11C-067 (2) 87 FLORENCE ST BP-2019-0508
GIs 4: COMMONWEALTH OF MASSACHUSETTS
Map:Block: I IC-067 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
CategM: INSULATION BUILDING PERMIT
Permit# BP-2019-0508
Project# JS-2019-000826
Est. Cost:$2012.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
CQnst.Class: Contractor: License:
Use Group: AMERICAN INSTALLATIONS LLC 106178
Lot Size(sq. ft.): 20908.80 Owner. PALMER DONALD R&BONNIE C
Zoning:URA(100)/ Applicant: AMERICAN INSTALLATIONS LLC
AT: 87 FLORENCE ST
Applicant Address: Phone: Insurance:
130 COLLEGE ST (413) 552-0200 WC
SOUTH HADLEYMA01075 ISSUED ON.1012512018 0.00:00
TO PERFORM THE FOLLOWING WORK.-WALL AND BASEMENT INSULATION AND 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 10/25/2018 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
r
Department'use only
RECEIVED City of Northampton Status l f Permit
Building Department Curb Cut/Ddveway Permit
212 Main Street SewerlSeptic Availability
OCT 2 4 2018 Room 100 Water/1Ne11 Availability''
N rthampton, MA 01060 Two Sets of Structural Pians
e 41 -587-1240 Fax 413-587-1272 Plot/Sife Plan's'
DEPT OF BUILDING INSPECTIONS Other:$ e
NMA 01060 p
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
1.1 PronerlvAddress: This section to be completed by office
Map- , l.J
Lot CaS?
87 Florence Street
Zone Overlay District
Elm St District. CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Donald&Bonnie Palmer 87 Florence Street Leeds,MA 01053
Name(Print) Current Mailing Address:
See attachedT (41586-2825
eWpSignature
2.2 Authorized Agent:
American Installations 130 College St., Ste 100 South Hadley, MA 01075
Name(Print) Current Mailing Address:
413-552-0200
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by perrvfd applicant
1. Building 2012.00 (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC) E114`4
5.Fire Protection
6. Total=(1 +2+3+4+5) Check Number
This Section For Official Use Only
Building Permit Number. Date
Issued:
Signature: h
Building Commissionedinspector of Buildings 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
Buildmg Dq artment
Lot Size
Frontage
Setbacks Front
Side L:= R:= L= R:= (�
Rear {� `
Building Height
Bldg.Square Footage �� YO
Open Space Footage % I� 1
(Lot area minus bldg&paved
awn
#of Parking Spaces r--�
Fill: -------��-----------
volume&Location) -- ': -----�—_ _-----�
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW O 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 PageL_L and/or Document#1
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 constriction 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 O NO O
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
s
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House Addition Replacement Windows Alteration(s) Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs 10] Decks [❑ Siding[p] Other 10k
Brief Description of Proposed
Work- Wall and basement insulation and air sealing throughout
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a.-If Now house and oraddition to existina ho usina,.complete the iollowinm
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, 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.
See attached
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
" fit-- •
Signature of /Agent Date 1071972018
s
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: Wesley K. Couture 106178
License Number
130 College St., Ste 100 South Hadley, MA 01075 9/29/19
Address Expiration Date
413-552-0200
Signature Telephone
9.t2eaistered Home Imaroiiemerit Contractors _ _ _ Not Applicable ❑
Wesley Couture 175982
Company Name Registration Number
American Installations 6126/19
Address Expiration Date
130 College St., Ste 100 South Hadley, MA 01075 Telephone 413-552-0200
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(8))
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....... 11 No...... ❑
11..:=Home Owner Ezemotioh
The current exemption for"homeowners"was extended to include Qwner-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 78% Sixth FAIJon Section 10835.1.
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 ofthe 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 haws 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
City of Northampton
/ Massachusetts
f
DEPARTMENT OF BMZDING INSPECTIONS y;
212 Main Street • Municipal Building
Northampton, MA 01060
Property Address: 87 Florence Street Leeds, MA 01053
Contractor
Name: American Installations
Address: 130 College Street Ste. 100
City, State: South Hadley, MA
Phone: 43-552-0200
Property Owner Donald&Bonnie Palmer
Name:
Address: 87 Florence Street
City, State: Leeds, MA 01053
I, American Installations (contractor)attest and affirm that the building I intend to
insulate does not have any open air(knob and tube)wiring in the spaces to be insulated and that I have
provided the property owner with a copy of this affidavit.
Contractor signature
'V- . Cssui�x,
Date 10/19/2018
1
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 by MGL c 111, S 150A.
Address of the work: 87 Florence Street Leeds, MA 01053
The debris will be transported by: American Installations
The debris will be received by: Waste Management of N.E
Building permit number:
Name of Permit Applicant
Date Signature of Permit Applicant
mass save
PARTNER
Licensed&Insured
MA CSL M.206178 American Installations Amer)canlnstallatlons.com
MA Reylslfutic"0 275482
130 College Street.Wke 100,South Hedley,hM 01075 Offkm(413)SS2-0200 Fax:(413)SS2-0202 •Emalk suppon@Amerlanlnstallatwi.com
Customer Name:Donald Palmer
Email:Palmer87@comcast.net
Phone:413-586-2825
Premise Address:87 Florence St,Northampton,MA 01053
Project ID:3332309
Date:Nov.30,2017
Job Description
Air Sealing at Estimated 62.5 CFM50 Per Hour 2 hr $185.16 $0.00
Exterior Door Weather Stripping (on AS job) 1 each $30.07 $0.00
Door Sweep(on AS job) 1 each $25.31 $0.00
Knee Wall-2"Thermal Barrier Polyiso 160 SF $764.80 $191.20
Rim Joist- 6" Fiberglass Batting 124 SF $334.80 $83.70
Kneewall Wall- 3" Fiberglass Batting 160 SF $305.60 $76.40
Sheathing Access 6 each $240.12 $60.03
Insulation Removal 100 SF $126.00 $126.00
Project Total $2,011.86
Weatherization incentive ($1,233.99)
Air sealing incentive ($240.54)
Total Program Incentive -$1,474.53
Customer Total $537.33
WARRANTY:American Installations,LLC wdl provide the above staled homeowner wth a 1 year wor6manshp warranty.
American"tallations,LLC hereby proposes to furevsh all material and labor to complete the above scope of work in accordance with the above specifications and all local and state
busking regulations forthe Taal Contract Value as stated herein.
ACCEPTANCE OF PROPOSAL: The above prices, specifications and conditions are TOTAL CONTRACT VALUE=S 537- 33
satisfactory and are hereby accepted.You are "honied to do work as sped0ed. 179,00 ❑
Down Payment=S
Payment WIII be 1!3 down prior l0 SLaR Of work,antl balance due Upon Completion. Pq0
Balance Due Upon Completion= S 35833
Donald R Palmer(Oct 8,20181
Signature Date
Property Owner(Print) (Sign) Date r]f'f
Representative:(Pnntl Minhael C:rand (Slgnl Date 11-29-17
I NK ADREW EN I A MAPOSU)a IN 1SPAGLAND THE IMPML S[SE Ot I HIS rADL ANDSNaLL al CCMSNIlR ED INE[N t rEWMEWN1 LV IN EPAAI IES NVClYtO,t MLS ADREMLMI KALI W LtN WERrDN INStAUOJICM.U.0 I"UNHIER AV EARED IQ AS-CG Pmy-.
AM INE WICIvLRp)MRPRD AOML NEPLIVEN IEA RLt EARE01O AS`ELRNI'.ANG vMg,,SUtxn TOM aPP110[IIIA1t aYr,A[GUl41 gN5lHD dIDUANRStN 1k AIAIEDr M&3SA[NU2115011[ONNLRRUI RWEDIMIr,AS W4E A5 a1L LDCAUSRIItDInItVd
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
k1V 600 Washington Street
Boston,MA 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print LeWbly
Name(Business/Organization/Individual): American Installations,LLC
Address: 130 College Street,Suite 100
City/State/Zip: South Hadley,MA 01075 phone#: 413-552-0200
Are you an employer?Check the appropriate box: Type of project(required):
I.❑ I am a employer with 60 4. ❑ I am a general contractor and 1 6. ❑ New construction
employees(full and/or part-time),* have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.t �• Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers'comp.insurance. 9. ❑ Building addition
[No workers'comp. insurance 5. ❑ We are a corporation and its
required.) officers have exercised their 10.❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 1 l.❑ Plumbing repairs or additions
myself. [No workers'comp. c. 152,§1(4),and we have no 12.0 Roof repairs
insurance required.]t employees. [No workers' I31A Other Insulation
comp. insurance required.]
"Any applicant that checks box 01 must also fill out the section below showing their workers'compensation policy information.
t I lomeowners who submit this afrodavil indicating they are doing all work and then hire outside contractors must submit a new allidavit indicating such.
'Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp,policy information.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information,
Insurance Company Name: Guard Insurance Companies
Policy#or Self-in( Id
s. Lic.#: ` pURWC609917 p Expiration Date: 09/04/2019
Job Site Address: O 1' YI.��� Jl City/State/Zip:
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 c. 152 can lead to the imposition of crimigal penalties of a
tine 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 up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
1 do hereby certify under lite pains and penalties of perjury that the information provided above is true and correct.
Si nal r : Date:
Phone#: 413-55f-0200
Oficial 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):
1. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Commonwealth of Massachusetts ConstrLictioln Supervisor
t Division of Professional Licensure Unrestricted-Burgs of arty use limp which contam
Board of Building Regulations and Standards less than 35,000 cubic feet(981 cubic meters)of enclosed
Constructibn Supervisor spw-e-
CS-106178 Upires:09/29/2019
WESLEY COUTURE
218 LATHROPSTREET.
SOUTH HADLEY-MA 01075
Failure to possess a current edition of the Massachusetts
State Building Code is cause for revocation of this license.
For information about this license
Commissioner Call(617)7273200 or visit www.massgovldpl
L77-
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 06/26/2019
SOUTH HADLEY,MA 01075
Update Address and return card. Mark reason for change.
SCA T 0 2OM-05/11 II A ':„—Q C2 R iml ,01 Eip!aymantmss#C–Pr
%lam (r-»rirzenauall�r ^��irsxr��r�ulis
Office of Consumer Affairs&Business Regulation
;} HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only
lU� ` TYPE:LLC before the expiration date. If found return to:
$ggistrationpiration Office of Consumer Affairs and Business Regulation
�x 175M 06/26/2019 10 Park Plaza-Suite 5170
AMERICAN INSTALLATIONS,L.L.C. Boston,MA 02116
WESLEY COUTURE
130 COLLEGE STREET SUITE 100
SOUTH HADLEY,MA 01075 UndersecretaryT valid without Signature
A� DATE p"e°°'"Y"q
CERTIFICATE OF LIABILITY INSURANCE 9/4/2018
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 certificate holder Is an ADDITIONAL INSURED,the pol"Ies)must be endorsed. If SUBROGATION IS WANED,subject to
the terms and conditions of the policy,certain policies may require an Endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER Linda Powers
Webber fc Grinnell E (413)586-0111 1 FAX (413)544-6481
8 Borth icing street .lyoweraPmlebberaadgrinnell.cam
INSURE AFFORDING COVERAGE NAIC f
Worthaapton )IIA 01060 81SURERA 1 rs Mutual Casualty
INSURED osuRERe:Berkshire Hathaway GUARD Ins. Co.
American Installations, LLC MSIJRFRC:
Attns Was & Suzanne Couture INSURERD:
130 College Street, Suite 100 INBURERE:
South Hadley UK 01075 INSURER F:
COVERAGES CERTIFICATE NUMBERX—ter Ssp 9-2019 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 REOUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH 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.
INSR TYPE OF INSURANC! mum MP we2"" "M LIMITS
.62L POLJCY NUMBER
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
DAMAGE TO MIM
A X CLAIMS-MADE F-1 OCCUR PREL41SES Me occurrence) S 500,000
5D3535217 9/4/2018 9/4/2019 MED EXP oneperson) S 10,000
PERSONAL 3 ADV INJURY S 1,000,000
GENL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2,000,000
Z POLICY❑J� 17 LOC PRODUCTS-COMP/OPAGO $ 2,000,000
a
AUTOMOBILE LUABILITYCOMBINED LI S 11000,000
A ANY AUTO BODILY INJURY(Per person) S
ALL OWNED Z SCHEDULED 5E3535217 9/4/2018 9/4/2019 BODILY INJURY(Per accIdeM) S
AUTOS AUTOS PROPERTY DAMAGE S
X HIRED AUTOS Z UTAUTA NON-OWNED$
Z
coil 821000 Z comp$2,000 pip ic $ 8,000
X UMBRELLA UAB EACH OCCURRENCE $ 1,000,000
A EXCESS LIAS CLAIMS-MADE AGGREGATE $ 1,000,000
DEO I XI FIETENTIHMOCCUR1 p SJ3535217 9/4/2018 9/4/2019 $
WORKERS COMPENBATION g
AND EMPLOYERS'LIABILITY
ANY PROPRIETORIPARTNERIEXECUTIVE YIN E.L.EACH ACCIDENT _ $ 500,000
OFFICERIMEMBER EXCLUDED? N/A
H (Mandalay in NH) M 0609917 9/4/2015 9/4/2019 E.L DISEASE-EA EMPLOYEE S 500,000
U a describe under
FOPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $00,000
A Commercial Prepazty SJL3535217 9/4/2018 9/4/2019 deductible$1,000
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLE;(ACORD 101,AddiforW RenwAol Schedule,mry be a8aohed N mom apace is ro***d)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Evidence Of Insurance THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
W Grinnell, CPCU, CICS ~-
®1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
INS025(2ouo1)