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30B-017 33 LIBERTY ST BP-2017-0852 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 30B-017 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Categow: Siding BUILDING PERMIT Permit# BP-2017-0852 Project Al JS-2017-001430 Est. Cost:$5344.00 Fee: $60.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ADAM QUENNEVILLE 070626 Lot Size(so. a.): 14592.60 Owner: MCCUSKER LORRAINE A Zoning: URB(100X Applicant: ADAM QUENNEVILLE AT: 33 LIBERTY ST Applicant Address: Phone: Insurance: 160 OLD LYMAN RD (413) 536-5955 0 Workers Compensation SOUTH HADLEYMA01075 ISSUED ON:1/11/20170:00:00 TO PERFORM THE FOLLOWING WORK:SIDING ON FRONT OF HOUSE 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 1/11/2017 0:00:00 $60.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner ___. Peparp>ept use ony - City of Northampton States arP s H Building Department Curb r• y t I 2011 212 Main Street Sevier Av'vaatlab : a t ter Room 100 Wafer p1AAvaesililty' � Northampton, MA 01060 TWp'Se¢fSlr$ti{er Pla"ris ;V - - -- phone 413-587-1240 Fax 413-587-1272 pious to P n"s OlherS f^ 'r - ,. APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING // SECTION 1 -SITE INFORMATION ( ' - /7-- `� 1.1 Property Address: This section to be completed by office 33 Liberty St 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: Thomas McCusker 33 Liberty St Florence, MA 01062 Name(Print) Current Mailing Address: d14-SAS-1141 Telephone Signature 2.2 Authorized Agent: Adam Quenneville 160 Old Lyman Rd South Hadley MA 01075 Name(Print) ,N Current Mailing Address: �(,J-v' 413-536-5955 Signature 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 5,344.00 2. Electrical (b)Estimated Total Cost of Construction from(6) 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5.Fire Protection 'l 6. Total=(1 +2+3+4+5) 5344.00 Check Number CC This Section For Oficial Use Only Building Permit Number: Date Dated: i Signature: ��' / "// Buil• g • missioner/Inspector of Buildings 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 _.__ Frontage .__.._ Setbacks Front --"' -" r n Side L i R: L: , R ____ 1 _- , 1 1,. '. Rear ' Building Height �.._.-_., -_-.—_ r--_— Bldg.Square Footage __ r _ % .,__ . _. 1 i Open Space Footage % _ __.___ _._ (lot area minus bldg&paved i _-_ parking) #of Parking Spaces ---. - - (volume&location) - _. ._._.. �1 I A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DONT KNOW Q YES 0 IF YES, date issued:' I IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW ® YES O 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 0 , Date Issued: ,� C. Do any signs exist on the property? YES 0 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 0 NO O 1 IF YES, describe size, type and location: E Will lII disturb the construction a aare'disturb ONO Q(clearing,grading,excavation,or filling)over 1 acre or is it part of a common plan that 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 n Replacement Windows Alteration(s) D Roofing FA Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs (pi Decks [O Siding[p] Other[p] Brief Description of Proposed Si Lira, J on.- �L.roast Frf Work: Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roil -Sheet 6a.If New house and or addition to existing housing, complete the following: a. Use of building:One Family X Two Family Omer 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. 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 Boor 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 Ta•OWNER AUTHORIZATION-TO SE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT Thomas McCusker as Owner of the subject property 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 1Mg Signature of Owner 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 Pant Name Signature of er/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor Not Applicable 0 Name of License Holder: Adam Quennevllle ......... CS 070626 U License Number 160 Old Lyman Rd.South Hadley, MA 01075 6/21/2017 Address Expiration Date 413.536-5955 • Signature Telephone 8.Rerdstered Home Improvement Contractor. Not Appkcabie ❑ Adam Quonneville 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.C.152,§25C(8)) 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 fil 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 789, Sixth Edition Section 1083.5.1. 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 S pervisor your presence on the job site will be required from time to time,during and upon completion of the work for which this pennit 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 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: 33 Liberty St Florence, MA 01062 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 Date Signature of Permit Applicant ra Proposal Submitted To Dale t't D TI.,-t., lc Cuter 1,3-paPLI Street ® ROOFINGIt QUENNEV�I�LLE -33NDOWS City Lzoo 3t rt 160 Old Lyman Road•South Hadley,MA 01075 fotrntt rr , QICL3 1.800.NEWROOF • 413.536.5955 IP^one#'s Email info®te00newroocnel Website:www.t Boonewroof.net H: D13-0 JOS w: MA Construction Supervisors Lic.#070626 MA Registration 11120982 D\umpSter Location Member of the Home Builders Association of Western Mass. CT Registration#575920 /]e(Dr WA� Member of the Building a Trade Asswiaten Member al the Better Business Bureau '- J wa e: �:.... ........ .^:.�^......„ ..r...=..�.. . ..«....m. .. .rt-�'—te. AREAS to be SIDED PROFILE COLOR )2e Brand J Front }d 'maw 51,,7 Clapboard �— a Siding— S ht•. ( r.,. — Left S Dutchciap f Corners C Back CORNERS WINDOWS&DOORS Right Standard x COLOR Other ____ Designef ',Mote only J Channel kir ()r"Y J Block Bran Style Color Location SM1 es _. Stone _._ Rounds },,, rest yl No I ayes: Vinyl/Wood Aluminum I I only where new mane ro be(ovens.Aden ovesmmiee gaoling&slung.Inc.wiu NOT remove a,beawa materiel. _..4iIM fiF -A 3/e" Tyvek I 1 Y AREASTO BE COVERED Front Left Back Right COLOR Ory COLOR Selig&Fascia Windows/Doors — Sat Only Garage/Paan Door Fascia Only % Cu R_ Double Garage Door fMr quad Oul Frame Plain Coll I ARMS/SP AIum Coll I r Mrr_.:..a...wa r :.y'•n.y ,,. .. _. ..:_ �n _ Com` _ ON Awnings up Ory Double 5'Sona Color. Storm Windows f Awns td a' Location.. Storm Doors I Awnings Over 8' YIN COLOR Burglar Cars' Existing Shutters wrap Porch Beams neem mwkelse.ryry Bars a be removed but not mmuarkd Wrap Porch Posts __ GABLE LVE�B _ '"'..r SpecifyIhelocations' _ .__ NEW SHUTTERS OtOLOR r 0,esea COLOR __ Rectangle I ski s(x Louvered Octagon Raised Panel .. aasMalCRrt r W roe I/lave reviewedandagree with.me job specificationsd above It rotted wood is discovered AFER removing the easel-1g acting,or if could not be t r. at thetime sale, there will be an addtmal charge of$0 00 SqFtfor Plywood and$500 per tifsFL for Dimensional Lumber Customer Signature / -e Date: rZ-40/%6 We Propose hereby to furnish materials and labor-complete in accordance with above specifications for the sum of. G Pdct w(yment r- TOWISale Price$ 53tiy-O0____._ Down Payments I IDc; Lo _ DIM Completion$ 35ry'<b ACCEPTANCE OF PROPOSAL:The elvn prices,specifications and conditions are satisfactory and ere hereby accepted. 6 you are sutwteed to do work as apMlled.Payment willbe/SEcom upon signing,and Marne due upon ecttMMe EBB unpaid balances shall roue with interest at 18%per annum.Purchase(s)will pay for all costs,expenses end reasonable T— lila.ot tram attorey'e fees Intoned by Adam Ouennevle Rodin.&Skiing.Inc.to rowan any eras due under this convect mace swam pato/43d�(.. Signature:/ it::" Phone! _ Dater01ZpL Salesperson's Signature: - AL Estimates are honored for sixty(60)days from above date Please remove all breakables from Interior wail anfaaes dudng installation.AOR&S will not be Mponslbe for damage. REa CERTIFICATE OF LIABILITY INSURANCE DATE(MWDE YY1) 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: It the certificate holder Is an ADDITIONAL INSURED,the policy(ies)must be endorsed. It 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(leu of such endorsement(s). PRODUCER CONTACT Melinda Karakula NAME: _........ __... ..__ ._.. FAX Goes ET McLain Insurance Agency PHONE Fat (413)534-7355 �taxa {,(4131536.9386 1757 Northampton Street ae mkarakulaagoesmclain.com P 0 Box 1120 INSURER/5j AFFORDING COVERAGE I NAICa Holyoke MA 01041-1128 IN$VRERA Nautilus Ins Company INSURED INSURER 13 AIM Mutual Ins Co • Adam Quenneville Roofing & Siding Inc INSuRERC: 160 Old Lyman Road INSURER@: I INSURER E: _.. �. _...I South Hadley MA 01075 INSURER is COVERAGES CERTIFICATE NUM BER: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. NOTKWTHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT W TH RESPECT TO WHICH THIS CERTIFICATE MAY HE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO AU. THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, (LIR'. TYPE• OF INSURANCE mudNR Iaµryn POLICY NUMBER 'IMDDIYYYY1'IMWDONYYI ICY EXP 1 LIMITS IX I COMMERCIAL GENERAL LIABILITY I (LEACH OCCURRENCE _ I5 1,000,000 H t—i Ib4EMA65ES RENEE) 199,009 A 1__ !CLONS-M DE i X !OCCUR (Raya92oRNE; 5_ _ 1 _ _ _ Dressler 5/23/2016 6/23/2017 MED EXP (Any oneperson) E 15,000 I{_ -__ I 1PERSONAL 8 ADV INJURY IS 1,000,000` !GENE AGGREGATE LIMIT APPLIES PER I 1 GENERAL AGGREGATE IS 2,000,000 ITOSS —_ xit;o-T La 1 .. ',PRODUCTS-caroPrw AGG I3 a,090,999 OTHER 1 I ,Emplayes Bone: 9 1,000,000 [AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1 $ I J Le _ Z ANY AUTO MOLY INJURY(Pe Person) 5 WEED AUTOS EDUCED ALL OWNED SCHEDULED GODLY INJURY(Par/cadent) 5 I___I I �I AUTOSZ.SMSVPROPERTY OnM4Lie I g-- _ I Un0 retr n18i II E UMBRELLA LIAR J OCCUR' EACH OCCURRENCE5 _3r 009 00 4+ XIEXCESS LIAR _ R!!MAIMS-MADE r,AGGREGATE 5 • X I EXC 1 RETENTIONS 10,0001 AN030622 8/13/3016 6/13/2019 I 15 [AANNDEMPPIOYERRLIAN SILTY YINTION ( % ISI?iUTE t c. :ANY PROPxETGRAARTNER+EXECI 'EL EACH ACCIDENT 3 1,000,000 1OFFCERMEM@ER EXCLUDED y I NIA _ D (Mandatory In NHl AWC4007012861-2016A 4/29/20164/29/201] :EL DISEASE-EA EMPLOYE$ 1,000,000 If yes roger er DESCRIPTION OF OPERATIONS hIow ':EL DISEASE-POLICY LIMIT 5 1,000,000 I I 1 ! • DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) Certificate holders are additonal insured on the above captioned OL policy; subject to policy forms, conditions, and exclusions. Adam Quevnevil le, 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. A"TNraICD REPRESEfiTATIVE �/J// M Karakula/MILADY /�/el...1 � I 01988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of AGGRO INSD25cmmu The Commonwealth of Massachusetts a -.1 Department of Industrial Accidents 0. 5 1 Congress Street, Suite 100 „. Boston,MA 02114-2017 ,a" t a` www.mass.gov/dia . - Workers'Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Leeiblf Name (Business/organization/individuair Adam Quenneville Roofing & Siding Inc._ Address: 160 Old Lyman Rd, City/State/Zip: South Hadley, MA 01076 phone#: 413.536.5955 Are you an employer?Check the appropriate box: Type of project(required): L®l am a employer with 15 employees(full and/or part-time)* 7. Q New construction ❑famasaleproprietororpartnershipandha+e no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.) 3 Q 1 am a homeowner doing all ark myself.[No workers'comp.insurance required.]t Demolition 4_0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole 1I.❑Electrical repairs or additions proprietors with no employees. 12.0Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached shear13,®Roof repairs These sub-contractors have employees and have workers'comp.insurance: 6.9 Nc arc a corporation and its officers have exercised their right of exemption per MGL C. 14.['Other 152,0(4),and we have no employees.(No workers'contp_insurance regwrd.) `Any applicant that checks box 01 must also fill out the section below showing their workers'compensation policy infomiation. 'Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. ontractors 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.pokey number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site infornmtion. Insurance Company Name: AIM Mutual Insurance Policy#or self-inc_Lic-#: AWC4007012861-2016A Expiration Date: 4/29/2017 Job Site Address: IL 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 MGI.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 limn 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 andpenalties of perjury that the information provided above is true and correct Sienahae: / Date: t L I Phone#: 413.536.5955 f Official use only. Do not write in this area,to he completed by city or town official City or Town: _ Permit/License# _ _ Issuing Authority(circle one): 1 I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Massachusetts Department of Public Safety V Board of Building Regulations and Standards License: CS-070626 Construction Supervisor ADAM AQUENNEVILLE _ 1Ho OLDLYMANRO SOUTH HADLEY MA 3I f"'1- VL— Expiration: Commissioner / OH/211/2017 Cl/if fr;ln ll/II,o1art/cre/ll o e i/IC.i.iredede//1 r = -. 111 Office of Consumer Affairs and Business Regulation 10 Park Plaza- Suite 5170 Boston, Massachusetts 02116 Flame Improvement Contractor Registration Registration: 120982 Type: DBA Expiration', 3/25/2018 Tit 419291 ADAM QUENNEVILLE ROOFING ADAM QUENNEVILLE — -- _-- -- -- - —�- --- 160 OLD LYMAN RD -- -- - - - ------- SO. HADLEY, MA 01075 Update Address and return card.Mark reason for change. El Address Ei Renewal ❑ Employment LI Lost Card ECA" 6 MI/MSM1t lt .1`7172. _' wi 23r •ate ° 19 ry g . t .'ir o.. t r .•.Wt 'ler '..St s 4' 1C"_ �C 1 1.P . t'•1C`_ _a.M n AiA.t_e wt_11_!.L✓_5"1t +.!'_'-S. A 14rs y!'} 1 1 3/4k STATE OF CONNECTICUT i DEPARTMENT OF F CONSUMER PROTECTION it,t si Be Itknown dhat A 1 , fi ADAM QUENNEVILLE . l : 160 OLD LYMAN ROAD SOUTH HADLEY, MA 01075-2632 , is:cuctufted by the Deparunent of Consumer Protection as a registered HOME IMPROVEMENT CONTRACTOR a` Registration # HIC:0575920 ! ADAM QUENNEVILLE ROOFING y . Effective 12/01/2015 �.1 Expiration: 11/30/2016 "• ^at I ! Jo AlanA therm G ner A `e KV "¢'4 ,{V .n"'. �.{L y`4 d`• 1`s d`+ " <1 arY w'. ot