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35-269 (22) BP-2024-0569 78 TURKEY HILL RD COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 35-269-001 CITY OF NORTHAMPTON Permit: Alts Renovations Repair PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit # BP-2024-0569 PERMISSION IS HEREBY GRANTED TO: Project# 2024 INSULATION Contractor: License: Est.Cost: 1600 AMERICAN INSTALLATIONS LLC 106178 Const.Class: Exp.Date:09/29/2025 Use Group: Owner: M PELLEGRINO CHARLENE Lot Size(sq.ft.) Zoning: RR Applicant: AMERICAN INSTALLATIONS LLC Applicant Address Phone: Insurance: 130 COLLEGE ST SUITE 100 (413)552-0200 AMWC32951 SOUTH HADLEY, MA 01075 ISSUED ON: 05/08/2024 TO PERFORM THE FOLLOWING WORK: ATTIC &BASEMENT INSULATION &WEATHERSEALING 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: Final: Final: Final: Rough Frame: Gas: Fire Department Driveway Final: Fireplace/Chimney: Rough: Oil: Insulation: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: 6/2- Fees Paid: $65.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner I r- i itTJgl DepF0k . iii City of Northampton %? . rl;, Building Department 1 t,�_ , 212 Main Street Room 100 ItISULA TI ON -,?t, :. ' Northampton, MA 01060 phone 413-587-1240 Fax 413-587-1272 OfJL.. Y ___ APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING ONLY SECTION 1 -SITE INFORMATION INSULATION PERMIT This section to be completed by office 1.1 Property Address �J —.�b`f— Do / 78 Turkey Hill Rd Map h Lot Unit Florence, MA 01062 ?one_/\ overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Pellegrino & Colby, Charlene & Brian 78 Turkey Hill Rd Florence, MA 01062 Name(Print) Current Mailing Address. See attached (413) 210-1577 Telephone Signature 2.2 Authorized Anent: American installations 130 College Street Ste. 100, South Hadley, MA 01075 Name(Print) / Current Mailing Address: �:1/ Zt (413) 552-0200 Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building 1,600 (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from(6) 3. Plumbing (1 Building Permit Fee c;.' i --- 4. Mechanical(HVAC) 0 5. Fire Protection 6. Total=(1 +2 +3+4+5) 1,600 Check Number ^ TIoO 6, This Section For Official Use Only Building Permit Number: (3P-zt 24 - D5t"'J IIsssued: Signature: ///;�� J-8 -26 2 Building Commissioner/Inspector of Buildings Date permits@Americanlnstallatinns.coni @ EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) SECTION 4-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable 0 Name of License Holder: Wesley K. Couture 106178 License Number 130 College Street Ste. 100, South Hadley MA 01075 9/29/2025 Address id/A. ( ) Expiration Date 413 552-0200 Signature Telephone 9.Registered Home Improvement Contractor; Not Applicable 0 American Installations 175982 Company Name Registration Number 130 College Street Ste. 100, South Hadley MA 01075 6/26/2025 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 IV No 0 Brief Description of Proposed Work NOTE: INSULATION ONLY Attic and basement insulation and air sealing throughout. 1, 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 zt_. 4/30/2024 Signature of Owner/Agent Date Pellegrino & Colby, Charlene & Brian ,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 4/30/2024 Signature of Owner Date City of Northampton Massachusetts ��s' *�.- .(e • DEPARTMENT OF BUILDING INSPECTIONS a'- 212 Main Street • Municipal Building w ,�� Northampton, MA 01060 ;•-... AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and subcontractors performing improvements or renovations on detached one to four family homes. Prior to 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: 1,600 Address of Work: 78 Turkey Hill Rd Florence, MA 01062 Date of Permit Application: 4/30/2024 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: 4/30/2024 Ilrnerican 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 /joy .Mpro�4 SAS...?..,r%.. Massachusetts •' „r •G t 't DEPARTMENT OF BUILDING INSPECTIONS •,-'` 212 Main StrNt •Municipal Building :may y Northampton, MA 01060 rry • ,fib 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: 78 Turkey Hill Rd (Please print house number and street name) Is to be disposed of at: K W Materials 6-Recycling, 138 Palmer Ave, West Springfield, MA 01089 (Please print name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) 4/30/2024 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. City of Northampton __ SAS... '_,.sir, �� ,✓� y 2..:'' #.. ,ice �•F Massachusetts ti`�` \ . a DEPARTMENT OF BUILDING INSPECTIONS �I+ A. r _. 212 Main Street • Municipal Building J`r• . oa a_• ^. Northampton, MA 01060 .fp�V .�1. MANDATORY FOR HOUSES BUILT BEFORE 1945 Property Address: 78 Turkey Hill Rd Florence, MA 01062 Contractor Name: American Installations Address: 130 College Street Ste. 100 City, State: South Hadley MA Phone: (413) 552-0200 Property Owner Name: Pellegrino & Colby, Charlene & Brian Address: 78 Turkey Hill Rd City, State: Florence, MA 01062 I, lt'cIry K. c;u etur (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 �;�� A G��— Date 4/30/2024 Page 1 of 1 mass save PARTNER txensed&insuredMACS(R:1Q6178 1111. 1111111 MARetVstrotion R 1/.5982 American Installations www.Americanlnstallations.com 130 College Street Suite 100,South Ndley,MA 01075•Office:(113)552.0200 Fax:(413)552.0202 •Email:supporlilRmeeican nslallations.com Customer Name:Charlene Pellegrino Email:Not provided Phone:413-210-1577 Premise Address:78 Turkey Hill Rd,Northampton,MA 01062 Mailing Address:78 Turkey Hill Rd.Northampton,MA 01062 Project ID:5240941 Date:April 17,2024 Job Description Measure Description Location Quantity Unit Total Cost Customer Cost Air Sealing at Estimated 62.5 CFM50 Per Hour Other 12 hr $1,279.08 $0.00 Door Sweep(with AS hrs) Other 4 each $118.64 $0.00 Exterior Door Weather Stripping (with AS hrs) Other 4 each $145.28 $0.00 Hatch -2"Thermal Barrier Polyiso Other 1 each $53.96 $13.49 Project Total $1,596.96 Weatherization incentive ($40.47) Air sealing incentive ($1,543.00) Total Program Incentive -$1,583.47 Customer Total $13.49 WARRANTY:American installations,LLC will provide the above stated homeowner with a 1-year workmanship warranty. American nstagations.LLC hereby proposes to furnish all material and labor to complete the above scope of work in accordance with the above specifications and al local and state bulling regulations for the Total Contract Value as stated herein. ACCEPTANCE OF PROPOSAL: The above prices, specifications and conditions are TOTAL CONTRACT VALUE r $ satisfactory and are her Eby accepted.You are authorized to do work as specified.Payment 0 will be 1/3 down prior to start of work,and balance due upon Completion. Down Payment- S ❑ PAD Balance our Upon Completion- $ 13.49 Signature Date Property Owner(Print) (Sign) MO Date /itkRepresentative:(Print) (See Ai Date 1NnAaeeMenlnmMrosmor•NnrxaAwlhe•[vttlsEwEwTrxsrAxAxosnnteecaesneAtolneernuaA,• nlsr'NA.MnowravEOTnnaeeeeAm.TnarrweaAMurml WALLA lows.ucwuwArTaxEr MAD roatow.nr. AND IN!CUSTOMtrI(S)NAME)MOAN Mt MEIew Ier/WEANED 10 AS'Olter.AND WASIE MULCT 10 AU ArrxO►IAlt LAWS,etDJNTIOeS AND OMOWrnus a NNE STALE Or AEASSAO,USt1 n OR CONN EC74UT MAUI NEST.AS was AS ALL LOCAL AlmSPCI IONS 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 RIGHT 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 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 OR 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 SAVES)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. 2S. AMERICAN INSTALLERS,LLC IS NOT AN AGENT OF ANY UTILITY COMPANY OF OTHER VENDOR WORKING BY,THROUGH,OR UNDER THE MASS SAVES ENERGY PROGRAM. 26. CLIENT IS REPSONSIBLE FOR THE PAYMENT OF ANY AND ALL FEDERAL,STATE,OR LOCAL TAXES THAT ARE APPLICABLE TO THIS AGREEMENT. The Commonwealth of Massachusetts Department of Industrial Accidents 7 Office of Investigations = Lafayette City Center 2 Avenue de Lafayette, Boston,MA 02111-1750 �� www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual):American Installations LLC Address:130 College St, 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): 1.0 I am a employer with 43 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling ship and have no employees These sub-contractors have 8. 0 Demolition workingfor me in anycapacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.: required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ i am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152,§1(4),and we have no Insulation employees. [No workers' 13.❑■ Other comp. insurance required.] 'Any applicant that checks box#1 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. :Contractors that check this box must attached an additional sheet showing the name 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 employees. Below is the policy and job site information. insurance Company Name: Berkshire Hathaway GUARD Insurance Policy#or Self-ins. Lic.#:AMV1IC487555 Expiration Date: 9/04/2024 78 Turkey Hill Rd Florence,MA 01062 Job Site Address: City/State/Zip:_ 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 S250.00 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 hereby certify under the pains and penalties of perjury that the information provided above is true and 1 4/30/2024 correct. Signature: 9. Date: Phone#: 413-552-0 00 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License # issuing Authority(check one): 1❑Board of Health 20 Building Department 30City/Town Clerk 4.0 Electrical Inspector 50Plumbing inspector 6.0Other Contact Person: Phone#: ACc RIJ CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) `--- 11/20/2023 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(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or 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 CONTACT Robert Walters III NAME: Alera Group,Inc. PHONE (413)586-0111 FAX (413)586-6481 (A/C.No.Extl; (A/C,No): Webber&Grinnell Division EMAIL rwalters@webberandgnnnell.com ADDRESS: 8 North King Street INSURER(S)AFFORDING COVERAGE NAIC N Northampton MA 01060 INSURER A: Employers Mutual Casualty Company 21415 INSURED INSURERS: AmGUARD/BH GUARD 43290 American Installations,LLC INSURER C: XS Brokers Insurance Agency Alpine Heat Pumps INSURER D: 130 College Street,Suite 100 INSURERS: South Hadley MA 01075 INSURER F: COVERAGES CERTIFICATE NUMBER: Exp 09/04/2024 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 TYPE OF INSURANCE AWL SUB!- POLICY NUMBER POLICY EFF POLICY EXP i LTRINSD WVD (MMIDD/YYYY] (MM/DD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCEDAMAGE TO S 1.000,000 CLAIMS-MADE XI OCCUR PREMISES(EaENTED occurrence) S 500,000 X Liquor Liability MED EXP 10,000 (Any one person) S A 5D3535224 09/04/2023 09/04/2024 PERSONAL BADVINJURY S 1,000,000 GENL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2,000,000 X POLICY X1PRO1-1 PRODUCTS-COMP/OP AGO S JECT LOC 0000020 , OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ A OWNED X SCHEDULED 5Z3535224 09/04/2023 09/04/2024 BODILY INJURY(Per accident) S AUTOS ONLY _ AUTOS , HIRED NON-0WNED PROPERTY DAMAGE S X AUTOS ONLY X AUTOS ONLY (Per accident) PIP-Basic S 8,000 X UMBRELLA UAB X OCCUR EACH OCCURRENCE S 1,000,000 A EXCESS UAB CLAIMS-MADE 5J3535224 09/04/2023 09/04/2024 AGGREGATE S 1.000,000 DED X RETENTION$ 10,000 S WORKERS COMPENSATION )/(PER OTH- AND EMPLOYERS'LIABILITY YIN /N STATUTE ER B ANY PROPRIETOR/PARTNER/EXECUTIVEN LA AMWC487555 09/04/2023 09/04/2024 (Mandatory E.L EACH ACCIDENT s 500,000 yEMBER EXCLUDED? 500,000 (Mandatoo ry In NH) E.L DISEASE-EA EM PLOYEE S If yes.deambe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S Pollution Liability C G74352546002 11/10/2023 11/10/2024 Occurrence Limit $1,000,000 Aggregate Limit $2,000,000 DESCRIPTION OF OPERATIONS I 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 THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Evidence of Insurance ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE n ;I I :.//f,„. /; _?j�' ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) Tho ACORD name and logo are registered marks of ACORD 491 Commonwealth of Massachusetts Division of Occupational Licensure Board of Building Regulations and Standards Cons �rvisor ES9aires: 09/29/2025 WESLEY COUTURE 139 PACKARDVILLE ROAD PELHAM MA -Q1002 • • t 1 • Commissioner - THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: LLC AMERICAN INSTALLATIONS, LLC Re 65982 130 COLLEGE STREET ration:Expiration: 06l26/2025 SUITE 100 SOUTH HADLEY, MA 01075 Update Address and Return Card. THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs 8 Business Regulation Registration valid for individual use only before the HOME IMPROVEMENT CONTRACTOR expiration date. If found return to: TYPE:LLC Office of Consumer Affairs and Business Regulation Registration Expiration 1000 Washington Street -Suite 710 175982 06/26/2025 Boston,MA 02118 AMERICAN INSTALLATIONS,LLC WESLEY COUTURE ` 130 COLLEGE STREET SUITE 100 SOUTH HADLEY,MA 01075 Undersecretary Not valid without signature