36-234 (3) 24 DIAMOND CT BP-2018-1287
GIS#: COMMONWEALTH OF MASSACHUSETTS
Mat,Vocx: 36-234 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Gateaory: INSULATION BUILDING PERMIT
Permit BP-2018-1287
Project JS-2018-002288
Est Cost: $5800.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: AMERICAN INSTALLATIONS LLC 106178
Lot Size(sa. ft.): 35370.72 Owner. CARLSON-SHAW CAROL A&CATHERINE M SHAW
Zoning: Applicant: AMERICAN INSTALLATIONS LLC
AT: 24 DIAMOND CT
Applicant Address: Phone: Insurance:
130 COLLEGE ST (413) 552-0200 WC
SOUTH HADLEYMA01075 ISSUED ON.61512018 0:00.00
TO PERFORM THE FOLLOWING WORK:ATfIC 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 Occuoancv Signature:
FeeTvpe: Date Paid: Amount:
Building 6/5/2018 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
Depadment use only
City of Northmp n Statue of pelma:
UN BuYdiW®ep rtm t Curb CuttDdvew y Pemdt
W^ +112 Main Set SeweNSepticAyallabTity .
Room 1 WathdWWrAvanabalty
DEPT.of oddA 01 60 Two Sets of Strucumi Own
-587-1272 PPUS tte Plans
OtherSpecfy
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAAMMILY DWELLING
SECTION 1 -SITE INFORMATION t7 v'1 a /2 O7
1.1 PmoerLyAddress: This section to be eempleted bbyomee
p, tineanG� Cid Map 3Q Let T37 uMr
Zone Overlay DtsUkL
EIm SL Dfsbict CB Dlstrid
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
Cawl Sr Cate Shaw 24 Diamond Court Florence, MA 01062
Name(Pdng O—m Mating Addmoo
14131977-1247
See attached Telephone
Signature
22 Authorized Agent•
American Installations 130 College St., Ste 100 South Hadley,MA 01075
tNome(Rkl) - Conant Haling Address:
�.Q21 �L. ('p�L�A, 413-552-0200
Slgnehrte TelePhone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)in be Official Use Only
completed pennit appUcant
1. Building 5,800 (a)Building Penna Fee
2. Elacuical (b)Estimated Total Cost or
Construction frau 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5.Fire Protection
6. Total= 1+2+3+4+5) 5,500 Check Number
This Section For Official Use Only
Building Permit N or. Dale
lasued:
S19 lure:
BuDdIrMiCiLlssionwAnspeaw of Buildings Date
Section 4. ZONING All Information Must Be Compteted.Permit CantBe Dedied Due To mplete information
Existing ProposedRequired y
_ BwldioY DpPPiaNat__
Lot Size
Frontage
Setbacks Front
Side L=R:= L= R=
Rear
Building Height
Bldg.Square Footage �—J C— %
Open Space Footage
(Cotaree mivua bldg&paved
Pusti.9)
#of Paricigg Spam f=J
Fill: —_ � _ ________
volume&L iov
A. Has a Special PermitNariance/Finding ever been issued for/on the site?
NO O DONT KNOW O YES O
IF YES,date issued:)
IF YES: Was the permit recorded at the Registry of DeedB
NO O DONT KNOW O YES O
IF YES: enter Book Page and/or Document#1
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 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: F-
D.
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 acfi ty disturb(clearing.grading,ezcavatlon,orfilling)over 1 acre or Is ft part of a common plan
that will disturb over l acre? YES NO O
IF YES,men a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Adtlitlon ❑ Replacement Windows Alterations) Roofing
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs M Decks (E3 Siding lot OtherlFYJ
Brief Description of Proposed
Work: Attic and basement insulation and air sealing throughout
Alteration of e)dsting bedroom_Yas_No Adding raw bedroom Yes _No
Attached Narrative Remm sling unfinished basement _ w _No
Plane Attached Roil -Sheet
On.If New house and or addition to ezistinrrhousina Complete the following,
a. Use of bugding:One Family Two Fam5y Other
b. Number of rooms in each family unit. Number of Bathrooms
Q Is there a garage attached?
d. Proposed Square footage of new censtruetion. Dimensions
e, Number of stories?
f. Method of heating? Misplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscherk Energy Compliance tone attached?
h. Type of construction
L Is construction within 100 ft of wetlands?_Yes _No. Is consbuction within 100 yr. floodplain-Yes—No
J. Depth of basement or cellar floor below finished grade
k. Will bolding conform to the Building and Zoning regulafions? -Yes—No.
I. Septic Tank_ City Sewer_ Priwite well_ City water Supply_
SECTION?a-OWNER AUTHORIZATION-TO BE COMPLETED=
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING
I. Carol &Cate Shaw ,as Owcer of the subject
property
hereby au0rorize American InstallaIF.,
ions
m act on my behaK In ail mattere relative to work au0torwit by IN bugding pam*alIIcalk,n.
See attached 5/30/2018
Slgnabre of Owner Date
I. American Installations as OwwdAuthorRed
Agent hereby declare that the statements and Information on the foregoing application are sue and accurate,tofu bast of my knowledge
and belief.
Signed underthe pains and penalties of pa wy.
American Installations
Print Name
fi— 5/30/2018
51 nehae of Owns nt Data
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction SupeMsor., Not Applicable ❑
Name of License Holder: WesleyK. Couture 106178
Lieaese Number
130 College St., Ste 100 South Hadley, MA 01075 9129119
Milani. Eaptratloo[late
1J> CbIA�A.vtR, 413-552-0200
SIBeaWre Telephone
9.Regism2d Horiielmpmwment Contmctcr.. _ Not Applicable ❑
Wesley Couture 175982
Company Name Registration Number
American Installations 6,16119
Address EzpimOon Date
130 College St., Ste 100 South Hadley, MA 01075 Telephone 413-552-0200
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.GA.c.152,§25C(8))
Wodrers Compensation Insurance allidav5 must be completed and submitted with this application.Failure to provide this affidavit W11 result
in the denial of the issuance of the building permIL
Signed AtfidevitAtached Yes....... 0 No...... ❑
11. :-Home Owner Exeml)tion
The corm " mptimfor"homeowners"was entended to include owner-oecuoted DwsUines of one(1) or two(2)families
and to allow such honwownam engage an individual fmbire who does not possess a license,provided that the owner ads
as supervisor.CMR 780. Stadia Edition Section 10535.1.
Deiipttion ofHomeowner:Person(s)who own a parcel of land on which hdsbe resides or intemis m reside,on which there
is,or is intended to be,awe or two family dwelling,attached or detached shuchuas accessorym suchuse and[or form
structures.A Person who constructs more than one home In a two varied shall not be considered a hourway.
Such"homeowner"shall submit to the Building Official,ma a form acceptable to the Building Officia4 that hdahe ahaU he
responsible for all such work Pearlbrimed under th buldi eras%
As acting Construction Supervisor yourpresonce on thejob site will be required from time to time,during and upon
completion ofthe work for which this permit is issued.
Also be advised that with reforms eto Chapter 152(Workers'Compensation) and Chapter 153(Liability ofEmployen;to
Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,yon may be 0able forperson(s)
you hire to perform work for you under this permit
The undmigred"homeowner"certifies and assumes teapotw)bility for aompiimce with the State BaEthngCode,City of
Northampton Ordinances,State and focal Zoning Laws and State ofMassachuselts 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: ;z�i i-,
The debris will be transported by:
�,H,coPe� c,u�dsu.
The debris will be received by:
Building permit number:
Name of Permit Applicant shaa7
17l3011A �.t l-Qt� IL. C6Lt,�A�
Date Signature of Permit Applicant -
ownlnted&l tri ccm
M Bim. • uremeda
MA at
ad IX:1v061785"2
American Installations Ma Regenepanns98z
t30ColllBl Sbett SUlre E00 bIM XaEIey.MAOIO)5 a OlflxaOnl55b0EW foe 1113155ENOE�Fmtll:fulgotlfArnealonlnatllMtlom.mm
Shaw,Carol&Cate 5/25/2018
m
24 Diamond Court Northampton MA 01062
4139772526 agolshweesq@Iive.com wm mx
466869 18-1769
.Nu
Quantity Unit Unit Cost Total
Air Sealing
AIRSEALING 14 manhour $ 85.00 $ 1,190.00
WEATHERSTRIP DOOR&ADD SWEEP 2 each I $ &1.00 15 16000
Air Sealing $ 1,350.00
Air Sealing Incentive $ (1,020.00)
Air Selaing W%Balance $ 330.00
Weathur n
ATTIC DAMMING-R-38 FIBERGLASS 148 sqh $ 2.05 $ 303.40
VENTILATION CHUTES 92 each $ 2.50 $ 230.00
ATTIC FLAT-8"OPEN R-30 CELLULOSE 1,368 sqk $ 1.44 $ 1,969.92
ATTICHATCH-SEAL&INSULATE 1 each $ LOGO $ 60.00
WHOLE HOUSE FAN COVER 1 each $ 209.21 $ 209.21
NEED RIDGE VENT 10 each $ 110.75 $ 1,107.50
VENT BATH FAN THRU ROOF 2 each $ 118.75 $ 237.50
BASEMENT SILLY R19 FG BATT 78 sqk $ 1.95 $ 152.10
Air Sealing W%Balance 1 Iumpsum $ 330.00 $ 330.00
REMOVE INSULATION 1W sqk $ 075 $ 120.00
Total Weatherization $ 4,719.63
Weatherization Incentive $ 3,449.72
Total Project $ 5,739.63
Total U6liry Contribution $ 4,469.72
Total Customer Contribution $ 1,269.91
w ague""adder mauuniena,"[will pmnee,M1e above vuw nnmmwmrwllM1 a x aevwar4memnlp wamnN
LLC 1.11,propom ra III all mabrlal ane levoab mmpMne andde I ofadu i"-pond-o—ah tMhoy aeceellleaude,and III Impend our,bollEing
n mnn,for 11.1.IDG mmrae Niue ss,ured 1—
ACCEPTANCE OF P do rai The above w ou,a deniiueom In it TOTAL CONTRACT VALUE= $ 1,269.91
condnlons arc xtialalmry and are herabyacaptee.You—
authorized
ouareauthorized to do work—pensee.Payment will be Ila down prior to Down Payment= $ 423.00 hhkx
narcmwn,k,ane wish"cue upon CemPlebort
Balance Due Upon Completion= $ 846.91 vain
5/25/2018
�...m n. 5/25/2018
TH IS AGREEMENFIS COMPOSED OF THIS PAGE AND THE REVERSE SIDE OF THIS PAGE AND SHALL BE CONSI DER ED THE ENTRE AGREEMENT BY THE PARTIES INV.LVED.THIS AGREEM ENT 15
BETWEEN AMEWCAN INSTALLATIONS,LLC HEREINAFTER REFERRED TO AS"COMPANY",AND THE CUSTOMEED)NAMED ON THE REVERSE SIDE,HEREINAFTER REFERRED TO AS"NEM}AND
WILL BE SUBJECT TO ALL APPROPRIATE TAWS,REGULATIONS AND ORDINANCES OF THE STATEOF MASSACHUSETTS OR CON SOCLU CUT RESPECTIVELY,AS WELL AS ALL LOULIURISDICTIONS.
THE FOLLOWING TERMS AND CON OITIONSALSO APPLY
1,THIS AGREEMENT IS SUBJECT TO THE APPROVAL OF A MANAGER OF THE COMPANY FOR THIS AGREEMENT TO BE EFFECTIVE UNDER ANY CONDITION.
3.SHOULD DEFAULT BE MADE IN THE PAYMENT OF THIS AGREEMENT,CHARGES SHALL BE ADDED FROM THE DATE THEREOF ATA RATE OF ONE AND ONE-HALF)1-1/E)PERCENT PER MONTH.
(18%PER ANNUM)WITH A MINIMUM CHARGE OF$3 W PER MONTH,AND IF PLACED IN THE HANDS OF AN ATTORNEY OR COLLECTION AGENCY FOR COLLECTION,ALL ATTORNEYS'FEB.
EXPENSES AND COSTS OF COLLECTION SHALL BE PAID BY THE CLIENT.IN ADDITION,NEW UNDERSTANEGi THAT IN FAILING TO PAY ACCORDING TO THE ABOVE TERMS,COMPANY MAY
HAVE THE RIGHT TOA ZEIN ON THE PROPEfltt,
3.THE COMPANY AGREES THAT WHEN DECAYS BECOME KNOWN TO THE COMPANY,THE COMPANY WILL ADVISE THE CLIENT AS SOON AS REASONABLE.
6.COMPANY AGREES THAT, NOTWITHSTANDING ANY AGREEMENT FOR MATERIALS AND/OR LABOR BETWEEN COMPANY AND THIRD PARTY,COMPANY IS RESPONSIBLE TO CLIENT FOR
COMPLETION OF ALL WORK(BOUNCE IN A TI MELY AND WORKMANLIKE WINNER.
S.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 MAYBE REQUIRED T.REGISTER OR MAIL INA WARRANTS CABG OR OTHER EVIDENCE OF OWNERSHIP AND USE OF
SUCH EQUIPMENT AND/OR PROW RS IN OROERTOARIVATESUCH 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
ADOHIQ'iAL EXPENSES,PREMIUMS OR COST SHALL BE ADDED TO THE TOTAL AGREEMENT AMOUNT.
].THE COMPRESS LIABILITY FOR CLAIMS ARISING OUT OF THIS AGREEMENT SHALL NOT EKCEED THE TOTAL AGREEMENT PRICE EXCEPT i0 THE EXTENT THOSE DAMAGES ARE PROVEN i0 BE
SOLES DUE TO THE COMPANY'S NEGLIGENCE.
0,DURING THE DURATION OF THE WORK,THE CLIENT'S 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.
COMPANY9 THE 5 NOT RESPONSIBLE FOR PREEXISTING DEFICIENCIES OR HAZARDOUS MATERIALS THAT MANIFEST THEMSELVES DURING THE CONSTRUCTION PROCESS.E.G.WOOD BUT
MOLDASBESTOS,NAIL POPS,DUCTWORK AND CONNECTIONS,PLUMBING AND VENT PIPES,DECKING DEFLECTION,ETC.IF A PRE-EXISTING DEFICIENCY OF HAZARDOUS MATERIAL 11
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 PROBLEMIS)ON A TIME AND MATERIAL BA515.CLIENT AGREES THAT SUCH CONCLUDES 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 DATE OF COMPLETION MAY DIFFER FROM THAT AGREED UPON,IF
APPLICABLE,UNDER THIS AGREEMENT.
10.THE COMPANY IS NOT RESPONSIBLE,AND THE CLIENT AGREES TO HOLD THE COMPANY HARMLESS,FOR ANY PROBLEMS ANO/OR DAMAGES,INLCUDING BUT NOT LIMITED TO MOM
GROWTH,ARISING FROM THE PERFORMANCE OF AIR SEALING WORK BY THE COMPANY AS A RESULT OF ANY KNOWN OR UNKNOWN MOISTURE CONOIPONS.
11.THE COMPANY 15 NOT RESPONSIBLE FOR AND THE CLIENT AGREES TO HOLD THE COMPANY HARMLESS.FOR ANY PROBLEMS AND/OR DAMAGES 0.ELATNG TO ICE DAMMING THAT MAY
ARISE DURING AND/OR AUER THE PERFORMANCE OF WORK BY THE COMPANY,
12.BEPgCEMEM OF OETERIORATEO 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,ELDER,TRIM,GUTTERS, DOWNSPOUTS, EXISTING SIDING AND
WINDOWS.DOORS,OIL CRIPPLER IN OWVEWAYS,HAIRLINE FRACTURES 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 LAWS IS REQUIRED TO APPLY FOR AND OBTAIN ALL(CONSTRUCTIONRELATEDPERMITS.THE COMPANY SHALL NOT
BE DEEMED RESPONSIBLE FOR DELAYS IN THE WORK DESCRIBED IN THIS AGREEMENT CAUSED BY REGULATORY PERMIT GPAMING OR INSPECTIONAL AGENCIES,AUTHORITIES,OR
INDIVIDUALS.
15.THIS AGREEMENT,INCLUDING THE PROVISIONS RELATING TO PRICE AND PAYMENT SCHEDULE,CANNOT BE CHANGED OR ALTERED EXCEPT BY A WRITTEN STATEMENT SIGNED Al BOTH THE
COMPANY AND THE CLIENT.
16.ANY REPRESENTAPONS,STATEMENTS,OR OTHER COMMUNICATION NOT WRITTEN ON THIS AGREEMENT ARE AGREED TO BE IMMATERIAL AND NOT RELIED ON BY EITHER PARTY,AND DO
NOT SURVIVE THE EXECUTION OF THIS AGREEMENT.
17.THI5 AGREEMENT CANNOT BE CANCELLED WITHOUT UP MUTUAL WRITTEN CONSENT OF BOTH PARTIES EXCEPT AS OTHERWISE SEF FORTH HEREIN.
18 THIS AGREEMENT,AND ANY WARMNESS)PROVIDED HEREUNDER SHALL NOT BE ASSIGNED EXCEPT SY 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 NEW SHALL BE
LIABLE FOR DAMAGES FOR THE GREATER OF THE COMPANMS ACTUAL DAMAGES OR 25%OF THE AGREEMENT FOR RESTOCKING FEE.
30,ANY CHANGES TO MATERIALS BY THE CLIENT BRAND,SME COLOR,ETC)AFTER SAID MATERIAL HAS BEEN DELIVERED OR IS IN ROUTE TO THE CLIENT COULD RESULT IN A 5%RESTOCKING
FEE BASED ON THE COST OF SAID MATERIALS,
21,THIS AGREEMENT SHALL BE EFFECTIVE ONLY UPON ITS EXECUTION BY ALL PAR➢ES HERETO PRIOR TO WHICH TIME IT SHALL BE DEEMED A PROPOSAL.TUE COMPANY RESERVES THE RIGHT
TO REVOKE THIS PROPOSAL 90 DAYS FROM DATE IT IS EXECUTED BY THE COMPANY IF IT IS NOT EARLIER EXECUTED BY THE CLIENT AND THE REQUIRED DOWN PAYMENT REPLIED 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 RIGHT TO REVISE IR PRICE IN
ACCORDANCE WITH ITS CMTS IN EFFECT AT SUCH TI ME.
23.IF ANY PROVISION OF THIS AGREEMENT SHOULD BE HELD TO BE INVALID OR UNENFORCgBLE THE VALIDITY AND ENFORCEBILIN OF THE REMAINING PROVISIONS OF THIS AGREEMENT
SHALL NOT BE AFFECTED THEREBY.
33.ARBITRATION.IN THE FVEM THE CLIENT AND COMPANY HAVE 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 ARBITRATION AS5IPCIATON TO RESOLVE THEIR DISPUTE.
24.ANYOSCWNT,PROMOTION.REIMBURSEMENT,OR OTHER PROGRAM THAT IS PARI OF A STATE SPONSORED UTILITY PROGRAM 11.MASS SAVE' ISSUBJECTTOTHEAVAILABILITYOF
QUALIFYING STATE SPONSORED PROGRAM AND WILL BE SUBJECT TO TERMINATION IF THE STATE SPONSEREO UTILITY PROGRAM IS DISCWMINUED.FURTHERMORE,THE TERMS AND
ONOITONS OF STATE SPONSORED UTLITY PROGRAMS MAY BE ALTERED OR UPDATED PERIODICALLY WITH OR WITHOUT NOTICE.
25.AMERICAN INSTALLERS,LLC IS NOT AN AGENT OF ANY UTILITY COMPANY OF OTHER VENDOR WORKING BY,THROUGH,OR UNDER THE MASS SAVE'ENERGY PROGRAM.
26.CLIENT IS REP50NSIBLE FOR THE PAYMENT OF ANY AND ALL FEDERAL,STATE,OR LOCAL TAXES THAT ARE APPLICABLE 70 THIS AGREEMENT.
The Commonwealth ofMossaehuseas
Department ofIndustrial s nu
Office of Investigations
600 Washington Street
Boston,MA 02111
US www.mass.gov/Via
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name musmess/Orgentrao.who4wowd): American Installations,LLC
Address: 130 College Street, Suite 100
City/State/Zip: South Hadley,MA 01075 - _ Phone tl: 413-552-0200
Are you an employer?Check the appropriate box: Type of project(required):
I.Nx i am a employer with 46 4. ❑ I am a general contractor and 1 6. ❑ New construction
employees(full and/or part-lime).' 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 sub-contractors have 3. ❑ Demolition
working for me in my 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
3.0 1 am a homeowner doing all work right of exemption per MGI. 11.0 Plumbing repairs or additions
myself.(No workers'comp. c. 152,§1(4),and we have no 12.❑ Roof repairs
insurance required.]t employees. [No workers' 13.[Xl Other Insulation --(
comp.insurance required.] --' --" -
"Any applicanl that checks box 91 must also Minn the scln..bdow showing their worken'compensation W le,nrii....on.
t tl.meuwuers whooaxoa nsaffidavit:.thea...ne,oeduln.allworkandnen him eul ide eunaactorsmmlsubmit onew.fiidavih indicating Inch,
:Ctoo.ewm no,Cacek this box must pmebyi an eddin.u.1 shoet showing thu.prat of the sub-c.nlraclors and their workers comp.policy infomnlion.
I am an employer that is providing workers'compemation insurance for my employees. Below is the policy and Job site
informatiml
Insurance Company Name: Guard Insurance Com➢anies -__
Policy N or Self4m. Lic.h:- AMWC897387 Expiration Date: 09/04/2018__
Job Site Address: 2A l7lt.wwryd Cour4 Ciry/State/Zi
p,GtoccVxleat A olfi'1�
Attach a copy of the workers'compensation policy deification page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead W the imposition of criminal penalties ofa
fine up to$1,500.00 and/or one-year imp,6onment,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 of the DIA for insurance coverage verification.
[do hereby cePrtify under the pains sand penahles of periary that the information provided above is true and correct
Sonet/ lu2d/h n.4 Q � _ _____ Darr
Phone p 413-55 -0200
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License k
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.Cityfrown Clerk 4. Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone a:
Commonwealth of Massachusetts Construction Supervisor
®� Division of Professional Licensure Unrestricted-Buildings of any use group Which contain
Board of Building Regulations and Standards less than 36,000 cubic fed(991 cubic meters)of endosed
Construction Supervisor eWet
CS-108178 EXpires:09/29/2019
WESLEY COUm.X E
218 LATHROPSTREEr
SOUTH HAOLEYMA 01076
Fahum b possess•current OMM uIlMe MaSWI1115e11s
Side Bidding Code Is cause for retracted.of Mb acerae.
For Information about tide licanca
Commissioner call(617)7V-32M or visit xv/wmass.gov/dpi
a\ r%�e (I%Cllyllilfll7(!K'fYt��7- C�C���lY.1.SlY-l'llfllf'-ft1
1x Office of Consumer Affairs and Business Regulation
10 Park Plaza - Sufte 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Type: LLC
AMERICAN INSTALLATIONS,LLC. Registration: 175982
130 COLLEGE STREET SURE 100 Expiration: 08/262019
SOUTH HADLEY,MA 01075
Upbls Adtlraae arq Mum card Merkraawnlce eflertga.
SCAT 0 NM-0 11 r'IAd.— l CaoualLEm¢I
Oy1R011 ❑alt Qnrd
M.of Consumer AMin BBufinees Raauleden
tl'I.;L HOMEIMPROVEMENTCONTRACTOR RacletMlon valid for individual use only
TYPE:LLC Isadore Meerpirallon data H ound return b:
Realstralion Excitation Office of Consumer Affairs and Business Reguleilon
175982 08126/2019 topark Naxa-Suka5lm
AMERICAN INSTALLATIONS,LLC. Soslon,MA 02116
WESLEY COUTUREIM
SOUTH ADLEY,MAuEGE TS,ITE 100
SOUTH HAOLEV,MA 01075 Undersecretary t valid without signature
A ® CERTIFICATE OF LIABILITY INSURANCE °"TE'"e°" "'
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 certifcate do"not confer rights to the
certificate holder In lieu of such endorsement(s).
PRODUCER LAME Linda Powers
Webber 6 Grinnell PHONE (413)586-0111aX 1o:I61315B6-6481
6 North Ring Street AUORE 5lpowera@aebberantlgrinnell.Com
INSURERS AFFORDINO COVERAGE NAICp
Northampton MA 01060 _ INSURERABm l0 ers Mutual Casualt
INSURED INSURERS Berkshire Hethawa GUARD Ina. Co.
American Installations, LLC INSVRERC:
Attn: Nes 6 SUraure Couture INRURER O:
130 College Street, Suite 100 InsuaaRE:
South Radley NA 01075 INSURER F:
COVERAGES CERTIFICATE NUMBERidester Earn 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.
IN9X TYPE OF INSIIRAHCE U p04CY NUMBER MOLILY TISM YEXP UNITS
LTR
LOMMERLUILGENEMLIABILTY EACN OCCURRENCE S 1,000,000
A R GLARE
'MAGE
�OOLUR PREMISES Ea occwence S 500,000
SO353521] 9/4/2017 9/1/2019 MED SAE(Any 008 Pennon) $ 10,000
PERSONAL B ATV INJURY S 11000,000
GEN'L AGGREGATE LIMIT APPLIES PER'. GENERAL AGGREGATE E 2x000,000
R POLICY PROi [:]LOL PRODUCTS-OUMPA)P AGO E 2,000,000
EC
OTHER $
AUTOMOBILE UAINUTY EeamE LE LI E 11000,000
A AM,AUTO BODILYINJURV(Pxyeeon) $
AUT.S ED R AUHOSULEp 52353521] 9/4/201] 9/4/2018 WDILYINJURY(PmeaJEenU $
NON DANEO P008WROTV�i AMAGE $
R HIRED AUTOS '4 AUTOS
vIP-Base a R,000
R UMBRELLA UAB OCLVft EACH CCLURRENLE E 1 000 000
A E%CE554AB CLAIMS MAGE AGGREGATE S 1 000 000
DED 'T RETENTIONS 10 °00 1311121 9/4/2017 9/4/2018 b
WORNERS COMPENSATION % STAi iE OERN
AND EMPLOYERS'UA&UT' YIN
ANY
OFFIC FRIMEMBOEREMCLUGEERO CU71VE N(A EL EACH ACCIOEM $ 500 000
8 (ManENwyln NN1 IIDN26°9911 9/4/2017 9/4/2019 E L DISEASE.EA EMPLOYE S 500 000
Ny EaurEO UMee
OE SLRIPTION OF OPERATIONS EeIOw ELOISFASE.POLICV LIMIT $ 500 000
A Commercial Property 573535211 9/4/2017 9/4/2018 dedudeble$1R03
DESCRIPTION OF OPERATIONS I LOLATIONSI VEHICLES(ADDED 101,ApOlNmul RemaM Schedule,maybe MatlN Nmore W6e Is required)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
EVldeuce Of Insurance THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
Kevin Joyce/LMP
01988-2014 ACORD CORPORATION. All rights reserved.
ACORD25(201WOl) The ACORD name and logo are registered marks of ACORD
INS0251x,iaL)