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24D-020
8 LAWN AVE BP-2019-0066 CIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:24D-020 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Cateaorv: INSULATION BUILDING PERMIT Permit# BP-2019-0066 Proiect# JS-2019-000100 Est.Cost $3849.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: AMERICAN INSTALLATIONS LLC 106178 Lot Size(sq.ft.): 8799.12 Owner. DENNIS ELISE C Zoning, URB(100)/ Applicant. AMERICAN INSTALLATIONS LLC AT. 8 LAWN AVE ApplicantAddress: Phone: Insurance: 130 COLLEGE ST (413) 552-0200 WC SOUTH HADLEYMA01075 ISSUED ON.711612018 0:00:00 TO PERFORM THE FOLLOWING WORK.ATfIC, 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 Occupancy Signature: FeeTyoe: Date Paid: Amount: Building 7/16/2018 0:00:00 $65.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner ::p, uL� 0 � ___ .TED ,Department use only City No ampton Status of Permit I JUL 1 3 20�rildi D partment Cutb CuODdvewayPermit. 21 Mai Street Sewer/SepticawdlaNtity !1� EGTI 100 WaterlWe3Aw,3eMlity.. 1FTT aFrun DiNcl PEC MA 01060 NORTHAMPTON. Two Seta OfStrudmra(Plara p one 413567-1240 Fax 413-567-1272 Pkimoe-Pians ODmrSPedfy APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR/TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be completed by office Map Lot Q 11Mt. 8 Lawn Avenue Zone Overlay District EIm at mswd CS olsbict SECTION 2-PROPERTY OWNERSHIPIAUTHORQED AGFM 2.1 Owner of Repots: Elise Dennis 8 Lawn Avenue Name (PM) Co(171— 3) 8 6Ad7d See attached Telephone 89 Signature 2.2 Authorized Apert: American Installations 130 College St., Ste 100 South Hadley,MA 01075 Hams(Fna) Comm McTlp Address: IL. . CGIAX _-I 413-552-0200 knabnre .� Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only cam teed by pennit applicant 1. Building 3849.00 (a)Building Permit Fee 2- Electrical (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Penult Fee 11 4. Mechanical(WAC) f 5.Fire Protection 6. Total=it +2f 3+4+5 3849.00 Check Number a This Section For ORisial Use Only Building Permit Nu mbe Date Issued: Signe e: onemmpaclordffupdngs Date Section 4. ZONING All Information Must Be Completed.Pamir Can Be Denied;Due To Inro(nPlele lofortnatba. Existing Proposed Required by Zoning tads coWmn m be failed in by Building DVatnmt Lot Sin —� --, Frontw SetbacksrF o Q O Side L:=R:= L:= RCI Rear Building Height Bldg.Square Footage �J O % C� Open Space Footage L� % L r— (Lotamminmbldg&paved 0 #ofFarking Spaces J G Fill: Ii ----- v Ieee` :Lowdw A. Has a Special PermittVariance/Finding ever been issued for/on the site? NO O DONT KNOW O YES Q IF YES,date issued 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 DocumentSF! 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: i E. Wil the constructlon ecti tydisanb(clearing,grading,excavation,milling)over 1 acre or Is it pan of a common plan that will disturb over 1 acre? YES O NO O IF YES,then a Northampton Storm Water Management Penft*om the DPW is required. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ I Replacement Windows Alteration(s) ❑ Rooting Elor Doors O Accessory Bldg. ❑ Demolition ❑ New Signs IO] Decks IO Sldirgii Other[ft Bdef Desuiptlon Prop�ad Work Athc wa�l and basemen[ insulation and air sealing throughout Aftmm% noferisIJngbedmom_Yes_No Addkgrmwbadmom_Yes No Attached Narrative Renovating unfinished basemerd Yes No Plans Attacher!Roll -Sheet 6a.If New and or addition to existing housing- Complete the following: a. Use of building:One Famili Two FamOy Other b. Number of moms in each family ung: Number of Bathrooms Q Is there a garage attached? d. Proposed Square footage of raw consimction. Dimensions e. Numberofstories? I. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction I. Is construction within 1008 of wetlands? Yes _No. Isconstructionwitldn100yr. floodplain_Yes_No J. Depth of basement a calm floor below finished grade k. Will building conform to the Building and Zoning regulations? _Yes_No. 1. Septic Tank_ City Sewer_ Pdvate well_ City ureter Supply SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, as Owner of the subject property hereby authorize American Installations o act on my behalf,in ail mallere reI a to wmk authorized by this building permit application. See attached 7/6/2018 Signsenearownsr Dale I, American Installations as Owner/Authorized Agent hereby declare that the statements and Information on the foregoing application are We and accurate,to the best of my knowledge and belief. Signed under the palms and penalties of perjury. American Installations Print Name � — 7/6/2018 w nrn LAA , SfgnaWeof rlAgem Date SECTION 8-CONSTRUCTION SERVICES e1 Licensed Cnstruction Supervisor. Not Applicable 17 Name of Lleeme Noma , WesleyK. Couture 106178 Lioeme Number 130 College St., Ste 100 South Hadley,MA 01075 9129119 Mdress Expiration dale �Kda.Aks. 1L Cry 413-552-0200 Signature Telephone 9.Registered Home lmoromementConiractor.. _ _ - Not Applicable ❑ Wesley Couture 175982 Comeam Name Registration Number American Installations 6126119 Address Expiratlon Date 130 College St., Ste 100 South Radley, MA 01075 Telephone 413-552-0200 SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c.152,$26C(8)) Workers Comperreation Insurance affidavit must be completed and submitted with this application.Failure to provide this affidavit will resuit In the dental of the Issuance of the building permil. Affidavit Attached Yes....... 0 No..._. ❑ 11. Home Owner E%emI)tAOII The current exemption fv"homeownvs"was extended to mchme Owav-oeatoted Dweiliner ofone(1) or two(2)Doilies and wallow such homeowner to engage an individual forbire who does not possess a license,provided that the ownv sets as supervisor.CMR 780 SkM Edition Section 108351 Definition offome erav:Penson(s)who ownaparcel ofland onwhich he/sheresides orintends mreside,onwhich Mere is,or is intended to be,a one or two family dwelling,attached or detached stmehuas accessory to such um rad/or fern struamrea.A person who Constructs mom than one home In a two-vear period shall not be considered a boannownear, Such"homeowner'shall mbndt to the Building Official,on a form acceptable to the Building OHmiaL thathdahe shall be rem naRude for W meh wok serf edunderthbnBdine erIDfL As acting Construction Saoeryimr your presence on thejob site will be required from time to than,timing and upon completion ofthe work for which this permit is Issued. Also be advised that with nefeaeaa to Chapter 152(Workers'Compepmtion) and Chapter 153(IbbilityefEmphryrn to Bmployces for injuries not resulting in Death)ofthe Massachusetts Genead Laws Amotated,ease maybeBable forperson(s) you hire to perksma watt for you under this pumiL The undensigncd"homeowner'oer ifies and assumes rmpomibility for compliance with the State Building Code,City of Northampton Ordinances,State and Local Zoning Laws and State ofMassachuset s General Laws Anaoteted see attached HomeownerSignature 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. 8 Lawn Avenue Address of the work: American Installations The debris will be transported by: The debris will be received by: Waste Management of New England Building permit number: Elise Dennis Name of Permit Applicant 7/6/2018 Date Signature of Permit Applicant City of Northampton Massachusetts Yi LEPAROWUM or aUIwD IRSPECIZOlr3 2`v, F 212 wie gtw6t • I iaipal suila nq �.VECs '—thw t.' W. 01060 '�I• 8 Lawn Avenue Property Address: Contractor Name: American Installations Address: 130 College Street Ste. 100 City, State: South Hadley, MA Phone: 43-552-0200 Property Owner Elise Dennis Name: Address: 8 Lawn Avenue City, State: Northampton, MA 01060 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 Date � I ll 14' mass save r°eealnPrrea • PARTNER MA rs a:1.,. , ""`°"`rOfpnO j/asu American Installations Psanu-Americanlnstallacons.com 130 CtlkR5bM SuaelDlsMA. .01 Omrc:that Kr'as ...W31 RL0}CE Fmek ruppenQNnntaxnfM4tlanarbm Customer Name:Elise Dennis Email:Not provided Phone:413-8967714 Premise Address;8 Lawn Ave,Northampton.MA 01060 Project 10:3432628 Date:July 2,2018 Job Description "*,w«xca2l." :.46k. tiWT,r. Air Sealing at Estimated 62.5 CFM50 Per Hour 8 hr $740.64 $0.00 Door Sweep (with AS his) 5 each $126.55 $0.00 Exterior Door Weather Stripping (with AS his) 5 each $150.35 $0.00 Insulation Removal 82 SF $103.32 $103.32 Rim Joist- 6" Fiberglass Batting 124 SF $334.80 $83.70 Hatch-2"Thermal Barrier Polyiso 1 each $46.28 $11.57 Damming 18 each $43.02 $10.76 Kneewall Wall - 2"Thermal Barrier Polyiso 255 SF $1,218.90 $304.72 Door-2" Thermal Barrier Polyiso 1 each $90.44 $22.61 Attic Floor-4" Open Blow Cellulose 672 SF $994.56 $248.64 Project Total $3,848.86 Weatherization incentive ($2,046.00) Air sealing incentive ($1,017.54) Total Program Incentive -$3,063.54 Customer Total $785.32 wAsswr V'.Arreman 1-tNt -A.LLC.1 proIt.MeIs—InM.M—M wM1Aa t yen rwrknembq wa'I'l ...M1`---Mr LLC MMPMpMP Y3 Dr-.AMI—...Mars m[omplttPm,aWve s[epe o1 vcrA in a[[or Wn[e W tl,:beaLort fpnitkamniartlxl IUM anE stare Lu leire rryJalion b Me:oM C V XrM vara`ai mIN reran. .11FT.nce o1 1M..c rl< alve pri[q aPenn[xipm ane MAdA-1 .r rorALCCWw VALUE- s 785.32 vtiarufpraM ne nnMva[[Mea vW area,Rl,uircetoaowuA.v:[e[ifiee.=avment mrm PA,—.-1 75000 El fleck we PM t/3 D"primtoox[!wan.'MaMawMeme Low Gmpleeon. PAN gs—nMMuponcIMga bn- 5 53S 12 seMn nopergoa—lP,Mt Elise Dennis son; (/��QV✓y/-°"^s oxe 7-2-IS aepre:enurlegPnM1 B.Zamer 7-2-I8 THIS AGREEMENT 15 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 REFERRED TO AS"COMPANY',AND THE CUSTOMERS)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 CONDIT ONS A60 APPLY 1. THIS AGREEMENT IS SUBJECT TO THE APPROVAL OF A MANAGER OF THE COMPANY FOO THIS AGREEMENT TO BE EFFECTIVE UNDER AHY CONDITION. E. SHOULD DEFAULT BE MADE IN THE PAYMENT OF THIS AGREEMENT,CHARGES SHALL BE ADDED FROM TH E DATE THEREOF AT A RATE OF ONE AND ONE-HALF IT 1/2) PERCENT PEP MONTH p8%PER ANNUM)WITH A MINIMUM CHARGE OF EOM PER MONTH,AND IF PLACED IN THE HANDS OF AN ATTORNEY OR COLLECTION AGENCY FOR COLLECTION,ALL AIIORNEYY FEES,EXPENSES AND COSTS OF COLLECTION SHALL BE PAID BY THE CLIENT. IN ADOTION,CLIENT UNDERSTANDS THAT IN FAILING TO PAY ACCORDING 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 WI LL ADVISE THE CLIENT AS SOON AS REASONABLE 0. COMPANY AGREES THAT,NOPNITHSTANDING ANY AGREEMENT FOR MATERIALS AND/OR LABOR BETWEEN COMPANY AND THIRD PARTY 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 OY THE MANUFACTURERS OF SUCH EQUIPMENT AND PRODUCTS. UNDER SUCH MANUFACTURERS WARRANTIES,THE CLIENT MPV BE REQUIRED TO REGISTER OR MAIL IN A WARRANTY CARD OR OTHER EVIDENCE OF OWNERSHIP AND USE OF SUCH EQUIPMENT AND/OR PRODUCES IN ORDER TO ACTIVATE SUCH WARRANTIES 6. THE QUOTATION ON THE PAGE HEREOF WES 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 ADDED TO THE TOTAL AGREEMENT AMOUNT. 7. THE COMPANY$UABILITY FOR CLAIMSARISING OUT OF THIS AGREEMENT SHALL NOT EXCEED THE TOTAL AGREEMENT PRICE EXCEPT TO THE EXTENT THOSE DAMAGES ARE PROVEN TO BE SOUPY DUE TO THE COMPANY'S NEGLIGENCE. B. WRING 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 HAIARWUS MATERIALS THAT MANIFEST THEMSELVES DURING THE CONSTRUCTION PROCESS, EG.WOOD ROT,MOL,ASBESTOS,NAIL POPS,DUCTWORKAND CONNECTIONS,PLUMBING AND VENT PIPES,DECKING DEFLECTION,ETC.IFA PRE-EXISTING DEFICIENCY OR HAZARDOUS MATERIAL IS ENCOUNTERED PRIOR TO OR DURING CONSTRUCTION,AND COMPANY IS HOMED IN WRITING,COMPANY WILL TRY TO ASSIST CLIENT WITHIN THE COMPANES MEANS AND CAPABILITIES TO CORRECT THE PROBLEMS 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 COMMONS TIE DURATION OF THE WORK AND SCHEDULED DATE OF COMPLETION MAY DIFFER FROM THAT AGREED UPON,IF APPLICABLE,UNDER THIS AGREEMENT. I0. THE COMPANY 6 NOT RESPONSIBLE,AND THE CLIENT AGREES TO HOLD TIE COMPANY HARMLESS,FOR MY PROBLEMS PND/OR DAMAGES,INLCUDING BUT NOT LIMITED TO MOLD GROWN,ARISING FROM THE PERFORMANCE OF AIR SEAUNG WORK BY THE COMPANY AS A RESULT OF ANY KNOWN OR UNKNOWN MOISTURE CONDITIONS. ]l. THE COMPANY IS NOT RESPONSIBLE FOR,AND THE CLIENT AGREES TO HOLD THE COMPANY HARMLESS,FOR ANY PROBLEMS AND/OR DAMAGES RELATING TO ICE DAMMING THAT MAY ARISE DURING AND/OR AFTER FEE PERFORMANCE OF WORK BY THE COMPANY. 13, REPLACEMENT OF DETERIORATED DECKING,FASCIA WARDS,ROOF JACKS,VENTILATORS,FLASHING,RAFTERS,JOISTS,INSULATION OR OTHER MATERIALS ARE NOT INCLUDED UNLESS OTHERWISE NOTED HEREIN, 13. THE COMPANY WILE NOT BE RESPONSIBLE FOR THE SCRATCHI NO OR DENTING OF INTERIOR WALLS AND CENNGS,FLOORS,TRIM,GUTTERS,DOWNSPOUTS,EXISTING SIMNG AND WINDOWS,CONS,OIL DROPLETS IN DRIVEWAYS,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 COMPANYS EXPENSE. EX THE COMPANY UNDER PROVISIONS OF CHAPTER 102A OFTHE GENERAL LAWS IS REQUIRED TO APPLY FOR AND OBTAIN ALL CONSTRUCTION-RELATED PERMITS. THE COMPANY SHALL TOT 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 HEATING TO PRICE AND PAYMENT SCHEDULE,CANNOT BE CHANGED OR ALTERED EXCEPTOY A WRITTEN STATEMENT SIGNED BY BOTH THE COMPANY AND LEE CLIENT. 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 DO NOT SURVIVE THE EXECUTION OF THIS AGREEMENT. 17. THIS AGREEMENT CANNOT BE CANCELLED WITHOUT THE MUTUAL WRITTEN CONSENT OF BOM PARTIES EXCEPT AS OTHERWISE SET FORTH HEREIN. 18. THIS AGREEMENT,AND ANY WARRANTpS)PROVIDED HEREUNDER SHALL NOT BE ASSIGNED EXCEPT BY OR WEN 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 ZS%OF THE AGREEMENT FOR RESTOCKING FEE. 30, 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. Zl, THIS AGREEMENT SHALL BE EFFECTNE 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 90 DAYS FROM DAZE IT IS 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 ED 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. 71. IF ANY PROVISION OF THIS AGREEMENT SHOULD BE HELD TO BE INVALID OR UNENFORCABLE,ME"LID"AND ENFORCESILIEW OF THE REMAINING PROVISIONS OF THIS AGREEMENT SHALL NOT BE AFFECTED THEREBY. 33. ARBITRATION:IN THE EVENT THE CLIENT AND COMPANY HAVE A DISPUTE REGARDI NO ANY OF THE PEEVES 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, 36. ANY DISCOUNT,PROMOTION,REIMBURSEMENT.OR OTHER PROGRAM THAT IS PART OF A STATE SPONSEREO UTILITY PROGRAM U.E.MASS SAVE')IS SUBJECT TO THE AVAILABILITY OF QUALIFYING STATE ENGINEERED PROGRAM AND WILL BE SUBJECT TO TERMINATION IF THE STATE SPONSERED UOUtt PROGRAM IS DISCOUNTINUED. FURTHERMORE,THE TERMS AND CONDITIONS OF STAN SPONSEREO UTILITY PROGRAM MAY BE ALTERED OR RELATED 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 LIVE'ENERGY PROGRAM. 26. CLIENT IS REPSONSIBLE FOR THE PAYMENTOF ANY ANDALL FEDERAL,STATE,OR LOCALTAXES MATARE APPLICABLE TO THISAGREEMENT The Commonweafth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 01111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le 'bl Name 0fuslmsslorgani.atintt/Individual: American Installations,LLC Address: 130 College Street,Suite 100 City/State/Zip: South Hadley,MA 01075 Phone 4: 413-552-0200 Are you as employer?Check the appropriate box: Type of project(required): LE I am a employer with 46 4. ❑ I am a genera)contractor and 1 6. [] New construction employees (full and/or pan-time).° have hired the sub-contractors 2.❑ 1 am a sole proprietor or purmer- listed on the attached sheet.t 7. ❑ Remodeling ship and have no employees These subcontractors have 8. ❑ Demolition working for me in any capacity. workers'comp.insurance. g. ❑ Building addition [No workers'comp, insurance 5. ❑ We are a corporation and its required.] officers have exercised their I0.❑ Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL I L❑ Plumbing repairs or additions myself [No workers'comp. c. 152.§1(4),and we have no 12.❑ Roof repairs insurance required.]t employees. [No workers' 13.©Other Insulation comp. insurance required.] - - -- 'Any applicant al l akekr box#1 moa also fill ML the u uw plow showing theh workersmmpemation policy information. t lomeowmra whooubmit this amdwil uWicming theyore data,all work mk Nen hire tomidecantrsavamust submit otrw amdia,u undwatin,such. �Cnwancto x Nm chime this Lox must unclad an additional sheet showing Ne tame.fila a st,-mnstun and than worlixtt'camp.pati Y Ioformatinn. I am an employer that is providing workers'eompemardan ltrsurance for my employees. Below is the policy sundials site information. Insurance Company Name: Guard Insurance Companies- __ _ __ Policy#or Self-ins. Lie.#: AM�/WC897387 Expiration Date: 09/04/2018_ Job Site Address:iS Lawn n RV (t City/State/Zip:NM bo M I MA Attack 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 ofa line up to$1,50U.00 and/or one-year imprisonment,as well as civil penalties in the form ofa STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. l da hereh,eenii under tine pains mud penal[tiess of perjury that the information provided above is true and correct Sim.ature, �1.u2j�l� .(_"_.fXA�C(/2A� Date: _ .. done#. / '/ 413-552//0200 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): I. Board of Health 2. Building Department 3.Cityfrown Clerk 4. Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: ®, Cormronwsaah of Massachusetts Conbuction Supervisor Division of Professional Lkensurs Unwariblialed-Buildings dant lql aoupwhl.h Caaain Board of Building Regulations and Standards bstM 96,000.Rhic feel(8011 elebia meters)denobsed Construction Supervisor syvee. CS-1DS178 ESpires:09/29/2019 - WESLEY COUTURE 218 LATHROP'BTREET n�1 SOUTH HADLEYMA 01075 FSBwe b possess errant WWon dike MsssachueBa BtsM Ball"Cads issues for revocation dtlis Berme. n Par lnkurm lsn.tori a"Bearq Cornmissloner Casalln 727.3200 or vbll tvwwmsss9aMpl rt111n ((aryr�yrnxtanrrlf� afJ( iUCnJ1�r��t�fe( 1 x =' Office of Consumer Affairs and Business Regulation 10 Park Plaza- Suite 5170 Boston, Massachusetts 02115 Home Improvement Contractor Registration Type: LLC 175982 AMERICAN INSTALLATIONS,LLC. �90r�pn6/26 130 COLLEGE STREET SUITE 100 6Tiredon: 008/2612019 SOUTH HADLEY,MA 01075 Update Addraeendr.lum.erd. Markrayonfor.hang.. SCA1 O k ML5/11 rl AJ.L-n- I]Rantn=' M Empleymnnf 113 I pet Cr ld N /�, 1 rnup•nuw/�/�,�' rl/iym�nJr'//i "', Oe keel Comair M.hea Rpalatlon MOMEIMPFIOVEMEHTCONTRCONTRAGTOR Recon, hknvtldfa lydMduo found ref y TYPE:LLC Offer.if Cons Marr fMr. Ifafd Business to: D 06126=19 OMaicConwmx 5170 mtl BUYnns RpWaflon \ 173982 08/28/2019 10 Perk Plm-Suaa 81]0 AMERICAN INSTALLATIONS,LLC. Baton,MA 02118 WESLEY COUTURE 130 COLLEGE STREET SUITE IM SOUTH HADLEY,MA 01075 Undersecretary 11t valid without signature AC00 a CERTIFICATE OF LIABILITY INSURANCE 8TE/14/201 T' 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($), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate hold.,Is an ADDITIONAL INSURED,the policy(ies)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 clu ficate holder In)leu of such endomement(s). PROWLERMTF T NAME. dLina POerars Webhen 6 GIinnell PRONE , (.413)586-0111 P No:p1315e6-6ea1 8 North Sing Street n ueiss:)powers@webberandgrinnell.oom INSURERS AFFORDING COVERAGE xAlcr Northaapton MA 01060 INSURESALa lO ere Mutual Casualty INSURED INSURER B Berkshire Hathaway GUARD Ins. Co. Aaerican Installations, LLC INSURER C: Attn: Wes 6 Suzanne Couture IxSVRER D: 130 College Street, Suite 100 INSURER E: South Hadley NA 01075 1 INSURER F' COVERAGES CERTIFICATE NUMBERSIaster 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. NOTVMTHSTANDING 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 CIAIMS. IN9R LTR TYPE ONSURANCE POMCY NUMBER POMCY EFF POLICY EMP MW M LIMITS COMMERCRIL GENEFALURBUW EACH OCCURRENCE f 1,000,000 A $ CLAIMS MACE ❑OCCUR PREMISES BB,acurter¢e f 500,000 $0353521') 9/1/2017 9/4/2019 MED CAP IAI,ane person) E 10,000 PERSONAL&ADV INJURY $ 11000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE S 2,000,000 $ POLICY PRO LOC PRODUCT$-COMPNP AGG E 2,000,000 JECT OTHER. f AUTOMOBILE LADLltt .11 E 11000,000 LYINJURY A ANY AUTO e001LV INJURY(Pelpelaw) E $ ALL ED SCREEDDLED SB3535217 9/4/2017 9/4/2018 eODILYINJURY U R,a=dW) EAOS AULDWEO EHRED AUTOS AUO$ NOPERT DMAGE Plla - E 8,000 R UMBRELLA UAE OCCUR EACH OCCURRENCE E 1,000,000 A EXCESS UAB CUIMSMADE AGGREGATE E 1,000,000 DED I -4 I RETENTION 30 000 ST3535217 9/4/2017 9/4/2018 E YJORNERS COMPENSAIpN x PER OTW AND EMPLOYERS UAMUFY YJN STATUTE I ER ANY FPOPPETOPARTNENEXEOUTIVE E.L EACH ACCIDENT E 500,000 OFFICERMEM BER EXOWDED7 ❑ NIA B pewabry In NRl VR'R0009917 9/4/2017 9/4/2018 EL DISEASE FA EMPLOYE E 500,000 tq8 dMA,roe uMer DESCR IPTIONOFWERATIONSEaIax EL DISEASE-POLICY LIMIT S 500,000 A Commercial Property —531211 9/4/2017 9/4/2018 deUdole$1.OW DESCRIPTION OF OPERATIONSI LOCLnONSI VEHICLES(ADDING 101,AddMonal RenuM SUIMUIe,m%Le MYcw HaM Fpace Ie nquima 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. AUTNO SEED REPRESENTATNE Kevin SDyae/LMP ��— — ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD25(2014/01) The ACORD name and logo are registered marks of ACORD INSO25 ]R,r,