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38B-067 245 SOUTH ST BP-2019-0479 GIS#: COMMONWEALTH OF MASSACHUSETTS Man:Block: 38B-067 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-2019-0479 Proiect# JS-2019-000776 Fe j.Cost: $13120,00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const,91ass: Contractor. License: t sg gra;_ ADAM QUENNEVILLE 070626 Lot Size(sa.ft.): 11761.20 Owner: CHAMN DAVID Zoning:URB(100)/ Applicant: ADAM QUENNEVILLE AT: 245 SOUTH ST Applicant Address: Phone: Insurance: 160 OLD LYMAN RD (413) 536-5955 Workers Compensation SOUTH HADLEYMA01075 ISSUED ON.•10/18/2018 0:00:00 TO PERFORM THE FOLLOWING WORK.-REMOVE EXISTING ROOF MATERIAL ON FLAT ROOF ONLY AND INSTALL NEW RUBBER ROOFING SYSTEM POST THIS CARD SO IT IS VISIBLE FROM THE NTUET 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 Dgv#Ltmtnt Fireplace/Chimney: Rough: ot Insulation: Final: Smoke; Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. CgqificaLe of Occupancy i nature: EeeTyne;., Date Paid: Amount: Building 10/18/2018 0:00:00 $40.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck r Building Commissioner City of Northampton ; Building Department � 212 Main Street Room 100 Northampton, MA 01060 phone 413-587-1240 Fax 413-587-1272 APPLICATION TO CONSTRUCT,ALTER,RE AIR, A O 4E OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION OCT 1 7 2018 (6P--I q-L1 2 f 1.1 Property Address: +`This ectic n to be completed by office DEPT.OF 15LULDING INSPECTIONS 3 G / NORTH ON ?AA01060 Lot Unit 245 South St Northampton, MA 01060 Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: David Charron 245 South St Northampton,MA 01060 Name(Print) Current Mailing Address: 413-537-8739 SQ k-- LC'ry'ncA Telephone Signature 2.2 Authorized Agent: F , � Q uu nnea111 lo, nc- 1 d wwanVJ, SIAJx Oad Name(Prin Current Mailing Address: j -�� q1�-536-SC) C s _ Signatufe Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building 13,120.00 (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 6. Total=0 +2+3+4+5) 13,120.00 j Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: l o(i ((A Building Commissioner/inspector of Buildings Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) 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 p Frontage Setbacks Front _m e Side L. R. ___ L R IF— Rear . . .. ............ Building Height Bldg.Square Footage "`= % � Open Space Footage �_ ...,, % _ (Lot area minus bldg&paved #of Parking Spaces ------ Fill:Fill: volume&Location A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DON'T KNOW YES Q IF YES, date issued IF YES: Was the permit recorded at the Registry of Deeds? NO Q DONT KNOW Q YES Q .m....,.....,._, �,.,, ad .... «p _ IF YES: enter Book Page' and/or Document# B. Does the site contain a brook, body of water or wetlands? NO ® DONT KNOW YES 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 ® NO Q IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO Q 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 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 ❑✓ Or Doors E] Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [p Siding[0] Other[O] Brief Description of Proposed Remove existing roof material on flat roof only and install new EPDM Rubber Roofing System. 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 SiPt:'1f New" 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 as Owner of the subject property (� CAR hereby authorize A-Aog 1.1,P�'��—����— �U(ARy lQ - S d t r\4 11� to act on my behalf, in all matters relative to work authorized by this building pbrmit application. (-0, C:k- to slay Signature of Owner Date 1, 1'�c �1r1 �t,t ll SZV1\� 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. Print Name 01 Signature of wner/Agent Date SECTION 8-CONSTRUCTION SERVICES 7 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: Adam QuenneVllle License Number 160 Old Lyman Rd South Hadley, MA 01075 CS 070626 Address Expiration Date 1& 8/21/2019 Signature Telephone 413-536-5955 9.RegWored 4 ne Itnurove tlt Cc►ntractdr� . Not Applicable ❑ ax,(\ nrve-o VW , g c \, Company Name 1 \ 1Registration Number \u© OSA �, �-�cl (Y G�}011 191093 Address Expiration Date A/L�1- Telephone 13 "SG 3/22/2020 SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.162,§26C(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...... ❑ City of Northampton SSS"� SSC Massachusetts DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building Northampton, 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-existing 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. Cost:—a ,1 rr� OC1D. Address of Work: p)y s sui't� Sy V`(1'(^-�/vf` mn MN- MOO Date of Permit Application: I hereby certify that: Registration is not required for the following 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.G.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: o Ie19103 c Date Contractor Name 111C Registration No. OR: Notwithstanding the above notice, I hereby apply for a building permit as the owner of the above property: Date Owner Name and Signature City of Northampton Massachusetts -G DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street •Municipal Building �v ,, f Northampton, MA 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: _ju s- Sc o+i-k 9 , (Please print house number and street name) Is to be disposed of at: (Please print na a and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: '1A 1 S Mul l�� Enfu��( C I cto (Company Nam and Address) ILl d I Elie 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. ARRAPA QYENNBVgLLE20 'a' VISA ROOFING 1W SIDING �1/ISAC ' ':% 2010 WINNER 160 Old Lyman Road•South Hadley•MA 01075 We are Licensed 1.800.NEW.ROOF • 413.536.5955 Fully Insured Email:infoCa)1800newroof.