35-051 (3) 960 RYAN RD COMMONWEALTH OF MASSACHUSETTS BP-2021-1750
Map:Block:Lot:35-051-001
Permit: Exterior Res CITY OF NORTHAMPTON
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
Permit# BP-2021-1750 PERMISSION IS HEREBY GRANTED TO:
Project# Contractor: License:
Est.Cost: $12899 070626
Const.Class: Exp.Date:08/21/2021
SADLOWSKI DOROTHY A&CHRISTINE A&
Use Group: Owner: KENNETH R DZIUBA
Lot Size(sq.ft.)
Zoning: WSP Applicant: ADAM QUENNEVILLE ROOFING & SIDING
Applicant Address Phone: Insurance:
1600LD LYMAN RD (413)536-5955
SOUTH HADLEY, MA 01075
ISSUED ON:08/19/2021
TO PERFORM THE FOLLOWING WORK:
STRIP&RESHINGLE
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.
Signature: I
! I .5.9 T1
Fees Paid: $40.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
Department use only
.-� tri-Ni'>• r City of Northampton Status of Permit:
l' Building Department Curb Cut/Driveway Permit
A. 212 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability
" ,' Northampton, MA 01060 Two Sets of Structural Plans
,' phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
ry
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:
960 2 Ftd Florence Ma 01062 Map 3,5 Lot t)S I Unit
Zone Overlay District
Elm St. District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Kenneth Dziuba 960 Ryan Rd Florence Ma 01062
Name(Print) Current Mailing Address: 413-586-4365
see contract
Telephone
Signature
2.2 Authorized Agent:
Adam Quennovilic 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 12,899.00 (a) Building Permit Fee
2. Electrical (b) Estimated I otal Cost of
Construction from (6)
3. Plumbing Building Permit Fee
140
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3+4 +5) 12,899.00 Check Number / O&C
This Section For Official Use Only
/--/7 cd Date
Building Permit Number: 6//��'a Issued:
Signature: 1 ,Ids', pli'v" X -�/ `- . VG/a)
Building Commissioner/Inspector of Buildings Date
operations.aqrs @ 9mail.com
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) n Roofing n
Or Doors ❑
Accessory Bldg. El Demolition ❑ New Signs [0] Decks [E] Siding 02] Other[El]
Brief Description of Proposed New roof, remvoe and replace existing roofing install new drip edge ridge vent and chimney to be rebuilt
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
Kenneth Dziuba
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 08/10/2021
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
08/10/2021
Signature of Owner/Agent Date
City of Northampton
sa
Massachusetts w� v'°
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street •Municipal Building
Nf Northampton, MA 01060 '1'v
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:
960 Ryan Rd Florence Ma 01062
(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)
l \
Signature of Permit Applicant or Owner at
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.
AVIOVAAVIAOW
CS VA IIEW48641161011111.11.IIE et
L./AWARDJ'�r�Y!
VISA. .. DISC vER
ewU
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: 413-2 0 7—412 5
Kenneth Dziuba 8/3/21
Street: Email:
960 Ryan Rd
City,State,Zip Code: Special Requirements:
Florence MA 01062 chimney to be rebuilt by All
PROPOSAL FOR: American Mason prior to roof install.
HOUSE GARAGE OTHER
STRIP RECOVER ultimate pipe boot with sleeve
}� included
-rs: t ]/ 2 3 4 Plywood Included: Yes or o
Tear off SLATE or SHAKES
COMPLETE ROOF PROTECTION SYSTEM:
P. We shall acquire appropriate permits for all work
)( Home exterior and landscaping to be protected
Z' Strip existing roofing to existing decking with full inspection DO NOT DO: shed
L� All project waste shall be removed by dumpster(dumpster for contractor use only)
y Install Ice&Water B. .er at all eaves 3' alleys,chimneys,pipes and skylights
• Install(151b.felt 41112taik underlayment over remaining decking area
R Install Metal drip edge at eaves and rakes 8"/5" vhi /brown)
`i, Install manufacturer's starter shingle on all eaves and rake edges
• Install new pipe boot f. :/vent accessories
Install ridge vent now • • • Cobra rolled/4'Baffled/Roll
Shingles:(standard 6 nails per shingle)
GAF Timberline HDZ Shingles Color: shakewood
GAF Ridge cap shingles
Warranty Options: 10
Y We guarantee our workmanship for full years
GAF System Plus Warranty
R. GAF Golden Pledge Warranty
Chimney Options:
Lead Counter Flashing ❑ Water Seal&Tuckpoint ❑ Rubberized Crown ,KI Cricket
❑ Mason needed(customer provided)
Additional material and labor charges may apply.
X Deteriorated existing decking will be replaced at$3.77 per sq.ft.and dimensional lumber at$7.00 per linear ft.,
after full inspection. Customer Initials:
We propose hereby to furnish materials and labor—complete in accordance with above specifications for the sum of: Total Due:($ 12899 )
ACCEPTANCE OF PROPOSAL:The above prices,specifications and conditions are Down Payment:($ 5399 )
satisfactory and are hereby accepted.You are authorized to do work as specified. 2nd Payment at Start Job:($ 7500 )
Payment will be 1/3 down at signing,1/3 at start of job,and balance due Balance Due Upon Completion:($ f inancefl
upon c pietion.
Date:V•3 # ,I Signature: •
Date: 8/3/21 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:_.
ACORD' CERTIFICATE OF LIABILITY INSURANCE CATE(MM/DOIYYYY)
�.+ 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(fes)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 CONTAt,T Sarah Premo
NAME;
Clayton Insurance Agency, Inc. PHONE (413)536-0804 FAX 413)53G-Te70
(A/C-Ne.Estl: tA/C,No)'
1649 Northampton Street E-MAIL ADDRESS' toninsurance.net
annREss spremo@claytoninsurance.net
O. Box 989 INSURERIS)AFFORDING COVERAGE NA IC 11
Holyoke mirk 01041-0989 INSURER A:Nautilus Insurance Company
INSURED
INSURER B:Arbella Insurance Co.
Adam Quenneville Roofing S Siding Inc. INSURERC:AIM Mutual Insurance Company
160 Old Lyman Road INSURER
South Hadley, MA 01075 INSURERE
I 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 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 RECUCED BY PAID CLAIMS
INSR A0nriSUeE— POLICY EFF POLICY FJ(P
LTR TYPE OF INSURANCE 'INSn MD POLICY NUMBER (MMIOD/YYYV) ,(MMIDO1VYVY) LIMITS
I X COMMERCIAL GENERAL LIABIUTY EACH OCCURRENCE 3 1,000,000
PREM)SESuE lES RENTED
odaman00t
AI CIP.7SP-0ADE X OCCUR _ 100,000
N141293315 6/23/2021 6/23/2C22 MED EX?(Any One Person) 3 5,000
PERSONA_S AOV INJURY s 1,000,000
GEN'L AGGREGATE L:MffA'PUES PER. GENERAL AGGREGATE s 2,000,000
X POL'iCY 4° T I hoc PRODUCTS-COMP/OP AGG 5 2,000,000
I (ZTHER
AUTOMOBILE LIABILITY COMa1NED SINGLE LIMIT 5 1,000,000
tEa acladert)
H I ANY AUTO BODILY INJURY;Per person) IS
ALL OWNED X SCHEDULED /020107095 6/23/2621 6,123/2022 BODILY INJURY P I
Per acodent b
AUTOS AUTOS I
X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE 5
AUTOS OW addidM
_ UNIN6f NDERINS MOTORISTS 5 100,000/300,000
X UMBRELLA LIAB I OCCUR EACH OCCURRENCE $ 5,000,000
—
A EXCESS LIAR CLAIMS-MADE AGGREGATE s 5,000.000
QED RETENTION a AN1242102 6/23/2021 6/23/2022 3
WORKERS COMPENSATION J X ?=R OTH-
AND EMPLOYERS'UABIUTY YIN STATUTE ER
ANY PROPRIETOR/PARTNER/EXECUTIVE E L EACH ACCIDENT 9 1,000,000
OFFICER/MEMBER EXC_UDE07 y 1 N/A
C (Mandatory in NH) AWC4007012861 4/29/2021 4/29/2022 EL DISEASE-EA EMP.OYEE S 1.000,000
If yes,descnbe u^der
DESCRIPTION OF OPERATIONS beow ' E.L.DISEASE-POUCY LIMIT S 1.000,000
I I I i I
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Addltlonal Remarks Schedule,may be attached If mom space is required}
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
Michael Reba_ l/ Grw/ 71..,,
I
9 1988-2014 ACORD CORPORATION. Alt rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
INS025(2014011
AThe Commonwealth of Massachusetts I Print Form 1
ems•-\
m 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 /� cPlease Print Legibly
Name(Business/Organization/Individual): A ce+r'1 (bien••w ii+ nn t W C 1 � 1''1,( t� )tc t►1 y lj i1 c
Address: (LO 0
City/State/Zip: sou T Iq 1 .o ("in Ot°lc Phone#: Li 13 —53(,_5 q55-
Are you an employer?Check the appropriate box: Type of project(required):
LK 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. I::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 8. ❑ Demolition
working for me in any capacity. employees and have workers' 9. ❑ Building addition
[No workers'comp.insurance comp. insurance.$
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. 1toof repairs
insurance required.]t c. 152,§1(4),and we have no
employees. [No workers' 13.0 Other
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.
`*Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. ^ _
Insurance Company Name: I'' l vet n5 u ic e`t C
Policy#or Self-ins. Lic.#: 0 i a V.I Expiration Date: Vacif a d
Job Site Address: -I(,p0 `Z..y Qn City/State/Zip: VI Os(CMC (1'14 0,U1.)
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 certi&under a airs and penalties of pedury that the information provided above is true and correct
`
Signature: Date: / 1QC1
C�
Phone#: ` ✓3L — 5955 J
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):
1. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
itt.ommonweattn or Massachusetts
Division of Professional Licensure
•
• • Board of Building Regulations and Standards
Const‘stuattbzY upervtsor
t
CS-070626 63pires:08/21/2023
ADAM A QUENNEV I:'
160 OLD LYMAN R.0;,.'1 4
SOUTH HADLEY 1
tfrl/S5=1`.10
Commissioner ; p t,' iFrnta.
P.-7->k WOMMO/italeald 0/g16doCtekaelto
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. Regis 191093
160 OLD LYMAN RD. Expi ration:ration: 03/22/22/2022
SO.HADLEY,MA 01075
Update Address and Return Card.
SCA I 65 20M-05/17
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d� �,,r_ ♦ I . ,M a 4� 8 +ti,1• �I" +,,Ar 1,r�_ _'1.4 . �.�"_ `:C_ '�` -'.':�}•'iA" -"�i` `+�'_,.. �l1"r.�'SA`' '1
STATE OF CONNECTICUT + DEPARTMENT OF' CONSUMER PROTECTION j E
Be it known that
i .:
;
w ADAM QUENNEVILLE r
I ' wr
160 OLD LYMAN ROAD
SOUTH HADLEY, MA 01075-2632
$ ' ,!:"...
has satisfied the qualifications required by law and is hereby registered as a i
HOME IMPROVEMENT CONTRACTOR ' .z
Registration # HIC.0575920
ADAM QUENNEVILLE ROOFING I :i.7f
`,,.. 01 Effective: 12/01/2020 1 T
Expiration: 11/30/2021 iidA. .42.741, flis
k; ^ ..
-, fil
Michelle Seagull,Commissioner z,
'IJ ill'"IIV��'' � l '!' J1F ; tip 1 t j IQ ��I•
,
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