16C-004 (3) 320 SPRING ST BP-2019-0039
GIS#: COMMONWEALTH OF MASSACHUSETTS
MU-.Block: 16C-004 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cateeorv, INSULATION BUILDING PERMIT
Permit# BP-2019-0039
Project# JS-2019-000053
Est Cost: $2228.00
Fee:$65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: AMERICAN INSTALLATIONS LLC 106178
Lot Size(sp. 11): 36285.48 Owner. IURADO KIM I
zoning: URA(100)/WSP(100)/ Applicant: AMERICAN INSTALLATIONS LLC
AT. 320 SPRING ST
ApplieantAddress: Phone: Insurance:
130 COLLEGE ST (413) 552-0200 WC
SOUTH HADLEYMA01075 ISSUED ON.71"0180:00.00
TO PERFORM THE FOLLOWING WORK.-WALL 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 7/9/20180:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
RE CEIVIEU Depadmerd use only,
C of Northampton Status of Permit
B Iding Department Curb CuUDdveway Permit
JUL - 6 2018 12 Main Street SaaerAepticAvagabni y
Room 100 WateiNJeA'AvaAebllity..
ort mpton,MA 01060 Two sets ufswdturtl Plans
DEFT.oP BUILDING 19 }35 7-1240 Fax 413-587-1272 PkWSiEe Piens
NOPTHAMPTON. DIheP:$peclfy
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION t-SITE INFORMATION 60-
1.1
0'1.1 Proo@rhr Address: This section to be/c�ot/9p)J..e ed byal iee
MepLot (/V I_Unit.
320 Spring Street
Zone Overlay District
EIm SLD,Wd - CBDISUW
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Kim )urado 320 Spring Street
Name(PdM) Cumnt MelA Address:
(917) 7�1-9215
See attached Telephone
Slgnsture
22 Authorized Agent
American Installations 130 College St., Ste 100 South Hadley, MA 01075
�Name(P�dM) - Cuent Melling Address:
413-552-0200
SlgroWre TBlephene
SECTION 3-ESTIMATED CONSTRUCTION CO§M
Item Estimated Cost(Dollars)to be Official Use Only
completed bennilapplicant
1. Building 2225.00 (a)Building Permit Fee
2. Elecbical (b)Estimated Total Coat of
Construction from
3. Plumbing Building Permit Fees/
4. Mechanical(HVAC) �J
5.Fre Protection
6. Total= 1 +2+3+4+5) 2225.00 Check Number
This Section For Official Use Only
Bull Permit Number. Date
Issued:
Signal /
Building Corm rlwpeoe r of BU waw new
Section 4. ZONING AU In(orma[bn Must Be Campklt tee.Pe,mCan Be Denied nue Ta lncamplett Worrell.
Existing Proposed Required by Zon�'.00gg
11'n cahpnn m6efandiaby ...
am"Bmg'nep.rgimr
Lot Size
Frontage
Setbacks Front
Side L:= R= L RE�L
Rear r—
Building Height O
Bldg Square Footage �—I %
Open Space Footage r,. % r..
miovs6Ma k Wvpl
Ellfnp r ' S aces kluua®
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:l�
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW O YES O
IF YES: enter Book Page and/or Document#1 !
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: E:=
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: i
E. Will the construction activity disturb(clearing,grading,excavagon,orfliOng)over i acre or Is it pert of a common plan
thataAldaturboverlacre? YES NO O
IF YES,then a Northampton Sturm Water Management Permilfrom the DPN Is required.
SECTION S-DESCRIPTION OF PROPOSED WORK(check all licable)
New House ❑ Addition ❑ I Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors O
Accessory Bldg. ❑ Demolition ❑ New Signs Io1 Decks (CJ Sldtng Q7J Omerllj�
Briefyn Of proposed
Work Wall and basement insulation and air sealing throughout
Alteration of existing bedroom_Vas_No Adding new bedroom Yes No
Attached Nanatne
Plans Atrsched Rall -Shell Renovating unfinished basemen[ _Yes No
6a.If New house and or addition to.e ctstirm housing comolstethe followim
a. Use of bugding:One Family Two Femgy Other
b. Number of rooms in each family unit Number of Bathrooms
G Is there a garage alladmd?
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
I. Method of heating? Fireplaces or Woodstmw Number of each_
g. Energy Comervabon Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
I. Is construction within 100 fL of mUmds?_Yes —No. Is canetmcgon wkhin 100 yr. floodplatn yes_No
J. Depth of basement or cellar floor below finished grade
k. Will building confirm 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 PERMIT
1• as Owner of the subject
property
herebyeuthorize American Installations
to act on my behalf,in all matters relative to work authorized by this bulkflng permit applicator.
See attached
sign wn,aCwmr Data 6/9,9/2018
1, American Installations .as Omer/Authorized
Agent hereby declare that the statements and Infomretion on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed underthe Palms and penalties of perjury.
American Installations
Prim Name
qM �. iin i 6/29/2018
Sign.WneotO�IPganl Date
SECTION 8.CONSTRUCTION SERVICES
81 U nsetl Construction Sunrvisar: Not Applicable ❑
Namaef Usama Notder: Wesley K. Couture 106178
License Number
130 College St., Ste 100 South Hadley, MA 01075 9/29/19
�Address� Expiration Data
1ra1.YXu(!.M U OffT& n�l, 413-552-0200
Slpnelure J Telepbme
8.$eaisteretlHorne Improvement Contractor. - _ Not Applicable ❑
Wesley Couture 175982
Company Name Regishatkm Number
American Installations 6/26/19
Address 5rpirdon Date
130 Coiiege St., Ste 100 South Hadley, MA 01075 Telephone 413-552-0200
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L e.152,§2SC(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application.Failure he provide 0rh affidavit will result
in the denial of the Issuance of the building permit.
Signed Affidavit Attached Yea....... BI No...... ❑
11. -Home Owner Exemution
The current exemption R¢"homeowners"was extended in include Owner-owmoled DwelBoax ofom(1) or two(2)fhmilies
and m aloes such homeowmer m mgage m individual for biro who dace not pmsese a rioense,providd thmthe owaer acts
as suoervlaor.CMR 780, Sixth Edition Section 10835.1.
Definition of Homeowaer:Persue(a)who own a parcel of land on which he/she resides or intends to maids,an which there
is,ur is intended to be,a one or two family dwelling,attached or detached structures accessory to such use and/or farm
structures.A person who constructs more,than one boom In a two ,riffir period shall not be considered a h mama
Such"homeowner'shall submit in the Building Official,an a form acceptable to the Building Official,that befshe shall be
rescousible for all such rk perforined under the bylklium pernalit
As acting Construction Supervisor yourpresence on thejob site will be required from time to time,during and upon
completion of the work for which thispermit is issued.
Aho be advised that with reference to Chapter 152(Workme Compensation) and Chapter 153(Liability ofhmployers to
Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,You may be WMe forperson(S)
you hire to perform work for you under this permit
The undersigned"homeowner"certifies and assuotes respomrbility for compliance with the State Building Code,City of
Northampton Ordinances,State and Local Zoning Lam 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: 20 Cpr I (TA 611ai
The debris will be transported by: hII1=-t-tu44 p �(1 JJ�
The debris will be received by: �( 1\ 1 R„ Q '
Building permit number:
Name of Permit Applicant
Date Signature of Permit Applicant
City of Northampton
.._.
Massachusetts '4�
DBpAAMSM' OF BOIZDSXG INSPS@ZOH3
213 sni 6twet N Capel 6ptldiW `'\ ✓Ot
LQ��It�� apztEuytm, W 01060
Property Address: LQ
Contractor
Name: American Installations
Address: 130 College Street Ste. 100
City, State: South Hadley, MA
Phone: 43-552-0200
Property Owner Kim ,IuYA
Name:
Address: no no f ai
�/1
City, State: 1� IU CDL' L all UL
I, American Installations (contractor)attest and affirm that the building I intend to
insulate does not have any open air(knob and tube)wiring in the spaces to be insulated and that I have
provided the property owner with a copy of this affidavit.
Contractor signature I
Date ��21
—a ren a nl......tioncmm
Inure
MACSL#:
American In61a1taNOFlai MARE'ni' aNw Nll59R2
np[o1Mre 5rrcNsuxe 1005WN WMy MAokO)s .office 31su@00 realm)5524002. Emaa:wPWrrBMn«bnlM4natlonxcam
lurado,Kim 6/27/2018
pM
320 Spring St Florence MA 01062
aw
91]]519215 )uratloldm@gmail.com wu
469268 ron p...o 18-2057
«.m Quantity unit Unit Cost ren Total
Nr5ea0ng
AIR SEALING 2 man hour $ 85.00 $ 170.00
WEATHERSTRIP DOOR&ADD SWEEP 2 each $ 80.00 $ 160.00
Air Sealing $ 330.00
Air Sealing lnaentine $ (330.00)
Air Selaing WK Balance $
Weatherbation
WALLS-WOOD-SIDED4"CELLULOSE 915 lsqft $ 1.95 $ 1,784.25
BASEMENT SILLS-R19 FG BATT 58 soft $ 1.95 $ 113.10
Total Weatherization $ 1,897.35
Weatherization Incentive $ 1,423.01
Total Project $ 2,227.35
Total Utility Contribution $ 1,753.01
Total Customer Contribution $ 474.34
WARRANTY:Area „or
n lmWaun,uC,dll prand, nb .we. an.—ner.ah,2wma^r
,w.rknipw,nann
Ann,—lnualam.. M1amby«.pawnofumlrbal m,lwaland nb.rtocmpinau»,mra...w.leork In arc -mare Wa1.na.We
. .n mm.n.na m,tnrtwlmn..nv.uw..wtw neem.
ACCEPTANCE or PRoposaL:n:e,ame pncee ucednmt--d! TOTAL CONTRAR VALUE= $ 474.34
conditions are ,dlfactc,and are hereby aaepted Youare
aWM1.nutlt.Eow.M1 as spetlfied.p.Ymentwdlbe Vdd.wnpripr Down Payment= $ 150.00 ❑
yoc:Onaf woIX.and balnp'e Em up. Comp m s' pAIO Balance Due Upon Completion= $ 324.36
6/27/)8
Ethan Seaman Ethan Seaman 6/27/18
THIS AGREEMENT IS COMPOSED OF THIS PAGE AND THE REVERSE SIDE OF THIS PAGE AND SHALL BE CONSIDERED THE ENTIRE AGREEMENT BY THE PARTIES INVOLVED.THIS
AGREEMENT 15 BETWEEN AMERICAN INSTALLATIONS,LLC HEREINAFTER REFERRED TOM"COMPANW,AND THE CUSTOMERLS)NAMED ON THE REVERSE SIDE,HEREINAFTER
REFERRED TOM"CUENT",AND WILL BE SUBJECT TO ALL APPROPRIATE LAWS,REGULATIONS AND ORDINANCES OF THE STATE OF MASSACHUSETTS OR CONNECTICUT
RESPECTIVELY,AS WELL MALL LOCAL JURISDICTIONS.
THE FOLLOWING TERMS AND CONDITIONS AM APPLY
1.THIS AGREEMENT 15 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 1/2)PERCENT
PER MONTH. (18%PER ANNUM)WITH A MINIMUM CHARGE OF $2,00 PER MONTH,AND IF PLACED IN THE HANDS OF AN ATTORNEY OR COLLECTION AGENCY FOR
COLLECTION,ALL ATTORNEYS'FEES,EXPENSES AND COSTS OF COLLECTION SHALL BE PAID BY THE CLIENT.IN ADDITION,CLIENT UNDERSTANDS THAT IN FAIUNG TO PAY
ACCORDING TO THE ABOVE TERMS,COMPANY MAY HAVETHE RIGHT TO A LEIN ON THE PROPERTY.
3.THE COMPANY AGREES THAT WHEN DELAYS BECOME KNOWN TO THE COMPANY,THE COMPANY WILLADVISETHE CLIENT AS SOON AS REASONABLE.
0.COMPANY AGREES THAT,NOTWITHSTANDING ANY AGREEMENT FOR MATERIALS AND/OR LABOR BETWEEN COMPANY AND THIRD PARTY,COMPANY 15 RESPONSIBLE TO
CLIENT FOR COMPLETION OF ALL WORK DESCRIBED IN A TIMELYAND 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 WARRANTY 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,PREMIUMSOR COST SHALL BE ADDED TO THE TOTAL AGREEMENT AMOUNT.
].THE COMPANY'S LIABWN FOR CLAIMS ARISING OUT OF THIS AGREEMENT SHALL NOT EXCEED THE TOTAL AGREEMENT PRICE EXCEPT TO THE EXTENT THOSE DAMAGES ARE
PROVEN TO BE SOLIS DUE TO THE COMPANY'S NEGLIGENCE,
8. 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.
9.THE COMPANY IS NOT RESPONSIBLE FOR PREEXISTING DEFICIENCIES OR HAZARDOUS MATERIALS THAT MANIFEST THEMSELVES DURING THE CONSTRUCTION PROCESS E.G.
WOOD ROT, MOLD,ASBESTOS,NAIL POPS,DUCTWORK AND CONNECTIONS, PLUMBING AND VENT PIPES,DECKING DEFLECTION,ETC.IF A PRE-EXISTING DEFICIENCY OR
HAZARDOUS MATERIAL IS ENCOUNTERED PRIOR TO OR DURING CONSTRUCTION,AND COMPANY 15 NOTIFIED IN WRITING,COMPANY WILL TRV TO ASSIST CLIENT WITHIN
THE COMPANY'S MEANS AND CAPABILITIES TO CORRECT THE PROBLEM(5)ON A TIME AND MATERIAL BASIS.CLIENT 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
DATE OF COMPLETION MAY DIFFER FROM THAT AGREED UPON,IF APPLICABLE,UNDER THIS AGREEMENT.
30,THE COMPANY 15 NOT RESPONSIBLE,AND THE CLIENT AGREES TO HOLD THE COMPANY HARMLESS,FOR ANY PROBLEMS AND/OR DAMAGES,MOLDING BUT NOT LIMITED
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 FOR,AND THE CLIENT AGREES TO HOLD THE COMPANY HARMLESS,FOR ANY PROBLEMS ANO/OR DAMAGES RELATING TO ICE DAMMING
THAT MAY ARISE DURING AND/OR AFTER THE PERFORMANCE OF WORK BY THE COMPANY.
12. REPLACEMENT OF DETERIORATED DECKING, FASCIA BOARDS, ROOF JACKS, VENTILATORS, FLASHING, RAFTERS, JOISTS, INSULATION OR OTHER MATERIALS ARE NOT
INCLUDED UNLESS OTHERWISE NOTED HEREIN.
13.THE COMPANY WILL NOT BE RESPONSIBLE FOR THE SCRATCHING OR DENTING OF INTERIOR WALLS AND CEILINGS,FLOORS,TRIM,GOITERS,DOWNSPOUTS,EXISTING SIDING
AND WINDOWS,DOORS,OIL DROPLETS IN DRIVEWAYS,HAIRUNE 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 COMPANYS EXPENSE.
16.THE COMPANY UNDER PROVISIONS OF CHAPTER 1E2A OF THE GENERAL LAWS IS REQUIRED TO APPLY FOR AND OBTAIN ALL CONSTRUCTION-RELATED 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,THIS AGREEMENT, INCLUDING THE PROVISIONS RELATING TO PRICE AND PAYMENT SCHEDULE,CANNOT BE CHANGED OR ALTERED EXCEPT BY A WRITTEN STATEMENT
SIGNED BY BOTH THE COMPANY AND THE CLIENT.
16.ANY REPRESENTATIONS,STATEMENTS,OR OTHER COMMUNICATION NOT 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.
ST.THIS AGREEMENT CANNOT BE CANCELLED WITHOUT THE MUTUAL WRITTEN CONSENT OF BOTH PARTIES EXCEPT AS OTHERWISE SET FORTH HEREIN.
18,THIS AGREEMENT,AND ANY WARRANTY(S)PROVIDED HEREUNDER SHALL NOT BE ASSIGNED EXCEPT BY OR WITH THE WRITTEN PERMISSION OF THE COMPANY.
19.IF THE CLIENT RMS TO PERFORM ITS OBLIGATIONS HEREUNDER OR TERMINATES THIS AGREEMENT WITHOUT THE PRIOR WR17EN 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 CLIENT(BRAND,STYLE.COLOR,ETC.)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 SAID MATERIALS.
21.THIS AGREEMENT SHALL BE EFFECTIVE ONLY UPON ITS EXECUTION BY ALL PARTIES HERETO,PRIOR TO WHICH TIME IT SHALL BE DEEMED A PROROML THE COMPANY
RESERVES THE RIGHT TO REVOKE THIS PROPOSAL 90 DAYS FROM DATE IT IS EXECUTED BY THE COMPANY IF 1115 NOT EARLIER EXECUTED BY THE CLIENT AND THE REQUIRED
DOWN PAYMENT RECEIVED PRIOR TO THE EXPIRATION OF SUCH 90 DAY PERIOD;AFTER 90 DAYS, AND IN THE EVENT COMPANY DOES NOT REVOKE THE PROPOML,
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 HEIR TO BE INVALID OR UNENFORCABLE,THE VALIDITY AND ENFORCOULITY 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 ARBITRATION
ASSOCIATION TO RESOLVE THEIR DISPUTE.
2E.ANY DISCOUNT, PROMOTION,REIMBURSEMENT, OR OTHER PROGRAM THAT 15 PART OF A STATE SPONSERED UTILITY PROGRAM (I.E.MASS SAVE')IS SUBJECT TO THE
AVAILABILITY OF QUALIFYING STATE SPONSORED PROGRAM AND WILL BE SUBJECT TO TERMINATION IF THE STATE SPONSERED UTILITY PROGRAM IS DISCOUNTINUED.
FURTHERMORE,THE TERMS AND CONDITIONS OF STATE SPONSERED UTILITY 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 15 PERSONS BLE FOR THE PAYMENT OF ANY AND ALL FEDERAL,STATE,OR LOCAL TAXES THAT ARE APPLICABLE TO THIS AGREEMENT.
The Commonwealth of Massuchasetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 01111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/ElectriciansfPlumbers
Applicant information Please Print Le®blv
Name Maxonco/OriesmatlomindMilitulh American Installations,LLC
Address: 130 College Street,Suite 100
City/State/Zip: South Hadley,MA 01075 Phone k: 413-552-0200
Are you an employer?Check the appropriate box: Type ofproject(required):
1.2 I am o emplover with 46 _ 4. ❑ I am a general contractor and 1 6. ❑ New construction
employees(full and/or part-time).` have hired the subcontractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.1 7. ❑ Remodeling
ship and have no employees These sub-contrrarms have 8. ❑ Demolition
working for me in any capacity. workers'comp.insurance. 9. ❑ Building addition
[No workers'camp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their l I0.❑ EleeVical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL I Qj Plumbing repairs in additions
myself [No workers'comp. c. 152,§1(4),and we have no 12.❑ Roof repairs
insurance required. t employees. [No workers' 13.[NOther n
comp.insurance required.] Insulation _
'Any appiiwnt Ilial clicks box gl must ale.lit.11W semiun It..sh.wing Their w.rken com,nestion pu11cy inf.mWion.
tIWrrwwwre wbo wbmitrbh amdavii imlicabig thcY.reduing all w.rk asd then hire.msid.ctwuxa irs marl sobmilonm allidavil indieusing such.
Co.lnm.rs Not chuck ihn bon mal attached an edd,owna sheet showing the same of the wt-commuton and their.4rx'com,poti y information.
I am an employer that is providing workers'compensation Insurance far my employees Below is the polity audlob site
information.
Insurance Company Name: Guard Insurance Companies _
Policy 4 or Self-ins. Lie.li: pAM�W�C�8�9y738,77 n� _ Expiration Date: 09/04r//2�018 y�
Job Site Address: o )f./I II Ill CCI1 A.tA Cityistawzip:EIQCPIR�NUQ_
Attach 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 oferiminal penalties ofa
line up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the Oulator. Be advised that a copy ofthis statement may be forwarded to the Office of
Investigations ofthe DIA for insurance coverage veri0cation.
I do hereby ceerdt,under the pains an/1d penalties of perjury that the information provided
'above
is true and correct.
Signature- �Lr!/h.n1 Q_ ( .H-(l� Date:
Phone d: 61 413-5510200
OJflclal use only. On not write in this area,to be completed by city or town offeiaL
City or Town: PermlttLicease h
Issuing Authority(circle one):
1. Board of health 2.Building Department 3.City?own Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone a:
Camnnwealth of Massachusetts Construe Sup�
®; Division of Professional Licensure Unrestricted-Wildslps starry use grout wt Sol contain
Board of Building Regulations and Standards Ins ted 35,000 cone feet(901 CUBIC maers)of enclosed
Construction Supervisor +pece-
CS-108178 Expires:08/292019 -
WESLEY COIfr11RE
210 LATIeTOveTREET
SOUTH FUUX EY MA 01075
Fallon to posses a coarsed edition oil Oar Massachusetts
state Building Coda is carp oar revocation oftho assess.
Far InbmMfbn shod Bis Seale
Commissioner Cal(517)727-3200arisew jnasa mfdpl
r%�P- �C1JYtlllOXtltf'-CZ�I� 4��C�/!/GICJJIY,('�ll.1P�1i' Office of Consumer Affairs and Business Regulation
10 Park Plaza- Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Type: LLC
Registration: 175982
AMERICAN INSTALLATIONS,I.I.C. E>ibiratlom 0828/2019
130 COLLEGE STREET SUITE 100
SOUTH HADLEY,MA 01075
Update Address and varum card. Mart runn for change.
S Al O =O 541
rl AdrL,.._ rl ❑Emptoytnetlt ❑!d•t Cnrd
- //, f.nnn.
_. \
HOME
L },' HOME INFROVEMENTCONTRACTOR Registration the parecon e. ofl found
only
ny1 ..t TYPE:LLC Oxon taronsumer data Sbundvarum e
Facirefion OMCstit ConsumerAffairsanti Business Regulation
1]5082 05!20@019 Ill ParkRm-9uhe 5170
AMERICAN INSTALLATIONS,LLC. Bowdon,MA 0211d
130 LEYCOL COUEGE SIRE
SO COLLEGE STREET SUITE 100 (valid wlth0ut signature
SOUTH HADLEV,MA 01015 Undersecretary 9
ACORba CERTIFICATE OF LIABILITY INSURANCE oA E(MMoa YI
9/14/2017
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 endoreemengs).
PRODUCER MART Linda POW0r9
Nehber 6 Grinnell PNONE (413)556-0111 Par X0:11131586-6481
8 North Sing StreetA UPREg3.lpowers@.eb .randgrinnel1.0.
INSURE 5 AFFORDING COVERAGE NAIOX
Northampton MA 01060 INSUMERAZeElOyerS Mutual Casualty
INSURED INSURERBHerkshire BathaNa GDAND IRS. CO.
A00rican Installations, LLC INSURERC:
Atte: Was 6 Susanna COUtGuB INSURERD:
130 College Street, Suite 100 INSURER E:
South Hadley lA 01075 1 INSURER F:
COVERAGES CERTIFICATE NUMBERddaeter 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 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 MAY HAVE BEEN REDUCED BY PAID CLAIMS.
Lm IHSR rypE OFINSURANLE ATLjSURR PoIICY NUMBER M 0 YEFF MP LICY FXP Lear.
COMMERCMLOENEMLUABROY FACH OCCURRENCE $ 11000,000
A R CLAIMSS MADE OCCUR PREMISESEd. S 500,000
503535211 9/./2010 9/4/2018 MED EAP(Any One(arson) 1 10,000
PERSONAL S AOV INJURY S 11000,000
GEN L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE E 2,000,000
A POLICY PRP ❑LOC PRODUCT$.COMPACT AGO S 21000,000
ECT
OTHER' 1
'70AUTOMOBILE LIAMLIry Eo em4Ea0i1 SINGLE LIMITS 11000,000
A A.AUTO
BODILY INJURY(Per(.nleon) E
ALLORNEO SCHEDULED
AUTOS X AUTOS 523535217 9/4/2017 9/4/2018 e001LV INJURY(PelwEenn E
NON0%MED PROPERTY DAMAGE E
A MIRED AlR05 '4 AUTOS Lne,a.Ynn
PIGUM- E 8,000
R UMBRELLA Lum OCCUR FACH OCCURRENCE E 11000,000
A EXCESS JAB CLAIMSfAPDE AGGREGATE E 11000,000
DED I 8 I GETENTIONI 10 000 5J3535217 9/</20P1 9/1/2018 E
NORXERSCOMPENSADONOTH.
AND EMPLOYERS'UABRI Y x STATUTE ER
ANY PRRMEMBEREXCWOERO EWTIVE YO NAA E L.EACH ACCIDENT S 500,000
OFFB IMandaury M Nm RAMC"MY 9/4/2017 9/4/2018 EL DISEASE-EA EMPLOYE S 500,000
Nye dexnW UMs
OESIJR IPNONOFWEREONNtd- E.L DISEASE.POLICY LIMIT 1 500000
A COumarcial Property SA3535217 9/1/2017 9/4/2018 dal—DA$1,no
DESCMPMNOFOPERATONSILOCAMNSIVEHICLES (ACOROSDLAddNIODal Rema1MSchMulamry La MlachedNmmeyam Mn .il d)
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.
AUTHORI2FD REPRESENTATIVE
Kevin Joyce/LMP
®1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD Dome and logo are registered marks of ACORD
INSD26x+wn