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24C-064 (12) 88 MASSASOIT ST COMMONWEALTH OF MASSACHUSETTS BP-2021-1953 Map:Block:Lot:24C-064- 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-2021-1953 PERMISSION IS HEREBY GRANTED TO: Project# ROOF Contractor: License: ADAM QUENNEVILLE ROOFING & Est. Cost: 23185 SIDING 070626 Const.Class: Exp.Date:08/21/2023 Use Group: Owner: EPPSTEINER ERINE E&ROBERT W Lot Size (sq.ft.) Zoning: URB 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: 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. Signature: et • V t y9 • 5115/ Fees Paid: $40.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1'272 Office of the Building Commissioner / Department use only w4..;144' City of Northampton �Cl Status of Permit: l>, r Building Department � rb Cut/Driveway Permit { , ; 212 Main Street s ,p,. ��p er/Septic Availability �� Room 100 n,� c-)/> 'EtWe vailability F Northampton, MA. /, ("Q Two ets ofAtructural Plans phone 413-587-1240 Fax 414;' 7/1,�n 2 / PI Site Plans ?° � cp, ther Specify APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVAtE cDEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION This section to be completed by office 1.1 Property Address: 88 Massasoit St Northampton Ma 01060 Map Lot Unit Zone Overlay District Elm St. District CB District SECTION 2 -PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Erin Eppsteiner 88 Massasoit St Northampton Ma 01060 Name(Print) Current Mailing Address: 508-479-6293 see contract _____.._............. Telephone Signature 2.2 Authorized Agent: Adam Quenneville 160 Old LymanRd South Hadley Ma 01075 Name(Prin Current Mailing Address: 413-536-5955 Signaturq/ Telephone SECTION 3 -ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building 23,185.00 (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee1/(, 4. Mechanical (HVAC) 5. Fire Protection !� 6. Total = (1 +2 + 3 +4 + 5) 23,185.00 Check Number i 000 D 22 a o This Section For Official Use Only Building Permit Number: f I ^ig Date J Issued: Signature: /// q- zs-w z i Building Commissioner/Inspector of Buildings Date operations.aqrs @ 9mail.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 ... r.. Building Height Bldg. Square Footage Open Space Footage LILTJ(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? YE$ NO ix 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: 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 Or Doors E Accessory Bldg. ❑ Demolition ❑ New Signs ED] Decks [IJ Siding [] Other[Di Brief Description of Proposed New roof, remove and replace existing, install drip edge, ridge vent, pipe boot flashing &ice&water barrier. 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, Erin Eppsteiner , 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 09/23/2021 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 / /)W�_/ 09/23/2021 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 8/21/2023 Addres Expiration Date 413-536-5955 Signature Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ 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 �, �� erg ti\. -� stc c , ..' Massachusetts w�� i `( DEPARTMENT OF BUILDING INSPECTIONS x 212 Main Street *Municipal Building Northampton, MA 01060 ,.,A'\:'' 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: 88 Massasoit St 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) OIE"----- Ci `3'\Y\ Signature of Permit Applicant or Owner D to 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. vi �2 cuutiliosamilielescaue b ve,(.) AWARD VISAZ DISC VER 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: Robert Eppsteiner 9/21/21 H: W: Street: Email: 88 Massasiot st robert.eppsteiner@gmail.com City,State,Zip Code: Special Requirements: Northampton MA 01060 Ultimate pipe boot 2" PROPOSAL FOR: ( HOUS GARAGE OTHER STRIP RECOVER Layers: 2 3 4 Plywood Included: Yes or No ❑ Qar off SLATE or SHAKES COMPLETE ROOF PROTECTION SYSTEM: ?s We shall acquire appropriate permits for all work x Home exterior and landscaping to be protected x Strip existing roofing to existing decking with full inspection DO NOT DO: x All project waste shall be removed by dumpster(dumpster for contractor use only) Install Ice&Water I t all eaves 3' alleys,chimneys,pipes and skylights _x Install(151b.felt Synthetic) nderlayment over r-;:..: ing decking area • Install Metal drip es and rakas(8' /5'i brown) ✓ Install manufacturer's starter shingle on a eaves and rake edges [x Install new pipe boot flashing/vent accessories ultimate pipe boot 2" • Install ridge yen -Snow Count ' Cobra rolled/4'Baffled/Roll Shingles:(standard 6 nails per shingle) GAF Shingles Color: Charcoal GAF Ridge cap shingles Warranty Options: Ex, We guarantee our workmanship for 10 full years i GAF System Plus Warranty • GAF Golden Pledge Warranty Chimney Options: M Lead Counter Flashing O Water Seal&Tuckpoint O Rubberized Crown O Cricket O Mason needed(customer provided) Additional material and labor charges may apply. 6 Deteriorated existing decking will be replaced at'tVb per sq.ft.and dimensional lumber at t/Y 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:($ 23, 185 ) ACCEPTANCE OF PROPOSAL:The above prices,specifications and conditions are Down Payment:($ 6,500 ) satisfactory and are hereby accepted.You are authorized to do work as specified. 2n i Payment at Start Job:($ Payment will be 1/3 down at signing,1/3 at start of job,and alance due Balance Due Upon Completion:($ 16, 685 ) upon completion. Date: 9/21/21 Signature: 9/21/21 James Bonavita Date: Estimator:(Print Name) (Sign Name) ATTENTION HOMEOWNERS:Please cover all personal belongings in the attic,g ge or storag reas to the possibility of roofing debris or dust coming in through cracks of the wood.Adam Quenr)eville Roofing will not be responsible for debris or dust in the attic or storage areas. Customer Initials: 9JJ 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 pm-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 maybe 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 gives 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. 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. LIABIUTY Company is not responsible for damage or loss caused in whole or in part by:the acts or omissions of other parties,trades or contractors;lightening,gale force winds (+110 mph),hailstorms,ice damage,ice damns(caused by thawing and freezing of ice,water or snow)hurricanes,tornados,floods,earthquakes or other unusual phenomena of the elements;structural settlement;failure,movement,cracking or excess deflection of the roof deck;defects or failure of materials used as a roof substrate over which Company's roofing material is applied;faulty condition of parapet walls,copings,chimneys,skylights,vents,supports or other parts of the building; vapor condensation beneath the roof;penetrations for pitch boxes;erosion,cracking and porosity of mortar and brick;dry rot;stoppage of roof drains and gutters; penetration of the roof from beneath by rising fasteners of any type;inadequate drainage,slope or other conditions beyond the control of Company which cause ponding or standing water;termites or other insects;rodents or other animals;fire;or harmful chemicals,oils,acids and the like that come into contact with Customer's roof and cause a leak or otherwise damage Customer's roof.If Customer's roof fails to maintain a watertight condition because of damage,by reason,of any of the foregoing,any applicable written limited warranty shall immediately become null and void for the balance of its term.Company accepts no liability to indemnify or hold Customer harmless for claims or damages to persons or property,except to the extent that such damage occurs during performance of Company's work and are the direct result of Company's error or omission.Notwithstanding the foregoing,Company shall not be responsible for damages to any area of the property upon which Company's work has not been completed nor is Company responsible for slight scratching or denting of gutters,oil droplets in driveways,hairline fractures in concrete, damage to flowers or landscaping,or minor broken branches on trees,plants or shrubbery.In no event shall Company be responsible for any type of damage resulting from vibrations,including,but not limited to,interior drywall damage,nail pops or disconnection of chimneys,flues,air ducts,ventilation shafts,exhaust vents,furnace vents or sewer vents.Customer understands and agrees that Company shall have no responsibility for damages of any kind to persons or property occurring after job completion. 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. 1ACG CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) 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 POUCIES 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 -CD CT Sarah Premo NAME; Clayton Insurance Agency, Inc. PHONE (413)536-0804 FAX 913)5]9-'B]9 INC.No.E9t4' (SiC,No(: _ 1649 Northampton Street E-MAIL remo@cla toninsurance.net ADDRESS: Y P. O. Box 989 INSURERS)AFFORDING COVERAGE NAIC s Holyoke MA 01041-0989 , INsuRERA:Nautilus Insurance Company INSURED INSURER B:Arbella Insurance Co. Adam Quenneville Roofing 6 Siding Inc. INSURER C:AIM Mutual Insurance Company 160 Old Lyman Road INSURER 0: 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 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 fS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN RECUCED BY PAID CLAIMS INSR I ADOL SUER- POLICY EFF POLICY EXP LTR i TYPE OF INSURANCE I IN,RD MIL POLICY NUMBER IMMIDD/VVYVI IMMIDOIVYVY) - LIMITS X COMMERCIAL GENERAL UABILITY I EACI^OCCURRENCE 5 1,000,000 DAMAGE !Ea�74o erencol A _ £CLAIMS-MADE ; X OCCUR ? 100,000 M312933:5 6/23/2021 6/23/2022 `MED EX'(Any one personi 5 5,000 PERSONAL 5 ADM INJURY `S 1,000,000 GEMLAGCREGATE LVII'APPUES PER: GENERALAGGREGATE 5 2,000,000 Pr2X POLICY T LOC PRODUCrs-COMP/OP..AGG S 2,000,000 OTHER: 5 AUTOMOBILE LIABILITY ' COM(Es BINED NGLf i.iM1T S 1,000,000 IANY AUTO BODILY INJURY(Per person) E H ALL OWNED SCHEDULED AUTOS AUTOS 2020107695 6/23/2C2L 6/23/2022 BODILY INJURY(Per acodent) 5 X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE 5 AUTOS /Per accirkan I _ _ uwNOI NDEPIN3MOTORISTS S 100,000/300,000 X UMBRELLA LIAB OCCUR 1EACH OCCURRENCE S 5,000.000 A EXCESS LIAR CLAIMS-MACE AGGREGATE 5 5,000,000_ DEC RETENTION 5 9512421002 6/23/2021 6/23/2022 5 WORKERS COMPENSATION RER OTH- AND EMPLOYERS'UABILITY Y/N X Sl'A(UTE ER ANY PROPRIETORIPA:RTNER/EXECUTIVE I E.L EACH.ACCIDENT 0 1 r 000,000 C OFFICER/MEMBER EXCLUDED? y I NIA (Mandatory in NH) t ANC400701296L 4/29/2021 4/29/2022 E.L.DISEASE-EA EMPLOYEE S 1,000,000 If yes.describe under ' DESCRIPTION OF OPERATIONS be,ow ' E.L.DISEASE POLICY LIMIT S 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may he attached It more space is numbed) For Informational Purposes Only I 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 Re Taa/E'HT /2 a/ P " 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025(201401) I ne communweaun Uf [VLuaJuc.111.3cssJ r ' Department of Industrial Accidents Office of Investigations 600 Washington Street / Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly //�� n Name (Business/Organization/Individual): 1"1 Jeirn GI Jrw \)t qt.- t n-L+J-C t'1o" 71 d,l rl 4 ri c Address: (GO 01 Li v„.,c,,,,, C L City/State/Zip: Sou% kckd (i 01.0C Phone #: 1113 -53( `5 955 - Are you an employer?Check the appropriate box: Type of project(required): l.4K I am a employer with i5 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_ El Remodeling ship and have no employees These sub-contractors have g. E Demolition working for me in any capacity. employees and have workers' [No workers'comp. insurance comp. insurance. $ 9. 0 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 1 l.❑ Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL 12.3,Roof 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 rill 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: r l �' u l��� �� �c �' Policy#or Self-ins. Lic.#: A tA C.- 1OO'10 i �5c( Expiration Date: 'f/t lll i 9 ' Job Site Address: b et 1 el ) t_D 'i 3-r City/State/Zip N"r0g 1r fl c (If.° ©/c('6 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 DR for insurance coverage verification. I do hereby certify under the ins an penalties of perjury that the information provided above is e and correct 7 Signature: Date: a3 ) i Phone#: AiI ` 53C — 5555— 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#: tr, uroislon or rroressionai ucensure Board of Building Regulations and Standards Cons(iWtitipAfttlp rvlsor CS-070626 * ., 6t,pires:08/21/2023 ADAM A QUIF,1,@N %r 3 ; 16O OLD LYMO ,• f� t� a SOUTH HADLIV //It ,,y,�,., ,J (1fSS'.I tt: Commissioner a' K D4rnc.4ia., (6.9 �J.%e yl�Laeitd 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 I 0 20M-05/17 J,.,a•_ •a ra_ . 'r' 4..A'. wi4 , ii"_ A*_ A.,* , A h-..-_Ai ,.p A a +Jr . ,r_ ♦ b A.,* A.24 - A.* . s.` 4 .: i ••••41 STATE OF CONNECTICUT + DEPARTMENT OF CONSUMER PROTECTION j Be it known that I. l l ADAM QUENNEVILLE 160 OLD LYMAN ROAD `i '5 SOUTH HADLEY, MA 01075-2632 H has sanstied the qualifications required by law and is hereby registered as a I • HOME IMPROVEMENT CONTRACTOR I l' Registration # HIC.0575920 • I ARAM QL'ENNEVILLE ROOFING • 1 , Effective: 12/01/2020 i i R Expiration: 11/30/2021 , .y • 4, Michelle Seagull.Commissioner