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211 ACREBROOK DR COMMONWEALTH OF MASSACHUSETTS BP-2021-1836 Map:Block:Lot: 29-363-001 Permit:Alts Renovations CITY OF NORTHAMPTON Repair PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit# BP-2021-1836 PERMISSION IS HEREBY GRANTED TO: Project# 2021 INSULATION Contractor: License: Est.Cost: 1000 AMERICAN INSTALLATIONS LLC 106178 Const.Class: Exp.Date: 09/29/2021 Use Group: Owner: STANKOWSKI JOZEF&JENNIFER Lot Size(sq.ft.) Zoning: WSP Applicant: AMERICAN INSTALLATIONS LLC Applicant Address Phone: Insurance: 130 COLLEGE ST (413)552-0200 AMWC187717 SOUTH HADLEY,MA 01075 ISSUED ON: 09/08/2021 TO PERFORM THE FOLLOWING WORK: INSULATION/WEATHERIZATION 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. Signature: $ ;_ OTO 1 • yC� '1 • Fees Paid: $65.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner i City of Northamp n ' .» DepI-Ir °�q� s4 � `� .40r0- Building Departme 20 q� ',-; <. �,•; `" 212 Main Street 9�yeG! (.: INSULA TIN ,.,..7 :1 O°''ri{ Northampton, MA 01060 i` phone 413-587-1240 Fax 413-587-1272 ,, �i, on y APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY D LLFNG ONLY SECTION 1 -SITE INFORMATION INS ULA TION PERMIT 1.1 Property Address: This section to be completed by office a l l /4Cr.-e_bro 6 k DR , Map Lot Unit /V1 Zone Overlay District L( fl c.►9fn Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: , // / S 5e-c d Jenn •�-e-r' S�LL+(��6uv%K t ailt9-ct-e-bra,,k, fie) lUo(4l,a 121r1 Name(Print) Current Mailing A dress: See attached 4//3 44 4.S'—S-003 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 ature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building / Q Q (a) Building Permit Fee 2. Electrical / (b) Estimated Total Cost of DConstruction from(6) 3. Plumbing 10 Building Permit Fee 4. Mechanical(HVAC) ii OG 5. Fire Protection 6 6. Total=(1 +2+3+4+5) / 00 D Check Number 10 3 L f Q],�� This Section For Official Use Only BuildingPermit Number: bA- o7) t u �"� Date Issued: (,� Signature: fife _/- 7 ZOZ 1 Building Commissioner/Inspector of Buildings Date permits@AmericanInstallations.com EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) SECTION 4-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable 0 Name of License Holder: Wesley K. Couture 106178 License Number 130 College Street Ste. 100, South Hadley MA 01075 9/29/2021 9/a9/20,1,,3 Address ,,� Expiration Date ,7 s%>ry (413)552-0200 Signature Telephone 9.Registered Home Improvement Contractor: Not Applicable 0 American Installations 175982 Company Name Registration Number 130 College Street Ste. 100, South Hadley MA 01075 6/26/2023 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 IC 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 Date e—f . i;1 5,f iL , as Ovine?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 5_a Signature of Owner Date City of Northampton Massachusetts At?' DEPARTMENT OF BUIZDING INSPECTIONS !?ea i Y. 212 Main Street • Municipal Building Js ti Cb \,; W':. 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.Coat. 0 O O Address of Work: d i ! fi"CI'1_bro t}k D(' Date of Permit Application: $' 3 O' I 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: Q_3 Q_A I American Installations 175982 (GDa ? . 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 4t,' . (4 • DEPARTMENT OF BUILDING INSPECTIONS t if A' t 212 Main Street •Municipal Building ' ,o. Northampton, MA 01060 fsf ` 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: al 1 (+Gre `ov (Please print house number and street name Is to be disposed of at: K e'a W Materials&Recycling, 138 Palmer Ave, West Springfield, MA 01089 (Please print name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) ignature of rmit 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. �,;, City of Northampton Massachusetts 4 f 1 a4 + DEPARTMENT OF BUILDING INSPECTIONS Z-. 'i'x 212 Main Street • Municipal Building . Northampton, MA 01060 s �\6W 'Y'ti MANDATORY FOR HOUSES BUILT BEFORE 1945 Property Address: alit /rCri 2roo k LDt j A/ort/ .mpi4i r- Contractor Name: American Installations , I ±- Address: 130 College Street Ste. 100 CE--3 -7'9( 7 O City, State: South Hadley MA Phone: (413) 552-0200 Property Owner • Name: JoZe .0 5 n i0i.JS K I Address: c21II I /9Cre,k--00 K r City, State: ,I/o i grfl ,P lac) /14h 1, Wesley K. Couture (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 /i7/ Date -,3o-a l The Commonwealth of Massachusetts Department of Industrial Accidents :_ ►_ Office of Investigations Lafayette City Center VOW= 2 Avenue de Lafayette, Boston, MA 02111-1750 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual):American Installations LLC Address:130 College St, 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.❑� I am a employer with 43 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. El New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' 9. El Building addition [No workers' comp. insurance comp. insurance.* required.] 5. ❑ We are a corporation and its 10.1=1 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.1=1 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.0 Other Insulation comp. insurance required.] *My applicant that checks box#1 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 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. Insurance Company Name: Berkshire Hathaway GUARD Insurance Policy#or Self-ins. Lic. #:AMWC262555 Expiration Date: 09/04/20221 Job Site Address: 7-1/ Aj ir=,r"4_ f,co*, /-�i� - City/State/Zip:�s r//A)/), " / A. 0/6` 2, 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 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 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. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: �{, ��t�.Gw�- Date: f'- ?d - a— Phone#: 413-552-0 00 0 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License # Issuing Authority(check one): 10Board of Health 20 Building Department 3❑City/Town Clerk 4.❑Electrical Inspector 5Elumbing Inspector 6.0Other 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 Constructton Supervisor space. CS-106178 Expires: 09/29/202' WESLEY COUTURE ` .. 139 PACKARDVILLE ROAD PELHAM MA 01002 .rf Failure to possess a current edition of the Massachusetts f State Building Code is cause for revocation of this license. • nlcu •; omrnissionet ,, .. -', "�— For information about this license Call (617) 727-3200 or visit www.mass.gov/dpl 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: 06/26/2023 130 COLLEGE STREET SUITE 100 SOUTH HADLEY, MA 01075 Update Address and Return Card. 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 06/26/2023 1000 Washington Street -Suite 710 AMERICAN INSTALLATIONS,LLC. Boston,MA 02118 Vi WESLEY COUTURE 130 COLLEGE STREET SUITE 100 SOUTH HADLEY,MA 01075 Undersecretary Not valid without signature ACO CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) �� OS/23/2021 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 have ADDITIONAL INSURED provisions or 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 Barbara Grynkiewicz NAME: Webber&Grinnell PAHONEN Ext): (413)586-0111 FAX No): (413)586-6481 8 North King Street E-MAILDSS: bgrynkiewicz@webberandgrinnell.com INSURER(S)AFFORDING COVERAGE NAIC# Northampton MA 01060 INSURER A; Employers Mutual Casualty Company 21415 INSURED INSURERS: AmGUARD/BH GUARD 43290 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: Exp 9/4/22 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 TYPE OF INSURANCE ADDL SUER POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTRINSD wVD (MM/DD/YYYY) (MMIDDIYYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $DAMAGE RETED 1,000,000 CLAIMS-MADE X OCCUR PREMISESO(Ea occurrence) $ 500,000 MED EXP(Any one person) $ 10,000 A 5D3535221 09/04/2021 09/04/2022 PERSONAL&ADV INJURY $ 1,000,000 GENIIAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY X FRO LOC PRODUCTS-COMP/OPAGG $ 2,000,000 JECT OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1.000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ A OWNED si,,/ SCHEDULED 5Z3535221 09/04/2021 09/04/2022 BODILY INJURY(Per accident) $ AUTOS ONLY /� AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ X AUTOS ONLY X AUTOS ONLY (Per accident) PIP-Basic $ 8,000 X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 1,000,000 A EXCESS LIAB CLAIMS-MADE 5J3535221 09/04/2021 09/04/2022 AGGREGATE $ 1,000,000 DED X RETENTION $ 10,000 $ WORKERS COMPENSATION X STATUTE EORH AND EMPLOYERS'LIABILITY Y/N 500.000 B ANY PROPRIETOR/PARTNER/EXECUTIVE Y N/A AMWC262555 09/04/2021 09/04/2022 E.L.EACH ACCIDENT $ • OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500.000 If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 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 THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Evidence of Insurance ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE I ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Page 1 of 2 41 mass save -icensed&insured 111.. y - PAR T N E MAcsl#:t116z1f1 . .MARegrstrerron it 1/5981 American Installations www.Americanlnstallations.com 130 College Street Suite 100,South Hadley,MA 01075• Office:(413)552-0200 Fax.(413)552.0202 • Email suppor LCAAmerica obis lallations.com Customer Name:Jozef Stankowski Email: Not provided Phone:413-695-5003 Premise Address:211 Acrebrook Dr.Northampton,MA 01062 Mailing Address:211 Acrebrook Dr,Northampton,MA 01062 Project ID:4239875 Date:May 24,2021 Job Description Measure Description Location Quantity Unit Total Cost Customer Cost Air Sealing at Estimated 62.5 CFM50 Per Hour 1 hr $92.58 $0.00 Exterior Door Weather Stripping (with AS hrs) 4 each $120.28 $0.00 Door Sweep (with AS hrs) 4 each $101.24 $0.00 Rim Joist-6" Fiberglass Batting 136 SF $367.20 $91.80 Insulation Removal 136 SF $171.36 $171.36 Project Total $852.66 Weatherization incentive ($275.40) Air sealing incentive ($314.10) Total Program Incentive -$589.50 WA1RANTy: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 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 Down Payment=5 ❑ will be 1/3 down prior to start of work,and balance due upon Completion. PAID Balance Due Upon Completion= S Signature Date Property Owner(Print) (Sign) Date Representative:(Print) (Sign) Date len AGREEMENT IS COMPOSED Or TNS PAGE AND TN;REVERSE SIDE Or THIS PAGE ASP SHALL RE CONSIDERED THE ENTIRE AGREEMENT NV THE PARTIES Nw0.YE0'MIS AGREEMENT IS BETWEEN AMERWI INSTASIAIIDMS,SAC NERE,NwT ER REFERRED TO AS YOMPANY, AND IMC COSTOMEAESI NAMED MOVE,14ERTAAf tr.v rus.rsED 10 AS-parr.•so wSl is sveecT 10 ALL APPRWRATE LAWS REGAMTONS AN ORDINANCES Of ME STATL Or MASSaO,LISETIS OR COMrrcl(CEn RePECINIIr.AS WELL AS ALL LOCAL I1.RSDI010M1 a ( Lf8 - 17-ar Page 2 of 2 11111601/. ..icensed&ensured MA CV a:I061/.9 PARTNER mass save MA Reg,strnnnn a l/SS82 American Installations www.Amerlcanlnsta0ations.com 130 College Street Suite 100,South Hadley,MA 01075•Office:(413)552.0200 rem:(413)552-0202 • Emaik supporteAmericanlnstalations.com Customer Name:Jozef Stankowski Email:Not provided Phone:413-695-5003 Premise Address:211 Acrebrook Dr,Northampton,MA 01062 Mailing Address:211 Acrebrook Dr,Northampton,MA 01062 Project ID:4239875 Date:May 24,2021 Customer Total $263.16 WARRANTY:American installations,LLC will provide the above stated homeowner with a 1-year workmanship warranty. American installations,LLC hereby proposes to fur rish all material and labor to complete the above scope o`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 Down Payment-S ❑ will be t/:3 down prior to start of work,and balance due upon Completion PAID Balance Due Upon Completion- $ J i fer Stankowski(Jun 12,202103:48 EDT) Signature Dote Property Owner(Print) (Sign) Date Representative:(Print) (Sign) Date EMS•GREEANNI IS COMPOSED OP INS PAGE AND THE ROWSE SIDE CA INK PANE AND SNKC BE coNyocRED THE Ester AGAFEMEM IN THE PAR11E5 I,f cssto'NIS AGREEMEST,5 BET WEER Nut AK AN INSTALLAWONS,LLc NEREwArter REWIRED TO AS"COMPANY, •ecne WSIOMWS)NAMED ARM,NUMMIP WEARS]to AS'Qaer,AND WAS DE SMUT T OALL APPrOPra.tLAWS,FEGACAt,ONS AND OroriutuES Of THE SLATE Or MASSAOIUSEI TS OR CORACLE NCnRESPECT WAN.AS WELL AS ALL LOCAL JURISDICTIONS