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24A-228
ACORD • CERTIFICATE OF LIABILITY INSURANCE OP ID DM DATE(MM /00/YYYY) 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 i NAIC INSURED INSURER A; AIM Hutual Insurance Ca•pany INSURER B: Travelers Ins . Co . Adam Quenneville Roofing & INSURER C: First Speciality Ins Corp , Siding Inc & Guttershutter P y 160 Old Lyman Road i INSURER0: 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. POLICY NUMBER • a D LTR NSR. TYPE OF INSURANCE DATE (MOWN) DATE (MMIDDJYY) LIMITS 1 GENERAL LIABILITY ! EACHOCCURRENCE $ 1000000 C 1 X COMMERCIAL GENERAL LIABILITY ! TBI 06/23/10 06/23/11 iFREMISES(Eaoocurencs} 5100000 CLAIMS MADE X OCCUR ' MED EXP (Any one person) $ 5000 I I PERSONAL & ADV INJURY $ 1000000 I � GENERAL AGGREGATE S 2000000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS • COMP /OP AGG i 52000000 POLICY PRO n LOG JECT AUTOMOBILE LIABILITY ! COMBINED SINGLE LIMIT S1000000 B _. ANY AUTO BA7450L946 11/01/09 11/01/10 ; (Ea accident) ALL OWNED AUTOS BODILY INJURY X . SCHEDULED AUTOS Per person) I X I HIRED AUTOS f BODILY INJURY 1$ X NON.OWNED AUTOS (Per accident) , I PROPERTY DAMAGE I (Per accident) 1 1 GARAGE LIABIUTY • I I AUTO ONLY • EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC : $ C AUTO ONLY: AGG S EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE S n OCCUR 7 CLAIMS MADE AGGREGATE 5 5 •� DEDUCTIBLE S RETENTION $ $ WGSIAIU• GIN. WORKERS COMPENSATION AND I TORY LIMITS I ER A i EMPLOYERS' LIABILITY AWC701286101 04/29/10 04/29/11 I E.L. EACH ACCIDENT $ 1000000 ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED, ' E.L. DISEASE • EAEMPLOYEE $ 1000000 If yes, describe under h SPECIAL PROVISIONS below j E.L. DISEASE • POLICY LIMIT : S 1000000 OTHER D Equipment Floater iIHN7140610 02/01/10 02/01/11 Rental Equipment $100,000 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES !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 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 REPRESENTATNES. AUTHO D REPRESENTATIVE -4tAel.e6 ACORD 25 (2001!08) ©ACORD CORPORATION 1988 . -= = _ . e l n s an • tan • ar • s 0 ax• o . u sing gu _ _ � f One A Place - Room 1301 if Boston, Massachusetts 02108 Construction Sup License .,. License CS: 70626 Restriction: 00 'Blrthdate: 812111971 - Expiration: 8/21/2011 Tr# 3712 I I AQANI'A , ' QUENNEVILLE 1' OLD LYMAN RD S : 'HADLEY, MA 01075 -- ?lite -67-4„,./a I Office of Consumer Affairs and usiness Regulation e 4 1 A', 10 Park Plaza - Suite 5170 ' — Boston, Massa,:” usetts 02116 Home Improvement _4 _ so. ctor Registration '= — Registration: 120982 l;. *� - w_.. Type: DBA " _ ( Expiration: 3/25/2012 Tr# 293069 fi ADAM QUENNEVILLE ROOFING -I -=-- ,, �,_, \':,..\ ADAM QUENNEVILLE f��:,_� 'r 160 OLD LYMAN RD �4� _;w - ) SO. HADLEY, MA 01075 r" 7 j : :1 s ,_ - rw ., „ , �� U pdate Address and return card. Mark reason for change. l Address ❑ Renewal E Employment ❑ Lost Card DPS -CA1 0 S0M- 04/04- G101216 STATE OF CONNECTICUT + DEPARTMENT OF CONSUMER PROTECTION `* ,:::I I Be it known that. '. ADAM QUENNEVIT T F e t A . 160 OLD JC,.h ROAD SOUTH ',9 �. 9 17 -2632 I i � " - '� i is certified by the Dep n , r c ,:., ...,section as a registered ` k 4 : , HOME IM M� P. L NTRACTOR Ir‘ i Regis s 1 : i 5 } - --, ti t'r r� } ADAM . QUENNEVILLE ROOFING Effective: l2 /01/2009 _ f4 ` Expiration: 11 /30/2010 .' The Commonwealth of Massachusab Department of of Accidents k Of _ ,; ... fice of Investigations = cV 600 Wasl big�con Street � -- • Boston, MA 02111 Sit''' www. gov/eha Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers A 1afrmatinn Please Print Legibly • r �ividual): , Na !. i• e , ' _ a . - - tl a \ a * "" 1 ✓!C. me( , Address: 120 ()I A Ly rAttyl d. C" /State/Zi , ') a! • ` s S 11 7 Phone #: - • _' • Icy �: _._...., _ ._. __ __ _ __- _ -- _ ____ Are ice an employer? Check the appropriate boa: Type of Project (requited): 1.1g1 I ethos a employer with J S 4. ❑ I am a general contractor a I er have hired the sub-contractors employees (full and/or part-time).* 6. ❑ New construction 2. ❑ 1 am a sole proprietor or partner- listed on the attached sheet 7. 0 Remodeling ship and have no employees These sum have g ❑ Demolition working for me in any ma employees and have workers' 9. ❑ Building addition [No workers' comp• insurance comp. insurance.t required.] 5. ❑ We are a a:epoca ion 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 watriccts' comp. right of exertion per MGL I2,Roof repairs insure= -1 t c.152, §1(4), and we have no I3.[} Other employees. [No workers' comp. insurance •] *Amy muthe hot that checks box It most also tiff out the section below diming their waders' comp ice lady iafosmariot I llomeoast a oho submit this affidavit irebusiog they ass &isgen work sod thou bit onus* eaatesmus mot submit* Door af5darit lothesriogsock =oat mooridst dust it h boxroom motelmdaa additiood that show* the muse oftesab•eoomeetors nsd>hos eisheibertrust drone =tides have employees If he tsaooaau+oo lava employees, they most tam's their cotqp. policy masher• l ant at employer thet br provkling atar*era' emspeosollon brarr+a cefor my employees. Below is the policy mod job she Insurance Company Name: A. t /A . u i-1,1 a l Y1SLt rla Ile e, P o l i c y # o r S e l f - - i n s . lac. #: 0 UDC,. 1 1 0 1 4 9 , 1 0 1 0 1 Expiration Date: 4/a R / abl lob Site Address: L K r 13f a P4 Qr, No c Alux...PPaq 1 AA p 606 V cit Attack a copy *fake workers' ampeasatda pay deel a ratlea page (skowlag deepolic7` .. ber aadeeiph'atiee date). Failure to secure coverege as required under Section 25A of MGL c. 152 cm lead to the imposition of criminal penalties of a fine up to 51,500.00 and/or one-year imprisonment, as wall 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 axle tomtit: doe and penalties teme*ey that the horommottots p aboae is Thee an correct. 5ignattare: Date: t t - 3 `► C? Phone #: lit 3-53 to - 5 q 9 official use only. Do not write in dole area, to be completed by city or town official City or Toms: Permit/License a laeaisg Authority (circle one): I. Board of Health 2. BaMisg meet 3. City/Town Clerk 4, Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Proposal Submitted To Date Str et ROOFING & ' ' t IDiN "a 114C. i .i . t 1 D a uCv €u .. x t � - City, , Zip a`+.be 160 Oki LyiTla F d , South Hadley, MA 0 1075 y Stat i t / Wit, o 1.800.NEW "1 413. 536.5955 Phone #'s 1 Email: info b1800newroof net Websita www:1800newroof.net H: 4 . „ � c w. MA Construction Supervisol3 iJ #d 26 ' ; l fA F 10tratiort, 1x4682 "`t Member of the Home B ui ld ers ccr� Western . Mass �, . i C T F ta t ration # 57 5 920 - Dump ster Location Member of the Building &Trade Asso ,`AS . Membersi the Better =Business Bureau" { DH ` , EV ',' Vent CV TW DHP Double Hung " ,. 3-Lite End Vent " ' 3 -Lite Center Vent Twin Double Hung -„ .Picture w/2 Double Hung Fiankers i► i minim ■ sNisi , .11111,1111111 . ell ��'4.4 �.4 1 ••• s 111111•1 - LW, ' W �II ss s ■ss i A at i±.� •■ss • ■ sss 11 ®I S Woodgrain Interiors VinyTColor Product Code Guicrlityles NAT . Natural Oak WH . White SS . Bayshore ST . Standard 5l6" . RP . Regal Perimeter GO . Golden Oak CA . Camel " "` SS : Seabrook - RC " .:Regal Colonial RFL . Regal Florentine CC . Colonial Cherry ' ET" .Earthtone NE .Northeast, 0 .. Gregorian 11 /16 "" .RFE. . Regal FlorentineElongated WW W . White Woodgrain ` W Williamsburg 11116" RF4 . Regal Prairie (2 passes) .. TB . Thin Brass BAY .: BOW 4 BOW 5 BOW 6 GARDEN I ij ' 8, � 4 gI ' hI® � IIII Woodgrain Interiors W ns " Sl'Iny1 Color . Product Code ' Grid Styles Glass Options NAT ,. Natural Oak o WIt . White i ' A Aurora >, . ST r Standard 5/8" G - Gregorian Stay-Clean Gass GO . Golden Oak OAK CA ., Camel' At L- Regal Grids " I W �. Williamsburg r Regal Glass CO ' TR 1/3-1/3.1/3 TR 1/4- 1/2 -1/4 QUAD Operating, Casement Single -Frame Equal -Cite Single -Frame 1/4- 1/2 -1/4 Single -Frame 4-Lite Triple Casement Triple Casement " - Casement l if J L., `ii' 1J r Existing Window New Window Existing Window New Window Measurements Measurements Rough Opening ,�' . ", a Rough Opening fd ' Looetbn style Meted style series q ,, t Location , Style Metal Style Series 8 t (Room/Floor) 'Code. y/N , 'Code" "Code" do E=1=1030 . , (Room /Flood "Code' .Y /N "'Code" Code ., wtdth I= ut I ®® ®ter ®®aim® a ® ®� ® ®a■e■1 e ® . x . N N '-' ® ® ®® a �simu®mein '..:. 20 ®®� ®®®® , '- N ® 11111111111111111111111111111111111111111111 ' 24 color of " ,, r - oil Window 1 Door Wrap # x < " ,N 'i„ 1,.t„r, t ' „- }, / l0oor Wrap WE opose.hereb to ftirilionniaterlale and labor - complete in accordance with above specifications for the sum of: Total Sale Price $ ' . s -, - Down Payment U Co $ " � C . ACCEPTANCE, OF,PROPOSAJ The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do work tts specified.. Payment will be 1/3 down upon signing, and balance due upon,pompletion, Unpaid balances shall accrue with Interest at 18% per, annum. Purchasers) 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. 1 ' Date: - Signature: -. Phone # Date: /` _ Salesperson's Signatures` r '" ' --------- Estimat: _ • re h•,-+ re or. ' y (60) days from above date Please remove all breakables from interior well surfaces during installation. AQR &S will not be responsible for damage. fvo OffARKAF ;sorif:ie ?NW H311§.1- rang Koig ppm Otton, tot ip9itut ,Irifut SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder 706'. o 1 License Number 160 Old Lyman Road �, 1'1 Address South Hadley, MA 01075 Expiration Date Signature Telephone 4 (3 -53 4- 5R5 9. Registered Home Improvement Contractor: Not Applicable ❑ Ada. Qierneville Roofing & Siding, Inr I ' l Oars ) Company Name Registration Number 160 Old Lyman Road 3 - s _ �z Address South Hadley, MA 01075 Expiration Date Telephone 4 113'83( - Semi — 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 fre 440iwtt t Mel` ili *S h :t Mit PC SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House [l Addition ❑ Replacement Windows Alteration(s) n Roofing El Or Doors l Accessory Bldg. ❑ Demolition El New Signs [O] Decks [p Siding [D] Other [0] Wor k : scription of Pr pq _o R� � a w ` ^ � w S Work: rsn.th vt - 1'�ev� 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 Ik - C I V�ei , as Owner of the subject property Quint W lit. hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. It - 3-1 0 Signature of Owner Date Ada Qum& Wag i , lie , 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. f"�CGLAN Qv e,hA.t.A.lctt,-c- Print Name 2 (( -3 -to Signature of Own 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 DONT KNOW YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW YES 0 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 o , 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, cavation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. Department use only City of Northampton Status of Permit: auiiding Department Curb Cut/Driveway Permit r � 212 Main Street Sewer /Septic Availability Room 100 Water/Well Availability V' 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 Q i t9(`avvv D( - Map Lot Unit U µH '1" � /Vo cAr�t� p4o 4 t Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: Alkat- cr■ C v G Pit Ii'. Nof4.a0 p 1 MN OtOGO Name (Print) Current Mailin Address: y�3 s 9 -aOi Telephone Signature 2.2 Authorized Agent: ada QvGVtihe.v4.ue !Go OIZ L yv.r\ 1 6ov4A't 1 �ad.kei ,NA Oto'�i Name (Print) Current Mailing Addre a, 't13 SIC - S"9SS Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building 1 S - (' (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) a.��lpo Check Number be This Section For Official Use Only Permit Number: Date Building Issued: Signature: Building Commissioner /Inspector of Buildings Date 46 4. BP- 2011 -0443 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block :24A 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 -0443 Project # JS- 2011- 000721 Est. Cost: $2511.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ADAM QUENNEVILLE 070626 Lot Size(sq. ft.): 29620.80 Owner: CLUTE MARTHA Zoning: URA[100)/ Applicant: ADAM QUENNEVILLE AT: 46 PILGRIM DR Applicant Address: Phone: Insurance: 160 OLD LYMAN RD (413) 536 -5955 0 Workers Compensation SOUTH HADLEYMA01075 ISSUED ON:11 /10/2010 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL 2 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 11/10/2010 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner