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42-010 BP-202 1-2055 1015 WESTHAMPTON COMMONWEALTH OF MASSACHUSETTS RD Map:Block:Lot: CITY OF NORTHAMPTON 42-010-001 Permit: Alts Renovations Repair PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit# BP-2021-2055 PERMISSIONIS HEREBY GRANTED TO: Project# 2021 ROOF Contractor: License: ADAM QUENNEVILLE ROOFING & Est.Cost: 13299 SIDING 070626 Const.Class: Exp.Date:08/21/2023 Use Group: Owner: RULE RONALD A& SALLY A 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:10/22/2021 TO PERFORM THE FOLLOWING WORK: REMOVE &REPLACE ROOF, NEW DRIP EDGE, RIDGE VENT, ICE/WATER BARRIER,PIPIE BOOT POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Service: Meter: Footings: Rough: Rough: House# Foundation: Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace/Chimney: Rough: Oil: Insulation: Final: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: i 1 Q 11-'1 I ' I Fees Paid: $40.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner Department use only ��- City of Northampton Status of Permit: r 'k Building Department Curb Cut/Driveway Permit t, 212 Main Street Sewer/Septic Availability j Room 100 Water/Well Availability �E "e �,� Northampton, MA 01060 Two Sets of Structural Plans ''""" " f phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans ,3 Other Specify ry APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION _. This section to be completed by office 1.1 Property Address: 1015 Westhampton Rd Florence Ma 01062 Map Lot Unit Zone Overlay District Elm St. District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Ronald &Sally Rule 1015 Westhampton Rd Florence Ma Name(Print) Current Mailing Address: 413-320-8740 see contract Telephone Signature 2.2 Authorized Agent: Adam Ouenna vine 160 Old LymanRd South Hadley Ma 01075 Name(Pr' Current Mailing Address: j 413-536-5955 Signatur Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building 13,299.00 (a) Building Permit Fee 2. Eiectricai (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee r-; � L 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2+ 3 +4 + 5) 13,299.00 Check Number ( ( C ) This Section For Official Use Only Building Permit Number: 1 19- ZCZI—Zo5S Date Issued: Signature: /(1) Z/- ZoZ I Building Commissioner/Inspector of Buildings Date operations.aqrs @ gmail.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 KNOW x YEF7 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? YE5 NO IX 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: 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 LxJ Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs ED] Decks [❑ Siding [p] Other[M] Brief Description of Proposed New roof, remove and replace existing install new drip edge, ridge vent, ice and water barrier, pipe boot 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 Ronald &Sally Rule 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 10/13/2021 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 10/14/2021 Signature of Ow er/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 Sign Lure 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 ❑ City of Northampton Massachusetts DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street •Municipal Building Utie, r - Northampton, MA 01060 S ` 410‘'�� 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: 1015 Westhampton Rd Florence 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) IC \440 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. ~`\% , n .. � v.. :. A �� :'vARD Yfr7M DISC-;VER �.... 160 Old Lyman Road•South Hadley•MA 01075 We are Licensed 1.800.NEW.ROOF • 413.536.5955 Fully Insured Email:info@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: 10/1/21 Phone#'s: C: Sally & Ronald Rule H 413-586-3562 W: Street: Email: 1015 Westhampton Rd City,State,Zip Code: Special Requirements: F1or,,nc , MA 01062 NEW GUTTERS AND DOWNSPOUTS PROPOSAL FOR: COLOR WHITE \HOUSE GARAGE OTHER WITH GUTTER COVERS TRIP RECOVER Layers: iy 3 4 Plywood Included: Yes. No Tear off SLATE or SHAKES COMPLETE ROOF PROTECTION SYSTEM: We shall acquire appropriate permits for all work Home exterior and landscaping to be protected / "Strip existing roofing to existing decking with full inspection DO NOT DO: j All project waste shall be removed by dumpster(dumpster for contractor use only) ,r Install Ice&Water Barrier at all eaves 3' &alleys,chimneys,pipes and skylights Install(151b.feltCynthenderlayment over remaining decking area /e"Install Metal drip edge at eaves and rake 5")tijbrown) .install manufacturer's starter shingle on all eaves and rake edges �tnstall new pipe boot - • •/vent accessories y'install ridge ve -Snow Country Cobra rolled/4'Baffled/Roll Shingles: PEWTER GRAY GAF Shingles Color: GAF Ridge cap shingles Warranty Options: I We guarantee our workmanship for full years GAF System Plus Warranty XI 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. $165 per XI Deteriorated existing decking will be replaced at Piece usedand dimensional lumber at$15 per linear ft., after full inspection. Customer Initials: We propose hereby to furnish materials and labor-complete in accordance with above specifications for the sum of: Total Due:($ 13,299 ) ACCEPTANCE OF PROPOSAL:The above prices,specifications and conditions are Down Payment:($ 4400 Pd C k satisfactory and are hereby accepted.You are authorized to do work as specified. 2nd Payment at Start Job:($ 4 4 0 0 ) #4 0 5 Payment will be 1/3 down at signing,1/3 at start of job,and balance due Balance Due Upon Completion:($ 4 4 9 9 ) upon compl0/1/21 n Date: 11 Signature: i Date: 10/1/21 Estimator:(Print Name) Joe Sn pe k ign Name) WF'�f 413-221-4329 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 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 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. ACRL7® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDOIYYYY) 6/24/2021 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT, If the certificate holder Is an ADDITIONAL INSURED,the policy(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 COµ1ALY Sarah Premo NAME; Clayton Insurance en rInc. PHONE (413)536-0804 FAX (A C,Noi: (413)530-7a7s INC,Ne.E3lI; 1649 Northampton Street ASS spremo@claytoninsurance.net P. O. Box 989 INSURER(S1.AFFORDING COVERAGE NAIC fl Holyoke to 01041-0989 INSURERA;Nautilus Insurance Company , INSURED INSURERS;Arbella Insurance CO. Adam Quenneville Roofing 6 Siding Inc. INsuRERc;RIM Mutual Insurance Company 160 Old Lyman Road INSURER D: South Hadley, MA 01075 INSURERS: _— 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. INBR TYPE OF INSURANCE 'ADDL—aUBR POLICY EFF POLICY EXP LIMITS LTR IN main Vn POLICY NUMBER JMMIDDTYYYY) IMMIDPJYYVYI X COMMERCIAL GENERALUABIUTY EACH OCCURRENCE $ 1,000,000 ff ^ 1�v � or OAMAOETO RENTED $ 100,000 A CLAIMS.MAOE f OCCUR PREMISES(Ea e Ram* NN1.293315 6/23/2021 6/23/2022 MED Do(Any one person) S 5,000 PERSONAL P.AOV INJURY 3 1,000,000 GEM.AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2,000,000 X POLICY 7PERCT 7 LOC PRODUCTS-COMP/OP AGG b 2,000,000 _OTHER: b AUTOMOBILE LIABILITY , ~( �p ED SNIT ; 1,000,000 ANY AUTO BODILY INJURY(Par person) E _ B ALL OWNED x SCHEDULED AUTOS X AUTOS 1020107095 6/23/2021 6/23/2022 BODILY INJURY(Per acddent) b NON-OVVNED PROPERTY DAMAGE S X HIRED AUTOS X AUTOS law 1m04010 g 100,000/300,000 UNINSIUNDERINS MOTORISTS X UMBRELLA LIAR ' OCCUR EACH OCCURRENCE $ 5,000,000 A EXCESS LIAR CLAIMS-MADE AGGREGATE $ 5,000,000 DED RETENTION 3 AN1242102 6/23/2021 6/23/2022 $ WORKERS COMPENSATION - X PER OTH STATUTE ER AND EMPLOYERS'LABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE E.L EACH ACCIDENT 9 1,000,000 N I A NH) C (Mandatory in NH) OFFICER/MEMBER EXCLUDED? Y AHC4007012861 4/29/2021 4/29/2022 E.L.DISEASE-EA EMPLOYEE b 1,000,000 If yes,descnbe under E.L.DISEASE POLICY LIMIT 9 1,000,000 DESCRIPTION OF OPERATIONS below III 1 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Ramming Schedule,may be attached If more apace la 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 ACCORDANCE WITH THE POLICY PROVISIONS. 160 Old Lyman Rd South Hadley, MA. 01075 AUTHORIZED REPRESENTATIVE Michael Regan/h'NT "", P i/-^- I ©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 Massacnuserrs L. Department of Industrial Accidents :~ Office of Investigations _ »a= 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): A.err- @1/4)Cr1e'tU t at-t- e-Cij t 5.14,1 y (1 ✓) Address: ILO 01 City/State/Zip: 500\e, heAkca 11''1 v O[015- Phone#: `�13 —53C 5 C155— Are you an employer?Check the appropriate box: Type of project(required): I.. I am a employer with 15 4. ❑ I am a general contractor and f 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 11.[] Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.1.,Roof repairs insurance required.]t c. I52, §I(4),and we have no 13.❑ 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. 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: rl t" (11 u 1 vG k 3 u✓c v' c. Policy#or Self-ins. Lic. #: A wC��0�0 � '�5�. Expiration Date: Va3/a Job Site Address: 1 0 LA e �0.r p�Cr� 2 City/State/Zip: } ( (hO 010C)- 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 certi6 under the pains and penalties of perjury that the information provided above is true and correct. Signature: , Date: 0//1)-1 C, Phone#: �� " ✓3C 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): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: ItDivision of Professional Licensure Board of Building Regulations and Standards Consr4t$41SUpprvisor '1 CS-070626 2:> i''''4'1.- : ::1,. Kitpires:08/21/2023 WOMB(.7'v ADAM Ati oireN*: (.' -,•: 160 OLD LYMAN SOUTH HADLEY PAP:,; , " ;•-' ) , 7.4 :.' 1:12IntAe' le•,. , 'ft Commissioner de.861). K' Yemtita... P7ge (62042vincviutzeald olgieaddadeedea Office of Consumer Affairs and Business Regulation 1000 Washington Street- Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Corporation ‘ , Registration: 191093 ADAM QUENNEVILLE ROOFING AND SIDING,INC. Expiration: 03/22/2022 160 OLD LYMAN RD. SO.HADLEY,MA 01075 Update Address and Return Card, scA I 0 20M-05/17 . — ... sy4s•/,'3,'11„:,1,,,,‘•.''',117,;?!.\ -'7;• " '7.3N%- cFSV:r.r.`•:7.::;‘!,.?/73;:\XI,7'VFN;('!I'FIP.Nr'.73W•r";:'";;;?.i•':r•:K,P4Z1,4:• .,:.,' -' .".•!.. ' . :', '' ;'1 ..:' .' ',:... A,'' .:.:.,.. • .1' ' '.,,y, .. -;•' :'•.,. '''':''.:„ 1. ''..•:,, ''' ••:;.• ;.',.,t',S' ' ' .:•'.: . . •,'.• •• ..1' • • ::•.1 '''•;:ik.. .;14:'.'W ': ..i..'._. ':.•ai_*'.. _. ..._ titi .4Je_ ikiki .',. .. _Ii-Ao'._..1,4_ 41.14•_..ls.A.L.. ___Aii•L -4%it',..:1Qe_L..._:- . lifv:. ...tk__AA':.:.!tfr___.•&,*_1 ..:.,;...•;: STATE S of.CONNECTICUT + DEPARTMENT OF CONSUMER PROTECTION .••• 1 Belt known that , , .,.$.. • , , ADAM QUENNEVILLE 160 OLD LYMAN ROAD SOUTH HADLEY, MA 01075-2632 P....,.. ; ; 1 1 r•"c-,,, ki'-'i ' , ',.,,,• has satisfied the quidifications required by law and is hereby registered as a . . :V,• , I '?:'' HOME IMPROVEMENT CONTRACTOR i - ••••'. ,-„,•i Registration # HIC.0575920 ‘.... I . I r'•::::4 0,'.•.i. ' ADAM QUENNEVILLE ROOFING -, -;.< I Effective: 12/01/2020 k te./A •;.... i Expiration: 11/30/2021 ( Michelle Seagull,Commissioner' : —.1 r• 4. i." --pr-a — 47-V!. ' ;4. 1 ,