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23A-167 61 PINE ST BP-2020-1131 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:23A- 167 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A) Category:ROOF BUILDING PERMIT Permit# BP-2020-1131 Proiect# JS-2020-001892 Est.Cost: $6875.00 Fee:$40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: ADAM QUENNEVILLE 070626 Lot Size(sg.ft.): 14810.40 Owner: GEORGE LAWRENCE Zoning. URB(100)/ Applicant. ADAM QUENNEVILLE AT. 61 PINE ST Applicant Address: Phone: Insurance: 160 OLD LYMAN RD (413) 536-5955 0 Workct-s Compensation SOUTH HADLEYMA01075 ISSUED ON.-511512020 0:00:00 TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE ROOF POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Service: Meter: Footings: Rough: Rough: House# Foundation: Driveway Final: 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 si�?n:�turc: FeeType: Date Paid: Amount: Building 5/15/2020 0:00:00 $40.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner Department use only City of Northampton \ Status of Permit: .� Building Department '' Curb Cut/Driveway Permit I 212 Main Street\: Sewer/Septic Availability_ � , Sewe /Sept c Room 100 �9 6� Water/Well Availability Northampton, M&/, 1060 r Two Sets of Structural Plans phone 413-587-1240 Fa5n587-1272 Plot/Site Plans Ttigyo'�o,° Other Specify APPLICATION TO CONSTRUCT, ALTER, REPAIR, gVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING :�n itis SECTION 1 -SITE INFORMATION `.. This section to be completed by office 1.1 Property Address: '7 �J ( ne Map Lot V Unit t k(etct (y)A Q���� } Zone Overlay District Elm St. District CB District SECTION 2 -PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) Current Mailin Address i"r Cc'•r\ .,C \ Telephone Signature 2.2 Authorized Agent: cm. �enhc.�.l\e fL,U Ciia L�►^.c.. 2l Scc ��n�le � n•.� Gic�1 Name(Pri Current Mailing Address: 1/ '-0 3 73(- r s Signature Telephone SECTION 3 -ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building (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 = 0 + 2 + 3 +4 + 5) Check Number Q�Q an This Section For Official Use Only Building Permit Number: LJ(�NL" Date ` Issued: Signature: / �j " /S -zozj Building Commissioner/Inspector of Buildings n Date rl 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: Rear Building Height Bldg. Square Footage % 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 O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DON'T KNOW YES Q IF YES: enter Book Page and/or Document # B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW _q 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 IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO IF YES, describe size, type and location: E. Will the construction activity disturb(clearing, grading, xcavation,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 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder:- Adek" U/�Y1/1CUl��� 0S G-70(1 a License Number GO oLQ- R,�1, � C?10 � 1a1 13-1 AddresExpiratio Date L 5 Signature Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ ✓�c�a ._ ��r,��, plc 2_v;,�►r\, -� S I t Inc Company Name Registrationd Number Addre U Expir tion ate Telephone L/13� 65 W 1r 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...... ❑ SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) EJRoofing Or Doors D Accessory Bldg. ❑ Demolition ❑ New Signs [p] Decks Siding [O] Other[a Brief Description of Proposed Work: litt bi,2l � pkccg- ncccl ors(' 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, Lau"AM as Owner of the subject property hereby authorize C-1()" Quee)"Cy% IIC to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date (✓ of Cc, as Owner/Authorized Agent hereby declare that the statem nts 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 d u l.iC, r".V GV\�\L Print Name Signature of Owner/Agent Date City of Northampton Massachusetts >. DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • 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 enti{h must/be registered. Type of Work: �t)c) Est. Cost: 1r�7 ) •CU Address of Work: 61 RtnC- T, Date of Permit Application: 5 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: � 55) 3�" 4c"., wtr►At,1[((_ �, .� 0109 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 212 Main Street • Municipal Building Northampton, MA 01060 SMyy`TQ 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 A` DEPART[ONT OF BUILDING INSPECTIONS pr 212 Main Street •Municipal Building a 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: b AV%t Y Dc,rep,cc- (Please print house number and street name) Is to be disposed of at: USA kQV II-NA rhV Ikn 0-,—J (Please prMt name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: LA5A 140LAA (S r},�jIkh �a Fh I� (Company Marne and Address) Signature of Permit Applicant or Owner at 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 I Congress Street,Suite 100 Boston, MA 02114-2017 www mass.gov/dia Wovkers' 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. ❑New construction _'.❑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. El Demolition 3.[]1 am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10E]Building addition 4.❑1 am a homeowner and will be hiring contractors to conduct all work on my property. 1 will ensure that all contractors either have workers'compensation insurance or are sole I LE]Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.a 1 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#I must also 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 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 the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: Phone#: Oficial use only. Do not write in this area,to be completed by city or town ofciaL 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#: ILILIE L�1�4w St?D V ISA Rri:AC_.Y iC 160 Old Lyman Road+South Hadley•MA 01075 We are Licensed 1.800.NEW.ROOF + 413.536.5955 Fully Insured Email:info 18Wnewroof.net Website:www.1800newroof.net Factory Trained MA Construction Supervisors Lic.0070626 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 PRC 38710 Proposal Submitted To: Date: Phone#'s: C: Lawrence George 4/23/2020 H: 617-913-2612 W: Street: Email: 61 Pine 5t City,State,Zip Code: Special Requirements: Florence MA 0'062 louse only 2 story section PROPOSAL FOR: GARAGE OTHER STRIP RECOVER r-1% Layers: 1 3 4 Plywood Included: Yes Allo} Tear off SLATE or SHAKES COMPLETE ROOF PROTEC 17ON SYSTEM: A We shall acquire appropriate permits for all work 110 Home exterior and landscaping to be protected A Strip existing roofing to existing decking with f till inspection DONOTDO: Garage,breezeway or porch A All project waste shall be removed by dum ster(dumpster far contractor use only) id Install Ice&Water Barrier at all eaves 3' 6' alleys,chimneys,pipes and skylights 0 Install(151b.felt ynthetic) nderlayment over remaining decking area � Install Metal drip a ge at eaves and rake 5" whi /brown) Install manufacturer's starter shingle on all eaves and rake edges 10 Install nea boot ent accessories 93 Install ridge ven -Snow Country Cobra rolled/4'Baffled/Roll Shingles:(standard 6 nails per shingle) GAF HD Shingles Color: Sarkvrood GAF Ridge cap shingles Warranty Options: We guarantee our workmanship for 10 full years ] GAF System Plus Warranty I GAF Golden Pledge Warranty Chimney Options: D4 Lead Counter Flashing L_] Water Seal&Tuckpoint E-.] Rubberized Crown i_1 Cricket ED Mason needed(customer provided) Additional material and labor charges may apply. /Q Deteriorated existing decking will be replaced at$3.77 per sq.ft.and dimensional lumber at$7.00 per linear ft., after full inspection. XCustomerinitials: (- We propose hereby to furnish materials and labor—complete in accordance with above specifications for the sum of: Total Due:($ 6,8 7 5 ) ACCEPTANCE OF PROPOSAL:The above prices,specifications and conditions are Down Payment:($2,47 5 ) satisfactory and are hereby accepted.You are authorized to do work as specfied. Balance Due Upon Completion:($ 4,4 0 0 } Payment will be 1/3 down at start of jobZandce due upon completion. `)11 Date: Zt M 0Suture: 3-348-3321 Date: 4/!23/2020% Estimator:(Print Name) Dustin Peters (Sign Name) 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 Quertneville Roofing will not be responsible for debris or dust in the attic or storage areas. "4Customer initials _ A�® CERTIFICATE OF LIABILITY INSURANCE DA4i2,2 QYY) 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(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 CONTACT Fe' Trudell NAME: Martin J Clayton Insurance Agency, Inc aIc No Ext: (413)536-0804 FAX No: (413)534-7074 1649 Northampton Street E-MAIL fJ-=da11Rmjn_1ay nn_ nm ADDRESS: P. O. BOX 989 INSURERS AFFORDING COVERAGE NAIC# Holyoke MA 01041-0989 INSURER A:Nautilus Insurance Company INSURED INSURERB:Green Mountain Insurance Company Adam Quenneville Roofing 6 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 ADDLISUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE iNsn wyn POLICY NUMBER MM/DDIYYYY MMIDDNYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE FX OCCUR DAM'ISESa occu GE T RENTED 100,000 PREMErrence $ X Y NN1000129 6/23/2019 6/23/2020 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'LAGGREGATELIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICYPRO LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea dent $ 1,000,000 acci B ANYAUTO BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED X Y 20030465 6/23/2019 6/23/2020 BODILY INJURY(Per accident) $ AUTOS AUTOS X HIREDAUTOS X NON-OWNED Per accci nDAMAGE $ AUTOS X UMBRELLA LIAR OCCUR EACH OCCURRENCE $ 5,000,000 A EXCESS LIAB CLAIMS-MADE AGGREGATE $ 5,000,000 DED I I RETENTION$ AN069764 6/23/2019 6/23/2020 $ WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITY Y STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE 1 N/A AWC40070128612020A 4/29/2020 4/29/2021 E.L.EACH ACCIDENT $ 1,000,000 OFFICERIMEMBER EXCLUDED? C (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Workers' Compensation benefits will be paid to Massachisetts employees only. Pursuant to Endorsement WC 20 03 06 B, no authorization is given to pay claims for benefits to employees in states other thar Massachusetts if the insured hires, or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on 41e date that this certificate was issued (unlese 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 Verificatior Search tool at www masa gnv/1_wd/wnrkars-cnmpansa inn/in,estigations/. 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/FMI ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD INS025 nnlann The Conzinonivealth ofAfassachusetts Department.of Industrial Accidents X Congress Street,Suite 100 Boston,MA 02114-2017 ivivwxiass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERA'IITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/rndividua[): Adam Quenneville Roofing & Siding Inc Address: 160 Old Lyman Rd City/State/Zip: South Hadley, MA 01075 Phone##: 413-536-5955 Are you an employer?Check the appropriate box: Type of project(required): 1.6/ l am a employer with__15 _employees(full and/or part-tune).* 7. ❑New construction 2.F-1 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 3.Q I am a homeowner doing all work myself.[Na workers'comp.insurance required.]t 10 Building addition 4.FJ[am a homeowner and will be hiring contractors to conduct alt work on my property. I wilt ensure that all contractors eitherhave workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.Q Plumbing repairs or additions 5.r_J I am a general contractorand I have hired the sub-contractors listed on the attached sheet 13.[ of repairs These sub-contractors have employees and have workers'comp.insurance3 14.❑Other 6.Q we arc a corporation and its officers have exercised their right of exemption per MGH c. 152,$1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#I must also fill out the section below showing their workers'compensution policy information. t liorneowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 'Contractors that checkthis box roust 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'conipensatiorz insurance for my ernployees. Below is the policy andjob site information. Insurance Company Name: AIM Mutual — AWC40070128612019A 4/29/2020 Policy P or Self-ins.Lic.#: Expiration Date: Job Site Address: LQ� �illx_p9, —A.0City/State/Zip: rV Attach a copy of the workers' compensation policy declaration page(showing the policy number and expi atiotl date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to SI,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 DTA for insurance coverage verification. /([a hereby certify under the ams and penalties of perjury that the information provided above is true and correct. Si nature: Date: -0 Phone : 413-536-5 55 rrofficial use only. Do zlot ivrite ill 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#: Commonwealth of Massachusetts • - • - Division of Professional Licensure Board of Building Regulations and Standards Constructibtil6tipprvisor i CS-070626 Wires: 08/21/2021 ADAM A f1UEDXNIE r 160 OLD LYMAN R SOUTH HADLEY oma` 47 C)/S�-i.all Commissioner Office of Consumer Affairs and Business Regulation 1000 Washington Street- Suite 710 Boston, Ma�husetts 02118 Home ImprovemeEoritractor Registration r__..c.. Type: Corporation a Registration: 191093 ADAM QUENNEVILLE ROOFING AND SIDINin r'IR1i 160 OLD LYMAN RD. Expiration: 03/22/2022 SO.HADLEY,MA 01075 'mak Update Address and Return Card. SCA t 0 20M-05117 STATE OF CONNECTICUT .j DEPARTMENT OF CONSUMER PROTECTION k Be it known that ADAM QUENNEVILLE 160 OLD LYMAN ROAD SOUTH H LEY'r:MA ,01075-2632 'l 1 yY? has satisfied the qualiie ns Iiy'taant� is.Hereby registered as a HOME IMP. NT CONTRACTOR (l Regis-ration. f 00.0575920 l i ADAM QUENNEVILLE ROOFING t Effective: 12/01/2019 i Expiration:: 11/30/2020 rr i 1 Michelle Seagull,Commissioner Lu,�r 1. N s 4 6 ■ . -