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18C-177 (2)
693 BRIDGE RD BP-2018-1346 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 18C- 177 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Cawgory INSULATION BUILDING PERMIT Permit BP-2018-1346 Proiect# JS-2018-002390 Est.Cost:$3100.00 Fee:$65.00 PERMISSION IS HEREBY GRANTED TO: const Class: Contractor: License: Use Group- AMERICAN INSTALLATIONS LLC 106178 Lot Size(sg ft.): 15812.28 Owner: COUCH KATHY C&CANDICE SALYERS Zoning:URB(100)/ Applicant AMERICAN INSTALLATIONS LLC AT.- 693 BRIDGE RD Applicant Address: Phone: Insurance: 130 COLLEGE ST (413) 552-0200 WC SOUTH HADLEYMA01075 ISSUED ON:6/18/20180:00:00 TO PERFORM THE FOLLOWING WORIL•ATIIC & BASEMENT INSUALTION 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 Shmature: FeeType: Date Paid: Amount: Building 6/18/20180:00:00 $65.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck-Building Commissioner J Shy-�a�m. Department use only h Northampton slaws ofPer mib ding Department Curb CuVI)n way Parrott 212 Main Street Se @b 212 aS� Room 100 Watw WeIrAvallabWty: cYe P orthampton, MA 01060 Two Sets of Structural:plans 413587-1240 Fax 413587-1272 Ptonk;"9 Plans Other Spedfy APPLICATI TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING RMATION SECTION 1 -SITE INFO /3?I t a /J 9(/ 1.1 ProDerNAddrass: This section to tie completed byeffitx /ya 693 Bridge Road Northampton MA 01060 Map I `I( , Lot 1I / U-it Zona Owrlay District /T� Elm SL District CS District - SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Kathy Couch& loanna Kent-Katz 693 Bridge Road Northampton MA 01060 Name(Print) Curers Mating Address: 12061226-1866 See attached Taaphone Signature 7-2 Authorized Aasm: American Installations 130 College St., Ste 100 South Hadley, MA 01075 Name tPMq - Current WIN Address: -Aly(.tM \(- • C,6 413-552-0200 Signature I TBNphons SECTION 3-ESTIMATED CONSTRUCTION COSTS item Estimated Cost(Dollars)to be Official Use Only oornpleted by perinkapplicant 1. Building 3,100.00 (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from 6 3. Plumbing Bugding Pernik Fee 4. Mechanical(HVAC) L7 5.Fire Protection 6. Total=it+2+3+4+5) 3,100.00 Check Number This Section For Official Use Only Building Permit Number Date Issued: Signaw 911MYrg Co brmmnspector of SuiHsgs Dais Section 4. ZONING All InfomWtion Must Be Completed.Permit Can Be Denied Doe To Incumpb)te Infarmaton Existing Proposed Required by Zoning Tbis column to be filled in by a.W4 Dcpeuaept Lot Size Frontage Setbacks Front Side L:= R;= LR. J Rear r— Building Height I_ Bldg.Square Footage % — O Open eree mim Space Footage J % trot me bdg k pevcd J #of Par ' S aces Fill: volmaekfamdm) 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:Ill IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW O YES O IF YES: enter Book� PageCI and/or Document#r 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: E. WBI the constructon ac"I disturb(dearklg,grading,excavation,or#IBng)over t acre or is It part of a common plan that wi8 daturb over 1 acre? YES O NO O IF YES,then a Northampton Storm Water Management Permllfrom the DPW is required. SECTION 5-DESCRIPTION OF PROPOSED WORK! heck all applicable1 New House Addition ❑ Replacemeo ffndows Afteration(si E] Roofing EDOr Doore O Accessory Bldg. ❑ DenrolWon ❑ New Signs ID] Decks M Sidinglo) Otherlfj Brief Description of Proposed Work Attic and basement insulation and air sealing throughout Alteration of existing bedroom_Yes_No Adding new bedroom Yes No Attached Namalwe Renovating unfinished basement _Yft NO Plans AOached Roll -Sheet ea.If New house and or addition to eodstina-housing.comolete the following: a. Use of building:One Family Two Family Other b. Number of rooms in each family unit Number of Bathrooms a. Is there a garage attached? d. Proposed Square footage of new construction. Dimensions e. Numberofstodes? I. Method of healing? Fkeplaces or Woodstoves Number of each g. Energy Conservation Comglance. Masscheck Energy Compliance form attached? h. Type of construction 1. Is construction wkhin 100 fLof elands?_Yes —No, Is cunstrudion wilhln 100 yr. floodplain Yes^No J. Depth of basement or cellar floor below finished grade k. Will building conform to the Building and Zoning regulations? _Yes_No. I. SeptleTank Cily Sewer_ Private well, City water Supply SECTION To-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, Kathy Couch &Joanna Kent-Katz as Owner of the subject property herebyauthorke _American Installations to act on my behalf,in all matters relative to work aulhorimd by this building permit application. See attached 6/12/2018 Signature downer Date I, American Installations ssOwnerlAulharized Agent hereby dedare thetthe statements and infortretlon on the Wregoing application ere tore and axurete,to the best of my knowledge and belief. Signed under the pains and peneWes of perjury. American Installations Print Name wlyl ,nA 6/12/2018 Signature Of DeredAg ant Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor Not Applicable ❑ Name of License Bolder a Wesley K. Couture 106178 Liceme Number 130 College St., Ste 100 South Hadley, MA 01075 9129119 Address Explreaen Data Uzzx 413-552-0200 SlOnelure `r' Telephone 9.Reaisiemd Homelmorovement Commctar:. . _ _ . . Not Applicable ❑ Wesley Couture 175982 Comoanv Name Registration Number American Installations 6/26/19 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.c.162,§26C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application.Failure to provide this affidavit vdll result In the denial of the issuance of the building permit SI ned AftidavitAilachod Yes....... IN No...... ❑ 11.'=Home Owner Exemption The cement exemption fbr"homeowners"was extended to include Owneroccuoted Dwellings ofmm(1) or two(2)fhmilics and to allow such homeowner ee engage an individual for bire who does not possess a liceoae,mvided tbatthe owner acts as supervisor.CMR 780, Sixth Edition Section 10835.1. Definition of Homeowrrer:Person(a)who own a parcel of land on which helshe resides or intends in reside,on which there is,or is intended to be,a one or two family dwelling,attached or detached structures accessory to such use and/or farm structures.A,Person ho constructs mom than home In twoPeriod shallnot he considered a hoe Such"homeowner'shall submit to the Building Official,one fame acceptable to the Building Officiay that hNshe shall he remom ittle,for all such workoerformed under the building permit, As acting Construction Sunervimr yom 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 referenceto Chapter 152(Wcekems'Compensation) and Chapterl53(laabilityaf1koployersto Employees for injuries not resulting inDeath)oldie Massachusetts Gene]Laws Annotated,you maybe liable forperson(s) you hire In perilous work for you under this permit The undersigned"homeowmer"cerOBes and assumes responsibility for compliance with the State Building Code,City of Northampton Ordlwmcn s,Stam and Local Zoning Laws and State ofMassachusetfs 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: 693 Bridge Road Northampton MA The debris will be transported by: American Installations The debris will be received by: Waste Management of NE - Chicopee Building permit number: Name of Permit Applicant Wesley Couture 6/12/2018 A>)� . \jL . C t§6 %A x. Date Signature of Permit Applicant BBB., . Licensed&Insured ® \ MA at s:106178 American Installations MA RMumprodo#125982 zoo Calkeeshensune[m,swe wafer.Nnozozs.oNw:14za1 ssznxoo Fac Ntal su.omx.shad:auppprtaAmedwnlnnalhdons.wm Couzhand Kent-Katz,Kathy and Joanna 5/11/2018 693 Bridge Read Northampton MA OIDW w... i"• 206.226.1866 KathycouchQaventionortimp IrMn 464345 m.m 18-1632 a Quantity Unit Unit Cost Total Afr Sealing AIRSEALING 10 Iman hour 1 $ 85.00 1$ 850.00 WEATHERSTRIP DOOR&ADD SWEEP 1 Intich 5 BO.00 I$ 80.00 Air Sealing $ 930.00 Air Sealing Incentive $ (930.00) Air Selaing W%Balance $ WeratheNeaOon BASEMENT SILLS-R19 FG BATT 106 s k $ 1.95 $ 206.70 ATTIC HATCH-SEAL&INSULATE 1 each $ W.00 $ 60.00 KNEEWAUL 2"RIGID BOARD 110 s k $ 3.85 $ 423.50 ATTIC FLAT-8"OPEN R-30 CELLULOSE 682 soft $ 1." $ 902.08 ATTIC DAM MI NG-R-38 FIBERGLASS 106 soft $ 2.05 $ 217.30 VENT BATH FAN THRU ROOF 1 each $ 118.75 $ 118.75 REMOVE INSULATION 106 sgft $ 0.75 $ 79.50 Total Weatherization $ 2,087,83 Weatherization Incentive $ 1,506.25 Total Project $ 3,017.83 Total Utility Contribution $ 2,436.25 Total Customer Contribution $ 581.58 Pr en2MV.Arkw—mme<nm,ISw we Prokke the,bP,a nows howwwwr with a2 wr workmanship wA-i Anvar mimmn.,uc ner.brP,w F,mrnater m.,m and labor mr.mplam me.bom soma k&w n—own -vew,In the abo.e memlamNn,11i I...l nknmewhemr, rvrymvar Ir In.Twmmrna vow w tarts liver AccEFTANCE OF PROPOSAL Tim above prima,spedlmaeana and TOTAL CONTRACT VALUE= $ 581.58 aondinons are ntmanpry and are herebyac«pma. Souare aurnon:m to do work nspearmewymena will be 1/3 down prior to Down Payment= $ 193 D n start W wok,and pa-Le up due on romper... Balance Due Upon Completion= $ 388.58 Couch and Kent-KRIz 5/11/2018 Craig Dra ovich 5/11/2018 THIS AGREE MENT IS COMPOSED OF THIS PAGE AND THE REVERSE SIDE OF THIS PAGE AND SHALL BECONSIDEREDiHE ENTIRE AGREE M ENT BY THE PARTIES I WOWED.THIS AG RE EVENT 15 BETWEEN AMERICAN INSTALLATIONS.LLC HEREINAFTER REFERRED TO AS"COMPANY',AND THE CUSTOMEME)NAMED ON THE REVERSE SIDE,HEREINAFTER REFERRED R1 AS CLIENT',AND WILL BE SUBJECT TO ALL APPROPRIATE LAWS,REGULATIONS AND ORDINANCES OF THE STATE OF MASSACHIJI OR CONNECTICUT RESPECTIVELY,AS WELL AS ALL L0CAL JUR1SDICTI0NS. THE FOLLOWING TERMS AND CONDITIONS ALSO APPLY 1 THIS AGREEMENT IS SUBJECT TO THE APPROVAL OF A MANAGER OF THE COMPANY FOR THIS AGREEMENT TO BE EFFECTIVE UNDER ANY CONDITION. 1 SHOULD DEFAULT BE MADE IN THE PAYMENT OF THIS AGREEMENT,CHARGES SHALL BE ADDED FROM THE DATE THEREOF ATA RTE OF ONE AND ONE HALF)1-1/31 PERCENT PER MONTH. DEF,PER ARGON)WITH A MINIMUM CHARGE OF$1 XG PER MONTH,AND IF PLACED IN THE HANDS OF AN ATTORNEY OR COLLECTION AGENCY FOR COLLECTOR,ALL ATTORNEYSFEES, EXPENSES AND C0ST5 OF COLLECTION SHALL BE PAID BY THE CLIENT.IN ADDI9ON,CLIENT UNDERSTANDS THAT IN FAILING TO PAY ACCORDING TO THE ABOVE TERMS,COMPANY MAY HAVE THE BIGHTTOA LEIN ON THE PROPERTY. 3.THE COMPANY AGREES THAT WHEN DELAYS BECOME KNOWN TO THE COMPANY,THE COMPANY WILL ADVISE THE CLIENT AS SOON AS REASONABLE. 4.COMPANY AGREES THAT,NOTWITHSTANDING ANY AGREEMENT FOR MATERIALS AND/OR LABOR BETWEEN COMPANY AND THIRD PARTY,COMPANY IS RESPONSIBLE TO CLIENT FOR COMPLETION OF ALL WORK DESCRIBED IN ATIRULY AND WORKMANLIKE MANNER. S.ALL WARRANTIES FOR EQUIPMENT AND PRODUCES SUPPLIED BY THE COMPANY UNDER THIS AGREEMENT SHALL BE THOSE GIVEN BY THE MANUFACTURERS OF SUCH EQUIPMENT AND PRODUCTS.UNDER SUCH MANUFACTURER'S WARRANTIES,TEE CLIENT MAY BE REQUIRED TO REGISTER OR MAIL IN A WARFANEY CARD OR OTHER EVIDENCE OF OWNERSHIP AND USE OF SUCH EQUIPMENT AND/OR PRODUCTS IN ORDER TO ACTIVATE SUCH WARRAMIES. 6,THE QUOTATION ON THE PAGE HEREOF DOES NOT INCLUDE EXPENSES OR CHARGES FOR BOND 0R INSURANCE PREMIUMS OR COSTS BEYOND NORMAL INSURANCE COVERAGE,ANY SUCH ADDITIONAL EXPENSES,PREMIUMS OR COST SHALL BE ADDED TO THE TOTAL AGREEMENT AMOUNT. ].THE COMPANWS LIABILITY FOR CLAIMS ARISING OUT OF THIS AGREEMENT SHALL NOT EXCEED THE TOTAL AGREEMENT PRICE EXCEPT TO THE EXTENT THOSE DAMAGES ARE PROVEN TO BE SOLEY DUE TO THE COMPANfS NEGLIGENCE. 8.DURING THE DURATION OF THE WORK,THE CLIENT'S HOMEOWNERS INSURANCE WILL BE RESPONSIBLE FOR ANY AND ALL DAMAGES AS LONG AS THE COMPANY HAS TAKEN THE APPROPRIATE ACTION TO PROTECT AREAS OF WORK. 9 THE COMPANY IS NOT RESPONSIBLE FOR PREEXISTING DEFICIENCIES OR REDIRECTS MATERIALS THAT MANIFEST THEMSELVES DURING THE CONSTRUCTION PROCESS E S WOOD ROT, MOLE,ASBESTOS,NAIL POPS,DUCTVORK AND CONNECTIONS, PLUMBING AND VEND PIPES, DECKING DEFLECTION,EEC IF A PREEXISTING DEFICIENCY OR HA3ARCOUS MATERIAL IS ENCOUNTERED PRIOR TOOR DURING CONSTRUCTION,AND COMPANY IS NOTIFIED IN W RTING,COMPANY WILL TRV TO ASSIST CLIENT WITHIN THE COMPANY'S MEANS AND CAPABILITIES TO CORRECT THE PRDBLEMIS)ON A TIME AND MATERIAL BASIS.CLIENT AGREES THAT SUCH CONDITIONS ARE UNAVOIDABLE BY THE COMPANY AND SHALL NOT BE CONSIDERED A VIOLATION OF THE AGREEMENT AND THAT DUE TO THOSE CONDITIONS THE DURATION OF THE WORK AND SCHEDULED DATE OF COMPLETION MAY DIFFER FROM THAT AGREED UPON,IF APPLICABLE,UNDER THIS AGREEMENT. 30.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 NOLO GROWTH,ARISING FROM THE PERFORMANCE OF AIR SEALING WORK BY THE COMPANY AS A RESULT OF ANY KNOWN OR UNKNOWN MOISTURE CONDITIONS. 11.THE COMPANY IS NOT RESPONSIBLE FOR,AND THE CLIENT AGREES TO HOLD THE COMPANY HARMLESS,FOR ANY PROBLEMS AND/OR DAMAGES ROUTING TO ICE DAMMING THAT MAY ARISE DURING AND/OR AFTER TXE PERFORMANCE OF WORK BY THE COMPANY. 13,REPLACEMENT OF DETERIORATED DECKING,FASOA BOARDS,ROOF JACKS,VENTILATORS,PLAGUED,RAFTERS,JOISTS,INSULATION OR OTHER MATERIALS ARE NOT INCLUDED UNLESS OMERW ISE NOTED HEREIN. 13.THE COMPANY WILL NOT BE RESPONSIBLE FOR THE SCRATCHING OR DEALING OF INTERIOR WALLS AND CEILINGS, FLOORS TRIM.GUTTERS, DOWNSPOUTS, LISTING SIDING AND WINDOWS,DOORS,OIL DROPLETS IN DRIVEWAYS,HAIRLINE FRACTURES IN CONCRETE OR BLACKTOP DRIVES AND WALKS,OR DAMAGE TO PLANTS OR SHRUBBERY.IF EXCESSIVE DAMAGE 15 CAUSED AS COMPANY,COMPANY WILL SEPAL OR REPLACE DAMAGED AREA ONLY AT COMPANWS EXPENSE, 4.THE COMPANY UNDER PROVISIONS OF CHAPTER 143A OF THE GENERAL LAWS IS REQUIRED TO APPLY FOR AND OBTAIN ALL CONSTRUCTION RELATED PERMITS.THE COMPANY SHALL NOT BE DEEMED RESPONSIBLE FOR DELAYS IN THE WORK DESCRIBED IN THIS AGREEMENT CAUSED BY REGULATORY PERMIT GRANTING OR INSPECTIONAL AGENCIES,AUTHORITIES,OR INDIVIDUALS. 15.THIS AGREEMENT,INCLUDING THE PROVISIONS REWTI NO TO PRICE AND PAYMENT SCHEDULE,CANNOT BE CHANGED OR ALTERED EXCEPT BY A WRITTEN STATEMENT SIGNED BY BOTH THE COMPANY AND THE CLIENT. 16.ANY REPRESENTATIONS,STATEMENTS,OR OTHER COMMUNICATION NOT WRITTEN ON THIS AGREEMENT ARE AGREED TO BE IMMATERIAL AND NOT KILLED ON BY EITHER PARTY,AND DO NOT SURVIVE THE EXECUTOR OF THIS AGREEMENT. 17.THIS AGREEMENT CANNOT BE CANCELLED WITHOUT THE MUTUAL WRITTEN CONSENT OF BOTH PARTIES EXCEPT AS OTHERWISE SET FORTH HEREIN. 19.THIS AGREEMENT,AND ANY WASUREFUS)PROVIDED HEREUNDER SHALL NOT BE ASSIGNED FACEPT BY OR WITH THE WRITTEN PERMISSION OF THE COMPANY. 19.IF THE CLIENT FAILS TO PERFORM ITS OBLIGATIONS HEREUNDER OR TEBMINATES THIS AGREEMENT WITHOUT THE PRIOR WRITTEN CONSENT OF THE COMPANY,THE CTENT SHALL BE LIABLE FOR DAMAGES FOR THE GREATER OF THE C0MPANYS ACTUAL DAMAGES 0R 35%OF THE AGREEMENT MR RESTOCKING FEE. 20.ANY CHANGES TO MATERIALS BY THE CLIENT)BRAND,SME,COLOR,ETC)AFTER SAID MATERIAL HAS BEEN DELIVERED OR 151N ROUTE TO THE CLIENT CW LD RESULT IN A 5%BE STOCKING FEE BASED ON THE COST OF SAID MATERIALS. 21 THIS AGREEMENT SHALL BE EFFECTIVE ONLY UPON ITS EXECUTION BY ALL PARTIES HERETO,PRIOR TO WHICH TIME IT SHALL BE DEEMED A PROPOSAL.THE COMPANY RESERVES THE RIGHT TO REVOKE THIS PROPOSAL 90 DAYS FROM DATE IT IS EXECUTED BY THE COMPANY IF IT IS NOT EARLIER EXECUTED RE THE CLIENT AND THE REQUIRED DOWN PAYMENT RECEIVED PRIOR TO THE EXPIRATION OF SUCH 90 DAY 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 ATSUOU TIME 31.IF ANY PROVISION OF THIS AGREEMENT SHOULD BE HELD TO BE INVALID OR ONENFORUBLE,THE VALIDITY AND ENFORCEBILIIY OF THE REMAINING PROVISIONS Of THIS AGREEMENT SHALL NOT BE AFFECTED THEREBY. 33.ARBITRATON'.IN THE EVERETTE CLIENT AND COMPANY HAVE A DISPUTE REGARDING ANY OF THE TERMS,CONDITIONS,PROVISIONS,OR PERFORMANCE OF THIS AGREEMENT,THE PARIES AGREE TO PUCE THE MATTER IMO ARBITRATION BEFORE AN INDEPENDENT ARBITRATOR ASSIGNED BY THE AMERICAN ARBITRATION ASSOCIATION TO RESOLVE THEIR DISPUTE. 24.ANY DISCOUNT,PROMOTION,REIMBURSEMENT,OR OTHER PROGRAM THAT IS PAW OF A STATE SPONSERED UTRITY PROGRAM(IF MASS SAVE')IS SUBJECTTO TNE AVAIL IMY OF QUALIFYING STATE SPONSERED PROGRAM AND WILL BE SCARIER TO TERMINATION IF THE STATE SPONSERED UTILITY PROGRAM IS DISCOUNINUED.FURTHERMORE,THE TERMS AND CONDITIONS OF STATE SPONSORED UTILITY PROGRAMS MAY BE ALTERED OR UPDATED PERIODICALLY WITH OR WITHOUT NOTICE. 25.AMERICAN INSTALLERS,LLC IS NOT AN AGENT OF ANY UTILITY COMPANY OF OTHER VENDOR WORKING BY,TRE000H,OR UNDER THE MASS SAVE'ENERGY PROGRAM. 26.CLIENT REPSONSIBLE FOR THE PAYMENT OF ANY AND ALL FEDERA45TATE,OR LOCAL TAKES THAT ARE APPLICABLE TO THIS AGREEMENT. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Irrvestigalions 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name p1.yiae..90rgani.auoNlndividua0: American Installations,LLC Address: 130 College Street, Suite 100 City/Stale/Zip: South Hadley,MA 01075 Phone#: 413-552-0200 Are you an employer?Check the appropriate box: Type of project(required): L Q 1 am a employer with 46 4. ❑ I am a general contractor and 1 6. ❑ New construction employees(full and/or pen.time).' have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.t 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. Demolition working for me in any capacity workers'camp.insurance. 9. ❑ Building addition [No workers'comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their Wo Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGI. 1 L❑ Plumbing repairs or additions myself. [No workers'comp. c. 152,§1(4),and we have no 12.0 Roof repairs insurance required. t employees. No workers' -� comp.insurance required.] 13.N Other- Insulation "Tny applicant IMI ehreks boz p I must also fll ow the section below showing IM1eir worken'compensation pulicY Informnion. �I Immeownvm who suMnit this affdavil indi<ming Nq arc Juing all work end IM1m him oulsidu conaacmrs mull submit o new alriJavil indicasing sucM1. :Cummclors Not<hwk This box mull onaehN an vddilioml sheet sM1uwmg the none attic subKonlrmmrs and their wnrkelz'comp.policy infonnwion. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and joh site information. Insurance Company Name: Guard Insurance Companies Policy Nor SelFins. Lic2#. AMWC8973877 _ Expiration Date' 09/04/2018_ Job Site Address: b LiIJ 1&i,1Qt— fw.6( -_City/Stam/Zip:M Attach a copy ofthe workers'compensation policy declaration page(showing the policy number and expiration dole). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition ofcriminal penalties ofa fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form oft STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy ofthis statement may be forwarded to the Office of Investigations ofthe DIA for insurance coverage verification. f do herchy certify under the pains a/n/Id penalties ufperjaty,that the information provided above is true and correct. S� Phone#: 6/ 413-5510200 Offlciat use only. Do not write in ails area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector b.Other Contact Person: Phone#: Commpoweafth of Massachusetts Con>dnolron Supervisor ®� Division of Professional Licensure UnrehiclM-Buildings of any use group Milch contain Board of Building Regulations and Standards lessIM 00.000 cubic fast(991 cultic meters)ofenelosed Construction Supervisor Sartori. CS-108178 Eppires:09/29/7019 - WESLEY COUTURE - Z7BLATHROPQTREET SOUTH HADLEY MA 01070 FastersWpossessseu Milianofthe Mms husetts state Building Cade Is"use for revaeaeun ofmn 0eense. `e� For Information about this Sc. Commissioner L/'"� Cast(017)727-3200 or visa www.mss.gowdpl rt/ficAo�rr�yrnua/erx�l aC��txJirrrlulefy 1, 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 E>�iration: 08/26/2018 SOUTH HADLEY,MA 01075 Update Address and Want Curti. Mark reason for ohnys. $ Al is MMO"l ^_ Add— n Q_w..t n Employment ❑!oat Carp "-� "ke of Conwmer Allain ABaalmer ReeNetle. HOMEIMPROVEMENTCONTRACTOR Registration valid for individual use only t / TYPE:LLC Wfore the supine..dads, If found return to: AAnlma gn EOpllgdgn OMCs of Consurrlar Affairs and Business Regulation 175982 O026mill 10 Park Mesa-Suite 5170 AMERICAN INSTALLATIONS,U.C. Bollen,MA 02118 WESLEYCOUTURE 1W COLLEGE COLLEGE STREET SURE IM SOUTH HADLLY,MA 01075 Undersecretary t valid without signature A ba CERTIFICATE OF LIABILITY INSURANCE eiiq/zo 17 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 pWicy(Ilrs)must be Endorsed. If SUBROGATION IS WANED,subject to Na 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 SRI of such endo sament(s). PRODUCER NAMEA Linda Powers Nabher 6 Grinnellvxoxe (813)586-0111 A. No_M131seF-Foal 8 North Hing Street PDD9ESSapow ra@webtrerandgri nell.Com a1XSURE S AFFORDING COVERNOE NA.I Northampton MA 01060 INSUFFEAMMEA10yerS Mutual Casualty INSURED INSURERBBerkBhire Hathenray GUARD Ins. CO. Marian Installations, LLC INSURERC: Attn: Nes S SULaMe Couture INSURER D: 130 College Street, Suite 100 INSURER E: SOYth Hadley HA 010755 INSURER F: COVERAGES CERTIFICATE NUMBERStaster exp 9-2DLS 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 WTH 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. IXSR TYPE OF INSURANCE POLICY EFF POLICY EUP ..a LTR POLICY NUMBER AUm NMDDPYYQ CORSI GENERAL LABIInY EACH OCCURRENCE $ 1,000,000 A X CIAIMSAIAOE 1:1 OCCDR PREMISES Ea S 500,000 SD3535211 9/4/2011 9/4/2010 MEOEXP(Anyone Irrew) $ 10,000 PERSONAL S ADV INJURY S 1,000,000 GENL AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE $ 2,000,000 PRO POLICY�IELECT LCC PRODUCTS CLI AGO S 2,000,000 4 OTHER'. $ AUTOMOBILE LIUEUDY EOM BSI OEOI IN L LIMIT S 1,000,000 A ANY Ane BODILY INJURY(Per Peron) $ AALL EO A. ALCXEO 543535217 9/4/2017 9/V2018 BODILY INJURY(PereyoenU $ NCNDR WNEO PROPERTY OHMAGE S X HIRED TDOAUTOS 'Z AUTO$ Pere. PIEoRA, IS 8,000 R UMBRELLA LIAR OCCUR EACH OCCURRENCE E 1,000,000 A __IIA. 61AIMS MADE AGGREGATE $ 1,000,000 DEO I X RETENTION 30 000 5J3535217 9/4/2017 9/4/203. S WORKERS COMPENSATOR PER OTW ANDEMPLOY."S'LNBILITY a STATUTE ER Y ANY PRWRIETORNARTNENE%EOUTIVE ❑ HIA EL EACH ACCIDENT S 500,000 B EXOWOE% OFFICENNMOER(Mbeed. ,EINm RRNCF09917 9/4/2017 9/4/2018 E.L.DISEASE0,EMPLOYE IS 500,000 M511 ewer L RI PTION OF OPERATIONS Ce YN E L.DISEASE m POLICY LIMIT S 500,000 A Commercial Property SA3s35211 9/4/2017 9/4/2010 JAI ITBOU DESCRIKION OF OPERATORS I LOCATIONS;VEHICLES(ADDED 101,AFEMIonal means SpIMub,ma,be Xnchel II more spare Ia reynlroo) 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. AUTIORQED REPRESENTATVE Kevin Joyce/LMP ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD INS025,YI