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17D-012 (65) Commonwealth of Massachusetts Division of Professional Licensure "M Board of Building Regulations and Standards Co n s t rtuctilon'S u pe ry i s o r C5-070626 Ettpires:08/21/2015 k .»s ADAM A QUENNEVILLE, 160 OLD LYMAtSI ROAD.. SOUTH HADLEY-MA 01075 Commissioner 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 SIDINCI, INi✓ s '` Registration: 191093 160 OLD LYMAN RD. Expiration: 03/22/2020 SO.HADLEY,MA 01075 e z :max i 1 $� Update Address and Return Gard. SCA t iS 24M-45,117 111, gia STATE OF CONNECTICUT + DEPARTMENT OF CONSUMER PROTECTION Be it known that ADAM QUENNEVILLE 160 OLD LYMAN ROAD SOUTH HADLEY, MA 01075-2632 has satisfied the qualifications required by law and is hereby registered as a HOME IMPROVEMENT'CON'T'RACTOR Registration # HIC-0575920 ADAM QUENNEVILLE R00FING Effecdve: 12/01/2018S66-M iN Expiration: 1.1/30/2019 MieheliesIwgoii,Commia loner The Commonwealth of Massachusetts Department of Industrial Accidents > I Congress Street,Suite 100 < Boston,MA 02114-2017 www.massgovldia «'orkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Leizibly 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.0 I am a employer with 15 employees(full and/or part-time).* 7. [❑New construction 2.E]I am a sole proprietor or partnership and have no employees working for me in $. Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.n I am a homeowner doing all work myself[No workers'comp.insurance required.]t 10 Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole I I.[]Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.© p Roof repairs These sub-contractors have employees and have workers'comp.insurance.$ 6.rl We are a corporation and its officers have exercised their right of exemption per MGL e. 14.Q Other 152,S 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. f liomeowners 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 far 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: - I 3 City/State/Zip: Q(`rLn(_e , "t CAN Attach a copy of the workers'compensation policy declaration p (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 th ains and penalties of perjury that the information provided above is true and correct. Si nature: Date: 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#: ACS CERTIFICATE OF LIABILITY INSURANCE DATE8/13/2018 Y) 08113/2018 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(les)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 NAMEMelinda Karakula :A T Goss&McLain Insurance Agency PH Nc (413)534-7355 No: (413)536-9286 1767 Northampton Street ADDAIL RESS: mkarakula@gossmclain.com P O BOX 1128 INSURER(S)AFFORDING COVERAGE NAIC t: Holyoke MA 01041-1128 INSURERA: 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. 1 LTR TYPE OF INSURANCE INSD POLICYNUMBER MMIDDN MM/DD X LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 PREMISES Ea occurrence $ 100,000 DAMAGE TO RENTEIT— CLAIMS-MADE X OCCUR MED EXP(Any one person) $ 15,000 — A Y NN952216 06/23/2018 06/23/2019 PERSONAL&ADV INJURY $ 1,000,000 GENLAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY Q PRO- Q 2,000,QQd JECT LOG PRODUCTS-COtiPlOPAGG $ 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 OCCUREACH OCCURRENCE $ 5,000,000 B EXCESS LIAB Hx CLAIMS-MADE AN055464 08/13/2018 08/13/2019 AGGREGATE $ 5,000,000 DED I X RETENTION$ 10,000 $ WORKERS COMPENSATION �/ PER OTH- AND EMPLOYERS'UABILITY X STATUTE ER ANY PROPRIETORIPARTNERIFXECUTiVE YIN 1,000,000 C OFFICER/MEMBEREXCLUDED? a NIA AWC4007012861-2018 04/29/2018 04/29/2019 E.L.EACH ACCIDENT $ (Mandatory In NH) 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 Bond Amount 20,600 3364848 04!1912018 04!19!2019 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES- (ACORD 101,Additional Remarks Schedule,maybe attached If more space Is required) Certificate holders are additonai 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(2016103) The ACORD name and logo are registered marks of ACORD 90AWARD ViSAW DiscovEg: 2010 WINNER 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.1800newroof.net Factory Trained MA Construction Supervisors Lit.#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: 7/11/18 Phone#'s: C: Meadowbrook Apartments H: W: Street: Email: 491 Bridge Rd-Building 3 City,State,Zip Code: Special Requirements: Florence,MA 01062 Resecure all gutters as needed With new brackets PROPOSALIFOR: HOUS GARAGE OTHER FTM RECOVER 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 dura ster(dumpsterfor contractor use only) V install ice&Water Barrier at all eaves 3' valleys,chimneys,pipes ^d Lk,lwS6+s 1,/- Install(151b.felt=nderlayment over remaining decking area V Install Metal drip edge at eaves and rakes E)5") white V install manufacturer's starter shingle on all eaves and rake edges V Install new pipe boot flashing/vent accessories V Install ridge vent-Snow Country f—Cobra—rolled J4'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 GAF System Plus Warranty GAF Golden Pledge Warranty Chimney Options: D Lead Counter Flashing 0 Water Seal&Tuckpoint 0 Rubberized Crown El Cricket O 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$7.00 per linear ft., after full inspection. Customer Initials: We propose hereby to furnish materials and labor-complete in accordance with above specifications for the sum of: Total Due: 19,125.00 ACCEPTANCE OF PROPOSAL.The above prices,specifications and conditions are Down Payment: TBC} satisfactory and are hereby accepted.You are authorized to do work a=Ifld. Balance Due Upon Completion:($ Payment will be 1/3 down at start ofiob,Ind balance due upon completion. Date:kt 9 e U 1%Signature veka bAft 1A Date: 10126/18 Estimator:(Print 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: �11C'LOZ The debris will be transported by: eA-A4 I C6-� The debris will be received by: kAn I I 1 I1 , .1 44 ► rte. Building permit number: Name of Permit Applicant Date Signature of Permit Applicant Version 1.7 Commercial Building Permit May 15,2000 SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11) Independent Structural Engineering Structural Peer Review Required Yes ® No SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT IMeadowbrook Apartments/Poah Communities w ®-------........ as Owner of the subject property Adam Quenneville Roofing& Siding Inc hereby authorizer .-. _..._,. ..� ._ ,_, �_�,, _a,� _�_, n—1--111-1--,,,,_ .,.,... ....,............... !to act on my behalf, in all matters relative to work authorized by this building permit application i� Signature of Owner Date I ' Adam Quenneville i 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 thg_pAl s and penalties ofperjur _w ., Adam Quenneville } Print Name Signature ol Owner/Agent Date SECTION 12-CONSTRUCTION SERVICES 10.1 Licensed Construction Suuervisor: Not Applicable ❑ Adam Quenneville ? ICS 070626 Name of License Holder: � --A -. - License Number 160 Old Lyman Rd South Hadley, MA 01075KK „rt 08/21/2019 Address Expiration Date ) 536-5955 „ Signature Telephone 1 —7SECTION 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 E) No 0 Version 1.7 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 36,000 C.F.OF ENCLOSED SPACE) 9.1 Registered Architect: Not Applicable Name(Registrant): ... __ a_� __ _ ..__ Registration Number Address # Expiration Date Signature Telephone 9.2 Registered Professional Engineer(s): ft Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date { Name Area of Responsibility w _ Address Registration Number ._------- Signature -_.Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date _ i� Name Area of Responsibility t Address Registration Number Signature Telephone I Expiration Date 9.3 General Contractor Adam Quenneville Roofing& Siding Inc Not Applicable ❑ Company Name: jAdam Quenneville_ — . __.._ Responsible In Charge of Construction 160 Old Lyman Rd South Hadley MA 01075 i Address lot536-5955 Signature Telephone Versionl.7 Commercial Building Permit May l5,2OOO 8. NORTHAMPTON ZONIWE� Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size Frontage Setbacks Front Rear Building Height Bldg.Square Footage Open Space Footage % (Lot area minus bldg&paved L--j #of Parking Spaces (volume&Location) A. Has aSpecial Permit/Variance/Finding ever been issued for/on the site? NO �~ «���� ����� DONT�NOVY YES �~� IF YES, date issued: IF YES: Was the permit recorded atthe Registry ofDeeds? NO ~_,K � DON7KNOVV YES - IF YES: enter Book Page and/or Document#'I | �� B. Does the dtecontain a brook, body ofwater nrwetlands? NO �~� DON-[ KNOW YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained 0 Date Issued: C. Doany signs exist nnthe pnopert ��y� YES «�� NO |FYES, describe size, type and Location: | ------------ D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO IF YES, describe size, type and location: | E. Will the construction activity disturb(clearing,grading, excavation,orfilling)over 1acre oriuitpart ofacommon plan that will disturb over 1 acre? YES ��K � NO K�3 �� 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 ✓❑ Change of Use❑ Other❑ Brief Description Remove existing asphalt shingles and install new asphalt shingle system. Of Proposed Work: SECTION 5-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 ❑ F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ I Institutional ❑ I-1 ❑ 1-2 ❑ 1-3 ❑ 3B ❑ M Mercantile ❑ 4 ❑ R Residential ❑ R-1 ❑ R-2 IZI R-3 ❑ 5A ❑ S Storage ❑ S-1 ❑ S-2 ❑ 56 ❑ U Utility ❑ Specify: M Mixed Use ❑ Specify: S Special Use ❑ Specify: COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND/OR CHANGE IN USE Existing Use Group: L, _. _ Proposed Use Group: Existing Hazard Index 780 CMR 34): .. Proposed Hazard Index 780 CMR 34) SECTION 6 BUILDING HEIGHT AND AREA BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY Floor Area per Floor(sf) 1st St 1 , nd 2nd I l 2 I . ..._...,....�. a rd 3rd 3 4tn . 4th i t _ 1 Total Area(sf) 1.. Total Proposed New Constructionsof Total Height(ft) _ Total Height It 7.Water Supply(M.G.L.c.40,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System: Public ❑ Private ❑ Zone .�,___ Outside Flood Zone[:] Municipal ❑ On site disposal system[:] Version].7 Commercial Building Permit Ma 15,2000 C E Iy ED ity of Northampton j wilding Department f OV ��8 212 Main Street Room 100 Northampton, MA 01060 nF�r o run_niNG 1NSP 41 5$7-1240 Fax 413-587-1272 "=O'i7HAMPTON,MA 01060 APPLICATION TO CONSTRUCT,REPAIR,RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING f� j SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be completed by office r--1. — 1491 Bridge Rd- Building 3 _ _ _ _. Map 1--7 Lot Unit ;Florence, MA 01062 1 Zone Overlay District I Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: iMeadowbrook Apartments 1�....�_.......�.'_,�.a....�.�,m...�..�.��...�., ,�. , i _ p [491 Bridge Rd Florence,MA 01062 Name(Print) Current Mailing Address: 617 840-9812 ! Signature Telephone 2.2 Authorized Agent: Adam Quenneville Roofing& Siding Inc 60 Old Lyman Rd South Hadley MA 01075 Name(Print) Current Maili�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. BuildingOe"vv $19,125 0 (a)Building Permit Fee I 2. Electrical .___.. (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee i A 4. Mechanical(HVAC) " ' 5. Fire Protection 6. Total=0 +2+3+4+5) to Check Number This Section For Official Use Only Building Permit Number Date Issued Signature: Building ommissi ner/Inspector of Buildings Date 491 BRIDGE RD-#3 BP-2019-0651 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 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-2019-0651 Proiect# JS-2019-001062 Est.Cost: $19125.00 Fee: $140.00 PERMISSION IS HEREBY GRANTED TO.- Const. O.const.Class: Contractor: License: Use Group: ADAM QUENNEVILLE 070626 Lot Size(sa.ft.): 1169150.40 Owner: MEADOWBROOK PRESERVATION ASSOCIATES LTD PARTNERSHIP zoning: URB(100)/WP(28)// Applicant. ADAM QUENNEVILLE AT. 491 BRIDGE RD - #3 Apolicant Address: Phone: Insurance: 160 OLD LYMAN RD (413) 536-5955 () Workers Compensation SOUTH HADLEYMA01075 ISSUED ON:12/5/2018 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 Occuaancy Sienature• 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