16D-008 (4) 4/ DATE(MWDdYYYY)
CERTIFICATE OF LIABILITY INSURANCE
�- 6/16/2014
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).
RODUCER -CONTACT Susan Nore V--
:oss 6 McLain Insurance Agency NE (413)534-7355 FAx {413)536-928b
.767 Northampton Street AiMS34 swareQgossmclain.com
1 0 Box 1128 INSURER(S)AFFORDING COVERAGE —-__----- _NAIC a_--
lolyoke MA 01041-1128 INSURERA:Liberty Mutual Insurance 24198
4SURED INSuRER a:Liberty Mutual Insurance _ 032
edam Quenneville Roofing 6 Siding Inc INSURERCA. I.M. Mutual Ins. Iqqmp 0050 _-
60 Old Lyman Road INSURER 0:
INSURER E:� --------------- - —'---
3outh Hadlex MA 01075 INAURIER F;
:OVERAGES CERTIFICATE NUMBER.,CL14 61800890 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. _
$R -----TYPE OF INSURANCE POLICY NUMBER LIMITS
TR
GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
DAMAGE
_X CO_IMMERCIAL GENERAL LIABILITY _$ _____100'000
4 CLAIMS-MADE n OCCUR TBD /23/2014 /23/2015 MED EXP(Arty one peroon) f 5,000
___ _ Protective PERSONAL 6 ADV INJURY S 1,000,000
GENERAL AGGREGATE _ $ _ 2,000,000
GEN'L.AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG S _ 2,000,000
X I POLICY PRO- LOC F
__CZV8INED SINGLE LIMIT
AUTOMOBILE LIABILITY
ANY AUTO BODILY INJURY(Per person)
ALL OWNED SCHEDULED BODILY INJURY(Per accident) 3;
AUTOS AUTOS PROPERTY DAMAGE $
v
NON-OWNED P
HIRED AUTOS AUTOS --- -----------------
-
$
X UMBRELLA LIAR X OCCUR EACH OCCURRENCE _ f_- 5,000,000
– EXCESS LIAR CLAIMS-MADE AGGREGATE -$ _ 5,000,000
DED X RETENTI N 10,00 BD /23/2011 /23/2015 $
WORKERS COMPENSATION OTH-
Y AND EMPLOYERS'LIABILITY
ANY PROPRIETORIPARTNERtEXECUTIVE YIN E.L.EACH ACCIDENT $ 1,000,000
OFFICERIMEMBER EXCLUDED? D NIA '-`
(Mandatory in NH) MCA007012861-2014A /29/2014 /29/2015 E.L.DISEASE-EA EMPLOYEE S 110001000
It yyes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 11000 000
DESCRIPTION OF OPERATIONS(LOCATIONS r VEHICLES (Attach ACORD 101,Additional Remarks Schedule,N more space Is required)
'arpentry, Siding and window contractor
:ERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Adam quenneville Roofing 6 Siding, Inc. ACCORDANCE WITH THE POLICY PROVISIONS.
(for permits only)
160 Old Lyman Road AUTHORIZED REPRESENTATIVE
South Hadley, MA 01075
Susan 9fare/S[.T>S
LCORD 25(2010105) ®1988-2010 ACORD CORPORATION. All rights reserved.
48025 �n+mA n+ TL. ar'npn nom.anr4 Inn+ annoy
Board ci:Building ReQuIFtions Una sztandaras
CS-070626
ADAM A QUENNEVILLE
160 OLD LiMAN-'RD
S HADLEY MA 01075
08121/2015
)c
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 120982
Tvpe: DBA
Expiration: 3/25/2016 Tr# 248645
ADAM QUENNEVILLE ROOFING
ADAM QUENNEVILLE
160 OLD LYMAN RD
SO. HADLEY, MA 01075
Update Address and return card.Mark reason for change.
SCA I C� 2OM-Wi I Address Renewal Employment C Lost Card
15!
r
STP,,TE-1 OF CONNECTICUT ^ DEPAR.TA11E-NIT (C)TI CONSUMER PROTECTIOIN
Be it known that
ADAM QUENNEVII.I.
160 OLD LYMAN ROAD
��EY`N -01075-2632
SOUTH HADL A U'-
is certified b�• the Dep# ent-of'66iisurnerProtect:ion as a registered
J,
HOME imp-R-O.-Vr.EMEN.,�T-:� CON,,TRACTOR
Regist THE, 575920
ADAM QUENNEVILLE ROOFING
ft i Effective: 12/01/2013
-1014
Expiration.: 11/30/2
VViltiarn M.Rubenstein,Commissioner
ANK TOW4
QVENNEVILLE
ROOFING 'V SIDING W WINDOWS T
160 Old Lyman Road•South Hadley,MA 01075
1.800.NEW ROOF • 413.536.5955 Winner of the
Email:info@1800newroof.net Website:www.1800newroof.net 2010
MA Construction Supervisors Lic.#070626 MA Registration#120982 TORCH AWARD
Member of the Home Builder's Association of Western Mass. CT Registration#575920
Member of the Building&Trade Association
Proposal Submitted To: Date Phone#'s C:
A POW&NI -7 q
H:q/- w: --
Street Email:
196 t�" MAIN
City,State,Zip Code
F 412PNt-1 Mlof D 106-2- -------
Proposal to furnish and install the following
`I-
AWAY
C'b c,oK G CoA-L-
W t-4 c`fC-_ 0PL( ar?C '
Siff _rTMNALLNE
rP 3. q_7 FT
I
lie
Z0 Ask us about
affordable bank
financing
We propose hereby to furnish materials and labor-complete in accordance with above specifications f r the sum of:Total Due($ 16M _)
ACCEPTANCE OF PROPOSAL: The above prices,specifications and conditions are �V Down Payment($ 'SC )
satisfactory and are hereby accepted.You are authorized to do work as specified.
Payment will be 113 down at start of job,and balance due upon completion. I Balance Due Upon Completion($ a )
Date: 7tt 0I 1 Y -_Signature:c� r' ` QQ�/ —
Date: —7[o Estimator:(Print Name) 5ty�r'_(Sign Name)
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.
The Common wadth of MauacAmle m
_= - ---- De{arox mj of Iwdwsc iwl Acadenrs
Office of jfrvaspiseaOns
?'� 6A0 FYt�sAitiu�oir .�nref
Workers' Cumpeasafiun Insurance Affiicbvit: Bander-&),ojufraclor-/Kiec�trickaas/Piumbcr-s
,-#Ppltcal $
t [alOt taaha0___.___ F$"" PTlllt �.E bl
Nantc Adam vuCniievINU 8001$119 IS
AdKltcss ttrll
C_11�/JtaW�Lt�. Su�,Yh ��+Jley 11PAXIC
Iry yva as taapleyrr? C7reck the appropriate bei: I Typc of project (required)
4 1 eat a aj caue-ackv +tad 1
`�'� 1 am A��� �� � aaarcr h New cawauctxin
la thU and�oi- ---amc hove aired tits ual-C 4aarcuxs �-
-_� I a4D 1 qlt praprsap or partttty- 40cod on tame aaacbad W%e.-l. L� Rocssc.„1e(,°fi
shop and SavC no employees Tbeet mb-coawadUr] hsvc g I)CM01,txx,
wart for aoe m ury a car �Pioyem and bAvc wveicsxs
tII6 xf}4 Y i y - HtL lclm( add,p cxi
(No worttn' comp autx*mr cowp. ir&*rancz.:
r"?Uae j ] We roc s corpmanou aacl its j 10-[_i Flectric,l r"a, o+ ,dd+txmle
S I am a hrsauvwO." &mlg 4.11 work officers have azarcised then I I L "'—A rears cr ad,ftt,cxu
mywif. f No workers'co", ru6bd of ezaaaptataa per fk14L I 12 Rcxsf rtyaxs
assurance regwsed. c 1)2, j1(4� and we brat no
tw+4ayam. [No wo "' ( S ) L`7 Otltc
tea
comp. iaauraace"wfuired.l
'!+ry ygbca our chacY,aaa o� aoaa,,+..lill e,n ar s.cd"ew bda+r t►•+rp4s•net rnrswn'cea�rwastt•a pMc7 rJeraurrint.
H�s who mebmt tea hsAkaoad n b6t4 A waai 4d*Am tart e0aad,le caaaac oars aaaw 4ad,0aa a a0w kaktowR ambc mmd —.a
t:ewr.c a,r.M chacl All 1000 taarr 9MIChad a,OOA*A.W,Aaar dta►Iry 00 a0aa*(a„M16-Ga1aa}C.4an wd,Ora W%*Ow a aw ma"menw,aoc+
..qw.T+.+ U ar,wh<oaa,cuw,k"v m viryv0s,4"7 sraw/q.iAO*mp* --to 'comp.pWk)F 0®OAa.
!asR aw i,wpilajvr t)ta!14 prsnilin� "s�sr*ers"e•ayt+•saart/t{ew lwssrstwarr jar a►r awrpr(wrwra. dwJw+►b Mi p�4lfe7'awl je► r�tr
r nS/inw anti
lnsurmce C;omp•ay Name Aiht tit„ivai insurance
F'i>1,cy a'Y Sal(-coa I-,c a 14V(,40,)il11 26611014A E.A+wap�Lm Dsic 1 R`fl1ti
lob Soh Amrw
,�, �,./�� �� _ - ---- -___. _ ctty�staoe�r�p_ t7,•,?�nce.
titta,ch a copy •f the w•rte"'compansadea peAcT Ai ciar'adea pegs(Abvw,*mg tha pilicy mmmber and azpitrati•a data).
F aslurc to sears coverage u required t ado Sec6m 25A of bf OL c 151 can lead to Ow iupar cmm of crie imW paaaltiics of 4
Asst Up to S 1,500.00 andlor one-year aaptisooaimt,a well as civil p,anakma m the ftars4t of a STOP WORK ORDER and a ftnr
of up to $250.00 a 44y adsusat the vsolator. Be advised that a cWy of Chu stateasecrt au be fbrwarderd to the Office of
Invests uctnu of the DIA fa an"macc covtsttiyt:vetibeation.
f Je horvby,cirro,ry fh#pniwJ A-44 pPewwwhift rrf Pirfbry t114N tl►x l#V*rW94djww prV-VjAP f abo-Im fa tru+a 1 cwrreei.
13-Z6�9 S
OfflCia/ naf mite in tkis airra, So AV Ceaap&e(v/h l*Y sr lVtv 4r *fflci.1
City or Iowa: -_- rcrn.Wl.icen,c r
1"wiitb Antherity(dretr one):
I. Beard of Heattit 1. Bmwiab Dvpartowat S. Citj(roww CZeri 4. Llectricca,l tnspc<l*c 5. rlwmbimkg In.specro(
6.Other
Getact lerHa: _. .__ Phone X:
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
Adam Quenneville CS-070626
License Number
160 Old Lyman Rd South Hadley MA 01075 8/21/2015
Address Expiration Date
413-536-5955
Sign re Telephone
9.Reastered Home Improvement Contractor: Not Applicable ❑
Adam Quenneville Roofing 120982
Company Name Registration Number
3/25/16
160 Old Lyman Rd South Hadley MA 01075
Address Expiration Date
Telephone
413-536-5955
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....... 6 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
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑✓
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [M Siding[o] Other[o]
Brief Description of Proposed
Work: Strip existing porch roof and install new asphalt shingles
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 X 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 CONTRACTOR APPLIES FOR BUILDING PERMIT
Sara Rowan
I, as Owner of the subject
property
Adam Quenneville Roofing and Siding Inc
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
Adam Quenneville
I, 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.
Adam Quenneville
Print N
L
Sig at a 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 Gm..m... .
Frontage ............
Setbacks Front r..
Side L:" R:, L: R:
Rear
Building Height
Bldg. Square Footage °
Open Space Footage
(Lot area minus bldg&paved
parking)
#of Parking Spaces .i
Fill: (�
volume&Location)__ _....
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO Q DON'T KNOW YES
IF YES, date issued:,,
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW #4-N YES 0
IF YES: enter Book Page` and/or Document#_
B. Does the site contain a brook, body of water or wetlands? NO (F) 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 , 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 0 NO e
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
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
f7r�p�t�rrt��I �y
1 City of Northampton to 0 "it
Building Department dilib t/G"fly , Pemml#
L 212 Main Street Room 100 WafertUUell Rwatik�xli +
JJL
Northampton, MA 01060 Two Sett 13-587-1240 Fax 413-587-1272 PIottsiteI-Ptans Other pedify
,
PLICATION 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
Map Lot Unit
186 North Main St
Florence MA 01062 Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Sara Rowan 186 North Main St Florence MA 01062
Name(Print) Currentljnns:
See Contract
Telephone
Signature
2.2 Authorized Anent:
Adam Quenneville 160 Old Lyman Rd South Hadley MA 01075
Name(Pi ) Current Mailing Address:
413-536-5955
Sign t e Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building 1608.00 (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=0 +2+3+4+5) 1,608 Check Number
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
186 NORTH MAIN ST BP-2015-0084
GIS#: COMMONWEALTH OF MASSACHUSETTS
Ma :Block: 16D-008 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-2015-0084
Project# JS-2015-000147
Est. Cost: $1608.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ADAM QUENNEVILLE 070626
Lot Size(sq.ft.): 7579.44 Owner: PETTIFORD LASHONDA& SARA P ROWAN
Zoning: URB(100)/WP(0)/ Applicant: ADAM QUENNEVILLE
AT. 186 NORTH MAIN ST
Applicant Address: Phone: Insurance:
160 OLD LYMAN RD (413) 536-5955 () Workers
Compensation
SOUTH HADLEYMA01075 ISSUED ON.712212014 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 Deuartment 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 7/22/2014 0:00:00 $35.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner