44-119 808 FLORENCE RD BP-2018-1168
GIS 4, COMMONWEALTH OF MASSACHUSETTS
Mao:Block:44- 119 CITY OF NORTHAMPTON
Lot:-DOI PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category, INSULATION BUILDING PERMIT
Permit BP-2018-1168
Proiect# JS-2018-002097
Est Cost:$3700.00
Fee:$65.00 PERMISSION IS HEREBY GRANTED TO:
Const Class: Contractor: License:
Use Grouo: AMERICAN INSTALLATIONS LLC 106178
Lot Siae(sa.R.): 35152.92 Owner: POLACHEK DANIEL W&TRACEY G
tonin : Applicant: AMERICAN INSTALLATIONS LLC
AT: 808 FLORENCE RD
Applicant Address: Phone: Insurance:
130 COLLEGE ST (413) 552-0200 WC
SOUTH HADLEYMA01075 ISSUED ON:5/8/2018 0:00:00
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:
Building 5/8/2018 0:00:00 $65.00
212 Main Street,Phone(413)587-1240, Fax(413)587-1272
Louis Hasbrouck—Building Commissioner
❑epdmen:useoiif}
City of Northampton Status of Permit
— 42019 Buil Ing Department Curb CWQriveway Pemdt
AIRY 2'2 Main Street SemeadSeptic Availabli ty
Room 100 WatedWelrAvallabmly,.
o-ar OF RJR DIN spr:cn rth mpton, MA 01060 Tiro Sets ofSbudNrel 0;
NORTHAMPTON m413-5 -1240 Faz 413-587-1272 PIoLSlle Pians
OlherSpedfy
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO
FAMILY DWELLING
SECTION 1-SITE INFORMATION
1.1 ProoertyAddress: Is section to be completed by office
til .
ROS Florence Road,Florence MA 01062 Map Lot jig Urdt
Zone Overlay District
EM St Dtabtd CS Disbld
SECTION 2-PROPERTY OWNERSHIPIAUTHORRED AGENT
2.1 Owner of Record:
Daniel Polachek 808 Florence Road, Florence MA 01062
Name(Print) Current Me l Address:
(413)883-0564
See attached Telephone
Signstwe
22 Authorized Aaem:
American Installations 130 College St., Ste 100 South Hadley, MA 01075
Name(P*d) Curtest Mail Addreac:
_ \C Chu 1`i'_.ti-._ 413-552-0200
Signaaae \ Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermflapplicant
1. Building 3,700.00 (a)Building Permit Fee
2. Eleddcal (b)Estimated Total Cost of
Consbuctim frau S
3. Plumbing Building Permit Fee
4. Mechanical(HVAC) lY
5.Fina Protection
e. Total=(1+2+3+4+5) 3,700.00 Check Number a
This Section For Official Use Only
Building Permit Number. Date
Issued:
SignaWre•
BUMhg Cc ebnemnspecOm of Buildings Date
Section 4. ZONING au Infornlatbm
n Most Be copmm
competed.Pee can Beee Denied Due To Ixanpm
ete INvratbn
Existing Proposed RequiredbyZoEbg
nie.olmnv W be fiaW m by
Betidug DWatmevt
Lot Sia --� --� U
Fronts o I L�— �
Setbacks Front 0 O
Side L:=R= LR=
�—
Reer
Building Height
Bldg.Square Footage O h
Open Space Footage % I--�
(Got.rte mivosbldgapry L�
v
#OfPuking Sam
Fill:
voluvrovlouuavl
A. Has a Special Permit/Vatiance/Finding ever been issued for/on the site?
NO O DONT KNOW O YES O
IF YES,date issued:l _�
IF YES: Was the permit recorded at the Registry of Deeds? _
NO O DONT KNOW 0 YES O
IF YES: enter Book Page and/or Documentgi _
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:
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: j
E. Will the construction activity disturb(clearing,grading,excavation,ortilling)over i am"Is it pad of a common plan
thatvdti disturb over t acre? YES O NO O
IF YES,then a Northampton Storm Wate[Management Permkham the DPW is required.
SECTION S.DESCRIPTION OF PROPOSED WORK Ichack all applicable1
New House ❑ Addition ❑ Replacement Wlndowa Alferation(s) ❑ Roofing El
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs 101 Decks [0 Sidinglp] Otherl4
Brief Description of Proposed
Work Attic and basement insulation and air sealing throughout
Alterallonof e>oeting bedroom,Yw_No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement _Yes No
PlansAftedred Roll -Sheet
.. _ . _.. .
se. New house and or addition to existlnahousing..comoletethe following,
a. Use of building:One Family Two Family Olher
b. Number of rooms in each family uclt Number of Bathrooms
a 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 men
g. Energy Comervation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
L Isc tructionwkhinlOOfLofmttands?_Yes _No. IsconstmctfonwhhlnlODyr. floodpialn_Yes_No
J. Depth of basement or velar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes_No.
1. SepifcTank_ City Sewer_ Pdvatewell` Caywater Supply_
SECTION 7a-OWNER AUTHORIZATION-TO HE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, Daniel Polachek
as Owner tithe subject
Property
herebyautiuuize American Installations
to act on my behalf,in all=here relative to work atdhodzed by Ods building permit application.
See attached 5/2/2018
Slgmem ot Dara, Date
L American Installations as Owreu/Aulhadzed
Agent hereby declare that time statements and information on the foregoing application are true and accurate,to One best of my knowledge
and ballet
Signed under the palm and penalties of pedury.
American Installations
Prim Name
5/2/2018
Signelue of dAgent
Data
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor. Not Applicable ❑
limm.tLimenti.1der. WesleyK Couture 106178
License Number
130 College St., Ste 100 South Hadley, MA 01075 9/29/19
Atltlresa EVIrstion Dale
S411.�0.... �' ��.M160&, 413-552-0200
Slgnatue Telephone
6.Registered Home lmorovemelit contractor. _: . . Not Applicable ❑
Wesley Couture 175982
Company Name Registration Number
American Installations h/2h/19
Address Expiration Date
130 College St., Ste 100 South Radley, MA 01075 Telephone 413-552-0200
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L e.152,§2SC(e))
Workers Compensation Insurance affidavit must be completed and submitted with this application.Failure to provide this affidavit will result
in tip:denial of the Issuance of tie buliding permit.
Signed Affidavit Attached Yes....... 61 No...... ❑
11. Home Owner Exemption
The correct exemption for"homeowners"was extended to imcludo Ownervoccuoied DweBimn ofone(1) o twe(2)families
aridto allowsuch homeAwamto engage an individual fierhire who does ned possess s licemae,provided that the owner acts
sussupervisor.CIMIRTIM. Sixth Edition Sectl n 10835.1
Definition of Homeowner:Person(s)who own a pawl ofland on which helshe resides or intends to reside,on which there
is,or is intended to he,a one or two family dwelling,attached or detached structures accessory to such use ardt or farm
strucnnrs.A Renson who comstracts more than home in atwo-year parted shall not be considered a homeowner.
Such"homeowner"shall=limit to the Building Offices],on a form acceptable to the Building Official.thatbe/ehe shall be
resmemaTde for all such work Performed under the builder¢permit
As acting Construction Supervisor your presence on the job site moll be required from time to time,during and upon
completion ofthe wok for which this permit is issued.
Also be advised thatwith refixence to Chapter 152(Workers'Compensation) and Chapter 153(ISabilityofEmployersm
Employees for i udce counselling in Death)ofthe Massachusetts General Laws Annotated,You may be table forpason(s)
you hire to perform work foryourmderthis permit.
The undersigned"homeowner"certifies and assumes responsibility forcomphance with the SmmBuilding Cade,City of
Northampton Ordirsances,State and Local Zoning Laws and State ofMassadments General Laws Annotaed.
Homeowaer 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: 808 Florence Road 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 U)zs r
5/2/2018 Cs�
Date Signature of Permit Applicant
a�4s sa
• mass save
.,emxa a bw.m
PARTNER
AFA1.. ILI !1%
&DIA".mrlana"As, American Installations www.Amerkininstanabors.com
130...uD,DsAPAuAsP,haLJev,MAOLOIS• OM.:Mia)a..rA.IN3115E-0LR sPAsfeppwi@NneA*.., sIiA
Customer Name:Daniel Polacheck
Email:Not provided
Phone:413-803-0564
Premise Address:808 Florence RQ Northampton.MA 01062
Project ID:3401832
Date:April 19,2018
Job Description
Yery9�Ja "l L.Y44�vin ...a
Rim Joist- 6" Fiberglass Batting 67 SF y $180.90 $45.22
Basement Wall -2"Thermal Barrier Polyiso 102 SF $487.56 $121.89
Attic Floor- 7"Open Blow Cellulose 512 SF $860.16 $215.04
Damming 12 each $28.68 $7.17
Bath Fan Hose 1 each $26.20 $6.55
Hatch-2'Thermal Barrier Polyiso 1 each $46.28 $11.57
Kneewall Gable-2"Thermal Barrier Polyiso 16 SF $76.48 $19.12
Sheathing Access 8 each $320.16 $80.04
Air Sealing at Estimated 62.5 CFM50 Per Hour 6 hr $555.48 $0.00
Door Sweep (with AS his) 2 each $50.62 $0.00
Exterior Door Weather Stripping (with AS hrs) 2 each $60.14 $0.00
Kneewall Slope -2"Thermal Barrier Polyiso 192 SF $917.76 $229.44
Project Total $3,610.42
Weatherization incentive ($2,208.14)
Air sealing incentive ($666.24)
Total Program Incentive -$2,874.38
Customer Total $736.04
.1.11 A rIi imtaPNorra.LLC rIl ProMae th.,i[aNeadn[wrrn wA.a lryear-,,-,oIP wawa At,
Am.i[a5131.111 LLCMre0vpW0Y5 b Ni 11 rrelenal artl A..1 LI LomPleteireaMve scope of-1 in OID,ro,viN:r.ea00.e Wailiatlonsard a0 beat arG"A.
eubire I,,nn iin ro1a1 r..wwe aamleelrrnn
OCCEPPAPICE OF PROVOiAL'. Thi IDL- pile; s[eel5crtions ane 1m0111-1 are TDTALCOMMCVALLA-s 736.04
alnA,1,DAa Pr,PPv=.roree.rlua,narano.i,eemaowoxnweneea.1a1wen1 mwn alms =s 240.00 ED o0
wallet/3 aown pnortrr Aart orwer4.aMmbreeeue upon f. det+rn. v PAID
aabnee wre upon corr,Pleion-s 496.04
saw
RPPen,own.^no Daniel Polachek lsisol k'+^r�j/���`t^/""�' one 4A918
Nx-n:.ive:IP.im1 B.Zamer Viz Dxe 4-19-18
THIS AGREEMENT 15 COMPOSED OF THIS PAGE AND THE REVERSE SIOE OF THIS PAGE AND SHALL BE CONSIDERED THE ENTIRE AGREEMENT BY THE PARTIES INVOLVED. THIS
AGREEMENT IS BETWEEN AMERICAN INSTALLATIONS,LLC HEREINAFTER REFERRED TO AS"COMPANY",AND THE CUSTOMER(S)NAMED ON THE REVERSE SIDE,HEREINAFTER
REFERRED TO AS"CLIENT",AND WILL BE SUBIECT TO ALL APPROPRIATE LAWS,REGULATIONS AND ORDINANCES OF THE STATE OF MASSACHUSETTS OR CONNECTICUT
RESPECTIVELY,AS WELL AS ALL LOCAL JURISDICTIONS.
THE FOLLOWING TERMS AND CONDITIONS AL50 APPLY
1, THIS AGREEMENT IS SUBJECT TO THE APPROVAL OF A MANAGER OF THE COMPANY FOR THIS AGREEMENT TO BE EFFECTIVE UNDER ANY CONDITION.
2, SHOULD DEFAULT BE MADE IN THE PAYMENT OF THIS AGREEMENT,CHARGES SHALL BE ADDED FROM THE DATE THEREOF AT A RATE OF ONE AND ONE-HALF)1-1/21
PERCENT PER MONTH.(18%PER ANNUM)WITH A MINIMUM CHARGE OF 5200 PER MONTH,AND IF PLACED IN THE HANDS OF AN ATTORNEY OR COLLECTION AGENCY
FOR COLLECTION,ALL ATTORNEYSFEES EXPENSES AND COSTS OF COLLECTION SHALL BE PAID BY THE CLIENT. IN ADDITION,CLIENT UNDERSTANDS THAT IN FAILING
TO PAY ACCOROING TO THE 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,
0. COMPANY AGREES THAT,NOTWITHSTANDING ANY AGREEMENT FOR MATERIALS AND/OR LABOR BETWEEN COMPANY AND THI RD PART,COMPANY IS RESPONSIBLE
TO CLIENT FOR COMPLETION OF ALL WORK DESCRIBED IN ATIMELY 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 WARRANTIES,THE CLIENT MAY BE REQUIRED TO REGISTER OR MAIL IN A WARRANT CARD OR OTHER
EVIDENCE OF OWNERSHIP AND USE OF SUCH EQUIPMENT AND/Oft PRODUCTS IN ORDER TO ACTIVATE SUCH WARRANTIES.
6. THE QUOTATION ON THE PAGE HEREOF WES NOT INCLUDE EXPENSES OR CHARGES MR BOND OR INSURANCE PREMIUMS OR COSTS BEYOND NORMAL I NSUPANCE
COVERAGE,ANY SUCH ADDIT"AL EXPENSES,FWAALIMSOACOST SHALLBC AWED TO THE TQTALAGREFMEERTAMOUNT.
]. THE COMPPNYS UAULIT FOR CLAIMS ARISING OUT OF THIS AGREEMENT SHALL NOT EXCEED THE TOTAL AGREEMENT PRICE EXCEPT TO THE EXT ENT THOSE DAMAGES
ARE PROVEN TO BE SCLEY DUE TO THE COMPANY'S NEGLIGENCE.
8. DURING THE DURATION OF THE WORK,THE CLIENTS HOMEOWNERS INSURANCE WILL BE RESPONSIBLE FOR ANY AND ALL DAMAGES AS LONG AS THE COMPANY HAS
TAKEN THE APPROPRIATE ACTION TO PROTECT AREAS OF WORK.
9. THE COMPANY IS NOT RESPONSIBLE FOR PREEXISTING DEFICIENCIES OR HAZARDOUS MATERIALS THAT MANIFEST THEMSELVES DURING THE CONSTRUCTION PROCESS.
E G.WOOD ROT,M0W,ASBESTOS,NAIL POPS,DUCTWORK AND CONNECTIONS,PLUMBING AND VENT PIPES,DECKING DEFLECTION,ETC, IF APRE-EXISTING DEFICIENCY
OR HAUROOUS 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 CORRECT THE PROBLEMS)ON A TIME ANO MATERIAL BASIS CUENT AGREES THAT SUCH CONDITIONS ARE
UNAVOIDABLE BY THE COMPANY AND SHALL NOT BE CONSIDERED A VIOLATION OF THE AGREEMENT AND THAT DUE TO THESE CONDITIONS THE DURATION OF THE
WORK AND SCHEDULED DAIS OF COMPLETION MAY DIFFER FROM THAT AGREED UPON,IF APPLICABLE,UNDER THIS AGREEMENT.
10. THE COMPANY IS NOT RESPON51&F,AND THE CLIENT AGREES TO HOLD THE COMPANY HARMLESS,FOR ANY PROBLEMS AND/OR DAMAGES,INLCUDING BUT NOT
UNITED TO MOLD GROWTH,ARISING FROM THE PERFORMANCE OF AIR SEALING WORK BY THE COMPANY AS A RESULT OF ANY KNOWN OR UNKNOWN MOISTURE
CONDITIONS.
11. THE COMPANY IS NOT RESPONSIBLE FOO,AND THE CLIENT AGREES TO HOLD THE COMPANY HARMLESS,FOR ANY PROBLEMS AND/OR DAMAGES RELATING TO ICE
DAMMING THAT MAY ARISE DURING ANO/OR AFTER THE PERFORMANCE OF WORK BY THE COMPANY
12. REPLACEMENT OF DETERIORATED DECKING,FASCIA BOARDS,ROOF JACKS,VENTILATORS,FLASHING,BATTLES,JOISTS,INSULATION OR OTHER MATERIALS ARE NOT
INCLUDED UNLESS OTHERWISE NOTED H EREIN.
13, THE COMPANY WILL NOT BE RESPONSIBLE FOR THE SCRATCHING OR DENTING OF INTERIOR WALIS AND CEILINGS,FLOORS,TRIM,GUTTERS,DOWNSPOUTS,EXISTING
SIDING AND WINDOWS,DOORS,OIL DROPLETS IN DRIVEWAYS,HAIRLINE FRACTURES IN CONCRETE OR BLACKTOP DRIVES AND WALKS,OR DAMAGE TO PLANTS OR
SHRUBBERY. IF EXCESSIVE DAMAGE ISCAUSED BY COMPANY,COMPANY WILL REPAIR OR REPLACE DAMAGED AREA ONLY AT COMPANYS EXPENSE.
10, THE COMPANY UNDER PROVISIONS OF CHAPTER 142A OF THE GENERAL LAWS 15 REQUIRED TO APPLY FOR AND OBTAIN ALLCONSTRUCIONAELATED PERMITS.THE
COMPANY SHALL NOT BE DEEMED RESPONSIBLE FOR DELAYS IN THE WORK DESCRIBED IN THIS AGREEMENT CAUSED BY REGULATORY PERMIT GRANTING OR
INSPECTIONAL AGENCIES,AUTHORITIES,OR INDIVIDUALS.
15. THISAGREEMENT,INCLUDING THE PROVISIONS RELATING TO PRICE AND PAYMENT SCHEDULE,CANNOT BE CHANGED OR ALTERED EXCEPT BYA WRITTEN STATEMENT
SIGNED BY WITH THE COMPANY AND THE CUENT.
16. ANY REPRESENTATIONS,STATEMENTS,OR OTHER COMMUNICATION NOT WR17EN ON THIS AGREEMENT ARE AGREED TO BE IMMATERIAL AND NOT RELIED ON BY
EITHER PARTY,AND 00 NOT SURVIVE THE EXECUITON OF THIS AGREEMENT.
17. THIS AGREEMENT CANNOT BE CANCELLED WITHOUT THE MUTUAL WRITTEN CONSENT OF pOH PARTIES EXCEPT AS OTHERWISE SET FORTH HEREON.
18. THIS AGREEMENT,AND ANY WARRANTYIS)PROVIDED HEREUNDER SHALL NOT BE ASSIGNED EXCEPTBY OR WITH THE WRITTEN PERMISSION OF THE COMPANY.
19, IF THE CLIENT FAILS TO PERFORM ITS OBLIGATIONS HEREUNDER OR TERMINATES THIS AGREEMENT WITHOUT THE PRIOR WRITTEN CONSENT OF THE COMPANY,THE
CLIENT SHALL BE LIABLE FOR DAMAGES FOR THE GREATER OF THE COMPANY'S ACTUAL DAMAGES OR 25%OF THE AGREEMENT FOR RESTOCKING FEE.
20. ANY CHANGES TO MATERIALS BY THE CUM(BRAND,STYLE,COLOR,ETC I AFTER SAID MATERIAL HAS BEEN DELIVERED OR IS IN ROUTE TO THE CLIENT COULD RESULT
IN A 5%RE-STOCKING FEE BASED ON THE COST OF MID MATERIALS,
21. THIS AGREEMENT SHALL BE EFFECTIVE ONLY UPON ITS EXECUTION BY ALL PARTIES HERETO,PRIOR TO WHICH TIME IT SHALL BE DEEMED A PROPOSAL THECOMPANY
RESERVES THE RIGHT TO REVOKE THIS PROPOSAL 9O DAYS FROM DATE IT IS FXENTED BY THE COMPANY IF IT 15 NOT EARLIER EXECUTED BY THE CLIENT AND THE
REQUIRED DOWN PAYMENT RECEIVED PRIOR TO THE EXPIRATION OF SUCH 9O DAY PERIOD;AFTER 90 DAYS,AND IN THE EVENT COMPANY DOES NOT REVOKE THE
PROPOSAL,COMPANY RESERVES THE RIGHT TO REVISE ITS PRICE IN ACCORDANCE WITH ITS COSTS IN EFFECT AT SUCH TIME.
22. IF ANY PROVISION OF THIS AGREEMENT SHOULD BE HELD TO BE INVALID OR UNPROVABLE,THE VAWITY AND ENFORCEOIUTY OF THE REMAINING PROVISIONS OF
THIS AGREEMENT SHALL NOT BE AFFECTED THEREBY.
23, ARBITRATION:IN THE EVENT THE CLIENT AND COMPANY HAVE A DISPUTE REGARDING ANY OF THE TERMS,CONDITIONS,PROVISIONS,OR PERFORMANCE OF THIS
AGREEMENT THE PARTIES AGREE TO PLACE THE MATTER INTO ARBITRATION BEFORE AN INDEPENDENT ARBITRATOR ASSIGNED BY THE AMERICAN AROITRATION
ASSOCIATION TO RESOLVE THEIR DISPUTE.
24, ANY DISCOUNT,PROMOTION,REIMBURSEMENT,OR OTHER PROGRAM THAT IS PART OF A STATE SPONSERED UTILITY PROGRAM(I.E.MASS MVP)IS SUBJECT TO THE
AVAILABILITY OF QUALIFYING STATE SPONEREO PROGRAM AND WILL BE SUBJECT TO TERMINATION IF THE STATE SPONSORED UTILITY PROGRAM 15 DISCOUNTINUED.
FURTHERMORE,THE TERMS AND CONONONS OF STATE SPONSEREO UTILITY PROGRAMS MAY BE ALTERED OR UPDATED PERIODICALLY WITH OR WITHOUT NOTICE.
25, AMERICAN INSTALLERS,DEC 15 NOT AN AGENT OF ANY UTILITY COMPANY OF OTHER VENDOR WORKING BY,THROUGH,OR UNDER THE MASS SAVE'ENERGY
PROGRAM.
26. CLIENT 15 REPSONSIBIE FORTHE PAYMENT OF ANY AND ALL FEDERAL,STATE OR LOCALTAXESTHATARE APPLICABLE TO THIS AGREEMENT.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www.muss.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contracton/Electricians/Plumbers
Applicant Information Please Print Leeibly
Name(13mimax/0rgantrntioNlndividun0: American Installations,LLC
Address: 130 College Street,Suite 100
City/Slate/Zip: South Hadley,MA 01075 Phone k: 413-552-0200
Are you as employer?Check the appropriate box: Type of project(required):
1,N 1 am a employer with 46 4. ❑ I am a general contractor and 1 6. ❑New construction
employees(full and/or pan-time).- have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.t 7. ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity, workers'comp. insurance. 9, ❑ Building addition
[No workers'comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑Electrical repairs or additions
1❑ 1 am a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repairs or additions
myself.]No workers' comp. c. 152,11(4),and we have no 12.❑ Roof repairs
insurance required.[t employees. [No workers' I7 [ Other- Insulation I
comp. insurance required.]
t _—
•Any raliutn Thal ebeeo hoe a t w sl alio fill out the utilian blow showins 0eir worker'wmpersatian Wlicy inf rmaion.
Hawwwmn who submit the amdavil mdicming N y ore doing all wale and then Lia wands cmaatms moa submit a new alfalavit indicators such.
;l"umsaeh a Nm check this box what mM1ehN an additional sheet sG,wing 0,name of the arab-e.wwclua and oeie wmkars comb.polity infwrion—
1 am an employer arm is providing workers'compensation insurance for my employees. Below is the policy and%ob site
informmion.
Insurmwe Company Name: Guard Insurance Companies
Policy h or Self-ins. LLGiiic, ti: AMt^WC731485 _ _ Expiration Date: 09/04/2018
Job Site Address: O O Y I() �(� -City/Sure/Zip: "nd , MA- 6464,-2—
Attach
4b({ZAttach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to 51,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00a day against the violator. Be advised that a copy ofthis statement may be forwarded to the Office of
Investigations ofthe DIA for insurance coverage verification.
I do hereby certify under the pains annfd penalties ofperjury that the information provided above is true and correct.
S' np t .h/�d/h.n0. Si ( •hY _.___._�i� ._.
1 61
Phone N: 413-55 -0200
LOfficialu:seonly.only. Do nut wnle in this area,to be completed by coy orsown offlcial.n: Permit/License hhority(circle one):Health 2.Building Department 3.City/fown Clerk 4.Electrical Inspector 5. Plumbing Inspector
son: Phoned:
Commonwsslth of Massachusetts construction Supeviwor
®� Division of Professional Licensers Uneukhoted-Buildings Starry use group which contain
Board of Building Regulations and Standards Iessthm 36,000 cubic IM(991 cubic ova"ofembsed
Construction Supervisor spiCe,
CS-108178 EXpires:09/29120,1y9 -
WESLEY COU7U2E — t
216uTHROrSTREEr
SOUTH HAOLEYMA01075 -
Eaews to poops a cement wagon attire Massachusetts
Side Building Code Is"use for revolution athis Nom".
For inkur etlan about this license
Commissioner ✓"� Call(917)72744 01 visk wwwJness.govfdpi
r%Aa�yt�rtnxrae{rtl�, r 'C��rrJurT�r�1n
e I 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 Mum card. Mark reason for chugs.
scA1 r, 2010-Ovll n Add; 11 Ra..'_,_n Q Employment ❑Lost Card
v�
HOME
I lwele Ae•ira a CONT•Be6uletl•n
tOME IMPROVEM :ULC
before Man valid for hts. N only
& TYPE:LLc Office m•",Won oat•. H d Bu ream to:
H0175M ¢ 06rA U19 Office of Consume Affairs and Business Rpulatlon
1]$002 08/28/2019 10 Park Pima-Suite 6170
AMERICAN INSTALLATIONS,LLC. Boston•MA 02116
WESLEY COUTURE
COLLEGEREET SUITE 100
SOUTH HADLEY,MA 01075 Undersecretary 106t
lid without signature
All 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: N 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
certHicate holder In lieu of such endomement(s).
PRODUCER CONTACTLinda PONBLe
NAME:
NebbeL L OL1Me11 PNONE (413)SB6-Dill FAXMAJ Nn:(0131 58 6-6e91
8 North Ring Street Af1MGRE33:1powexs 0webberandgrinnell.com
INSUREGS)AFFORDING COVERAGE NAICp
NoLthamptou MA 01060 INSURERAXIMPlOyar. Mutual Casualty
INSURED INSUMNEBerkshire HathanNay GUARD Ins. Co.
American Inatallations, LLC IxSURERG:
Attn: Nes S Susanne Couture INSURER D:
130 College Street, Suite 100 INSURER F:
South Hadley MA 01075 INSURER F:
COVERAGES CERTIFICATE NUMBERefaatar Bap 9-1018 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. NOTMSTHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT NTH 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 MY HAVE BEEN REDUCED BY PAID CLAIMS.
IHSR I TYPE OFAUDI WeR
POLICY EFF ZGENERAL
LTM PoIICY NUMBER N LIMITS
COMMERCIAL GENEML LIPBIVry
EACH OCCURRENCE $ 1,000,000
A R CIAIMSMAOE OCCUR MISE Eaomu e S 500,000
50353521] 9/J/201] EXP(AnymegROn) 8 10,000
SONAL B ADV INJURY $ 11000,000
GEML AGGREGATE LIMIT APPLIES PER. ERAL AGGREGATE 3 2,000,000
jEC �LOL OUCiS.COM PAP AGG 3 2.000,000
OTHER: 3
AUTOMOBILE LIABIIRY IN L LIMI 3 1,000,000
u]N 'A ANY AUTO ILYINJURY(FRAR-n) 3
ALLO.AUTOS ED y' AUTOSULEO 5E35352ll 9/4/201] ILY INJURY(Peramoun) 3
HIRED AUi05 R NON-0KNEO PERTY DAMAGE AUTOS emEMl
PIP.Ou. 3 8,000
X UMBRELLA UAB OCCUR EACH OCCURRENCE $ 1,000,000
A EUCESS WB CLAIMS-MACE AGGREGATE S 1,000,000
OED I X I RETENTION$ 10,000 SJ3535217 9/4/2017 9/4/2018 $
NO RERS COMPENSATION a PER T -
AND EMpLOYERS'UABIUTY ./IN $TAiUiE ER
ANY PROPRIETORIPARTNERFXECUTIVE EL EACH ACCIDENT S 500,000
H OFFICERIMEMEER EXCLUDED? ❑N/A
(MCMnory In NM) u1lNC F.99L, 9/4/2017 9/4/2018 E L OI5EA5E.EAEMPWYE 3 500,000
My mecum umlar
DESCRIPTION OF OPERATIONS WM EL DISEASE-POLICY UMIi $ 500,000
A Co®ercial Property 5A3535211 9/4/2017 9/4/2018 Oe =Ue Sl W3
DESCRIPTONOFOPERALONSILCRIMUNSIVEMCLES (ACOM101,AEEMOnal WaM SChWule,nuy BaMcC Irmaepnela.quir )
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Evidence Of Insurance THE EXPIRATION OATS THEREOF, NOTICE WILL BE OEUVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORNED REPRESENTATIVE
KOvill Joyce/LMP � -
01988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
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