23A-240 (2) 57 MANN TER BP-2018-0996
GIS 4: COMMONWEALTH OF MASSACHUSETTS
Mao:Block:23A-240 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TOTHEGUARANTY FUND (MGL c.142A)
Categorv: INSULATION BUILDING
V ILDING PERMIT
Permit# BP-2018-0996
Proiect# JS-2018-001808
Est.Cost:53262.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor. License:
Use Group: AMERICAN INSTALLATIONS LLC 106178
Lot Size(sa. R.): 8973.36 Owner: ROGERS LEROY A&DANIEL ROGERS
zoning: URB(100)/ Applicant. AMERICAN INSTALLATIONS LLC
AT: 57 MANN TER
Applicant Address: Phone: Insurance:
130 COLLEGE ST (413) 552-0200 WC
SOUTH HADLEYMA01075 ISSUED ON:4/3/20780:00:00
TOPERFORM THE FOLLOWING WORK:KNEEWALL & 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:
Drivcw.y 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:
FeeTvoe: Date Paid: Amount:
Building 4/3/2018 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
Department use orq
" Ci Northampton Status of Permit
c
Building Department curb'CuNDdvevray Pemdt
212 Main Street Sewer/Septle Availabltgy
Room 100 WebidlNeg Availabfigy..
Northampton,MA O1O6O Twosetsofstrucituml Preis
phone 413587-1240 Fax 413587-1272 Maeda Plans
OtherSpedty
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A/O�NE OR TWO
-CO FA( DDIMIILY VEWNG
RMATION t7
SECTION i-SITE INFOQ G D — ct(
1.1 Prooerte Addrass: This section to be com�.pJ1g'(�Jd byal ice
Map o� l'q Lot a' r " lkwt.
57 Mann Terrace Zone Overlay District
Eim SL Dbtri4 ce Dbbkt
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
Daniel Ropers &Audrey Levere 57 Mann Terrace , f a6�.k i „k, MA 0)0(c L
Name(Prim) Current MaAb—gAdd— 7
13) 433-6002
See attached Telephone
signature
7-2 Authorized Agent
American Installations 130 College St., Ste 100 South Hadley, MA 01075
Nsme(Prim) Current Mating Adlnnu:
I.v 2.LL n k GM�y+1 413-552-0200
s�neexe Tl Tebphone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Olfidal Use Only
completedb permit applicant
1. Building $3262.00 (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from s
3. Plumbing Building Permit Fee A/�
4. Mechanical(HVAC) 0
5.Fire Protection
6. Total=(1+2+3+4+5) $3262.00 Check Number a'
This Section For Official Use Only
Building Permit Number. Data
termed:
Signature:
Building Commheionerhospector of B-ldmgs Date
s;;t.11 4. ZONING All Information Must Be completed.Pemdt Can Be Denied nue To Inramplete Information
Existing Proposed Requited by Zoning
ibhcvlumvto be 6BW mbY
Building Depa�mt
Lot Size � i C^—�
Frontage -- � �— —�
Setbacks Front O
Side L:= R:= 1;=R= 0
Rear J
Building Height
Bldg.Square Footage
Open Space Footage �-
(lMammivosbNg&paved
Paricim)
#of Parkin S aces
Fill: r—_ _
(vo)vme&luufiov)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW O YES O
IF YES,date issued:I�
IF YES: Was the permit recorded at the Registry of Deeds? _
NO O DONT KNOW C) YES O
IF YES: enter Book L Page and/or Document#F ---!
B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW O YES O
IF YES,has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained O , Date Issued:
C. Do any signs exist on the property? YES O NO O
IF YES,describe size, type and location.
D. Are there any proposed changes to or additions of signs intended for the property? YES O NO O
IF YES,describe size,type and location: L
E. Wll the construction activity disturb(clearing,grading,excavation,orglBng)over f acre or Is It pan of a common plan
thatwlidisturb over 1 acre? YES O NO O
IF YES,then a Northampton Stout Water Maragernent Peri ttfrom the DPW is required.
SECTIONS-DESCRIPTION OF PROPOSED WORK(check all applicablel
New House ❑ Addition ❑ Rep
Orlacement Windows Alteratlon(s) Roofing
Doo s
Accessory Bldg. ❑ Demolition ❑ New Signs [p] Decks 1q Sidingo] Other[A
Brief Desuiption of Propuosseedd
Worse Kneewall and basement insulation and air sealing Ulroughou t
Alteration of oxisti g bedmom_Yes_No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basemen[ Yes NO
Plaice Attached Roll -Sheet
So.if New house and or addition to existing-housing Complete the following.
a. Use of building:One Family Two Famiy Ogler
b. Number of rooms in each family unit Number of Bathrooms
—
c. Is them a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Numberofstories?
L Method of heating? Fireplaces or Woodstm es Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
1. Is construction within 1D0 ft.m wetlands?^Yes —No. Is comtruction within 100 yr. floodplain----Yes---No
1. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zomng regulations? Yes_No.
I. Septic Tank_ CitySewcr_ Private well_City waterSupply_
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I. as Amer of the subled
property
herebyauthorize American Installations
m act on my behalf,in all magens relative to work authored by this building permit application.
.Sae attached 3/29/18
Stimseveofowner Data
I, American Installations as Ouner/Audmitzad
Agent hereby dedare that the statements and Infomcetion on the foregoing application ere bus and accurate,to the beat of my knovdedge
and belief.
Signed under the pains and penalties of perjury.
American Installations
Prim Name
I,J,a ll k- ,C , . 3/29/18
Signature of /A®em Data
SECTION 8-CONSTRUCTION SERVICES
8.1 licensed Construction Supervisor. Not Applicable ❑
Name&Lim..",der: Wesley K. Couture 106178
License Number
130 Colle¢e St., Ste 100 South Hadley, MA 01075 9/29/19
Adtlmes Eapimtion Date
V.J1A i CG\1 nx T 3-5552-0200 _
lephone
II.Rehdstered HomelmorovemerifContractor. _ _ Not Applicable ❑
Wesley Couture _ 175982
Company Name Reglstra0on Number
American Installations 6126/19
Address Expiration Date
130 College St., Ste 100 South Hadley, MA 01075 Telephone 413-552-0200
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L e.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 Affidav[tAttached Yes....... 11 No...... ❑
11. -Home Owner Exemption
The client exemption for"homeowners"was extended to include Owneroccuoied Beeline;of oro(1) or two(2)families
and to allow,such homeowner to engage an individual to hire who does not poetess a license,provided that the owner acts
as supervisor.CMR 780, Sixth Edition Section 108.3.5.1.
Definition of Homeowner:Person(a)who own a parcel of land on which he/she resides or intends to reside,on which there
is,or is intended to be,a one or two family dwelling,allwhed or detached structures accessory to each use and/or farm
structures.A Person who constructs more than one home in a two-veer period shall not be considered a homeowner.
Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official,that he/she Shan be
reseensible for aM seckwerknerformed under the bending permit.
As acting Construction Supervisor your presence on thejob site will be required from time to time,during and upon
completion ofthe work for which this permit is issued
Also be advised that with reference to Chapter 152 iVodcars'Compensation) and Chapter 153(Liability ofbmployem to
Employees for injuries notresnitiog in Death)of di:Massachusets General Laws Anwrated,veru may be sable forpemon(s)
you hire to perform work for youumder this permit
The undersigned"homeowner"cedifics and assumee responsibility for compliance with the Stare Building Code,City of
Northampton Ordinances,State and Local Zoning Iaws and State ofMassechusetts General Laws Annotated.
Homeowner Signature
City of Northampton
Massachusetts
DSpaaRlffiaP OF BVXMuW ZaSBBOTZOW +g
212 Mean e[saot a I i=psl Builth,
We th ptun, M 01060 g'A6
Property Address: 57 Mann '1'errace
Contractor
Name: American Installations
Address: 130 Coll eee Street Ste. 100
City, State: South Hadley,MA
Phone: 43-552-0200
Property Owner
Name: Daniel Rosers&Audrey Levere
Address: 57 Mann Terrace
City, State: Florence, MA
I, American Installations (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
3/29/18
City of Northampton 212 Main Street, Northampton, MA 01060
Solid Waste 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.
Address of the work: 57 Mann Terrace Florence, MA 01062
The debris will be transported by: American installations
The debris will be received by: Waste Management - Chicopee MA
Building permit number:
Name of Permit Applicant Wesley Couture
3/29/18 0 ixi, " k . CtgLQ a A.
Date Signature of Permit Applicant
• mass save
m:<a a nw.M
PARTNER
mA.Rr'r no...;...A, American Installations wwn.Amerkminstaaations.cam
nio Cdk..Sbeel..Ifo'swM Rdry•MP Ol%S OK¢: int,SSb0aMfa.:IN315a'OWE ema[suppwrBPmertnnYnOANaoni.an
Customer Name:Leroy Rogers
Email:Not provided
Phone:413433-6002
Premise Address:57 Mann Terrace. Normamplon. MA 01062
Project 10:3389078
Date:March 24,2018
Job Description
Measure Description Quantity Unit ,TOW Cost -Gu arrat,Cost
Air Sealing at Estimated 62.5 CFM50 Per Hour 4 hr $370.32 $0.00
Exterior Door Weather Stripping (on AS job) 3 each $90.21 $0.00
Door Sweep (on AS job) 3 each $75.93 $0.00
Rim Joist- 6' Fiberglass Batting 112 SF $302.40 $75.60
Kneewall Slope - 2" Thermal Barrier Polyiso 312 SF $1,491.36 $372.84
Temporary Access 3 each $283.47 $70.87
Insulation Removal 132 SF $166.32 $166.32
Kneewall Slope - 6" Fiberglass Batting 132 SF $281.16 $70.29
Access: Sheathing Access for Air Sealing Only 5 each $200.10 $0.00
Project Total $3,261.27
Weatherization incentive ($1,76879)
Air sealing incentive ($736.56)
Total Program Incentive -$2,505.35
Customer Total $755.92
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AccmArrr e= =ao=osn.: -Ire .nr- r. am ,.Pesos .r I'A.coxrznrvAwe-s 755.92
a ane.renvmva res• .,e. rr� e%wA as o.nwa.=armor. .00
200 &3_
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se /A a,�..,e o.e ev..�nv�,*�.•= s
555,92
Wbl 3/24/2018
n.pmr 0+'.a Iprma Isla,v >a;e
a naeemat—pr; iyem 3/24/2018
THIS AGREEMENT IS COMPOSED OF THIS PAGE ANGELIC REVERSE SIDE OFFERS'AGEAND SHALL RECONSIDERED THE ENTIRE AGREEMENT BY THE PARTIES INVOLVED. THIS
AGREEMENT IS BETW EEN AMERICAN INSTALLATIONS,LLC HEREINAFTER RUPEES D TO AS"COMPANY,AND THE CUSTOMERS)NAMED ON THE REVERSE SIDE,HEREINAFTER
REFERRED TOM"CLIENT",AND WILL BE SUBJECT TO ALL APPROPRIATE UWS, REGULATIONS AND ORDINANCES OF THE STATE OF MASSACHUSETTS OR CONNECTICUT
RESPECTIVELY,AS WELL MALL LOCAL JURISDICTIONS.
THE FOLLOWING TERMS AND CONDITIONS ALSO APPLY
1. THIS AGREEMENT IS SUBJECT TO THE APPROVAL OF A MANAGER OF THE C OMPPNV FOR THIS AGREEMENTTO BE EFFECTIVE UNDER ANY CONDITION.
2 SHOULD DEFAULT BE MADE IN THE PAYMENT OF THIS AGREEMENT,CHARGES SHALL BE ADDS D FROM THE DATE THEREOF AT A RATE OF ONE AND ONE-HALF(I ME)
PERCENT PER MONTE(]B%PER ANNUM)WITH A MINIMUM CHARGE OF i2 GO PER MONTH,ANO IF PLACED IN THE HANDS OF AN ATTORNEY OR COLLECTION AGENCY
FOR COLLECTION,ALL ATTORNEYSFEES,EXPENSES AND COSTS OF COLLO TION SHALL BE PAID BY THE CLIENT. IN ADDITION,CLIENT UNDERSTANDS THAT IN FAILING
TO PAY ACCORDING TO THE ABOVE TERMS,COMPANY MAY HAVE THE RIC HT TO A LEIN ON THE PROPERTY
3. THE COMPANY AGREES THAT WHEN DECAYS BECOME KNOWN TO THE CO MEAN C THE COMPANY WILL ADVISE THE CLIENT AS SOON AS REASONABLE.
4. COMPANY AGREES THAT,NOTWITHSTANDING ANY AGREEMENT FOR MA-ERIALS AND/OR LABOR BETWEEN COMPANY AND THIRD PARTY COMPANY IS RESPONSIBLE
TO CLIENT FOR COMPLETION OF ALL WORK DESCRIBED IN A TIMELY AND WORKMANLIKE MANNER.
5, ALL WARRANTIES FOR EQUIPMENT AND PRODUCTS SUPPLED BY THE COMPANY UNDER THIS AGREEMENT SHALL BE THOSE GIVEN BY THE MANUFACTUR ERS OF SUCH
EQUIPMENT PND PRODUCTS. UNDER SUCH MANUFACTURER'S WARRAN IR,TiE CLIENT MAYBE REQUIRED TO REGISTER OR MAIL INA WARRANTY CARD OR OTHER
EVIDENCE OF OWNERSHIP AND USE OF SUCH EQUIPMENT AND/OR PRODUCTS IIJ ORDER TO ACTIVATE SUCH WARRANTIES.
6. THE QUOTATION ON THE PAGE HEREOF DOES NOT INCLUDE EXPENSES OR CHARGES FOR BOND OR INSURANCE PREMIUMS ESCORTS BEYOND NORMAL INSURANCE
COVERAGE,ANY SUCH ADEMONAL EXPENSES,PREMIUMS OR COST SHALL BE ADDED TO THE TOTAL AGREEMENT AMOUNT.
2. THE COMPµyS LIABILRV FOR CIAIM5PP151N6 OUT OF THIS 4GREEMENI SHALL NOT EXCEED THE TOTAL AGREEMENT PRICE EXCEPT TO THE ECT ENT TNO5E 6 NXC{$
ARE PROVEN TO BE SOLEY DUE TO THE COMPANY'S NEGLIGENCE.
0. DURING THE DURATION OF THE WORK,THE CLIENTS HOMEOWNERS INSI IRANC E WILL BE RESPONSIBLE FOR ANY AND ALL DAMAGES AS LONG AS THE COMPANY HAS
TAKEN THE APPROPRIATE ACTION TO PROTECFAREAS OF WORK,
9. THE COMPANY IS NOT RESPONSIBLE FOR PREEXISTING DEFICIENCIES OR HOER000S MATERIALSTHAT MANIFEST THEMSELVES DURING THE CONSTRUCTION PROCESS.
EG WEED ROT,MOLD,ASBESTOS,NAIL FOPS,DUCTWORK AND CONNECT LONS,PLUMBING AND VENT PIPES,DECKING DEFLECTION,ETC.IFA PPE-EXISTING DEFICIENCY
OR HAZARDOUS MATERIAL IS ENCOUNTERED PRIOR TO OR DURING CONTRUCTION,AND COMPANY IS NOTIFIED IN WRITING,COMPANY WILL TRY TO ASSIST CLIENT
WITHIN HIS COMPANY'S MEANS AND CAPABILITIES TO CORRECT THE PF OBLEM(SI ON A TIM E AND MATERIAL BASIS, CLIENT AGREES THAT SUCH CONDITIONS ARE
UNAVOIDABLE BY TILE COMPANY AND SHALL NOT BE CONSIDERED A VIOLATION OF THE AGREEMENT AND THAT DUE TO THESE CONDITIONS THE DURATION OF THE
WORK AND SCHEDULED DATE OF COMPLETION MAY DIFFER FROM THAT i,GREE)UPON,IF APPLICABLE,UNDER THIS AGREEMENT.
10. THE COMPANY IS NOT RESPONSIBLE,AND THE CLIENT AGREES TO HOLD THE COMPANY HARMLESS,FOR ANY PROBLEMS AND/OR DAMAGES,INLCUDING BUT NOT
LIMITED TO MOLD GROWTH,ARISING FROM THE PERFORMANCE OF AIR SEAL114G WORK BY THE COMPANY AS A RESULT OF ANY KNOWN OR UNKNOWN MOISTURE
CONDITIONS.
11. THE COMPANY IS NOT RESPONSI BLE FOR,AND THE CLIENT AGREES TO I IOLD T HE COMPANY HARMLESS,FOR ANY PROBLEMS AND/OR DAMAGES RELATING TO ICE
DAMMING THAT MAY ARISE DURING AND/OR AFTER THE PERFORMANCE OF WORK BY THE COMPANY
12. REPLACEMENT OF DETERIORATED DECKING,FASCIA BOARDS,ROOF)ACTS,VENTILATORS,FLASHING,RAFTERS JOISTS,INSULATION OR OTHER MATERIALS ARE NOT
INCLUDED UNLESS OTHERWISE NOTED HEREIN.
13. THE COMPANY WILL NOT BE RESPONSIBLE FOR THE SCRATCHING OR DENTING OF INTERIOR WALLS AND CEWNG,FLOORS,TRIM,GUTTERS,DOWNSPOUTS,EXISTING
SIDING AND WINDOWS,0000.,OIL DROPLETS IN DRIVEWAYS,HAIRLINII FRACTURES IN CONCRETE OR BLACKTOP DRIVES AND WALKS,OR DAMAGE TO PLANTS OR
SHRUBBERY. IF EXCESSIVE DAMAGE 15 CAUSED BY COMPANY,COMPANY MILL REPAIR OR REPLACE DAMAGED AREA ONLY AT COMMENTS EXPENSE.
14, THE COMPANY UNDER PROVISIONS OF CHAPTER 142A OF THE GENERAL AWS 5 REQUIRED TO APPLY FOR AND OBTAIN ALL CONSTRUCTION RELATED PERMITS THE
COMPANY SHALL NOT BE DEEMED RESPONSIBLE FOR DECAYS IN THE WORK DESCRIBED IN THIS AGREEMENT CAUSED BY REGULATORY PERMIT GRANTING OR
INSPECTIONAL AGENCIES,AUTHORDIES,OR INDNIDUALS.
15. THIS AGREEMENT,INCLUDING THE PROVISIONS RELATING TO PRICE AND'AYMIiNT SCHEDULE,CANNOT BE C HANGED OR ALTERED EXCEPT BY A WRITTEN STATEMENT
SIGNED BY RUTH THE COMPANY AND THE CLIENT.
16. ANY REPRESENTATIONS,STATEMENTS,OR OTHER COMMUNICATION NO I WRITEN ON THIS AGREEMENT ARE AGREED TO BE IMMATERIAL AND NOT RELIED ON BY
EITHER PARTY,AND DO NOT SURVIVE THE EXECUTION OF THIS AGREEMEI IT
12. THIS AGREEMENT CANNOT BE CANCELLED WITHOUT THE MUTUAL WRITTEN CONSENT OF BOTH PARTIES EXCEPT AS OTHERWISE SET FORTH HEREIN.
18. THIS AGREEMENT,AND ANY WARRANTYCB PROVIDED HEREUNDER SHALL NOT RE ASSIGNED EXCEPT BY OR WITH THE WRITTEN PERMISSION OF THE COMPANY.
19 IF THE CLIENT FAILS EO PCRFORM ITS OBLIGATURS HEREUNDER OR TERMINATES THIS AGREEMENT WITHOUT THE f1i WRNTEN CONSENT OFTHE COMPANY,THE
CLIENT SHALL BE LIABLE FOR DAMAGES FOR THE GREATER OF THE COMPIMES ACTUAL DAMAGES OR 25%OF THE AGREEMENT FOR RESTOCKING FEE.
20. ANY CHANGES TO MATERIALS BY THE CLI ENT IRELAND,STYLE,COLOR,ETC)AFTER SAID MATERIAL HAS BEEN DELIVERED OR IS IN ROUTE TO THE CLIENT COULD RESULT
IN A 5%RE STOCKING FEE BASED ON THE COST OF SAID MATERIALS.
21. THIS AGREEMENT SHALL BE EFFECTIVE ONLY UPON ITS EXECUTION BY ALI PARTIES HERETO,PRIOR TO WHICH TIME IT SHALL BE DEEMED A PROPOSAL THE COMPANY
RESERVES THE RIGHT TO REVOKE THIS PROPOSAL SO DAYS FROM DATE IT IS EXECUTED BY THE COMPANY IF IT IS NOT EARLIER EXECUTED BY THE CLIENT AND THE
REQUIRED DOWN PAYMENT RECEIVED PRIOR TO THE EXPIRATION OF SL CH 50 DAV PERIOD;AFTER 90 DAYS,AND IN THE EVENT COMPANY DOES NOT REVOKE THE
PROPOSAL COMPANY RESERVES THE RIGHT TO REVISE ITS PRICE IN ACCORDANCE WITH ITS COSTS IN EFFECT AT SUCH TIME.
22. IF ANY PROVISION OF THIS AGREEMENT SHOULD BE HELD TO BE INVALID OR UHENFORO BLE,THE WIDELY AND ENFORCEBILITY OF THE REMAINING PROVISIONS OF
THIS AGREEMENT SHALL NOT BE AFFECTED THEREBY.
23. ARBDRATION'.IN THE EVENT TH E CLIENT AND COMPANY HAVE A DISPU HE REGARD NG ANY OF THE TERMS,CONDITIONS PROVISIONS,OR PERFORMANCE OF THIS
AGREEMENT,THE PARTIES AGREE TO PLACE THE MATTER INTO ARBITRATION BEFORE AN INDEPENDENT ARBITRATOR ASSIGNED BY THE AMERICAN ARBITRATION
ASSOCIATION TO RESOLVE THEIR DISPUTE.
24. ANY DISCOUNT,PROMOTION,REIMBURSEMENT,OR OTHER PROGRAM PLAT IS PART OF A STATE SPONSERED UTILITY PROGRAM RE.MASS SAVE')15 SUBJECT TO THE
AVAILABILITY OF QUALIFYING STATE SPONSORED PROGRAM AND WILL BE SUBJECT TO TERMINATION IF THE STATE SPONSERED UENTY PROGRAM 15 D15COUNTINUED.
FURTHERMORE,THE TERMS AND CONDITIONS OF STATE SPONSERED UTII TTY PROGRAMS MAY BE ALTERED OR UPDATED PERIODICALLY WITH OR WITIOUT NOTICE.
25. AMERICAN INSTALI£RS,WE IS NOT AN AGENT OF MY UTILITY COMPANY UP OTHER VENDOR WORKING BY,THROUGH,OR UNDER THE MASS SAW ENERGY
PRWRAM.
26, CLIENT IS REPSONSIBLE FOR THE PAYMENT OF ANY AND ALL FEDERAL,SUiR,OR LOCALTAXES TiATARE APPLICABLE TO THIS AGREEMENT.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
wi 600 Washington Street
Boston,MA 02111
wlvw.mu isgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Lettibly
Name tBasrcaxrargar,fanlvoromdio;daa}7: American Installations,LLC _
Address: 130 College Street,.Suite 100
City/Slate/Zip: South Hadley,MA 01075 phone i!: 413-552-0200
Are you an employer?Check the appropriate bus: 1'ype of project(required):
1.0 [am a emptoyer with 46__ <. El I am a general contractor and 1 6, Q New comornction
employees(full and/or pan-time)* havehired thesub-contractors 7 Remodeling
n, I am a sole proprietor or partner- listed on the attached sheetr
ship and have no employees rhes,,sub-contractors have 8. [-j Demolition
.
working for me in any wworkers'coraP insurance.
paciN. 9, Q Building addition
tNo workers comp, insurance 5. We area corporation and its 10.❑Electrical repairs or additions
required.) officers have exercised their
3.[] f am a homcownor doing all work right of exemption per MGI. 11.0 Plumbing reports or additions
myself [No workers'comp. n152,§1@),and we have no 12,� Ruofrepaira r,
insurance required.1 employees. (No workers' f3.�other Insulation
comp. insurance required.I
'�\sty pppliclnl rhar cMoks box nl mop elxo fol ono the seelian blow showing their wnrken'wmlrcnsalinn W)icy inlurmalion.
'iraa c mfs who submit that ofrMisil oidi wvs Ihey ah(tail at wc,k and Ihan hit awia,1--ea all moot wbma a iw -b4of o-l—u-1 suel,.
anvxmrs mar,hc i in,,box mon anecM1N an aJdirioml,,beer showing @e nam,al.thc-I vs a mnars and Poch wewkm,,, o.p,rah,mfonnlliiun.
t am un emplescramisproriaing warhers'cottpemadarr inrearemerfor my employees Below is thepolicy and%ob site
it fornmtiom
Insurance Company Name: Guard Insurance Companies
Policy#or S<If-Ins. Lic.#. AMWC_731485 -_.. .._--__ Expiration Date: 09/04/2018
Job Site Address:5—! 1�1cJ1h �4'\.'',` e �.,_Cinr/State/7,ip:_ 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 ofa
One up to li150U.00 aM/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violamr. Be advised trust a copy ofihis statement maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
Ido hereby terrify unr/er the puirp anf/d pena�hie_s.�ofprrjerry/hat rhe irtfarma/tan prnvlded nbove rs true and,,osteon.
Pbnnc k. 413-55.-0200 .�,...
Official ase only. Do not write in the area,to he completed by elry or town official.
City or Town:_ ._,- Permft/License# _
Isav3ng Authority(circle aney.
i.Board of Health 2. Building Department 3.Cityfl'oven Clerk 4. Electrical Inspector S. Plumbing Inspector
b.Other
contact Person: Phone#:
Cusnnonweakh of Massachusetts Construction Supervreor
Divisionof Professional Licensure Unrestricted-Buildings of any use group which contain
Board of Building Regulations and Standards less ted 35A S cubic fact(891 cubic rMers)of enclosed
Construction Supervisor space.
CS-106178 Espires:09/29/2019 -
WESLEY COUTURE
218 L.ATHROV$rREET "1)
s
SOUTH HAOLEY1A 01075 2'
Fahm W possess a current edition of Bre Massachusetts
Shte Building Code Is cause for revocation ofthh license.
For Information obmrt this Beans
Carrunissloner cal(617)727-3200 or vhB wwwmassgwidpl
n�flP ((�C�Jlt Jllfllltlr£'fYfffl f )-4C,CYJJff-C'f7
eA ' Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Type: LLC
AMERICAN INSTALLATIONS,LLC. Registration: 175982
130 COLLEGE STREET SUITE 100 E1�Iration: 08/28/2019
SOUTH HADLEY,MA 01075
Update A ldreas arta ratum card. Mark reason for change.
scA1 c 2,1M- iIi n Aden—es _0 f1cy.__1 L1 Emplaymenf 111Lost Card
Ounce or ecneumsr Attain E 9usinew ne,waeen
;r .L ..i+ HOME IMPROVEMENT CONTRACTOR Regbhatbn valid for individual use only
Y1 �... TYPE:LLC beforethe expiration dale 6 found returnto:
P Reolstralion Exoiralmn Office W Consumer Affairs and Business Regulation
175982 09/2612019 10 Park Rm-Suite 5170
AMERICAN INSTALLATIONS,LLC. Boston,MA 02116
WESLEY COUTU RE C...a_-
130COLLEGE STREET SUITE 100
valid without signature
SOUTH HADLEY.MA 01075 Undersecretary 1110"
A� CERTIFICATE OF LIABILITY INSURANCE 8/14/2017
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(les)must he endorsed. If SUBROGATION IS WAIVED,Subject to
the terms and conditions of the Policy,certain policies may require an endorsement. A statement on this certl8cate does not confer rights to the
certificate holder in lieu of such endomement(s).
PRODUCERTLinda Powars,
AS ME
Webber, b Grinnell PHONE (413)586-0111 1SAX Ru:ulBlseR-Sam
8 North Ring Street .GORE apowersgwebberandgrinnell.com
INSURE s AFFORDING LOVEfGGE NAW.
Northampton NA 01060 INSURERAEm to ra Mutual Casualt
INSURED INSURERBECrkshlre BatherNa BDARD InB. Co.
Amerioan Installations, LLC INSURPRC:
At"; Wes 6 Susanne Couture INSURER D:
130 College Street, Suite 100 INSURER E:
South Radley HA 01075 1 INSURER F:
COVERAGES CERTIFICATE NUMBER34aster Earp 9-2018 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.
My
INSR
LIR TYPE OFINSANCE A POICT HUMBER MOLCEFFML
DWT$
COMMERCML GENEML UARIIRT
EACX OCCURRENCE E 1,000,000
A A CIAIMSJngGE ❑OCCUR pREMI E$ EED
a NT rtm $ 500,000
80353521] 9/4/2017 9/4/2018 MEDEXP(Anyone Porsm) Is 10,000
PERSONAL a ADV INJURY $ 11000,000
GEN L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE E 2,000,000
R POLICY[:]PHE ❑ LOC PRODUCT$-COMPIOPAGG S 2,000,000
OTHER $
AUTOMOBILE LABILITY a adore LE LIMIT L 11000,000
A ANY AUTO BODILY INJURY Por pmsonl Is
A-11AUTOS*ED X 'UTODULED 5L353521] 9/4/201] 9/A/2018 WOI LY INIURVIPoractiEelU $
A TREOAUTOS A NONDNNEDpROPERTYGAMAGE S
AUTOS jPeramear,
PIP-Baas S 8,000
A VMGnEL1A lIgB OCCUR EACH OCCURRENCE S 1 000,000
A EXCESS WB CIAIM$A1ADEAGGREGATE L 1 000,000
DED XRETENTIONS 10 000 SJ3535217 9/4/201] 9/4/2018 s
WORRERSCOMPENSEDON PER OUT
AND EMPLOYERS UABn1TY YIN r STATUTE ER
NY YNCERIETONPARTNER,E%ECUTIVE EL FAULT ACCIDENT E 500,000
OFFICEIGMEMOES 8 M-Iin NO E%LWDUe ❑ NIA yppC6099ll 9/4/2017 9/4/2018
T G—ce uMer E L.DISEASE-EA EMPLOYE E 500,000
DE$CRIPUONOFOPERATIONSEeIm E.L DISEASE-POLICY LIMIT S 500,000
A Commercial Property 5A3535217 9/4/2017 9/4/2018 dancers$1 XO
DESCRIPTOR OF OPERATIONS I LOCATIONS I VEHICLES (ACORD IN,Amele lRemaMsSCRyule,maybe IYacM16p Nmom space Is required)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
EV1denCe OP Insurance THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHOMZED REPRESENTATIVE
Kevin Joyce/LMP
C 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
INS025 uInA H,