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23D-093 26 NUTTING AVE BP-2019-0093 GIS 4: COMMONWEALTH OF MASSACHUSETTS MM-.Block:23D-093 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 4 BP-2019-0093 Project# JS-2019-000148 Est Cost$4100.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: AMERICAN INSTALLATIONS LLC 106178 Lot Size(sa.ft.): 13808.52 Owner: SPENCER NORMAN A Zoning:URB000)/ Applicant: AMERICAN INSTALLATIONS LLC AT. 26 NUTTING AVE Applicant Address: Phone: Insurance: 130 COLLEGE ST (413) 552-0200 WC SOUTH HADLEYMA01075 ISSUED ON.712412018 0:00:00 TO PERFORM THE FOLLOWING WORIGATTIC AND BASEMENT INSUALTION AND AIR SEALING THOUROUT 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 4 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 7/2420180:00:00 $65.00 212 Main Strect,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner - Department use 6iily" CityNorthampton Statusof Pe,mil 23 2018 Buil[Room g Department Curb CutlDril—yPmmit JUL 2MainStreet Se dSepgc Availatill. 100 We! ellIAwilab®ItyUa DIhpion, MA 01060 moo BetsofSWCtimilptims 1240 Fax 413-587-1272 PIOUSite Plans —r 011ier Spectiy APPLICATION TO CONSTRUCT,ALTER,REPAIR RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE DIFORMATION bp- `q' '4 3 1.1 Proyerty Address: ] This section to be completed byal im 26 Nutting Avenue, Florence MA 01062 map Loi as Unit. Zone OMISyDlamc EIm SL District.. ce District SECTION 2-PROPERTY OWNERSHIPIAUTHORRED AGENT 2.1 Owner of Record: Norman Spencer 26 Nutting Avenue Florence MA 01062 Name(Pdm) Cup Maft Address: (41'1) 587-0801 See attached Telephone Signature 2.2 Authorized Agent: American Installations 130 College St., Ste 100 South Hadley, MA 01075 Nam,(P&d) - - ` CuneM Mating Address: y, �2�UAASI�A 413-552-0200 Signebxe Teiepinne SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Coat(Dollars)to be Official Use Only cam ted by pennita cent 1. Building $4,100.00 (a)Building Perms Fee 2. Elecbiral (b)Estimated Total Cost of Carchuotion from 3. Plumbing Building Permit Fee �`-"�ry//{I' 4. Mechanical(HVAC) 6 S.Rro Protection 6. Total= 1 +2+3+4+5) $4,100.00 Check Number s� This Section For Official Use Only Data Building Permit Number. Issued: Sigrulure: Buldhe halanedinspeow of Bwldkvs Date Section 4. ZONING All Infonnatlon Must Be Completed.Pemdt Can Be Dented Due To Incomplete Infomwtlon ' Meting Proposed Required by Zoaiog niseut.mbe BBedniby Buildlugpyutmwt Lot Size Fron Setbacks Front O Side L:=P-= L:= R:= �] U Rear Building Height Bldg.SWM Footage Open un edvm bWBkgvW LTJ % LJ t--I Peking) #of Parking Spaccs Fill: — Yoiuue&U fic ) IL 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:) IF YES: Was the permit recorded at the Registry of Deeds? _ NO O DONT KNOW YES O IF YES: enter Book PageL I and/or Document#i ! B. Does the site contain a brook, body of water or wetlands? NO O DOME 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. 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 consWGion activity disturb(clearing,grading,excavation,or filling)over 1 acre or is K pan of a common plan Ural will disturb over 1 acre? YES O NO O IF YES,then a Northampton Storm Water Management permit from the DPW is required. SECTION 5-DESCRIPTION OF PROPOSED WORK Icheck all applicablel New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofrrp ❑ Or Doors O Accessory Bldg. ❑ Demolition ❑ New Signs [[31 Decks M Siding o71 Other Ift Brief Description M Proposed Work Athc and basement insulation and air sealing throughout AOaration of e>osting bedroom_Yes_No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement _Yes No Hans Attached Roll -Sheet 6a.If New house and or addition to eitisting housing,complete the following: a. Use MbuOddng:One Family Two Famiy Other b. Number of rooms In each family unit Number of Bathrooms c. Is there a garage attached? d. Proposed Square footage of new cansbuction. Dimensions e. Number of stades? I. Method of heating? Fireplaces or Woodstoves Number M each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction I. Iswmtructionwthin100a.ofweUwds?_Yes _No. lemrsWCOonwithln100yr. floodplain Yes_N0 1. Depth of basement or cetiarfloor below finished grade k. Will building conform to the Building and Zoning regulations? Yes_No. I. SeptIcTank_ Cly Sewer_ Private wait_ Cly water Supply_ SECTION Ta-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, Norman Spencer ,as Owner Milo subject property herebyauthorke American Installations to act on my behalf.In at mattem relative to work authorized by this buikflrg permit application. ,See attached 7/19/2018 Signature ofOwner Date I, American Installations as Owner/Aullwdzed Agent hereby declare that the statements and Irdmmation on the foregoing application are hue and accurate,to the beat M my knowledge and belief. Signed under the pains and penalties ofpefury. American Installations Print Nemo \L ct,, , 7/19/2018 SlgreluraM Agent Data SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ mannaotLicereatioid WesleyK. Couture 106178 License Number 130 CofleZe St., Ste 100 South Hadley,MA 01075 9129119 Address Fxptmtbn Date y2t4 413-552-0200 Signahre 7 Telephone O Registered N m knorelvernerit Contractor _ Not Applicable ❑ Wesley Couture 175982 Company Name Registration Number American installations 6/26!19 Address Fxpimgon Date 130 College St., Ste 100 South Radley, MA 01075 Telephone 413-552-0200 SECTION 10-WORKrRS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c,152,S 25C(6)) Workers Compensation Imurenee affidavit must be completed end submitted with this appUmUon.Faidue to provide this affidavit 14 resu0 In the denial of the Issuance or the building permit. Slgrred AMdevOAtlached Yes....... ffi No...... ❑ 11. -Rome Ovs ner Exemption The current eumption for"hovuowner$'was extended to include Owoermcmded DweMugi ofone(1) m twc(2)femilies and to allow such homeowner to engage an individual for hire who does not possess a licwse,provided thatthe owner acts as supervisor.CMR 780, Sixth FARIon Section 10835.1. Defmitiun ofHomoowner:person(s)who owns parcel of land on which he/she resides or intends to residF cn which there is,or is intended to be,a one or two family dwelling,attached or detached structures accessory to such use rad/or farm oucn¢es.A person who constructs more than one home in a two ear period shall not be considered a homeowner. Such"homeowner'shell submitto the Building Official,on a form acceptable to the Building Official,that he/she shall be ressonsible for all seek work performed under the building Perrait. As acting Construction Supervisor yourpresance on tbe job site will be required tiom time to time,during and upon cumplatim of the work for which rids permit is issued. Also be advised that with reference to Chapter 152(Workers'Compemation) and Chapter 153(Liabilityoftimployers to Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,you may bailable forperson(s) you hire to petlbrm work for you under this permit The undersigoed"homeowner'certifies and usum:s responsibility foreompliance with the State Building Code,City of Noribanom.Ordinances,State and Local Zoning Laws and State ofMassacbusetts General Laws Amended. Homeowner Signature City of Northampton Massachusetts ,FFc OSPAR226Mf or Burmum ZNS Z=ONS i ,jl• 212 MY 0tiot • Nome psl Suilaw lbztha ton, . 01060 Property Address: 26 Nutting Avenue, Florence NIA 01062 Contractor Name: American Installations Address: 130 College Street Ste. 100 City, State: South Hadley MA Phone: 43-552-0200 Properly Owner Name: Norman Spencer Address: 26 Nutting Avenue City, State: Florence MA 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 7/19/2018 City of Northampton 212 Main Street, Northampton, MAO 1060 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: 26 Nutting Avenue Florence The debris will be transported by: American Installations The debris will be received by: Waste Management of N.E. Building permit number: Name of Permit Applicant Wesley Couture 7/19/2018 W txR, �. Czrl.un , Date Signature of Permit Applicant JILL ;f, � MA"" Ol BBB' Llttnsea&Insured • MA CSL#:IOS1l8 American Installations MAReaisrmRcr117S82 130rMapsVae[SUXe dad,satin waNY.MPoao3.Pau:N05514x00sav:l4131 M5 O.anall:wppprLOAmnlonkMa4tlwe.wm Spencer Norman 5/21/2018 26 Nwtting Avenue Florence MA 01062 (413158)-0801 �•ni n0rmspen@'uno.con, 466497 u^ 18,1734 'waw Quantity Unit Unit Cost ' Total NrSealin{ AIR SEALING1 12 Iman hour $ SSW $ 1,020.00 WEATHERSTRIP DOOR&ADD SWEEP 3 each $ SC.W $ 240.00 Air Sealing $ 1,26000 Air Sealing Incentive $ (1,020.00) Air Selaing WX Balance $ 240.00 weetMrawti n ATTIC FLAT-6"OPEN R-22 CELLULOSE 1,560 sqk $ 1.32 $ 2,05930 VENTILATION CHUTES 46 each $ 2.50 $ 115.00 ATTIC DAMMING-R-38 FIEERGIASS 72 sqk $ 2.05 $ 147.60 ATTIC HATCH-SEAL&INSULATE 1 each $ 60.00 $ 60.00 Air Sealing WX Balance 1 lum sum —7=w $ 240.00 FLIP/SIASH EXISTING 1,500 k $ 0.25 $ 390.00 Total Weatherization $ 3,011.80 Weatherization l ncentive $ 1,966.35 Total Project $ 4,031.80 Total Milky Contribution $ 2,986.35 Total Customer Contribution $ 1,015.45 WMMH3Y.Merc�n InmlWunx urwlll'.ehh aWvaurN Mmeizv,.rwoM1man,nlpw.nann. ne.� ne.,we wbmwaunuremlantl beo h—pkre MeaWexecearwadmaemreann wnF the...e ip.0mromana,ll l .I.a wb eumy erai a ,e neee nein,,. ecaPTeNa OF PROPOSAL The above pdees,­hi,.e TOTALCONTRACTVALUE= $ 1,045AS ea.anw„e.r.H3bnnarv.ne.,.r—tvii.p3m.r ,umen.a 3oaawark assceuRad.paymem win b<ps eawn prmrm Down Payment= $ 348.00 IM CC rbr M—k,ane Glanaa—w,Lompktlan. in Balance Due Upon Completion= $ 697.45 NornfaHALC e Spencer Norman 5/21/2018 «M Blamer 5/21/2018 .iieaom rou epi-. —1—1—o—eer—kern THIS AGREEM ENT IS COMPOSED OF THIS PAGE AND THE REVERSE SIDE OF THIS PAGE AND SHALLOE CONSIDERED THE ENO RE AGREE MEW BY THE PARTIES I NVOLVED.THIS AGREEMENT IS BETWEEN AM ORIGIN INSTALLATIONS,LLC HEREINAFTER REFERRED TO AS"COMPANY',AND THE CUSTOMBERS)NAMED ON TIE REVERSE SIDE,HEREINAETER REFERRED TOM'CLIENCT,AND WILL BE SUBJECT TO ALL APPROPRIATE TAWS,REGULATIONS AND ORDINANCES OF THE STATE OF MASSACHUSETTS OR CON RECTI CUT RESPECTIVELY,AS WELL AS ALL LOCAL JURISDICTIONS. THE FOLLOWING TERMS AND CONDITIONS A6Q APPLY 1.MIS AGREEMENT IS SUBJECT TO THE APPROVAL OF A MANAGER OF ME COMPANY FOR THIS AGREEMENT TO BE EFFECTIVE UNDER ANY CONDITION. 2.SHOULD DEFAULT BE WOE IN THE PAYMENT OF THIS AGREEMENT,CHARGES SHALL BE ADDED FROM THE DATE THEREOF AT A RATE OF ONE AND ONEHALF Jl-1/$I PERCENT PER MONTH. Oft PER ANNUMI WITH A MINIMUM CHARGE OF$1 AM PER MONTH,AND IF PLACED IN THE HANDS OF AN ATTORNEY OR COLLECTOR NEI FOR COLLECTION,ALL ATTORNEYS'FEES, EXPENSES AND COSTS OF COLLECTION SHALL BE PAID BY THE CLIENT.IN ADDITION,CLIENT UNDERSTANDS THAT IN FAILING TO PAY ACCORDING TO THE ABOVE TERMS,COMPANY MM HAVE ME RIGHT TO A LEIN ON ME PROPERTY. 3.THE COMPANY AGREES THAT WHEN DELAYS BECOME KNOWN TO THE COMPANY,ME COMPANY WILL ADVISE THE CLIENT AS SOON AS REASONABLE. G,COMPANY AGREES THAT, NOTWITHSTANDING ANY AGREEMENT FOR MATERIALS AND/OR LABOR BETWEEN COMPANY AND THIRD PAM,COMPANY IS RESPONSIBLE TO CLIENT FOR COMPLETION OF ALL WORK DESCRIBED IN ATIMELY AND WORKMANLIKE MANNER, S.ALL WARRANTIES FOR EQUIPMENT AND PRODUCTS SUPPLIED RE ME COMPANY UNDER THIS AGREEMENT SHALL BE THOSE GIVEN SY ME MANUFACTURERS OF SUCH EQUIPMENT AND PRODUCT.UNDER SUCH MANUFACTURER'S WARRANTIES,THE HENT MAY BE REQUIRED TO REGISTER OR MAIL IN A WARPANT GRD OR OTHER EVIDENCE OF OWNERSHIP ANO USE OF SUCH EQUIPMENT ANO/OR PRODUCTS IN ORDER TO ACTIVATE SUCH WARRAWES, 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 AL ITIONpL EXPENSES,PREMIUMS OR COST SHALL BE ADDED TO ME TOTAL AGREEMENT AMOUNT. ].THE COMPASSES UABIUTY FOR CLAIMS ARISING OUT OF THIS AGREEMENT SHALL NOT EXCEED THE TOTAL AGREEMENT PRICE EXCEPT TO THE EXTENT THOSE DAMAGES ARE PROVEN TO BE SOLD DUE TOME COMPANYS 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. P THE COMPANY IS NOT RESPONSIBLE FOR PREEXISTING DEFICIENCIES OR HF2ARDOUS MATERIALS THAT MANIFEST MEMSELVES DURING THE CONSTRUCTION PROCESS.EG.WOOD ROT, MOI,ASBESTOS,NAIL POPS,DUCTWORK AND CONNECTIONS,PLUMBING AND VENT PIPES,DECKING DEFLECTION,ETC,IF A PRE-EXISTING DEFICIENCY OR HANRCCAS MATERIAL IS ENCOUNTERED PRIOR TO OR DURING CONSTRUCTION,AND COMPANY IS NOTIFIED IN WEEPING,COMPANY WILL TRY TO ASSIST CLIENT WITHIN THE COMPANIES MEANS AND CAPABILITIES TO CORRECT THE PREPLEWS)ON A TIME AND MATERIAL BASIS.CLIENT AGREES THAT SUCH CONDITIONS ARE UNAVOIDABLE BY ME COMPANY AND SHALL NOT BE CONSIDERED A VIOLATION OF ME AGREEMENT AND THAT DUE TO THESE CONDIR ONS THE DURATION OF THE WORK AND SCHEDULED DATE OF COMPLETION MAY DIFFER FROM THAT AGREED UPON,IF APPLICABLE,UNDER THIS AGREEMENT. 10.THE COMPANY 15 NOT RESPONSIBLE,AND THE CREW AGREES TO HOLD THE COMPANY HARMLESS,FOR ANY PROBLEMS AND/OR DAMAGES,INLCLIONG BUT NOT LIMITED TO MOLD GROWTH,ARISING FROM THE PERFORMANCE OF AIR SEALING WORK BY THE COMPANY ASA RESULT OF ANY KNOWN OR UNKNOWN MOISTURE CONDITIONS, 11,ME COMPANY IS NOT RESPONSIBLE FOR,AND THE CLIENT AGREES TO HOLD THE COMPANY HARMLESS,FOR ANY PROBLEMS AND/GR DAMAGES RELATING TO ICE DAMMING THAT MAY ARISE DURING AND/OR AFTER THE PERFORMANCE OF WORK BY THE COMPANY. I2.REPLACEMENT OF DETERIORATED DECKING,FASCIA BOARDS,ROOF JACKS,SWEATERS,TUSHING,AMI J(XAS INSULATION OR OTHER MATERIALS ARE NOT INCLUDED UNLESS OTHERWISE NOTED HEREIN. 13,THE COMPANY WILL NOT BE RESPONSIBLE FOR THE SCRATCHING OR SENDING OF INTERIOR WALLS AND CEILINGS, FLOORS, TRIM,GUIIERS, DOWNSPOUTS, EXISTING SIDING AND WINDOWS,DOORS,OIL DROPLETS IN DRIVEWAYS,HAIRLINE FRACTURES IN CONCRETE OR BLACKTOP DRIVES AND WAIXS,OR DAMAGE TO PUNTS OR$HRUBBEM,IF EXCESSIVE DAMAGE IS CAUSED BY COMPANY,COMPANY WILL REPAIR OR REPLACE DAMAGED AREA ONLY AT COMPANY'S EXPENSE. 16.THE COMPANY UNDER PROVISIONS OF CHAPTER 142A OF ME GENERAL LAWS IS REWIRED TO APPLY FOR AND OBTAIN ALL CONSTRUCTION RELATED PERMIT$,THE COMPANY SHALL NOT BE DEEMED RESPONSIBLE FOR DELAYS IN THE WORK OFSCRIBEO IN THIS AGREEMENT CAUSED BY REGULATORY PERMIT GPAMING OR INSPECTIONAL AGENCIES,AOMORITIES,OR INDIVIDUALS 15.THIS AGREEMENT,INCLUDING ME PROVISIONS RELATNG TO PRICE AND PAYMENT SCHEDULE,CANNOT BE CHANGED OR ALTERED EXCEPT BY WRITTEN STATEMENT SIGNED BY BOTH THE COMPANY AND THE CLIENT. 16,ANY REPRESENTATIONS,STATEMENTS,OR DIMER COMMUNICATION NOT WRITTEN ON THIS AGREEMENT ARE AGREED TO BE IMMATERIAL AND NOT RELIED ON BY ETHER PATEN,AND DO NOT SURVIVE THE EXECUTION OF THIS AGREEMENT. 17,THIS AGREEMENT CANNOT BE CANCELLED WRHMT THE MUTUAL WRITTEN CONSENT OF BOTH PARTIES EXCEPT AS OTHERWISE SET FORTH HEREIN. OR THIS AGREEMENT AND ANY WARRANTYG)PROVIDED HEREUNDER SHALL NOT BE ASSIGNED EXCEPT BY OR WITH THE WRITTEN PERMISSION OF ME COMPANY. 19.IF THE CLIENT FAIT TO PERFORM ITS OBLIGATIONS HEREUNDER OR TERMINATES THIS AGREEMENT WITHOUT ME PRIOR WRITTEN CONSENT OF THE COMPANY,THE CLEW SHALL BE LIABLE FOR DAMAGES FOR ME GREATER OF THE COMPANY'S ACTUAL DAMAGES OR 25%OF THE AGREEMENT FOR RESTOCKING FEE. 20,ANY CHANGES i0 MATERIALS RY THE CLIENT(BRAND,STYLE,COLOR,ETC.I AFTER SAID MATERIAL HAS BEEN DELIVERED OR 15 IN ROUTE TO THE CLIENT CW LD RESULT IN A5%RE-STOOPING FEE BASED ON THE COST OF SAID MATERIALS. 21, THIS AGREEMENT SHALL BE EFFECTIVE ONLY UPON ITS EXECUTION BY ALL PARTIES HERETO,PRIOR i0 WHICH TIME IT SHALL BE DEEMED PROPOSAL.THE COMPANY RESERVES THE RIGHT TO REVOKE THIS PROPOSAL SO DAYS FROM DATE R IS EXECUTED BY ME COMPANY IF IT IS NOT EARLIER EXECUTED BY THE CLIENT AND ME REQUIRED DOWN PAYMENT RECEIVED PRIOR TO TILE EXPIRATION OF SOW 90 DAY PERIOD,AMR 90 DAYS,AND IN THE EVENT COMPANY DOES NOT REVOKE THE PROPOSAL COMPANY RESERVES THE RIGM 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 UNENFOREARLE,THE VALIDITY AND ENFORCESILM OF THE REMAINING PROVISIONS OF THIS AGREEMENT SHALL NOT BE AFFECTED THEREBY. 23,ARBITRATION.IN THE EVEMTHE CLIENT AND COMPANY HAVE A DISPUTE REGARDING ANY OF THE TERMS,CONDITIONS,PROVISIONS,OR PERFORMANCE OF THIS AGREEMENTT THE PARTIES AGREE TO PLACE THE MATTER IMO ARBITRATION BEFORE AN INDEPENDENT ARBITRATOR ASSIGNED BY THE AMERICAN ARBITRATION ASSOCIATION TO RESOLVE THEIR DISPUTE. 20.ANY DISCOUNT,PROMOTION,REIMBURSEMENT,OR OTHER PROGRAM THAT IS PAW OF A STATE MONGERED UTILITY PROGRAM(LF.MASS SAVE')IS SUBJECT TO THE AVAIUBIUTY OF QUALIFYING STATE SPONSEREO PROGRAM AND WILL BE SUM SET TO TERMINATION IF ME STATE SPONSERED UTILITY PROGRAM IS OISCOUNTINUED-FURTHERMORE,TILE TERMS AND CONDITIONS OF SIRE SPONSERED UTERI 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 MA55 SAVE'ENERGY PROGRAM. 26.CLIENT IS REPSONSIBLE FOR THE PAYMENT OF ANY AND ALL FEDERAL STATE,OR LOCAL TAXES THAT ARE APPLICABLE TO THIS AGREEMENT, The Commonwealth ofMassachurens DepartmentOffice fIn Investigations Accidents OjJee ojl++vestigations 600 Washington Street Boston,MA 02111 www.mass.gov/Jia Workers' Compensation Insurance Affidavit: Builders/Contracton/Electricians/Plumbers Applicant Information Please Print Leaibly Name(IlusinesyDrganieatioNlndividuaU: American Installations,LLC Address: 130 College Street,Suite 100 City/State/Zip: South Hadley,MA 01075 _ _ Phone 4: 413-552-0200 Are you an employer?Check the appropriate box: Type of project(required)' I.[XI I am o employer with 46 — 4. 0 1 am a general contractor and 1 6. r-1New construction employees(full and/or pan-lime). have hired the sub-contractors 2.❑ 1 am a sole proprietor or purtner- listed on the attached sheet t 7. ❑ Remodeling ship and have no employees Tliese sub-contractors have B. ❑ Demolition working for me in anv capacity. workers'comp. insurance. 9, ❑ Building addition [No walkers'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 ofcxemption per MGI. I I.❑ Plumbing repairs or additions myself. [No workers'comp. c. 152,§1(4),and we have no 12.❑ Roofrepairs insurance required.]I employees. [No workers' 13Other Insulation_ comp. insurance required.) --- on 'Any opplaanl Ihnl checks box gl must also 611 out the svnian blow eurum,a0ew worYen'comatio pensn policy Inf rm ttion. y Itomeowmuwhoelt the tux must ateethad ainte thi ore suing allwork end time biro oNeidutumrMorscowl submits new a1TJeolatMihorr snch. rConlroctors Nul chuck thus bps coral oltmhe0 nn eJJitionel sheet showing the name'01 the sub-controcmn anJ their wrclsuli comp.policy inPormaliun. I am an employer that is providing workers'compensation insurance far my employees. Below is the policy and job site minermmimt. Insurance Company Name: Guard Insurance Companies Policy a or Self-in,. L/a iA: AMWC897387a Expiration Date: 09/04/2018 Job Site Address: (—e .] Yn/A IiUJ M _City/State/Zip: ��2[y,[l01 hAQ b pZ Attach a copy of the workers'compenessilion policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. i 52 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalfies 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 ofthe DIA for insurance coverage verification. I do hereby certify,under the pains a/n/Id penalties ofperjury that the informationProvided �aabo{cee�is true and correct. Stimulate- Y._ l __..-..._Dat_':�_J_La�yd10 Phone a: 413-55 -0200 Ofeial use only. Do not write in this area,to be co"Ided by city or town official. City or Town: Permit/License a Issuing Authority(circle one): 1. Board of Health 2.Building Department 3.Citylfown Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone a: Commonwealth of Massachusetts Construction Supervaor Division of Professional Licensure Unrestricted-Buildings m any rule gaup wtdch contain Board of Building Regulations and Standards lass than 36.000 cable fed(Mi cui ie meters)of enclosed COnstructibn Supervisor spece. CS-108178 E;pires:09/29/2010 - WESLEY COUTURE 210LATHROF9TREET + SOUTH HAOLEY MA 01078 Fakure W possess a carted eNUon of the Massachusetts Baste BrdMing Code Is cause for revocation of Das Been". Far Information abort this Beaty Commissioner Call(617)727J200 de visk wwwmesgov/dpi n��e (f'(�YY13Yl�J1 fCtCf1'(�f!- (�J��ll':tJfYIY'l-tlJf'�� I K\ Office of Consumer Affairs and Business Regulation 10 Park Plaza- Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Type: LLC AMERICAN INSTALLATIONS,LLC. Regxpratidn: 175982 130 COLLEGE STREET SUITE 100 Ekpira0on: 08/28/2018 SOUTH HADLEY,MA 01075 Updste Address ant return card. Mark reason for change. sca, a :rom.ov„ n Addy^mss ❑P.sa me 0 Employment 0 Lost Cnrd Was of Consumer Mein a Business Reauleeon .iY ROME INPROVEMEHr CONTRACTOR Registration vNMfor individual use only 1 ,i! TYPE:LLC before Me aepirsbon cadc p found return W: Registration Enlreffion ON 10 OPe o Consumer Af1lams and Business Regulation 175982 AMERICAN INSTALLATIONS,LLC, Boefon,MA 02116 WESLEY COUTURE ,�-C�Q�� 130 COLLEGE STREET SUITE 100 :J SOUTH HADLEY,MA 01075 Undersecretary *valid without SlgnaturO A� CERTIFICATE OF LIABILITY INSURANCE 8/14/2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)must E°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 certificates holder in lieu of such endomemOM(s). PRODUCER NAME T Linda Powers Webl]er 6 Grinnell PHONEAs 1 (413)586-0111 FAN No.1U315B6-6481 8 North sting Street no IL .lpowers@webherandgninnell.com INSURE S AFFORNNGCOVERAGE NAW p Northampton MA 01060 NeuRSER.MaRploysi Mutual Casualty _ INSURED INSUREReberkshire Hathawass, BOARD Ins. CO. American Installations, LLC INSURERC' Attn: wes 6 S..... Couture INSURER.: 130 College Street, Suite 100 INSURER_E:_ South Badley MA 01075 INSURER F: COVERAGES CERTIFICATE NUMBERMaster Esp 9-2018 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE POLICY HUMBER MWOCD'YYYY MLO E%P UNITSR COMME0.CWL GENERAL UAMUIY EACH OCCURRENCE b 1,000,000 A X CLA'sa A0E El OCCUR PREMISE Ee =EDSA E 500,000 203535217 9/4/2017 9/4/2015 MED ENP Any one Venom S 10,000 PERSONAL8ADNINJURY S 11000,000 GEML AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE b 2,000,000 R POLICYEl OT LOC PRODUCTS-COMPIDP AGO $ 21000,000 OTHER. AUTOMOBILE UAa1LITY COMBINE7MREaawden LE LIMI S 11000,000 A ANY AUTO BODILYINJVRY(Pw Pmonl s AALL VTOSwED X AUTOSULED 5¢3535217 9/4/2017 9/4/2015 BODILY INJURY IPe,a'_ ij E X HIRED AUTOS R BOTTOMED NED Pesev1R.�MAGE s PIP-Basic S 8,000 X UMRRELIALIAB OCCUR EACX OCCVRRENCE S 1 000,000 A "Cas LIA9 CIAIMSMADE AGGREGATE $ 1,000,000 DEC I X I RETENTION 10,000 27353521] 9/1/201] 9/1/2018 b MR."WMPENSATON PER i AND EMPLOYERS LIAMU]Y yIN K STATUTE ER BANY PRWRIETONPARTHEAIENCLUTIVE ❑ NIA EL EACH ACCIDENT S 500,000 OFFICERIMEAIBER E LJUEJo2 (ManEalwy In NH) U1MC609917 9/4/2017 9/4/2018 E DISEASE-EA Ei s 500,000 n y S aee�n6e comer DESCRIPTION OF OPERATIONiii.- EL.DISEASE-POLICY LIMIT I S 500.000 A Comearcial Property 501 9/4/2017 9/4/2010 EaucSMe S1 PLb DMMPTWN OF OPERATIONS I LOCA]WNSI VEHICLES (ACOM IM,AddRiMal Remnb ScWule,ney Ee aftachW N..R.Pee Ia rt ul.I 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. AUTHORIZED REPRESENTATIVE Nevin Joyce/LMP ^"' ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS0251munn