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32A-207 Nov -08 -2010 06:00 PM Remillard Insurance 1 - 413 - 538 - bUIU cic cycy CERTIFICATE OF LIABILITY INSURANCE OP ID LL DATE (MM1DDlYYYY) 11/09/10 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder-in lieu of such endorsement(s). PRODUCER (AN IAUI NAME: PHONE FAX Remillard Insurance Agcy, Inc _ANA E#): _ (NC, No): 79 Lyman Street ADDRESS: South Hadley MA 01075 - PRODUCER -" Y CUSTOMER ID n: ADAMQ -1 Phone -538 -7862 Fax:413 -538 -7179 INSURER(S) AFFORDING COVERAGE NAIC INSURED INSURER A: First Specialit Ins Cor. Adam Quenneville Roofing & INSURER B: Travelers Ins. Co. Siding Inc. & Adam Quenneville -- - - -•- Roofing Inc & GutterShutter INSURER c: AIM Mutual Insurance Company Of Western MA 160 Old Lyman Road Comp an D: Hanover Insurance Com an 22292 _ South Hadley MA 01075 INSURER E INSURER F : COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: I THIS IS TO CERTIFY THAT 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 SSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR '--'_ .. --.. AUULSUBF' ". "`_ — POCTCYEFI- POLTCY6XP' - ' LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER (MM(DDIYYYY) I(MM /DD1YYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE ! $ 100 0 00 0 " DAMAGE I U RLN I tU —" - A X COMMERCIAL GENERAL LIABILITY IRG98441 06/23/10 06/23/11 PREMISES (Ea occurrence) 1 $ 100000 CLAIMS -MADE X1 OCCUR MED EXP (Any one person] I $ 2500 y _ PERSONAL & ADV INJURY $ 1000000 GENERAL AGGREGATE $ 2000000 GEL AGGREGATE LIMIT APPLISS PER: PRODUCTS - COMPlOPAGG $ 2000000 PRO - POLICY JECT LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1000000 (Ea accident) $ ANY AUTO BA7450L94 11/01/10 11 /01 /11 BODILY INJURY (Per person) $ ALL OWNED AUTOS — -- - - BODILY INJURY (Per accident) $ X SCHEDULED AUTOS PROPERTY DAMAGE 2( HIRED AUTOS (Per accident) i $ X NON -OWNED AUTOS 3 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE { AGGREGATE $ DEDUCTIBLE - -" ! —_ 5 RETENTION $ $ C WORKERS COMPENSATION AWC701286101 04/29/10 04/29/11 X WCSTATU- x OTH- AND EMPLOYERS' LIABILITY TORY LIMITS ER _ YlN ANY PROPRIETORIPARTNERIEXECUTIV ' E.L EACH ACCIDENT $ 1000000 N /A OFFICER/MEMBER EXCLUDED? y J -- - - "" (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ 1000000 If yes, desaribo under DESCRIPTION OF OPERATIONS below E.L. DiSblASE - POLICY LIMIT $ 10 0 0 0 0 0 D Equipment Floater IHN7140610 02/01/10 02/01/11 Rental Equipment $100,000 DESCRIPTION OF OPERATIONS/LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE ADAMQUE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Adam Quenneville Roofing & Siding AUTHORIZED REPRESENTATIVE 160 Old Lyman Rd. South Hadley MA 01075 © 1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009109) The ACORD name and logo are registered marks of ACORD L--- _ _- igon.s aril tan• are s ! _ii �� o ars o .u l eg _ fo One Ashburton Place - Room 1301 e i Boston, Mas 02108 X4.4~ �� Construction Supervisor License :: 7 0626 License CS: ' Restriction: 00 '...:-. • - . ., rthdate: 8/2111971 E ration: 8/21/2011 Tr1t 3 12 Xplf 7 AQAM'A QUENNEVILLE 1'60 01...b 'LYMAN RD S "HADLEY, MA 01075 , ,•..; : 2Z?e m&n€oeah o/��ac%e� __-„-„., )1, e ml_ . Office of Consumer Affairs and usiness Regulation f 10 Park Plaza - Suite 5170 .0 Boston, Massa":'usetts 02116 Home Improvement' :.),I. ctor Registration Registration: 120982 f Type: DBA r r;_ x Expiration: 3/25/2012 Tr# 293069 ADAM QUENNEVILLE ROOFING _ W ADAM QUENNEVILLE " _ _, 160 OLD LYMAN RD K,:-.., = - ( � SO. HADLEY, MA 01075 c 7-7, = /' ter \� � S , R ,� Update Address and return card. Mark reason for change. --- Address E Renewal fl Employment Lost Card DPS -CAI 0 50M- 04/04- G101216 { ` STATE OF CONNECTICUT + DEPARTME NT OF CONSUMER PROTECTION • Be it known that ADAM UENN Q EVITT.F,' 160 OLD S Z, i ROAD >..:: SOUTH �� - ;' , ';''`' s -''',.,,' a .175-2632 ' \ � ire gr; is certified by the Dep lt. n 1 ' ' . Ri tection as a registered . HOME IMPRO T PbNTRACTOR f t. .:::„, � •,._ s r ( i Regis., w ; d 5920 i •TRANS U " -; N te r ADAM QUENNEVILLE ROOFING I Effective 12/01/2009 I Ex. iration: 11 30 2010 _ • ` ` ' The Commonwealth of Massachusetts Department of Industrial Acc ft444 _' Office oflnve g�fows 4 , - ?' 600 Walt Street , Boston, MA 02111 ss www aaass.gov/diia Workers' Compensation Insurance Am davit: Builders / Contractors /Ektetrieiana/Phunbers Apnlicaut n Please Prat Legibly • i N . 1 .— Name ( ): N .! ilk � . % A, ► - ' a • ado "' A ✓tt, Address:_ 1 L ( ()(d LrpA4v, ' d. , BM ♦ it ■ l f1 Phone #: ) - _. -. Are rat as employer? Check the appropriate box: T ype of Proieel (Milked): 1.154 lam a employer with 16- 4. 0 I am a general contractor and I employees (full and/or parmime)• have hired the sub - contactors 6. ❑ New construction 2.0 lama sole proprietor or partner- listed on the wed sheet. 7. Q Remodeling ship and have no employees These sub-conbactors have & 0 Demolition for mein any capacity. employees and have workers' 9. 0 Budding addition [No workers' cane insurance comp. insurance.: requhed.] 5. 0 we area corporation and its 10.0 Electrical repairs or additions 3. ❑ 1 am a homeowner doing all work ‘ officers have exercised their 11.0 Plumbing repairs or additions comp. myself. [No workers' right of exemption per MGL ,s ice 1 t c. 152, § 1(4), and we have no l3.[} employees. [No workers' Other comp. insurance ] .. . 'Any apgiaoet>bat died= boat di most oho 91 out the section below shoed* their voodoos' comp ion policy information. t Homoowaba mho submit this adtidraiodmaaieg they am doings* mot aodtheabiae raids 000mrs es smamtsehmita soda Maao*.sadh SCeor emett otdm *66 box most atorbed ' sheet 6imims the some ot bese6 cootraetoos modststemobether argot show entities here employees. If the solKoshoeto s hoe employees, they most provide their ' coop. policy somber. I anti sett employer that b rprovlikse workers' costratsmilom bwaw.a a for mry employees. Below is Ike polk , turdJob site A� u ii Insurance Company Name: A k f" l . U l n r U r 11 t °ice. / Policy # or Self -ins. Lie. #: 0 f _ 9 O [A9, (r, 1 D l Expiration Date: / 02 q /0R6! i Job Site Address: 3o Q'1 er PI G.c e , + ( Ckalate p: iOt`d,{ o ffaM a 6 -ton, M6k 01 l08 Attach e copy of the workers' compensation policy dKdtratio. page ( **policy nataber aad 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 51, 500.00 and/or one-year intprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurranee coverage verification. I do hereby cote wa e r the ardp sash tr afro** drat due bra partite above a owe end Signature; Date: 11 - 11 -1 Pte #: zit 3- 53(0- ,Sates' Official sase only. Do mot write in Lisa urea, to be cornpl Led by elty or tourer efideL City or Tow: Permit/License # basis6 A.Worify (circle one): 1. Beard of Beaakb 2. Building Deparbaeat 3. City/Town Cleric 4. Electrical inspector 5. Ptemobiag inspector r 6.Other Contact Person: Phone #: / . VISA Haslet :.) c.a DIJCOVER I QIJENN EN/II IL- ROOFING & SIDING, INC. 160 Old Lyman Road, South Hadley, MA 01075 1- 800 - NEW -ROOF • 413. 536 -5955 Email: info@1800newroof.net Website: www.1800newroof.net MA Construction Supervisors Lic. #070626 MA Registration #120982 Member of the Home Builder's Association of Western Mass. CT Registration #575920 Member of the Building & Trade Association Member of the Better Business Bureau Proposal Submitted To: Date Phone #'s J Street Job Name: City, State, Zip Code Job Location: Proposal to furnisnd install the following [/ Re -Roof ❑ Tear -Off ❑ Gutter / /_ G tom. i f �F .r f / l / .>.r I ,, is } - 7 Ask us about affordable bank financing We Propose hereby to furnish materials and labor - complete in accordance with above specifications for the sum of: dollars ($ 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 at start of job, and balance due upon completion. Date:_ / Signature: Phone # 1 / � /7 :M Date: " r / t/ Estimator's Signature: — Estimates are honored for sixty (60) days from above date 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 Quennevilfe Roofing will not be responsible for debris or dust in the attic or storage areas. j "49 OM . 0.111744 014 fps ( 116 goepot . 1tptit: iv HNI if 1 ivo co riii010 Ni.i31 'mg 604;difroir ill.i v -00!,.: .. ... SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Adam Qeennevile Roofing & Siding, Inc. 7 0 240. Name of License Holder : ty,� Lyman 161 Old Lymu Road License Number South Hadley, MA 01075 - - 1- t I Address Expiration Date 413 - 5 3 C? C9cS Signature Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ Ain. QmNevile Roofing & Siding, Inc. I - 2-o Rka Company Name 160 Old Lyman Road Registration Number Sofa Hadley, MA 01075 3 " Address Expiration Date Telephone 4/3 — 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 Amsniev 'Me 6. PIO I ilt• 10 Ow* iffshig !$' SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House Addition ❑ Replacement Windows Alteration(s) Roofing Si Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [o] Decks [0 Siding [0] Other [0] Brief Description of Proposed , of_ Work: . • bexar `rL ° EP r (dc-e ,r uc-r r k 1 a n 1 4/ 1! ar- o f 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 O CONTRACTOR APPLIES FOR BUILDING PERMIT I, , 1 I of. e\ ' ` e , as Owner of the subject property Ain hereby authorize *mit bag & Sling, Inc, to act on my behalf, in all matters relative to work authorized by this building permit application. 1( - /H -/ Signature of Owner Date Mu Nude & 1st , 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. d Qv e A ne vi'ile Print Name Oz- 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 BIdg. Square Footage Open Space Footage G A) (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 YES 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 ® DONT KNOW YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 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 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 40 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 A 212 Main Street Sewer /Septic Availability %) Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans .. ne 413 - 587 - 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 3o (3v -'ter Plate AP} I Map Lot Unit N a"' ° I µf\ 0 1 0 Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: AO. C► I cc rL R� �- 3 0 6 vk \ e c Pl ats $00( 4410.0,064.1 pMei- Name (Print) Current Mailina Address: OtAGo 'N3 -Sf>"f- I 'tSJ Telephone Signature 2.2 Authorized Agent: A Aom QuGVlntvc ►tom j , 0LL rha" R .& . Hea.te.Ttit44 Name (Print) Current Mailing Address: c se" Signature Telephone Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only mpleted by permit applicant 1. Building ry0 O (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) 4 g00, oo Check Number /K ,c This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner /Inspector of Buildings Date 3+ B I ERP! " BP - 2011 - 0462 GIS #: COMMONWEALTH OF MASSACHUSETTS -LL v 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 -0462 Project # JS- 2011- 000744 Est. Cost: $2900.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ADAM QUENNEVILLE 070626 Lot Size(sq. ft.): 12980.88 Owner: REED CHARLES A & EILEEN 0 TRUSTEES Zoning: URC(100)/ Applicant: ADAM QUENNEVILLE AT: 30 BUTLER PL Applicant Address: Phone: Insurance: 160 OLD LYMAN RD (413) 536 -5955 () Workers Compensation SOUTH HADLEYMA01075 ISSUED ON:11/16/2010 0:00:00 TO PERFORM THE FOLLOWING WORK: NEW 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 11/16/2010 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner