31B-136 135 STATE ST BP-2019-1220
GIs 4: COMMONWEALTH OF MASSACHUSETTS
Map:Black;3 1 B-136 CITY OF NORTHAMPTON
Lot; -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildina DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category,ROOF BUILDING PERMIT
FMPI4 BP-2019-1220
Proiect4 JS-2019-001974
Est.Cost: $21000.00
Fee:540.00 PERMISSION IS HEREBY GRANTED TO:
Const,Class: Contractor: License:
Use Grnuo; ADAM QUENNEVILLE 070626
Lot Size(sa.to: 6751.80 Owner: KELLER FRANCIS W JR&CAROL F
Zoninw URC(100)/ Applicant: ADAM QUENNEVILLE
AT: 135 STATES
Applicant Address: Phone: Insurance:
160 OLD LYMAN RD (413) 536-59550 Workers
Compensation
SOUTH HADLEYMA01075 ISSUED OM5/18019 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:
Find: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Qqi 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 Sienature:
FeeType: Date Paid: Amount:
Building 5/1/20190;00:00 $40.00
212 Main Street,Phone(413)587.1240,Fax:(413)587.1272
Louis Hasbrouck—Building Commissioner
YO F
_ Department use only
C of Northam L ` LC
Pelmif.
Building Dep merRECL1\tl.' D Veway Permit
i 212 Main S Set ptAvailabilityRoom 10 n llvailabiliryNorthampton, M 01 0 A'� 4 of tructural Plans
phone 413-587-1240 Fa 41 587-1272 Wagaggial
1T pr nmiolnir W�
APPLICATION TO CONSTRUCT,ALTER,R OR DEMOLJS/HjA ONE OQR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION 3 7�l�a a
1.1 Property Address � rrThhis section to be completed by office
� Q
Map 3(& Lot (3(� Unit
135 State St Northampton, MA 01060 Zone Overlay District
Elm St District CS Distdd
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
Carol Keller 135 State St Northampton,MA 01060
Name(Print) Cunard Mailing Address: 413-584-3404
SR - l/ CX Ytm t+ TNapliMe
SignaWe
2.2 Authorized Age"" � � L
ATAO(Y\t (" ,- Qoo{T)LU Ylryy'I I IV1X Ileo �Id 1 u1v1n n PSI . S0,TkO u
Name(Prim) ,n ' Current Mailing ALdres . aO
I-I 13-55
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building 21,000.00 (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 8
3. Plumbing Building Permit I"
4. Mechanical(HVAC)
5.Fire Protection
6. Total=(1 +2+3+4+5) 21,000.00 Check Number
This Section For Official Use Only
BuiMingDate
Panni[Nu r:
awed:
Signature: '5 201
Building CommissionerlinspMor of Buildings Data
produelion @ 1800newroof.net
EMAIL ADDRESS(REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
Section 4. ZONING All Information Mus[Be Completed. Permit Can Be Denkd Due To Incomplete Information
Existing Proposed Required by Zoning
This column to b<rilled in by
Building Depvnment
Lot Sia L_...
Frontage
Setbacks Front - - I
Side U R: L:—i _R=
Rear 0
Building Height
Bldg.Square Footage %
Open Space Footage % J
(Wt arms minus bull,@Med L
k of Puking Spaces
Fill:
volume&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW Q YES O
IF YES, date issued: _J
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW O YES O
IF YES: enter Book Page, and/or Document X
B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW O YES 0
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 0
IF YES,describe sire, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES O NO O
IF YES, describe size, type and location: C
E. Will the construction activity disturb(Gearing,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.
i
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alterationts) ❑ Roofing Q
or Doors O
Accessory Bldg. ❑ Demolition ❑ New Signs [CI Decks [p Siding[E31 Other[E3]
Brief Description of Proposed Rcai cxiwng roof rimn.l artl Insall rcw asphalt shingle ryrtem
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
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?
In. 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 Poor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No.
I. SelpeticTal CitySewl Prwate well City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
( m
1, !LI V�o 110 f 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
Sii CC,nlmct NI3GIt°4
Signal of Owner /� Date
I.
!-te�Y]YY� l U 1.�✓Iyy I IP as Owner/Authorized
Agent hereby declare Mat the statements aMin ..hot,on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
"ryl Q "j A li s UI1
PnM Name
/ 1130 �9
Signature of r/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable 0
Name of License Holder. Adam Quenneville
License Number
160 Old Lyman Rd South Hadley, MA 01075 CS 070626
Address Emiral'an Dale
8@1/2019
Signature Telepinine
413-536-5955
e."W
n�R 111 Home lm Contractor: Not Applicable 0
Company NameC � Registration Number
1l,30 bd I .lumrl Yy1A 610 1S 191093
Address Expiration DateTelephone u13-�o-m1 3/22/2020
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.O.L.c.182,5 25C(S))
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.......A- No...... 0
City of Northampton
Massachusetts M125.s
s
DEPARTMENT OF NDIDDING INSPECTIONS
212 H&in Strut " Nmicipal nullG ng N� qCA
NorM�ton, Mx 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,mademization, conversion,
improvement,removal, demolition, or construction of an addition to any pmoxisfing owneroccupied building containing
at least one but not mom than four dwelling units....or to structures which am adjacent to such residence or building"be
done by registered contractors.
Note:If Ike homeownerd.
(( has contracted wilh a corporation or LLC,that entity must be registere
Type of Work: EoOT Est.Cost 00°O
Address of Work: 13s Sab S+. Nor+-kamrytry) Mr- OlOcon
Date of Permit Application: I3O\1q
I hereby certify that:
Registration is not required fm 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 pedury:
1 hereby apply for a building permit as the agent of the owner:
! � OtiOct 3
Dam Contractor Name HIC Registration No.
OR:
Notwithstanding the above notice,I hereby apply for a building pennit as the owner of the above property:
Date Owner Name and Signature
City of Northampton
Massachusetts n� L "✓��
DEPARTMENT OF BUILDING INSPECTIONSa
•Municipal Building
212 Main Street
Northen�ton' ! 01060 T✓j�-':�ij(i
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:
/35 3+0V S+.
(Please print house number and street name)
Is to be disposed of at:
(15A OF
(Please print ame and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
UUA ' ! C Ylluf(vn �I Fn�u CTdloD82
( anpany Na a and Address)
A,� `i -;0�t9
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.
ENNAM
4vguM fn, ww»p� VISAS Iiiifl
IM Old Lyman Road•South Heeler,MA 01075 We are Licensed
1".NEW.ROOF a 413.536.5955 Fully Insured
E.H:,nforl80onewroofnet website:anvw.fa0an.vnooi.irt Factory Trained
MA construction supervisors tic 0070626 MA Registration#12082 Factory Certified Installers
MemEer of the Home trustees Mex.ofvammen man. CTRnistratlo0#57$920
MemM....r%.'re exYem PP c 387M
Proposal Submitted To: Dm: Phone#'s: C:413-584-3404
Carol Keller 4/24/19 H: W:
Street Emall:
135 State St
City,State,Mp Code: Special Requirements:
Northampton MA 01060 install rubber EPDM on upper roof
PROPOSAL pOg: where all 3 valleys meet.
HOUSE GARAGE OTHER
ST111P RECOVER do driveway aide first because its
layer: 1 03 4 Phw.d Incl.cled(21orNo a shared driveway.
Tear oft IATErZSHAKES
02MPIfFEROOF PRMCWNSYSTEM:
iY We shall acquire appropriate permits for all work
M Home exterior and landscaping to be protected
9 Strip existing roofing to existing decking with full inspection DO NOTDO: no porches
N NI project waste shall he remoeed by dumpater(dumpsterfor contractor use only)
dk Install ice&Water Banner at all eaves 3'walleys,chimneys,pipes and skylights
As Install(151b.felt hstk)ndedayment over remaining decking area
it Install Metal drip edge at eaves and rakes ee S" hits brown(
Lfl Install manufacturers starter shingle on all eaves and rake edges
TR Install new pipe boot flashing/vent accessories
V Install ridge vent-Snow Country/Cobra rolled/4'Baffled kD
Shingles:(standard 6 nails per shingle)
Tamko Heritage Shingles Cnbnslatestone gray
Tamko Ridge cap shingles
Warranty Options:
01 We guarantee our workmanship for 1� full years
.: GAF System Plus Warranty
I GAF Golden Pledge Warranty
Chimney Optlorss:
Rl Lead Counter Flashing I-1Water Seal&Tudspoint El Rubbericed Crown C Cricket
L Mason needed(customer provided)
Additional material and labor charges mry apply.
II Deteriorated existing decking will be replaced at$3.77 per sq.ft.and dimensional lumber at$7.00 Per linear ft.,
after full inspection. Ckseomer lnkiou.
weprwshe.evm Mnr#maemaNatl NM-eomgnem aaxM�a uebaeowgwrleWHb#waanrF. Tonal Dir:021000 1
ACCE"MaWMP L:7Mabo Wces,
oMftr an l Down Payment:1$ 7 0 0 0 1
ww
WrrarMWyaxpW.Yuu.masteponcompletlon:014000
1
f areniA nR b.t/a#own r wm ct rah.•"e a hnx eue poen nam#IerYux
Date: U s3%T/44 signature: 64alue �l
Nw: 4/24/19 Estimator:(MM Name)Robe r t Croteau (sign Namel
ATTENTION HOMEOWNERS:Please coast all personal belongirp In the ask,garage ar storage Arps duelothe
posslbllily of roofing debris or dust coming in through cracks of the wood.Adam QuenrrWlle RooflngwN rot be
responsible for debris or dust In the attic or storage areas. Customer lnitfuls:
ACOR03 CERTIFICATE OF LIABILITY INSURANCE w;;p18"Y'
THIS CERTIFICATE IS ISSUED ASA MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EUEND 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: tithe conflicts holder h 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 endoreemeM. A statement on
this certificate does not confer rights to the celSficale hostler In lieu of such endonamaM(s).
PROd10ER XµE. Melinda Narakula
Goes B Mclean Insurance Agency �eX (413)534-7355 oo (413)538-9286
1767 Nadhem%on Street ,ApM1Ess: mkarekUlaggossmctain.cam
PO Box 1128 INSUREmS)AFIQOWCOYEMQ MMC•
Holyoke MA 01041-1128 IMORERA: Nautilus Insurance Company
IMURW IMUREaa: Nautilus lnsumnco,Company
Adam Ouennedlle Roofing B Siding Inc haptaic: A.I.M.MuWal Ins Co.
160 Old Lyman Road INSURER g; The Bond Exchange,Inc.
IN UN ER E:
South Hadley MA 01075 lM ERF-
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. NDTWRNSTANDINGANY REQUIREMENT,TERM OR CONDITION OFANYCONTRACT OR OTHER DOCUMENT WITH RESPECTTO WHICH THIS
CERTIFICATE MY BE ISSUED OR MAY PERTNN,THE INSURANCEAFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECTTOAU-THETERMS.
EXCLUSIONSAND CONDITIONS OF SUCH PODCIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLNM9.
lmll
LTR TYPE OFINRURANLE INM pore PONCYMMBCR NY..lCEMLDABMM,9O usersx -"..CIALOENIWY DcHOCCURREN(X f 1'000'000
CINASMPDE ®OCCUR PREMISES E 100'000
• MED EAPAXme Deem) f 15'000
A Y NN952216 06232018 D11=019 Pm,,NW_sa Iwu, f 1.006000
GBILAGGREGale.IF .FFA: GENEMAGGREGATE f 2'000'000
=E- )FyT LOC PRODUCTS r. .WM.G f 2.0t)000
OT1ER Employee Barents S 1,800.000
NROMMILEUMIMY E FM—WDI INGLE LIMIT k
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Mss) NCNOWNED PR YMMAGE B
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uMelzw Lw pppgR F.Vl1�I1RIMNCE i 5.000AW
B EaCE8a WB cNAbLL•nE ANO55464 OSI132018 DBI132019 ,AGGREGATE s 5,000.000
OED RETENTIONS 'DOW E
WOnRFABCWPENBMNIX PER OTH-
AM EMPLOYERS DNNTY YIN STAT E ER
C ANYRtOPNETOR EXCLUDED?
ILE%ECMME ❑Y NIA AWC4007012861-2015 04282018 042912019 E.LEACHACCIDEM f 1,000,000
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Surety Bond-HSS AMMW BOM Amount 20,000
O 3364848 04H92018 ON192019
DE�PoPIXINOFOPfIUNOMILOCI.TOMIYEMCIFB(ACORD 1M,AhBtlmMRMnvb BNeM1l4 mayMMxlxJXmmerpw MrWr�
CeMcide holden are additonal nsuled on Me soave captioned GL polity;subject to polity forms,conditions,and exclusions.More Ouennedlle,as an
officer.Is excluded tram to Workers Camp policy.
CERTIFICATE HOLDER CANCELLATION
SHOULDANY OF THEASOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
Adam Ouenneville Roofing B Siding Inc. ACCORDANCE WITH THE POLICY PROVISIONS,
AOTNONZED REPMSEMATW
tig 2015ACORDCORPORATION. All rlghtereNrved.
ACORD 25(2013103) The ACORD name and Ingo are registered marks of ACORD
AC'ORd CERTIFICATE OF LIABILITY INSURANCE °AreNAII°°"Y"T
o4/2=019
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 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
cartMcate holder In lieu of such endoraemen a.
PROWRA CO •cT Fe Tmdell
..___
MARTIN J CLAYTON INSURANCE AGENCY INC
EMNL3a.
1649 NORTHAMPTON ST WE 5 IxsuRERIBAFFORONDCQVIUM E MANS
_______—_T___
HAIA 01061 NwREa A: AIM MUTUAL INS CO
asseence _ 33.758
ADAM OUENNEVILLE ROOFING 8 SIDING INC NauR6Rr. -
mum o:
180 OLD LYMAN ROAD wwRSSE: ..............
SOUTH HADLEY MA 01075 1 DJSUMA1
COVERAGES CERTIFICATE NUMBER: 393099 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 REOUIREMENT,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 CI-AMS.
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DMAunoN°r OPERATIONS IA TIONS r YExICLES IACORD 101,UdIMMl Iuwb sdnal..mar M YuoRNN 6gw isrrgWM1
Workers'Compensation benefits will be paid b Massachusetts employees only.Pursuant to End°Bement WC 20 03 06 B.no authorization is given to pay
claims for benefits to employees in states other than Massachusetts if Me FFsured hires,or has hired those employees outside of Massachusetts.
This cerfifficats of Insurance shows me policy In force on the date that this certificate was issued(unless the expiration date on the above pDlry,precedes Ne
Issue date oftris oeNficele d insurance). The status done covemW can be monitored dely by accessing the Proof of Coverage-Coverage Verification
Search tool at www.mass.govllwdAv°riders-mmpensdien/nvestigalbnsl.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES DE CANCELLED BEFORE
THE EXPI"I N DATE THEREOF, NOTICE WILL BE DELIVERED IN
Adam Quenneville Roofing & Siding Inc ACCORDANCE W THE POLICY PROVISIONS.
160 Old Lyman Read A°TWMIPREPMSEmATNE
D
y a
'D.-f,
South HadleMA 01075 !.
Daniel M.Croy,CPCU,Vice President-Residual Merkat-WCRIBMA
®1988.2814 ACORO CORPORATION. All rights reserved. I
ACORD 25(201,1101) The ACORD name a nd logo are registered marks of ACORD
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street,Suite 100
Boston,MA 02114-2017
www.massgov/dla
IV1Forkers'Compensation Insurance Affidavit:Builders/Contmetors/Eleclricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name(Business/OrganivnlioMndividmi):Adam QBenneville Roofing&Siding Inc.
Address:160 Old Lyman Rd
City/State/Zip:South Hadley, MA 01075 phone#:419-536-5955
Arc you an emptoyerr Chsck M1s appropriate bei Type of project(required):
I. J]l am a employer with 15 cmploycs(MImNorpm-limc)• 7. ❑New construction
2.❑lamawlcpmpriemrorpannerdt3pmdhavenoemployeeswmking formcm 8. ❑Remodeling
my capacity.[No workers'comp.insurance requires]1
l❑Iamahwneownerdoingallworkmyself Moxvarksm''comp.insurancem,dood.]s 9. ❑Demolition
4.❑I an a homeowner and will be hiring contractors to conduct all work on my property. I will 10[]Building addition
ensure that all comraton either have work¢rs'compensation seurance more so to It.❑Electrical repairs or additions
proprietors with no employ. 12.❑Plumbing repairs or additions
5❑1 an a gearal romratm and I have hired the subcontractors lined on the attached shM. 13.QROof repairs
These smno
ubactms heveemployees and have workmoiers'cummoi
6.❑We area corporation amlipomcers have exereiscd Heir eight ofesoneseon per MGL c 14.❑Other
152,61(4),and we have re employees.leo workers'comp.insurance pyuimal
•Any uppl lean'that checks box al main iso fill am the section below showing their workers'compensation polity information.
r I Iemenwners wM10 submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such
I('exuact...that check this box must attached an additional sheet showing the name of the subcomeactors and state whether or not hose entities have
employees. If the subcontractors have employees,they must provide their workers comp policy number.
Jam 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 0 or Self-ins.Lie.h:AWCC40070128611-2OR R Expiration Date:4I2920o'?O
Job Site Address: 135 iket S City/StmeJZip:Nor 6t/)1Pi7r) Aq- UIaOo
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date}
Failure on secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00
and/or ono-year imprisonment,as well as civil penalties in the form of 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 Once of Investigations of the DIA for insurance
coverage verification.
J do hereby certify under the p sand penalties of perjury that the information provid d ah venin true and correct.
SignatureDate�30 �)'I
Phone R:413-536-5955
Official use only. Do not write in this area,to be completed by city or town official
City orTown: Permit/License g
Issuing Authority(circle one):
1.Board of Health 2. Building Department 3.Citylraw n Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone st:
_ ®p Cormronwealth of Massachusetts
c'T! DNislon of professional Licensure
Board of Building Regulations ano Standards
ConstrV<Hon 5opervisor
CS-070626 Eapires:08/21/2019
ADAM A DDENNEVILLE
150 0LD LYMAW ROAD
SOUTH HADLEY•JAA 0011075 ,
Commissioner
Office of Consumer Affairs and Business Regulation
One Ashburton Place- Suite 1301
Boston, Massachusetts 02108
Home Improvement Contractor Registration
Type: Corporation
ADAM DUENNEVILLE ROOFING AND SIDING. INC. Registration: 191083
160 OLD LYMAN RD. Eaprafion: 03/2W"o
SO.HADLEY,MA 01075
Update Address aM Petum Card.
' .• mows„
STATE OF CONNECTICUT 1 DEPARTMENT OF CONSUMER PRO E("I'ION
B.it known ihat
ADAM QUENNEVILLE
160 OLD LYMAN ROAD
SOUTH HADLEY, MA 01075-2632
has satisficd the qualifications required by law and is hereby registered as a
r HOME IMPROVEMENTCONTRACTOR
Registration # HIC.0575920
ADAM QUENNEVILLEROOPING -
Effective: 12/01/2018
Expiration: 11/30/2019 mN
hirteele soe�u,cnm .y
I!
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