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36-128 (7) 279 BROOKSIDE CIR BP-2021-0134 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 36- 128 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-2021-0134 Proiect# JS-2021-000213 Est.Cost: $2126.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: AMERICAN INSTALLATIONS LLC 106178 Lot Size(sg. 1): 31188.96 Owner. LEAVITT MARIAH zoninc: Applicant: AMERICAN INSTALLATIONS LLC AT: 279 BROOKSIDE CIR Applicant Address: Phone: Insurance: 130 COLLEGE ST (413) 552-0200 WC SOUTH HADLEYMA01075 ISSUED ON:8/4/2020 0:00:00 TO PERFORM THE FOLLOWING WORK.-ATTIC 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 8/4/2020 0:00:00 $65.00 212 Main Street,Phone(413)587-1240, Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner �\04\nz Dep City of Northam it x'a Building Departme �91,��0 212 Main Street To�� IINSULA TION Room 100 ?y�sA rf Northampton, MA 01060 p ONLY -:,"'Ihone 413-587-1240 Fax 413-587-1 ..v, 4R. ;, APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING ONLY SECTION 1 -SITE INFORMATION INSULATION PERMIT 1.1 Property Address: This section to be completed by office Y /i Map yjLot� Unit ,M Sfoo&l Je.. l-1lRde - Zone Overlay District /"-'/o o R-ew--- A Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: . A,21 aii (_E a v J rr 7 ra oKs oRefxellgoi Name(Print) Current Mailing Address: See attached �/j3 - Telephone Signature 2.2 Authorized Agent: American Installations 130 College Street 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 pen*nit applicant 1. Building / (a)Building Permit Fee (Q 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:6 r)-a l 3 Date Issued: Signature: 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 9/2912021 Address Expiration Date 552-0200 Siprtature Telephone 9.Reaistered 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....... JC No...... ❑ Brief Description of Proposed Work NOTE: INS ULA TION ONLY Attic and basement insulation and air sealing throughout. I, 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 Nam Signatu a of Own e ent Date V I, q' /q Zea , 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 applicati n. See attached e2e e Signature of Owner Date City of Northampton .✓ ",-y.' i Massachusetts �� ' �: '••-c� DEPARTWNT OF BUILDING INSPECTIONS ' (n 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 perfornring 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: $ Address of Work: / q noe,,S,�cie Cate /—!a 1Q PAC e Date of Permit Application: I hereby certify that: Registration is not required for the following reason(s): _Work excluded by law(explain): _Job under S 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: 7/3/ Ro American Installations 175982 Dfite Contractor Name HIC Registration No. OR: Notwithstanding the above notice, I hereby apply for a building permit as the owner of the above property: Date Owner Name and Signature City of Northampton Massachusetts h; DEPARTMWT OF BUILDING INSPECTIONS yJ' a 212 Main Street *municipal Building Northampton, MA 01060 �Jdn •�... 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: oC b� (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 P4&hd App cant or Owner Rete 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 1 mass save Licensed&Insured PA R T N E R MA CSL b:206178 MA Registration x 175982 American Installations www-Americaninstallations.com 130 Colace Street Suite 100,South Hadley,MA 01075•Office;(413)552-0200 Fax:(413)552.0202• Email;support@Americanlnstallations.com Customer Name:Mariah Leavitt Email:Not provided Phone:413-586-0583 Premise Address:279 Brookside Circle,Florence,MA 01062 Mailing Address:279 Brookside Circle,Florence,MA 01062 Project ID:3970873 Date:Jan.21,2020 Job Description Measure Description Location Quantity Unit Total Cost Customer Cost Damming Living Space 24 each $57.36 $0.00 Propavent Living Space 2 each $8.32 $0.00 Open Wall- 3" Fiberglass Batting Living Space 25 SF $47.75 $0.00 Open Wall -2" Thermal Barrier Polyiso Living Space 25 SF $119.50 $0.00 Attic Floor-9"Open Blow Cellulose Living Space 1040 SF $1,892.80 $0.00 Project Total $2,125.73 Weatherization incentive ($2,125.73) Total Program Incentive -$2,125.73 Customer Total $0.00 WARRANTY:American Installations,LLC will provide the above stated homeowner with a 1-year workmanship warranty. American Installations,LLC hereby proposes to furrish 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 conditions are TOTAL CONTRACT VALUE= 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 due upon Completion. Down Payment=S ❑ PAID Balance Due Upon Completion= S Signature '_.n.Ii-Le vitt(Jdn 25.2020) Date Property Owner(Print) ISignl Date Representative:(Print) (sign) Date THIS AGREEMENTS COMPOSED OF THIS PAGE AND THE REVERSE SIDE OF THIS PAGE ANO SHALL BE CONSIDERED THE ENTIREAGREEMENT BY THE PARTIES INVOLVED THIS AGREEMENT 15 BETWEEN AMERICAN INSTALLATIONS,LLC HEREINAFTER REFERRED TO AS YAMPMY-. A NO THE CUSTOMERS)NAMED ABOVE,HERDh AFT ER REFER RED TO AS-CLIENT',AND WILL BE SUBJECT TOALL APPROPRUTE LAWS,REGULATIONS AND ORDINANCES OF THE STATE OF W SSA04USLl TS OR CONNECTICUT RESPECTIVELY,AS WELL AS ALL LOCAL JURISDICTIONS The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street,Suite 100 r*� Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly 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): l.®I am a employer with 70 employees(full and/or part-time).* 7. ❑New construction 2. 1 am a sole proprietor or partnership and have no employees working for me in $. Remodeling any capacity (No workers'comp.insurance required.] 9. El Demolition 3 0 1 am a homeowner doing all work myself.(No workers'comp.insurance required.)' 10 Q Building addition 4.0 1 am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12. Plumbing repairs or additions 5.a 1 am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0 Roof repairs fhese sub-contractors have employees and have workers'comp.insurance., 6.0 we are a corporation and its officers have exercised their right of exemption per MGL c. 14.©Other Insulation 152,§1(4).and we have no employees.(No workers'comp.insurance required.] *Any applicant that checks box k I must also fill 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 trate 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. 1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site Information. Insurance Company Name: Berkshire Hathaway GUARD Policy#or Self-ins.L�iilc.#: A/�MWCi04�9875 Expiration Date: 09/04/2020 Job Site Address: ` 7 i7nodiW�8e Q1 K City/State/Zip: /areAf-a- D(nbt Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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 up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do herebt,certify under the pains and penalties of pettimy that the information provided above is true and correct. Signature: Date:_-_- oa Phone#: 413-552-01/00 __ __ _ Official use only. Do not write in this area,to be completed by city or town offrciat 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 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 Ejcpires. 091'M2021 WESLEY COUTURE 139 PACKARDVILLE ROAD PELHAM MA 01002 Failure to possess a current edition of the Massachusetts ti State Building Code is cause for revocation of this license. Commissioner �,�_./ •%��''"�'�--�--- For information about this license Call (617) 727-3200 or visit www.mass.gov/dpl •//lP �/�'i'J?�/�GC�/!c/��P.t2'CC�O'�✓���J'•r2'fa2CC��t°�.�cl Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: LLC Registration: 175982 AMERICAN INSTALLATIONS,LLC. Expiration: 06/26/2021 130 COLLEGE STREET SUITE 100 SOUTH HADLEY, MA 01075 Update Address and Return Card. SCA 1 O 2OM-05/17 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: Reglstration Expiration Office of Consumer Affairs and Business Regulation 175982 06126/2021 1000 Washington Street -Suite 710 AMERICAN INSTALLATIONS,LLC. Boston,MA 02118 WESLEY COUTURE /7 y// 130 COLLEGE STREET SUITE 100 SOUTH HADLEY,MA 01075 Undersecretary Not valid without signature ACo CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 8/28/2019 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 S Grinnell ONE -0111 -6481A/ ( ) 8 North King Street E-MAIL ADDRESS: 1powers@webberandgrinnell.com INSURERS AFFORDING COVERAGE NAIC# Northampton MA 01060 INSURER A:Employers Mutual Casualty INSURED INSURER 13:Berkshire Hathaway GUARD Ins. Co. American Installations, LLC INSURER C: Attn: Wes & Suzanne Couture INSURER D: 130 College Street, Suite 100 INSURER E: South Hadley MA 01075 INSURER F: COVERAGES CERTIFICATE NUMBER:Master Exp 9-2020 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, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUBR POLICY EFF POLICY EXP TYPE OF INSURANCE LTR POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X CLAIMS-MADE ElOCCUR DAMAGE (RENTED 500,000 PREM"ES Ea occurrence $ 5D3535217 9/4/2019 9/4/2020 MED EXP(Any one person) $ 10,000 PERSONAL 8 ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X JECT LOC PRODUCTS-COMP/OPAGG $ 2,000,000 POLICY ❑ PRO OTHER $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident 1,000,000 ANYAUTO BODILY INJURY(Per person) $ A ALL OWNED SCHEDULED 5Z3535217 9/4/2019 9/4/2020 BODILY INJURY(Per accident) $ AUTOS X AUTOS NON-OWNED PROPERTY DAMAGE X HIRED AUTOS X AUTOS Per .'den) ciden $ X CoII$2,000 X comp$2.000 PIP-Basic S 8,000 X UMBRELLA LAB OCCUR EACH OCCURRENCE S 1,000,000 A EXCESS LIAB HCLAIMS-MADE AGGREGATE S 1,000,000 DED I X I RETENTION $ 10,000 1 5J3535217 9/4/2019 9/4/2020 $ WORKERS COMPENSATION x PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E .EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? ❑ NIA B (Mandatory in NH) AMWC994153 9/4/2019 9/4/2020 E .DISEASE-EA EMPLOYEE S 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E .DISEASE-POLICY LIMIT 1 $ 500,000 A Business Personal Property SA3535217 9/4/2019 9/4/2020 deductible$1 000 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/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 THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE W Grinnell, CPCU, CIC ��ll•- T� 'Y ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025 i201401)