49-036 (2) 326 GLENDALE RD BP-2017-0980
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:49-036 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-2017-0980
Project# JS-2017-001689
Est.Cost: $14500.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: ADAM QUENNEVILLE 070626
Lot Size(so. ft.): 30012.84 Owner: PRATT KEITH
Zoning: Applicant: ADAM QUENNEVILLE
AT: 326 GLENDALE RD
Applicant Address: Phone: Insurance:
160 OLD LYMAN RD (413) 536-5955 O Workers
Compensation
SOUTH HADLEYMA01075 ISSUED ON:2/28/2017 0:00:00
TO PERFORM THE FOLLOWING WORK STRIP EXISTING ROOF AND INSTALL NEW
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 2/28/2017 0:00:00 540.00
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 CuUDriveway Permit
212 Main Street sewer/Septic Availability
Room 100 WatereNell Availability
Northampton, MA 01060 Two Sets of SWduralPlans
phone 413-587-1240 Fax 413-587-1272 PbUSite'f'lans
Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWOyFAMILY DWELLING
SECTION 1 -SITE INFORMATION :" w/ 7- ?"QC)
1.1 Property Address: This section to be completed by office
2017
326 Glendale Rd FEB 2 a M p Lot Unit
Northampton, MA 01060 L
ne Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Keith Pratt 80 Barrett St Apt. B3 Northampton, MA 01060
Name(Print) Current Mailing Address:
See Contract 802-238-7112
elephone
Signature
2.2 Authorized Agent:
Adam Quenneville Roofing&Siding Inc. 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. Building (a)Building Permit Fee
14500.00
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) 14500.00 Check Number
This Section For Official Use Only
Building Permit Number: Date
saved:
Signature: J7/ . / 05 —)O —12
Building Commissioner/Inspector of Buildings Data
Section 4. ZONING Alt 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 minusbldg&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 0
IF YES, date issued:'
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW O 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 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 O
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 Alteration(s) ❑ Roofing 2
Or Doors IC
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [D Siding[0] Other[0]
Brief Description of Proposed
Work: sfry rg ,,.,r,.,,and inaall newacnhait cninglec
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
ea.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 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
i. Keith Pratt ,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 42ril7
Signature of Owner Date
IIII
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 4-
'4A In
Signature of Owner/Agent Date
SECTION 8•CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable 0
Name of License Holder: Adam Quenneville CS 070626 U
License Number
160 Old Lyman Rd South Hadley MA 01075 8/21/17
Address Expiration Date
✓✓✓✓✓✓////// 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 3/25/18
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(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 108.3.5.1.
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 budding permit.
As acting Construction Supervisor your presence on the job site will he 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
P)AM � � a
QUENNEVILLE Winner of the TORCH AWARD �'Cafti I
ROOFING W SIDING w WINDOWS
160 old Lyman Road•South Hadley•MA 01075 We are Licensed
1.800.NEW.ROOF • 4135365955 Fully Insured
EmaiP.infoRD180Onewroolnet website.www.1800newroofnet Factory Trained
MA Construction Supervisors Lc K070626 MA Registration#120982 Factory Certified Installers
Member M then me BullAMC.of Western Mass. CT Registration#575920
member of the Building&Trade Ass«mron F.v.c 38710
Phone W's: C:(fca)d3$-R.7/a
W
Street Email:
3a . 6&.4h R1
City,State,Zip Code: Special Requirements:
PROPOSAL FOR:
.eUS GARAGE OTHER
/� RECOVER NEW GUTTERS
Layers: & 2 3 4 Plywood Included: Yes o�
• Tear off SLATE or SHAKES i3 A•„Et
COMPLETE ROOF PROTECTION SYSTEM: / ) •
We shall acquire appropriate permits for all work
7( Home exterior and landscaping to be protected /e�
% Strip existing roofing to existing decking with full inspection DO NOT DO: .3C
-/ti All project waste shall be removed by dumpster(dumpsterfor contractor use only)
L. Deteriorated existing decking will be repla^ced at$3.77 per sq.ft.after full inspection Customerinitials:
Install Ice&Water Barrier at all eaves 3'N valleys,chimneys,pipes and skylights
zC Install(151b.felt ts9nthet9tlnderlayment over remaining decking area
. Install Metal drip edge at eaves and rakes@/5”CM brown)
7q Install manufacturer's starter shingle on all eaves and rake edges
. Install new pipe boot flashing/vent accessories
)C Install ridge vent npantry Cobra rolled/4'Baffled/Roll
Shingles:(standard 6 nails per shingle)
GAF Shingles 25 year 30 Year 1 50 Year Color:
CAP Ridge cap shingles
Warranty Options:
74 We guarantee our workmanship for 10 full years(see our warranty coverage page)
GAF System Plus Warranty
2. GAF Golden Pledge Warranty
AQRS Recommendations:
% Lead Counter Flashing Water Seal&Tuckpoint Rubberized Crown l-Metal Chimney Cap
_ Replacing old skylights(or waiver must be signed) - Mason work(or waiver must be signed)
Heated panel roof system Insulation -Ventilation
Opted out of AQRS recommendations Customer Initials:
e prohereby to turner materials and labor—con, iet In accordance w.ar above specacanans m,the torn or: Total Due:($. ne/V0
ACCEPTANCE OF PROPOSAL The above prices.specifications and conditions are Down Payment-($ O 1
sausraciory and are hereby accepted.Yon are authorized to do work as specified. Balance Due upon Completion:(5 ',two )
Payment will be 1/3 down at start ofjob,and balance due upon completion.
