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23A-055 (5) BP-2021-1988 35 MAPLE ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 23A-055-001 CITY OF NORTHAMPTON Permit: Alts Renovations Repair PERSONS CONTRACTING WI I H UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit # BP-2021-1988 PERMISSIONIS HEREBY GRANTED TO: Project# ROOF Contractor: License: ADAM QUENNEVILLE ROOFING & Est. Cost: 6650 SIDING 070626 Const.Class: Exp.Date:08/21/2023 Use Group: Owner: FITZGERALD REALTY CORPORATION 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:10/07/2021 TO PERFORM THE FOLLOWING WORK: NEW ROOF ON BACK PORCH 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: 4 • • >9 3-11 *I Fees Paid: $40.00 212 Main Street, Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner Version1.7 Commercial Building Permit May 15, 2000 />";'''' / �\�Y\� Department use only / / *�/ ,„ City of Northampton Status of Permit: ullding Department Curb Cut/Driveway Permit� � OAT � ����� - ��� /212 Main Street Sewer/Septic Availability \ „tiT F <90c9/ Room 100 Water/Well Availability °9ryq�po6v,/ Northampton, MA 01060 Two Sets of Structural Plans oN 'll phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans A�AD osa�QNs Other Specify APPLICATION TO - S�UCT, REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be completed by office Maple St Florence Ma 01062 Map ^ Lot O Unit 36 Zone Overlay District Elm St. District CB District SECTION 2 -PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Ted Boyer 29 Maple St Florence Ma Name(Print) Current Mailing Address: 413-835-5689 Signature See contract Telephone 2.2 Authorized Agent: Adam Quenneville Roofing & Siding 160 Old Lyman Rd South Hadley Ma Name(Print) Current Mailing Address: if 413-536-5955 Signature /l/ Telephone SECTION 3 -ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building 6,650 (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) w U 5. Fire Protection 6. Total = (1 + 2+ 3 +4 + 5) Check Number 1 /133 This Section For Official Use Only Building Permit Number Date 0- al !a '6 Issued Signature: //& lb - 6 zaz) Building Commissioner/Inspector of Buildings 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 ❑ Existing Wall Signs ❑ Demolition El Repairs Additions ❑ Accessory Building El Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing® Change of Use❑ Other Brief Description New roof on back wrap around porch,install drip edge,ice barrier,and new pipe boot. Of Proposed Work: SECTION 5-USE GROUP AND CONSTRUCTION TYPE USE GROUP (Check as applicable) CONSTRUCTION TYPE A Assembly CIA-1 ❑ A-2 ❑ A-3 ❑ 1A I CI A-4 El A-5 ❑ 1 B ❑ B Business ❑ 2A ❑ E Educational ❑ 2B ❑ F Factory ❑ F-1 ❑ F-2 ❑ 2C El H High Hazard ❑ 3A ❑ I Institutional CI 1-1 CI 1-2 ❑ 1-3 CI3B ❑ M Mercantile ❑ 4 ❑ R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑ S Storage ❑ S-i ❑ S-2 ❑ f 5B CI U Utility ❑ Specify: M Mixed Use ❑ Specify: S Special Use ❑ 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) 1st 0 1st 0 2nd 0 2"d 0 3rd 0 3rd0 4th 0 4th 0 (sf) p Total AreaTotal Proposed New Construction (sf) Total Height (ft) 0 Total Height ft 0 7. Water Supply(M.G.L. c. 40, § 54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone❑ 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 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 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 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 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. Version).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 53 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 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: 29 Maple St Florence Ma The debris will be transported by: Adam Quenneville Roofing &Siding Adam Quenneville Roofing & siding The debris will be received by: Building permit number: Name of Permit Applicant Adam Quenneville Roofing &Siding 09/29/2021 Date Signature of Permit Applicant 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 Ted Boyer 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 09/29/2021 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 pains and penaltiesv en itwil of perjury. Print a�me 09/29/2021 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 , 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 I� I No 7 QUENNEVILLr : e�° AWARD ynCA At DISC VEa ROOFING w f) l N +. 20r0 w€YNEQ .: 160 Old Lyman Road•South Hadley•MA 01075 We are Licensed 1.800.NEW.ROOF • 413.536.5955 Fully Insured Email:infof 1800newroof.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: 413-835-5689 Fitzgerald Realty (Ted Boyer) 9/20/21 H. W: Street: Email: 29 Maple St City,State,Zip Code: Florence MA 01062 Proposal to furnish and install the following: we will pull all appropriate permits for work. we will remove and dispose of all roofing debris down to decking on back wrap around porch. we will install new white drip edge we will install full ice barrier. we will install GAF Timberline HDZ shingles we will install new pipe boot 10 year AQRS warranty all rotted or deteriorated decking will be replace at $4.16/sq ft and $14/ linear ft. if full plywood is needed $2800 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:($665 0 ACCEPTANCE OF PROPOSAL:The above prices,specifications and conditions are Down Payment:($2217 satisfactory and are hereby accepted.You are authorized to do work as specified. 2"a Payment at Start Job:($ Payment will be 1/3 down at signing,1/3 at start of job,and bal e du Balance Due Upon Completion:($4 9 33 upon comp, ion. Date. 1 Signature: t TSTS Date:9/20/21 Estimator:(Print Name) Robert Croteau (Sign Name) , /14.... 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. . % , A® 6/24/2021 CERTIFICATE OF LIABILITY INSURANCE ° Y' 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(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 CONTAL.1-Sarah 9remo NAME; Clayton Insurance Agency, Inc. AC,PHO Na Exttr (413)536 0804 ac NOI[ (4131534-'970 1649 Northampton Street E-MAIL AODRE3s spremo@claytoninsurance.net P. O. Box 989 INSURER(S)AFFORDING COVERAGE NAIC,a Holyoke MA 01041-0989 INSURER A: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 D 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 IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS INSR 4 1100L EUBR I POLICY EFF POLICY EXP LTR I TYPE OF INSURANCE I INSD min POLICY NUMBER I(MMIDD/YYYY) IMMIDD/YYYY1 LIMITS j X COMMERCIAL GENERAL UA&UTV EACH OCCURRENCE $ 1,000,000 DAMAGE TO REM,ED A f 1 CLAIMS-MADE I X OCCUR EREMLSES IEa,N.Pwarnoet _ 100,000 NN12933:5 6/23/2021. 6/23/2022 MED EX?(Any one person) i 5,000 PERSONA:_X.ADM INJURY 'S 1,000,000 GEN-L AGC-REOATE L'MI r A.'PLI ES PER: 2,000,000 GENERAL AGGREGATE b PRO. X POLICY JJECT LOC PRODUCTS-COMP/OPAGG b 2,000,000 f OMER: S f AUTOMOBILE LIABILITY 'C 1dE NcA6 LIMIT b 1,000,000 itril EI I ANY AUTO BODILY INJURY;Per person) S ALL OWNED SCHEDULED AUTOS X AUTOS :C20107895 6/23/202: 6(23/2022 BODILY INJURY(Per accident) 8 X NON-OWNED PROPERTY DAMAGE S X HIRED AUTOS - AUTOS (Pa scoOMR _ I UNINSI.NOERINS MOTORISTS $ 100,000/300,000 X UMBRELLA UAB ^ OCCUR ' _, EACH OCCURRENCE S 5.000,000 A EXCESS LIAR CLAIMS-MADE AGGREGATE `E 5,000.000 DEC RETENTION S M412,12162 6/23/2021 6/23/2022 g WORKERS COMPENSATION PER O'Itt- AND EMPLOYERS'UABILITY YIN X STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE I E L EACH.ACCIDENT $ 1,000,000 OFFICERIMEMBER EXCLUDED? I Y 'NI CA (Mandatory in NH) A5C4007012861 4/2s/2021. 4/29/2022 EL DISEASE-EA EMPLOYEE $ 1,000,000 If yes.describe under DESCRIPTION OF OPERATIONS be,ow E.L.DISEASE-.POLICY LMIT b 1.000,000 DESCRIPTION OF OPERATIONS!LOCATIONS/VEHICLES(ACORD 101,Addltlortal Remarks Schedule,may he attached It moo apace is required) For Informational Purposes Only CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Adam Quenneville Roofing 6 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 Regan/EMT iTZWz.,-/ ,'" ) 1 ©1988.2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025(201401) The Commonwealth of Massachusetts ""I1 w..= Department of Industrial Accidents f 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 Name(Business/Organization/Individual): /"I`-�Prrh (aQC',,vK�t tit, IC.�JCI ''1,( yt4,i ply i"tc Address: ILO 0 t c\ L L L (J City/State/Zip: 5ou1% I\16 1 ka Orl Ph G1(1c Phone#: 13 -53C 5 q55— Are you an employer?Check the appropriate box: Type of project(required): 1..[I am a employer with 15 4. El I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. 0 New construction 2.El I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling ship and have no employees These sub-contractors have 8. 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. I am a homeowner doing all work officers have exercised their 1 1.0 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 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: 1.''� M u%vetl n5 i is cc- Policy#or Self-ins.Lic. #: AwC'1GO10 f a' C.( Y/�Q/a n Expiration Date: / 1 Job Site Address: (i n11Ne'1 '`� City/State/Zip:oC(C►lt t]ov ti MA ONO? 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 under the 2denalties ofperjury that the information provided above iscorrect. C� true and Signature: Date: 9/)-1/4) ] Phone#: '1 13 - -/3L - 5 9 5 5- 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#: VDivision of Professional Licensure • ` Board of Building Regulations and Standards Consgvittt %Upervisor .1 CS-070626 . * r I jtpires:08/21/2023 ADAM A QUFI,_QN V i 160 OLD LYNMN • IIA SOUTH HADL ,Y • Coll missioner lairit' K. Ettr,t3sa_. QT4e W rnoV P4,/ddackede s 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. Re 191093 160 OLD LYMAN RD. Expiration:pration: 03/22/22/2022 SO.HADLEY,MA 01075 Update Address and Return Card. $CA 1 03 20M-05/17 r A,* 4r 4 .Y 4r .�r 4r 4r *L.* 1* 4r fi .r 41. 42* 4h.. 4r 4r 4dr' 4r 4r 4Ar i STATE OF CONNECTICUT + DEPARTMENT OF CONSUMER PROTECTION II Be it known that I ,_ i i ADAM QUENNEYILLE 160 OLD LYMAN ROAD t5 SOUTH HADLEY, MA 01075-2632 `, has sanstied the qualifications required bylaw and is hereby re stered as a y �{ Kt i j HOME IMPROVEMENT CONTRACTOR I .�; Registration # HIC.0575920 � ADAM QUENNEVILLE ROOFING . I Effective: 12/01/2020 ' Ri 'Lid -dies741, , „, ,. Expiration: 11/30/2021 il i Michelle Seagull,Commiaosoner • mw r a r _ rb..--. _ ♦ ♦1LLIJLrwn F