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29-029 258 RYAN RD BP-2020-0687 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:29-029 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: demolition BUILDING PERMIT Permit# BP-2020-0687 Proiect# JS-2020-001173 Est. Cost: $1550.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO.- Const. O:Const.Class: Contractor: License: Use Group: ADAM QUENNEVILLE 070626 Lot Size(sq.ft.): 21170.16 Owner: ADAM ROBERT zoning: Applicant: ADAM QUENNEVILLE AT: 258 RYAN RD Applicant Address: Phone: Insurance: 160 OLD LYMAN RD 413 536-5955 Workers Compensation SOUTH HADLEYMA01075 ISSUED ON:12/4/2019 0:00:00 TO PERFORM THE FOLLOWING WORK.-REMOVE 2 CHIMNEYS AND PLYWOOD OPENING AND TIE IN SHI GLES 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 DeDartment 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 Sig(nature: Feer e: Date Paid: Amount: Building 12/4/2019 0:00:00 , $40.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner Department use only ��i rr,�r City of Northampton SW Permit: ;`� h � Building Department Guf�ut/DrReway Permit 212 Main Street Sew r/Sep>fc Availability Room 100 W erNV011 Availability Northampton, MA 01060 T o Se of Structural Plans phone 413-587-1240 Fax 413-587 272 lot/S e Plans the Specify APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be completed by office �J Qral, Q.j Map Lot 0C* 1 Unit +O�c ry C (��� O 10 6a- Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record:_1 �} (' ( Cobcf\ Qc4ckr. a5El Q,r: /orence n1C., o/O Name(Print) (l Current Mailing ddress: r 0, LJ�^ `)e c G!`,1( C>C Telephone Signature 2.2 Authorized Agent: r� J (/!1 ', '�01r1 QVr�"(-Ui � ��V11r� (-,-J oic-J --7('^,te� '�� �(� �,, M'3 Name(P int) Current Mailing Address: 3 '5- Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building 550, 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 45 6. Total =0 +2 + 3+4+ 5) 1 j j o-CU Check Number This Section For Official Use Only Building Permit Number: f U[A/ / Date Issued: Signature: 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 Frontage Setbacks Front Side L:= R:= L:= R:= C� Rear Building Height (--I Bldg. Square Footage % O Open Space Footage % (Lot area minus bldg&paved parking) #of Parking Spaces Fill: (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DON'T KNOW YES Q IF YES, date issued:[- IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW YES IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NOQ DON'T KNOW ja YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? ° Needs to be obtained 0 Obtained Q , Date Issued: C. Do any signs exist on the property? YES ® NO IF YES, describe size, type and location: , D. Are there any proposed changes to or additions of signs intended for the property? YESO NO IF YES, describe size, type and location: E. Will the construction activity disturb(clearing, gradingvation, or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES Q NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) _7 New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑ Or Doors D Accessory Bldg. ❑ Demolition 29_ New Signs [O] Decks [0 Siding[0] Other[a Brief Description of Proposed n Work: Dl;woOGlk ?Int Gn �lc /n ��InrIC� 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 existinci 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 OWNERSAGENTOR CONTRACTOR APPLIES FOR BUILDING PERMIT I, loo jr;\ A as Owner of the subject property hereby authorize A JelY, Qucnnr Qi to act on my behalf, in all matters relative to work authorized by this building permit application. ji La] I Signature of Owner Date I Iy C'wN 0 vt,,.,C V" 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 under the p .yns and penalties of perjury. Print Name Signature of Owner/Agent Date SECTION 8 -CONSTRUCTION SERVICES 8.1 Licensed Construction,,/^Supervisor: Not Applicable ❑ Name of License Holder: A r Ur-, Q*,xe y U i I�L `'s 0 1 0`D(11 License Number 11,0 o C., nn U 4 (Y),O. 016-1 � a/a ► 1ai Addres Expi ation bate /-/1-3 53G 571-� Signature Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ A(4 ,.,•\ (�vnn Vrll< 0"Jin 11,111097 Company Name 0 Registration Number !U0 of (,c.., 2Z mQ, 0107) ^3l as t w Address Expi tion to Telephone 913 53c, 5 i) J 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....... X No...... ❑ ct1�ari,�c� City of Northampton {; Massachusetts DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building yvk rad 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, demoli'on, or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than our dwelling units....or to structures which are adjacent to such residence or building"be done by registered contractors. Note.If the homeowner has ontracted with a corporation or LLC,that entity must be registered. n C- Type of Work: �� I�1hL `Zc+�Uvea, Est.Cost: �5J .t"v' Address of Work: 5� 7�v1 2 �o�enCc rnC� Qlc)C,Z Date of Permit Application:_ I hereby certify that: Registration is not required for the following reason(s): _Work excluded by law(explain): _Job under$1,00 .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 edury: I hereby apply for a buildingermit as the agent of the owner: I Q 1/1)7111 4 ( e^ 0urnnc-l'�t rcU�,,P,11 4JIc'In � �/? L �Q��TJ Datd Contractor Name HIC Registration No. OR: Notwithstanding the above n ice,I hereby apply for a building permit as the owner of the above property: Date Owner Name and Signature City of Northampton Massachusetts �,�' � `'<< y .G DEPARTMENT OF BUILDING INSPECTIONS yy 212 Main Street • Municipal Building —r:! 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. City of Northampton Massachusetts N(rk DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street •Municipal Building Northampton, MA 01060 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: 01� k �C�Ci i`(,C (hc' a10 (Please print h se number and street name) Is to be disposed of at: 15 ry)u►Ic►, 2d— ?• {_ ���.lilln i } ('�' I sib CIX C� �� � (Please print name and I ation f facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) J I I Iii 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 Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 www massgov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print I.eeibly 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. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in $, ❑Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 3.[:]l am a homeowner doing all work myself[No workers'comp.insurance required.]? 10❑Building addition 4.[—]1 am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑ p ROof repairs These sub-contractors have employees and have workers'comp.insurance.: 6.❑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#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 under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under thepains andpena/ties ofperjury 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#: � y AMMAu QYENNEVI AwA-RoIxsc ROOFING w SIDING WNNEft V'SA� '0 ' 160 Old Lyman Road•South Hadley•MA 01075 We are Licensed 1.800.NEW.ROOF • 413.536.5955 Fully Insured Email:info@1800newroof.net Website:www.1800newroof.net Factory Trained MA Construction Supervisors Lic.#070626 MA Registration#120982 Factory Certified Installers Member of the Home Builder's Assoc.of Western Mass. CT Registration#575920 Member of the Building&Trade Association P.P.0 38710 Proposal Submitted To: Date: Phone#'s: C! Robert Adam 11/20/2019 H: W: Street: Email; 258 Ryan Road radam@me.com City,State,lip Code: Florence, MA 01062 Proposal to furnish and install the following: Remove two chimneys down to roof line Dispose of bricks, concrete, and flue Install new plywood to match exisitng roof conditions Install new ice&water barrier over new wood and be into roofing Install shingles color closest to match Total Due 1,550+20 Passes to the movies Ask us about affordable bank financing! 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.Please remove any lawn ornaments or yard furniture.Adam QuennevLUe Roofing will not be responsible for debris or dust in the attic or storage areas. Customer Initials: we pmpse huseby D furnish awt edats am!tsimr—ra mpie*et accordance witleahove specification far the sun,of: Toi:al A.ae:($ 1,550.00 ACCEPTANCE OF PROPOSAL:The above prices,specifications and conditions are Down Payment:($ 500.00 ) satisfactory and are hereby accepted.You are authorized to do work as specifie 2"d Payment at Start Job:($ 550.00 ) Payment will be 1/3 down at signing,1/3 at start of job,and balance due Balance Due Upon Completion:($ 500.00 ) upon completion +20 Passes to the movies Date: 2l Signature: Date. 11202019 Estimator.(print Name)S.Minkler � Estimates are honored for sixty(601 days from above date. R NOTICE OF SCHEDULE CHANGES The contractor agrees that when delays become known tothe Contractor,the Contactor will advise the Owner as soon as reasonable. DELAYS IN THE COMPLETION SURE TO HIDDEN CONDITIONS The Owner hereby acknowledges and agrees that in certain remodeling work,the demolition of portions of the pre-existing structure may reveal additional defects,conditions or the need for additional work,which must be repaired,altered or carried out in order to commence or complete the work described under the contract.In such case(s),the Owner agrees that the duration of the work and the scheduled date of completion may differ from the date on the front,and that such variation which is not avoidable by the Contractor shall not be considered to be a violation of the contract. ADDITIONAL WARRANTY INFORMATION All warranties for equipment supplied by the Contract under the Agreement shall be those given by the manufacturers of such equipment,which shall be and are hereby passed through directly to the Owner.Under such manufacturer's warranties,the Owner may be required to register or mail in a warranty card or other evidence of ownership and use of such equipment in order to activate such warranties. The warranty give the Owner specific legal rights,and Owner may also have other rights which vary from state to state.Under Massachusetts law,sale of goods carry an implied warranty of merchantability and fitness for a certain purpose.All material is guaranteed to be as specified.All work shall be completed in a workmanlike manner,according to standard practices.Any alteration or deviation from above specifications Involving extra costs will be executed only upon written orders and will become an extra charge over estimate.All agreements are contingent upon strikes,accidents or delays beyond control. SUBCONTRACTING Contractor agrees that,notwithstanding any agreement for materials and/or labor between Contractor and third party,Contractor is responsible to Owner for completion of all work described in a timely and workmanlike manner. NO ACCEEFRATiON OF PAYMENTS BUT FSCROWWGAtt0V4F!F The Contractor may not require payments to be made in advance of the times specified in the Payment Section(front)for the reasons the he deems himself or the payments to be insecure.If,however,he deems himself to be insecure,he may require,as a prerequisite to continuing the work described herein,that the balance of the payments under this contract that are In control of the Owner,shall be placed in a joint escrow that requires the signature of both the Contractor and the Owner for withdrawal. You agree to pay cash according to the terms shown above or,if we approve your credit,to sign a note provided by us for payment of the amount due.You also agree to sign a completion certificate upon completion of the work.If you fail to pay according to the above terms and have not signed our note,the entire unpaid amount becomes immediately due,and you must pay a collection cost equal to our actual collection costs up to 15%of the total amount you owe,plus attorney's fees and court costs.In addition,you understand that by failing to pay according to the above terms,the Contractor may have a claim against you which may be enforcedagainst your property in accordance with the applicable lien-laws. INSURANCE Contractor will be responsible to Owner or any third party for any property damage or bodily injury caused by himself,his employees or his subcontractors in the performance of,or as a result of,the work under this Agreement.Contractor agrees to carry insurance to cover such damage or injury. The Contractor recognizes his obligation to maintain a workers'compensation insurance policy to cover his employees.Contractor further recognizes the obligation of any and all subcontractor to maintain a workers'compensation policy to cover their employees. Contractor maintains a liability insurance Policy with minimum coverage limits of one million dollars($1,000,000.00) CONSTRUCTION RELATED PERMIT ACQUISITION The Contractor under provisions of Chapter 142Aof the General taws is required to apply for and obtain all construction-related permits.The Contractor shall not be deemed responsible for delays in the work described in this Agreement caused by regulatory permit granting or inspectional agencies,authorities or individuals. MODIFICATION This Agreement including the provisions relating to price and payment schedule cannot be changed except by a written statement signed by both the Contractor and the Owner.However,cancellation by Owner is allowed in accordance with the Notice of Cancellation. COMPLETENESS OF AGREEMENT FOR EXECUTION The Owner is hereby advised that he should not sign this Agreement unless and until all blank sections have been filled in or marked as void,deleted or not applicable,and until all exhibits and related or referenced documents that are incorporated herein are attached hereto. COPY OF AGREEMENT TO BE GIVEN TO OWNER The Laws of Massachusetts shall govern this Agreement.it must be executed in duplicate,and an original,signed copy hereof shall be given to the Owner at time of execution.No work under the Agreement shall begin prior to the signing of the Agreement and transmittal to the Owner a copy thereof. ARBITRATION In the event the Owner and Contractor have a dispute re ardin ny of the terms,conditions,provisions or performance of this contract,the parties agree to place the matter into arbitration before ani ent trator assigned by the American Arbitration Association to resolve their dispute.Owners acknowledgement of arbitration clause CANCELLATION _ Owner may cancel this contract within three business days of executing this document.Such cancellation must be in writing and delivered to the Contractor. Contractor reserves the right to cancel this contract at any time within thirty days of the date of this contract.If we cancel you will be promptly notified in writing by an authorized officer of Adam Quenneville Roofing&Siding Inc.If we cancel,we will promptly return any down payments)you have made. ACO CERTIFICATE OF LIABILITY INSURANCE DATE(MM DD YYYY) 6/24/2019 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..If the certificate holder is an ADDITIONAL INSURED,the policy(ies)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 CUNIAUl NAME: Sarah Premo Martin J Clayton Insurance Agency, Inc. (PH C No Ext: (413)536-0804 ��No: 14131534-7e74 1649 Northampton Street EWAILss: spremo@mjclayton.com ADDRE P. O. Box 989 INSURERS AFFORDING COVERAGE NAIC 4 Holyoke MA 01041-0989 INSURER A:Nautilus Insurance Company INSURED INSURER B:Green Mountain Insurance Company Adam Quenneville Roofing s 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADOL SUER POLICY NUMBER MM DPOLI CY EFF POLICY EXP LTR DIIYYYYL (MM/DDrYYYYl LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMA6'TO RENTED A CLAIMS-MADE M OCCUR PREMISES Ea occurrence S 100,000 X Y NN1000129 6/23/2019 6/23/2020 MED EXP(Any one person) S 5,000 PERSONAL S ADV INJURY S 1,000,000 GENIAGGREGATELIMITAPPUESPER. GENERAL AGGREGATE S 2,000,000 POLICY [_XJ PRO LOC PRODUCTS-COMP/OPAGG S 2,000,000 JECT OTHER: S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 Ea accident ANYAUTO BODILY INJURY(Per person) S B ALL OWNED SCHEDULED AUTOS X AUTOS X y 20030465 6/23/2019 6/23/2020 BODILY INJURY(Per accident) S NON-OWNED PROPERTY DAMAGE X HIREDAUTOS X AUTOS Pereccident $ S X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 5,000,000 A EXCESS LIAB HCLAMS-MADE AGGREGATE $ 5,000,000 DED RETENTIONS AN069764 6/23/2019 6/23/2020 $ WORKERS COMPENSATION x PER- OTH- AND EMPLOYERS'LIABILITY STATUTE ER YIN ANY PROPRIETOR/PARTNERrEXECUTIVE ❑ NtA AWC4007012861 - 4/29/2019 4/29/2020 E.L.EACH ACCIDENT S 1,000,000 OFFICERIMEMBER EXCLUDED? C (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE S 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT S 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 107,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(2014101) The ACORD name and logo are registered marks of ACORD INS025(201401) r � i {4 The Commonwealth of Massachusetts Department_of Industrial Accidents 1 Congress Street,Sttite 100 Boston,MA 02114-2017 ,M www mass.gov/dia NVorkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTI&G AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): Adam Quenneville Roofing & Siding Inc Address: 160 Old Lym n Rd City/State/Zip: South Hadley, MA 01075 Phone#: 413-536-5955 Are you an employer?Check the appropriate box: Type of project(required) 1.VI am a employer with _employees(full and/or part-time).* 7. ❑New construction 2.E]I am a sole proprietor or partnership and have no employees working for me in $, ❑Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 3.❑i am a homeo,.vner doing all work myself.[No workers'comp.insurance required.]' 10 F1 Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole I I.❑Electrical repairs or additions proprietors with no employees. 12.WRouof mbing repairs or additions 5.❑I am a general contractorand I have�ircd the sub-contractors listedon the attached sheet. 13. 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 MGI.c. 1�.[J Other _ 152,51(4),and we have no employ s,[No workers'comp.insurance required.] *Any applicant that checks box#t must als4 fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they arc 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 ant an employer that is providing workers'conWeirsation insurance for my employees. Below is the policy and job site information. Insurance Company Name: AIM Mutual _ A C40070128612019A4/29/2020 Policy#or Self-ins..Lie.#: Expiration Date: Job Site Address:d S� `\�C, City/State/Zip: Attach a copy of the workers compensation policy declaration page(showing the policy number and expexp rte). 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 ell 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 i his statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ida hereby certify under thpains and penalties of perjury that the information provided above is true and correct. Si nature: Date: Phone#: 413-536-t055 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 s Contact Person: Phone#: l I I F Commonwealth of Massachusetts '® Division of Professional Licensure Board of Building Regulations and Standards Construct 6n!§upervisor CS-070626 Expires:08/21/2021 S ADAM A QUENNE11 160 OLD LYMAN R SOUTH HADLEY MA ll 5 Commissioner OTce of Consumer Affairs and Business Regulation One Ashburton Place - Suite 1301 Boston, Massachusetts 02108 Home Improvement Cpntractor Registration Type: Corporation Registration: 191093 ADAM QUENNEVILLE ROOFING AND SIDING,INC.. 160 OLD LYMAN RD. Expiration: 03/22/2020 SO.HADLEY,MA 010751 III U pdate Address and Return Card. SCA, c, 2a?a•o5;i 7 fi:- ;�fl'.Y Y.5{� :•'Sh15(:'•h •':5r;n. g11F., .' ,.^.ti f� ..y,,.,^ .r.v,;t, M1;rv.. .tit• G�:\?i ':/.a :qT;rl::i"1,, .t`t•."... x° ISTATE OF CONNECTICUT + DEPARTMENT OF CONSUMER PROTECTION Be it known that r ADAM QUENNEVILLE 160 OLD LYMAN ROAD j SOUTH HADLEY MA 01075-2632 _y i has s tis6cd the qualifications required by law and is hereby i-egistered as a ' j HOME IMPROVEMENT CONTRACTOR Registration # HIC.0575920 ADAM QUENNEVIL .E ROOFING Effective: 12/01/2015 Expiration: 11/30/2019 , r Michelle Seagull,Commissioner