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36-324 (3) BP-2021-2288 238 CARDINAL WAY COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 36-324-001 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-2021-2288 PERMISSION IS HEREBY GRANTED TO: Project# REPAIR ROOF Contractor: License: Est.Cost: 2762 070626 Const.Class: Exp.Date:08/21/2023 Use Group: Owner: MASAMITSU MICHAEL J & DIANNA L 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:12/14/2021 TO PERFORM THE FOLLO WING WORK: REPAIR HIP&RIDGE 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 .5.2 • 59,31T Fees Paid: $40.00 212 Main Street, Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner Department use only o 1:4A►rt r�'�, City of Northampton ,' ,,,,r Status of Permit: 1'Tp;1r" Building Departmen ' C •::.- Curb Cut/Driveway Permit 1 ,; 2 212 Main Street '-/ Sewer/Septic Availability ' Room 100 Water/Well Availability , , , ,.0 ..r:304 Northampton, MA 1060 C 1 0 Two Sets of Structural Plans a ' phone 413-587-1240 Fax. i -587-1272'C- Plot/Site Plans Or- ^ F,Tti�`<<0, `/^ 9ther Specify j APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENBVAT.g1 i EMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be completed by office 238 Cardinal WayFlorence Ma 01062 Map - Lot --->._)-y Unit Zone Overlay District Elm St. District CB District SECTION 2 -PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Michael Masamitsu 238 Cardinal Way Flroence Ma 01062 Name(Print) Current Mailing Address: 413-727-2496 see contract Telephone Signature 2.2 Authorized Agent: Adam Quenneville 160 Old LymanRd South Hadley Ma 01075 Name(P t) 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 2,762.00 (a) Building Permit Fee Electrical 2. ���,,��,�al (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) -0 40 5. Fire Protection 6. Total = (1 + 2 + 3+4 + 5) 2,762.00 Check Number f i ,3" This Section For Official Use Only Building Permit Number: c I - as U DateIssued: �` 7�7 Signature: i j 2-15-uzi 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 ? YES 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 jI 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 X Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [El] Decks [El Siding [1=1] Other[al] Brief Description of Proposed repair hip& ridge on homeGAF snow country ventalation 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 Michael Masamitsu 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 12/06/2021 Signature of Owner Date I, Adam Quenneville , as Owner/Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. Adam Quenneville (1, Print Name J % 12/06/2021 Signature of Owner/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 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 Addr Expiration Date '/ �_____ Telephone413-536-5955 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 r � � Massachusetts '-\\Y! :tal µ, t k �_+, f DEPARTMENT OF BUILDING INSPECTIONS c f �e�' 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: 238 Carndinal Way Florence Ma 01062 (Please print house number and street name) Is to be disposed of at: Adam Quenneville Roofing&Siding 160 Old Lyman RD South Hadley Ma (Please print name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: Adam Quenneville Roofing & Siding 160 Old Lyman Rd South Hadley Ma (Company Name and Address) /( ir-\OP\ \ 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. ZSL...11cV2;2\, io A X- GeRWiiiI QU NNEVILLE ROOF z' °(, WINDOWS More Life. Less Money. Guaranteed. ,F1140 160 Old Lyman Rd • South Hadley, MA 01075 1.800.NEW.ROOF • 413.536.5955 Email: roofshampoo@l800newroof.net Website: www.1800NEWROOF.net MA Construction Supervisors Lie.#070626 MA Registration#191093 Member of the Home Builder's Assiociation of Western Mass. CT Registration#575920 Member of the Building and Trade Association Customer Michael Masamitsu Address: 238 Cardinal Wa annamasamitsu31@gmail . com' - City: Florence State: MA ZIP: 01062 Em f 'm1234@comcast .net _-- Home: 413-801-0991 Office: Cell: 413-727-2496 NO BILL WILL BE SENT -- PAYMENT DUE UPON COMPLETION OF WORK. Roof Shampoo® is the eco-friendly roof cleaning solution that does NOT contain chlorine bleach. The proprietary Roof Shampoo®product is safe for your landscaping. Our state-of-the-art equipment delivers a soft, gentle low-pressure water rinse. Absolutely NO damaging high pressure and NO scrubbing. The Customer agrees that Adam Quenneville Roofing has the right, at its sole discretion, not to proceed with the job if working conditions are deemed unsafe. In addition to algae growth, which is characterized by dark, streaking stains, some roofs also have lichen colonies, fungus, and moss. Lichen colonies,moss,and thick algae sometimes eat through the granules on the shingles into the roof deck. Removing these may reveal granule loss caused by the lichens,moss,or thick algae growth.Adam Quenneville Roofing is not responsible for granule loss due to the damage caused by lichen colonies, moss,and thick algae. The Customer affirms that there are no existing roof leaks,failed flashing,leaky vent pipes,or other opportunities for water intrusion into the home or basement through windows,foundation cracks,etc. Roof MaxxTM is an all-natural plant based treatment that's 100% safe for people, pets, property, and the environment.A renewably sourced, bio-based alternative, Roof Maxx's scientific formulation uses the latest green technology offering benefits to worker and consumer health, the environment, America's economy and energy security. 100% SAFE BIO-BASED... GREEN AND CLEAN! Adam Quenneville Roofing hereby offers to perform the work listed below for the amount shown. Shingle Color: Weathered Wood DESCRIPTION OF WORK AREAS Roof Maxx $ Clean algae,fungus,and/or moss related stains by treating areas(s)indicated Roof Shampoo $ 3, 570 below. Roof Tune Up $ 495 Roof in Front of House Only Roof in Back of House Repair $ 3, 250 Coupon Discount $ 1, 097 X Entire Roof Other Affected Areas 6 218 Repair: Hip and Ridge Repair on home Total All Services $ , GAF Snow Country Ventilation 3, 218 *5 Year Transferable Roof Maxx TM Warranty Deposit Received $ *1 Year Roof Shampoo® Guarantee of no re-growth* Balance Due $ 3, 000 DATE: 12/0 4 CUSTOMER SIGNATURE:ACCEPTANCE OF PROPOSAL:The above prices,specifications and conditions are satisfactory and are hereby accepted.You are authorized to do work as specified.Payment will be 1/3 down at time of signing,and balance due upon completion. DATE: 12/0 4 SALESPERSON:(Print Name) Ron Dion (Sign Name) AC D CERTIFICATE OF LIABILITY INSURANCE [An(MMIDONYYY) ',64.--''' 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 en ADDITIONAL INSURED,the policy(los)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 MPPA"' Sarah Prmmo Clayton Insurance Agency, Inc. "ONE (413)535-0804 1i ,c,Nol: taxat114-Te14 1649 Northampton Street q Ar `M remo@ala toninsurance.net AOORE+e$t Y _ P. O. Sox 989 INSURER($)AFFORDINO COVERAGE NAIC Y Holyoke MA 01041-0989 INsuRERA:Mautilus Insurance Company INSURED INSURER H:Arbella Insurance Co. Adam Quenneville Roofing & Siding Inc. mmAteRC:AIM Mutual Insurance Company 160 Old Lyman Road INSURER D: South Hadley, MA 01075 INSURER e: I 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 PODGY 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 —._._ iFR /�OTiL � ` ___�... I POLICY._._..__._.. .. EFF POLICY ail, c� TYPE OR INSURANCE ;NCO•MD, POI,ICV NUMpER (MM IY VI fflDVY 0,2j0cpryvyi LIMITS X COMMERCIALGENERALUABIUTY _____ g 1,000,000 A CLAIMS-MADE X OCCUR 0� #5Ai% F 100,000 ,..._.,.._.. 'SrIEM 3P.5 tea x�ms�ak $ v� .W N1412813:5 6/23/2021 6/23/2022 MED EX^(Any one parson) S 5,000 PERSONAL A AOV INJURY $ 1,000,000 'DEN'L AGOREGATE LIMITAPPUES PER. GENERALAGOREOATE S 2,000,000 ( X (POLICY r Lin. + i LOG pROOUCTS-COMPt0P AGO S 2,000,000 ort.ER� 5 au7oMoSILE Uaalu ry cc itepl4P1]I E LOUT S 1,000,000 H ANY AUTO BODILY INJURY IF?‘Pernonl 3 AU.OWNED X SCHEDULED AUTOS AUTOS /020107095 6/23/202L 6/23/2022 BODILY INJURY(Per acc.dentI S X HIRED AUTOS X EON-0WNED PROPERTY DAMAGE 3 _ - UNINGN IN NOERS MOTORISTS 5 100,000/300,000 XI UMBRELLA LIAR ^� OCCUR EACH OCCURRENCE $ 5,000,000 A EXCESS LAB CLAIMS-MADE AGGREGATE S 5.000.000 0e0 RETENTION 5 A141242102 6/23/2021 6/23/2022 5 WORKERS COMPENSATION PER I 0TH- ANDEMPLOYERS'UABILITY YIN X 91'AiUrE 1 ER ANY PROPRIETOR/PARTNER/EXECUTIVE I E.L EACH ACCIDENT S 1,000,000 OFFICER/MEMBER EXCLUDED? Y N f A C (Mandatory in NH) AWC4007012861 4/29/2021 4/29/2022 E.1. DISEASE•EA EMPLOYEE S 1,000,000 If yyea,dnS.nbO under DESCRIPTION OF OPERATIONS below E.L.DISEASE POUCY LIMIT F 1,000,000 r DESCRIPTION OF OPERATIONS f LOCATIONS!%rescues(ACORD 101,Additional Remarks Schedule,may by attached It more spade la required) 9'or tnfarmational Durpaaoe Only CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Adam Qnenneville Roofing 6 Siding Inc THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN 160 Old Lyman Rd ACCORDANCE WITH THE POLICY PROVISIONS. South Hadley, MA 01075 AUTHORIZED REPRESENTATIVE I Pii2:h<i a; Regan/MT /�CoGrwa� ' CO 1088-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025(201401) The C'ommonweaun of tvtassacnusem, .., Department of Industrial Accidents MOM•11 _,'' — Office of Investigations 600 Washington Street r —,:= ' Boston,MA 02111 •..�� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information /� f 1 Please Print Legibly Name(Business/Organization/Individual): A e eztn, t//�-� lrN-v,.uuer t ttt, dt t 76 (rei(, Address: (GO 0 I ►vv,,. CA. City/State/Zip: 5o01.N 1\1t ,tcz Pt) O[©'ic Phone#: L(13 -53L 5g55" Are you an employer?Check the appropriate box: Type of project(required): 1.4 I am a employer with 15 4. ❑ I am a general contractor and 1 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 g, El Demolition workingfor me in anycapacity. employees and have workers' p n' 9. ❑ Building addition [No workers'comp. insurance comp.insurance.: required.] 5. [] We are a corporation and its 10.❑ 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.❑ Roof repairs insurance required.]i' c. 152,§1(4),and we have no employees. [No workers' 13.0 Other comp. insurance required.] "Any applicant that checks box III 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 subcontractors 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: 1 t- ("i v 1 vek‘ Policy#or Self-ins. Lic. #: A W C,4 00101 agC ( Expiration Date: Vail 9 D 238 Carindal Way Florence Ma 01062 Job Site Address: City/State/Zip: _ 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 certibtanderilte pains and realties of perjury that the information provided above is true and correct. Aciad' CZuennel/((e 12/06/2021 Signature: Date: Phone#: ( 1' — 5 3L - 5 15 c-. Ofcial 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#: 1 .-- Commonwealth of Massachusetts Vi Division of Professional Licensure Board of Building Regulattons and Standards Constractibititopsvisor it CS-070626 ' V;;' ,,; tre3prres:08/21/2023 ADAM A QUENNEV4I0 ' ri 180 OLD LYMAN RO',4 4 SOUTH HADLEY MA '', ,'' ' 0 \\ Commissioner & .0, K tfepicha o (1 eliVit())1 flieri& ( f1a ddarAreooa, 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. seA I i.'s zor,t-oll7 •':.•:`-'''.:,1: '..,o,.':,.,AA:.:A.y,,,.''4i,?k,.'',;,.,N-„,„..4'v,%...:,„,44„-zer-,'4,,ir 1'-,,,o4J-!.'..,;'.3',4.1',..0 f.):,,,,o,;:•34:.",;,,,,A,,,,:'..„.4.-m,-,,,,*,-,..v,,,,,,:,-,,,,,lf--,,,li.:.:tz'''',',.? .;,-#... :4,,, , ..,fi, ', A '''.I.' .'.4t '''.,...,ii r', ,-,,li',"'''.1,,,:-..*:;,:42,,,i7,4,,,,,,,.,4..-„,4.-i:..-.ii.,, ,, ,,,,,i,• •„I -y.,4, ,. . 4, -..-,•,..1...,,- ' ,;,/, s', ,1 :,:)i,-,',...4,, 11..--4 . . i `,.., STATE OF CONNECTICUT + DEPARTMENT OF CONSUMER PROTECTION 7.. .4' Be it known that 7 at ADAM QUENNEVILLE ,.. , \., 160 OLD LYMAN ROAD . , a SOUTH HADLEY, MA 01075-2632 ) i 4 I * R •:,:' has satisfied the qualifications required by law and is hereby registered as a v * HOME IMPROVEMENT CONTRACTOR Registration # HIC.0575920 :,.'4,--. ; ADAM QUENNEVII.I.li ROOFING "A.\.... .......;; Effective: 12/01/2021 .,. 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