08-004 (4) 377 COLES MEADOW RD BP-2020-0238
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:08-004 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-2020-0238
Proiect# JS-2020-000408
Est.Cost: $2000.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO.-
Const.
O:Const.Class: Contractor: License:
Use Group: AMERICAN INSTALLATIONS LLC 106178
Lot Size(sa. ft.): 87729.84 Owner. TRAN KIM
Zoning: RR(100)/RI(74)/WSP(26)/ Applicant: AMERICAN INSTALLATIONS LLC
AT. 377 COLES MEADOW RD
Applicant Address: Phone: Insurance:
130 COLLEGE ST (413) 552-0200 WC
SOUTH HADLEYMA01075 ISSUED ON.812712019 0:00:00
TO PERFORM THE FOLLOWING WORK.-ATTIC 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 Si�,Yuature:
FeeType: Date Paid: Amount:
Building 8/27/2019 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
c Dep
Gi7�+ City of Northampton 'n�__�
Building Department
212 Main Street AUG 2
Room 100 6 201 I SULATION
Northampton, MAo.
phone 413-587-1240 Fax�1 '�� � { pNL Y
T '
ON-ASA orCT NS
APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DW ONLY
SECTION 1 -SITE INFORMATION INS ULA TION PERMIT
1.1 Property Address This section to be completed by office
377 Coles Meadow Road Map Lot unit
Northampton, MA 01060 Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
'['ran, Kim 377 Coles Meadow Road,Northampton, MA 01060
Name(Print) C n M itn A dress:
See attached ��� ) ` 0 28
Telephone
Signature
2.2 Authorized Agent:
American Installations 130 College Street Ste. 100, South Hadley, MA 01075
Name(Print) Current Mailing Address:
(jQ t4 K. �'� (413) 552-0200
Signature �-j Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building $2,000.00 (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee 006-
4.
Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) $2,000.00 Check Number
This Section For Official Use Only
Date
Building Permit Number Issued:
Signature: -a Zo l 7
Building Commissionerlinspector of Buildings Date
production @ americaninstallations.com
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 4-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: Wesley K. Couture 106178
License Number
130 College Street Ste. 100, South Hadley MA 01075 9/29/2019
Address Expiration Date
(413) 552-0200
Signature J Telephone
9.Registered Home Improvement Contractor: Not Applicable ❑
1 nncricafl Installations 175982
Company Name Registration Number
1,30 College Street Ste. 100, South Hadley MA 01075 6/26/2021
Address Expiration Date
Telephone A 3) 552-0200
SECTION 5-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....... IS,I No...... ❑ �re
Brief Description of Proposed Work 1 SIO TC: INS ULA TION ONL Y
Attic insulation and air sealing throughout.
1, American Installations- Wesley Couture 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.
Wesley K. Couture
Print Name
I d 1P-v,t a 4 K. COI Ju 8/21/2019
Signature of Owner/Agent Date
1, Fran, Kim 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 8/21/2019
Signature of Owner Date
City of Northampton
s ✓' Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS ?'
212 Main Street • Municipal Building
Northampton, MA 01060
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and
subcontractors performing improvements or renovations on detached one to four family homes. Prior to
performing work on such homes,a contractor must be registered as a Home Improvement Contractor("HIC").
M.G.L. Chapter 142A requires that the"reconstruction, alteration, renovation,repair, modernization, conversion,
improvement,removal, demolition, or construction of an addition to any pre-existing owner-occupied building containing
at least one but not more than four dwelling units....or to structures which are adjacent to such residence or building"be
done by registered contractors.
Note:If the homeowner has contracted with a corporation:or LLC,that entity must be registered
Type of Work: Insulation Est.Cost: $2,000.00
Address of Work: 377 Coles Meadow Road
Date of Permit Application: 8/21/2019
I hereby certify that:
Registration is not required for the following reason(s):
_Work excluded by law(explain):
_Job under$1,000.00
Owner obtaining own permit(explain):
Building not owner-occupied
x Other(specify): Contractor pulling permit for homeowner
OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED
CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT
ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND
UNDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK
PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION.
Signed under the penalties of perjury:
I hereby apply for a building permit as the agent of the owner:
8/21/2019 American Installations 175982
Date Contractor Name HIC Registration No.
OR:
Notwithstanding the above notice, I hereby apply for a building permit as the owner of the above property:
K.
Date Owner Namd and Signature
City of Northampton
Massachusetts ��}" J.-
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street •Municipal Building Jy. Ca
Northampton, MA 01060
Debris 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.
The debris from construction work being performed at:
377 Coles Meadow Road
(Please print house number and street name)
Is to be disposed of at:
Waste Management of New England, Chicopee, MA 01020
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
Signature of Plermit Applicant or Owner Date
If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the
Building Department as to the location where the debris will be disposed.
Page 1 of 2
• mass save
icensed&Insured PARTNER
MA LSI p:106 178
MA Registration a 175982 American Installations www.Americaninstallations.com
130 College Street Suite 100,South Hadley,MA 01075• Office:(413)552.0200 Fax:(413)552-0202• Email support@Americaninstallatimstom
Customer Name:Kim Tran
Email:k_tran5@hotmail.com
Phone:509-539-0828
Premise Address:377 Coles Meadow Rd, Northampton, MA 01060
Mailing Address:377 Coles Meadow Rd, Northampton,MA 01060
Project ID:3874200
Date:Aug. 15,2019
Job Description
Measure Description Location Quantity Unit Total Cost Customer Cost
Air Sealing at Estimated 62.5 CFM50 Per Hour Living Space 6 hr $555.48 $0.00
Door Sweep (with AS hrs) Living Space 2 each $50.62 $0.00
Exterior Door Weather Stripping (with AS hrs) Living Space 2 each $60.14 $0.00
Hatch -2"Thermal Barrier Polyiso Living Space 1 each $46.28 $11.57
Attic Floor- 6"Open Blow Cellulose Living Space 644 SF $1,043.28 $260.82
Damming Living Space 74 each $176.86 $44.21
Project Total $1,932.66
Weatherization incentive ($949.82)
Air sealing incentive ($666.24)
Total Program Incentive -$1,616.06
Customer Total $316.60
WARRANTY:American Installations,LLC will provide the above stated homeowner with a 1-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'Otal Contract Value as stated herein.
ACCEPTANCE OF PROPOSAL: The above prices, sped'ications and conditions are TOTALCONTRAC—VALUE=S 5'
60
satisfactory and are hereby accepted.You are authorized to do work as specified.Payment 100.00
Down Payment=S ❑
will he 1./3 down prior to start of went,and balance due upon Completion. PAID
Balance Due Upon Completion= 5 216 60
8-15-2019
y,nature Kim Tr n(Aug 19,2019) Date
Tran,Kim
Property Owner(Print) (Sign] Date
C.Dragovich 8-15-2019
Representative:(Print} (Sign) Date
IMS AGREEMENT IS COMPOSED CF TMS PAGE ANU 1HE REVERSE SIDE OF THIS VALE AND SHALL BE CONSIDERED THE ENTIRE AGREEMENT IN THE POTIES INVOLVED-HIS AGREEMENT IS BETWEEN AMERICAN INSTALIATIONS,LLC HEREINAFTER REFERRED TO AS TOMPANV-.
ANOTHE LOSTOMERNS)MAMED ABOVE,HEREINAFTER REFERRED TO AS-CLIENT'.AND W ILL BE SUBJECT TOALL APPROPRIATE LAWS.REBUUTIONS AND ORDINANCES OF THE STATE Of MASSACHUSETTS OR CONNECTICUT RESPECTIVELY,AS WELL AS ALL LOCAL JURISDICTIONS
Pape 2 of 2
• mass save
Licensed&insured
MACS1#.7061 , %, PARTNER
78
MA Regwravon n 275982 American Installations www.AmericanInstallations.com
130 College Street Suite 100,South Hadley,MA 01075 • Office:(413)552.0200 Fan:(413)552-0202- Emaik supportLIDAmericanlnstallations.com
Customer Name:Kim Tran
Email:k_tran5@hotmail.com
Phone:509-539-0828
Premise Address:377 Coles Meadow Rd, Northampton, MA 01060
Mailing Address:377 Coles Meadow Rd,Northampton,MA 01060
Project ID:3874200
Date:Aug. 15,2019
Total Program Incentive -$1,616.06
Customer Total $316.60
WARRANTY:American installations,LLC will provide the above stated homeowner with a 1-year workmanship warranty.
American installations,LLC hereby proposes to furnish all material and labor to completethe above scope of work in accordance with the above specifications and all local and state
building regulations for the-otal Contract value as stated herein.
ACCEPTANCE Or PROPOSAL: The above prices, specifications and conditions are TOTALCONTRAC-VALUE=S
satisfactory and are hereby accepted.You are authorized to do work as specified.Payment
will be 1/3 down prior to start of work,and balance Payment=S e due upon Completion. PAID
Balance Due Upon Completion= 5
Sigroture Date
Property Owner(Print) (Sign) Date
Representative:(Print) (Sign) Date
TMS AGREEMENT IS COMPOSED OF TMS PAGE AND THERE VERSE SIDE Or TIPS PAGE AND SMALL SE CON SIDEREO TME ENTIRE AGREEMENT BY THE PM71ES INVOLVED THIS AGREEMENT IS BETWEEN AMERICAN IMF,ALIATIONS,LLC HEREINAFTER REFERRED TO AS'COMPANM,
AND THE CUSTOMER(S)NAMED ABOVE,MEIIDNAFTER REFER RED TO AS'CLIENT.AND WILL BE SUBJECT TOALL APPROPRNTE LAWS,REGUUTONS AND ORDNAN02S Of THE STATE OF MASSACFLISETTS OR CONNECTICUT RESPECTIVELY,ASW ELL AS ALL LOCAL JURISDICTIONS
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
ky 600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organizatiotvindividuai): 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):
1.n I am a employer with 60 4. ❑ 1 am a general contractor and 1 6. ❑ New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet.t 7• ❑ 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.❑ I 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.❑ Roof repairs
insurance required.]t employees. (No workers'
comp. insurance required.] 13.®Other Insulation
*Any applicant that checks box fit must also RII out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
Contractors that check this box must attached an additional sheet showing the name ofthe sub-contractors and their workers'comp.policy information.
1 am an employer that is providing workers'compensation insurance for nW employees. Below is the policy and job site
information.
Insurance Company Name: Guard Insurance Companies
Policy#or Self-ins. Lic.M URWC609917 ,r� _ Expiration Date: 09/04/2019 _
Job Site Address: N-44,,� N-44,, t I2.� City/State/Zip:_�� 04 Q�
Attach a copy of the workers'compensation policy declaration page(showing the policy number and ex iratn date
.
Failure
to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal 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 the pains and penalties of perjury that the information provided Move is true and correct.
Signature. 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 Z. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6-Other
Contact Person- Phone#:
Commonwealth of Massachusetts Construction Supervisor
Division of Professional Licensure Unrestricted-Buildings of any use group which contain
Board of Building Regulations and Standards less than 35,000 cubic feet(991 cubic meters)of enclosed
Construction Supervisor space.
CS-106178 Expires: 09129/2019
WESLEY COUTURE _
218 LATHROP STREET ' 9
SOUTH HADLEY MA 01075
Failure to possess a current edition of the Massachusetts
State Building Code is cause for revocation of this license.
n f For information about this license
Commissioner Call(617)727-3200 or visit www.mass.gov/dpi
471:1�C'yl�G���
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Type: LLC
Registration: 175982
AMERICAN INSTALLATIONS. LLC. t
130 COLLEGE STREET SUITE 100 !"j - Expiration: 06/26/2019
SOUTH HADLEY, MA 01075 t`
`•9.'t!'�L..ySj pi's Q',''
Update Address and return card. Mark reason for change.
SCA i •^ 201,4-05/11
n Add-=-- n 1-1 Eirpl4ys+BIIL_0!.oSt Gard
a_ ��f' 1Ialt)ttI')tII:PIY�f/I I/ (II7.SNlPfJtl1F�>f'
" Office of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only
TYPE: LLC before the expiration date. If found return to:
Registration Expiration Office of Consumer Affairs and Business Regulation
175982 06,126/2019 10 Park Plaza-Suite 5170
AMERICAN INSTALLATIONS,LLC- Boston,MA 02116
WESLEY COUTURE
130 COLLEGE STREET SUITE 1C0 �)
SOUTH HADLEY,MA 01075 Undersecretary valid without signature
Aco CERTIFICATE OF LIABILITY INSURANCE DATE(MWDDIYYYY)
Ill 1 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 policy(ies) must be endorsed. If SUBROGATION IS WAIVED, 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 CONTACT Linda Powers
NAME
Webber & Grinnell PHON�9Enq (413)586-0111 EACX. .f413Msee-e4e1
8 North King Street IN ,AMAML $:lpowers@webberandgrinnel1.com
--_ - ------
INSURER(§)AFFORDING COVERAGE NAIC✓t _
Northampton __ -. MA 01060 INSURER A: l rta Mutual Casualty
INSURED INSURER B:Berkshire Hathaway GUARD Ins. Co.
American Installations, LLC INSURERC:
Attn: Wee & Suzanne Couture INSURER D:
130 College Street, Suite 100 INSURER E:
South Hadley MA 01075 INSURER F:
COVERAGES CERTIFICATE NUMBER:Master Exp 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 REQUIREMENT, 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,
EXCLUSION_S AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR - ADDL SUBR POLICY EFF POLICY EXP
LTA TYPE OF INSURANCE INSD WVQ POLICY NUMBER iMWDDIYYYXL (MMilYY LIMITS
COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE § 1,000,000
A X CLAIMS•MADE OCCUR DAMAGE TO RENTED 500,000
PREMISES Ea occurrence $
5D3535217 9/4/2018 9/4/2019 MED EXP(Arty one person) $ 10,000
PERSONAL$ADV INJURY $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000
X POLICY❑PRO F7LOC 2,000,000
JECT PRODUCTS-COMP/OP AGG $
OTHER: $
AUTOMOBILE LIABILITY EOMBICNdED SINGLE LIMIT $ 1,000,000
ANY AUTO BODILY INJURY(Per person) $
A ALL OWNED SCHEDULED
AUTOS X AUTOS 523535217 9/4/2018 9/4/2019 BODILY INJURY(Per accident) $
X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $
AUTOS P
X Coll 52.000 X comp52,000 PIP-Basic $ 8,000
X UMBRELLA LIAR OCCUR EACH OCCURRENCE $ 1,000,000
A EXCESS LIAR HCLAIMS-MADEGGREGATEA $ 1,000,090
DED X RETENTIONS 10,000 5J3535217 9/4/2018 9/4/2019 $
WORKERS COMPENSATION I PER 11-
AND EMPLOYERS'LIABILITY Y/N X TA F
ANY PROPR ETOR/PARTNERE.L.EACH ACCIDENT $ 500,0
rEXECUTIVE 00
OFFICER/MEMBER EXCLUDED? ❑N/A
B (Mandatory In NH) URWC609917 9/4/2018 9/4/2019 E.L.DISEASE-EJB EMPLOYEE $ _ 500,000
If yes,describe under
DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ 500,000
A j Commercial Property SA3535217 9/4/2018 9/4/2019 deductible$1,0D0
I
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Evidence of Insurance I THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
�W Grinnell, CPCU, CIC fly-- `� Y�
®1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
INS025 i2014W)