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23C-030
ACDRD CERTIFICATE OF LIABILITY INSURANCE OP D DM DATE(MMIOD/YYYY) or. • -1 05 03/10 PRODUCER THIS CERTIFICATE IS ISSUED AS AMA ER 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 BYITHE POLICIES BELOW. South Hadley MA 01075 Phone: 413 -538 -7862 Wax ; 913- 538 -7179 _ INSURERS AFFORDING COVERAGE NAIC # INSURED INSURER A: AINNotnat Znsarano. company Adam Quenneville Roofing & INSURERS Travelers Ins. Co gg ding Inc INSURER;C: Scottsdale Ins Co . 160 Old Ly man Road INSURER'D: South Hadley MA 01075 INSURER t: COVERAGES- THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED MOVE FOR THE POUCY 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 OMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. p� POLICY iNSK W DMMIDD 1,Y) DT NMWDDlYTI LTR N U L POLICY SRC TYPE OF INSURANCE POLICY NUMBER LIMITS GENERAL LIABILITY EACHOCCUIi B 1000000 — C X COMMERCIALGENERALUABILITY CPS1034980 06/23/09 06/23/10 PR I'sEss(E c 8100000 CLAIMS MADE © OCCUR MED EXP (An parson) S 5000 PERSONAL 6 ACV INJURY S 10 0 0 0 0 0 GENERALAOQREGATE _ $ 2000000 GEN'L AGGREGATE UMIT APP`UUE PER: PRODUCTS • COMP/OP AGO 8 2000000 POLICY i l JEC ( I LOC • AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO BA7450L946 11/01/09 11/01/10 (Eaecddent) 91000000 AU. OWNED AUTOS BODILY INJURY X SCHEDULED AUTOS (Perpereon) X HIREDAUTOS BODILY INJURY • X NON•OWNEO AUTOS (Per accident) PROPERTY DAMAGE $ (Per exldent) GARAGE LIABILITY AUTO ONLY- EA ACCIDENT S ANY AUTO .OTkIEATHAN EA ACC $ AUTO ONLY: AGO 5 EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $ — 1 OCCUR n CLAIMS MADE AGGREGATE S • E DEDUCTIBLE S RETENTION 6 S WORKERS COMPENSATION AND X ' LI �1 EMPLOYERS LIABILITY A AWC701286101 04/29/10 04/29/11 E.LEAGHACCIDENTT s 1000000 ANY PROPRIETOPJPARTNER,EXECUTIVE OFFICER/MEMBER EXCLUDED? EJ_DISEASE .EAEMPLOYEE 51000000 II PEGI yea IAL PROVISIO deaaibe under NS below E.E.L. DISEASE • POUCY LIMIT B 1000000 S OTHER DESCRIPTION OF OPERATIONS/ LOCATIONS / VEHICLES 16XCLUEION6 ADDED 6Y ENOORSEMENTJ SPECIAL PROVISIONS —' CERTIFICATE HOLDER CANCELLATION � Q . SHOULDIANY OF THE ABOVE DESCRIBED POLICIES QE CANCELLED BEFORE THE EXPIRATION Adam Qllennevil le Roofing " DATE THEREOF, THE ISSUING INSURER mu. ENDEAVOR TO MAIL 30' SAYS WRITTEN • Brian NOTICE TO THE CERTIFICATE HOLDER NAMED TO TOE LEFT, RUT FAILURE TO DO SO SHALL f ax #536-1448 IMPOSE NO OCLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER. ITS AGENTS OR PO Box 612 South Hadley MA 01075 REPRESENTATIVES ^ AUTHO ED REPRESENTATI� ACORD 25 (2001/08) ACORD CORPORATION 1988 . ` Tile C . bn wvea1th. a ' ttchttseits. . . • Department of In ad Aecetetets �.,,, �.,_,.:, of inpestig irons � e '= . 600 Washington ..,, , ._ , �`treet f �1� i nn,. 02111 .� =0, www mass gavfdia Workers' - Compensation insurance Affidavit' Builders/ ContractorsiElectricians /Plurctbers. Applicant Information Please Print Ably Name (Ru ' ): Arkitn) n ntaia c Ile vty_ Address: /6.9 C n R 004 City /St p�: � � ta OLO?, Phone #: Li IS SS&tS Are you an employer? Check the appropriate box: Type of project (required): J. Eri am n with. I.5 . 4.:0I am a. general contractor midi ' � +� have the sub 6. 0 New construction (full and/or part- tine). 7. Remodeling ship and have no employees - These sub - contractors have a. Q Demolition working for me in any capacity. workers' camp. Vi e. 9. .0 Building addition [No workers' comp. insurance 5. 0 We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additio 3.0 1 am a homed doing all wort. . right of exemptiOn. per MEN. 11.0 PYruubing repairs or additio myself. [No workers' comp. c. 152, §1(4), and we have no 12.0 Roof repairs . insurance. requited] t employees.. [No workers' 13:Q Other comp. • ianeeirequired-j *Any applicant that checks box #1 must also fill out the section below showing their - Workers' compensation policy iafoam alion. t H.ondeowners who- submit this affidavit indieating.they arc doing all work and then hire outside contractors must submit a new affidavit indicating such. tContaactnts that check ibis box must atteocbad an additional sheet showing tie name of the sab- contractors and their as rkers' comp. policy iaformati oa. I am. cart employer rha1 is pravairmg worms.' compensation insurance for my employees. ..lelmr! is the parity and'Jaib site information. , � � 4 t Insurance Company Name: ij it St? tic _ Policy # or Self -ins. Lic. #: AUK C - 7O Fa t (a I ()l Expiration Date: " aq - A. } I 1 Job Site Address: ga /�I / )i tY "'r oral' . Ad O iOi City/StatefZip: f 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 Grnaainal penalties of a Tine up. to. $1,500:00 and/or. one imprisonment aavaa..as.civ l iienaties inntlue farm.cif a:STOP t El_ and.a of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Invesigat ons ate e k Rif fastainioo comasa rwirwakian. I do hereby certify wider the pains and penalties of perjwy that tie information provided above is true and correct Signature: Date: 5 Li—lb Phone #.,_ L i 13 33(k s 956 ' Official use .11to not write in this area, to be completed kji ortown official City or Town: Permit/License # • Issuing Authority (rink one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector f. Phunbing Inspector .. •6.'Other TL L. • : . : . , j ► _-._ oar• o •u z . •m g e l�ns arif tans are s • • h - One Ashburton' Place - 1301 • ,�� Boston, Mass 02108 . • • Construction Su License • • L icense CS: 70626 . , • Restrti 00 8irt : • 8/2'1 11971 Expiration: 8/21/2011 Tr# 3712 AQAM `A ' QUENNEVILLE ' 160 O ' LY Ru S ; ` HADLEY, MA 01075 -- • Update Address and ca Mark for nge Ca Q Addres Renewal reason Lost rd -__ • ?72e / 4� ,rte slim- Office of Consumer Affairs and usiness Regulation c =- 10 Park Plaza - Su 5170 =. Boston, Massai,, usetts 02116. Home Improvement (, n tctor Registration Registration: 120982 =—,*--- r' —' Type: DBA . - �y = / Expiration: 3/25/2012" Tr# 293069 - ADAM QUENNEVILLE ROOFINe ......_ ADAM QUENNEVILLE ^ ! 160 OLD LYMAN RD a _ i SO- HADLEY, MA 01075 :1j� ` ' - d ' q %�/ Update Address and return card. Mark reason for change. Address Renewal [l Employment Lost Card DPS -CA1 0 50M- 04/04- G101216 'lie lti" r =tia #, . - — .r'" 117? l iii' y 5�1;. 1 i s fir• �.. " r =i " � r _ - 5:t • ie' • t� - :. i • ^ tJ 0 r.• i•• '-1 :r. Faf• ` .ti p . ': {'•: ✓.:�. ri . ' •t • i w. , i' tt . O - 1 ry ' '4,,,,.,,,!.. ' ' : t 1 . d s• i• .`i' emu, � . ` t . Y , ' tt � , 8 : - , � = . a' . 175 .� fi � - • � ,' da }, 7 , .t rt4'• }i1'�' . S ' "J� ` i� _ 1 t _ I I- . 1 . r � rte` . l; r `. '•r 7i :. ?'( t 7 r F: •r:� ..J,. esn '£s ' W •• t lr Ctltl • 9 �$ � t _ r ' , l 'J I . i 1 �{ •i, L .: I i . r..t• W' Z � ' t - • 5 . t ~ � • ;,r . :: Y 'T t� "i • /�" s-d •SI.. 1 fr rT'! H . .S, r i � - „r•• • S r.,",!...!. ,: r.� _ . S :;1......, t ...!d: . Yr ::- 4 �; S At' : :ii• . t ; i r,' , ii.+ 5 , •ta iS �,{ Y.r .t • i' I. � l 't 1 I t '+ T^'l y R r "..r R t7 +•:•d r 7 .: �i • ,. ,.� - `'' 'mi _. •t - - 5}a,LS i 'i : L•� +� �' ta i `Y ' A D ANt .., VISA Maste 4 DIJC�VER inii■I Qu 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: /C4r0 KO(ytYs J /,,2 �® H:�6 ✓ `�`" ✓ ©6Ce Street / Email: Z2 k A4Q 'add Ter, Car& ann . 0 Veryr on /.. City, State, Zipf Special Requirements riCr e& A 0/04 ,2-- 5/? (00'7‘ vn y ii . Complete Roof System r. /f vV10 We shall acquire all appropriate permits for all work I/0/ c- h ,Gle 7 4 Home exterior and landscaping to be protected f A 0 Entire existing roofing materials to be removed to existing decking cr M Deteriorated existing decking will be replaced at $3.47 per sq.ft. Xi Install Ice & Water Barrier at all eaves, valleys, chimneys, pipes, skylights and sidewalls tgl Install 15 lb. fel , Synthetic) underlayment over remaining decking area g Install Metal drip edge at eaves and rakes (8' ,((hite)brown / copper) Install manufacturers starter shingle on all eaves and rake edges X Install new pipe boot flashin.4 ; copper) j1 Install new step flashing where necessary standar. copper) Ja Install Hand nailed rigid baffled continuous ridge vent ❑ Install proper soffit ventilation Shingles: / (6 nails per shingle) V'Ggi ( Shingles III 25 year �� 30 year III 50 year Color 11-/ G�Oel Ge E k Ridge cap shingles Warranty Options: V We guarantee our workmanship for 10 full years (see our warra y coy r e) / El GAF ELK System Plus warranty ., L ° G/ l — I' ❑ GAF ELK Golden Pledge warranty /�' / Chimney Options: t ' ; ' I `7 0 Lead Counter Flashing 0 W of Seal & Tuckpoint Rubberized Crown MI Metal himney Cap to furnish materials nc r f r - complete in a'se6 with a S • e We Propose hereby for the sum of: r > rf4 y 1 `�, p p ! / G� Total Sale Price $ V F 7 VD�Yw Payment $ r 00 Upon Completion $ 6, , 7 _ ACCE OF PROPOSAL: The above price 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 a1mum. Purchaser(s) will pay'for all costs, expenses and reason- able attorney's fees incurred by • am Quenneville Roofing and - Siding; int3 To recover any sums due under this contract. / I r Date: 1 Signature: ,Z /. _ ; Jim/ Phone # Date: / A 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. - 1/09 SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : 70 0) lU License Number Address Q � o ppu�iie m a ll Expiration Date 180 He y Ni 01075 ature Soa Telephone y13 53 (Q - 91S5 9. Registered Home Improvement Contractor: Not Applicable ❑ Company Name ik0 6At� © � d Registration Number / tlu 21044 ,t1 `y 0 � as ` Address tow VIN / o 5 Expiration D to — Telephone -S3/'SS 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 D Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding [0] Other [0] Brief Description of Proposed am Work: 51Y 10 , 1 a O - fesV) ;n k raof" 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? XC 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 l Arn l K r y y SJ) as Owner of the subject prop Q hereby authorize � ► tl I R40 r 1 Aq - S 1 CI \ >1 to act on my beha all matters relative to work authorized by this bblilding permit appli idn. S ignature of Owner Date 1, Ptc YY1 C" 7'1 ti �Ie1 1 'e,\ i t 1 W e_ O 11 4 Sc c 1 ('lam • , as Owner /Authorized Agent hereby declare t at the statements and information o thej regoing applicati re true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. Arla yn lau P.n ne.,v 1 I ( e_- Print Name 1/ �y Signature of Owne gent 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 ►,$ YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO DONT KNOW 11� YES 0 IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW ta, YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained Q , Date Issued: C. Do any signs exist on the property? YES © NO Q 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 YES, then a Northampton Storm Water Management Permit from the DPW is required. Department use only - City of Northampton Status of Permit: r ,,(AQ Building Department Curb Cut/Driveway Permit 11 ".v 2 Main Street Sewer /Septic Availability Mp` S Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Strur .rral 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 G � /-A ctr o6 � �� y a, Q Map Lot Unit f l �" 0 ren C� Ad 0/PGA Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: ii Carol K©cy+o ( ? ./I p plek)6C 'Ter. F /v/841a.° AA Name (Print) Current Mailirt Address: i n 3 - 5 - V1 -SG 4� S Telephone Signature 2.2 Authorized Agent: + T / J � _/ 9JQYV 6ibp12rlfv►/k 'Roof � Si - cilt p l9IP AO oid C I�1/l/'1 ed (5 / OA c- Name (Print) -J Current Mailing Address: / 0/07> 03- S36 -5Q Sign Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building l, 1 Z7 Q r7 (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 n � 6. Total = (1 + 2 + 3 + 4 + 5) 41 9, 327, d o Check Number /75,7 This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner /Inspector of Buildings Date A' :WOOD TER BP- 2010 -1094 GIS #: COMMONWEALTH OF MASSACHUSETTS k: 23C - 030 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- 2010 -1094 Project # JS- 2010- 001611 Est. Cost: $9387.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ADAM QUENNEVILLE 070626 Lot Size(sq. ft.): 60112.80 Owner: KORYTOSKI CAROL Zoning: URB(100)/ Applicant: ADAM QUENNEVILLE AT: 82 MAPLEWOOD TER Applicant Address: Phone: Insurance: 160 OLD LYMAN RD (413) 536 -5955 0 Workers Compensation SOUTH HADLEYMA01075 ISSUED ON:6/3/2010 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 6/3/2010 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo