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23C-010 (2)
54 LANDY AVE BP-2018-1128 GIS a: COMMONWEALTH OF MASSACHUSETTS Map:Block 23C-010 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Derma: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A) CategoryINSULATION BUILDING PERMIT Permit ft BP-2018-1128 Project JS-2018-002030 Est.Cost- $3900.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group' AMERICAN INSTALLATIONS LLC 106178 Lot Size(sa. ft.): 4704.48 Owner: .JONES MICHAEL D&PARMALEE I Zoning: URB(100)/ Applicant. AMERICAN INSTALLATIONS LLC AT: 54 LANDY AVE AoplicantAddress: Phone: Insurance: 130 COLLEGE ST (413) 552-0200 WC SOUTH HADLEYMA01075 ISSUED ON.5/1/20180:00:00 TO PERFORM THE FOLLOWING WORIL•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: Building 5/1/20180:00:00 $65.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner - . Department Use,ordj _ — Ry f Northampton status of Permit APR 30 2018 uil ng Department Curb Cut/Ddveway Pemit 21 MainStreet sewgdSepgc Avallabllity . Room 100 WatxIWeA Availa6i11ty. nFar oFetni DINGINSPECTI rthe npton, MA 01060 TWO Sets of Sbuctural'Plane �'O—�" 11T0 s -1240 Fax 413-587-1272 Pbti§Ite Plans Odler8pedfy APPLICATION TO CONSTRUCT,ALTER,REPAIR RENOVATE OR DEMOLISH AONNE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Pmoerte Address: This section to be completed byalfice 54 Landy Avenue, Florence MA 01062 Map a` Lot 610 Una. Zone Oveday District Elm St District- CB District SECTION 2-PROPERTY OWNERSHIPIAUrHORR DAGENT 2.1 Owner of Record: Parmaleee Jones 54 Landv Avenue,Florence MA 01062 Name(PdnQ Cumem MagAddress: (4131587-5991 See attached Telephone Sig stme 2.2 Authorized Agent American Installations 130 College St., Ste 100 South Hadley, MA 01075 Name(PW) Cwrant Ma7up kid.: Wal c.,, 1L ('��aA a 413-552-0200 Signese. I Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only complby ermgapplicant 1. Building 3,900.00 (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) C7 S.Fre PmtecWn 6. Total= 1 +2+3+4+5 3,900.00 Check Number This Section For Official Use Only Building Permit Number. Date Issued: O Signature: � �d Robing C'Omqglonecinspector of Buildings D Section 4. ZONING AU Information Must Se C mlaeted.Permit Can Be Demed Due To Inmmptete Infmmetion Existing Proposed Required by Zoning This column robe BIW In by BuMiag DcpvOowt Lot Size C —� Frontage L— Setbacks Front 1= O Side L:=&= LJ= R:= L,] Rear J Building Height Bldg.Square Footage L� Ye Oootage L %waSinFL� r (vo(umn e:tmdw A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DONT KNOW O YES O IF YES,date Issued:I I IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW G YES O IF YES: enter Books J Page 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 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,ortilrmg)over 1 acre"a U pan of a common plan thatwfidlsdtrboverl acre? YES O NO O IF YES,then a Northampton Storm Water Management Permit from the DPW is required. SECTION 5.DESCRIPTION OF PROPOSED WORK(check all applicable) New louse ❑ Atltlition ❑ Replacement Windows Alteration(s) Q Roofing ❑ or Doors O Accessory Bldg. ❑ Demolition ❑ New Signs [[31 Decks M Sidingp:31 Other[& Brief Description of Proposed Work Attic and basement insulation and air sealing throughout Alienation of edsting bedroom_Yes_No Adding new bedroom_Yes ,No Attached Narrative Renovating unfinished basement _Yes No Plarrs AUached Rog -Sheat 6a,if New house and or addition to existing housing,complete the following: a. Use of building:One Fatuity Two Famgy Other b. Number of rooms in each family unit Number of Bathmoms c. is there a garage attached? d. Proposed Square footage of new construction. Dimensions e. Number of sorieso f. Method of hearing? Fireplaces or Woodstoves Number of each- 9. ach_g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction I. Is construction within t00 fL of wegmds?_Yes —No. Is construction within t00 yr. floodplain_Yes`No j. Depth of basement or cellar floor balow finished grade k. Will building conformto the Building and Inning regulations? _Yes_No. I. Septic Tank_ City Sewer_ Pdvatewell_ Cdywmer Supply_ SECTION To-OWNER AUTHORI7AnON-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMR I, Parmalee Tones as Om rof&a subject property herebyauthor¢e American Installations to act on my behalf,in all matters relative to work authorized by this building pemdt application. See attached 4/26/2018 Signature of Owner Dare 1, American Installations as Owner/Authorized Agent hereby declare that the statements and irdormetion on the oregoing application are bue and accurate,o ilia best of my knowledge and belief. Signed under the pales and penalties of perjury. American Installations Prim Name (� ��. IA.�as, L:(()A.�A♦ g- 4/26/2018 Signehae of Owns Agent Date SECTION 6-CONSTRUCTION SERVICES 8.1 Lice s dConstruction Supervisor. Not Applicable ❑ Nameottleamig Rower: Wesley K. Couture 106178 Ikarwe Number 130 College St., Ste 100 South Hadley, MA 01075 9129119 Address Expiration Date wpXAA k x 413-552-0200 � bm Telephone y Registered Himprovement Cotrecto Not Applicable ❑ Wesley Couture 175982 ComnemrName Registration Number American Installations _ 6/2fi/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.1S2,§2SC(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 _ I.SigmadAffidavitAtisched Yes...... 21 No...... ❑ 11. -Home Owner Exemution The currant exemption for"homeowners^was extended to include Owoerocemoied Dwellioes ofom(1) m two(2)families and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner sets as supervisor.CMR M. Slrth Edition Section 10835.1. Defnitiun ofHomeowner:Person(a)who came parent ofland onwhich helshe resides or intends in mside,on which there is,or is intended to be,a one or two family dwel ing,allmhod or detached structures accessory to such use and/or farm strucbaea.A person who constructs mom than home to a tun veer Period shall not he considered a h eowper. Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official,that hdahe shag he responsible for all such work performed under the building:permit As acting Construction Supery1n r your pretence on the job site will be required from time to time,during and upon completion ofihe work for which this parentis issued. Also be advised thatwith reference to Chapter 152(Workers'Compensation) and Chapter 153(LiabilityofEmployers to Employees for injuries not resulting in Death)ofthe Massachusetts General Leers Annotated,you may be Bible forperson(s) you hire to perform work for you under this permit The undersigned"homeowner"certifies and assumes responsibility for compliance with the Stale Building Code,City of Northampton Ordinances,Slide and Local Zoning Laws and State ofMassachusems Genual Laws Annewed. 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: 54 Landy Avenue Florence MA 01062 The debris will be transported by: American Installations The debris will be received by: Waste Management of NE - Chicopee Building permit number: Name of Permit Applicant QA,sl r., 4/26/2018 `3Axu,,4 lC. Date Signature of Permit Applicant S ' ;�� www.Nnmlmnlm[xlla,lonr cum SII B® 5�6tz • Licensed&Insured MA ata 106178 American Installations MAFegetm0on M3898Z 130[otlett So-M yne t00,SJIM Ron,MA 01015 OMre:ln31 M2,0Q.fav:(413)S.,G0Ea Email:AR ar MneessamsMlhnwn.wm Jones,Parmalee 2/19/2018 M ri 54 Lardy Avenue Florence MA 01062 or,4135855991 massloneses@comcast.net 460377 18.0700 Quantity Unit Unit Cort m Total MrSealing AIR SEALING8 man hour $ BSAD $ 680.00 WEATHERSTRIP DOOR&ADD SWEEP 3 each $ 8000 $ 240.00 Air Sealing $ 920.00 Air Sealing Incentive $ (920.00) Air Selaing W%Balance $ - wwtherizaaon ATTIC➢CFDAMMING-R-38FIBERGIASS 108 sft $ 205 $ 221.40 ATLAT-12"OPEN R-42 CELLULOSE 760 Stift $ 1.68 $ 1,276.80 PULL-DOWN STAIR-THERMADOME,BUILT-UP 1 each $ 237.65 $ 237.65 VENTILATION CHUTES 68 each $ 2.50 $ 170.00 BASEMENT SILIS-R19 FG BATT 84 sgft $ 195 $ 163.80 BASEMENT-INSULATE BULKHEAD DOOR&INSULATE 1 each $ 110.00 $ 110.00 REMOVE INSULATION 1,000 Stitt $ 0.75 $ 750.00 Total Weatherization $ 2,929.65 Weatherization Incentive $ 1,634.74 Total Project $ 3,849.65 Total Utility Contribution $ 2,554.74 Total Customer Contribution $ 1,294.91 WARIUPtt bmnranlmolbtwny LLC willrmmeme Sri spends omow M1nnwaha 3yverw or—hlp,eamMc. —0.111 anby pr oobrmse all Per—S.'a ansc—lnmOlHeme aEovwnM1 e—ohgd m as-rap reason-speoreat 1.1cerl lmaland mate Raises RAaPR111NeTOA1.11.111 adored Nnln. ACCEPTANCE OF PROPOSAL Tae aboe paces,spealriadons and TOTAL CONTRACT VALUE= $ 1,294.91 mnaamn:are SPI.O.wand a,e relief sco,o ed.lou are authodmiltar— —occuwd.Paymennww Re 1/3 down prior to Down Payment= $ 431.00 ME eon of work,and pia Cmmpl.non Euo pa.— v, ( I Balance Due Upon Completion= $ 863.91 2/19/2018 nmmro.Alnml ,///foam// �• 2/19/2018 THIS AGREEMENT IS COMPOS EO OF THIS PAGE AND THE REVERSE SIDE OF THIS PAGE AND sH ALL BE CONS I DE RED ME ENTIRE AGREEMENT BY THE PARTIES INVOLVED.THI5 AS RE EMEW IS BETWEEN AMERICAN INSTALLATIONS,LLC HEREINAFTER REFERRED TO AS"COMPANY",AND THE CUSTOMERS(NAMED ON TIE REVERSE SIDE,HEREINAFTER REFERRED TO AS"CLIE',AND WILL BE SUBJECT TO ALL APPROPRIATE LAWS,REGULATIONS AND ORDINANCES OF THE STATE OF MASSACHUSETTS OR CONNECTICUT RESPECTIVELY,AS WELL AS ALL LOCALIURISDICT10N5. THE FOLLOWING TEE M5 AND CONDITIONS ALSO APPLY I.THIS AGREEMENT IS SELECT TO THE APPROVAL OF AMPNAGER OF THE COMPANY FOR TH S AGREEMENT TO BE EFFECTIVE UNDER ANY CONDITION. L SHOULD DEFAULT BE MADE IN THE PAYMENT OF THIS AGREEMENT,CHARGES SHALL BE AT DEO FROM THE DATE THEREOF ATA RATE 0f ONE AND ONE-HALF(31/2)PERCENT PER MONTH, (UPS PER ANNUM)WITH A MINIMUM CHARGE OF$30D PER MONTH,AND If PLAC 01N-XE HANDS OF AN ATTORNEY OR COLLECTOR 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 TIE 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. P.COMPANY AGREES THAT,NOTYITHSTANOING AM AGREEMENT FOR MATERIALS 4ND/CR LABOR BETWEEN COMPANY AND THIRD PARTY,COMPANY IS RESPONSIBLE TO QIENT FOR COMPL71ON Of ALL WORK DESCRIBED IN AIMPLY AND WORKMANIIXE MANNER. 5.ALL WARRANTIES FOR EQUIPMENT AND PRODUCTS SUPPLIED BY THE COMPANY U)DER-HIS AGREEMENT SHALL BE THOSE GIVEN BY THE MANUFACTURERS OF SUCH EQUIPMENT AND PRODUCTS.UNDER SUCH MANUFACTURERS WARRANTIES,THE CLIENT MAY BE REQUIRED i0 REGISTER OR MAIL IN A WARRANh URD OR OTHER EVIDENCE OF OWNERSHIP AND USE OF SUCH EQUIPMENT AND/OR REGULAR IN ORDER TO ACDVATE SUCH WARRANTIES. 6.THE QUOTATION ON THE PAGE HEREOF DOES NOT INCLUDE EXPENSES OR CHARGES FOR PONO OR INSURANCE PREMIUMS OR COSTS BEYOND NORMAL INSURANCE COVERAGE,ANY SUCH ADDJPONAL EXPENSES,REFILL MS OR COST SHALL BE ADDED TO TINE TOTAL AGREEMENT EMOUIT 7.THE COMPANY'S LIABILITY FOR CLAIMS ARISING OUT OF THIS AGREEMENT SHALL NOT EXCEED THE TOTAL AGREEMENT PRICE EXCEPT TO THE EXTENT THOSE DAMAGES ARE PROVEN TO BE SOLEY DUE TO THE COMPANY S GLIGENCE 0,DURING THE DURATION OF THE WORK,THE CLIENTS HOMEOWNERS INSURANCE WILL BE RESPONSIBLE FOR ANY AND ALL DAMAGES AS LONG AS TIE COMPANY HAS TAKEN THE APPROPRIATE 9.THE COMPANY IS NOT OT RESPONS BLE FOR OF DEFICIENCIES OR HA2ARDER S CIA-EARNS THAT MANIFEST THEMSELVES DURING THE CONSTRUCION PROCESS,CIE.WOOD ROT, MOUS,ASBESTOS,NAIL POPE DUCTWORK AND CONNECTIONS,PLUMBING AND VERA FRES DECKING DEFLECTION,ETC,IF A PRE-EXISTING DEFICIENCY OR GOERING.MATERIAL IS ENCOUNTERED PRIOR TO OR DURING CONSTRUCTION,AND COMPANY IS N07FIED N WI TUNS,COMPANY WILL TRY TO ASSIST CLIENT WITHIN THE COMPANY'S MOANS AND CAPABNTIES TO CORRECT THE PBOBLEM(5(ON A TIME AND MATERIAL BASIS.CLIENT AGREES THAT SUCH CONDITIONS ARE UNAVOIDABLE BY THE COMPANY AND SHALL NOT BE CONSIDERED A TREATVIOLATION OF THE AGREEMENT AND DUE TO THESE CONDITIONS THE MEAT ON OF THE WORK AND SCHEDULED DATE OF COMPLETION NO DIFFER FROM THAT AGREED UPON,IF APPHCABIE,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 ME COMPANY AS A RESULT Of ANY KNOWN OR UNKNOWN MOISTURE CONDITIONS. Il.THE COMPANY IS NOT RESPONSIBLE FOR AND THE CLIENT AGREES TO HOLD THE CS MPPVY HARMLESS,FOR ANY PROBLEMS ANO/OR DAMAGES RELATING TO ICE DAMMING THAT MAY ARISE DURING AND/OR ASTER THE PERFORMANCE OF WORK BY THE COMPANY, 12,REPLACEMENT OF DETERIORATED DECKING,FASCIA BOARDS,ROOF JACKS,VENTILATORS FUSWNG,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(IF INTERIOR WALLS AND CEILING$SNORE TRIM,GUTTERS,DOWNSPOUTS,EXISTING SIDING AND WINDOWS,DOORS,OIL DROPLETS IN DRIVEWAYS,HAIRLINE FRAC US ES IN CONCBE E DY FLACKTDP DRIVES AND WALKS,OR DAMAGE TO PLANTS OR SHRUSBERY.G EXCESSIVE DAMAGE IS CAUSED BY COMPANY,COMPANY WILL REPAIR OR REPLACE DAMAGED AREA ONLY AT COMPANYS EXPENSE. 16.THE COMPANY UNDER PROVISIONS OF CHAPTER 1ASA OF THE GENERAL LAW515 REIUIRE)TO APPLY f0R AND OBTAIN ALLCONSTRUTI ON RELATED PERMITS.THE COMPANY SHALL NOT BE DEEMED RESPONSIBLE FOR DELAYS IN THE WORK DESCRIBED IN MIS AGREEMENT CAUSED BY REGULATORY PERMIT GRANTNG OR INSPECTIONAL AGENCIES, AUTHORITIES,OR INDIVIDUALS. 15.THIS AGREEMENT,INCLUDING THE PROVISIONS RELATING TO PRICE AND PAYMENT CHEO JLE CANNOT BE CHANGED OR ALTERED EXCEPT BY A WRITTEN STATEMENT SIGNED BY BOTH THE COMPANYANDTHECUSTIT 16.ANY REPRESENTATIONS,STATEMENTS,OR OTHER COMMUNICATION NOT WRITTEN ON M 5 AGREEMENT ARE AGREES TO BE IMMATERIAL AND NOT RELIED ON BY EITHER PARTY,AND DO NOT SURVIVE THE EXECUTION OF THIS AGREEMENT, 17 THIS AGREEMENT CANNOT OE CANCELLED WITHOUT THE MUTUAL WRIIIENCONSENT OF LOTH PARTIES EXCEPT AS OTHERWISE SET FORTH HEREIN. IB.THIS AGREEMENT,AND ANY WARMNTY(S(PROVIDED HEREUNDER SHALL NOT BE AS;GNED EXCEPT BY OR WITH THE WRITTEN PERMISSION OF THE COMPANY. 19.IF THE CLIENT FAIR TO PERFORM JUS OBLIGATIONS HEREUNDER OR TERMINATES THIS AGREEMENT WITHOUT THE MIOR WRITTEN CONSENT OF THE COMPANY,THE CLIENT SHALL BE LIABLE FOR DAMAGES FOR ME GREATER OF THE COMPANY'S ACTUAL DAMAGES OR 15%C=ME AGREEMENT FOR RESTOCKING FEE. 20.ANY CHANGES TO MATERIALS BY THE CLIENT(BRAND,STYLE.COLOR,ETC I AFTER$A D UR ERIAL HAS BEEN DELIVERED OR IS IN ROUTE TO THE CLIENT COULD RESULT IN A 5%RE-STOCKING FEEBASED ON THE COST OF SAID MATERIALS. 21.THIS AGREEMENT SHALL BE EFFECTIVE ONLY UPON ITS EXECUTION BY ALL PARTI FS PRETQ PRIOR TO WHICH TIME IT SHALL BE DEEMED A PROPOSAL.ME COMPANY RESBIOES THE RIGHT TO REVOKE THIS PROPOSAL 9D DAYS FROM DATE IT IS EXECUTED BY THE COMPANY R C IS NOT EARLIER EXECUTED BY THE CLIENT AND THE REQUIRED DOWN PAYMENT RECEIVED PRIOR TO THE EXPIRATION OF SUCH 90 DAY PERIOD;AUER 90 DAYS,AND IN THE EVENT COMPANY DOS NOT REVOKE THE PROPOSAT,COMPANY RESERVES THE RIGHT TO REVISE ITS PRICE IN ACCORDANCE WITH ITS CMTS IN EFFECT AT SUCH TIME, II,IF AM(PROVISION OF THIS AGREEMENT SHOULD BE HELD TO Be INVALID OR UNE IFORCABLE,ME VALIDITY AND ENFORCEBILIIY OF ME REMAINING PROVISIONS OF THIS AGREEMENT SHALL NOT BE AFFECTED THEREBY. 23.ARBITRATION:IN THE EVENT ME CLIENT AND COMPANY HAVE DISPUTE REGARDINS ANY OF ME TERMS,CONDITIONS,PROVISIONS,OR PERFORMANCE OF THIS AGREEMENT,THE PARTS AGREE i0 PLACE THE MATTER INTO ARBITRATION BEFORE AN INDEPENDENT ARBITI VOR ASSIGNED BY THE AMERICAN ARBITRATION ASSOCIATION TO RESOLVE THEIR DISPUTE. 24.ANY DISCOUNT,PROMOTION,REIMBURSEMENT,OR CHER PROGRAM AAT 15 PART OF A STATE SPONSERED UTILITY PROGRAM R E,MASS SAVE'(IS SUBJECT TO THE AVAILABILITY OF QUALIFYING STAT:SPONSERED PROGRAM AND WILL BE SUBJECT TO TERMINATION IF TIE STATE SPONSERED UTILITY PROGRAM IS DISCW MINDED.FURTHERMORE,THE TERMS AND CONDITIONS OF STATE SPRNSEREO UTILITY PROGRAMS MAY BE ALTERED OR MOSUL D PER ONSALLY WITH OR WITHOUT NOTICE. 25,AMERICAN INSTALLERS,LLC IS NOT AN AGENT OF My UTILITY COMPANY Of OTHER'IENOCI WORKING BY,THROUGH,OR UNDER THE MAA SAVE`ENERGY PROGRAM. 26.CLIENT IS BEP50NSIBLE FOR THE PAYMENT OF ANY AND ALL FEDERA4 STATE,OR LOS AL TALES 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 Lceibly Name(Business/OrganimdoNlndividum): 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 boa: __7 Type orpro)eat(reyulred} --- I.[x] I am a employer with 46 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time)." have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.r 7. ❑ Remodeling ship and have no employees These subcontractors have g. ❑ Demolition working for me in anv capacity workers'comp. insurance. 9. ❑ Building addition [No workers'comp. insurance 5. ❑ We are a corporation and its required.) officers have exercised their 10.❑ Electrical repairs or additions 3-❑ 1 am a homeowner doing all work right of exemption per MGL I L❑ Plumbing repairs Or additions myself. ]No workers'comp. c. 152,§1(4),and we have no 12.❑ Roof repairs Insurance required.]I employees. ]No workers' U.❑Other Insulation comp. insurance required.] --- - ___ -Any ap 1d,adl mm checks box X I mus also all oauM1e,¢lsn below showing their workercompenmtion policy information. t I lommwre.who su ora,d s arfrdavil indicating an,aro doing all work and Nen Lire oorldc contractors dies,submit a new alidavit indicating such. :Connacmrs Nvl dunk aha boa mualmaehed an additional aloat shows,ft name or du:suh-cona.tm and their workan comp.poli.,inrommaon. I am an employer that is providing workers'compensation insurance for my employem Below is the policy and job site i,formWion, Insurance Company Name: Guard Insurance Companies Policy#or Self-ins. Liic'.ti: AMWC731485 _ _ Expiration Datee:/ 09/04/2018_ Job Site Address: �l_ Wdl, "OlAc _City/State/Zip:s�r Attach a copy of the workers'compfTnsation policy declaration page(showing the policy number and expiation date). Failure to secure coverage as required under Section 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 ofa STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations ofthe DIA for insurance coverage verification. Ido hereby certify under the pains a/n�d penalties of perjury that the information provided above is true and correca S__rg- L2AIA4`e Q ( '.fh(tTuRQ _._..—_-Date: _111 L 1.Y Phone#:._ 413-55 -0200 Oficial 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.Citvffown Clerk 4. Electrical inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Coreronwealth of Massachusetts Construction Supensucer ®� Division of Professional Licensure Unrestricted-Br1WTngs of any use group which contain Board of Building Regulations and Standards has than 38,000 cubic felt(991 cubic instars)of eslosed Construction Supervisor fie' CS-106178 EXpires:09/29/2019 WESLEY COU 218 LATI ROrgTREET "a SOUTH HAOLEYMA 01078 3` Fa4ure to possible a curtest eMou of the Mosachuseas Site Binding Cade Is cause for revocation of Mks 0cense, For lrrstrrrralian about this Wens, Commissioner Call ISM 717-3240 or vwt www.mass.gowdp '\ r��n -rl�x�un�rruerr�l - rC /��rturTrrte e a> :' 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: 1759M 130 COLLEGE STREET SURE 100 Expiration: 08/26/2019 SOUTH HADLEY,MA 01075 Update Mdreas and return card. Mark reason for change. scri t. :om.osnl n AdN^mss n Re-me-n-sal n Emp-loyment 0!Oat Cerd /7,, Y, ........... XOMEIMPi10TYK:U-CONTRACTOR Rpire Me ex irdfor late. If found nd my J. TYPE:LLC before theonsurer date. Nbundreturn to: 6917%62 ff E,Nroer26 690 Office Conwmer 51M and BuanblaRpWHlon 1]5942 46/24/2414 14 Padt%oto-Suede 5174 AMERICAN INSTALLATIONS,LLC. Salton,MA 02116 WESLEY COUTURE NfC 130 COLLEGE STREET SUITE 1M �^ SOUTH HADLEY,MA 01075 Undersecreiry t valid without signature ACO CERTIFICATE OF LIABILITY INSURANCE W E,NWDO 8/14/2019 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(ions) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endoreemeld. A statement on this certlecate does not confer rights to the certificate holder in lieu of such endomement(s). PRODUCERMAT NONE: Linda P... Webber S Grinnell (413)586-0111 FC No: 8 North Ring Street ADORIE aLPovera@Nebberandgrinnell.coM INSURESINS)AFFORDING COVERAGE NATO Northampton NA 01060 INSUREPAYagplovers Mutual Casualty INSURED INSURER.A.EXIhlre Bathaum GUAR) IRa. CO. AID9ISC8n Inat.1lati oa, LLC INSURER C' Attn: Wes S Suzanne Couture INSURER.: 130 College Street, Suite 100 INSURER E: South Badley NIIL 01075 INSURER F: COVERAGES CERTIFICATENUMBER:MNster RSP 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 PATH 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 rypE OFADDLNUET POLICY EFF POLICY E%P LTR POLICY NUMBER NM.D.DYYUUMIR COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE E 1,000,000 A R CLAIMSMAOE El OCCUR PREMI E Ee o6u-- § 500,000 5.35353ll 9/G/p01] 9/1/2018 MED E%P(AnY ore l'srson) E 10,000 PERSONAL B AUV INJURY 5 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE S 2,000,000 R POO POLICY JECT LOC PRODUCTS-COMP/OP AGO S 3,000,000 OTHER S AUTOMO&LE LIABILIttEa IIIIN $ 1,000,000 A ANY AUTO BODILY INJURY IPI Nunn, E ALL AUTO$ EO R AAUTOOSULFD 523535217 9/4/3017 9/4J2018 BODILY INJURY IPernmeRnh E R HIRED AUTOS R NONCANDED PROPERTY DAMAGE $ AUTOS P.'Mr,mi PIPTRAN, E 8,000 R UM BRELLA LIAB OCCUR EACH OCCURRENCE E 1,000,000 A EXCESS IIA. GWMSAADE AGGREGATE $ 1,000,000 DED '4 RETENTION 30 000 573535217 9/./2011 9/4/2018 § WORNERS COMPENSATON a PER TX AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETOPPARTNEWEXECUTIVE EL EACH ACCI DEE 500,000 B OFFICERMEMBER E%CUUm O] � N14 M IMandI In NM ReSt IO991] 9/4/2017 9/4/2018 EL DISEASE-EA ENIcYll S 500,000 T dean.�n n DESCRIPTION OF OPERATIONS EeImr E L DISEASE-POLICY LIMIT E 500.000 A Commercial eroperty 1-13121, 9/4/2011 9/4/301B d-J-PIles1PA" DESCMPTONOFOPEM9DNSILOCATIONSIVEMCLESIACORDI01,AddNlonal Re *s&[ ule,mftbealmchWUMMsYceM Vulmdl CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Evidence Of Insurance THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORMEDREPRESENTATIVE Kevin Joyce/LMP --' ©1988-2014 ACORD CORPORATION. All rights reserved. ADORE,25(2014/01) The ACORD name and logo are registered marks of ACORD INSO25n.1e.n