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23A-042 9 WEST CENTER ST BP-2020-1254 GIS#: COMMONWEALTH OF MASSACHUSETTS Mo.-Block:23A-042 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE AC ESS TO THE GUARANTY FUND (MGL c.142A) Category: Siding BUILDING PERMIT Permit# BP-2020-1254 Proiect# JS-2020-002112_ Est.Cost:$40874.00 Fee: $60.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: ADAM QUE NEVILLE 070626 Lot Size(sq.ft.): 84 94.2 0 Owner: 111:;nRSON CLAY Zoning: URB(100)/ Applicant. ADAM QUENNEVILLE AT: 9 WEST CENTER ST Applicant Address: Phone: Insurance: 160 OLD LYMAN RD 413 536-5955 Workers Compensation SOUTH HADLEYMA01075 ISSUED ON:611812020 0:00:00 TO PERFORM THE FOLLOWINGWORK:SIDING 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 nature: Feer e: Date Paid: Amount Building 6/18/2020 0:00:00 $60.00 212.Main Street,Phone(413)587-1240, Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner Department use only IIII City of Northampton status of Permit: Building Department Curb Cut/Driveway Permit + 212 Main Street Sewer/Septic Availability Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans Other Specify �i 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 Map ol�) 74 Lot Q�Z� Unit 9 West Center St Florence Ma 01062 Zone Overlay District Elm St.D'cc'•- CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Clay Pearson 9 West Center St Florence Ma Name(Print) Current Mailing Address: s 850-832-7035 see contract Telephone Signature 2.2 Authorized Agent: Adam Quenneville Roofing & Siding 1A0cPdMy"nW fL0R6N i4 W1& Siding Name rint) Current Mailing Address: JA Adenneville Roofing & Siding Signa re Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building 40,874.00 (a) Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) t6j� CJS 5. Fire Protection 6. Total = 0 +2+ 3+4+5) I— ) 1 O'% Check Number 65 7 This Section For Official Use Only ,� ��� rissued:Building Permit Numb r: 60ate �!" � Signature: (�'�O -z/m 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: 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. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors 1:3 Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [0 Siding [©] Other[O] Brief Description of Proposed Remove all current siding and replace with new vinyl siding,caver all soffit with vented vinyl,wrap all windows and door with casing Work: 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 Clay Pearson as Owner of the subject property Adam Quenneville hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. see contract 6/8/2020 Signature of Owner Date I, Adam Quenneville 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. Adam Quenneville Print Name 6/8/2020 Signature of wner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: Adam Quennville CS-070626 License Number 160 Old Lyman Rd South Hadley Ma 01075 8/21/2021 Address Expiration Date 413-536-5955 Signature Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ Adam Quenneville Roofing&Siding Inc 191093 Company Name Registration Number 160 Old Lyman Rd South Hadley Ma 01075 3/22/2022 Address Expiration Date Telephone-413-536-5955 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...... ❑ City of Northampton * Massachusetts _ DEPARTMENT OF BUILDING INSPECTIONS 212Main 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 entity must be registered. 4 Ll Type of Work: J t 1' Est. Cost: , �� Address of Work: Ce✓�\e� Date of Permit Application: tl 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 43R ENTERING INTO CONTRACTS WITH UNREGISTERED CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT ELIGIBLE FOR AND DO NOT HAVE ACCESS O 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: 010( au � w, Qv nn V%It, (0 U Dae 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 �5 s a, Massachusetts DEPARTMENT OF BUILDING INSPECTIONS x" 212 Main Street • Municipal Building �. t Northampton, MA 01060SSt 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 rx Massachusetts ' DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street •Municipal Building � -•-" Northampton, MA 01060t � ,,�� 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: 9 West Center St Florence Ma 01062 (Please print house number and street name) Is to be disposed of at: C,Cj 0 iL rvva. f2-A OL (� � (Please print name and location bf facility) Or will be disposed of in a dumpster onsite rented or leased from: Adam Quenneville Rooting & Siding 160 Old Lyman Ri South Hadley Ma (Company Name and Address) Signature cf 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 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. ❑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.❑I am a homeowner 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. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.E]Plumbing repairs or additions 5.[:]I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑ repairs re airs 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 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 the pains andpenalties ofperjury that the information provided above is true and correct. Signature: Date: Phone#: Oficial use only. Do not write in this area, to be completer)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#: t1LL Ul JI.V VLV IJ L-1Y YLICU ��A *� ��y✓YC 1, QUIENNIEVIL�.I�Y_i.�' .ea x. �KVJA 111 SA :. DISC VER C, £ .-d s:y, +► `.a f R.t 1 Y.;r ,mss,�Trl' 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 Builders Assoc.of Western Mass. CT Registration#575920 Member of the Building&Trade Association PRC 38710 Proposal Submitted To: Date: Phone#'s: C: CLAY PEARSON 6/4/20 H: 850-832-7035W: Street: Email: 9 WEST CENTER ST CLAYPEARSON@GMAIL.COM City,State,Zip Code: FLORENCE MA 01062 Proposal to furnish and install the following: 1) OBTAIN ALL PERMITS NECESSARY TO DO PROJECT. 2) DELIVER DUMPSTER OR TRAILER TO DISPOSE OF ALL DEBRIS. 3 STRIP OFF ALL EXISTING SIDING AND INSPECT DECKING. 4) WRAP ALL WINDOW AND DOOR CASINGS WITH PVC ALUMINUM COIL. 5) COVER ALL SOFFITS WITH VENTED VINYL AND WRAP ALL FACIA WITH COIL. 6) COVER ALL WALLS OF HOME BEING DONE WITH INSULATED VIRGIN VINYL SIDING. COLOR MIDNIGHT BLUE. WHITE CORNER POSTS 7) INSTALL NEW VINYL LIGHT BLOCKS,DRYER VENTS,LOUVRES WHERE NEEDED. 8) REMOVE AND REINSTALL ANY STORM DOORS,STORM WINDOWS,SHUTTERS,AND GUTTERS AND DOWNSPOUTS THAT ARE REUSABLE. 9) ANY ROTTED WOOD DISCOVERED AFTER STRIP ($4.00 SQ FT $5.00 LIN FT) 10) LIFETIME WARRENTEE ON ALL MATERIALS. 11) PRICE INCLUDES ALL MATERIALS,LABOR,TAX,DISPOSAL OF ALL DEBRIS. Ask us about affordable bank financing! ATTENTION HOMEOWNERS:Please cover all personal belongings in the attic,garage or storage areas due to the possibility of roofing debris or dust coming in through cracks of the wood.Please remove any lawn ornaments or yard furniture.Adam Qu nnewlle Roofing will not be responsible for debris or dust in the attic or storage areas. Customer Initials: We propose hereby to furnish materials and labor-complete in accordance with above specifications for the sum of: Total Due:($ 40874 ) ACCEPTANCE OF PROPOSAL:The above prices,specifications and conditions are Down Payment:($ 4,000 satisfactory and are hereby accepted.You are authorized to do work as specified. 2nd Payment at Start Job:($ K) Payment will be 1/3 down at signing,1/3 at start of job balance d Balance Due Upon Completion:($ ��i,✓J) Ctb►� upon completion. //11 Date: (r" '--( ` 44 nature: Date: Estimator:(Print Name) i f(Sign Name)/ J 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 polity 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. t � ACRE) CERTIFICATE OF LIABILITY INSURANCE DA4(M2M/DDD/YYYY) F / /2020 THIS CERTIFICATE IS ISSUED ASA 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 NAME: Fey Trudell Martin J Clayton Insurance Agency, Inc ATONE Ext: (413)536-0804 AIC,NO: (413)534-7874 1649 Northampton Street E-MAIL ftr„dPli(am'�1a t-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 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 I rypE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LTR POLICY NUMBER MMIDDNYYY MM/DDNYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGET RENTED A CLAIMS-MADE X OCCUR 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 GENIAGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY a JEo 7 LOC2,000,000 PRODUCTS-COMP/OPAGG $ OTHER $ AUTOMOBILE LIABILITY Oaaccident)tINEDSINGLE LIMIT E $ 1,000,000 BANYAUTO BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED 20030465 6/23/2019 6/23/2020 BODILY INJURY(Per accident) $ AUTOS AUTOS X Y NON-OWNED PROPERTY DAMAGE X HIRED AUTOS X AUTOS Per accident $ I X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 5,000,000 A EXCESS LIAB HCLAIMS-MADE AGGREGATE $ 5,000,000 DED I I RETENTION$ AN069764 6/23/2019 6/23/2020 $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY �,I N X STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE AWC40070128612020A 4/29/2020 4/29/2021 E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? ❑NIA 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 _F DESCRIPTION OF OPERATIONS I 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 claimE for benefits to employees in states other thar 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 (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 Verificatior Search tool at www-marc_gs/1 c;d/work ra— mmpnG- ;nn/i n 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(2014/01) The ACORD name and logo are registered marks of ACORD INS025 onl4n11 S � T'i're Coninyomvealth of Massachusetts Departlnertt.of Industrial Aecidents X Congress Street,Sidte 100 Eoston,t1IA 02114 2017 ivwmtnassgovldia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organi2ation/rrtdividual). Adam Quenneville Roofing & Siding Inc Address: 160 Old Lyman Rd City/State/Zi p: South Hadley, MA 01075 Phone#: 413-536-5955 Are you an employer?Check the appropriate box: Type of project(required): l.NdIam a employer with__15 (full andlorpa—tune):* 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_ El Demolition 3.0 I am a homeowner doing all cork myself.[ltro workers'comp.insurance required.]t 10 F]Building addition 4-❑[am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure thatall contractors either have workers'compensation insurance oraresole I LE]Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.Q ram a general contractorand I have hLecd the sub-contractors listed on the attached sheet. 13.❑Roof rcpaits� These sub-contractors have employees and have workers'comp.insurance.z 14.XOther 6.F-1 We are a corporation and its officers have exercised their right of exemption per 1-ICrL G. 152,J I(4),and we have no employees.[No workers'comp.insurance required.] Any applicant that checks box#1 must also fr11 out the section below showing(heir 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- * Con tractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities ltnve employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I anz air employer that isproviding workers'compensation insurance for my ernployees. l3eloly is the policy and job site tltf 01"J11 atiOl t. Insurance Company Name: AIM Mutual _ AWC40070128612019A 4/29/2024 Policy�or Self-ins.Lie.#: Expiration Date: ii Job Site Address: 9 LJ Cen<er � T City/State/Zip: f71c"fer"Ce rr w olm 7- Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under�MIGL c. I52,§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 tine 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. 1 rla hereby certify under th aims and eltaldes ofperjwy that the itiforrnatian provided above is true artd correct. Signature' Date: 10 _ Phone 4: 413-536-5 55 Otfftcial use only. Do not write ilt this area,to be coJJlpletetf 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.EIectrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: i . t3 arrt oT au{feting Regulati-ons and Standards s �CTitStirT��S`t1�74i^+ItSOr s. CS-070626 ; Stpires:06/2112021 ADAM A RUENN 160 QLD LYMAN SOUTH HADLEY Comm i sioner --- V��6uw�6 o Office of Consuff or Affairs and Business Regulation 1000 iii' shington Street- Sine 71,0 Boston, Ma shhusetts 021118 Home lmprouemer actor Registration Type: Corporation ADAM QUENNEV LLE ROOF'IMG AND SiD � -' ms;'µ Registration_ 19f093 i 60 OLD LYMAN RD. *' -- - !_xpiration 03/22/2022 SO.HADLEY,,MAI U1075 9: w Update Address and Return Card. $CA; 0 2GIV-05/17 MENT OF ' R PP-0 160 3. t his satisfied thed c Fxe ebp re -99e-Md.as a qu ' P 4RACI.: d :k.O , ADW RV V'Tt.'lXG 01 f f. ira^dob: 0-130/2020, x • _ lldiinLi`Ife:3e;�u1F•Eomrois�ianer