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24B-007 71 BARRETT ST BP-2020-0429 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:24B-007 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-2020-0429 Proiect# JS-2020-000734 Est.Cost: $1670.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: ADAM QUENNEVILLE 070626 Lot Size(sq.ft.): 33105.60 Owner: MARK A PANZICA Zoning: URB(100)/ Applicant: ADAM QUENNEVILLE AT. 71 BARRETT ST Applicant Address: Phone: Insurance: 160 OLD LYMAN RD (413)536-5955 O Workers Compensation SOUTH HADLEYMA01075 ISSUED ON.10/9/2019 0:00:00 TO PERFORM THE FOLLOWING WORK.-REMOVE AND REPLACE CAP AND RIDGE VENT 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 Occupancy Sip-nature: FeeType: Date Paid: Amount: Building 10/9/2019 0:00:00 $40.00 212 Main Street, Phone(413)587-1240, Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner F� - ------ Department use only rrti-r City of Northampton tatus of Permit: urb C 111 /Driveway PermitBuildin9 DpartmeQCT 4 2019C f� ( , 212 Main Street ewer/ eptic Availability At Roorr 100' ater ell Availability l Northampt0 MA'� un_DiNc;ir�saE C WO S Sells of Structural Plans I1T✓ r 1. AN1r70N.MA 0100 phone 413-587-1240 Fax T5'IotSite Plans Other Specify APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION �"' 00 1.1 Property Address: This section to be completed by office 6ew(c1\ 5T Map q6 Lot D0 7 Unit C 11�;,,eT� m ►b O�'U Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT 2.1 Owner of Record: s^r,GCi� �J^tr`,ZtC \ , fl !JQf(�II 1 /Uc�i1b..�� Ole) (wove Name(Print) Current Mailing Address: j� C Cin\CGS\ Telephone Signature 2.2 Authorized Agent: !)i(-?1 Name(Print) Current Mailing Addres : tii 3 - S3(.- 5955 Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building IG 70 co (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 +2 +3+4 + 5) 1, SCI .uv Check Number l g This Section For. Official Use Only Building Permit Number: Date Issued: Signature: 3 Aq Building Commissioner/Inspector of Buildings Date 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 Lot Size r., Frontage Setbacks Front Side L:E.-j R:= L:= R:= Rear �� t Building Height r---� Bldg. Square Footage "/0 Open Space Footage % (Lot area minus bldg&paved parking) #of Parking Spaces ►--1 Fill: volume&Location A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DONT KNOW lc�X YES Q IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DON'T KNOW YES O IF YES: enter Book Page, and/or Document# B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW '�D YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained Q , Date Issued: C. Do any signs exist on the property? YES Q NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES © NO IF YES, describe size, type and location: _ 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 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 Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [[3] Decks [Q Siding [p] Other[t7] Brief Descript' n of Proposed Work: pcehct" + ''eDlo.(- e Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes 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? 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 . I. Septic Tank City Sewer Private well City water Supply SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, � ' I�,r� \0, )-u C C' as Owner of the subject property 11 nn hereby authorize /Q NC�r^ l��e►1r1CUt �� t. to act on my behalf, in all matters relative to work authorized by this building permit application. C �o r.1 CGC t /G Signature of Owner Date Que✓1r1ev11as 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. A(`CA r" Gurn,.e U1 Ike- Print Name 4 /lam 3 f g Signature of Ow er/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: AJctw. (&VcnyV cut lk C) 0-700-a License Number SO 11 (� p-in -�]D I I Addres U Expiration bate 'Lid 53(,, 5i� Signature Telephone S.Registered Home Improvement Contractor: Not Applicable ❑ � -1io9J? Company Name Registration Number lt,o OiJ L rr,G,r., 2a_ 50 I40A, -) I a.)-/ Do Address Expiration Date — &::� — Telephone`1/j 53G 5 1c�k SECTION 10-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....... No...... ❑ City of Northampton • rr, `S �I Massachusetts S' DEPARTMENT OF BUILDING INSPECTIONS x 212 Main Strout • Municipal Building Northampton, 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-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 registered contractors. Note:If the homeowner has contracted with a corporation or LLC,that entity must be registered Type of Work: a("CX1 r, Est. Cost: L 7U Address of Work: —( � 30;,(( 11 A)0Ci he.—p lvn rn va O 10 L Date of Permit Application:__ 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 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: I hereby apply for a building permit as the agent of the owner: 1013116, A r .7,w% Q�Pr•�.u,lac. rZr, ' 1� „ �rc 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 > Massachusetts DEPARTMENT OF BUILDING INSPECTIONS r T: 212 Main Strout • Municipal Building �a C Northampton, MA 01060 Massachusetts Residential Building Code Section 110.R5.1.2 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 110.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. Lt City of Northampton �C Massachusetts DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street •Municipal Building . ~, 1 Northampton, MA 01060 . .r 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: Oi (Please print house number and street name) Is to be disposed of at.- (Please t:(Please print name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: USA Naell",, 4 o Q�c.tic1�-,� �.,� I � wiu .) Q. G-t)C'CIA C1 0c,00,(Compan ame an Addr s) 10 1310 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. \ The Commonwealth of Massachusetts v Department of Industrial Accidents a 0 I Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.[]I am a employer with employees(full and/or part-time).* 7. E]New construction 2. I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 371 I am a homeowner doing all work myself.[No workers'comp.insurance required.]' 4.F I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10❑Building addition ensure that all contractors either have workers'compensation insurance or are sole I L❑Electrical repairs or additions proprietors with no employees. 12.[]Plumbing repairs or additions 5.r7 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.[]Roof repairs These sub-contractors have employees and have workers'comp.insurance.* 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.F]Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. *Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required trader 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 the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: Phone#: 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#: AURA& reta a, QIJENNEVILLE ROOF: MAXM,�►XX �oo� ROOFING v SIDING v WINDOWS More Life. Less Money. Guaranteed. 160 Old Lyman Rd • South Hadley,MA 01075 1.800.NEW.ROOF • 413.536.5955 Email:roofshampoo@1800newroof.net Website:www,1800NEWROOF.net MA Construction Supervisors Lic.#070626 MA Registration#191093 Member of the Home Builder's Assiociation of Western Mass. CT Registration#575920 Member of the Building and Trade Association Customer Mark Panzica Address: 71 Barrett St City: Northampton State: MA ZIP: 01060 Email: Home: 413-584-2177 Office: Cell: NO BILL WILL BE SENT -- PAYMENT DUE UPON COMPLETION OF WORK. rinse.Roof Shampoo@ is the eco-friendly roof cleaning solution that does NOT contain chlorine bleach.The proprietary Roof Shampoo@ product is safe for your landscaping.Our state-of-the-art equipment delivers a soft,gentle low-pressure water i I damaging high pressure and / scrubbing. The Customer agrees that Adam Quenneville Roofing has the right,at its sole discretion, not to proceed with the job if working conditions are deemed unsafe. In addition to algae growth, which is characterized by dark, streaking stains, some roofs also have lichen colonies,fungus, and moss. Lichen colonies, moss,and thick algae sometimes eat through the granules on the shingles into the roof deck. Removing these may reveal granule loss caused by the lichens,moss,or thick algae growth.Adam Quenneville Roofing is not responsible for granule loss due to the damage caused by lichen colonies, moss,and thick algae. The Customer affirms that there are no existing roof leaks,failed flashing,leaky vent pipes,or other opportunities for water intrusion into the home or basement through windows,foundation cracks,etc. ' tt b. II for people, pets, property, environment.A renewably sourced, bio-based alternative,Roof Maxx's scientific formulation uses the latest green technology offering benefits to worker and consumerenvironment, economy and energy security. 100% BIO-BASED... 1 Adam Quenneville Roofing hereby offers to perform the work listed below for the amount shown. r emo v e bolt near chimney and put 1 shina under hole alona with under DESCRIPTION OF WORK AREAS Roof Maxx $ gash s Clean algae,fungus,and/or moss related stains by treating areas(s)indicated Roof Shampoo $ 1100 below. Roof Tune Up $ 495 Roof in Front of House Only X Roof in Back of House Repair $ 1670 Entire Roof Other Affected Areas Coupon Discount $ 8162449 replace all cap with new vent + cap Total All Services $ shingles are certainteed oakwoMd Deposit Received $ 800 cc 5 Year Transferable Roof MaXXTM Warranty *1 Year Roof Shampoo® Guarantee of no re-growth* Balance Due $ 1649 DATE: /0 -1 I cEUSTOMER SIGNATURE: ACCEPTANCE OF PROPOSAL:The above prices,specifications and conditions are satisfactory and are her a cepted.You are authorized to do work as specified.Payment will be 1/3 down at time of signing,and balance due upon completion. 10/1/19 Robert Croteau DATE: SALESPERSON:(Print Name) (Sign Name) 1 � AC ORV CERTIFICATE OF LIABILITY INSURANCE DATE(M TE(M6/24/2019) 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 certificate holder in lieu of such endorsement(s). PRODUCER GUNIAUT Sarah Premo NAME: Martin J Clayton Insurance Agency, Inc. PHONE (413)536-0804 FAx ({13)53{-,B7{ AIC No Ext: AIC No 1649 Northampton Street E-MAIL ADDRESS: spremo(4mjclayton.com P. O. Box 989 INSURERS AFFORDING COVERAGE NAIC# Holyoke MA 01041-0989 INSURER A:Nautilus Insurance Company INSURED INSURER B:Green Mountain Insurance Company Adam Quenneville Roofing b Siding Inc. INSURERC:AIM Mutual Insurance Company 160 Old Lyman Road INSURER D: INSURER E: South Hadley MA 01075 INSURER F: COVERAGES CERTIFICATE NUMBER:2019 MASTER 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, INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE WVD POLICY NUMBER MMIDDIYYYY MM/DDrfYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE aX OCCUR OAMA 100,000 PREMISES Ea occurrence $ X Y NN7000129 6/23/2019 6/23/2020 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY S 1,000,000 GENI AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,000 POLICY JECT �LOC PRODUCTS-COMPIOPAGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY EOMEI'NE�DtSINGLE LIMIT $ 1,000,000 B ANYAUTO BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED 20030465 6/23/2019 6/23/2020 BODILY INJURY Per accident S AUTOS AUTOS X Y ( ) X HIREDAUTOS X NON-OWNED PROPERTY DAMAGE S AUTOS Per accident $ X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 5,000,000 A EXCESS LIAR HCLAIMS-MADE AGGREGATE $ 5,000,000 DED I I RETENTION S AN069764 6/23/2019 6/23/2020 $ WORKERS COMPENSATION PER 12 TH- AND EMPLOYERS'LIABILITY YIN x STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE AWC4007012861 4/29/2019 4/29/2020 E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? ❑NIA C (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE S 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below I E DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Workers' Compensation benefits will be paid to Massachusetts employees only. Pursuant to Endorsement WC 20 03 06 B, no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires, or has hired those employees outside 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 policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage - Coverage Verification Search tool at www.mass.gov/lwd/workers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE FOR PERMITS ONLY THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Michael Regan/FMT ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025(201401) The Commonwealth of Massachusetts Department of Industrial Accidents 0 I Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY'. Applicant Information Please Print Legib[y Name (Business/Organization/Individuaq: Adam Quenneville Roofing & Siding Inc Address: 160 Old Lyman Rd CityiState/Zip: South Hadley, MA 01075 Phone#: 413-536-5955 Are you an employer?Check the appropriate box: Type of project(required): 1.V1 am a employer with _employees(full and/or part-time).* 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. E]Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition In 1 am a homeonTer doing all work myself.[No workers'comp.insurance required.]t 10 Building addition 4.❑1 am a homeowner and will be hiring contractors to conduct all work on my property. [will ensure that all contractors either have workers'compensation insurance or are sole 1 1.❑Electrical repairs or additions proprietors with no employees. 12.Q Plumbing repairs or additions 5.F-1 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.Fq<000f repairs These sub-contractors have employees and have workers'comp.insurance.' 6.F_1 we are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#l must also fill out the section below showing their workers'compensation policy information. t homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. *Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees, If the sub-contractors have employees,they must provide their workers'comp.policy number. I ani an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: AIM Mutual Policy#or Self-ins.Lic.#: AWC40070128612019A Expiration Date: 4/29/2020 Job Site Address: ��� 3 City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and a piration 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. Ido hereby certify under a pains and penalties of perjury that the information provided above i true and correct. Signature: - Date: 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#: E Commonwealth of Massachusetts- v Division of Professional Licensure Board of Building Regulations and Standards Constructi6ri'ttlpervisor CS-070626 Expires:08/2112021 ADAM A QUENNEVILLE 160 OLD LYMAN RD 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 SIDING, INC. Registration: 191093 160 OLD LYMAN RD. Expiration: 03/22/2020 SO.HADLEY,MA 01075 Update Address and Return Card. SCA 1 b 20W05'17 ��it ,r{•'�:: vt`s%� :tii5+ ii• :�'�' `•i;i AiZ�.; ,��. ;�. :r.� - - - - � A, .C•'' t 1.h ''l r ti. �� Y::r, 1•.%,y_ V S hiYF11. �:•1•.;*. :IT ..; ,,..- rt '14, STATE OF CONNECTICUT + DEPARTMENT OF CONSUMER I'RO 1'ECTION I Y' Be it known that ADAM QUENNEVILLE 160 OLD LYMAN ROAD = `v SOUTH HADLEY, MA 01075-2632 iL has satisfied the qualifications required by lav and is hereby registered as a ' 't HOME IMPROVEMENT CONTRACTOR Registration # HIC.0575920 �: ADAM QUENNEVILLE ROOFING I Effective: 12/01/2018 Expiration: 11/30/2019 `r Michelle Senguil,Comminioner "s j t .