036-212 .r.
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t __�_ One Ashburton Place - Room 1301
Boston, Massachusetts 02108
•
Construction-Supervisor L
•
License CS: 70626
Restriction: 00
- r: 9 •
Expiration 8121/1 8/211200 71 9 Tr# 3
ADAM A QUENNEVILLE
160 OLD LYMAN RD
S HADLEY, MA 01075
Update Address and return card. Mark reason for change
Address Renewal Lost Card
DPS -CA1 Ca 50M- 07/07- PC8490
' sty Board o Cuilding ' egulat ons an• • tan. arr s
- = -�_( One Ashburton Place - Room 1301
--- Boston. Massachusetts 02108
• Home Improvement: Contractor Registration
•
•
Registration: 120982
:.: .:. - Type: DBA
.
Expiration: 3/25/2010 Tr# 264937
ADAM QUENNEVILLE ROOFING:' :::.
ADAM QUENNEVILLE
160 OLD LYMAN RD
SO. HADLEY, MA 01075 _ •
Update Address and return card. Mark reason for change. ard
El Address 0' Renewal 0 Employment 0 Los
DPS -CA1 c 50M -07/07- PC8490 t C
i Be it known that,
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1 ADAM QUENNEVI � -.-a
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` - RX4'ate /Time 07/09/2009 14:55 1 413 538 6010 P.001
Jul -09 -2009 02:38 PM Remillard Insurance 1 -413- 538 -6010 1/1
.
ACORD CERTIFICATE OF LIABILITY INSURANCE DATE (MMlDDtYYYY)
OP ID ADAM LL LL 07/09/09
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 NAIC#
INSURED INSURER A: AIM Mutual Dasuraace Company
INSURERS: Travelers Ins. Co.
Adam Quenneville Roofing &
Siding Inc INSURERC: Scottsdale Ins Co.
160 Old Lyman Road INSURER D:
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.
1NbR ALAS POLICY N UMBER • s • s 6N' LIMITS
LTR INSRE TYPE OF INSURANCE DATE (MMIDDPYY) DATE (MOD/VI
GENERAL LIABILITY EACH OCCURRENCE s 1000000
C X COMMERCIAL GENERAL LIABILITY CLS103498 UAMAGt I U HEN EU
06/23/09 06/23/10 PREMISES (Ea occurenre) 5 50000
CLAIMS MADE ( X OCCUR MED EXP (Any one person) $ 5000
PERSONALa 3 1000000 —
GENERAL AGGREGATE 3 2000000
OEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - AGGREGATE
COMP/OP AGG 3 2000000
T POLICY n PROCT • fl \ LOC \\ _
JE
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT S 5000000
$ ANY AUTO BA7450L946 ' /01/08 11/01/09 (Ea accident)
ALL OWNED AUTOS
BODILY INJURY $
X SCHEDULED AUTOS \ (Per person)
X HIRED AUTOS BODILY INJURY
X NON -OWNED AUTOS
PROPERTY DAMAGE
(Poraecidenl) 3
5
(Per accident)
' K GARAGE LIABILITY I AUTO ONLY - EA ACCIDENT 3
ANY AUTO I 4 OTHER THAN EA ACC S
AUTO ONLY: AGG 5
EXCESS/UMBRELLA LIABILITY /// ) EACH OCCURRENCE 5
7 OCCUR n CLAIMS MADE AGGREGATE 3
S
DEDUCTIBLE 3 -
RETENTION $ a
- X WC STATU• 101 E H-
WORKERS COMPENSATION AND
TORY LI MITS X ER
A
EMPLOYERS' LIABILITY AWC701286101 04/29/09 04/29/10 E.L. EACH ACCIDENT 31000000
ANY PROPRIETORJPARTNERIEXECUTIVE
OFFICER/MEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYEE $ 1000000
if as describe under
SPECIAL PROVISIONSbalow E.I. DISEASE• POLICY LIMIT 31000000
OTHER
DESCRIPTION OF OPERATIONS / LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT 1 SPECIAL PROVISIONS
L
CERTIFICATE HOLDER CANCELLATION
DAMQuE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN
Adam Quenneville Roofing Inc. NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
fax #5 3 6 -144 8 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
PO Box 612
South Hadley MA 01075 REPRESENTATIVES.
AUTHOFZE
ACORD 25 (2001108) Vr7Gy (,J` � f cr").1144 10 ACORD CORPORATION 1988
4-: i lij . ...‘d •-• I= V - Ujjize UJ
->i Et* 6 '1 •
-600 Washington Street
.. .
....•
Boston, MA 02111 .
..• —.I- ,.
.., -- )-iiin-y.mass.gov/dia
. . .
Workers' Compen4tiori If Affidavit: Builders/Contractors/Elect
Applican( Tnfonnation • . . Please Priiit Legibly .
• ‘t r)
. .
Name 03usincss/organizationandividu2.1).... .., • it. II , n ' u ■ 11 \\ A • vr
i . i k t r) • , t ,
Address: 'Li) Old (---Urr 1.(r)(9.S.1 • , •
. .
1
City/State/Zip: '' ' ft, AAA • ..: All ,14-- OttiC Phone #: L i 1 53L.
- . . . .. , . .
Are yo ain employer"! Check tbc appropri bOs: ' : .. Type of project (reqnired):
1. I ain a employer with ) .-- , 4. ill'I'arn a general Contracto and I 6. Ej New construction
„,,, yi (f an par t_ti me ) . * . • have hired the 5111) ctors
2. fl I am a. tole proprietor or parmer listed on the atthed sh et. I . ac
7 rj Remodeling
• ship ari have no employees These s h:ve 8. El Demolition •
• working for rne in any capacity. . workeri' comp. insuran e. ' 9. 0 Builling,addition
[No -workers' comp. insurance 5. E] We are a corporation its • •
10.0 Electrical repairs or. additions
• require;!d.) , of5cers have exercised hrir . ,. , , . • .
3. ri I am a homeowner doing all work . right of exemption per i GL 1 l .0 Plumbing repairs or additions
tnyself [No workers' comp. • c. 152, §1 (4), and we h.ve no ' 12 repa
insurance required.) mployees. [No worke .'
13.0 Oth?' . .
• .4 comp. insurance rcquir. d.]
t4
at A pp li can t ' checks box #1 must also fill out the scction below showing their workers' ompensation policy information.,
•
t Horneown 3 ers o submit this affidavit indicating they are ,doing all :work and then liire outs' a c contractors must submit a ne'v, affidavit indicating such: .
•
I Conti that check this lxrs must attached an iisiditio sheet il:Mwiitir thC su. ..itacto; their workers' comp. policy informatioq.
• ' i .
I am: an employer that Lc providing worke is' co rn p enSation insurance for y employ es.' Beldn is' the policy and job site
. . .
•
information. i ' • t
Insurance CoMpany Name: A.) i---s. fl • oii,d),.: . . . ,,s .. . ... .
. •
•
Policy # or Skf-ins- Lic. #: IALIJ C- . ..20 i ZA/10•10 , • Expiron Date: Lir a-9 - a0, 1 Q
•
. .
,
Job Site A.ddiress: City/Ste/Zip: .' • ' • •
1 . . .• .
. . . •
Attach a. cop of the workers' compensation policy declaration page (showing iiie policy number and expiration date).
Failure to se$ coverage as required under Section 25A of MGL C. 152 c 311 lead to be imposition of ernimi al penalties of a
the up to S1000.00 and/opone 'imprisonment, as.wal as civil penalti :As in the f� nn of a.STOP•WORIC ORDER and a fine
of up to $259.00 a day against thc violator. Be advised that a copy of thisltatementiLaybc forwarded to the Office of
Investigaiion of the DIA for insurance coverage verifiCation. .. • .
, . .
" —...•_— ' " ...._____. . ____.
1 do hereby eertifr unde,jjepains and penalties ofpiddly that the information pravided abo've i true and ebrreet
..,
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. . .
Signature: . , • Date:
.,--:-. . •
Ph ne #sliY13 ..(i, 1.-59 • ,. . . • . . .
• • • • . '
• '
:i •1 .
Official use on Do not.Write in this 'area, to be completed by city or toW . .
n officiaL . • . , '
! • .
City or Town: .- . • . Permit/Lit ense # . • •
1, ) .
Issuing Authority (circle oi3e): ' • . .
' .
... .
1. Boardof Health 2."Builaing Department 3. City frown 'Oerk • 4 Electrical Inspect()); 5. Plumbing Inspector
6. Other l' • . 1 . • •
.. • •• • ' . . • . . ., • Contact rerson: • Phone #:
• . - • . . .. '. — 7 . '
. ..,
• •
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, • • . . .
•
• • . . . •
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A D A M
VISA naasfe M.. DISCOVER
1 r -, ,,!-, QUENNEVILLE www.1800newroof.net
Y 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 @1800newro 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 #'ss // [ Work:
A I/1504 gyan G _3.,O j H: l /,3 14 gq`J
Street Email:
= $hiec4 L P7 .
City, State, Zip Code Special Requirements
air /CIA- 010 5c /41 0 0 ii .
s%' LI:h
Complete Roof System
lyi We shall acquire all appropriate permits for all work
IE Home exterior and landscaping to be protected
❑ Entire existing roofing materials to be removed to existing decking
24 Deteriorated existing decking will be replaced at $3.47 per sq.ft.
❑ Install Ice & Water Barrier at all eaves, valleys, chimneys, pipes, skylights and sidewalls
❑ Install (15 Ib. felt / Synthetic) underlayment over remaining decking area
[.Install Metal drip edge at eaves and rakes (8 "I,/ 5" (white /'•rown copper)
❑ Install manufacturers starter shingle on all eaves and rake edges
Install new pipe boot flashi (standar copper)
�-mns step flashing where necessar standar / copper)
tatt
❑ Install Hand nailed rigid baffled continuous ridge vent
❑ Install proper soffit ventilation
Shingles: (6 nails per shingle) ,
k Shingles ❑ 25 year [1430 year ❑ 50 year Color tO /' k T ' C CV
Ridge cap shingles
Warranty Options:
® We guarantee our workmanship for 10 full years (see our warranty coverage)
❑ GAF ELK System Plus warranty -
❑ GAF ELK Golden Pledge warranty
Chimney Options: r "}{C4�.(r G,, �, �/
[A, Lead Counter Flashing .Water eal & Tuckpoint A . Rubberized CI)pwn F,24Metal Chimney Cap
We Propose hereby to furnish ma erials and labor complete in €,c o dance w ith - l above specifications for the sum of:
k r ; 3 l i
Total SalP' P rice,$ r 1 0 Down P ment $ / , Upon Completion $ a 7 Y
ACCEPTANCE OF PROPOSAL: The above prices, sp cifications and co ditions a re sa and are hereby accepted.
You are authorized to do work as specified. Payment ill be 1/3 down upon signing,//and balance due upon completion.
Unpaid balances shall accrue with interest at 18% per a um. Purchaser(s) ,1 for all costs, expenses and reason-
able attorney's fees incurred by Adam Quenneville Roofing and Siding, Ipo-to recover any sums due under this contract.
G /
��� 61 Phone# (G �.5Z`/g'
Date: Signature:_
Date: 1! ! , ~ c J' 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 : 0 Cl s a `c
Adam Quenneville Roofing & Siding, Inc. License Number
160 Old Lyman Road R �L -- 0
Address SaUth Hadley, MA 01075 Expiration Date
Telephone
`
9. Registered Home Improvement Contractor Not Applicable ❑
Company Name Adam uuennevllle Ruulnug & Siding., l WC , t 9NOqt
160 Old Lyman Road Registration Number
v MA (11117 a "O ",V i V
Address
South Hadley
Expiration Date
Telephone 53C, 5 9 5 ,5
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6)) 1
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 I No ❑
11. - Home Owner Exemption
The current exemption for "homeowners" was extended to include Owner - occupied Dwellings of one (I) 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 0
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [C] Siding [0] Other [0]
Brief Description of Proposed
Work: I, 1 &gr. o L oc t5 ■CY)
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 housinq, 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
, 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
P o rn E .LAfl W' 1t4 , as Owner /Authorized
Agent hereby declare that the statements and inforr,fation on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
�YY— Colic" ✓,L E?
Print Name
Signature of Owner/ 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 j DONT KNOW 0 YES Q
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW YES 0
W YES: enter Book ` Page and /or Document #
8. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW Q YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES 0 NO 0
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.
—�-r.
Department use only
City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
212 Main Street Sewer /Septic Ava
5 2009 Room 100
1Nater/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 413 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
Map Lot Unit
as 2C \"1 l.,asn
Zone - Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
∎; �V 0oe.,nc J1A
Name (Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
Aram 0uenneville Roofing & Siding, Inc,
160 Old Lyman Road
Name (Print South Hadley, MA 01075 Current Mailing Address:
CA c isS
Si ature 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
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) 00 Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
25 BIRCH LN BP- 2010 -0052
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 36 - 212 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: roofing BUILDING PERMIT
Permit # BP- 2010 -0052
Project # JS- 2009 - 000858
Est. Cost: $4100.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ADAM QUENNEVILLE
Lot Size(sq. ft.): 77101 .20 Owner: RYAN R ALLISON
Zoning: SR(100)/ Applicant: ADAM QUENNEVILLE
AT: 25 BIRCH LN
Applicant Address: Phone: Insurance:
160 OLD LYMAN RD (413) 536 -5955 ()
SOUTH HADLEYMA01075 ISSUED ON:7/16/2009 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL SHINGLES OVER ONE LAYER
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 7/16/2009 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo