Loading...
29-101 (4) s;.,.. The Conznionwealth ofMassaclutsetts Department of Industrial Accidents _�. Office of litvestigations *A 600 Washington Street Boston,Mass. 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/FIectricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/individual): American installation Address: 3�!I Al ew 4vn 3k . City/Mate/Zip:_ Sou--J- A-oLt\/ . /• A A 1 b'7 S Phone#:_ $-:S- _c;sa-O a0 d Are you an employer?Check the appropriate box: Type of project(required): 1:�&am an employer with ;3 =1.01 am a general contractor and 1 6.D New construction employees(full and/or part time).* have hired the sub-contractors 2.01 am a sole proprietor or partner- listed on the attached sheet. 7•❑Remodeling ship and have no employees These sub-contractors have 3.0Demolition working for me in any capacity. employees and have workers' 9. Building addition ! [No workers'comp.insurance comp.insurance. required] 5.0)h1e are a corporation and its 10.❑Electrical repairs or additions .3 I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself [No%vorkeW comp. right of exemption perm MGL insurance required]: c.152;§ 1(4),and we have no 12.❑Roof repairs employees.[no workers' — / c 1 comp.insurance required.] 3.�Other Yt SUl �lDr') *:any applicant that checks box:.1 must also fill out the section below shoving their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all-.Pori:and then hire outside contractors must submit a new affidavit indicating such. sContactors that check:this box must attach 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.theN must provide their-.Yorkers'comp•policy number. I am an employer that is providing workers'compensation insurance for m}r employees.Below is the pollen and job site information. insurance Company Name: i I)p 6i-i-f6('r1 Zrlr,uY oLYicX Policv T or Self-ins.Lic. B t 3 Expiration Date: q–LA– I y Job Site Address: City/State/Zip: 6Uw� 1'M 1 1,n n lc�) C� 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 152 can lead to the imposition of criminal penalties of a fine up-to--$1.500.00•andlor-one year imprisonment as well as civil penalties in the form of a STOP WORK ORDER an&i fine of $250.00 a day against violator.Be-advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for coverage verification. 1 do herby cent fi�under the pains andpenalties ofperiurt,that the information provided above is trite anti correct. Si�lzatare: 1� t.�A Date. � L Print a\came: ju 20r n i(c? T. C O ta�'Ll�C' Phone E. l 3 _ 'S 5 R– Official use only Do not write in this area to be completed by city or town official City or Town: Permit/license lk Issuing Authority(circle one): I.Boat d of Heath 2. Building Department 3.Cityffow-n Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact person: Phone 9: www.AmericanInstallations.com auk BB ° R,oi o Licensed&Insured �i MA CSL#:106178 MA Registration#175982 American Installations 341 Newton Street,South Hadley,MA 01075 Office:(413)552-0200 Fax:(413)552-0202 Email:support @Americanlnstallations.com Kimberly,Riopelle 7/24/2014 (Last) (First) (Drte) 15 BrierwoodDr. Florence MA 01062 (Address) (City) (State) (zip) (413)297-5342 kriopelle @servicenet.org (Home) (Cell) (Email) 402213 14-570 (Site ID) (Job M) Quantity Unit Unit Cost Total No-Cost Measures Air Sealing-Days Per Man Hour 8 man hour $ 75.00 $ 600.00 Total No-Cost Measures Incentive= $ 600.00 Weatherization` Open Attic 4"Cellulose 1,200 sqft $ 1.08 $ 1,296.00 Attic Hatch Seal(Q-Lon)&Insulate 2"R-13 Thermax 1 each $ 60.00 $ 60.00 Crawlspace Wall 2"Thermax or equiv.and 2"on sill 128 sqft $ 3.52 $ 450.56 Additional Air Sealing 4 man hour $ 75.00 $ 300.00 Total Incentivized Weatherization= $ 2,106.56 Total Non-Incentivized Weatherization= $ - Total Project= $ 2,706.56 Total Utility Contribution= $ 2,179.92 Total Customer Contribution WARRANTY:American Installations,LLC will provide the above stated homeowner with a 2 year workmanship warranty. American Installations,LLC hereby proposes to furnish all material and labor to complete the above scope of work in accordance with the above specifications and all local and state building regulations for the Total Contract Value as stated herein. ACCEPTANCE OF PROPOSAL:The above prices,specifications and TOTAL CONTRACT VALUE_ $ 526.64 conditions are satisfactory and are hereby accepted. You are authorized to do work as specified.Payment will be 1/3 down prior Down Payment= $ 175.00 ❑ to start of work,and balance due upon Completion. PAID Balance Due Upon Completion= $ 351.64 7/24/2014 Sign.— Dale Property Owner(Print) /'� n� Prope Owner(Sign) Dale 7/24/2014 Represen[rtrve(Pont) Representrtrve(Sign) Drte THIS AGREEMENT IS COMPOSED OF THIS PAGE AND THE REVERSE SIDE OF THIS PAGE AND SHALL BE CONSIDERED THE ENTIRE AGREEMENT BY THE PARTIES INVOLVED.THIS AGREEMENT 15 BETWEEN AMERICAN INSTALLATIONS,LLC HEREINAFTER REFERRED TO AS"COMPANY",AND THE CUSTOMER(S)NAMED ABOVE,HEREINAFTER REFERRED TO AS"CLIENT',AND WILL BE SUBJECT TO ALL APPROPRIATE LAWS,REGULATIONS AND ORDINANCES OF THE STATE OF MASSACHUSETTS OR CONNECTICUT RESPECTIVELY,AS WELL AS ALL LOCAL JURISDICTIONS. SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: \[--) 1 1- Wesley y License Numb r 341 Newton St , (� Address South Hadley, Expiration Date 413-552-0200 Signature Telephone 9.Registered Home Improvement Contractor: Not Applicable ❑ Company Name PgMriudll 11IStallatiOlIS Registration Number 341 Newton Street � � S,nut. .4"ey,A-4-A A10-7s Address 413-552-0200 Expiration Date Telephone 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 th uilding permit. Signed Affidavit Attached Yes.... .. No...... ❑ 11. - Home Owner Exemption The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)families and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor.CMR 780, Sixth Edition Section 108.3.5.1. Definition of Homeowner: Person(s)who own a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two family dwelling,attached or detached structures accessory to such use and/or farm structures.A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. As acting Construction Supervisor your presence on the job site will be required from time to time,during and upon completion of the work for which this permit is issued. Also be advised that with reference to Chapter 152(Workers'Compensation) and Chapter 153(Liability of Employers to Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,you may be liable for person(s) you hire to perform work for you under this permit. The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of Northampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [[1] i liCof p Other Brief Description o s Work: L. 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 as Owner of the subject property iAmerican Installations hereby authorize to act on my behalf,in all matters relative to work authorized by this building permit application. - (I echW O� C�-- Signature of Owner Date American Installations 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. American Installations Print Name Signature of O / nt Date t._ 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 0 DONT KNOW ® YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO ® DONT KNOW ® YES 0 IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO ® DONT KNOW Q YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained © Obtained O , 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 IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES O NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Department use only i �� ity of Northampton Status of Permit: . �� uilding Department Curb Cut/Driveway Permit AUG ��� 212 Main Street Sewer/Septic Availability 204 i�./ Room 100 Water/Well Availability N rthampton, MA 01060 Two Sets of Structural Plans' Electric, Plumbing c 1001 587-1240 Fax 413-587-1272 Plot/Site Plans Northampton, 0 Other Specify APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be completed by office `-) 6° -c (000(� '\bc' Map Lot Unit VU->nof MA o\wa Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) Cu t d Telephone Signature 2.2 Authorized Agent: Wesley Couture 341 Newton St American Installations NamQrintj So uth RMON 4*0 675 341 Newton Street 413-552-0200 South Hadley, MA 01075 ignatu Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total=0 +2+3+4+5) Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2015-0144 APPLICANT/CONTACT PERSON AMERICAN INSTALLATIONS LLC ADDRESS/PHONE 341 NEWTON ST SOUTH HADLEY (413)552-0200 PROPERTY LOCATION 15 BRIERWOOD DR MAP 29 PARCEL 101 001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid KD Typeof Construction: INSTALL ATTIC&BASEMENT INSULATION New Construction Non Structural interior renovations Addition to Existine Accessory Structure Buildine Plans Included: Owner/Statement or License 106178 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON IN_ FPRMATION PRESENTED: Approved Additional permits required(see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project: Site Plan AND/OR Special Permit With Site Plan Major Project: Site Plan AND/OR Special Permit With Site Plan ZONING BOARD PERMIT REQUIRED UNDER: § Finding Special Permit Variance* Received&Recorded at Registry of Deeds Proof Enclosed Other Permits Required: Curb Cut from DPW Water Availability Sewer Availability Septic Approval Board of Health Well Water Potability Board of Health Permit from Conservation Commission Permit from CB Architecture Committee Permit from Elm Street Commission Permit DPW Storm Water Management Delay ature of Building Officia Date Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning requirements and obtain all required permits from Board of Health,Conservation Commission,Department of public works and other applicable permit granting authorities. * Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of Planning&Development for more information. 15 BRIERWOOD DR BP-2015-0144 GIs#: COMMONWEALTH OF MASSACHUSETTS Map-.Block: 29- 101 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: INSULATION BUILDING PERMIT Permit# BP-2015-0144 Project# JS-2015-000253 Est. Cost: $2100.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: AMERICAN INSTALLATIONS LLC 106178 Lot Size(ss . ft.): 12066.12 Owner: RIOPELLE DAVID&KIMBERLY Zoning: Applicant: AMERICAN INSTALLATIONS LLC AT. 15 BRIERWOOD DR Applicant Address: Phone: Insurance: 341 NEWTON ST (413) 552-0200 WC SOUTH HADLEYMA01075 ISSUED ON.81412014 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL ATTIC & BASEMENT INSULATION 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: Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace/Chimney: Rough: Oil: Insulation: Final: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy Siznature: FeeType: Date Paid: Amount: Building 8/4/2014 0:00:00 $55.00 212 Main Street,Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner