24C-073 (2) •
•
li _ = c oar. o ul . m ' e ul ' ions an. tancar. s
_, g g
'`'" One Ashburton Place - Room 1301
•
Boston, Massachusetts 02108
•
Construction Supervisor License '
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License CS: 70626
' Restriction: 00
Birthdate: 812'111971
• Expiration: 8/21/2011 Tr# 3712
ADAM A QUENNEVILLE
160 OLD LYMAN RD
S HADLEY, MA 01075 -.-
• Update Address and return card. Mark reason for change
- n Address [] Renewal El Lost Card
•
DPS -CA1 t5 50M- 07/07- PCB490
(.5 ,,,,, _ ea, :. 4 ,.....,.„. ; ,.., r Board o Buildin Re ons ans • tan. a r�
= (= One Ashburton Place - Room 130.1.. ' ..
''-° Boston. • Massachusetts 02108 • ~ .
Home Improvement:-Contractor Registration
• •
Registration: 120982
Type: DBA
•
•
Expiration: 3/25/2010 Tr# 264937
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• ADAM QUENNEVILLE ROOFIN • :
:= ...• ..
G ' • •
ADAM QUENNEVILLE .. -_
160 OLD LYMAN RD
SO. HADLEY, MA 01075 ' ' .
Update Address and return card. Mark reason for change.
' 0 Address ' a Renewal 0 Employment 0 Lost Card
DPS -CA1 Ci 50M- 07/07- PC8490
r a Be It k nown that 1
nt 7
i `ADAM QU •
140 OI,D" f ROAD
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:, sotyylp H m' X01075 2632 � r ���-
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.7::::iiIii AD AM QUEN E N JLL ROOF IN v
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RX Date /Time 04/04/2009 12:02 1 413 538 6010 P.001
Sep -04 -2009 01:44 PM Remillard Insurance 1- 413 - 538 -6010 1/1
ACORD CERTIFICATE OF LIABILITY INSURANCE OP ID LL DATE(MM!ODlYYYY)
ADAMQ -1 09/04/09
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
Phone:413- 538 -7862 Fax:413- 538 -7179 INSURERS AFFORDING COVERAGE NAIL#
INSURED INSURER A: Scottsdale Ins Co.
INSURER B: Travelers Ins. Co.
Adam Quenneville Roofing a
Siding Inc INSURER C: arm mutual Insurance Company
160 O Lyman Road INSURER 0:
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.
INSA�1 PO POLICY EXPIRATION
LTft )NSR TYPE OF INSURANCE J POLICY NUMBER E (MM10DP(Y) DATE (MMDD,'YY) LIMITS
GENERAL LIABILITY EACH OCCURRENCE S 1000000
A X COMMERCIAL GENERAL LIABILITY CLS1034980 06/23/09 06/23/10 PREMISES (Ea ocaurence) 5 50000
CLAIMS MADE I OCCUR MED EXP (Any one person) S 50 00
-- % PERSONAL & ADV INJURY S 1000000
GENERAL AGGREGATE ° s 2000000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG s 200000 0
n C n POLICY JECT I LOC �— /
AUTOMOBILE LIABILITY
B ANY AUTO BA7450L946 11/01/08 11 /01 /09 COMBINED SINGLE LIMIT 1000000
(Ea accident)
ALL OWNED AUTOS BODILY INJURY
X SCHEDULED AUTOS (Per person)
X HIRED AUTOS
BODILY INJURY $
X NON•OWNEDAUTOS c � \ (Per accident)
U PROPERTY DAMAGE S
(Per accident)
GARAGE LIABILITY AUTO ONLY - EA ACCIDENT S
1 ANY AUTO OTHER THAN EA ACC S
AUTO ONLY: AGG S
EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE S
n OCCUR n CLAIMS MADE AGGREGATE S
S
DEDUCTIBLE S
RETENTION 5 5
WORKERS COMPENSATION AND X I OR AI S I ER
TO RY LLIMITS � X. ER
EMPLOYERS' LIABILITY
C AWC701286101 04/29/09 04/29/10 E.LEACHACCIDENT 51000000
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYEE 510000 0 0
If yes. describe under
SPECIAL PROVISIONS below C, E.L. DISEASE - POLICY LIMIT 51000000
OTHER 1 (lf
DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT! SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
PYNCHON SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
% DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10. DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY HIND UPON THE INSURER, ITS AGENTS OR
REPRESENTATIVES.
AUTOO ED REPR SENTATIVEv 6E/74 ACORD 25 (2001/08) @ ACORD CORPORATION 1988
t. `'_ .... 'N 1,=i z Office of lnvesngalwn,
"� ••600 Washington Stree
. 'Boston, MA 02111
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wnnv.mass.gov /dia
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Workers' Compensation Insurance Affidavit: Builders/ ontractors [Electricians/Plumbers
Applicant* .Inform ation Please Priilt Lezibly
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Name (Business/Organization /Individual): POICifY1 3,Ul',Y1NVI ti VN('` 1 .
L J
Address:, 1 ( vi a O la C —um�xn R (-xx d .
a yA- YlC»J Phone #: 9 53 Lt. Si55s
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City /State /Zip:_ ' o �� .. • _
Are yo an employer? Check the appropi bodx: ' ' . Type of project (required):
1. I am a 1 oyer with m P l 6... am 4 ❑'I' a general contracto and I
6. El New construction
employees (full and/or part- time).* . • have hired the sub-con.,: ctors
2. ❑ I am a. ole proprietor or partner- listed on the attached sh et. l '7• ❑ Remodeling
• ship an,lol have no employees These sub - contractors h :ve 8. ❑ Demolition •
working for sue in any capacity. workers' comp. insuran e. 9 ❑ Building,addition •
[No workers' comp. insurance 5. ❑ We are a corporation ..d its •
' officers have exercised it 10.0 Electrical repairs or. additions
required_]
3.1 I I am a homeowner doing all work . right of exemption per i GL i LEI Plumbing repairs or additions
myself, [No workers' comp. ' • c. 1'52, §1(4), and we h.ve no 1 l2.2<of repairs
insurance required.] t ' employees. [No work ,'
13.0 Oth�
comp. insurance rGquir d.]
Any applicant ' a cheeks box #1 must also f111 out the section below showing their workers' ompcnsation policy information. .
t Horn e-owners o submit this affidavit indicating they are doing all work and then•hu a outsiac contractors must submit a new affidavit indicating suet]. .
tContractors that check this box. must attached an additional ahcpt showing the.name of the an.. .atraefois' d their workers' comp. policy information.
I a an employer that is providing worlc compensation insurance for y emplo Below is' the policy and job site
information_ i �
Insurance Company Name: )) / l / • • • 04.0 • 7 �'S ••
I
Policy # or Self -ins. Lie. #: A (.A) c - 2c) I a.'E 1 l`7•� C , 'Expiration Date'._ LLr✓ ,pi -9,01 0
Job Site Add � � / J °i !{ 50 ° 1 � City /S :ate•/Zip: N F,-1" VsetVr� - ocl A N 0 tv(� 0
Att 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 cm lead to be imposition of ciirn.imal penalties of a
fine up to 51500.00 and/or one 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•: tatementtcay be forwarded.to the Office of
Investigatiou, of the DIA for insurance coverage verification. • .
i under t anis and enaltis o e that the in o rncat.on ravided above s true and i
I do hereby ett •c orrect
h e
P P. fPrl Y f . , ■
sign ature : • _ Date: I i AO D • Phone #: i fL 3 Vi #' "S . . •
•
i
Official u se on Do not wrifr' in this area, to be completed by city or town official .
City or Town: Permit/License # • •
Issuing Authority (circle one):
1. Board of Health 2..Builc'1i Department 3. City(Town Cl 4, Electrical Inspector 5.Plumbipg Inspector
6.Other� I •
.
. • •
Contact Person ? Phone #•
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_ : D A Ai lik VISA Masre `' ' } e.••a DIICSVER
C IU E N N 1E 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 @l800newroof.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:
y
Vi Q1 ..r' . kr /rf i(,fC`, H: `, tc e (,() Cell:
Street Email:
H9 rr10,S'S-�6c�\ ,4 vi 6 l l Q o l r i n $1r -° OL.
City, State, Zip Code Special Requirements Rook-P. 13 1
he rlti Vlo�p1 n ( t ti. '\ 1 I E, C, litil'n nt , C, .
f \J 0, orirl 'a 1 r a ri fl" 4T -sh; 1Yl i � , L 4 ° r r�£ CuJ 4.-
Complete Roof System 0 -,,,,,,, l tic, i f 1,,_ )'`-�-
R We shall acquire all appropriate permits for all work 1.__ ,) (E A-
.Home exterior and landscaping to be protected .Ar , ca r1 i°vN A i I!) 110 `1 j C
:.g] Entire existing roofing materials to be removed to existing decking 0 n rl P: ilu j t C : :l I
g Deteriorated existing decking will be replaced at $3.47 per sq.ft.
A Install Ice & Water Barrier at all eaves, valleys, chimneys, pipes, skylights and sidewalls
g Install (15 Ib. felt Synthetic) underlayment over remaining decking area 5 N a _ Q t-C.c-A. c)L_
.3 Install Metal drip edge at eaves and rakes (8" e (white /'„rown copper)
..E Install manufacturers starter shingle on all eaves and rake edges
❑ Install new pipe boot flashing (standard / copper) Art_ no r1C,
El Install new step flashing where necessary (standard / copper) i fl 0 (le,
-n. Install Hand nailed rigid baffled continuous ridge vent
❑ Install proper soffit ventilation _____,__
/-
Shingles:
( Halls per shingle)
02
°£ Shing e year N 30 year ❑ 50 year Color 1,4,) ai.vi ,,- Lard
G+• Ridge cap shingles
Warranty Options:
3 We guarantee our workmanship for 10 full years (see. our- - warranty coverage)
t GAF ELK System Plus warranty ( C�
❑ GAF ELK Golden Pledge warranty j " ' i
c .3 ii e .,_ ', « , � 7 63
Chimney Options:
7 r 0 ('1:
La Lead Counter Flashing ❑ Water Seal & Tuck int ❑ Rubberized Crown ❑ Metal Chimney Cap
We Propose hereby to furnish materials and labor - complete accordance with above speciflca ions for the sum of:
1 i - I' -O 't h 1, m ict y
- Total Sale Price $ 3a r1C% , C10 Down ayment $ Upon C pletion $ 1 i 41
ACCEPTANCE OF PROPOSAL: The above prices, ecifica rte' d are sa i factory and are hereby accepted. .
You are authorized to do work as specified. Payment I be 1/3 down upon signin nd balance due upon completion.
Unpaid balances shall accrue with interest , 18% pp r �rchaser(s jil ay for all costs, expenses and reason-
able attorney's fees incurred by y m au evil) oofing and Siding, rnc. to recover any sums due under this contract.
i,/
Date: . ' I I � Signatures - f ` �
Phone #
Date: j I i C 0 T E Signature: i.r.._ S
ATTENTION HOMEOWNERS: Please cover � I personal belongings in the attic, garage or storage areas due to the NIP
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 0
Name of Lic 070(.(23.(k elise Holder :
Adam UeCI8VIl a #t11Pilil g & sift() Ill4.. License Number
60 Old Lyman, - a - I
Address 'ln "' Expiration Date
ignature Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
aocosx
Company Name 4001 l uommilie Hotl)ing & itl9ly? ':f,; Registration Number
'Ian Oil Lyman Roac, 3 - As
Address '` uT01° 4101.1, 011Y0 Expiration Date
Telephone C 5155
SECTION 1D- 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 0
11. - Home Owner Exemption
The current exemption for "homeowners" was extended to include Owner occupied Dwellings of one (I) o 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 on 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 ar.d/ 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 a /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 nd 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 mployers to
Employees for injuries not resulting in Death) of the Massachusetts General Laws Annotated, you may be li ble 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 C de, City of
Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotat .
Homeowner Signature
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SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [Dl Decks [C] Siding [O] Other [Dl
Brief Description of ProposedJ, n C
Work: Lrtk
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. flooclplain 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, _ as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I, I r v u ik _, as Own- • • orized
Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my • : •
and belief.
Signed under the pains and penalties of perjury.
ai p
Print Name L'G
lr -o o7
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 0 DONT KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW 0 YES 0
IF YES: enter Book Page and /or Document #
S. Does the site contain a brook, body of water or wetlands? NO Q DON'T KNOW Q YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained I , Date Issued:
C. Do any signs exist on the property? YES Q NO O
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 0
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 Q
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
City of Northampton
Department use only
Status of Permit:
Building Department 212 Main Street
curb cut/Driveway Permit
Sewer /Septic Availability'
n' - ' Room 100 Water/Well Availability
,
1_ : -' Ndrtharrlpton, MA 01060 Two Sets of Structural Plans
phone 41.- 583-1'240 Fax 413 - 587 -1272
Plot/Site Plans
O ther 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
Map Lot Unit
ti
`—! / ` Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
V ,I C G em vt y\-e.K Lit /`1c 3S ?Soi I Ski N oe6 -�m _MA- core:.)
Name (Print) \ Current Mailing Address:
Telephone S (, it O 7 5-
Signature
2.2 Authorized Agent:
Adam Utiefili +Viiiti r' U((liri9l c 0 Name (Print) Current Mailing Address:
lea Oki Lyman n �y 5 '�anth lie.dlev. MP. I , " r (�
Si re Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building
3��p .vim (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) OW10 c� Check Number / /3-3 35-
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
BP- 2010 -0576
GIS #: COMMONWEALTH OF MASSACHUSETTS
/4e M3 _ 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 -0576
Project # JS- 2010 - 000816
Est. Cost: $3290.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ADAM QUENNEVILLE 070626
Lot Size(sq. ft.): 16117.20 Owner: GENGLER DAVID W & KAREN M OLSE
Zoning: URB(100)/ Applicant: ADAM QUENNEVILLE
AT: 48 MASSASOIT ST
Applicant Address: Phone: Insurance:
160 OLD LYMAN RD (413) 536 -5955 () Workers
Compensation
SOUTH HADLEYMA01075 ISSUED ON:12/3/2009 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP & SHIINGLE 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 12/3/2009 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo