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24C-068 (7) The Commonwealth of Massachusetts Department of Industrial Accidents _' Office of Investigations 11w 1 Congress Street, Suite 100 Boston,MA 02114-2017 } '':•�.� www.mass:gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Adam I uenneville Roofin &Sidin Inc. Address: f(00 Old tha.11 7P--carid. City/State/Zip: ... ID..! * 1107S- Phone#: 1(3 53td-�c S S Are you an employer?Check the app'i priate box: general contractor and I Type of project(required): 1.[� I am a employer with i s 4. ❑ I am a 8 employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.0 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' [No workers' comp. insurance comp.insurance. 9. ❑Building addition required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.(g Roof repairs insurance required.] t c. 152, §1(4),and we have no 13.❑ Other employees. [No workers' comp.insurance required.] *Any applicant that checks box#I 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. ;Contractors 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. 1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: A % f u l .L11 SUf a n C3z-- Policy#or Self-ins. Lic. #:A1A)C.4007&id?tot A01 J A Expiration Date: ti —02.9 O[ Job Site Address: 1 t 1 -5r t City/State/Zip: Q , Mg- 4/06 L) 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 t,f 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 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 do hereby certify under the pains and penalties of perjury that the information provided above is true and correct mature: Date: c7 /013 13 Phone#: 4\ S3 5`./ S c 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 Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: A iDr CERTIFICATE OF LIABILITY INSURANCE °/24/2 13 SURANGE 6/24/2013 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 holler Is an ADDITIONAL INSURED, the poRcy(les) 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 endorsements). PRODUCER - ,ACT Lynne Methot, Ext. 102 Foley Insurance Group Inc. sat (413)214-7474 (413)214-1447 37 Elm Street Km: RNURIdt(i)AMMO NS COVERAGE MICA West Springfield MA 01089-2703 emote*A:Peerless Insurance Company 24198 mum waurtea e,American Fire & Casualty 24066 Adam Quenneville Roofing & Siding Inc. INSURER Ohio Casualty Insurance Co. 24074 160 Old Lyman Road memo o AIM A/R INSURER E; , South Hadley MA 01075-2632 NtsiMenF: COVERAGES CERTIFICATE NUMBER,:CL1362407069 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. AINSURANCE Or URANCE UND D POLICY SWIM J ) 41WWM, LOFTS GENERAL LIABILITY EACH OCCURRENCE y 1,000,000 X COaMERcIA1 GENERAL UABalTY DAMAIN TO RENTED 100,000 A .ct. ss moe I O1 OCCUR 3L6912267 PRISMS ooemeew) $ 5,000 6/23/2013 6/23/2014 MEDEXP{Mgonepason) $ PERSONA,4 ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GENI.AGGREGATE LMIT APPUES PER PRODUCTS-COMP/OP woo I 2,000,000 n n n POLICY x T we , -sIoE $AUTOwnLE UAEAS Y l T 1,000,000 X ANY AUTO BODILY INJURY(Per person) $ E- „,,, ALL OWNED —SCHEDULED BA■55622645 6/23/2013 6/23/2014 BODILY INJURY(Per soodsnO $ AUTOS AUTOS HIRED AUTOS — AUTOS D E $ PIP.Ssic $ _ UMBRELLA LAS OCCUR EACH OCCURRENCE s 5,000,000 C X EXCESS UAe CLAIMS AAADE AGGREGATE , 5,000,0001 MO I J WEAPONS 175055622645 6/23/2013 6/23/2014 $ D WORKERS coememAnoN X I r�TA'tU- I UMITS AND e1IPLOYNS$UA5IJTY ANY PROPRETORPARTNEREXECUTIVE I OFFICER/MEMBER EXCLUDED” ` I N/A E.L.EACH ACCIDENT $ 1,000,0001 (MsledideryinNH) A91C40070128612013A 4/29/2013 4/29/2014 E1 DISEASE•EA EMPLOYEE\$ 1,000,000 ES6ssclbs IPTION OF OPERATORS below E.L.DISEASE-POLICY LIMIT i 1,000,000 I i =SORPTION OF OPERATORS I LOCATIONS I MOLES(Attach ACORD 101,Additional Remote Schedule,It more spats Is required) 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 POUCIES 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 �� �y ACORD 26(2010105) ©1988-2010 ACORD CORPORATION. All rights reserved. INRn25 nn sox, , 'Ma Af:rlRrl Hams and Innn era renietararl marks PO Ar:rlPrl 5 C43 AZTAi Crd DISCOVER 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 1.800.NEW ROOF • 413.536.5955 Fully Insured 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 the Building 411.Trade Association P.P.C.38710 Proposal Submitted To: Date Phone#'s C: 1113-C,4 5 .36'( CC:r 7Lr 7j��`Z�13 H: W: Street Email: -70 g5 cA:5 c, Z SA p� v c_ () Co f v tL; , C o City, State,Zip Code Special