Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
10B-049 (2)
15 UPLAND RD BP-2019-1315 GIs#; COMMONWEALTH OF MASSACHUSETTS M4•Block: 10B-049 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-2019-1315 Project JS-2019-002123 Est.Cost:$2025.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO. Const Class: Contractor: License: Use Groun: ADAM QUENNEVILLE 070626 Lot Size(sa. ft.): 13024.44 Owner: WOICIR MICHAEL&EMILY Loomw URA(100)/ Applicant: ADAM QUENNEVILLE AT: 15 U&6ND RD Applicant Address: Phone: Insurance: 160 OLD LYMAN RD (413) 536-5955 0 Workers Compensation SOUTH HADLEYMA01075 ISSUED ON. /2112019 0:00:00 TO PERFORM THE FOLLOWING WORK:STRIP & S H I N G L E 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: --�Ugl4gy R; at Fireplace/Chimney; Rough: Qil: Insulation: Final: 5—l Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occuoancv Siaggturg: jee 1,20: Date Paid: Amount: Building 5/21/2019 0:00:00 $40.00 212 Main Street, Phone(413)587.1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner ECOVED City of Northmpt n Building Dep rtm t MAS 212 Main S reef j Room 0 OF rduol�w 111-PNorthampton, M O'POBTON inn phone 413-587-1240 Fax 413-587-1272 1yV a , APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A/ONE OR TWO FAMILY DWELLING ATION `O`� SECTION 1 -SITE INFORMto- 1.1 1.1 Property Address: This section to be completed by office Map fl Lot 6 yq Unit 15 Upland Rd Leeds, MA 01053 zone Overlay District Elm St.Dlsblct CS District SECTION 2-PROPERTY OWNERSHIPIAUTHORRED AGENT 2.1 Owner of Record: Michael&Emily Wojcik 15 Upland Rd Leeds,MA 0153 Name(Print) Current Mailing Address. 413-695-6624 Telephone Signature 2.2 Authorized Anent: I lin Old Lurr n n 2d �i,1 In IZcUz, , mA Name(Print) Current Mailing Adtlr OI O �j S S9SS Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building 2,025.00 (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee ly/ 4. Mechanical(HVAC) r 5. Fire Protection 6. Total=0 ,2+3-4+5) 2,025.00 Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: 5- Building Commissionedhopector of Buildings Date production @ 1800newroof.net 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 r .. Lot Size ! _ if Frontage Setbacks Front -' — 1 Side L' R.i_. L:)._ R:[ - - Rear Building Height -"I Bldg. Square Footage I r' a f - Open Space Footage ad Dat area minus bldg&paved L _ arkin #of Parking Spaces - rFill: _...... I_ _.. __. vowme&t .hca -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:. IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW O YES O IF YES: enter Book I. Page.. and/or Document if B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW O YES Q 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 © NO O IF YES, describe size, type and location: E. Wil 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. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windom Alteration(s) ❑ Roofing Q Or Doors C] Accessory Bldg. ❑ Demolition ❑ New Signs [OI Decks [q Siding(0] Other[DJ Brief Description of Proposed Remove existing roof materiel and install new asphalt shingle system on garage only. 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 aa.If Ifew IloNse and abWA1on to ekWune biiWrlo e0mP1*%1thedonowina: 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? I, Method of heating? Fireplaces or Woodsloves Number of each g. Energy Conservation Compliance. Mawcheck Energy Compliance form attached? h. Type of construction L Is construction within 100 fl.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 Septic Tank City Sever 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 Adam Quenneville Roofing&Siding Inc hereby authorize to act an my behalf,in all matters relative to work authorized by this building permit application. Suze_ finer Signature of Owner Date h-F I, corm ©LA-LAX 1 A 11 �-fi--- 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. Sigfn�ed,under the pains and penalties of perjury. triarv\ QL�lI t Print Name s �n X19 Signature of Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor. Not Applicable ❑ Name of License holds, Adam QuenneVllle License Number 160 Old Lyman Rd South Hadley, MA 01075 CS 070626 Address Expiration Date 8/21/2019 Signature Telephone 413-536-5955 9.R/�aeleforod NomaimotevemeM:'L:OMfeCb(F7` Not Applicable 11AcVxry\ Ql 11_x�rlcut� LP.- ILOO{-'1 u�A J C/-idt V1 P4 lA� Company Name j —j Registration Number 16o aid Mft 0J0'1�, 191093 Address Expiration Date TelephoneUI.2— � 59 3/22/2020 SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.C.152,§26CS)) 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 Massachusetts \/ `s DEPAItTNENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building SOgC M.r'Cl,am 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-exish'ng owneroccupied 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 reeistered contractors. Note:Lf the homeowner has contracted with a corporation or LLC,that entity must be registered Type of Work: QOottnyl Est.Cavt: 10DS �o Address of Work: S �A(>1(And IBJ. Lt_tA-� r MA �IO53 Date of Permit Application: I hereby certify that: Registration is not required for the following reasori _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: 1 hereby apply for a building permit as the agent of the owner: 4c ) 119A far^ 0U_LA_&#-y 0 l e_ I q 1093 Contractor Name HIC 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 DERARTHENT OF BUILDING INSPECTIONS yl fe' 212 Main street a Municipal Build ng \\`•`.,moi! �pCs Morthaepton, a 01060 t� Massachusetts Residential Building Code Section 110.115.1.2 Homeowner: Person(s)who own a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/ or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Section I I O R5.1.3.1 Any homeowner performing work for which a building permit is required shall be exempt from the licensing provisions of 780 CMR 110.R5, provided that if a homeowner engages a person(s) for hire to do such work, then such homeowner shall act as supervisor. Such homeowner shall submit to the Building Official, on a form acceptable to the Building Official, that he/she shall be responsible for all such work performed under the building permit. As acting Construction Supervisor your presence on the job site will be required from time to time, during and upon completion of the work for which this permit is issued. Also be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to Employees for injuries not resulting in Death) of the Massachusetts General Laws Annotated, you may be liable for person(s) you hire to perform work for you under this permit. City of Northampton Massachusetts 6 DEPARTMENT OF BUILDING INSPECTIONS 212 Mein Stzaetipel Building NaetLemptonan, tNA M 01060 •`^ypP Debris Disposal Affidavit In accordance of the provisions of MGL c 40, 554, 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: IS (�0l112 � qtr (Please print house number and street name) Is to be disposed of at: UtA A(ktLlnal IS Mullen ( I E4uld CT (Please print na a and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: 1ASA 11d� 1 v4lS IVlutlen Qd �nfulc� CT (Company Nam nd Address) SIn Signature df 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. pYlNNlV�LL6. ®Vnwriao V�$A� 10 old kyman Road•South Hadley•MA 03075 We are U.nsed 1".14M.R001c • 413.5365955 Fullylnsurend Emal:mlo®lawnwo.of.net Wallace:www.fro0newmd.net Fartory Trained MA Constructor Supervisors Ot RIUM6 MARegISVa0onp120982 Factory Certified Installers nwnanal eemx tale•.Moc,aw•x•m Wu. aReentrant#575920 vv.vlm•twahatn.Aurnxn "'.class PmposalSubmitted To: Date: Phmie Ks: C: 413-695-6624 goily 6 Michael Wojcik 5/09/1 H: w: Street: 15 Upland Ad Email: ennvojeik@aol.com City,State,Op Code: Special Requirements: GARAGE RUDE ONLY PROAC2 Bring buggy or trailer for HOUSE GARAGE OTHER cleanup STRIP RECOVER myerd:(� 3 4 Plywood Included Yes o©o ❑ Tear off SLATE$SHARE$ COMPIETH ROOF PROIE[NONSYSTFM gr' We shall acquire appmprate permlls for all work 6( Home exterior and landscaping to be proterted 3r' Strip existing roofing to exiting decking with full inspection OON0500: V All project waste shall be removed by dumpsler(dumpsterfor[onfmctw use only) ❑ Install lee&Water Banter at all eaves 3'16,valleys,chimneys,pipes and skylights ¢' Install(nib.feM n e E ndedayment over remaining decking area fy Install Metal drip edge at eaves and mkeco/5'kt011brown) ➢1 Install manufacturer's starter shingle on all eaves and eke edges ❑ Install new pipe boot flashing/vent accessories ❑ Install ridge vent-Snow Country/Cobra rolled/4'Baffled/Roll Shlneles:(standard 6nails per shingle) Angitic Black 7 M�{n Shingles Color: T�4 AAT0 Ridge rap shingles Warranty OptlpM: )e we guarantee our workmanship for full Years l GAF System Plus Warranty J GAF Golden Pledge Wamnty Ulmney Options, O Lead Counter Flashing 0Water Seal&Turkpolnt O Rubberided Crown OCricket 0 Mason needed(customer provided) Additional materal and labor charges may apply. qL Dnerieratel existing decking will be,replaced a 53.W R.and dimensional lumber M 57.00 per linear f., after full Inspection. Cusromea lnkiols: • n.,.gmmrnro..uw.•m uw-mmaauxe•m.m.wnn.aw.. rmm..mer: Tow Due:(5 700 1 Ed CC pone ce,NmFO swelowe PrrH,aedRwed Down Paymem:l5 1325 I vWartwyeaare Maeayampa4 rm•n•wvlaeeroaoavran�lalpwlnw. Retinue Due Upon Completion:l5 1 Ba'nNM an.he W sow"at wart Wldes," IMgCpeupaq/rnlpl pn. oaa 5/9/19 Signature: Date: 5/9/19 Edpmawr.(Pant Hamel Joe Snope 413-2&ANe? ATTENTION HOMEOWMRS:PIAsk u ccove rall"Honal belongings In theattic,gerUe or storaR udue tothe panall yof roofing call crdust[.ming inthrough colds ofthewood.Adam OuepaRgidla,Rmfing will not be responsible tar deers or dust in the attic or storap areas. Conn. rM]ebIc ACO a CERTIFICATE OF LIABILITY INSURANCE °"0 Ovoz2ots A)M019 " THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS CERTIFICATE DOES NOTAFFIRMATWELY OR NEGATIVELYAMEND,EILTEND 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. RUNS cerHBcete holder is an ADDITIONAL INSURED,the poll,pes)..at have ADDRIONAL INSURED pmAidens ar be endanad. N SUBROGATION IS WAIVED,subject io lle terms and conditions of the pollry,certain policies may mquim an endorsement A efetement on this cartMcats does not confer rights to the certificate holder In lieu of such andamoment(s). PRODUCER xXNE, MIKerekVle Gash&McLain lnsU2n08 AgenqPxoxxa (413)531-7355 OR xo (913)538-8208 1767 NOMampton Street ADMESmkMakule@gossmclaln.COm POB.1128 IXBUREfl(SIAFFORgNG COVERAGE NAIC0 Holyoke MA 01041-1128 INSURERA: Nautilus lmArance Company Ixauua INSURER B: Nautilus lnsumnce Company Adam OuenneVllle Roofing&Siding Inc INEUBER c: The Sond Exchange.Inc 160 Old Lyman Road INSURER D: INSURER E: South Hadley MV, 01075 INSURER F' COVERAGES CERTIFICATE NUMBER: CL185IU974 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 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. L1PRR TYPEOFIx8U ANCE MLICYNUMBE0. rp.yp E POO putiondi LIMITS G MMERCI WNERALLMBILITV FgG1pCfAIRMNCE $ 1'000000 GUIMSAuaoE �OCCUR PREMISES Es—op f 100.000 MEDFXP(AnYonrn ) f 15'000 A Y NN02216 0623/2010 0023/2019 PEMOra.1LSAGVIH111 S 1.000,000 GENLAGGREGATE UMITAP UES PER GENERALAGGREWTE S 2'000,000 PWIcv PR6 OTXER'. JECi LOC PRODUCTS-CONI $ 2,000 Employee B@refits $ 1,000.000 AU MMLE LIAMLn COM�aNSINGLE LIMIT $ ANYAUttI SODILYINJI.RY(Por Prtaon) S AAU OSDONLY SALHOS RCOILV INJVAV IPrevJmn f NON.oMNEo SEM. f Nuios OrvLv Auros ONLY Ye..mMn1 UOUarIpSUreCmDlDOst BI S x U16RELlA. OCCUR EACH OCCURRENCE f 6.ODD'WD B IXCE.USE oLAIMBMADE AN065484 00/132010 0&1321118 AGGREGATE $ 6'000,000 I.E. RFTENTNn S 10,000 a MOR[EM COMM MUTON ggNlE ER MDEMPLOYERYLMBRRV YIN ANYM, PRIETOR?ARINEND{EIXnnVE NIA E.L EACXACCIDFNT S CfFICERMEMBER IXCLUDEM (M qln NH) EL DISMSE-EA EMPLOYEE $ Xyn 4nabeunM DE%RIPTION OG WEMTION9 bebx ELOISEASE-POLICYLIMIT S Mond Amount 20,000 C SteadySontl-HSS AMIiab 3364048 04/192019 04/1912020 °ESCRImpXOFOPER1TMxl8/LOCATOXBIVEMCLES IACORD 18t,A4dWniulRmbBWtluMmry bcRWcaM XmontWu4nyul'apl CertRosts holders am edditonel main xi on be above captioned GL pO11,subject to M11c,forms,contlitlons,and Bedusicns.Adam Oue inavillo,as an ofiiwr,Is exdWad from the WorkMS Camp policy. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE OF MBEO POLICIES BE CANCELLED BEFORE THE EXPIRATION DAIS THEREOF,NOTICE WILL BE DELIVERED IN Adam OuenneAlle RwfW&Siding Inc. ACCORDANCE WITH THE POLICY PROVISIONS. AVINOR�a R@REBFNTITVE ID 106B-2015 ACORD CORPORATION. All Nghts reserved. ACORD 25(2016103) The ACORD name and logo am nglstarod marks of ACORD - AC;I e CERTIFICATE OF LIABILITY INSURANCE 0i ass.rYI `� 042312019 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, E)CTEND 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 pollcy(ies)most 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 corticate holder in lieu of such endomement(s. PRODUCER CONTACTFeTmdell -I"& MARTIN J CLAYTON INSURANCE AGENCY INC PRONE (41331.5 1e0a ' RP1 _.D_R�L,, Itrud0am)clayton.com __ __ __ 1649 NORTHAMPTON ST RTE 5 - _"__ ------INUTUAL INSDOING COVFALGE _N__AICP HOLVOKE . . MA 01041 wsuRER AIM MUTUAL INS CO j 33]56 _ _. _ -- INSURED INSURERS: ADAM QUENNEVILLE ROOFING&SIDING INC IxsuRERc: UUMUNUIR 160 OLD LYMAN ROAD ,Nseav E. SOUTH HADLEY MA 01075 1 WsoRPa f' 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 REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT CR 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. PODL SBB-A` Wjp TYPEOFINSURANLE PO..INUMBER WpOM' MAV marms COMMERCMLOENERAL WBILITY EA CH OCCURRENCE b _ LlA1MEMADE occuR "� I PRE�1._6EpE I_ -_ Env fMv _ S _ NIA PERsgU a AD r o—n1L __ LGGENLAGGREGATELIMITAPPLIES PER kGENERALAGGREGRE S POLICY 1. IPRO JJECi LOC (PRODUCTS COM%OPAG_G E OTHER. ! E FAUTCMOSLLELMBILRY COMBN IN LELIMIT S ANY AUTO ! BODILY NJVR (P yrsml 5 ALL OV.NED F�AUTOSECHIEDULED NIA J 6oDRv INJuar Pe Hmn s Aur s OY OED -PROPERTYGAMAGE I HIREOAUTO$ AWNUi05 " � E UMBREL OAS OCCUR EACHOOCURRENCE E%CE99 LIAB_LAMS-MADE: j NIAL, AGGREGATE 'DEC I RETENTIONS b IWORKF SCOMPENSATION V OTH AND EMPLOYERs'1JABILRY ^ $TATUIE 1. IBR__ ANYPRO'iNCTORRARTNENEFECUTIVE rIN, ! EL EACH ACCIDENT -1 S 1 BDD.D99 A O1nCo HSNBERvcLU i NIA NIA MAI AWC40070128612019A 04129120190412912020.x— ----� — IMaMIM>YFNNI EL DISEASE EA EMPLOYEE S 1 DBQOOO Mp Nx@e"I 3 OrWRTIM OF OPERATIONS uiso IBI.DISEASE-POLICY LIMIT E 1,000,000 I ! NIA DESSNPMNOPOPETMT101JSJLMAVONSIWMLES(CORD101,AEdabnalftu SMMUIe,Mabe AMNdRmaa...M requMi Worsens'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 0306 B.nD authorization is given to pay claims for benefits to employees in states other than Massachusetts if the Insured hires,or has hired those employees words of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above polity precedes the Issue dale of Nis certificate of insurance). The status of Nis coverage can be mentioned deify by accessing the Prpof cf Coverage-Coverage Verification Search tool at Wavy.mass.govllwdMorsem.compensationfinvestgationsl. 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 WDR THE POLICY PROVISIONS. 160 Old Lyman Road AUTHORUEDREPRESENTATNE South Hedley MA 01075 Daniel el M.Cr vJ ey.CPCU,Vise President-Resitlual Market-WCRIBMA ®1988-2014 ACORD CORPORATION. All rights reserved. . ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD �\ The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street,Suite 100 Boston,MA 02114-1017 wwwmass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Eleetrieians/Piumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. A I' Information Please Print Leeibly Name tBusine s/Organiz tion/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 ampluya?Check We appropriate box: Type of project(required): Lmlemannploare,th 15 ii'loyeeatfulland/orpnt-tfirc)' 7. ❑New construction z.❑lama rale pmptatm or parmeMiP and lmvenn empbyen wading tonnem 8. E]Remodeling any capmity.(No workers'compinsurance required.) J.❑I am a homeowner doors all workm if Naworkers'com .inmmnce d 1 El Demolition ga myself I p require ]' 4.❑lama hommwarandwill hoAldo tractors to condtutdlwodon m 10 Building addition g can my twill etawue Naull mnmcmn eitherhave wod<rs'mmpcnmtion insmmme onmsolc IL❑Elec[ncai repairs or additions proprietors with no anploon., 12.❑Plumbing repairs or additions 5fl I ams semmlcommoner and 1 have hued the sub-coattacmm listed on the anazhed sheet. 13.Q Roof repairs Theseinal,t ortars have employees and have wmican.,comp.imwancet 6.❑We ve acoryoommitad is otficm have exercisW tM1cir rightnfasc n must per MGL c. 14.❑Other 152,91(4),andwe Aavenoemployees.[N-mixer-.mon,.inmmm,meuitadi 'Any applkma that cloaks boa a1 mug also fill out the section below slwwing their workers'compensation policy information. e flooreawner,who submit this affidavit militants they am dnhtg a6 workand that hire on side smarectors must submit a new affidavit md.g.,such. :Convectors that chackthu We mug atsched an militating sheat showing Me woe of Mee subcontractors sial state whallharu rat time entities neve employees, lithe subcontnctombavecxnployecs,May must provide their xixkers'comp.policy number. I am an employer that isproviding avorkers'compensation inmrancefor my employees Bdow is the policy and job site information. Insurance Company Name: AIM Mutual Poboy#orself-ins.Lie.#: AWC400701288612019A Expiration Date: 4129/2020 , Job Site Address: 1 S U i2 i cI rld Qd City/State/Zip: � e CIS ,-I 'rs�1 "s n U I DS 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 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cenro),under thepa/t/�}h�on/d penalties of perjury that the information provided above is nue and correct Signature: Y Date PhraneM 413-536-5955 Official use only. Do not write in this area,to be completed by city or town official.. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: f t ( Commewealth of Massachusetts DNI96n of P(O}RSbOal L..asVte Board of Building Regulation$and 5land,ods Co nstru 7H0n Superviso r CS-070626 Expires: 0812112019 "AMA OUENNEVILLE 100 MO LYMAN ROAD, > SOUrtf NAMEY(MA 811,0,76 Commissioner v Office of Consumer Affairs and Business Regulation One Ashburton Place -Suite 1301 Boston, Massachusetts 02108 Home Improvement Contractor Registration Type: Corporation ADAM OLIENNEVALE ROOFING AND SID @IG NIO,` '' ' Registration: 191095 160 OLD LYMAN RD. Expireiion: 0312=20 SO.HADLEY,MA 01078 'f' r . . Update AddrossarM RaVsrr Card STATE OF CONNECTICUT + DEQ RnTMEt k � hNT OF CONSUMER PROTECTION at ADAM QUENNEVILLE 160 OLD LYMAN ROAD SOUTH HADLEY, MA 01075-2632 has satisfied the qualifications regoiMd by law and is hesebp a:cyistcrnd as a HOME IMPROVEMENT CONTRACTOR Registration # HIC.0575920 ADAM QUENNEVILLE ROOFING f Effective. 12/01/2018 jExpiration: 11/30/2019 Mkh RSmrull,CammWloon