23A-162 61 PINE ST BP-2020-0785
GIS#: COMMONWEALTH OF MASSACHUSETTS
MQ:Block:23A- 167 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
Permit# BP-2020-0785
Proiect# JS-2020-001365
Est.Cost:$3277.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: AMERICAN INSTALLATIONS LLC 106178
Lot Size(sq. ft.): 14810.40 Owner: DEINES EMILY
Zoning: URB(100)/ Applicant. AMERICAN INSTALLATIONS LLC
AT: 61 PINE ST
Applicant Address: Phone: Insurance:
130 COLLEGE ST (413) 552-0200 WC
SOUTH HADLEYMA01075 ISSUED ON.11812020 0:00:00
TO PERFORM THE FOLLOWING WORK.-ATTIC AND BASEMENT INSULATION AND AIR
SEALING THROUGHOUT
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
FeeTytm Date Paid: Amount:
Building 1/8/2020 0:00:00 $65.00
212 Main Street, Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
i
Ev
IV
Dep
City of Northampton JAN 8 20T
OR
Building D par t i
Ma�.Stre��RFelinnrn1rir� p
k Room 100 oN Mq FC7 ONS
INSULA TION
Northampton, MA 01060 �
phone 413-587-1240 Fax 413-587-1272 ONL
APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING ONLY
SECTION 1 -SITE INFORMATION INSULATION PERMIT
1.1 Property Address
This section to be completed by office
,Q
Map )" ' Lot I (/, /--7
Unit
61 Pine Street Zone Overlay District
Eim Sr.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Emily Deines &Lawrence George 61 Pine Street
Name(Print) C}Iq�rlt)M�iGpg�ddcess:
See attached Telephone 4llII lJ�1
Signature
2.2 Authorized Agent:
American Installations 130 College Street Ste. 100, South Hadley, MA 01075
Name(Print) Current Mailing Address:
� 0 4 0 1A V- C-M kt�u (413) 552-0200
Signature a Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building 3277.00 (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC) / ()
5. Fire Protection IIIJJJ���
6. Total=(1 +2+3+4+5)
277.00 Check Number 30
�nThis Section For Official Use Only
Building Permit Number:�y �M/ 7 105' Date
Issued: /
Signature: /a�
Building Commissioner/Inspector of Buildings Date
production @ americaninstallations.com
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 4-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of license Holder: Wesley K. Couture 106178
License Number
130 College Street Ste. 100, South Hadley MA 01075 9/29/2021
Address Expiration Date
11 �001LA .L- CCAJ,W (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 6/26/2021
Address Expiration Date
Telephone_(413)552-0200
SECTION 5-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....... J0 No...... ❑
Brief Description of Proposed Work NO TE: INS ULA TION ONL Y
Attic and basement insulation and air sealing throughout.
I, American Installations - Wesley Couture as Owner/Authorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
Wesley K. Couture
Print Name
IA� �. c 1;2/2020
Signature of Owner gent Date
1= ,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 1/2/2020
Signature of Owner Date
City of Northampton
Massachusetts s.-A.
a
DEPARTMENT OF BUILDING INSPECTIONS ?'
212 Main Street • Municipal Building
•': Northampton, MA 01060 ria `10
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.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 four dwelling units....or to structures which are adjacent to such residence or building"be
done by registered contractors.
Note:If the homeowner has contracted with a corporation:or LLC,that entity must be registered
Type of Work: Insulation Est.Cost: 3277.00
Address of Work: 61 Pine Street
Date of Permit Application: 1/2/2020
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 owner-occupied
x Other(specify): Contractor 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.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:
1/2/2020 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:
1/2/2020 WWJ24 E " I
Date Owner Nam and Signature
City of Northampton
r Massachusetts
N-
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street *Municipal Building
,., Northampton, MA 01060 sJ'y ,..• �1J
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:
61 Pine Street
(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:
.�merican Installations
(Company Name and Address)
1�- COAU'e
Signature of Pefmit 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.
City of Northampton
Massachusetts
a,J DEPARTMENT OF BUILDING INSPECTIONS
J b
212 Main Street • Municipal Building
i Northampton, MA 01060 ?O�
MANDATORY FOR HOUSES BUILT BEFORE 1945
Property Address: 61 Pine Street
Contractor
Name: American Installations
Address: 130 College Street Ste. 100
City, State: South Hadley MA
Phone: (413) 552-0200
Property Owner
Name: Emily Deines &Lawrence George
Address: 61 Pine Street
City, State: Florence, MA 01062
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
Date 1/2/2020
�+ www.Americanlnstallations.com
BBB Licensed&Insured
rating ,� mass save MA CSL#:106178
American Installations PARTNER MA Registration#175982
130 College Street Suite 100,South Hadley,MA 01075•Office:(413)552-0200 Fax:(413)552-0202•Email:support@Amerkaninstallations.com
Emily Deines
(first LLH) (Orta)
61 pine st Florence MA 01062
(Ad-) (ary) I-) (lip)
617-913-2612 emdeines gmail.corn
(RimarY) 15«ondanl (Email)
495871 19-3809
)sae IOI 11eb RI
Quantity Unit Unit Cost Total
Air Sealing
AIR SEALING 8 man hour $ 85.00 $ 680.00
WEATHERSTRIP DOOR 4 each $ S8.00 $ 232.00
DOOR SWEEP 4 each $ 25.00 $ 100.00
Total Air Sealing Value $ 1,012.00
Utility Air Sealing Incentive $ (1,012.00)
Weatherization
BASEMENT-INSULATE BULKHEAD DOOR&INSULATE 1 each $ 110.00 $ 110.00
CRAWLSPACE WALL R10 RIGID BOARD 116 each $ 4.05 $ 469.80
ATTIC FLAT-14"OPEN R-49 CELLULOSE 384 sqft $ 1.80 $ 691.20
ATTIC DAMMING-R-38 FIBERGLASS 104 sgft $ 2.05 $ 213.20
VENTILATION CHUTES 65 each $ 2.50 $ 162.50
ATTIC HATCH-SEAL&INSULATE 1 each $ 60.00 $ 60.00
ATTIC FLAT-6"OPEN R-22 CELLULOSE 396 sqft $ 1.32 $ 522.72
SHEATHING ACCESS 1 each $ 35.00 $ 35.00
Total Weatherization Value $ 2,264.42
Utility Weatherization Incentive $ (1,698.32)
Total Project Value $ 3,276.42
Utility Weatherization/Air Sealing Incentive $ (2,710.32)
Weatherization Balance $ 566.11
Total Customer Contribution $ 566.11
WARRANTY:American Installations,LLC will provide the above stated homeowner with a 1 year workmanship warranty.
American Installations,LLC hereby proposes to furnish all material and labor to complete the above scope of work in accordance with the above specifications and all local and state building
regulations for the Total Contract Value as stated herein.
ACCEPTANCE OF PROPOSAL:The above prices,specifications and TOTAL CONTRACT VALUE_ $ 566.11
conditions are satisfactory and are hereby accepted.You are
authorized to do work as specified.Payment will be 1/3 down prior to Down Payment= $ 188.00 ®12/28/2019
start of work,and balance due upon Completion. PAID
Balance Due Upon Completion= $ 378.11
12/28/2019
sP,a"aa aaa
Emily Deines 12/28/2019
RapeM Ouaer l0.intl Primp YOrmer lS'�1 Dale
Lukasz Socha �9 12/28/2019
Raprasenbeae(ramal Rap,a,am, RN wu
THIS AGREEMENT 15 COMPOSED OF THIS PAGE AND THE REVERSE SIDE OF THIS PAGE AND SHALL BE CONSIDERED THE ENTIRE AGREE MEM BY THE PARTIES INVOLVED.THIS AGREEMENT Is BETWEEN AMERICAN INSTALIATIONS,LLC HEREINAFTER REFERRED
TO AS'COMPAW',AND THE CUSTOMER(5)NAMED ABOVE,HEREINAFTER REFERRED TO AS'CIIENT',AND WILL BE SUB1ECr TO ALL APPROPRIATE LAWS,REGULATIONS AND ORDINANCES OF THE STATE OF MASSACHUSETTS OR OONNECTx TRESPECTIVELY,
AS WELL AS ALL LOCAL IURISDIRIONS.
THIS AGREEMENT IS COMPOSED OF THIS PAGE AND THE REVERSE SIDE OF THIS PAGE AND SHALL BE CONSIDERED THE ENTIRE AGREEMENT BY THE PARTIES INVOLVED.THIS AGREEMENT IS
BETWEEN AMERICAN INSTALLATIONS,LLC HEREINAFTER REFERRED TO AS"COMPANY",AND THE CUSTOMER(S)NAMED ON THE REVERSE SIDE,HEREINAFTER REFERRED TO AS"CLIENT",AND
WILL BE SUBJECT TO ALL APPROPRIATE LAWS,REGULATIONS AND ORDINANCES OF THE STATE OF MASSACHUSETTS OR CONNECTICUT RESPECTIVELY,AS WELL AS ALL LOCAL JURISDICTIONS.
THE FOLLOWING TERMS AND CONDITIONS ALSO APPLY
1.THIS AGREEMENT IS SUBJECT TO THE APPROVAL OF A MANAGER OF THE COMPANY FOR THIS AGREEMENT TO BE EFFECTIVE UNDER ANY CONDITION.
2.SHOULD DEFAULT BE MADE IN THE PAYMENT OF THIS AGREEMENT,CHARGES SHALL BE ADDED FROM THE DATE THEREOF AT A RATE OF ONE AND ONE-HALF(1-1/2)PERCENT PER MONTH.
(18%PER ANNUM)WITH A MINIMUM CHARGE OF$2.00 PER MONTH,AND IF PLACED IN THE HANDS OF AN ATTORNEY OR COLLECTION AGENCY FOR COLLECTION,ALL ATTORNEYS'FEES,
EXPENSES AND COSTS OF COLLECTION SHALL BE PAID BY THE CLIENT.IN ADDITION,CLIENT UNDERSTANDS THAT IN FAILING TO PAY ACCORDING TO THE ABOVE TERMS,COMPANY MAY
HAVE THE RIGHTTO 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 A TIMELY AND WORKMANLIKE MANNER.
5.ALL WARRANTIES FOR EQUIPMENT AND PRODUCTS SUPPLIED BY THE COMPANY UNDER THIS AGREEMENT SHALL BE THOSE GIVEN BY THE MANUFACTURERS OF SUCH EQUIPMENT AND
PRODUCTS.UNDER SUCH MANUFACTURER'S WARRANTIES,THE CLIENT MAY BE REQUIRED TO REGISTER OR MAIL IN A WARRANTY CARD OR OTHER EVIDENCE OF OWNERSHIP AND USE OF
SUCH EQUIPMENT AND/OR PRODUCTS IN ORDER TO ACTIVATE SUCH WARRANTIES.
6.THE QUOTATION ON THE PAGE HEREOF DOES NOT INCLUDE EXPENSES OR CHARGES FOR BOND OR INSURANCE PREMIUMS OR COSTS BEYOND NORMAL INSURANCE COVERAGE,ANY SUCH
ADDITIONAL EXPENSES,PREMIUMS OR COST SHALL BE ADDED TO THE TOTAL AGREEMENT AMOUNT.
7.THE 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 CLIENT'S HOMEOWNERS INSURANCE WILL BE RESPONSIBLE FOR ANY AND ALL DAMAGES AS LONG AS THE COMPANY HAS TAKEN THE
APPROPRIATE ACTION TO PROTECT AREAS OF WORK.
9.THE COMPANY IS NOT RESPONSIBLE FOR PREEXISTING DEFICIENCIES OF.HAZARDOUS MATERIALS THAT MANIFEST THEMSELVES DURING THE CONSTRUCTION PROCESS.E.G.WOOD ROT,
MOLD,ASBESTOS,NAIL POPS,DUCTWORK AND CONNECTIONS,PLUMBING AND VENT PIPES,DECKING DEFLECTION,ETC. IF A PRE-EXISTING DEFICIENCY OR HAZARDOUS MATERIAL IS
ENCOUNTERED PRIOR TO OR DURING CONSTRUCTION,AND COMPANY IS NOTIFIED IN WRITING,COMPANY WILL TRY TO ASSIST CLIENT WITHIN THE COMPANY'S MEANS AND CAPABILITIES
TO CORRECT THE PROBLEM(S)ON A TIME AND MATERIAL BASIS.CLIENT AGREES THAT SUCH CONDITIONS ARE UNAVOIDABLE BY THE COMPANY AND SHALL NOT BE CONSIDERED A
VIOLATION OF THE AGREEMENT AND THAT DUE TO THESE CONDITIONS THE DURATION OF THE WORK AND SCHEDULED DATE OF COMPLETION MAY DIFFER FROM THAT AGREED UPON,IF
APPLICABLE,UNDER THIS AGREEMENT.
10.THE COMPANY IS NOT RESPONSIBLE,AND THE CLIENT AGREES TO HOLD THE COMPANY HARMLESS,FOR ANY PROBLEMS AND/OR DAMAGES,INLCUDING BUT NOT LIMITED TO MOLD
GROWTH,ARISING FROM THE PERFORMANCE OF AIR SEALING WORK BY THE COMPANY AS A RESULT OF ANY KNOWN OR UNKNOWN MOISTURE CONDITIONS.
11.THE COMPANY IS NOT RESPONSIBLE FOR,AND THE CLIENT AGREES TO HOLD THE COMPANY HARMLESS,FOR ANY PROBLEMS AND/OR DAMAGES RELATING TO ICE DAMMING THAT MAY
ARISE DURING AND/OR AFTER THE PERFORMANCE OF WORK BY THE COMPANY.
12.REPLACEMENT OF DETERIORATED DECKING,FASCIA BOARDS,ROOF JACKS,VENTILATORS,FLASHING,RAFTERS,JOISTS,INSULATION OR OTHER MATERIALS ARE NOT INCLUDED UNLESS
OTHERWISE NOTED HEREIN.
13.THE COMPANY WILL NOT BE RESPONSIBLE FOR THE SCRATCHING OR DENTING OF INTERIOR WALLS AND CEILINGS, FLOORS,TRIM,GUTTERS, DOWNSPOUTS, EXISTING SIDING AND
WINDOWS,DOORS,OIL DROPLETS IN DRIVEWAYS,HAIRLINE FRACTURES IN CONCRETE OR BLACKTOP DRIVES AND WALKS,OR DAMAGE TO PLANTS OR SHRUBBERY.IF EXCESSIVE DAMAGE IS
CAUSED BY COMPANY,COMPANY WILL REPAIR OR REPLACE DAMAGED AREA ONLY AT COMPANY'S EXPENSE.
14.THE COMPANY UNDER PROVISIONS OF CHAPTER 142A OF THE GENERAL LAWS IS REQUIRED TO APPLY FOR AND OBTAIN ALL CONSTRUCTION-RELATED PERMITS.THE COMPANY SHALL NOT
BE DEEMED RESPONSIBLE FOR DELAYS IN THE WORK DESCRIBED IN THIS AGREEMENT CAUSED BY REGULATORY PERMIT GRANTING OR INSPECTIONAL AGENCIES,AUTHORITIES, OR
INDIVIDUALS.
15.THIS AGREEMENT,INCLUDING THE PROVISIONS RELATING TO PRICE AND PAYMENT SCHEDULE,CANNOT BE CHANGED OR ALTERED EXCEPT BY A WRITTEN STATEMENT SIGNED BY BOTH THE
COMPANY AND THE CLIENT.
16.ANY REPRESENTATIONS,STATEMENTS,OR OTHER COMMUNICATION NOT WRITTEN ON THIS AGREEMENT ARE AGREED TO BE IMMATERIAL AND NOT RELIED ON BY EITHER PARTY,AND DO
NOT SURVIVE THE EXECUTION OF THIS AGREEMENT.
17.THIS AGREEMENT CANNOT BE CANCELLED WITHOUT THE MUTUAL WRITTEN CONSENT OF BOTH PARTIES EXCEPT AS OTHERWISE SET FORTH HEREIN.
18.THIS AGREEMENT,AND ANY WARRANTY(S)PROVIDED HEREUNDER SHALL NOT BE ASSIGNED EXCEPT BY OR WITH THE WRITTEN PERMISSION OF THE COMPANY.
19.IF THE CLIENT FAILS TO PERFORM ITS OBLIGATIONS HEREUNDER OR TERMINATES THIS AGREEMENT WITHOUT THE PRIOR WRITTEN CONSENT OF THE COMPANY,THE CLIENT SHALL BE
LIABLE FOR DAMAGES FOR THE GREATER OF THE COMPANY'S ACTUAL DAMAGES OR 25%OF THE AGREEMENT FOR RESTOCKING FEE.
20.ANY CHANGES TO MATERIALS BY THE CLIENT(BRAND,STYLE,COLOR,ETC.)AFTER SAID MATERIAL HAS BEEN DELIVERED OR IS IN ROUTE TO THE CLIENT COULD RESULT IN A 5%RE-STOCKING
FEE BASED ON THE COST OF SAID MATERIALS.
21.THIS AGREEMENT SHALL BE EFFECTIVE ONLY UPON ITS EXECUTION BY ALL PARTIES HERETO,PRIOR TO WHICH TIME IT SHALL BE DEEMED A PROPOSAL.THE COMPANY RESERVES THE RIGHT
TO REVOKE THIS PROPOSAL 90 DAYS FROM DATE IT IS EXECUTED BY THE COMPANY IF IT IS NOT EARLIER EXECUTED BY THE CLIENT AND THE REQUIRED DOWN PAYMENT RECEIVED PRIOR TO
THE EXPIRATION OF SUCH 90 DAY PERIOD;AFTER 90 DAYS,AND IN THE EVENT COMPANY DOES NOT REVOKE THE PROPOSAL,COMPANY RESERVES THE RIGHT TO REVISE ITS PRICE IN
ACCORDANCE WITH ITS COSTS IN EFFECT AT SUCH TIME.
22.IF ANY PROVISION OF THIS AGREEMENT SHOULD BE HELD TO BE INVALID OR UNENFORCABLE,THE VALIDITY AND ENFORCEBILITY OF THE REMAINING PROVISIONS OF THIS AGREEMENT
SHALL NOT BE AFFECTED THEREBY.
23.ARBITRATION:IN THE EVENT THE CLIENT AND COMPANY HAVE A DISPUTE REGARDING ANY OF THE TERMS,CONDITIONS,PROVISIONS,OR PERFORMANCE OF THIS AGREEMENT,THE PARTIES
AGREE TO PLACE THE MATTER INTO ARBITRATION BEFORE AN INDEPENDENT ARBITRATOR ASSIGNED BY THE AMERICAN ARBITRATION ASSOCIATION TO RESOLVE THEIR DISPUTE.
24.ANY DISCOUNT,PROMOTION,REIMBURSEMENT,OR OTHER PROGRAM THAT IS PART OF A STATE SPONSERED UTILITY PROGRAM(I.E.MASS SAVE•)IS SUBJECT TO THE AVAILABILITY OF
QUALIFYING STATE SPONSERED PROGRAM AND WILL BE SUBJECT TO TERMINATION IF THE STATE SPONSERED UTILITY PROGRAM IS DISCOUNTINUED.FURTHERMORE,THE TERMS AND
CONDITIONS OF STATE SPONSERED UTILITY PROGRAMS MAY BE ALTERED OR UPDATED PERIODICALLY WITH OR WITHOUT NOTICE.
25.AMERICAN INSTALLERS,LLC IS NOT AN AGENT OF ANY UTILITY COMPANY OF OTHER VENDOR WORKING BY,THROUGH,OR UNDER THE MASS SAVE•ENERGY PROGRAM.
26.CLIENT IS REPSONSIBLE FOR THE PAYMENT OF ANY AND ALL FEDERAL,STATE,OR LOCAL TAXES THAT ARE APPLICABLE TO THIS AGREEMENT.
27.THE CLIENT CONSENTS TO USING AN ELECTRONIC SIGNATURE TO SIGN THIS AGREEMENT AND BE LEGALLY BOUND TO THE CLIENT'S ACCEPTANCE OF THE AGREEMENT. BY ELECTRONICALLY
SIGNING THE AGREEMENT,THE CLIENT ALSO CONSENTS TO ENTERING INTO THIS AGREEMENT IN ELECTRONIC FORM. tHE CLIENT ACKNOWLEDGES THAT THE CLIENT'S ELECTRONIC
SIGNATURE WILL HAVE THE SAME LEGAL FORCE AND EFFECT AS A HANDWRITTEN SIGNATURE.
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street,Suite 100
Boston,MA 02114-2017
www mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print I egibly
Name (Business/Organization/Individual): 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.®I am a employer with 70 employees(full and/or part-tune)." 7. New construction
2.❑I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling
any capacity.[No workers'comp.insurance required.]
9. El Demolition
1F-1 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
10 Q Building addition
4.❑1 am a homeowner and will be hiring contractors W conduct all work on my property. twill
ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions
proprietors with no employees. 12.Q Plumbing repairs or additions
5.O I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs
These sub-contractors have employees and have workers'comp.insurance.t
6.❑we are a corporation and its officers have exercised their right of exemption per MGL c. 14.0 Other Insulation
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
*Any applicant that checks box#i must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
lContractors that check this box must attached an additional sheet showing the natne of the sub-contractors and state whether or not those entities have
employees. if the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employee& Below is the policy and job site
information.
Insurance Company Name: Berkshire Hathaway GUARD
Policy#or Self-ins.Lic.#:j�AMWC049875 _ Expiration Date: 09/04/2020
Job Site Address:- 'r±L f n,_ ,S,t yuf City/State/Zip:_R1f4h=0Mo,
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL a 152,§25A is a criminal violation punishable by a fine up to$1,500.00
and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify under the pains and penalties of perjury that the informationprovidel ab ve is true and correct
I
Signature: Date:
Phone#: 41 -
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone#:
Commonwealth of Massachusetts Construction Supervisor
Division of Professional Licensure Unrestricted -Buildings of any use group which contain
Board of Building Regulations and Standards fess than 35,000 cubic feet (991 cubic meters) of enclosed
Construction Supervisor space.
CS-106178 =r. _ . ..021
WESLEY COUTURE
139 PACKARDVILLE ROAD
PELHAM MA 01002 a
Failure to possess a current edition of the Massachusetts
State Building Code is cause for revocation of this license.
Commissioner � For information about this license` Call (617) 7273200 or visit www.mass.gov/dpi
Office of Consumer Affairs and Business Regulation
1000 Washington Street - Suite 710
Boston, Massachusetts 02118
Home Improvement Contractor Registration
Type: LLC
AMERICAN INSTALLATIONS,LLC. Registration: 175982
130 COLLEGE STREET SUITE 100 Expiration: 06/26/2021
SOUTH HADLEY,MA 01075
SCA 1 J 2pM-e5/17 Update Address and Return Card.
.71"- '/».i 1-~1'ew111" V.
Office of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only
TYPE:LLC before the expiration date. If found return to:
Registration Expiration Office of Consumer Affairs and Business Regulation
175982 06/26/2021 1000 Washington Street -Suite 710
AMERICAN INSTALLATIONS,LLC. Boston,MA 02118
WESLEY COUTURE i
130 COLLEGE STREET SUITE 100j-w,
SOUTH HADLEY,MA 01075 Undersecretary t valid without signature
ACS 0�1Z0® CERTIFICATE OF LIABILITY INSURANCEDATE(MM/DDYYYV)
78/28/2019
THIS CERTIFICATE IS ISSUED ASA MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER NAME: Linda Powers
Webber & Grinnell PHONE (413)586-0111 FAx
A/C No x IA/C,NO (913)586-6981
8 North King Street E-MAIL
ADDRESS: 1powers@webberandgrinnell.com
INSURERS AFFORDING COVERAGE NAIC#
Northampton MA 01060 INSURERA:Employers Mutual Casualty
INSURED INSURER B:Berkshire Hathaway GUARD Ins. Co.
American Installations, LLC INSURER C:
Attn: Wes & Suzanne Couture INSURER
130 College Street, Suite 100 INSURER E:
South Hadley MA 01075 INSURERF:
COVERAGES CERTIFICATE NUMBER:Master Exp 9-2020 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR I ADDL SUER POLICY EFF POLICY EXP
LTR TYPE OF INSURANCE POLICY NUMBER MM DD YYYY MM DDYYYV LIMITS
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
DAMAGE TO RENTED
A X CLAIMS-MADE OCCUR PREMISES Ea occurrence $ 500,000
SD3535217 9/4/2019 9/4/2020 MED EXP(Any one person) $ 10,000
PERSONAL&ADV INJURY $ 1,000,000
GENT AGGREGATE LIMITAPPLIES PER GENERAL AGGREGATE $ 2,000,000
X PRO 2,000,000
POLICY JECT LOC PRODUCTS-COMP/OPAGG $
OTHER $
AUTOMOBILE LIABILITYEO aBINEDtSINGLE LIMIT $ 1,000,000
AIx.
ANYAUTO BODILY INJURY(Per person) $
ALL OWNED X SCHEDULED 523535217 9 4/2019 9/4/2020 BODILY INJURY Per accident $
AUTOS AUTOS / ( )
HIREDAUTOS X NON-OWNED PROPERTY DAMAGEAUTOS Peraccident $Coll$2,000 X comp$2,000 PIP-Basic $ 8,000-
x
,000X UMBRELLA LIAR OCCUR
EACH OCCURRENCE $ 1,000,000
A EXCESS LIAB HCLAIMS-MADE
AGGREGATE $ 1,000,000
DED I X I RETENTION $ 10,000 513535217 9/4/2019 9/4/2020 $
WORKERS COMPENSATION PER OTH-
AND EMPLOYERS'LIABILITY YIN x STATUTE ER
ANY PROPRIETOR/PARTNER/EXECUTIVEE.L.EACH ACCIDENT $ 500,000
OFFICER/MEMBER EXCLUDED? ❑ NIA
B (Mandatory in NH) AIIWC994153 9/4/2019 9/4/2020 E .DISEASE-EA EMPLOYEE $ 500,000
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000
A Business Personal Property SA3535217 9/4/2019 9/4/2020 deductible$1,000 500,000
DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Evidence of Insurance THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
W Grinnell, CPCU, CIC
11988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
INS025(201401)