28-013 (17) 256 SYLVESTER RD BP-2018-1158
GIS 4: COMMONWEALTH OF MASSACHUSETTS
MU.Block:28-013 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-2018-1158
Project# JS-2018-002077
Est.Cost $5200.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: AMERICAN INSTALLATIONS LLC 106178
Lot Size(sg ft.): 390733.20 Owner: LOSERT KIRSTIN&MARA SLA WSKY
Zon_ .ne: Applicant: AMERICAN INSTALLATIONS LLC
AT: 256 SYLVESTER RD
ApplicantAddress: Phone: Insurance:
130 COLLEGE ST (413) 552-0200 WC
SOUTH HADLEYMA01075 ISSUED ON:517/20180.00:00
TO PERFORM THE FOLLOWING WORKATTIC 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:
FeeTVpe: Date Paid: Amount:
Building 5/7/2018 0:00:00 $65.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
Department use oily
I✓L V E jy
of Northampton status Of Permit
lding Department Curb Cutf)rivewzy Pemdt
YAY 12 Main Street SewedSepaaAvailabiity- 4 zoneRoom 100 Waterr/WellAvailablity
ampton, MA 01060 TvroSets ofStructuralr..PT of BUILDING INs 87-1240 Fax 413-587-1272 Pl6VSIie PlaNDH1nHfAPiON.MA010
Other SpecIN
APPLICATION TO CONSTRUCT,ALTER,REPAIR RENOVATE OR DEMOLISH A ONE ORTWO FAMILY DWELUNG
SECTION 1 -SITE INFORMATION
1.1 Pmperty Address: Thfgs section to be edmpletetl by office
256 Sylvester Road Florence, MA 01062 Map & a Lot �� ✓ Unit
Zone Overlay District
EIm SL lxatriG CB bated
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
Kristin Losert &Mara Slawsky 256 Sylvester Road Florence MA 01062
Nam.(Print) Corton"Mea "dd"o e
See attached (617) 404620
Signature
TelepMnv
2.2 Authorized Agent-
American
gentAmerican Installations130 College St, Ste 100 South Hadley,MA 01075
Name 1pri t) Conent Mailing Adtlreaa:
413-552-0200
Signature Tebptrone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cos!(Dollars)to be Official Use Ordy
completed by Perrote scam
1. Building 5,200.00 (a)Building Perritt Fee
2. Electrical (b)Estimated Total Coat of
Construction from 6
3. Plumbing Bugdng Permit Fee
4. Mechanical(HVAC)
S.Fire Protection
6. Total=(1+2+3+4+5) 5,200.00 Check Number
This Section For Official Use on
Building Permit Number Date
Issued:
Sign He s
Bu1dFgC a icrNmnspectorof BuildwVs Dais
SeCtinn 4. ZONING All Information Must Be Completed.Permit Can 6e Denied Due To Incomplete Information
Existing Proposed Requited by Zoniog,.,
T6&wiw m be aBW blry. .`a
Bvildiv6Oepm oat
Lot Sim C^—�
Frontage --�
Setbacks Front
Side L:= R:= L:= R:=
Rear
Buiiding Heighti� I�
Bldg.Square Footage M /,
Open Space Footage Yo �—;
(Lawnuom bM6&Pavcd 0 U ��
erld
N of Parking S aces
Fill:
volume&[mdoo
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
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW YES O
IF YES: enter Book J Page and/or Documentfi`_
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:
1 F-
C. Do any signs exist on the property? YES (D NO O
IF YES, describe size, type and location
D. Are there any proposed changes to or additions of signs intended for the property? YES O NO O
IF YES,des:r he size,type and location:
E. WIII the construction acgvdy disturb(clearing,(iredi g,excavation,orfilling)over t acre a is it part of a common plan
that will disturb over tame? YES O NO O
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
r
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicabilel
New House ❑ Addition Q rNew
cement Windows Alteretion(s) ❑ Roofing
ors ED
Accessory Bldg. ❑ Demolition ❑ igns Ip] Decks [p Siding p=l] Other[&
Brief Description of Proposed
Work Attic and basement insulation and air sealing throughout
Alteration ofehdaling bedroom_Yes_No Adding new bedroom_Yes No
Attached Nanative Renovating unMished baseent _Yea No
Plans Attached Rog -Sheet
sa.lf New house and or addition to existing housing.Complete the followinni:
a. Use of building:One Famgy Twp Family Other
b. Number of rooms in each family unit Number of Bathrooms
c. Is them a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
I. Method of heating? Fireplaces or Woodstoves Number of each_
g. Energy Conservation Compliance. Masscheck Energy Compliance farm attached?
h. Type of construction
1. Is construction within 100 ft of wetlands?_Yes —No. Is construction within 100 yr. floodplain_Yw_No
1. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes_No.
I. Septic Tank_ CitySewer_ Private well_City water Supply,
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMR
1, Kristin Losert&Mara Slawsky as Owner of the subject
property
herebyauthorize American Installations
to act on mybehalf,in all matters relegve to work authorized by this bolding permit application.
See attached 4/24/2018
Slgnaeue of Owner Date
I, American Installations as Owner/Authorized
Agent hereby declare that the statements and information an the forego application are true and accurate,to the beat of my knowledge
and belief.
Signed under the pains and penalties of perjury.
American Installations
Prim Name
4/24/2018
Signehae of O%nedAtent Date
,
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Nameof Ucensa Holder: Wesley K. Coulure _ 106178
Uos.Number
130 College SL, Ste 100 South Hadley, MA 01075 _ 9129119
\Address Expiation Dare
CtR1j�i413-552-0200 _
SignaNre --._ Telephone
9.Registered Home lmorovement Contractor. - Not Applicable ❑
Wesley Couture 175982
Company Name Registration Number
American Installations 6126119
Address Expiration Date
130 College St., Ste 100 South Hadley, MA 01075 Telephone 413-552-0200
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.6.1-c.132,§2SC(b))
Workers Compensation Insurance affidavit most be completed and submitted with this application.Falure to provide this offdevitwil resat
in the denial of the issuance of the building permit _
Signed Affidavit Attached Yes....... IN No...... ❑
1L Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellhovs 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 1083. .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 smremres 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 OtficiaL that he/she shall be
responsible for all such work performed under the bmIlding Permit
AsactingConstruetion Supervisor yourpresencemthejobsitewillberequiredfromtim wtime,duringandupon
completion of the work for which this permit is issued.
Also be advised that with reference to Chapter 152 iYorkers'Compensation) and Chapter 153(Liability ofEmployers to
Employees for igjuries not resulting in Death)ofthr.Massachmetls General Laws Annotated,You may be liable for person(s)
you hire to perfa mwork for you under this permit
The undersigned'$omecwnce'certifies and assumes responsibility for compliance with the State Building Cade,City of
Northampton Ordinances,State and Local Zoning Iaws and State of Massachusetts 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: 256 Sylvester Road Florence MA 01062
The debris will be transported by: American Installations
The debris will be received by: Waste Management of New England - Chicopee
Building permit number:
Name of Permit Applicant
4/24/2018 W,i yQi,A„ k . Ca�.T.ianSi
Date Signature of Permit Applicant
a
r<
x ua n�� • mass save
.ea cv agrmrre , PARTNER
American Installations wwwJunmmnlnzbllaV onz.cwn
sm mete Mr.Suitt 1m.swn Iwaq.ra mms. 01i N1.1..raa:1.4 nx auz. f.nat suppor,@OmneeNee4aen
Customer Name:Kristin Losen
Email:Not provided
Phone:617-407-4620
Premise Address:256 Sylvester Rd.Northampton,MA 01062
Project to:3403301
Date:April 23,2018
Job Description
tAeasura 0eptjan .F& T't1p1 Geet
Air Sealing at Estimated 62.5 CFM50 Per Hour 16 hr $1,481,28 $0.00
Exterior Door Weather Stripping (with AS his) 4 each $120.28 $0.00
Door Sweep (with AS his) 4 each $101.24 $0.00
Insulation Removal 120 SF $151.20 $15120
Rim Joist- 6" Fiberglass Batting 120 SF $324.00 $81.00
Attic Floor- 8"Open Blow Cellulose 1652 SF $2,907.52 $726.88
Hatch - 2"Thermal Barrier Polyiso 1 each $46.28 $11.57
Damming 28 each $66.92 $16.73
Project Total $5.198.72
Weatherization incentive ($2,508.54)
Air sealing incentive ($1,702.80)
Total Program Incentive -$4,211.34
Customer Total $987.38
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nS:Jation,n.rre.eLV r,,—r iuriN Yr rtureny a i IaLw n emrNMe I.aMveuvpe ,r-1 n I—Iranae vaP .1 aM io.
r..,rear—int itis,v--VM avoteJMwv
.canner, o. mo=ose-: -I2 ami e:. :aui:x:.r: am I are -o..n:coeran11.1m-1 987.38
sansexm,rano.ei..esr a...9ma.=ware,vrorl2e:o ao..dz as saa;rea.=amm:
rt,—n,ns 300.00 �_
u.YlEe 1/3 Mrm l*Iu:onm crvcr\.atl bffirteauermnrtndeom. Mr= �
sre / eaa,:<oueuvm r-rylHion- s 687.38
mo- 4/23/2018
n�pu:r owrr lvnml IWni Jxe
nemnm:am2ym; Garrett Demers Ilam pare 4/23/2018
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 REPORT ED TO AS'COMPANY-,AND THE CUSTOMERRI NAMED ON THE REVERSE SIDE,HEREINAFTER
REFERRED TO AS"CLIENT",AND WILL BE SUBJECT TO ALL APPROPRIATE LAN S, REGULATIONS AND ORDINANCES OF INE STATE OF MASSACHUSETTS OR CONNECTICUT
RESPECTIVELY,AS WELL AS ALL LOCAL JURISDICTIONS.
THE FOLLOWING TEI'.MS AIJD CONDITIONS ALSO APPLY
1. THIS AGREEMENT IS SUBJECT TO THE APPROVAL OF A MANAGER OF THE i OMPANY FOR TH IS AGREEMENT TO BE EFFECTIVE UNDER ANY CONDITION
2. SHOULD DEFAULT BE MADE IN THE PAYMENT OF THIS AGREEMENT,CHARGESiHALL BE ADDED FROM TH E DATE THEREOF AT A RATE OF ONE AND ONE HALF)1-1/2)
PERCENT PER MONTH.IDEAS PER ANNUM)WITH A MINIMUM CHARGE OF$3 W PER MONFH,AND IF PLACED IN THE HANDS OF AN ATTORNEYOR COLLECTION AGENCY
FOR COLLECTION,ALL ATTORNEYSFEES,EXPENSES AND COSTS OF COLLI CTION SHALL BE PAID BY THE CLIENT. IN ADDITION,CLIENT UNDERSTANDS THAT IN FAILING
TO PAY ACCORDING TO THE ABOVE TERMS,COMPANY MAY HAVE THE R143HT TO A LEIN ON THE PROPEfl1Y
3. THE COMPANY AGREES THAT WHEN DECAYS BECOME KNOWN TO THE CC MPANY THE COMPANY WILL ADVISE THE CLIENT AS SOON AS REASONABLE.
0. COMPANY AGREESTHAT,NOTWITHSTANDING ANY AGREEMENT FOR MATERIAL AND/OR LABOR BETWEEN COMPANY AND THIRD PARTY,COMPANY IS RESPONSIBLE
TO CLIENT FOR COMPLETION OF ALL WORK DESCRIBED INATIMELY AND NORK MANLIKE MANNER,
5. ALL WARRANTIES FOR EQUIPMENT AND PRODUCTS SUPPLED BY THE CO ARAM UNDER THIS AGREEMENT SHALL BE THOSE GIVEN BY THE MANUFACTUR ERS OF SUCH
EQUIPMENT AND PRODUCTS. UNDER SUCH MANUFACTURER'S WARRANTIES,THE CLIENT MAYBE REQUIRED TO REGISTER OR MAIL INA WARRANT'CARD OR OTHER
EVIDENCE OF OWNERSHIP AND USE OF SUCH EQUIPMENT AND/OR PRODUCTS IN ORDER TO ACTIVATE SUCH WARRANTIES.
6. THE QUOTATION ON THE PAGE HEREOF DOES NOT INCLUDE EXPENSES OR CHARGES FOR BOND OR INSURANCE PREMIUMS OR COSTS BEYOND NORMAL INSURANCE
COVERAGE,ANY SUCH ADDITIONAL EXPENSES,PREMIUMS OR COST SHALL BE ADDEDTO TILE TOTAL AGREEMENTAMOUNT.
]. THE COMPANY$LIABILITY FOR CLUMS ARISING CUTOFF THIS AGREEMEN'SHALL NOT EXCEED THE TOTAL AGREEMENT PRICE EXCEPT TO THE EXTENTTHOSE DAMAGES
ARE PROVEN TO BE SOLEY DUE TO THE COMPANYS NEGLIGENCE.
0. DURING THE DURATION OF THE WORK,THE CLIENTS HOMEOWNERS INSJRAM E WILL BE RESPONSIBLE FOR ANY AND ALL DAMAGES AS LONG AS TILE COMPANY HAS
TAKEN THE APPROPRIATE ACTION TO PROTECT AREAS OF WORK.
9. THE COMPANY IS NOT RESPONSIBLE FOR PREEXISTING DEFICIENCIES OR F SEAFOODS MATERIALS THAT MANIFEST THEMSELVES DURING THE CONSTRUCTION PROCESS.
E.G.WOOD ROT,MOLD,ASBESTOS,NAIL POTS,DUCPWORK AND CONNEC'IONS,PLUMBING AND VENT PIPES,DECKING DEFLECTION,ETC,IF A PRE-EXISTING DEFICIENCY
OR HAZARDOUS MATERIAL IS ENCOUNTERED PRIOR TO OR DURING CONSTRUCTION,AND COMPANY IS NOTIFIED IN WRITING,COMPANY WILL TRY TO ASSIST CLIENT
WITHIN THE COMPANY'S MEANS AND CAPABILRIES TO CORRECT THE PIEDUEM)S)ON A TIME AND MATERIAL BASIS, CLIENT AGREES THAT SUCH CONDITIONS ARE
UNAVOIDABLE BY IDE COMPANY AND SHALL NOT BE CONSIDERED A VIC TRADED OF THE AGREEMENT AND THAT DUE TO THESE CONDITIONS ME DURATION OF THE
WORK AND SCHEDULED DATE OF COMPLETION MAY DIFFER FROM THAT\GREED UPON,IF APPLICABLE,UNDER THIS AGREEMENT,
10. THE COMPANY 15 NOT RESPONSIBLE,AND THE CLIENT AGREES TO HOLE,THE COMPANY HARMLESS,FOR ANY PROBLEMS AND/OR DAMAGES,INCLUDING BUT NOT
LIMITED TO MOLD GROWTH,ARISING FROM THE PERFORMANCE OF AIF SEALING WORK BY THE COMPANY AS A RESULT OF ANY KNOWN OR UNKNOWN MOISTURE
CONDITIONS.
11. THE COMPANY 15 NOT RESPONSIBLE FOR,AND THE CLIENT AGREES TO TOLD THE COMPANY HARMLESS,FOR ANY PROBLEMS AND/OR DAMAGES REEATI NO TO ICE
DAMMING THAT MAY ARISE DURING AND/OR AUER THE PERFORMANCE OF WORK BY THE COMPANY.
12. REPLACEMENT OF DETERIORATED DECKING,FASCIA BOARDS,ROOF JAC$VENTILATORS,FLASHING,RAFTERS,JOISTS,INSULATION OR OTHER MATERIALS ARE NOT
INCLUDED UNLESS OTHERWISE NOTED H EREIN.
13. THE COMPANY WILL NOT BE RESPONSIBLE FOR THE SCRATCHI NG OR DENTING OF I NTERIOR WALLS AND CFILINGS,FLOORS,TRIM,GUTTERS,DOWNSPOUTS,EXISTING
SIDING AND WINDOWS,DOORS,OIL DROPLETS IN DRIVEWAYS HAIRLIN'FRX MESS IN CONCRETE OR BLACKTOP DRIVES AND WALKS,OR DAMAGE TO PLANTS OR
SHRUBBERY. IF EXCESSIVE DAMAGE 15 CAUSED BY COMPANY,COMPANY WILL REPAIR OR REPLACE DAMAGED AREA ONLY AT COMPANY'S EXPENSE,
10. THE COMPANY UNDER PROVISIONS OF CHAPTER 162A OF THE GENERAL LAWS IS REQUIRED TO APPLY FOR AND OBTAIN ALL CONSTRUCTIONRELATED PERMITS, THE
COMPANY SHALL NOT BE DEEMED RESPONSIBLE FOR DELAYS IN THE WORT: DESCRIBED IN THIS AGREEMENT CAUSED BY REGULATORY PERMIT GRANTING OR
INSPERIONAL AGENCIES,AUTHORITIES,OR INDIVIDUAL.
15. THIS AGREEMENT,INCLUDING THE PROVISIONS RELATING TO PRICE AND PAYMENT SCHEDULE,CANNOT BE CHANGED OR ALTERED EXCEED BY A WRITTEN STATEMENT
SIGNED BY BOTH THE COMPANY AND THE CLIENT.
16 ANY REPRESENTATIONS,STATEMENTS,OR OTHER COMMUNICATION NCT WR17EN ON THIS AGREEMENT ARE AGREED TO BE IMMATERIAL AND NOT RELIED ON BY
EITHER PARTY,AND DO NOT SURVIVE THE EXECUTION OF THIS AGREEME JT.
17. THIS AGREEMENT CANNOT BE CANCELLED WITHOUTTHE MUTUALWRIT EN CCNSENTOF BOTH PARTIES EXCEPTAS OTHERWISE SET FORTH HERRN.
19. THISAGREEMENT,AND ANY WARRANTYL)PROVIDED HEREUNDER STATE!NOT 13E ASSIGNED EXCEPT BY OR WITH THE WRITTEN PERMISSION OF THE COMPANY.
19. IF THE HENT FAI IS TO PERFORM In 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 COMPANHSACTUAL DAMAGES OR 25%OF THE AGREEMENT FOR RESTOCKING FEE.
20. ANY CHANGES TO MATERIALS BY THE CLIENT IRELAND,SEATS,COLOR,ETC I AFTER SAI D MATERIAL HAS BEEN DELIVERED OR IS IN ROUTE TO THE CLIENT COULD RESULT
IN A S%RE STOCKING FEE BASED ON THE COST OF SAID MATERIAL.
21. THIS AGREEMENT SHALL BE EFFECTIVE ONLY UPON ITS EXECUTION BY AL.PARTIES HERETO,PRIOR TO WHICH TIME IT SHALL BE DEEMED A PROPOSAL THE COMPANY
RESERVES TINE RIGHT TO REVOKE THIS PROPOSAL 90 DAYS FROM DATE IT 15 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 9J DAY PERIOD:AUER 90 DAYS,AND IN THE EVENT COMPANY DOES NOT REVOKE THE
PROPOSAL COMPANY RESERVES THE RIGHT TO REVISE In PRICE IN ACCC ROANS WITH ITS COSTS IN EFFECT AT SUCH TIME.
22, IF ANY PROVISION OF THIS AGREEMENT SHOULD BE HELD TO BE INVALIC OR U VEN FORCABLE THE VALIDITY AND ENFORCEBILITY OF THE REMAINING PROVISIONS OF
THIS AGREEMENT SHALL NOT BE AFFECTED THEREBY.
23, ARBITRATION'.IN THE EVENT TH E CLIENT AND COMPANY HAVE A DISPL TE REGARD NO ANY OF THE FORMS,CONDITIONS,PROVISIONS,OR PERFORMANCE OF THIS
AGREEMENT,THE PARTIES AGREE TO PUCE THE MATTER IMO ARBITRATION BEFORE AN INDEPENDENT ARBITRATOR ASSIGNED BY THE AMERICAN ARBITRATION
ASSOCIATION TO RESOLVE THEIR DISPUTE.
20. ANY DISCOUNT,PROMOTION,REIMBURSEMENT,OR OTHER PROGRAM THAT IS PART OF A STATE SPDNSERED UTILITY PROGRAM IF MASSSAVE°IISSUBIECTTOTHE
AVAILABILITY OF QUALIFYING STATE SPDNSERED PROGRAM AND WILL BI SUBR 0 TO TERMINATION IF THE STATE SPDNSERED UTILITY PROGRAM IS DISCOUNTINUED.
FURTHERMORE,THE TERMS AND CONDITIONS OF STATE SPDNSERED UTI.ITY PROGRAMS MAY BE ALTERED OR UPDATED PERIODICALLY WITH OR WITHOUT NOTICE.
25, AMERICAN INSTALLERS,LLC IS NOT AN AGENT OF MY UTILITY COMPANY OF OTHER VENDOR WORKING BY,THROUGH,OR UNDER THE MASS SAVE'ENERGY
PROGRAM.
26. CLIENT 15 REPSONSIBLE FOR THE PAYMENT OF ANY AND ALL FEDERAL,STRE OR LOCAL TAXES MAT 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/Jia
Workers' Compensation Insurance Affidavit: Builders/Contracton/Eleetricians/Plumbers
Applicant Information Please Print Lc 'blv
Name(Buslmas/organiza6oNlndlviduap: American Installations,LLC
Address: 130 College Street,Suite 100
City/State/Zip: South Hadley,MA 01075 __ phone i!: 413-552-0200
Are you in employer?Check the appropriate box: Type of project(required} -
1.0 I am a employer with 46 - 4. [-] I am a general contractor and I 6. E] New construction
employees(full and/or pan-time)! have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed em the attached sheet.t 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working formein any capacity. workers'comp. insurance. q, ❑ Building addition
]No workers' comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.E]Electrical repairs or additions
3.
Ll am a homeowner doing all work right ofexemption per MGL I I.❑ Plumbing repairs or additions
myself.[No workers'comp. c. 152,§1(4),and we have no 1 12.❑ Roof repairs
insurance required.]' employees. [No workers' 13.N Other-Insulation —I
comp. insurance required.] -'
'Any applicantIMIeMcp Doe XI mull also pll ort the section below ffiowina theirworken'con,amenim Wlue Information.
I lnmrownan who suMnit flee affiche l Indican.,they am doing all wank and Nen him outside contrition;must submit anew a ndervil so cuting such.
:Cumradvrs Na clxttt IM1Is boo must oludreJ nn additional sheu stowing the name.1 the-h-cw tmemm and fluen warken'com,.aofuy iafvnnoush
lam an employer that is provlding workers'compem'mran insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: Guard Insurance Companies_ - i _
Policy A or Self-ins. Licc.q. AMWC_731,485,, �. /J / __ Expiration Date: 09/04/2018
Job Site Address: `? 5LJL 1^xik Aye-g1 ie gOA City/State/Zip: foog hA 6)662
Attach a copy of the workers'compo sation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL :52 can lead to the imposition of criminal penalties of a
fine up to S 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 maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
lots hereby,certify under the points annd proof i_ess of perjury that the information providedabove is true and carrect
S/-/I/M Axl Q 1 .fNl7.U115L_.. Date:
Phonee# 413-551'0200
Official use ofay. Do not write in this area,to be completed by city or town official
City or Town: Permit/License 4
Issuing Authority(circle one):
I. Board of Health 2. Building Department 3.Cityrrown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone N:
_ Commonwealth of Massachusetts Construct1OA Supervisor
® Division of Professional Licensure Unrestricted-Su9Sngs oraly we group vdikofl contain
Board of Building Regulations and Standards Ins train 36,000 erotic fast(991 cubic main*of enclosed
Construction Supervisor "Pace.
CS-106178 E3pires: DW29/2019
WESLEY COUTURE
216LATHROPSTREET
SOUTH HADLEY MA 01075 -
Faison to possible a carried eAUm of the MnsaWuselta
State Building code is cause for revocation of U&geanse.
For fire nolIon WON this gems
Commissioner Call(8171727dYM orvMBwww.rrpssgov/dpi
'C���rtsrrrlMifl/
t
'--` Office of Consumer Affairs and Business Regulation
10 Park Plaza- Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Type: LLC
75982
AMERICAN INSTALLATIONS,LLC. Registration: 012
130 COLLEGE STREET SUITE 100 Expiradon: 0 08/28/2019
SOUTH HADLEY,MA 01075
Update Address and mum card. Mak reason for clung".
$ Al u MIADS'11
rT Add:--s rat p_a.wl rat Employment I]Lost cord
oMke w Coneumar Analis a Business Regulation
NOMEIMPROVEMENTCONTRACTOR Registration uWld for individual use only
.,ytt TYPE:LLC before Bre expiration date. r bund return to:
Renlstretlon mon Office of Consumer Affairs and Business Regulation
175982 OS/2&2019 10 Park Mass-Sure 5170
AMERICAN INSTALLATIONS,LLC. Boston,MA 02116
130 COLLEGE STREET SUITE 100 J �—b
SOUTH HADLEY,MA 01075 Undersecretary % t valid WIthOMt signature
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 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 endomement(s).
PRODUCER CONTACT Linda Powexa
XAME:
Webber 6 Grinnell F;,E lrb. (413)586-0111 P.C. (413)586-1401
NCNo:
8 North Ring Street ADORIBe .powers@wehherandgximell.com
INSURE s AFFORDING COVERAGE q
Northampton IA 01060 INSURERAEO 1 Mutual utual CasualC
INSURED INSURERBPerkshire HathawayGUARD Ins. Co.
C
American Installations, LLINSURERC:
Attn: Wes 6 Suzanne Couture INSURER D:
130 College Street, Suite 100 INSURER E'
South Hadley NA 01075 INSURER F'
COVERAGES CERTIFICATE NUMBERblBster 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.
INSR I TYPE OF INSURANCE L VRR POLICY FfF POLICY ENP
LTR POLICY NUMBER MM' MM'D UNITS
COMMERCIAL GENERAL UABIIf1Y
EACH OCCURRENCE E 1,000,000
A R CWMSMAOE ,�OCCUR
PREMISES Ea occurrence S 500,000
50353531] 9/4/2017 9/4/2018 MEO CXP(A ,..1-1 E 10,000
PERSONAL B AOV INJURY S 1,000,000
GENL AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE S 2,000,000
R POLICY[::]EEC PRO- [:]LOC PRODUCTS-COMProP AGG E 2.000,000
OTHER E
AUTOMOBILE LABILITY TM9N IN LELIMIT $ 1,000,000
a aPcAam1
A ANY AUTO BUD LY INJURY(Pw VYU,) $
ALL OVMED $CHEDVLED
AUTOS
XAUTOS 5Z3535217 9/4/2017 9/4/2018 WDILY INJURY Per awderr $
R HIRED AUTOS R NON..EO pROPERTYOAMAGE $
AUTOS Paeo-fam
PIP Bmo $ 8,000
R UMBRELLAUAB OCCUR EACH OCCURRENCE 8 1,000,000
A EXCESS UAB CLAWSJAACE AGGREGATE $ 1,000,000
LEO I y- I RETENTION$ 10 000 51353521] 9/4/2017 9/4/2018 1 y
WORKERS COMPENSAPONPER OTH-
ANDEMPLOYERS'LIABIUIY YIN x STATUTE ER
ANY PROPPETORIPARTNENEXECVTIVE E.L EACH ACCIDENT $ 500,000
H Nandaum,EBE EXCLUCED7 ❑ IA inygC 609917 9/4/2011 9/4/2018
I awry I E L.DISEASE-EA EMPLOYE 8 500 000
11 yea,eeunee„mer
OESCR PTION OF OPERATIONS LHnx EL.DISEASE-POLICY LIMIT s 500:0
OOo
A Commercial Property 5A3535217 9/4/201] 9/4/2018 dedloce$1 Or
DESCRU'DON OF OPERATIONS LOCAHONSI VEHICLES(BOUND 101,AEUXIonal Remarb Sc1lebm,may be Valued 8 more R aCe Is Ny VymP l
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY of THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Evidence Of Insurance THE EXPIRATION DATE THEREOF, NONCE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORMED REPRESENTATVE ../�
Kevin Joyce/LMP •" --
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ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
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