17D-060 (9) 20 GARFIELD AVE BP-2017-1226
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17D-060 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: Siding BUILDING PERMIT
Permit tt BP-2017-1226
Project# JS-2017-002061
Est.Cost: $2400.00
Fee: $60.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ADAM QUENNEVILLE 070626
Lot Size(sq. ft): 28880.28 Owner: HUTCHINSON MARY
Zoning: URB(100)/ Applicant: ADAM QUENNEVILLE
AT: 20 GARFIELD AVE
Applicant Address: Phone: Insurance:
160 OLD LYMAN RD (413) 536-5955 0 Workers
Compensation
SOUTH HADLEYMA01075 ISSUED ON:4/26/2017 0:00:00
TO PERFORM THE FOLLOWING WORK STRIP & REPLACE DORMER VINYL SIDING
SYSTEM WITH NEW FLASHING
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 4'26/2017 0:00:00 $60.00
212 Main Street.Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
. _ - _. ..
1 City of Northampton Status of Permit: Department use only
1 APR 2 6 Cdl.' Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
L.L _. Room 100 Water/Well Avaaabeity
------ — 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,RENOVATE OR DEMOLtSH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION t?, (7. 71Ra7C0
1.1 Property Address: This section to be completed by office
20 Garfield Ave Map ./2 /0 Lot oC' O Unit
Florence, MA 01062 Zone Overlay District
Elm st.District CS District
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT 1
2.1 Owner of Record:
Mary Hutchinson 20 Garfield Ave Florence, MA 01062
Name(Print) Current Mailing Address:
4135301
Telephone
Signature
2.2 Authorized Agent:
Adam Ouenneville Roofing&Siding Inc. 160 Old Lyman Rd South Hadley MA 01075
Name(Print) 4 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
2400.00
2. Electrical (b)Estimated Total Cost of
Construction from(6)
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5.Fire Protection �r CPO 6. Total=(1 +2+3+4+5) 2400.00 Check Number jf el 7
This Section For Official Use Only
Building Permit Number: _ ---- Dae
Isse
Dates:
Signature,'
issi .,..:�'-' 4.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
(Lot arca 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 0 DONT KNOW Q YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW O 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 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 O
IF YES,then a Northampton Stoml 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 ❑
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [p] Decks [p Siding Oa] Other[co
Brief Description of Proposed
Work: Slip and renlare dormer vinyl siding system with new flashing
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
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
Mary Hutchinson
property ,as Owner of the subject
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 9I15I
Signature of Owner Date
MIIIIIII
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 I I
Signature of Owner/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: Adam Quenneville CS 070626
License Number
160 Old Lyman Rd South Hadley MA 01075 8/21/2017
Address Expiration Date
Signature Telephone
413-536-5955
9.Registered Home Improvement Contractor: Not Applicable ❑
Adam Quenneville Roofing 8 Siding Inc. 120982
Company Name Registration Number
160 Old Lyman Rd South Hadley MA 01075 3125/18
Address Expiration Date
Telephone 413-536-5955
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.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 )8/ 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 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: 20 Garfield Ave 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
41,0l-
Date Signature of Permit Applicant
LAI
ProposSum EmeTo, a� Date
Street
IL QUENNEVILLE .4.‘" 3r Ave_
® ROOFING W SIDING V WINDOWS City,State,Zip Code
160 Old Lyman Road•South Hadley,MA 01075 F.Er, MA- Of0�d
1.800.NEW ROOF • 413.536.5955 Phone ps
Email info 0180onewroof net Websflewww.1800newrool net H. 03 30- L W_
MA Construction Supervisors Lk.#070626 MA Registration#120982 Dumpster Location
member of the Home Bwkers Association el Western Mass, CT Registration#575920
Member ci the Bellamy BTrade 0.99otiatien member of Better Business Bureau -' ---- - "-- "'-I
rim: .'7'W/f IDta ` .. _
.- AREAS to be SIDED PROFILE COLOR
Size Brand torn✓-T,.S,✓4u
Front Clapboard X Y' Siding 1.Skte Goy
Len Dutcbdap _ Corners
Back CORNERS WINDOWS&DOORS
Brr9bt
StandarOther DF..± Pa*. Designer X wooed r COLOR
O, M^., Meg J Channel G`7 ---
J Block
Brand Style Color Location
Shakes --_- _
Stone _ ._._—
Rounds _, _.
•P.SIDISSOSIMESKOP14,1 yea® No( I If Yes: Vinyl/wood rq Aluminum I I
Only w.e
a
a.w.,Adam oser.,.wre Rooting&siemgire. ab
mu.NOT remove aenos mere,,.!.
"'' w. . =^
3./th I 1 TWek MMV�rI�.--nnmm��
AREASTO BE COVERED City COLOR
Front Left Back Right COLOR
Song E.FasciaWindows/Deers
x C. Loi___ ---- Garage/Patio Door
Soffit Only - Double Garage Door '
Fascia Onlyh� i2 ft - Build Out Frame
Plain Coil PVC Aluminum Col I x I
(Sy py Doubles"sonic Color
Storm Windows Awnings up to 8 Location.
Storm Doors Awnings Over 8y/N COLOR
Burglar Bars' Existing Shutters Wrap Perth Beams
a lye mea! Wrap Porch Posts
•in vacuo _._
thrum-Bars can
GABLE VENTS NEW SHUTTERS
Specify the locations.
Ory COLOR ie,„. COLOR
Rectanglen ____ _
Octagon
OctatagoLouvered
Raised Panel
h;f3E1Eaa S.
I have reviewed and agree with the job specifications described above,
It roved wood Is discovered AFTER removing the existing siding.or II it could not be Beatified at the lime of sale,
there will be an additional charge of$d 00 per Sq.Ft. or Plywood and$500 per Lin.Ft.for Dimensional Lumber
Customer Signature: Date:
We Propose hereby to furnish maletlals and labor-complete in accordance with above specilcavons for the sum Of
02400Ce
Total Sale Prise$ Down Paymentsf _ Upon Completion$ /600
ACCEPTANCEOFPROPOSAL:The above paces,specifications and condlsors are satisfactory and ate hereby accepted, a
you am authorized to do work as specified.Payment will be t!e Own upon signing,and balanceduo upon completion. BBB
Unpaid balances shag accrue with Interest at 18%per annum.Purchaser(s)will pay for all ousts,expenses andreasonabl T—
enamef.fees Insured byAdam Ouennevil &siding,Inc.i• sums due under this contract. mivecmaaw
Date: '09/!O Signature: s "la i _ Phone n `iS a M/m1
Date: 4i7 Salesperson's Signature
Estimates are honored for sixty(60)days from above date
Please remora all breakables from interior wall surfaces during installation.AGNS will not be responsible or damage.
ut
A ROC ae CERTIFICATE OF LIABILITY INSURANCE
bTi;4 6
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 policy(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 lieu of such endorsement(s).
PRODUCER CCOO,NTACT Melinda Karakuls
Gotta & McLain inaurance Agency PHONE EAik(413)534-7355 FA�y1['4,r 04191536-9ae6
1767 Northampton Street AE'xA1L mkarakuia@gosemolain.cam
P 0 Box 112$ INSURER/SI AFFORDING COVERAGE I NAICP
Holyoke MA 01041-1128 _ INSURERANautilue Ina Company I_
INSURED INSURERS AIX Mutual Ina Co rr _
Adam Quenuevllle Roofing & Siding Inc IxwRERc:
160 Old Lyman Road w :ssaERD:
INSURER Ei
South Hadley MA 01075 INSURER F:
COVERAGES CERTIFICATE NUMBER:C1.1662903220 REVISION NUMBER:
TBIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTVATHSTANOMG 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,
L
p .. -.ADOCLOR. .... . _POLICY Err ' POLICVE)P I
LTR TOM OGINCA man'WVO POLICYM'MW
NUMBER 'IMI(SYYI IMOOn'YYYI LIMITSXCOMMERgAL GENERAL UAeLLITY j @fH(Y'tllRftENCE IS 1,000.090
_ ,DAMAGE TO 0.CN'IEJ
A CLAMS-MADE OCCUR _PPCA" 6'cBiEa60461-ence) $ _ 100,000
1
x16E5342 6/23/2016 1 6/23/2011 [MED EXP(Any one Gerson) $_ _ 15,000
'�-I -- 1,000,000
PERSONAL&APV INJURY $
I GESS AGGREGATE LIMIT APPLIES PER. • GENERAL AGGREGATE I$ 2,000,000
X POLICY LLce...._PRth IPRODUCTS_ COMP/OPAGO'S 2,090,000
__
1
OTHER. Employee eenaPs S 1,090,000
1 AUTOMO&LE LIABILITY COMBINED SINLuLE LIMIT $
(Ea accident) _ _ _.....
ANY AUTO BODILY INJURY(Per man) I5
_ 1 ALLED SCHEDULEDam I I BODILY INJURY aLent1$
OSE
Auras
PROPERTY OAMdGE
MREO AUTOS _Autos )velavven4 S
Unuerinsured mstsoCaI split I$
UMBRELLA LIAR OCCUR LEACHOCOURRENCE IE 1.000,000
`w IA E%CESR LIA' X l CLAIM&MADE ,AGGREGATE S
GED
X�ftETENiiDNS 30.0001 AN030421 6/13/2016 0)13/3017 g
'WORYFRSCO,ANOEMPLOYE P'LIABION I F (STAILRE CSX
,ANO EMPLOYERS'LIAEiDTY � ._tER
ANY PROPRIEBOWEXCLUDWIXECITVE YIN E.L.EACH ACCIDENT 1$ 1,.000 000
''O andatoMEMBER EXCLUDED, Y I NIA
D NM yes a IIOo NH) I1 AWC4007012861-2016,0 4/29/2016 4/29/2019 EL DISEASE-EA EMPLOYE: $ 1,000,000
DESCRIPTION OP OPERATION$0llpw 1 I I EL.DISEASE-POLICY LIMIT.$ 1,000,000
DESCRIPTION Or OPERATIONS I tOCAI1ONS I VEHICLES IACORO 101.AdtlMOpal Remarks Schedule,may be attached Honore apace M1 required)
Certificate holders are additonal insured on the above captioned GL policy/ subject to policy farms,
Conditions, and exclusions. Adam {Menne-4111e, as an officer, is excluded from the Workers Camp policy.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OP THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NONCE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORED REPRESENTATIVE �///// / ,, J
I M Karakul a/MINDY ///l�s4N4 .r 14X)/60-ra_U.
®1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD
INS025 rpmane
I ,yam
The Commonwealth of Massachusetts
I git Department of Industrial Accidents
;el= 1 Congress Street, Suite 100
8`—
_.,_{_{_ 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):
L®I am a employer with 15 employees(full and/or parttime)' 7. ❑New construction
2E11 am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling
any capacity.[No workers'comp.insurance required]
3.01 am a homeowner doin ll work m sel! No workers'com .i suranc d 9. Demolition❑
g a L Y P o crequirc .]'
4.0 I am a homeowner and will be hinng contractors to conduct all work on my property. I will 10❑Building addition
ensure that all contractors either have workers'compensation insurance or arc sale 11.❑Electrical repairs or additions
proprietors with no employees.
12.0 Plumbing repairs or additions
5❑r am a general contractor and I have hired the sub-contractors listed on the attached sheet
13.Z Roof repairs
These subcontractors have employees and have workers'comp.insurance.;
6.E]We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other
152,41(4).and we have no employees.[No workers'comp.insurance required.]
`Any applicant that checks box AI must also fill out the section below showing their workers'compensation policy information.
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 subcontractors have employees,they must provide their workers'comp.policy number.
l 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.Lie,#: 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 DR for insurance
coverage verification.
I do hereby certify under the pain 4)td penalties of perjury that the information provided above is true and correct
Signature: /rDate: g/ar(��
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
b.Other
Contact Person: Phone#:
Massachusettsnon:
t or uty
4, it Board at Building Regulations and Stcansafedards
License: CS-070626
Construction Supervisor
ADAM A QUENNEVILLE
160 OLD LYMAN RDc
SOUTH HADLEY MA:
t"''- C/A_:.. Expiration,
Commissioner 08121/2017
C?(-2.11/(86 ttrntonwea7447 4/C- e<L1achwtetto
Office of Consumer Affairs and Business Regulation
LI
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration'. 120982
Type: DBA
Expiration: 3/25/2018 Tra 419291
ADAM QUENNEVILLE ROOFING
ADAM QUENNEVILLE
160 OLD LYMAN RD –
SO. HADLEY, MA 01075 --- . -- -- - -- -
Update Address and return card.Mark reason for change.
11 Address LL Renewal pi Employment L Lost Card
SCA1 4 YOM-0L1I
v'ACS. i 1. 7n "fi iv k a ? su '4II \ tt?,.i it s7 IC
'" a 2 . . c d :,
aP " '=des' *LP. y' Iw`1,v '+,M .�C�,a "_ 'rfp` 'p�'_'�l`_ 'Ss� , "
..:: ie— 'ti.!�'- - s_'1C �.P`i
STATE OF CONNECTICUT 4. DEPARTMENT OF CONSUMER PROTECTIONa
t *4( Be it known that
S;
t...1� I ADAM QUENNEVILLE
160 OLD LYMAN ROAD
SOUTH HADLEY, MA 01075-2632 r
11::;111
is certified by the Department of Consumer Protection as a registered
Et�.
HOME IMPROVEMENT CONTRACTOR
4iJ Registration # HIC.0575920 I
i'ln ' ::
a ADAM QUENNEVILLE ROOFING ^-
�]__�_ �i
Effective: 12/01/2016 V
,1 j P'xpiration: 11/30/2017 A. v r a 4*
I Jo Athan than A.1a ennuniSsiAnct
t'77.
.e.cIA- re s.n 4„ a7'r'-W-7.74\' ✓ri ./Try, 'r' ' "eV ..-V 'ate' _,.,�f. .97 --400. --VG Tr., ,14 47G nr'h or.: k-.