38A-079 BP-2021-2192
48 CHAPEL ST UNIT G COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
38A-079-001 CITY OF NORTHAMPTON
Permit: Alts Renovations
Repair
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
Permit # BP-2021-2192 PERMISSIONIS HEREBY GRANTED TO:
Project# SKYLIGHTS Contractor: License:
ADAM QUENNEVILLE ROOFING &
Est. Cost: 5999 SIDING 070626
Const.Class: Exp.Date:08/21/2023
Use Group: Owner: SMITH NANCY
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:11/17/2021
TO PERFORM THE FOLLOWING WORK:
NEW SKYLIGHTS
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: Atv\&_,i
,
Fees Paid: $100.00
212 Main Street, Phone(4l3)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
Versionl.7 Commercial BuildingZPermit May 15, 2000
Department use only
City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
NOV 1 5 2021 I 212 Main Street Sewer/Septic Availability
• I Room 100 Water/Well Availability
• i Northampton, MA 01060 Two Sets of Structural Plans
• ,THA•,IProC.MAdl. prre 413-587-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT, 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
48 Chapel St Unit G Northampton MA Map Lot Unit
Zone Overlay District
Elm St. District CB District
SECTION 2 -PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Nancy Smith 48 Chapel St unit G Northampton Ma
Name(Print) Current Mailing Address:
413-320-8633
Signature See contract Telephone
2.2 Authorized Agent:
Adam Quenneville Roofing & Siding 160 Old Lyman Rd South Hadley Ma
Name(Print) Current Mailing Address:
413-536-5955
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building 5, 99,00 (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4)
4. Mechanical (HVAC) " __ I C'
5. Fire Protection
6. Total = (1 + 2 + 3 +4 +5) Check Number 1q
This Section For Official Use Only
Building Permit Number Date
�� �� •�!`/, Issued
Signature:/ !'Z
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❑ Repairs® Additions ❑ Accessory Building
Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other
Brief Description 3 new skylights,remove existing and install new velux skylights install ie and water barrier per manufactors instructions
Of Proposed Work:
SECTION 5-USE GROUP AND CONSTRUCTION TYPE
USE GROUP (Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A-1 ❑ A-2 ❑ A-3 ❑ 1A I ❑
A-4 ❑ A-5 ❑ 1 B ❑
B Business ❑ 2A ❑
E Educational ❑ 2B I ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
I Institutional ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ 3B ❑
M Mercantile ❑ 4 ❑
R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑
S Storage ❑ S-1 ❑ S-2 ❑ 5B ❑
-
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)
1 s _. 1st
2nd
O 2
_____ "d I _. 0
3u _ - 3rd _ 0
•
Total Area (sf) Total Proposed New Construction,(sf)
Total Height(ft) i 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
J La
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 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 ? YE5. NO
IF YES, describe size, type and location:
E. Will the construction activity disturb clearin ,gradin excavation, or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Version1.7 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 12
Name(Registrant):
Registration Number
Address
Expiration Date
Signature Telephone
9.2 Registered Professional Engineer(s):
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
9.3 General Contractor
Not Applicable
Company Name:
Responsible In Charge of Construction
Address
Signature Telephone
Versionl.7 Commercial Building Permit May 15,2000
SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes No
SECTION 11 -OWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
Nancy Smith , 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 11/09/2021
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 penalties of perjury.
AcQa,',nc .) n i i
Print Name
11/09/2021
Signature o 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 x No
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: 48 Chapel St Unit G Northampton Ma
The debris will be transported by: Adam Quenneville Roofing & Siding
The debris will be received by: Adam Quenneville Roofing &Siding
Building permit number:
Name of Permit Applicant Adam Quenneville Roofing &Siding
11/09/2021 i4/i/
Date Signature of Permit Applicant
Irzy
AWARD VISACZ
160 Old Lyman Road•South Hadley•MA 01075 We are Licensed
1.800.NEW.ROOF • 413.536.5955 Fully Insured
Email:info(ca1800newroof.net Website:www.1800newroof.net Factory Trained
MA Construction Supervisors Lit.#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: I Phone#'s: C:
Nancy Smith/Wildwood Court 11/8/2021 H: W:
Street: Email:
48 Chapel St. Unit G
City,State,Zip Code:
Northampton, MA 01060
Proposal to furnish and install the following:
We will pull all appropriate permits associated with skylight installation
Skylight will be installed in conjunction with new roofing system Yes/No
We will remove and dispose of shingles around the perimeter of the skylight
We will remove and dispose of 3 exisitng skylight(s)
We will provide and install 3 Velux skylights &associated flashing kit
Skylight will b-11271 unit / vented unit
Skylight model C06
We will install ice and water barrier per manufacturers instructions around skylight perimeter
We will install new shingles around skylight perimeter
Shingle color Closest Match-Weatherwood
Skylight will have factory installed solar blind Additional 649.00each =1,947.00 to be added to total
Federal tax credit eligibility 26 %If solar blind is choosen
Federal tax credit savings 2.065.96 If solar blind is chooser,
Solar blind will be Light Filtering/Room Darkening
No interior trim work is associated with the skylight installation
Please clear and cover area directly below the skylight prior to work commencement
Any deteriorated wood will be replaced at 5.99/sq ft 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 Qupptri ville Roofing will not be responsible for debris or dust in the attic or storage areas.
Customer Initials: r��J
We propose hereby to furnish materials and labor-complete in accordance with above specifications for the sum of: Total Due:($ 5,999.00 )
ACCEPTANCE OF PROPOSAL:The above prices,specifications and conditions are I Down Payment:($ 1,999.00 )
satisfactory and are hereby accepted.You are authorized to do work as specified. I 2nd Payment at Start Job:($ 2,000.00 )
Payment will be 1/3 lown at signing,1/3 at start of and bala due � jI Balance Due Upon Completion:io ($ 2,000.00 )
upon comp , /s'2yt / L{ (d (�/ �9
Date: �� r P Signature: /7/ e JO 144 (,(n/.il
Date: 11/8/2021 Estimator:(Print Name) (Sign Name) 4 5 7,YZe Zjie.,c-
Estimates are honored for sixty(60)days from above dote.
VOTICE OF SCHEDULE CHANGES
—he contractor agrees that when delays become known to the Contractor,the Contractor will advise the Owner as soon as reasonable.
CELAYS 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 addition;
defects,conditions or the need for additional work,which must be repaired,altered or carried out in order to commence or complete the work describes
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 te-
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 he and
are hereby passed through directly to the Owner.Under such manufacturer's warranties,the Owner may be required to register or mall in a warranty card
or other evidence of ownership and use of such equipment in order to activate such warrantee:,
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.accordine to standard practices.Any alteration or deviation from above specifications involving extra costs will be executed only
:non 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 manne;
NO ACCELERATION OF PAYMENTS BUT ESCROWING ALLOWED
Inc 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
`Se 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 rnust 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 ciarm
i..ainst you wnicn may oe 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 inlur.
The Contractor recognizes his obligation to maintain a workers'compensation insurance policy to cover his employees.Contractor further recognizes tot
obligation of any and all subcontractor to maintain a workers'compensation policy to cover their employees.
-)ntractor 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 t;
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
1wner may cancer this contract within three business days of executing this document.Such cancellation must be in writing and delivered to the Contractor.
',ontractor 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 A Siding Inc.If we cancel,we will promptly return any down payment(s)you have made.
I ® DATE(MM/DONYYY)
ACCIRD 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.
IMPORTANT, If the certificate holder Is an ADDITIONAL INSURED,the pollcy(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°
,NAM6;
Clayton Insurance Agency, Inc. PHONEQ )( (413)536-0804 FAx
(Alc,No)%ulnsse-,a,a
ex
1649 Northampton Street A0DRESS, apremO@ laytoninsurance.net
P. 0. Box 989 INSURERS'AFFORDING COVERAGE NAIL Y
Holyoke MA 01041-0989 INSURER A;Nautilus_Insurance.Company
INSURED INSURER B:Arbella Insurance Co,
Adam Quenneville Roofing 6 Siding Inc. IN9URERC:AIM Mutual Insurance Cospany
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 POUCY PERIOD
INDICATED NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR TYPE OF INSURANCE 'At�L SUBR POLICY EFF POLICY EXP LIMITS
LTR INSJI MO POLICY NUMBER IMMIOOlVYYY) (M aiveYY�
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
A CLAIMS-MADE X OCCUR PREp oTED 100,000
PREEMMISES lS acrrrndny) 5
NN1.283315 6/23/2021 6/23/2022 MED EXP(Any one person) S 5,000
PERSONAL S ACV INJURY 5 1,000,000
OWL AGGREGATE UMITAPPUESPER: CENERALAGOREGATE S 2,000,000
X POLICY n zo, 1-1 LOCPRODUCTS-CQMPIOPAGG S 2,000,000
S
OTHER:
AUTOMOBILE LIABILITY 6.CC.IOINED SONGL6 LIMIT 5 1,000,000
(Ea am6 1I
ANY AUTO BODILY INJURY(Per person) 3
B ALL OWNED SCHEDULED
AUTOS X AUTOS 1020107995 - 6/23/2021 6/23/2022 BODILY INJURY(Per acodent) 3
NON-OWNED PROPERTY DAMAGE y
rX FUREDAUT09 R AUTOS IPaNnll $ 100,000/300,000
UNINSNDERINS MOTORISTS
X UMBRELLA LIAR OCCUR EACH OCCURRENCE S 5,000,000
- --
A EXCESS LIAR CLAIMS-MADE AGGREGATE S 5,000,000
DEC RETENTION 3 AN1242102 6/23/2021 6/23/2022 $
WORKERS COMPENSATION X P8R 0TH
AND EMPLOYERS UABH.ITY STATUTE ER ,
YIN
ANY PROPRIETORIPARTNERIEXECUTIVE E.L EACH ACCIDENT S 1,000,000
OFFICERIMEMEER EXCLUDED? Y N IA
C (Mandatory in NH) •AWC4007012661 4/29/2021 4/29/2022 E.L.DISEASE-EA EMPLOYEE 5 1,000,000
If yes,describe under
DESCRIPTION OF OPERATIONS below E. DISEASE-POUCY LIMIT $ 1.000,000
} 1
DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space la required)
For Informational Purposes Only
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Adam Quenneville Roofing Siding Inc THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
ACCOROANCE WITH THE POLICY PROVISIONS.
160 Old Lyman Rd
South Hadley, Mk 01075
AUTHORIZED REPRESENTATIVE
Michael Regan/Ef-(T ry / P -"
1
Cep 1S88•2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
INS025(2D1aap
The Commonwealth of Massacnuseus
.. Department of Industrial Accidents
="Sar Office of Investigations
�" 600 Washington Street
•� c Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information /� n Please Print Legibly
Name (Business/Organization/Individual): A cle , GI erysw t tl t., ( cic)�1 t 1 4
Address:
i G0 0 City/State/Zip: 5OvIV\ 1\1 obt3 (' K) Oio)c Phone#: Ll13 —53c.`5(155—
Are you an employer?Check the appropriate box: Type of project(required):
1..gr I am a employer with 15 4. ❑ I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. ID 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'
[No workers'comp. insurance comp. insurance.: 9. ❑ 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 11.❑ Plumbing repairs or additions
myself. (No workers'comp. right of exemption per MGL 12E1 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: t" M v vCkt n3 t)✓'�'�c�'
Policy#or Self-ins. Lic. /it: A w C dOol o I - "C Expiration Date: r/o II a
y` �
Job Site Address: !'X+,'r City/State/Zip: /Uc,t; -. 1 Mil Q/pG G
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 pains and penalties of perjury that the information provided alloy is true and correct.
Signature: Date: � di
Phone#: 4( f 3 ` 5 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#:
VI Division of Professional Licensure
Board of Building Regulations and Standards
ConstNtftfhttoitUpprvisor
`1
CS-070626 2:> .ew Aires:08/21/2023
ADAM A QUE,IONEy.'c i'• .e ';• ,:
160 OLD LYMANo f1 a
' SOUTH HAOL�,Y . 1
f�� i
r(�,1�•t'tl* s
CJ ?,
Commissioner ,diw K. L7G aba....
Q. o/ri�/lf2Q4'uteetil G ai Ci a laduaP d
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
180 OLD LYMAN RD.
SO.HADLEY,MA 01075
Update Address and Return Card,
SCA I o 120M-05/17
:{•� .}(,: ;/•(%V((.'tom^•Y',:i• r' P'�yt,��.,, ;` i:i.. .�,n:^T.,. .,, •1' ,+•• � ���..v�. .:,;
',:•;',::J::,s,',.;.,Z.;,.s.':s.::.,F:..
: *� �,-#. k4 ate_ 4.�_ ..+o _ �.�+_ _1,.•� .�_ �w�`:tir_.;A_ :�; tfr_ :�_ *.� �"�r_ .+,.fr_ .,p_._-o,': _ p_.
STATE OF:CONNECTICUT + DEPARTMENT OF CONSUMER PROTECTION 1.;
I, 'tie it known that A:�. ?/
1 ADAM QUENNEVILLE ,
160 OLD LYMAN ROAD . ' it ,
SOUTH HADLEY, MA 01075-2632 Ii ,,
". i I z
ti
, ,
I is-
>' has sattstied the yu thtu:at.ious_required by law and is hereby registered as a'r 1 HOME IMPROVEMENT CONTRACTOR
Registration # HIC.0575920
, , 1 ADAM QUENNI:VILLE ROOFING ;;<�'.:
'�`.' I Effective: 12/01/2020
Expiration: 11/30/2021
i.y.- Michelle Seagull,Commiwiloeer
i (irk
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