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12C-063 (7) 9 CLOVERDALE ST BP-2017-1159 GIS n: COMMONWEALTH OF MASSACHUSETTS Map:Block: 12C-063 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-2017-1159 Projecta JS-2017-001960 Est. Cost:$4200.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: ADAM QUENNEVILLE 070626 Lot Size(sa.ft.): 7492.32 Owner: DELANEY JOHN B&JUNE L TRUSTEES Zoning: RI(100)NRA(I00)/WSP(100)1 Applicant: ADAM QUENNEVILLE AT: 9 CLOVERDALE ST Applicant Address: Phone: Insurance: 160 OLD LYMAN RD (413) 536-5955 0 Workers Compensation SOUTH HADLEYMA01075 ISSUED ON:4/20/20170:00:00 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 Anal: Final: Final: Rough Frame: Gas: Fire Department Fireplace/Chimney: Rough: OI: 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 Occu•anc Si nature: FeeType: Date Paid: Amount: Building 4/20/2017 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 212 Main Street Sewer/Septic Availability Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans Other Specify APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATEyORR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION Qf_/% /73 9 1.1 Property Address: This section to be completedbyoffice 11 Cloverdale Street Map 43 C Lot CV J Unit Florence MA 01062 Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: John Delaney, Jr 11 Cloverdale Street Florence MA 01062 Name(Print) Current Mailing Address: See Contract 417-556-0564 Telephone Signature 2.2 Authorized Agent: Adam Quenneville Roofing&Siding Inc. 160 Old Lyman Rd South Hadley MA 01075 Name(Print)ofIv/ 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 4200.00 (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from(6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection -0 6. Total=(t +2+3+4+5) 4200.00 � Check Number / prQ� __. This Section For Official Use Only Building Permit Number: Date Issued: Signature: direr Building ommissioner/Inspector of uildings 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 Side L: R: L R: Rear Building Height Bldg. Square Footage Open Space Footage (Lm 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 Q DONT KNOW O 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 Book Page and/or Document # B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW O YES 0 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 0 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 Alteration(s) I I Roofing Or Doors CI Accessory Bldg. ❑ Demolition ❑ New Signs [C] Decks [p Siding[0] Other[C] Brief Description of Proposed Work: sanwaea roofing en garage ad iwtall new,,phw shinggs. Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes _ No Plans Attached Roll -Sheet 6a.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 John Delaney,Jr ,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 t4 I j8I �7 Signature of Owner Date Adam Quenneville Roofing&Siding Inc. ,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 Signature of Owner/Agent Date SECTION 8•CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable 0 Name of License Hower: Adam Quennevitle CS 070626 U License Number 160 Old Lyman Rd South Hadley MA 01075 8/21/2017 Address ry Expiration Date �lf'`s.-i 413-536-5955 Signature Telephone 9.Registered Home Improvement Contractor Not Applicable ❑ Adam Quenneville Roofing 120982 Company Name Registration Number 160 Old Lyman Rd South Hadley MA 01075 3/25118 Address /} Expiration Date Telephone 413-536-5955 SECTION 10•WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§25C(5)) 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 0 11. - Home Owner Exemption The current exemption for"homeowners"was extended to include Owner-occupied Dwel rocs 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 stmetures 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 bundles 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 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: 11 Cloverdale Street Florence MA 01062 The debris will be transported by: Complete Disposal 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. 1411g1 11 Date Signature of Permit Applicant A LA M BBB QUENNEVILLE Winner uf the TORCH AWARD immus VISA *act�:�" ' `" ROOFING V SIDING V WINDOWS 160 old Lyman Road•South Hadley•MA 01075 We are Licensed 1.800.NEW.ROOF • 413.536.5955 Fully Insured Email,info@laoonewroofnet Website:www.i soonewroofnet Factory Trained MA Construction Supervisors Lic.Vo70626 MA Registration#120982 Factory Certified Installers Member of he Home Builder's Assoc.of western Mass CT Registration 4575920 Member of the Bulldog&Trade Association PPC 30710 Proposal Submitted To:5),NC✓- Date: Phone 49: C: Jak,3 elerr TV) `lilei11 H' w. Street: V Email: II cid ' - 51 City,State,Zip Code: Special Requirements: noit•1CC P 010 1 PROPO _OR: HOUSE OTHER STRIP RECOVER NEW GUTTERS Layers:O 2 3 4 Plywood Included: Yes or No Tear off SLATE or SHAKES COMPLETE ROOF PROTECTION SYSTEM: X We shall acquire appropriate permits for all work A Home exterior and landscaping to be protected /I n . $ Strip existing roofing to existing decking with full inspection DO NOT DO: NO05( 0A PQh0 A All project waste shall be removed by dumpster(dumpsterfor contractor use only) �/I A Deteriorated existing decking will be rN�y°laced at$3.77 per sq.ft.after full inspection Customer Initials:9 4-C A Install Ice&Water tall eavdl¢�'/6',valleys,chimneys,pipes and skylights A Install(151b felt Syntheti underlayment er remaining decking area )( Install Metal drip edge at eaves and rake (8' /5") whl /brown) A Install manufacturer's starter shingle on all eaves and rake edges A Install new pipe boot flashing/vent ss ' A. Install ridge vent-Snow Country Cobra rolle /4'Baffled/Roll Shingles:(standard 6 nails per shingle) (-,(egt� _ ^y GAC Shingles 25 year BC 3PYBe ear 50 Year Color: ml`ee (gm ) GQT Ridge cap shingles WarrantyOptions: A 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 for waiver must be signed) 15rr00 Heated panel roof system Insulation Ventilation J n`o 5010 Pc(U Cu,r Opted out of AQRS recommendations Customer Initials: py We ease eenymmrnihmatenals and labor-complete in accordance with abovesveoeahons for the sum of. Total Due:($530,0) ) ACCEPTANCE OF PROPOSALThe above prices,specifications and conditions are e e9S Down Payment: $20O6 uo ) satisfactory and are hereby accepted.You are authorized m do work as specified. cid Balance Due Upon Completion:($ 33(0-° ) Payment will be 1/3 down at start ofjob,and balance due upon completion. Date: d//L/7 Signature: 7czm-c— dIAj . J //// Date:1+I id( l-1 Estimator:(Print Name) �o� . r e. Z (sign Name) -4-;-LP— Estimales'are honored 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 the attic or storage areas. Customer Initials: Acorn, CERTIFICATE OF LIABILITY INSURANCE DATE MWODi) 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 ce tflcate holder is an ADDITIONAL INSURED,the poHcy(ies)meet 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 _NEMp€,, Goes & McLain Insurance Agency Via, (413)539-7355 .1F Nei.(<ID ee9-1.2e6 1767 Northampton Street A`eDRE"9a.nilcarakula&goasmclain.eom P 0 Box 1128 INSURER(SJ AFFORDING COVERAGE NAICa Holyoke MA 01041-112$ _ INSURER NanCilUe III6 C00flaIIy I_. INSURED INSURERS AIM Mutual Ina CO -_ Adam Ouenneville Roofing & Siding Inc INSURER C: 1,60 Old Lyman Road INSURER o: INSURER E: I South Hadley MA 01075 INEURERF: I COVERAGES CERTIFICATE NUMBER:CL1662403220 REVISION NUMBER: THIS 15 TO CERTIFY THAT THE POLICIES Or INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTV,ITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF MY CONTRACT OR OTHER DOCUMENT LATH 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 CLAMS __ 0..00.0. __.._ _ IMP TYPE OF INSURANCE A06LSilOP r POLICY IT POLICY EXP LIMITS INGII WO) PQ41CY NUMBER 1MMIDDIYYYYI IMM1VDDIYYYYI X ICOMMERCIAL GENERAL IIq@ILITYY,000,000 EACH OCCURRENCE 5 'TSAR GE TD RENEEZ A CUNS HADE d OCCUR ...E4E $Est keY!'E}.i5 iDe,coo I!ry6e53{p 6(29(3016 6/2 /2oIi MED %P(Any onepa$ s I5,O00 • _ L, PERSONAL&AOVINJURY s 1,D00,000 GENE.A.GGRMATE LIMIT APPLIES HER —II Ili GENERAL AGGREGATE Is 2,000,000 X coin.'� PRO- _I'LOC j PRODUCTS-COMP/OP AGO IS 2.000,000 OTHER, ( Emphyee Etenefils IS 1,009,000 AUTOMOBILE tIASltltt I COMHINELSINCLE MIT $ 1 EJ [' ns1 I ANY AUTOI BODILY INJURY(Peiperson) $ ALL ONMF.0 flSCHf.GULEO BODILY INJURY(r' r cciden9 $ AUTOS AUTOS • NON•O\M't0 1PROPERTY DAMAGE 5 I EGGED AUTOS AUTOSi,.(P@emierm .UMxnnsvzimumIasdd r3 DED UMBRELLA BREL CAB I 1 OCCURS MI EACH OCCURRENCEE , S 1,000 4000_ Q �'EXCESS XII RETENTIONS X •CLAIMS-MADE, AGGREGATE S ONS 1,0001 AN030621 9/13/2016 B/LS/2017 S IWORKERS COMPRNSAnON X 16TAi1TE i AND EMPLOYERS'LW&UTY ANY FROPRIRTO P TNEREKEDO1IVE YIN' I 6L EACH ACCIDENT ,a 1,000,000 OFFICEFAIEMBER EXCLUDED' IY 'IINtA 'I � D (Mandatory In NHl II AWN007012661-2016A 9/29/2016 4/29/3017 E.L.DISEASE-EAEMPLOYEC S 1,000,000 IYe:cescnb uroer DESCRIPTIONCF9PERATIONSNeNw E.I.DISEASE-POLICY LIMITS 1.000,000 I • I DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101.AddMenal Romans Schee/01e,may be attached 11more&Eau,Is regatta Certificate holders are additonal insured on the above captioned OL policy; subject to policy forms, conditions, and exclusions. Adam puenneville, as an officer, is excluded from the Workers Comp policy. CERTIFICATE HOLDER CANCELLATION SHOULD ANYOF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE /��/ / �l M Karakula/MINDY /v(l.Lu-. -‘ - @11988-2014 ACORO CORPORATION. All rights reserved, ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS0251Pn,N,„ • The Commonwealth of Massachusetts Department oflndustrialAccidents =„Ipl 1 Congress Street,Suite 100 Boston,MA 03114-2017 04, 7'4s www.tnass.govldia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name{BusinesstOrganixatiortIndividualt: Adam Quennevihe 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): L�l am a employer with 15 employees(full andior par4time)* 7. EJ New construction 2 91 am a sole proprietor or partnership and have no employees working for me in S. O Remodeling any capacity.{No workers'comp.insurance required.] - 30lamahomeownerdoingallworkmyself[No workers'comp.insurance required.]' 9. ❑Demolitiotr 14.9Iamehomeownerand will behiring contractors toconduct all work onmyproperty. I will O Building addition ensure that all contractors either have workers'compensation insurance or are sole lis[]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 sheet These sub-contactors have employees and have workers'comp.insurances ]i.®Roof repairs 6.9 We are a corporation and its officers have exercised their right of exemption per MGL Q.QOthe[ 152,§I(4),and we have no employees,[No workers'comp.insurance required.) *Any applicant that checks box XI 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 oldie sub-contractors and state whether or not those entities have employees. If the subcontractors have employees,they must provide their workers'camp.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.Lia#: AWG4007012$61.2016A 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 S1,500.00 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 forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pal and penalties of perjury that the information provided owe ' true and correct, `111 �1 Signature: Date: 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 S.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 A QUENNEVILLE i,. 18001DLYMANRD Ojj SOUTH HADLEY MAr Fit{}` S tIIII ('-.ars CA L.. Expl ration. ..������ �! Commissioner / 08/21/2017 • � _. 'I lIC t>r rr�iJl.J17 C'fidtr�;7rj/t / ''/ lrl.i. l!!l11t;1e/ w Office of Consumer Affairs and Business Regulation 10 Park Plaza- Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 120982 Type: DBA Expiration: 3/25/2018 Tr# 419291 ADAM QUENNEVILLE ROOFING ADAM QUENNEVILLE 1E0 OLD LYMAN RD SO. HADLEY, MA 01075 - ----- -- - -------- - Update Address and return card.Mark reason for change. ecu, 0 20M 05.11 ..� Address ElRenewal I] Employment fl Lost Card < i r gr r + / cp. i . M}5 r _, y ^ :?� Fti ' '&� ma _y_ 4y' '4y' S . l .412 " . t j STATE OF CONNECTICUT + DEPARTMENT OF CONSUMER PROTECI TION � �yy Tie itknown that ADAM QUENNEVILLE `4 (44 160 OLD LYMAN'ROA.D A SOUTH 1-LADLEY, MA 01075-2632 is certified by the Department of Consumer Protection as a registered t HOME IMPROVEMENT CONTRACTOR Registration # HIC.0575920 ADAM QUENNEVILLE ROOFING e 4j Effective: 12/011?615 -_ i Expiration: 11/30/2016 (jV1 }F\ iJ th nA t ni Cn nksionef x`4"i°. :4r i". +l's w1 41 i'e 14" ,r1 _„1 C. C. :re `C2`.✓�u'e/,�,.,aV?✓�a��r:✓., ./.4..t,/`.:'n /' /` ... ✓Yd P,. /4 n'.. .. "'a .n ... . ... . . :.... .�.