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29-383 (8) BP-2023-0901 27 BROOKWOOD DR COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 29-383-001 CITY OF NORTHAVIPTON Permit: Alts Renovations Repair PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit# BP-2023-0901 PERMISSION IS HEREBY GRANTED TO: Project# INSULATION 2023 Contractor: License: Est. Cost: 3900 AMERICAN INSTALLATIONS LLC 106178 Const.Class: Exp.Date: 09/29/2023 Use Group: Owner: BELKIN ALLEN L&MARY JEAN O'REILLY Lot Size (sq.ft.) Zoning: WSP Applicant: AMERICAN INSTALLATIONS LLC Applicant Address Phone:• Insurance: 130 COLLEGE ST SUITE 100 (413)552-0200 AMWC32951 SOUTH HADLEY, MA 01075 ISSUED ON: 07/12/2023 TO PERFORM THE FOLLOWING WORK: INSULATION/WEATHERIZATI ON 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: Final: Final: Final: Rough Frame: Gas: Fire Department Driveway Final: Fireplace/Chimney: Rough: Oil: Insulation: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: I 1 1 • , • '1 • Ii Fees Paid: $65.00 212 Main Street,Phone(413)587-1240,Fax (413)587-1272 Office of the Building Commiss' ner 1-1r—� 21-1828 • C f�� __� iL T 1971 Dep / A MyJ City of North pto JUL i r "i Building Dep rtme t 20 212 Main treetc.,,T 0 SULA TION 414 Room Oe--__NOqT BUICDIIyG 1N '`. > Northampton, • MA 0106 HA TON MAflo;;,T)'vs phone 413-587-1240 Fax 413-587-1272 QJJt Y APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING ONLY SECTION 1 -SITE INFORMATION INSULATION PERMIT This section to be completed by office 1.1 Property Address: 27 Brookwood Drive Map Lot Unit Florence, MA 01062 Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Belkin & O'Riley,Allen & Mary Jean 27 Brookwood Drive, Florence, MA 01062 Name(Print) Current Mailing Address: 4135529080 Sec attached Telephone Signature 2.2 Authorized Agent: American Installations 130 College Street Ste. 100, South Hadley, MA 01075 Name(Print) / Current Mailing Address: ,7;1/i" (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 3900 (a)Building Permit Fee 2. Electrical 0 (b)Estimated Total Cost of Construction from(6) 3. Plumbing 0 Building Permit Fee 4. Mechanical(HVAC) 0 oc 5. Fire Protection 6. Total=(1 +2+3+4+5) 3900 Check Number M.35 �r �i This Section For Official Use Only Building Permit Number: 60"09 ' -/el Date Issued: Signature: � / 7- ll-ZOZ3 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 9/29/2023 Address (,//;/ /./ Expiration Date (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 6/26/2025 Address � A- 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 jtj No 0 Brief Description of Proposed Work NOTE: INSULATION ONL Y 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 6/26/2023 Date Belkin &O'Riley,Allen&Mary Jean , 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 6/26/2023 Signature of Owner Date City of Northampton j a Massachusetts . , N * 4 DEPARTMENT OF BUILDING INSPECTIONS '` 41 QZ 212 Main Street • Municipal Building �- �.a 4°° " Northampton, MA 01060 44 \ 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 Irst.Cost: 3900 Address of Work: 27 Brookwood Drive, Florence, MA 01062 Date of Permit Application: 6/26/2023 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: 6/26/2023 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 ,�M ff Sys s;�.. / �' Massachusetts h<*t,' DEPARTMENT OF BUILDING INSPECTIONS �-. •�,. y 212 Main Street •Municipal Building Jd �a \ � ,.a- Northampton, MA 01060 s� ' i�� 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: 27 Brookwood Drive, Florence, MA 01062 (Please print house number and street name) Is to be disposed of at: K 2'r 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) 6/26/2023 Signature of Permit 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. �cH�MP\ City of Northampton Massachusetts A.: I4( '* „ * 1.4 DEPARTMENT OF BUILDING INSPECTIONS ti�` ,D 212 in Street • Municipal Northampton, M 01060uildinq MANDATORY FOR HOUSES BUILT BEFORE 1945 Property Address: 27 Brookwood Drive, Florence, MA 01062 Contractor Name: American Installations Address: 130 College Street Ste. 100 City, State: South Hadley MA Phone: (413) 552-0200 Property Owner Belkin & O'Riley, Allen & Mary Jean Name: Address: 27 Brookwood Drive City, State: Florence, MA 01062 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 V/ Date 6/29/2023 Page 1 of 2 41,94/1 mass save licensed&insured PARTNER MA CSLa:10617g MA Registration#175982 American Installations www.Americanlnstallations.com 130 College Street Suite 100,South Hadley,MA 01075•Office:(413)552.0200 Fax:(413)552-0202 a Emaik support@AmericanInstallations.com Customer Name: Allen Belkin Email:Not provided Phone: 413-552-9080 Premise Address:27 Brookwood Dr,Northampton,MA 01062 Mailing Address:27 Brookwood Dr,Northampton,MA 01062 Project ID:4364944 Date:Nov. 17,2021 Job Description Measure Description Location Quantity Unit Total Cost Customer Cost Air Sealing at Estimated 62.5 CFM50 Per Hour Other 14 hr $1,296.12 $0.00 Attic Floor-7"Open Blow Cellulose Other 1404 SF $2,358.72 $589.68 Bath Fan Hose Other 1 each $26.20 $6.55 Damming Other 26 each $62.14 $15.53 Hatch-2"Thermal Barrier Polyiso Other 1 each $46.28 $11.57 Propavent Other 12 each $49.92 $12.48 Project Total $3,839.38 Weatherization incentive ($1,907.45) Air sealing incentive ($1,296.12) 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 braiding regulations for the Total Contract Value as stated herein. ACCEPTANCE OF PROPOSAL: The above prices, specifications and conditions are TOTAL CONTRACT VALUE=S satisfactory and are hereby accepted.You are authorized to do work as specified.Payment Down Payrrent=S ❑ 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 THIS AGREEMENT IS COMPOSED OF THIS PAGE AND THE REVERSE SIDE OF THIS PAGE AND SHALL RE CONSIDERED THE ENTIRE AGREEMENT AV THE PARTIES INVOLVED.T HS AGREEMENT 15 BETWEEN AMERICAN INSTAWTIONS,LLL HEREINAFTER REFERRED TO AS-COMPANY, AND THECUSTOMERfS)NAMED ABOVE,HEREINAFTER REFERRED TO AS'CLIENT',AND WC.RE SOWELL TOALL APPROPRLATE LAWS,REGULATIONS AN DORDINANERS Of THE STATE Of MASSAOIUSET IS OR CONNELTICUT RePECTRIELT,AS WELL AS ALL LOCAL IURISD Cl IONS Licensed&insured PARTNER Page 2 of 2 MACS!#:106178 mass save MA Registration It 175982 American Installations www-Americanlnstallations.com 130 College Street Suite 100,South Hadley,MA 01075•Office:(413)552-0200 Fax:(413)552-0202• Email:supportgiMmericanlnstallations.com Customer Name: Allen Belkin Email:Not provided Phone: 413-552-9080 Premise Address:27 Brookwood Dr,Northampton,MA 01062 Mailing Address:27 Brookwood Dr,Northampton,MA 01062 Project ID:4364944 Date:Nov. 17,2021 Total Program Incentive -$3,203.57 Customer Total $635.81 WARRANTY:American installations,LLC will provide the above stated homeowner with a 1-year workmanship warranty. American installations,LLC hereby proposes to furnish all material and labor to complete the above scope of work in:accordance with the above specifications and all local and state btilding regulations for the Total Contract Value as stated herein. ACCEPTANCE OF PROPOSAL: The above prices, specifications and conditions are TOTAL CONTRACT VALUE=$ satisfactory and are hereby accepted.You are authorized to do work as specified.Payment Down Payment=; - ❑ will be 1/3 down prior to start of work,and balance due upon Completion. PAID Balance Due Upon Cornpletion= S Allen Belkin Sithati.106.(May 2,202316:05 EDT) Date Property Owner(Print) (Sign) Date Representative:(Print) (Sign) Date THIS AGREEMENT IS COMPOSED OF THIS PAGE AND THE RELEASE ODE OF THIS PAGE AND SHALL BE CONSIDERED THE ENTIRE AGREEMENT BY THE PARTIES TWINNED.THIS AGREEMENT IS BETWEEN AMERICAN I NSTALLAllow.LLC HEREINAFTER REFERRED TO AS'COMPANY', ANODE CUSTOMER(S)NAMED ABOVE.HEREINAEI ER R EfERRED 10 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 Al RISC,.CI IONS The Commonwealth of Massachusetts Department of Industrial Accidents V=mom — s Office of Investigations y1 ATM= MI Lafayette City Center � 2 Avenue de Lafayette, Boston,MA 02111-1750 wM 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): 1.0 I am a employer with 43 4. ❑ I am a general contractor and I 6. El New construction employees (full and/or part-time).* have hired the sub-contractors 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 10.0 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.❑ Roof repairs insurance required.] t c. 152, §1(4),and we have no Insulation employees. [No workers' 13.© Other 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. tContractors 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. #:AMWC332951 Expiration Date:09/04/2023 Job Site Address: 27 Brookwood Drive City/State/Zip: Florence, MA 01062 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 perjusy that the information provided above is true and correct Signature: Date: 6/26/2023 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): 11=1Board of Health 20 Building Department 31:City/Town Clerk 4.0 Electrical Inspector 5E'lumbing Inspector 6.0Other Contact Person: Phone#: Commonwealth of Massachusetts IFDivision of Professional Licensure Board of Building Regulations and Standards onstruelt%ietopp.rvisor s CS-106178 Expires: 09/29/2023 WESLEY COUTURE 139 PACKARDVILLE ROAD PELHAM MA 01002 I 1 Ir` *4 4 `__0 /1 n ram. I r^ ' Commissioner cU zi f. LIC.4,1.1c .c , THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affair and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Imero ement Contractor Re istration z =t rrrsalr�f ; ` talrfl1111 ► -/fMelir i- v Mai wulnel141t ,,,. Type: LLC e iStiration: 175982 AMERICAN INSTALLATIONS, LLC �",� = _; E 6ation: 06/26/2025 130 COLLEGE STREET SUITE 100 itis el! SOUTH HADLEY, MA 01075 111/4 Update Address and Return Card. THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs&Business Regulation Registration valid for individual use only before the HOME IMPROVEMENT CONTRACTOR expiration date. If found return to: TYPE: LLC Office of Consumer Affairs and Business Regulation Registration Expiration 1000 Washington Street -Suite 710 175982 06/26/2025 Boston,MA 02118 AMERICAN INSTALLATIONS, LLC ,/, , -, r * V WESLEY COUTURE w1 * /`l"e- 130 COLLEGE STREET SUITE 100SOUTH HADLEY,MA 01075 v Undersecretary ithout signature A�® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDrYYY) 08/30/2022 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 PHONE (413)586-0111 FAX (413)586-6481 (A/C.No.Ext): (A/C,No): 8 North King Street L bgrynkiewiczia�webberandgrinnell.com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC f 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 9/4/23 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 POUCY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD WVD (MM/DD/YYYY) (MM/DD/YYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED XI CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ 500,000 X Liquor Liability MED EXP(Any one person) $ 10,000 A 5D3535223 09/04/2022 09/04/2023 PERSONAL&ADV INJURY $ 1,000,000 GEN-'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2'000'000 POLICY( JEC n LOC PRODUCTS-COMP/OP AGG $ 2'°°0'000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 _ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ A AWNED SCHEDULED 5Z3535223 09/04/2022 09/04/2023 BODILY INJURY(Per accident) $ AUTOS ONLY /� AUTOS XHIRED X NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY /_� AUTOS ONLY (Per accident) PIP-Basic $ 8,000 X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 1,000,000 A EXCESS LIAB CLAIMS-MADE 5J3535223 09/04/2022 09/04/2023 AGGREGATE $ 1,000,000 DED XI RETENTION$ 10,000 $ WORKERS COMPENSATION �/I PER OTH- AND EMPLOYERS'UABIUTY �I STATUTE ER Y/N 500,000 B ANY PROPRIETOR/PARTNER/EXECUTIVE N/A AMWC332951 09/04/20�2 09/04/2023 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 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD