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42-147 (6) 907 WESTHAMPTON RD BP-2018-1063 GIS#: COMMONWEALTH OF MASSACHUSETTS Map Block:42 - 147 CITY OF NORTHAMPTON Lot-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: INSULATION BUILDING PERMIT Permit# BP-2018-1063 Project JS-2018-001919 Est.Cost: $3900.00 Fee: $65.00 PERMISSIONIS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: AMERICAN INSTALLATIONS LLC 106178 Lot Size(sp. ft.): 30012.84 Owner: WOODLAND ANDREW S&TERI A Zoning, Applicant: AMERICAN INSTALLATIONS LLC AT: 907 WESTHAMPTON RD Applicant Address: Phone: Insurance: 130 COLLEGE ST (413) 552-0200 Liability SOUTH HADLEYMA01075 ISSUED ON:4/18/20180.00:00 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: 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 Sienature: FeeType: Date Paid: Amount: Building 4/18/20180:00:00 $65.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner _ s _'jtI_I Deparbrem use only City of Northampton Stabs of Permit AN 17 Building Department Curb CutlOnvewayPemst 212 Main Street SewerlSepbcAvailabllityr Room 100 water1w.UAv il.1,. ty.. pEp[nF 9Ui.f M1Y3 L'- FCnGNS vom,+nuarorv,ww a+^sa Northampton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 Fax 413-587-1272 P1oVSRe Plans elt.uspedfy APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DpWEWNG SECTION 1 -SITE INFORMATION 1.1 Properly Address: This section to be completed byoffice 907 Westhampton Road Northampton MA 01062 Map 4,:A Lot_—.Z,,fq Unit Zone Overlay District EM St District CS District SECTION 2-PROPERTY 0WNERSHINAUTHORIZED AGENT 21 Owner of Record: Andrew Woodland 907 Westhampton Road Northampton MA 01062 Name(Print) Correa ma" a Adlress: (413) 563-4016 .See attached Telephone SignaWm 22 Authorized Agent American Installations 130 College St., Ste 100 South Hadley,MA 01075 Name(Print) Current Maatg Addrea c American Installations 413-552-0200 Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Esgmated Cost(Dollars)to be Official Use Only Comm] by rmfiapplicant 1. Building 3,900.00 (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) S.Fire Protection 6. Total=(1 +2+3+4+5) 3,900.00 Check Number This Section For Official Use Only Building Pemtit Number Data Issued: Signa W-z4Zza BuQdtgIssionedmspecbrof Swungs Date Section 4. ZONING AB Information Must Be Comptetel.PermR Can Be Denied ma[b Due To Incomplete Inforn Existing Proposed Required by Zoning nis caluom b be Mel in by Bugding Depmrmeot Lot Size �� C Frontage Setbacks Frost Side L:= R:= L:� Rear J r— Building Height �d O Bldg.Square Footage �—' O % t� Op-Space Footage % gmmm minusbNgat»ved volume&lumrim) L A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DONT KNOW Q YES O IF YES,date fssued:l I IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW O YES O IF YES: enter Book i Page and/or Document#I I I 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 C) NO O IF YES,describe size,type and location: D. Are there any proposed changes to or additiors of signs intended for the property? YES O NO O IF YES,describe size,type and location: E. Will the mnstrudbn activity disturb(clea ing,,grading,excavation,orliling)over t acre or Is K part of a mmman pian that will disturb overt acre? YES O NC O IF YES,then a Northampton Storm Water Management PermKfrom the DPW is required. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicablel New House ❑ Addition ❑ Replacement Wintlows ANeration(s) Roofing or Doors EJ Accessory Bldg. ❑ Demolition ❑ New Signs (p] Decks IO SldinglO] Otherlit Brief Description of Proposed Work: Attic and basement insulation and air sealing throughout Alienation of erlsting bedroom_Yes_No Adding newbedroom_Yea No Attached Nartarwe Renuvabng unfinished basement _Yes No Plans Attached Roll -Sheet 6a.If New house and or addition to existing housinc.cotnolote the foliowitim a. Use of building:One Family. Two Family Other b. Number of rooms in each family unit Number of Bathrooms Q Is there a garage attached? d. Proposed Square footage of new construction. Dimensions e. Number of stories? I. Method of healing? Fireplaces or Wondsloms Number of each_ g. Energy Conservation Compgance. Masscheck Energy Compliance form attached? h. Type of construction I. Is construction mlhin 100 ft of wegands?_Yes —No. Is construction withia 100 yr. floodplain Yes_No J. Depth of basement or wilarfloorbelowfinished grade k. Will building conform to the Building and Zoning regulations? Yes_No. I. Septic Tank_ Clty Sewer_ Pdvatewell_ CQywater Supply_ SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, Andrew Woodland as Ovmer of the subject Property herebyauthorae AmericanInstallations to act on my behalf,In at matters reladve to work authorized by this building permit application. See attached 4/11/2018 SlgrmWreofowner Data I, AericInstallations .as Ovmar/Augrwired !gemnt herebyan declare Nat the statements and information on the foregoing appfiration aro We and accurate,to the beat of my knowledge and belief. Signed under the pains and penalties of perjury. American Installations Prim Name American Installations 4/11/2018 Signalise of Omer/Agent Data SECTION 8-CONSTRUCTION SERVICES 8.1 licensed Construcilon Supervisor: Not Applicable ❑ Namaof Umrccltetder Wesley K. Couture _ 106178 IJ..Number 130 College St, Ste 100 South Hadley, MA 01075 _ 9129119 Address ExpireBm Date CRSS 413-552-0200 _ SlpnaMe Telephone 9.RedisteredHome Improvement Contractors Nol Applicable ❑ Wesley Couture 175952 Company Nam. Registration Number American Installations _ 626119 Address Expiration Date 130 College St., Ste 100 South Hadley, MA 01075 Talepnone 413-552-0200 SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c.152,§25C(6)) Workers Compensation Insurance affidavit must be completed and submi0ad with this application.Failum to provide Mh affidavit will result in the denial of the Issuance of the budding permit _ Signed Affidavit Attached Yes....... IN No...._ ❑ 11. -Home Owner Exemution Theomentexemptionfm'homgowns^wasextendedOmclude Owner-oecuoied DweMneaofone(1) or two(2)1hrie ies VA wallow snob homeowner to engage an individual for hire who does not possess a license,provided tlmtthe owner mets as ervisor CMR 780 Sixth Edition Seeti108.35.1 Definition of Homeowner:Person(s)who own a parcel ofland on which he/she resides or intends to reside,on which awe is,or is intended to be,a one or two family dwelling attached or detached shuctmes accessory to such me and/or farm sunniness.A person who constructs mom than one home in a two-year Period shall not be sidered a homeowner- Such "homeowner"shall submit to the Building Official.an a form acceptable to the Building OfllchiL that he/she 0211 be responsible for all such work perfumed under the baildhM nermll. As acting Construction Supervisor yumpresence on the job site will be required fiumtime to time,during and upon completion ofthe work for which this permit is issued Also be advised that with reference to Chapter 152(Wedups'Compemation) and Chapter153(LiabitityofHmplayerste Employees for injuries rat resulting in Death)ofthe Massachusetts General Laws Annotated,you may be Noble forperson(s) you hire to pedormwork for you undo this permit The undersigned'homemenes'certifies and assumes responsibility for compliance with the State Building Code,City of Northampton Ordinances,State and Local Zoning laws and State ofMassacbusem General Laws Annotated. Homeowner Signature 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: 907 Westhampton Road Northampton MA 01062 The debris will be transported by: American Installations The debris will be received by: Waste Management of NE - Chicopee Landfill Building permit number: Name of Permit Applicant American Installations 4/11/2018 \,J) Date Signature of Permit Applicant AIM Yaa "�� • mass save PARTNER American Installations zn rowteshen sr.zm,san rxa.y,.0 elms.oma:x131 ssz-omo ra.:luy sszamz.Rost sypoapanvYanmmwCwu[w Customer Name:Andrew Woodland Email:Not provided Phone:413-563-4016 Premise Address:907 Westhampton Rd,Northampton.MA 01062 Project to:3394287 Date:April 3,2018 Job Description Measure Description Cit+andb Writ Towow Cuakum Cost.. Air Sealing at Estimated 62.5 CFM50 Per Hour 12 hr $1,1 mm $0.00 Exterior Door Weather Stripping (with AS hrs) 3 each $90.21 $0.00 Door Sweep(with AS bra) 3 each $75.93 $0.00 Insulation Removal 120 SF $151.20 $151.20 Rim Joist- 6" Fiberglass Batting 120 SF $324.00 $81.00 Door- 2"Thermal Barrier Polyiso 1 each $90.44 $22.61 Attic Floor - S'Open Blow Cellulose 1164 SF $1,792.56 $448.15 Bath Fan - Vent to Rood 1 each $141.30 $35.32 Damming 26 each $62.14 $15.53 Project Total $3,838.74 Weatherization incentive ($1,807.83) Air sealing incentive ($1,277.10) Total Program Incentive -$3,084.93 Customer Total $753.81 .1., .,n.�.saaa,.. �zaa r.,uc he.ewam�•m n.,.mai�..z.:a a,eraeo.a.omdnerk,m.<...a o<.o..a.:.aaa,.ewr:ne,eo..w..ir�.aoo:Na.r n.a re:e: �CrI mo=an.- h- -k 5r m. .,e .a�m.w a,e ro-n.coarw�c vuus- s 753.81 yn:.si�.way:M.m....n.a-o„aaaroaaa:om,.on a:wtt�+m. ..,a..: .al�e zn m... ar„ „ssa.,�•.<n.:.eea,,.eaewm�vP.ra,. :�-.vrr�,.r-s 50.00 � 4/3 /18 v.o 103.81 4/3/18 xertim.= (I., Iim Piermanon rscol Jim Piermarint o.a 4/3/18 THIS AGREEMENT IS COMPOSED OF THIS PAGE AND THE REVERSE SIDE OF THIS PAGE PND SHAU BE CONSIDERED THE ENTIRE AGREEMENT BY THE PARTIES INVOLVED. THIS AGREEMENT 15 BETWEEN AMERICAN INSTALLATIONS,LLC HEREINAFTER REFERRED T I AS"COMPANY',AND THE CUSTOMERS)NAMED ON THE REVERSE SIDE,HEREINAFTER REFERRED TO AS"CLIENT",AND WILL BE SUBJECT TO ALL APPROPRIATE LAMS, RE 3ULFT1ON5 AND ORDINANCES OF THE STATE OF MASSACHUSETTS OR CONNECTICUT RESPECTIVELY,AS WELL AS ALL LOCAL JURISDICTIONS. THE FOLLOWING TEEMS AND CONDITIONS ALSO APPLY 1. THIS AGREEMENT IS SUBJECT TO THE APPROVAL OF A MANAGER OF THE:OMF MY MR THIS AGREEMENT TO BE EFFECTIVE UNDER ANY CONDITION. 2. SHOULD DEFAULT BE MADE IN THE PAYMENT OF THIS AGREEMENT,CHI RGES SHALL BE ADDED FROM THE DATE THEREOF AT A RATE OF ONE AND ONE-HALF IT 1/2) PERCENT PER MONTH,ry8%PER ANNUM)WITH A MINIMUM CHARGE OF S3 CK PER MONTH,AND IF PLACED IN THE HANDS OF AN AIIORNEY OR COLLECTION AGENCY FOR COLLECTION,ALL ATTORNEYS'FEES,IXPENSES AND COSTS OF COLLI ICTIO'4 SHALL BE PAID BY THE CLIENT. IN ADDITION,CUENT UNDERSTANDS THAT IN FAILING TO PAY ACCORDING TO THE ABOVE TERMS,COMPANY MAY HAVE THE RI3HTI)A LEIN ON THE PROPERTY. 3. THE COMPANY AGREES THAT WHEN DELAYS BECOME KNOWN TO THE CC METALS,THE COMPANY WI LL ADVISE THE CLIENT AS SOON AS REASONABLE. 4. COMPANY AGREES THAT,NOTWITHSTANDING ANY AGREEMENT FOR MLTERIE,6 AND/OR LABOR BETWEEN COMPANY AND THIRD PARTY,COMPANY IS RESPONSIBLE TO CLIENT FOR COMPLETION OF ALL WORK DESCRIBED IN A TIMELY AND PORI MANLIKE MANNER. 5. ALL WARRANTIES FOR EQUIPMENT AND PRODUCTS SUPPLIED BY THE COMPAK Y UNDER THIS AGREEMENT SHALL BE THOSE GIVEN BY THE MANUFACTURERS OF SUCH EQUIPMENT AND PRODUCTS UNDER SUCH MANUFACTURER'S WARRANTIES, HE CLIENT MAYBE REQUIRED TO REGISTER OR MAIL INA WARRANTY CARD OR OTHER EVIDENCE OF OWNERSHIP AND USE OF SUCH EQUIPMENT AND/OR PROCUCTS N ORDER TO ACTIVATE SUCH WARRANTIES. 6. THE QUOTATION ON THE PAGE HEREOF DOES NOT INCLUDE EXPENSES OR CHARGES FOR BOND OR INSURANCE PREMIUMS OR COSTS BEYOND NORMAL INSURANCE COVERAGE,ANY SUCH ADDITIONAL EXPENSES,PREMIUMS OR COSI"SHALL BE ADDED TO THE TOTAL AGREEMENT AMOUNT. ]. THE COMPARYS LIABILITY FOR CLAIMS ARISING OUT OF THIS AGREEMEN T SHA LNOT EXCEED THE TOTAL AGREEMENT PRICE EXCEPT TO THE EXTENT TH05E DAMAGES ARE PROVEN TO BE SOLEY DUE TO THE COMPANY'S NEGLIGENCE. 8. DURING THE DURATION OF WE WORK,THE CLIENT'S HOMEOWNERS INSURANCE WILL BE RESPONSIBLE FOR ANY AND ALL DAMAGES AS LONG AS WE COMPANY HAS TAKEN WE APPROPRIATE ACTION TO PROTECT AREAS OF WORK, 9. THE COMPANY IS NOT RESPONSIBLE FOR PREEXISTING DEFICIENCIES OR FAZAR)OUS MATERIALS THAT MANIFEST THEMSELVES DURING THE CONSTRUCTION PROCESS. EG,WOOD ROT,MOLD,ASBESTOS,NAIL POPS,DUCNJORK AND CONNEC TIONS PLUMBING AND VENT PIPES,DECKING DEFLECTION,ETC.IF A PRE-EXISTING DEFICIENCY OR HAZARDOUS MATERIAL IS ENCOUNTERED PRIOR TO OR DURING CONSTRW TON,AND COMPANY IS NOTIFIED IN WRITING,COMPANY WILL TRY TO ASSIST CLIENT WITHIN THE COMPANY'S MEANS AND CAPABILITIES TO CORRECT THE PROW YES)ON A TIME AND MATERIAL BASIS. CLIENT AGREES THAT SUCH CONDITIONS ARE UNAVOIDABLE BY WE COMPANY AND SHALL NOT BE CONSIDERED A VIIRATI N OF THE AGREEMENT AND THAT DUE TO THESE CONDITIONS THE DURATION OF THE WORK AND SCHEDULED DATE OF COMPLETION MAY DIFFER FROM THAT AGRE D UPON,IF APPLICABLE,UNDER THIS AGREEMENT, 30. THE COMPANY 15 NOT RESPONSIBLE,AND THE CLIENT AGREESTO HOLD ME COMPANY HARMLESS,FOR PITY PROBLEMS AND/OR DAMAGES,INLCUDING BUT NOT LIMITED TO MOLD GROWTH,ARISING FROM THE PERFORMANCE OF AIN SERI NO WORK BY THE COMPANY AS A RESULT OF ANY KNOWN OR UNKNOWN MOISTURE CONDITIONS. 11. THE COMPANY IS NOT RESPONSIBLE WR AND THE CLIENT AGREES TO HOLE THE COMPANY HARMLESS,FOR ANY PROBLEMS AND/OR DAMAGES RELATING TO ICE DAMMING THAT MAY ARISE DURING AND/OR AFTER THE PERFORMANCE OF W ORK BY THE COMPANY. 12. REPLACEMENT OF DETERIORATED DECKING,FASCIA BOARDS,ROOF JACKS,VI NTILATORS,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 DEVTINC OF INTERIOR WAIFS AND CEILINGS,FLOORS,TRIM,GUTTERS,DOWNSPOUTS,EXISTING SIDING AND WINDOWS,DOOM,OIL DROPLETS IN DRIVEWAYS,HAIRUNE FRATURES IN CONCRETE OR BLACKTOP DRIVES AND WALKS,OR DAMAGE TO PLANTS OR SHRUBBERY, IF EXCESSIVE DAMAGE IS CAUSED BY COMPANY,COMPANY WILL REPAIR OR REPLACE DAMAGED AREA ONLY AT COMPANYS EXPENSE. 10. THE COMPANY UNDER PROVISIONS OF CHAPTER 102A OF THE GENERAL LAW`IS REQUIRED TO APPLY FOR AND OBTAIN ALL CONSTRUCTION RELATED PERMITS THE COMPANY SHALL NOT BE DEEMED RESPONSIBLE FOR DELAYS IN THE WOK DESCRIBED IN THIS AGREEMENT CAUSED BY REGULATORY PERMIT GRANTING OR INSPECTIONAL AGENCIES,AUTHORITIES OR INDIVIDUALS. 15. THISAGREEMENT,INCWDINGTHE PROVISIONS RflATINGTO PRICEAND PARK ENTSCHEDUIE,CANNOTBE CHANGEDOR ALTERED EXCEPT BYAWRITTEN STATEMENT SIGNED BY PATH THE COMPANY AND THE CLIENT. 16. ANY REPRESENTATIONS.STATEMENTS,OR OTHER COMMUNICATION NOT AT TTEN ON THIS AGREEMENT ARE AGREED TO BE IMMATERIAL AND NOT RELIED ON BY EITHER PARTY,AND DO NOT SURVIVE THE EXECUTION OF THIS AGI BIT. 17, THIS AGREEMENT CANNOT BE CANCELLED WITHOUT WE MUTUAL WRITTEN C)NSENT OF BOTH PARTIES EXCEPT AS OTHERWISE SET FORTH HEREIN. 18, THIS AGREEMENT,AND ANY WARNERMHOS)PROVIDED HEREUNDER SHAT NOT BE ASSIGNED EXCEPT BY OR WITH THE WR17EN PERMISSION OF THE COMPANY. 19. IF THE CLIENT FAILS TO PERFORM ITS OBLIGATIONS HEREUNDER OR TERMINA E5 THIS AGREEMENT WITHOUT THE PRIOR WRITTEN CONSENT OF WE COMPANY,THE CLIENT SHALL BE LIABLE FOR DAMAGES FOR THE GREATER OF THE COMPANY`ACTUAL DAMAGES OR 25%OF THE AGREEMENT FOR RESTOCKING FEE. 20. ANY CHANGES TO MATERIALS BY THE CUENT(BRAND,SHIFT,COLOR,ED.)AF ER SAID MATERIAL HAS BEEN DELIVERED OR IS IN ROUTE TO THE CUEM COULD RESULT INA SAA RE-STOCKING FEE BASED ON THE COST OF SAID MATERIALS. 21. THIS AGREEMENT SHALL BE EFFECTIVE ONLY UPON ITS EXECUTION BY Al L PRE TIES HERETO,PRIOR TO WHICH TIME IT SHALL BE DEEMED A PROPOSAL THECOMPANY RESERVES THE RIGHT TO REVOKE THIS PROPOSAL 90 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 SLCH V DAV PERIOD,AFTER 90 DAYS,AND IN THE EVENT COMPANY DOES NOT REVOKE THE PROPOSAL,COMPANY RESERVES THE RIGHT TO REVISE ITS PRICE IN ACC(RDAPCE WITH ITS COSTS IN EFFECT AT SUCH TIME. 22. IF ANY PROVISION OF THIS AGREEMENT SHOULD BE HELD TO BE INVALID OR I NENFORCABLE,WE VILELY AND ENFORCEBILILY OF THE REMAINING PROVISIONS OF THIS AGREEMENT SHALL NOT BE AFFECTED THEREBY, 23. ARBITRATION.IN THE EVENT THE CLIENT AND COMPANY HAVE A DISPI NE R.CARDING ANY OF THE TERMS,CONDITIONS,PROVISIONS,OR PERFORMANCE OF THIS AGREEMENT,THE PARTIES AGREE TO PLACE THE MATTER INTO ARBITRATIO4 BEFORE AN INDEPENDENT ARBITRATOR ASSIGNED BY THE AMERICAN ARBITRATION ASSOCIATION TO RESOLVE THEIR DISPUTE. 24. ANY DISCOUNT,PROMOTION,REIMBURSEMENT,OR OTHER PROGRAM I HATH PART OF A STATE SPONSORED UTILITY PROGRAM L.E.MASSMVE°)ISSUBJECTTOTHE AVAILABILITY OF QUALIFYING STATE SPONSORED PROGRAM AND WILL BE SUB ERTO TERMINATION IF THE STATE SPONSERED UTILITY PROGRAM 15 DISCOUNTINUED, FURTHERMORE,THE TERMS AND CONDITIONS OF STATE SPONSERED UT CITY PROGRAMS MAY BE ALTERED OR UPDATED PERIODICALLY WITH OR WITHOUT NOTICE. 2S. AMERICAN INSTALLERS,DEC IS NOT AN AGENT OF ANY UTILITY COMOANY OF OTHER VENDOR WORKING BY,THROUGH,OR UNDER THE MABS SAVE'ENERGY PROGRAM. 26. CLIENT 15 REMONSIBLE FOR THE PAYMENT OF ANVAND ALL FEDERAL,STATE,i IR LOCALTAXES THATARE APPLICABLE TO THIS AGREEMENT The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 91 600 Washington Sheet Boston,MA 01111 www.mass.gor/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lcabiv Name (Business/Organii tionlindividual): American Installations,LLC Address: 130 College Street,Suite 100 City/State/"Lip: South Hadley,MA 01075 Phone d: 413-552-0200 Are you an employer?Check the appropriate box: Tyl pe,lir project(required). I.fJ 1 am a employer with 46 _ 4. ❑ 1 am a general contractor and I - b. ❑ New construction employees(full and/or para-ho.e).' have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.1 7. ❑Remodeling ship and have no employees These subcontractors have 8. ❑ Demolition working for me in anv capacity. workers'comp. insurance. 9. ❑ Building addition (No workers'comp. insurance 5. ❑ We are a corporation andits required) officers have exercised their I 10.❑ Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself. (No workers'comp. c. 152,§1(4),and we have no 12.0 Roof repairs insurance required. employees. (No workers' comp,insurance required.) 13.❑Other InSUlatlon —JI 'flue aaalicam mai checks this aI muse also fin on,me arehvn 4rw snowing theywohec mmprns stax inulol'oar rnrnihn. :Any nwhook his orisv usitti,htsd noamernae snout allwoo nM mm nimomsior-euoyours arami submithmwrry, .sh k:untraclors mai check his toe marl gltaeM1ed an additional sM1mi showing iM1c name of sed'wb<onvucmn and Inch workcis'emmp.twliry inromwiiun. I am an employer that is providing workers'compensation insurance for my employee& Below is the policy and job site informmiot,_ Insurance Company Name: Guard Insurance Companies Polic q or Self-ins.Lic g: AMWC731485 Y ___ __ . Expiration Date. 09/0pp4/2018 _ Job Site Address: un O (AM &WA _ Ciry/State/Zip:_�Q�p-t a.Wt� b�0(o� 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 25 of MGL c. 152 can lead to the imposition of criminal penalties of 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 hereb),,ecrely,under the Palms a/n/fid prnullies of perjury that the information provided above is true and correct. Shu �cW."'�a+a/h�Jle 4 l .fNI�A.- Dix; 1 .... PI�Z 413-55 -0200 Official use only. Do not write in this area,to be completed by city or town official. City or Town: PermitlLicense is Issuing Authority(circle one): I. or of Health 2. Building Department 3.Cityrrown Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone# C,arvnonweaah of Massachusetts Construction Supervisor Division of Professional Lcensure Unrestricted-Buildings of any use group eition contain Board of Building Regulations and Standards less than 30.000 obis lest P91 cubic material of enclosed Construction Supervisor fie' CS-106178 E3pires:09/29/2019 WESLEY COUTURE 21SLATRROVATREEr SOUTH SOIRN NADLBY01A 01076 Feature to Poaese a cuerent edgou of the Masnrdrusetis Ends BOOM Code ismark for revocation of this license. For bill Ion al eul thb license Cminissioner Call(617)7274208 or visit wwvitr asegov/diol fes , �'�i(� ((nl�7ljtn�ttt��rrl�ft- n�JC�/G(TrJlrrtsrttJ� 4 , V 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 Elgkratlon: OB/2W2019 SOUTH HADLEY,MA 01075 Update Address and Mum card. Mark reason for change. SCA, 6 =kn 111 n Addr.^ n oy.._.._i 0 Employment CCI Lost Card y -"� OalHOME IM AReiraa CONTRACTOR Repulaaon NOMEIM PROTYPENT LLC before theeapirklar foes. If o nd only TYPE:LLC beforetheontainer date. If found nNm e t Re1759 bn Booke062BIaen Office of Container Affairs and Business Regulation 1]5982 08/20/2019 10 Perk Fara-Boas 51]0 AMERICAN INSTALLATIONS,LLC. Boston,MA 02116WESLEY COUTURE //^ 13p COLLEGE STREET SUITE 100 Cb LLL--���L171 SOUTH HADLEY MA 81075 Undersecretary ,W valid without signature ACC)Ro® 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 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 endomement(s). PRODUCER CONTACT Li.DUEL P..O I. NAME: Webber s Grinnell PHONE (413)586-0111 F 'Y Ii1315R6-6<Sl No: 8 North Ring Street pO�IESglpowers@webberandgrinnell.com INSURE 5 AFFORDINGCOVERAGE NAIGN Northampton HA 01060 INSURENABe to rs MutualCasualt INSURED INSURERS Berkshire Bathawa GDAND Ins. Co. AmellCan Inatallatlons, LLC IHSVRERC: Attn: Wes 6 Su ranne Couture INSURER.: 130 College Street, Suite 100 INSURER E: South Hadley HA 0107$ 1 INSURER F: COVERAGES CERTIFICATE NUMBERTIaster Exp 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. NOTWTHSTANDING 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. IL R TYPsoF PsuNANER o0L POLICY XVMRER MPOUCYEFF oroYYYn MILKY E.WDUTYYYYT LIMITS ?COMMERCML GENERAL LIABILITYEACHOCCVRRENCE E 1,000,000 ACWM511ppE �OCLUR A RE E 5001000 PREMISE$ Ea a-ame Sn3535217 9/./2017 9/4/2018 MEDA%P(Anycreprson) S 10,000 PERSONAL a ADV INJURY $ 1,000,000 GENL AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE E 2,000,000 X Re" YEl JFOOT FLOG PRODUCTS-COMP/OPAGG s 2,000,000 OTHER AUTOMOBILE LIABILITY aBINEaDI LE LIMIT S 1,000,000 A ANY AUTO BODILY INJURY per pe000 S ALLO—ED R SCHEDULED 523535217 9/4/2017 9/4/2019 BODILY INJURY 1—NaEm1 E AUTOS ANT. ( I R NON-0VVNED PROPERTY DAMAGE HIRED AUTOS R AUTOS px a,ti4ml $ pIPBasic s 8,000 R UXBRELUP LIAa OCCUR EACH OCCURRENCE S 1,000,000 A EACESS LIAR CLAIMSNAOE AGGREGATE 8 1 000,000 DEO R RETENTIONS 10,000 573535217 9/4/2017 9/4/2018 g WORKERS COMPENSATIONNUPER TH- AND EMPLOYERS' BILITY STATUTE R ANY F ROPNETORNARTNEWERECUTIVE EL.EACH ACOIDEM E B OFFICERMEMBER EKLLUOEOi ❑N/A 500,000 (MaMalory In NH) VRWCfi09910 9/4/2017 9/4/2018 EL DISEASE-EA EMPLOYE 8 50D,000 myee eesenhe Nmer DESCRIPTIONOF OPERATG)N5°elw, E L DISEASE.POLICY LIMIT g s00 000 A commercial Property SA3535217 9/4/2017 9/o/2OOI eMumele$1 Mer DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD toy A4Emonal Penance Schedule,may be AaeLM if more apace Is mqulrtE) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Evidence of Insurance THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORRED REPRESENTATIVE Kevin SOyce/LMP -- ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025um.ml