35-089 (5) 1195 HURTS PIT RD BP-2019-0951
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:35-089 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cateeorv�INSULATION BUILDING PERMIT
Permit4 BP-2019-0951
Proiect4 JS-2019-001587
Est Cost$3200.0
Fee:S65,0o PERMISSIONIS HEREBY GRANTED TO:
Const.Claw Contractor: License:
Use Grouo� AMERICAN INSTALLATIONS LLC 106178
Lot Size(sB ft.): 9713.88 Owner: Josh Bain
zoning: APPUcant: AMERICAN INSTALLATIONS LLC
AT: 1195 BURTS PIT RD
Applicant Address: Phone: Insurance:
130 COLLEGE ST (413) 552-0200 WC
SOUTH HADLEYMA01075 ISSUED ON.•3/6/20I9 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 Deportment 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 3/620190:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
I°I b _CEIVED
01.
City of Northampton kAA4 2x19
Building Department -
j 212 Main Street �A �I
i* Room 100 r ON
I 1 •7
1 Northampton, MA 0106 -- n. .nno :wo
phone 413-587-1240 Fax 413-587-1272 ONLY
APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING ONLY QjP',L-c /
SECTIONI-SITE INFORMATION INSULATION PERMIT
1.1 Prooertv Address:
This section to be completed b mine*
1195 Burts Pit Road Map Lot 6 Unit
Florence, MA 01062 Zorre O a nay District
Elm SL Disblct Ca District
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
Josh Bain 1195 Burts Pit Road Florence,MA 01062
Name(Print) c nem Meilin Address:
See attachedY205) 83594437
Telephone
Sgnatum
2.2 Authorized AeeM:
American Installations 130 College Street Ste 100 South Hadley MA 01075
Name(Print) Current Mailing Address.
I n�a il a CfuL�A (413)552-0200
SigneWre TelePhme
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed bit avolicarm
1. Building $3,200.00 (a)Building Permit Fee
2. Elec ,cal (b)Estimated Total Cast of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5.Fire Protection
6. Total=(1 +2+3+4+5) $3,200.00 Check Number 7
This Section For Official Use On
Building Permit Numbe Date
Issued: n
Building Commissioner/lmpeaor of Shci Ings Date
EMAIL ADDRESS(REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 4-CONSTRUCTION SERVICES
8.1 Licensed Constmcdon Supervisor: Not Applicable ❑
Name of License Noieer: Wesley K. Couture 106178
License Number
130 College Street Ste. 100, South Hadley MA 01075 9/29/2019
Mdress Expiration Date
(413)552-0200
5ynature Telephone
9.Registered Nome knmpvemeM Contractor. Not Applicable ❑
American Installations 175982
Company Name Registration Number
130 College Street Ste. 100, South HadleyMA 01075 612612019
Address Expiration Date
AID 1.114. k C&l�A Telephone (473) 552-0200
SECTION 5-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(S))
Workers Compensation Insurance affidavit must be completetl 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-..... .f No...... ❑
Brief Description of Proposed Work NOTE: INSULATION ONLY
Attic and basement insulation and air sealing throughout.
I, American Installations as Owner/ApingdZed
Agent hereby declare that the statements and information can the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
Wesley K. Couture
Print Name
2/27/2019
Signature of Oadar/Agent Date
I. Josh Aairt as Owner of the subject
property
hereby authorize American Installations
to act can my behalf,in all matters relative to work authorized by this buiding permit application.
'<;L . -tu (u ,d 2/27/2019
Signalsm of Umar Date
City of Northampton
r Massachusetts tirss 4- �rc
T
G � nepaarMaar OF eoxzorxc zaspacrrous
220 win st'set . n Icipal Building
aotthempton, eat 01060
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and
subcontractors performing improvements or renovations on detached one to four family homes. Prior to
perforating work on such homes,a contractor most be registered as a Home Improvement Contractor("HIC").
M.G.L.Chapter 142A requires that the"reconstruction, alteration, renovation,repair,modernization,conversion,
improvement,removal,demolition,or construction of an addition to any pre-existing owner-occupied building containing
at least one but not more than Pour dwelling units....or to structures which are adjacent to such residence or building"be
done by registered contractors.
Note:Ifthe homeowner has contracted with a corporation or LLC,that entity must be registered
Type of Work: Insulation Est.Cost: $3,200.00
Address of Work: 1195 Burts Pit Road
Date of Pemtit Application: 2,127/2019
I hereby certify that:
Registration is not required for the following reason(s):
_Work excluded by law(explain):
—Job under$1,000.00
_Owner obtaining own permit(explain):
Building not owneraccupied
x Other(specify): Contractor pullingpermitfor homeowner
OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED
CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE ROME IMPROVEMENT WORK ARE NOT
ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND
UNDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK
PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION.
Signed under the penalties of perjury:
I hereby apply for a building permit as the agent of the owner:
2/27/2019 American Installations 175982
Date Contractor Name HIC Registration No.
OR:
Notwithstanding the above notice, I hereby apply for a building permit as the owner of the above property:
Date Owner Name and Signature
City of Northampton
tQd89aCr1U9E1:♦:H
Y
➢NPI OF BUILDING INSFN@IONS
2122Il�Ln ln StMpp
w • ieipel aullGin9
Nor•<hw♦mpWn, nu 01060
Debris 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.
The debris from construction work being performed at:
1195 Burts Pit Road
(Please print house number and street name)
Is to be disposed of at:
Waste Management of New England, Chicopee, MA 01020
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
Signature of Permit Applicant or Owner Date
If, for any reason,the debris will not be disposed of as indicated, the Applicant or Owner shall notify the
Building Department as to the location where the debris will be disposed.
• /-/%��` _oureriwnlnrbllario n. or,
f B® i MW • LicenseE&InrwM
\ MA CSL A 3X78
American Installations MA Regerranow a 275982
E30 CaINae FbaMSuna zOY,swN Maley,mRgzMs•OIRw:IaUl sss-0300 Ea X:lalal ssz-0IOz• FmeII:wpppr[lAmerlwnlmbllauma.wm
Bain,Josh 2/8/2019
1195 Buns Pit Road m Florence MA 01062
205-835-0437 josh bain@hotmailcom .nn Im
s.
4]]149 w • 194)515
�w
Quantity Unit Unh Cost wn Total
MrSealinl
AIRSEALING 10 manhour $ 85.00 $ 850.00
WEATHERSTRIP DOOR&ADD SWEEP 3 each $ 80.00 $ 240.00
Air Sealing $ 1,090.00
Aa Sealing Incentive $ (1,020.00)
Air Selaing W%Balance $ 70.00
Weratherbatlon
ATTIC DAMMING-R-38 FIBERGLASS M42each
$ 2.05 $ 180.40
ATTIC FLAT-10"OPEN R-37 CELLULOSE $ 1.56 $ 1,029.60
ATTIC HATCH-SEAL&INSULATE $ 60.00 $ 120.00
FINISHED CEILING ACCESS $ 135.00 $ 135.00
SHEATHING ACCESS $ 35.00 $ 105.00
VENT BATH FAN THRU ROOF $ 118.75 $ 118.75
VENTILATION CHUTES $ 2.50 $ 220.00
CRAW15PACE WALL RIO RIGID BOARD $ 4.05 $ 170.10
Air Sealing W%Balance 1 lump sum $ ]D.00 $ ]0.00
Total Weatherization $ 2,148.85
Weatherization Incentive $ 1,611.64
Total Project $ 3,368.15
Tobi UUliry Contribution $ 2,631.64
Total Customer Contribution $ 537.21
wPPictorm PmaXun lnsblltluva,n[willpmmaetM ohne sWMnomwwwrwnnalywarwoamamblp w.nnry.
nwaonlna 'aackwa,n rwalakwassionIliksI all ninina-no labor[a o,wan .darks gMnonewmNanawnn distwowapwMacknsandalllwwand anu I ..,
n iounim a Inn.11 fmbatl Vow as Nba Mnin.
ACCEPTANCE of PROPOsAL'.The abbe riwa,specifoans and TOTAL CONTRACT VALUE a $ 537.21
mnanortawasanabnpryana aw newbyse'anea.vuuare
aoreonaento do work as spenaea.Payment wal be l/s down prarw Down Payment= Is 179.00 0
an orwork,and balance saw,C rrwenon. sun
2/
1 /i5P Balance Due Upon Completion= $ 358.21
2/0/2019
""e_ 2/8/2019
-I.—Ises,snownweas to.r.ummu mraram-,kele on.dass,- a.—ainnwe..b•a uwa.wwi --nava.'solIs-ebm---wwe on
W IS AGREEMEST IS COMPOSED OF MIS PAGE AND Me REVERSE SIDE OF THIS PAGE AND SHALL BE CONSIDERED THE F RI AGREEMENT BY THE PARTIES INVOLVED.TH1$MREEMEW IS
BETWEEN AMERICAN INSTALLATIONS,UL HEREINAFTER REFERRED TO AS'COMPANY',AND THE CUSTOMENSI NAMED ON THE REVERSE SIDE,HEREINAFTER REFERRED TOM'WENT,AND
WILL BE SUN EST TO ALL APPROPRIATE LAWS,REGULATOFS AND ORDINANCESOF THE STATE OF MASSACHUI OR CONNECTICUT RESPECTIVELY,AS WELL AS ALL LOCAL JURISDICTIONS
THE FOLLOWING TERMS AM CONDITIONS ALSO APPLY
I.THIS AGREEMENT IS SUBJECT TO THE APPROVAL OF A MANAGER Of ME COMPANY FOR THIS AGREEMENT TO BE EFFECTIVE UNDER ANY CONDITION,
3.SHWLD DEFAULT BE MADE IN THE PAYMENT OF THIS AGREEMENT,CHARGES SHALL BE ADDED FROM THE DATE THEREOF ATA MU OF ONE AND ONE HALF(1.1/I)PERCENT PER MONTH.
NB%PER ANNUM)WITH A MINIMUM CHARGE OF SQ W PER MONTH,AND IF PLACED IN TIE HANDS OF AN ATTORNEY OR COLLECDCN AGENCY FOR COLLECTION,ALLATTORNEYS'FEES,
EXPENSES AND CASTS 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 MAYS BECOME KNOWN TO THE COMPANY,ME COMPANY WILL ADVISE THE CLIENT AS SOON AS REASONABLE,
4.COMPANY AGREES THAT NOTVITHSTANOING ANY AGREEMENT FOR MATERIALS ANO/OR LABOR BETWEEN COMPANY AND THIRD PARTY,COMPANY IS RESPONSIBLE TO CLIENT FOR
COMPLETION OF ALL WORK DESCRIBED IN A TIMELY AND WORKMANLIKE MANNER.
5.ALL WARMWICS FOR EQUIPMENT AND PRODUCTS SUPPOED BY THE COMPANY UNDER THIS AGREEMENT SHALL BE THOSE GIVEN BY THE MANUFACTURERS OF SUCH EQUIPMENT AND
PRODUCTS UNDER SUCH MANDFARURIEWS WARRANTIES,THE HENT MAY BE REWIRED TO REGISTER OR MAIL IN A WARRANTY GRD OR OTHER EVIDENCE OF OWNERSHIP AND USE OF
SUCH EQUIPMENT AND/OR PRODUCTS IN CODER TO ACTIVATE SUCH WARRANTIES.
N THE QUOTATION ON THE PAGE HEREOF LUES 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
T.THE COMPANY'S UABILLry FOR CLAIMS ARISING OUT OF THIS AGREEMENT SHALL NOT EXCEED THE TOTAL AGREEMENT PRICE EXCEPT TO THE EKTENT MORE DAMAGES ARE PROVEN i0 BE
SOFTY WE TO THE CO RFANY S NEGUGENCE
0,CURING THE DURATION OF ME WORK,THE CLIENTS HOMEOWNERS INSURANCE WILL BE RESPONSIBLE FOR ANY AND ALL DAMAGES A$LONG AS THE COMPANY HAS TAXER THE
APPROPRIATE ACTION TO PROTECT AREAS OF WORK.
9.THE COMPANY IS NOT RESPONSIBLE FOR PREEXISTING DEFICIENCIES OR HAURDWS MATERIALS THAT MANIFEST THEMSELVES DURING ME CONSTALPI PROCESS.EG.WOOD ROT,
MOLD,ASBESTOS, HALL POPE.WCRVORK AND CONNECTIONS, PLUMBING AND VENT PIPES,DECKING DEFLECRCN,ETC.IF A PREEXISTING DEFICIENCY OR HPZANCYALS MATERIAL IS
ENCOUNTERED PRIOR TO OR DURING CONSTRUCTION,AND COMPANY IS NOTIFIED IN WRITING,COMPANY WILL TRY TO ASSIST CLIENT WITHIN ME COMPANY'S MEANS AND CAPABILITIES
TO CORRECT THE PROBLEMIS)ON A TIME AND MATERIAL PASS.CLIENT AGREES THAT SUCH CONDITIONS ARE UNAVOIOABLE BY THE COMPANY AND SHALL NOT BE CONSIDERED A
VIOLATION OF THE AGREEMENT AND THAT DUE TO THESE CONDRIONS THE DURATION OF THE WORK AND SCHEDULED DATE OF COMPLETION MAY DIFFER FROM MAT AGREED UPON,IF
APPLICABLE,UNDER THIS AGREEMENT.
ID,THE COMPANY IS NOT RESPONSIBLE AND THE CLIENT AGREES TO HOLD THE COMPANY HARMLESS,FOR ANY PROBLEMS AND/OR DAMAGES,INLCUDIW BUT NOT LIMITED TO MOLD
GROWTH,ARE&W FROM THE PERFORMANCE OF AIR SCALING WORK BY THE COMPANY ASA REWLT OF MY 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 ROTATING TO ICE DAMMING THAT MAY
ARISE WRING AND/OR AFTER THE PERFORMANCE OF WORK BY ME COMPANY.
13,REPLACEMENT OF OETERICRAM DECKING,FASCIA BOARDS,ROOF JACKS,VENTILATORS,FLASHING,RAFTERS,JOISTS,INSULATION OR OTHER MATERIALS ARE NOT INCLUDED UNLESS
OMERWLSE NOTED HEREIN.
13,THE COMPANY WILL NOT BE RESPONSIBLE FOR THE SCRATCHING OR DENTING OF INTERIOR WALLS AND CEILINGS,1100RS.THIS,CATERS, DOWNSPOUTS EXISTING SIDING AND
WINDOWS,DOORS,OIL DROPLETS IN DRIVEWAYS,HNRLINE FRACTURES IN CONCRETE OR BLACKTOP DRIVES AND WALKS,OR DAMAGE i0 PLANTS OR SHRUBBERY.IF EXCESSIVE DAMAGE IS
CAUSED BY COMPANY,COMPANY WILL REPAIR OR REPLACE DAMAGED AREA ONLY AT COMPANY'S EXPENSE.
14.THE COMPANY UNDER PROVISIONS OF CHAPTER LAI OF THE GENERAL LAWS IS REQUIRED TO APPLY FOR AND OBTAIN ALL CONSTRUCTIONRELATEDPERMITS.ME COMPANY SHALL NOT
BE DEEMED RESPONSIBLE FOR DELAYS IN THE WORK DESCRIBED IN MIS AGREEMENT CAUSED BY REGULOTAY PERMIT GRANTING OR INSPECTIONAL AGENCIES,AUTHORITIES,OR
INDIVIDUALS,
15.THIS AGREEMENT,INCLUDING THE PROVISIONS RELATING i0 PRICE AND PAYMENT SCHEDULE,CANNOT BE CHANGED OR ALTEREO EXCEPT BY A WRITTEN STATEMENT SIGNED BY BOTH ME
COMPANY AND THE NENE
I6.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.THIS AGREEMENT CANNOT BE CANCELLED WITHOUT ME MUTUAL WRITTEN CONSENT OF BOTH PARTIES EXCEPT AS OTHERWISE SET FORTH HEREIN,
18.THIS AGREEMENT,AND ANY WARRANTY)$)FRAM CES HEREUNDER SHALL NOT BE ASSIGNED EXCEPT BY OR WITH ME WRITTEN PERMISSION OF THE COMPANY.
19.IF THE CUEM FAILS i0 PERFORM THE OBLIGATION$HEREUNDER OR TERMINATES THIS AGREEMENT WITHOUT THE PRIOR WRITTEN CONSENT OF THE COMPANY,THE CLIENT SHALL BE
LIABLE FOR DAMAGES FORME GREATER OF THE COMPANY'S ACTUAL DAMAGES MIS%O ME AGREEMENT FOR RESTOCKING FEE.
IG.ANY CHANGES TO MATERIALS BY THE CLIENT BERAND,STYLE,COLOR,ETC)AFTER SAID MATERIAL HAS BEEN DELIVERED OR IS IN ROUTE TO THE CLIENT COULD RESULT IN AS%RESTOO(ING
FEE BASED ON THE COST OF SAID MATERNLS.
Il,MIS AGREEMENT SHALL BE EFFECTIVE ONLY UPON ITS MOUTON BY ALL PARTIES HERETO,PRIOR TO WHICH TIME IT SHALL BE DEEMED A PROPOSAL.ME COMPANY RESERVES THE RIGHT
TO REVOKE THIS PROPOSAL 90 DAYS FROM DATE R 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 SO DAYS,AND IN ME EVENT COMPANY DOES NOT REVOKE THE PROPOSAL COMPANY RESERVES THE RIGHT TO KIDS F 14 PRICE IN
ACCORDANCE WITH RS CUTS IN EFFECT AL SUCH TIME.
II.IF ANY PRWISION OF MIS AGREEMENT SHOULD BE HELD TO BE INVALID OR UNENFMCABLE.THE VALIDITY AND ENFORCEMLTY OF ME REMAINING PROVISIONS OF THIS AGREEMEW
SHALL NOT BE AFFECTED THEREBY.
33.ARBITRATION:IN ME EVENT ME CLIENT AND COMPANY HAVE DISPUTE REGARDING ANY OF THE TERMS,CONDITIONS,PROVISIONS,OR PERFORMANCE OFMI$AGREEMENT,THE PARTES
AGREE TO PLACE THE MATTER INTO ARBITRATION BEFORE AN INDEPENDENT ARBITRATOR ASSIGNED BY THE AMERICAN ARBITRATION ASSOOATION TO RESOLVE THEIR DISPUTE,
14,AW DISCOUNT,PROMOTION,REIMBURSEMENT,OR OFFER PROGRAM THAT IS PAW OF A STATE SPONSORED UTILM PROGRAM BE MASS SAVE`)IS SUBJECT TO THE AVAILABILITY OF
CAL INCA STATE SPONSERED PROGRAM AND WILL BE SUN ECT TO TERMINATION IF THE STATE SPONSERED UTILITY PROGRAM IS CISCdINTWUED,FURTHERMORE,THE TERMS AND
CONDITIONS OF STATE SFONSERED UTILITY PROGRAMS MAY BE ALTERED OR UPDATED PERIODICALLY WITH OR WITHOUT NOTICE.
I5.AMERICAN INSTALLERS,LLC IS NOT AN MEW OF ANY UTILITY COMPANY OF OMEN VENDOR WORKING BY,THROUGH,OR UNDER THE MASS SAVE'ENERGY PROGRAM.
26,CLIENT IS REPSONSIBLE FOR ME PAYMENT OF ANY AND ALL FEDERAL,STATE,OR LOCAL TAXES THAT ARE APPLICABLE TO MIS AGREEMENT.
The Commonwealth ofMassachuseas
Department of Industrial Accidents
Office of Investigations
wi 600 Washington Street
Boston,MA 01111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Businesdorgani,aGomindividuap: 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):
1.9 1 am a employer with 60 4. ❑ I 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 parmer- listed on the enriched shed.1 7. ❑Remodeling
ship and have no employees These sub-contactors 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.❑ I am a homeowner doing all work right ufexemption per MGL I I.❑ Plumbing repairs or additions
myself[No workers'comp. c. 152,§1(4),and we have no 12.0 Roofrepairs
insurance regnired.1 t employees. [No workers' 13.®Other Insulation
_ comp. insurance required.] '- —
'Any appliant that clerks box al must alio IID wa im section blow showing their worman aewfom
mptiun Mlky Inmtion.
t Nomawten wM10 submit thu aRidavit indicating Is,arc doing all warb am then hire.needc evmmchon must submit u new iandwit mdlcaning such.
eNnoacmrslhatcMrk this box muatnmehcl an Wditbnal shat showing rbc mine of Nx subconttecsors aM they wwluns'cmnp.1plicy int cion.
1 am an empkyerlhm is providing workers'rompemadon lnsurauce formy employees. Below is the policy and job sae
information
Insurance Company Name:—Gu—
Policy
ame: GuPolicy h or Sel&ins. Lic.9 URnWC609917 Expiration Date: 09/04/2019
Job Site Address: I � �"�/ K"JW Y aoaa City/StmefZip:-T--1 rat r/,� G)5z2.
Attach a copy ofthe 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 Families of a
fine up to$1,500.00 mid/or one-year imprisonment,as well as civil penalties in the form ofa STOP WORK ORDER and a fine
of up to 5250.00 a day against the violamr. Be advised that a copy of Chis statement maybe forwarded to the Office of
Investigations ofthe DIA for insurance coverage verification,
I do terebyy ceQ(Jrtify under nee punninx a/nJApenalliLer.ofperjury that eke infonsubdon provided above is true and correct.
itinjulre, U ( .r9dt�,Ll/TSI�
Phone u, - 413-55f0200 1Tf'-
QQfeial use only. Do not more in this area,to be conplded by city or town official
City or Town: Permit/License p
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Persian: Phone d:
Coffin n"atlh of Massachusetts Oora bootion Supervbar
Division of Professional Licensure Unrastrbtad-Susdkrgs of any sa group vd9ch mntaln
Board of Building Regulations and Standards Ins than sailed cook W(891 cubic mNere)ofencbsed
Construction Supervisor ip1CC0.
CS-106178 E;pires:09/29/7019
WESLEY COUTURE M1 _
218 LATXROP-4TREET �'
sovrx aaA ohne
poses•sraMt adtleo/Me Mssachusela
n Stwe BldiMrtS Code bcause for revocation ofthb Sans.
Far Infornrtlen abmd Iris acense
Commlaalanar ✓"� Cas(617)72742H or vIM vrawmas4pv/dpi
v
n�fe- �a�rryrta�rr«er+�rl� n�C-/l/1�19�rr�,rciel�.l
- i Office of Consumer Affairs and Business Regulation
10 Park Plaza- Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Typd: LLC
AMERICAN INSTALLATIONS,LLC. Re Oratlon: 175882
130 COLLEGE STREET SUITE 100 EReg
08/28/20/9
SOUTH HADLEY,MA 01075
Update Mdressandralumnrd. MMkraaaunforehansa.
SCp1 tl xoM05/n
n Add:r� n P�•_..t IIEmplOymani []last Card
p3eaotE IMPROVEMENT
CONToeRpulellon
HOME IMPf10TYK:L CONrpgDTOR Registration Vr for IndW{duN usa only
TYPE:LLC O tua r Conixoner data. I d nd Business ro:
� 7') EI@Imtl90 101c iCOnsmn Alalrs grid Business RgNelon
>rs;,. 174982 03!26/2019 10 PMk Placa-Suks 6170
AMERICAN INSTALLATIONS,LLC. Boston,MA 02116
WESLEY COUTURE C�
130 COLLEGE STREET SUITE 100
SOUTH HADLEY.ISA 01075 Undersecretary 111161
Valid Withbut Signature
CERTIFICATE OF LIABILITY INSURANCE
9/4/]019
TIES CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO MOMS UPON THE CERTIFICATE HOLDER THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, E)rFEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE BELONG MSUREN(S), A JTHO D
REPRESENTATIVE OR PRODUCER,AND INE CERTIFICATE HOLDER.
IMPORTANT: E Me ewMi m holder Is an ADDITIONAL INSURED,the pollcy(ls)name be alldelre. N SIEROGATION IS WAMED,"bled!lo
Ute terme and 00WHIO la of Ow policy,cwtIan polkMs may regWm an ondom melt A Wtwlent on tlde OwBEeW dos not confer dolds to One
vardflMe holder in lleuolau0h s.
N Olfl via I..
Nehhsr 4 Oilnnell (413)596-0111 IM MAIM....
9 North A131E ELHet n ,SDORei9E919bbei90dBi1®911.COe
wpl AMp19M10 9
Wortha.pt. IIA 01060 a4kadIA'XIII Netaal CAeYalt
a8la. ReR Olarlulii Mthmamw SIGNED IOa. Co.
Asailoan IaetallatLoce, e.Tr aNtimc,
Attar Nn,. A SuaeOce Coctuia
130 Colleen, Street, Suits 100 RGE.
South Hadley M 01075
COVERAGES CERTIFICATE HUNGMR: tn,r Bad, 9-2019 REVISION HUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSMED IMAM ABOVE FOR THE POLICY PERIOD
INDICATED. NOTVIIIHSTANDINO ANY REQUIREMENT,TERM OR CONOIT ON OF ANY CDNmACT OR OTHER DOCLAENT WITH RESPECT M WHICH THIS
CERTIFICATE MY BE ISSUED OR AMY MUNN,THE INSURANCE AFFORDED BY THE POUCIES DESCRIBED HWIBN IS SUBIECT TO ALL THE TERMS,
EXCLUSIONS AND OONDIMNS OF SACH POLICIES.MITE SIIDVrN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
TROT FNDGXR ER . LRtta
WOfIQeWaAL.110M EALl�CW1PFI91.E f 11000,000
A Z CLAIMHIMLIE D It 500,000
W3333217 9/5/201, 9/1/2019 L09 EMP f 10,000
PeNONnL a MY MIRY f 11000,000
OFN.Ap .AWpIUUppM�TAfVl1EM: ODpU QRIYMTE , 2.000,000
2 PgM;v�JEC! E:1NpO pRlD11L'19-CO,pgp AOp F 21000,000
s
ADTDY .LMWT f 110001000
A NIYAUIO 9NILv lwum(R,Pti'n) a
Z � 0 912539]17 9/512010 9/4/2019 anOtya NwY1M,asbny f
2 WNEDAVr09 Z NONOM® DYIIGE f
• Ctllf20b Z CORY M,Wp RPf 9.000
Z 11119mW'LW OCCOn FIGHOCpaRQ44 f 11000,900
A �' �� CUIx9IM0E AOOREpATE f X10001000
Z10.000 503999]17 ./✓2019 914/2019 1
D
maW COIMMAIICII 9
NIaI/LOYeM'MRGrtY Y/N
. Ncanpaa,an PAgrxalOEIlEW1ry£ E.L EICX.VU'OBIT f 500,000
OFpay0.yaNHFR g0.11pEq x/A
8 OMtl1Y,TMNp m�g609937 9/4/201e 1/5/2039 E.L IMaFA9E-FAE , 50000
n 99Bne9 OF
E.L WME a $00,00
A 0."2 pcoyarty S 335217 9/4/2018 9/412019 S�9xal4il,tla
OACItI1NIN OF 01fl1ATAN9/LOGTNNN/YWCLN(ACORU1w.A0aMW M,rYxf[bWX x/MxY4xCXsnxpwY,yM,M
crn,nF[CATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DE9CNwE0 POLICIES BE CANCELLED BEFORE
Baldn,t]ge Of Insurance THE EXPIRATION DATE THEREOF. NOME WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
A09101%1=RFGtlwITAIVE // n
H Gunnell, CPCU, C1C L✓^ll-�— � Y' I'
0188&2014 ACORD CORPORATION. All Nghb n»arved.
ACORD 2$(201"1) The ACORD name end logo w YeSbiwatl marlw of ACORD
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