17C-281 107 NORTH MAPLE ST BP-2017-042$
cis#: COMMONWEALTH OF MASSACHUSETTS
Man:Block: 17C-281 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-2017-0428
Project if JS-2017-000714
Est.Cost: $1$Q00.00
Fee:$40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group ADAM QUENNEVILLE 070626
Lot Size(sq.t): 9060.48 Owner: DEVLIN MARK
Zoning:URB(I001 Applicant: ADAM QUENNEVILLE
AT: 107 NORTH MAPLE ST
Applicant Address: Phone: Insurance:
160 OLD LYMAN RD (413) 536-5955 0 Workers
Compensation
SOUTH HADLEYMA01075 ISSUED ON:10/3/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:REMOVE EXISTING ROOF MATERIAL &
INSTALL NEW ASPHALT SHINGEL SYSTEM
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:
FinaO 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 10/3/2016 0:00:00 S40.00
212 Main Street,Phone(413)587.1240.Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
i f{.7 City of Northampton � '� � ;` � Vr'�'+Vd
Building Department s
�'. � 212 Main Street a°5-7;Ive
q. $
Room 100 �" • y ..
‘OPar Northampton, MA 01060 ; :1 . 3 '' -'l
tcphone 413-587-1240 Fax 413-587-1272 P SI(e
c1 "' OfItRE%Spfy'..- +.... +a�,^�` ' rir* tm ...." s
LIGATION 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 byoffice
107 North Maple St Map Lot Unit
Florence, MA 01062 Zone Overlay District
Elm SL District CB District
SECTION 2•PROPERTY OWNERSHIP/AUTHORIZED AGENT
3.1 Owner of Record:
Mark Devlin 107 North Maple St Florence, MA 01062
Name(Print) Current Mailing Address:
413-5674045
See Contract
Telephone
Signature
$.2 Authorized Agent:
Adam Quenneville 160 Old Lyman Rd. South Hadley, MA 01075
Name(Print) ✓I Current Me ng Address:
413-536-5955
Signature Telephone
• SECTION 3-ESTIMATED CONSTRUCTION COST$,
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1, Building (a)Building Permit Fee
$18,000.00
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) $18,000.00 Check Number3&/19,2
This Section For Official Use Only
Building Permit Number: Iss
Issued'
Signature: 915 71e/
i
Building Commissioner/Inspector of Buildings Date
p
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 iv by
Building Department
Lot Size . _ '..__ �._
Frontage
Setbacks Front
_
Side I . _I R:i... L:I R:..
Rear ....__._ ,.__'.
Building Height
Bldg.Square Footage
Open Space Footage
(Lot area minus bldg&paved L.__! __. J _.....—.
parking)
#of Parking Spaces — [ --r
Fill: _.._._._._ ._.._.._.. .. _
(votnme&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW Q YES O
IF YES,date issued:;.
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW 0 YES O
IF YES: enter Boots E Page: i and/or Document#,
B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW Q 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 ll 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 0
IF YES, describe size,type and Location: : ,
E. Win the construction activity disturb(cli anng,grading,excavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES ! 1 NO 1(a
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
,SECTION 5-DESCRIPTION OF PROPOSED WORK Icheck all applicable)
New House 0 Addition 0 Replacement Windows Alteration(s) ❑ Roofing
Or Doors
Accessory Bldg. 0 Demolition ❑ New Signs [C] Decks [0 Siding[0] Other[C]
Brief Description of Proposed
Work: Remove existing roof material and Install new asphalt shingle system.
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
Sa,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
a. Number of stories?
f, Method of heating? Fireplaces or Woodstoves` Number of each
g. Energy Conservation Compliance, Masstlreck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft.of wetlands? , Yes No. Is construction within 100 yr. floodplain YesNo
J. Depth of basement or cellar floor below finished grade ,_
c Will building conform to the Building and Zoning regulations? Yes No.
I. Septic Tank City Sewer Private well City water Supply
SECTION 70-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
Mork Devlin as Owner of the subject
property
hereby authorize Adam Quenneville
to act on my behalf, in all matters relative to work authorized by this building permit application.
1a7/i' ..
Signature of Owner Dale
i, Adam Quenneville ,as OwnarfAuthorized
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 Name //,/d l /_
/// am eihn bk
Signature of OwneriAgent pate
SECTION 8•CONSTRUCTION SERVICES
SI Licensed Construction Supervisor Not Applicable 0
Noma of License Holder:Adam Quennevilte CS 070626
License Number
160 Old Lyman Rd.South Hadley,MA 01075 8/21/2017
Address Expiration Date
413-536-5955
Signature Telephone
9,Redkterad Home improvement Contractor Not Applicable 0
Adam Quenneville Roofing 120982
Company Name Registration Number
160 Old Lyman Rd.South Hadley,MA 01075 3/25/2018
Address Expiration Date
'✓�''�� Telephone 413-536-5955
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152, 250(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 c4 No 0
11. -Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dweffines 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,CMN 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,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 wider the Marline 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 he 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,von may he 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
ALZ,�L_M_J✓ VU (]
BBB —
QUENNEVILLE Winner theTORCHAWARD ° °° pis""ta
ROOFING 1r 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@ls00newroofnet Website:wwebsite,www.1 OnewroSfnet Factory Trained
MA Construction Supervisors Liz.4070626 MA Registration 0981 Factory Certified Installers
Member of the Home Budders Assoc.or Western Mass. CT Registration 3575920
Member of the Building&Trade Association PPS 38710
Proposal Submitted To: Date: Phone Ws: C:1i43)575-/'5-
/&/ PetlN q62/6c HQ63)5-e7-Vo W:
Street: Email:
107 X8.7 A9/e SI- /b1C OM 3 € c._..,{.^af
City,State,Zip Code: Special Requirements:
F /•-ee Al 010 ?Std ?.d c, • ktr .h ✓•s t
PROPOSAL FOR: 1...E A/
HOU GARAGE OTHER f ./ / ./ s�A�/ S�.�e +
STRI RECOVER NE d tJl e gym
Layers: I 3 4 Plywood Included:r brN u`/ F,rC. •"`f `•1•
75 Tear offLAT or c4,--r/5 'r°`��"j`'
COMPLETE ROOF PROTECTION SYSTEM:
X We shall acquire appropriate permits for all work
X Home exterior and landscaping to be protected 1 /
X Strip existing roofing to existing decking with full inspection DO NOT DO: St
X All project waste shall be removed by dumpster(dumpsterfor contractor use only)
X Deteriorated existing decking will be replaced at$3.77 per sq.ft.after full inspection Customerinitials: y14.c")
-,c Install Ice&Water Barrier at all eaves M 0 valleys,chimneys,pipes and skylights
X Install(1516.felt/$ynthedc underlayment over remaining decking area
7( Install Metal drip edge at eaves and rakes®/5"{ whit /brown)
X Install manufacturer's starter shingle on all eaves and rake edges
)c Install new pipe boot flashing/vent accessories
Install ridge vent-Snow Country/Cobra rolled/4'Baffled/Roll r7
Shingles:(standard 6 nails per shingle) /
//Q�If to
/ 7
GAF Shingles 25 year A-30 Year 50 Year Color: P
GAP Ridge cap shingles
Warranty Options:
/. We guarantee our workmanship for 10 full years(see our warranty coverage page)
GAF System Plus Warranty
GAF Golden Pledge Warranty
AQRS Recommendations:
Lead Counter Flashing _ Water Seal&Tuckpoint Rubberized Crown Metal Chimney Cap
Replacing old skylights(or waiver must be signed) Mason work (or waiver must be signed)
Heated panel roof system Insulation _ Ventilation
Opted out of AQRS recommendations Customer Initials:
We proposehereby to furnish mztenah and labr—complete m accordance wall above specinwnons for the sum ofTotal Doe.($ /SOoo )
ACCEPTANCE OF PROPOSAL:The above prices,specifications and conditions are Down Payment:($ fi^• "✓' )
satisfactory and are hereby accepted.You are authorized to do work as specified. Balance Due Upon Completion:IS
Payment will be 1/3 down at start of job,and balance due upo r completion.
Date: 9 I L1 I)b Signature: 1ik_A-4\ / //• /` / ��
Date: 5/3r16 Estimator.)Print Name) �tr-� �i[. . (Sign Name) /G// /' /�- _ t—
�r-
Estimates are honored for sixty(601 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. Customer Initials: 17
AcF CERTIFICATE OF LIABILITY INSURANCE DATE`MMpDny.Tl
u„„..- 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(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the poilcy(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 Iles of such endorsemengs).
PRODUCER CONTACT Neliada &arakela ..t1AME _.
Goss & McLain Insurance Agency PHONE moi {413)534 PAx 7355 - oicNei(413.536.9ERa
1767 Northampton Street p_pps.mkarakuia@gosemolain.com
P 0 Box 1128 _ INSURERIS)AFFORDING COVERAGE _ I NAICa
Holyoke MA 01041-1128 INSURER A Naut ilea Ins Company
INSURED INSURER RAIN Lacteal Ise Co
Adam ❑uenueville Roofing & Siding Inc INBURERC:
160 Old Lyman Road msuaER O:
INSURER E:
South Hadley MA 01075 INSURER F: I
COVERAGES CERTIFICATE NUMBER:CL1662403220 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,
ISAAo 609R mum,mum, FF POLICTESP
LW' TYPE OF INSURANCE INSD'MLR, POLICY NUMBER 'I IMM'D YYI IMOD/TIM LIMITS
SICOMMERCIAL GENERAL LIARILWri EACH OCCURRENCE 'S 1,000,000
DAMAGE TORR`NTED
A JCtA1M>MADE X OCCUR 6/23/1016 6/23/201] !WEDERR(Any on INJURY E 1,015,00
NN605342 I PRE ISP tE 0
.. _ _ 0
I_J
GEN'L AGGREGATE LIMIT APPLIES PER'. I GENERAL AGGREGATE L5 2,000,900
_A POUCH _�PRO- L.=.LOC .PRODUCTS COMP:OPADD S -..... 2,000,000
OTHER. I
{ Emq v Benefitsern
IS
1,000,000
AUTOMOBILE II/talker I COMBINED SINGLE OMIT
OaccieI
ANY AUTO
� O Lr INJURY(P .Felson) s
AU OWNED r6C SCHEDULED
BODILY INJURY Lar ncuoanu S
AUTOS
t ANN-04N£D ! PROPERTY DAMAGE S
HIRED AUKS ___ AUTOS LlEac mtle+l ... , _.
I i I Dndennsured mMp151 BI split 1 S
UMBRELLA LIAR . OCCUR I j EACH OCCURRENCE IS 1,000,000
c x EXCESS DAB_ [ R CLAIMS-MADEI AGGREGATE 9
I R I AN030622 0/13/2016 0
,CSD= IRETENifONa YQC03� ( ( )13/301] ( 5
AND EMPLOYERS'
PER :ORµ
AND UABIUTY YIA,i ' AH ACCIDENT`ER
AWC9007011P61-2016A 9/29/2016 4/29/201]
E ry — _ 5 1,000,000
D 'IDFFICERAIEM84R EXCLUDED uUVEy NIA. EL cHs 1,000,000
IManCb In NNI FL DISEASE-EA EMPLOYE__
y RI be oNer
[DESCRIPTIONGP OPERATIONS PPIPW LEI.DISEASE-POLICY LIMIT IS 1,000,000
I
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,AJheisP°I Remarks Scheeme,may be attached It mare space is cereal)
Certificate holders are additonal insured on the above captioned GL policy; subject to policy forms,
conditions, and exclusions. Adam Duenneville, as an officer, 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 PRONSIONS.
AUTHOPoZEO REPRESENTATIVE ��j/////////
M Karakuls./MILADY 7"/7/ -
01988-2014 ACORD CORPORATION. All rights reserved,
ACORD 25(2414M1) The ACORD name and logo are registered marks of ACORD
INSinsni io
The Commonwealth of Massachusetts
Department of Industrial Accidents
_151 _ 1 Congress Street,Suite 100
ei
Boston, MA 02114-2017
i s
www.mass.gov/dia
`" Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO HE FILED WITH THE PERMITTING AUTHORITY.
Applicant information Please Print Legibly
Name (Business/organi>ation/lndividuap: Adam Quennevllle 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):
1_1E11 am a employer with 15 encloyces(full andforpart-limey 7. ❑New construction
20 I am a sole proprietor r partnership and have no employees working for mc io 8, Remodeling
any capacity.[No workers'comp.insurance required.)
3.I am a homeowner doing all work myself[No workers'comp.insurance required.]* 9. E]Demolition
4_flI am a homeowner and will be luring contractors to conduct all work on my property. t will 10 pHuilding addition
ensure that all contractors either have workers'compensation insurance or are sole II.J Electrical repairs or additions
proprietors with no employees' 12.❑Plumbing repairs or additions
50 I am a general contractor and 1 have hired the sub-contractors listed on the attached sheet13.®ROofrepairs
These sub-contractors have employees and have workers'comp.insurance.:
b.❑W'e are a corporation and ns officers have exercised their right of exemption per NIGL c. 14.0Other
152,§1(4),and we have no employees.[No workers'comp,insurance required]
'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy in Formation.
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 hose
employees. Vibe snbsoatracros 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
AWC4007012861-2016.0 ; 4/29/2017
Policy#or Self-ins. Expiration Date.
Job Site Address: l d 7 D Y L M \ S4, City/State/Zip: \Ore fle c , M A O(Cu ).o
Attach a copy of the workers'compensation po icy 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 SI,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 S250.00 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 eertjfr under the pains an penalties of perjury that the information provided+ above is true and correct
Sits /° � _.. Date: /A' 7/no
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):
I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
ps _ , , _ _
,�. Massachusetts Department of Public Safety
Board of Building Regulations and Standards
License: CS-070626
Construction Supervisor ti-
ADAM AQUENNEVILLE. 14^ry ' =-i
180 OLD LYMAN RD a lI� 3"
SOUTH HADLEY MA i 3
rr '� 1b1ltff t
-.n CCL. Expiration
Commissioner 08121/2017
(7/4 7r0B?iitorrinerr/fAn H //i7.i.lrtr/rrJe//1
., estrit
e ., Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration. 120982
Type: DBA
Expiration: 3/2512018 TM 419291
ADAM QUENNEVILLE ROOFING
ADAM QUENNEVILLE - -- - -_-- --" -_--
160 OLD LYMAN RD - - ---------
SO. HADLEY, MA 01075 --- -- -- - ---- - -- -
Update Address and return card.Mark reason for change.
{-: Address ❑ Renewal rlmpym
Employment Lost Card
SCA c am este — I
+..` Rt' '!a+ 'u' 41.2."-4,1! 144. 2S.+. .0 Sl 'SP' .c1` "S!"_ V' +s7r' 4+ Ai. 'SC ;VolSC_ "'SP
3
STATE OF CONNECTICUT + DEPARTMENT OF CONSUMER PROTECTION ION Itt
f Reit known that
II+ `s
;i ADAM QUENNEVILLE f�
r 160 OLD LYMAN ROAD
4
{ SOUTH HADLEY, MA 01075-2632
a
{ is certified by the Department of Consumer Protection as a registered I 1j
it
HOME IMPROVEMENT CONTRACTOR is
1. y Registration # I-IIC:0575920 0
4
*' ADAM QUENNEVILLE ROOFING
,o, 12/01/2015
- Expiration: 11/30 12016ar i'
J lM1 A 11 ,L LA ,A
,i1 Ml fi .V nom* ^r 4W ,P w4 fi ry\ ' YY`
4135361448 AQRSFAX 11'.5734 a . 10-05-2016 111
City of Northampton 212 Main Street,Northampton,MA 01060
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as
a condition of the building permit all debris resulting from the construction
activity governed by this Building Permit shall be disposed of in a properly
licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
Address of the work: 10.7 /f orkt (Nth, � ctarerc-e--
The debris will be transported by: USA Hauling&Recycling Inc.
The debris will be received by: USA Hauling&Recycling Inc.15 Mullen Rd Enfield,CT
Building permit number
Name of Permit Applicant Adam Quenneville Roofing&Siding Inc.
Date Signature of Permit Applicant