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: David Charron 10/6/2018 H: 413-537-8739 W: Street: Email: 245 South St. City,State,Zip Code: Northampton MA 01060 Proposal to furnish and install the following: Get any permits necessary. Remove deck and old flat roof plus inspect roof deck and replace any rotted wood $3.77 sq.ft. extra then install new EPDM rubber roof, walk pad on entire roof plus vinyl railing around perimeter of roof and a gate where ladder is dispose of all waste from project and haul away Ask us about affordable bank financing! ATTENTION HOMEOWNERS:Please cover all personal belongings in the attic,garage or storage areas due to the possibility of roofing debris or dust coming in through cracks of the wood.Please remove any lawn ornaments or yard furniture.Adam Quenneville Roofing will not be responsible for debris or dust in the attic or storage areas. Customer Initials: We propose hereby to furnish materials and labor-complete in accordance with above specifications for the sum of: Total Due:($ 13,12 0 ) ACCEPTANCE OF PROPOSAL:The above prices,specifications and conditions areDown Payment:($ ---- ) satisfactory and are hereby accepted.You are authorized to do work as specified. I Balance Due Upon Completion:($ f inanic$ Payment will be 1/3 down at signing,and balance due upon completion. Date: /V I r -7GLflgnature: Date: 10/6/2018 Estimator:(Print Name)Dustin Peters (Sign Name) . t/;� AT� Estimates are honored for sixty(60)days from above date. AC R® CERTIFICATE OF LIABILITY INSURANCE F DATE(MMIDDNYYY) 08/13/2018 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 have ADDITIONAL INSURED provisions or 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 NAME CONCT Melinda Karakula Goss&McLain Insurance Agency PAn NNo Est: (413)534-7355 No): (413)536 9286 1767 Northampton Street E-MAIL mkarakula@gossmclain.com ADDRESS: P O BOX 1128 INSURER(S)AFFORDING COVERAGE NAIC# Holyoke MA 01041-1128 INSURER A: Nautilus Insurance Company INSURED INSURER 13: Nautilus Insurance Company Adam Quenneville Roofing&Siding Inc INSURER C: A.I.M.Mutual Ins Co. 160 Old Lyman Road INSURER D: The Bond Exchange,Inc. INSURER E: South Hadley MA 01075 INSURER F: COVERAGES CERTIFICATE NUMBER: CL185104974 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. INR TYPE OF INSURANCE P U Y FF PO I Y EXP LIMITS LTR NSD D POLICY NUMBER MMiDD MMIDD X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 GE TO RENTED CLAIMS-MADE �OCCUR PREMISES Ea occurrence $ 100,000 MED EXP(Anv one person) $ 15,000 A Y NN952216 06/23/2018 06/23/2019 PERSONAL&ADV INJURY $ 1,000,000 GEN'LAGGREGATELIMIT APPLIES PER: GENERAL AGGREGATE $ 2.000,000 POLICY PRO 2,000,000 JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: Employee Benefits $ 1,000,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANYAUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident Underinsured motorist BI $ X UMBRELLA LIAB � OCCUR EACH OCCURRENCE $ 5,000,000 B EXCESS LIAB —1 CLAIMS-MADE AN055464 08/13/2018 08/13/2019 AGGREGATE $ 5,000,000 DED I X1 RETENTION$ 10,000 $ WORKERS COMPENSATION X STATUTE OH AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTNE YIN FACHACCIDENi $ 1,000,000 C OFFICER/MEMBEREXCLUDED? N/A AWC4007012861-2018 04/29/2018 04/29/2019 E.L. (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 1f ves,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ Surety Bond-HSS Affiliate Bond Amount 20,000 D 3364848 04/19/2018 04/19/2019 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space is required) Certificate holders are additonal insured on the above captioned GL policy;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 Adam Quenneville Roofing&Siding Inc. ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVES ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of Industrial Accidents d 1 Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gov/dia Vorkers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Leeibly 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.Q I am a employer with 15 employees(full and/or part-time).* 7. []New construction 2.❑1 am a sole proprietor or partnership and have no employees working for me in 8. FIRemodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 3.M I am a homeowner doing all work myself[No workers'comp.insurance required.]' 10 Q Building addition 4.[:]l am a homeowner and will be hiring contractors to conduct all work on my property. 1 will ensure that all contractors either have workers'compensation insurance or are sole 11.E]Electrical repairs or additions proprietors with no employees. 12.E]Plumbing repairs or additions 5.M I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.Q Roof repairs These sub-contractors have employees and have workers'comp.insurance.* 6.M We are a corporation and its officers have exercised their right of exemption per MGL c. 14.[:]Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box 41 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.#:AWC4007012861-2018 Expiration Date:4/29/2019 �n Job Site Address: C)LA LA-,-� City/State/Zip:�(;x`o�--,a(�( &(- `` `R Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). 0l CLOO 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 theins and penalties of perjury that the information provided above is t ue and correct. Si nature: � Date: �b d 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#: r Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Construction Supervisor CS-070626 Expires:08/21/2019 ADAM A QUENNEVILLE 160 OLD LYMAN ROAD SOUTH HADLEY MA 01075 Commissioner C4 Office of Consumer Affairs and Business Regulation One Ashburton Place - Suite 1301 Boston, Massachusetts 02108 Home Improvement Contractor Registration Type: Corporation ADAM QUENNEVILLE ROOFING AND SIDING,.INC. _ Registration: 191093 160 OLD LYMAN RD. Expiration: 03/22/2020 SO.HADLEY,MA 01075 Update Address and Return Card. SCA 1 A 2041-05,17 V G STATE OF CONNECTICUT ♦ DEPARTMENT OF CONSUMER PROTECTION Be it known that I ADAM QUENNEVILLE 160 OLD LYMAN ROAD SOUTH HADLEY, MA 01075-2632 e i is certified by the Department of Consumer Protection as a registered i HOME IMPROVEMENT CONTRACTOR Registration # HIC.0575920 ADAM QUENNEVILLE ROOFING 1 Effective: 12/01/2017 Expiration: 11/30/2018 i Michelk Seagull,Commissioner � I