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29-548 (3) i The Commonwealth of Massachusetts n Department oflndustrialAccidents Office oflnvestigations 600 Washington Street Boston,Mass 02111 www.massgov/dia ' Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organizationdgdividual):_ Am PP i r li In r ♦ f S.++V 1 Address:­-1 0U_� �1e�Tk City/State/Zip:-9 36U,�N e—, MA di Phone#:_ y 1J-5_a_ oaoo Are on an employer?Check a appropriate box: Type of project(required): 1 I am an employer with. a& 4.01 am a general contractor and I 6.❑New construction 2.(�employees(full and/or part time)* have hired the sub-contractors ?.❑Remodeling 1 am a sole proprietor or partner- Iisted on the attached sheet. ship and have no employees These sub-contractors have 8.❑Demolition working for me in any capacity. employees and have workers' [No workers'comp.insurance comp.insurance.# 9.❑Building addition required] 5.OWe are a corporation and its 10.❑Electrical repairs or additions 3.©I am a homeowner doing all work officers have exercised their myself [No workers'comp. right of exemption perm MGL 11.❑Plumbing repairs or additions insurance required]t c.152,§1(4),and we have no 12.❑Roof repairs employees.[no workers' 13. Other comp.insurance required.] kt-L "Any applicant that checks box#1 must also fill out the section below showing their workers'compensation polity information. tHomcowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contactors ibat 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 emolovees.they must provide their workers'comp.MIIey 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:_ Guanct — Policy for Self-ins.Lic.# U Rw C co V"1`1 l I Expiration Date:­q ) I Job Site Address: City/State/Zip:_ 0(d(o.a 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 and/or one year imprisonment as well as civil penalties in the form-of a STOP WORK ORDER and a finerof $250.OU a day against violator.Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for coverage verification. I do herby certo under the pains and penalties ofperjury that the infortnation provided above is true and correct. Signature: Date. 1 C3 Print Name•c�U��•+r+d }p�,-'-t�lP, Phone#• Official use only Do not write in this area to be completed by city or town official City or Town: Permit/iicense#: Issuing Authority(circle one): I.Board of Heath 2. Building Department 3.Cityfrown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact person: Phone#• www.Americaninstallations.com BBB ® CONTRACTOR Licensed&Insured • MA CSL#.106178 L MA Registration b 175982 American Installations 130 College Street Suite 100,South Hadley,MA 01075•Office:(413)552-0200 Fax:(413)552-0202 • Email:support@Americanlnstallations.com Greene,Emily 8/17/2015 (1-0 (Fi.) (0-0 19 Indian Hill Florence MA 01062 (A*—I Kfty) tswl) OF) 413-586-3592 ohiodove @aol.com (Home) 4C 1) (Emain 412185 15-1385 tsAelm trpeq Quantity Unit Unit Cost Total Air Sealing AIR SEALING 8 Iman hour 1$ 85.00 $ 680.00 Total Air Sealing $ 680.00 Total Air Sealing Incentive $ 680.00 Weatherization DOOR WEATHERSTRIPPING W/SWEEP 1 each $ 75.00 $ 75.00 DAMMING R-38 117 linear ft $ 2.05 $ 239.85 FLAT-8"OPEN R-28 597 sqft $ 1.37 $ 817.89 HATCH SEAL&INSULATE 1 each $ 60.00 $ 60.00 2"RIGID BOARD 200 sqft $ 3.50 $ 700.00 BATH VENT THRU ROOF 2 each $ 118.75 1$ 237.50 VENTILATION CHUTES 50 each $ 2.00 $ 100.00 Total Incentivized Weatherization $ 2,230.24 Total Project $ 2,910.24 Total Utility Contribution—$ 2,352.68 Total Customer Contribution F$ 557.56 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= $ 557.56 conditions are satisfactory and are hereby accepted.You are authorized to do work as specified.Payment will be 1/3 down prior to Down Payment= ❑ start of work,and balance due upon Completion. PAID _._ Balance Due Upon Completion=—$ 557.56 ff h,er 0 xt> 5!g°MVt° Ort! d`Y _ytA tJ _O rope w�r Oct aEli "J PmHK+TE O•per lPHml Prty !Silo) Wt! Aepreumawelprlm) rx ISK�.) care 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 IS BETWEEN AMERICAN INSTALLATIONS,LLC HEREINAFTER REFERRED TO AS'COMPANY-,AND THE CU5TOMER(S)NAMED ABOVE,HEREINAFER REFERRED TO AS-CUENT',AND WILL BE SUBIECrTO ALL APPROPRIATE LAWS,REGULATIONS AND ORDINANCES OF THE STATE OF MASSACHUSETTS OR CONNECTICUT RESPECIIVELY,AS WELL AS ALL LOCAL JURISDICTION$. SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: Weclev C'nIltilre. 10(0 11$' 130 College St. License Number South Hadley,MA 01075 C.o21. l 7 Address 413-552-0200 Expiration Date Signature Telephone 9.Registered Home Improvement Contractor: Not Applicable ❑ American Installations 1 159� a Company Name Registration Number South Hadley,MA 01075 Address 41 SS7 Q2Q(1 (�- a7• f7 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 the building permit. Signed Affidavit Attached Yes....... 0' 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 El Replacement Windows [Alteration(s) Roofing Or Doors 171 Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [[] Siding[p] Other[ iv1,5 v Brief Descripption of Proposed II U Work: A�1 i 1 bra vwivl i%V-J�a� d 0 ay� oUG�avj- 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. 1. 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 property as Owner of the subject American Installations hereby authorize to act on my behalf,in all matters relative to work authorized by this building permit application. S� 0;�(-V�\ ip -I'l-(�5- 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 American Installations 1 0 [� I Signature of Owner/Agent Date 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- l Rear ( I Building Height Bldg.Square Footage °lo 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 O DONT KNOW Q YES O — IF YES, date issued: � IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW O YES O IF YES: enter Book i } Page( and/or Document#1 B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW O YES Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained O , Date Issued: C. Do any signs exist on the property? YES O NO O IF YES, describe size, type and location:D. Are Are there any proposed changes to or additions of signs intended for the property? YES O NO 0 IF YES, describe size, type and location: j 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 © NO 0 IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Department use only h ---- ity of Northampton Status of Permit: B ilding Department Curb-Cut/Driveway Permit Z � � 12 Main Street Sewer/Se tic Availabili NOV p� t�. Room 100 Water/Well Availability pEpr.OF AUILDING iNSPECf1GNNort ampton, MA 01060 TWO Sets of Structural Plans.: A 01060 NO AM a 13-587-1240 Fax 413-587-1272 Plot/Site Plan's 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 0d,1 I,AI,aVA �6• Map Lot Unit. Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: sy IVl C'\ r���,; a` I�nr,�;o v1 Name(Print) Current Mailing Address: Telephone elephone 2.2 Authorized Agent: American Installations 130 College St. Name(Print) oU a ey, A ailing Address: 413-552-0200 Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building LO ay (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=(1 +2+3+4+5) 9,ova, 9,L4 Check Number This Section For Official Use Only Building Permit Number: rate d: Signature: Building Commissioner/inspector of Buildings Date File#BP-2016-0614 APPLICANT/CONTACT PERSON AMERICAN INSTALLATIONS LLC ADDRESS/PHONE 130 COLLEGE ST SOUTH HADLEY01075(413)552-0200 PROPERTY LOCATION 21 INDIAN HILL MAP 29 PARCEL 548 001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT ___1 Fee Paid Building Permit Filled out Fee Paid Typeof Construction: INSTALL ATTIC&BASEMENT INSULATION New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 106178 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION PRESENTED: 4-A15—proved 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 iti y Sign re o uilding'Official 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. 21 INDIAN HILL BP-2016-0614 GIs#: COMMONWEALTH OF MASSACHUSETTS Man:Block: 29-548 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: INSULATION BUILDING PERMIT Permit# BP-2016-0614 Project# JS-2016-001031 Est. Cost:$2910.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO Const.Class: Contractor: License: Use Group: AMERICAN INSTALLATIONS LLC 106178 Lot Size(sa. ft.): 12632.40 Owner: RUBIN SYLVIA LYNN Zoning: Applicant: AMERICAN INSTALLATIONS LLC AT: 21 INDIAN HILL Applicant Address: Phone: Insurance: 130 COLLEGE ST (413) 552-0200 WC SOUTH HADLEYMA01075 ISSUED ON.111412015 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 Signature: FeeType: Date Paid: Amount: Building 11/4/2015 0:00:00 $65.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner