37-081 (2) 60 PLATINUM C1R BP-2019-1010
GIs 4: COMMONWEALTH OF MASSACHUSETTS
Map Block:37-081 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Categm-v INSULATION BUILDING PERMIT
Permit BP-2019-1010
Project d JS-2019-001663
Est.Cost. $2600.00
Fee: 565.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: AMERICAN INSTALLATIONS LLC 106178
Lot Size(so. It.): 30753.36 Owner: NNAJI PATRICIA
Zoning: Applicant: AMERICAN INSTALLATIONS LLC
AT.- 60 PLATINUM CIR
Applicant Address: Phone: Insurance:
130 COLLEGE ST --(413L552-0200 WC
SOUTH HADLEYMA01075 ISSUED ON.•3/19120I90:00:00
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: Housed 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 sig t e:
FeeType: Date Paid: Amount:
Building 3/t9/20190:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
EIVED 6P 14, toto
City of Northampt
Building DepartmL17MAR
1 2619212 Main Stree ��AT
Room 100OcI:uu ni INBP CNorthampton, MA 0I.1.nW7 MAOtilad l
.... phone 413-587-1240 Fax 413-587-1272 ONLY
APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING ONLY
SECTION I-SITE INFORMATION INSULATION PERMIT
1.1 Property Address: This section to be cornpleQted by Mlle
,� 0
60 Platinum Circle Map 7 Lot Lo / Unit
Florence,MA 01062 Zone _ Overlay District
Elm St DlsWct CB DIahIR
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Nnaii Patricia P.0 Box 462 Northampton MA 01061
Name(Phot) Current Meiling Address:
See attached (4131230-1096
Telephone
Signature
2.2 Authorized Agent
American Installations 130 College Street Ste. 100 South Hadley, MA 01075
Name(Phnp Current Mailing Address'.
(413) 552-0200
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
com Ieted by pernifitacolicant
1. Building $2,600.00 (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 8
3. Plumbing Building Permit Fee /
4. Mechanical(HVAC) ('
5. Fire Protection l7
6. Total=(1 +2+3+4+5) $2,600.00 Check Number y
This Section For Official Use On
Da e
Building Permit Numb
e . Issued: Q ��jj p
Signature: ✓ -I D-zU 1 /
Bustling Commhsionemnspecmr of Buildings (� Date
V
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 4-CONSTRUCTION SERVICES
8.1 Lie ensed Construction Supervisor: Not Applicable ❑
Name of License Holder: Wesley K. Couture 106178
License Number
130 College Street Ste. 100, South Hadley MA 01075 912912019
Address Extortion Date
(413)552-0200
Signature Telephone
9.Registered Home Improvement Contractor. Not Applicable ❑
American Installations 175982
Company Name Registration Number
130 College Street Ste. 100, South Hadley MA 01075 612612019
Address 1�_U. Expiration Date
U�cs k &W—UA-1 Telephone (413) 552-0200
SECTION S.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....... FJ No.._.. ❑
Brief Description of Proposed Work [RUT-E.- INSULATION ONLY
Attic and basement insulation and air sealing throughout.
1, Wesley K. Couture as Owner/Authorized
Agent hereby dedare that the statements and infounatien on 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
W C;MITIj i 3/11/2019
SignaWre of r/Agent Date
I, Nr i Patricia 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 3/11/2019
Signature of Owner Date
City of Northampton
Massachusetts
( q
12;12 Min
OF n8 Mnxca Zl Building
\ 212 MSn 8teaat • l re, 010 Building
anrthampton, MA 03060 Ryr'�ij\\a
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
performing work on such homes,a contractor must be registered as a Home Improvement Contractor("HIC").
M.C.L. Chapter 142A requires that the`reconstruction, alteration, renovation, repair,modarniratlon, conversion,
improvement,removal,demolition, or construction of an addition to any pre-existing owner-occupied building containing
at least one but not more than few dwelling units....or to structures which are adjacent to such residence or building"be
done by registered contractors.
