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35-038 (7) 190 WEST FARMS RD BP-2019-0304 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 35 -038 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Cat gory: INSULATION BUILDING PERMIT Permit# BP-2019-0304 Project# JS-2019-000495 Est.Cost: $3231.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: AMERICAN INSTALLATIONS LLC 106178 Lot Size(sq. ft.): 127195.20 Owner: MATHIESEN MARISA&MCLOUGHLIN MOLLY zoning: Applicant: AMERICAN INSTALLATIONS LLC AT. 190 WEST FARMS RD Applicant Address: Phone: Insurance: 130 COLLEGE ST (413) 552-0200 WC SOUTH HADLEYMA01075 ISSUED ON:9/16/2018 0:00:00 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 Signature: FeeType: Date Paid: Amount: Building 9/16/2018 0:00:00 $65.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner 7A;PPLICATION Department use only City of Northampton Status of Permit: Building Department Curb Cut/Ddveway Permit 8 212 Main Street SewerlSeptic-AvailabilityRoom 100 Water/Well'AvailabilityFC IONS N rthampton, MA 01060 Two Sets of Structural Plans ne 4 -587-1240 Fax 413-587-1272 PIot/Site P.,lans Other Specify N TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMC,I/LY DWELLING SECTION 1 -SITE INFORMATION `40— /� �O / This section to b7�6 pl�tgd by office 1.1 Property Address: 'Ipt MapLot Unit 190 West Farms Road Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT 2.1 Owner of Record: Marisa Mathiesen &Molly Mcloughlin 190 West Farms Road Name(Print) Current Mailing Address: 1113) 205-6788 See attached Telephone Signature 2.2 Authorized Agent: American Installations 130 College St., Ste 100 South Hadley, MA 01075 Name(Print) Current Mailing Address: see attached 413-552-0200 Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building 3231.00 (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5.Fire Protection 6. Total=0 +2+3+4+5) 3 Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: at� 2f!6 1 j[,Q Building Commissionerlinspector of Buildings Date Section 4. ZONING All Information Must Be Completed.Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size Frontage Setbacks Front Side L:= R:I I L:= R:= Rear i 1 i---•� Building Height Bldg.Square Footage % `� I Open Space Footage % (Lot area minus bldg&paved parking) #of Parking Spaces r---j -� ---� Fill: f ---------;,_---------------- ( ----------- (volume&Location) _-_------ 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:1 j IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW O YES O IF YES: enter Book ; Page and/or Document#! 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 obtainedO Obtained O , Date Issued: C. Do any signs exist on the property? YES O NO 0 1 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. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES O NO O IF YES,then a Northampton Storm Water Management Permit from the DPW is required. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) Q Roofing Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [C] Siding[p] Other[69 Brief Description of Proposed Work: Wall and basement insulation and air sealing throughout Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 6a.It New house and or addition to existinghousing, complete the following: a. Use of building:One Family Two Family Other b. Number of rooms in each family unit: Number of Bathrooms c. Is there a garage attached? d. Proposed Square footage of new construction. Dimensions e. Number of stories? f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction I. Is construction within 100 ft.of wetlands? Yes No. Is construction within 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. Septic Tank CitySewer Private well City water Supply SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner of the subject property hereby authorize American Installations to act on my behalf,in all matters relative to work authorized by this building permit application. See attached Signature of Owner Date (S/24/2018 1, American Installations as Owner/Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed under the pains and penalties of perjury. American Installations Print Name Signature of OwribriAgent Date 2 SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: Wesley K. Couture License Number 130 College St., Ste 100 South Hadley, MA 01075 9/29/19 Address Expiration Date \C. 413-552-0200 Signature Telephone 9.Registered Home Improvement Contractor: _ Not Applicable ❑ Wesley Couture 175982 Company Name Registration Number American Installations 6126119 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.152,§25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application.Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached Yes....... N No...... ❑ 11. Home Owner Exemption The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)families and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor.CMR 780, Sixth Edition Section 108.3.5.1. Definition of Homeowner:Person(s)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,attached or detached structures accessory to such use and/or farm structures.A person who constructs more than one home in a two-year 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 shall be responsible for all such work performed under the building permit. As acting Construction Supervisor your presence on the job site will be required from time to time,during and upon completion of the work for which this permit is issued. Also be advised that with reference to Chapter 152(Workers'Compensation) and Chapter 153(Liability of Employers to Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,you may be liable for person(s) you hire to perform work for you under this permit. The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of Northampton Ordinances,State and Local 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: 190 W est Farms Road The debris will be transported by: American Installations The debris will be received by: Waste Management of N. E Building permit number: Name of Permit Applicant �6IZ�I1 � ���. � • Date Signature of Permit Applicant City of Northampton Massachusetts DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street * Municipal Building ......... JCa Northampton, M& 01060 190 West Farms Road Property Address: Contractor Name: American Installations Address: 130 College Street Ste. 100 City, State: South Hadley, MA Phone: 43-552-0200 Property Owner Marisa Mathiesen &Molly Mcloughlin Name: 190 West Farms Road Address: City, State: Northampton, MA 01062 1, 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 8/24/2018 • mass save -icensed&insured PARTNER MA C51#:106178 , MA RegIstrotTon#175982 American Installations www.AmericanInstallations.com 130 College Street Suite 100,South Hadley,MA 01075 • Office:(413)552-0200 ran:(413)552-0202 • Email: support@Americaninstallations.com Customer Name: Marisa Mathiesen Email: Not provided Phone:413-205-6788 Premise Address: 190 W Farms Rd,Northampton, MA 01062 Project to:3457421 Date:Aug.22.2018 Job Description Quantity Unit Total Cost Customer Cost Rim Joist- 6" Fiberglass Batting 118 SF $318.60 $79.65 Kneewall Wall- 2" Thermal Barrier Polyiso 270 SF $1,290.60 $322.65 Kneewall Floor-6"Open Blow Cellulose 64 SF $103.68 $25.92 Damming 18 each $43.02 $10.75 Cut and Finish Access 3 each $373.59 $93.40 Door - 2" Thermal Barrier Polyiso 1 each $90.44 $22.61 Whole House Fan Box - 2" Thermal Barrier Polyiso (with AS hrs) 1 each $187.70 $0.00 Open Wall - 2" Thermal Barrier Polyiso 56 SF $267.68 $66.92 Air Sealing at Estimated 62.5 CFM50 Per Hour 6 hr $555.48 $0.00 Project Total $3,230.79 Weatherization incentive ($1,865.71) Air sealing incentive ($743.18) Total Program Incentive -$2,608.89 Customer Total $621.90 WARRANTY:American Installations,LLC Will provide the above stated homeowner with a 1-year workmanship warranty. American Installations,LLC hereby proposes to furnish all material and labor to complete the above scope of work in accordance with the above specifications and all local and state building regulations for the Total Contract Value as stated herein. ACCEPTANCE OF PROPOSAL: The above prices, speci`ications and conditions are TOTAL CONTRAC-VALUE-S 621.90 satisfactory and are hereby accepted."Ou are authorized to do work as specified.°ayment Down Payment= 5 200.110 ® cc will be 1/3 down prior to start of work,and balance due upon Completion. PAID Balance Due Upon Completion= S 421,90 Signature Date Property owner(Print) Molly McLoughlin {Sign% " I Q u i U Date 8-22-18 Representative:(Print) B.Zanier (Sign) 13- Zv-Wtk-f Date 8-22-18 TNI%AGREEMENT IS COMPOSED CF THIS PAGE AND THE REVERSE 5 D OF THIS PAGE AND SHALL BE CONSIDERED THE ENTIRE AGREEMENT BY THE PARTIES INV O VED'XIS AGREEMENT IS BETWEEN AMERICAN INSTALLATIONS,LLC HEREINAFTER REFERRED WAS'COMPANY-, ANOTHE W STOMERISI NAMED ABOVE,HEREINAIT ERREFER REO 1C AS-CLIENT,AND WILL BE SUBJECT TOAD.APPROPRIATE LAWS,REGULATIONS AND ORDINANCES OF THE STATE OF MASSACHUSETTS OR CONNECTICUT RESPECTIVELY,AS WELL AS ALL LOCAL IU RI501 Cl1ON5 THIS AGREEMENT IS COMPOSED OF THIS PAGE AND THE REVERSE SIDE OF THIS PAGE AND SHALL BE CONSIDERED THE ENTIRE AGREEMENT BY THE PARTIES INVOLVED. THIS AGREEMENT IS BETWEEN AMERICAN INSTALLATIONS,LLC HEREINAFTER REFERRED TO AS"COMPANY',AND THE CUSTOMER(S)NAMED ON THE REVERSE SIDE,HEREINAFTER REFERRED TO AS"CLIENT",AND WILL BE SUBJECT TO ALL APPROPRIATE LAWS,REGULATIONS AND ORDINANCES OF THE STATE OF MASSACHUSETTS OR CONNECTICUT RESPECTIVELY,AS WELL AS ALL LOCAL JURISDICTIONS. 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. 2. SHOULD DEFAULT BE MADE IN THE PAYMENT OF THIS AGREEMENT,CHARGES SHALL BE ADDED FROM TH E DATE THEREOF AT A RATE OF ONE AND ONE-HALF(1-1/2) PERCENT PER MONTH.(18%PER ANNUM)WITH A MINIMUM CHARGE OF$2.00 PER MONTH,AND IF PLACED IN THE HANDS OF AN ATTORNEY OR COLLECTION AGENCY FOR COLLECTION,ALL ATTORNEYS'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 TO A LEIN ON THE PROPERTY. 3. THE COMPANY AGREES THAT WHEN DELAYS BECOME KNOWN TO THE COMPANY,THE COMPANY WI LL 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 ATIMELY AND WORKMANLIKE MANNER. 5. ALL WARRANTIES FOR EQUIPMENT AND PRODUCTS SUPPLIED BY THE COMPANY UNDER THIS AGREEMENT SHALL BE THOSE GIVEN BY THE MANUFACTURERS OF SUCH EQUIPMENT AND PRODUCTS. UNDER SUCH MANUFACTURER'S WARRANTIES,THE CLIENT MAY BE REQUIRED TO REGISTER OR MAIL IN A WARRANTY CARD OR OTHER EVIDENCE OF OWNERSHIP AND USE OF SUCH EQUIPMENT AND/OR PRODUCTS IN 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 COST SHALL BE ADDED TO THE TOTAL AGREEMENT AMOUNT. 7. THE COMPANYS LIABILITY FOR CLAIMS ARISING OUT OF THIS AGREEMENT SHALL NOT EXCEED THE TOTAL AGREEMENT PRICE EXCEPT TO THE EXTENTTHOSE DAMAGES ARE PROVEN TO BE SOLEY DUE TO THE COMPANY'S 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 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 A PRE-EXISTING DEFICIENCY OR HAZARDOUS 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(S)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 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 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 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 JACKS,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 CEILINGS,FLOORS,TRIM,GUTTERS,DOWNSPOUTS,EXISTING 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 IS CAUSED BY COMPANY,COMPANY WILL REPAIR OR REPLACE DAMAGED AREA ONLY AT COMPANYS EXPENSE. 14. THE COMPANY UNDER PROVISIONS OF CHAPTER 142A 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 RELATING 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 THE EXECUTION OF THIS AGREEMENT. 17. THIS 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 WRITTEN 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 LIABLE 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(BRAND,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 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 BY 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 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 INTO 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 PART OF A STATE SPONSERED UTILITY PROGRAM(I.E.MASS SAVED)IS SUBJECT TO THE AVAILABILITY OF QUALIFYING STATE SPONSERED PROGRAM AND WILL BE SUBJECT TO TERMINATION IF THE STATE SPONSERED UTILITY PROGRAM IS DISCOUNTINUED. FURTHERMORE,THE TERMS AND CONDITIONS OF STATE SPONSERED 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,THROUGH,OR UNDER THE MASS SAVE'ENERGY PROGRAM. 26. CLIENT IS REPSONSIBLE FOR THE PAYMENT OF ANY AND ALL FEDERAL,STATE,OR LOCAL TAXES THAT ARE APPLICABLE TO THIS AGREEMENT. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations k1V 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organizatiordlndivldual): American Installations,LLC Address: 130 College Street,Suite 100 City/State/Zip: South Hadley,MA 01075 Phone#: 413-552-0200 Are you an employer?Check the appropriate box: Type of project(required): 1.J I am a employer with 60 4. ❑ 1 am a general contractor and l 6. New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet.t 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers'comp. insurance. 9. ❑ Building addition [No workers'comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers'comp. c. 152,§1(4),and we have no 12.E] Roof repairs insurance required.]t employees. [No workers' 13.©Other- Insulation comp.insurance required.] *Any applicant that checks box NI must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they arc doing all work and then hire outside contractors must submit a new allidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. 1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Guard Insurance Companies Policy#or Self-ins. Laic.#:',�fU�RcWtC60/9�917 �n Expiration Date: 09/04/2019 Job Site Address: Igo V VITT (/Ins�lUd City/State/Zip:. Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. 1 do hereby certify under the pains and penalties of perjury that the information provided pbove`is true and correct Si ature: Date: Phone#: 413-55 -0200 Oficial use only. Do not write in this area,to be completed by city or town official City or Town: PermitlLicense# Issuing Authority(circle one): 1. Board of Health 2.Building Department 3.CitylTown Clerk 4. Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone##: Commonwealth of Massachusetts Construction Supervisor Division of Professional Licensure Unrestricted-Buildings of any use group which contain Board of Building Regulations and Standards less than 35,000 cubic feet(991 cubic meters)of enclosed Construction Supervisor space. CS-106178 Expires: 09/29/2019 WESLEY COUTURE 218 LATHROP STREET SOUTH HADLEY MA 01075 Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. For information about this license Commissioner Call(617)727-3200 or visit www.mass.gov/dpi 3 �a 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 Expiration: 06/26/2019 SOUTH HADLEY,MA 01075 Update Address and return card. Mark reason for change. SCA1 0 20101- /11 rl Addr 7 oe..o...ai n Employment 7 I,Ostrard °-" Office of Consumer Affairs&Business Regulation i, HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only a,= TYPE: LLC before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation 175982 06/26/2019 10 Park Plaza-Suite 5170 AMERICAN INSTALLATIONS,LLC. Boston,MA 02116 WESLEY COUTURE 130 COLLEGE STREET SUITE 100 �.. SOUTH HADLEY,MA 01075 Undersecretary valid without signature C' ® DATE(MWDONYYY) A111 C� CERTIFICATE OF LIABILITY INSURANCE 9/4/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies)must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Linda Powers NAME: Webber ✓r Grinnell PI�HCONE (413)586-0111 FAX No,_(413)586-6481 No.Exit, 8 North King Street E-MAIL ADDRESS:1powaro@webberandgrinnell.com __ INSURER�S�AFFORDING COVERAGE NAIC Y Northampton MA 01060 _ _!wuRERA,2nV1oyers Mutual Casualty INSURED INSURER B:Ber)Cshire Hathaway GUARD Ins. Co. American Installations, LLC INSURERC: _ Attn: Wes be Suzanne Couture INSURER D: 130 College Street, Suite 100 INSURER E: South Hadley MA 01075 INSURER F: COVERAGES CERTIFICATE NUMBER Master Exp 9-2019 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL UBR I POLICY EFF POUCY EXP LTR TYPE OF INSURANCE POLICY NUMBER YYI (MMIDD/YYYYI LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCUHHENCE $ 11000,000 A Z CLAIMS-MADE �OCCUR DAMAGE TO 000 DAMAGE R.M.R occurrence $ 5D3535217 9/4/2018 9/4/2019 MEOEXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GENT AGGREGATE LIMIT APPLIES PER: I GENERAL AGGREGATE $ 2,000,000 X POLICY❑JECT E LOC I PRODUCTS-COMP/OP AGO $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY 20= SINGLE LIMIT $ 11000,000 E accident) A ANY AUTO BODILY INJURY(Per person) $ ALL OWNED 1xx SCHEDULED 523535217 9/4/2018 9/4/2019 BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED I PROPERTY DAMAGE S X HIRED AUTOS AUTOS (Per accident) x Cal 52,000 comp 52,000 ' PIP-Basic $ 8,000 X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 1,000,000 A EXCESS UAB CLAIMS-MADE AGGREGATF $ 1 000 000 OED I X I RETENTIONS 10,000 5J3535217 9/4/2018 9/4/2019 $ WORKERS COMPENSATION i x PTRSA TE ER OTH- AND EMPLOYERS'LIABILITY Y/N I ANY PROPR.ETORrPARTNER,EXECUTIVE E.L.EACH ACCIDENT $ 500,000 B OFFICERIMEMBER EXCLUDED? ❑N/A (Mandatory in NH) UMM609917 9/4/2018 9/4/2019 E.L.DISEASE-EA EMPLOYEE $ _ 500,_000 It yes.describe under DESCRIPTION OF OPERATIONS belo. E.L.DISEASE-POLICY UMIT $ 500,000 A Commercial Property 5JL3535217 9/4/2018 9/4/2019 deductible$1.000 I DESCRIPTION OF OPERATIONS!LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule.may be attached it more space is required) 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. AUTHORIZED REPRESENTATIVE W Grinnell, CPCU, CIC f - z::> ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025(201401)