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17A-002 (3) BP-2023-0129 212 SPRING GROVE AVE COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 17A-002-001 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-2023-0129 PERMISSION IS HEREBY GRANTED TO: Project# ROOF 2023 Contractor: License: ADAM QUENNEVILLE ROOFING & Est. Cost: 14399 SIDING 070626 Const.Class: Exp.Date: 08/21/2023 Use Group: Owner: FLEMI DETENBER LORE A&MAR!Y D Lot Size (sq.ft.) Zoning: RI/URA/WSP Applicant: ADAM QUENNEVILLE ROOFING & SIDING Applicant Address Phone: Insurance: 160 OLD LYMAN RD (413)536-5955 AWC4007012861 SOUTH HADLEY, MA 01075 ISSUED ON: 02/02/2023 TO PERFORM THE FOLLOWING WORK: STRIP AND REROOF FLAT ROOF ON BACK 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: Final: Final: Final: Rough Frame: Gas: Fire Department Driveway Final: Fireplace/Chi 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: .1 • 1. )02 . Fees Paid: $40.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner • Department use only r,r City of Northampton Status of Permit: yrBuilding DepartmerliEU Curb Cut/Driveway Permit .�, . 212 Main Street ` 2023 Sewer/Septic Availability 6 Room 100 Water/Well Availability _f Northampton, MA 0110,50 ' 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: /'7 212 Spring Grove Ave Florence MA 01062 Map (14 Lot QV!/ Unit Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Lore Detenber 212 Spring Grove Ave Florence MA Name(Print) Current Mailing Address: 413-427-9146 see contract Telephone Signature 2.2 Authorized Agent: Adam Quenneville 160 Old LymanRd South Hadley Ma 01075 me(Prirlt1 Current Mailing Address: aii/QuenneVi(e v 7,67 or Pa,It 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 14,399.00 (a)Building Permit Fee 2. Electrical 0 (b)Estimated Total Cost of Construction from (6) 3. Plumbing 0 Building Permit Fee ,(� 4. Mechanical(HVAC) 4-0 5. Fire Protection 0 6. Total=(1 +2+3+4+ 5) 14,399.00 Check Number Gblli4P This Section For Official Use Only Building Permit Number:_,a,3" /v� Date Issued: Signature: //���C-- 2 -Z-26Z 3 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 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 II 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 I I Or Doors E Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [EJ Siding[0] Other[iEi Brief Description of Proposed flat roof on back of house, remove existing, new insulation baord,drip edge, EPDM rubber,tie under shingle 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, Lore Detenber , 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 01/31/2023 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 /1� 01/31/2023 Signature wner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable 0 Name of License Holder: Adam Quennville CS-070626 License Number 160 Old Lyman Rd South Hadley Ma 01075 8/21/2023 Addres Expiration Date if 413-536-5955 Sig ature Telephone 9. Registered Home Improvement Contractor: Not Applicable 0 Adam Quenneville Roofing&Siding Inc 191093 Company Name Registration Number 160 Old Lyman Rd South Hadley Ma 01075 3/22/2024 Addres ' Expiration Date Telephone_`1 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 of Northampton -, n r,-i, ,� tip, Massachusetts t44,4,1) DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street •Municipal Building Northampton, MA 01060 �J 'i.„ ,,-,," 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: 212 Spring Grove Ave 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) are QUennetr(je --,; '>Y,'r'::,�-: 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. t UI EVILt g� L WARD "VISA DS VER ? 0 0 €" 2010 w:w nra 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: 1/27/23 Phone#'s: C: 413-427-9146 Lore Detenber H: W: Street: Email: 212 Spring Grove Ave City,State,Zip Code: F1orPnce. MA 01062 Proposal to furnish and install the following: location of flat roof if applicable g, g OF HOUSE we will pull all appropriate permits for work. we will remove all roofing material down to decking and dispose ono we will go over existing roof yes =to we will install fiber board over entire roof ye no we will install ISO insulation board 451MIlt.no 1 inches we will install E••_ rubber membrane on entire roof. we will install eO brown C6 drip edge around perimeter of roof. we will install cover strip over all drip edge. we will turnbar rubber up all walls and chimneys. we will counter flash chimney with lead, no we will tie rubber up under shingles yes no shingle color Fox Hollow G,ay we will install new rubber boots around pipes. 10 year AQRS labor, material and workmanship warranty. all rotted or deteriorated decking will be replaced at $5.19/sq ft special requierements: FIBERBOARD OVER 3 SEASON PORCH ISO BOARD OVER REST Ask us about affordable bank financing! ATTENTION HOMEOWNERS:Please cover all personal belongings in the attic,garage or storage areas due to the possibility of roofing debris or dust coming in through cracks of the wood.Please remove any lawn ornaments or yard furniture.Adam Quenneville Roofing will not be responsible for debris or dust in the attic or storage areas. Customer Initials: We propose hereby to furnish materials and labor—complete in accordance with above specifications for the sum of: Total Due:($ 141 399) 4800 P. CK# ACCEPTANCE OF PROPOSAL:The above prices,specifications and conditions are Down Payment:($ ) satisfactory and are hereby accepted.You are authorized to do work as specified. 2nd Payment at Start Job:($ ) 478 Payment will be 1/3 down at signing,1/3 at start of job,and anc d Balance Due Upon Completion:($ 11, 921 ) upon completion. Date: 1/27/23 Signature. Date: 1/27/23 Estimator:(Print Name) Joe Snopek (Sign Name) Estimates are honored for sixty(60)days from above date. 413-221-4329 A�® 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 CONTACT Sarah Premo NAME: Clayton Insurance Agency, Inc. (A/C.NE.Eat): (413)536-0804 FAX Na): 1a17>s34-79,0 1649 Northampton Street ADDRESS: spremo@claytoninsurance.net P. O. Box 989 INSURER(S)AFFORDING COVERAGE NAIC M Holyoke MA 01041-0989 INSURER A:Nautilus Insurance Company INSURED INSURER B:Green Mountain Insurance Co Adam Quenneville Roofing a Siding Inc. INSURERC:Gray Surplus Lines Ins. Co. 160 Old Lyman Road INSURERD:AIM Mutual Ins. Co South Hadley, MA 01075 INSURER E: 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 ADOL SUBR POLICY EFF POLICY EXP TYPE OF INSURANCE LTR INSD-_WVD POLICY NUMBER (MM/DD/YYYY) (MMIDD/VYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO A CLAIMS-MADE I X I OCCUR PREMISES(Ed o currrrence) $ 100,000 X BI 6 PD DED $2,500 NN1283315 6/23/2022 6/23/2023 MED EXP(Any one person) $ 5,000 PERSONAL 8ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 I PROT- I I 2,000,000 POLICY JEC LOC PRODUCTS $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ S ALL OWNED SCHEDULED AUTOS X AUTOS 20124137 6/23/2022 6/23/2023 BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE $ X HIRED AUTOS X AUTOS (Per accldonl) UNINSIUNDERINS MOTORISTS $ 100,000/300,000 X UMBRELLALIAB -OCCUR EACH OCCURRENCE S 5,000,000 C EXCESS LIAR CLAIMS-MADE AGGREGATE $ 5,000,000 DED RETENTION$ 002428191 6/23/2022 6/23/2023 $ WORKERS COMPENSATION X PER OTH- ER ER AND EMPLOYERS'LIABILITY ,,I N ANY PROPRIETOR/PARTNER/EXECUTIVE NIA D E.L.EACH ACCIDENT S 1,000,000 aR/MEMNEXCLUDED? Y 4/29/2022 4/29/2023 (Mandatory In NH)H) AWC4007012861 E.L.DISEASE-EA EMPLOYEE $ 1,000,000 II yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 5 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached It more space Is required) For Informational Purposes Only CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Adam Quenneville Roofing 6 Siding Inc 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/FMT /22,47'a-r' P 4*- I ©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 Zig/ Division of Professional Licensure ' Board of Building Regulations and Standards Constr tt'> tl+f tipervisor CS-070626 ? ',-', 1,pires:08/21/2023 ADAM A QUENNEVILLE 160 OLD LYMAN RD .4 0 ; SOUTH HADLEY MA 01075 4. Commissioner (1,i 0. K. THE COMMONWEALTH OF MASSACHUSETTS 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: 03/22/2024 160 OLD LYMAN RD. SO.HADLEY, MA 01075 • Update Address and Return Card. cZ rI��i^`r'3 f' .:t��``` 4t.``,s V1 t* lji 1:1,r+�3 s., ^VOv �,.4 li 4„Mkte.. . t ta51f': r}''l f° .�f %';g .'t'�"q: 5 Mt't;,.".� ffJ�i In, ^mot' y;-;, . ir fi W._ .. «..a. ,., ..__ i ;Y.d'h e. s STATE, OF CONNECTICUT + DEPARTMENT OF "ONSUMER PROTECTION ; :'*._ Be it known that :: ADAM QUENNEVII,I,E 7�� . 160 OLD LYMAN ROAD �, SOI..TTH HADLEY, MA 01075-2632 f s j °' �:We F � has satisfied the qualifications required by 1'i and.is hereby registered as a �� HOME IMPROVEMENT CONTRACTOR �a Registration # HIC.0575920 ADAM QT. Ir.NN1:VLt,L,1:�.ROOFINGei- ' Effective: 12/01_/2021 4I,' 4 i 'Expiration: 03/31/2023 r 'i itjA•��, Michelle Seagull,Commissioner 1 r r`, * S.SfIr:-- TV I M e r ! dR e r Ms r c t s qs tg ° s,,r ' 1:T, :w y , r,, Z ,i c lWr - r ' e '11r ° � . 4 ' ✓f + sy .,y `i ":t- , ,.%-0q /1 "t ;1'V:. •$140. e :*:, �iV'7lY. r '04 ' '. Vs'''. t``'v. '' ''. '. ,,'' dw: s ,ttr. .,' �' :••',ti9 ,. -' ' .'a' rt. ). . - , . 4, ,4. f. 4 .... > ''' r_ t . . t 0-'' 1 � tg The Commonwealth of Massachusetts Department of Industrial Accidents ,' Office of Investigations 600 Washington Street 10E11 -' Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information /� (� -. Please Print Legibly Name(Business/Organization/Individual): Act (, Uen v t I�� Ut t r ✓)(- Address: ILO 01 A Li►v,r,,, �- u City/State/Zip: 5.01)% 140,gr _ (hio G(olc Phone#: 13 -53C`5955— Are you an employer?Check the appropriate box: • Type of project(required): l,pi.I am a employer with 15 4. ❑ I am a general contractor and I 6. New construction employees(full and/or part-tine).* 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. ❑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.❑ 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 12.E1 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 fit 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. tContractots 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 L�1 u l UG /t5 / 1 Policy ti or Self-ins.Lic. : A WC.90Ob 0 (ag�,( Expiration Date: LOCl/II a 3 212 Spring Grove Ave 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 ee'rtlfu an the pains and penalties of perjury that the information provided above is true and correct. 46,7 C2uennedle Date: �1/3112 02 3 Signature: C� q Phone l#: � �3 ` 533c — 5 I5 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): I.Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: