35-122 (7) 25DREWSEN DR BP-2018-1064
GIs#: COMMONWEALTH OF MASSACHUSETTS
MV.Block: 35- 122 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cateeorv: INSULATION BUILDING PERMIT
Permit# BP-2018-1064
Project# JS-2018-001920
Est Cost: $3200.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: AMERICAN INSTALLATIONS LLC 106178
Lot Size(sa.ft.): 9016.92 Owner: ST GEORGE CHRISTOPHER T&ILENE K GERHARDT
Zonin : Applicant: AMERICAN INSTALLATIONS LLC
AT: 25 DREWSEN DR
Applicant Address: Phone: Insurance:
130 COLLEGE ST (413) 552-0200 WC
SOUTH HADLEYMA01075 ISSUED ON.-4/18/20180:00:00
TOPERFORM THE FOLLOWING WORKATTIC & 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# 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:
FeeTvpe: Date Paid: Amount:
Building 4/18/20180:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
L:I
ofiv
City of Northampton Status of PermR
BOAding Department Cur'leCulformsymyPeffult-
212 Main Street 3awer/Sapgo-Avaimbiliy
Room 100 WommetrA evab6lty.
Northampton. MA 01060 Twp sem ofSulaurat Plane
phone 413-557-1240 Fax 413-567-1272 Plet/Ske Plans .
Ogrer Speciy
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE ORIIEMOLISH AONE OR TWO FAIRLY OWMING
r7Pm�rtv
D'E{NFORMAnON Lyi 9• ( �' IDOL/
Tho section w ba comptated by�ce
ddrese:Drivc Florence,MA OIg62rJ.aP -J�..+6" tot Ida- UnxZaneO.wmYDmtrktElm StDtehia CBDletrietROPERTY OWNERSHIPIAUIHORIZED AGENT
21 Owner Of Recerd:
Ilene Gerhardt &Christopher St. George 25 Drewsen Drive Florence MAO lG62
Name(Print) Cuireni Pdd""
_(413162 -5841
See attached Teleplow
519now,
22 AWhodged Anent;
American Installations 130 College St Ste 100 South Radley,MA 01075
Neme(N.0 Come Wag Admees
American Installations 413-552-0200
signalwe Tebpnnna
SECTIONS RMNIATED CONSTRUCTION COSTS
Ron Esgmated Cost(Deilam)to be Official Use Drily
wm eted MR fount
1. Buidmg 3,200.00 (a)suaft Point Fee
2. EUmbical (b)Esamekd TotalCost of
Conbimbon Tom
3. Plumbing Buildtne Penn
R
4. Mechanical(HVAC) (f
S.Fxa Protaction
6. ToIW=(1 +2+3+4+§L 1 3,200.00 Check Number w6
Thin SecSon Fw ORkial MW MAY
Date
Building Permit Number. ksued:
SlHnature. ' /8 f
SUHeg Co bMdlnePed.'StdW ge Date
Section 4. ZONING ALL Information Must Be Completed.Permit Can Be Denied Due To Incomplete Infonm[bn
Existing Proposed RegwredbyZomag
i IsWuuawbefiBMmby
BandiuB Dgattneul
Lot Size
Frontage
Setbacks Front
Side LR- L:=R:=
Rear
Building Height
Bld&Square Footage O �— %
Open Space Footage 0-4
(Lot arse m1noebW66 Pmsd
0
9o Parking Spaces
Fill:
(volvom&I.omd®1
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW Q YES O
IF YES,date tssued:l
IF YES: Was the permit recorded at the Rs.-gistry of Deeds?
NO O DONT KNOW O YES O
IF YES: enter Book —J Page and/or Document#L
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 Commission7
Needs to be obtained O Obtained O , Date Issued:
C. Do any signs exist on the property? YES U NO O Aw
IF YES,describe size,type and location: F I
D. Are there any proposed changes to or additions of signs intended for the property 7 YES O NO O
IF YES,describe size,type and locatiom L
E. Will the construction activity disturb(clearing,grading,excavation,orfilling)over i acre or is it pan of a common plan
that willdisturb over i acre? YES O NO O
IF YES,then a Normampton Storm Water Managenrerd Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all anN1
New House ❑ Addition ❑ Replacement Windows Alteration(sl ❑ Roofing ❑
or Doors O
Accessory Bldg. ❑ Demolitic ❑ New Signs [a Decks M Sidingon] Other[EA
Brief Description of Pmposed
Work Alhc and basement insulation and air sealing throughout
Alteration of mdsting bedroom_Yes_No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement _Vas No
Plarm Attached Roo -Sheet
se.If New house and or addition to existing housing.complete the following,
a. Use of building:One Family. Tyro Family Other
b. Number of rooms in each family unit Number of Bathrooms
o. Is there a garage attached?
it. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of heating? Fireplaces or Woodstm es Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
L lswnstmctionwlthint00tt.ofwatlands?_Yes _No, IsoonstrucfionwiMin100yr. 000dplain Yes_No
J. Depth of basement or cellar floor below finished grade
k. Will building wrdorm to the Building and Zoning regulations? Yw_No.
L SePticTank_ CitySewer_ Pdvateweg_ Cdywater Supply_
SECTION Ta-OWNER AUTHORRATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, Ilene Gerhardt&Christopher St. George as Owner of the subject
property
hereby authorize American Installations
to act on my behalf,in e6 mattera ra1sWe b cork aulmmitned by this building permit apptke#Dn.
See attached 4/11/2018
Signetera of Omer Date
I, American Installations as Owner/Auttmdzed
Agent hereby declare that the statements and bdomm0on on the foregoing application are true and accurate,to the beat of my knowledge
and belief.
Signed under the pains and penalties of perjury.
American Installations
Priya Name
American Installations 4/11/2018
Slw,k eof OwneriAgent Data
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of LSeeroeNOMer: WesleyKC',outure 106178
deems Number
130 College St., Ste 100 South Hadley, MA 01075 _ 9/29/19
Address EXPIMU n Date
S,p�i Aad„ Ac, L'6\dJZ7413-552-0200
Slpnebsa Telephone
9.Registered Home Improvement Contractors - Not Applicable ❑
Wesley Couture 175982
Companv Name Reelsbstim Number
American Installations
6/26/19
Address Fxpiratlon Date
130 College St., Ste 100 South Hadley, MA 01075 Telephone 413-552-0200
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVH(M.G.L c.152,§25C(e))
Workers Compensation Insurance affidavit must be completed and submitted with this application.Failure to provide this affidavit w01 result
in the denial of the issuance of the buMmil pennit _
Slimed AffidavitAtached Yas....... m No...... ❑
11. -Home Owner Exemption
The current exemption for"homeowners"was erteoded m include Owner-occupied Dwellings of oro(I) m two(2)families
and to allow such homeownerto engage an individual for him who does not possess a license,provided that the owner sets
as supervisor.CMR 780, Sixth Edition Section 10835.1.
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 he,a use,or two family dwelling,attached m detached structures accessory to such we and/or farm
structures.A Demon who str fs more than home in a M rid sball notM considered a homeaviree
Such"hom<ovmer'shall=limit in the Building Official,on a form acceptable to the Building Ostial,that he/she shag be
resoonsible for all seek work performed under the badldine permit
As acting Construction Supervisor you presence on the job site will be required from time to tion,during and upon
completion ofthe work for which this permit is issued.
Also be advised that with reference to Chapter 152 R'orkers'Compematim) and Chapter 153(Liabiilityoffimployers to
Employees for injuries rat resulting in Death)ofthe Massachusetts General Laws Annotated,von maybefiabte forpersou(s)
you hire to perform work for you under this permit
The undersillned'homeowner"certifies and assumes respomhbilityfor compliance with the State Budding Code,City of
Northampton Ordinances,State and Local Zoning Iaws and State ofMawachusetts General laws Annotated
Homeowner Signature _
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: 25 Drewsen Drive Florence, MA 01062
The debris will be transported by: American Installations
The debris will be received by: Waste Management of NE - Chicopee Landfill
Building permit number:
Name of Permit Applicant American Installations
4/11/2018
Date Signature of Permit Applicant
s .
%�1 Amenonlna[allatlpnamm
B® ,eiiiea� Lice nsed&Insured
• MA6(N: "178
American Installations MAReeb[mhon 1v59a2
lad Cdlgesnen sul<e xm,soon weer,MAoxms•otwe:l4xal sszaxao Fa.:l4v155xmoz• amara:mplrpr<!Am«Icanlnnllenom.se n
Gerhardt&SL George,Ilene&Christopher 4/3/2018
25 Drewsen Or pm Florance MA 01062
413 626 5841 an ikgerhaNt@gmail.com o� "a
465 729 18 1219
Quantity Unit Uen Cost Total
Air SesRng
AlR SEALINGi 10 Iman hour $ 85.00 $ &50.00
WEATHERSTRIP DOOR&ADD SWEEP 3 each $ 80.00 $ 240.00
WEATHERSTRIP DOOR 1 leach I $ 58.00 I $ 5800
Air Sealing $ 1,148.00
Air Scull,Incentive $ µ,020001
Air Selaing W%Balance $ 128.00
Weathe oration
XT FIC FLAT 9"OPEN R-33 CELLULOSE 1,032 sglt $ 1.50 $ 1,548.00
ATTIC DAMMING-R-38 FIBERGLASS 50 salt $ 2.05 $ 102.50
VENTILATION CHUTES 74 each $ 250 $ 185.00
ATTICHATCH-SEAL&INSULATE 1 each $ SEIM $ 6000
BASEMENT-INSULATE BULKHEAD D00R&INSULATE 1 each $ 110.00 $ 11000
Air Sealing W%Balance 1 lumpsum $ 128.00 $ 128.00
Total Weatherization $ 2,133.50
Weatherization Incentive $ 1,600.13
Total Project $ 3,153.50
Total Utility Contribution $ 2,620.13
Total Customer Contnbutlon $ 533.38
menon ms awns,LLc wiI pr-ad,t a eaut nmecwner wnM1a v...wrk—aria amn,
resew pr antltlhbno eamplmrlu aWve amps al wort l—scare.—an.ni—Isas. pedlleallnnvanO alllrcal are Amu
mit ua numNe 1..1.,1—I.I.a.,woos nWnl
AMPMNCE OF PROPOI T2 above pnces,asrd—t......d TOTAL CONERACTVALUE= $ 533.38
conditions areadonutc and are Feet,accepted.you are
amdonaetl rp hwark ae scer�e.d.pa,mentwm Fal/ldpwnpnm Down Payment= $ 150-00 ❑
to auA otwo,k,and balance due uFon complel ed
Balance Due Upon Completion= $ 383.38
4/3/18
a
Ethan Seaman Ethan Seaman 4/3/18
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 15 BETWEEN AMERICAN INSTALLATIONS,LLC HEREINAFTER REFERRED TO AS"COMPANY-,AND THE CUSTOMER(5)NAMED ON THE REVERSE SIDE,HEREINAFTER
REFERRED TO AS'CLIENr,AND WILL BE SUBIECT TO ALL APPROPRIATE JAWS,REG ILATIONS AND ORDINANCES OF THE STATE OF MASSACHUSETTS OR CONNECTICUT
RESPECTIVELY,AS WELL AS ALL LOCAL JURISDICTIONS.
THE FOLLOWING THE MS AND CONDITIONS A60 APPLY
1.THIS AGREEMENT 15 SUBJECT TO THE APPROVAL OF A MANAGER OF THE CON PEANY FOR THIS AGREEMENT TO BE EFFECTIVE UNDER ANY CONDITION.
2,SHOULD DEFAULT BE MADE IN THE PAYMENT OF THIS AGREEMENT,CHARGE`.SHALL BE ADDED FROM THE DATE THEREOF AT A RATE OF ONE AND ONE-HALF(1 1/2)PERCENT
PER MONTH. 118%PER ANNUND WITH A MINIMUM CHARGE OF $2.W PIR MONTH,AND IF PLACED IN THE HANDS OF AN ATTORNEY OR COLLECTION AGENCY FOR
COLLECTION,ALL ARORNEYS'FEES,EXPENSES AND COSTS OF COLLECTION SHAD.BE PAID BY THE CLIENT.IN ADDITION,CLIENT UNDERSTANDS THAT IN FAILING TO PAY
ACCORDING TO THE ABOVE TERMS,COMPANY MAY HAVE THE RIG HT TO A LEN 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 ATI MELY 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 WARRANTI iS,THE CLIENT MAY BE REQUIRED TO REGISTER OR MAIL IN A WARRANTY CARD OR OTHER
EVIDENCE OF OWNERSHIP AND USE OF SUCH EQUIPMENT ANDAM 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,ANYSULH ADDITIONALETYENSR,PRLMIUNR OR COST SHALL BE ADDED TO THE TOTAL AGREEMENT AMOUNT.
].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 INSURIACE 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 HA ARDCUS MATERIALS THAT MANIFEST THEMSELVES DURING THE CONSTRUCTION PROCESS EEG
WOOD ROT,MOLD,ASBESTOS,NAIL POPS DUCTWORK AND CONNECTIONS,PLUMBING AND VENT PIPES, DECKING DEFLECTION, ETC,IF A PREEXISTING DEFICIENCY OR
HPIARDOUS 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 CORRECTTHE PROBLEM(5)ON A TIME AND MATERIAL BASS.CLIENT AGREES THAT SUCH CONDITIONS APE 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 APPLICABI E,UNDER THIS AGREEMENT.
10.THE COMPANY IS NOT RESPONSIBLE,AND THE CLIENT AGREES TO HOLD THIS COMPANY HARMLESS,FOR ANY PROBLEMS AND/OR DAMAGES,INLCUDING BUT NOT LIMITED
TO MOLD GROWTH.ARISING FROM THE PERFORMANCE OF AIR SEALING WO IN BY THE COMPANY AS A RESULT OF ANY KNOWN OR UNKNOWN MOISTURE CON ONIONS.
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 PND/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 FRACTURTS 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 NWS IS REQUIRED TO APPLY FOR AND OBTAIN ALL CONSTRUCTION-RELUEO PERMITS.THE
COMPANY SHALL NOT BE DEEMED RESPONSIBLE FOR DELAYS IN THE WORK DESCH BEC IN THIS AGREEMENT CAUSED BY REGULATORY PERMIT GRANTING OR INSPECTIONAL
AGENCIES,AUTHORITIES,OR INDIVIDUALS-
15.THIS AGREEMENT, INCLUDING THE PROVISIONS RELATING TO PRICE AND 'AYM-NT 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 VIR17EN ON THIS AGREEM ENT ARE AGREED TO BE IMMATERIAL AND NOT RELIED ON BY ETHER
PARTY,AND DO NOT SURVIVE THE EXECUTION OF THIS AGREEMENT.
]T.TH5 AGREEMENT CANNOT BE CANCELLED WITHOUT THF MUTUAL WRITTEN CONSENT OF BOTH PARTIES EXCEPT AS OTHERWISE SET FORTH HEREIN.
18,THIS AGREEMENT,AND ANY WARRAMY(5)PROVIDED HEREUNDER SHALL NOT BE ASSIGNED EXCEPT BY OR WITH THE WRITTEN PERMWRM OF THE COMPANY,
19.IF THE CLIENT EMU 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 ACTL AL DAMAGES OR 25%OF THE AGREEMENT FOR RESTOCKING FEE. L
20,ANY CHANGES TO MATERIALS BY THE CLIENT(BRAND.STYLE.COLOR,ETO)AFTER SAID MATERIAL HAS BEEN DELIVERED OR IS IN ROUTE TO THE HENT 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 AU.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 15 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 RIGHTTO REVISE ITS PRICE IN ACCORDANCE WITH TS CCSTS IN EFFECT AT SUCH TIME.
22. IF ANY PROVISION OF THIS AGREEMENT SHOULD BE HEIR TO BE INVALID CR ONENFORCABLE,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 - 1I5
AGREEMENT, THE PARTIES AGREE TO PNCE THE MATTER INTO ARBITRATION BEFORE AN INDEPENDENT ARBITRATOR ASSIGNED BY THE AMERICAN ARBITRAL V
M50CIATION TO RESOLVETHEIR DISPUTE.
24,ANY DISCOUNT, PROMOTION,REIMBURSEMENT,OR OTHER PROGRAM TEAT IS PART OF A STATE SPONSERED UTILITY PROGRAM (LE.MASS SAVE`) IS SUBJECT TO TH'L
AVAILABILITY OF QUALIFYING STATE SPONSERED PROGRAM AND WILL BE BURR CT TO TERMINATION IF THE STATE SPONSERED UTILITY PROGRAM IS DISCOUNTINUED.
FURTHERMORE,THE TERMSAND CONDITIONSOF STATE SPONSERED UTILIT PROGRAMS MAY BE ALTERED OR UPDATED PERIODICALLY WITH OR WITHOUT NOTICE.
25,AMERICAN INSTALLERS,LLC N NOT AN AGENT OF ANY UTILITY COMPANY OF OTHE Y 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
Department of Industrial Accidents
Office of investigations
wi 600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(BusincsstOrganialtion/Individual): American Installations,LLC
Address: 130 College Street,Suite 100
City/State/Zip: South Hadley,MA 01075 Phone 4: 413-552-0200
Are you an employer?Check the appropriate box: T of ro'ect(required); --1
Yik P a
I.U 1 am a employer wish 46 4. ❑ I am a general contractor and 1 b. ❑ New construction
emplo)'ees(full and/or port-time).' have hired the sub-contractors
1❑ 1 am a sole proprietor or partner- listed on the attached sheet. t 7. ❑ Remodeling
ship and have no employees These subcontractors have g. ❑ Demolition
working for me in env capacity. workers'camp. insurance. 9. ❑ Building addition
[No workers'comp. insurance 5. ❑ We am a corporation and its
10.❑Eectrical repairs or additions
required.] officers have exercised[heir
l
3.LJ1 am a homeowner doing all work right of exemption per MGI. I I.❑ Plumbing repairs or additions
myself. [No workenscoma c. 152,§1(4),and we have no 12.0 Roof repairs
insurance required. I employees. I'No workers' -- j
13-EN Other. Insulation
comp.insurance required-1
'AMY aupi-ail W0I tlmcks bas fit mus also 611 om tM1e action below oiavc g Ihcir workers'mmixreacon to W licy in(ormnion.
I kung ncrs wbesubmit this afndivh inJmming a,amdoingall wort and Wm himamsik,uumnctors moat mWanaanewal6davil indicaing sod,.
=Cuntmdors Wal check IM1¢dos mml atoched an addilbnal(heel ehuwing de name ul'tbe subcomrenurs and Ihcir wnrkcri comp.pohry eforvaiwe
I am an employer floor is providing workers"compensation insurance far my employees. Below is thepo/icy and job she
informmion.
Insurance Company Name: Guard Insurance Companies
Policy#ur Sel Fins. Loc.#: (�AMWC731485 - _ -,_ Expiration Date- 09/04/2018
Job Site Address: 25 p('u,.:An pM ML. Cityistate/zip:_ ^-_ — N* OW 67
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expo tion date).
Failure m secure coverage as required under Sectiun 25A of MGL c. 152 can lead to the imposition of criminal penalties ofa
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 m$250.00 a day against the violamr. Be advised that a copy of this statement maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby ceerrify under the pains a/nJd prrsuhi�es of perjury that the information providedaboveis true and carrecr.
S' _t__ LQ__ -___.-Date: 1111.11
413-55 -0200 1
Official use only. Do not write in this area,to be remained by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
I. Board of Health 2. Building Department 3. City?own Clerk 4.Electrical Inspector 5. Plumbing Inspector
b.Other
Contact Person: Phone#:
®. Commonwealth of Massachusetts Construction Supervisor
Division of Professional Licensure LkimMid O-BuOdmp o/any use group which ofisoun
Boats of Building Regulations and Standards Was than 30,000 orbic fast(""eWic rrrters)ofendosed
Construction Supervisor fie'
CS-106176 Expires:09/29/2019
WESLEY COLFrURE
SOUTI HADA STREET
SOV7R NAOLEYf01101070
Eaaure W possess a Camrrl o Mm of the Maswachuwtts
SMb Building Cade b errss M rwacatlon oftlds OCNae.
for InbMtbn about les license
CanmissianeT Call(617) m79-3200 or visit wwwmaegovldpl
e n�fJP (fC1 JJl JJl fz J1 fltg{y(ff/. �I J(��n,JJ(YffJ tlJPtf�:1
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Type: LLC
AMERICAN INSTALLATIONS,LLC. Registration: 175982
130 COLLEGE STREET SURE 100 Expiration: 06/26/2019
SOUTH HADLEY,MA 01075
Update Address and return wit. Mark reason for change.
E4A1 O 2JM0Y11
rl Addr— 0 w--ne...e1 m Emplayment 111 Lost Cnrd
//., f.
OMiw of Coneumw Afftlu a business Rsaulaaon
NOME IMPROVEMENT CONTRACTOR Registration valid for individual use only
TYPE:LLC before Me expiration date. M buns return to:
? J.: Reaictratlon Explosion Office of Consumer Affairs and Business Regalauon
."' 175902 O1L28/2019 10 Park Faze-Suite 5170
AMERICAN INSTALLATIONS,LLC. Bestan,MA 0a116
W ESLEV COUTURE
130 COLLEGE STREET SUITE I W �\ �—
SOUTH HADLEY,MA 01075 Undersecretary t t valid without signature
cAre
A� CERTIFICATE OF LIABILITY INSURANCE 8/14/2017
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(les)must be endorsed. If 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 C..TRCT LSndd PONOra
NHME:
Hatcher 6 Gridmell Pxoxe (433)586-0111 FA% 11131s86-
rc No: m
B North Ring Street E'^V0L 1 opera@webberan nnell.com
GDDREss: P dgri
INSURE 5 AFFORDIN G COVERAGE NANCY
Northampton MA 01060 INSUBERARIBRIOYRUES Mutual Casualty
INSURED I zURER.JSBrkshlre Hathaway GUARD Ins. Co.
AIDOr1Can Installations, LSC INSURER C:
ALLR: Wes 6 Susanne Couture INSURER D:
130 College Street, Suite 100 INSURER E:
South Hadley MA 01075 1 INSURER F:
COVERAGES CERTIFICATE NUMBERMaster Exp 9-2018 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.
IL1RR TYPE OF INSURANCE R PoLICY FfF pOLICYE%P
PoLICY NUMBER MM'ODIYYYI MW LIMITS
COMMERCIAL GENERAL LU BILITY
EACH OCCURRENCE E 1,000,000
A R C1IM5MA0E OCCURAMA D S 500,000
PREMISES Ee ort e
5D353521] 9/4/2017 9/4/2018 RED EXPIMy one
nepMon) $ 10,000
PERSONAL a AW INJURY E 11000,000
GENL AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE $ 2,000,000
%
POLICY❑`EL'T 0LOC PRODUCTS-COMP/OPAGG $ 2,000,000
OTHER
AUTOMOBILE UABRUl COMBINED SINGLELIMIT 5 1,000,000
a.-OPY
A ANY ALTO BODILY INJURY(For JMI S
ALL ONTIED R SCHEDULED 52353521] 9/4/2017 9/1/2018 BODILY INJURY ParavaOenU S
AUTOS AVip9
R HIRED AUTOS R ANONJDANEO UTOS (P.—P.0
ReOa MG GI AMAGE y
PI.—P $ 8,000
R UMBRELLA LAB OCCU0. EACH OCCURRENCE 5 1,000,000
A EXCESS LIAB CLAIMS MgDE AGGREGATE S 1 000 000
DEC I X I RETENTIONS 10,000 51353521] 9/1/2011 9/4/2018 IS
MORRERS COMPENSATION I ER O H-
AND EMPLOYERS'LABILITY LIN x STATUTE ER
V PROPRIETORPARTNERIE%ECUTIVE EL EACH ACCIDENT $ 500,000
OFFICERMEMBER E%CLUOED] ❑ NIA
B IMandtlwyln NHl URNC60991] 9/1/2011 9/1/2018 E L DISEASE�EA EMPLOYE $ 500,000
CadeunEe LUM
a
RIPTIONOFOPERATIONSbelmu EL DISEASE-PoLICY LIMIT 1$ 500,000
A Commercial PiopeztY 5-115211 9/4/2017 9/4/2018 dMLMPe$100)
DESCRIP90N OF OPERATIONS LOCATIONS I VEHICLES(AMIND 101,Mdulonal Rams.%S[IIMure,may be AU IM N mm"ce Is nyulmd)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
EVidOnCE of I...ErInCe THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATVE
Kevin ,TOyce/LMP
p 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo am registered marks of ACORD
INSO2S,,uJnu