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Section 4. ZONING Alt Information Must Be Completed.Perm¢Can Be Denied Due To Incumptete Information
Existing Proposed Required by Zoning
This mlumn m ba fiBW in by
Building DVannuat
Lot Size — —i � —�
Frontage
Setbacks Front O
Side L:= R:= L:= ICL.__I
Rear J i_I riJ
Building Height
Bldg.Square Footage
Open Space Footage
([ .mina bldg&Mal
;sald-g)
N of Parking Spam �� C
Fill: —_-- -----_—_—___
vo)ame&Inwlim)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO Q DONT KNOW O YES O
IF YES,date issued:I I
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW O YES O
IF YES: enter Book Page and/or Document N1
B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW O YES O
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 there any proposed changes to or additions of signs intended for the property? YES O NO O
IF YES, describe size,type and location:
E. Will the construction activity disturb(clearing,grading,excavation,orfilfing)over t acre or is it part of a common plan
that will disturb over lam? YES O NO O
IF YES,gran a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPQSED WORK(check all appRo
New Howse ❑ 1 Adddlon ❑ I ReplacemeMWindows AH"atiags) ❑ Roofing ❑
ar Doors El
AccessorySidg. [. Demolition, ❑ Naw Signa I01 Decks. (D Sidin91101 Mart
Btief Description of Proposed
Wok Attic and basement insulation and air sealing throughout
Alteration of existing bedmom^Yes^No Adding new bednom, Yes No
Attached Narrative Renovating unfr fished basement -__Yes _No
Plans Attached Roll -Sheet
Sa.If New house and or addition to exisiting housing,complete thefollowing:
a. Use of building:One Family Two Family Qiher
b. Number of roams,in each family unit Number of Safrtcams
c. Is there a garage attached?
d. Proposed Square footage of new consWction. Dimensions
e. Number of stories?
I. 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 700 fL of wefands?_Vas —No. Is construction within 700 yr. fioodplain Yes__--No
J. Depth of basement or milar four below finished grade
k. Will bldg conform In the Subdig and Zoning regulations? `Yes`No.
I. Sept ;Tank_ CitySewer_ Private well_ City water Supply
SECTION 7a•OWNER AUTHORIZATION•TO DE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLES FOR BUILDING PERMIT
1, hili-es��rin A'_ [�\;.aSClP as Omrerofthesubject
property
hereby authorize American Installations
to act on my behalf,In all matters relative to work authorized by this building permit appricatiom
See attached 9- Iw- %A
Sgnature of Owner Data
1, American installations as OwaermAdhomed
Agent hereby declare that the statements and IMnrmafon on the foregoing appfcafon aro true and accurate,to the best of my knowledge
and belief.
Signed under the pains and penaifies of perjury.
.American Installations
Prim Name ^
American Instaflations
Signature of Dwnerl end Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licansed Construction Supervisor: Not Applicable ❑
Namanllbevst tmtdme Wesley K Couture 100178
License Number
130 College St, Ste 100 South Hadley,MA 01015 9124119
Address Explosion Data
413-552-0200
Ignature Telapiwne
9.Registered Rome Improvement Contractor. _ _ Not Applicants 13
Wesley Couture ll5982
Company Name Registration Number
American Installations 612119
Address Expectant Date
130 College St., Ste 100 South Hadley, MA 01015 Telsphone'113-552-0200
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(fii c.152,§2SCgiN
Workers Compensation Insurance affidavit must be completed and submitted with this application.Failure to provide this affidavit will result
In Ste demi of Us issuance#ure binding pennA
Signed Affidavit Attached Yes....... 9 No...... ❑
11. - Home Owner Exemption
The curtem exemption for"homeowuera"was worried be include Owner occupied Dwellings of one(1) or two(2)families
and to allow such homeowner m engage an individwl for hire who does ant possess a ficurse,prnvidsd th8tthe owner acts
as supervisor.CMR 780, SLyth Edition Section 1083.5.1.
Definition of Homeowner.Person(s)who owe a parcel of land on which he/she resides or intends to reside,on which there
is,or is intended an te,a Dna or t"family dwelling,attached ordetacbed structures accessary,to such use ands or fawn
structures,A person who constructs more than one home In a two-year varied shall not be considered a homes w,
Such"homeownre shall submit to the Building Official,on a form acceptable to the Building OSwiaL thathefshe shall be
riddbq�wtgja for all m wor o ed mudgr the e
As acting Construction Supervisor year pressure on thejob site will be required from time to time,during and upon
completion of the work far which this permit is issuaL
Also be advised that with reference to Chapter 152(Workers'Compensation) and Chapter 153(Liability of Employers m
Employees for injuries not resulting in Death)of the Massachusetts General Laws Anantared,van may be Sable for per aids)
you hire to performwork fmyouunder this prank
The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of
Northampton Ordinances,Stam and Local Zoning Laws and Stake ofMassaehusetta General laws Annotated.
Homeowner Signature
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
tby MGL c 111, S 150A.
Address of the work: 511 -IisC p u
The debris will be transported by: American Installations
The debris will be received by: Waste Management of NE - Chicopee Landfill
Building permit number:
Name of Permit Applicant American Installations
1
Date Signature of Permit Applicant
S r-.
www.Amenra1
nn4l.non:xom
• Licensed&Insured
M/CSL A106178
American installations MA Repbhubnn A175982
]30 COIIpge Sbeer SUMe]OO,SoufM1Xatlleg MA 01U]S IXflre:(<1315RNOO Pox:(413)SW4ZN •email support@AmManlm lWn s.om
Rae,Patterson&Mellow 1/31/2018
512 Burts Pit Road Florence MA 01062
14131589-2462 ami hanegreensparrillamanducast.not
las
460243 1FMy
SAI 18-0454
Quantity Unit Unit Cost Total
Air$'sling
AIRSEALING 8 man hour $ 85.00 $ 68000
WEATHERSTRIP DOOR&ADD SWEEP 1 each $ 8000 $ 80.00
Air Sealing $ 16000
Air Sealing Incentive $ (160.00)
Air Seising M Balance $ -
WeaMerrtarion
BASEMENT SILLS-R19 FG BATT 132 soft $ 1.95 $ 251.06
BASEMENT-INSULATE BULKHEAD DOOR&INSULATE 1 each $ 11000 $ 110.00
ATTICFLAT-10"OPEN R-37CELLULOSE 1,040 sqk $ L56 $ 1,62240
ATTICDAMIAMG-R-38FIBERGLASS 18 sqft $ 2.05 $ 36.90
AT1C HATCH-SEAL&INSULATE 1 each $ 6000 $ 60.00
KNEEWALL-2"RIGID BOARD 34 soft $ 3.85 $ 130.90
REMOVEINSULATION 132 sqk $ 0.15 $ 99.00
Total Weatherization $ 2,316.60
Weatherization Incentive $ 1,663.20
Total Project $ 3,026.60
Total Utility Contribution $ 2,423.20
Total customer Contribution $ 653.40
WARRANTY mIlas.11,11111hem,u<.11 wi
rer anada hommwoer Its rvrtma
ia lv=a. omp ry
wanan .
arby Amito much h u nalana doth m usmwe nepe N waa
mae -moe in, In mea ,in mem a seow,fiaen
hn led all heal ,it m<e
h. �narerNatlan,
or Teal cemraavaw.mooed comm.
ACCEPTANCE or PROPOSAL The abort paces.spennnnon:and TOTAL CONTRACT VALUE= $ 653.40
ry
onarmenes are aandeteana are Poetry....tried.v
authorities to do worxa:aperleed.Payment will be 1/3 down Prier Down Payment= $ 217.00 Lid
w s,an hewer"and balance dua upon completion. pA,u
Balance Due Upon Completion= $ 436.40
Patterson Rae 1-31-18
Barryl. Zamer 1-31-18
The Commonwealth of Massachusetts
Department of Industrial Accidents
Offet:e of Investigations
600 Washington Street
Boston,MA 02111
www.mossgav/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbcrs
Applicant Information Please Print Lceibly
Name(Itmo ess7GrganlraticavlothAdw9): American Installations,LLC
Address: 130 College Street,Suite 100
City/State/Zip: South Hadley,MA 01075 Phone#:_ 413-5--552-0200
Are you an employer?Check the appropriate box: Type of project(required)'.
L ff3 I am a cm (oyer with 4b 4- ❑ 1 am a general contractor and 1 d
p _ ❑ New wnstnrco.n
employees(full and/or pan-limej.* have hired the sub-contrxdors
2.(] f am a sok prophet., grace,grace,tne
listed on the attached sheat r 7, Remodeling
ship and have no employees These sub-conoactors have 8. U Demolition
working for me in env capacity, workers'Comp. insuranec. 9. Building addition
[No workers'comp. insurance 5. [j We are a corporation and its i 10:-] Electrical repairs or additions
o"f need.] officers have exercised their
3.(.] [am a homeowner doing all work right of exemption per MGI. I I.El Plumbing repairs or additions
myself.INo workers'comp_ c. 152,§I(4),and we have: J 13.0 Roof repairs
L-7=
required. t employees. (No workers' InsulationOther
comp.insurance required. —"' .�
"Any Oppliuni thatchecks au,#1 musalso all out the odu,n WOW Showing theirwurkLr mmpensaoon cath,Infor"WOOn.
ilrwemx,srs who subu.Nix ellnvh inauaring nc,y are avingait work aro note hue eere a,vu 10,1 maul submit a new at)iav¢rc my mg such.
"Cunt our,4ID1 ChlCk lAiz Epl lnuAerlachtd..sidan. rhael3he Witon pam[uf 1hr OO-outme WISand thal lonvui tamp.lIDllry..f.—Mali,
f am as rmphryrr char is provrdirrq rvarkrrs'romp¢n5ndan tmaramrJnr my emgdnyres. 8rtnw u thrpatug axd jab sae
information.
Insurance Company Name:_ Guard Insurance Companies
Policy#or Selfire. l.w.#: AMWC731485_ Expiration Date 09/04/2018__`
lob Site Address:_,{,�{ 7- �(''v'„`. .._City/StateiZip: r, _r ..,nr N1 "ltplo'yL.
Attach a copy of the workers'compensation poticy,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
fine no to$!SOo.00 and/.,one-year impria mirern,as weft as civil penalties in rhe form of a STOP WORK ORDFR anti a fine
of upto$25000 a day against the violawr. Be advised that a copy of this statement may be IDrwarded to(lie Office of
Investigations of the DIA for insurance coverage verification.
I do hereby ceey/dif,y__under rhe pains and penalties of perjury that the infarmaoon provided abme it true and correct.
S-¢natiK3a"'./d/AAtC
Phone#: 0200
Ofjchd use only. Do amt write in this area,to be eomplefed by city or town offlchd
City or Town: Pcradt/License#
Iss i ng Authority teirele one):
L Board of Health 2. Building Department 3.Cilytrown Clerk 4. E'lecirical Inspector 5. Plumbing Inspector
n.Other
Contact Person: Phone#:
Commonwealth of Massachusetts Construction Supervisor
®� Division of Professional Licensure Unrestricted-Buildings ofanyuse groupwhich contain
Board of Building Regulations and Standards lass than 66,000 cubic read(991 cubic mail of enclosed
Constructibn Supervisor
space.
CS-106178 EYpires:09/29/2019
MSLEY COI=JRE
218 LATHROP55TREET [t
SOUTH HADLEY MA 01075
Failure to possess a current edition otthe Massachusetts
State Building Code Is GYR for revocation of BIK license.
CZ Far infometlon about this icense
Commissioner CA(617)727-1200 or visit vmrwmass-9ovMpl
�'�l1P C��1l7jjznytt[�et�t'fi� a�C���irJ:l«ry7t�Je��S
Office of Consumer Affairs and Business Regulation
10 Park Plaza- Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Type: LLC
AMERICAN INSTALLATIONS,LLC. Registration: 175982
130 COLLEGE STREET SUITE 100 Expiration: 06/26/2019
SOUTH HADLEY,MA 01075
Update Address and return card Mark reason for charge.
SCA1 0 RWM 11
Enmilayment E2 mad Card
Ll
HOME IMPROVEMENT CONRiALTOR beoreMlonvMMtx irMe.I fo use our
TYPE:LLC before Te xryuaer dab. H bunt return e
: L ReabbxMn Exp' 'pO Office of Consumer Attain and Business Regulation
1r5902 06/26/2019 10 Park Plaza-Buie 5170
AMERICAN INSTALLATIONS,LLC. Sosho r.MA 02116
WESLEY COUTURE
WESUIF LFGE COUTUREET SUITE 100 y
SOUTH HADLEY,MAI U�erst.�retary / t valid without signature
A�Rly CERTIFICATE OF LIABILITY INSURANCE 8/14/2017
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 corti icato holder is an ADDITIONAL INSURED,the policy(ies) must to ondoraed. If SUBROGATION IS WAIVED,subject to
the*me and condMbns of the polky,Ceitam pWkies may meulre an alldonlement A statement on this certHlCate does net COnter rights to the
tortigcaW holder in ileo of such andorsemmA(s).
PRODUCER CD.TACT LinCa In.werB
Webber S Grinnell PtroR (413)586-0111 .uis)saS aaOn
8 North Bing Street A' Il�a..lpowers@webber_ndgrimell.aom
aLauREwsl AFraRONu covenaOE NAcx
Northampton NTA 01060 IXSURERAAEm to ora Hutual Casualty
INSURE) IN$URERB:HmrkOIUn 8aLI184aV GOARD Sn8 CO.
American Installations, LLC INSURERC
At": Nes $ Susanna Couture INSURER D:
130 College Street, Suite 100 ANSURERE:
South Badley NA 01075 INSURER F:
COVERAGES CERTIFICATE NUMBER,1KNg r Exp 9-2018 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 CONTRACTOR OTHER DOCUMENT YOUR 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.
IN9YI TYPE OFIXSUMXCE POLICY NUM M ONE MAVDC RP UMI"
COMMERCAL LOENE(RAL UJOBRDY EACXAOC Y Sr000,000
A R CLACE IMAMA ]OCCUR PF MISER e $ 500,000
5035352D 9/412019 9/6/2018 MED EXPY,oepvavnl S 10,000
PERSONAL&ADVINJURY S 1,000,000
GERLAGOREGATE LIMIT APPLIES PER'. GENERALAGGREGATS % 21000,000
A POLGY�IECT LOC PROWCTS-COMProP PtiO S 21000,000
OTNER.
0.UWMOBILELIABNtt IN IN L E 11000,000
BODILY INJURY LEO
A PNY AUTO S
ALL 0V. 50E SUTEEDDULE $L]53521T 9/C/2011 91./2V18 WOOLY INJURY E.,015
ALI MC."NED PROPERTY E %
'4 NIRED AUTOS A AUTOS
PIP-Save % $1000
A UM@REI.tA ttaa OrCUE EACry 0.^^UPRENCE 8 1,000 000
A E%CESS IJAB LIAIMSMAOE PGOREGATE R 1 000 000
DED A R5TOU'PJUS AO 000 503535217 9/4/2019 9/¢/2038 5
XORXGRSCOMPEXSAOON % SIT TE qN
D EMPLOWAs UAMUTY YIN
PflOPRIETORIARTNEPIE%EOUTNE �N10. E.L EPLXPC.CICENT S 60 000
AN
BCORO PANDONS,
fes"epryy el NN)WCLWEU4 L_ pRp.6.M., 9lA/2017 911/2018 Et.0.5FA5E-EA EMFtOYE $ 500 000
S �W^EB 1fFw FL.DISEASE-PoucY LIMIT s 500,000
DESCRIPTION OF OPERATORS Mlw
A CamOY icail Pzapa,tY 5D3d3521T 9)0/2011 9(6/^v01a pNuceYe bt(M
OESCI®TWN OF OPERATIONS I LOCAipN$l MPRICLES IACORD 1-1,JM1PN-lRamaM1A&Nedfle,mryMNucaeE MII,Ore OPOO" artyuitttll
CERTIFICATE HOLDER CANCELLATION
SHOULD AMY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
EVld--- O£ SnSllrance THE E%HRATfON DATE THEREOF, NOTICE WILL BE DELIVERED M
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTNORIZEDREPRESENTATVE
Kevin Joyce/LMP9)1988-2014 ACORD CORPORATION. All lights reserved.
ACORD 25(2D14101) The ACORD nama and logo are registered marks of ACORD
INS026rnnano