31A-173 (4) BP-2022-0035
40 MAYNARD RD COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
31A-173-001 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-2022-0035 PERMISSIONISHEREBYGRANTED TO:
Project# ROOF Contractor: License:
ADAM QUENNEVILLE ROOFING &
Est. Cost: 7299 SIDING 070626
Const.Class: Exp.Date:08/21/2023
Use Group: Owner: SMITH STEPHEN D&JOLIE B
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:01/12/2022
TO PERFORM THE FOLLO WING WORK:
- 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:
Gas: ( Final: Final: Rough Frame:
•
Rough: Fire Department Driveway Final: Fireplace/Chimney:
Final: Oil: Insulation:
J I
Smoke: Final:
•
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Signature:
4,1
91-41a, -
Fees Paid: $40.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
•
Department u se only
1 City of Northampton status of Permit
• y
' ,,,____I
�ti' Building Department Curb Cut/D`riveway Permit-
�, , � 212 Main Street Sewer/Septic Availability
'- kl j Room 100 Water/We'II aAvailability
IL-111i "
Northampton, MA 01060 Two Sets of Structural Plans
'
�- ,fi a 413-587-1240 Fax 413-587-1272 PIot7SiteEPlans
Other Specify
/4PPLICATIO TO CONSTRUCT,ALTER, REPAIR;RENOVATE OR DEMOLISH A ON .O.. , .._ - ..
' E OR TWO FAMILY DWELLING
I it---— --:::-
SECTI75N 1,=SITE INFORMATION
1.1 Property Address:
This:section to be completed by office
C ti Ft s :� J y
40 Maynard Rd Northampton Ma 01060 Map`V � •� Lot �� Unitx` 2 .
Zone ,Overlay,District: j.
Elm District. C B Dist_rict �
SECTION 2`,PROPERTY OWNERSHIPIAUTHORIZED AGENT •
2.1 Owner of Record:
Steve Smith 40 Maynard Rd Northampton Ma 01060
Name(Print) Current Mailing Address: 413-320-8367
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
Signat re Telephone
SECTION 3-`ESTIMATED'CONSTRUCTION?COSTS
Item Estimated Cost(Dollars)to be i Official Use Only
completed by permit applicant - `'`
1. Building 7 299 00 (a)Building Permit Fee `.
2. Electrical I (b)Estimated Total Cost of
;-::.�Construction,from..(6) ,.w
. .i.•,.::.:;'f:;51.;':!::::::,..;!;:,':;:: ::::',..:.:!..!i',1,,,,ii-,:-.,,,,,,''':;::;:,::::.'„.!:„.i..,;;-;;•ii•ir:i.j...-. ..,,;..:,•:;•::,-,'„;:::..e..1.,
3. Plumbing Building Permit.Fee
4. Mechanical (HVAC)
5. Fire Protection .
6. Total=(1 +2+3+4+5 • 7,299.00 r`Check'Number,.: . ... ,
' This:Section For;Official Use'Only- :" : .
' 'H.o�d�r . Date
::Building Permit,Number. -. :', . `:, . .....
`.Issued
1
2
$ignature. _ �._ . !, /2 ZDZZ.
:•,Buildin j Commissionerllnspector of-BuildinTf gs"„ . 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 1�.
Setbacks Front
Side L:E L R:_J L: ., R: = ,w
Rear _] :w..._.,...„,�, J
Building HeightET L._..._..
Bldg. Square Footage l % _. m.
l _ _ i
Open Space Footage %
(Lot area minus bldg&paved = � _I
parking)
#of Parking Spaces r--..---..--- L
fi
Fill: I
(volume&Location) d
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 L Page ... . ...I and/or Document#q
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: NO .
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTIO5-'DESCRIPTION OF"PROPOSEDWORK-(Cheek all'a'N" pplicable)'
.. .
New House ❑. Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [El Siding[0] Other[El]
Brief Description of Proposed New roof, remove and replace existing roofing rear of house&3 ulltimate pipe boots
Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet.
s .If"New-ti �
� a� ouse and or;`additon.to.exi'stinq li3oiustng.'=3completelhe.followiinq:
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;;;
Steve Smith
I3 ! , 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 01/07/22
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
01/07/2022
Signature of Ow /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
Addre Expiration Date
413-536-5955
Si nature Telephone
9'. Registered Home nprovemeni Contractor .... ' , , `r „x v Not Applicable ❑
Adam Quenneville Roofing&Siding Inc 191093
Company Name Registration Number
160 Old L. man 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 Ki No 0
ia
City of Northampton
HA
Massachusetts
',
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street •Municipal Building ;Sb•, •
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:
40 Maynard Rd Northampton Ma 01060
(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)
' Inc
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.
. E1 '';1 . -. ^tea ../X-G G ..
r- .. AWARD /r7 t7A DISC'.°>VER "€•
�.ro.^ m .c..,,,. w:•," -^c` 10,0 WtNNFR ' ...nmeSeg
160 Old Lyman Road•South Hadley•MA 01075 We are Licensed
1.800.NEW.ROOF • 413.536.5955 Fully Insured
Email:info@1800newroof.net Website:www.1800newroof.net Factory Trained
MA Construction Supervisors Lic.#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: Phone#'s: C:
Steve Smith 12/29/2021 H: W:
Street: Email:
40 Maynard Rd stevenoho@yahoo.com
City,State,Zip Code: Special Requirements:
Northampton , MA 01060 remove and replace roof on rear
of the home from ridge back
PROPOSAL FOR: "only this slope is 2 layered and
HOUSE GARAGE ( THE replacing 3 dry 'rotted pipe boots
STRIP RECOVER with Ultimate Pipe Boots on
Layers: Q 2 3 4 Plywood Included: Yes or No rear of home
O Tear off SLATE or SHAKES
COMPLETE ROOF PROTECTION SYSTEM:
�cl We shall acquire appropriate permits for all work
N Home exterior and landscaping to be protected
3 Strip existing roofing to existing decking with full inspection DO NOT DO:
O All project waste shall be removed by dumpster(dumpster for contractor use only)
IN Install Ice&Water Barrier at all eaves 3'/0 valleys,chimneys,pipes and skylights
N Install(151b.felt(MVO underlayment over remaining decking area
N Install Metal drip edge at eaves and rakes&5"(/brown)
El Install manufacturer's starter shingle on all eaves and rake edges
1 . Install new pipe boot flashing/vent accessories
• Install ridge vent now Count /Cobra rolled/4'Baffled/Roll
Shingles:
GAF Timberline HDZ Shingles Color: Pewter Gray
Ridge cap shingles
Warranty Options:
L We guarantee our workmanship for 1.0 full years
❑ GAF System Plus Warranty
❑ GAF Golden Pledge Warranty
Chimney Options:
El Lead Counter Flashing O Water Seal&Tuckpoint O Rubberized Crown El Cricket
O Mason needed(customer provided)
Additional material and labor charges may apply.
C Deteriorated existing decking will be replaced at$5.1J par sq.ft.and dimensional lumber at $15 per linear ft.,
after full inspection. Customer Initials:
We propose hereby to furnish materials and labor—complete in accordance with above specifications for the sum of: Total Due:($ 7,299 )
ACCEPTANCE OF PROPOSAL:The above prices,specifications and conditions are Down Payment:($ 1,8 9 9 )
satisfactory and are hereby accepted.You are authorized to do work as specified. Balance Due Upon Completion:($ 5,4 0 0 )
Payment will be 1/3 down�t start of job,an balance due upon p mpletion.
Date: `J Z/v�L Signature. ✓/
Date: 01/04/2021 Estimator:(Print Name) Ron Dion (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 the wood.Adam Quenneville Roofing will not be
responsible for debris or dust in the attic or storage areas. Customer Initials:
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 mall 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.
DATE IRT' CERTIFICATE OF LIABILITY INSURANCE
kil`..., 6/24/2021
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION'ONLY:AND CONFERS'NO'RIGHTSUPON,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 pofcy(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 ondorsament(s).
PRODUCER < - 44,1, T .. .. _
NAM13t Sarah"BrwLao
Clayton Insurance Agency, Inc. pHie exty (413)536-0804 \{A,c No0413)$34- •
7S74,
1649 Northampton Street NAIL
P :ADDRESS:apremoQalaytoninsuranco.net
•
R. O. BOX 989INSURER(SLAFFOROINO COVERAGE NAIC R
13oiy0ko .. 2 01041-9989 IN8URERA:Nautilus_Insurance..Company u
INSURED INSURER 0:Arbella Insurance Co.
Adam Quenneville Roofing 6 Siding Inc. INSURER.C:AIM Mutual Insurance Company
160 Old Lyman Road INSURER D:
South Hadley, MA 01075 INSURER Ei
.INSURER I' .. ..
COVERAGES CERTIFICATE NUMBER:2021 MASTER REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE I8SUE0 OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. - '`
11SSR' L,6U013
VDT'. TYPE OF INSURANCE POLICYlaITTY PMMINYY P
1N60'�ftlt% PO JOY NUMBER 11�WVV.VL lMMlDOIYYVYI _ LIMITS-,
X COMMERCIAL GENERALUAOILITY EACH occURRENCE s 1,000,000
A CLAIMS•MAOE 1-1 OCCUR DAMAGE 7rSRENTtO 100,000
MI PRESE$CEIc arM+C+a! $
J..... NNI.2033L5 6/23/2021 6/23/2022 MEO EXP(Any one golson) $ . 5,000
,PERSONAL.A AOV INJURY. s 1,000,000
, 05frt::A GGREOA�TGUMITAPPUES PER; CENERALAGOREGATE ,s 2,000,000
" X POLICY'.(' .1 - .. .
l '.IECT n LOC PRODUCTS-COMPlOPAGG 3 2,000,000
"M EM . S
AUTOMOBILE LIABILITY :Ies C+MSINCii SINSLEuMii' 3.. 1,000.,000
H ANYAUTO BODILY INJURY(POYPeraon) '1,
ALL OWNED '—"SCHEDULED
AUTOS 8' AUTOS 102010709E 6/23/2021 6/23/2022 BODILY INJURY(Peraccidont) $
X. FIIREDAUT09 X NON-OWNED PROPERTY WJA E S
—,,AUTOS 'IP'6r�cCil3tt111 ,
.. u _ , IJNINeNNOERINS MOTORISTS S 100,000/300,000
X UMBRELLALIAB OCCUR EACH OCCURRENCE. $ 5,000,000
A EXCESS LIAR CLAIMS•MADE AGGREGATE .$_ 5,000,000
ow RETENTION s AN1242102 6/23/2021 6/23/2022 g:
—r WORKERS COMPENSATION ' -PER r.Ol - `
AND EMPLOYERS'LIABILITY Y/ii X STATUTE I•ER
'ANY PROPRIETOR/PARTNER/EXECUTIVE El EACH ACCIDENT 4' 11000,000
OFFICER/MEMBER EXCLUDED? Y N/A
C Mandatory InNH) 'AHC6007012661 - 4/29/2022 4/29/2022 EL DIBEASE.EA EMPLOYEE $ 1,000,000
If yam doegnbe under
DESCRIPTION OF OPERATIONS below.. 1 EL DISEASE-POUCY LIMITS 10 000:,OM
•
DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES.(ACORD 101,Addllonel Remarks Modulo.,miy a5 ettaehsd.II mom apaso laraqutisd) '
B'or Informational Purposes Only
CERTIFICATE HOLDER- . . CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Adam Qusnnevillo Roofing 6 Siding Inc THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
160 Old Lyman Rd ACCORDANCE WITH THE POLICY PROVISIONS.
South Hadley, 10. 01075 -
AUTHORIZED REPRESENTATIVE
is f l3a i- Regan/ I /1r�oGrwr�
01088.2014'ACORD,CORPORATION. Alf(Write reserved.
A CORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
INS025(2014011
The Gontmonweatuz of 1viassacnusears t ,
Department of Industrial Accidents
Office of Investigations
,rtlll 600 Washington Street
o • Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers
Applicant Information Please,Print Legibly
1
Name(Business/Organization/Individual): Aa P�tr� �.ufn!+�'.�j:t�C. �t;1�1!f J YQ! t�,,'1=►�,y t'�y:r)(5,
Address: GO 01 . ._L'` "ti ek'
City/State/zi 5ov1k 1\10,ltra (hr4 OI0C Phone # 11 53`'3(15T
Are you an employer?Check the appropriate box: - Type of project(required):
1.4g I am a employer with 15 4. El 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 8. Q Demolition
working for me in any capacity: employees and have workers'
9. ❑ Building addition
[No workers'comp.insurance comp.insurance
required.] 5.,0 We are corporation and its 10.0 Electrical repairs or additions
3.0 I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself.[No workers comp. right of exemption per MGL
Y '. P 12g Roof repairs
insurance required.]t c. 152,§1(4),and we have no
employees. [No workers' 13.LJ Other,
comp.insurance required..
*Any applicant that checks box Y!must also till 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,
t am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. _
Insurance Company Name: A LM M u cuGA j t1Stp fc.vncc-
Policy#or Self-ins.Lic. II: A WC 90010 I a$L + Expiration i ate 9 a 0
Job Site Address: 40 Maynard Rd 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 DIA for insurance coverage verification.
I do hereby certifyitmdkothe pains and penalties of perjury that the information provided above is true and correct.
4104 auehheVlle 01/07/2022
Signature: G'/o7r2,2. Date:
Phone li 413 — 5 c — 5 9 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#:
,$$$ Commonwealth of(Viassachusetts
Division of Professional Licensure ,
'.- Board of Building Regulations and Standards
ConsU'AtathilitiiSrVisor
CS-070626 ,,-, ci,,,-:-'-.-;:-. ' 64„,
treS;'08/21/2023
ADAM A11NN 4 ?180 OLD LY14N RDflC ,,, -., ,:,..? 0 •.;,,.-4 ,—
SOUTH HADM , .. k.,.
,, 44--
.1•It-,, ' ,N, 47.4,..°' 4... ,:, .
'. ,
Commissioner $,
d 1,, it bie,...i.b.,
_...,...
...._P,,cl'ilicie (6 ,M0,941fielit t7; ,'a (9- C")-1/104h-iceffe,teztt-, ,„(
Office of Consumer Affairs and Business Regulation
1000 Washington Street- Suite 710
Boston, Massachusetts 02118
.-
Home improvementContractor Registration
• Type: Corporation
Registration: 191093
:
ADAM QUENNEVILLE ROOFING AND SIDING:;N Expiation 03/22/2022
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160 OLD LYMAN RD.
SO.HADLEY,MA 01075 , ' :, ,..,` t•.:',-,,,« . ,':.
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Update Address and Return Card.
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ria;1 ' STATE OF CONNECTICUT + DEPARTMENT OF CONSUMER PROTECTION 1 N„Nitl
Be it known that
.,Taft ADAM QUENNEVILLE
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160 OLD LYMAN ROAD
SOUTH HA1)' LE Y,--%';',M.A' . , 01075-2632
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HOME IMPROVEMENT,-CONTRACTOR
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ADAM QUENI\JEVII,J,E ROOFING
EEffxepcitrivaet:i o1n2/0013/2/03211/2023 ;"'
. . Michelle Seagull,Commissioner
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