35-057 (6) BP-2021-2027
955 RYAN RD COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
35-057-001 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-2021-2027 PERMISSION IS HEREBY GRANTED TO:
Project# ROOF Contractor: License:
ADAM QUENNEVILLE ROOFING &
Est. Cost: 14199 SIDING 191093
Const.Class: Exp.Date:03/22/2022
Use Group: Owner: MARTIN MICHAEL A& ELISETH M ETO
Lot Size (sq.ft.)
Zoning: WSP Applicant: ADAM QUENNEVILLE ROOFING & SIDING
Applicant Address Phone: Insurance:
1600LD LYMAN RD (413)536-5955 AWC4007012861
SOUTH HADLEY, MA 01075
ISSUED ON:10/14/2021
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:
A , .
Fees Paid: $40.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
Department use only
i4'r; . City of Northampton Status of Permit:
r • ' 4.'?' Building Department / '*. �// Curb Cut/Driveway Permit
'f 212 Main Street �'*, / r/Septic Availability
Room 100 C/ J r ell Availability
, ,1!.;. Northampton,Northampton, MAt. c •0 �'� Two ets of Structural Plans
"--' phone 413-587-1240 Fa0t4)r i -1272 49j Plo Site Plans
ti94�P/4,, •tfter Specify
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVA *,-s•EM ISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: This section to be completed by office
955 Ryan Rd Florence Ma 01062 Map Lot lJnit
Zone Overlay District
Elm St. District_ CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Mike& Eliseth Martin & Eto Martin 955 Ryan Rd Florence MA
Name(Print) Current Mailing Address: 413-531-9925
see contract
Telephone
Signature
2.2 Authorized Agent:
Adam Cuenne ville 160 Old LymanRd South Hadley Ma 01075
Name(Prin 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 14199 (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4'
4. Mechanical (HVAC) 6
5. Fire Protection
6. Total = (1 + 2 + 3 +4 + 5) 14199 Check Number 6 °q 73
^� This Section For Official Use Only
Building Permit Number: 6 p_°2�'a0� 1 De
Isated:
J �
Signature: :112 /�/ - ) ZUZ 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
Building Height
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DONT KNOW x YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOWbe 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? YES NO (
IF YES, describe size, type and location:
E. Will the construction activity disturb clearing, gradin excavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YE j NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing )1
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs OD] Decks [❑ Siding OD] Other[l
Brief Description of Proposed New roof, replace existing roofing, install drip edge, ridge vent, ice&water barrier, roll roofing on porch
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
Mike & Eliseth Martin& Eto Martin
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 10/06/2021
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
/ 10/06/2021
Signature of Ovtner/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
Address Expiration Date
413-536-5955
Signature Telephone
9. Registered Home Improvement Contractor: Not Applicable 0
Adam Quenneville Roofing &Siding Inc 191093
Company Name Registration Number
160 Old Lyman Rd South Hadley Ma 01075 3/22/2022
Address Expiration Date
Telephone 413-536-5955
SECTION 10-WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152,§25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes X No 0
City of Northampton
�t --r45"" Sys...�!' N.ys Massachusetts ��r '�
ti wr 4.
'a DEPARTMENT OF BUILDING INSPECTIONS °.
/41, 212 Main Street •Municipal Building ,.) ��1��
Northampton, MA 01060 S�'W 3'�‘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:
955 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)
(tAtkW
Signature of Permit Applicant or Owner Date
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.
att.11lo l �l ilf l +r 111.111.1 /' )( VISA VISA CD'. DISGyE
balk
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: 913-531-9925
Eliseth Eto Martin & Mike Martiit0/02/21 H. W:
Street: Email:
955 Ryan Rd. Skytop19177@comcast.net
City,State,Zip Code: Special Requirements:
Florence, MA, 01062
Rolled Roof on Porch
PROPOSAL FOR:
HOUSE GARAGE OTHER Block of Gable Vents
STRIP RECOVER with Plywood
Layers: 1 2 3 4 Plywood Included: Yes or No
ill Tear off SLATE or SHAKES
COMPLETE ROOF PROTECTION SYSTEM:
-Z We shall acquire appropriate permits for all work
x Home exterior and landscaping to be protected
Strip existing roofing to existing decking with full inspection DO NOT DO:
All project waste shall be removed by dum•ster(dumpster for contractor use only)
• Install Ice&Water Barrier at all eave irt6' alleys,chimneys,pipes and skylights
e Install(151b.felt/ ynthetic nderlayment ver remaining decking area
Install Metal drip edge at eaves and rake (8" 5") Op/brown)
• Install manufacturer's starter shingle on all eaves an. ake edges
' Install new pipe boot flashing/vent cessories
Install ridge vent-Snow Country Cobra rolle /4'Baffled/Roll
Shingles:(standard 6 nails per shingle)
GAF HDZ Shingles Color: Charcoal
GAF Ridge cap shingles
Warranty Options:
p We guarantee our workmanship for 10 full years
H GAF System Plus Warranty
GAF Golden Pledge Warranty
Chimney Options:
( Lead Counter Flashing O Water Seal&Tuckpoint O Rubberized Crown O Cricket
O Mason needed(customer provided)
Additional material and labor charges may apply. 4.00 10
%f. Deteriorated existing decking will be replaced,af-efrper sq.ft.and dimensional lumber at per linear ft.,
7 v 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:($ 14199 )
ACCEPTANCE OF PROPOSAL:The above prices,specifications and conditions are Down Payment:($ 8000 )
satisfactory and are hereby accepted.You are authorized to do work as specified. 2nd Payment at Start Job:($
Payment will be 1/3 down at signing,1/3 at start of job,and balanc due alance Upon Completion:($ 0
upon completion. / 0% 12 Month Program
Date: 1 0/0 2/2 1 Signature:
Date: 10/02/21 Estimator:(Print Name) Nate Flacks (Sign Name) r\-/
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:
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 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.
LIABILITY
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.
•
1 ® DATE(MMIDDIYYYY)
A EP CERTIFICATE OF LIABILITY INSURANCE
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.
IMPORTANT1 if the certificate holder Is an ADDITIONAL INSURED,the policy(les)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 Prem=
en Clayton Insurance HONE (413)536-0804F'AX
Nor ulnslo- a,a
Y Agency, Inc.. INC.No.Extl;
1649 Northampton Street "AIL slepremo@claytoninsurance.net
AOFIRES
P. O. Box 989 INSURERS)AFFORDING COVERAGE NAIC Y
Holyoke tg! 01041-0989 INSURERA;Nautilus Insurance Company
-INSURED INSURER 8:Arbella Insurance Co.
Adam Quenneville Roofing S Siding Inc. INsuRERc:AIM Mutual Insurance Company
160 Old Lyman Road INSURER D:
South Hadley, MA 01075 INSURER E:
INSURER F: •
COVERAGES CERTIFICATE NUMBER:2021 t4+STER 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 NOTWTHSTANDING 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.
IM1ISR TYPE OF INSURANCE ADS!we� POLICY NUMBER (MMIOOTYYYYI IMM10RfrYYYI LIMITS
LPOLICY EFF POLICY EXP
TR INSDf7 .
X COMMERCIAL GENERALIJABIUTY EACH OCCURRENCE $ 1,000,000
DAMAGE TO RENTED 100,000
A CLAIMS-MADE X OCCUR PREMISES Ite,5 $v6 dall $
N141.293315 6/23/2021 6/23/2022 MED EXP(Any one person) S 5,000
PERSONAL 3.ADV INJURY 5 1,000,000
GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGOREGATE 5 2,000,000
X POLICY [ PRO• LOC PRODUCTS-COMP/OP AGG S 2,000,000
I 1 I IECT
S
OTHER:
AUTOMOBILE LIABILITY 9l�I HGLE LIMIT ; 1,000,000
BODILY INJURY(Per person) I
B -
ANY AUTO ALL OWNED
,_SCHEDULED
X 1020107E193 - 6/23/2021 6/23/2022 BODILY INJURY(Per acadenl) $
AUTOS AUTOS
PROPERTY DAMAGE $
X HIRED AUTOS X AU
NOTON-OWNED aa
S (Reg 01111 UNINSAJNOERINS MOTORIOTS $ 100,000/300,000
X UMBRELLA LAB OCCUR EACH OCCURRENCE S 5,000,000
A EXCESS LIRE _CLAIMS-MADE AGGREGATE $ 5,000,000
DEO RETENTION S AN1242102 6/23/2021 6/23/2022 S
WORKERS COMPENSATION X PER AfUTE 0ER
1
AND EMPLOYERS'LIABILITY YIN
ANY PROPRIETOR/PARTNER/EXECUTIVE EL EACH ACCIDENT $ 1,000,000
OFFICER/MEMBER EXCLUDED? Y N I A
C (Mandatory in NH) AWC4007012861 4/29/2021 4/29/2022 E.L.DISEASE-EA EMPLOYEE 5 1,000,000
It yes.describe under E.L,DISEASE-POLICY LIMIT S 1.000,000
DESCRIPTION OF OPERATIONS belay ,
1 i I I 1 -�-
DESCRIPTION OF OPERATIONS 1 LOCATIONS!VEHICLES(ACORD 101,Addldonal Remarks Sohadula,rmy ha attached If more apace Is r equtred)
For Informational Puryoees Only
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OP THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Adam Quennevillo Roofing 6 Siding Inc THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS,
160 Old Lyman Rd
South Hadley, MA 0I075 AUTHORIZED REPRESENTATIVE
Michael Regan;L'!iT l��1""'/ P "`
I
C9 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 Massacnusens
`._... Department of Industrial Accidents
= :.
' =4, Office of Investigations
a 600 Washington Street
=�=c Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information /� /� (1 Please Print Legibly
Name(Business/Organization/Individual): A yv
(46m 0.0e .1W t ttc_ lLCICJt t'1� 4. Tld.l rl Y 4 ii C
Address: ;GO 0( c ►w,�„� (J
City/State/Zip: 50uVe\ he AtcAA (1 01o1C Phone #: k!3 -53C 5(155—
Are you an employer?Check the appropriate box: Type of project(required):
1.K I am a employer with 15 4. ❑ I am a general contractor and [
employees(full and/or part-time).* have hired the sub contractors 6. El New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have 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 110 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12E2 Roof repairs
insurance required.]t c. 152, §1(4),and we have no 13.0 Other
employees. [No workers'
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
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.
t am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. _ 1
Insurance Company Name: V t VG\ InS V✓c"C C-
Policy#or Self-ins. Lic. #: A WC.-90C10 l an ( Expiration Date: Vali a a
Job Site Address: ` 55 - r City/State/Zip: -flo(t' C (fl GOoL)
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 certib,under the p and penalties of perjury that the information provided above is true and correct.
Signature: JJJJJJ Date: /C/C7)/
Phone#: 1 ( F 53c - 5959"
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#:
, VC Division of Professional Licensure
Board of Building Regulations and Standards
Consto,tiAti► upprvisor
CS-070626 , cI',!'t'EF pires:08/21/2023
ADAM A QUF,AINEV
160 ow LYMAN fatii -; =4'''
SOUTH HADLEY MA,
f ss a
:� i A
Commissioner dwi.a K'. Y t
QY2 e (620470 t4uoeaJd o Ca��addad c Ltd
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 3
180 OLD LYMAN RD. Expiration:piration: 03/22/2/2022
SO,HADLEY,MA 01075
Update Address and Return Card.
SCA I 0 20M-05/17
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STATE OF CONNECTICUT + DEPARTMENT OF' CONSUMER PROTECTION :`.:P:"
:1e it known that ill s::�y
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h: "`< t ADAM QUENNEVILLE - '
160 OLD LYMAN ROAD i �'
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SOUTH HADLEY, MA •01075-2632
, 1 has satisfied the qualifications required by law and is hereby registered as a +
',1+,; , HOME IMPROVEMENT CONTR. ACTOR
Registration # HIC.0575920 '`'`
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D;_, ADAM CUENkVILLE toiIN( ,i i ,;
Q. I Effective: 12/01/2020 '`':
I • Expiration: 11/30/2021 44;7 i.}. s,
..' Michelle Seagull,Commissioner I r,~/y
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