22D-109 33 AVIS CIR BP-2017-0929
GIS u: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 22D- 109 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-2017-0929
Project# JS-2017-001581
Est.Cost: $3303.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: AMERICAN INSTALLATIONS LLC 106178
Lot Size(sq. ft.): 27834.84 Owner: SUPRENANT ROBERTI.&TAMMY R
Zoning: URA(I00)/WSP(100)/ Applicant: AMERICAN INSTALLATIONS LLC
AT: 33 AVIS CIR
Applicant Address: Phone: Insurance:
130 COLLEGE ST (413) 552-0200 WC
SOUTH HADLEYMA01075 ISSUED ON:2/7/2017 0:00:00
TO PERFORM THE FOLLOWING WORK:ATIIC AND 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 ft Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY Bit REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occueanc si•nature:
FeeType: Date Paid: Amount:
Building 2/7/20170:00:00 $65.00
212 Main Street, Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
File# BP-2017-0929
APPLICANT/CONTACT PERSON AMERICAN INSTALLATIONS LLC
ADDRESS/PHONE 130 COLLEGE ST SOUTH HADLEY (413)552-0200
PROPERTY LOCATION 33 AVIS CIR
MAP22D PARCEL 109 001 ZONE URAiOO)/WSP(I0O.E
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
(.3
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
FPaid Permit Filled out
Fee Paid
Typeof Construction: ATI IC A D B EMEN'I.INSULATION&AIR SEALING THROUGHOUT
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Buildin&Plans Included:
Owner/Statement or License 106178
3 sets of Plans'Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO MATION PRESENTED:
Approved Additional permits required(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 Variance*
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
_ De .4 in 6:1.
Signatu :uil.m ,Official 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 40A Contact Office of
Planning& Development for more information.
Department use esiy 17-0188
City of Northampton status of Permit
rte' \ Building Department Cwt Cut/Dnveaay p0muT
!� 0,0 212 Main Street Sewgdsephcayallabdiry —
- ' Room 100 WaterNYell'Avaltabflity
Northampton,MA 01060 TWO bets of strridttl(al Plans
phone 413-587-1240 Fax 413-587-1272 proUSite�ens
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
1.1 PropeNYAddress: This section to be completed by office
33 Avis Circle Florence,MA 01062 Map Lot Unit.
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIPIAUTHORRED AGENT
2.1 Owner of Record:
Tammy Suprenant 33 Avis Circle Florence, MA 01062
Name(Print) Current Mailing Address:
(413)204-5540
See attached Telephone
Signature
2.2 Authorised Agent:
American Installations 130 College St.,Ste 100 South Hadley,MA 01075
Name(Print) Current Melling Ad&ess:
American Installations 413-552-0200
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS,
item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. BuidIng $3,303.10 (a)Building Permit Fee
2. Electrical (b)Eslmeted Total Cost of
Construction from(6)
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5.Fire Protection / 4066-
/��^
6. Totaln(1 +2+3+4+5) $3,303.10 Check Number 31`7i2 4066
This Section For Official Use Only
Building Permit Number.
Issued:
Signature:
SuP4bi9 ComralsganerAnspector of Bufids®s pate
Section 4. ZONING All Information Must Be Completed.Permit Can Be Dented Due To Incomplete Information las
Existing Proposed Required by Zoning wr a
'Ibis column mire filled in by •~>
Building DI:mamma
Lot Size 1 ---I
Frontage i (--
Setbacks Front
Side L:i R: I L:I I R: I I I I— I
Rear I I En
Building Height L____I 1
Bldg.Square Footage I-7 I % III I I I
Open Space Footage
teat area minus bldg&caved I I I I I nn
patting)
#of Parking Spaces -)
Fill: 1 -_-_____-.
(volume&location) - —_____—__
A. Has a Special PermitNariance/Finding ever been issued for/on the site?
NO O DONT KNOW Q YES O
IF YES,date issued:I
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW 0 YES O
IF YES: enter Book I I Page I and/or Document#I
B. Does the site contain a brook,body of water or wetlands? NO O DONT KNOW O YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained O , Date Issued:
•
C. Do any signs exist on the property? YES O NO O
IF YES,describe size,type and location: I I
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:
E. Will the construction activity disturb(clearing,grading,excavation,or Nang)overt acre oris it part of a common plan
that will disturb over 1 acre? YES O NO O
IF YES,then a Northampton Storm Water Management Permit from Bre DPW is required.
SECTION 87 DESCRIPTION OF PROPOSED WORK Wreck all appltsable)
New House n Addition ❑ Replacement Windows ( Alteration(s) ❑ Roofing ❑
Or Doom d
Accessory Bldg. ❑ Demolition 0 New Signs (o) Decks ft j Siding DOI Other(
Brief Description of Proposed
Wort Attic anAd Bbasement insulation and air sealing throughout
Alteration of Staling bedroom ,Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
ea.If New house and or addition to existing^housing,.comolete the following.
a. Use of budding:One Family Two Family Other
b. Number of rooms in each family unit Number of Bathrooms
C. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number f stories?
f. Method of heating? Fireplaces or Woodsloves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
t. Is construction within I00 tt of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No
L Septic Tank City Sewer Private well City waterSupply
SECTIONTa-OWNER AUTHORIZATION-To BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
Tammy Suprenant 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.
Sec attached 1/31/17
Sgnatum of owner Date
I, American Installations as Owner/Authorized
Agent hereby declare that the statements and triton eon on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
American Installations
Print Name
American Installations 1/31/17
Signature of Owner/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Snpervison Not Applicable ❑
Name of License Holder: Wesley K. Couture 106178
License Number
130 College St., Ste 100 South Hadley,MA 01075 9/29/17
Address ,7 Expiration Date
�i(4.fi i /, !C ( (F7 (3.552-0200
Signature (r Telephone
p.Registered Hornetmpreeement Contractor. . _ _ Not Applicable ❑
Wesley Couture 175982
. ..
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 18-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 at the building permit.
Signed Affidavit Attached Yes Ri No 13
11..=Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-accuoied Dwellings of one(I) 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
fs supervisor.CMR 780. Sixth Edition Section 1883.5.1.
pefinition of Homeowner:Person(s)who owes a parcel of laud 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 accessory to such use and/or farm
structures.A Denali 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 Braiding Official,that he/she shall be
responsible fqr aH such work performed under the Wilding permit
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 hi Death)of the Massachusetts General Laws Annotated,you may be flaMe 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 Loral Zoning Laws and State of Massachusetts General Laws Amotated.
Tiomeowner Signature
City of Northampton
Massachusetts 4
feWieY ^. s
DEPANTNBNT OF BUILDING INSPSCTIONS 7.
212 Nein Street a Mmicipal Mutates
_ Northampton, MP 01060 YJ'
Property Address: 33 Avis Circle Florence, MA 01062
Contractor
Name: American Installations
Address: 130 College Street Ste. 100
City,State: South Hadley,MA
Phone: 43-552-0200
Property Owner Y Suprenant
Stenant
Name: F
Address: 33 Avis Circle
City,State: Florence, MA 01062
I, American Installations (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.
Contract r"nature
sure
&r lC ( c`-f.r ,�c
Date Clt
1/31/17
,i wwwAmencanh:mneors.mm
iBBB 1
® • Licensed W��. MA CSL M:106178
American Installations MA Registration#175982
noCollege street Suite 100,south Hadley,MA 01075•OMa:4131552-0200 fax: 4L31552-0202•Email:support@NnetlonInstalhtlonemm
Suprenant,Tammy 1/26/2017
33 Avis Circle Florence MA 01062
Minor) Med413-204-5540 tsuprenant@comcast.net •i rvw
eftwel Yen MOO
445907 17-0188
MOM Quantity Unit Unit Cost Total
Alr/Duct Sealing
AIR SEALING 10 man hour $ 85.00 $ 850.00
WEATHERSTRIP DOOR&ADD SWEEP 1 each $ 80.00 $ 80.00
Air/Duct Sealing $ 930.00
Air/Duct Sealing Incentive $ (930.00)
Air/Duct Salaing WX Balance $ -
Weatherization
ATTIC HATCH-SEAL&INSULATE 1 each $ 60.00 $ 60.00
VENT BATH FAN THRU ROOF 2 each $ 118.75 $ 237.50
VENTILATION CHUTES 100 each $ 2.50 $ 250.00
ATTIC DAMMING-R-38 FIBERGLASS 160 sqft $ 2.05 $ 328.00
ATTIC FIAT-S'OPEN R-30 CELLULOSE 1,040 sqft $ 1.44 $ 1,497.60
Total Weatherization $ 2.373.10
Weatherization Incentive $ 1,779.83
Total Project $ 3,303.10
Total Utility Contribution $ 2,709.83
Total Customer Contribution $ 593.28
WARRANTY American lnstallatmw,Lc will provide the above stated homeowner with z 2 year workmanship warranty.
neral and beer m complete the above scope of work in accordance weh the above scerneatuns and all ml end state buialry
regulations for the Total Contract Value as stated nerem.
ACCEPTANCE OF PROPOSAL:The above prices,specifications and TOTAL CONTRACT VALUE= $ 593.28
conditions are satisfactory and are hereby accepted.you are
autnonzed to do work as specified.Pwill be 1/3 down poor to Down Payment= $ 197.00 %DC 1-27-17
start of work,and balance due upon Completion.
ere n
Sun Balance Due Upon Completion= $ 396.28
1-27-17
r .Joel Martell
/, 1-27-17
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 CUSTOMERS)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.
(16%PER ANNUM)WITH A MINIMUM CHARGE OF 52.00 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.
S.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 ATIMELYAND 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
SOLER DUE TO THE COMPANY'S NEGLIGENCE.
S.DURING THE DURATION OF THE WORK,THE NT 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 CONNECUONS,PLUMBING AND VENT PIPES,DECKING DEFLECTION,ETC.IF A PRE-EXISTING DEFICIENCY OR HAZARDOUS MATERIAL 15
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 PROBLEMS)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 ANO SCHEDULED DATE OF COMPLETION MAY DIFFER FROM THAT AGREED UPON,IF
APPLICABLE,UNDER THIS AGREEMENT.
10.THE COMPANY IS NOT RESPONSIBLE,ANO 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.
U.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.
IS.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 WITHOUTTHE 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 CP/INGESTO 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%RESTOCKING
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 SE INVALID OR UNENFORCABLE,THE VALIDITY AND ENFORCEBIUTY 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 5PON5ERED PROGRAM AND WILL BE SUBJECT TO TERMINATION IF THE STATE SPONSERED UTILITY PROGRAM IS OISCOUNTINUED.FURTHERMORE,THE TERMS AND
CONDITIONS OF STATE SPONSERED UTILITY PROGRAMS MAY HALTERED 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.
25.CLIENT IS REPSONSIBLE FOR THE PAYMENT OF ANY AND ALL FEDERAL,STATE,OR LOCAL TAXES THAT ARE APPLICABLE TO THIS AGREEMENT.
The C'ommanwealth of Massachusetts
Department of Industrial Accidents
. lear, Office of Investigations
600 Washington Street
Cil_
C__ Boston,MA 011!1
r»uw.mtrss.gnv/Jia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information ,! Please Print Legibly
Name tBusmesstOrgaoitattoN6ldividualt: American Installations,LLC
Address' 130 College Street,Suite 100
City/Slate/Zip: South Hadley,MA 01075 Phone#: 413-552-0200
.Are you an employer?Check the appropriate but Type of project(required):
ill I am a employer with _31 _ 4. ❑ lam a general contractor and[ I 6. ❑ New construction
] employees(full and/or part-Time).` have hired the sub-contractors
'_.❑ 1 am a sole proprietor or partner- listed on the attached sheet. t 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers'comp.insurance. 9. ❑ Building addition
[No workers comp, insurance 5. ❑ We are a corporation and its
required_] officers have exercised their 1f1.1,1 Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGI. 1 L❑ Plumbing repairs or additions
myself[No workers'comp. c. 152,§I(A),and we have no 12.❑ Roof repairs
insurance required.�t employees. [No workers' ly.❑s. Other Insulation
comp,insurance requfred.I
'Any applicahl drat Nvchs box III 'BUM aixo nil ora lbs section below showing their workers'nmpensalion policy information.
'1itarinewitete who submit this affidavit ittlievtiny shy ore ruing all lynch and Ilam him mraide amtrneaxs mot:Mend a new afaaviz intlwmne such
4itlnractors thal cheek this bo muss stunned an sedii'onal ahem showing the name tams:snbconlrncIOS and then workers'comp.pohoy il,JOrtnallon.
I am an employer i/wi is providing workers'compensation insurance far nty emtphniees. Below is the polity and jab Site
information.
Insurance Company Name: Guard Insurance Companies
Polley#or self ins Lie.#: AMWC731485 Expiration Date: 09/04/2017
Job Sire Address: '^' r\VIS, CtT X_Q city/state/zip:_'C` \Otnt-Q.�, Mc1/4 0 O(D2
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 ofa
line tip to$4500 00 and/or one-year imprisonment-as well at civil penalties in the form of a STOP WORK ORDER amnl a litr=
of up to 5250.00 a day against the violator. Be advised that a copy of this statement may he forwarded to the Office of
Investigations of the DIA far insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Si-nature: w1_.__ a/Ir - .rrll--4011IF • _..._........_Date:__
1131. 1
Phone n: 413-S5-50200
Official use only. Do not write in this area,to he completed by city or town official
City or Town: Permit/License#_,,,
Issuing Anthority(circle one):
' I. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
I Contact Person: Phone#: „__
AC R� m
CERTIFICATE OF LIABILITY INSURANCE 9�l�zo atm
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed, N SUBROGATION IS WANED,subject to
the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER COmmRCT Linda pests
Webber b Grinnell (413}586-0111 FAX (t33)5PH fi4B1
J$f Ho fill I jorn 1
D North King Street AWREss:1poworsewebberandgrinnell_cont
B .. __.
INSURER(S)AFFORDING COVERAGE NMC
Northampton RA 01060 INsuRERAZmployere Mutual. Casualty
%WURED ygwcRs Berkshire Hathaway Gms.RD /no. co.
American installations, LLC INSURER C:
Attn: Web $ Suzanne Couture INSURER O'.
130 College Street, Suite 100 INSURER E:
south Hadley ILA 01075 !WIRER£:
COVERAGES CERTIFICATE NUMBER Las ter €xp 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 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.
I`jR FA 1 EXP I
TYPE OF INSURANCE ee�� POUCY NUMBER IMNWnWnTf111CT Elf swDwYYT(1; UNITS
'COMMERC4I GENERAL I1ARLLm LACK OCCURRENCE S 1,000,000
A 1 X 1 CLAINSMADE I OCCUR P ce S 500,000
E a._.,., m s
Ps e
X LiquOr Liability I 50353521'1 19/</21115 9/4/2011 MEG UP Any m µfam
e ) IS 10,000
lii __ . Y
PERSONAL ADM INJURY I S 1..OD0,000
GENE AGGREGATE LIMIT AARLSIG PER , GENERAL AGGREGATE •S 2.000,000
XI Potty TogF Lac 1 PRODUCTS COMPJOP AGO 1 2,000,000
-IOTKEP. ' S
AUTOMOBILE LIABILITY qqM NEEDSINGLE LIMIT s 1,000,000
A ANY AUTO to accident)
INJURY(Per person) S
- ALL OWNEGSCMEOULED
AGMS X AUTOS 5Z3535213 . 9/4/201.6 914/201'I SOLELY INJURY Sider excaaYl S
X toren AUTOS x..AUTOS
TIED iGE_ S
I ,
plPBesic 8,000
X UMRNElw LIAB OCCUR 'EACH OCCURRENCE iS 1,000,000
A EXCESS UAB CLAIMS-MADE: AGGREGATE '5 1r 000,000
DEO I X 'RETENTIONS 00,000 533535219 9/4/2016 9/4/2019
WORKERS CO AMW X I PERNTL —15T1-1
AtOEMPLOYERS'UTAWDTY YIN' STA
EF ........
ANYROPRIETORPARTNER6%ECUTNE —iIINIA EL EACH ACCIDENT $ 500,000
EMBER EXCLUDED?andatary In NH)
B MURWC606917 9/4/2016 1
D 9/4/2017 EL DISEASE-EA EMPLOYEE S 500,000_
II yes 6e
be under
ESCRIPTIpON OF OPERATIONS Daww EL OIBEASE- OLI4,1Y llMli $ 5000 00
A Corermaarea a1 Property SA3S352f] 9/4/2016 2/4/2011 ItMLYeSf600 $20,000
'tlwiuMle9W2 $40,000
•
DESCRIPTION OF OPERATORS/LOCATIONS I VEHICLES(ACORO 101,AOtltllmwl Remarks Scradele.may be attached Il more apace 6 mqulrtd)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUn4OAZEO RE PVESENFA1WE
Kevin Joyoe/ V..P 1---.:^— _ ""y
01988-2014 ADORE)CORPORATION. All rights reserved.
ACORD 26(2014101) The ACORD name and logo are registered marks of ACORD
1E5025 copy,.
itMassachusetts -Department of Public Safety Unrestricted-Buildings of any use group which
Board of Building Regylations and Standards contain less than 35,000 cubic feet(991m)of
Construction Supenisar MEM enclosed space.
License: CS-106178
067 r.
WESLEY COUTUJtE Att 1111
166 NORTH MAIN gen =i.
South Hadley 117eY01�!] -
(\�/J Failure to possess a current edition of the Massachusetts
e's , n.a State- Building Code is cause for revocation of this license.
�,.L.,d, Expiration
commissioner 09/29/2017 FR DIG Licensing nfomation visit www.Mass.6w/DPS
3 • Office of Consumer Affairs and Busi ss Reg lation
js
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 175982
Type: LLC
Expiration: 6/27/2017 Tr# 265208
AMERICAN INSTALLATIONS, LLC.
WESLEY COUTURE
130 COLLEGE STREET SUITE 100
SOUTH HADLEY, MA 01075
Update Address and return card.Mark reason for change.
scar 0 20M 05/11 0 Address 0 Renewal 0 Employment El Lost Card
-76, w twaf/L ryio/1, . /,,,,u,
Off fConsumerAffairs&Business Regulation License or registration valid for individul use only
Na SOME IMPROVEMENT CONTRACTOR
9before the expiration date. If found return to:
eglstmbon: 175982 Type:
Office of Consumer Affairs and Business Regulation
Explmtlon 62]1201]. LW 10 Park Plaza-Suite 5170
Boston,MA 02116
AMERICAN INSTALLATIONS,LLC
WESLEY COUTURE , r / _
130 COLLEGE STREET SUITE 100
SOLJTHHADLEY,MA01D]5 ` .i r
Undersecretary N valid without signature