36-030 (2) - Dep
OR
ri City of Northampton
�y Building Department 11C ")0j
212 Main;Stret _---- I
SULATION
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Room �r—�-un� ,.
Northampton, MA 01�'66,F,ar s
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phone 413-587-1240 Fax 413-5�1-272
-- ONLY
APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING ONLY
SECTION 1 -SITE INFORMATION INS ULA TION PERMIT
1.1 Property Address This section to be completed by office
Map_ (__ Lot 30 Unit
I 1 Sunimerfield Street Zone Overlay District
Elm St.District GB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Sandra Cistrowksi 11 Summerfield Street
Name(Print) CuM3b ZZw
See attached Telephone
Signature
2.2 Authorized Acient:
American Installations 130 College Street Ste. 100, South Hadley, MA 01075
Name(Print) Current Mailing Address:
�)&2m �_ cmtvu (413) 552-0200
Signature I Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building 3957.00 (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) 3957.( Check Number
�/
This Section For Official Use Only
�r `
Building Permit Number:/'�)Y �(./ Dated:
Signature: Maz 1 0
69
Building Commissioner/Inspector 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 9/29/2021
Address Expiration Date
Lb AA � (413)552-0200
Signature J Telephone
9.Registered Home Improvement Contractor: Not Applicable ❑
American Installations 175982
Company Name Registration Number
130 College Street Ste. 100, South Hadley MA 01075 6/26/2021
Address Expiration Date
Telephone (413)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....... No...... ❑
Brief Description of Proposed Work NOTE: INSULATION ONLY
Attic and basement 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
)QVW _ GAA& 12/13/19
Signature of Owner gent Date
1, , 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 12/13/19
Signature of Owner Date