23A-165 (9) 71 PINE ST BP-2022-0088
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:23A- 165 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-2022-0088
Project# JS-2022-000156
Est.Cost: $3599.00
Fee:$40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: ADAM QUENNEVILLE 070626
Lot Size(sq.ft.): 26702.28 Owner: VILLIERS JILL DE
Zoning: URB(100)/ Applicant: ADAM QUENNEVILLE
AT: 71 PINE ST
Applicant Address: Phone: Insurance:
160 OLD LYMAN RD (413) 536-5955 () Workers
Compensation
SOUTH HADLEYMA01075 ISSUED ON:7/23/20210:00:00
TO PERFORM THE FOLLOWING WORK:NEW FLAT ROOF ON BACK REAR
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.
),• yg . TA
Certificate of Occupancy Signatu(•:
FeeType: Date Paid: Amount:
Building 7/23/2021 0:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
/ Department use only
. 4. City of Northampton 49)<(`• Status of Permit:
`74.!, Building Department' . Curb Cut/Driveway Permit
212 Main, tree ` � j�tj' ewer/Septic Availability
:,,,
MainoorK 1070 tr �� /Well Availability
°: '` Northampton,,\ ,n 60 v' tee of Structural Plans
; .";-, phone 413-587-1240 Faux 4 �/ 7-12727-/ P t/Site Tans
�17,6�'ti they pecify
In n�
1p
APPLICATION TO CONSTRUCT,ALTER, REPAIR, R R DE OLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: This section to be completed by office
71 Pine St Florence Ma 01062 Map a Lot i(,/ --- Unit
Zone Overlay District
Elm St. District CB District
SECTION 2 -PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Jill De Villiers 71 Pine St Florence Ma 01062
Name(Print) Current Mailing Address: 413-386-7725
see contract
Telephone
Signature
2.2 Authorized Agent:
Adam Quenneviile 160 Old LymanRd South Hadley Ma 01075
Name(X..", 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 3,599.00 (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC) #14t/
5. Fire Protection
6. Total = (1 + 2 + 3 +4 + 5) 3,599.00 Check Number iO /6I
This Section For Official Use Only
�;� g Date
Building Permit Number: '✓ Issued:
Signature:Sig //.,4Z 7- Z3-ZdzI
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 be 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 DON'T KNOW be 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? YE$ NO X
IF YES, describe size, type and location:
E. Will the construction activity disturb cl aring,gradin excavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YE 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) n Roofing L d
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs JI] Decks [❑ Siding [El] Other[Ell
Brief Description of Proposed New flat roof on back rear level corner, remove and replace roofing, install insulation board and drip edge
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
Jill De Villiers
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 07/20/2021
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
X__
07/20/2021
Signature of Owner/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
Addres 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
Addres 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 tc'�
trS 1_ * Ti
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street •Municipal Building
Northampton, MA 01060 '
"1�
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:
71 Pine 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)
\)-t
Signature of Permit Applicant or Owner Da e
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.
ie a it
t3UE U4SV*LLM w* a ...,AWAa0 C a O IA C> 1//siA "i "SCPYER wielliirW1ll
rx 0 J r i Ni S 1 I
160 Old Lyman Road•South Hadley•MA 01075 We are Licensed
1.800.NEW.ROOF • 413.536.5955 Fully Insured
Email:infoie1800newroof.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&l rode Association P.P C 38710
Proposal Submitted To: Date Phone#'s: C: 'if),3'• 376' I72.
, 11( & pE Jt11/e(S '/4(�(/.21 H: W:
Street: Email:
'?1 PrtV S k Iorepce Ji)k.V'LL. I e Sml-(k , EO1)
City,State,Zip Code:
/Ic c51( b
Proposal to furnish and install the following:
location of fiat roof if applicable AA +! t` ,( ('Orjt,er-
we will pull all appropriate permits for work.
we will. remove all roofing material down to decking and dispose o' /no
we will go over existing roof yes
we will install fiber board over entir oof yes tiei
we will .install ISO insulation board 1 no t inches
c.y :
we will install rubber membrane entire oof.
we will install whi /brown C6 drip edge around perimeter of roof.
we will install r strip over all drip edge.
we will turnbar rubber up all walls and chimne s.
we will counter flash chimney with lead yes n'
we wi.l..l tie rubber up under shingles yes 1't shingle color
we will install new rubber boots around pares.
0 year AQRS labor, material and workmanship warranty.
all rotted or deteriorated decking will be replaced
at_ $3.77/sq ft
special requierements: 5O '/'
W 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 Que`nevijle Roofing will not be responsible for debris or dust in the attic or storage areas.
Customer Initials: X
ff '
We propose hereby to furnish materials and labor-.complete in accordance with above specifications for the sum of: Total Due:($3)5-j�y1 )
ACCEPTANCE OF PROPOSAL:The above prices,specifications and conditions are Down Payment:($ � t;'r )
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 lob,and balance due Balance Due Upon Completion:($� 39 7 I
upon completion. , '
Date: fL/t 30. Signa gr Ifture: V (tt w/ A
Dater"1t�tra/Od( Estimator:(PrMtName) aPt.t� ej}01,y1ll1 (Sign Name), �'"-�-..�,,,__
Estimates are honored for sixty f60)days from above date. .i-"'
,0 w
ACC,RE) CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDlYYYY)
6/24/2021
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT. If the certificate holder is an ADDITIONAL INSURED,the policy(Ies)must be endorsed. If SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER CONTACT Sarah ?rem
NAME;
Clayton Insurance Agency, Inc. PHONE (413)536-0804 SAX 413)53i-7a7C
(NC.No.EMI: (NC,Nor
1649 Northampton Street E-MAIL ADDREss:spremo@claytoninsurance.net
P. O. Box 989 INSURERISI AFFORDING COVERAGE NAIC 6
Holyoke MA 01041-0989 INSURER A:Nautilus Insurance Company
INSURED
INSURER 8:Az/Della Insurance Co.
Adam Quenneville Roofing & Siding Inc. INSURER C:AIM Mutual Insurance Company
160 Old Lyman Road INSURERD:
South Hadley, MA 01075 INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER:2021 MASTER REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES 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 8E 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 Ai S
UM- POLICY EFF POLICY EXP
LTR Mtn POLICY NUMBER IMMmoonvr j JIRMIDONYYYI LIMITS
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
DAMAGE TO RENTED
A CLAIMS-MADE I X OCCUR Ramses iEasccw'a+cel a 100,000
NH129331.5 5/23/2021 6/23/2022 MED EXP(Any one person) S 5,000
IIIPERSONA L.4ADVINJURY S 1,000,000
GEN1,AGGREGATE LMIT APPLIES PER; GENERAL AGGREGATE L 2,000,000
X POLICY J£CT I I LOC PRODUCTS-COMP/OP AGG S 2,000,000
OTHER S
AUTOMOBILE LIABILITYCOMBIN
i SINGLE(}MIT 3 1,000,000
Ms laANY AUTO BODILY INJURY(Per person) S
IIALL OWNEC SCHEDULED
AUTGS x AUTOS 1020107093 6/23/2021 6/23/2022 BODILY INJURY(Per accident) 3
ig HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $
AUTOS (Per 7cOMPX1
'• IJNINS/LNDERINS MOTORISTS $ 100,000/300,000
UMBRELLA LIAB �r OCCUR • EACH OCCURRENCE $ 5,000,000
A EXCESS LIAR CLAIMS-MADE AGGREGATE S 5,000.000
DED RETENTION a" AN1242102 6/23/2021 6/23/2022 S
WORKERS COMPENSATION 1?ER OTH-
AND EMPLOYERS'LIABILITY YIN X j Sl A(L fE ER
ANY PROPRIETOR/PARTNER/EXECUTIVE E L EACH ACCIDENT S 1,000,000
OFFICERIMEMOER EXCLUDED? Y N IA
C (Mandatory in NH) ARC4007012661 4/29/2021 4/29/2022 E L.DISEASE-EA EMPLOYEE $ 1,000,000
If yes.describe under
DESCRIPTION OF OPERATIONS beow E L DISEASE-POLICY LIMIT 3 1,000,000
DESCRIPTION OF OPERATIONS f LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached It mom space la moulted)
For Informational Purposes Only
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Adam Quenneville Roofing & Siding Inc THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
160 Old Lyman Rd ACCORDANCE WITH THE POLICY PROVISIONS.
South Hadley, MA 01075
AUTHORIZED REPRESENTATIVE
M1:h3e1 Regal/I/NT /y �.r P Yam,,
1
@'J 1988.2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
INS025 I2a14a1)
The Commonwealth of Massachusetts Print Form
Department of Industrial Accidents
—"" Office of Investigations
»„�., 600 Washington Street
---�/ Boston, MA 02111
a www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information / i/� Please Print Legibly
Name(Business/Organization/Individual): A ck r'\ �1 ven )t��C- (Loot i'16 'tf, 71di r f el C
Address: 1 GO ®1 v L L
City/State/Zip: 5001,\ 14 lc6 (11 01 C15.-- Phone#: L(l 3 -rJ3�-`5 955—
Are you an employer?Check the appropriate box: Type of project(required):
1.81 I am a employer with 15 4. ❑ I am a general contractor and I
employees(full and/or part-time).* have hired the sub contractors 6. El New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g. ❑ Demolition
working for me in any capacity. employees and have workers'
[No workers' comp. insurance comp. insurance.$ 9. ❑ Building addition
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers'comp. right of exemption per MGL 12, Roof repairs
insurance required.]t c. 152,§1(4),and we have no 13.Q Other
employees. [No workers'
comp. insurance required.]
*Any applicant that checks box#1 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.
l'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.
l am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. Q _
Insurance Company Name: �l v Vim, 115 0 ic- C'
Policy#or Self-ins.Lic.#: A w C 4-fOo1 0 i ( Expiration Date: 10919
!
Job Site Address: —1 k t"� 5-4 City/State/Zip:PC(Ct1(C M10 0lC L 3-
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify un the pains and penalties of pesjury that the information provided above is true and correct
Signature: Date: -3/)0 a
Phone#: ` 5 3L — :J 9 5 7
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
IF- Division of Professional Licensure
Board of Building Regulations and Standards
ConstrutAALtOpervisor
CS-070626 ', Expires' 08/21/2021
it ,,,
ADAM A QUENNEV' .: 7
180 OLD LYMAN R t 1- .--- ,
SOUTH HADLEY MA' ' --:'
•-
./, ,\ } •
i —
k e itsi, I WI.'
Commissioner AJA,..4.4_41/4"4-•"•1"-----
P7i,e Wo4n4(nvl1ve,aid oPilf,a4/saeitz4p.A
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 tli 2014.4.05i 17
tk
4 41
. .*,...;:..,.i.,p..",.;.,:•g:i'n;,..;.4?,1.,..::''4iir:1:::....s-e:::411,..0':.41,::;1''l;. ..;:::141:'141.1' :.7 '':.'");!;S:-. .''';'4:: .::;:;':;.4%,..t.1:::::441;;.4 ''' 44;41;:St:''‘..i? :Civ. :
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. iP......1. t _4'1P__Ik.A.P... _Ibtlik' .A.,_ .1.A.,_ .1_1Lfr_ _41....A_v___ .':: 'Ibi..4.P.' 41-.‘'.. tr.414. .' _111fr-._?" Ail'i lli.fr.: ''_41iii`' ''..-;:•2'.4'44 i , _
ik t STATE OF CONNECTICUT + DEPARTMENT OF CONSUL MR PROTECTION
. „
Be it known that
.`,. Ill
/ i ADAM QUENNEVILLE
.11 11 160 OLD LYMAN ROAD
SOUTH HADLEY, MA 01075-2632
1
(,-,
,• iml
'if
; • •:.:;
....:....:ii has satisfied the qualifications required by law and is hereby registered as a
... ,
HOME IMPROVEMENT CONTRACTOR ...i...
.t:
,... -
gt.'91 1 A Registration # HIC.0575920
(14 i 1 .•• '.::':' ,
ADAM QUENNEVILLE ROOFING
li.,si I c
gig ,J1i 'Zj.
Effective: 12/01/2020
?,-:.2 fi, Expiration: II/30/2021
.A -
Michelle Seagull,Commissioner...,,,.
. ‘r.... .*I **Il
*416Looilaer**XL-•;AO '''lb