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24D-271 (4)
The Commonwealth of Massachusetts „ Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,Mass. 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): P`I�A� ��(�-��-�� ` do� LL` A' �L Address: c3,41 /J 2W�n City/State/Zip:SSOUJA 6=A1e_V MR ftj!5 Phone#: 4.3-552- Da00 Are you an employer?Check the appropriate box: Type of project(required): 1. I am an employer with-- 1,1 4.®1 am a general contractor and 1 6.❑New construction f ``employees(full and/or part time).* have hired the sub-contractors 7.p Remodeling 2.0 1 am a sole proprietor or partner- listed on the attached sheet. 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.# required] We are a corporation and its 10.❑Electrical repairs or additions 3.0 I 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(4),and we have no 12.❑Roof repairs employees.[no workers' comp.insurance required.] 13. Otherk *Any applicant that checks box#1 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 am an employer that is providing workers'compensation insurance for my employees.Below is the policy and job site information. 1 11 Insurance Company Name: �a(`T C� U n n C Ll)(-1�CC S n At' nGe 01(JMjP(A"Q Policy#or Self-ins.Lic.#: � r G�� (� C3 Expiration Date:: Q y �� Job Site Address:N gTr-'�l n C*• City/State/Zip: ^ ""`" kn A ow) 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 fine of $250.00 a day against violator.Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for coverage verification. I do herby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature:t Date: Print Name:c�U 20 nn� Cou-I�•f� Phone#: 413 �,�a-D2�o c7 Official use only Do not write in this area to be completed by city or town official City or Town: Permit/license#: Issuing Authority(circle one): I.Board of Heath 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact person: Phone#• 8 '' � � .$ www.Americanlnstallations.com auk I BEI&C I rwrrmrWwc counumm 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�A icanlnstallations.corn Rueda,Maria 10/20/2014 (last) (First) (Date) 1 Franklin Court Northampton MA 01060 (Address) (cny) (state) (zip) (413)341-3132 mhrueda @yahoo.com (Home) (CAR (Email) 404875 14-0952 (54e ID) Ilob#) Quantity Unit Unit Cost Total Air Sealing AIR SEALING 6 man hour $ 75.00 $ 450.00 DOOR WEATHERSTRIPPING W/SWEEP 2 each $ 75.00 $ 150.00 Total Air Sealing $ 600.00 Total Air Sealing Incentive $ 600.00 Weatherization CRAWLSPACE WALL R10 RIGID INSL 111 scift $ 3.52 $ 390.72 THERMADOME WITH WOOD BUILD-UP 1 each $ 237.65 $ 237.65 FLAT-9"OPEN R-32 784 sgft $ 1.36 $ 1,066.24 DAMMING R-38 26 linearft $ 2.05 $ 53.30 Total Incentivized Weatherization $ 1,747.91 Total Project $ 2,347.91 Total Utility Contribution $ 1,910.93 Total Customer Contribution $ 436.98 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= $ 436.98 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= $ 145.00 IN 145.00 start of work,and balance due upon Completion. PAID Balance Due Upon Completion= $ 291.98 SignM Date Maria Rueda 10/20/2014 Property Owner(Print) Property b7er(Sgn) Date Crai A.Dra ovich 10/20/2014 Representative Prin[) Representatiye(Si,n) Date THIS AGREEMENT IS COMPOSED OF THIS PAGE ANDTHE 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 MALL LOCAL JURISDICTIONS. SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Q Name of License Holder: Wesley Couture 1 O W`� 341 Newton St License Number South Hadley,MA 01075 A d ss 413-552-0201) Expiration Date Signatur4 Telephone f 9.Registered Home Improvement Contractor: American Installato:ls Not Applicable ❑ 341 Newton Street �1�q, Company Name South Hidley,M Registration Number 413-552-0200 l 0�1 Address 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 bu' ing 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 appllicable New House Addition Replacement Windows Iteration(s) Roofing Or Doors ID Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [M Siding[ ] Other Brief: r'�o VqC--sI , I I� —�� `^ _ „ ^^ I: ^ >� . Work: F'�"1 L �1 � 'mil � `��.(,f� ICU Ili 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 1, \�\a ,as Owner of the subject property hereby authorize American Installations to act on my behalf,in all matters relative to work authorized by this building permit application. SPA G-�b-Q� czn 2 w J_- 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 7�-P�Q�� - �0-21-vj Signature of O er/ nt 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 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 Q DONT KNOW © YES IF YES, date issued:; IF YES: Was the permit recorded at the Registr/of Deeds? NO O DONT KNOW © YES O IF YES: enter Book ' Pagel i and/or Document#! 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 © Obtained , 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 O NO Q IF YES, describe size, type and location: i 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 Q NO Q IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Department use only I� --- — City of Northampton Status of Permit: 'Building Department Curb Cut/Driveway Permit OCT 2 4 2014 212 Main Street Sewer/Septic Availability Room 100 WaterMell Availability. Electric, Plumbing&Gas InspectiorN rthampton, MA 01060 Two Sets of Structural Plans Northampton, MA o -587-1240 Fax 413-587-12'.72 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 Map Lot Unit �rC ntV, ) ct. too(')c�qicr),MA (v� Zone Overlay District vl Ellin St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Ulci a wadi 1 G-OnY_J in (A. &Dahc oh)(\ A Name(Print) C t 1�iling� ' s; — 13^ I eleepphh'ollne 1 Signature 2.2 Authorized Agent: Wesley Couture 341 Newton St Nam (Print) u tl eye ddress: 413-552-0201 S gnature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building 1 (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Constriction 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-2015-0474 APPLICANT/CONTACT PERSON AMERICAN INSTALLATIONS LLC ADDRESS/PHONE 341 NEWTON ST SOUTH HADLEY (413)552-0200 PROPERTY LOCATION 1 FRANKLIN CT MAP 24D PARCEL 271 001 ZONE URB(100) THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid Typeof Construction: INSTALL ATTIC INSULATION New Construction Non Structural interior renovations Addition to Existing- Accessory Existing- Accessory Structure Buildiny,Plans Included: Owner/Statement or License 106178 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFOR PRESENTED: pproved 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 em la �-- Signature of Building Of jal 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. I FRANKLIN CT BP-2015-0474 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 24D-271 (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-2015-0474 Project# JS-2015-000903 Est. Cost: $1800.00 - Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: AMERICAN INSTALLATIONS LLC 106178 Lot Size(sq. ft.): 9365.40 Owner: RUEDA MARIA Zoning: URB(100) Applicant: AMERICAN INSTALLATIONS LLC AT. 1 FRANKLIN CT Applicant Address: Phone: Insurance: 341 NEWTON ST (413) 552-0200 WC SOUTH HADLEYMA01075 ISSUED ON.1012812014 0:00:00 TO PERFORM THE FOLLOWING WORK.INSTALL ATTIC 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 10/28/2014 0:00:00 $55.00 212 Main Street,Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner