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36-104 ACORD CERTIFICATE OF LIABILITY INSURANCE OP ID DM DATE(MMIDINYYYY) 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 • Phone: 413--538 -7862 Fax :413- 538 -7179 INSURERS AFFORDING COVERAGE NAIC INSURED INSURER A: AIM Mutual Insurance Company INSURER B: Travelers Ins . Co . Adam Quenneville Roofing & INSURER C: First Speciality Ins Corp Siding Inc & Guttershutter P X 160 Old Lyman Road INSURER 0: 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. •r• • POLICY NUMBER D• ATE ( I If •• D •N LIMITS LTR NSR• TYPE OF INSURANCE DATE MMlDDlW MMl } DATE {DD/W) I GENERAL LIABILITY !EACH OCCURRENCE 51000000 AM I C r X COMMERCIALGENERALLIABILITY TEl 06/23/10 06/23/11 P U S (E K eo tN ccur IU ence) S 100000 CLAIMS MADE X OCCUR MED EXP (Any one person) $ 5000 I PERSONAL &ADV INJURY : $ 1000000 GENERAL AGGREGATE $ 2000000 GERM AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2000000 POLICY PRO. 1-7 LOG JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ : ANY AUTO BA7450L946 11/01/09 11/01/10 (Ea accident) 5 1000000 ALL OWNED AUTOS i BODILY INJURY S ' X . SCHEDULED AUTOS /Per person) I X I HIRED AUTOS BODILY INJURY 1$ X NON -OWNED AUTOS (Per accident) ' I PROPERTY DAMAGE (Per accident) 1$ r GARAGE LIABILITY , AUTO ONLY • EA ACCIDENT $ , ANY AUTO • I OTHER THAN EA ACC I $ AUTO ONLY: AGG S EXCESS /UMBRELLA LIABILITY EACH OCCURRENCE 5 n OCCUR ( I CLAIMS MADE I AGGREGATE S S DEDUCTIBLE RETENTION $ I A I WORKERS COMPENSATION AND i-- TORY S LI ITS I I OTH- E R EMPLOYERS' LIABILITY p ` ANY PROPRIETOR/PARTNER/EXECUTIVE AWC701286101 04/29/10 I 04/29/11 I E.L. EACH ACCIDENT $ 1000000 OFFICER/MEMBEREXCLUDED? j E.L. DISEASE - EA EMPLOYEE 5 100 000 0 If yes, describe under SPECIAL PROVISIONS below E .L. DISEASE - POLICY LIMIT :$1000000 OTHER D Equipment Floater IHN7140610 02/01/10 02/01/11 Rental Equipment $100,000 DESCRIPTION OF OPERATIONS / LOCATIONS I 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 3 0 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 ED REPRESENTATIVE ACORD 25 (2001/08) © ACORD CORPORATION 1988 . . # . , ,o • . • • I .1 ' 1 , ,, IP IlA 1 ,.• • oars o tii,, 1 ing ' egulalons aria tans are s One Ashburton Place - 1301 Boston., Massachusetts 02108 Coristruction'Supervisor License . License CS: 70626 .. .. ..- ... .. Restriction: 00 :- . :.. ". - . • .- ' . .- .Birthdate: 8/21/1971 .... .. .. .. Tr# 3 . ._ Expiration: 8/21/20 .__. APAM'A QUENNEVILLE 160 OLD 'LYMAN RD ' ...'. S'HADLEY, 1\AA 01075 . . - ..' .. . ?ii; ,e ,f,.///4,,,,,,,„ite,„,e14. , 0 , Office of Consumer Affairs and siness Regulation 7 .t.f 7 ------- 1 , 10 Park Plaza - Suite 5170 Boston, Massakusetts 02116 Home Improvement zt‘ctor Registration Registration: 120982 r -- 7-A (:1) Type: DBA ---z....-7-_-.4 v .11" Expiration: 3/25/2012 Tr# 293069 ADAM QUENNEVILLE ROOFING ADAM QUENNEVILLE '\,;\,, W :{4 7E 160 OLD LYMAN RD SO. HADLEY, MA 01075 . l ,:/ Update Address and return card. Mark reason for change. Address 1i Renewal 0 Employment El Lost Card UPS-CM 0 50M-04/04-G101216 1 STATE OF CONNECTICUT + DEPARTMENT OF CONSUMER PROTECTION I i Be it known that ADAM QUENNEVITtE 160 OLD MAN ROAD SOIJTELV - , ! /- 1 ,'-'c'fi 14, .„.., , f,1 • is certified by the DePat.ti ' u f as a registered HOME IMPRCK§,. t ' ,..., - .P `-.: -:, -- - ' -",i, eiix Re' *i=4G. ,...,,...... .§7 1 .1:?-• ADAM QUENNEVILLE ROOFING i*,..1! Effective 12/01/2009 ...... 1 .:i i- I E . i . ,' Expiration 11 : /30/2010 Jerry Farrell, Jr., Commissioner • The Commonweal of Maa Department of Industrial Accidents 4 s Office of In vestigations chusetts L ; , 600 Washington Street Boston, MA 02111 -.r wow mass.gov /dig Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): A C • L i • (t . I \ ` a ' t f 'iC Address: Il2 0 DA L rn q, �' 8- City /State/Zip: c ? ' e A' i 01 7 Phone #: I - ' 3 . - � Are you an employer? Check the appropriate box: Type of project (required): 10 I am a employer with 15 4. 0 I am a general contractor and I employees (full 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 sub - contractors have 8. 0 Demolition working for me in any capacity. employees and have workers' 9. 0 Building addition [No workers' comp. insurance comp. insurance.: required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3.0 I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12 ,Roof 4 1 c. 152, , and we have no employees. [No workers insurance required.] t § �) 13.0 Other ' comp. insurance required.] Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t homeowners who submit this affidavit indicating they are doing all workload that hire outside contract must submits new affidavit indicating such. *Contractors that check this box moan attached an additional sheet showing the tame of the sob- contractors and state whether or not those entities have employees. If the sub- oontracten have employees, they must provide their workers' gyp. policy number. I am an employer that is providing workers' compensation Insurance for my employees. Below is the policy and Job site information. Insurance Company Name: A- \ /A A u. a t. J ) , Is i r j it � E. • Policy # or Self -ins. Lic. #: A 1A.!C.. 9 0 L 9. to i C) ( Expiration Date: / c ci/cgi I Job Site Address: 13 I Q ty r- t S ki 1 } tkd . Flocev ce_ Pc City/State/Zip: 0 \ 0 G ;._ 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 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 certify under the pains and penalties ofperjury that the information provhiedd above is true and correct. Signature: Date: 0 '2u - I d Phone #: iii ,3- 53( -955 Official ase only. Do not write in this area, to be completed by city or town officiaL City or Town: Permit/License # Issuing Authority (circle one): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Numbing Inspector 6. Other Contact Person: Phone #: , • D VISA c.a DIJC.VER CCU E N N EV 1 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: °,ar Ltc 1 /.,i1, 6Z ,c, 8//i / /+6 H: 4 1 1 3 - 3'86 - /22,6 Cell: Street ((( Email: q31 &rt PT RJ, City, State, Zip Code Special Requirements 114 '4417 loreAcr M/4 O /06 2 L C Complete Roof System V We shall acquire all appropriate permits for all work V Home exterior and landscaping to be protected V Entire existing roofing materials to be removed to existing decking [V7 Deteriorated existing decking will be replaced at $3.47 per sq.ft. g Install Ice & Water Barrier at all eaves, valleys, chimneys, pipes, skylights and sidewalls [Install (15 lb. felt 413 underlayment over remaining decking area RrInstall Metal drip edge at eaves and rakes() 5 ") a)/ brown / copper) [Install manufacturers starter shingle on all eaves and rake edges [Install new pipe boot flashing (tandar copper) NA ❑ Install new step flashing where necessary (standard / copper) [Install Hand nailed rigid baffled continuous ridge vent NA ❑ Install proper soffit ventilation Shingles: (6 nails per shingle) G4F/ 1k Shingles ❑ 25 year '30 year ❑ 50 year Color ~�11 ‘e ,,,,,,,J J G I F/F I k._ Ridge cap shingles Warranty Options: W We guarantee our workmanship for 10 full years (see our warranty coverage) VGAF ELK System Plus warranty A / t El GAF ELK Golden Pledge warranty /V 17°` ~i Chimney Options: 40 -'' - ^ &/ / ---_,./." [Lead Counter Flashing [ Water Seal & Tuckpoint ❑ Rubberized Crown ❑ Metal Chimney Cap We Propose hereby to furnish materials and labor - complete in accordance with above specifications for the sum of: Total Sale Price $ 7822. Down Payment $ 2. 6') 7 00 `� Upon Completion $ L i5 , —� ACCEPTANCE OF PROPOSAL: The above prices, 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 annum. Purchaser(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 r this / contract. Date: A • , / a Si Y , V 4 - ( u.2 ' a — d !a Phone # e I aS .� (� Date: _ I • �) Estimator's Signature: 1 ..-C 1 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. 09 SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : : I 1! I ! , , . 1 70 6) '.1 License Number 160 Old Lyman Road - ( I Address South Hadley, MA 01075 Expiration Date Signature Telephone 41 $ 3G Sc‘ s - 9. Registered Home Improvement Contractor: Not Applicable ❑ Qucnaevile Rosfm & Siding, Inc. Registration ► o`t �, Company � Number 160 Old Lyman Road 3 s - Address South Hadley, MA 01075 Expiration Date Telephone 4 3 - AS S 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 If 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!‘,111,0 i'-if. ':: gi 11t:: SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Eg Or Doors El Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [D Siding [0] Other [0] Brief Description of Proposed Work: Slv ael (bo� 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, 1l0-C ba(`ol n 2. , as Owner of the subject property h� . hereby authorize Adam Nude R & Sid*, Inc. to act on my behalf, in all matters relative to work authorized by this building permit application. -zo- l0 Signature of Owner Date Ain Qom& Roe* & Si dig, g, 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. t6k&.avr Qk.)er,+Nev %\ \Z Print Name — a0 1 127 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 ® DON'T KNOW YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO ® DON'T KNOW 0 YES IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO ® DON'T KNOW ® YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained i© Obtained Q ,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 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 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. Department use only — 7 7,; City of Northampton Status of Permit t B Department Curb Cut/Driveway Permit 212 Main Street Sewer /Septic Availability Room 100 Water/Well Availability AUG 2 4 2010 Northampton, MA 01060 Two Sets of Structural Plans phone 413 - 5E17 - 1240 Fax 413 - 587 - 1272 Plot/Site Plans Other Specify = APPLICATION TO CON RTS UCT, 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 q3 a� `.E S P; 1` U , Map Lot Unit Flot'ence, 1 A Ok 0 G 1 Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: �o<< ba.c-o. O Z 60. a3k Boo- fi r R Name (Print) Current Mailing Address: 413-strc, -t - Telephone Signature 2.2 Authorized Agent: Ado Quen�nne Siding, Inc, Name ( 160 Old Ly ®YD RuE) Current Mailing Address: (Pri — South Hadley, MA 01075 1413 - 63c - s� ss - Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building $ '- (a) Building Permit Fee ) 1( ,00 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) 4/ 7,%, -21,00 Check Number 1 X � ` ,03' This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner /Inspector of Buildings Date ♦ 5 931 B prr : RD 1 ' BP- 2011 -0165 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Bloek: 36 -104 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 -0165 Project # JS- 2011- 000270 Est. Cost: $7822.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ADAM QUENNEVILLE 070626 Lot Size(sq. ft.): 20908.80 Owner: DZIUBA WILLIAM M & BARBARA A TRUSTEES Zoning: SR(1)/URA(99)/ Applicant: ADAM QUENNEVILLE AT: 931 BURTS PIT RD Applicant Address: Phone: Insurance: 160 OLD LYMAN RD (413) 536 -5955 () Workers Compensation SOUTH HADLEYMA01075 ISSUED ON:8/25/2010 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 8/25/2010 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner