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18-003 (2) 426 HATFIELD ST BP-2017-0670 ols#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 18-003 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-2017-0670 Project# JS-2017-001093 Est.Cost:$16590.00 Fee:$40.00 PERMISSION IS HEREBY GRANTED TO: Const Class Contractor: License: Use Group: ADAM QUENNEVILLE 070626 Lot Size(sci.It): Owner: SKIBISKI MAYA zoning: Applicant: ADAM QUENNEVILLE AT: 426 HATFIELD ST Applicant Address: Phone: Insurance: 160 OLD LYMAN RI) (413) 536-5955O Workers Compensation SOUTH HADLEYMA01075 ISSUED ON:11/15/2016 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 11/15/2016 0:00:00 S40.00 212 Mast Street, Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner __ Department use only F • _, i City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit 4 - • j 212 Main Street Sewer/Septic Availability Room 100 Water/Well Availability orthampton, MA 01060 Two Sets of Structural Plans phoua-413-587-1240 Fax 413-587-1272 Plot/Site Plans I ._'_. —_ Other Specify APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION II -0 7O 1.1 Properly Address: This section to be completed by office 426 Hatfield Street Map Lot Unit Northampton, MA 01060 Zone Overlay District Elm St District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: John Skibiski 426 Hatfield Street Northampton, MA 01060 Name(Print) Current Mailing Address: 413-626-1038 Telephone Signature 2.2 Authorized Agent: Adam Quenneville 160 Old Lyman Rd South Hadley MA 01075 Name(Print) Current Mailing Address: 413-536-5955 Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building11 5610e o (a)Building Permit Fee 2. Electrical VJ (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) l6SClu°" U U Check Number >r.Fj//(� '/ 44"T This Section For Official Use Only Date Building Permit Number: Issued: Signature: - Building Commissioner/Inspector of Buildings Date Section 4. ZONING AU 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 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 O DONT KNOW O YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW ® YES 0 IF YES: enter Book Page and/or Document # 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 over 1 acre? YES O NO 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 © Addition ❑ Replacement Windows Alterations) 0 Roofing Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks ID Siding[O] Other[O] 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 Se,If New house and or addition tD 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 R.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 I John Skibiski as Owner of the subject Properly hereby authorize Adam Quenneville Roofing&Siding Inc. to act on my behalf, in all matters relative to work authorized by this building permit application. See Contract i i } t 4 1 7 LC' Signature of Ormw Date 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 Print Name q JJYYdk__ i i191 ] (4° Signature of Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable 0 Name of License Holden Adam Quenneville CS 070626 U License Number 160 Old Lyman Rd.South Hadley, MA 01075 8/21/2017 Address Expiration Date ✓/y,�/V/ 413-536-5955 Signature Telephone 9.Registered Home Improvement Contractor: Not Applicable 0 Adam Quenneville Roofing HIC 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.e.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 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 Slate of Massachusetts General Laws Annotated. Homeowner Signature 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: 426 Hatfield Street Northampton, MA 01060 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 ouenneville it 9 Date Signature of Permit Applicant QUENNEVILLE w;nom of the ro„ „AN no V1=04 glkoveIL Iv ROOFING 'V SIDING V WINDOWS 160 Old Lyman Road•South Hadley•MA 01075 We are Licensed 1.800.NEW,ROOF • 413.536.595S Fully Insured Email.intot I$00oewrpotnet Website.www.1800newrootnet Factory Trained MA Construction Supervisors tic.#070626 mg Registration X120902 Factory Certified Installers Mambo-a the Hone BLIMP t'%.Astor of wesmm Mass. CT Registration#575920 Menthes['Stile Building&Trask Association OP C 38710 Pin osal Submitted To: Date: Phone ti's: C: Jo . C 4 sk I I lV H:t'IO" 5Pi(x- Pin W: Street: Email: 40l° 14a1frcld 5-t City,State,Zip Code; Special Requirements: IJOr7).‘C..,r Th rix, Of CCC PROPOSAL FOR: OWCGAJtAa) IP RECOVER NEW GUTTERS Layers: 1 2(3, 4 Plywood included: Yes Tear off SLATE 3!SHAKES 4QMPLETE ROOF PROTECTION SYSTEM: 4 We shall acquire appropriate permits far all work Home exterior and landscaping to be protected /�, A Strip existing roofing to existing decking with full inspection DO NOT DO: r)Od'n or Slot A All project waste shall be removed by dumpster(dumpsterfor contractor use only) k Deteriorated existing decking will be replaced at$3.77 per sq.ft after full inspect• erInitial s: 8¢. X im-tali Ice&Water all eaves 3'/6,valleys,chimneys,pipes and skylight install j151b.felt Synthetic derlaymenp.otver re ring decking area A. Install Metal drip edge at eaves and rake (8" 5")(white brown) W Install manufacturer's starter shingle on all eaves an•ra e edges * Install new pipe boot flashing(vent d rcessus Install ridge vent-Snow Country(Cobra rolledd t x Baffled Shingles:(standard 6 nails per shingle) L(4 i,_r V ^� Cttt..r-ae4- GAP Shingles S 25 year?C30 Year - 50 Year Color: O Ter le r t*'^T_•``_(MC Ridge cap shingles Warranty Options: C We guarantee our workmanship for 10 full years(see our warranty coverage page) .%'GAF System Plus Warranty g GAF Golden Pledge Warranty AQRS Recommendations: . Lead Counter Flashing "' Water Seal&Tuckpoint -_ Rubberized Crown Metal Chimney Cap Replacing old Skylights(orwager must be signed) _Mason work for waiver must be signed) " Heated panel roof system _ Insulation Te Ventilation Opted out of AQRS recommendations Customer initials: wr ProWu herebyrnmmaterials awl labor-compote in accordance with at,.specifications kg the swear: Total Due:(5 i(e 5S0,tia) ACCEPTANCE OF PROPOSAL: above prices,specibo6ons and conditions are eel-PT,,FOy Q' Down Payment:($ 5O) 0 satisfactoryand are hereby accepted.You are authorized to do work as specified. 11 Balance Due Upon Completion:($] I:r10.ea1 Payment wllrbe tl3down nag and isigla rcedueuooncOmptjort N'ro Deft 1 ( -1'—J{ _L ._ _signature' / Date:lll lllRE Estimator:(P Name) ``�r'oli Se ZAe'‘l"- (Sign Name) fs'Ab Estlnutnare honored for sixty(601daysfromabovedate. AT fENTIONHOMEOWNERS:Please coves 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 Ouenneville Roofing will not be responsible for debris or dust in the attic or storage areas. Customer Initials: A °° CERTIFICATE OF LIABILITY INSURANCE DATE(MINDO1YYYi 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 poiicylies)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 CONTACT Melinda Rarakula Gose a McLain Insurance Agency "ONE (413)534-7355W.111._0211, LIND t31315J6.92e6 1767 Northampton Street j sA mkarakulaagos smmc'ain.com _.. i.._._. P 0 Box 1128 INSURER(S)AFFORDING COVERAGE _ __NAILX _ Holyoke MA 01041.1128 INSURERA Nautilus Ins Company . __I ... .__ _-_ N8WE0 INSURER Mutual Ina CO _ .__. 1 Adam queaneville Roofing & Siding Inc INSURER__. _..__ _. ._._ ._.- _ 160 Old Lyman Road iN5uREn o: _ _ INSURER E. _. . South Hadley MA 01075 INSURER UPERFo COVERAGES CERTIFICATE NUMSER: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. NOTWTHSTANDINO ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT VWTH 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 COMMERCIAL GENERAL L4&UTY _ C !NFL ADOL MOM POLICY FF POLICY ESP LIMITS TYPE OF INSURANCE _ LIR1NSn VNn POLICY HUNKER IMWDO IMWppIYp'p I EACH OCC.URREaCE 5 i,OGv.TOO A J LNIMS.MAOE (R ;OCCUR i.. I pRNM SEEES2 Al E 100,000 1 N14685392 6/23/2016 . 6/23/2017 . MED CRP(Any mepsovn) 5 15,000 PERSONAL RADS INJURY 6 1,000,000 GENL AGGREGATE LIMIT APPLIES PEP 'GENERAL AGGREGATE $ 2,000,000 PRO- 'S p)11C al dE S IC'A FEmk Y e PKk+AGG $ _ 2.000.000 OTHER. I6 1,000,000 AUTOMOBILE LIABILITY I 1 nvaiNeo00 SINGLE LIMIT I6 , ANY AUTO _ 1 1 60OILY INJURY(Perpw,anl Ifi I— •ALL OWNED c I SCHEDULED I i NcNoI 80011Y WUR 1, 9C[ItlenO f NON-0 2ED 'PROPERTY DAMAGE 15 V. i FIRED AUTOS AUTOS II I I UlyIennsured melee DI spPo $ UMBRELLA We ' OCCUR EACH OCCURRENCE $ 1�o0L00 C, x 1 EXCESS LIAR IX CWMSMADEI AGGREGATE _ I6 'DED a IRETENTIONS 10,0001 An030622 I, ej13/2015 T/13/301, ' (S :WORKERS COMPENSATION . PER DTH_ I IANC EMPLOYERa'UAPRYIN IrY g STATUTE C¢,_ I ANY PROPRETORIPARTNERIEXECUTIVE � P.L.EACH ACCIDENT MI6 1,000,000 D OFFILER/MEMBER EXCLUDED? 31 NIA (MenEalorylnNm 21604007012261-201.6A 4/29/20161, 1/29/2017 EL DISEASE EA EMPLOYEE$ 1.000,000 Vy Smote under DESCRIPTIONOFOPERATIONS Wowf PI.DISEASE-POLICY LIMIT $ 1,000,000 I I DESCRIPTION OF OPERAlONB I LOCATION91 VEHICLES (ACOR0101.AedXIO Rerks Schedule,may be attached R more space M required) Certificate holders are additonal insured onn the above captioned OL policy; subject to policy forme, Conditions, and exclusions. Adam quenneville, 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 PROVISIONS. AUTHORIZED REPRESENTAfVE //%% I M Ralakula/MILADY /'T//r _(" ^' : ®1468-2014 ACORD CORPORATION. All rights reserved. ACORD 25;2014/01) The ACORD name and logo are registered marks of ACORD INS025rm,mll The Commonwealth of Massachusetts 1 s ft Department of Industrial Accidents P. -AIL= 3 1 Congress Street,Suite 100 E W.8rt— ti MTV Boston,MA 02114-2017 Stly 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 1 am a employer with 15 employees(full and/or pan time).` 7. ❑New construction 2.0 1 am a sole proprietor or partnership and have no employees working for me in S. ❑Remodeling any capacity.[No workers'comp.insurance required.] 3_❑I am a homeowner doingall workmself.[No workers'comp. t19. ❑Demolition Y insurance hiring4.❑Iamahomeowner and will becontractors to conduct all work on0❑ Building addition my property. Iwill ensure that all contractors either have workers'compensation insurance or arc sole 11.0 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.❑l am a general contractor and f have hired the sub-contractors listed on the attached sheet 13,®Roof repairs These subcontractors have employees and have workers comp.insurance) 6.0 We arc a corporation and its officers have exercised their right of exemption per MGL c. 14.❑O he[ 152,§1(4),and we have no employees.[No workers'comp.insurance required.] "Any applicant that checks box PI 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. 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$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.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 pai and penalties of perjury that the information provided above is true and correct Signature: Date: I i J)I} I1 (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#: a. Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CS-070628 Construction Supervisor ADAM A QUENNEVILLE 160 OLD LYMAN RD. t SOUTH HADLEY MA, s K tr Rt ;f Esel wr. C& .. Expiration: Commissioner 0B121!2017 toir,ii?emoearj/l r/ `'IYir.;iacktifi /.1 m Office of Consumer Affairs and Business Regulation 3; 4 10 Park Plaza- Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 120982 Type: DBA Expiration: 22512018 Telt 419291 ADAM QUENNEVILLE ROOFING ADAM QUENNEVILLE - - - - - - 160 OLD LYMAN RD SO. HADLEY, MA 01075 -- -.-- -- -- --- ----- Update Address and return card.Mark reason for change, sen= q zou ouv 111 Address f j Renewal [1 Employment 11 Lost Card (1:777i747'0.m0.mcit1"✓'`\/1520/7:`,41`./ \P... '?^ s. ry .x., :x f� any ry 4... 1C, df •.0 Eft: `al' t.0 1C _ 1w a yr "tie sem. 111 qt { W2.2>,x � _ _ sti STATE OF CONNECTICUT + DEPARTMENT OF CONSUMER PROTECTION t' Be it known that 9. ADAM QUENNEVILLE 160 OLD LYMAN ROAD SOUTH HADLEY, MA 01075-2632 is certified by the Deparvnent of Consumer Protection as a registered HOME IMPROVEMENT CONTRACTOR Registration # HIC.0575920 , .11ADAM QUENNEVILLE ROOFING t T ♦� h I' , ; Effective: 12/01/2015 a� Expiration: 11/30/2016 J" tl 0411111iF41110¢1 (( ♦V xs a<1 ♦ 4 4 rZ ,r .vZ � ,r4 YW � A`« 0"r' � t �1 ♦ w ,iG �w ,'