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10-012 (4) 507 KENNEDY RD BP-2018-0103 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 10-012 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-2018-0103 Project# JS-2018-000171 Est. Cost: $12933.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: ADAM QUENNEVILLE 070626 Lot Size(sq.ft.): 26397.36 Owner: O'BRIEN EDWARD F&ANDREA M Zoning: RR(100)/WSP(100)/ Applicant: ADAM QUENNEVILLE AT: 507 KENNEDY RD Applicant Address: Phone: Insurance: 160 OLD LYMAN RD (413) 536-5955 0 Workers Compensation SOUTH HADLEYMA01075 ISSUED ON:7/28/2017 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 7/28/2017 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 4S. �� 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 DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION / 7 /0 3 This section to be completed by office 1.1 Property Address: 507 Kennedy Rd Map ( Lot Unit 6� Leeds, MA 01053 Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Edward &Andy O'Brien 507 Kennedy Rd Leeds, MA 01053 Name(Print) Current Mailing Address: See Contract 413-586-2726 Telephone Signature 2.2 Authorized Agent: Adam Quenneville 160 Old Lyman Rd South Hadley MA 01075 Name(Print`�o 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 $12,933.00 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) _ $12,933.00 Check Number ..;736-A 5 This Section For Official Use Only Date Building Permit Number: Issued: Signature: c rr 7/2:2 Building Commissioner/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 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 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW ® YES Q IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO © DONT KNOW Q YES Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained © Obtained ® , Date Issued: C. Do any signs exist on the property? YES Q 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 i© 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 Q 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) n Roofing Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [Q Siding[0] Other[D] Brief Description of Proposed Work: Remove existing roof material and install new asphalt shingle system. 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 Edward &Andy O'Brien as Owner of the subject property hereby authorize Adam Quenneville to act on my behalf, in all matters relative to work authorized by this building permit application. See Contract —1 I ?io I I 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 Print Name ia\..............., 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 License Number 160 Old Lyman Rd South Hadley MA 01075 8/21/2017 Address Expiration Date 413-536-5955 Signatur 74"--- Telephone 9.Registered Home Improvement Contractor: Not Applicable 0 Adam Quenneville Roofing 120982 Company Name Registration Number 160 Old Lyman Rd South Hadley MA 01075 3/25/2018 Address Expiration Date i4.--.—__ 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 X No 0 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: 507 Kennedy Rd. Leeds, MA 01053 The debris will be transported by: USA Hauling&Recycling Inc. The debris will be received by: USA Hauling &Recycling Inc. Building permit number: Name of Permit Applicant Adam Quenneville Date Signature of Permit Applicant LSID),[6:\,/ BBB Q U E N N E V I L L E Winner f the TORCH AWARD VISA rill DISCOVER e ROOFING 1r 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@l800newroof.net Website:www.1800newroof.net Factory Trained MA Construction Supervisors Lic.#070626 MA Registration#120982 Factory Certified Installers Member of the Home Builder's Assoc.of Western Mass. CT Registration#575920 Member of the Building&Trade Association P.P.0 38710 Proposal Submitted To: Date: Phone#'s: C: Cclweacr_'t Ar)(4. C)6C ien 11il1l1 O/i3 SFfC a-I)(, W: Street: Email: 5c-1 Kew-v.4 (Z. . City,State,Zip Code: Special Requirements: Lee CrII OfC'.) Remo, 0,nA c-e.?lac Q. C.A cCO?boQ/e PROP R: Q)or,g C 0 e C (l . Wketc r4'e 4- CU°11 HOUSE GARAGE OTHER _ O STRI' RECOVER NEW GUTTERS W r1h (4l�c�ti� I +P--... Layers: 1 OZ 3 4 Plywood Included: Yes or No LI Tear off SLATE or SHAKES ` COMPLETE ROOF PROTECTION SYSTEM: Cu51a.,.cc ce5?x,-);,6lc QC ea,tf11tnl X We shall acquire appropriate permits for all work X Home exterior and landscaping to be protected N Strip existing roofing to existing decking with full inspection DO NOT DO: A All project waste shall be removed by dumpster(dumpsterfor contractor use only) r A Deteriorated existing decking will be repl d at$3.77 per sq.ft.after full inspection Customer Initial s:. £. P. Install Ice&Water t all eaves 3'76J valleys,chimneys,pipes and skylights k Install(151b.fel Synthetic underlaymerver remaining d- .ing area A Install Metal drip edge at eaves and rakes)88'' /5")(white brown A Install manufacturer's starter shingle on all eaves and rake edges N Install newg pipe Snow Co ent accessories /� Install ridge vent Snow Countr /Cobrarrrolled/4'Baffled/Roll Shingles:(standard 6 nails per shingle) Li ic'itn' GAC Shingles 25 year,X 30 Ycdr '_'. 50 Year Color: C/41 Ridge cap shingles Warranty Options: if- We guarantee our workmanship for 10 full years(see our warranty coverage page) 7 GAF System Plus Warranty - GAF Golden Pledge Warranty AQRS Recommendations: Lead Counter Flashing Water Seal&Tuckpoint Rubberized Crown [ Metal Chimney Cap I Replacing old skylights(or waiver must be signed) I.--i Mason work (or waiver must be signed) --; Heated panel roof system CI Insulation LII] Ventilation I ' Opted out of AQRS recommendations Customer Initials: We propose hereby to furnish materials and labor—complete in accordance with above specifications for ttrhe sum of: Total Due:($0733.0%) ACCEPTANCE OF PROPOSAL:The above prices,specifications and conditions are C Cr S8 13 Down Payment:($41300'C ) satisfactory and are hereby accepted.You are authorized to do work as specified. Balance Due Upon Completion:($3C,33 co ) Payment will be 1/3 down at start of job,and balance due upon completicia, . ( Date: 7/ '�/ 7 Signature: 4"''d . �" Date: 1/11/(7 Estimator:(Print Name) )Ca`1 �" (Sign Name �-- 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 DATE(MM/DD/YYYY) 6/21/2017 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 CONTACT Melinda Karakula NAME: Goss & McLain Insurance Agency (NC. ): (413)534-7355 (q/C.No):(413)536-9286 1767 Northampton Street ADDRESS:mkarakula@gossmclain.com P 0 Box 1128 INSURER(S)AFFORDING COVERAGE NAIC# Holyoke MA 01041-1128 INSURER A Nautilus Ins Company INSURED INSURER B Nautilus Ins Company Adam Quenneville Roofing & Siding Inc INSURER CA.I.M. Mutual Ins Co. 160 Old Lyman Road INSURER D:SureteC Ins company INSURER E: South Hadley MA 01075 INSURER F: COVERAGES CERTIFICATE NUMBER: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. NOTWITHSTANDING 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. INSR ADDL SUER LTR TYPE OF INSURANCE INS!).WVtZ POLICY NUMBER (MM/DDY/YYYY) IMM/DD/YYYPY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE X OCCUR DAMAGE TO RENTED 100,000 PREMISES(Ea ocamence) $ X NN822755 6/23/2017 6/23/2018 MED EXP(Any one person) $ 15,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY PRO- JECT LOC PRODUCTS-COMP/OPAGG $ 2,000,000 _ OTHER: Employee Benefits $ 1,000,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE _ AUTOS (Per accident) $ Underinsured motorist BI split $ X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 1,000,000 A EXCESS LIAB X CLAIMS-MADE AN030622 8/13/2016 8/13/2017 