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42-063 (4) BP-2023-1799 998 WESTHAMPTON RD COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 42-063-001 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-2023-1799 PERMISSION IS HEREBY GRANTED TO: Project# 2023 ROOF REPAIR Contractor: License: ADAM QUENNEVILLE ROOFING & Est. Cost: SIDING 070626 Const.Class: Exp.Date: 08/21/2025 Use Group: Owner: SCHMITH MARY L Lot Size (sq.ft.) Zoning: WSP Applicant: ADAM QUENNEVILLE ROOFING & SIDING Applicant Address Phone: Insurance: 160 OLD LYMAN RD (413)536-5955 AWC4007012861 SOUTH HADLEY, MA 01075 ISSUED ON: 01/02/2024 TO PERFORM THE FOLLOWING WORK: REPAIR DAMAGED AREA, REMOVE EXISTING SHINGLES, INSTALL UNDERLAYMENT &NEW SHINGLES 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: 0:914)44,. Fees Paid: $40.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner ; I_ _11 t=l c The Commonwealth of Massachusetts Board of Building Regulations and Standards FOR MUNICIPALITY Massachusetts State Building Code,780 CMR USE r o _ building Permit Application To Construct,Repair,Renovate Or Demolish a Revised Mar 2011 One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number33P 20223 -("791 1 Date Applied: Building Official(Print Name) Signature ate SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 998 Westhampton Rd Florence Ma 01062 tn-C.43 -00 j 1.1a Is this an accepted street?yes X no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: 1/3612 _ -, I-7`f Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public 0 Private 0 Zone: _ Outside Flood Zone? Municipal 0 On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: _Mary Schmith _Florence Ma 01062 Name(Print) City,State,ZIP 998 Westhampton Rd Florence Ma 413-584-8954 No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building Owner-Occupied 0 Repairs(s) Alteration(s) 0 Addition 0 Demolition ❑ Accessory Bldg. 0 Number of Units Other IX Specify:_ Brief Description of Proposed Work Repai,rmove tarp on back slope and repair damaged area 3 sq remove existing shingles and install new syntheti cunderlayment and new shingles SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ 4,500.00 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ ❑Standard City/Town Application Fee ❑Total Project Costa(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire n a Suppression) $ Total All Fees:$ YD— op Check No)453 I Check Amount: �-O--- Cash Amount: 6.Total Project Cost: $ 4,500.00 0 Paid in Full 0 Outstanding Balance Due: City of Northampton 212 Main Street, Northampton, MA 01060 Solid Waste 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. Address of the work: 998 Westhampton Rd Florence Ma The debris will be transported by: Adam Quenneville Roofing&Siding The debris will be received by: Adam Quenneville Rooting&Siding @160 Old Lyman Rd South Hadley Building permit number: Name of Permit Applicant Adam Quenneville Vi.r:II4 iry p.ffiil(er iziziizoz' 12/21/2023 ore C.2uenneVille Date Signature of Permit Applicant d 1dr lam' f � i'gUINNEVILLI s,` AWARD disc-wErt ._ Fr O O F l rt z- • s t >a i to t7 VISA*: 1o;u wir<vdu 160 Old Lyman Road•South Hadley•MA 01075 We are Licensed 1.800.NEW.ROOF • 413.536.5955 Fully Insured Email:infoCr+�1800newroof.ne( 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 Memberotthe Building&Trade Association P.P.0 387i0 Proposal Submitted To: Date:O/)tO/Z) Phone It's: C: 1"‘ S�VI`�� 'k H: yi —S 6 1 % 1S4W: Street: 9 St \A)-CSL�a- e vo K\ Email: City,State,Zip Code: T hh. �f is✓ � I."" 0 Proposal to furnish and install the following: w�- w� U� r fav •c,, ��,rp �vti r. s w4 �\ w d V\ r� vr,.� r— p d.-Pev ets5 c. �./'�,� t,. f 3c4/ A ro *•—• S 1,1 n j! t, S G vim.t < is 0\, -a( � S VN 0 (A. V 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 meterias and labor--complete in accordance with above specifications for the sum of: Total Due:($ S(,y Q ) ACCEPTANCE OF PROPOSAL:The above prices,specifications and conditions are Down Payment:($ it I S e)0 satisfactory and are hereby accepted.You are authorized to do work as specified. 2ne Payment at Start Job:($ Payment will be 1/3 down at signing,if3 at start of job,and balance due Balance Due Upon Completion:($3/O Cab upon completion. 8 1[;� Date: i; � �; v� nattrra:— y���� �V, r�. /� / Date' 2 0/9-1stimatcr:(Print Name) l s'1'I `14*f7�i r tj' f (Sign Name) Estimates are honored for sixty(60)days from above date. v The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ="isI= 600 Washington Street ==} Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information /� II Please Print Legibly Name(Business/Organization/Individual): Adew, QUenvvc )tl�i- ILoU ti 5'tclt,1 ( elC. Address: (LO 01 A jJ City/State/Zip: 5ou'ih 140,4Act (tilto GI O 57 Phone#: '(13 —53c.`3(65— Are you an employer?Check the appropriate box: Type of project(required): l.�I am 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.❑ 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 El Building addition [No workers'comp.insurance comp.insurance.t required.] S. ❑ 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.[]Plumbing repairs or additions myself.[No workers'comp. right of exemption per MGL 12.E6 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#1 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. !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 M u 1 vek1 'I'5 0 Policy if or Self-ins.Lic.b: A LOC.4i001 O I L I Expiration Date: 04/29/2024 I I Job Site Address: 998 Westhampton Rd 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 eertitroundenithe pains and penalties of perju . - ttlon provided above is true and correct. ,12/21/2023 Signature: /-+dan C.CuenneVille Date: Phone#: w t 3 — 53C — 5955" 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#: ACC0121=1 CERTIFICATE OF LIABILITY INSURANCE DATE (M Y)/2023 T 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 Lauren Eckhardt NAME: Clayton Insurance Agency, Inc. (AIC No ExO; (413)536-0804 FAX No, (413)534-7e74 1649 Northampton Street E-MAD P. 0. Box 989 INSURER(S)AFFORDING COVERAGE NAIC# Holyoke MA 01041-0989 INsuRERA: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 INSURERD:AIM Mutual Insurance Company South Hadley, MA 01075 INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER:2023 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 POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL UABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE X OCCUR DAMAGE TO RENTED 100,000 PREMISES (Ea occurrence) $ X BI & PD DED $2,500 BN965983 6/23/2023 6/23/2024 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L 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) B ANY AUTO BODILY INJURY(Per person) $ ALL OWNED B SCHEDULED 200/7429 6/23/2023 6/23/2024 BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE X HIRED AUTOS X 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$ GSL101401 6/23/2023 6/23/2024 $ WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE NIA E.L.EACH ACCIDENT $ 1,000,000 OD (MandatoryEMBER In NH)EXCLUDED? y AWC4007012861 4/29/2023 4/29/2024 ( ry E.L.DISEASE-EA EMPLOYEE $ 1,000,000 It 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 it 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 i (Michael Regan/FMT /174 u-/ P ©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 10 Division of Occupational Licensure Board of Building Re ulations and Standards Const{ prtt ISrvisor ram` CS-070626 . 7471 . i spires:08/21/2025 ADAM A QUENNE t E 160 OLD LY N R s" ji SOUTH HADL Y '. , Ifs ;C r fj'Olr,k 3;l ll� r Commissioner .l,Eb/.,LGf., 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 ADAM QUENNEVILLE ROOFING AND SIDING, INC. Registration: 033/22/21093 024 160 OLD LYMAN RD. Expiration: 2/2 SO.HADLEY, MA 01075 Update Address and Return Card. y} t it yn.;:`! 0,,,.., .ir � aly......;2 !r r. !r , r �e *,irSl)a -a.T t Z+ �m 'rr � t Di fr t " ! ,, s�: t ! ,a ! ! �h � xz� � ti �*,..� n a a.,Kr Yn r' ^ vd x r 1 � kd� �!r• +3, �� >����u2 � � .��`� _ rya ` �w ► � �»+ '� ... __ .__�._M...._. _ ' ; I STATE OF CONNECTICUT + DEPARTMENT OF CONSUMER PROTECTION i fi z Be it known that I J. ,,, j .F i ADAM QUENNEVILLE i , , 5 160 OLD LYMAN ROAD ° i SOUTH HADLEY, MA 01075-2632 . r 1 I ,t f' has satisfied the qualifications required by law and is hereby registered as a ' "Al,1 t HOME IMPROVEMENT CONTRACTOR I i i,,,,,,,,,,,,:::;,,,:, i ' i ADAM QLUENNEVILLE ROOFING t i" i Registration #: HIC.0575920 I n, e, yr =' p� !' Effective: 04/01/2023 i k z� /)41.1Z Expiration: 03/31/202444.d." ! Michelle Seagull,Commissioner (s 9:, 'tom.•}, L_. .___.... ,_.... gsa k,•3... ,i. �., +i n.�r +titi t. :. � „ ' A^ti f e v, J� 6s t ,, 0 ;k, Y w .,t-�'ta' i. . r ri =a• r.'z -.. ,.F i s <J,r. 2>s1,.. ...ti.,y , f . r i