Note:If Me homeowner has contracted with a corporation or LLC,that entity must be registered
Type of Work: Insulation Est.Coat: $2,600.00
Address of Wmk: 60 Platinum Circle Florence MA 01062
Date of Permit Application: 3/11/2019
I hereby certify that:
Registration is not required for the following reason(s):
_Wmk excluded by law(explain):
Job under$1,000.00
_Owner obtaining own permit(explain):
_Building not owner-occupied
x Other(specify): Contractor ding permit for homeowner
OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED
CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT
ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND
UNDER M.C.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILFIES 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:
3/11/2019 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
"
Massachusetts
DEPARTfffiiT OF HpISDING ZNHFECTIONa _ -
212 IYin 9tzaat Z.ipal Building
NaitLampten, M D1060
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:
60 Platinum Circle
(Please print house number and street name)
Is to be disposed of at:
Waste Management of New Cngland, Chicopee MA01020
(Please pont name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
LJc —
Signature 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.
3�D www.Ame,la.nm.r,ll.annemm
BBS Lice sed&Insured
\ MA CSL F 105]]8
American Installations MA RegisfmNanYll598x
1]p Ullge yrMSulre z00 SouN IYaler,rARD1Ws.OIfl<a:lu]I SS]LHp Nc lax]IssxOx02. [man:auppw�lAmMonlnabl480ntcwn
Nnaji,Patricia 12/27/2018
60 Platinum Circle Florence MA 01062
nr
1413)230-1096 4132301096LBwan.not vn
477830 18-3696
v a Quantity Urn Unit Cost + Total
Air Sealing
AIR SEALING 10 man hour $ 8500 $ 850.00
WEATHERSTRIP DOOR&ADD SWEEP 1 3 leach $ 80.00 15 240.00
Air Sealing $ 1,090.00
Air Sealing Incentive $ (1,020.00)
Air Selaing W%Balance $ 70.00
Weathertration
ATTIC FLAT-71 OPEN R-26 CEUU LOSE 860 jqft $ 1.38 $ 1,186.80
SHEATHING ACCESS 1 each $ 35.00 $ 35.00
ATTIC HATCH-SEAL&INSULATE 1 each $ 60.00 $ 60.00
BASEMENT-INSULATE BULKHEAD D00R&INSULATE 1 each $ 110.00 $ 110.00
ATTICDAMMING-11-38 FIBERGLASS 18 sqR $ 2.05 $ 36.90
Air Sealing W%Balance 11um sum $ 70.00 $ 70.00
Total Weatherizalion $ 1,498.70
Weatherization Incentive $ 1,124.03
Total Project $ 2,518.70
Total Utility Contribution $ 2,144.03
Total Customer Contribution $ 374.68
nun n . rmn.,ucww praaaan.amw:mannm.own.rwnnaxror+wnm,na,iP w.n.nq.
AMHk
uc 46M wnoow,torimuhIII mtlenal anaubwmenmoMa.an.abcv.Stype Mworkm uwN.nu wlman.aMv<:pttabtlnn..na anlwlane:ub
e.na ry•r.NMlona ro.me rw I mm,.rt v.lu.w saee n.rtm.
ACCf WANCE Df PecLeAC me alone price,rPecflanomentl TOTAL CONTRACT VALUI $ 374.68
cone'....ere utishnory aneart M1ercbyaaepad Youart
eothonzed[ ao wmkeapedfied P.,—,,will be 1p down prbr Down Payment= $ 106.00 ❑
w stanol work.and Wlena d,e upon CompMion PA.c
/"Gj} Balance Due Upon Completion= $ 274.68
a... Nnaji,Patricia / w 12/27/2017
w-n B.Zamer 6. Zancr 12/27/2018
THIS AGREEMENT IS COMPOSED OF THIS PAGE AND THE REVERSE SIDE OF THIS PAGE ANO SHALL BE CONSIDERED THE ENTIRE AGREEMENT BY THE PARTIES INVOLVED.THIS ,
AGREEMENT IS BETWEEN AMERICAN INSTALLATIONS,DEC HEREINAFTER REFERRED TOM-COMPANW,AND THE CUSTOMER(5)NAMED ON THE REVERSE SIDE,HEREINAFTER
REFERRED TOM"CLIENT",AND WILL BE SUBJECT TO ALL APPROPRIATE LAWS,REGULNTIONS ANO ORDINANCES OF THE STATE OF MASSACHUSETTS OR CONNECTICUT
RESPECTIVELY,AS WELL AS ALL LOCALJURISOICTIONS.
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 THE DATE THEREOF ATA RATE OF ONE AND ONE-HALF(1-1/2)PERCENT
PER MONTH. (18%PER ANNUM)WITH A MINIMUM CHARGE OF$200 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 RIGHF TO A 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 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 WARRANIY CARD OR OTHER
EVIDENCE OF OWNERSHIP AND USE OF SUCH EQUIPMENTANO/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.
T.THE COMPANY'S 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 COMPANY'S NEGLIGENCE.
8. DURING THE DURATION OF THE WORK,THE QUENT'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.
W00D ROT,MOI,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 PROBLENI 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.
30,THE COMPANY IS NOT RESPONSIBLE,AND THE CLIENT AGREES TO HOLD THE COMPANY HARMLESS,FOR ANY PROBLEMS AND/OR DAMAGES,INCOMING BUT NOT UMITED
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 ANO/OR AFTER THE PERFORMANCE OF WORK BY THE COMPANY.
12.REPLACEMENT OF DETERIORATED DECKING, FASCIA BOARDS, ROOF JACKS, VENTILATORS, FVSHING, RAFERS, 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 WALE AND CEILINGS,FLOORS,TRIM,GUTTERS,DOWNSPOUTS,EXISTING SIDING
AND WINDOWS,DOORS,OIL DROPLETS IN DRIVEWAYS,WIIRLINE 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.
14.THE COMPANY UNDER PROVISIONS OF CHAPTER 142A OF THE GENERAL LAWS IS REQUIRED TO APPLY FOR AND OBTAIN ALL CONSTRURION-REIATED 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 INDIVIDUAIS.
15,THIS AGREEMENT, INCLUDING THE PROVISIONS ROUNDING 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.
1I.THIS AGREEMENT CANNOT BE CANCELLED WITHOUT THE MUTUAL WRITTEN CONSENT OF BOTH PARTIES EXCEPT AE OTHERWISE SET FORTH HEREIN.
18,THIS AGREEMENT,AND ANY WARRANTY(5)PROVIDED HEREUNDER SHALL NOT BE ASSIGNED EXCEPT BY OR WITH THE WRITTEN PERMISSION OF THE COMPANY.
19, IF THE CLIENT FAI6 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,MILE,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 IT$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 BYTHE 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 RIGHTTO REVISE ITS PRICE IN ACCORDANCE WITH ITS COSTS IN EFFECTATSUCH TIME.
22, IF ANY PROVISION OF THIS AGREEMENT SHOULD BE HELD TO BE INVALID OR UNENFORCABLE,THE VALID"AND ENFORCEBIUTY 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 B E,MASS SAVE')IS SUBJECT TO THE
AVAILABILITY OF QUALIFYING STATE SPONSERED PROGRAM AND WILL BE SUBJECT TO TERMINATION IF THE STATE SPONSERED UTILITY PROGRAM IS DISCOUNTINUEO.
FURTHERMORE,THE TERMS AND CONDITIONS OF STATE SPONSERED UTINY 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 REPSONSIOLE FOR THE PAYMENT OF ANY AND ALL FEDERAL STATE,OR LOCAL TAXES THAT ARE APPUCABLE TO THIS AGREEMENT.
The Commonwealth of Maselackneens
Department of Industrial Accidents
Ogee of Investigations
wi 600 W"hington Street
Boston,MA 02111
wivw.rnassgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le 'bl
Name(Business/OrganintioNlndividual): 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):
I.O 1 am o employer with 60 4. ❑ I am a general contractor and 1 6. ❑New construction
employees(full and/or pan-lime).' have hired the sub-contractors
2.❑ 1 am a sole proprietor or punnet- listed on the attached sheet 1 7. ❑Remodeling
ship and have no employees These subcontractors have 8. ❑ Demolition
working for me in any capacity. workers'comp. insurance. 9, ❑ Building addition
INo workers'comp. insurance 5. ❑ We are a corporation and its
required.) officers have exercised their 10,L] 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. a 152,§1(4),and we have no12.❑ Roof repairs
insurance required.]t employees. [No workers'
_ comp.insurance required.] 13.®Other Insulation
'Any applicant that checks box#I mail atro fill not xxown blow showing thin worsen'com onsaion polity infomndon.
t Ilam mix..who submiuhis alba il'mdiwting tbvy arc doing all nay,end thin him onside cummmms muse submit o new alralavit nal.hng loch.
lComm o s not clack this box must attached an additional sheet showing the name or the ios m aa:mrs and front wmkct'comp. lay milosm mm.
I am an employer that is providing workers'compemadon/murancefor my employers. Below is the policy and job site
Informadmc
Insurance Company Name: Guard Insurance Companies
Policy#or SelRins. Lic.9:n URWC609917Expiration Date: 09/04/2019
Job Site Address: � Pt P nt Vt�vt l ala City/state/zip:—N.AM
Attach a copy of the workers'compensation policy declaration page(showing the policy re,an r and ex iratiun 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 ofa 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 w the Office of
Investigations ofthe DIA for insurance coverage verification.
I do hereby cenlfy,under the pains and penalties of perjary that the information provided above is true and correct.
ignaturc,pAdxltv raulzs� Dow
3
/ 61 .
Phone N: 413-55 -0200
Oficial use only. Do not write in this area,to be completed by city or town ofJiciaf
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.Cityrrown Clerk 4. Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone#:
Commonwealth of MassachusettsColuiradilon Supervisor
®; Division of Professional Licensure Unrestricted-Buadings of any um group wMeh rwraaln
Board of Building Regulations and Standards less than 36'000 MING feet(est Crbo adlenai of a IOMd
Construction Supervisor egace
CS-108178 EXpirea:09/29/2019
WESLEYCOIAURE
718 LATHROKSTREET
SOUTH HAOLEY-MA 01076
Fanun w pomns a avant omm ofthe Mmmctssedat
State Building Cada is cause for rmosatlon ofthis Scans.
!/f—� For Indarresrbn seotd dela Bcarw
Commissioner Call(817)727X200 or visit wwwmass.govldq
� � n�fn- tlla�rt-iytn�tr«e�r�l� a�C� 1:1cr��rc.ief�:l
I
Office of Consumer Affairs and Business Regulation
*s 10 Park Plaza- Suite 5170
Boston, Massachusetts 02116
Home improvement Contractor Registration
.. Type: LLC
Registration: 175982
AMERICAN INSTALLATIONS,LLQ
Eq�iradon: 0&2827019
130 COLLEGE STREET SUITE 100 -
SOUTH HADLEY,MA 01075
Update Address and Mum and. Mer,Mason for cMnga.
SCAT o mrn.11 n Addr p o�.....M C2 Employment 13 Lost Cord
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`f, 1 HOME IMI+ROAMMENT CONTRACTOA Registration veld far Individual se oNy
TYPE:LLC 1Htore the operation sera. dfound Mum m:
1^` f I' gplM[MgO Expirationu Offlof Consumer Affairs alt Business Regulation
`c >`r 175982 06/202019 loped Nsa-Sulte5l"
AMERICAN INSTALLATIONS,LLC. Boston,NA Sells
WESLEY COUTURE
130CO'LPGE STREET SUITE 100 J wand withoul8l signature
SOUTH HADLEY.MA m075 Undersecretary 9
A>d CERTIFICATE OF LIABILITY INSURANCE 9/6eW2'0'1e
THIS CERTIFICATE 13 ISSUED AS A MATTER OF MFOIN/ATIOPf ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY ABE ND, On END OR ALTER THIS COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING M9WER(SB AUTHORISED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
OWO"T -. N Ne confiscate holder 16 an ADDITIONAL INSURED,the pBMy(Ha)much be endorsed. N SUBROGATION N WANED,subod to
the Nermf and eerMldon,of to policy,cwWn policies may raqulm all endMemNlmtl. A eWement On this 08N11CMe does not copier r!"to Ile
curtness,holder In IMu of much andp
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Anna Was 6 9eeenua conic. p;
130 College Street, quite 1DO
South Badly Y 01073
COVERAGES CERTIFICATE NUMWR:Neeter >dm 9-2019 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE USTEO BBA.HAW:BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE PORTLY PERIOD
INDICATED. NOTWTTHSTANNNO ANY PEOUPFMEM,TERM OR CONDIITON OF ANY CONTRACT OR OTHER DOCUMENT WITH RE9PEi:T TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE rotJDIES DESCRIBED HEREIN IS SUBJECT TO ML THE TEITN9.
MMUSSJNS AND CONDITIONS OF SWI POLJCIES.LIMITS SHOVM NAY HAVE BEEN REDIICAD BY PMD CWIAS.
R.. Treawas 1YRd or' Wle
WYYeRCIK ONOAI Wmury BCH OLLI i 1,000,000
A Z C,Am&. Ef 500,000
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PERSONAL,AUVINA " f 1,000,000
oENLA001EWTE u1rt REPLIES P91: OEHER.LL AOOI®ATE i 1.000,000
i PCIA:Y�JJELR ❑I 111on11CIf.Ld1P,VP/,nn t 2,000,000
t
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