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31B-314 (9) 15 PARK AVE BP-2017-0750 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:3IB-314 CITY OF NORTHAMPTON Lot:-000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) ,Category:INSULATION BUILDING PERMIT Permit# BP-2017-0750 Project JS-2017-001257 Est.Cost: $2358.00 Fee:$65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Ilse Grouo AMERICAN INSTALLATIONS LLC 106178 Lot Size(so.ft.): Owner: MIEHER STUART Zoning:URCj100)/ Applicant: AMERICAN INSTALLATIONS LLC AT: 15 PARK AVE Applicant Address: Phone: Insurance: 130 COLLEGE ST (413)552-0200 WC SOUTH HADLEYMA01075 ISSUED ON:12/9/2016 0:00:00 TO PERFORM THE FOLLOWING WORK:ATTIC & BASEMENT 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 N 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 TTS RULES AND REGULATIONS. Certificate of Occupancy Signature: FeeType: Date Paid: Amount: Building 12/9/2016 0:00:00 $65.00 212 Main Street, Phone(413)587-1240.Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner File#BP-2017-0750 APPLICANT/CONTACT PERSON AMERICAN INSTALLATIONS LLC ADDRESS/PHONE 130 COLLEGE ST SOUTH HADLEY (413)552-0200 PROPERTY LOCATION 15 PARK AVE MAP 31S PARCEL 314 000 ZONE URC(OOV IBIS SECTION FOR OFFICIAL USE ONLY: PERMIT tTION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Pai Building Permit Filledout Fee Paid Typeof Construction:_ATTIC&RAS _. SULATION&AIR SEALING THROUGHOUT New Construction Non Structural interior renovations _Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License..106178 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION PRESENTED: —Approved Additional permits requited(see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project: Site Plan AND/OR Special Permit With Site Plan Major Project: Site Plan AND/OR Special Permit With Site Plan ZONING BOARD PERMIT REQUIRED UNDER: § Finding Special Permit Variances Received&Recorded at Registry of Deeds Proof Enclosed. Other Permits Required: Curb Cut from DPW Water Availability Sewer Availability Septic Approval Board of Health Well Water Potability Board of Health Permit from Conservation Commission Permit from CB Architecture Committee Permit from Elm Street Commission Permit DPW Storm Water Management. Demolition Delay 1. i / .% -7-/d'_. . re o d din ial - Date Note: issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning requirements and obtain all required permits from Board of Health,Conservation Commission,Department of public works and other applicable permit granting authorities. *Variances are granted only to those applicants who meet the strict standards of MGL 40k Contact Office of Planning&Development for more information. 16-2094 • " Department Eisen* City of Northampton Stags of Permit Q,� Building Department crab Cut,tnvewdy Permit � 212 Main Street IrrsewarM.eapticava))abAlty.- Room 100 WateriWell Avagabiluty Northampton, MA 01060Two 5ers of Studtural'P.lana phone 413-587-1240 Fax 413-587-1272 Ptoa`51Ter�ns 9 � / APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR IWO FAMILY DWELLING SECTION 1-SITE INFORMATION 1.1 Property Address: This section to be completed by office 15 Park Avenue Map Lot Unit_„ Zone Overlay District _. Elm St District. . CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Stewart Mieher 15 Park Avenue Northampton,MA 01060 Name(Print) Conant Mari Address: (413)695-8799 See attached Telephone Signature $2 Authorized Agent American Installations 130 College Sr., Ste 100 South Hadley, MA 01075 Name(Print) Current Marg Address: American Installations 413-552-0200 Signature Telephone SECTION$-ESTIMATED CONSTRUCTION COSTS Kern Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building $2,358.32 (a)Building Permit Fee 2. Electrical (b)Esgmated Total Cost of Construction from(6) 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5.Eve Protection /_ j' 6. Total=(1+2+3+4+5) $2,35832 Check Number 3y ffr This Section For Official Use Only Building Permit Nudo,, . Date Dated' Signature: BuMhtg CommissioncreinsPector of eualings gym Section 4. ZONING AU Information Must Be Completed.Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning Ms column to ba filled in by Building Dcpneaomt Lot Size Frontage I Setbacks Front Side L: R I L: Rear I I r l Building Height Bldg.Square Footage I — I I % I I Open Space Footage % (Comma minus bldg&paved I L I I I I I parking) N of Parking Spaces r-1 Fill: r (volume alomdou) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DONT KNOW O YES 0 IF YES,date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW 0 YES 0 IF YES: enter Book' I Page I and/or Document ff L B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW O YES 0 IF YES,has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained O , Date Issued: I C. Do any signs exist on the property? YES O NO 0 IF YES, describe size,type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES O NO O IF YES, describe size, type and location: I E. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 NO O IF YES,then a Northampton Storm Water Management Permit from the DPW is required. SECTION S-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition 0 Replacement Windows Aheratiants) 0 Roofing 0 Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs gni Decks [Q Suring IC) Others it Bdaf Oesrsiption grproposed Wo$c Attic and basement insulation and air sealing throughout Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet se,If New house and or addition to existing housing,complete thefollowing: a. Use of building:One Family Two Fam1ly Other b. Number of rooms in each family unit: Number of Bathrooms c. Is there a garage attached? d. Prrpos-d Square footage of new construc . Dimensions e. Number of stories? f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masseheck Energy Compliance form attached? it Type of construction I. Is construction milt 100 ft.of wetlands? Yes No. Is c'onstrugion within 100 yr. Ooodpiain Yes No j. Depth of basement or cellar floor below finished grade k. Witt building conform bale Building and Zoning regulations? Yes No. I. Septic Tank City Sewer Private well City water Supply SECTION 7a OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT Stewart Mieher ,as Comer of the subject peupertY hereby authorize Antcrican Installations to act on my behalf,in all matters relative to work authorized by this building permit application. See attached 12/1/16 Signature of Owner Date I, American Installations as Owner/Authorized Agent hereby declare that the statements and information on the foregoing application are Imre and accurate,to the best of my knowledge and belief. Signed under the pains and penalties of perjury. American Installations ..,._ Print Name American Installations 12/1/16 Manakin)of OwnerlAgera Date SECTION 8•CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable Name of Oconee Weldor: Wesley K. Couture 106178 License Number 130 College St., Ste 100 South Hadley,MA 01075 9/29/17 Expiration Date P AIgnaturea ( 413-552-0200 Telephone t•t Istered Hou• •rove nit , •ntractort Not Applicable CI Wesley Couture A175982 Company Name Registration Number American Installations 6/27/17 Address Expiration Date 130 College St., Ste 100 South Hadley, MA 01075 Telephone 413-552-0200 SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.C.102,§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 ofthe building permit Signed Affidavit Attached Yes ai No CI 11. -Rome Owner Exemption The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)families and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner acts as soperviser.CNIR 700. Sixth F•dition Section 100.3-5.1. Definition of Homeowner:Person(s)who own a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two family dwelling,attached or detached structures orangery to such use and/or farm structures.A Person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official,that Wake shall he responsible for all such work performed under the building pewit. As acting Construction Supervisor your presence on the job site will be required from time to time,daring and upon completion of the work for which this permit is issued. Also be advised that with reference to Chapter 152(Workers'Compensation) and Chapter 153(Liability of Employers to Employees for injuries not resulting in Death)of the Massachusetts General Las Annotated,you pray be Viable for person(s) you hire to perform work for you under this permit The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of Northampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature City of Northampton L j Massachusetts ri DHain OF WELDING INSPECTIONS 212 NeiEN fas 212 n Street • Naniei0Building pC Northampton, NA 01060 Property Address: 15 Park Avenue Northampton, MA 01060 Contractor Name: American Installations Address: 130 College Street Ste. 100 City, State: South Hadley, MA Phone: 43-552-0200 Property Owner Stewart Mieher Name: Address: 15 Park Avenue City,State: Northampton, MA 01060 I, American Installations (contractor) attest and affirm that the budding 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" tur Date Contractor" 12/1/16 a�, BBB www Ama„ n sulaions in PLI.1.111-111 Licensed&Insured MA CSL 07:106178 American Installations MA Registration N 175982 130College Street Suite lea.South Hadley,MA 01075•Office:1123)552-0200 Fax:(413)551-0202•Email:suppnnednerkanmauu4ona.wn Mieher,Stuart 11/28/2016 15 Park Avenue Northampton MA 01060 Lied (413)695-8799 srmieher@gmail.com w m. 443 337 lan.o 16-2090 Ike 41 Quantity Unit Unit Cost Total Air/Duct Sealing AIR SEALING 4 man hour $ 85.00 $ 340.00 Air/Duct Sealing $ 340.00 Air/Duct Sealing Incentive $ 134000) Air/Duct Selaing Wit Balance $ - Weatherization FLAT-10”OPEN R-49 450 sqk 1.69 $ 760.50 DAMMING R-38 26 linear ft 2.05 $ 53.30 2"RIGID BOARD 152 soft 3.50 $ 532.00 SLOPE-8"DENSE PACK R-26 152 sqft 1.91 $ 290.32 COMMON WALL-4" 112 sqk 1.85 $ 207.20 STAIRWELL 1 each 175.00 $ 175.00 Total Weatherization $ 2,018.32 Weatherization Incentive $ 1,513 14 Total Project $ 2,358.32 Total Utility Contribution $ 1,85374 Total Customer Contribution $ 504.58 WARRANTY:.Amerman installations.LLC will rovde the afro slated homeowoerwdh'2 year wormanship warranty. hereby proposesand labor to complete me above scope of work in accosdaroe Hahn the above specifications and all local and state Mingress tons fo the Total Contract as date herein t ACCEPTANCE Of PROPOSAL.The above pikes.specinonons and TOTAL CONTRACT VALUE= $ 504.58 conditionssatisfactory tisfacand ahereby accepter you authonaetl CO do work as specified.Payment will be 2/3 down pnorto Down Payment= $ 168.00 start !work,and balance due upon Completion. PAID Balance Due Upon Completion= $ 16 4 AA7/. uxll/0e/n/16 [al Couture tiwni 11/19/16 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(5)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 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$200 PER MONTH,AND IF PLACED IN THE HANDS OF AN ATTORNEY OR COLLECTION AGENCY FOR COLLECTION,ALL ATTORNEYS'FEES,EXPENSES AND COSTS OF COLLECTION SHALL BE PAID BY THE CLIENT.IN ADDITION,CLIENT UNDERSTANDS THAT IN FAILING TO PAY ACCORDING TO THE ABOVE TERMS,COMPANY MAY HAVE THE 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 15 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 DF 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 EYTENT THOSE DAMAGES ARE PROVEN TO BE SOLEY DUE TO THE COMPANY'S NEGLIGENCE. 0. 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 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 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. The Commonwealth of Massachusetts eft Department of Industrial Accidents L Office of Investigations a � 11. 9 .w 600 Washington Street Boston, MA 02111 www.nasagov/die Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Nameovisae.arzhaaninifionllnAddlialy American Installations,LLC Address: 130 College Street,Suite IOU City/Slate/ZIp: South Hadley,MA 01075 Phone r,: 413552-0200 Are you an employer?Check the pprol iate bo.- Tr Type of prf- t( equtrctly 1 t%] lam a.'rnplover with 31 4_ LI I ate a general contractor and i 6. Di New construction einployees thin and/or pan time)* have hired the subcontractor pCmodebng 2.1lam s\le proprietor or panrrgr- listed on the attahed s1 eft sh'p and have as employees These sub-contractors - 8 Li Demolition worktng br Mc in any capacity- workers'comp insurance g_ 0 Ruiidiau addition {No workers'comp.insurance 5. ❑ We are a corporalion and its required.) officers have exercised their 30.71 Electrical repaim or additions am! III Plumbingrepairs or additions ].Lfahomenwnm doing oil\vrrrk right of exemption per Will, � ip myself.[No workers'comp. C. 152,§1(4),and we have no I'-.❑ Roof repairs insurance required.f' employees. [No workers' on comp.insurance required_ .. ) f's Other In au .. _ aprOwasil Slut oileAS box.!must dlw til W, hu scroon raw shooing stoir workro compossot pan poi Pry illfiltillM1011 �_.... I Imnunwncn who sohmn Ibrs 31nduvii,nJmot pp the arc doing vll soot and[lira him omsidu conmwlors mon snh,Jl u new Arsdavn irLJoling such. lbmr35Inrs thio cbxck lint buss muss auortiss1 nn additional Theo showing the'wont of be sub-con:mconra and their worker'_ramppolicy information. • I am an employer that ix providing wen-ken'compensation insurance for nn employees. Beta:is the polity and job site informant Insurance Company Name_ Guard Insurance Companies. Policy b or Self ns Lie.li. URWC609917 Expiration Daie' 09/04/2017 lA Job SiteAddress- lS ?OXk NitfL €-- p City/State7l eaut�l -Atm T ` O\OoO 7 4 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 MGI.c. 152 can Lead to the imposition ofcriminal penalties of a tine up Io.$1500.00 and/or one-year imprisonment,as well as civil penalties in the form ora STOP WORK ORDER anti a line of up to$25000 a day against the w Miator. Be advi5Ed ihtt a copy lits statement ma:, in forwarded to the Office of in.esligarious of thy DIA for insurance coverage verification_ l do hereby certify mater the pains and dppenalties of perjury,that are information providedaboveis true and Correa. .w.._ Date;._tj.i l k— Ph dm e'. 413552-0200 I. Official se only. Do not wont.in this area,In be completed by oily or town official CBI:or Town: AumitlTiecnse Y. 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 a:..__—. a ACO o CERTIFICATE OF LIABILITY INSURANCE DA9i1i2_DsYY1 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 CERTIRCATE 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 pollcylies)must be endoned N 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 g g Linda Powers Webber & Grinnell PHONE (613)586 0111 ep gPl_I 3)596-6461 8 North Xing Street Wiese, AOe im,s % 1413)5e6-0111vdgrivnoll.cos -_-. INSURER(S)WORDING CCOVERAGE _.. N/IC a Northampton MA 01060 INsuRaA:Employers Mutual Casualty r INSURED saunas Berkshire Ratta WARD Ina CO American Inatallatiova, LLC POURER C: ._.. Attn: Wee 6 Suzanne Couture INSURER D: 130 College Street, Suite 100 INSURER 1 South Hadley MA 01075 INSURER, COVERAGES CERTIFICATE NUMBERMaster Sap 9-2017 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%MTH RESPECT TO NMICH 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. ALAIWIWVMM POYCY NUMBER IMWOWYU•YI IMWCMYYYI LASTS TYPE OF INSURANCE POLICY EFF POLICY EXP COMMERCIAL GENERAL UABIUTY IF 1,000,000 EACH OCCURRENCE A X LIAIMSMPDE I` ''.ODOUR AmAse TO RENTED Ig 500,000 -- - PREMISES Pa wnrtTlpl LiquorW3535217 9/4/2016 li 9/4/2017 MED ENPyM me Prom) s 10,000 X Liability III 1 PERSONAL 6AW INJURY 5 1,000,000 GEAR AGGREGATE LIMIT APPLES PER. I GENERAL AGGREGATE E 2,000,000 ^ X I POLICY reD' JEGT n La %tOOLCIS-COMPAP A00 S 2,000,000 I OTHER: $ AUTOMOBILE ua9LTY I COMBINED SINGLE Limit $ 1_000,000 yNe IEesm __.. A '`.ANY AUTO BODILYIruLerryvp.,.u,) s AUTOS ALL ED r__.SCHED=lee 553535217 9/4/2016 9/4/2017 BODILY INJURY IPE aatlMl $ - - - EO PROPERTY DAMAGE X HIRED AUTOS X AUTOS _05.1EPO ,0 $ _ I pIp.aym 5 8,000 X''.UMBRELLA WB GLH EAC.OCCURRENCE 5 1,000,000 __ •Fl(Ql9 LAB _ CLAIMBM.oe: AGGREGATE 4$ 1,000,000 A ' OW X I RETENTIONS 10,000 I I�15,13535217 9/4/2016 9/4/2017 I$ [WORKERSCOMPENSATON 1 a PER AND EMPWYERt LIABILITY YIN ,4'TATUtE ER _ ANY NpPRIETURPARTIERIEXECInNE • EL EACH ACCIDENT IS 500,000 B •OFFICER/MEMBERIIO MEnEER E%CLED+ N/A _ EA EMROVEE$ 5_00u000 Xee s.AnIn NH) j 0¢IF609917 9/4/2016 9/4/2017EL DISESE erate woe DESCRIPTION QF OPERATIONS belowE L DISEASE-POUCY UIIT I I 500,000 A 1 Committal Al Property 5A3535217 9/4/2016 19/4/2017 eeavaw s.cm 920,000 e einem 540,000 mammon OFOPERATONS/LOCATIONS/VOCISS(AGGRO 101 Additional Renta seeds may 9e MIxMC II more pace ft impaired' CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCMBEO POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Kevin Joyce/LMP C_ .— -- ------- ©1988-2016 AGGRO CORPORATION. A11 rights reserved. ACORD 24(2016/01) The ACORD name and logo are registered marks of ACORD INSO25°amen kip Massachusetts-Department of Public Safety Unrestricted-Buildings of any use group which Board of Building Regulations and Standards contain less than 35,000 cubic feet(991m)of Cnnatrucfnn Supenisnr 1111111111INC e.r.ctoscd space. License:CS-106178 ct, WESLEY COUTU,*B o. 16 NORTH Sou hHadle M of *„ South Balky MA=Ol Failure to possess a anent edition of the Massachusetts �1 a - -Stale Building Code is muse for revocation of this kense. r./w...C�6fd. sns' Expiration Commissioner 09/29/2017 RNDps Licensing inIwm®Ibn visit wwwMess.Gov/DV$ s_ Office of Consumer Affairs and Busi- ss Reg'.-lation - „a 10 Park Plaza- Suite 5170 Boston, Massachusetts 02116 Home Improvement C, hjrractor Registration Registration: 175982 - Type: LLC Expiration: 6/27/2017 Ti0 265208 AMERICAN INSTALLATIONS, LLC - WESLEY COUTURE ,_ _.. - - 130 COLLEGE STREET SUITE 100 SOUTH HADLEY, MA 01075 Update Address and return card.Mark reason for change. scat 0 20M435/II - 0 Address Q Renewal Q Employment 0 Lost Card c96.a wmoeoll4 9C,Eg su ch rul7 Office rConsomer Alkire&Badmen Regulation License or registration valid for individul use only OME IMPROVEMENT CONTRACTOR before the expiration date. If found retars to: on: 175982 Type: Office of Consumer Affairs and Business Regulation Expiration 827201? LLC 10 Park Pheca-Suite 5170 Boston,MA 02116 AMERICAN INSTALLATIONS,FfC 130 COUNRE 130 COLLEGE STREETSl1RftU0 _,tY���,� L/-./li/ SOUTH HADLEY:MA 01075- Undersecretary N valid wit signaturt