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30B-118 (7) BP-2021-2193 65 WARD AVE COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 30B-118-001 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-2021-2193 PERMISSION IS HEREBY GRANTED TO: Project# ROOF Contractor: License: ADAM QUENNEVILLE ROOFING & Est. Cost: 7200 SIDING 070626 Const.Class: Exp.Date:08/21/2023 ZIMBALIST ANDREW S & SHELLEY ABEND Use Group: Owner: ZIMBALIST Lot Size (sq.ft.) Zoning: RR/URA/WP 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 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: I , O To, • • yd Fees Paid: $40.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Buildinc Commissioner �� Department use only City of Northampton /� d status ofPegnit: , R Building Department'' Nov Curb Cut/DrivOway Permit 212 Main Street S Sewer/5eptiCrAvailability Room 100 -T Wate NVeII,Availability ` Northampton, MA 01060 r��im�NC - Two/Sets$f Structural Plans 4` ,c, f . rn phone 413-587-1240 Fax 413-587- ,1`1`o 'ton,t/Site Plans '`' Other Specify 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: _ r` 65 Ward Ave Northampton Ma 01060 Map - ' Lot /1 ) Unit Zone Overlay District Elm St. District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Andrew& Shelley Zimbalist 65 Ward Ave Northamtpon Ma Name(Print) Current Mailing Address: 413-586-7636 see contract Telephone Signature 2.2 Authorized Agent: Adam Quenneville 160 Old LymanRd South Hadley Ma 01075 Name(PRt, ..... 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 7,200.00 (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 1/L/� 5. Fire Protection 6. Total = (1 + 2 + 3 +4 +5) 7,200.00 Check Number 11 I `Cy g / This Section For Official Use Only Building Permit Number: , -a4/101/�/� Date Issued: Signature: /L€ 1 i- )L- 2OZ 1 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 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 x YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained , Date Issued: C. Do any signs exist on the property? YES NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YE! NO x IF YES, describe size, type and location: E. Will the construction activity disturb cl aring, gradin ex avation, 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 IY Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs 0] Decks [❑ Siding ED] Other[M] Brief Description of Proposed New roof on garage, replace existing install new drip edge, ridge vent, ice&water barrier, pipe boot flashing 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 Andrew&Shelley Zimbalist 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 11/10/2021 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 iy / 11/10/2021 Signature of Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: Adam Quennville CS-070626 License Number 160 Old Lyman Rd South Hadley Ma 01075 8/21/2023 Address Expiration Date 413-536-5955 Signature Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ Adam Quenneville Roofing &Siding Inc 191093 Company Name Registration Number 160 Old Lyman Rd South Hadley Ma 01075 3/22/2022 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 A ��,.-,. `), Massachusetts ' i r f' {" DEPARTMENT OF BUILDING INSPECTIONS o *' 212 Main Street •Municipal Building �. Northampton, MA 01060 k���tky „,� � 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: 65 Ward Ave Northampton Ma (Please print house number and street name) Is to be disposed of at: Adam Quenneville Roofing&Siding 160 Old Lyman RD South Hadley Ma (Please print name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: Adam Quenneville Roofing & Siding 160 Old Lyman Rd South Hadley Ma (Company Name and Address) At_.. . itC,\,)-k 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. area arllhs con ILLmireciuit 19 ayA R 9 VISA V S A H r DISC py,°x,,,t 160 Old Lyman Road•South Hadley•MA 01075 We are Licensed 1.800.NEW.ROOF • 413.536.5955 Fully insured Email:in(ok11t10On wro ii oar website:www.1a00newroof.net Factory Trained MA Construction Supervisors tic.#070626 MA Registration N120982 Factory Certified Installers Member of the Home Guilder's Assoc.of western Mass, CT Registration#5/5920 member*,the 8ui1ding P.Trade Association P.P.0 38710 Proposal submitted To: • Date:/0/ 2.`/2)1 Phone Ws: C:9 13'3 70. 6f 6 T`ith° • 1`1 bQ £ cS,t4 L.t f`f Z4 tAl2)VV1-tSI—H: w: Street: Email: 4 Act City,State,Zip Code: Special Requirements: e PROP* _,.,,,,,&: 7� / ( .d, iC SS.E 4II OTHER 1 ,k) 5��� ' 'i i- c U�F-�fl 2 (.,I t Y" STRIp1 ECOVER c }- P 1, erS: 2 3 4 Plywood Included: Yes or No F 1v r ' Q. -i ,,, IC) off SLATE Qr SHAKES COMPLETE ROOF PROTECTION SYSTEMw h 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: _: All project waste shall be removed by dumps (dumpster for contractor use only) Install ice&Water Barrier at all eaves 3'/6',v'ileys,chimneys,pipes and skylights Install(151b.felt/Synthetic)underlayme a r remaining decking area Install Metal drip edge at eaves and ra' s(8 /5")(white/brown) Install manufacturer's starter shingle o . eaves and rake edges Install new pipe boot flashing/vent accessories Install ridge vent-Snow Country/Cobra roiled/4'Baffled/Roll Shingles:(standard 6 nails per shingle) Shingles Color: re)I Ridge cap shingles Warranty Options: we guarantee our workmanship for fa full years GAF System Plus Warranty GM Golden Pledge Warranty Chimney Options: 0 Lead Counter Flashing L:J Water Seal&luckpoint Li Rubberized Crown 0 Cricket 0 Mason needed(customer provided) Additional material and labor charges may apply. es : 'i G We proposer lwrahyt,furryisltmatarlatsandtebor-uimpJeteinacrorefancwwitltagwespesl�atkinsforWaaumof: ' =$ /ZJX), ) ACCEPTANCE OF PROPOSAL:The above prices,specifications and conditions are Down Payment:($21 /0 a ) satisfactory and are hereby accepted.You are authorized to do work as specified. 2nd Payment at Start Job:($Z I `2 U^1 I Payment will be 1/3 down at signing,1/3 at a . ,.lance due Balance Due Upon Completion:($ >C 7 �i •com, n i 2 ! I tom' Date' Estimator:(Print Name) —(Sign Name) 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. tit • ,enpevll a Roofing will not be responsible for debris or dust In the attic or storage areas. -�`if 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 pea-existing structure may reveal additional defects,conditions or the need for additional work,which must be repaired,akered 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, ADOmONAL 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 warrantyof merchantabilky and fitness fora certain purpose.All material is guaranteed to boas specified.All work shall be completed In a workmanlike manner,according to standard practices.Arty 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 tabor 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 tines 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 fall to pay according to the above terms and have not signed our note,the entire unpaid amount becomes tmmedlatety due,and you must pay a collection cost equal to our actual collection costs up to 15%of the total amount you owe,plus attorneys fate and court costa,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 arty 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 covet 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 Omits of one million dollars(51,000,000.00) 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 shaft 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 incc tudrng the provisions relating to price and payment schedule cannot be changed except by a written atetemem signed by both tyre 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 run 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 shaft govern this Agreement.It must be executed In duplicate,and an original,signed copy hereof shall be given to the Owner at time at execution.No work under the Agreement shell begin prior to the signing of the Agreement and transmittal to the Owner a copy thereof. ARBITRATION ran 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 p a( dra ass' ned by the American Arbitration Association to resolve their dispute.Owners in acknowledgement of arbitration lo : 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 payments)you have made. 0 AFRO CERTIFICATE OF LIABILITY INSURANCE DATE(MMIODIVVYY) 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 CUNTALr Sarah Premo .NAME: Clayton Insurance en rInc. PHONE (413)536-08D4 'FAX u",No): (417)176-7e74 .(NC.NO Est): 1649 Northampton Street AOIgiss,spremolialaytoninsurance.net 8. O. Box 989 INSURER(S).AFFORDING COVERAGE NAIC Y , Holyoke MA 01041-0989 INSURER A:Nautilus_Insu,rance.Company INSURED INSURER B:Attalla Insurance Co. Adam Quenneville Roofing b 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 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 A6IIL'SUBR— POLICY EFF POLICY EXP LIMITS L TYPE OF INSURANCE TR „INRn WMn,- POLICY NUMBER (MMIQOIYYYY) EMMIDP(YVVYI X COMMERCIAL GENERALUABIUTY EACH OCCURRENCE 3 EN 1,000,000 n 'DAMAGE TORTES- $ 100,000 A CLAIMS.MAOE t 3 I OCCUR PREMISES(E0 oc i7T6'1C I NN7.283313 6/23/2021 6/23/2022 MED EXP(Any one person) S 5,000 PERSONAL 3 AM/INJURY S 1,000,000 OEN%AGGREGATE UMIT APPUES PER; GENERALAGGREGATE S 2,000,000 JP0LICY[1 PR,: n LOC ' PRODUCTS-COMP/OP AGG S 2,000,000 OTHER: S AUTOMOBILE LIABIUTY ,COM61N�D SINGLE I.FMIT ; 1,000,000` (Es amdeM) ANY AUTO BODILY INJURY(Per person) 3 H AU.OWNED X SCHEDULED AUTOS L020107093 - 6/23/2021 6/23/2022 BODILY INJURY(Per accident) S _AUTOS NON-OWNED PROPERTY DAMAGE i X U FIIRED AUTOS X AUTOS Per eccide 11 IJNINS/UNOERINSMOTORIPTS $ 100,000/300,000 X UMBRELLA LIAR OCCUR EACH OCCURRENCE S 5,000,000 ----a A EXCESS LIAR CLAIMS-MADE AGGREGATE $ 5,000,000 DEO RETENTION 3 9.11242102 6/23/2021 6/23/2022 $ WORKERS COMPENSATION X SAjUTE 01I1-1- ER AND EMPLOYERS'UASILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L EACH ACCIDENT 4 1,000,000 OFFICERIMEMBER EXCLUDED? Y N/A C IMandetory in NH) .A➢WC4007012861 4/29/2021 4/29/2022 E.L-DISEASE-EA EMPLOYEE E L,000,000 If yes.describe under DESCRIPTION OF OPERATIONS below EL DISEASE-POUCY LIMIT S 1.000,000 l DESCRIPTION OF OPERATIONS ILOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may he attached If more space Is requited) Tor 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 SE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 160 Old Lyman Rd South Hadley, MA 01075 AUTHORIZED REPRESENTATIVE Michael Re Tan/b'HT r7 ^- /c f ©1988.2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS023(201401) The Commonwealth of lv.[assacrruseua 1 ` Department of Industrial Accidents MEMO r Office of Investigations '• . 600 Washington Street �— ! Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information c nn ` n �1 Please Print Legibly Name(Business/Organization/Individual): A clean 63.uen ..0 t tk. (2_6 Jt l'1�( t$' Yt i rti�e- ri L Address: (LO 0 I A L.y City/State/Zip: 50v51.N NeAkta (11 K) 010 )5 Phone#: r 3 -53`-5 q55- Are you an employer?Check the appropriate box: Type of project(required): I am a employer with 1.5 4. ❑ I am a general contractor and I 6. New construction employees(full and/or part-time).* have hired the sub-contractors 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 I1.❑ Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL 12.1E Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' I3.0 Other comp. insurance required.] *Any applicant that checks box it must also fill out the section below showing their workers'compensation policy information. 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. l am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. _ Insurance Company Name: u l uG n5 V lc�t L Policy#or Self-ins.Lic. #: A w C_9ao10 `���- ( Expiration Date: tip Il a Job Site Address: 6 ) & ' Af(-- City/State/Zip:A)"kt- e07-1c-\ Thi Q(0C C) 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$I,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 above is true and correct. Signature: / ' Date: I>�O U Phone#: '1 (3 - 5 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#: 11! Division of Professional Licensure Board of Building Regulations and Standards Consrls tkitilp¢rvisor i CS-070626 `lKytpires:08/2112023 ADAM AQUOINEY 4 1' •4' -• 160 OLD LYM N o f l, ` . • SOUTH HADLfyY NWr . li.#0t, Commissioner daik g. Ye . CJ:40 (69047vi2cv2weald olg/liaddadtadeito 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. RCA I s3 20M-05/17 n ,, 'i _i ` ,t 'a;`'•: e;.r,. 1 • „+',.r.•;,• :! t:. i s :', ,t.. ' ' STATE O•F:CONNECTLCUT + DEPARTMENT OP CONSUMER PROTECTION i `Be.it known that i :, ADAM QUENNEYILLE , (.. . 160 OLD LYMAN ROAD , ' SOUTH HADLEY, MA 01075-2632 i ',; l I: 1 i i has satisfied the qualific:ations required by law and is hereby regtstered as a „ i I HOME: IMPROVEMENT CONTRACTOR i 1. 4 I Registration # HIC.0575920 I ADAM QUENNEVILLE ROOFING l '1 Effective: 12/01/2020 .• .. Expiration: 11/30/2021 1 `i. .:• '"" Michelle Seagull.Commissioner i - ';� I ,..,; «, ,. fi l .. fit, S.Y • -n ^v .4.- ,5. J ,�r,