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32C-177 (21) 300 PLEASANT ST BP-2020-1164 GIS#: COMMONWEALTH OF MASSACHUSETTS MV.-Block: 32C- 177 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-2020-1164 Project# JS-2020-001965 Est.Cost: $29500.00 Fee: $210.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: ADAM QUENNEVILLE 070626 Lot Size(sa.ft.): 18338.76 Owner: NAIDORF MARK Zoning_GB(100)/ Applicant: ADAM QUENNEVILLE AT: 300 PLEASANT ST Applicant Address: Phone: Insurance: 160 OLD LYMAN RD (413)536-5955 O Workers Compensation SOUTH HADLEYMA01075 ISSUED ON.512712020 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 Signature: FeeType: Date Paid: Amount: Building .5/27/2020 0:00:00 $210.00 212 Main Street, Phone(413)587-1240, Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner Version 1.7 Commercial Building Permit May 15, 2000 Department use only City of Northampton Status of Permit: Yo� /\ Building Department Curb Cut/Driveway Permit - ,. 212 Main Street Sewer/Septic Availability S9lo Room 100 Water/Well Availability orthampton, MA 01060 Two Sets of Structural Plans me 4 -587-1240 Fax 413-587-1272 Plot/Site Plans Other Specify APPLICATIO �, NSTRUCT, REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING i SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be completed by office 300 Pleasant St Northampton MA 01060 Map C• Lot / 77 unit Zone Overlay District Elm St. District CB District SECTION 2 -PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Mark Na dorf_. " ,3,00„_Pleasant,Slt Northampton Ma 01060. Name(Print) Current Mailing Address: 4133740633 Signature See contract Telephone 2.2 Authorized Aqent: Adam Quenneville Roofing_& Siding 160 Old Lyman Rd South Hadley Ma Name(Print) Current Mailing Address: / 4135365955 Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building 29500.00 (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) Q 5. Fire Protection 6. Total = 0 +2 + 3 +4 + 5) p'1 5(X) ,ro Check Number This Section For Official Use Only Building Permit Number Date l- D —1 /0 91 Issued Signature: Building Commissioner/Inspector of Buildings Date Versionl.7 Commercial Building Permit May 15,2000 SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 CUBIC FEET OF ENCLOSED SPACE Interior Alterations ❑ Existing Wall Signs ❑ Demolition❑ Repairs❑ Additions ❑ Accessory Building❑ Exterior Alteration ❑ Existing Ground Sign❑ New Signs ❑ Roofing❑./ Change of Use❑ Other ❑ Brief Description Enter a brief description here. Remove and replace flat roofing with duro-last roofing system. Of Proposed Work: SECTION 5-USE GROUP AND CONSTRUCTION TYPE USE GROUP (Check as applicable) CONSTRUCTION TYPE A Assembly A-1 E) A-2 E) A-3 El 1A 1:1El A-4 ❑ A-5 ❑ 1B ❑ B Business 2A ❑ E Educational ❑ 2B I ❑ F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ Institutional ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ 3B ❑ M Mercantile ❑ 4 ❑ R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑ S Storage ❑ S-1 ❑ S-2 ❑ 5B ❑ U Utility ❑ Specify: M Mixed Use ❑ Specify: S Special Use ❑ Specify: COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND/OR CHANGE IN USE Existing Use Group: Proposed Use Group: Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34): SECTION 6 BUILDING HEIGHT AND AREA BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY Floor Area per Floor(sf) 15 1s, 2nd 2nd 3 rd 3rd 4 h 4th Total Area (sf) Total Proposed New Construction (sf) Total Height (ft) Total Height ft 7. Water Supply(M.G.L. c. 40, § 54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone❑ Municipal ❑ On site disposal system❑ Versionl.7 Commercial Building Permit May 15,2000 8. NORTHAMPTON ZONING 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 O YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DON'T KNOW O YES O IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO O DON'T 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 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 O IF YES,then a Northampton Storm Water Management Permit from the DPW is required. J Versionl.7 Commercial Building Permit May 15,2000 SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES-FOR BUILDINGS AND STRUCTURES SUBJECT TO CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116(CONTAINING MORE THAN 35,000 C.F.OF ENCLOSED SPACE) 9.1 Registered Architect: Not Applicable ❑ Name(Registrant): Registration Number Address Expiration Date Signature Telephone 9.2 Registered Professional Engineer(s): Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date 9.3 General Contractor r 1 Ada,►, UC ,,cu11 c dC t T 51dikii C, Not Applicable ❑ Company Name: 'd C�An Q uC/1+1t tJ 1 1 L Responsible In Charge of Construction 1 c o 01j L,_ma�, 2 �� l�ac��t /�,G 016 7 1 Address b--�/ yI3 53(5gFT— Signature Telephone Versionl.7 Commercial Building Permit May 15,2000 SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11) Independent Structural Engineering Structural Peer Review Required Yes O No 0 771 SECTION 11 -OWNER AUTHORIZATION -TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT Q l��it as Owner of the subject property hereby authorize /41 oam. Qvenry t \L to act on my behalf, in all matters relative to work authorized by this building permit application. 5�C_ Gnitcc 5 di 3 Signature of Owner Date I, Ads`", "�` �ne�'�1��" 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. A 4a.f QtRnrC v �lr_ Print Name Signature of 0 ner/Agent Date SECTION 12-CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: Adam Quenneville CS-070626 License Number 160 Old Lyman Rd South Hadley Ma 01075 08/21/2021 Address Expiration Date 4135365955 Signature Telephone SECTION 13-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 O No 0 City of Northampton 212 Main Street, Northampton, MA 01060 Solid Waste 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. Address of the work: 300 Pleasant St Northampton Ma 01060 The debris will be transported by: Adam Quenneville Roofing&Siding The debris will be received by: Adam Quenneville Roofing&siding Building permit number: Name of Permit Applicant Adam Quenneville Roofing &Siding 11ld-O Date Signature of Permit Applicant QVEINNEVIIIII.L6 ,. YISQ'yr+ DISC VER � ' 'r^ 0 0 0 d S . 1 i r t �i 160 Old Lyman Road•South Hadley•MA 01075 We are Licensed 1.800.NEW.ROOF • 413.536.5955 Fully Insured Email:info@180onewroof.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: Mark Naidorf 5/5/2020 H: W: Street: Email: 300 Pleasant St. City,State,Zip Code: Northampton, Ma 01060 Proposal to furnish and install the following: Install Duro-last roofing system. Install Per Duro-last scope of work. 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 Quenneville Roofing will not be responsible for debris or dust in the attic or storage areas. Customer Initials: We propose hereby to furnish materials and labor—complete in accordance with above specifications for the sum of: Total Due:($29,500.00 ) ACCEPTANCE OF PROPOSAL:The above prices,specifications and conditions are Down Payment:($10,000.00) satisfactory and are hereby accepted.You are authorized to do work as specified. I Balance Due Upon Completion:($19,500.00) Payment will be 1/3 down at signing,and balance due upon completion. Date: 5/8/2020 Signature:r� Date: 5/5/2020 Estimator:(Print Name)S. NI(rlKlei' (Sign Name),7tZZA4-4-7�'� Estimates are honored for sixty(60)days from above date. NOTICE OF SCHEDULE CHANGES The contractor agrees that when delays become known to the Contractor,the Contractor 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 ACCELERATION OF PAYMENTS BUT ESCROWING ALLOWED 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 enforced against 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 142A of the General Laws 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 regarding any of the terms,conditions,provisions or performance of this contract,the parties agree to place the matter into arbitration before an independent arbitrator 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 payment(s)you have made. CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) F4/2/2020 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 PHONE (413)536-0804 FAX A/C No t: A/C,No): 1649 Northampton Street E-MAIL...ADDREft-rudeTi@miclayton-com P. O. BOX 989 INSURERS AFFORDING COVERAGE NAIC 0 Holyoke MA 01041-0989 INSURER A:Nautilus Insurance Company INSURED INSURERe:Green Mountain Insurance Company Adam Quenneville Roofing & 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 I ADDLR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER MMIDDNYYY MM/DD/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE �OCCUR DAMAG TOR NTED 100,000 PREMISES Ea occurrence $ X Y NN1000129 6/23/2019 6/23/2020 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY � PRO-- LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY EOMaBINdEeDtSINGLE LIMIT $ 1,000,000 B ANYAUTO BODILY INJURY(Per person) $ ALL OWNEDX SCHEDULED 20030465 6/23/2019 6/23/2020 BODILY INJURY(Per accident) $ AUTOS AUTOS X Y X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident $ X UMBRELLA LIABOCCUR EACH OCCURRENCE $ 5,000,000 A EXCESS LIAB HCLAIMSMADE AGGREGATE $ 5,000,000 DED RETENTION$ AN069764 6/23/2019 6/23/2020 $ WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITY Y/N TATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE AWC40070128612020A 4/29/2020 4/29/2021 E.L.EACH ACCIDENT $ 1,000,000 OFFICERIMEMBER EXCLUDED? ❑N/A 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 I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached it more space is required) Workers' Compensation benefits will be paid to Massachtsetts employees only. Pursuant to Endorsement WC 20 03 06 B, no authorization is given to pay claim: for benefits to employees in states other than Massachusetts if the insured hires, or has hired those employees outside of Massachusetts. Thi; certificate of insurance shows the policy in force on the date that this certificate was issued (unles: 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_qov/T_wd/war a s—comnenaa tion/i ryes tigations/. 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 l�r�Gv.•r' l % �,� ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025 nn14n1I The Contmonlvealth of Massachusetts Department.of Industrial Aceidents 1 Congress Street,Srtite 100 a Bostom RIA 02114-2017 M 1v1vw.nt ass gov/dia Corkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED NY7TH THE PERMTTTII\G AUTHORITY. Applicant information Please Print Levib[v Name (susiness/Organization/rndividual): Adam Quenneville Roofing & Siding Inc Address: 160 Old Lyman Rd City/State/Zip: South Hadley, MA 01075 Phone 9: 413-536-5955 Are you an employer?Check the appropriate boa: Type of project(required)' 1.Ndlamaemployer with�,5employees(firlland/or part-tune).* 7. ❑New construction 2,❑I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 9_ El Demolition 3.0 1 am a homeovmcr doing all work myself.[NTo workers'comp.insurance required.]t 10 F]Building addition 4.f7l I am a homeowner and will behiring contractors to conduct all work on my properly. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.Q Plumbing repairs or additions 5.❑I am a general contractorand I have hued the sub-contractors listed on the attached sheet 13.[3-lfoof repairs These sub-contractors have employees and have workers'comp.insurance.t 14.E]Other 6.0 We are a corporation and its officers have exercised their right of exemption per h1CrL C. 152,§1(4),and we have no employees.(No workers'canp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing(heir workerscompensation 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 checkthis box must attached an additional sheet showing the name of the sub-contructors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers comp.policy number. I ally an eluplayer that is providing workers'contpelrsatioit insuraltce for my employees Maly is the policy attd job site i1rf01'l/tat101t. Insurance Company Name: AIM Mutual — AWC40070128612019A 4/29/2020 Policy;#or Self-ins.Lic.#: E:tpiration Date: Job Site Address: 30U �L_1a,L1a+,-4 City/State/Zip: 0 Attach a copy of the workers'compensation policy declaration page(showing the policy number and a iratiott date). Failure to secure coverage as required under,LIGL c. 152,§25A is a criminal violation punishable by a fine up to 51,500.00 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 v hereby certify ander th ains alyd penalties of perjttry that the irtforntation provided above is true and correct. ap Signature: Date: S ay- Phone 4: 413-536-5955 official use only. Do not write in this area,to be completed by city or toren official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Torn Clerk 4.Electrical Inspector 5.PIumbing Inspector 6.Other Contact Person: Phone#: unrrswn of Protessionaf Licensure Board of Building Regulations and Standards Cons#A# t 6.4`tdrtpgrvisor - r; CS-070626 + Wires:OV21/2021 ADAM A QUE/ilN :r 160 OLD LYM>fIY ft SOUTH HA DL Y Commissioner 07 j (21-he Wommowwe.,141 Office of Consumer Affairs and Business Regulation 1000 Washington Street- Suite 710 Boston, Massachusetts 02118 Home Improvenl Coatractor Reggistration . _ Type: Corporation . Registration: 191093 ADAM QUENNEVILLE ROOFING AND SIDING,,i " +� ' Expiration 03/22/2022 160 OLD LYMAN RD. SO.HADLEY,MA 01075 Y. ,qf, r Update Address and Return Card. SCA t 4 20kt-05/;7 4-. STATEOF CON1riECT > 1 + DE.PITti£E VT OF CO'�ISiI F'1QT1 014 Be it kn:ozxrti thea r A m QUENNEVILLE. 160 OLD LY1' A i �. 01075.2 2 C �i � . s .. •. .-'. -.._ .;�p�� yam` ' {"`-�, has satisfied the qu ' bp Ladisb�firegistered'as a l' OR R-" a ADAM QUENNEVILLE R010 tG i Effective= 12/01/2019 Xp 'on: 11/30/2020,, dor I Mlchepe5e�ggp,Emhmiesioner I+ From: o l - 01025 To: Louis Hasbrouck Building Commissioner City of Northampton 212 Main Street Northampton, MA 01060 The Massachusetts Building Code, section 107.1 allows for an exclusion from requirements for construction control in certain situations. In accordance with code section 104.10, 1 request that you grant a modification to waive the requirement for construction control of the project at 900 p v ink -:5-4 No -tvx yam- / c.0 because the work is of a minor nature, will not affect s ructural elements, health, accessibility, life or fire safety, and will be done in accordance with the prescriptive requirements of the code. Thank you for your consideration. Respectfully, }} p. 4 C•PG'