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209CARDINAL WAY COMMONWEALTH OF MASSACHUSETTS BP-2021-1873 Map:Block:Lot:36-319-001 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-202 1-1873 PERMISSION'S HEREBY GRANTED TO: Project# INSULATION Contractor: License: Est. Cost: 5200 AMERICAN INSTALLATIONS LLC 106178 Const.Class: Exp.Date:09/29/2023 Use Group: Owner: DIXON JAMES JR&TERRI 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:09/14/2021 TO PERFORM THE FOLLOWING WORK: INSULATION 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: I3:)$171 • (� • � yQY Fees Paid: $65.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner // 4; / ., Depp OR .. .., .AMA City of North'amp n I.. _ Building Department Sep 212 Main S r et 1 3INS TION ,, �i 1 Room 106'' <90(9 ,. -7 } Northampton, MA i)r�, phone 413-587-1240 Fax 4 �it,- p / 0!!!.. Y tilq'��ocb•,nN9 ,• it/ APPLICATION FOR INSULATION FOR A ONE OR TWO FAMIL WEG ONLY SECTION 1 -SITE INFORMATION INSULATION PERMIT 1.1 Property Address: This section to be completed by office aoCi CaK.c�l na-` Way,..... Map Lot Unit _l ` Zone Overlay District 1 l 01 ,1✓llce_ /tiVi 01 o 6 a Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: 'rerr► 4- clnames ixo (N aO9 Cck.cch\a1 Lk)ai FLURenev Name(Print) Current Mailing Address: See attached $h 4— ( 7'7- 9756 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 permit applicant 1. Building 5, an C7 (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of 6 Construction from(6) 3. Plumbing G Building Permit Fee 4. Mechanical(HVAC) a 5. Fire Protection 0 6. Total=(1 +2 +3+4+5) S aoa Check Number /al d This Section For Official Use Only ,,a/'/g 7 3, Building Permit Number: ✓ Date Issued' Signature: ///�� el' Pi* 202 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 9/29/20? 7 —j Address Expiration Date (413)552-0200 �a 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 6/26/20ef }� 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 jla No 0 Brief Description of Proposed Work NOTE: INSULATION ONL Y Attic and basement insulation and air sealing throughout. 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 Signatu f Owner/Agent Date I, sl4rvx.e.s )I XvYI ,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 3-a.ti -al Signature of Owner Date City of Northampton Massachusetts C - •'�f DEPARTMENT OF BUILDING INSPECTIONS ?. vy 212 Main Street • Municipal Building J` 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: S pW 0 Address of Work: OD 9 Car C:111110,1 c.y �'i�Ug.Gv1Ce Date of Permit Application: Cl_ - a' 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 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: Date Owner Name and Signature City of Northampton /,. Mp, ...,.. /?i �X, \ / /1 .-'�' ,` Massachusetts ,�5f 9: '<<. 4�� f , DEPARTMENT OF BUILDING INSPECTIONS ys rah 212 Main Street •Municipal Building J6:', +� Northampton, MA 01060 4 4' ��' 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: o20 a Car ;(-i IA)a, (Please print house number and street name) Is to be disposed of at: K er 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) Vignatu of Permit Applicant or Owner Date 41 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. YHAM City of Northampton ''i t � Massachusetts .t& e f DEPARTMENT OF BUILDING INSPECTIONS S. 212 Main Street • Municipal Building 3+. Northampton, MA 01060 115 MANDATORY FOR HOUSES BUILT BEFORE 1945 Property Address: r)10 ! (l1(el i OCA-k l.(J QUA 1f Contractor Name: American Installations O D y Address: 130 College Street Ste. 100 City, State: South Hadley MA Phone: (413)552-0200 Property Owner Name: 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 Date The Commonwealth of Massachusetts Department of Industrial Accidents 1_110, Office of Investigations _=IM= Lafayette City Center 2Avenue 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): l.E 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. ❑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 workingfor me in anycapacity. employees and have workers' p h 9. ❑ Building addition [No workers' comp. insurance comp. insurance.: required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 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 Insulation employees. [No workers' 13.© Other comp. insurance required.] *Any 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: 09/04/2022 Job Site Address: � '7 CAre t. A.L. IdilA'/ City/State/Zip:isrC'1cC• {'I'fA. ''/B40 .4— 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. 96).10.0___Signature: Date: Phone#: 413-552-0 00 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 3DCity/Town Clerk 4.11 Electrical Inspector 5Elumbing Inspector 6.0Other Contact Person: Phone#: Commonwealth of Massachusetts Division of Professional Licensure Board of Building Re ulations and Standards Co ns pu sty r { ■t CS-106178 spires: 09/29/2023 WESLEY COUTURE 139 PACKARDVILLE R ? PELHAM MA 01002 OicsnipiOub • Commissioner c� A . tf ri 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 i Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:LLC before the expiration date. If found return to: 8491111211040, ,g210100211 Office of Consumer Affairs and Business Regulation 175982 06J26/2023 1000 Washington Street -Suite 710 AMERICAN INSTALLATIONS,LLC. Boston,MA 02118 WESLEY COUTURE 12i 130 COLLEGE STREET SUITE 100 a � Not valid without signature SOUTH HADLEY,MA 01075 Undersecretary _ACO CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 08/23/2021 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 1PHONE J Extl: (413)586-0111 No): (413)586-6481 8 North King Street ADDRIESS: bgrynkiewicz(dwebberandgrinnell.com INSURER(S)AFFORDING COVERAGE NAIC R Northampton MA 01060 INSURER A: Employers Mutual Casualty Company 21415 INSURED INSURER B: 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. 1LTR TYPE OF INSURANCE INSD S POLICYI WVD POLICY NUMBER (MM/DDIYYYY) (MMDD/YYYY) UMITS COMMERCIAL GENERAL LIABIUTY EACH OCCURRENCE s 1,000,000 CLAIMS-MADE OCCUR PREMISES(EaEoccurrence) $ 500,000 I' �I MED EXP(Any one person) $ 10,000 A 5D3535221 09/04/2021 09/04/2022 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE UMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY xl jE a n LOC PRODUCTS-COMP/OP AGG $ 2,000.000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ A OWNED X SCHEDULED 5Z3535221 09/04/2021 09/04/2022 BODILY INJURY(Per accident) $ _ AUTOS ONLY AUTOS HIRED s,/ NON-OWNED PROPERTY DAMAGE $ X AUTOS ONLY AUTOS ONLY (Per accident) PIP-Basic $ 8,000 X UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ 1,000,000 A EXCESSLIAB CLAIMS-MADE 5J3535221 09/04/2021 09/04/2022 AGGREGATE $ 1,000,000 DED X RETENTION$ 10,000 $ WORKERS COMPENSATION OTH- AND EMPLOYERS'LIABILITY X STA UTE ER Y/N 500,000 B ANY PROPRIETOR/PARTNER/EXECUTIVE ri N/A AMWC262555 09/04/2021 09/04/2022 E.L.EACH ACCIDENT $ (Mandatory In N ) EXCLUDED? 500,000 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 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 THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Evidence of Insurance ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 26(2016/03) The ACORD name and logo are registered marks of ACORD A+ www.Americanlnstallations.com Atk BBB Licensed&Insured Aa�nroireslRrsso rating mass save MA al.#:106178 American Installations PARTNER MA Registration#175982 130 College Street Suite 100,South Hadley,MA 01075•Office:(413)552-0200 Fax:1413)552-0202•Email:support@Americanlnstallatlons.com Dixon,Terri&James 3.24.21 (First Last) (Date) 209 Cardinal Way Florence MA 01062 (Aecras) (CDy) (state) (LPI 311716 21-0437 (SRe ID) (lob u) Quantity Unit Unit Cost Total Air Sealing AIR SEALING 16 man hour $ 85.00 $ 1,360.00 WEATHERSTRIP DOOR 4 each $ 58.00 $ 232.00 DOOR SWEEP 4 each $ 25.00 $ 100.00 Total Air Sealing Value $ 1,692.00 Utility Air Sealing Incentive $ (1,692.00) Weatherization ATTIC HATCH-SEAL&INSULATE 1 each $ 60.00 $ 60.00 FINISHED KNEEWALL ACCESS 1 each $ 135.00 $ 135.00 4"FLAPPER KIT THROUGH ROOF 1 each $ 118.75 $ 118.75 4"INSULATED HOSE ONLY 1 each $ 60.00 $ 60.00 ATTIC DAMMING-R-38 FIBERGLASS 82 sqft $ 2.05 $ 168.10 ATTIC FLAT-7"OPEN R-26 CELLULOSE 1,772 sqft $ 1.38 $ 2,445.36 KNEEWALL-2"RIGID BOARD 114 sqft $ 3.96 $ 451.44 Total Weatherization Value $ 3,438.65 Utility Weatherization Incentive $ (2,578.99) Total Project Value $ 5,130.65 Utility Weatherization/Air Sealing Incentive $ (4,270.99) Weatherization Balance $ 859.66 Total Customer Contribution $ 859.66 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 Total Contract Value as stated herein. ACCEPTANCE OF PROPOSAL:The above prices,specifications and TOTAL CONTRACT VALUE= $ 859.66 conditions are satisfactory and are hereby accepted.You are authorized to do work as specified.Payment will be 1/3 down prior to Down Payment= $ 200.00 200.00 start o k,and balance due upon Comple' n. A D Balance Due Upon Completion= $ 659.66 ale Ignature Date Adam Zwick Al Representative Al Rep Signature Date THIS AGREEMENT IS COMPOSED OF THIS PAGE AND THE REVERSE SIDE OF THIS PAGE AND SHALL BE CONSIDERED THE ENTIRE AGREEMENT BY THE PARTIES INVOLVED.THIS AGREEMENT IS BETWEEN AMERICAN INSTALLATIONS,LLC HEREINAFTER REFERRED TO AS"COMPANY",AND THE CUSTOMER'S)NAMED ABOVE,HEREINAFTER REFERRED TO AS"CLIENT",AND WILL BE SUBJECT TO ALL APPROPRIATE LAWS,REGULATIONS AND ORDINANCES OF THE STATE OF MASSACHUSETTS OR CONNECTICUT RESPECTIVELY,AS WELL AS ALL LOCAL JURISDICTIONS. at- oy37 9,a7. a (