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25A-040 (5)
BP-2021-2256 16 SWAN ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 25A-040-001 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-2021-2256 PERMISSION IS HEREBY GRANTED TO: Project# roof Contractor: License: Est. Cost: 2799 070626 Const.Class: Exp.Date:08/21/2023 Use Group: Owner: DERSHAM DAVID H&MOLLY A WATKINS Lot Size (sq.ft.) Zoning: URB Applicant: ADAM QUENNEVILLE ROOFING & SIDING Applicant Address Phone: Insurance: 1600LD LYMAN RD (413)536-5955 AWC4007012861 SOUTH HADLEY, MA 01075 ISSUED ON:12/02/2021 TO PERFORM THE FOLLOWING WORK: NEW ROOF UPPER LOWER SLOPE OF HOUSE 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: ( ' it '1 . • y9 - ' I Fees Paid: $40.00 212 Main Street, Phone(413) 587-1240,Fax:(413)587-1272 Office of the Buildine Commissioner \� Department use only .rr City of Northamptoth Status of Permit: f``� rl Building Department `-11, Curb Cut/Driveway Permit `X ( j �f►:I 212 Main Street -_._.' Sewer/Septic Availability ' Room 100/ Dee Water/Well Availability � Northampton, MA 01060 / ()C2 Two Sets of Structural Plans ., phone 413-587-1240 Fax 41:4-5Q7-1272 Plot/Site Plans f+1,-;- �'Other Specify APPLICATION TO CONSTRUCT, ALTER, REPAIR, REND E' R DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION This section to be completed by office 1.1 Property Address: �) 16 Swan St Northampton Ma 01060 Map Lot C/ 6-b Unit Zone Overlay District Elm St. District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: David Dersham 16 Swan St Northampton MA Name(Print) Current Mailing Address: 413-923-1860 see contract Telephone Signature 2.2 Authorized Agent: Adam Quenneville 160 Old LymanRd South Hadley Ma 01075 Name(Pri Current Mailing Address: /' 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 2,799.00 (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) (/ 5. Fire Protection 6. Total = (1 + 2 + 3 +4 + 5) 2,799.00 Check Number l j 2,0 1 This Section For Official Use Only 6V aZ) aa-5�p Date Building Permit Number: Issued: Signature: ', /Z 2 20?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 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 clearing, gradin excavation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YE I 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 El Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [D) Decks [❑ Siding i<7] Other[all Brief Description of Proposed New roof front upper lower slope of house, remove&replace existing roofing, install drip edge, ridge vent 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 I David Dersham , 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 11/22/2021 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. Adam Quenneville Print Name 11/22/2021 Signature of 0 ner/Agent Date SECTION 8 -CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Adam Quennville CS-070626 Name of License Holder: 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 19'1093 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 '' Massachusetts /. ,t ',,. DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street •Municipal Building � ,- Northampton, MA 01060 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: 16 Swan St 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) i l it).91(:).i Signature of ermit 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. 11/29/21,7:38 AM David Dersham-1637332936459.jpg(3024x4032) G1 E E WEu}`yFi$ li$ ±sau wltRtr[ WA VISAS ax^. Lyman Road•South Itadley`MA4ln7? We are Licensed i.AQU.NEW.AOOC + 413.336.595B Putty Insured £,",a _a3f-21...sLLt,c.L wes,,ir.www,isdonesortor.not Factory Trained MA cAnstnortd,c,„paru:,,_s i c attnr5,6 Mn ergAteauon a12l>182 Factory Certified Installers eremh -*ce ._:<i M,,. Ci See r a¢,�ii5 r5914 *.T<,.r..,,3r cK a�•ar n¢a;„e.�.v..,N:u,:,„ e ss 36rt o Propaasai Submitted To: Date ?hone d's:413-923-1860 C: Dave Der-sham 11/15/2021 H 413-923-8003(M91Jy) Street. in dersh7234@gmail:com 16 Swan St. a ... . a Maas. sera City,State,Zip Code: Special Requirements: Northam ton,MA 01060 l.�� PROPQSAt FOR: 61TNls. GARAGE 01HHER IBIEINI RECOVER Front upper low 3lnpe section only layers' D 2 3 4 Plywood Included:Yes o No Tear off SLATE Q SHAKES COMPLETE ROOF PROTECTION SYSTEM' R We shall acquire appropriate permits for all work x Home exterior and landscaping to be protected Rest or horse x Strip existing roofing to existing decking with full inspection 00 NOT 00; - X All proiect waste shall be removed by dumpster tdumpster for contractor use only) x Install Ice&Water Barrier at ail eaves 3'®valleys,chimneys,pipes and skylights Sr install(25Ib felt'Sent eticlunderlayment(��over remaining decking area IY x Install Metal drip edge at eaves and rakes 5") i®' brown) x install manufacturer's starter shingle on all eaves and rake edges x Install new pipe boot flashing/vent accessories X Install ridge vent-Snow Country/Cobra rolled/4'Baffled ez Shingles:(standard S nails per shingle) u55F T,mce,l,ne HOZ �.. — Shingles Color: To Be Detemnnod H02 Ridge cap shingles Warranty Options: We guarantee our workmanship for 10 full years OAF System Plus Warranty GAF Golden Pledge Warranty Chimney Options; ., Lead Counter Flashing Water Seal&Tuckpoint l..Rubberized Crown Cricket - Mason needed(customer provided) Additional material and labor charges may apply. a Deteriorated existing decking will be replaced at$5.99 per sq.it.ano ounensional iumaer us;7 DO ia::1.00ar ft., after fur'inspection. Customer Initials:mmw sf Cu • r ry i-rmir matrr ais End labor-complete in accordance oth above senottraoom forme sum of Total Due:)$ 2.79'3.00 ) ACCEPTANCE Or PROPOSAL-The above prices,specifications and conditions are Down P ment:IS 999 ) satisfactory and are hereby accepted.You are authorized to do work as specified. 2ntl Payment tart Job:($ 900,Of) ) Payment will be 1/3 down at signing,1/3 at start of Job,and balance due Balance Due Upo ompietio q�900_00 IuPan r t g. = MVatkins (14C4 Date- :gnaaae yo�� SiMitJkier -ry,,��1 /� [Yste. 'T;t?x'?9-� Crt,n,atr,IPrint Name) {Sign Narne)�X�3..L"¢aL Y/K.Kft'�",A.4. r.a-.`' ATTENTION HOMEOWNERS Please cower 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.• .,a https://wwwl.marketsharpm.com/VF_Attach/850/74122/David Dersham-1637332936459.jpg 1/1 A CC)R!Y CERTIFICATE OF LIABILITY INSURANCE I 6 /2 4/20"":;;21 ' ,.. 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 CER11FICATE HOLDER. IMPORTANT` If the certificate holder Is an ADDITIONAL INSURED,the poilcy(les)must be endorsed. It 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 _/CG 2T Sarah Aremo Clayton Insurance Agency, Inc. PHgONa t4L3)536-0804 tg1Jc,Nq): tataltle-»Te '1 J is atilt 1649 Northampton Street ao�aesy:spramo3alaytoninsuraneu.not B. O. BOX 909 INSURERS(AFFOROING COVERAGE NA:C a Holyoke KA. 01041-0989 +NsuReRA:Nautilus Insurance Company — INSURED INSURER a:Arbella Insurance Co. Adam Quenneville Rooting' G Siding Iuo. INSURER C:ADS Mutual Insurance Company i 160 Old Lyman Road 'Nausea D South Hadley, KA 01075 'r:suPeg e r MAURER R 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. Trawl— 'A'9TS�III POLICY SEE POLICY EXP LIMITS 4� TYPE CP INSURANCE ..03204.wD_ R,DLICYNUKDFR FICOI`YYYI,tVM10`ONYYYr,_ X COMMERCIAL GENERAL UABiUTY EACH OCCURRENCE 3 1,000,000 "TDIAOG TOREFD 100,000 A ,CLAIMB MADE X I OCCUR pmgonI5BJ le,( RGA+rr5'eI 3 NN1213313 6/23/2021 6/23/2022 MED EXP I,hny one maw) f 5,000 PERSONAL S AOV INJURY s 1,000,000 ' OENLAGGRevATE LIMIT APPLIES PER: GENERAL AGGREGATE 1 8 2,000,000 X I J Jar LOC PRODUCTS.COMP/OPAGG f POLICY 2,000,000 OT)IER: 8 AUTOMOBILE WAS IUTY "CGsABrNEO SINGliuWT j 1,000,000 (Err unie d ANY AUTO BODILY INJURY(Per parson) 7 B AU.OWNED SCHEOIJLED TOS 1020307693 6123/2021 6/2712022 60DlLY INJURY(Per acodenlJ 3 AUTOS ©NON--OWNNED wtooERTr OAuAde e _x. HIRFO AUTOS ©AUTOS ,-.ELL,tea UNINSAJNOTRIN3 MOTORISTS $ 100,000/300,000 X UMBRELLA UAB OCCUR EACH OCCURRENCE S 5,000,000 A EXCEaBUAB CLAth1S•MAOE AGGREGATE ,a 5,000.000 CEO I 1 RETENTION S AN1242102 6/23/2021 6/23/2022 S WORKERS COMPENSATION X SrA DISH- rntuT ER AND E4tpLOYERB'UABX.ITY Y I N ANY PROPRIETOR/PARTNER/EXECUTIVE EL EACH ACCIDENT 4 1,000,000 OFPICERtHIEMOCR EXCLUDED? !Y 1 N I A C (Mandatary in NH) '1U1C1001012ee1 4/29/2021 4/29/2022 EL.DISEASE•EA EMPLOYEE S 3,000.000 Ir/as,dda:dba under E.L.DISEASE POLICY UMR f 1.000.000 DESCRIPTION OF OPERATIONS Delow - .. DESCRIPTION OP OPERATIONS 7LOCATIONS I VEHICLES(ACORD 101,AddlSarel R.msr'es Schedule.may be elte abed It mon space le required) 9'or Informational Purposed, Only CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Adam Qi anneville Rooting 6■ Siding' Ina 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/EMT rr z....' P ..,. _ I - Cat 1988.2014 ACORD CORPORATION. All rights reyurvut). ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD IN3025(2o140u l:,Warn. , Office of Investigations " "" 600 Washington Street %i :. . ,, $ Boston, MA 02111 www.mass.gov/dia Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information /� ��}} Please Print Legibly Name(Business/Organizationilndividual): A�&r1 Qv ene A)t t k. ( is t 16 + Yt d. r (fig(- Address: i GO 0 1 A L*I' ___ City/State/Zip: 5au h heAlc,4 (hica 0l05. Phone#: Li 13 -53C-5(15 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 I employees(full and/or part-time). have hired the sub-contractors 6. ❑ New construction 2.❑ t am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g, 0 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 3.0 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.FI Roof repairs insurance required.)t c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other comp. insurance required.] "Any applicant that checks box#l 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. tContractors 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 infornunion. _ Insurance Company Name: ie. n�0 f< v'\ c Policy#or Self-ins. Lic.#: A WC.4100101 D'TC 1 Expiration Date: 1 J a(1/a Job Site Address: 16 Swan St City/State/Zip: Northampton Ma 01060 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$250,00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DEA for insurance coverage verification. I do hereby ceritbmuttiorike pains and penalties of perjury that the information provided above is true and correct. Ada,, Quennev/(e �- 11/22/2021 Signature: Date: .e;_, c Phone#: 11 (3 - 'D . c — 5 9 5 5- Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: Constv0t$iittippryisar CS-070626 ::.> vv't. ..'"::.f. ,. 6c.,pires:08/21/2023 ADAM A QUe,,IONEV'',,-iliP„1:7,• -;: 160 OLD LY4N ottg ,'•,:i.' -;,', .-.-,-. 4. SOUTH HAOLV Mil ..,l ,,t; • " > .3 ,., ,, •1 '4:, t .w•''' ,1*. ., • Commissioner de)? K Yeem.i.w.... ... _ . . _. _ . ._ .... . ....._... . g?"%e (604,vinowaxAa4 chiglicazzokaaela 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. Registration: 191093Expiration: 03/22/2022 160 OLD LYMAN RD. ' SO.HADLEY,MA 01075 Update Address and Return Card. SCA I 0 ZOM-05/17 . . .,/,` ,`,',T,:17.7"Ni.'''-'-\Vr,--^,, ''''T"\t/•"-',"N.,',„?'":7-\!,, 'r*,':\y"-;',V,77, -,--V-,'—'N',71:•-:'\'/',7,-'\!,""* .t'' ';''''' '''','N(`:-:,;',.N.!7'7N/" .'.*".),'T'v,'1" ..\\/, ,:,,' '; : . .: . : .2. ' : ' : : ' . . 2 ' *.;' ' ; • ., ' ' ' . ' :, — , ' ,', '.:I'''.s.< 4,...,v_ 4.Ar. .1,fr, 41.fr, .41S.P., 111.P`,.. A.,- ,e1fr. ,?'...AP'.. *OP 14.fr, stde.. t.fr. 11,r. .*.fr_ *.P. 4tt.._ .. ,, . ... . .. II* ...` r --1 ;,. STATE OF.CONNECTICUT + DEPA.RTMENT OP' CONSUMERRO PTECTION' it n, 'Belt known that . to' ',,, 4,' :i•' ADAM QUENNEVILLE .,..: ',' .,,. 160 OLD LYMAN ROAD SOUTH HADLEY MA 01075-2632 / .;;.,.: ...„, . ..: .0 )1• ' has sart.sfied the qualifications required by law auci is hereby registered as a . • . -• HOME IMPROVEMENT CONTRACTOR kt '• Registration # HIC.0575920 „., Fsi 41';' ):t Cfr ADAM QUgNNEVILLE ROOFING 1 ".-..; Effective: 12/01/2020 4./4 .ie4, 0.10 Expiration: 11/30/2021 Michelle Seagull.Com misalorer - - - -- — fir;•\.\%, A A