Loading...
29-438 (2) 59 ELLINGTON RD BP-2021-1190 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:29-438 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: Siding BUILDING PERMIT Permit# BP-2021-1190 Project# JS-2021-001993 Est.Cost: $14665.00 • Fee: $60.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: ADAM QUENNEVILLE 070626 Lot Size(sq. ft.): 10018.80 Owner: THIEME CHARLES& MARIE ROGERS Zoning: Applicant: ADAM QUENNEVILLE AT: 59 ELLINGTON RD Applicant Address: Phone: Insurance: 160 OLD LYMAN RD (413) 536-5955 () Workers Compensation SOUTH HADLEYMA01075 ISSUED ON:4/16/2021 0:00:00 TO PERFORM THE FOLLOWING WORK:NEW 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. I ! •z 3-11 •I Certificate of Occupancy Signatu FeeType: Date Paid: Amount: Building 4/16/2021 0:00:00 $60.00 212 Main Street, Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner Department use only ��, r_Ts/,Y� City of Northampton fG N. Status of Permit: f - h,�., �------ Building Department ��i. { Curb Cut/Driveway Permit > Al '4t 212 Main Street 4,p� :Suer/Septic Availability � - Room 100 3 Water/Well Availability , 4- Northampton, MA 01-0 -tic; Two Sets of Structural Plans ' phone 413-587-1240 Fax 4( 5, -1272 Plot/Site Plans `..,Other Specify ,-ri( S 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: 59 Ellington Rd Florence Ma 01062 Map ,0 Lot 1-1� 9 Unit Zone Overlay District Elm St. District_ CB District SECTION 2 -PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Charles & Marie Thieme 59 Ellington Rd Florence Ma 01062 Name(Print) Current Mailing Address: 413-584-7342 see contract Telephone Signature 2.2 Authorized Agent: Aaam Quenneville 160 Old LymanRd South Hadley Ma 01075 Name(Priittv, Current Mailing Address: 413-536-5955 Signat e Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building 14,665.00 (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 0O 5. Fire Protection 6. Total = (1 +2 + 3 +4 + 5) 14,665.00 Check Number ` L lJ U This Section For Official Use Only `y ' Building Permit Number: 07/-.` 4 Date Issued: Signature: �/il - 1141 ZQZI Building Commissioner/Inspector of Buildings Date operations.aqrs @ gmail.com EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) Section 4. ZONING AU 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 be 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? YE5 NO 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? YE disturb NO x 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 n Or Doors E Accessory Bldg. ❑ Demolition ❑ New Signs [El] Decks [[] Siding p] Other[D] Brief Description of Proposed New siding on house, remove and replce exisiting siding, install insulation board, wrap windows&doors coil 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 Glades I, , 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 04/09/2021 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 .I " 04/09/2021 Signatur of Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable 0 Name of License Holder: Adam Quennvi►le CS-070626 License Number 160 Old Lyman Rd South Hadley Ma 01075 8/21/2021 Addre Expiration Date 413-536-5955 Signature Telephone 9. Registered Home Improvement Contractor: Not Applicable 0 Adam Quenneville Roofing&Siding Inc 191093 Company Name Registration Number 160 Old Lyman Rd South Hadley Ma 01075 3/22/2022 Addr s 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 v.,tit rv-r4� $, r` Massachusetts f. , ..,, , ,, y` DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street *Municipal Building -4 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: 18 Mulberry St Leeds Ma 01053 (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) )t,- 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. ALL UIbLUUINTTb AeeL1t:U ADAA. /t * X� QUENNEoOriNVILLE AWARD VISAS MSC VER 160 Old Lyman Road•South Hadley•MA 01075 We are Licensed 1.800.NEW.ROOF • 413.536.5955 Fully Insured Email:info@i800newroof.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: MARIE & CHARLES 4/6/21 H: 413-584-7342 W: Street: Email: 59 ELLINGTON RD CHARLESTHIEME860@YAHOO.COM City,State,Zip Code: FLORENCE MA 01062 Proposal to furnish and install the following: 1) OBTAIN ALL PERMITS NEEDED TO DO PROJECT 2) PROVIDE DUMPSTER ON PROPERTY TO DISPOSE OF ALL DEBRIS 3) REMOVE EXISTING SIDING FROM HOME AND DISPOSE OF IN DUMPSTER 4) INSTALL WIND WRAP VAPOR BARRIER AND 3/8 FOAM INSULATION BOARDS ON HOME 5) REPLACE ALL DAMAGED WOOD AROUND WINDOWS,DOORS,AND OVERHANGS NEEDED TO DO COMPLETE PROJECT 6) WRAP ALL FACIA, WINDOW AND DOOR CASINGS WITH PVC ALUMINUM COIL USING ARCHITECTURAL BENDS WITH BUILT IN J CHANNEL COLOR ( SANDLEWOOD) 7) INSTALL VINYL SOFFIT ON ALL OVERHANGS AND VENT WHERE NEEDED COLOR( SANDLEWOOD 8) INSTALL VIRGIN VINYL SIDING OVER INSULATION ON HOME CLAPBOARD/DUTCH LAP TIER KAYCAN WIDTH 4 INCH COLOR AZURE BLUE CORNER POST COLOR SAME AS SIDING 9) INSTALL VINYL LIGHT,SPLIT,RECESS BLOCKS, DRYER VENTS AND LOUVRES ALL SAME COLOR AS VINYL SIDING COLOR( SAME AS SIDI)NG ALL ROTTED OR DETERIORATED WOOD UNDERNEATH EXISTING SIDING WILL BE REPLACED AT '..$.120 PER SHEET (4X8 PLYWOOD TO CODE) PRICE INCLUDES ALL MATERIALS, LABOR, DISPOSAL OF DEBRIS DO NOT DO BACK PORCH SPECIAL REQUIREMENTS: IF POSSIBLE DO NOT REMOVE AWNING IN BACK, IF REMOVED, REINSTALL 5 PAIR OF LOUVRED SHUTTERS CRANBERRY 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:($ 1 4, 665 ) ACCEPTANCE OF PROPOSAL:The above prices,specifications and conditions are Down Payment:($ 1, 6 65 ) 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 balance due Balance Due Upon Completion:($ FINANCEip uponc4/6/ Date: Signature:/6/omplet1 21 Signature: 4/6/21 DAVE AREL Date: Estimator:(Print Name) (Sign Name) y 1 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. I II I..r1I I... yr LIt'\OIL1 I T IfVJUKAN(.;C I 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 (413)534-7874 (A/C,No.EMI: (ANC,No): 1649 Northampton Street E-MAIL spremo@claytoninsurance.net ADDRESS: P.O.Box 989 INSURER(S)AFFORDING COVERAGE NAIC 0 Holyoke MA 01041-0989 INsURERA: 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: C12062304009 REVISION NUMBER: THIS IS TO CERTIFY THATTHE POUCIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POUCY 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 TYPE OF INSURANCE ADDL SUER POLICY EFF POUCY EXP LIMITSLTRINSR WVD POLICY NUMBER (MM/DD/YYYY) (MMIDDIYYYY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTW .I CLAIMS-MADE I XI OCCUR PREMISES(Ea occurrence) $ 100,000 MED EXP(Any one person) $ 5,000 A NN1143748 06/23/2020 06/23/2021 PERSONAL BADVINJURY $ 1,000,000 GEN'LAGGREGATE LIMITAPPLIES PER: GENERALAGGREGATE S 2,000,000 POLICY Xl JET _ LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT s 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) S AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) $ X UMBRELLA UAB OCCUR EACH OCCURRENCE $ 5,000,000 A EXCESS UAB CLAIMS MADE AN088790 06/23/2020 06/23/2021 AGGREGATE $ 5,00,000 DED REI ENTGON$ PER $ WORKERS COMPENSATION oTH- ER AND EMPLOYERS'LIABILITY Y/N STATUTE C ANY PROPRIETOR/PARTNER/EXECUTIVE Y N!A AWC4007012861 04/29/2020 04/29/2021 EL EACH ACCIDENT $ 1,000,000 - OFFICER/MEMBER EXCLUDED? (Mandatory in NH) EL DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below EL DISEASE-POUCY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS!VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached it 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 !'2Z, P' ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Tire Commonwealth of!vfassacfausetfs *— — +, Department of dnriztsfrial Accidents { 1 Congress Street,Suite 100 __ I; d Boston,16 1021112017 - ' xvzvty tnass.eou/dia no Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Numbers. TO BE FILED WITH IHh.FERMI TTLt G AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/lndividual): Adam Quenneville Roofing & Siding Inc Address: 160 Ofd 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): I.Mif am a employer with 15 employees(full and/or Bart tbneJ_* 7. 0 New construction 2.0 I am a sole proprietor or partnership and haven employees working forme in 8. EI Remodeling any capacity,[No v<orkes'camp.insurance required.] 3.Q lam a homeowner doing all work myself[No workers'comp.insurance required.]t 9. 0 Demolition IC)Q Building addition a_0 I am a homeowner and will behiring contractors td conduct elf work an my property. t wilt . ensure that all contractors either have workers'compensation irsurarce or are sole 1I.0 Electrical repairs or additions proprietors with no employe-. 12.0 Plaacing repairs or additions 5.0 I our a general contractor and I have hired the sub-contractors listed ore the attached sheet I3.0 Roof r atrs These sub-contractors have employees and have workers'comp.inswance.t 14.15 6.1 1 We area corporation and its officers bane exercised their right of exemption per fvfGL e_ Other 1 4 I'1 Q 152,i I(a),and we have no employees.[Na workers'camp.insurance required] *Any applicant that checks box 41 must also fill out the section below showing(heir 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'camp.policy number I arcs an employer that is providing workers'cotnpetzsation insurance for my employees. Below is the policy and fob site iiz-fonnetloir. Insurance Company Name: AIM Mutual Policy#orsett-ins.Lic.#:- AWC4007G128612019A Expiration Date: /1 6� v a fob Site Address: I ell I r* ,( Ir 1-0- 0.--� City/State/Zip: Tic, " (hp �(r�(- ) Attach a copy of the workers'coillpensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c.152,§25A is a criminal violationpunishable by a fine up to 51,500.00 andf 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. I do hereby certify under the pains yipetwities of perjury that the inforrnationprovided above is trice and correct Signa[ure: / Date: y///yd0 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#: ��.. .•v.a .. , ¶UO?30411LIJCttS r Division of Professional Licensure ' Board of Building Regulations and Standards ConstrkiCtf ritti 'rvlsor CS-070626 ;:,. :.;: Expires:08121/2021 ADAM A QUENNEY:a.., ';,; 160 OLD LYMAN R iit SOUTH HADLEY MA' 4r 4777 /, (4y,i.ii'j1 Commissioner it/.r..,4 /41*" C=�9 € WOwi`JnG"V''/Gwe(.!r'V(/7I1 Pili�l.G4iGiae!/4azett Office of Consumer Affairs and Business Regulation 1000 Washington Street- Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Corporation ADAM QUENNEVILLE ROOFING AND SIDING,INC. Registration: 1 093 Exxp 03 piration: 03l22/22l2022 160 OLD LYMAN RD. SO.HADLEY,MA 01075 Update Address and Return Card. sca a A 2OM sii7 el; ' 15:'\ ..;`A /: ..\/ r,✓•,±:•i+.:•. rf :7;•.<;A,/ 7 .t:;. V✓.. `~.r'., 1/r`'"�,I'`%'`?1. '7:'''/"_7:*/ :4,• 77 -- a. I` i w a�i ar.Y * w�b' w I�_ at AraMiY_ a�Ic�w f• ♦ ,V__.�.•�f• _ .`� 4 STATE OF CONNECTICUT + DEPAR TMENT ARTMENT OF CONSUMER PROTECTION Be it known that I. i. . ADAM QUENNEVII-LE . i I 160 OLD LY .t 'ROAD i SOUTH HADLEY, A .A.. 01075-2632 3 (' , . # I '.�. • has satisfied the qualifications requited by taw and is hereby registered as a r HOME IMPROVEMENT CONTRACTOR I f i / Registration # HIC.0575920 1I L s' ARAM QIIENNEVILLE ROOFING 1 1 Effective: 12/01/2020Lid I • • 11 ! Pb0fl/3O/2O21 : ' .441# 1 1 11 Michelle Seagull,Commissioner 1