38D-027 (2) AC'o LIABILITY INSURANCE DATE ("IM'D°"""'
4 C ERTIFICATE OF L 2/13/2013
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 HO _DER.
IMPORTANT: If the certificate hoiden is an ADDITIONAL INSURED, the poiicy(iesi must he endorsed. If SUBROGATION IS WAIVED, subyect 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
NAME: Lynne lthot, Ext. 102
Foley Insurance Group Inc. N o � (413) 214 -7474 FAX mi l, (413)214 -1447
tAic. 37 Elm Street sA- tp @foleyinsurancegroup.com
INSURER(S) AFFORDING COVERAGE NAIC #
West Springfield MA 01089 -2703 INSURER A :Peerless Insurance Company 24198
INSURED INSURER B :Safety Indemnity 33618
Adam Quenneville Roofing & Siding Inc. INSURERC:Scottsdale Insurance Co.
160 Old Lyman Road INSURERD AIM A/R
INSURER E :
South Hadley MA 01075 -2632 J INSURER F:
COVERAGES CERTIFICATE NUMBER:GL1 11106664 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED B LOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR C NDITION OF ANY CONTRACT OR OTHER DOCUMENT VMTH 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 AY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR ADM UBR POLICY EPP POLICY EXP LIMITS
LTR TYPE O( INSURANCE INSR INVD POL CY UMBER 1MNfOD/YYYY1 ( .WIDDIYYYY)
GENERAL LIABILITY EACH OCCURRENCE S 1,000,000
100,000
X COMMERCIAL GENERAL LIABILITY PREMISES Ea NTE occurrence) $ 5 000
A I CLAIMS.MADE n 6/23/2012 6/23/2013 OCCUR 9L6912267 MED EXP (Any one person) $ r
PERSONAL & ADV INJURY _$ 1, 000 , 000
— GENERAL AGGREGATE $ 2 , 000 , 000
GEN'L AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMP/OP AoG $ 2,000,000
— 1 POLICY I x l J ri LOC $
COMBINED SINGLE LIMIT
AUTOMOBILE UABWTY (Ea accident) $ 1,000,000
X ANY AUTO BODILY INJURY (Per person) $
B — ALLOMMEO 1----1 SCHEDULED 6215480 11/1/2012 11/1/2013 BoDILY INJURY (Per accident) $
AUTOS AUTOS
OJED PROPERTY DAMAGE $
_ HIRED AUTOS ^ AUTOS (Per accident) —
PIP -Basic $
UMBRELLA UAB OCCUR EACH OCCURRENCE $ 5,000,000
C X - EXCESS LIAR CLAIMS -MADE AGGREGATE $ 5,000,000
DED 1 1 RETENTIONS 0082909 ( 6/23/2012 6/23/2013 $
D WORKERS COMPENSATION X I NYC STATU I 10 ER
AN EMPLOYERS' LIABIUTY TORY LIMITS
ANY PROPRIETOR/PARTNERIEXECUTIVE ( Y � IN E.L. EACH ACCIDENT $ 1,000,000
OFFICER/MEMBER EXCLUDED?
(Mandalay In NH) ) 1 " I N / A MC70128610121012 4/29/2012 4/29/2013 E.L. DISEASE - EA EMPLOYEE $ 1, 000 , 000
1t yeSs, CRIPTION deeaibe under PERATIONS below E.L. DISEASE - POLICY UMIT $ 1,000,000
DE
DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES (Attach ACORD 101, Additional Remarks Schedule, N mae space is moulted)
1
1
1
;
i
CERTIFICATE HOLDER 1 CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
For Permitting Purposes
l
AUTHORIZED REPRESENTATIVE
1 <
Brian Fo /LYNNE
-- =— —� -ice
ACORD 25 (2010/05) @ 1988-2010 ACORD CORPORATION. All rights reserved.
INSf25 nnrnns1 ni Tho A rnPf Hama anti Inn^ aro ronieforo.l mark*: of Annum
z z , — )4v\ V, /S/� I '' dlo c.a DISCOVER
MIME Q U E N N E V I L L E www.1800newroof.net
ROOFING V' SIDING ■ WINDOWS We Are Licensed
160 Old Lyman Road • South Hadley, MA 01075 F Insured
1.800.NEW ROOF • 413.536.5955 y
Email: info @1800newroof.net Website: www.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 8.4rade Associati P.P.C. 38710
Prf9litted T Date Phone #'s C:
1,150/) 1 i 1gp3 ,r H: i3 bw: l3-, -
Street �� Email:
14 w(p00 � : P fi- / A ' a 64 Pt-I L , Ce-■
City, State, Zip Code Special Requirements:
❑ Recover ❑ Strip ❑ Layers
Complete Roof System
We shall acquire all appropriate permits for all work
XI Home exterior and landscaping to be protected
Nr Strip existing roofing to existing decking and dispose of. Do not Do.
Jg' Deteriorated existing decking will be replaced at $3.47 per sq.ft. after full inspection.
X Install Ice & Water Barrier at all eaves, valleys, chimneys, pipes and skylights
X Install (151b. felt Syntheti)underlayment over remaining decking area
X Install Metal drip edge at eaves and rake-0 5 ") (white /brown /copper) �`
install manufacturer's starter shingle on all eaves and rake edges BBB
B
X Install new pipe boot flashing standard opper) / vents 1
X Install Snow Country o Cobra rolled vent ridge veil° Winner of the
2010
❑ Install proper soffit ventilation TORCH AWARD
Shingles: ( 6 nails per shingle) 4,, 7� f n a �� WOO
V
r4 F 17 12 - Shingles E] 25 111 25 year ¥3A -ye 50 year Color
Ridge cap shingles
Warranty Options:
❑ We guarantee our workmanship for 10 full years (see our warranty coverage)
❑ GAF System Plus warranty `
X GAF Golden Pledge warranty
Chimney Options:
` 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 Due ( $ q 7D®. )
ACCEPTANCE OF PROPOSAL: The above prices, specifications and conditions are Down Payment ($ )
satisfactory and are hereby accepted. You are authorized to do work as specified.
Payment will be 1/ down at start of job, and B ala y e due upon completion. ' Balance Due Upon Completion ($ 9 16 )
Date: g f 7 1 3 Signature: - ,,ii i • i A `∎ C.....:__ C i • 6
Date: f hr3 // 3 Estimator: (Print Name) TO ■ " 14 J . 4 ., (Sign Name) 4 %/
/ r /�,
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 Quenneville Roofing will not be
responsible for debris or dust in the attic or storage areas.
1. 7A Massachusetts ., ' ''
` DEPARTMENT OF BUILDING INSPECTIONS _ a D * z .
l i t / �` ' . .: r y f '0
,pai' -yam 212 Main Street Municipal Building ;Sk
Northampton, MA 01060 411::—.;-:r \‘
INSPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his /her
construction supervisor. The state defines "Homeowner" as, " Person(s) who owns a parcel on which
he /she resides or intends 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 home owner."
The building department for the City of Northampton wants any person(s) who seek to use the home
owner exemption, to act as their own construction supervisor, to be aware that by doing so you
become responsible for compliance with state building codes and regulations. The inspection
process requires that the building department be called to inspect work at various stages, which include
foundationlfoc #in s before backfill sonotube holes /before .our a rou h buildine, insnectio.
(before work is concealed), insulation inspection (if required) and a final building inspection.
The building department requires these inspections before the work is concealed, failure to secure
these inspections can result in failure to obtain a certificate of occupancy until the work can be
inspected.
If the homeowner hires other trades to perform work (electrical, plumbing & gas) the homeowner will be
responsible to make sure that the trades hired secure their proper permits in conjunction to the building
permit issued, and that they get their required inspections. Failure of the individual trades to secure
the permits and inspections as required can DELAY the project until such time as the proper permits
and inspections are made
1, Adam Quenneville Roof &. Sidi%q lie understand the above.
(Home owner /residenf signatr� 1 exemption)
1 will call to schedule all required building inspections necessary for the building permit issued to me.
Date .3)
Address of work location /9 btaripc6 - t,.t4-
AG4,karyt-0 nth 01o100
Department of Industrial A ccudents
al - v---t Office of Investigations
- - �
600 Washington Street e
. ',_ ,-:-;
S' h 0. t Boston, MA 02111
�: , www. mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians /Plumbers
Applicant Information Adam a Inc, lease Print Legibly
Name ( Business /Organization/Individual): Adam Quennevllle Roofing & Siding, nc, _
Address: //CD Old *tan ' Toad--
ad
City/State/Zip: • ■► �tGc�X _ IL OA Phone #: qIJ�'J�3�'�9S
c .
/State /Zi •
Are you an employer? Check the appropriate box: Type of project (required):
1. /:1 I am a employer with /cc 4. ❑ I am a general contractor and I
employees (full and /or part - time).* have hired the sub - contractors C New construction
2-, U I am a sole proprietor or partner- listed on the attached sheet. 7. [] Remodeling
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. [] We are a corporation and its 10.0 Electrical repairs or additions
3. C I am a homeowner doing all work officers have exercised their 11. ❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.] t c. 152, § 1(4), and we have no
employees. [No workers' 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 work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub - contractors and state whether or not those entities have
employees. If the sub - contractors have employees, they must provide their workers' comp. policy number.
Iarn an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
.information. _
Insurance Company Name: AT )V, MO 4ucti J -I 1 Su ru,McJ-
Policy # or Self-ins. Lic. #: A OC, ' I d 1,4'.0 161 Expiration Date: q 0 — 0261 3
Job Site Address: / i-l-aptpchp 31404- City /State /Zip:, I I d i t LA Olob
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 $1,500.00 and/or one -year imprisonment, as well as civil penalties in the four 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.
Ido hereby certify under the pains and penalties of perjury that the information provided above is true and correct
Signature: Date: .3 )/4(1
Phone #: /13 S35 9.cC
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 11 7, B Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing inspector
+1 6. Other •
I >n,.,...,, 44.
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction S rvi r: Not Applicable ❑
� quennevilk Roofing& Siding, Inc So t o a (P
Name of License Holder :
160 (Hd Lyman Road License Number
South Hadley, MA 01075 Zia I ) 1 3
Addr Expiration Dale
n / ti13 53b -Ssc
Signature Telephone
9. Registered Homed e t r t ; , ,' Not Applicable ❑
' iii Ciu vI Ik moortig &Siding, Inc:
/AO gel
Company Name 160 Old Ly ®an Road Registration Number
South Hadley MA 01075 . 3 s iy
Address Expiration Date
Telephone 1 I3"L
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 Ow a E er �u
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 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
•
.1
, SECTION 5- 'DESCRIPTION OF PROPOSED WORK (check all applicable) ,
New House [i Addition 1 Replacement Windows Alteration(s) n Roofing
Or Doors D
Accessory Bldg. ri Demolition 0 New Signs EDl Decks [ , Siding [D] Other [01
Brief DeEcciption of Proposed f / j ,
Work: K•� (1' 0a Q D ) ` l 0 r36S 4 latsi- ll� \ 4,0 614 -F X1.01' laS •
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
sa, !f New house and or addition to sxistinq housing _com tho_fiollawing_
I a. Use of building : One Family Two Family Other
b Number of r in each family unit: Nu umbe of B athrooms
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
OW AGENTORCONTRACTOR APPLIES FOR BUILDING PERMIT
I ak5br 4 �, jl ___2/240C , as Owner of the subject
property �' " ` (y p
hereby authorize Qaennevillc Roofing idan 1
to act on my b alf, in all matters relative to work at3thorizedy t his building permit application.
3 3I /dJ / ►.3
Signature of Owner • Date
1, , ( „ 1 ii / ' , ! , i ' , as Owner /Authorized
'
Agent heresy •' '. = '. " !'
' ' ". wn r' 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.
Ada Quenneville Roofing & Siding, Inc,
Pr�nt Na
pr____�X 3 i `i 1 13
Signature of Owner /Anent Date
Section 4. ZONING Alt Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by ioning
This column to be filled in by ile
Building Department
Lot Size
Frontage •
Setbacks Front
Side L: R:_
Rear
Building Height
Bldg. Square Footage
% 7 ---
Open Space Footage % ---
(Lot area minus bldg & paved —
parking)
i
# of Parking Spaces
Fill:
(volume & Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DONT KNOW 010 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW YES C3
IF YES: enter Book Page. and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO (20 DONT KNOW YES (3
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. WH 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 a
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
C Department use only
,,/, "X.: 9 \
�SO k of Northampton Status of Permit:
\ G . \ o‘ - ' 3 - ilding Department Curb Cut/Driveway Permit
1016 o�y %\ 212 Main Street Sewer /Septic Availability
.9' o' Room 100 Water(Well Availability
of `� Northampton, MA 01060 Two Sets of Structural Plans
o • phone 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
q ) 1 h " ' 511.04 Map Lot Unit
T � 0 Zone Overlay District
Efm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT -_
2.1 Owner of Record: 1 -
45011 t- Apuk ZT if AuLti r 1 Ais II iii411 1 11/1
Name (Print) /� o ,� - Current Mailing A .r ss: ��y 610114
- t4A n ' Si p �3
Telephone
Signature
2.2 Authorized Agent:
Adam Quenne1illeRoofzng &Siding, Inc. 160 did oil " Q., 0. P(, � olo 73 -
Name (Print Current Mailing A ress:
Signature Telephone
SECTION 3 -- ESTIMATED CONSTRUCTION COSTS -
Item Estimated Cost (Dollars) to be - Official Use Only
completed by permit applicant
r
1. Building it' . n �h (a) Building Perm Fee
2. Electrical (b) Estimated Total Cost of
Construction from (6) _
3. Plumbing Building Permit Fee-
4. Mechanical (HVAC)
5. Fire Protection
�/ J
6. Total = (1 + 2 + 3 + 4 + 5) `7 MI 00 Check Number . , A i � .
-_" - This Section For Official Only_ _.:. .
Date
Building Permit Number issued:
Signature:
Building Commissioner/Inspector of Buildings Date
14 HAMPDEN ST BP- 2013 -0830
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 38D - 027 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 -0830
Project # JS- 2013- 001429
Est. Cost: $9700.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ADAM QUENNEVILLE
Lot Size(sq. ft.): 5619.24 Owner: MALLOY ALISON F
Zoning: URB(100)/ Applicant: ADAM QUENNEVILLE
AT: 14 HAMPDEN ST
Applicant Address: Phone: Insurance:
160 OLD LYMAN RD (413) 536 -5955 0
SOUTH HADLEYMA01075 ISSUED ON:3/15/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:REMOVE 1 LAYER & 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 3/15/2013 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner