17A-181 (4) BP-2022-1076
193 NORTH MAPLE ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
17A-181-001 CITY OF NORTHAMPTON
Permit: Alts Renovations
Repair
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
Permit # BP-2022-1076 PERMISSION IS HEREBY GRANTED TO:
Project# 2022 ROOF Contractor: License: Ili
ADAM QUENNEVILLE ROOFING &
Est. Cost: SIDING 070626
Const.Class: Exp.Date:08/21/2023
Use Group: Owner: ROSS VANESSA &ELIZABETH LARKIN
Lot Size (sq.ft.)
Zoning: URB Applicant: ADAM QUENNEVILLE ROOFING & SIDING
Applicant Address Phone: Insurance:
160 OLD LYMAN RD (413)536-5955 AWC4007012861
SOUTH HADLEY, MA 01075
ISSUED ON:09/01/2022
TO PERFORM THE FOLLOWING WORK:
INSTALL NEW ROOF ON GARAGE & RIDGE VENT ON MAIN 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:
Final: Final: Final: Rough Frame:
Gas: Fire Department Driveway Final: Fireplace/Chimney:
Rough: Oil: Insulation:
Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Signature: '
I )13kt
• ' ' y0
_ l
Fees Paid: $40.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
Department use only
��4ti .ci.-Jj tf City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
' , 7 212 Main Street Sewer/Septic Availability
,iie
r t i' Room 100 Water/Well Availability
\ "" *,
ry ' Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 Plot/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:
193 N Maple St Florence Ma 01062 Map /7 Lot / Y 1 Unit 156)
Zone U go3 Overlay District
Elm St. District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT I
2.1 Owner of Record:
Vanessa Ross 19 N Maple St Florence MA
Name(Print) Current Mailing Address: 413-230-7878
see contract
Telephone
Signature
2.2 Authorized Agent:
Adam Ouennevillet 160 Old LymanRd South Hadley Ma 01075
Name(Pri Current Mailing Address:
ar✓f aueYlhelllle ,,; '8""^y 413-536-5955
OB/19/103.^
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building 6,144.00 (a) Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from(6)
3. Plumbing Building Permit Fee 0I
4. Mechanical(HVAC)
5. Fire Protection
6. Total = (1 +2+3 +4 + 5) 6,144.00 Check Number 121 Ij 3
This Section For Official Use Only
P 2022-1 O7 b Date
Building Permit Number: pj Issued:
i
Signature: / /� 1- t 20Z2
Building Commissioner/Inspector of Buildings Date
kaylee.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 p
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
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 ? YEI 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) n Roofing I 7
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [El] Decks [0 Siding DO] Other[E
Brief Description of Proposed new roof on garage, remove existing, install underlayment,drip edge,and new ridge vent on main house
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
Vanessa Ross
I , as Owner of the subiect
property
Adam Quenneville
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
see contract 08/29/2022
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 penal' s of perjury.
Adam Quenneville
Print Name
08/29/2022
Signature of er/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
idi, ..
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 3/22/2024
Address Expiration Date
Telephone_`13-536-5955
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
<Sz r�
itT Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS
a r1� �,� 212 Main Street •Municipal Building
--q '` 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:
193 N Maple St Florence 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)
41a4 auenneVllle 72 r, :.,,, ,..,,<,
ignature of Permit Applicant or Owner Date
If, for any reason, the debris wiii 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.
1 t' /
8 1�,/A W A z� Disc ven
VISA C,
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 Builder's Assoc.of Western Mass. CT Registration#575920
Member of the Building&Trade Association P.P.0 38710
Proposal Submitted To: Date: 08/24/22 Phone#'s: C:413-230-7878
Vanessa Ross H: W:
Street: Email:
193 N Maple St. parteraross@gmail.com
City,State,Zip Code: Special Requirements:
Florence, MA, 01062 Ridge Cap Installation on the main
GARAGE
home
HOUSE GARAGE OTHER
STRIP RECOVER Install rolled roof on top section of the
garage
Layers: 14:k 3 4 Plywood Included: Yes No
J Tear off SLATE or SHAKES
COMPLETE ROOF PROTECTION SYSTEM:
it We shall acquire appropriate permits for all work
41 Home exterior and landscaping to be protected Don't even stand on it
{ Strip existing roofing to existing decking with full inspection DO NOT DO:DO not touch garage flat roof
l All project waste shall be removed by dumpster(dumpster for contractor use only)
Install Ice&Water Barrier at all eaves 3'/6',valleys,chimneys,pipes and skylights
I Install(151b.felt 40!'nderlayment over rema.ning decking area
Install Metal drip edge at eaves and rakes'l?5")(lair brown)
4 Install manufacturer's starter shingle on all eaves and ra e edges
Install new pipe boot flashing/vent accessories
Install ridge vent-Snow Country/Cobra rolled/4'Baffled/Roll
Shingles:(standard 6 nails per shingle) Hickory
GAF HDZ Shingles Color:
GAF Ridge cap shingles
Warranty Options:
We guarantee our workmanship for 10 full years
I GAF System Plus Warranty
J GAF Golden Pledge Warranty
Chimney Options:
O Lead Counter Flashing O Water Seal&Tuckpoint O Rubberized Crown O Cricket
O Mason needed(customer provided)
Additional material and labor charges may apply. 5.19 $15
Deteriorated existing decking will be replaced atier sq.ft.and dimensional lumber af 't—per linear ft.,
after full inspection. Customer Initials: NHL
We propose hereby to furnish materials and labor—complete in accordance with above specifications for the sum of: Total Due:($6,144 )
ACCEPTANCE OF PROPOSAL:The above prices,specifications and conditions are Down Payment:($500
satisfactory and are hereby accepted.You are authorized to do work as specified. 2nd Payment at Start Job:($
Payment will be 1/3 down at signing,1/3 at start of job,and balance due Balance Due Upon Completion:($Finance )
upon completion.
Date:08/24/22 Signature:
Date;08/24/22 Estimator:(Print Name) Nate Flacks (Sign Name) n/....—)=7.
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:
-
A�C,ORD® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY)
6/23/2022
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(ies)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 NAME:CT Sarah Premo
Clayton Insurance Agency, Inc. PH NE,Exu:O (413)536-0804 jac,No): (411>s14-,e,4
1649 Northampton Street E-MAIL s remo@cla toninsurance.net
ADDRESS: p Y
P, 0. Box 989 INSURER(S)AFFORDING COVERAGE NAIL A
Holyoke MA 01041-0989 INSURER A:Nautilus Insurance Company
INSURED
INSURER B:Green Mountain Insurance Co
Adam Quenneville Roofing s Siding Inc. INsuRERc:Gray Surplus Lines Ins. Co.
160 Old Lyman Road INSURERD:AIM Mutual Ins. Co
South Hadley, MA 01075 INSURERS:
INSURER F:
COVERAGES CERTIFICATE NUMBER:2022 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 ADDL SUBR
LTR TYPE OF INSURANCE INS!) WVD POLICY NUMBER POLICY POLICY EXP
(MMIDD/YVYY1 (MM/DDIYYVV] LIMITS
X COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE $ 1,000,000
A CLAIMS-MADE I X I OCCUR DAMAGE TO RENTED 100,000
PREMISES(Ea occurrence) $
X BI 6 PD DED $2,500 NN1283315 6/23/2022 6/23/2023 MED EXP(Any one person) $ 5,000
PERSONAL BADV INJURY S 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000
X POLICY! J JET I I LOC PRODUCTS-COMP/OPAGG $ 2,000,000
OTHER: $
AUTOMOBILE LIABILITY (OMBIINdED1)SINGLE LIMIT $ 1,000,000
B ^ANY AUTO BODILY INJURY(Per person) $
ALL
AUTOS OWNED X SCHEDULED 20124137 6/23/2022 6/23/2023 BODILY INJURY(Per accident) $
X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE
AUTOS (Per accident) $
UNINSIUNDERINS MOTORISTS $ 100,000/300,000
X UMBRELLALIAB OCCUR
.--_— EACH OCCURRENCE S 5,000,000
c EXCESSLIAB CLAIMS-MADE AGGREGATE $ 5,000,000
DED I RETENTION$ - 002428191 6/23/2022 6/23/2023 $
WORKERS COMPENSATION •X PER OTH-
AND EMPLOYERS'LIABILITY ,//N STATUTE ER
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000
OF EXCLUDED? Y N/A
D (Mandatory In NH) ARC4007012861 4/29/2022 4/29/2023 E.L.DISEASE-EA EMPLOYEE $ 1,000,000
I(yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required)
For 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 BE DELIVERED IN
160 Old Lyman Rd ACCORDANCE WITH THE POLICY PROVISIONS.
South Hadley, MA 01075
AUTHORIZED REPRESENTATIVE
Michael Regan/FMT / ,4 P 2 ,,,
(>1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
INS025(201401)
Commonwealth of Massachusetts
• Division of Professional Licensure
�' Board of Building Regulations and Standards
ConstttTDt�lS1}A�rvisor
CS-070626 ;J' r 65ptres 08/21/2023
ADAM A QUEI�NEVI I 'v! i f `"� ar`a ''
160 OLD LYMAN RD ;, ;i�, .1 Er, -� t?t
SOUTH HADLF,Y MA,r D0, / ' ^. .W. I`'`
rs: � +' yfr`
x
Commissioner v1vi n. pCtmLV1&.
(T e (?Qnefino••nu/eae t' o, c 711a.<1:1acheoe 1•
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: 13
160 OLD LYMAN RD. Expiration: 03/22/22022
SO.HADLEY,MA 01075
Update Address and Return Card.
SCSI •., 2"M11.05/17
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\,.. /'P I 1 �' '�", I 1 '•t'i� 4y•�.> ;;^,, .: ' 00• \iiCC N+ r'::,i.
; STATE OF CONNECTICUT + DEPARTMENT OF CONSUMER PROTECTION -,,,,If
,` I Be it known that e
Xi' ( ;!
'4, ADAM QUENNEVILLE J:
- 160 OLD LYMAN ROAD 1 ;y-;
�, 1 +','_1''0.,
;f i SOUTH HADLEY, MA 01075-2632 , ' `
E>3 Yb r/.
! I t�P(F.,"lam.
has satisfied the qualifications required by law and is hereby registered as a `�
'4 '. i HOME IMPROVEMENT CONTRACTOR i .;.,,,:,
Registration # HIC.0575920
oy' I (
ADAM QUENNEVIL,LE ROOFING i,.,
Y%
:`' 12/01/2021 I
��: Effective: ;, •�
' 2�i5
1 Expiration: 03/31/2023 .E `/Q ,F,
S Michelle Seagull,Commissioner t
'+',,. 5 s \t t � b 1 I .. 1 71 1 / .... 11 • In — �� t �r I
vv nth >i l )) ,•i+ + \ {e ���\. •H• ss ) 1'y\ y• �) to 1i
4i C)yi �V Y-f '1 '1�.,r P 'r, Ir' R•.1j' l .'1:+ y
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
"mil= 600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information /n� Please Print Legibly
Name(Business/Organization/Individual): /�c CLy'\ uerlr'-1)14t- I/�—00(1 I rd 51d.1 r]}� 4'✓�C
Address: ILO 0 A L)
City/State/Zip: 50v1% ReAkt (" Glob Phone#: t 3 -Jr3`"5 g55
Are you an employer?Check the appropriate box: Type of project(required):
1.8:1 lam a employer with 15 4. ❑ I am a general contractor and I 6. ❑New construction
employees(full and/or part-time)."' have hired the sub-contractors
2.❑ l 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' q Building addition
[No workers' comp. insurance comp.insurance.:
required.] 5. ❑ We are a corporation and its l0.0 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.frj Roof repairs
insurance required.]t c. 152,§1(4),and we have no
employees.[No workers' 13.0 Other
comp.insurance required.]
'Any applicant that checks box NI 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
information.
Insurance Company Name: A LP,- (l u 1,"\ 1,/15 0 fc \Cv / q
Policy#or Self-ins.Lic.4: A W C.900I O I agL LI/�Expiration Date: I/a 3
Job Site Address: 193 N Maple St City/State/Zip: Florence Ma 01062
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 ceertifviunder vhe p and penalties of perjury that the information provided above is true and correct.
Atlan ( uenneVit(e ,
Signature: Date: 08/2 /2022
Phone#: L r3 ` 53C — 595c
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#: