24D-108 (2) The Conmzonwealth of Massach usetts
Department of Industrial Accidents
Office of Investigatimis
rO
600 Washington Street
} Boston,Mass. 02111
www.mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual):
American installations
Address:_ 3Y1 Afew 4on 3 - .
City/State/Zip: S ouil-N I z)Lt / . 11.4 m w-i S Phone#: 9`"2__,- G 5a-O a0 d
Are you an employer?Check the appropriate box: Type of project(required):
1:�am an employer with 3 4.0 I am a general contractor and 1 6.❑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
f ship and have no employees These sub-contractors have S.❑Demolition
working for me in any capacity. employees and have workers'
9.❑Building addition
[No workers'comp.insurance comp.insurance.x
required] 5.0We are a corporation and its 10.❑Electrical repairs or additions
3.01 am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions
myself [No workers'comp. right of exemption perm MGL
insurance required]t c. 152,§ 1(=1),and we have no 12.❑Roof repairs
employees.[no workers' /
13.XOther
comp.insurance required.] Y1 SUl 7R10�)
"Any applicant that checks box R1 must also rill out the section below showing their workers'compensation policy information.
tHomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
Contactors 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,they must provide their workers'comp.policy number.
I ann an employer that is providing workers'compensation insurance for my employees.Below is the polity acrd job site
information. .� f
insurance Company dame: 1{] 1�72.
P i-1 0r'ri :11r La�CX 0 r, n
Policy T or Self-ins.Lic.-. G S(� U Ej- e a8 q 69 -Ll— 13 Expiration Date: -!- -/n��y
Job Site Addres M ` - k 5 City/State/Zip:, I l..�l�_ f Vr) P I 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 MI GL 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 __
$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.
I!do herby cert jr under the pains and penalties of perjure that the information provided above is true and correct.
Signana•e: � Date:
Print A'ame: 514 Z an n t�.� C o Lk+u-c•_ Phone- �l� - ��"02^D 0,0 O
Official case only Do not write in this area to be completed by city or town official
City or Town: Permittlicense#:
Issuing Authority(circle one):
l.Board of Heath 2. Building Department 3.City/Town Clerk t.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact person- Phone#•
www.Americaninstallations.com
B B" y r�iacimoe
co licensed&Insured
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@Americaninstallations.com
Lambert&Cushing Deborah&Frank 8/28/2014
(Last) (First) (Date)
277 State Street Northampton MA 01060
(Address) (Cay) (state) (zip)
207-751-2416 cushingLA @gmail.com
(Home) (Cell) (Email)
403519 14-722
(Site ID) (Jot a)
Quantity Unit Unit Cost Total
No-Cost Measures
AIR SEALING 2 man hour $ 75.00 $ 150.00
Total No-Cost Measures Incentive= $ 150.00
Weatherization
SLOPE-6"DENSE PACK R-19 128 sqft $ 1.86 $ 238.08
CRAWLSPACE R-19&RIGID BOARD 128 sqft $ 3.66 $ 468.48
CRAWLSPACE WALL R10 RIGID INSL 333 sqft $ 3.52 $ 1,172.16
PLASTIC GROUND COVER 623 sqft $ 0.77 $ 479.71
Total Incentivized Weatherization= $ 2,358.43
Total Non-Incentivized Weatherization= $ -
Total Project= $ 2,508.43
Total Utility Contribution= $ 1,918.82
Total Customer Contribution=F$ 589.61
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_ $ 589.61
conditions are satisfactory and are hereby accepted. You are
authorized to do work as specified.Payment will be 1/3 down prior Down Payment= $ 196.00 ® 8/28/2014
to start of work,and balance due upon Completion. PAID
Balance Due Upon Completion= $ 393.61
8/28/2014
Sig—r. Data
Property Ow (PI nt) rope er IS Date
Wyatt Couture 8/28/2014
RepresentMi-IPrint) Repm—give(Sign) Date
THIS AGREEMENT 15 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 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: L o 1 Wp_31ey Couture License Number
341 Newton St
e.,utb Usalev_MA 01075
Addres �� Expiration Date
413-552-0200
Signature Telephone
9.Registered Home Improvement Contractor: Not Applicable ❑
A mnrinon Tna4 �rnroc '�]r- /,71<� �
Company Name Registration Number 341
Smith Newton Street L2
Address SQ»th Nadle MA n1075
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 the building 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 ID
Accessory Bldg. ❑ Demolition ❑ New Signs [[3] Decks [EM Siding[ ] Other 161�
Brief Description of P p d `� ^ c�
Work: ca 1 k L7� '� 'en+ `1 n��� "1 L � �c
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 1 � U h(D'CCU A i 1 !\ as Owner of the subject
property American installations
hereby authorize
to act on my behalf,in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I, 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
Nme can Installations ---
Signature of Owner/Agent Date
r
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 ® DONT KNOW ® YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW ® YES
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES
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 0 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 ® NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Department use only
ity of Northampton Status of Permit:
uilding Department Curb Cut/Driveway Permit
�u ` 70 4 212 Main Street Sewer/Septic Availability
^___�F %Jne___! Room 100 Water/Well Availability[lectric, PIumG;ng O'tipr0 ham ton, MA 01060 Two Sets of Structural PlansNorthernpt�, 50 IIVV p 413-587-1240 Fax 413-587-1272 Plot/Site Plans
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
Q-1 �� � �� Map Lot Unit
CA ICU+ Zone Overlay District
I �� Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Curs. ^A^,1,^^cy'\
rPSS:
C' n —
Telephone'
elep�ione
Signature
2.2 Authorized Agent:
American Installations
Name(P i 341 Newton Street Current Mailing Address:
South Hadley, MA 01075
413 552 0200
s r Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
com leted 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=(1 +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-2015-0283
APPLICANT/CONTACT PERSON AMERICAN INSTALLATIONS LLC
ADDRESS/PHONE 341 NEWTON ST SOUTH HADLEY (413)552-0200
PROPERTY LOCATION 277 STATE ST
MAP 24D PARCEL 108 001 ZONE URB000)
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildiny,Permit Filled out
Fee Paid CFO a
Typeof Construction: INSTALL ATTIC&BASEMENT INSULATION,AIR SEALING THROUGHOUT
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
INF ATION 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
Demolition D lay
4- iell"
Signature of Building 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.
277 STATE ST BP-2015-0283
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24D- 108 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-2015-0283
Project# JS-2015-000543
Est. Cost: $2300.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: AMERICAN INSTALLATIONS LLC 106178
Lot Size(sq.ft.): 4617.36 Owner: LAMBERT DEBORAH A
Zoning: URB(100)/ Applicant: AMERICAN INSTALLATIONS LLC
AT. 277 STATE ST
Applicant Address: Phone: Insurance:
341 NEWTON ST (413) 552-0200 WC
SOUTH HADLEYMA01075 ISSUED ON.911512014 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL ATTIC & BASEMENT INSULATION, AIR
SEALING THROUGHOUT
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 9/15/2014 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner