I is boesart au aoas.ddiriomi dims sbowinaibe lame ohbesabmoareaolors aalleteabdher scoot those anthem lone employee. Into sob-cooliactems hoe employees, they mom powide their ' gyp. policy ameba. I are an employer that isprovidbgg workers' compensation bra nmsce for ng► employees. Below is the policy and job site Insurance Company Name: t /V\ l l'}-1 l Q TrsU h C e.... P o l i c y # or S e l f - i n s . L i c . #: P IBC.. 1 1 0 1 , 4 9 , 4 1 1 0 1 Expiration Date: VO2 9 j I I lob Site Address: (tom ()AAA. So A()AAA. M A Z n SA- • F lorcnce male City :O 1 c0 (, ` Attadr a copy of the workers' compaaat►tisa policy declaration page (skewing the policy .weber and eapiratan 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 S1, 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 cat& ranter the ardpen ibtes efperjary that the hsfdrnaa tom provided above Is trice and Signature; Date: 10 - 2 (o -10 Phone it: L (I 3 - 53 (a - 5 s;" Official use oily. Do not write in this area, to be completed by dry or town efdaL City or Tors: Permit/License It _ Issuieg Authority (circle one)- 1. Board of Health 2. Beading Department 3. Citytroan Clark 4. Electrical Inspector S. Plumbing Inspector - 6. Other Contact Person: Phase #: fi 1 D n %AIM VISA and 7 _ DIICOVER CCU E N N EV I LLE www,1800newroof.net ROOFING & SIDING, INC. 160 Old Lyman Road, South Hadley, MA 01075 We Are Licensed 1-800-NEW-ROOF • 413 -536 -5955 Fully Insured Email: info@ 1800newroof.net Factory Trained MA Construction Supervisors Lic. #070626 MA Registration #120982 Factory Certified Installers 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 P.P.C. 38710 Proposal Submitted To: Date Phone #'s Work: 7'c i1,2-0±11/ o H - `{ j�r!� l Cell: ..J�L/ Street Email: 16 b, M City, State, Zip Code Special Requirements L ' 1.. t( C l 6, (6, Complete Roof System X We shall acquire all appropriate permits for all work 52 Home exterior and landscaping to be protected • Entire existing roofing materials to be removed to existing decking • Deteriorated existing decking will be replaced at $3.47 per sq.ft. • Install Ice & Water Barrier at all eaves, valleys, chimneys, pipes, skylights and sidewalls ® Install 15 lb. fe / Synthetic) underlayment over remaining decking area Ki Install Metal drip edge at eaves and rakes (8" ' whr / brown / copper) (1 Install manufacturers starter shingle on all eaves and rake edges X Install new pipe boot flashing (stan / copper) El Install new step flashing where necessar stan / copper) • Install Hand nailed rigid baffled continuous ridge vent ❑ Install proper soffit ventilation Shingles: (6 nails per shingle) Shingles ,[ 25 year ❑ 30 year ❑ 50 year Color 33r Ridge cap shingles Warranty Options: (23I We guarantee our workmanship for 10 full years (see our warranty coverage) ❑ GAF ELK System Plus warranty ❑ GAF ELK Golden Pledge warranty d� Chimney Options: Y` ❑ Lead Counter Flashing ❑ Water Seal t' uckpoint ❑ Rubberized Cro n ❑ Metal Chimney Cap We Propose hereby to furnish materials and labor - omplete in accordance with above spe. fications for the sum of: Total Sale Price $__ "f ) ' Down Pay ent $ �.. � _,.'" Upo Completion $ ACCEPTANCE OF PROPOSAL: The above prices, sp- ifications and conditions are .atisfactory and are hereby accepted. You are authorized to do work as specified. Payment wi .e 1/ down upon si • • • g, and balance due upon completion. Unpaid balances shall accrue with interest at 18% per annu . • - 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! /7 ;U Signature it_tt .. ' Phone # -_ - -_ _ Date: Estimator's Signature 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 and Sidings will not be responsible for debris or dust in the attic or storage areas. i R iqw 0 I tt h • ;I ofti p UP! KviiN ANN 6. K eior SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : Ado Qiesatville Rook & S d Int 7D 6 a 6 16 O ld i ynsa R oad License Number South Hadley, MA 91075 r6 Address Expiration Date Date `Il3- s3(. -sci s- Signature Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ A ()gnome Roet�g& Sidug, Iue. i a o Company Name 160 Old Lyman Road Registration Number South Hadley, MA 01075 Address Expiration Date Telephone `fl � 5 - S3& -S4" 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 0 1(titiCki =1„:, "Plf ,(444)0#‘ eNiet SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Or Doors D Accessory Bldg. El Demolition El New Signs [O] Decks [[J Siding [0] Other [0] Brief Description of Proposed Work: Si(' avva. ft. 01.1 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 I, steel Cq S 04 as Owner of the subject property Ada Quemeile hereby authorize R , b, In to act on my behalf, in all matters relative to work authorized by this building permit application. (o - .6 IC Signature of Owner Date Atha nevi le Roofing & Siding Int , 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. i4 a� G?)e rveii t( Print Name �rJ 1C7_l0 Signature of Owner /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 ® DONT KNOW a YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO © 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 ® 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 flp IF YES, then a Northampton Storm Water Management Permit from the DPW is required. Department use only 1 C of Northampton Status of Permit: n' 1 -, _ - - Building Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability 2 10 Room 100 Water)Well Availability OCI 2 Northampton, MA 01060 Two Sets of Structural Plans ;, phone 413 - 587 - 1240 Fax 413 - 587 - 1272 Plot/Site Plans f _ r "j 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 l0W Sou A.h, MA' ' Map Lot Unit FlortAct - ,wA 011)( Q Zone Overlay District Elm St District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: ,S' k 0.. Rya'1 I o Sf SovVINfhas S+ Flocc I M I. Oto 64 Name (Print) Cu ent Mailing Address: 413 ssr ����g Telephone Signature 2.2 Authorized Agent: Aaavv% (?u e . A A t V t t\ t 1 4 O OIL 1. y ft. {.c Sou 1,1% 1411Ms..s, MX t)t o 7s Name (Print) ��`� Current Mailing Address: 413 -S3G -sans Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building if So (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 4< o o Check Number /.1.5r 13 5 This Section For Official Use Only Building Permit Number: I s g Issued: Signature: Building Commissioner /Inspector of Buildings Date BP-2011-0395 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: BUILDING PERMIT Permit # BP-2011-0395 Project # JS- 2011- 000654 Est. Cost: $4500.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ADAM QUENNEVILLE 070626 Lot Size(sq. ft.): 23696.64 Owner: RYAN SHEILA K & JOHN E DAHL Zoning: URB(100)/ Applicant: ADAM QUENNEVILLE AT: 108 SOUTH MAIN ST Applicant Address: Phone: Insurance: 160 OLD LYMAN RD (413) 536 -5955 () Workers Compensation SOUTH HADLEYMA01075 ISSUED ON:10/28/2010 0:00:00 TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE 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 10/28/2010 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner