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36-223 (3) ACORD, CERTIFICATE OF LIABILITY INSURANCE OP ID DM DATE(MMIODIVIYY) 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 -78 62 Fax :413- 538 -7179 INSURERS AFFORDING COVERAGE i NAIC # .. INSURED INSURER A: AIM Mutual Ineurance Company INSURER B: Travelers Ins . Co . Adam Quenneville Roofing I NSURER C: First Speciality Ins Corp Sidingg Inc & Guttershutter P Y 160 Old Lyman Road ' INSURERD: 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. LTR NSR. TYPE OF INSURANCE POLICY NUMBER DATE (MM/DDNY) DATE (MOONY) LIMITS GENERAL LIABILITY t EACH OCCURRENCE 8 1,000000 C X COMMERCIAL GENERAL LIABILITY ; TBI 06/23/10 06/23/11 1 PREMISES (Ea occurence) S 100000 CLAIMS MADE X OCCUR ' MED EXP (Any one person) $ 5 00 0 i I PERSONAL 8 ADV INJURY 81000000 GENERAL AGGREGATE 52000000 GEM. AGGREGATE LIMIT APPLIES PER PRODUCTS • COMPIOP AGG j 82000000 7 POLICY 7 PRO• T n LOC f JEC _ I AUTOMOBILE LIABILITY ! COMBINED SINGLE LIMI S 10 0 0 0 0 0 B ANY AUTO BA7450L946 11/01/09 11 /01 /10 ; IEaa$dent) ALL OWNED AUTOS BODILY INJURY S ' X . SCHEDULED AUTOS (Per person) X I HIRED AUTOS i BODILY INJURY X NON -OWNED AUTOS (Per accident) 1 ; PROPERTY DAMAGE I • (Per accident) $ `. I GARAGE LIABILITY I I AUTO ONLY • EA ACCIDENT : $ ` ANY AUTO OTHER THAN EA �AGCC ' 5 AUTO ONLY: G 1 8 I EXCESS /UMBRELL ^ ALIABILITY I EACH OCCURRENCE _ S n LI OCCUR I CLAIMS MADE I AGGREGATE r S S ~ ' DEDUCTIBLE I S RETENTION 8 8 WCSIAIU• I WORKERS COMPENSATION AND TORY LIMITS I OI E H- R A EMPLOYERS' LIABILITY AWC701286101 04/29/10 04/29/11 I E.L. EACH ACCIDENT 51000000 ANY PROPRIETOR/PARTNERIEXECUTIVE OFFICER/MEMBER EXCLUDED? I ' E.L.DISEASE- EAEMPLOYEE S 1000000 If yes, describe under SPECIAL PROVISIONS below 1 E.L. DISEASE • POLICY tJMR' ? 8 1 0 0 000 OTHER D Equipment Floater IHN7140610 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 HOLDER NAMED TO THE LEFT, BUT FAILURE TO 0080 SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHO ED REPRESENTATIVE 44 ,20.1 ACORD 25 (2001108) • © ACORD CORPORATION 1988 . , , .. 1- , Iw / . , 44 0 ,4 ' of 4 ' 4 , o ars o :u • mg egul xans aril tans are s If _' a = One Ashburton Place - . Room 1301 5 Boston, Massachusetts 02108 • Construction ' Supervisor License License CS: 70626 • • • • 7 Restriction: 00 , ' Birthdate: 8/21/1 Explration: 8/21/20 Tr# 3712 AQAMA QUENNEVILLE -: 1.60 ' LYMAN RD : : - -- S`HADLEY MA 01075 * = ?7L eoiivotoituiecrita I =i t if - T1 '.. Office of Consumer Affairs and usiness Regulation 1 i- 10 Park Plaza - Suite 5170 ,..•� Boston, MassaR.'usetts 02116 Home Improvement ; t . ctor Registration i— Registration: 120982 Type: DBA ;IMF s Expiration: 3/25/2012 Tr# 293069 ADAM QUENNEVILLE ROOFIN ,M W` , • ADAM QUENNEVILLE • 160 OLD LYMAN RD \ -i= I,. SO. HADLEY, MA 01075 1 C 'rl = ^ __. v o ti Update Address and return card. Mark reason for change. 0 Address D Renewal E Employment 0 Lost Card DPS -CA1 0 50M- 04/04- G101216 STATE OF CONNECTICUT + DEPARTMENT OF CONSUMER PROTECTION ,t • B.e It known that ADAM QUENN VAT .T F E 160 OLD oh j' ROAD / .. SOUTH . iK °v9 -"1"s / I • 9 0 75-2632 I ,; i is certified by the Dep rt., n i,,, 0 h tection' a registered I ■ ' HOME IMPR3( , M NTRACTOR I Regis ,4 -i . � ,� 520 = •. aArvs rl ; - . ADAM QUENNEVILLE ROOFING # , 4 Effective: 12/01/2009 E i rat i on: , + k 4 : p 11/30/2010` Terry Farrell Tr.. Commissioner { - The Commonwealth of Massachusetts . Department ofI�Accidents a: , =' Office of Investigation r: - 600 Washington Street V•11.• _ Boston, MA 02111 www.mass.govitha Workers' Compensation Insurance Affidavit: Builders FContractora /i lect ricians/Plumbers Anulialnt Inforaation Please Print Legibly 1 Name ( ): A I. I u �. / A t - • a • s s rIC.. Address: 042 ()I A I-7 in gr C d. e '' / l a Phone#: . ' '' • Are you an employer? Check the appropriate boa Type of Project (required): 1.154 I am a employer with j g _ 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ❑ New c ction 2.0 1 am a sole proprietor or partner listed on the attached sheet. 7. ❑ Remodeling ship and have no employees sub-contractors have 8. ❑ Demolition working for me in any Wi employees and have workers' 9. ❑ Building addition [No workers' comp. insurance OOII insurance.: required.] 5. ❑ 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. right ofexempaon per MGL [NE►s comp. 12. ltoofrepairs insurance requirex1.1 t c.152, §1(4), and we have no 13.❑ Other employees. [No workers' comp. insurance required.] •Any appiiaot mat ducks boot al mast rho IN cat the section below thew g their voodoos' compeinadm policy infarction t llouro+a tan who aubu itibis at vie hawing they an doimag watoodd enhinl Made ccottactros must MoohoDow *admit iudicuiogsuch . s oserselsasthor check thia box attsr bedoo additional a6cCtaivwngire own oft hesob- coetndarasdsouv atether eruct thole entities bore = g l o m s . 1f t6e wbuoaaaceus have employees, they rout 'wide their ' comp. policy noun . . Ism au employer that isgarbling workers' compensation Insurance. for aty employers. Blow is the policy and site Insurance � Company Name: R-1 /A A u i-bl a t rtsu rah t P, Policy # or Self- ins. Lic. #: A WC, 1 10 i�� (cc [ 0 [ Expiration Date: Va c t 1 l o b Site Address: P i (1' i n4 t CAPS' L r,. ne - City /State/Zip: Nor`4k% s$s4on % /k Al, Ol o G 2 Attack a copy of the welters' rata #KS pricy declaration page (showing the policy seeder and 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 ono-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 to hereby carder the andpdrobke ofperfa,y that the hsfbnnathas provided above Is true anicorrect. %feature: Date: q t7 - l o aprte L fI3 -53(r 5—c Official nee only. Do not write in thb area, to be completed by city or town eldaL City or Town: , Perrit/hicense # Issuing Authority (circle one): 1. Board of Health 2. Bagtding Department 3. City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector 6. Other Contact Person: Phone #: AD 4 M N7;. 1 MarA Cust.# Date !C� QUENNEVILLE ROOFING & SIDING, INC. Street Address Citv State Zip 1.800 • NEW ROOF F q ,N, ;, f e l' hast y wor t ha y/a fl A 010a 413.536.5955 1800NEWROOF.NET Home Phgn #, � � �� Work Phone # E -mail COMMERCIAL . RESIDENTIAL t1l3 `j 5 y 160 Old Lyman Road • South Hadley, MA 01075 I hereby authorize you to proceed with the diagnosis for a minimum charge of $ X StraightForward Pricing® Replace 4 SQ of shingles, Stepflash/Counterflash 41' to 50' of wall, Replace 51' to 7 65' of valley, Reflash 17' to 25' chimney, Construct cricket and flash 3' to 6' wide chimney, Roof or Siding cleaning 2,001 sq. ft. - 3,000 sq. ft. Cover fascia or rake with Aluminum 51' - 65' Replace 22 -30 slates. Quantity x $1637 ea = Replace 3 SQ of shingles, Stepflash/Counte d . r 31' to 40' of wall Re .lace 41' to 6 50' of valley, Reflash 16' to 20' chimne r • . • oof or Siding cleaning 1,501 sq. ft. - 2,000 sq. ft. over fascia or rake with Aluminum 41'- / 7 50' Replace 16 -20 slates. Quantity x $1277 ea = 1 a (. Replace 2 SQ of shingles, Steptash/Countertash 21' of 30' of wall, Install 51' to 5 70' of ridge vent, Replace 31' to 40' of valley, Reflash or replace up to 2 Customer Supplied skylight (no interior trim work), Install 250' to 350' of drip edge, Reflash 13' to 16' foot chimney, Roof or Siding cleaning 1,001 sq. ft. - 1,500 sq. ft. Cover fascia or rake with Aluminum 31' -40' Replace 11 -15 slates. Quantity x $839 ea = Replace 1 SQ of shingles, Stepflash/Counterflash 11' to 20' of wall, Install 31' to 50' 4 of ridge vent, Install 21' to 30' of valley, Clean 251' to 350' of gutter, Reflash 9' to 12' chimney (perimeter) or small stone chimney, Replacement of customer supplied skylight (no interior trim work). Tear off and re- shingle 2nd story bay window. Install 101' to 200' of dripedge, Roof or Siding cleaning 501 sq. ft. - 1,000 sq. ft. Cover fascia or rake with Aluminum 21' -30' Replace 7 -10 slates. Quantity x $694 ea Reflash up to 8' perimeter chimney, Replace 1 to 2 bundles of shingles, 3 Stepflash/Counterflash 6' to 10' of wall, Install 51' to 100' of drip edge, Install 4 to 8 hat vents, Dryer hose connections, Replace up to 15' of valley, Tear off and re- shingle 1st story bay window, Install up to 30' of ridge vent. Minor tuckpointing and watersealing of chimney (<3' in height), Re- stepping and IceGuard 2'x4' skylight, Installation of curbmount skylight, Clean 150' to 250' of gutter, Install 51' to 100' of drip edge. Cover fascia or rake with Aluminum 11' -20', replace 4 -6 slates. Roof or Siding cleaning up to 500 sq. ft. Quantity x $559 ea = Soil boot replacement, Replace up to 1 bundle of shingles or up to 20 shingle tabs, 2 Stepflashing/Counterflashing less than 5' of wall, Installation of up to 50' of drip edge, Installation of up to 3 hat vents, 10' or less of gutter /fascia replacement, Clean 31' to 150' of gutter, Reflash electric pole/heat stack, Crop up to 30' of valley. Replace 1 -3 slates. Cover fascia or rake with Aluminum 10' or less. Install rubberized crown on chimney cap. Install stainless steel cover on chimney flue. Quantity x $387 ea = 1 Roof certifications of Gutter cleaning (up to 30') Quantity x $159 ea = (Add 30% for roof pitches greater than 6/12) Custom Request Quantity x $ ea: _ Quantity x $ ea: _ Quantity x $ ea: _ Recommenda f 2 0 1 �OJ ^ v' �5 / O r/OUS to //a I I hereby authorize you to proceed with the above StraightForward Price® of $ 11/7 7 7 X / Paid via: Cash, Check (# ) Credit Card Diagnost • Fee MC, Visa, AE CC# Exp. Total Due today $ 1j/ 9' Q Work performed to my satisfaction Scheduled Arrival Time Actual Arrival Time Thank You! SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Gay, Name of License Holder : : I' ii 11, ;41 i , a . � � I r �� l . "6 License Number South Hadley, Lyman Road - q South Address Hadley, MA 01075 Expiration Date 413 -g-3(. - '- Signature Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ Adam Quennevi le Roofing & Siding, Inc. ►�o �� z Company Name 160 Old Lyman Road Registration Number Address South IIadky, MA 01075 3 -2s- t), Expiration Date Telephone 1 -Y13'534 -SgSS 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 (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 AC Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [0 Siding [0] Other [0] Brief Description of Pro osed Work: Akti tt:� X 11' +0 Nto' e0C RAT. V¢rn+ 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, kCIXA itka.rttil , as Owner of the subject property ((��■■ hereby authorize Ado Qum* Roofing & Siding, Inc. to act on my behalf, in all matters relative to work authorized by this building permit application. 9-17- io Signature of Owner Date Ail Queuevilk Roofing & Siding, 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. A Q1/4/ch Print Name Gg--> q -17 -10 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 C IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW YES IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO Q DON'T KNOW ip 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 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 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 ® 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 212 Main Street Sewer /Septic Availability SEP 2 1 2010 Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans phone 413 -537 -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 � t,v n 4ccA, Ch'l.Qne Map Lot Unit No r` 4 TN.aA.1p.c A t MAA otoG1 Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: KeVi n Mc r k $9 w ; M-c.c . L North AM 00Y\ /t4 A Name (Print) Current - — SIC4 Telephone c � Signature 2.2 Authorized Agent: Ada-vh U.,e_W Vilic 1 Go Old L r"aA Ra 501)-00t 144:4-Met MR Name (Print) Current Mailing Addre AZ— 411 — r c irr Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building 1 7 7 (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 1 47 7, 00 Check Number / '0 3 This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date 89 WINTERBERRY LN 4J, BP- 2011 -0265 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block 36 - 223 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 -0265 Project # JS- 2011- 000438 Est. Cost: $1477.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ADAM QUENNEVILLE 070626 Lot Size(sq. ft.): 74052.00 Owner: MARKEY KEVIN & ANN HALLOCK Zoning: SR(100) //WP/WSP II Applicant: ADAM QUENNEVILLE AT: 89 WINTERBERRY LN Applicant Address: Phone: Insurance: 160 OLD LYMAN RD (413) 536 -5955 0 Workers Compensation SOUTH HADLEYMA01075 ISSUED ON:9/22/2010 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL RIDGE VENT 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 9/22/2010 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner