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23A-042 (2) 9 WEST CENTER ST BP-2021-0941 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:23A-042 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-2021-0941 Project# JS-2021-001610 Est.Cost:$3500.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: ADAM QUENNEVILLE 070626 Lot Size(sq. ft.): 8494.20 Owner: PEARSON 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:2/26/2021 0:00:00 TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE BACK LOWER RIGHT ROOF ONLY 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. , fliTCertificate of Occupancy Signal e: r ' ✓ FeeType: Date Paid: Amount: Building 2/26/2021 0:00:00 $40.00 212 Main Street, Phone(413)587-1240, Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner Department use only ��� rrr,�r � City of Northampton HE�� Status of Permit: /f Building Department Curb Cut/Driveway Permit - Oil't' 212 Main Street fEB , Sewer/Septic Availability Room 100 Water/Well Availability Northampton, MA 010 TwoSetsof �� p 6� Structural Plans phone 413-587-1240 Fax 41_ - 7:1 72 Plot/Site Plans Other Specify APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION This section to be completed by office 1.1 Property Address:9 W Ceter St Florence Ma 01062 Map 42 l/4 Lot 0442—, Unit Zone Overlay District Elm St. District CB District SECTION 2 -PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Clayton Pearson 9 W Center St Florence Ma 01062 Name(Print) Current Mailing Address: 850-832-7035 see contract Telephone Signature 2.2 Authorized Agent: Adam Quenneville 160 Old LymanRd South Hadley Ma 01075 Name(Prin Current Mailing Address: 413-536-5955 Signatu e Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building 3,500.00 (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) *� 5. Fire Protection 6. Total = (1 + 2 + 3 +4 + 5) 3,500.00 Check Number 9 753 This Section For Official Use Only Building Permit Number: —g -/ DateIssued: Signature: / 2- Zy- ZOZ/ Building Commissioner/Inspector of Buildings Date operations.aqrs @ gmail.com 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 DON'T KNOW x YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO DON'T KNOW x YES IF YES: enter Book Page and/or Document # B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW YES` IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained , 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? YES NO x IF YES, describe size, type and location: E. Will the construction activity disturb cl aring, grading.excavation, or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YE jI NOIX 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 D Or Doors E Accessory Bldg. ❑ Demolition ❑ New Signs [p] Decks [❑ Siding [El] Other[CO Brief Description of Proposed roof back lower right only, remove and replace existing roofing, install ice and water, drip edge, ridge vent 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 I, Clayton 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 02/22/2021 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 il.//- 02/22/2021 Signature of Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable 0 Name of License Holder Adam Quennville CS-070626 License Number 160 Old Lyman Rd South Hadley Ma 01075 8/21/2021 Address Expiration Date /U/// .------ 413-536-5955 Signature Telephone 9. Registered Home Improvement Contractor: Not Applicable 0 Adorn Ouenneville Roofing & Siding Inc 191093 Company Name Registration Number 'tjO OH Lyman Rd South Hadley Ma 01075 3/22/2022 Addres Expiration Date /i4. . Telephone 413-536-5f)55_ 1 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 0 City of Northampton bR ,.‹ 4 S Massachusetts �:, „, x DEPARTMENT OF BUILDING INSPECTIONS +z ar 212 Main Street • Municipal Building - , Northampton, MA 01060 J•s�`W ;;0‘^' AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application The Office of Consumer Affairs and Business Regulation ("OCABR") regulates the registration of contractors and subcontractors performing improvements or renovations on detached one to four family homes. Prior to performing work on such homes, a contractor must be registered as a Home Improvement Contractor("HIC"). M.G.L. Chapter 142A requires that the"reconstruction, alteration, renovation, repair, modernization, conversion, improvement, removal, demolition, or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units....or to structures which are adjacent to such residence or building"be done by registered contractors. Note:If the homeowner has contracted with a corporation or LLC, that entity must be registered. Type of Work.• Gd'1 Est. Cost: 3OL) Address of Work: I W CC c1i cr S-4 Date of Permit Application: ap)' a l 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: �+ a aa-lai Ac or. 0urnnet) sk- e04s� I 1 o7Q 3 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 je. P oti s !c !, Massachusetts ee ,' # %,., Iit' DEPARTMENT OF BUILDING INSPECTIONS IIT � ` � ��tsi 212 Main Street *Municipal Building Northampton, MA 01060 "-;l. 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 W Center st Florence Ma (Please print house number and street name) Is to be disposed of at: Adam Quenneville Roofing &Siding 160 Old Lyman RD South Hadley Ma (Please print name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: Adam Quenneville Roofing & Siding 160 Old Lyman Rd South Hadley Ma (Company Name and Address) /44-7'' 4-14-3--1 14-1 Signatur 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. CtilltallEIMINIIIIE ILAi Y/{TyC- ,... AWARD VISA DISC,y ER 160 Old Lyman Road•South Hadley•MA 01075 We are Licensed 1.800.NEW.ROOF • 413.536.5955 Fully Insured Email:info@l800newroof.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: 8 50-8 32-7 0 35 Clayton Pearson 2/18/21 H: W: Street: Email: 9 West Center St City,State,Zip Code: Special Requirements: Florence MA 01062 back lower right side only. PROPOSAL FOR: full ice barrier. remove siding and run icebarrier up HOUSE GARAGE OTH wall with new flashing then STRIP RECOVER reinstall siding. Layers: 2 3 4 Plywood Included: Yes or lP ❑ Tear off SLATE or SHAKES COMPLETE ROOF PROTECTION SYSTEM: p` We shall acquire appropriate permits for all work 1( Home exterior and landscaping to be protected X Strip existing roofing to existing decking with full inspection DO NOT DO: anything else All project waste shall be removed by dumpster(dumpster for contractor use only) cc Install Ice&Water Barrier at all eaves 3'/6',valleys,chimneys,pipes and skylights full Install(151b.felt/Synthetic)underlayment over remaining decking area Install Metal drip edge at eaves and rake/5")Mr, brown) 7. Install manufacturer's starter shingle on all eaves and rake edges }s Install new pipe boot flashing/vent accessories < Install ridge vent-Snow Country/Cobra rolled/4'Baffled Ro Shingles:(standard 6 nails per shingle) GAF Timberline HDZ Shingles Color: fox hollow gray GAF Ridge cap shingles Warranty Options: We guarantee our workmanship for 10 full years ❑ GAF System Plus Warranty ❑ GAF Golden Pledge Warranty Chimney Options: O Lead Counter Flashing O Water Seal&Tuckpoint O Rubberized Crown O Cricket O Mason needed(customer provided) Additional material and labor charges may apply. K Deteriorated existing decking will be replaced at$3.77 per s .ft.and dimensional lumber at$7.00 per linear ft., after full inspection. Customer Initials: We propose hereby to furnish materials and labor—complete in accordance with above specifications for the sum of: Total Due:($ 3500 ACCEPTANCE OF PROPOSAL:The above prices,specifications and conditions are Down Payment:($10 0 0 c c ) satisfactory and are hereby accepted.You are authorized to do work as specified. 2nd Payment at Start Job:($ Payment will be 1/3 down at signing,1/3 at start of job,and bal a due ce Due Upon Completion:($2 5 0 0 upon cor,3 letion. Date: C//�/Z( Signature: Date: 2/18/21 Estimator:(Print Name) Robert Croteau (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 Quenneville Roofing will not be responsible for debris or dust in the attic or storage areas. Customer Initials: 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 easels),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 gives 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 providfd 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 end 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. 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. LIABILITY Company is not responsible for damage or loss caused in whole or in part by:the acts or omissions of other parties,trades or contractors;lightening,gale force winds (+110 mph),hailstorms,ice damage,ice damns(caused by thawing and freezing of ice,water or snow)hurricanes,tornados,floods,earthquakes or other unusual phenomena of the elements;structural settlement;failure,movement,cracking or excess deflection of the roof deck;defects or failure of materials used as a roof substrate over which Company's roofing material is applied;faulty condition of parapet walls,copings,chimneys,skylights,vents,supports or other parts of the building; vapor condensation beneath the roof;penetrations for pitch boxes;erosion,cracking and porosity of mortar and brick;dry rot;stoppage of roof drains and gutters; penetration of the roof from beneath by rising fasteners of any type;inadequate drainage,slope or other conditions beyond the control of Company which cause ponding or standing water;termites or other insects;rodents or other animals;fire;or harmful chemicals,oils,acids and the like that come Into contact with Customer's roof and cause a leak or otherwise damage Customer's roof.If Customer's roof fails to maintain a watertight condition because of damage,by reason,of any of the foregoing,any applicable written limited warranty shall immediately become null and void for the balance of its term.Company accepts no liability to indemnify or hold Customer harmless for claims or damages to persons or property,except to the extent that such damage occurs during performance of Company's work and are the direct result of Company's error or omission.Notwithstanding the foregoing,Company shall not be responsible for damages to any area of the property upon which Company's work has not been completed nor Is Company responsible for slight scratching or denting of gutters,oil droplets in driveways,hairline fractures in concrete, damage to flowers or landscaping,or minor broken branches on trees,plants or shrubbery.In no event shall Company be responsible for any type of damage resulting from vibrations,including,but not limited to,Interior drywall damage,nail pops or disconnection of chimneys,flues,air ducts,ventilation shafts,exhaust vents,furnace vents or sewer vents.Customer understands and agrees that Company shall have no responsibility for damages of any kind to persons or property occurring after job completion. 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, " I ® DATE(MM/DD/YYY1') AC ACa1?L'® CERTIFICATE OF LIABILITY INSURANCE r `......-- 06/23/2020 { THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS ICERTIFICATE 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 have ADDITIONAL INSURED provisions or 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 Sarah Premo _NAME: Clayton Insurance Agency,Inc. iqONN Exd: (413)536-0804 AAC,Noy. (413)534-7874 1649 Northampton Street ADMDRESS: spremo@claytoninsurance.net P.O.Box 969 INSURER(S)AFFORDING COVERAGE NAIC a Holyoke MA 01041-0989 INSURER A: Nautilus Insurance Company INSURED INSURER e: Green Mountain Insurance Company 20680 Adam Quenneville Roofing&Siding Inc. INSURER C: AIM MUTUAL INSURANCE COMPANY 160 Old Lyman Road INSURER D: , INSURER E: South Hadley MA 01075 INSURER F: COVERAGES CERTIFICATE NUMBER: CL2062304009 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 ADDLSUBR POLICY EFF POLICY EXP UMITS LTR TYPE OF INSURANCE _INSD_WVD POLICY NUMBER JMM/DD/YYYY) (MM/DD/YYYY) X COMMERCIAL GENERAL LIABILJTY EACH OCCURRENCE $ 1,040,000 . DAMAGE TO REN I EU 100,000 CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) -$ MED EXP(Any one person) $ 5,000 A NN1143748 06/23/2020 06/23/2021 PERSONAL BADVINJURY $ 1,000,000 GEN'L AGGREGATE LIMITAPPUES PER: GENERAL AGGREGATE $ 2,000,000 POLICY JECT X PRO LOG PRODUCTS-COMP/OPAGG $ 2,000,000 $ OTHER: AUTOMOBILE IJABIUTY COMBINED SINGLE OMIT g 1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ g OWNED �./ SCHEDULED 20035707 06/23/2020 06/23/2021 BODILY INJURY(Per accident) $ AUTOS ONLY 0—, AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ X AUTOS ONLY r X AUTOS ONLY (Per accident) $ X UMBRELLA LAB OCCUR EACH OCCURRENCE $ 5,000,000 A EXCESS UAB CLAIMS MADE AN088790 06/23/2020 06/2312021 AGGREGATE $ 5.00,000 DED RETENTION$ _ $ WORKERS COMPENSATION X STA UTE ER AND EMPLOYERS'LIABILITY Y/N 1 ANY PROPRIETOR/PARTNER/EXECUTIVE Y N JA AWC4007012861 04/29/2020 04/29/2021 EL EACH ACCIDENT $ , , C OFFICER/MEMBER EXCLUDED? 1000,000 (Mandatory in NH) EL DISEASE-EA EMPLOYEE $ , If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below EL DISEASE-POUCY UMIT $ I I I DESCRIPTION OF OPERATIONS/LOCATIONS 1 VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) For Informational Purposes Only CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Adam Quenneville Roofing&Siding Inc ACCORDANCE WITH THE POLICY PROVISIONS. 160 Old Lyman Rd AUTHORIZED REPRESENTATIVE South Hadley MA 01075 � 1 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts E —Or t'1, Department of industrial Accidents MC 'I` i 1 Congress Street,Suite 100 Boston,IPIA 021112017 - 10 wfvw mass goy/din Workers'Compensation Insurance Affidavit:Builders/Co ntractors/EIectricians/Plumbers. TO BE FILED WITH THE PERMUTING AUTHORITY. Applicant Information Please Print Legibly Name(Boviness/Orgartization/Individuat): Adam Quennevilie Roofing & Siding Inc - Address: 160 Old Lyman Rd City/State/Zip: South Hadley, MA 01075 Phone ff: 413-536-5955 Are you an employer?Check the appropriate box: Type of project(required): I.Vl am a employer with }t 5 employees(full and/or part tune).* 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working forme in 8. Remodeling 9_ El Demolition 10 0 Building addition any capacity.[No workers'comp.insurance required.' 3.I r--�I I am a homeowner doing all work myself[No workers'comp.insurance required.]t 4-1 I am a homeowner and will behiring contractors tet conduct all work on my property. t will ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors witlino employees. 12.0 Plumbing repairs or additions 5.I I f ern a general contractor and I have hired the sub-contractors listed on the attached sheet I31Zoof repairs These sub-contractors have employeesand have workers'comp.insurances 6.I i We are a corporation and its officers have exercised their right of exemption per NICOL c_ 14.Q Other I32,§1(4),and we have no employees.[No workers camp.insurance required.] '"Any applicant that checks box#I must also fill out the section below showing their workers'coutn.nsation 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 isprovidirrg workers'compensation insurance for my employees Below is the policy and fob site information_ Insurance Company Name: AIM Mutual Policy 4 orSeit=ins.Lie.#:. AWC40070128612019A Expiration Date: 4fila / 04.)0 Job Site Address: (.&) C-L I 11 r r 51- City/State/Zip:ric(^nv: A_ 0 IOC,)- 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 S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and acne of up to S250.00 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 tic hereby certify under the airiss and penalties of perjury that the infar i,zation provided above is true and correct. Signature: d v Date: 1,)-6).-7)-1 Phone . 413-536-5955 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one); I. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6-Other Contact Person: Phone#: Commonwealth of Massachusetts lit Division of Professional Licensure Board of Building Regulations and Standards Construct6ri I1periisF)r CS-070626 Exp i res:08/21/2021 ADAM A QUENNEV a ; • 160 OLD LYAkAN R 6 i r SOUTH HADLEY MA. s 4e /� 1 i • 9 • f — • Commissioner Aj,�L,r,YJ.i -- �� ?o/m nelutvca12A orP.46.4uzcAu%p 1`� Office of Consumer Affairs and Business Regulation 1000 Washington Street- Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Corporation Registration: 191093 ADAM QUENNEVILLE ROOFING AND SIDING,INC. Expiration: 03/22/2022 160 OLD LYMAN RD. SO.HADLEY,MA 01075 Update Address and Return Card. SCA 1 A 20M-05117 0;µ t ,,V'y �� 4 by ♦ ,, ,., 3:, a, it �. ,I 7sp t '..`ry },y l't+' ,v `S-•ns •,.. i\ r 'y` t° {e'V -'n*.,. �•"'0 : f.' ,✓ �'v ' .jL:'•, A` ,4: . •' ..'li��1."',,,surer `i `•s• NMid ' j . vs.. �� -- n ,t a 3', - .9 ... �y, � fin: �A: �f .,r! ,n,'a w '•,K t..:vl A� ,M'' tr. „ :r$•:. �;.;<'.i lY' A1;9, _ i STATE OF CONNECTICUT + DEPARTMENT OF CONSUMER PROTECTION j` r j Be it;known that ADAM QUENNEVILLEi ,' •i Y , 160 OLD LYMAN ROAD SOUTH HADLEY, MA 01075-2632 ;; <;_« 1 . has satisfied the qualifications required by taw and is hereby registered as a 1 HOME IMPROVEMENT CONTRACTOR ,4• 1„' S. . Registration # HIC.0575920 ik.,,Tli,. ADAM QUENNEVILLE ROOFING Effective: 12/01/2020 lipm. 1//ilExpiration: 11/30/2021 ! g iMichelle Seagull,Commissioner PE ,- n.. ._ . __Ni :a/ ng Via,.