17D-012 (68) Commonwealth of Massachusetts
�? Division of Professional Licensure
Board of Building Regulations and Standards
Constructlbn'Supervisor
CS-070626 Ex'Pi res:08/21/2019
ADAM A QUENNEVtLLE=
160 OLD LYMAAN ROAD.
SOUTH HADLEY-MA 01076 ;
Commissioner
Office of Consumer Affairs and Business Regulation
One Ashburton Place - Suite 1301
Boston, Massachusetts 02108
Home Improvement.Contractor Registration
Type. Corporation
m
ADAM QUENNEVlLLE ROOFING AND S!D!NR_G7NC egistration: 191093
F)piration: 03/22/2020
160 OLD LYMAN RD.
SO.HADLEY,MA 01075 '+
r r ,
Update Address and Return Card.
SCA t 20M•05:17
STATE OF CONNECTICUT t DEPARTMENT OF CONSUMER PROTECTION
Ile it known that
ADAM QUENNEVILLE
160 OLD LYMAN ROAD
SOUTH HADLEY, MA 01075-2632
has satisfied the qualifications requited by la-vv and is hereby registered as a
HOME IMPROVEMENT'CONTRACTOR
Registration # HIC.0575920
ADAM QUENNEVILLE ROOFING
Effective: 12/01/2018
Expiration: 11/30/2019 Wtla:>uuestagun,Commissioner i
The Commonwealth of Massachusetts
Department of IndustrialAccidents
I 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.
Aaalicant 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.E✓ I am a employer with 15 employees(full and/or part-time).* 7. ❑New construction
In I am a sole proprietor or partnership and have no employees working for me in
8. ❑Remodeling
any capacity.[No workers'comp.insurance required.]
9. El Demolition
3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
10❑Building addition
4.❑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.❑Electrical repairs or additions
proprietors with no employees.
12.❑Plumbing repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. pC Roof repairs
These sub-contractors have employees and have workers'comp.insurance.t ❑ p
6.❑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#1 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 ((��
Job Site Address: 4 q B r 1 2d City/State/Zip: � 1(0a nct I ► Ih pCoZ
Attach a copy of the workers'compen§4tion policy declaration p e(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$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify under OK pains and penalties of perjury that the information provided above isue and correct.
Signature: Date: � ' ak 1'e
Phone#:413-536-5955
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
DATE(MMIDONYYY)
AC40 CERTIFICATE OF LIABILITY INSURANCE
41,.� i
08I13t2018
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on
this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
PRODUCER NAME T Melinda Karakula
Goss&McLain Insurance Agency PHONEo E (413)534-7355 No:AIC (413)536-9286
1767 Northampton Street F-MAJLs: mkarakula@gossmciain.com
P O Box 112$ INSURER(S)AFFORDING COVERAGE MAIC If
Holyoke MA 01041-1128 INSURER A: Nautilus Insurance Company
INSURED INSURER B: 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAYBE 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.
ILTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MMIDO E MMIDD FF PO XP LIMITS
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
DAMAGE TO REN I EIT_
CLAIMS-MADE �OCCUR PREMISES Ea occurrence $ 100,000
MED EXP(Anv one person) $ 15,000
A Y NN952216 06/23/2018 06/2312019 PERSONAL&ADV INJURY $ 1,000,000
GENLAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000
POLICY a JET F1 LOC PRODUCTS-COMPIOPAGG $ 2+000,000
OTHER: Employee Benefits $ 1,000,000
AUTOMOBILE LIABILITY COMBINEDSINGLE 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 UAB Hx CLAIMS-MADE AN055464 08/13/2018 08/13/2019 AGGREGATE $ 5,000,000
DED I X RETENTION$ 10,000 $
WORKERS COMPENSATIONX $TATLJTE ORH-
AND EMPLOYERS UABILITY YIN 1,000,000
ANY PROPRIETOR/PARTNER/EXECUTNE E.L.EACH ACCIDENT $ _
C OFFICER/MEMBER EXCLUDED? NIA AWC4007012861-2018 04/29/2018 04!29!2019 1,000,000
(Mandatory in NH) E.L.DISEASE-FA EMPLOYEE $
If yes,describe under 1,000,000
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $
Surety Bond-HSS Affiliate Bond Amount 20,000
D 3364848 04119/2018 04!19!2019
DESCRIPTION OF OPERATIONS I LOCATIONS I 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 REPRESENTATIVE
O 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
9A w TRXD VISA40 DISCOVER
2010 WINNER ::11 E
160 Old Lyman Road-South Hadley*MA 01075 We are Licensed
1.800.NEW.ROOF * 413.536.5955 Fully Insured
Email:info@1800newroof.net Website:www.180onewroof.net Factory Trained
MA Construction Supervisors Lic.#070626 MA Registration#120982 Factory Certified Installers
Member of the Home Buildees Assoc.of Western Mass. CT Registration#575920
Member of the Building&Trade Association P.Pc 38710
Proposal Submitted To: Date: 7/11/18 Phone#'s: C:
Meadowbrook Apartments H: W!
Street: Email:
491 Bridge Rd-Building I
City,State,Zip Code: Special Requirements:
Florence,MA 01062 Resecure all gutters as needed With new brackets
PROPOSAL FOR:
HODS GARAGE OTHER
rTM9 RECOVER
—Layer 1034 Plywood included: Yes or
D Tear off SLATE or SHAKES
COMPLETE ROOF PROTECTION SYSTEM.
V we shall acquire appropriate permits for all work
V Home exterior and landscaping to be protected
V Strip existing roofing to existing decking with full inspection DO NOT DO:
V All project waste shall be removed by clumpster(dumpsterfor contractor use only)
V install Ice&Water Barrier at all eaves 3'(Dvalleys,chimneys,pipes aadik*U@W
Y/ Install(151b.feltfSYnthe7c) nderIayment over remaining decking area
• install Metal drip edge at eaves and rakesQ 5") white
• install manufacturer's starter shingle on all eaves and rake edges
V Install new pipe boot flashing/vent accessories
install ridge vent-Snow Country Cobra rolled 4'Baffled/Roll
Shingles:(standard 6 nails per shingle)
GAF Timberline Lifetime Shingles Color:
GAF Ridge cap shingles
Warranty Options:
V we guarantee our workmanship for 10 full years
I GAF System Plus Warranty
GAF Golden Pledge Warranty
Chimney Options:
EJ Lead Counter Flashing 0 Water Seal&Tuckpoint EJ Rubberized Crown El Cricket
ED Mason needed(customer provided)
Additional material and labor charges may apply.
V Deteriorated existing decking will be replaced at$3.77 per sq.ft.and dimensional lumber at$7.00 per linear ft.,
after full inspection. Customer Initials:
We propose hereby to furnish materials and labor-complete in accordance with above specifications for the sum of; Total Due:($19,125.00
ACCEPTANCE OF PROPOSAL*The above prices,specifications andconI'
d Ho are
Down Payment:($ TBTBC!satisfactory and are hereby accepted.You are authorized to do work as specified. Balance Due Upon Completion:($
Payment 11 be 1 3 down at tart If J b d balance due upon completion.
"
Date:I I start
49
Date: 10/26/18 -Estimator:( rint Name) Adam Quenneville (Sign Name)
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:
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: I � . ��
m110Wz
The debris will be transported by: 'Pq - l
The debris will be received by: .i 11�
Building permit number:
Name of Permit Applicant l O1-kk rt,1' LV i I l.Q- Qo o- t v e l'` I '
U v
(I �4sF 1[k j A4,�
Date Signature of Permit Applicant
Version 1.7 Commercial Building Permit May 15,2000
SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11) 7
Independent Structural Engineering Structural Peer Review Required Yes 0 No 4
SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
Meadowbrook Apartments I Poah Communities
__._. .. as Owner of the subject property
Adam Quenneville Roofing& Siding Inc `to
hereby authorize . _ ,.. __. _.�
act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
1
Adam Quennevtlle 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, enalties of perjury_
lAdam Quennevtlle
Print Nam�,p�
Signature of Owner/Agent Date
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Adam Quennevtlle CS 070626
Name of License Holder
License Number
160 Old Lyman Rd South Hadley, MA 01075 s 0$/21/2019
� .�., ,. �..._ .m.. .... ..��_
Address Expiration Date
413) 536 5955
Signature Telephone
SECTION 13-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 G) No 0
Versionl.7 Commercial Building Permit May 15,2000
SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES-FOR BUILDINGS AND STRUCTURES SUBJECT TO
CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116(CONTAINING MORE THAN 35,000 C.F.OF ENCLOSED SPACE)
9.1 Registered Architect:
Not Applicable ❑
Name(Registrant):
Registration Number
Address
Expiration Date
L _s
Signature Telephone
9.2 Registered Professional Engineer(s):
€ l
Name Area of Responsibility
f f
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
€ i _ _-
Signature Telephone Expiration Date
------------
---_--------,m _,......, .
Name Area of Responsibility
Address Registration Number ee
Signature Telephone Expiration Date
a
.,._. , __ __._------------ I
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
9.3 General Contractor
jAdam Quennevtlle Roofing& Siding Inc Not Applicable ❑
Company Name:
Adam Quennevtlle i
Responsible In Charge of Construction
160 Old LymanµRd South Hadley MA 01075
Address
[(413) 536-5955
Signature Telephone
Versionl.7 Commercial Building Permit May l5.2UUU
8. NORTHAMPTON ZONiRZ7
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
-----------------------------------------
Lot Size
Setbacks Front
Rear
Building Height
Bldg. Square Footage
0110
Open Space Footage %
of Parking Spaces L
(volume&Location)
A. Has aSpecial Permit/Variance/Fi ndi ngever been issued for/on the site?
��/�� ��
NO ����� DON'T KNOW YES �~�
|FYES, date issued:
IF YES: Was the permit recorded atthe Registry ofDeeds?
NO �� D
«�� um / xnuvv /ES
IF YES: enter Book Page and/or Document# i
B. Does the site contain abrook, body of water orwetlands? NO «���� DON7NNOVV YES
IF YES, has permit been or need to be obtained from the Conservation Commission?
Needs tobembtained «�� Obtained ��x Date
\
«�� «�� ' '
C. Doany si �� ��QnsexistontheproperLy� YES x�� NO �~�
IF YES, describe size, type and Location:
D. Are there any proposed changes to or additions of signs intended for the property? YES 0NO
IF YES, describe size, type and location: |
E. Will the construction activity disturb(clearing, grading,excavation,orfilling)over 1acre orisbpart ofacommon plan
that will disturb over 1acre? YES ��K � NO ���
��
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Versionl.7 Commercial Building Permit May 15,2000
SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations ❑ Existing Wall Signs ❑ Demolition❑ Repairs❑� Additions ❑ Accessory Building❑
Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing El Change of Use❑ Other❑
Brief Description [Remove existing asphalt shingles and install new asphalt shingle system.
Of Proposed Work:
SECTION 6-USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A-1 ❑ A-2 ❑ A-3 ❑ 1A ❑
A-4 ❑ A-5 ❑ 1B ❑
B Business ❑ 2A ❑
E Educational ❑ 2B I ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H Hiah Hazard ❑ 3A ❑
I Institutional ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ 3B ❑
M Mercantile ❑ 4 ❑
R Residential ❑ R-1 ❑ R-2 ❑D R-3 ❑ 5A ❑
S Storage ❑ S-1 ❑ S-2 ❑ 5B ❑
_.__------------------------------- - _...
U UtilityE] Specify:
M Mixed UseElSpecify:
_ w e_ _
S Special Use ❑ Specify:
k
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND/OR CHANGE IN USE
Existing Use Group: Proposed Use Group: Is
Existing Hazard Index 780 CMR 34): _ Proposed Hazard Index 780 CMR 34): 1�
SECTION 6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY
Floor Area per Floor(sf)
—------------
St
St �, 1
nd 2nd
i
Ma
3rd s
3rd
4m
4t� t
Total Area(sf) Total Proposed New Constructions(sf
Total Height(ft)
Total Height ft
7.Water Supply(M.G.L.c.40,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
Public ❑ Private ❑ Zone F Outside Flood Zone[-] Municipal ❑ On site disposal system❑
6
r Version 1.7 Commercial Building Permit Ma 15,2000
ity of Northampton
N T/ 2 q,::2 018 uilding Department
212 Main Street
Room 100
Ft;;i F'MjC,iNsPFCTIONs NOhampton, MA 01060
1"-1;_'10NMAo,oso
--- phone 413'587-1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT,REPAIR, RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: This section to be completed by office
491 Bridge Rd- Building 1 Map P Lot C Z Unit
!Florence, MA 01062
Zone Overlay District
I - -------- - Elm St.District CS District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
iMeadowbrook Apartments 1491 Bridge Rd Florence,MA 01062
Name(Print) Current Mailing Address:
61 7 840-9812 _
Signature �k Q- C Al ACS Telephone
2.2 Authorized Anent:
AdQuenneville Roofing& Siding Inc 160 Old Lyman Rd South Hadley MA 01075
[ am
Name(Print) Current Mailing Address:
E 536 5955
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building - $19,125.00 (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
I Construction from 6 4
3. Plumbing F Building Permit Fee
4. Mechanical(HVAC) �� °« �
5. Fire Protection
6. Total=(1 +2+3+4+5) "A' Check Number 7
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:///;,I
Building Co missionedlnspector of Buildings Date
491 BRIDGE RD-#1 BP-2019-0652
GIS#: COMMONWEALTH OF MASSACHUSETTS
MV.Blgck: 17D-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-2019-0652
Project# JS-2019-001063
Est.Cost:$19125.00
Fee:$140.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor- License:
Use Group: ADAM QUENNEVILLE 070626
Lot Size(sg.ft.): 1169150.40 Owner: MEADOWBROOK PRESERVATION ASSOCIATES LTD PARTNERSHIP
Zoning:UR]3(100)[WP(28) Applicant: ADAM QUENNEVILLE
AT. 491 BRIDGE RD -#1
Applicant Address: Phone: Insurance:
160 OLD LYMAN RD (413) 536-5955 Workers
Compensation
SOUTH HADLEYMA01075 ISSUED QN.11/SA018 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: 2k 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 12/5/2018 0:00:00 $140.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck--Building Commissioner