Requirements: u r,r te..r„�- Z n v. fv-1 n �� a( � �' - -- (a 4^�� f _ C.. r� Gl o l P( 0 r1 t� k v r) ❑ Recover Ex Strip Cl Layers Complete Roof System We shall acquire all appropriate permits for all work Home exterior and landscaping to be protected 1JO 4' 31,c_ Nr Strip existing roofing to existing decking and dispose of. Do not Do. n,(. ^ 140,1 - Deteriorated existing decking will be replaced at$3.47 per sq.ft.after full inspection. _ ; Install Ice&Water Barrier at all eaves,valleys,chimneys,pipes and skylights Install(151b.felt Synthetic) nderlayment over remaining decking area Install Metal drip edge at eaves and rake ( 5") white rown/copper) 6 Install manufacturer's starter shingle on all eaves an rake edges BBB X,InstalcSnow Country r Cobra rolled vent ridge vent Winner of the 2010 --Q n TORCH AWARD Shingles: ( 6 nails per shingle) --,>r'}r'P'_c C.,(4, C Shingles ❑ 25 year N'31year ❑ 50 year Color O y 3 SA Grw -- r A Ridge cap shingles Warranty Options: .❑ We guarantee our workmanship for 10 full years(see our warranty coverage) ❑ GAF System Plus warranty _GAF Golden Pledge warranty Chimney Options: ❑ Lead Counter Flashing ❑ Water Seal&Tuckpoint ❑ Rubberized Crown ❑ Metal Chimney Cap We propose hereby to furnish materials and labor-complete in accordance with above specifications for the sum of:Total Due($ j( 00 •C'U ) ACCEPTANCE OF PROPOSAL: The above prices,specifications and conditions are P at a Down Payment($ I CIO 0U satisfactory and are hereby accepted.You are authorized to do work as specified. Cam_ Payment will be 113 down at start of job,and balance due,upon completion. ,--_ Balance Due Upon Completion($ 3500 ) Date: 3'I t 13 Signat Date: / 3'11173 Estimator:(Pr t Name) ,SCOTT j e Cl{rq 6/_ Sign Name) f,�z.t�, 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. Versionl.7 Commercial Building Permit May 15,2000 ^ '` � �~ . SECTION 10- r� ���� ` � , . — Independent Structural Engineering Structural Peer Review Required • Yes 0 No © SECTION � |'`� DVVNEQSAGENTOR �FORo �- � ( 1, ' _____-_-__'os Owner cf�anu�m�pmpady . __ __ _ . �� �� ___- . '{o ho�byou�or�o^ ---------------------------� act on to work authorize by this building permit �/ �� .�o �� ' ' —=�- ~~a '�� ~ Signature of Owne Date = ~�--- -�'=—==-._17._= =-``— `� ________� .en ,_ _ . " ~ Agent hereby declare tha the statements and information on the foregoing application are true and accu ete.00 the best of my and belief. Print tVame ,44,--- , 915-/13 , ,,, „ ._ __ :Signature of Owner/Agent Date SECTION 12'CONSTRUCTION.SERVICES 10.1 Licensed Construction Sup enhamr Not Applicable�e O . � Nameof _____________________�___�_` ^~~~ = License Number ---- 0m� ---'----------- l ------'- -� "°"=t=y"���"��~ w�. �___-_._ Address Nm���m�o��& ��?5 __ Expiration A.----- ��---''`--' — --- C�/ / // �- �7 °/ � fir Signature Telephone SECTION 1; r • _ �'c�*�r�`�'� �-�° Workers Compensation Insurance affidavit mus be completed and submitted with this applicaon. Failure to provide this affidavit will result in the denial of the issuance of the building permit. �� �� 8�nndA�de�Auaohed Yes �� No �� ___'~~ _ ' ' Version L?Commercial Building Permit May 15,MOO SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTION;-SERVICES-FOR BUILDINGS AND STRUCTURES SUBJECT TO CONSTRUCTION CONTROL PURSUANT.TO 780 CMR 116(CONTAINING MORE THAN 4000 G.F.OF Ei LOSED SPACE) 9.1 Registered Architect: __. __________ _ --_. "' Not Applicable 0 Name(Registrant): _ _- __ .__ ,_._.v,._ _,_ ..__.._._. ._ _.___._._._ Registration Number Address ____"'"`°`"__— Expiration Date Signature Telephone 9.2 Registered Professional Engineer(s): Name Area of Responsibility Address Registration Number — Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility i Address _ M_ _ Registration Number .. _._ _ . __^• — Signature Telephone Expiration Date Name Area of Responsibility Address ______ _.�._._. _ Registration Number -- y_ Signature Telephone .... � Expiration Date _.. 9.3 General Contractor �. �._.__.__... _._: _ Not Applicable 0 Company Namealellkilleyf M 1ac,_. ,____-.._.._____—_. Responsible in Charge of C t c' n o r y,ifkit1075. _Adddress_-_ � ` Signature Telephone , • Versionl.7 Commercial Building Permit May 15,2000 8. NORTHAMPTON ZONING Existing Proposed Required by zoning This column to 6e filled in by Building Department Lot Size Frontage Setbacks Front Side L_ R: Rear Building Height Bldg.Square Footage ____ ___. oo ___..___ Open Space Footage w (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 (T DONT KNOW (3 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 G. DONT KNOW 0 YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained , Date Issued: _�Y� C. Do any signs exist on the property? YES (3 NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the c opefty.? .YES, 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 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. Version1.7 Commercial Building Permit May 1 ,2000 SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 CUBIC FEET OF ENCLOSED SPACE .,.- Interior Alterations ❑ Existing Wall Signs ❑ Demolition❑ Repairs❑ Additions ❑ Accessory Building 0 Exterior Alteration ❑ Existing Ground.Sign❑ New Signs❑ Roofing L� Change of Use❑ Other❑ Brief Description r Enter a brief description here. �. k �.S Of Proposed Work:R-42-0,17-1%<- I r D�F- S I.-+�d",i 't�,p 0-e--P i� '-4i lt-tw tip '�"'� • SECTION 5-USE GROUP AND CONSTRUCTION TYPE' I USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly ❑ A-1 ❑ A-2 ❑ A-3 0 1A 1 0 A-4 ❑ A-5 ❑ 1B ❑ B Business ❑ 2A ❑ E Educational ❑ 2B - r ❑ F Factory ❑ ■ ■ 2C ❑ H Nish Hazard ❑ 11111111.11111111111111.1111111111 3A ❑ I Institutional ❑ I-1 ❑ 1-2 ❑ 1-3 ❑ 313 NI M Mercantile ❑ i 4 Q R Residential ❑ R-1 ❑ R-2 ❑ R-3 0 5A ❑ S Storage ❑ S-1 ❑ S-2 ❑ 5B ❑ U Utility E3 Specify: -- -- __. .____- M Mixed Use ❑ Specify: S Special Use ❑ Specify: w_.__..._.__..._- _.____ . .__..___,.,__..__-_.__-____._. ` _ COMPLETETHIS SECTION IF EXISTING-BUILDING UNDERGOIN.G-RENOVATIONS,ADDITIONS AND/OR CHANGE IN USE Existing Use Group: - Proposed Use Group: -_,.,._._,_-__r,__..._.______-_.,-._.___ _______ .. Existing Hazard Index 780 CMR 34): __. Proposed Hazard Index 780 CMR 34): _.M _ _q_ ___.___ SECTION 6 BUILDING HEIGHT AND AREA BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION . OFFICE USE:ONLY Floor Area per Floor(sf) 151 . ___._. -...,.._,_ 1st -- 2nd _.'_ _._____.__-.__ _____._.__ 2nd _ _ 3ro _.._..,__._._._..__.__._...._......_ ..__.. 3'd ,_ _� 4� Total Area (sf) Total Proposed New Construction(sf) __ Total Height(ft) ___________._,.:.:_,._s._ Total Height ft 7.Water Supply(M.G.L.c.40,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System: Public ❑ Private 0 Zone __________ Outside Flood Zone Municipal ❑ On site disposal system Version1.7 Commercial But!din. Permit Ma 15,2000 _ , Departmeht use,only - , City of Northampton Status of Permit: • . . ,- - Building Department Curb Cut/Driveway Perrniti! — iU L. - ) — 6 2013 t j 212 Main Street , Sewer/Septic-Mailability Room 100 Water/Well Availability - , Electric,Plumbing&Gas Inspections Northampton, MA 01060 Two Sets of Structural Plans ' ‘ : Northampton,MA 0101P_,. , _ . -- 13-587-1240 Fax 413-587-1272 Plot/Site Plans Other Specify APPLICATION TO CONSTRUCT,REPAIR,RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: . This section to be completed by office -70 yY\cvssaso(4 51-c-t-r,A Map Lot Unit 0 trig-AlaiN_A)I ti I\1 M A 01010C) Zone Overlay District EtmStDtrict cB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT . 2.1 Owner of Record: _PS,A-er _ _ __.________________ ' .. ____ :4ALI.,1-:( —7 0 rnlet-S$14- C I 4- 'f.-si_. OPLIMet-ntphl Ma Name(Print) Current Mailing Address: 0 J4Dici) t1/3- ip9S,3Ce"P Signature ,,,-,&,,t rpt,...414.4t 4- Telephone 2.2 Authorized Ac(ent:_ A _ Name(Print) Current Mng_Address: 413-S3 ie-S-9 SS Signature /7' \__. Telephone SECTION 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) S 5. Fire Protection 6. Total=(1 +2+3+4+5) 1; La °0 Check Number 62 7o 47,65' This Section For Official Use Only Building Permit Number Date Issued Signature: Building Commissioner/Inspector of Buildings Date 70 MASSASOIT ST BP-2014-0296 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 24C-068 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-2014-0296 Project# JS-2014-000493 Est. Cost: $5600.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ADAM QUENNEVILLE 070626 Lot Size(sq. ft.): 13068.00 Owner: CONTUZZI PETER J &BELLESIA GIOVANNA T Zoning: URB(l00)/ Applicant: ADAM QUENNEVILLE AT: 70 MASSASOIT ST Applicant Address: Phone: Insurance: 160 OLD LYMAN RD (413) 536-5955 () Workers Compensation SOUTH HADLEYMA01075 ISSUED ON:9/10/2013 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 9/10/2013 0:00:00 $35.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner