29-539 (3) 42 INDIAN HILL BP-2019-1034
GIs#, COMMONWEALTH OF MASSACHUSETTS
MaR.Block:29-539 CITY OF NORTHAMPTON
Lot-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit. Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cateeory� INSULATION BUILDING PERMIT
ermit# BP-2019-1034
Project# JS-2019-001691
Est. Cost: $1600.00
Fee $65 00 PERMISSION IS HEREBY GRANTED TO.-
Const.
O.Const.Class: Contractor: License:
Use Group: AMERICAN INSTALLATIONS LLC 106178
Lot Size(sq. 111 12675.96 Owner: MARTINEAU STEVEN&HOLLY A
Zoning: Applicant: AMERICAN INSTALLATIONS LLC
AT: 42 INDIAN HILL
Applicant Address: Phone: Insurance:
130 COLLEGE ST (413) 552-0200 WC
SOUTH HADLEYMA01075 ISSUED ON:3/21/20190.00:00
TO PERFORM THE FOLLOWING WORKATTIC INSULATION AND AIR SEALING
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 TIIE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
FeeType: Date Paid: Amount:
Building 3/21/20190:00:00 $65.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
Iq-0$q$- R zP [q,pw
l� � y
City of Northampton
RECEIVED °e
— Oullding Department
212 Main Strec t MAA 22 19 J LA T
;'.• � - Room 100
9
Northampton, MA 106 ��
�.; phone 413-587-1240 Fax 13-5r@3. � lnar, NsaFctlons
n0�nr rA'<�rP7on ednmaab
APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING ONLY
SECTION 1 -SITE INFORMATION INSULATION PERMIT
This section to be completed by mice
1.1 Fromm,Address'.
42 Indian Hill Road Map I Lot _Unit
Florence, MA 01062 Zone Overlay District
Erin SL District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Martineau Holly&Steven 44 Indian Hill Road Florence MA 01062
Name(Pring Gu(413)4331�rara Ma"I Atltlre-562ss8:
See attached Telephone
Signature
2.2 Authorized Agent:
American Installations 130 College Street Ste. 100, South Hadley, MA 01075
Name(Print)� /+ Current Mailing Address'.'e CPTi 1 UIf - (413) 552-0200
Signature J Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by Permit applicant
1. Building $1,600.00 (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
ConstruRion from 8
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protechan
6. Total=(1 +2+3+4+5) $1,600.00 Check Number
This Section For ORkial Use Only
Data
Building Permit Number: Issued'.
Signature: 1z ? 3 ' Z(} -Zoi9
Building Commissionedlmpector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 4-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Nameorueanss Hali Wesley K. Couture 106178
License Number
130 College Street Ste, 100, South Hadley MA 01075 912912019
Address Expiration Date
��gy�l k a �, �t� �9 , (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 Hadl ey MA 01075 612612019
Address Expiration Date
V- Telephone (413) 552-0200
SECTION S.WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.C.161,§25C(61)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this a(fdavit will result
in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes...... X No.. . ❑
Brief Description of Proposed Work NOTE: INSULATION ONLY
Attic insulation and air sealing throughout.
1, Martineau,Holly&Steven/American Installations as Owner/Authorized
Agent hereby declare that the statements and information on the foregoing application am true and accurate,to the best of my knowledge
and belief.
Signed under the pains and penalties of pegury.
Wesley K. Couture
pPrint Name
04� �lAt` Il 3/16/2019
Signature of /Agent Date
Martineau, Hotly&Steven as Owner of the subject
property
hereby authorize American Installations
to @\ct on my behalf,in all matters relative to work authorized by this building permit application.
I, )r(, V-72,17" 3/16/2019
Signature of Date
City of Northampton
Massachusetts
sc
232 Nein MunicipalBuildingNorthan,ton, m 01060 y Cn
StreetAFFIDAVIT
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 fancily homes. Prior to
performing work on such homes,a contractor must be registered as a Home Improvement Contractor("HIC").
M.G.L. Chapter 142A requires that the"reconstruction, alteration,renovation,repair,modernizffibn, conversion,
improvement,removal, demolition, or construction of an addition to any pre-existing owneroccupied 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:lfthe homeowner has contracted with a corporation or LLC,that entity must he registered.
Typeof Work: Insulation Est.Cost: $160000
Address of Work: 42 Indian Hill Road
Date of Permit Application: 3/16/2019
I hereby certify that:
Registration is not required for the following reason(s):
_Work excluded by law(explain):
—Job under S 1,000.00
_Owner obtaining own permit(explain):
_Building not owneroccupied
x Other(specify): Contractor pulling perm it 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.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:
3/16/2019 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
/ .d'. ..I. iy5•Y fC
rQ889dChY8EYt8
F
➢212 bftEs OF BUILDING INSuildin N8
212 lLin Stva.t •xnniclpal a�iltling
�.,,. xarU.vQtwn, e9. 01030
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:
42 Indian Hill 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 If
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.
; "► www.Amenr,nlnn,llxlonsso,n
BBB. �C Licensed&Insured
® \ Ma CSL p';06lAmerican Installations Ma Se9isnonma 75982
zao calve soeetmrce xoo,somx ruakr,xu osazs.Ohre:l+lsl ssx.mm h.:Hzs)sszNoz. Email:o:oPortlanean nammums.[mm
Martini Holly&Steve 3/11/2019
42 Indian Hill Road lFa Florence MA 01062
4134335628 hacoopermanineau@gmaii.com w
�
481932 �r,�l �+� 19 0898A
an.oi Ouantlly Unit Unit Cort Total
rAIALIN
It G 6man hour $ 85.00 $ 510.00
WEATHERSTRIP DOOR&ADD SWEEP 1 learn $ 80.00 $ 80.00
Air Sealing $ 590.00
Air Sealing Incentive $ (590.00)
Air Selaing W%Balance IS -
Weatherizatlan
ATTIC HATCH-SEAL&INSULATE 1 leach $ 60.00 $ 60.60
AMC FIAT-5"OPEN R-19 CELLULOSE 560 Ill $ 1.26 $ 705.60
ATTIC DAMMING-R-38 FIBERGLASS 60 sqk $ 2.05 $ 123.00
VENTILATION CHUTES 48 each $ 2.50 $ 120.00
Total Weatherizalion $ 1,008.60
Weatherization Incentive $ 907.74
Total Project $ 1,598.60
Total Utility Contribution $ 1,497.74
Total Customer Contribution $ 100.86
WwRMxn:sul mall al LLC all PAlla,me wri NtM xomwwnnv,the s wer—kille,xlp IamotV.
meX[a .—presser,ILC Isp, rn fune ll mMennles lINanmi m.......
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rawlmon,w,u,Telwnvauvelpeenaashers
AMEmANCEOFPROPCSAL OIl prices,sPeanauoos and TOTAL CONTRACT VALUE= $ 100.86
roneoons are mwectul ne arc xereeyaccePree.yo.are
,nmonreameawo•Lassl uee.1wrr:enrw'xleex/3eewn P•lo•m Down Payment= $ 33.00 Ear,
son or won,,na mune eve upon wmq=uon. Palo
Balance Due Upon Completion= $ 67.86
L3/11/2019
ri
�^^ 3/11/2019
THIS AGREE MEW IS COMPOSED OF THIS PAGE AND THE REVERSE SIDE OF THIS PAGE AND SHALL BE CONSIDER EO THE END RE AGREEMENT BY THE PARTIES INVOLVED.THISAGREEMENT 15 ,
SETW EENAMERIUN INSTALLATIONS,LLC HEREINAFTER REFERRED TO AS"COMPANY",AND THE CUSTOMEREM NAMED ON THE REVEREENSE,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 IURISDICTION,
THE FOLLOWING TERMS AND CONDITIONS ALSOAPPLY
1.THIS AGREEMENT 15 SUBJECT TOTHE APPROVAL DFA MANAGER OF THE COMPANY FOR THIS AGREEMENTTO BE EFFECTIVE UNDER ANY COMMIT ON
2.SHOULD DEFAULT BE MADE IN THE PAYMENT OF THIS AGREEMENT,CHARGES SHALL BE ADDED FROM THE DATE THEREOF AT A.OF ONE ANO ONE HALF 11/21 PERCENT PER MONTH.
JIM PER ANNUM WITH A MINIMUM CHARGE OF 52 OU PER MONTH,AND IF PLACED IN THE HANDS OF AN ATTORNEY OR COLLECTION AGENCY FOR COLLECTION,ALL ATTORNEYSFEB,
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 HOW TO A LEIN ON THE PROPERTY.
3.THE COMPANY AGREES THAT WHEN DECAYS BECOME KNOWN TO THE COMPANY,THE COMPANY WILL ANISE THE CLIENT AS SOON AS REASONABLE.
A.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 A TIMELY AND WORKMANLIKE MANNER,
S.ALL WARMNTIES FOR EQUIPMENT AND PRODUCTS SUPPLIED BY THE COMPANY UNDER THIS AGREEMENT SHALL BE THOSE GIVEN BY THE MANUFACTURERS OF SUCH EQUIPMENT ANO
PRODUCTS.UNDER SUCH MANUFACTURER'S WARRANTIES,THE CLIENT MAY BE REQUIRED TO REGISTER OR MAIL IN A WARRANTY CARO OR OTHER EVIDENCE DF OWNERSHIP ANO USE OF
SUCH EQUIPMENT ANO/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
ACTITCNAL EXPENSES,PREMIUMS OR COST SHALL BE ADDED TO THE TOTAL AGREEMENT AMOUNT
).THE COMPANY'S LIABILITY FOR CLAIMS ARISING OUT OF THIS AGREEMENT SHALL NOT EXCEED THE TOTAL AGREEMENT PRICE EXCEPT TO TIE EXTENT THOSE DAMAGES ARE PROVEN TO BE
SOLLY DUE TO THE COMPANWS NEGLIGENCE,
B.DURING THE DURATION OF THE WORK,THE CLIENTS 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 HASAR000S MATERIALS THAT MANIFEST THEMSELVES DURING THE CONSTRUCTION PROCESS E G.WOOD ROT,
MOLD,ASBESTOS,NAIL POPS, DLC LGORK AND CONNERIONI PLUMBING AND VENT PIPES,DECKING DEFLECTION,RL IF A PREEXISTING DEFICIENCY OR HAZARDOUS MATERIAL 15
ENCOUNTERED PRIOR TO OR DURING CONSTRUCTION,AND COMPANY IS NOTIFIED IN WRLDNG,COMPANY WILL TRY TO ASSIST CLIENT WITHIN THE COMPANY'S MEANS AND CAPABILITIES
TO CORRECT THE PROBLEMIS)ON A TIME AND MATERIAL BASIS.WENT AGREES THAT SUCH CONDITIONS ARE UNAVOIDABLE BY THE COMPANY AND SHALL NOT BE CONSIDERED A
VIOLATION OF THE AGREEMENT AND THAT DUE TO THESE CONORIMS THE DURATION OF THE WORK AND SCHEDULED ORE OF COMPLETION MAY DIFFER FROM THAT AGREED UPON,IF
APPLICABLE UNDER THISAGREEMENT.
30.THE COMPANY IS NOT RESPONSIBLE,AND THE CLIENT AGREES TO HOLO THE COMPANY HARMLESS,FOR ANY PROBLEMS AND/OR DAMAGES,INLCUOING BUT NOT UNITED TO MOLD
GROWTH,ARISING FROM THE PERFORMANCE OF AIR SCALING WORK BY THE COMPANY ASA RESULT OF ANY KNOWN OR UNKNOWN MOISTURE CONDITIONS,
Il,THE COMPANY IS NOT RESPONSIBLE FOR,ANO THE CLIENT AGREES TO HON THE COMPANY HARMLESS,FOP ANY PROBLEMS AND/OR DAMAGES RELATING TO ICF DAMMING THAT MAY
ARISE DURING ANQIOR AUER THE PERFORMANCE OF WORK BY THE COMPANY,
12 REPLACEMENT OF DETERIORATED DECIDE,FASCIA BOARDS,READY JACKS,VENTILATORS FLASHING,RANGES,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 ANO
WINDOWS,CODES,OIL DROPLETS IN DRIVEWAYS HAIRLINE FRACTIOUS IN CONCRETE OR BLACKTOP DRIVES AND WALKS,OR DAMAGE TO PLANTS OR SHRUBBERY.IF EXCESSIVE DAMAGE 15
CAUSED BY COMPANY,COMPANY WILL REPAIR OR REPLACE DAMAGED AREA ONLY AT COMPANWS EXPENSE,
16.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 INSPECTIONAT AGENCIES,AUTHORITIES,OR
INDIVIDUALS,
15.THIS AGREEMENT,INCLUDING THE PROVISIONS REUTNG TO PRICE AND PAYMENT SCHEDULE,CANNOT BE CHANGED OR ALTERED EXCEPT SY A WRITTEN STATEMENT SIGNED BY BOTH THE
COMPANY AND THE CLIENT.
16,ANI REPRESENTATIONS,STATEMENTS,OR OTHER COMMUNICATION NOT WRITTEN ON THIS AGREEMENT ARE AGREED TO BE IMMATERIAL AND NOT PETTED ON BY EITHER PARTY,ANO 00
NOT SURVIVE THE EXECUTION OF THIS AGREEMENT
12.THIS AGREEMENT CANNOT BE CANCELLED WITHOUT THE MUTUAL WRITTEN CONSENT OF BOTH PARTIES PACKET AS OTHERWISE 5ET FORTH HEREIN.
SB.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 ILS OBLIGATIONS HEREUNDER OR TERMINATES THIS AGREEMENT WITHOUT THE PRIOR WRITTEN CONSENT OF THE COMPANY,THE CLIENT SHALL Al
LIABLE FOR DAMAGES FOR THE GREATER OF THE COMPANWS ACTUAL DAMAGES OR 25%OF THE AGREEMENT FOR RESTOCKING FEE.
20.ANY CHANGES TO MATERIALS BY THE CLIENT(GRAND,STYLE,COLOR,GO AFTER SAID MATERIAL HAS BEEN DELIVERED OR IS IN ROUTE TO THE CLIENT COULD RESULT IN A 5%RE-STOC ISG
FEE BASED ON THE COST OF SAID MATERIAL.
21,THIS AGREEMENT SHALL BE EFFECTIVE ONLY UPON ITS BEW71ON 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 lORTO
THE EMPIMTON OF SUCH 90 DAY PERIOD,AFTER 90 DAYS,AND IN THE EVENT COMPANY DOES NOT REVOKE THE PflOPOUL,COMPANY RESERVES THE RIGHT TO RMSE ITS PRICE IN
ACCORDANCE WITH ITS COSTS IN EFFECT AT SUCH TME.
22.IF ANY PROVISION OF THIS AGREEMENT SHOULD BE HELD TO BE INVALID OR UNENFORUBLE,TIE VALIDITY AND ENFORCEBNTY OF THE REMAINING PROVISIONS OF THIS AGREEMENT
SHALL NOT BE AFFECTED THEREBY.
23,ARBITRATION'.IN THE NENRHE CLIENT AND COMPANY HAVE A DISPUTE REGARDING ANY OF THE TERMS,CONDITIONS PROVISIONS,OR PERFORMANCE OF THIS AGREEMENT,WE 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 15 PART OF A UAM SPONSERED UTILITY PROGRAM IE MASS SAVE'l IS SUBJECT TO THE AVAILABILITY OF
QUALIFYING STATE SPONSEREO PROGRAM AND WILL BE SUBJECT TO TERMINATION IF THE STATE SPONSERED UTILITY PROGRAM 5 OISCOUNTNUED.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 OFFER 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 TAKES THAT ARE APPLICABLE TO THIS AGREEMENT.
The Commonwealth ofMassackusetts
Department of Industrial Accidents
Ogee of Investigations
600 Witshington Street
Boston,MA 02111
www.rnass.gov/dila
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leribly,
Name(Business/Organinld.o lndi.iduap: American Installations,LLC
Address: 130 College Street,Suite 100
City/Stale/Zip: South Hadley,MA 01075 Phone #: 413-552-0200
Are you an employer?Check the appropriate box: Type of project(required):
L❑x I am a employer with 60 _ 4. ❑ I am a general contractor and 1 6. ❑ New construction
employees(full and/or pan-lime).` have hired the subcontractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.1 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in anv capacity. workers'comp.insurance. 9. ❑ Building addition
[No 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. c. 152,11(4),and we have no 12.❑ Roof repairs
insurance required.]t employees. [No workers'
comp, insurance required.] I I 13.®Other_Insulation
aA,Wis..'dal cheeks box#1 muss also fill oul the scans.brio.usowint(heir woden'camps osm.n polity infonnnion.
t 1 hwmowrmw who suhmh rho aadovil ind,eift,lh,.m dum ell work end uses him omsidn cunttaet.must uoxo l a new.1Th1wh insinv n"such.
:Cunaactoa Nm chmk this box even etnchcd an additional shed showing the nam.of Ism s.b ,xi .1w,and Amir worken'comp.posiq Lfoevwl.
I am an employer the 1s providing workers'con pensadon insurance for my enlplamea Below is the poacy and job site
infOr IOM
Insurance Cumpany Name: Guard Insurance Companies
Policy#or Self-ins. Lie.#: URWC609917 Expiration Date: 09/04/2019
Job Site Address: TL ' Q I'(ld1 4h 0n d City/State/Zip: F1G yA h 2_
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 5250.00 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.
I do barelyJceerrliify�under the pains mad penalier_Of perjury altal the information provided above is true and correc6
Signature
Phone#,/ 413-552'0200
O)rcial use only. Do not write in this area,to be complded by city or town of(chut
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 Massachusetts Construction,Supervisor
®: Division of Professional Licensure Unrestricted-Buildings ofanyw group which count
nn
Board of Building Regulations a nd Standards Yes than 80,000 cubic W(Set cubic met"of enclosed
Construction Sope"isor space
CS-108178 F4pires:0812912019
WESLEYCOIAVRE
218 U1TIgtOPSTREET t1
SOUTH HADLIMMA 01075 si
... Faave o possess a cement edition oche Massachusetts
Stan Building Code Y"use for revocation ergs,Seems.
information about BIY Scams
Commissioner L/ Can(617)774250 or vhdt wwvUruawgw/dq
0/( lh--qj—f lr l-lf1Pf'
IS
P Office of Consumer Affairs and Business Regulation
10 Park Plaza- Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Type: LLC
AMERICAN INSTALLATIONS,LLC. Re xpirs on. 06/25
130 COLLEGE STREET SURE 100 E>�Iralion. 08/28/2018
SOUTH HADLEY,MA 01075
Update Addrasendretum card. Mark meson for change.
e Al 0 20MMIl ❑ Add._ n R.n�_,..sI L.Fmphrymsnt El felt Cwrd
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TYPE:LLC Mora Ms expiratConsumion dale. a ted Mum e
.t rr 0625019 Office of lue-SurAffalre and Resines Regulation
�.�-�_�? 1T5982 06/28/2019 10 Perk Meie-Suns 5170
AMERICAN INSTALLATIONS,LLC. Boson,MA Oxalo
WESLEY COUTURE �--
130 COLLEGE STREET SUITE 100
SOUTH HADLEY.MA 01075 UndersecreYry I"valid without slgnaturo
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THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO FIGHTS UPON THE CERTIFICATE HOLDER THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, OMNI) OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOSS NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING MUREM), AU HORUD
REPRESENTATIVE OR PRODUCER,TWD THE CERTIFICATE HOLDER
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INDICATED. NOlYA1HSTANdND ANY REODREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT V TH RESPECT TO WHICH THIS
CERTIFICATE NAAY BE ISSUED OR MAY PERTAIN.TIE INSURANCE AFFORDED BY THE PMCIES DESCRIBED HEREN IS SUIUMT TO ALL THE TERMS.
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LAWS SHOVAN MAY NAVE BEEN REMOIS)BY PAD CLAIMS.
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