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38A-065 (10) 1Ia_,.achusetts - Department rlf Public Safer1 9 Board of Buil din =_ Regulations and Standards License: CS 70626 ADAM A QUENNEVILLE 160 OLD LYMAN RD N S HADLEY, MA 01075 ". Expiration: 8212013 ( •..nuuis.iorier Tr#: 21002 "t ?/L A ip, Office of Consumer Affairs and yt_MoadteiZea ness Regulation . .. -....,.= / 10 Park Plaza - Suite 5170 � ' °� Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 120982 Type: DBA Expiration: 3/25/2014 Tr# 222024 ADAM QUENNEVILLE ROOFING ADAM QUENNEVILLE 160 OLD LYMAN RD SO. HADLEY, MA 01075 Update Address and return card. Mark reason for change. 1 L 11 Address Renewal 1 1 Employment 1 l Lost Card DPS -CA1 Co 50M- 04/04- G101216 .. _..... " -.... �. .. ;ma / ` `•y a �, !.,�. \ S • �S � V J ,�,. 1� lr:y! i �:,:r" t•' t i'v �Yj t�tr., _'I Lam '�' � t lV i'i i I' ,', ' . }t t : ; °P —\ i i h>, , . :a , i 1; r 1 T , t h t)1), } ' +';) ,04 'ij� Bt } a 1 t( t, } t; P ,.) l? . }jai! ¢ „k l „i J v t �1 i } „ 4 , 4 , ei 9I, 1, t y', 1) t,.},f1). }tt �: , 1 ".AII• �),D i� tilt ; �7 g S 1l ''tl ,.a, . , t, ' °� b ,,, } tii, � '"•J 10 :tf iiii .' fri 1 �1�, t 444 P,jA, ,r( k i 0 p 1 1 01 6 � ko ! � (.. ` . 4 : ? • � � , l IR�4oir '1,01P 1 ��A ' 1! �J .i, . ... } t , ,. 4', ,�� ' "�„' Ak�i ' t� 1', �P� 1:. � � � �Y�10.�(ty L ' y! _ i, � �!! '�4 /►" '�1� '. •. - r a»' \ ,, ' STATE OF CONNECTICUT + DEPARTMENT OF CONSUMER PROTECTION of B e it known that ,�` ADAM QUENNEVILLE 160 OLD LYMAN ROAD -- `f,r SOUTH HADLEY, MA 01075 -2632 "''l y � � ,....%..: , 4 is certified by the D epartment of Consumer Protection as a registered HOME IMPROVEMENT. CONTRACTOR :;:*1:-. x Registrati n H':C:0575920 '' r ,.� .� ADAM QUENNEVILLE ROOFING • »;1 ■ Effective: 12/01/2012 >, t ' , Expiration: 11 /30 /2013 ' -i •uC^ William M. Rubenstein, Commissioner A` °RD CERTIFICATE OF LIABILITY INSURANCE 2A�3i o 3 ) 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 CONTACT Lynne Methot, Est. 102 NAME: y Foley Insurance Group Inc. ( � N d , (413) 214 - 7474 (Al. N o): (413)214 - 7447 Ex 37 Elm Street p AIL lmethot @foleyinsurancegroup.com INSURER(S) AFFORDING COVERAGE NAIC # West Springfield MA 01089 -2703 INSuRERA :Peerless Insurance Company 24198 INSURED INSURER B :Safety Indemnity 33618 Adam Quenneville Roofing & Siding Inc. INSURERC:Scottsdale Insurance Co. 160 Old Lyman Road INSURER° A/R INSURER E : South Hadley MA 01075 -2632 INSURER F: COVERAGES CERTIFICATE NUMBER:CL1211106664 REVISION NUMBER: 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 ISSUED 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP W LIMITS LTR INSR VD POLICY NUMBER (MMIDD/YYYY) (MM/DD/YYYY1 GENERAL LABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 100 000 X COMMERCIAL GENERAL LIABILITY PREMISES (Ea occurrence) $ A CLAIMS-MADE ( X OCCUR 31,6912267 6/23/2012 6/23/2013 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGO $ 2,000,000 7 POLICY 1 JE a I LOC $ AUTOMOBILE LABILITY COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 B X ANY AUTO BODILY INJURY (Per person) $ ALLOWNED 1 SCHEDULED 6215480 11/1/2012 11/1/2013 BODILY INJURY (Per accident) $ AUTOS NON -OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS (Per accident) PIP -Basic $ UMBRELLA LAB OCCUR EACH OCCURRENCE $ 5,000,000 C X EXCESS LAB CLAIMS -MADE AGGREGATE $ 5,000,000 DED 1 I RETENTION $ XLS0082909 6/23/2012 6/23/2013 $ D WORKERS COMPENSATION X WC STATU- S ER �OTH- AND EMPLOYERS' LIABILITY TORY LIMIT Y / N ANY PROPRIETOR/PARTNER /EXECUTIVE E.L. EACH ACCIDENT $ 1,000,000 OFFICER /MEMBER EXCLUDED? N NIA A WC7012861012012 4/29/2012 4/29/2013 (Mandatory In NH) E.L. DISEASE - EA EMPLOYEE $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS /LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, it more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. For Permitting Purposes AUTHORIZED REPRESENTATIVE Brian Foley/LYNNE '---11-,e ACORD 25 (2010/05) © 1988-2010 ACORD CORPORATION. All rights reserved. INS(125 (?Minns) m Tho ARr1Rn nnmo sand Innn aro ronictororl m arkc of A nPn The Commonwealth of Massachusetts lA ' iiti a Department of Industrial Accidents .., ) ( Office of Investigations 600 Washington Street Boston; Mass. 02111 www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians /Plumbers Applicant Information Adam Please Print Legibly Name (Business/Organization/Individual) : Adam Quenneville Roofing & Siding, Inc, Address: H I� o 0161 i- iI i-Y1 Ct r l {R 0 a rt City /State /Z () f '1 CJ 1-e ij i �V, ' Phone #: L 13 6'36- - 15-q6. 'S J c)10 Are you an employer? Check the appropriate box: Type of project (required): 1.)K 1 am an employer with ('j 4. 1 am a general contractor and 1 6. Li New construction employees (full and /or part time).* have hired the sub - contractors 7 ; -; Remodeling 2. C.1 l am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub - contractors have 8.' ! Demolition working for me in any capacity. employees and have workers' 9. Building addition [No workers' comp. insurance comp. insurance. required] 5.1 We are a corporation and its 10. i l Electrical repairs or additions 3. i_; I am a homeowner doing all work officers have exercised their 11. Plumbing repairs or additions myself [No workers' comp. right of exemption perm MGL insurance required] t c. 152, § 1(4), and we have no 12. fl Roof repairs employees. [no workers' 13. Li Other comp. insurance required.] *Any applicant that checks box ril must also rill out the section below showing their workers' compensation policy information. +Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Contactors that check this box must attach an additional sheet showing the name of the sub - contractors and state whether or not those entities have employees. if the sub- contractors have ern lo ees, the must rovide their workers' corn . 'obey number. 1 am an enrplgyer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: /' r M M t[tit a.1 . L its it.ro vi Lr e Policy # or Self -ins. LLic. #: A V1J C W I k /0 1 Expiration Date: q - d q- 020 /3 Job Site Address: 0 g„,,{'+, S4 ,t)dCi-kz,„ City /State /Zip: MA 01 D `ei I 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 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one year imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of $250.00 a day against violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for covera:e verification. I do herby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: /'-- Date: gy p? / -/3 Print Name: /7 U-� I/Nl 01.L1 61 fl-e. if i I Le Phone #: `t 1 3 - 5 J 3 �: -- C15 S Official use only Do not write in this area to be completed by city or town official City or Town: Permit/license #: Issuing Authority (circle one): 1.Board of Heath 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact person: Phone #: SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : ; l 11 7 p� II I HC. License Number 160 Old Lyman Road $"gig 3 Addre n II ' I ' MA 01075 Expiration Date Addre S Br "ure Te -ph•ne� 9. Registered Home I"mtrovement Contractor = : ` Not Applicable ❑ Adam Quenneville Roofing & Siding, Inc. / O 9t'a Company Name Registration Number 160 Old Lyman Road Address South Hadley, MA 01075 Expiration Date Telephone w 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 x- 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 faun 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 Repfacernehl Windows Alteration(s) n Roofing IX Or Doors 0 t 'r i i Accessory Bldg. [i Demolition n New Signs [DI ; E.Deicics 4 k t; r , Siding ID] Other [0] Brief Description of Proposed r t Work: G Oui) it1 I-14 J ail d /Teiotort Roof Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached RoII - Sheet sa If I>few,hou and er addition to existing h m ousing,_cop)eii he_ allowing: 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 FOR BUILDING PERMIT- _ (a r� f , as Owner of the subject property 3 hereby authorize t4 ciaj Z.9) U P fl1 to I/ iI ( � 100 1 - 1✓i to act on my behal , in all matters relative to work authorized by this buildi permit application. Signature of Owner Date ate I, . � J _4 1 , , a / , as Owner /Authorized Agent hereby dec are that the statements and infor !:tion on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. /9.car" 1) U et? n et/ IJ/ Print Name dj , / — Sianaturef0 er /Agent Date Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information e Existing . Proposed Required by 'Zoning This column to be filled in by Building Department . • 1,.'i Lot Size r ' Frontage -- - Setbacks Front _ Side L:-----: R: --- L R: . 1 - Rear - -----._• Building Height Bldg. Square Footage i % s ii Open Space Footage _�' ___ (Lot arca minus bldg & paved _____ _,. _ ..________ ,_____i _ parking) I , I # of Parking Spaces ` Fill: , .. !. (volume & Loeatiot) w - ,� - p i! — A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO DONT KNOW 0 YES 0 • ' I5 K date issued:, ". "', NI.' i .. c: •! 't, `',-.•' 1 . '': 1 / 4, ;r4.".".'" .`.1.1' . 1")',', IF YES: Was thelterrnit recordeil at,theRegistry of Deeds? NO 0 . ° DONT KNOW 'Q YES 0 IF YES: enter Book i Page ! and /or Document #! B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW Q YES 0 IF YES, has a permit been or need to be obtained from the Conservatiosi Commission? Needs to be obtained 0 Obtained , Date lssb C. Do any signs exist on the property? YES 0 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 0 NO tr. IF YES, then a Northampton Storm Water Management Permit from the DPW is required. �" _ - Departmeit use only Fi L _e,-4- I, t f - Cit of Northampton Status of Permit: Building Department Curb CutlDriveway Permit FEB 7 2013 212 Main Street Sewer /Septic Availability ROOM 100 Water/Well Availability ` rthampton, MA 01060 Two Sets of Structural Plans DEFT. OF BUIivi 4c ,,.;,i E`' NORTHAMPTON, MA 41 - 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 ill GOz l e s4 • Map Lot Unit 'l/ r (_ , �Y1 ' `++ ame , A , o to o Zone Overlay District _ Elm St. CB District SECTION2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: �o n oftiln.oth yo u.rga. 121 Earle 5+. ljo r 4k a 1i1-Dn MA O t of o Name (Print) Current Mailing Address: 1 yl3. 81. 13/5 Telephone Signature 2.2 Authorized Agent: fldarA i denne viIle qr,04"14 l�U Did Lyman t c So. d(e Name (Print) Current Mailing Addres g—Z-- 1113''' 5361 - s qs Signature T elephone SECTION 3 -- ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building d 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. Totalo= (1 + 2 + 3 + 4 + 5) / a l L/. 00 Check Number qr _ - This Section For Official Use Only_ : Date Building Permit Number. issued: Signature: . Building Commissioner /Inspector of Buildings Date • 188 EARLE ST BP- 2013 -0781 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 38A - 065 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: ROOF BUILDING PERMIT Permit # BP- 2013 -0781 Project # JS- 2013- 001334 Est. Cost: $1214.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ADAM QUENNEVILLE 070626 Lot Size(sq. ft.): 10802.88 Owner: YOURGA JONATHAN & PAULINE PARKER Zoning: SI(97)/URC(3)/ Applicant: ADAM QUENNEVILLE AT: 188 EARLE ST Applicant Address: Phone: Insurance: 160 OLD LYMAN RD (413) 536 -5955 () Workers Compensation SOUTH HADLEYMA01075 ISSUED ON:2/25/2013 0:00:00 TO PERFORM THE FOLLOWING WORK:COUNTERFLASHING & REPAIR 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 2/25/2013 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner