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38D-036 33 HARLOW AVE (wrong map block on card) 33 HARLOW AVE BP-2021-1074 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:35-040 CITY OF NORTHAMPTON Lot:- PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: ROOF BUILDING PERMIT Permit# BP-2021-1074 Project# JS-2021-001818 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.): 485415.00 Owner: DAHLBERG ANDREW Zoning: SR/WSPII Applicant: ADAM QUENNEVILLE AT: 33 HARLOW AVE Applicant Address: Phone: I itsiirairce: 160 OLD LYMAN RD (413) 536-5955_) Workers Compensation SOUTH HADLEYMA01075 ISSUED ON:3/29/2021 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, w Certificate of Occupancy Signature: • • 'r + 51-.1 ' FeeType: Date Paid: Amount: Building 3/29/2021 0:00:00 $40.00 212 Main Street, Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner ("'E— E Department use only ,;act r City of Northamp O --�. St tus of Permit: Building Department Ci rb Cut/Driveway Permit 212 Main �� � , Street ,AAR 7 6 2021 Sewer/Septic Availability Room 100 W 'ter/Well Availability PE Northampton, MA 01060__�------'_"'�i c Sets of Structural Plans 1S '741— phone 413-587-1240 Fax 4'f3N p ' 1h.:;Ao�nilot/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: 7,� j� 33 Harlow Ave Northampton Ma 01060 Map 30 `.2 Lot �� Unit Zone Overlay District t?Im St. District CB Dist(ict SECTION 2 -PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Andrew& Kimberly Dahlberg 33 Harlow Ave Northampton MA Name(Print) Current Mailing Address: 413-570-5031 see contract Telephone Signature 2.2 Authorized Agent: Adam Q enneville 160 Old LymanRd South Hadley Ma 01075 Name(Print) Current Mailing Address: ►�/ 413-536-5955 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 3,500.00 2. Electrical (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee /r � 4. Mechanical (HVAC) 5. Fire Protection �� 6. Total = (1 + 2 + 3 +4 + 5) 3,500.00 Check Number This Section For Official Use Only 7y Date Building Permit Number: �Q Issued: Signature: 3- Z9 - ZOZl 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 DONT 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 x 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 IF YES, describe size, type and location: E. Will the construction activity disturb clearing, gradin excavation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YE II NO 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 ❑X Or Doors ❑ Accessory Bldg. ❑ Demolition El New Signs [p] Decks [❑ Siding [El] Other[EIJ Brief Description of Proposed New roof on shed dormer only, remove and replace existing roofing, install new 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, Kimberly&Andrew Dahlberg 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 03/24/2021 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 - 03/24/2021 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 413-536-5955 Signat re Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ Adam Ouenneville Roofing & Siding Inc 191093 Company Name Registration Number 16C) 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 0 City of Northampton Massachusetts .. �, I 1�� 1 DEPARTMENT OF BUILDING INSPECTIONSrf 212 Main Street 'Municipal Building b� ✓ 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: 33 Harlow Ave Northampton 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) Signature of Permit Applicant or Owner Date If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the Building Department as to the location where the debris will be disposed. c�u�IP/IiVEv���E 4r�'l AWARD VISA a DISCOVER 160 Old Lyman Road•South Hadley•MA 01075 We are Licensed 1.800.NEW.ROOF • 413.536.5955 Fully Insured Email:info@1800newroof.net Website:www.1800newroof.net Factory Trained MA Construction Supervisors Lic.#070626 MA Registration#120982 Factory Certified Installers Member of the Home Builder's Assoc.of Western Mass. CT Registration#575920 Member of the Building&Trade Association P.P.0 38710 Proposal Submitted To: Date: 3/ €s f . i Phone#'s: C: A IN el).-C-1A-1 0 k 1 H: W: Street: Email: 33 Ho.r i0 /3.v.� City,State,Zip Code: Special Requirements: 4/t1t 1 W, D 0:'1 /"qi 0 0 (L 0 S a 0 f y,"--el PROPOSAL FOR: > V I�QIJSE GARAGE OTHER STRIP RECOVER Layers: 1 2 3 4 Plywood Included: Yes or No 7 Tear off SLATE or SHAKES COMPLETE`�, ROOF PROTECTION SYSTEM: WI We shall acquire appropriate permits for all work Home exterior and landscaping to be protected Strip existing roofing to existing decking with full inspection DO NOT DO: (Li', All project waste shall be removed by dumpster(dumpster for contractor use only) �,,!//Install Ice&Water Barrier at all eaves 3'/6',valleys,chimneys,pipes and skylights i,,Y//Install(151b.felt/Synthetic)underlayment over remaining decking area ;K/Install Metal drip edge at eaves and rakes(8"/5")(white/brown) lit Install manufacturer's starter shingle on all eaves and rake edges �//Install new pipe boot flashing/vent accessories V Install ridge vent-Snow Country/Cobra rolled/4'Baffled/Roll Shingles:(standard 6 nails per shingle) arm Shingles Color: F Ridge cap shingles Warr,an ptions: We guarantee our workmanship for 1 0 full years GAF System Plus Warranty GAF Golden Pledge Warranty Chimney Options: ead Counter Flashing ❑ Water Seal&Tuckpoint CI Rubberized Crown O Cricket O Mason needed(customer provided) Additio I material and labor charges may apply. Deteriorated existing decking will be replaced at$3.77 er sq.ft.and dimensional lumber at$7.00 per linear ft., after full inspection. Customer Initials: We propose hereby to furnish materials and labor-complete in accordance with above specifications for the sum of: Total Due:($ 31 s p </ ) ACCEPTANCE OF PROPOSAL:The above prices,specifications and conditions are Down Payment:($ I ..O 0 ) satisfactory and are hereby accepted.You are authorized to do work as specified. '7tlae ($ Payment will be 1/3 down at signing,1/3 at start of job,and balance due Balance Due Upon Completion:($ 2/ )vC.') upon corn let n. Date: t c\ l [signature: Date: J 1 I t .f _Lk Estimator:(Print Name) Cirve IS �( f S (Sig ame) 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 Quennevi Roofing will not be responsible for debris or dust in the attic or storage areas. Customer Initials: I -A,��U CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 06/23/2020 { 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 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. PHONE : (413)536-0804 FAX Not, (413)534-7874 1649 Northampton Street EMAIL spremo@claytoninsurance.net ADDRESS: P.0.Box 989 I INSURER(S)AFFORDING COVERAGE NAIC# Holyoke MA 01041-0989 INSURER A: Nautilus Insurance Company INSURED INSURER B: 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: CI-2062304009 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. IAOOL SUER POLICY EFF POUCY EXP ILTRR TYPE OF INSURANCE INSD WVD POUCY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) UNITS X COMMERCIAL GENERAL UABIUTY EACH OCCURRENCE $ 1,000,000 DAMAGE TO EU CLAIMS-MADE XI OCCUR PREMISES(Eat oat ccurrence) $ 100,000 MED EXP(Any one person) $ 5,000 A NN1143748 06/23/2020 06/23/2021 PERSONAL&ADV INJURY s 1,000,000 GEN'LAGGREGATE UMITAPPUES PER: GENERALAGGREGATE $ Z,000,000 I POLICY I XI'e I LOC PRODUCTS-COMPIOPAGG $ 2,000,000 $OTHER: AUTOMOBILE UABIUTY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ B OWNED X SCHEDULED 20035707 06/23/2020 06/23/2021 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED X NON-OWNED PROPERTY DAMAGE $ X AUTOS ONLY /�AUTOS ONLY (Per accident) $ X UMBRELLA UAB 5 000 OCCUR EACH OCCURRENCE $ , , — 000 A EXCESS UAB CLAIMS•MADE AN088790 06/23/2020 06/23/2021 AGGREGATE $ 5,00,000 DED RETENTION$ $ WORKERS COMPENSATION XI PERTUTE OTH- AND EMPLOYERS'LIABILITY STA ER r/N 1,000,000 C ANY PER/MEMB R)PARTNER/EXECUTIVE Y I N/A AWC4007012861 04/29/2020 04/29/2021 EL EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? 1000,000 (Mandatory in NH) EL DISEASE-EA EMPLOYEE $ , If yes,describe under 1000,000 DESCRIPTION OF OPERATIONS below EL DISEASE•POUCY UMIT $ , 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 J f(pk„r. p _ ©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 ''!, Department of Industrial Accidents 1 1 Congress Street,Suite 100 ( Boston,Ifs 02111 2017 - ives� www.mass.gov/dia SLorkers'Compensation Insurance Affidavit:Builders/Contractors/EIectricians/Plumbera- TO BE FILED Vt1TH fit PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): 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): t.it am a employer with 15 employees(full aodfor part tune)." 7. Q New construction 2.0 I am a sole proprietor or partnership and have no employees working forme in 8. Q Remodeling any capacity,[No workers'comp_insurance required.] 9_ El Demolition 3.Q I am a homeowner doing all work myself[No workers'comp.insurance required.] 10 Q Building addition tam a homeowner and will behiring contractors to conduct all work on my property. 1 will ensure that all contractors either have workers'compensation insurance or are sole 11.0 EIectrical repairs or additions proprietors with no employees. 12.0 Plambing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet i3; Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 6.1 1.We are a corporation and its officers have exercised their right of exemption per bIGL c- 14.El Other 152,§I(d),and we have nit employees.[No workers'comp.insurance required.l 'Any applicant that checks box 41 must also fill out the section below showing(heir workers'compensation policy infommtion. 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 fob site iltfol-twat olr. Insurance Company Name: AIM Mutual Policy I orSelt=ins.Lie.#:- AWC40070-128612019A Expiration Date: Li/Ial 3 fob Site Address: 33 I lari0t0 A i e- CitylState/Zip:No rr)/3 01oL U Attach a copy of the workers'compensation policy declaration page(showing the policy number andlexpiratlori date). Failure to secure coverage as required underNIGL 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 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. 1 do hereby cent.°,under the pains penalties of perjury that the information provided above is tare and correct Signature: Date: 3'a3 2 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 CIerk 4.Electrical inspector S.Plumbing inspector 6.Other Contact Person: Phone#: Commonwealth of Massachusetts �r Division of Professional Licensure / > ' Board of Building Regulations and Standards .Constrtictidr %tlpervisor CS-070626 L!pires:08121/2021 ADAM A QUENNEY ' : '`'•' _. 160 OL0 LYMAN R " SOUTH HADLty MA �, I.#. v • Commissioner n�/,.,,,,i„)t/r�— — �Tf.{� �'/�hy/�/l �L�LC? /�asac�iust 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 L3 20A1.05117 .�; `77 772: .ti, : . :r�.', Svf{••i. 1�. .':Y(': r{vie • •.+••�q;: t.. 2 ... f i� � ��.,;.11....•.,•.�• ••....Hys.� ,; . ..f•.',•}d •.+;:j.?�:.4.' ..l'.itiL' tt}' �� �,/��'f1,, 4 ( I STATE OF CONNECTICUT + DEPARTMENT OF CONSUMER PROTECTION !l Be it known that E- I' ii` ADAM QUENNEVILLE i 160 OLD LYMAN'ROAD SOU 160 TH HADLEY, MA 01075-2632 i • ¢t has satisfied the qualifications required by taw and is hereby registered as a HOME IMPROVEMENT CONTRACTOR Registration # HIC.0575920 A II - I ADAM QUENNEVILLE ROOFING f. _ ► Effective: 12/0I/2020 itliz (; JEXP::1Qfl11/3O/2021 Michelle Seagull.Commissioner 1