Date: )/13//7 Signature: rt2.11#24f-7- /,/ //
Date: aha dr Estimator(Print Name) /1 Gl... (Sign Name) .�I</ Gf—
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. Customer Initials:
A�a CERTIFICATE OF LIABILITY INSURANCE BATE'MN,DONYY„
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 poncyiies)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 Karakuls
HAMA: . .._ —.... — .
Goes & McLain Insurance Agency PF (413)534-7355 H uv1536.928S _.
177 Northampton Street A0 L55 mkarakula@goasmciain.com
P 0 Box 1128 INSURERS!)AFFORDING COVERAGE NAIGp _
Holyoke MA 01041-1126 INSURER A*Mutllu Ins Company
.I...U. __. _ . ..
INSURED INSURER AIN„MV CLal IIIn Co
Adam Quenneville Roof WAD s Siding Inc msyREsc:
160 Old Lyman Road INSURER D;
INSURER E:
South Hadley MA 01075 INSURER F;
COVERAGES CERTIFICATE NUMBER:CL1662403220 REVISION NUMBER:
THIS 15 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 YMHICH 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.
1N$µ' - IADDLifUER _ .. POLJCV err POUCYEXp — - _ - —
TRI TYPE OF INSURANCE MAST)I wvp' PQLICY NUMBER IIMMIDDOYYVI IMANDOM V1l
yLIMITS
X I COMMERCIAL GENERAL LIABILITY 1I EACH OCCURRENCI'i 5 1,000,000
r ,'Dula RRJTES
CtAMS-MA X OCCUR 100.000
A _ I WED EXP An cm rccet I$ _
° 6/23/]016 { 6/23/2017 .MED EXP IAy pmmn) S 15,000
NN6653§2
PERSONAL&ADV INJURY S 1,000,000
•
_GEN
, E GGREGMELIIMIT AP LES PER I GENERAL AGGREGATE 5 2,000,000
X l POLICY a _Ta' l LOC f PRODUCTS-COMP/OP AGG IS 2,000,000
1I OTHER. j Empinyee Sera 1$ 1,000,000
AUTOMOBILE LIABILITY i ICOMBNED SINGLELIMIT 5
_ 1i ANY AUTO [(@0@DILY INJURY(Per Person) $
•
ALL OWNEISOlILED IBODL NJURY(Pry(Poe S
fAUTO.. N6D
IRON-OWNED
:EO {Per
Ede DIIMA E 5
i__ IHIRED AUTOS ___;AUTOS _ l
i
.a UMe ns2 N mmonm SI sp4f 5
'UMBRELLA JAB
OCCUR EACH OCCURRENCE 5 1,000,000
Ly L g EXCESS LIAR R I CL11M5.MADE AGGREGATE _ 5..___
•
DEC X 'RETENTIONS 10,000 AN030612 8/13/201.6 ' 0/13/2017 $
WORKERS COMPENSATION ' IX (PEATHTE L
AND EMPLOYERS'LABILITY YtN .—.—
AN”(PROPRE1'0 pARTNERExE'WVE "N A: I E.L.EACH ACCIDENT 3 1,000,000
.OFFICERTMEMOER EXCLUDED' LY
b II/Mandatory In NN) ANC40070.121361-2016A 4/29/2036 4/29/2017 LEL DISEASE EA EMPLOYEE S 1,000,000
If desenb ornar
'DESCRIPTION OF OPERATIONS ROAR I EL DISEASE.POLICY LIMITS 1.000,000
I
I 1 I I
DE$CRIP1ON OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks SchedIII ,may be attached ttmore space Is requladl
Certificate holders are additonal insured on the above captioned GL policy; subject to policy forms,
conditions, and exciuBiona. 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 REPRESENTATIVE J// ,� J �
�
M Karakul a/MINDY //7/7/12-4'.0A�-,- ___-
rC 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of AGGRO
INS025nnlalt+
The Commonwealth of Massachusetts
1917114-1
9171!.?: 1— Department of Industrial Accidents
W I tI; I� e9 1 Congress Street,Suite 100
' Boston,MA 02114-2017
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):
®i am a employer with 15 employees(full and/or parttime)." 7, p New construction
201 am a sole proprietor or partnership and have no employees working for me in S. []Remodeling
any capacity-.[No workers comp.insurance required_]
3.0 I am a homeowner doing all work myself.[No workers'comp,insurance required]t 9, ❑Demolition
4.0 I Am a homeowner arid will be hiring contractors to conduct all work on my property. 1 will p 0 Belding addition
ensure that all mntracKnseitlier hate workers'compensation insurance or are sole 11.0 Electrical repairs or additions
proprietors with no ctnplotccs.
12.0 Plumbing repairs or additions
5,0 l am a general contractor and l have hired the sub-contractors listed on the coached sheet, I1,®Roof repairs
These subeomracmrs haze employees and have workers'comp.insumucel
60 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.0 Other
152,§t(4},and we have no employees. No workers'compinsurance required]
`Any applicant that checks box el must also fill out the section below showing their workers'compensation policy information.
s Homeowners who submit this affidavit indicating they arc doing all work and the,,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 protide 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
_ AWC4007012861.2016A 4/2912017
Policy N or Self-ins.Lie.#. Expiration Date:
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 S T500.00
andfor 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 fonvarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify under the pal . rid penalties of perjury that the information provided above is true and correct
Signature.; Date: aid&/l7
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#:
----
— Massachusetts Department of Public Safety
0 If
Board of Building Regulations and Standards
License: CS-070626 !
Construction Supervisor
ADAM ADUENNEVILLE
160 OLDLYMANRD p ,
SOUTH HADLEY MA,y t1 g
fff
zc a_ Expiration:
Commissioner 08/21/2017
47.2 1 e -on,n/ontoerr�/ tr�/r>/-ire.,.,aderdei/3
Office of Consumer Affairs and Business Regulation
' ' '—"a 10 Park Plaza- Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 120922
Type: DBA
Expiration: 3/2512018 Trp 419291
ADAM QUENNEVILLE ROOFING
ADAM QUENNEVILLE -- _- - -_- - - - ---
160 OLD LYMAN RD -- -- --- - -- """--SO. HADLEY, MA01075 -- -.._- ---..__- -- - -_
Update Address and return card.Mark reason for change.
7.; Address [-1 Renewal ❑ Employment i Lost Card
SCA 0 20V OSryr
lilt
E 3 s:� a ya .v7rr �
CI A iA" .14:„..±-14.1.,.,:11,k
1w: 1c.' • �af:. ''V' 1B s 1r 1t ._1C '
•.C -+t-4s' �t1' tC_ �C �i
' ,;;1i STATE OF CONNECTICUT + DEPARTMENT OF CONSUMER PROTECTION CV
• '
Be it known that
I
/4 ADAM QUENNEVILLE
4I 160 OLD LYMAN:ROAD
SOUTH HADLEY, MA 01075-2632
is certified by the Department of Constmier Protection as a registered I
HOME IMPROVEMENT CONTRACTOR ,
N.
Registration # HIC.0575920
t
1ADAM QUENNEVILLE ROOFING n
a' Effective: 12/01/2015
•'> j Expiration: 11/30/1616 c a `
P ZI J iM A I(aniq C 11 1
d4 s 1 • +n d d1 'w^. s"L A5. ..S -r.4 ,a c"S w"4h r d a
/`.5.,-rte,..:'hrs . j •' .V ✓` t., l ^s !' Jv „ ,. .. , . H, .. ,.
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: 326 Glendale Rd 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 Quenneviile
B/dk117
Date Signature of Permit Applicant