36-014 (6) 47 FOREST GLEN DR BP-2017-0441
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:36-0]4 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-2017-0441
Project# JS-2017-000739
Est. Cost:$3300.00
Fee:$40.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ADAM QUENNEVILLE 070626
Lot Size(sq.ft.): 13982.76 Owner: AUBREY JOHN H&DEBORAH 1
Zoning: Applicant: ADAM QUENNEVILLE
AT: 47 FOREST GLEN DR
Applicant Address: Phone: Insurance:
160 OLD LYMAN RD (413) 536-5955 n Workers
Compensation
SOUTH HADLEYMA01075 ISSUED ON:10/7/2016 0:00:00
TO PERFORM THE FOLLOWING WORK REMOVE EXISTING ROOF MATERIAL &
INSTALL NEW ASPHALT SHINGLE SYSTEM ON BACK OF HOUSE ONLY
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 sienature:
FeeType: Date Paid: Amount:
Building 10/7/2016 0:00:00 $40.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
Department use only .
City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
Q -- 212 Main Street Sewer/Septic Availability_
- ea, Room 100L
WatorrneilAvailability
„1„,49.004'
ry n e'`� Northampton, MA 01060 Two Sets of Structural Plans
d:d8^P`'. • one 413-587-1240 Fax 413-587-1272 P10/Site Plans
,•w. Other Specify
lir
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 try office
47 Forest Glen Dr Map Lot Unit
Florence, MA 01062 Zone Overlay District
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
John Aubrey 47 Forest Glen Dr Florence, MA 01062
Name(Print) Current Mailing Address:
413-388-8022
See Contract Telephone
Signature
al Authorized Anent:
Adam Quenn ville 160 Old Lyman Rd South Hadley MA 01075
Name(Print) Current Mailing Address:
413-536-5955
Signature Telephone
....
SECTION 3-ESTIMATED CONSTRUCTION COSTS 1
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£LZ
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5.Fire Protection
s.
6. Total=(1 +2+3+4+5) s_. oD° Check Number ,/Gr/d
This Section For Official Use Only
Building Permit Number Date
Issued:
Signature: fillirer— /4– [7 //t`j/
Buidkrg Commissioner/Inspector of Buildings Date
Section 4. ZONING AU Information Must Be Completed.Permit Can Be Denied Due To Incomplete Information
_®® Required by Zoning
This column to be filled in by
Building Department
Frontage
Setbacks Front
Side L: _ It:. L: R:
Rear
Building Height 111.11111.
Bldg.Square Footage
Open Space Footage
(Lot arca minus bldg&paved
,atkln,)
if ofParkint S.aces MEM
Fill: 11111.11111
volume&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW YES 0
IF YES,date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW O YES O
IF YES: enter Book Page and/or Document it
B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW O YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained O , Date Issued:
C. Do any signs exist on the property? YES O NO O
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES O 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 aver 1 acre? YES O NO w
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(Check all applicable)
New House 0 Addition 0 Replacement Windows Alteration(s) ❑ Roofing
Or Doors 0
Accessory Bldg. ❑ Demolition 0 New Signs [D] Decks [0 Siding Ipl Other[E ]
Brief Description of Proposed
Work: Remove existna roof matazfel and install new asphalt stende system on back of house only
Alteration of existing bedroom Yes X No Adding new bedroom Yes X No
Attached Narrative Renovating unfinished basement Yes X No
Plans Attached Roll -Sheet
St 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 la-OWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
i, John Aubrey .as Owner of the subject
property
hereby authorize Adam Quenneville Roofing
to act on my behalf,in all matters relative to work authorized by this building permit application.
Bee Contract
Signature of Owner Date
i, Adam Quenneville 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 iPrint Name / 9130)10
Signature of Owner/Agent Date
SECTION 8-CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor: Not Applicable 0
Name of License Render: Adam Quennevilie CS 070626
License Number
160 Old Lyman Rd South Hadley MA 01075 8/21/2017
Address ,r Expiration Date
413-536-5955
Signature Telephone
9.Registered Home Improvement Contractor- Not Applicable 0
Adam Quenneville Roofing 120982
Company Name Registration Number
160 Old Lyman Rd South Hadley MA 01075 3!a S 1119
Address ,r ,
Telephone 413-536-5955 Expiration Date
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 V No
11. - Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(I) 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 108.35.1.
Definition of Homeowner:Person(s)who own a parcel of land on which he/she resides or intends to reside,on which there
is,oris 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 Construclion 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 Codc,City of
Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
L£� , D A M BBB �!,...�rp#
QUENNEVILLE Winneroft_rTORCheHAWARD VISA
abDIc.°"
ROOFING V SIDING V WINDOWS
160 Old Lyman Road•South Hadley•MA 01075 We are Licensed
1.800.NEW.R00F • 413.536.5955 Fully Insured
Email:Info@18o0newroofnet Website'.www.1800newroolnet Factory Trained
MA Construction Supervisors Lic.#070626 MA Registration#120982 Factory Certified Installers
Member of the Home Builders Assoc of Western Mass. CT Registration 575920
Member of the Bulldog&Trade Association PP.0 3BI10
Proposal Submitted/� To: Date Phone A's Cc113-38a- 303)
s Vov foinc<y. 91a� 1u H: W'.
Street: U \ Email:
f-n Voce Sx G(<n !fir
City,State,Zip Code: Special Requirements:
V I oter•.ce 2-14 010W Co E} Icc en GaieC ei
PROPOSAL FOR:
HOUSE GARAGE OTHER }r (� 1
STRIP RECOVER NEW GUTTERS 1C04\ Ot mC&sn 1'AGvS<- an .. OV(r
Layers:�2 3 4 Plywood Included: Yes or No �G� (,Ofn4o.,) 0nl7
Tear off SLATE or SHAKES
COMPLETE ROOF PROTECTION SYSTEM:
X We shall acquire appropriate permits for all work
X Home exterior and landscaping to be protected
k Strip existing roofing to existing decking with full inspection D0 NOT 00'.GGre•SC or cc eV Oh ie'»C
A All project waste shall be removed by dumpster(dumpsterfor contractor use only) J
)( Deteriorated existing decking will be repla d at$3.77 per sq.ft.after full inspection Customer Initials:
A Install Ice&Water all eaves 3' alleys,chimneys,pipes and skylights
k Install(151b.felt Synthet ) nderlayment ver re decking area
A Install Metal drip edged eaves and rake (8"/5) hite brown)
c Install manufacturer's starter shingle on all eaves and rake edges
Install new pipe boo _ ent accessories
N. Install ridge vent Snow Country obra rolled/4'Baffled/Roll
Shingles:(standard, 6 nails per shingle) Gi k'(, -, '/
c.)GU Shingles 25 year x 3Bi'22r 50 Year Color: /YlC fcrj
C'4 C' _ Ridge cap shingles
Warranty Options:
X We guarantee our workmanship for 10 full years(see our warranty coverage page)
X GAF System Plus Warranty
GAF Golden Pledge Warranty
AQRS Recommendations:
Lead Counter Flashing Water Seal&Tuckpoint Rubberized Crown Metal Chimney Cap
Replacing old skylights(orW aier must be signed} Masonwork (or waiver must be signed)
Heated panel roof systemInsulation Ventilation
Opted out of AQRS recommendations Customer Initials: q
We propose hereby to furnish materials and labor-complete in accordance with above specfcatiomforthexsum of. Total Due:1533U0.c4 I
ACCEPTANCE OF PROPOSAL:The above prices,specifications and conditions are P2rIN2 Down Payment:(5 f fGo,cP )
satisfactory and are hereby accepted.You are authorized to do work as specified. Balance Due Upon Completion'($. a a po.coI
Paymenten/nt�will be 1/3 down at start ofjob,and balance duet upon completion.
Date`/-a7-JIO& signature.) Lek . a,I .P /l
Date: gI)�IlL Estimator: rint Name) Je pj Se 2-i PLOY (Sign Name) //w-
Estimates Sre ho red for sixty 160)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 t he attic or storage areas. Customer Initials:
. a CERTIFICATE OF LIABILITY INSURANCE 1 DATE` "
6/24/2016
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(5), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the pollcy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy,certain policies may require art endorsement. A statement on this certificate does not confer rights to the
certificate holder In Ileu of such endorsement(s).
CONTACT
PRODUCER .NAME Melinda Karakuls _
Goss s McLain Insurance Agency PvNDNE Eat (413)534-735S t. ,,_2.,:±.(1.4(534 (26(
1767 Northampton Street, appFttes.mkarakulalegosomclain.com -_
P 0 Box 1128 INSURER(S)AFFORDING COVERAGE NAM p
Holyoke MA 01041-112B INSURER A Nauti lus Ins Company _ -_ -
INSURED INSURER B:AIM Mutual Ins Co
Adam Duenneville Roofing & Siding Inc wsuRERc,
160 old Lyman Road INSURER 0:
INSURERE.
-
-- _
South Hadley MA 01075 INSURER
COVERAGES CERTIFICATE NUMBERSL1662403220 REVISION NUMBER:
THIS IS TO CERMET THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWTHSTANDINC ANY REQUIREMENT, TERM ON 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 ALI.. THE TERMS.
EXCLUSIONSAND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSP -- - KDDLEUBEI - - POLICY EFF POLICY EAP LIMITS
OR TYPE OF INSURANCE INRn4wD'I POLICY NUMBER IMWDOIW'(YI IMAVODE/VY(I'
I_X ;COMMERCIAt6ENERAL LIABILITY . I EACH OCCURRENCE $ 1,000,000
•_ OAMAGE TOR Nt26
A W ___
1 I CMS MADE _.X OCCURrF,REMISES(E ggylnce] 5 100,000
J I NNE 6/23/201.H 6/23/2017 MED EXP(Ay 1, 'Son) $ 15.000
_ —..
PERSONAL B ADV INJURY 5 1,000,000
BEN'L AGGREGATE LIMIT APPLIES PER j GENERAL AGGREGAYE ,S 2,000,000
X_FOLKY _,1 Jon- ( I.ICC t' I PRODUCTS.COMP/00 AGO S 2,000,000
4 —
i IOTHER. @mpmyyeeeenet% 5 1,000,000
I AUTOMOBILELIAMLITYI I '•
COMBINED SINGLE LIMIT $
accident)
ANY AUTO POOL INJURY IP Person) S
^ALL OVrNfD i SCHEDULED I &ODILY INJURY(Per scuds t 5
.HIRED A4riC$ �1N •
NOOWNED i PROPERTY CAMA(�iE $
AUTOS , SeeTuee9
I �II. �Wp red mMPnRI QI split I S _.. ._
UMBRELLA LIAB 1 'OCCUR IEEACH OCCURRENCE j5 1,000,000
C x EXCESS UAB I X CIAIMSMADE __GGREGATE _ 5
' IDED I X IPETENSNN$ 10,000 I AN03062-2 4/1313016 14/13E2019 S
WORKERS COMPENSATION PER I ODI-
IANOEMPLOYERSUA&LLiY YIN 'T STAT ITE ER
PROPRIETOR/PARTNER/EXECUTIVE EL.EACH ACCIDEM 5 1,000,000
D OFFICERMEM%ER EXCLUDED y�..N IA I
(Mas.abry In NH) AWC40P10].21161-2016A 4/29/2016 4/29/201] IIEy_DISEASE,EA EMPLOYEE $ 1,000,000
oII Ee5m03 uMKK POLICY LIMIT 15 1,000,000
ESY,P PTION(JFOPERATION9 tlelpN EL.CISEABE-
I
I
DESCRIPTOR OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,AddIloMt Remade Schedule.may be attached IT more space Is requfNa
Certificate holders are additional insured on the above captioned OL policy; subject to policy forme.
conditions, and exclusions. Adam Ouenneville, as an of dicer, is excluded from the Workers Comp policy.
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.
AUTHORIZEDREPRESENTATIVE f�j/q//q/ j
M Xarakula/MILADY /4/ .tom yam . _.—
W 1 g88-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logoareregisteredmarks of ACORD
INS02Snmam.
r
The Commonwealth of Massachusetts
—We
.—..7,, "moo
Department of Industrial Accidents
a —'"4,l_ 1 Congress Street, Suite 100
4= t—
4).‘,.-4,-.07
=a�_Ee Boston,MA 02114-2017
` 4, www.mass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): Adam Quenneville Roofing &Siding Inc.
Address: 160 Old Lyman Rd.
City/State/Zip: South Hadley, MA 01075 Phone#: 413.536.5955
Are you an employer?Check the appropriate box:
Type of project(required):
LEI am a employer with 15 employees(full andlorpart-time).* 7. ❑ New construction
2.0 1 am a sole propnetor or partnership and have no employees working for me in 8. ❑Remodeling
any capacity.[No workers'comp.insurance required.]
3.0 I am a homeowner doing all work myself.[No workers'camp.insurance required.]
9. ❑Demolition
40I am a homeowner and will be hiringcontractors to conduct all work on my10❑Building addition
4
propem. Iww
ensure that all contractors either have workers'compensation insurance or are sole I1.0 Electrical repairs or additions
proprietors with no employees. 12.❑Plumbing repairs or additions
5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.®Roof repairs
These sub-contractors have employees and have workers'comp.insurance.:
6.0We are aw tion and its officers have exercised theirri ht ofexem tion14,DOther
corporation g p per MGL c.
152,§1(4d and we have no employees.[No workers'comp.insurance required.]
*Any applicant that cheeks box Al must also till out the section below showing their workers'compensation policy information.
*Homeowners who submit this affidavit indicating they arc 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.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name' AIM Mutual Insurance
Policy#or Self-ins.Lic. #: AWC4007012861-2016A Expiration Date: 4/29/2017
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to 51,500.00
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.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
Si.nature: A Date: 9t3bil(p
Phone#:
413.536.5955
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 if:
,®_ Massachusetts Department of Public Safety
Board of Building Regulations and Standards
License: CS-070626
Construction Supervisor
ADAM A QUENNEVILLE
160 OLD LYMAN RD. a. .f
SOUTH HADLEY MA -
C/L— Expiration:
G Commissioner OS/21!2017
<-7
/C `(� n 7171770)1(11e017/ /11,!(I/.i.;a dit(;i[9l6
rc-
P Office of Consumer Affairs and Business Regulation
a'ne ',y 10 Park Plaza- Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 120982
Type: DBA
Expiration: 3/25/2018 TM 419291
ADAM QUENNEVILLE ROOFING
ADAM QUENNEVILLE - - - -- --- - - - - —_. _.
160 OLD LYMAN RD
SO. HADLEY, MA 01075
Update Address and return card.Mark reason for change.
sent C M.105/11 —. Address r Renewal j Employment [1 Lost Card
b. ..r
'ate 1r' +.0 •.C' 1 4t° 1P' '�C 1C �.Y M .=+,p° '�' *C 1B ALP F wA' -SAY`�
STATE OF CONNECTICUT ♦ DEPARTMENT OF CONSUMER PROTECTION
�...; Be it known that
ADAM QUENNEVILLE .14
I E
160 OLD LYMAN ROAD •
SOUTH HADLEY, MA 01075-2632
is certified by the Department of Consumer Protection as a registeredN.
HOME IMPROVEMENT CONTRACTOR 1
,' Registration # I-IIC.0575920
I; a
ADAM QUENNEVILLE ROOFING E11 ffective: 12/01/2015
•
Expiration: 11/30/2016 Q,
hl AlanA.n Came, ,r
g'F .r4. " ti. ,Y p^ �4 1.4-71" e'4 .� :pJ4 fi