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ACORD CERTIFICATE OF LIABILITY INSURANCE OF ID DM DATE(MM/DONYYY) 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 Mutual Ineu. - - ante Company INSURER B: Travelers Ins . Co . Adam Quenneville Roofing & IN SURER C: Fi rst Speciality Ins Corp Siding Inc & Guttershutter p y 160 Oid Lyman Road i i INSURER D: 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 REOUIREMENT, 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. a POLICY NUMBER - a T a LTR NSR. TYPE OF INSURANCE DATE (MM /ODlW) DATE (MM /DOIYYJ LIMITS 1 GENERAL LIABILITY I EACH OCCURRENCE S 1000000 A(,�t 1 U KIN I tU C X COMMERCIAL GENERAL LIABILITY ; TBI 0 6/ 2 3/ 10 0 6/ 2 3/ 11 U AM PREMISES (Ea oocurence) s 100000 CLAIMS MADE X OCCUR ' MED EXP (Any one person) $ 5000 PERSONAL B ADV INJURY ! $ 100 0 00 0 GENERAL AGGREGATE $ 2000000 GE'L AGGREGATE UMFT APPLES PER PRODUCTS• COMP/OP AGG i$ 2000000 — 1 POLICY 7 PRO- n LOC JECT AUTOMOBILE UABILITY 1 COMBINED SINGLE LIMIT B A NY AUTO BA7450L946 11/01/09 11/01/10 I (Eaaadent) 5 1000000 I ALL OWNED AUTOS BODILY INJURY ) X SCHEDULED AUTOS ! Per person) I S X I HIRED AUTOS f BODILY INJURY X NON•OWNED AUTOS 1 (Per accident) $ PROPERTY DAMAGE 1 I (P« accident) 1 $ , ■ GARAGE LIABILITY I 1 + AUTO ONLY • EA ACCIDENT $ ....—i � I ANY AUTO OTHER THAN EA �CC ; $ AUTO ONLY: AGG I $ • I EXCESS /UMBRELLA LIABILITY EACH OCCURRENCE S L OCCUR I CLAIMS MADE 1 AGGREGATE S i S I DEDUCTIBLE s RETENTION $ S I W W TATU - Ol H - ORKERS COMPENSATION AND ' TO S LIMT I ER A , EMPLOYERS' LIABILITY AWC701286101 04/29/10 04/29/11 I E.L. EACH ACCIDENT $ 1000000 ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBEREXCLUDED? I ' E.L. DISEASE - EA EMPLOYEE $ 1000000 If yes, describe under ` SPECIAL PROVISIONS below j E.L. DISEASE • POLICY UMT E $ 1000000 OTHER D Equipment Floater iIHN7140610 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 HOLOER NAMED TO THE LEFT, BUT FAILURE TO 00 SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER. ITS AGENTS OR REPRESENTATIVES. AUTOO D REPRESENTATIVE ACORD 25 (2001108) © ACORD CORPORATION 1988 -1 'I, 1 44 1 .4'1 _ i =c, • . oars o :u sing ' egu1 ions an. tans arts in' - _: One Ashburton Place - . Room 1301 If Boston, Massachusetts 02108 . Construction'Siuei License prvsor e • License CS: 70626 , • • • Restriction: 00 • , t • , 1 . • . • Birthdate: 8/21(1 Expiration: 8/21/2011 Tr# 3712 APAM A QUENNEVILLE 1'60 .OLD LYMAN RD • - :. • -- S''HADLEY, MA 01075 — ,?./1 Office of Consumer Affairs and usiness Regulation 1,e - 6 2 0 - 0 , 02 , 104 - twecla , , 4 ' / 4 •, -I -f= 10 Park Plaza - Suite 5170 �._* Boston, Massa,.usetts 02116 Home Improvement ,,,q t: ctor Registration Registration: 120982 y Type: DBA 7 , . .... Expiration: 3/25/2012 Tr# 293069 ADAM QUENNEVILLE ROOFIN M ' ~ ADAM QUENNEVILLE 160 OLD LYMAN RD - = Jo SO. HADLEY, MA 01075 C, = —=--- ,,,_„ F \ 'fir' f s � , �� Update Address and return card. Mark reason for change. D Address 0 Renewal 0 Employment 0 Lost Card DPS -CA1 0 50M- 04/04-G101216 ` STATE OF CONNECTICUT + DEPARTMENT OF CONSUMER PROTECTION 1 Be it known that 'E : - ADAM QUENNEVJT .T P 160 OLD o ROAD e, i e 75 -2632 i SOUTH ,, • 1 , 7 .• rte= , . is cer tified by the Dep t n f n�,•. tection as a registered i HOME IMPR M a M' P O NTRACTOR 1 Regis - - k 0 1: R,grvsr ADAM QUENNEVILLE ROOFING 1 i Effective: 1 { L I . Expiratl.on /30 .:. , Jerry F arrell, Jr,, Commissioner i The Commonwealth of Massachwels _ Department of Inanarkel Aeddents ' v_ f Office of Invest ons — Was gton Ste` kb, = �= Boston, MA 02111 www.nsamgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant information Please Print Leabty • Name( Y ! se e . / , ► ' • i • ` a v A v1.. Address: ILO ()(A Ly P A an ci. `` gyp _ City/SM:f(. ' ,'� go `_ • ; Hb1 phone l I _ . _ T' -- Are you an employer? Check the , ' 1 1 ' box: +7 Pe of ruled (required): 1.J I am a employer with 1 a, 4. 0 I am a general contractor and I employees (frill and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.0 I am a sole proprietor or partner listed on the attached sheet. 7. 0 Remodeling ship and have no employees These subcontractors have S. 0 Demolition working for me in any deity. employees and have workers' 9. Building addition [No workers' camp- 'insurance a comp. iurstuaucae.= required.] 5.0 We area 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 %Waken' COMp. right of exemption per med.' . insurance l t c.152, §1(4), and we have no 13.[} Other employees. [No workers' comp. insurance required.] tmeoweera. Ho submitdu'e g a bawl* dorog all nark eod�haeeu�de' cad compensation efficient balicalingoach — tQamaeeorstiet check thisbeaaeatettechedausdiionddotiow ®61hesomeofthe nbcoatreelem rLeMerorn entities bore employees. Ink .ehaoarnaoes have employees, they most pmvide tbak wodoere comp. policy member. her. I on ea employer tbd is provkling workers' composed*" insurencefor ny employees. Blow L the policy end jabs*e a � ff Insurance Company Name: �T t \ A t�l'.I.l a t. 1'1SU rla >■ t Policy # or Self -ins. I.ic. #: P lA . 7 O A9, In 1 0 [ Expiration Date: (1/2 9 61 r lob site Address: t39 RI v er ho,.nlc kL Ncf'4n.ppes A City/State/Tap: O IOC() Attach a copy Fire workers' compeasadon policy declarathee page (showleg dee policy meeker and date* Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the won of ui... tal penalties of a fine up to S1, 500.00 and/or one-year impeisooaent, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a dry against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigadons of the DIA for insurance coverage verification. //ID hereby eerie under weepeneliks ofperfrary Set the brforwratton pnovrdadebove is true end Signadu+e. Date: G - cf -10 Phone #: z il 3 t o - , -9 sS" Offidel use only. Do not write In iris area, to be complied by city or town q fdat City or Town: • Peneit/Lieense # Issuing Authority (circle o.): 1. Douai of Keenly 2. Big Department 3. City/ Town Clerk 4. Electrical inspector 3. Plumbing inspector ° R Other Contact Person: Phone #: r moms VISA MasFerw • I DIfC•VER QUENNEVILLE ROOFING & SIDING, INC. 160 Old Lyman Road, South Hadley, MA 01075 1- 800 - NEW -ROOF • 413-536-5955 Email: info@l800newroof.net Website: www.1800newroof.net MA Construction Supervisors Lic. #070626 MA Registration #120982 Member of the Home Builder's Association of Western Mass. CT Registration #575920 Member of the Building & Trade Association Member of the Better Business Bureau Proposal Submitted To: Date Phone #'s G /N/Y 2 EKtDon/ 9 -io H: / 3 - . 5 4 - , 1 3 5 3 w : Street Job Name: /39 X? it/ E2t3Awc (L City, State, Zip Code Job Location: No474g/1v - roAi /114 O/ 6o Proposal to furnish and install the following � ❑ Re -Roof Tear -Off ❑ Gutter CJ Reu0 5X m),G nooFi.,i ,00wN EcK/ 6 * d /J, c J of lc} nn CL- 0 /J I Y/Lou/og d /)57 -4L< A ek, >A) 006 NA /GE2s ' - NEEDED � pp RO fl /1 l"/ /)U/OE IA) [ c NEW 3 /y — F13E4,8.,140 A-7744-11e° PROW DEck /nl‘ PROW0 + //t/S 4 me &...) El) RU1O8ez. ROOF .r y,5 To / Spoec ire cq / /e.A S t P20 v /pG * /N - 7 - . L NE L-) Oil EDGE' METsf•G 7 / a es SPEC /c / C4Ti o �►S P20 wo9 6wtieas 1,ti /7N . /S VEli/Z »o4 e4 QvE I viLL WORK mit, 41 Wea/t4,ITy w�p Ask us about affordable bank financing We Propose hereby to furnish materials and labor - complete in accordance with above specifications for the sug of: 7"HRE6 Th0OJAn/D . ice I.0102EO ,fi6(..Lc 2S dollars($ 419 0•"'" 3 YHAce ACCEPTANCE OF PROPOSAL: The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do work as ecif d. Payment will be 1/3 down at start of job, and balance due upon completion. Date: -3 to Signature: o - i ) Fie # Date: 3 Estimator's Signatur : Estimates are honored for sixty (60) days from cove vi ATTENTION HOMEOWNERS: Please c •ver 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 will not be responsible for debris or dust in the attic or storage areas. , t7 • .4 • „; ■'. 710 17 . '14 ,0111,3r, '1;!. SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: �s Qum* '■Q Not Applicable ❑ Name of License Holder : Adam Q-`" flc * Roofing & Siding, Inc. r?d 160 Old Lyman Road License Number South Ridley, MA 01075 - Address Expiration Date 413 - S3. -S9 Signature Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ Iao q Company Name Adam Quennevilk Roofing & &dug, Inc. Registration Number 160 Old Lyman Road 3 Address South Hadky, MA 01075 Expiration Date Telephone N 1' 3 -534-510 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 ow.kup ro* Anfyllgto peorg fAcit SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Es Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [0 Siding [D] Other [D] Brief Description of Proposed Work: ReMpuG. ex' <4m,FIA* `t>crF IN4tkoC S 1 1164 - 0 013erimnncA Ep . Rv6t1srQoe .crS 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 1, C nc.)Reo cco( , as Owner of the subject property hereby authorize & k to act on my behalf, in all matters relative to work authorized by this building permit application. 9-4s--10 Signature of Owner Date Ail Q befog & Sidig, Inc' , 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. avv■ Out vvve_vi 11� Print Name 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 YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO (3 DONT KNOW Q YES 0 IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO Q 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 0 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 Q NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. Department use only City of Northampton Status of Permit: ,Building Department Curb Cut/Driveway Permit ,0 " 212 Main Street Sewer /Septic Availability 1 \ Room 100 Water/Well Availability S�Q ;North lmpton, MA 01060 Two Sets of Structural Plans - phone,4i3.5'g7 -1240 Fax 413 - 587 -1272 Piot/Site Plans Other Specify APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION This section to be completed by office 1.1 Property Address: 139 R vet 130"14- R Map Lot Unit itfor}Au‘slAt. MA 01060 Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: ( i r t k cs-a0 139 9:-'Vca bo 4. /Vor I AA otoGa Name (Print) Current Mailing Address: 1 113 - sssq -S3Ss Telephone Signature 2.2 Authorized Agent: / —ta.vvt G?.,e,nrvcv ;llt Co I DID. Lyn e.„ Qc� so 4t f Ie , & 01. 5 7 Name (Print) Current Mailing Ad ess: 1 1 1 3-S3G -so( ss— Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building 3 3D V (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) 1 3 Check Number /IS 95 y 35 This Section For Official Use Only Permit Number: Date Building Issued: Signature: Building Commissioner /Inspector of Buildings Date 139 RIVERBANK BD r BP- 2011 -0240 GIS #: COMMONWEALTH OF MASSACHUSETTS Map :Block: 25 023 ' 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 -0240 Project # JS- 2011- 000403 Est. Cost: $3300.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ADAM QUENNEVILLE 070626 Lot Size(sq. ft.): 7579.44 Owner: REARDON SHEILA M & CYNTHIA M REARDON Zoning: SC(100)/ Applicant: ADAM QUENNEVILLE AT: 139 RIVERBANK RD Applicant Address: Phone: Insurance: 160 OLD LYMAN RD (413) 536 -5955 0 Workers Compensation SOUTH HADLEYMA01075 ISSUED ON :9/16/2010 0 :00 :00 TO PERFORM THE FOLLOWING WORK :INSTALL NEW EPDM RUBBER ROOF SYS 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 9/16/2010 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner