44-067 (2) 993 FLORENCE RD BP-2019-0046
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:44-067 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-2019-0046
Proiect# JS-2019-000061
Est Cost:$4000.00
Fee: $65.00 PERMISSIONIS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: AMERICAN INSTALLATIONS LLC 106178
Lot Size(sq.ft.): 10018.80 Owner: RHOADS SUSAN D&MARK D
Zoning: Applicant: AMERICAN INSTALLATIONS LLC
AT: 993 FLORENCE RD
Applicant Address: Phone: Insurance:
130 COLLEGE ST (413) 552-0200 WC
SOUTH HADLEYMA01075 ISSUED ON:7/10/20180:00:00
TOPERFORM THE FOLLOWING WORK.-ATTIC & 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 signature:
FeeTvve: Date Paid: Amount:
Building 7/10/2018 0:00:00 $65.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
DepaMmm use oiilf
LDEPTOPS
C of NorthamptonsmtuofPemllbUL - 9 2018 Bul Ing Department Cd16 CuVDdveaay permit2 2 Main StreetRoom 100 WaiddWell'AwilabIlity.OIL ING wSPECTI rth mpton, MA 01060FITHAIA 10 2 358 -1240 FaX413-587-1272 Piattle Pisns�
Other$petl(y _
APPLICATION TO CONSTRUCT,ALTER,REPAIR RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION I -SITE INFORMATION 61-
1.1 Proeeriv Address: {Thais section to be compllteete]d byalica
Map —1-1 Lot ,rr�Unit
993 Florence Road Northampton MA 01062
Zone Overlay District
Elm St.District- Ca Dlabict
SECTION 2-PROPERTY OWNERSHIPIAUTHORQEDAGEWT
2.1 Owner of Record:
Susan &Mark Rhoads 993 Florence Street,Florence,MA 01062
Nam(Pdnt) Dm rt Mail"
ag Address:
413-695232
See attached Telephone
a
22 Authorized Anent:
American Installations 130 College St., Ste 100 South Hadley, MA 01075
Name(Pdng Current Mating Mdreae:
C In NIT, , 413-552-0200
Mgnemre Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permitapplicant
1. Building 4,000.00 (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Conatructioll from 6
3. Plumbing Building Permit Fee J/
4. Mechanical(HVAC)
5.Fire Protection
6. Total m1 +2+3+4+5 4,000.00 1 Check Number o�7
This Section For Official Use Only
Building Permit Number. Date
ue
Issd:
Signature: /
Building Commis. nspedw of SuAdings Date
Section 4. ZONING AB information Must Be Completed.Perms Can Be Dented On To Incomplete Womration
Existing Proposed Required by Zoning
Tbia caiumn robafifla inq
BOBdu,a OiPemvmt
Lot Size
Fronwile
Setbacks Front O
Side L:� R: L:= RCS U
Beerr-
Building Height J
Bldg.Square Footage %
Open Space Footage %
taramines bids&saved
o
#of Puking Spaces
FII:
volume&Iowdoo
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW O YES O
IF YES,date issue4-1
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW O YES O
IF YES: enter Book PageC� and/or Document#[_.�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=
C. Do any signs exist on the property? YES O NO O
IF YES,describe sin,type and location: F—
D.
—D. Are there any proposed changes to or additions of sign intended for the property? YES O NO O
IF YES,describe size,type and location:
E. Will the construction activity disturb(dearing,goading,excavatton,or filling)over i ase or Is B part of a mmmon plan
that v411 disturb over i am? YES O NO O
IF YES,than a Northampton Stonm Water Managament Permit from the DPW is required.
SECTION S-DESCRIPTION OF PROPOSED WORK(check all apPlicebt )
New House ❑ Addition ❑ ReplaeemaMWNdows Alteration(s) ❑ Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolltlon ❑ New Signs (p] Deeks [O Siding B7] Otheritt
Brief Description of Proposed
Work A[hc and basement insulation and air sealing throughou[
Alteration of existing bedroom_Yes_No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Y" No
Plans Aftadted Rog -Sheet
Ga.H NOW house and or addition to existing,housing complete the foilowinp:
a. the of building:One FamM Two Famiy Other
b. Number of rooms In each family unit Number of Bathrooms
a Is Mere a garage atlsched?
d. Proposed Square footage of new,construction. Dimensions
e. Number ofstories?
f. Method of hearing? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
1. Is wnsWction within 100 ft of wetlands?_Yes —No. Is construction within 100 yr. floodplain Yes_No
1. Depth of basement or caller floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes_No.
I. Sepric Tank_ Cly Sewer_ Private well_ Cly water Supply_
SECTION Ta-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, Susan &Mark Rhoads as Owner of the subject
property
hereby authorize American Installations
to act on my behalf,in all matter,relative b vnrlr authorized by this buikOng permit application.
see attached 7/3/2018
Slimoure of Owner Data
I, American Installations as Omer/Authorized
Agent hereby declare that the statements and Information on the foregoing application era We and accurate,to the beat of my knowledge
and belief.
Signed under the pains and penalties of perjury.
American Installations
PrintName
SA\
rT♦ A / 7/3/2018
MP
Data
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Suoarvkor: Not Applicable ❑
Namegf Unease Holder, WesleYKCouture 106178
License Number
130 College St, Ste 100 South Hadley, MA 01075 9/29/19
''Add. Expiration bate
WghQ3.. jL CGV1DXAi 413-552-0200
SlpnaMa Telephone
9 Registered Ho m haprovennentContra to _ _ - _.. Not Applicable ❑
Wesley Couture 175982
Comoanv Name RegistruUm Number
American Installations x[26/19
Address F�iretlm Date
130 College St., Ste 100 South Hadley, MA 01075 Telephone 413-552-0200
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(S))
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 permilt.
Signed AfgdavilAtmched You....... 0 No...... ❑
11.r Home Owner-Exemption
The cement exemption fog"homeowners"was extended in include Owu"-ocmoied Dwellings ofow,(1) m two(2)hmilies
end to allow such homeovmer to eagage an individual f"bire who does not possess a license,provided that the owner acts
as suoervisv.CMR 780. Sixth Wiflon Section 10835.1.
Uefmithm of Homeownv:Person(s)who oam a parcel of landonwhich hdshe resides or intends to reside,on which there
is,or is intended to be,a me or two family dwelling attached"detached structures accessory to such we cod/"June
structures.AAPersoa mft constructs were than one home In a tw"ar period&hall not be considered a homeowner.
Such"homeovmu"shall submit to the Building Official,on a form acceptable to the Building 011icial chat hdshe shahbe
responsible tir ane d,worknerformed under the building +
As acting Construction Suoervis yourpreaence on thejob site will be required from time in time,during end upon
completion ofibe work for which this permit is issued.
Also be advised thmwith mferenceto Chapter 152(Workers'Compereatim) and Chapter 153(Liability ofEmployers to
Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,You may be gable forpemon(s)
you hire to perform work for you unit"this peark
The undersigned'9mmeowner"certifies and assumes responsibility for compliance with the SmtaBuilding Code,Qty of
Northampton Ordiaacene,Stam and Land Zoning laws and State of Massachusetts 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: 993 Florence Road
The debris will be transported by: American Installations
The debris will be received by: Waste Management of N.E. - Chicopee
Building permit number:
Name of Permit Applicant American Installations
7/3/2018 , V- COEL&Z I
Date Signature of Permit Applicant
ass s�
• mass save
,,.en¢dsiDoks PARTNER
ASas3>a
MA sa,n.onon.vs5az American Installations www.Amerinnlnsblbtlons.com
SDCOYSf 5bM 9ile im.SYM Mlday.MA p1E13-Dill¢:NSSISSt-0LAru:ll{M 9L0}OS.[TYl IUNerldMnwkanMWMtlMAfOm
Customer Name:Mark Rhoads
Email:Not provided
Phone:413-586-5360
Premise Address:993 Florence Rd,Nonhampton,MA 01062
Project to;3431384
Date:June N.2018
Job Description
Air Sealing at Estimated 62.5 CFM50 Per Hour 12 hr $1,110.96 $0.00 r
Exterior Door Weather Stripping (with AS hrs) 2 each $60.14 $0.00
Door Sweep (with AS hrs) 2 each $50.62 $0.00
Door -2"Thermal Barrier Polyiso 1 each $90.44 $22.61
Rim Joist-6" Fiberglass Batting 100 SF $270.00 $67.50
Hatch - 2"Thermal Barrier Polyiso 1 each $46.28 $11 57
Attic Floor- 8"Open Blow Cellulose 1248 SF $2,196.48 $549.12
Damming 28 each $66.92 $16.73
Propavent 22 each $91.52 $22.88
Project Total $3,983.36
Weatherization incentive ($2,071.23)
Air sealing Incentive ($1,221.72)
Total Program Incentive -$3,292.95
Customer Total $690.41
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THIS AGREEMENT IS COMPOSED OF THIS PAGE ANO THE REVERSE SIDE OF THIS PAGE AND SHALL BE CONSIDERED THE ENP RE AGREEMENT BY THE PARTIES INVOLVED. THIS
AGREEMENT IS BUTWEENAMERICAN INSTALLATIONS,LLCHEREINAFTER REFERRED TOM-COMPMr,AND THE CUSTOMERS)NAMED ON THE REVERSE SIDE,HEREINAFTER
REFERRED TO AS'CLIENT",AND WILL BE SUBJECT TO ALL APPROPRIATE LAWS,REGULATIONS AND ORDINANCES OF ME STATE OF MASSACHUSETTS OR CONNECTICUT
RESPECTIVELY,AS WELL AS ALL LOCAL JURISDICTIONS,
THE FOLLOWING TERMS AND CONDITIONS ALSO APPLY
1, THIS AGREEMENT IS SUBJECT TO TIE APPROVAL OF A MANAGER OF THE COMPANY AOR THIS AGREEMENT TO BE EFFECTIVE UNDER ANY CONDITION.
2, SHOULD DEFAULT BE MADE IN THE PAYMENT OF THIS AGREEMENT,CHARGES SHALLBE ADDED FROM TH E DATE THEREOF AT A KATE OF ONE AND ONE HALF(1-1/2)
PERCENT PER MONTH.118%PER ANNUM)WITH A MINIMUM CHARGE OF$3 OD PER MONTH,AND IF PLACED IN THE HANDS OF AN ATTORNEY OR COLLECTION AGENCY
FOR COLLECTION,ALL A70RNEYY FEES,EXPENSES AND COSTS OF COLLECTION SHALL BE PAID BY THE CLIENT. IN ADDITION,CLIENT UNDERSTANDS THAT IN FAILING
TO PAY ACCORDING TO THE ABOVE TERMS,COMPANY MAY HAVE THE RIGHT TOA LEIN ON THE PROPERTY.
3. THE COMPANY AGREES THAT WHEN DELAYS BECOME KNOWN TOME COMPANY,THE COMPANY WILL ADVISE THE CLIENT AS SOON AS REASONABLE.
0. COMPANY AGREES THAT,NOTWITHSTANDING ANY AGREEMENT FOR MATERIALS AND/OR LABOR BETWEEN COMPANY AND THIRD PARTY,COMPANY IS RESPONSIBLE
TO CLIENT FOR COMPLETION OF ALL WORK DESCRIBED INATIMELY AND WORKMANLIKE MANNER.
5. ALL WARRANTIES FOR EQUIPMENT AND PRODUCTS SVPPUED BY THE COMPANY UNDER TIIS AGREEMENT SHALL BE THOSE GIVEN BY WE MANUFACTURERS OF SUCH
EQUIPMENT AND PRODUCTS, UNDER SUCH MANUFACTURER'S WARRANTIES,THE CLIENT MAYBE REQUIRED TO REGISTER OR MAIL INA WARRANTY CARD MOM HE
EVIDENCE OF OWNERSHIP AND USF OF SUCH EQUIPMENT AND/OR PRODUCTS IN ORDER TO ACTNATE SUCH WARRANTIES.
6, THE QUOTATION ON THE PAGE HEREOF DOES NOT INCLUDE EXPENSES OR CHARGES FOR BOND OR INSURANCE PREMIUMS OR COSTS BEYOND NORMAL INSURANCE
COVERAGE,ANY SUCH ADDITIONAL EXPENSES,PREMIUMS OR COST SHALL BE ADDED TO THE TOTAL AGREEMENT AMOUNT.
]. THE COMPANY$LIABILITY FOR CLAIMS ARISING OUT OF THIS AGREEMENT SHALL NOT EXCEED THE TOTAL AGREEMENT PRICE EXCEPT TO THE EKTENT THOSE DAMAGES
ARE PROVEN TO BE 5O1 DUE TO THE COMPANY'S NEGLIGENCE.
S. DURING THE DURATION OF THE WORK THE CLIENTS HOMEOWNERS INSURANCE WILL BE RESPCHABLE 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 HAZARDOUS MATERIALS THAT MANIFEST THEMSELVES DURING THE CONSTRUCTION PROCESS,
E.G.WOOD ROT,MOLD,ASBESTOS,NAIL POPS,DUCTWORK AND CONNECTIONS,PLUMBING AND VENT PIPES,DECKING DEFLECTION,ETC,IF APRE EXISTING DEFICIENCY
OR HAiMMUS MATERIAL IS ENCOUNTERED PRIOR TO OR DURING CONSTRUCTION,AND COMPANY IS NOTIFIED IN WRITING,COMPANY WILL TRY TO ASSIST CLIENT
WITHIN THE COMPANY'S MEANS AND CAPABILITIES TO CORRECT THE PROBLEM)5)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 THESE CONDITIONS THE DURATION OF THE
WORK AND SCHEDULED DATE OF COMPLETION MAY DIFFER FROM THAT AGREED UPON,IF APPLICABLE,UNDER THIS AGREEMENT,
10, THE COMPANY 6 NOT REYONSIBLE,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 SEALING WORK BY THE COMPANY AS A RESULT OF ANY KNOWN OR UNKNOWN MOISTURE
CONDITIONS.
ll. THE COMPANY IS NOT RESPONSIBLE FOR,AND THE CLIENT AGREES TO HOLD TH E COMPANY HARMLESS,FOR MY PROBLEMS AND/OR DAMAGES RELATING TO ICE
DAMMING THAT MAY ARISE DURING AND/OR AUER THE PERFORMANCE OF WORK BY THE COMPANY
12, REPLACEMENT OF DETERIORATED DECKING,FASCIA BOARDS,RMP JACKS,VENTILATORS,FLASHING,RAFTERS,IOISTS,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 CEILINGS,FLOORS,TRIM,GUTTERS,DOWNSPOUTS,EXISTING
SIDING AND WINDOWS,LOOKS,OIL DROPLETS IN DRIVEWAYS,HAIRLINE FRACTURES 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 COMPANY'S EXPENSE,
10. THE COMPANY UNDER PROVISIONS OF CHAPTER I42A OF TIE GENERAL LAWS 15 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 FUMING 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 RELIED ON BY
EITHER PARTY,AND DO NOT SURVIVE ME EXECUTION OF THIS AGREEMENT.
17. TH IS AGREEMENT CANNOT BE CANCELLED WITHOUT THE MUTUAL WRITTEN CONSENT OF BOTH PARTIES EXCEPT AS OTHERWISE SET FORTH HEREIN,
18, THIS AGREEMENT,AND ANY WARRANTY(S)PROVIDED HEREUNDER SHALL NOT BE ASSIGNED EXCEPT BY OR WITH THE WR17EN PERMISSION OF THE COMPANY,
19. IF THE CLIENT FAILS TO PERFORM ITS OBLIGATIONS HEREUNDER OR TERMINATES THIS AGREEMENT WITHOUT THE PRIOR WRITTEN CONSENT OF THE COMPANY,THE
CLIENT SHALL BE LWBLE FOR DAMAGES FOR THE GREATER OF THE COMPANY'S ACTUAL DAMAGES OR 25%OF THE AGREEMENT FOR RESTOCKING FEE.
20, ANY CHANGES TO MATERIALS BY THE CLIENT DRAND,STYLE,COLOR,FTC.)AFTER MID MATERIAL HAS BEEN DELIVERED OR IS IN ROUTE TO THE HENT COULD RESULT
IN A 5%RE-STOCKING FEE BASED ON THE COST OF MID 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 15 NOT EARLIER EXECUTED BY THE CLIENT AND THE
REQUIRED DOWN PAYMENT RECEIVED PRIOR TO ME EXPIRATION OF SUCH 99 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 IT$COSTS IN EFFECT AT SUCH TIME.
22, IF ANY PROVISION OF THIS AGREEMENT SHOULD BE HELD TO BE INVALID OR UNENFORCABLE,THE VALIDITY AND ENFORCEBILITY OF THE REMAINING PROVISIONS OF
THIS AGREEMENT SHALL NOT BE AFFECTED THEREBY
23, ARBITRATION,IN THE EVENT THE CLIENT AND COMPANY HAVE A DISPUTE REGARDING ANY OF THE TERMS.CONDITIONS,PROVISIONS,OR PERFORMANCE OF THIS
AGREEMENT,THE PARTIES AGREE TO PLACE THE MATTER IMO ARBITRATION BEFORE AN INDEPENDENT ARBITRATOR ASSIGNED BY THE AMERICAN ARBITRATION
ASSOCIATION TO RESOLVE THEIR DISPUTE.
20, ANY DISCOUNT,PROMOTION,REIMBURSEMENT,OR OTHER PROGRAM THAT IS PART OF A STATE SPONSERED UTILITY PROGRAM E.F.MASS SAVE')IS SUBJECT TO THE
AVAILABILITY OF QUALIFYING STATE SPONSERED PROGRAM AND WILL BE SUBJECT TO TERMINATION IF THE STATE WONSERED UTILITY PROGRAM IS DISCOUNTINUED.
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 OMER VENDOR WORKING BY,THROUGH,OR UNDER THE MASS SAVE'ENERGY
PROGRAM.
26, CLIENT IS REPSONSIBLE FOR THE PAYMENTOF ANYAND ALL FEDERAL STATE,OR LOCALTAXES THATARE APPLICABLE TOTING AGREEMENT.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Waghinglon Street
Boston,MA 02111
www.massgos/Jia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Busimss/ofgmiatiomindividuab: American Installations,LLC
Address: 130 College Street,Suite 100
City/Slate/Zip: South Hadley,MA 01075 Phone it: 413-552-0200 _
Are you an employer?Cheek the appropriate box: Type of project(required):
I.O I am a employer with 46 4. ❑ 1 am a general contractor and 1 6. ❑ New construction
employees(full and/or part-time).• have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached slleef t ?, ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity, workers'comp.insurance. 9, n Building addition
LNo workers'comp. insurance 5. ❑ We are a corporation and its
required.) officers have exercised their 10L] Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repairs or additions
myself.(No workers'comp. c. 152.§Ila),and we have no 12.❑ Roof repairs
insurance required. t employees. [No workers'
comp.insurance required.] IJ.FA O[her Insulation
'Any apptimal Ihm checks 1,v%#1 morins.fill ora IM1e>�+lion blow showing rbeir warten'compenssrion paltry mfunnwion.
I I lomeowncn who suMninh is aflidavir tuf.., g Ihcy me doing all.6,nni fl ue him olNide cunomaon moa wbmil uniw.0k avis illdkuling such.
:t'mdmd.rs Oral check 01s box mull wuahfd en addi....1 A.,showing she name of a.subcommaan aM theh work<•m'comp.policy informalron.
I am an employer then is providing workers'compenrenton imurance for M employees. Below is the polity and job site
Information.
Insurance Company Name. Guard Insurance Companies
Policy#or Self-ins. Lico#: AMW_C897387_ Expiration Date: 09/04/2018 _
Job Site Address: �- f7
Twana f. City/State/Zip: [�x✓�xa Yom'\ rYF 0(cy z
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration th te).
Failure to secure coverage as required under Section 25A 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 he forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
f do hereby cerrity under the pains a�nnld penalties of perjury that the Information prothleldl erb�o Iv1eI isss true and correct.
Slya�Jre/9(ya✓ 1;014N4 l .64f Date _._I I'll1A_
Phone N: '/ 413-55 -0200 I 1
O
fficialonly. Do not wale in this area,to be completed by city or town ofj Bari.
n: Permit/License#
ority(circle ane):
Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
son: Phan.#:
Corrnunwealth of Massachusetts Construction SrIPMVMor
®; Division of Profwsiowl Licensure MmeWk1N-SuaginBsorsmy use group which contain
Board of Building Regulations and Sunklards lass than 35,M5 rabic ted(991 crbla numbers)of enclosed
Construction Supervisor apace'
CS-108178 ESpires:09/29/2019 -
WESLEYCOUTURE
svuT"WW,OrREET "�
SOUTHHAOLEYMA 01075
Fal m to possess a erwrand none..1the MwsadluseBs
SMS BWMW4 Code 15 C1111110 for rwocatbn of this Battu.
CJ, n For Irllarintlon about ban Yc u as
Commissioner 13,1101'077V4 M or Visit wwwalMasgovldPI
�� r'��� ((�nljt�srnjtrvnTr�l� n��C�iUlrr:t.ur�ltrlef�.1
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s 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: 175882
130 COLLEGE STREET SUITE 100 Expiration: 08/28/2019
SOUTH HADLEY,MA 01075
Under,Andrew,1nd retum card. Mark renown for chengs.
$ Al n :W ub'11
n Addr.e G1 p_.._,,,..I n Employment ❑Ldet Crrd
HOME
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HOMEIMPROVEMENT COMRACTOR unionRegistrationmeepMidfm Individualwaohiy
TYPE:LLC unionmeConsumer
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91MI145t1® Exci06126 B19 OmcaofC e-Suff,5171) and BUNwes Ryulaeon
175052 OSRB@019 10Pn(k Pim-SUA,1 6170
AMERICAN INSTALLATIONS,LLC. Boston,MA 02115
WESLEY COUTURE C ` --
130 COLLEGE STREET SUITE 100
valid without signature HADLEY,MA 01075 Underfacretary t
DATE
bei ACOIRH 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 CenlficM holder Is an ADDITIONAL INSURED,the policy(ias)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 Nis certificate does not confer rights to the
Certificate holder in lieu of such endoreement(s).
PRODUCERET
NAMME. Linda POMBrs
$febber 6 Grinnell 1PHONE
. . . (413)586-0111 FA%(AC.Xo "131586.....
:
8 North Icing Street AUAIL 1powera@rebberandgrinnell.D.
INSURE AFFORUNGCOVERAGE NAICIf
Northampton MA 01060 INSURIERAMUNFlOVERCS Mutual Casualty
INSURED INSURER B Berkshire Hatluarway GDARD Ina. CO.
American Installations, LLC INSURE0.C:
Attn: Nes 6 Suzanne Couture INSURER D:
130 College Street, Suite 100 INSURER E:
Scotia Badley MA 01075 1 INSURER F:
COVERAGES CERTIFICATE NUMBERNerster exp 9-2018 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTINITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
ITR TYPE OFIHSUMXCE ADDPOLICY HUMBER POLICYEFF MMDzy,YJRLICYE%P "MIT$
COMMERCIAL GENERAL UMBILITYEACH OCCURRENCE E 11000,000
A A LIAIMS�MADE OCCUR PRBA E VIELSRGE ToE.o___ E 500,000
5D3535.17 9/4/2017 9/4/2018 MEOE%P(Anyprearar E 10,000
PERSONAL A ARV INJURY S 1,000,000
GE NL AGGR ELATE LIMIT APPLI ES PER GENERAL AGGREGATE S 21000,000
X
P.-CYE]JECi E] LOC PRODUCTS COMPIOPAGG $ 2,000,000
OTHER: $
AUTOMOBILE LIAMLITY EaemGEml IN LELIMIT E 1,000,000
A ANYAUTO BODILY INJURY(Per rami E
AUTOALL S�ED A AUI30TOS
5. 3535211 9/4/2017 9/4/2018 BODILY INJURY(Pe,aaaCay) E
X XIREO AVTOS A NONEO PROPERTY DAMAGE $
AUTOS perace
PIP-Basic $ 8,000
A UMBRELIA DAB OCCUR EACHOCCURRENCE E 1,000,000
A E%CESS LIAR CUIMSJ.IADE AGGREGATE $ 1,000,000
QED I -T I RETENTION$ 1 000 5/353521/ 9/4/2017 9/4/2010 $
WORKERS COMPENSAION PER OTH-
ANDEMPLOYERSLIABILJtt YIN x STATUTE ER
ANY PROPRIETOPIARTNERIEYECVTIVE EACH CH ACCJMRT $ 500,000
B obertory In NH�E%CLUOED7 ❑ NIA opRcA.E9T, 9/4/2017 9/4/2018 EL DISEASEFA EMPLOYE S 500,000
ny ee".1mar
DESCRIPTION OFOPERATI ONS ONw' ELOISEASE-POLICYLXUT $ 500,000
A Commercial Property 5A3535217 9/4/2017 9/4/2018 neausee$1 WD
DESCRIPTION OF OPERATIONS LOCATIONS VEHICLES(ACORD 101,Additional Remeha Sessidi may be a0cre0 Nme.apace Is rtqulreEl
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Evidence OP InsuraTlCe THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTN0.REPRESENTATIVE
Kevin Joyce/LMP
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