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23B-021 (2) BP-2023-1191 208 NORTH ELM ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 23B-021-001 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-2023-1191 PERMISSION IS HEREBY GRANTED TO: Project# ROOF 2023 Contractor: License: ADAM QUENNEVILLE ROOFING & Est. Cost: 54040 SIDING 070626 Const.Class: Exp.Date:08/21/2025 Use Group: Owner: SIMPSON JANE M&LISSA A BROUWERS 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: 09/26/2023 TO PERFORM THE FOLLOWING WORK: ROOF REPAIRS 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: (004 0 gr- Ak, i Na. 10A Fees Paid: $40.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner i i... i-- Fi v � . Departme t use my SEp `O t�-o_r.:Li City of Northampton - . oI;: : 2S c)b��" g '. Building Departme 4i/G Curb ' Irt•-way Permit o�,T caQ � ;_, �, 212 Main Stree ._ : /Septi Avail-.ility no,°p� ;fix i Room 100 / �P,o �Wa'.f ell •vaila'.ilit /11/°/NG./ •o 3` '' Northam ton, MA 01060- Noq' ii, ii wo Sets .' Strip ural Plans '4q o CT-o w ' p i Soso �s phone 413-587-1240 Fax 413-587 72 ,`, -,..,r.• : 'Tans 4 g0cify APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH • *NE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION This section to be completed by office 1.1 Property Address: 208 North Elm St Northampton Ma 01060 Map Lot Unit Zone Overlay District Elm St. District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Lissa Brouwers 208 North Elm St Northampton ma 01060 Name(Print) Current Mailing Address: 413-387-5149 see contract Telephone Signature 2.2 Authorized Agent: Adam Cluenneville 160 Old LymanRd South Hadley Ma 01075 Name(Prirp Current Mailing Address: Adat/auennel/IIe 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 5404.00 (a)Building Permit Fee 2. Electrical 0 (b)Estimated Total Cost of Construction from (6) 3. Plumbing 0 Building Permit Fee 4. Mechanical (HVAC) 4L.11) 5. Fire Protection 0 6. Total = (1 +2+3+4+ 5) 54040.00 Check Number / I /4 e6 This Section For Official Use Only Building Permit Number: Q J o-dl3--/Av DateIssued: Signature: / b J T • I Building Commissioner/Inspector of Buildings Date kaylee.agrs @ gmail.com EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing I-I Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [p Siding Ell Other(ill Brief Description of Proposed repair roofing in specified areas on contract,removeing and replacing shingles in those areas 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 Lissa Brouwers , 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 08/22/2023 ...............______.-_. Signature of Owner Date l 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 08/22/2023 Signature of Owner/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 8/21/2025 Address Expiration Date 413-536-5955 Signature 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 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 X No ❑ City of Northampton e,i nsr,r� tis - s o it Massachusetts 't ,$, r r__ w; d. ! f DEPARTMENT OF BUILDING INSPECTIONS ' �,, 212 Main Street •Municipal Building �i- ". —'' Northampton, MA 01060 j:6*.iv 1v� 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: 208 North Elm St 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) 41 a v7 Quenneviite �,��:' 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. /�!�i�( AAA, �lt tea, ; n A QUENNEVILLE AWARD Y/SAS'° DISC VER 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 C 38710 Proposal Submitted To: Date: Phone#'s: C: (413) 387-5149 Lissa Brouwers 08/21/2023 H: W: Street: Email: 208 North Elm St kitbrouwers@gmail.com City,State,Zip Code: Northampton, MA 01060 Proposal to furnish and install the following: We will pull all appropriate permits as needed We will dispose of all work related waste We will remove the old shingles on the front slope and where they are sliding reattach the decking where it's popped and replace rotted boards as needed reinstall new roofing system in these areas : -F8 Drip Edge - 8" -Ice and water barrier along the eaves -Synthetic vapor barrier -Starter shingles -Shingle and Cap Color: GAF Timberline HDZ - Color Pewter Gray We will remove existing ridgevent only where highlighted and on front slope and install GAF' Snow Country Ridgevent with Cap Shingles This Slope redone eave to n � R4 � ridge. Joined by new Ridgevent `� �a "a a r Deck Inspection in both areas � `mod ��%° � � ` This area Patched � sec -► Replace this section of Ridgevent _ �� � tit Ask us about ,e � affordable bank "' f 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:($Included ACCEPTANCE OF PROPOSAL:The above prices,specifications and conditions are Down Payment:($with ) satisfactory and are hereby accepted.You are authorized to do work as specified. 2""Payment at Start Job:($shampoo ) Payment will be 1/3 down at signing,1/3 at start of job,and balance due Balance Due Upon Completion:($bundle ) upon completion. Date: 08/21/2023 Signature: Date: 08/21/2023 Estimator:(Print Name) Ron Dion (Sign Name) Estimates are honored for sixty(60)days from above date. AcoRO DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 4/12/2023 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. lac NO Coll (413)536-0804 (A/C,No): (413)534-78'4 1649 Northampton Street AODRIess: spremo@claytoninsurance.net P. 0. Box 989 INSURER(S) AFFORDING COVERAGE NAIC# Holyoke MA 01041-0989 INSURER A:Nautilus Insurance Company INSURED INSURER B:Green Mountain Insurance Company Adam Quenneville Roofing & Siding Inc. INSURERc:Gray Surplus Lines Insurance Company 160 Old Lyman Road INSURER D:AIM Mutual Insurance Company South Hadley, MA 01075 INSURERE: 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSD WVD POLICY NUMBER (MM/DD/YYYY) (MMIDD/YYYY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE RENTE A CLAIMS-MADE X OCCUR PREMISESO(Ea occurrence) $ 100,000 X EI & PD DED $2,500 NN1423290 6/23/2022 6/23/2023 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENII AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY PRO-JECT LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ B ALL OWNED SCHEDULED AUTOS X AUTOS 20047429 6/23/2022 6/23/2023 BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE $ X HIRED AUTOS AUTOS (Per accident) UNINS/UNDERINS MOTORISTS $ 100,000/300,000 X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 5,000,000 C EXCESS LIAB CLAIMS-MADE AGGREGATE $ 5,000,000 DED RETENTION$ GSL100712 6/23/2022 6/23/2023 $ WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER YIN ANY PROPRIETOR/PARTNER/EXECUTIVE N/A E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? y D (Mandatory in NH) AWC4007012561 4/29/2023 4/29/2024 E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) For Informational Purposes Only. Workers' Compensation benefits will be paid to Massachusetts employees only. Pursuant to Endorsement WC 20 03 06 B, no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires, or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued (unless the expiration date on the above policy precedes the issue date of this certificate of insurance) . The status of this coverage can be monitored daily by accessing the Proof of Coverage - Coverage Verification Search tool at www.mass.gov/lwd/workers-compensation/investigations/. 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 F ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025(201401) The Commonwealth of Massachusetts .` Department of Industrial Accidents _ Office of Investigations "mil= 600 Washington Street Boston,MA 02111 �.r www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information /� /� /} Please Printnt Legibly Name(Business/Organization/Individual): A c e r �ven#vcll t t�c- `2_ t 1X 'tclt q y� 4l ✓]C Address: (G0 O A Lr vre„L U Q City/State/Zip: 501)% 140,4Act (1110 0joIc Phone#: 'i I -Jr'3 ,`5g55 Are you an employer?Check the appropriate box: • Type of project(required): lArI am a employer with 15 4. ❑ I am a general contractor and [ 6. El New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition workingfor me in anycapacity. employees and have workers' P tY• 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 11.0 Plumbing repairs or additions myself.[No workers'comp. right of exemption per MGL I2.[] 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 N I 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 contactors 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. l am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job the information.Insurance Company Name: A 1't'"1 My ivek-1 fc.\Cc' Policy#or Self-ins.Lic.It: A 1*JC ci0010 l agL( Expiration Date: 40 f/93 Job Site Address: 208 North Elm st 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of investigations of the DIA for insurance coverage verification. I do hereby ee'rtifoutnderthe pains and penalties of perjury 4 rtlon provided above is true and correct. an'I QuennWlle 08/22/2023 Signature: Date: Phone#: '1 13 ` 5 3c — 5 1 a 5 5' Official use only. Do not write in this area,to be completed by city or town officiaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: Commonwealth of Massachusetts �` Division of Occupational Licensure Board of Building Re ulations and Standards ConstotilloritiSkfpervisor F CS-070626 4 „ f 6ksires:08/21/2025 ADAM A QUINN 4'.: ... ',',.y 1; 160 OLD LYMAN ' F : SOUTH HADtY �` r6•4' o 0r x �v, '` Commissioner j-,eVa,/,*, THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Corporation Registration: 191093 ADAM QUENNEVILLE ROOFING AND SIDING,INC. Expiration: 03/22/2024 160 OLD LYMAN RD. SO.HADLEY, MA 01075 Update Address and Return Card. 2 1(. ,$g�! ,yky = r�Pr v4 Yv , r t:. 1 1 . I M �`;,4 �+"5,;Z: .'i% t"{,; .)1.,.r 1,h,;�',-4{M YJ ": • 'C411•.A :4V.,2, .&7, `T -;: C ,+,y�am�. .' Kr.,,,V'fi4F y tGgay''• ce �f.ry. G�5,'�', +rb�"'�„r����t+,F 'k A 0('�c,°. ¢ rp J�L. �; Fn41,. � 41.,. i h ,� �: .':• z Sg#\, 7fe A R f„ ° f c; { ' . hereby1.':11?":4;.; 1 has satisfied the qualifications required b) law and is a nt k . IMPROVEMENT CONTRACTOR , . z i 4. ti 7 f.. istration #: rii ¢I" I I �I • z{ A _.: . ta tY r l'v v`i. 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