31B-053 (6) 26 LANGWORTHY RD MBP-2018-00135
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot 31B-053-001 CITY OF NORTHAMPTON
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
Permit# MBP-2018-00135
Project# 26 LANGW ORTHY RD
Est.Cost: 5075
Fee:65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group:
Lot Size(sq. ft.): Owner: GULLERUD STEVEN 0 &BEILI YANG
Zoning: Applicant:
AT: 26 LANGWORTHY RD
Applicant Address: Phone: Insurance:
130 COLLEGE ST (413) 552-0200
SOUTH HADLEY, MA 01075 ISSUED ON: 08/04/2017
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:
FeeType: Date Paid: Amount: Check Number:
Insulation 08/07/2017 65 4766
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
17-1901
Department use drily
City of Northampton Status of Permit
•
Building Department Curb Gut/Dnveway Permit
•✓�` 212 Main Street Sewer/SepticAvailability
Room 100 Water/WellAvailabiitty
Northampton, MA 01060 Two Sets of StructuralPlans
phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans . .
Other Specify; .
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
f't
SECTION 1-SITE INFORMATION e3P--4 017/
/4(5-
4
This section to be completed by office
1.1 Property Address:
26 Langworthy Road Map .-? 1 1. Lot 063 Unit.
Northampton, MA 01060
Zone Overlay District
Elm St»District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Steven Gullerud 26 Langworthy Road Northampton, MA 01060
Name(Print) Current Mailing Address:
(650)291-1064
See attached Telephone
Signature
2.2 Authorized Agent:
American Installations 130 College St., Ste 100 South Hadley, MA 01075
Name(Print) Current Mailing Address:
American Installations 4I3-552-0200
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building $5,075.03 (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from(6)
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5.Fire tin
�^
6. Totall==(1{1+2+3+4+5) $5,075.03 Check Number ilia
i�W/6fV/
This Section For Official Use Only
Date
Building Permit Number. Issued:
Signature ri /1.--"LO / -r4ttl-4 .. i 17/17
Building Commissioner/Inspector of Buildings Date
Section 4. ZONING AU Information Must Be Completed.Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size I 1 ---1
I
Frontage �-----.
Setbacks Front I
Side L: I R:I I L: . R: I I-__1 1V-1
� I ( i----I
Rear I I
Building Height I---7
Bldg.Square Footage —1 ! % .J I--I
Open Space Footage %
(Lot area minus bldg&paved y 1 1 ——1
parking)
#of Parking Spaces r_I1 —1 i
Fill: ---- - --- I ---- --- - —
(volume&Location) ' �Y-- _—�---A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DON'T KNOW 0 YES 0
IF YES, date issued:( 1
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW O YES 0
IF YES: enter Book 1 I Page I and/or Document#� f
B. Does the site contain a brook, body of water or wetlands? NO O DON'T 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
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 O NO 0
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ED Addition EJ Replacement Windows Alteration(s) D Roofing D
Or Doors 0
Accessory Bldg. D Demolition D New Signs VA Decks [E] Siding 1):3] Other E ]
Brief Description of proposed
Work: 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
6a.If New house and or addition to existing housing.complete the following:
a. Use of building: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 of stories?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
I. Is construction within 100 ft.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.
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
I. Steven Gullerud ,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 8/1/17
Signature of Owner Date
I, American Installations 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.
American Installations
Print Name
American Installations 8/1/17
Signature of Owner/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable 0
Name of License Holder: Wesley K. Couture 106178
License Number
130 College St., Ste 100 South Hadley, MA 01075 9/29/17
Address/ Expiration Date
(/(Le l K ( 3-552-0200
Signature / Telephone
9.Registered Horne Improvement Contractors Not Applicable 0
Wesley Couture 175982
Company Name Registration Number
American Installations 6/26/19
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.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 IN No 0
11.:—Home 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 supervisor.CMR 780, Sixth Edition Section 108.3.5.1.
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 accessory 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 he/she shall be
responsible for all such work performed under the building permit.
As acting Construction Supervisor your presence on the job site will be required from time to time,during 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 Laws Annotated,you may be liable 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
e•cv ... ''-'e
Massachusetts
3 , t t,..I
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street a Municipal Building
Northampton, MA. 01060
Property Address: 26 Langworthy Road Northampton, MA 01060
Contractor
Name: American Installations
Address: 130 College Street Ste. 100
City, State: South Hadley,MA
Phone: 43-552-0200
Property Owner
Name: Steven Gullerud
Address: 26 Langworthy Road
City, State: Northampton, MA 01060
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.
1
Contrai MiN j r
i...b.
.
C
Date
8/1/17
City of Northampton 212 Main Street, Northampton, MA 01060
Solid Waste 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.
Address of the work: 26 Langworthy Road Northampton, MA 01060
The debris will be transported by: American Installations
The debris will be received by: Waste Management of New England - Chicopee
Landfill
Building permit number:
Name of Permit Applicant Wesley Couture
8/1/17 (1.(44, K ,(2(
Date Sig ture of Permit Applicant
Licensed&Insured L www.Americanlnstailations.com
MA CSL 8:106178 American Installations
MA Registration 8175982
-Efficient Home Services-
130 College Street suite 100,South Hadley,MA 01075•Office:1413)552-0100 Fax:(413)552-0202•Email:support@IAmerlcanlnstallations.com
AIR SEALING PROPOSAL
Steres Gulkrnd
26 LANGWORTHY RD
Northampton,MA 01060-2122
Site ID:500850172495
Project ID:P00050378117
Customer ID:C00050173808
Contract ID:20170726 ASEAL
Description Quantity Location
PeOorrn Air Sealinsi at Estimated 62.5 CFM50 Per Hour 2 V'fiSI ce $168.61
^— —— Sub Total: $168.64
Utility Incentive Share $168.64
Customer Contribution $0.00
WARRANTY:American Installations,LLC will provide the above stated homeowner with a 2 year workmanship warranty,
American Installations,LLC hereby proposes to furnish all material and labor to complete the above scope of work In acconlance with the above specifications
and all bol and state building regulations for the Total Contract Value as stated herein.
ACCEPTANCE OF PROPOSAL:The above prices,specifications and conditions TOTAL CONTRACT VALUE=5 0
are satisfactory and am hereby accepted.You are authorized to do work as D
specified.Payment will be 1/3 down prior to start of work,and balance due Down Payment=$ PAID
upon Completion. Balance Due Upon Completion=$0
Jul 27,2017
Signature Date
Property Owner(Print) (Sign) /)) Date
Representative:(Print) (Sign) L"�- Date1
7
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LLC Katnntte Kt MUD TO AS.COMPAMr,MO MI CUSIOMIRM MAARD A50M1.MrerWnte REINED TO RS LEMr.Icon WIIU ei SUMO lO ALLMPeORWTE UM.REGULATIONS S YID cannons Or NE SIMS
Of MASSAOIUYTISOR CaNKCDCUr 115PECTIVRY,AS Will M AIL LOW.RMatOICIWNS
111111 Licensed&Insured `• www.American Posta Ilations.com
MA CSL 8:106178 American Installations
MA Registration#175982
-Efficient Home Services-
130 College Street Suite 100,South Hadley,MA 01075•Office:(413)552-0200 Fax:(413)552-0202•Email:support6Americaninstaliations.com
WEATHERIZATION PROPOSAL
Steven GuHerod
26 LANGWORTHY RD
Northampton,MA 01060-2122
Site ID:S00050172495
Project ID:P000503781(7
Custotner ID:C00050173808
Contract ID:20170726 WORK
Descrtptlon Quantity Location
Instal 2'Thermal Barrier!Aim on Open Kneewall Slope 210 pvingSpace _-_..__..._._..._...-.-.._._._.......___6924.00
Kneewat Slope Enclosed Cellulose Dense Pads 6' 418 Living Space 11,07426
Instal 7 Thermal Banter Poh(bo On Open Gable Wag 35 Lhlki9 Space 1154.00
Insulate Gable Wag With 4•Dense Pack Cellulose 35 Living Space 680.65
Sheathing Access 2 N/A $72.28
Insulate Wood Sided Wal With 4"Dense Pact Cellulose ._._. 800 � fiSPace 11.768.00 ..
insulate 3rd FL Wood Sided Wall With 4^Dense Pack Ce8ulose 350 Living Space 1833.00
Sub Toter: 14.906.39
Utility Incentive Share $3,679.79
Customer Contribution 11.226.60
WARRANTY:American Installations,LLC will provide the above stated homeowner with a 2 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 conditions TOTAL CONTRACT VALUE=S 1,226.60
are satisfactory and are hereby accepted.You are authorised to do work as Down Payment=S 100.00 Q
specified.Payment will be 1/3 down prior to start of work,and balance due PAID
upon Completion. snr ' balance Due Upon Completion=5 826.60
Jul 27.2017
Signature .o-' ,, •. .. Date
Property Owner(Print) (Sign) / /Qj�✓�/� Date /y
Representative:(Print) (Sign) i1L,[/�_ Date 7/—'-Cif>
IMO AGtjtIIM 6 COMPOSES on Mai Mt MO MIASMA MOE Of fico PAGE MMOIMO.at E306JOI0D IN[010E AGettMEMT n THE MIMES IMVOILTO 616 vGaII MINT6 MwWSN Mx AAUP I6TAWTIO46,
tcc NIRWATlEn REFERRED TO AS'CnMPMY,Mie THE CUSTOM(63)16660 WA0Vf.MEenNAntn KEE IID IO AS-atom,Allo Will SE SIRxcT TO All AP160166Tt LAWS.ftGUU0OMS AMOOaDINaeCIS Of TMS
STATE Of ratSTACMIISITTS 011 COHNSCrICUT atSMIC6VILT,AS WELL A.S ALL loMAM 666106tes1
•
ACO� DATE(MWDOIYYYI7
�� CERTIFICATE OF LIABILITY INSURANCE 9/1/2016
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 POUCIES
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 pollcy(les)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 CONTACT Linda Powers
NL1ME:
Webber i Grinnell AAICNNo-E1df: (413)586-0111 lAK
No,(413)566-6191
8 North King Street hep ,lpowers@webberandgrinnell.cam
INSURERjS)AFFORDING COVERAGE _...- NAIL ll
Northampton MA 01060 INstha*lbaployera Mutual Casualty, .. _ __.
INSURED INSURER B Berkshire Hathaway GUARD Ins. Co.
American Installations, LLC INSURER C: _ _
Attn: Wes 6 Suzanne Couture INSURER D: -_
130 College Street, Suite 100 INSURERE: _—_
South Hadley MA 01075 INSURER F: .
COVERAGES CERTIFICATE NUMBER3dster Exp 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.
INSR TYPE OF INSURANCE ADDL SUER M1N EFF POLICY EXP -��LIMITS
LTR 1N30 MND POUCY NUMBER (wwONYYYY) IMWDDIYYYYI
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
DAMAGE TO RENTED 500,000
A X CLAIMS-MADE OCCUR PREMISES/Ea occurrence) $
X Liquor Liability 15D3535217 9/4/201.6 9/4/2017 MEDEXP(Anyoneperson) S 10,000
PERSONAL 8 ADV INJURY $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000
X POLICY! Tei }LOC PRODUCTS-COMP/OP AGG S 2,000,000
OTHER' $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000
(Ea accident)
A ANY AUTO BODILY INJURY(Per person) S .�
ALL. ED UTOS —‘,7 SCHEDULED 553535217 9/4/2016 9/4/2017 BODILY INJURY(Per accident) $
X! HIRED AUTOS X NON-OWNED PROPERTY DAMAGE
AUTOS I (Per accdentl. f.-----....___.....___._... .......
_.f.,.,, PIP-Basic
$ 8,000
X UMBRELLA UAB OCCUR E EACH OCCURRENCE S 1,000,000
A EXCESS UAB r CLAIMS-MADE AGGREGATE $ 1,000,000
DED X RETENTIONS 10,000_ _5,73535217 9/4/2016 9/4/2017 $
WORKERS COMPENSATION x STATUTE ETPOT H
AND EMPLOYERS'UABIUTY
ANY PROPRIETOR/PARTNER/EXECUTIVE YIN E.L.EACH ACCIDENTS
B 500 X000
.OFFICER/MEMBER EXCLUDED? N/A
(Mandatory In NH) DRRC609917 9/4/2016 9/4/2017 E.L.DISEASE-EA EMPLOYEE S 500,000
IfSsCRdePOe uOrdF
OPERATIONS below I _ E.L DISEASE-POLICY LIMIT $ 500,000
A Coasaerci al Property SA353521.7 9/4/2016 9/4/2017 deduced.51,000 $20,000
dedua6ae$1,000 $40,000
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Sehadul.,may be attached If more space Is ngulred)
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 POUCY PROVISIONS.
AUTHORIZED REPRESENTATIVE
Kevin Joyce/LMP
--<::—=-::5 -----_-
01988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD
INS025 mum
ip 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(991111 )of
Construction Suneiiicoril enclosed space.
License:CS-106178 w
WESLEY COUTUJtE fl,
166 NORTH MAIN S l
South Hadley MA?01
- Failure to possess a current edition of the Massachusetts
"e,� ,� *`� State Building Code is cause for revocation of this license.
J..�w.r .� arts► Expiration For DPS Licensing information visit: www.Mass.Gov/DPS
Commissioner 09/29/2017
r- ill
�t)2-
C� Office of Consumer Affairs and Business Regulation
10 Park Plaza- Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
x: Type: LLC
AMERICAN INSTALLATIONS,LLC. Registration: 175982
130 COLLEGE STREET SUITE 100 Expiration: 06/26/2019
SOUTH HADLEY,MA 01075
Update Address and return card. Mark reason for change.
SCA 1 0 20M-05111
_�� G / / n Addre 0 R .%!�n_Employment_I]i ost_Cord
mile II, ,,.,,,,,,x,11/, (^41.,.,,,,I,,,.elli
Office of Consumer Affairs&Business Regulation
t „vi«-4A HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only
i . TYPE:LLC before the expiration date. If found return to:
` )i ,. 13saistatinn Expiration Office of Consumer Affairs and Business Regulation
175982 06/26/2019 10 Park Plaza-Suite 5170
AMERICAN INSTALLATIONS,LLC. Boston,MA 02116
WESLEY COUTUREC. 12-C-6211----- // 41--COLLEGE STREET SUITE 100
SOUTH HADLEY,MA 01075 Undersecretary valid without Signature
The Commonwealth of Massachusetts
Department of Industrial Accidents
MI a Office of Investigations
_'n=_ 600 Washington Street
Boston,MA 02111
�' .•�1,,�'` 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 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):
I.[] Lam a employer with 46 4. ❑ I am a general contractor and l 6. ❑ New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I 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 area corporation and its
required.] officers have exercised their
10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGI. 11.0 Plumbing repairs or additions
myself.[No workers'comp. c. 152,§I(4),and we have no 12.❑ Roof repairs
insurance required.]t employees. [No workers'
comp. insurance required.] 13.1A Other Insulation
*Any applicant that checks box HI must also fill out the section below showing their workers'compensation policy information.
t I lomeowners who submit this affidavit indicating they arc 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 their workers'comp.policy information.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: Guard Insurance Companies
Policy#or Self-ins. Lic. #: AMWC77314485 Expiration Date: 09/04/2017
(Q A A
Job Site Address: R. 1 Rd• City/State/Zip: 14 D� -m, nl t
Attach a copy of the workers'compensation ohcy declaration page(showing the policy number and expiration date). Cit C)
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$250.00 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 's true and correct.
Signature; Date: C.V 11
Phone#: 413-55 -0200
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):
I. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#: