22D-059 (4) BP-2021-2297
33 FLORENCE RD COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
22D-059-001 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-2021-2297 PERMISSIONIS HEREBY GRANTED TO:
Project# ROOF Contractor: License:
ADAM QUENNEVILLE ROOFING &
Est. Cost: 6499 SIDING 070626
Const.Class: Exp.Date:08/21/2023
DIHLMANN ROBERT A & BARBARA J LAWLESS-
Use Group: Owner: DIHLMANN & S DIHLMANN
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:12/15/2021
TO PERFORM THE FOLLOWING WORK:
NEW ROOF LOWER SECTION MAIN 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: Cgi
frifsrt.
Fees Paid: $40.00
212 Main Street, Phone(413) 587-1240,Fax:(413)587-1272
Office of the Building Commissioner
Department use only
o�;ik City of Northa ptREC FI\ Status of Permit:
', , -. Building Departure t —`— L Curb Cut/Driveway Permit
�, 212 Main Street DEC 1 Sewer/Septic Availability
r , .I 'I Room 100 4 [�' Water/Well Availability
'11'"`� - �- Northampton, A 0 060 Two Sets of Structural Plans
-'�.' phone 413-587-1240 ax 4, .Plot/Site Plans
„_ UI_ 1NC INSi-
r1 __ .M, f 't i r Specify
nRTHAMPT
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION J
1.1 Property Address: This section to be completed by office
33 Florence Rd Florence Ma 01062 Map Lot Unit
Zone Overlay District
Elm St. District__ ___ CB District
SECTION 2 -PROPERTY OWNERSHIP/AUTHORIZED AGENT I
2.1 Owner of Record:
Barbara& Robert Dihlamann 33 Florence Rd Florence Ma
Name(Print) Current Mailing Address: 413-586-3431
see contract
Telephone
Signature
2.2 Authorized Agent:
Adam Quenneville 160 Old LymanRd South Hadley Ma 01075
Name(Print) 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 6,499.00 (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from(6)
3. Plumbing Building Permit Fee
4. Mechanical(HVAC) 7
5. Fire Protection
6. Total =(1 + 2+ 3+4+5) 6,499.00 Check Number /1 `/
This Section For Official Use Only
Building Permit Number: n aZi r �"-.7 —. Date
Issued:
Signature: ---' _ 1 Z -/'I - 7 Z (
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:
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 DON'T KNOW X YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW X YE4--1
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 ? YE5 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 121
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [p] Decks [❑ Siding ga Other[134
Brief Description of Proposed New roof on lower section main roof, remove&replace existing roofing, install new 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
Robert& Barbara Dihlamann
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 12/08/2021
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
12/08/2021
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
Addres 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
Telephone 3-536-5955
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 ;lorthampton
!^ ''� Massachusetts r
�`
e� f �'. wz ��i,
IGv DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street *Municipal Building kti
Northampton, MA 01060 r
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:
33 Florence Rd 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 1 v nrin F: `:youth Hadley Ma
(Company Name and Address)
�/
1>A1 1 a-1
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.
y _.t
-44
«Itaurl ovir•iillli v'ila.a.wE AWAR0 V/SA DISC;yER
.. v:R BM
160 Old Lyman Road•South Hadley•MA 01075 We are Licensed
1.800.NEW.ROOF • 413.536.5955 Fully Insured
Email:info@l800newroof.net Website:www.1800newroof.net Factory Trained
MA Construction Supervisors Lic.#070626 MA Registration#120982 Factory Certified Installers
Member of the Home Builders Assoc.of Western Mass. CT Registration#575920
Member of the Building&Trade Association P.P.0 38710
Proposal Submitted To: Date: 12/7/21 Phone#'s: C:
Robert & Barbara Dihlmann H: W:
Street: Email:
33 Florence rd. bbsb34@aol.com
City,State,Zip Code: Special Requirements:
Florence ma 01062 roofing only Lower roofing sections
PROPOSAL FOR: of Main House.
HOUSE GARAGE OTIIE'
STRIP RECOVER
Layers: 1 2 3 4 Plywood Included: Yes or No
Tear off SLATE or SHAKES
COMPLETE ROOF PROTECTION SYSTEM:
X We shall acquire appropriate permits for all work
R Home exterior and landscaping to be protected
X Strip existing roofing to existing decking with full inspection DO NOT DO: Upper Main House or
4tl All project waste shall be removed by dum. ter(dumpster for contractor use only) Garage
Install Ice&Water :- "-rat all eaves 3' Allb;Ileys,chimneys,pipes and skylights
g Install(151b.fel Synthetic)u derlaym . ver re.. • .ecking area
Install Metal drip edge at eaves and rak ,")(white/.rown)
x Install manufacturer's starter shingle on all eaves an. rake edges
X 1 Install new pipe boot flashing/vent accessories
Xl Install ridge vent-Snow Country/Cobra rolled/4'Baffled/Roll
Shingles:
GAF Shingles Color: Barkwood
GAF Ridge cap shingles
Warranty Options:
X We guarantee our workmanship for 10 full years
GAF System Plus Warranty
GAF Golden Pledge Warranty
Chimney Options:
® Lead Counter Flashing O Water Seal&Tuckpoint O Rubberized Crown O Cricket
E Mason needed(customer provided)
Additional material and labor charges may apply.
Deteriorated existing decking will be replaced at 55.19 per sq.ft.and dimensional lumber at $15 per linear ft.,
after full inspection. Customer Initials: W
We propose hereby to furnish materials and labor—complete in accordance with above specifications for the sum of: Total Due:($ 6,499 )
ACCEPTANCE OF PROPOSAL:The above prices,specifications and conditions are Down Payment:($ 2,000 )
satisfactory and are hereby accepted.You are authorized to do work as specified. Balance Due Upon Completion:($ 4,499 )
Payment will be 1/3 down at start of job,and balanc due u on co p tion.
Date: 12/7/21 Signature:
12/7/21 James Bonavita
Date: Estimator:(Print Name). (Sign Name)
ATTENTION HOMEOWNERS:Please cover all personal belongings in the attic,g rage or storage areas due to the
possibility of roofing debris or dust coming in through cracks of the wood.Adam Que.n J Qe Roofing will not be
responsible for debris or dust in the attic or storage areas. Customer Initials•.L'/
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 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,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.
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
to 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
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.
D
AC' CERTIFICATE OF LIABILITY INSURANCE DATE(MMDONYYY)
6/24/2021
THIS CERTIFICATE IS ISSUED ASA 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 certtftcate holder Is en ADDITIONAL INSURED,the policy(tes)must be endorsed. II 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
certlfIcate holder In lieu of such endorsomont(s)•
PRODUCER CCU/TACT
CMS: Sarah Promo
Clayton Insurance Agency, Inc. °cJ"1l' (413)536-0804 we ", I41 )b34-,e7a
1649 Northampton Street E-MAIL Ao,„"s+ yramo@ale tonlnsuramce.net
B. 0. Box 989 INSURER(SI AfFORDINO COVERAGE NAIC rr
HolyokeMA 01041-0989 lINSURER A:NALJtilu9 Insurance Commanv
INSURED INSURER B:Arbella Insurance Co.
Adam Quenneville Roofing 6 Siding Inc. INSURER c AIM Mutual Insurance Company
160 Old Lyman Road INSURER D:
South Hadley, MA 01075 INSURER E
1 INSURER F:
COVERAGES CERTIFICATE NUMBER:2021 MASTER REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE t3EEN ISSUE()TO THE INSURED NAMED ABOVE FOR THE POUCY PERIOD
INDICATED NOTWITHSTANDING ANY REQUIREMENT,TERM 02 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
If.3� �� TALIDL IrIy'i1R. _..---- _........ Y POLICY EFF _ POLICY EXP LIMITS
J,TR TYPE OF INSURANCE' D Inwo o04t4YNUMBER tMMJtt JYYYY) ( Mn0J'rYYVI ILNS 1 u
1
x COMMERCiaU GENERALUAR1UTY 1,000,000
EACH OCCURRENCE S
7F+TSJI7( R5T887 D
A ..._ I CLANS-MACE I X ,OCCUR PREPIMIES lei 44+4MnCe) S 100,000
�� ._..._ NNl.2911:E 6/23/2021 6/23/2022 MEO EXP(Ant one person) -S 5,000
...._. l PERSONAL P.Any INJURY s 1,000,000
GEN'LAOORCOATEOMIr APPLIES PER. GENERAL AGOR EOATE S 2,000,000
X POLICY
(- .1Eer LOG PRODUCTS-COMPIOPAGG S 2,000,000
I OTt•ER 4
Au-to/AmuLIABILITY f a pnt1I.'Illti(yLC LMaIT S 1,000,000
H ,.µ_ANY AUTO BODILY INJURY(Per person) 3 ��
ALL OUlT1ED x SCHEDULED
AUTOS AUTOS /020107093 6/23/2021 6/23/2022 BODILY INJURY(Per acadent) S
X HIRF.DAUT09 X NON-OWNED PROPERTY DAN UE y
-_-. AUTOS VOL.( fr011
t UNINS1UNOERINSMOTORISTS S 100,000/300,000
X UMBRELLA LIA9 OCCUR EACH OCCURRENCE S 5.0004000
EXCESS LIAB
A CLAIMS-MADE ADDREOATE ^s 3.000.000
Df:D RETENTION 0 AN12421J2 6/23/2021 6/23/2022 5
WORKERS COMPENSATION X 9l STAIR 2:1-
AND EMPLOYERS'UABH_ITY V I N UTE ER
ANY PROPRIETORIPARTNER7f_XECUTIVE E.L EACH ACCIDENT 4 1,000,000
OFFICERrMEMDCR EXCLUDED? ' Y I N IA
C IMandalory in NHl —J ANC4007112961 4/29/202t 4/29/2(122 E,L DISEASE•FA EMPLOYEE S 1,000,000
It gyee,dox:rlbu UnOer
OESCRIPTION OF OPERATIONS 0e+ow EL DISEASE PODGY LIMIT 1 0 1,000,DOD
I , _
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORO 101,Addtdonel Reraarlre Schedule,may be elleohad It mons■paeo le required)
O'er Informational Purpaaea 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
160 Old Lyman Rd ACCORDANCE WITH THE POLICY PROVISIONS.
South Hadley, MA 01075
AUTHORIZE°REPRESENTATIVE
t•I:<:hael Regan/'e'HT ry k/ �' " _.
CD 1013t3-2014 ACORD CORPORATION. All rights rosrrrvod.
ACORD 25(2014/01) The AG OP.. _,,: and logo are registered marks of ACORO
1143025(201401(
The G'ontmonweattn of Irtassacnuseus
r Department of Industrial Accidents
6 3 •
ormolu Office of Investigations
=1.611l 600 Washington Street
•= Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information /�_! (1 Please Print Legibly
Name(Business/Organization/Individual): A cterh Glue lrvt>)1 WC- 1C_Gtd'C t'1 741•'t lJt r7 4,
Address: la 0
City/State/Zip: 50v't k 1\1 o,.c.lt., ('h tci _._04 015^ Phone #: `t►3 53 C.=5 955—
Are you an employer?Check the appropriate box: Type of project(required):
I. I am a employer with 15 4. Li 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. D Demolition
working for me in any capacity. employees and have workers' 9. El Building addition
[No workers'comp. insurance comp.insurance.:
required.] 5. 17 We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 1 I.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.]t c. (52,§I(4),and we have no
employees. [No workers' 13.❑ Other_
comp. insurance required.]
'Any applicant that checks box ttt 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: A 1-n1 Thu 1 ocAA�NM- ,15 d lencc-
Policy#or Self-ins.Lic. #: A W C.&10010 t 1. Expiration Gate: LOV 9
170 Pine Acre Rd Springfield Ma 01129
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 certify{<undrrftkerpains and p altie, of'perjury that the information provided above is true and correct.
Acian'J C...uenneV1((e 12/07/2021
Signature: Date:
Phone#: ]3 ` 5 3C ' 5 1 5 s—
Official use only. Do not write in this area,to he 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
b.Other
Contact Person: Phone#:
lOrir Commonwealth of Massachusetts
Division of Professional Licensure
Board of Building Regulations and Standards
CS-070626 Expires:08/21/2023
ADAM A QUENNEVILLE
180 OLD LYMAN RD
SOUTH HADLEY MA o1016
of',k 110'
Commissioner 'ci.ogQA K biF.ord-ra—
....,..„.
rJ4 ‘'.f ..(`)//,)j,,,/(' ''011710(///1/./ off-- 744,..uctrAte4efft
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 end Return Card.
SUA 1 a 'Ort,1•05(17
f!•(:;;W:::",n''S"t1,2:'''':14A"49,'l':11%),'',,M•.,"1.'1j i'k,%!3';',,,2'0:11,,,,70' ',,"1,'".,'-,:,.,4 ', 'v'''',,',,. ,`' l': ,,,,:: :: ',./,/',,.;:e":,,,,'4,Zom, •;.'0", t.,4" ,t',.'4Vst .4,,A1,, :P1'4,1,, 4..:4,4it;4
'i.,,,t,.
STATE OF CONNEC'FICU I- + DEPARTMENT OF CONSUMER PROTECTION
Be it known that
ADAM QUENNEVILLE
160 OLD LYMAN ROAD
SOI:111.1 t IADLEY, M.A. 01075-2632 1 i',•,,,'''',-,
Ilip. ,c,
has satisfied the(1,,all'IL.L.!otis required by law and is hereby registered as a
:•,,-1 i
..-;;,..z •
HOME IMPROVEMENT CONTRACTOR I 4.
..4 Registration # ITIC.0575920
1 '
°g,-...,...,
1 ,*0
ADA114 QUENNEVILLE ROOFING
i lks4
:i6:,..- Effective: 12/01/2021 (• .i,k-
, ..
tfk: Expiration: 03/31/2023
. ...,
Michelle Seagull,Commissioner
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