AGGREGATE $ _ DED X RETENTION$ 10,000 , AN030622 8/13/2017 8/13/2018 $ WORKERS COMPENSATION _ AND EMPLOYERS'LIABILITY Y/N X STATUTE EERH ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? y N/A C (Mandatory In NH) AWC4007012861-2017A 4/29/2017 4/29/2018 E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under -DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 D Surety Bond - HSS Affiliate 3364848 4/19/2017 4/19/2018 BOND AMOUNT 20,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) THD At-Home Services, Inc. and The Home Depot are additonal insured on the above captioned General Liability insurance; subject to policy forms, 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 REPRESENTATIVE �'/�//�� M Karakula/MINDY %�"i ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025(2014011 rviassacnusetts uepartment or Fitraric sarety Vti Board of Building Regulations and Standards ..-- License: CS-070626 Construction Supervisor ADAM A QUENNEVii.LE, ... '/,- 14,," -- 160 OLD LYMAN-RD,, SOUTH HADLEXIMA,ti., F i NI.ol'A'"—X". CA__:_. Expiration: Commissioner 08/21/2017 --- - -— — — - gc,14 (6.,,e,„itx oi_ , , Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 ....." Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 120982 -7.:7---•-=.:.--:4aZ.-_-- _--..- Type: DBA Expiration: 3/25/2018 Tr# 419291 ADAM QUENNEVILLE ROOFING ADAM QUENNEVILLE 160 OLD LYMAN RD -,-,-,,,; Tf,_'--t_. ::' ' ''', ',--7.==t r- ,`='"--' '' - SO. HADLEY, MA 01075 T.,,,, ',:::_-•.,..,_--,----_-_-.- .,.:- Update Address and return card.Mark reason for change. 0 Address 0 Renewal D Employment 0 Lost Card scal 0 20M-05/11 • rf• •it:.:•;,i!,,,,i,,,,,,i.,•::,,:;•;,;;,,,,, ..s.,,;.m)::,,,:i.,:.:;.1,,.: ,..,..,.,„;:,1:1;:,: ,":::::'v,;:.:;; L ''1.':'4'1:),,:,,r$4 '„ '4:::'''', '•''7'''',-If '' ' ''' '' .'; '' ''1.4:*.*:,-'t...41'1,,: '''.:x'''',0.'•-.1::::::''',,, ' '- STATE OF CONNECTICUT '-+ DEPARTMENT OF CONSUMER PROTECTION Be it known that ADAM QUENNEVILLE ..: 160 OLD LYMAN ROAD ,.,,,,,.!•. SOUTH HADLEY, MA 01075-2632 <..--,...• is certified by the Department of Consumer Protection as a registered It: .i.- HOME IMPROVEMENT CONTRACTOR It., ....- . . t., .„..„... Registration # HIC0575920 .. , ADAM QUENNEVILLE ROOFING .., ..... H,. Effective: 12/01/2016 ' *.; k ,:.... Expiration: 11/30/2017 -.,•.„,:1:. t Jo,athan A.hams,Commissioner _ , ,.:'• .. ,... 77-S.'..":„:„7.11 ii; '.,1,41,1r*:.•ri, ,:,,,,,,,111r1"'7,7;,17- T.:::11(V.,,---7;017V,,,,,,•1'*-,,,,,i,„ •,-...iii,, ,,,vp -.,., 7— The Commonwealth of Massachusetts 6 1, Department of Industrial Accidents mi ►m 1 Congress Street,Suite 100 MIK C Boston, MA 02114-2017 vwww.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.p✓ 1 am a employer with 15 employees(full and/or part-time).* 7. J New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. El Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 30 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 Q Building addition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. ]3.®Roof repairs These sub-contractors have employees and have workers'comp.insurance.: 6.0 We are a corporation and its officers have exercised their right of'exemption per MGL c. 14.ED Other 152,§1(4),and we have no employees.[No workers'comp.insurance required] *Any applicant that checks box#I 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 Policy#or Self-ins. �Lic. #:AWC4007012861-2017A Expiration Date:4/29/2018 Job Site Address: � Xc.Y? W i1 nechi 12J. City/State/Zip: Leeds; t o v I L(— 77) 3 Attach a copy of the workers' compensation*licy 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 pain .and penalties of perjury that the information provided above is true and correct. Signature: Date: —4)-(40 I 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#: