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31B-097 ZiL D ,Z-ZZY-y , BBB QUENNEVILLE Winner of the 2010 ROOFING V SIDING WINDOWS TORCH AWARD 160 Old Lyman Road • South Hadley, MA 01075 1.800.NEWROOF 413.536.5955 Clalms.AQRS @gmail.com MA Construction Supervisors Lic.#070626 MA Registration#120982 CT Registration#575920 HOME EXTERIOR AGREEMENT Name i 3k31 EJ- -f r t'_O+. L�OL� Date' '" Ins. co CO t E -'- ` CI �.�� aim# Address = - vA ,- , C Ph Fx 1,4 CstZ F!A A r1 A r-r-G1-- j L4/"; (i f.30 0 StaffAd1j:- Phone #'s H 1413-r ti—CD I I'7, C Ind. Adj. °c t,ao.._t 2')A,4.---Z._./ k.__I Email --7F,i - "_;,":-3,v5— c-r/ (F\ -.6.54 .- 7q-3 Proceeds Roofing Materials Roofing $ Brand of Shingles (-' Color Siding $ Style of Shingles 1 1 t'- t!rr?-_t_t wit' -1417) Gutters $_ Sq.of Shingles tTh i, Ridge p --r-C) E°-'J,m 1,1 $ Tear Off: yeses no❑ 1 2 3 $ f Underlayment`:' r4t iC Ridge ent h4 iG Leak Barrier (C'k-- t •t -- C- +C7C' TOTAL $ E `� ---� All supplements approved by the homeowner's insurance lompany are to be Drip Edge t Aluminum: w brown LF f-. k . included into the Total of the contract agreement and must be paid to Adam Fleshings !C1 1-4.E" a_r Quenneville Roofing&Siding, Inc. Permits Furnished (6 nails per shingle) Decking$ `‘-'0 /sheet Homeowner's initials: ALL Checks Payable to Adam Quenneville Roofing&Siding,Inc. We will pick up all debris throughout the building proc ss.We Payment Schedule will roll your yard with a magnetic roller.All debris will be removed,hauled away, and recycled whenever possible. Deductible Check: '7 $ �( D "------ (from Client) Dat Check# Amount Siding Materials -� 4' Brand of Siding First Insurance Draft:5M r 3t l e., $ - 0 Amount Style of Siding Dutch Lap❑ Clapboard❑ (from Client) at Check# Amount p p Color Supplement Draft: $ Amount of Siding (from Client) Date Check# Amount House Wrap yes❑ •o❑ Itel Report yes❑ no❑ Fascia LF / Color: Upgrade Payment: $ Soffit SF Color: (from Client) Date Check# Amount Eaves %vented % olid Li Rakes Solid Gutters & Downspouts Aluminum, LF Company's Limited Warranty:2 years on full replacement contracts and Color ownspouts 2"x 3"❑ 3"x 4"Li repair contracts. No warranty exists until this contract is paid in full. Leaf Protection Contract is contingent upon insurance company approval and limited to the Job Details amount and scope of that approval. Customer agrees that Adam Quenneville Roofing&Siding, Inc. will perform all home exterior work approved by the insurance company above.Any additional out of pocket expenses must be agreed upon before work begins. Homeowner's Initials: General Contractor: Homeowner acknowledges Adam Quenneville — Roofing&Siding, Inc. as a general contractor and as such will be entitled to 10%overhead and 10%profit, as allowed by insurance standards. Notice of Cancellation:You the customer, may cancel this agreement at any time prior to midnight of the third business day of this agreement. - (see reverse side for Notice of Cancellation and Explanation of this right.) Homeowner's initials: --- a Q _ � ? i I ,) Customer Subject to Agreement Date Adam Quenneville Roofing rSiding,Inc.Representative Date i tii?i, Pci 3 x.013 0 Customer Agreement Date Management Approval Date This contract is subject to final approval from authorized management of Adam Quenneville Roofing & Siding, Inc. Adam Quenneville Roofing & Siding, Inc. reserves the right to deny any contract within 48 hours of the date on this contract. If contract is denied all monies paid by customer shall be returned within 48 hours of the date on this contract. This contract consist of this page and the reverse side of this pages and shall be considered the entire contract by the parties involved Q CERTIFICATE OF LIABILITY INSURANCE 4/24/2013 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 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 rCiOO,ACT Lynne Methot, Ext. 102 Foley Insurance Group Inc. a/c°Nro Fttn (413)214-7474 (ac.No):(413)214-7447 37 Elm Street EMAIL -I methot@foleyinsurancegroup.com com ADDRESS: y g p' 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. INSURER C:Scottsdale Insurance Co. 160 Old Lyman Road INSURER D AIM A/R INSURER E: South Hadley MA 01075-2632 INSURERF: COVERAGES CERTIFICATE NUMBER:CL1342406968 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 LIR INSR VD POLICY NUMBER (MMIDO/YYYY) (MM/DDIYYYY) GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 100 000 X COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) $ — A CLAIMS-MADE X OCCUR GL6912267 6/23/2012 6/23/2013 MEDEXP(Anyoneperson) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY X JECPRO T LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT _ (Ea accident) $ 1,000,000 B X ANY AUTO BODILY INJURY(Per person) $-ALL OWNED SCHEDULED 6215480 11/1/2012 11/1/2013 BODILY INJURY(Per accident) $ AUTOS _ AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS _ AUTOS (Per accident) PIP-Basic $ 8,000 UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 C X EXCESS LIAB CLAIMS-MADE AGGREGATE $ 5,000,000 DED RETENTION$ XLS0082909 6/23/2012 6/23/2013 $ D WORKERS COMPENSATION X WC STATU- 'OTH- AND EMPLOYERS'LIABILITY TORY LIMITS ER ANY PROPRIETORJPARTNER/EXECUTIVE Y N N/A E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? 7012861012013 4/29/2013 4/29/2014 (Mandatory in NH) AWC7012861012013 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/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) Proprietor/Partner/Executive Officer/Member exclusion applies on Workers Compensation. The certificate holder named below is included as an additional insured for general liability coverage for ongoing operations if required by written contract, permit, or agreement executed prior to a loss. 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 r! '"` T--° ; -- ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INSfl 5 oninncl n1 The.ACARr1 n.me..nel Inn.,rare.rnnicfnro,'I mode*of ACl117I1 The Commonwealth of Massachusetts or: 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 j Please Print Legibly Name (Business/Organization/Individual): Adam Quennevilte Roofing&Siding,Int — ----_--- Address: 1 LP 01C C- `tryinvi Dad - `-- City/State/Zip: ��� '1 ��;�tG� E'�j/ t ' Phone#: t 1 �j' i �j _ 6--c/6' � `Y 5 - Are you an employer?Check the appropriate box: L J L l Type of project(required): 1,X I am an employer with 1.�____ 4. .. I am a general contractor and I 6. L. New construction employees(full and/or part time).* have hired the sub-contractors Remodeling 2. I 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.i We are a corporation and its 10. ' Electrical repairs or additions 3. i am a homeowner doing all work officers have exercised their 1 I. Plumbing repairs or additions myself [No workers' comp. right of exemption perm MGL J insurance required]t c. 152, § 1(4),and we have no 12. Roof repairs I employees. [no workers' 1:3. -, Other_____ comp. insurance required.] *Any applicant that checks box#1 must also fill 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 ent o ees,the must rovide their workers'corn . sulk'number. --- I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and joh site information. M p Insurance Company Nam .r i'1 e:_ __ 1'`_i a.-I /n5a't4nee ----------- __ Policy #or Self-ins. Lic. ti:___Aitil C., '?V I Ai'/ 10 1 Expiration Date: `t—al q— v2U41/ Job Site Address:_0.3-. C�( C.t-k6s Sc ( City/State/Zip: � t � � ► �'t _ tG�yc copy of the workers' compensation lie declaration page(showing the policy number and expiration (date). Attach a py pe po . 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 coverage verification. ____,d I do herby certifty under the pains and penalties of perjury that the information provided above is true and correct. 1�., Signature: d' Date: �1—_ Phone #• q i�> 4)3 6- ci f Print Nanre: L 11 n�. V L -----_-_ rOicial use only Do not write in this area to be completed by city or town official i City or Town: Permit/license#: � _—__ __ _ Issuing Authority(circle one): !.Board of Heath 2. Building Department 3. City/Town Clerk 4. Electrical inspector S. Plumbing Inspector 6.Other Contact person: Phone#: L-_ --_-.-_J SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Q Not Applicable ❑ Name of License Holder: (� ),C N''\€ 1 -Q /1 L,. ∎ __License Number c, c A . JuKc,,,, rc)cc( s- kGc LA . ' , ,\ \---- Add/ins 1 Expiration Date 5/3/1 3 rat re Telephone 9.Registered Home Improvement Contractor: Not Applicable ❑ \k3\ (.1.11`A, C\i C MQAJ \c_ \-- Cf.L)-C--k N Qt, A \ 1 Company Name Registration Number "I6C.) C_'> A L ,K,Ck IC\ ,-.- ID LI (1 (4 Address Expiration Date Ll '\\ L A T i33 .�-)L2' ,7! elephon J J '� ..... _ 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 e( No ❑ 11. — Home Owner Exem 1aon The current exemption for"homeowners"was extended to include Owner-occupied Dwellinass_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 SECTION 5-'DESCRIPTION OF PROPOSED WORK(check all applicable) ,, New House n Addition + I Replacement Windows Alteration(s) I I Roofing i I Or Doors D Accessory Bldg. El Demolition n New Signs [e11 Decks [❑ Siding[p] Other ID] Brief Description of Proposed Work: 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 CONTRACTORAPPLIES.FOR BUILDING PERMIT': 1, 1 -(, CAA V -G;v,a rw A ,as Owner of the subject property hereby authorize \)A.„,,,,t ` v,,, ,c ,/( � (t (r_ (cv--i oo\ to act on my behalf, i all matters relative to work'authorized by this building permit application. c c e, , v 3 Signature of Owner Date / I k„�'"���: r : ...a�? ,.,,..:,-..-.-.:•-,,,,eo .... „'.�w,. �vza ‘ar �x,,', {%� Na�. : I, t--4 C 1leu\e_V j �� k ( , as Owner/Authorized Agent hereby declare that the statements and information on the forego9 application are true and accurate, to the best of my knowledge and belief. L1 Signed under the pains and penalties of perjury. , P-F. . m Qc A e r\i\e_ \/ \ Q Print N. e IR • Si ature .f OwnerlAaent Date , Section 4. ZONING AU Information Must Be Completed.Permit Can Be Denied Due To Incomplete Information p Existing Proposed Required by'�oning 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 (2) DON'T KNOW 0 YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 IF YES: enter Book : Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 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 (3 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 0 IF YES,then a Northampton Storm Water Management Permit from the DPW is required. S 6° _----- i t-il - Department use only --vir----m .... 6 g City of Northampton ov5o\o,t,i_r_cc,_ NtAw \01.6,001,19 Building Department L°6 DEF114.01,m40,Ap-rot,i, 212 Main Street Room 100 Northampton, MA 01060 phone 413-587-1240 Fax 413-587-1272 Status of Permit: Curb Cut/Driveway Permit ti. Sewer/Septic Availability Water/Well Availability TwO Sets of Structural Plans 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 C 0 3 Ec\usi,-, A -Dctk_ccu Map Lot Unit Zone Overlay District I .N- C\(--)\s,',_ C' Elm St.District CB District _ SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT , . 2.1 Owner of Record: • IZClr\CAC\ ISVCitkAec.....6 0',?--) Ac k -C }c- v),(- Name(Print) Current Mailing Ad(r%\ 5 L-k" '- C:c)k.--A-ccAc Telephone\--.. Signature 2.2 Authorized Agent: fte __,... ‘- c)oke.( 5. 4- 6d.Cv.i., % Name(P' Current Mail Address: Si. tore phone •_ SECTI$N 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) ‘C) 5C> Check Number d 661 6 A 5.3 6--- - - - - _ , - . - _----. - This Section For Official-Use Only_ - - - - - - Date •Building Permit Number: - - Issued: - .- - signatute. - _ . Building Commissionerilnspector of Buildings Date 23 EDWARDS SQ BP-2013-1055 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 31B-097 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-2013-1055 Project# JS-2013-001746 Est.Cost: $10598.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ADAM QUENNEVILLE 070626 Lot Size(sq. ft.): 3005.64 Owner: STAWIECKI CLARA B&RONALD D&KAREN EVELYN STAWIECKI Zoning: URC(100)/ Applicant: ADAM QUENNEVILLE AT: 23 EDWARDS SQ Applicant Address: Phone: Insurance: 160 OLD LYMAN RD (413) 536-5955 () Workers Compensation SOUTH HADLEYMA01075 ISSUED ON:5/7/2013 0:00:00 TO PERFORM THE FOLLOWING WORK:STRIP & 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 5/7/2013 0:00:00 $35.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner