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32C-074 (4) 15 MAPLE AVE COMMONWEALTH OF MASSACHUSETTS BP-2021-1955 Map:Block:Lot:32C-074- 001 CITY OF NORTHAMPTON Permit: Exterior Res PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit# BP-2021-1955 PERMISSIONIS HEREBY GRANTED TO: Project# SIDING Contractor: License: ADAM QUENNEVILLE ROOFING & Est. Cost: 43498 SIDING 070626 Const.Class: Exp.Date:08/21/2023 Use Group: Owner: GANDARA MENTAL HEALTH CTR INC Lot Size (sq.ft.) Zoning: URC Applicant: ADAM QUENNEVILLE ROOFING & SIDING Applicant Address Phone: Insurance: 160 OLD LYMAN RD (413)536-5955 AWC4007012861 SOUTH HADLEY, MA 01075 ISSUED ON:09/28/2021 TO PERFORM THE FOLLOWING WORK: 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. Signature: ' (� wX 1 10 Fees Paid: $280.00 2l2Main Street, Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner Versionl.7 Commercial Building Permit May 15,2000 Department use only \ City of Northampton Status of Permit: /jam Building Department Curb Cut/Driveway Permit 1/ 4.) 212 Main Street Sewer/Septic Availability sep oom 100 Water/Well Availability fin? ►4 orthdmpton, MA 01060 Two Sets of Structural Plans _ °^fir eve phone . 13-587-1240 Fax 413-587-1272 Plot/Site Plans yA�tir'in Other Specify fin, lc� APPLICATIO RUGT, REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING / OTHER THAN A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION This section to be completed by office 1.1 Property Address: 15-17 Maple Ave Northampton Ma 01060 Map 3,4 C Lot Of7 Unit Zone Overlay District Elm St. District CB District SECTION 2 -PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Joe Martins 15-17 Maple Ave Northampton Ma Name(Print) Current Mailing Address: 413-214-5442 Signature See contract Telephone 2.2 Authorized Agent: Adam Quenneville Roofing & Siding 160 Old Lyman Rd South Hadley Ma 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 4'1 498 (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) Check Number I Ott al This Section For Official Use Only Building Permit Number Date a/ji 16/C. Issued Signature: //72 Building Commissioner/Inspector of Buildings 1 Date Versionl.7 Commercial Building Permit May 15,2000 SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 CUBIC FEET OF ENCLOSED SPACE Interior Alterations El Existing Wall Signs ❑ Demolition Repairs Additions El Accessory Building Exterior Alteration ❑ Existing Ground Sign El New Signs❑ Roofing❑ Change of Use❑ Other Brief Description New siding,we will go over existing siding,install 3/8 fanfold insuation board,bent metal wrap on all doors,windows and fascia,vinyl soffit, then new vinyl clapblard siding. Of Proposed Work: SECTION 5-USE GROUP AND CONSTRUCTION TYPE USE GROUP (Check as applicable) CONSTRUCTION TYPE A Assembly El A-1 El A-2 El A-3 El1A I El A-4 El A-5 El 1 B El B Business El 2A El E Educational El 2B F Factory El F-1 El F-2 El 2C El H High Hazard El 3A El 1 Institutional El 1-1 El 1-2 El 1-3 El 3B El M Mercantile El 4 El R Residential El R-1 El R-2 El R-3 El 5A El S Storage El S-1 ❑ S-2 El 5B I El • Utility El Specify: l M Mixed Use El Specify: S Special Use El Specify: COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND/OR CHANGE IN USE Existing Use Group: Proposed Use Group: Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34): SECTION 6 BUILDING HEIGHT AND AREA BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY Floor Area per Floor(sf) 1 1st Q _ _ __ 0 0 3 d ._ . .. _. �._ __. 0 3rdµ W 0 4th 0 4th 0 Total Area (sf) Total Proposed New Construction (sf) _.. Total Height(ft) 1 0 m Total Height ft I 0 7. Water Supply(M.G.L. c.40, § 54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System: Public ❑ Private 0 Zone Outside Flood Zonal] Municipal ❑ On site disposal system❑ Versionl.7 Commercial Building Permit May 15,2000 8. NORTHAMPTON ZONING 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 0/0 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 YE1-1 IF YES: enter Book Page and/or Document # B. Does the site contain a brook, body of water or wetlands? NO DON'T 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 ? YE5 NO IF YES, describe size, type and location: E. Will the construction activity disturb clearin ,gradin excavation, or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. Versionl.7 Commercial Building Permit May 15,2000 SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES-FOR BUILDINGS AND STRUCTURES SUBJECT TO CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116 (CONTAINING MORE THAN 35,000 C.F. OF ENCLOSED SPACE) 9.1 Registered Architect: Not Applicable Name(Registrant): Registration Number Address Expiration Date Signature Telephone 9.2 Registered Professional Engineer(s): Name Area of Responsibility Address Registration Number { Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date 9.3 General Contractor Not Applicable Company Name: Responsible In Charge of Construction Address Signature Telephone Versionl.7 Commercial Building Permit May 15,2000 SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11) Independent Structural Engineering Structural Peer Review Required Yes n No SECTION 11 -OWNER AUTHORIZATION -TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I Joe Martins , as Owner of the subject property hereby authorize Adam Quenneville to act on my behalf, in all matters relative to work authorized by this building permit application. See contract 09/22/2021 Signature of Owner Date 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 pal s and penalties of perjury. .& ILO t LI Print Name 09/22/2021 Signature f Owner/Agent Date SECTION 12-CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: Adam Quenneville CS 070626 License Number 160 Old Lyman Rd South Hadley Ma 08/21/2023 Address Expiration Date ti� 413-536-5955 Signature Telephone SECTION 13-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 1-1 No n City of Northampton 212 Main Street, Northampton, MA 01060 Solid Waste 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. Address of the work: 15- 17 Maple Ave Northampton Ma The debris will be transported by: Adam Quenneville Roofing&Siding The debris will be received by: Adam Quenneville Roofing &Siding Building permit number: Name of Permit Applicant Adam Quenneville Roofing &Siding 09/22/2021 Av Date Signature of Permit Applicant ADAM `'°` QURNNEV LLE AWARD wsecvea R O O F f N G S I D I N G 2010 W,NNEN 'VISA �s�z 160O1d Lyman Road•South Hadley•MA 01075 We are Licensed 1.800iNEW.ROfj1F • 413.536.5955 Fully Insured Email:Info@1800newroof.net Website:www.1800newroof.net Factory Trained MA Construction Supervisors Llc.11070626 MA Registration#120982 Factory Certified Installers Member of the Home Builder's Assoc.of Western Mass. CT Registration#575920 Memberof the Building&Trade Association P.P.0 38710 Proposal Submitted To: Date: Phone#'s: C: Gandara Center 9/9/2021 H: W: Street: Email: 15-17 Maple Ave City,State,Zip Code: Northampton, MA 01060 Proposal to furnish and install the following: We will pull all appropriate permits associated with the following siding installation We will remove exising siding and dispose of/Go-over Existing We will install House Wrap/3/8"fanfold insulation board We will Install custom bent metal wrap on all windows,door,fascia,Smooth/Pvc coated aluminum Coil stock color; White We will install vinyl soffitt on all overhangs vented soffit as required&solid where not required Soffit color; White We will install new vinyl siding system manufactured by; Kaycan Siding style;Clapboard/Dutchlap/Shakes Siding tier; Timberlake 1! '/7� Siding width; D4 3C1 I 19 3 Siding color; Standard colors Corner color; White Light block color; White Splitblocks,j-blocks,&dryer vent hood color; White J-channel around windows,doors,rooflines,color; White We will remove and install Pairs of shutters color; Style;Louvered/Raised panel We will install gable vents Color; Any deteriorated we L ea thing will be replace .99 Sq Ft Customer initials: Ask us about Optional Gutters add- 3,499.00 J affordable bank financing! ATTENTION HOME• t5:Please cover all personal belongings in the attic,garage or storage areas due to the possibility of roofi @-debris .r dust coming In through cracks of the wood.Please remove any lawn ornaments or yard furniture.Adam ra uenneyill: Roofing will not be responsible for debris or dust In the attic or storage areas. Customer Initial We propose hereby to furnish materials and labor—complete in accordance with above specifications for the sum of: Total Due:(S 39,999.00 ) ACCEPTANCE OF PROPOSAL:The above prices,specifications and conditions are Down Payment:($ 13,333.00 ) satisfactory and are hereby accepted.You are authorized to do work as specified. 2"d Payment at Start Job:($ 13,333.00 ) Payment will be 1/3 down at signing,1/3 atTfstart of ob,and balance due Balance Due Upon Completion:($ 13,333.00 ) upoe com-1 Date: . t i 1 , Date: Ca( Signature: Date: 9/9/2021 Estimator: rint Name)S. MInK!eV (Sign Name)5 µP../t-%�6iyr Estimates are honored for sixty(60)days from above date. . NOTICE OFSCHEDULEJCHANGES The contractor agrees khat 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, NC 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 fall 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 falling 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 aillability Insurance policy with minimum coverage limits of one million dollars($1,000,000.00) CONSTRUCTION RELAYED 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 OFAGREEMENTTO BE GIVEN TO OWNER The Lawsof 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 Quennevllle Roofing&Siding Inc.If we cancel,we will promptly return any down payment(s)you have made. R/°"r!C� DATE� DA (MM/DDIYYYY) `..C... CERTIFICATE OF LIABILITY INSURANCE 6 MMXID 21 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 Premo NAME; Clayton Insurance Agency, Inc. PHONE (413)536-0804 FAX a1J)sJa--e,o (NC No.BAN. LA C,Noi: _ 1649 Northampton Street E-MAIL spremo@clay toninsurance-net AGGRESS: P. O. Box 989 INSURER(S)AFFORDING COVERAGE NAIC C Holyoke MA. 01041-0989 INSURER A:Nautilus Insurance Company INSURED INSURER B:Arbella Insurance Co. Adam Quenneville Roofing & Siding Inc. INSURER C AIM Mutual Insurance Company 160 Old Lyman Road INSURER D South Hadley, MA 01075 INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER:2021 basnR 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 REDUCED BY PAID CLAIMS INSR J (POOL!SUBS' POLICY EFF POLICY EXP LIR TYPE OF INSURANCE !CUM Wvn POLICY NUMBER (MMIOO/YYYY) 1MMIDDIVYVY) LIMITS I X COMMERCIAL GENERAL UABIUTY EACH OCCURRENCE 3 1,000,000 A I CLAIMS-MADE f X l OCCUR PREMISES llEa 1csrarancal _DAMAE TO RENTED 100,000 y NN12933:5 6/23/2021 6/23/2022 MED ECP CAny ono person) 6 5,000 PERSONAL,4 A0V INJURY 3 1,000,000 GEN'L AGGREGATE Limo-APPLIESPER: GENERALAGGREGATE S 2,000,000 X :POLICY PRO. LOC PRODUCTS-COMP/OP AGG 3 2,000,0001 I OThER: 3 AUTOMOBILE UABIUTY + BIN NGLE LIMIT 3 1,000,000 (Ea amdfirt, B ANY AUTO BODILY INJURY,Per person) It ALL OWNED X SCHEDULED /020107993 6/23/2021 6123/2022 BODILY INJURY(Per accident S �. AUTOS ,AUTOS ) X HIRED; AUTOS X AUTOS NED PROPERTY DAMAGE S -, ,_,_AUTOS iPa s (19 _ UNINS/UNCERINSMOTCRISTS S 100,000/300,000 w X .UMBRELLA UAB OCCUR EACH OCCURRENCE 3 3,000,000 A EXCESS LIAR �,CLAIMS-MADE AGGREGATE $ 5,000,000 _DEO I RETENTIONS AN1242102 6/23/2021 6/23/2022 $ WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITY Y1 N STAlSTE _ ER - ANY PROPRIETOR/PARTNER/EXECUTIVE I Et EACH.ACCIDENT 3 1400,000 000 OFFICER/MEMBER EXCLUDED? Y [NIA C (Mandatory in NH) AWC4 007 012861 4/29/2021 4/29/2022 E.L.DISEASE-EA EMPLOYEE S I,000,000 It yes.describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POUCY LIMIT _3 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional 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 I Michael Regan/EMT //2Zy3 / P 43 . . ©1988•2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025(201401) ,- ` ine commonweal in ly 11F1a33ucisuarssa I. Department of Industrial Accidents 6. t. Office of Investigations 600 Washington Street = y Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information /� ii L lG�/� 3CJt n Please Print Legibly Name(Business/Organization/Individual): A4e.rh GI0esllv'4 )t 11 t'16 4 714,1 r g P rel Address: t GO O► L vr.an C L City/State/Zip: 5ot)% Ne,Alcb (ii to Ot 01 c Phone#: L(13 -53`-5(155- Are you an employer?Check the appropriate box: Type of project(required): 1.4K 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. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling ship and have no employees These sub-contractors have g, 0 Demolition working for me in any capacity. employees and have workers' [No workers'comp. insurance comp.insurance.: 9. ❑ Building addition required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3.D I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL l2 Roof repairs insurance required.]t c. 152,§1(4),and we have no employees. [No workers' 13.�Other 3 i i I. comp.insurance required.] J *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. Q _ Insurance Company Name: 1 i'' M u l yea I/1 j kl r'c cc- Policy#or Self ins.Lic.#: A W C C100,0 i an Expiration Date: VaCit a Job Site Address: 1.5 �� � ��� IdVC City/State/Zip:/`Jor Ilgr�l o-N T/J O 10C 0 Attach a copy of the orkers'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 under the pains and realties of perjury that the information provided above is true and correct Signature: Date: 9 f )'t Phone#: 4( i 3 - 5 3c - 5 9 5 C / 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#: uwIsrvn 1/1,-ru,esa,uner L./censurer 1' Board of Building Regulations and Standards t. Constrdtfbttifttprwsor j CS-070626 .. * 61,ptres:08/21/2023 ADAM A QUIWN V 160 OLD LYMLOIN • • SOUTH HADLIY i Commissioner )n,�it A t7Grrrtt&L Q9 e m i► anweaJ C��facA€eoe4&o 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 4 0 20M-05/17 f- -- `;"�/ ` f-"^��•- ram- ✓ -^` '%;�/ ✓ �ti /< i` .N/ ,*^.."'�✓: ,:� �. S f-�^.;f ..- "'�' '-''\ "�; � cam. '".\ �. -.f.;,;;: v 4 s a mob' * * 0 A .4, ` * Ai*_ A I A'o'_ A..* A *• - �4_ A a .A...* • A *' * *K' ar Ir n u * ys A �.. STATE OF CONNECTICUTDEPARTMENT OF' CONSUMER PROTECTION 11 'l ` I. Be it known that I I ) l i ADAM QUENNEVILLE ,. 160 OLD LYMAN ROAD SOUTH HADLEY MA 01075-2632 I 11 l it has satisfied the qualifications required by law and Is hereby registered as a I HOME IMPROVEMENT CONTRACTOR I: --<)t l Registration # HIC.0575920 L ! ,, Y ADAM QUENNEVILLE ROOFING ti il ., Effective: 12/01/2020 I g4.0,1I 44.40/4" , Expiration: 11/30/2021 li ) Michelle Seagull.Commissioner q r ��. _—. woo jj�� �o Fr1, j� .. .- . �ewvt .66IX i . + c ..,.....�.EL..V 1.4 1.....r..816.-L.. i