Loading...
32A-116 (2) ;S r. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,Mass. 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information hecicain ; Please Print Legibly Name(Business/Organization/Individual): Xo k � 1 OnS LL 1 Address: 3`41 AI eW i�n (St&�e± City/State/Zip:s86UJ '£V/ A 61615 Phone#: Y0- 552- OaOO Are you an employer?Check the appropriate box: Type of project(required): 1 I am an employer with 4.0 I am a general contractor and 1 6.❑New construction employees(full and/or part time).* have hired the sub-contractors 7.❑Remodeling 2.01 am a sole proprietor or partner- listed 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' 9.❑Building addition [No workers'comp.insurance comp.insurance.$ required] 5.QWe 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(4),and we have no 12.❑Roof repairs employees.[no workers' 13. Other la-V10 comp.insurance required.] � *Any applicant that checks box#1 must also fill 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 1 i Insurance Company Name: garj�oc�A Untle_cLl)(-1TeC'S ,__1r_YISAC' ace. 0,t1 42CkCkY\(I Policy#or Self-ins.Lic.#:� G lD U p N Expiration Date:: Q 1��� Job Site Address:—1V �1 City/State/Zip: 0�)Q s tI1� v`Dto v 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: Date: 1'- Print Name:c�(,I7n An go CoU+u Ce_, Phone#: 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): LBoard of Heath 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact person: Phone#• ` % = www.Americanlnstallations.com on- B. s mmcwAnI6 v • Licensed&Insured MA CSL k 106178 MA Registration N 175982 American Installations 341 Newton Street,South Hadley,MA 01075•Office:1413)552-0200 Far..1413)S52-0202•Email:support@Amerkaninstallations.com Wheeler Mary&Melany 9/19/2014 IMW (FW oute1 90 Market Street Northampton MA 01060 (Aea,a,l tc^vl rwul lZIP) (413)230-6997 mwheeels55 @gmail.com Memel 1ce11 ITnv�n 404327 rsReol 14-832 IMB•I Quantity Unit Unit Cost Total Air Sealing AIR SEALING 2 man hour $ 7S.001 150.00 DOOR WEATHERSTRIPPING W/SWEEP 4 leach $ 7S.001$ 300.00 Total Air Sealing $ 450.00 Total Air Sealing Incentive $ 450.00 Weatherization INSULATE EXISTING DOOR 1 each $ 73.91 $ 73.91 HATCH SEAL&INSULATE 1 each $ 60.00 $ 60.00 CRAWLSPACE WALL R10 RIGID INSL 186 sgft $ 3.52 $ 654.72 PLASTIC GROUND COVER 924 sgft $ 0.77 $ 711.48 Total Incentivized Weatherization $ 1,500.11 Total Project $ 1,950.11 Tota!Utility Contribution $ 1,575.08 Total Customer Contributioni$ 375.03 WARRANTY:American installations,LLCwiil provide the above stated homeowner with a 2 yearworkmanship 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= $ 375.03 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= $ 125.00 ❑ start of work,and balance dug4pon Completion. PAID- / Balan a Due Upon Completion= $ 250.03 sit—, WN N'apaFYDwe,tP,intl PropetyDwier(LRn Ogle �T/ IM*SREEMENT"OMPOSM OF THIS PAGE AND THE REVERSE SIDE OF THIS PAGE AND SNAIL BE CONDDEREDTHE ENIIREA(REEMEM BVME PARTIES INVOLVED.THIS AGREEMEIMS BETWEEN MIEMM INSTALLATIONS,LLC HEREINAFTER REFERREOTOAS YDUPANY',ANDTHE CUSTOMER(sl MMED ABOVE.HEREINAFTERREFERREDTOAS MAENT',AND WILL BESMNECTTO ALL APPROPRIATE LAWS,REOULATIOM AND OROMANCESOFTHE STATE OF MASSACHUSETTS ORCONNECTICUT RFSPECTIVELY,AS WELLMALL IDEALIURISDICWt4S. SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Wesley Couture Not Applicable ❑ Name of License Holder: 130 College St. South Hadley,MA 01075 License Number 413-552-0200 Address Expiration Date Signature Telephone 9.Registered Home Improvement Contractor: Not Applicable ❑ American Installations M.s G Company Name 130 College St. Registration Number South Hadley,MA 01075 (0 ^a� )<�;- Address 413-552-4200- - — 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......NY 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 1:1 Accessory Bldg. ❑ Demolition ❑ New Signs [O] Dec s idi g[p] Ot P<- Brief Description of Proposed , Work: / '�Y ��1 ���Y�� l J1�1 `f� Q C v 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, ` \ r' \�� Q Q 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 1, 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 painsArA&%� ftn$ Print Name American Install Ions 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 nis column to be filled in by Building Department Lot Size Frontage Setbacks Front Rear Building Height Bldg.Square Footage % Open Space Footage % (Lot area minus bldg&paved #of Parking Spaces (volume&Location) A. Has Finding ever been issued for/on the site? �� �� NO x���� DQNTKNOVV �_� YES �~� IF YES, dnteissue& / IF YES: Was the permit recorded a1 the Registry ofDeeds? NO ~����� KNOW,~,, YES �� --���_- IF YES: enter Book | | Page[— l and/or Document#F---------- -� B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs tmbeobtained Obtained y—� Qate ;ssmed' r----------'---� �-� ^ �_� ' ' 1__ ________ � C. Do any signs exist on the property? YES « / NO �_�� � ---------------'-------------------------------1 IF YES, describe size, type and location: | � '-------------------'------ ............. --'------ D. Are there any r~,~~^~ ~~' s~~tooradditionsofsignsintendedfortheproperty? YES — NO 0 | � -� -- -------------'-----'----'-- |F YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre nvisd part cfu common plan thowiUdistuMbover1aore? YEGK��� NO ���l IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Ix" Department use only City of Northampton Status of Permit �\o�� Building Department Curb Cut/Driveway Permit A `E � PLC 212 Main Street Sewer/Septic Availability, Room 100 Water/WellAvailability Northampton, MA 01060 Two Sets of Structural Plans phone 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 Prope�rtyAddress: This section to be completed by office q�� \– / i -it 5�7�°<-)t Map Lot Unit Nod-- r�amt �, M� o�O�oC7 Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: "atu a HAp 1 ue r qo c�la� s L) , Name(Print) Cy-- =ss: — I? �1 Telephone Signature 2.2 Authorized Aaent: American Installations Name(P' t) 130 II rrentlNailinp,,� s: South H ey, MMHH V 2-0200 Signature Telephone SECTION 3-E (MATED 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-2015-0548 APPLICANT/CONTACT PERSON AMERICAN INSTALLATIONS LLC ADDRESS/PHONE 341 NEWTON ST SOUTH HADLEY (413)552-0200 PROPERTY LOCATION 90 MARKET ST MAP 32A PARCEL 116 001 ZONE URC(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 Tyaeof 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 INFO ION 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 Delay Signature of Bui in fficial 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. 90 MARKET ST BP-2015-0548 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 32A- 116 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Categoa: INSULATION BUILDING PERMIT Permit# BP-2015-0548 Project# JS-2015-001052 Est. Cost: $1500.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: AMERICAN INSTALLATIONS LLC 106178 Lot Size(sq. ft.): 9321.84 Owner: WHEELER MARY L&MELANY THOMPSON-WHEELER Zoning URC(100)/ Applicant. AMERICAN INSTALLATIONS LLC AT. 90 MARKET ST Applicant Address: Phone: Insurance: 341 NEWTON ST (413) 552-0200 WC SOUTH HADLEYMA01075 ISSUED ON.11/14/2014 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 11/14/2014 0:00:00 $55.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner