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38C-059 (4) 392 SOUTH ST SP-2019-1465 GIS#: COMMONWEALTH OF MASSACHUSETTS Ma x.Block:38C-059 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A) Category: ROOF BUILDING PERMIT Permit# BP-2019-1465 Proiect# JS-2019-002377 Est.Cost:$8300.00 Fee:$40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class, Contractor: License: Use Group: ADAM QUENNEVILLE 070626 Lot Size(sp.ft.): 6011.28 Owner., CAHILLANE CHRISTOPHER P& Zoning, URB(looy Applicant. ADAM QUENNEVILLE AT: 392 SOUTH ST Applicant Address: Phone: Insurance: 160 OLD LYMAN RD (413) 536-5955 0 Workers Compensation SOUTH HADLEYMA01075 ISSUED ON.•6124120190:00:00 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 Hunt: 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 Occupancy Signature: FeeType: Date Paid: Amount: Building 6/2420190:00:00 $40.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner Grim City of Northampton status Building Department Curb CuliDruieway Parmil 212 Main Street Sewer/Septic Availability_ Room 100 Water/Well Availability— Northampton, vailability Northampton, MA 01080 Two Sets of Structural Plans phone 413-587-1240 Fax 413-587-1272 PIOUS Othe . APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE/OR DEM LISHh�VLAIIIIIIUWENG SECTION i -SITE INFORMATION 1.1 Properly Address: p is tion be completed by flit MaP�JiIG 392 South St Northampton, MA 01060 zone "_- Overlay District Elm St.District Ca District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Chris Cahillane 392 South St Northampton,MA 01060 Name(Print) Current Melling Address: 413427-4004 SIR_ rC&MC.1- Telephone Signature 2.2 Authorized Aoent• n�3 �nm ©I t t.y auil la KootT via I lnD OI r1 1 arvynn 12.1 . 51xH lea dU u TY)14 Name(Pit currem mailigAm a: OIC, 13- S3lD-S`i 55 SignatureTelephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only wm leted by per-mr:applicant 1. Building 8,300.00 (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from 6 3, Plumbing Building Permit Fee �'Q 4. Mechanical(HVAC) 5. Fire Protection 6, Total=(1 +2+3+4+5) 8,300.00 Check Number s This Section For Official Use Only Building Pemit Num r: Date Issued: it, 42 Signature: Building Commissionerlinspector of Bw1dings 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 filed in by Building nepanment Lot Size �_ ..._. i. Frontage Setbacks Front Side L:= R:= L:I_ R: .._... _.� Rear 0 0 Building Height —J� Bldg.Square Footage Open Space Footage % (Lot area minus bldg&paved! hin p ofParking Spaces Fill: volume&Location A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO Q DONT KNOW O 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 Page and/or Document N B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW O YES O 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 O NO O IF YES, describe size, type and tocation: 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 Q Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [O Siding() Other[ Brief Description of Proposed Remove existing omfoumnal and imtsll new asphalt shingle system. Work: Alteration of wasting bedroom_Yes x No Adding new bedroom Yes x No Attached Narrative Renovating unfinished basement _Yes * No Plans Attached Roll -Sheet ea. 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? 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. L Septic Tank_ City Sewer_ Private well City water Supply SECTION 74-OWNER AUTHORIZATION-TO BE COMPLETEDWHEN OWNERS ,AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, C .t-tS l .QhiII(lYIR-- . as Owner of the subject property Adam Quenneville Roofing&Siding Inc hereby authorize to act on my b/e�half, in all matters relative to work authorized by this building permit �aapplication. Lkq Signature of Owner /� Date I, 4,40,tlyt at.l. -hritut I L 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 Signature of Omier/Agent Date I SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: Adam Quenneville License Number 160 Old Lyman Rd South Hadley, MA 01075 CS 070626 Address ,1pirauon Date 8/21/20011 /(/�[-//_� 6/21/ 9 SignatureTelephone 413-536-5955 S.Realstairsd Home Im rovement Con r• Not Applicable 13ATdnwl �i lu e u v11L of)13 u 1 �s1dtiAC Company Name Registration Number It.p Old lump.-t Qd• 191093 AddressExpiration Date Telephpnau1?�"��0. 1 3/22/202 SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.C.152,§25C(8)) 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 buil g permit. Signed Affidavit Attached Yes....... No...... ❑ City of Northampton _ Massachusetts J 1� MPARTNENT OF BUILDING INSPECTIONS o 212 Mnin atx.et r Hunici01l auiltling Noxtb�tan, !A 01e60 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, orconstmction 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 reeistered contractors. Note:!f the homeowner has contracted with a corporation or LLC,that enthy must be registered Type of Work: LOO{-t coq Est.Cost: 19� !Ou Address of Work: 392y_ 1"�'y NOr'�RYYLI Jf� rap 01WO Date of Permit Application: W I"11 c , 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 owneroccupied 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: e ,0111 Adam fii u.t,Itllr.v� jQ QWL73 Date 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 6. Massachusetts c z 212 main OF Bo LDIAGMunicipal IES Building NS 212 Msin Street •xenicipsl xuiltling C� Northampton, em 01060 C0 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: 392- SOUL \ S�. (Please print house number and street name) Is to be disposed of at: Ut eeWci-- -) `l- - . IS MItiIIRYI EnfLLkj CT owzl (Please print name and location of facility) Or will be disposed Jr p--osed of in a dum�pster onsite rented or leased from , : 1uLluti S M QJ, Enfuld CT D(00%Z (Company Name and Address) lD 1J- I,, 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. ����i /A`r-"A\/AW 0Y�NNM V9LL� ® µwet ao VtSAC 160 Old Lyman Road•South Hadley•MA 01075 We are❑censed I.800.NEW.ROOF a 413.536.5955 Fully Insured Email:Info®1800newroofne[ Websire:www.laaonewrroF.nel FactoryTrained MA Cons[recdon Sopervisors Uc.#070626 MARegistra[Ion#120982 Factory Certified Installers Meavow.fahewee Wllde".—awemm Maw, CTRegislra[Ion#575930 Membnaftle euAdryaTra*PYWaWi v,pC3W10 Propasal Submitted To: Date: Phone Ift 0: 413-427-4004 Chris Cahillane 6/13/19 H: W: Street: Email: 392 South St billing: 384 south at City,State,Zip Code: Special Requirements: Northampton NA 01060 full ice barrier on back lower PROPOSAL FOR: slope roof HOUSE GARAGE OTHER STRIP RECOVER es:vers: 1 2 3 4 Plywood Included: Yes oOl n ❑ Tear off SLATE or SHAKES \J COMMETE ROOF PN07FCTION SYSTEM: 4 We shall acquire appropriate permits for all work [It Home ex[erbr and landscaping to be protected Strip existing mofing to existing decking with full inspection DONOT00: garage 41, All project waste shall be removed by clumpster(dumpsterjor commuter use only) p4 Install Ice&Water Barrier at all eaves ]/®valleys,chimneys,pipes and skylights A Install 1151b.felt/ nthetc umdsrlayment over remaining decking area AInstall Meal drip edge at eaves and rakes 5-liZE0 brown) O Install manuhcturer's starter shingle on all eaves and rake edges M Install new pipe boot Flashing/vent accessories .9 Install ridge vent-Snow Country/Cobra rolled/W RaffedRol Shingles:(standard 6 nails per shingle) Tamko Heritage Shingles Color:RUatiC Black Tooke Ridge cap shingles Warranty Options: 12 Weguarantseourworkmanshipfor 10 Poll years ❑ GAF System Plus Warranty ❑ GAF Golden Pledge Warranty Chimney Options: A Lead Counter Flashing Water Seal&Tuckpoint ORubbenasd Crown l7 Cricket 0 Mason needed(customer provided) Additional material and labor charges may apply. ❑ Deteriorated existing decking will be replaced m$3.77 Per sq.ft.and dimensional lumber at$7.0 per linear ft., after full inspection. Cusepmerhadmas: WemoP hemb Mml:hn coalsandlaew-c=MH inacwHamewdham sa dfir stmmewm N: Total Due:($ 8300 1 ArEPTAlCr of FROMM:The now pdoe aperMrHlemendmndabman been Payment:($financed srtlsfanery am xe MMby as ,ad.You are mmwl[edm da work aaapecalao 2"a Payment at Stan lob:IS ) eaymertwill he lye down at al{nha,1/3 at start a IoI%aM balan¢due Balance Due Upon Completion:IS 1 upon completion. / Date: b']S- /9 Signature: la #Iz � y //ff gate: 6/13/19 Estimator.(pdnl Name)Robert Croteau ($ian Name) L+�/U14 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 Flooding will not be responsible for debris or dust in the attic or storage areas. Customer lnhials: ACO CERTIFICATE OF LIABILITY INSURANCE �Demvzgls THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLYAND 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. N the confidants holder is an ADDITIONAL INSURED,the policy(les)must have ADDITIONAL INSURED provlslons or be endorsed. If SUBROGATION IS WANED,subject to the Name and conditions Of the polity,contain policies may require an endorsement. A statement on this cortlficafe dose not confer rights to the cortlflcob holder In lieu of such endomeament(s). PROOUCEe Melinda Kand is Goes N McLain Issuance Agency PxoxE (413)530.7355FAX Na: (413)536-91 1761 Northampton Street Appgceg; 'kteakulaigigosamdanean PO B.TIM INSURERMlAM MNGGOVEMOE sales Hatreds MA 01041-1128 IMRERA: Nautilus Insurance Do jam meuxm Image.: Nautilus Insurance Company Allam Centreville Roofing 9 Siding Inc W WRlNp: The Band Exchange,Inc 160 ad Lyman Flood INWRERD: INWM E: South Hedley MA 01075 INWRER F: COVERAGES CERTIFICATENUMBER: CL185104974 REVISION NUMBER: THIS ISTD CERTIFYTHAT THE POLICIES OF INSURANCE LISTED BELOW IUVE BEEN ISSUEDTO THE INSURED NAMEDABCA E FORTHE POLICY PERIOD INDICATED. NOTWITHSTANDINGANY REQUIREMENT,TERM OR CONDITION OFANYLONiRACi OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAYPERTAIN.THE INSURANCEAFFORDED BYTHE POLICIES DESCRIBED HEREIN IS SUBSECTTOALLTHE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMIT"SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR MEOFINBMAXOEfifing, sand N..m LIYIrs OMIIEACLLLOEXERAL W9aM EACHOCWRRENCE Is 1.000.000 GAWSMUDF ®OCWN PREMIBEB { 100-M .111.1 { 15.000 A Y NNN2216 1161232019 06232019 pmemso I.0AwI u" a 1.000i GEMwGRAGITEUMITMeUESPER: GENERIL AGGREGATE ! Z000'O0O FCIICY®I T LOC P0.0M.-C0MFIO1AGG 52.000.000 OTXER'. Employee BaMfils s 1p00.000 AURnIDBILE LIAIAdY diseases)Nes n e Axvwro SCOGr INURYIPxpxe[n1 { MYNm 9W .LYW11RY1Pxet'3WL1 isCknew IIY SU ELEO HIRED NONOAEL PERI .A.E E AVTO&M1Y CNEAVIDS ONLY disaaccess UUnndownsured Internet Bl s u YeREluuAB accw 0&OCCURRENCE S 5.000,000 B ENCEae uAe QuxsMAOE A1,1055464 091132019 wl=19 ams aTE a 5.0001000 OLEO IXREIFN110.$ 10-M ! MORIMAB fAYRXBATYN SMA OTM N10lYPLOYIRSMABl1rY YIN TME ER Ar1YRtOPRIERIWHiRRTHFA£1ICUINE E] NIA ELYe EACHACCENT Ci F10E1LMEMBER E%0.UOEOi (YYWbYFN10 EL USF E-FAEAaX.OYEE $ "Midwvbsumor pE$CMPIION OFOFFRAIIONSaYon EL DISEASE-PMICYLIMM S Surely Bond-HSS Affect Bond Amount M.M C 3364849 04/192019 OU192020 OMR NOFOPEIUTXN31LWATN SMMCLEB(1CGR0101,ALltlaryl RYrarb BNNuM,myMMaeMeXngn LpN�NnetlreB Cautious nodes ea addllOrel Insured On the above captioned GL policy;subject to policy bands,Cordillera,and mduslons.Adam Quenne dile,as an oNcer,is eNduded Cam Vole Verdes Comp policy CERTIFICATE HOLDER CANCELLATION SHOULD ANYOF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Adam Ouenneville Roofing B Siding Inc ACCORDANCE WITH THE POLICY PROVISIONS. AMMOFED REPREBFMAT�rN�EnU/� 0 1119 8-3 015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo am Registered mark{of ACORD ! AC ROe CERTIFICATE OF LIABILITY INSURANCE °"T`OMeO" m oa232019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER($), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the pollcy(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 certificate holder In lieu of such endorsement a. PRODUCER NAME romACTFe_Trud_e_II__ MARTIN J CLAYTON INSURANCE AGENCY INC °gin,-!dl_ (ata)53 0604 _rw""c.a,, _ Sumas IBudell da com a�O _SL �m1_,.�ro 1649 NORTHAMPTON ST RTES _ _ WsuAGW ATFMMXB WY91Ace �wue� HOLYO(E _ MA 01041 U.S..;DUs AIM MUTUAL INS CO _ _ 33756 0. NB°RERB: ADAM OUENNEVILLE ROOFING&SIDING INC INSURERC: INSURER O: _ — 1800LDLYMANROAD wserzEVE: SOUTH HADLEY MA 01075 1 INSURER 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 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. MaF0 amYDIICY FOYCY EYP ..._. TitTY PE OF INSURANCE MUCYNURBER I Wm WMMEROALGENERRALW&UTY YFMNOCCUflflEHCE ! GAIMSIMOF ` -1OCGM I M IVES Ea omnnm ! _...... _ - I secul Mymepason) !_ u _ WA PFRSCHALaAW.. ! 'OENLAgtliEFMTE LMrt APPL1Fa PFR: I DEHERKA(%iLEWIE F ___.-..___._ PWGY�PRP JECT `.LOC PROWCTB-CCLPNPAOO ! OrHER'. ! WTOMONLFLNBILT' I ^aJ IN LF LIMIT ! ANNAUTO B°OSY MJORY IPa P—) ! ALL OWNED .�- SCHEDULED B NIA ODILY INJUfiPmeN.np I wms Wu ! AUTOS HIREDAUTOS 40?U0WNED PgOPERTV1AMAGE ! ! _ UM ""UAa MCUR EACHOCCURRENCE ! excwwa _'�G,1,Nl,woE NIA AaDREDAm s I DIED I RETExigNS I ! LwOR ImSCOWENIIATION x ANDFMPLOYERS-UMIUM ATUTE ". FR ANYPROPNEIORPARIOERIElEcurs" YIM. EL.FACXALCIDENT f 1.DDD.DDD A OrFCEkVEMa[nrXcLUDFD, O WA MW AWC40070128612019A 06/292019.141/282020 feew.",MNNN El.DIBFISE-FAEMROTEEI! 1,0130DBD CESCRIPIION OF OPERATIONS lab✓ EI.GSFASEPOLICYLIMn ! 1,000.0DO i NIA DEBCRIPMN OF Wf ATIONSILDwMNSIWMLes IAcono+Pl.Aeelw,N.I R...n.san.a,M,.,.y a..nrRn.e xmeH.P.a I.r.RINr.e) Workers'Compensation benefits will be paid to Massachusells employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization Is given W pay claims for benefits to employees in states other than Massacnusess U the Insured hires.or has hired those employees outside of Massachu Ieffs. This certificate of Insurance shows the Policy In force on the date Met this celdhcate was issued(unless the eapiralbn date oD the all policy precedes the Issue date of this onfificele of insurance). The status Of this coverage can be mon tonad dally by acre asirlg the Proof of Coverage-Coverage Verification Search tool at www.mass gov/WdAAorkers pensatioMnvedigatbnsl. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXHRATWN DATE THEREOF, NOTICE WILL BE DELAERED IN Adam Quenneville Roofing R Siding Inc ACCORDANCE WITH THE POLICY PROVISIONS. 160 Old Lyman Road Y.WCDREPRESEMATNF South Hadley MA 01075 Daniel M.Cr Y,CPCU,Yce PreNdent-Residual Merkel-WCRIBMA ®1888-2010 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 700 Boston,MA 02114-1017 snvinnasassgoy/dia U,k%krkers'Compensation insurance Affidavit:BaBders/Contractors/ElectricianstPlumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Annlieaot Information Please Print Legibly Name(BmineWOrganimtionadividaaq: Adam Quenneville Roofing & Siding Inc Address: 160 Old Lyman Rd City/State/Zip: South Hadley, MA 01075 Phone k: 413-536-5955 Anson an employer!Click at appropriate Dox: Type of project(required): I.R(l moa in krya with�5—anploYm(full enNorpo-tiwnc).' 7. ❑New construction 2.❑Iona wlepmpriaarmmmwshipaMMvenoempbyenwar m fomehs 8. E]Remodeling eq rapacity.INo worken'comp_i vwnui a requ,wint] 5.❑lana M1omcowadoing all owk myself[No workerscom,inwrnce mquvalj 9. ❑Demolition 4.❑I ana ha,vo—and will m hidna cooaao l to cmmlwt an wmkon no notion. I will 10❑Building addition awme dol.0 wnrrx Coheir have woAcri.,man.irmmnce or mcote 11.❑Electrical repairs or additions ppaimma wim,a anploveea. 12.❑Plumbing repairs or additiom 5. l am a gewnl convetto nnid i in.hired the coli-convenors lead on the smched when. 13.®RooCrepairs These subconlmetars have e,nployecs ad have worken comp iwvurcer 6.❑We are a coronion and ha officers have cxarciwd thair right ora crwoion per MGL c. 14.❑Other I4,41(a),end we M1evc noanplgxa.(No woken'romp insnancerequnod] "My appikrm aa[eMcksbox pl mart elw fill out tae emtion bclosv showing IMir xarkers'conrynnetion pphay infnwnkn. t li.a.nea who saloon@illamdevirodi liryanyartdoingasworkandthmhheomsideconvwtmmwisubmitanewemdnitmdketingswh. tc.orne is bet chmkasu box moat mabod no additional•hea showing Clic ware ofthesubconannorscod ante whahurer rat Chase enatiaa have anployms. line subY,mnactos have employees,they met provide their workerscom,poli,number. /am an employer that isproviding workers'compensation insurancefm my employees Below icthepal/cyandjob site Information. Insurance Company Name: AIMMUtual Policy N or Self-ins Lic.#: AC�WC400701�2+8`612019A Expiration Date: 4/29/2020 Job Site Address, 3q2— SXX)Y1r\ Js City/Statelzip: M D saffire{� n Attach a copy of the worken'compensation policy declaration page(showing the policy oumberaodWatflusdate). aettio Failure to secure coverage as required under MOL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or onayear 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 maybe forwarded to the Once of Investigations of the D1A for insurance coverage verification. /do herby eenl(y ander r pains amrApenalties ofperjury t/tat the infornra"onDrovded iave is ate and correctq Signature: Date' 1 1 ! Phone#: 413-536-6955 Offleiu/are only. Do not wire in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): I. Board of Health 2.Building Department 3.Ckyrfown Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#: a ® comngnweahh of Massachusetts Division of Professional Lkensure Board of Building Regulations and Standards Constructlon'Supervisor CS-070626 Eap i res:06212019 160 OLD LYMAN ROAD A SOUTH HADLEY MA 01076 sp commfaalenar ✓/LP (�//72I724/L!/JP.�.'Lr!.JL �!//UCI.r)r)Q.'(.'lll�)P-ff1 Office of Consumer Affairs and Business Regulation One Ashburton Place- Suite 1301 Boston, Massachusetts 02108 Home Improvement Contractor Registration Type: Corporation ADAM OUENNEVLLE ROOFING AND SIDINGWC.y Registration: 1910M 160 OLD LYMAN RD. Expiration: 0322/2020 SO.HADLEY,MA 01075 - Update Address and Return cents. 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 quahf¢etions ri quited by law and is hereby tegisteted as a HOME IMPROVEMENT CONTRACTOR Registration # HIC.0575920 ADAM QUENNMLLE ROOFING �T— Effective: 12/01/2018 -_ Expiration: 11/30/2019 mme.da.a ,f .,mmle,o,.r