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44-082 (6) 893 FLORENCE RD BP-2019-0081 GIs 4: COMMONWEALTH OF MASSACHUSETTS Map-.Block:44-082 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-2019-0081 Proiect# JS-2019-000123 Est.Cost $12384.00 Fee:$40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: UseGrouo: ADAM QUENNEVILLE 070626 Lot Size(sp.ft.): 15028.20 Owner: GILIBERTO MARJORIE J tonin : Applicant. ADAM QUENNEVILLE AT. 893 FLORENCE RD Applicant Address: Phone: Insurance: 160 OLD LYMAN RD (413) 536-5955 O Workers Compensation SOUTH HADLEYMA01075 ISSUED ON:7123120180.00:00 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 7/23/20180:00:00 $40.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner City of Northampton Building Department 4�7 212 Main Street �l Room 100 Northampton, MA 01060 phone 413-587-1240 Fax 413-587-1272Ly y� APPLICATION TO CONSTRUCT, TE"�Pl�l NCR Ntill"NB�YN§41E LLISH A !ORO FAMILY DWELLING SECTION i -SITE INFORMATION DIV 0 1 1.1 PropertyAddress: h'iis//section to be completed by office � Lot 06his Unit 893 Florence Rd Florence, MAn1�J^ YOverlay District Elm SL District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Marjorie Giliberto 893 Florence Rd Florence, MA 01062 Name(Print) Current Madir g Address: 413-586-6399 Telephone Signature 2.2 Authorized Aaent. Adam Quenneville Roofing 160 Old Lyman Rd South Hadley MA 01075 Adam Quenneville Roofing 160 Old Lyman Rd South Badley MA 01075 Name(Print) ,r Current Mailing Address: Adam Quenneville Roofing 160 Old Lyman Rd South Hadlcy MA 01075 Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed bermitapplicant 1. Building 12384.00 (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee Y' 4. Mechanical(HVAC) / 5. Fire Protection 6. Total=(1 +2+3+4+5) 12384.00 Check Number This Section For Official Use Only Date Building Permit Number: Issued: Signature: g Building CommissionedInspector of BoiWirgs Date EMAIL ADDRESS(REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) Se:tion 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 Dcpanmenl Lot Size Frontage Setbacks Front Side U R: Li R: _ Rear Building Height Bldg.Square Footage 't, % (- Open Space Footage an (Loi area minus bldg S paved parkas) #of Parking Spaces Fill: i _.... li.... . _.. . volumc&Loaaiion A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O 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 Pages and/or Document N 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 0 IF YES, describe size, type and location: E. Wil 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 Storm Water Management Penni:from the DPW is required. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Wintlosre Altemtion(s) E:] Roofing ✓❑ Or Doo s El Accessory Bltlg. ❑ Demolition ❑ Now Signs [0] Decks [p Siding[0] Other Io] Brief Description of Proposed Remove existing roofaimend and install new asphalt shingle a,smm. Work: Alteration of existing bedroom_Yes X No Adding new bedroom Yes X No Attached Narrative Renovating unfinished basement Yes x No Plans Attached Roll -Sheet ea.If Newhouse and or addNbn to w4fi oo houslfw:comoloW the followInG a. Use of building: One Family Two Family Other b. Number of rooms in each family unit. Number of Bathrooms c. Is Mere a garage attached? J, Proposed Square footage of new construction. Dimensions e. Number of stories? f. Method of heating? Fireplaces or Woodsloves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction I. Is construction within 100 it 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 Ta-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES 1 F_OR BUILDING PERMIT I, M(J(] 0rIQ LI II bQ Y'TI]- as Owner of the subject property Adam Quenneville Roofing&Siding Inc hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. 1I lilt Signature of--Owns, Date I, F 8afYI I as OwnerlAuthorized 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. Maim �UIlI�hDIJiI� Pont Name , t1� Illy Signature of Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Nei of License hold, Adam Quenneville License Number 160 Old Lyman Rd. CS 070626 Address Expiration Date South Hadley, MA 01075 8/21/2019 Signal Telephone 413-536-5955 9.Replatil HMO Improvelirlonln1c-tor:. C cc Not Applicable ❑ Nc{a ry1 Q 11 Y11'\l 111 ltd Qoni-IV IACompany Name nn '' ,1l- ,, 11 '''' Registration Number 1l D �� LA.AYY1GlY) IC_c'1 ��VI V-�f�11�� Din 191093 Address ,J Expiration Date ^� Telephone u 3-�1�5e1 3/22/2020 SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.O.L.c.162,§261 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 b lding permit. Signed Affidavit Attached Yes....... No._... ❑ City of Northampton _ Massachusetts o c i DEPARTMENT OF BUSLIIZIJG INSPECTIONS 212 Mein etraet Huwv 01060 1l auiltlinq Northamptoo n, MA 01060 AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and subcontractors performing improvements or renovations on detached one to four family homes. Prior to performing work on such homes,a contractor must be registered as a Home Improvement Contractor("HIC'). M.G.L. Chapter 142A requires that the"reconstruction, alteration, renovation, repair, modernization, conversion, improvement, removal, demolition, or construction of an addition to any pre-exisfing owner-occupied building containing at least one but not more than four dwelling units....or to structures which are adjacent to such residence or building"be done by registered contractors. Note:If the homeowner has contracted with a corporation or LLC,that entity must be registered Type of Work: Est. Cos[: �yF 01"Q vc Address of Work: a -YIC.I-. K.,cr I- IOfQ-VCR. m'F� d(0(DZ Date of Permit Application: I hereby certify that: Registration is not required for the fallowing reason(s): _Work excluded by law(explain): Job under$1,000.00 _Owner obtaining own permit(explain): Building not owner-occupied Other(specify): OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER M.C.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION. Signed under the penalties of perjury: I hereby apply for a building permit as the agent of the owner: 'Ilnliy /- bA "v;lLe 191093 Date 1 Contractor Name HIC Registration No. OR: Notwithstanding the above notice, 1 hereby apply for a building permit as the owner of the above property: Date Owner Name and Signature City of Northampton Massachusetts ,c (a DEPANTHENT OF BUILDING INSPECTIONS � 212 Hain Street .Hu�uciPel Suil `v Northampton, w 01060 Debris 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. The debris from construction work being performed at: A93 Rorencz 2�1. (Please print house number and street name) Is to be disposed of at: (Please print name and location of facility) Or will be 1disposed of in a dumpster onsite rented or leased from: USS 1 11� �Y1Q ` CEL,UL,lNRyS ML(II f 'En6 kL j OF (Company Nanja and Addr s) & -1hW Signature of Permit Applicant or Owner Date If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the Building Department as to the location where the debris will be disposed. AMMOSAIL pY�NNltVgLL� qv"d VtSAGC wcwn SW Old Lyman Road•South Hadley•MA 01025 We aro Licensed 1.80D.NEW.R00F a 413.536.5955 Fully Insured Email:'nfmal800newrootm, webslts:www.ieodrwroof.nn FactoryTralned MA Construction Supervisors Lid,M70626 MA Registration#120982 Factory Certified Inatalll6 MemnerdlM xome 9mMaJ:A:erc.dwemmMas. CT Regisortbn#575920 MemnndMe puOEIM&irate NfviNm IIr M710 Proposal Submitted To: Date: Phone Ws: C Marjorie Giliberto 7/11/18 H 413-586-6399 W Street: Email: 893 Florence Rd 1ibwpt(Igsnail.com City,State,Tip Code: Special Requirements: Florence, MA 01062 PROPOSALFOR: HOUSE GARAGE OTHER STRECOVER layers: 02 3 4 Plywood Included: Yes a No ❑ Tear off SLATE or SHAKES COMPLETE ROOF PROTECTION 5IVSTEM: Ih We shall acquire appropriate permits for all work a❑ Home exterior and landscaping to be protected IR Strip existing roofing to existing decking with full inspection DONOTDO: N All project waste shall be removed by dumpster(dumpsterfor contractor use only) • Install Ice&Water Barrier at all eaves 3'Ovalleys,chimneys,pipes and skylights Pd Install(151b.fel Syntheti nderlaymen ver remaining decking area IA Install Metal drip edge at eaves and rak (8" S" whit brown) • Install manufacturer's starter shingle on aves and rake edges R Install new pipe baa[ as ' vent accessories d Install ridge ven -Snow Count Cobra rolled/4'Baffied/Rail Shingles:(standard 6 nails per shingle) GAF Shingles Color: Biscayne Blue GAF Ridge cap shingles Warranty Options: LF Weguaranteeourworkmanshipfor 10 full years ❑ GAF System Plus Warranty ❑ GAF Golden Pledge Warranty CAlmney Options: 74 Lead Counter Flashing UWater Seal&Tuckpoint O Rubberized Crown E]Cricket 0 Mason needed(customer provided) Additional material and labor charges may apply. N Deteriorated existing decking will be replaced at$3.77 per sq.ft.and dimensional lumber at$7.00 per linear ft., after full inspection. NSEomer lnidak: w.P�w.a n.,aMmmmi:nm muumu6o,-wmgexmaaorean<e wrmaewa raenr,m.:rsme:�md Total Due:($ 12,384 ( Pd CC ACCFPfNIRaF pROPOSiL:Th/ahosw pdm,spedflotbmartl wWtlem arc Down Payment:IS 4384 aisfadory a,ld an lwrabya—mal.you em amMdze#mdpwwkupedRe#. r Balance Due Upon Completion:($ 8000 1 %ymeM WE ae 1/3 dm,at rrartoll/a,Intl aalanx due Ypan[wnalMbn. /11/18 Date Signature: I .�•�/� Date: 7/11/18 Es[imamc(Print Namel Joseph $nopelr(Sign Name) 413-221-4329 ATTENTION HOMEOWNERS:Please corer 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 Quonnevllle Roofing will not be responsible for debris or dust In the colt or storage areas. CustomerinRials ACROe CERTIFICATE OF LIABILITY INSURANCE DATE IMMLD%WY) re/za2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATNELY OR NEGATNELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED By THE POLJCIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHOAUDD REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT. N the cor .M holder is an ADDITIONAL INSURED,Me poliCy(las)must have ADMONAL INSURED proulaioma or IN endorsed. If SUBROGATION IS WANED,sub4act b the tam19 and conditions d UIe policy,certain polkas.may require an aMonomant. A statement on this mNR does not confer,rights to Na cal mW hostler In lieu d such andomemellt(S). Pnmucka MdindB Karakuls NAME: Goes&McLain Instance Agency PHONE (413)534-7355 A^xL ry. (413) 6-9286 1757 Nonf amplon Street AOMIESS: mNmkula®gofamdain.wnn PO Bout 1128 INWRMtIS)AFFO GLOVE W NAICI Hdyoka MA 01041-1126 lX MA: Nautlluslnwlance Company M6VPF➢ INM/RER B: MBUMUBInsuande Corn,my Adam Quenneville Roofing&Siding Inc INandon O: AI M.Mutual Ins Co. 160 Old Lyman Road INSURERD. The Bond EXChenge,Inc. xMai Sodh Hadley MA 01075 MsndEnruRF: COVERAGES CERTIFICATE NUMBER: CLI85104974 REWSION NUMBER: THIS IS TO CERTIFY THATTHE POLICIES OF INSURANCE LISTED BELOW HOVE BEEN ISSUED TO THE INSURED NAMEDABOVE FOR THE POLICY PERIOD INDICATED. NOTATHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF MY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO MICH THIS CERTFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCEAFFORDED BY THE POLICIES DESCRIBED HEREIN 15 SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHORN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IN L. TYPEOFINSURANLE BULLMnA P0.ICY HUNBEn LIMN mi LIMITS x COMYEIICIALGMIExLLL1ABHJtt FACX IX:CURflENCE f t'OOD'DPo CUIMSMALE ©OCCUR PREYIBEe 3 100'000 M FD Ev(AMwM pxePnl f 15.000 A NN852218 08/232018 0623/2018 PEASONaLt ADVINJURY 3 1"0000 GENLAGGREGATE IIMRAWUES PER. 2,000,000 GENERALAGGREMTE 3 PIXILY 0 JEPo- O La PRODUCTS-CCMPiOPAGG f 2'•000 oiNE6. Employee Endefd. f 1000,00 AUTDNOBILE LIABILITY GEMa ti en ANY Anip BOpLYINJURY(Pxpnm) f OWNFD SCHEDULED BCpLY IHJURY(Pm.) f AUTCb ONLY AVTOB ED AUTOS OXLV HIRE. HUTORON, pgCpERT'pAMAGE a DIbBM3Med motoraM Bl s x UNFELAWB GCCU0. .—"N' CCURRENCE a 3'000,000 0 MEN use cuM.MA. ANOV522 08/132017 OM132018 AGCREGAIE a 3,000,000 OEO X 0.ElENTON f 10'DOD a WDRI{EMe COYPErJ8ATIX1 R A EMPLOYERB'UABLm' IX STATUTE ER ANY PROPRIETgiIMRTNENIAECUTNE EL EAAPGILENT a1"0,000 C' C CFAMEMWR E%LLUDEni O N/A Avc4DD70tzeei-2D1e DG292018 04282019 LX It-adhcEAn E. AL.CNEASE-EA EMPLOYEE It 1000,000 OESCRIPTONDFOPERAT1IXiBEW.w EL000,000 Surety Bond-HSSAifdiate Bord Annum 20,000 D 3384948 0N192018 0//192018 MWRIPTgNOFOPE nMSILOLAMNSIVEXICLFS MCCMD1p1,A4EItlmtlRmmWSWJi4,mgb Ma[IM llmmtpo BlapJA4I CuTfirete Madera are Btldilonal insured on the above captioned GL pd'ICy',Subject to pollry horde,conditions,Mq ex0dua ns.Adam Quennevuk,as an Officer,is excluded horn the Mies Comp policy CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXP RATKIN DATE THEREOF,NOTICE WILL BE DELIVERED IN Man,QcenneYllle Roofing&Siding Inc. ACCORDANCE WRH THE POLICY PROVISIONS. AUTIORU'ED REPRESEXTATNE 019833016ACORD CORPORATION. All righb rewTVed. ACORD 26(2016413) The ACORD memo and Mgo are registered marks dACORD �\ The Commonwealth of Massachusetts Department of IndustrialAccidems I Congress Street,Suite 100 Boston,MA 02114-20177 www.mass.gov/dia Ulki-ki,ins'Compommustia, Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED W PIN THE PERMITTING AUTHORITY. Applicant Information Name (Business/OTanlzatlon/Indlvidaal):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 bra: Type of project(required): I l am a employer with 15 employces(fvlland/orpart-time)• 7. New construction 2C]Iimasole proprietor arpnnncrshipaad have no employees wofkmg for ma in $,Remodeling any capacity.IN.wade¢ comp_ituumoce required_) 3.Olamahome1xmadoi11all1mkm111(INewcarrus'comp.morma,vquired.)' 9. ❑Demolition 41 am a homeowner and will be hirin 10 ❑ Building addition g contractors to conduct all work nn my property. i will ensure that all with no rad,de ernavewaukers'uompenmtinn insurenecw aresole ILQ Electrical repairs or additions propriGors with no employees. 12.❑Plumbing repairs or additions 5,❑I e a sabot contractor have and I have hired the have war taneo, in on the auache4 sheet mere sob.comracma hove omployees and have waders'comp.insurance: 13.®Roof repairs 6.❑We are a corporation and its mrana,have-e,.,wd thou right.1 exert,on per MGL e. 14.QOther_ `2A ya),and we hove no employees Ilo,workers'campmormnce required I Any applicant that checks has#I must also ill out the section below showing their workers'compensation policy Information. Iovers mns who submit this affidavit Indicating may are doing all work and then hire outside contractors most submit v new affidavit indicating sucr. tComractors that aback this box most attached an additional sheet showing the name ofthe snbaooneatots and Arae whemn cam ran mo>c irides have employees. ICihe subcontractors haveemployces,iFey moat provide their weakens'comp.policy number. /am an employer that is providing workers'compensation insarancefor my employees. Below is the policy andjob site information. Insurance Company Name:AIM Mutual Policy#or Self-ins.Lima#:A IWC4007012861-201(8 Expiration Date:4/29/20190 Job Site Address: (]'Ll i"�QY p.�'�.P�. Cll. City/State/Zip:��VYLe—MN UckvZ 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 andlor one-year imprisonment,as well as civil penalties in the form ofa STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statemem may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby resel under the pains and penalties of perjury that the information provided above its true and correct. Signature: Date' 7 ,1711+ phone k:413-536-5955 Oficial 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#: Caouood. fth of MassaMuseits ®' Dimsron of hofessidnal Lcensure Board of Budding Regulations and Standards ConstruCtlon supermsor CS-070626 Expires:00/212019 ADAM A OUENNEVILLE 160 OLD LYMAN ROAD Fy SOUTH HADLEY MA 01070 Commissldner Office of Consumer Affairs and Business Regulation One Ashburton Place -Suite 1301 Boston, Massachusetts 02108 Home Improvement Contractor Registration Type: Corpora0pn ADAM OUENNEVILLE ROOFING AND SIDING,INC. Repiration: t191093100 OLD LYMAN RD. ExExpiration: 03/221'2020 SO.HADLEY,MA 01075 Update Address and Rewrn Card. '.ca i a mswsry STATE OF CONNECTICUT ♦ DEPARTMENT OF CONSUMER PROTECTION Be irlmoum thnt ADAM QUENNEVILLE 160 OLD LYMAN ROAD SOUTH HADLEY, MA 01075-2632 i is terrified by the Department of Consumer Pmtrrtm,t as a regim and HOME IMPROVEMENT CONTRACTOR Registration # HIC.0575920 ADAM QUENNEVILLE ROOFING Effective: 12/01/2017 Expiration: 11/30/2018 nt�n.lk sr.ean.caamwaarr