38D-034 (4) 23 HARLOW AVE BP-2019-1069
GIS x: COMMONWEALTH OF MASSACHUSETTS
MwBlock: 38D-034 CITY OF NORTHAMPTON
Lot-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: INSULATION BUILDING PERMIT
Permax BP-2019-1069
Pro iectft JS-2019-001736
Est.Cost: $2600.00
Fee: S65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: AMERICAN INSTALLATIONS LLC 106178
Lot Size(sp.11): 4486.68 Owner: GUPTA SANIIV&KATHLEEN M WELLSPRING
Zoning,URB(100)/ Applicant: AMERICAN INSTALLATIONS LLC
AT: 23 HARLOW AVE
ApplicantAddress: Phone: Insurance:
130 COLLEGE ST (413) 552-0200 WC
SOUTH HADLEYMA01075 ISSUED ON:3/27/20190:00:00
TO PERFORM THE FOLLOWING WORKATTIC AND KNEEWALL INSULATION &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 M 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 3/27/2019 0:00:00 $65.00
212 Main Street,Phone(413)587-1240, Fm:(413)587-1272
Louis Hasbrouck—Building Commissioner
' 61.1 ,. P- lei - roG9
EIVED
City of Northam n
i Building Depa nt MAR 2 l 2019.
212 Main Stree /l
Room 100 TIM'-
l.IM'-
Northampton, MA0O60ora10oir=ruurnn 1h5PECT10NB
rdm O
�..
phone 413-587-1240 Fax 4 NPA .MA 10� ONi Y
APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING ONLY
SECTION I-SRE INFORMATION INSULATION PERMIT
1.1 Property Address: k ueWn to be completed y office
23 Harlow Avenue
Map 3 D Lot 03(.? Unit
Northampton,MA 01060 Zone Overlay District
Elm SL Disbict CS District
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
Wellspring&Gupta Kathleen&Saniiv 23 Harlow Avenue,Northampton,MA 01060
Name(Print) Current Mailing Address:
See attached .(41 3) 710-9051
Telephone
Signature
2.2 Authorized Agent:
American Installations 130 College Street Ste. loo, South Hadley MA 01075
Name(Print) Curent Mailing Address:
y C (413) 552-0200
SignaNre Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed brmit aDolicant
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) #605
5.Fire Protection
6. Total=(1 +2+3+4+5) $2,600.00 Check Number 3097
This Section For Official Use Drill,
Oat,
Build ng Permit Nu r: Issued: �/ p
Signature:
Building Commissioneranspec1or of Buildings Date
EMAIL ADDRESS(REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 4-CONSTRUCTION SERVICES
SA Licensed Cons clip.Supervisor. Not Applicable
Nameof License Roldo. WesleyKCoulure 106178
License Number
130 College Street Ste. 100, South Hadley MA 01075 9/2912019
Morass Expiration Date
(4131552-0200
Signature Telephore
9.Registered Nome Improvement Contractor. Not Applicable ❑
American Installations 175982
Company Name Registration Number
130 College Street SIv. 100, South Hadley MA 01075 6/26/2019
Address
p� p Expiration Date
SAI-s'Aw:A/t k (, A3n s Telephone (413)552-0200
SECTION 5-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,5 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....... .0 No..... ❑
Brief Description of Proposed Work NOTE: INSULATION ONLY
Attic and kneewall insulation and air sealing throughout.
I, American Installations as OwnenAuthadzed
Agent hereby declare(hat the statements and information on the foregoing applical are true and accurate,to the best of my knowledge
and belief.
Signed under the pains and penalties of penury.
Wesley K. Couture
Prim Name
,t.ti V . ��A,�AAO R 3/23/2019
Signs. dAgent Data
I, Wellspring&Gupta, Kathleen &Sanjiv 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.
or rt_ aA1nt A 3/23/2019
Signature of Owner Dale
City of Northampton
s —
�� - Massachusetts
` DEPMrIMENT OF Sarwim; INSPECTIONS
\ 212 Wan Street • M nlaipal S"Iding
4.. Narthan,ton, rA oio6a 3j1�
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 perforating 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.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 owneroccupied building containing
at least one but not more than lour dwelling units....or to structures which are adjacent to such residence or building"be
done by registered contractors.
Note:If the homeowner has contracted Wilt a corporation or LLC,that entity must be registered
Type of Work: Insulation Est.Cost: 52,600.00
Address of Work: 23 Harlow Avenue
Date of permit Application: 3/23/2019
I hereby certify that:
Registration is not required for the following reason(s):
_Work excluded by law(explain):
_lob under S 1,000.00
_Owner obtaining own permit(explain):
_Building not owneroccupied
x Other(specify): Con tractor pulling 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 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 pemri[as the agent of the owner:
3/23/2019 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
%. -..r
' Massachusetts 3r
f l
DBDILDIN6INBNB
212Igin SQe •Mncipal Building
aorthnu,tan,
J� JCs
!P 01060
Debris Disposal Affidavit
In accordance of the provisions of MGL c 40, 554, I acknowledge that as a condition of the building
permit all debris resulting from the construction activity govemed 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:
23 Harlow Avenue
(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 Appl'rant or Owner shall notify the
Building Department as to the location where the debris will be disposed.
— City of Northampton
1 ' Massachusetts
I D£PAR2TgNI OF SUZAUZW ZRSP£C!rrW5
212 win
aoitnemptcnMnici"IBuildingM 01060
JLS JCT
MANDATORYFOR HOUSES BUILT BEFORE 1945
Property Address: 23 Harlow Avenue
Contractor
Name: American Installations
Address: 130 College Street Ste. 100
City, State: South Hadley MA
Phone: (413)552-0200
Property Owner
Name: Wellspring&Gupta Kathleen &Sanliv
Address: 23 Harlow Avenue
City, State: Northampton MA
1, Wesley K. Couture (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
L,u1u1 12 Ct1A�n+
Date
3/23/2019
1440 A www.Mnena........ .i..<.<cm
e® turnerned 6 insured MA CSL#:106178
7
American Inatallationa Ma aePisn4nw v5982# s982
130 Wlge�eel bM lOp,SouM Waky,MNp10R.gam:14131551Ltpp Fn:n131553d303. Email:wpp0rtlAmMunlnmglh0amrpn
WallString&Gupta,Knthlee«nn&Sanjive 3/15/2019
23 Harlpw Ave Northampton MA 01060
ma
4132109052 kwellstrinaiLm
cow.n
g@gm
481413 Paralun pre 19-0927
n..m
Quantity Unit Unit Cost Pin Total
Air Sealing
AIRSEALING 12 jamin hour 1 $ 85.00 1 $ 1,020.00
WEATHERSTRIP DOOR&ADD SWEEP 3 leach 1 $ 80.00 1 $ 240.00
Air Sealing $ 1,260.00
Air Sealing Incentive $ 11,020.00)
Air Sell WX Balance $ 240.00
Waatherl#ation
ATTICFINT-12"FLOORED R-38 DENSE CELLULOSE 61t 1sqft $ 2.17 $ 138.80
KNEEWALL FLOOR-8"OPEN R-30CELLULOSE 64 fsqft $ 1.44 $ 92.16
KNEEWALL-2"RIGID BOARD 32 sqk $ 3.85 $ 123.20
KNEEWALL HATCH-INSULATE&WS 1 each $ 60.00 $ 60.00
KNEEWALL SLOPE-2"RIGID BOARD 160 sgll $ 3.85 $ 616.00
KNEEWALL SLOPE-2"RIGID BOARD 40 salt $ 3.85 $ 184.80
BASEMENT-INSULATE BULKHEAD DOOR&INSULATE 1 each $ 110.00 $ 110.00
Air SealingWit Balance 1 lumpsum $ 2411.00 $ 240.00
Total Weatherflation $ 1,565.04
Weatheri3ation Incentive $ 1,173,78
Total Project $ 2,585.04
Total Utility Contribution $ 2,193.78
Total Customer ConMbution $ 391.26
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mnumovoinm.Twi w.r„r<ve—entaa n.2h.
AMEPTRKE OF PROPQAb.The move Pines,amodiraeons and TOTAL CONTRACT VALUE= $ 391.26
authorizes are ssnssaua, am,areoRnent w 1l M./3 dorm
amnoneeataoworkas specinM.nymenewm olp gown Prior o Down Payment= $ 130.00
am odwnh.ana'calana du.upon Compinbn. vain
Al3/1 Balance Due Upon Completion= $ 26
om/ 3/15/2019
Garrett Demers u,mnp�•nl w. 3/15/2019
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THIS AGREEMENT IS COMPOSEO OF THIS PAGE AND NE HEVERSE S I DE OF THIS PAGE AND SHALL OE CONS I DE RED THE ENFI RE AS RE EM ENT BY ME PARTIES I NVOLVEO.THIS AG RE EVENT IS
BETWEEN AMERICAN INSTAUATONS,LLC HEREINAFTER REFERRED TOM"COMPANY',AND THE CUSTOMERS)NAMED ON THE REVERSE SIDE,HEREINAFTER REFERRED TO AS"CLIENT",AND
WILL BE SUM ECT TO ALL APPROPRIATE LAWS,REGULATIONS AND ORDINANCES OF THE STATE OF MASSACHUSETTS OR CONN ECTYR T RESPECTIVELY,AS WELL AS ALL LOCAL NRISOIMONS
.
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 COND71ON.
2.SHOULD DEFAULT BE MADE IN THE PAYMEM OF THIS AGREEMENT,CHARGES SHALL BE ADDED FROM THE DATE THEREOF AT A RATE OF ONE AND ONE-HALF(I 1/2)PERCENT PER MONTH.
(18%PER ANNUM)WITH A MINIMUM CHARGE OF SZ CAPER MONTH,AND IF PLACED IN THE HMM 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 M A LEIN ON THE PROPERTY.
3.THE COMPANY AGREES THAT WHEN DELAYS BECOME KNOWN TO THE COMPANY,THE COMPANY WILL ADVISE THE CLEW 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
COMPLE11ON OF ALL WORK DUMBED TN ATIMELY AND WOM AFWUKE 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 MANUFACTURERS WARRANTIES,THE CLIENT MAY BE REQUIRED TO REGISTER OR MAIL IN A WARRA Y GRD OR OTHER EVIDENCE OF OWNERSHIP AND USE OF
SUCH EQUIPMENT AND/OR PRODUCTS IN SEDER TO ACTIVATE SUCH WARRANTIES.
6.THE QUOTATION ON WE PAGE HEREOF OOFS NOT INCLUDE EXPENSES OR CHARGES FOR BOND OR INSURANCE PREMIUMS OR COWS 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 ARMING OUT OF THIS AGREEMENT SHALL NBT EXCEED THE TOTAL AGREEMENT PRICE EXCEPT TO THE EXTENT TiOSE DAMAGES ARE PROVEN TO BE
SOLEY WE TO THE COMPAWS NEGLIGENCE.
B.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 6 NOT RESPBNS IBLE FOR PREEXISTING DEFICIENCIES OR TA ARCOUS MATERIALS THAT MANIFEST THEMSELVES MIRING THE CONSTRUCTION PROCESS E.G.WOOD ROT,
MOLD,ASBESTOS,NAIL POPS,DUCTWORK AND CONNECTIONS,PLUMBING AND VENT PIPES,DECKING DEFLECTION,AC,IF A PPE{XISTNG DEFICIENCY OR HAEARDOUS MATERIAL IS
ENCOUNTERED PRIOR TO OR DURING CMSTRUCTIXi,AND COMPANY IS NOTINED IN WRITING,COMPANY WILL TRY TO ASSIST CLIENT WITHIN THE COMPANY'S MEANS AND EAPABILITIES
TO CORRECT THE PROBLEM(5)ON A TIME AND MATERIAL BASIS.CLIENT AGREES THAT SUCH CONONIONS 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 AGREEMEW,
10.THE COMPANY IS NOT RESPONSIBLE,AND THE CLIENT AGREES TO HOLD THE COMPANY HARMLESS,FOR ANY PROBLEMS AND/OR DAMAGES,INLCUDING BVL NOT LIMITED TO MOL.
GROWTH,ARISING FROM THE PERFORMANCE OF AIR SEALING WORK BY THE COMPANY ASA RESULT OF ANY KNOWN OR UNKNOWN MOISTURE CONDITIONS.
21 THE COMPANY IS NOT RESPONSIBLE FOR,AND THE CLIENT AGREES TO HOLD THE COMPANY HARMLESS,FOR ANY PROBLEMS AND/OR DAMAGES PEOPLING M ICE DAMMING THAT MAY
ARISE DURING AND/OR AFTER THE PERFORMANCE OF WORK BY THE COMPANY,
12.REPLACEMENT OF DETERIORATED DECKING,FAMAR BOARS,ROOF TACKS,VENTILATORS,FUSHING,RAFTERS,JOISTS,INSULATION OR OTHER MATERIALS ARE NOT INCLUDED UNLESS
OW EMISE NOTED HEREIN.
13.THE COMPANY WILL NOT BE RESPONSIBLE FOR THE SCRATCHING OR DENTING OF INTERIOR WALLS AND CEILINGS, FUCKSM TRIM,GUTTERS, DOWNSPOUTS,EXISTING SIDING AND
WINDOWS,DMRS,OIL DROPLETS IN DRIVEWAYS,HAIRLINE FRACTURES IN CONCRETE OR BLACKTOP DRIVES AND WALKS,OR DAMAGEM PLAMS ORSHRUBBERY.IF FACEWEVE 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 UWS 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 DRAWING OR INSPECTIONAL AGENCIES,AUTHORITIES,OR
IN.IVIDUALS.
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 CLEW,
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 CONSULT OF MYTH PARTIES EXCEPT AS OTHERWISE SET FORTH HEREIN.
18,THIS AGREEMENT,AND ANY WARRENTY(5)PROVIDED HEREUNDER SHALL NOT BE ASSIGNED EXCEPT BY OR WITH THE WRITTEN PERMISSION OF THE COMPANY.
19.IF THE CLIENT EAUS TO PERFORM W OBLIGATIONS HEREUNDER OR TERMINATES THIS AGREEMENT WITHOUT THE PRIOR WRITTEN CONSENT OF THE COMPANY,THE CLEW SHALL BE
LIABLE FOR DAMAGES FOR THE GREATER OF THE COMPANY'S ACTUAL DAMAGES OR GOG OF THE AGREEMENT FOR RESTOCKING FEE.
20,ANY CHANGES TO MATERIALS BY THE CLIENT(BRAND,SME,CQUOR ETC)AFTER SAID MATERIAL HAS BEEN DELIVERED OR IS IN ROUTE TO THE CLIENT COULD RESULT IN A5%RESTOCKING
FEE BASED ON THE NST OF SAID MATERIALS.
21 THIS AGREEMENT SHALL BE EFFECTIVE ONLY UPON RS EXECUTION BY ALL PARTIES HERETO PRIOR TO WHICH TIME IT SHALL BE DEEMED A PROPOSAL THE COMPANY RESERVES THE RIGHT
TO REVOKE THIS PROPOSAL 9O DAYS FROM DATE T IS EXECUTED BY THE COMPANY IF IT 15 NOT EARLIER EXECUTED BY THE CLEW AND THE REQUIRED DOWN PAYMENT RECEIVED PRIOR TO
THE EXPIRATION OF SUCH 9D DAY PERIOD,AFTER 90 DAYS,AND IN THE EVENT COMPANY DOES NOT REVOKE LIFE PROPOSAL,COMPANY RESERVES THE RIGHT TO REVISE ITS PRICE IN
ACCORDANCE WITH ITS COSTS IN EFFECT AT SUCH TIME
22.IF ANY PRWISION OF THIS AGREEMENT SHOULD BE HELD TO BE INVALID OR UNENFORCABLE,THE VALIDITY AND ENFORCEBILRY OF THE REMAINING PRWISIONS 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 PARIES
AGREE TO PLACE THE MATTER INTO ARBITRATION BEFORE AN INDEPENOE W ARBITRATOR ASSIGNED BY THE AMERICAN ARBITRATION ASSOCIATION TO RESOLVE THEIR DISPUTE.
24.ANY DISCOUNT,PROMOTION,REIMBURSEMENT,OR OTHER PROGRAM THAT IS PAW OF A STATE SPONSERED UTILITY PROGRAM(LE.MASS SAVE' IS SUBJECT TO THE AVAILABILITY OF
QUAUMNG STATE SPONSERED PROGRAM AND WILL BE SUMECT M TERMINATION IF THE STATE SIMMERED UTILITY PROGRAM IS DISCdJWJNUED.FURTHERMORE,THE TERMS AND
CONDITIONS OF STATE SPONSORED UTILITY PRW DAMS PM LBE ALTERED OR UPDATED PERIODICALLY WITH OR WITHOUT NONCE.
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.QUEM IS REPSONSIBLE FOR THE PAYME W 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
600 Washington Street
Boston,MA 01111
www.masxgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leeibiv
Name(Busimess/OrgmiaatioNmdidduab: American Installations, LLC
Address: 130 College Street,Suite 100
City/State/Zip: South Hadley,MA 01075 Phone#: 413-552-0200
Are you as employer?Check the appropriate box: Type ofproject(required):
I.❑x t am a employer with 60 4. E] I am a general contractor and 1 6. E]New construction
employees(full and/or part-lime).' have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet._ y. ❑Remodeling
ship and have no employees These sub-contractors have g. ❑ 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.
3.0
repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself [No workers'comp. c. 152,§1(4),and we have no 12.❑ Roof repairs
insurance required.)t employees. [No workers'
13.9 other_Insulation
comp. insurance required.]
'Any applicam Ilei checks box#1 mull atm fill uul au sc:tian below showing ae'vwoners compmwsion policy informnion.
t l lumeawm:m who submit Wx man ail stud s ng aey al suing all work and Nun him masidaontwt i Amon submit o nese comp.
w t indicating such.
:Conlmclors sal check ais box must amchM an adalmnal shttt slwwing 0e name of Ile sub<onlmturs aM them workers'comp.policy wrormalion.
I am an employer that is provlding workers'compencadon iroumm a for m v employees. Below is the policy and job site
information.
Insurance Company Name: Guard Insurance Companies
Policy#or Self-ins. Lie.#: URWC609917_ _ Expiration Date: 09/04/2019
Job Site Address: Z3 IAarlt)L� hain yt City/State/Zip:9Ah ib,*— i,-A,
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
line up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form are STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of
Investigations ofthe DIA for insurance coverage verification.
f do hereby cePrtify under thepains mal penal�lier_of perjury that the information provided above is true and correct
S JOC)g*�l, A,", lL f 4tt�l15>__ Daw
Phone#: 61 413-552'/0200
OJfchd ase only. Do not write to this area,to be conpleted by city or town official
City or Town: PermittLicense#
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3.Cityllbwn Clerk 4.Electrical inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Commonwealth of Massachusetts Coordination Supervieor
-®: Division of Professional Licensure Unrestrkfed-Buildings ufarry rue group which contain
Board of Building Regulations and Standards Isstha 36,000 cubic Rd(M cubic meters)ofenclosed
Construction$bpeN150f space.
CS-100175 Ebpirs:09/29/7019
WESLEY COIFFURE -
218 LATHROFBTREET t1
SOUTH HADL&-MA 01076 tl
Fallon to possess a scalene fAeon of Msss
Side Building Code tes
es for revaeetlaado ihte Somas.
of Beans.
Par InFmmtlbn abaul this licaMe
Commiscloner call(617)72/-200 avMe ww a fraw govldpl
I>.
_ Office of Consumer Affairs and Business Regulation
10 Park Plaza- Suite 5170
1 „
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Type: LLC
AMERICAN INSTALLATIONS,U.C. Registration: 175982
130 COLLEGE STREET SURE 100 EWiraflon. OW26/2019
SOUTH HADLEY,MA 01075
Update Address and Mum card. Mark noon for change.
scat o xmw " n Add— 110-- _IuI 12EmR1yrnam I0Lost Cwrd
causer CenranrArdlrs 0 suma00 Reputed.
4kQ. '1 HOMEIMPROYEME CONTRACTOR Registration valid for Individual us only
I., TYPE:LLC before the expiration date. If bund Mum o:
apbVOlmD ExPIration OMa of Consumer Affairs and gustiness Regulation
175502 06/26/1019 10Prk Rasa-Sulte6170
AMERICAN INSTALLATIONS,LLC. Soaim,MA 02116
WESLEY COUTURE
130 COLLEGE STREET SUITE 100
SOUTH HADLEY,MA 111075 Undersecretary t valid without signature
A�d CERTIFICATE OF LIABILITY INSURANCE 9/4/20 10
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(SL AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER
MPOTITANT: It Os certllMOa haMar N an ADDITIONAL INSURED,the po k-ANN)mast be endorsed. N SUBROGATION E WANED,aub)att to
16 UPON Od OMW m Of She policy,came"PolkNs Ory mgdre an endOraMnenlL A atalenllard On INS CNPdSaeto does not confer dghb to the
ertlReala holder M ON of 9PNd1 •.
NeIDUCER Linda 9oYYiN
MabhNr A Grlmall t{13)366-0111 .mmaanfuv
S North King street L ,lOoaaraNaebbesssdNri�all.caw,
WPIRa fR011rN0eOVw,MOe Nue.
NOZChaYytOn NAL 01060 K A 1 • Notasl CILIK
vasxmv,"ark*Mr Baths GDAAD Iva. CO.
Aw,Nrlaaa Inst ilaC1onN, Ime RRRC;
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130 Collage Street, Suite 100 HIPARMA
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COVERAGES CERTFICATENUMBERAMNter SM 9-2019 REWSON NUMBER:
THIS IS TO CERTIFY WAT THE POLICIES OF INSURANCE LISTED BEOW HAVE BEEN 199RD TO THE INSURED NAMED{ROVE FOR THE Pq.ICY PERIOD
INDICATED. NOTWRHSTANgND ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WRIT RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDRT BY THE POUCHES OESCRIBED HEREIN IS SUB£CT TO ALL THE TERMS,
EXCLUSIONS AND 13WENS OF SUCH POLICIES.LIMITS SHONIN MAY HAVE SEEN REDUCED BY PAD CLAa.15.
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CERTIFICATE HOLDER CANCELLATION
SHOULD ARY OFTNE ABOVE DEACRa POLICIES BE CANCELLED BEFORE
SOSd.—. of IaNZana! WE EZPIRA N DATE THEREOF, NOTICE WILL BE DELNERED IN
ACCORDANCE VOW THE PDLIDV PROVISIONS.
AWORCIN3 RE MAUVE
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O 1988-2016 ACORD CORPORATION. All Hghb rsesrYetl.
ACORD 26(2014101) The ACORD mus and logo as reglowed maria of ACORD
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