03-004 (5) 540 COLES MEADOW RD BP-2019-1310
GIs# COMMONWEALTH OF MASSACHUSETTS
Mao:BlOck:03-004 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cateeom INSULATION BUILDING PERMIT
ermit# BP-2019-1310
Proiect# JS-2019-002118
Est Cost:$11700 00
Fee: 6 .00 PERMISSION IS HEREBY GRANTED TO:
const class: Contractor: License:
Use(3roun- AMERICAN INSTALLATIONS LLC 108178
Lot Size(sa,ft.): 1878.00 0WIter: PIERS-GAMBLE CLARK
Zoning, RR(1011/WSP(101VWP(55s.8/ Aoolicant. AMERICAN INSTALLATIONS LLC
AT. 540 COLES MEADOW RD
AoolicantAddress: Phone: Insurance:
130 COLLEGE ST (413) 552-0200 WC
SOUTH HADLEYMA01075 ISSUED ON.5121/20190:00:00
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: PYeD ur t Fireplace/Chimucy:
Rough: ; 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:
Feekne: Date Paid: Amount:
Building 5/21/20100:00:00 $65.00
212 Main Sheet,Phone(413)5$7-1340,Fax:(413)581-1272
Louis Hasbrouck--Building Commissioner
City of Northampton)I r ,
Building Department '
212 Main Street MAY 1 7 2f�A 1 A TON,
{{ �. Room 100
SLY L/`1
1' Northampton, MA 010 0 nv 1� null 1 mrtrEcnoNs
w phone 413-587-1240 Fax 413 587-1 dN Mnoaoac N j Y
APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING ONLY r
SECTION I -SITE INFORMATION INSULATION PERMIT A¢�Or9'•/ayo
1.1 Properly Addreaa: /,'Thus section to be completed y once
540 Coles Meadow Road May Lot R/
Northampton, MA 01060 Zorn Overtay District
Elm at Dlswct CB District
SECTION 2-PROPERTY OWNERSHIPIAUTHORQED AGEthT
2.1 Owner of Record:
Piers-Gamble,Clark&Marissa 540 Coles Meadow Road, Northampton,MA 01060
Name(Prim) Current Mailing Address:
See attached 14141275-8756
Telepho e
Signature
2.2 Authorized Agent
American Installations 130 College Street Ste. 100, South Hadley, MA 01075
Name(Prim) Currem Mailing Address:
(413)552-0200
SignaWre Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completedby anitapolicant
1. Building $11,700.00 (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC) 5
5.Fire Protection
6. Total=(1 +2+3+4+5) $11,700.00 Check Number
This Section For Official Use Only
Building Permit Number: Date
Issued: q
Signature: 5" 21201 I
Building Commissionerllnspector of Buildings Dale
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION e-CONSTRUCTION SERVICES
8.1 Licensed Corotruction Supervisor. Not Applicable Cl
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
Slgnaty—� Telephone
9.Registered Home lmprovamant Contractor. Not Applicable ❑
American Installations 175982
Company Name Registration Number
130 College Street Ste. 100, South Hadley MA 01075 6/2612019
Address Expiration Date
�p ..- CE11rr In a Telephone (413)552-0200
SECTION 5-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e.152,12SC(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....... 1M No...... ❑
Brief Description of Proposed Work NOTE: INSULATION ONLY
Attic and basement insulation and air sea ling throughout.
1, American Installations as OwnedAuthorized
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
�R l.ww Y- 5/16/2019
Signature of Owner em Date
I, Piers-Gamble, Clark&Marissa as Owner of the subject
properly
hereby auModze American Installations
to act on my behalf,in all matters��re-la�tive to work authorized by this building permit application.
�.1g2>Le�� K uy.lJli 5/16/2019
signature of Data
a City of Northampton
�
Massachusetts
i
( ' raP2 iftin r 68 BUILDING al Building
21r Mavn strut o Municipal Building
xercheoQ?len, PA 03060
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 most be registered as a Home Improvement Contractor("H1C).
M.G.L.Chapter 142A requires that the"reconstruction,alienation, renovation,repair, modernization,conversion,
improvement,removal,demolition, or construction of an addition to any ome existing owneroccupied building containing
at least one but not more than four dwelling units....or to structures which are adjacent to such residence orbuilding"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: $11700.00
Address of Work: 540 Coles Meadow Road
Date of Permit Application: 5/16/2019
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 owneroccupied
x Other(specify): Contractor pulling permit 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.
5/16/2019 American Installations 175982
Date Contractor Name HBC 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 c
�' •¢ ° Massachusetts
DEPHHTIffiiT OF HMWMG INSPECTIONS
222 1 in SCr t e Municipal 0uildinq
�., 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:
540 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)
U)L4�.1 . n l x A
Signature of Per i 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.
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owes mw.etl PARTNER
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Ma"`perm"°n°vrssr American Installations wwwAmertnnlmallatons.mm
1300Ik{e Street kila iph,5°uM lbdqMR O1W5 OMs:tov".OLpfen:IM3155E-0IDir FmYI auppatJ/une['[enlnabllNma.[an
Customer Name:Clark Piers Gamble
Email:garrisonpiersgamble@kuhnriddle.com
Phone:413-335-8756
Premise Address:540 Coles Meadow Rd Northampton,MA 01060
Mailing Address:540 Coles Meadow Rd,Northampton,MA 01060
Project ID:3021302
Date:May 14,2019
Job Description
Nessus Deatalpioer +' .sir,.- Location QuigniRy Writ That Cost Customer Cast
Air Sealing at Estimated 62.5 CFM50 Per Hour Living Space 12 hr $1,110.96 $0.00
Insulation Removal Living Space 560 SF $705.60 $705.60
Rim Joist-2"Thermal Barrier Polyiso Living Space 120 SF $573.60 $143.40
Basement Wall - 2"Thermal Barrier Polyiso Living Space 160 SF $764.80 $191.20
Exterior Perimeter-4" Dense Pack Cellulose Living Space 864 SF $2,134.08 $533.53
Hatch -2"Thermal Barrier Polyiso Living Space 2 each $92.56 $23.14
Cut and Finish Access Living Space 1 each $124.53 $31.13
Kneewall Wall -2"Thermal Barrier Polyiso Living Space 440 SF $2,103.20 $525.80
Kneewall Wall - 4" Dense Pack Cellulose Living Space 440 SF $1,113.20 $278.30
Kneewall Floor- 3"Open Blow Cellulose Living Space 480 SF $672.00 $168.00
Attic Floor- 3"Open Blow Cellulose Living Space 560 SF $784.00 $196.00
Kneewall Slope -3" Fiberglass Batting Living Space 210 SF $401.10 $100.27
Propavent Living Space 120 each $499.20 $124.80
Damming Living Space 40 each $95.60 $23.90
Gable Vent (12'x12") Aluminum Living Space 4 each $458.56 $114.64
Project Total $11,632.99
Weatherization incentive ($7,362.32)
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..'snita{atimf,LLC Earehv.Aet,e A—t all rmteriN vd labor m[omdelelleaWres[cpe°f wah in a[[°rM[e Nth[Mahaue spe[iri[ati°niantl atl b[al aM stall
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Customer Name:Clark PiersGamble
Email:garrisonpiersgamble@kuhnnocile.com
Phone:413-335-8756
Premise Address:540 Coles Meadow Rd, Northampton,MA 01060
Mailing Address:540 Coles Meadow Rd,Northampton,MA 01060
Project ID:3821302
Date:May 14 2019 Pre-Weatherization barrier incentive ($250.00)
Air sealing Incentive ($1,110.96)
Total Program Incentive -$8,723.28
Customer Total $2,909.71
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Germ Dem— Germ Demers 511412019kse.-Iasi-(er.l 1518n1 pate
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www.ntassgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/OrganivuioW[ndividuap: American Installations,LLC
Address: 130 College Street,Suite 100
City/State/Zip: South Hadley,MA 01075 _ Phoned: 413-552-0200
Are you an employer. Check the appropriate box Type of project(required).
I ❑ I am a employer with 60 4. ❑ 1 am a genera[contractor and I 6. ❑ New construction
employees(full and/or pan-time)P have hired thesub-wmracturs
2.❑ 1 am a sole proprietor or partner- listed ori attached sheet.t 7. ❑ Remodeling
ship and have no employees These sub commchns 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 to Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL [1,D Plumbing repairs or additions
myself.IN.workers' comp. c. 152,§1(4),and we have no 12❑ Roof repairs
insurance required.]t employees. [No workers'
_ 13.,E Other Insulation
comp. insurance required.] _ -- —
"AnyaPPliwntthateM1ecksboxM mug atm I is nut thin section below showing their workers mmpeffamen policy information.
't lomwwnm who submit this affidavit indicating they me doing all work and thin hire omsidu o anexams must submit o nmv atlieviva inmcatins such.
:Conlrmlors thin chink this box mml attached an additional sheet showing the name of the subcommemm and thea workus'come.polim mleo m ar
I am an employer that is providing warkers'eompensation insurance for my employees. Below h the policy and jab site
infornmtime.
Insurance Company Name: Guard Insurance Companies _ _ _
Policy llor Sel6ina Lic.N. UR//WC609917 /J_ j_ Expiration Date: 09/04/201_9_
)ob Site Address: 540 CdpC MQ,B nodi Rt�d City/State/Zip: 011—� 0(�_�tf/� d[
Attach a copy of the workers'compensation policy declaration page(showing the policy numbertion 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 viulatur. Be advised that a copy of this statement maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I da hereby certify under the pains and penaltiesof perjury that the information provid'e—dI above
is true and correm
Sirna[ure' ./f(L _._ __ Data..�B I1�I I A
Phone it 413-552//0200
Offtcia/use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License if
Issuing Authority(circle one):
I. Board of Health 2. Building Department 3.Cityfrown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contac/Person: phone q:
Com en of Professional
of Massachusetts
Construction Supervisor
®t
Diemen Bion of Professional and St re Unreart 35, 9c relate,
of any ate group rs)of commit
Board oBuibing Regulations and standartls Tess than 36,000 cubic reef(991 cubic mNersl of encbsetl
ConstrUdibn Supervisor space.
CS-106176 Ei pirea:09/292019
WESLEYCOUTURE �'
218 LATHROWSTREET.
SOUTH HAOLEY-b111 0107fi
Failure to possess i current edHion of the Ma deachu sari
state,Building Code ex cause for revocation of Mie hcMR.
For Incarnation abort Bills ft.Commissioner Call(61717274200 or visR w .mass.goaelil
� n%�e �aryr�rrf�yrrc�errl��- r��'C/�{r1�tnT�«.set�s
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. Expiration: 0626/2019
130 COLLEGE STREET SUITE 100
SOUTH HADLEY,MA 01075
Update Address and return card. Mark reason for change.
SGt J eVMa5:11
M— Air.._ n o_..em�i n Employment C1 LgsS Card
wine of Cons mer anain a Business Regulaon
HOME IMPROVEMENT CONTRACTOR Registration valld for!Individual me only
TYPE:LLC batch.the expiration date. If bund return to:
F a-; RwLstratbn ExajrEion Office of Container Allain and Business Regulation
1759x2 O6I2 19 10 Park Plara-Suite 5170
AMERICAN INSTALLATIONS,LLC. Boston,MA 02116
WESLEY COUTURE
130 COLLEGE STREET SUITE 100 01075 �jtyBI1d WIShOU[Bl nature
SOUTH HADLEY,MA Undersecretary / g
'*�d CERTIFICATE OF LIABILITY INSURANCE wTE eMtp n
9/4/2018
ME CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE GOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE ODES NOT CONSTITUTE A CONTRACT UETWEEN THE ISSUING INSURER(5), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: H Me cer illcate holder Is an AODMONAL INSURED,Me policy(Nal)must be endorsed. H SUBROGATION IS WANED,subject to
the terms Bntl mlMitlons of the policy,vermin policies may require an antloreamerlL A statement on MIs eerBBcats does net eonM rights to Me
tareBcale holder in lieu of su0h entl a.
MWaCER Ueda POFare
tsab s Grill w1011e (413)586-0111 FA2 .1411Tse6-ue1
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INRIRE RFFONaM4CWEM0E HiVL1
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w90Rm AhAFWRB:Ber1 mALL a Bath .y GBA9D Ina. Co.
Ameriosn Inatallatioaa, T.TZ WSulanc:
Attn: Nee A SU.. COxture WWRm D:
130 College attest, Suits 100 IMKIRER E:
Scmth Waaler NA 0107s
COVERAGES CERTIFICATE NUMBERIeacter SxP 9-2019 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE USTEO BELOW HAVE BEEN ISSUED TO THE INSURED IWSMED ABOVE MR THE POLICY PERIOD
INDICATED. NOTWFISTMIDNG ANY REQUIREMENT.TERM OR CONDIUM OF MY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURMICE AFFORDED BY THE POU MS DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDICEO BY PMD CLAIMS.
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PaRaDNA.6AWIMURY S 1.000.000
GMHAGGREWT 1JMn AnKIMPm: GEnEMLAOpREGATE E 2.000,000
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8 VYBREW UAs OCCLR EALN CoDuAREXCE E 11000,000
A IMoM LAID o.u.IMOEAGGREGATE E 1,000,000
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CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
S iQe6Oe Of ILBUrs31Ce THE EX IRAMDN DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH TIE POLICY PROVISIONS.
AVm0FuED REPREFOMATIVE
N Gr13D.e11, CPLD, CIC
01,38-2014 ACORD CORPORATION. All rights reserved.
ACORD M(2a14M) The ACORD mme EM logo are registered mart of ACORD
INS025......