42-128 (3) 960 WESTHAMPTONRD BP-2019-0149
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map.Block:42. 128 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-2019-0149
Proiect# JS-2019-000249
Est.Cost- $2300.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License.
Use Group AMERICAN INSTALLATIONS LLC 106178
Lot Size(so ft.): 16857.72 Owner. MICOLINI ALEXANDRIA
Zoning: Applicant: AMERICAN INSTALLATIONS LLC
AT: 960 WESTHAMPTON RD
ApplicantAddress: Phone: Insurance:
130 COLLEGE ST (413) 552-0200 Liability
SOUTH HADLEYMA01075 ISSUED ON:8/7/20180:00:00
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 Occupancy Sienature:
FeeType: Date Paid: Amount:
Building 8/7/20180:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
I I - 232
_ 6 P-i9 -I qq
LI V C __. Depamrem use poll.
of 4orthampton Status ofPemdt:
B Aldin Department Curb Cut0dveway Pemdt
AUG - 6 2010 212 lain Street sewer 6epacAva labg Cy .
R om 100 WaterNyati Availability;
No hem n, MA 010M Two Sets of8b saurw-isns
rc;:r nr r;moi E
soiariinM�1�11. 4AB-&17- 40 Fax 413587-1272 PbVSi(e Plans
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 comprd by Office
960 Westhampton Road, Florence MA 01062 Map 4L Lot / Unit
Zone Overlay District
Elm SL DMria CS Dism.
SECTION 2-PROPERTY OWNERSHIPIAUTHOZQ DAGENT
2.1 Owner of Record:
Pablo &Alexandra Micohni 960 Westhampton Road Florence MA 01062
Nam.(Pdng C `sv*MaDng Addmas:
t954129R-5500
See attached Telephone
Signelwe
2.2 Authorized Agent
American Installations 130 College St., Ste 100 South Hadley, MA 01075
N.(11" Cwrem MalFo Addie e:
\d- . O (. 413-552-0200
Sigiwhiro Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
gain Estimated Cost(Dollars)to be Oltidal Use Only
completed by penafta Roam
1. Building 2,300.00 (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construdfon from
3. Plumbing Building Penult Fee
4. Mechanical(HVAC)
5.Fee Protection
S. Total=(1+2+3+4+5) 2300.00 Check Number
This Section For Official Use Only
Building Permit Nu Date
Issued:
Signa
t� 6 Big esipladdnepacmr of Buldings Dais
Section 4. ZONING All Information Most De Completed.Penult Can De Denied Due To Incomplete Infermatbn
Existing Proposed Required by Zoning
nn Column m be filled In by
Bmldlvg Uepumeos
Lot Size ----.—� —�
Frontage
Setbacks Front
Side L= It= L= R 0 �J
D
Building Ideight O O
Bldg.Square Footage F= $A O
Open Space Footage
(totaan miovs bldg kpaved
#ofPudding Spaces
FBI:
volume klaadm �1 --_—
A. Has a Special PermittVariance/Finding ever been issued for/on the site?
NO O DONT KNOW O YES O
IF YES,date issued-1
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW O YES O
IF YES: enter Book Page —__j and/or Document#F` I
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. 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 activity disturb(cteadng,grading,excavation,or Whig)over 1 acre or Is it pan of a oomman plan
that w@ dlsbrrb over 1 acre? YES O NO O
IF YES,then a Northampton Sturm Water Management PennKaom the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all Iioablel
New House E] I Addition ❑ I Repkcemant Windows Alterstion(s) ElRoofing ElOr Doors O
Accessory BMg. ❑ Demolition 0 New Signs n Decks M Siding Q]) Other[A
Brief Description of roposed
Work: Attic and basement insulation and air sealing throughout
Alteration of existing bedroom_Yee_No Adding clew bedroom Yes No
Attached Narrative Renovating unfinished basement yes No
Plans Attached Roil -Sheet
Ga.If New house and or addition to e-ltisUna'housinu.Complete the following:
a. Use of batiding:One Famgy Two Famgy Other
b. Number of rooms in each family unit Numberof Ballrooms
c. Is there a garage a0ached?
d. Proposed Square footage of new,construction. Dimensions
e. Number of stories?
I. Method of heoOng? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
1. Is construegon wdhin 100 fLof wetiwmds?_Yes —No. Is constrwdiwi wltlOn 100 yr. lloodptain Yes_No
1. Depth of basement or colarfloor below finished grade
k. Will building conform to the BuOtling and Zoning regulations? Yes_No.
I. Septic Tank_ City Sewer_ Private vel_ City water Supply
SECTION To-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, Pablo &Alexandra Micohni as Owner of the subject
property
herebyeuthorize American Installations
to act on my behalf,in all matters relative to work authorized by Oft building permit application.
Cee attached 8/2/2018
SlgwWre of owner Oak
I, American Installations as OwnerlAallorized
Again hereby tlerdare Nat the statements and Information on the foregoing application are true and accurate,to Ore best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
American Installations
Print Name
�\C, cx xr� 8/2/2018
SlgwWao/Owr r/Agem Dots
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construdon Supervisor. Not Applicable ❑
Nameafucenee NPrder, WeslepKCouture 106178
License Number
130 College St., Ste 100 South Hadley, MA 01075 9129119
Address Expiration Data
ams ?
\L. Coxfluy. 413-552-0200
Slenehae Telephone
9.Redsmred time improvementCo cixer. _ _ _ Not Applicable ❑
Wesley Couture 175982
Company Name Registration Number
American Installations 6/26/19
Address Expiration Data
130 College St., Ste 100 South Hadley, MA 01075 Telephone 413-552-0200
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.G.152,§26C(8))
Workers Compensation Insurance affidavit must be completed and submitted with this appficaeon.Future to provide this aMtlavft will result
In the denial of the Issuance of the building pernut.
Slimed Affidavit A1lacbed Yes....... 6i No...... ❑
11. -Home Owner Exemption
The current exemption for"homeowaece Wes extended to include QnjlL- ccanledDweBi Ofone(1) m two(2)$milies
and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner acts
as supervisor.CMR M. Sixth Milan Section 16835.1.
DefmiUon of Ronreowner.Poison(s)who own a parcel oflared on which he/she resides or intends to rmidA on which there
is,or is intended to be,a one or twofamily dwelling,attached or detached structures accessory to such use and/or farm
structures.A person who contracts mthan one home in a two-year Period shall not be considered A lereptinse
Such"homeowner'shall summit m the Building Official,on a form acceptable to the Building Officialantd h sheshag he
responsible for all suchwork Performed under the bulldbee perm/
As acting Conatrnetion Supervisor your presence,on thejob site will be requited from time to time,during and upon
completion ofibe work for which this permit is issued.
Also be advised that with reference in Chapter 152(Workers'Compemation) and Chapter 153(UabilityofEmpioyere to
Employers for injuries not resulting in Death)ofthe Massachusetts Cmncrsl Laws Amented,rou mavbeffablemrperson(s)
you hire to perform work for you under this peudL
The undersigned"homeowner"certifies and assumes responsibility for compliance with the Stam Building Code,City of
Northampton Ordinances,State and Local Zoning Lewy and State ofMassachus sus General taws Annotated
Homeowat r 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: 960 Westhampton Road
The debris will be transported by: American Installations
The debris will be received by: Waste Management of N.E. - Chicopee
Building permit number:
Name of Permit Applicant Wesley Couture
8/2/2018 �V- Cm,>l—, A
Date Signature of Permit Applicant
• mass save
nSPa s mm,ea PARTNER
Ma rs e:rr«rre
American Installations srww.AmxiEanmsblbtims.com
iT[WraP5bM 5rib iN.EeuM 1YJq.MPmWSe DR:M13155L0]OO FY:W915EEAIDE[ETei aWR/tMmniEnMYb4'ona[xn
Customer Name:Pablo Micolini
Email:Not pr.vm.d
Phone:954298-5500
Premise Address:960 Westhampton Rd,Northampton,MA 01062
Pruteot ID:3444808
Date:July 31,2018
Job Description
Door-2"Thermal Barrier Polyiso 1 each $90.44 $22.61
Exterior Door Weather Stripping (with AS hrs) 3 each $90.21 $0.00
Door Sweep (with AS hrs) 3 each $75.93 $0.00
Air Sealing at Estimated 62.5 CFM50 Per Hour 6 hr $555.48 $0.00
Cut and Finish Access 1 each $124.53 $31.13
Damming 28 each $66.92 $16.73
Attic Floor- 10" Open Blow Cellulose 640 SF $1,216.00 $304.00
Project Total $2,219.51
Weatherization incentive ($1,123.42)
Air sealing incentive ($721.62)
Total Program Incentive -$1,845.04
Customer Total $374.47
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i
sM.nure 7/31/2018
P[Peu,Oa+rer lPrin[ ISNI DrtP
x.PeSPxooroP:lmnet Garrett Demers Garrett Demers
Iswa wre 7/31/2018
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 IS BETWEEN AMERICAN INSTALLATIONS,LLC HEREINAFTER REFERRED TO AS"COMPANY',AND THE CUSTOMEF)S)NAMED ON THE REVERSE SIDE,HEREINAFTER
REFERRED TO AS"CLIENT",AND WILL BE SUBJECT TO ALL APPROPRIATE LAWS,REGULATIONS AND ORDINANCES OF THE STATE OF MASSACHUSETTS OR CONNECTICUT
RESPECTIVELY,AS WELL AS ALL LOCAL JURISDICTIONS,
THE FOLLOWING TERMS AND CONDITIONS ALSO 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 TH E DATE THEREOF AT A RATE OF ONE AND ONE-HALF IF 1/2)
PERCEM PER MONTH(18%PER ANNUM)WITH A MINIMUM CHARGE OF SO 00 PER MONTH,AND IF PLACED IN THE HANDS DEAN ATTORNEYOR COLLECTION AGENCY
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 MAY HAVE THE RIGHT TOA LEIN ON THE PROPERTY.
3. THE COMPANY AGREES THAT WHEN DELAYS BECOME KNOWN TO THE COMPANY,THE COMPANY WILL ADVISE THE CLIENT AS SOON A5 REASONABLE.
A COMPANY AGREES THAT,NOTWITHSTANDING ANY AGREEMENT FOR MATERIALS AN D/OR LABOR BETWEEN COMPANY AND THIRD PARTY,COMPANY'S RESPONSIBLE
TO CLIENT FOR COMPLETION OF ALL WORK DESCRIBED IN ATIMELY AND WORKMANLIKE MANNER.
5, ALL WARRANTIES FOR EQUIPMENT AND PRODUCTS SUPPLIED BY THE COMPANY UNDER THIS AGREEMENT SHALL BE THOSE GIVEN BY THE MANUFACTURERS OF SUCH
EQUIPMENT AND PRODUCTS. UNDER SUCH MANUFACTURER'S WARRANTIES,THE CUENT MAYBE REQUIRED TO REGISTER OR MAIL INA 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,PREMIUMS OR COST SHALL BE ADDED TO THE TOTAL AGREEMENT AMOUNT.
J. THE COMPANY'S LIABILITY FOR CLAIMS ARISING OUT OF THIS AGREEMENT SHALL NOT EXCEED THE TOTAL AGREEMENT PRICE EXCEPT TO THE EXTENT THOSE DAMAGES
ARE PROVEN TO BE SOIEN DUE TO THE COMPANY'S NEGLIGENCE.
8. DURING THE DURATION OF THE WORK,THE CLIENTS HOMEOWNERS INSURANCE WILL BE RESPONSIBLE FOR ANY AND ALL DAMAGES AS LONG AS THE COMPANY HAS
TAKEN THE APPROPRIATE ACTION TO PROTECT AREAS OF WORK.
9. THE COMPANY IS NOT RESPONSIBLE FOR PREEXISTING DEFICI ENCIES OR HA RDOUS MATERIALS THAT MANIFEST THEMSELVES DURING THE CONSTRICTION PROCESS,
E.G.WOOD ROT,MOLD,ASBESTOS,NAIL POPS,DUCTWORK AND CONNECTIONS,PLUMBING AND VENT PIPES,DECKING DEFLECTION,ETC. IFA PRE-EXISTING DEFICIENCY
OR HA]ARDOUS MATERIAL IS ENCOUNTERED PRIOR TO OR DURING CONSTRUCTION,AND COMPANY 15 NOTIFIED IN WRITING,COMPANY WILL TRY 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.
10. THE COMPANY IS NOT RESPONSIBLE,AND THE CLIENT AGREES TO HOLD THE COMPANY HARMLESS,FOR ANY PROBLEMS AND/OR DAMAGES,INLCUDING 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 TH E COMPANY HARMLESS,FOR ANY PROBLEMS AND/OR DAMAGES RELATING TOILE
DAMMING THAT MAY ARISE DURING AND/OR AFTER THE PERFORMANCE OF WORK BY THE COMPANY
13. REPLACEMENT OF DETERIORATED DECKING,FASCIA BOARDS,ROOF JACKS VENTILATORS,FLASHING,PATTERS,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 CEIUNGS,FLOORS,TRIM,GLITTERS,DOWNSPOUTS,EXISTING
SIDING AND WINDOWS,COORS,OIL DROPLETS IN DRNEWAYS,HAIRLINE FRACTURES IN CONCRETE OR BLACKTOP DRIVES AND WALPS,OR DAMAGE TO PLANTS OR
SHRUBBERY, IF EXCESSIVE DAMAGE ISCAUSED BY COMPANY,COMPANY WILL REPAIR OR REPLACE DAMAGED AREA ONLY ATCOMPANY'S EXPENSE.
14. THE COMPANY UNDER PROVISIONS OF CHAPTER IQA OF THE GENERAL LAWS IS REQUIRED TO APPLY FOR AND OBTAIN ALL CONSTRUCTIWRELATED PERMITS, THE
COMPANY SHALL NOT BE DEEMED RESPONSIBLE FOR DELAYS IN THE WORK DESCRIBED IN THIS AGREEMENT CAUSED BY REGULATORY PERMIT GRANTING OR
INSPEQIONALAGENCIES,AUTHORTIES,ORINDIVIDUALS.
15. THIS AGREEMENT,INCLUDING THE PROVISIONS REIATING 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.
13, THIS AGREEMENT CANNOT BE CANCELED WITHOUT THE MUTUAL WRITTEN CONSENT OF BOTH PARTIES EXCEPT AS OTH ERWISE SET FORTH HEREIN,
10. 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 FAILS TO PERFORM In 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 2S%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.
31. THIS AGREEMENT SHALL BE EFFECTNE ONLY UPON ITS EXECUTION BY ALL PARTIES HERETO,PRIOR TO WHICH TIME IT SHALL BE DEEMED A PROPOSAL THE 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 WENT AND THE
REQUIRED DOWN PAYMENT RECEIVED PRIOR TO THE EXPIRATION OF SUCH SO DAY PERIOD,AFTER 90 DAYS,AND IN THE EVENT COMPANY DOES NOT REVOKE THE
PROPOSAL COMPANY RESERVES THE RIGHT TO REVISE In PRICE IN ACCORDANCE WITH ITS COSTS IN EFFECT AT SUCH TIME.
33, IF ANY PROVISION OF THIS AGREEMENT SHOULD BE HELD TO BE INVALID OR UNENFORCABLE,THE VAUD'TY AND ENFORCEBILITY OF THE REMAINING PROVISIONS OF
THIS AGREEMENT SHALL NOT BE AFFECTED THEREBY.
33. ARBITRATION:IN THE EVENT THE CLIENT AND COMPANY HAVE A DISPUTE REGARDING ANY OF TH E TERMS,CONDITIONS,PROVISIONS,OR PERFORMANCE OF THIS
AGREEMENT,THE PARTIES AGREE TO PEACE THE MATTER INTO ARBITRATION BEFORE AN INDEPENDENT ARBITRATOR ASSIGNED BY THE AMERICAN ARBITRATION
ASSOCIATION TO RESOLVE THEIR DISPUTE.
34, ANY DISCOUNT,PROMOTION,REIMBURSEMENT OR OTHER PROGRAM THAT IS PART OF A STATE SPONSERED UTILITY PROGRAM)LE MASS SAVE')155UBJECT TO THE
AVANABIUTY OF QUALIFYING STATE SPONSERED PROGRAM AND WILL BE SUBJECT TO TERMINATION IF THE STATE SPONSERED DFUUTY PROGRAM IS OISCOUNTINUED.
FURTHERMORE,THE TERMS AND CONDITIONS OF STATE SPONSERED UTILITY PROGRAMS MAY BE ALTERED OR UPDATED PERIODICALLY WITH OR WITHOUT NOTICE,
35. AMERICAN INSTALLERS,LLC IS NOT AM AGENT OF ANY UTILITY COMPANY OF OTHER VENDOR WORKING BY,THROUGH,OR UNDER THE MAY MVP ENERGY
P0.0GRAM,
36. CLIENT IS REPSONSIBLE FORTHE PAYMENT OF ANYAND ALL FEDERAL,STATE,OR LOCALTAXES THATARE APPLICABLE TO THIS AGREEMENT.
The Commonwealth of Massaehuselts
Department of Industrial Accidents
Office of Investigations
wi 600 lYwhinglon Street
Boston,MA 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Lceibly
Name(Bminess/Orgmiu tioNlndividual): American Installations,LLC
Address: 130 College Street,Suite 100
City/State/Zip: South Hadley,MA 01075 Phone d: 413-552-0200
Are you an employer?Cheek the appropriate box: Type of project(required):
I.O I am a employer with 46 — 4. ElI am a general contractor and 1 6. E]New construction
employees(full and/or part-lime).' have hired the sub-comracturs
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.1 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity, workers'comp. insurance. 9, ❑ Building addition
[No workers'comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their ME 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.❑ Reef repairs
insurance required.)I employees. [No workers'
_ comp. insurance required.] 13.[]Met Insulation
'Any applicant hat checks box MI must also all ML he section below showing their worker compmosaynt Wbeyiouria wn.
I Ilomeuwmrs whosubmit this saidavit ut ieainb thatan doingall workend then hire omsida can,.. must submitonesv alivYvit indicotingsura.
:Lunaactors that check this box Most atiocled an additional Acet showing the name of the sub-contractor and dw,r wmksmi eomp policy in6rmmion.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy andjob site
information.
Insurance Company Name: Guard Insurance Companies
Policy Vor Sel&ins. Lw.4. A'M`W_ C897387_ Expiration Date: 09/04/2018
W _ /�
Job Site Address: 16 a rNl (MJY3 am City/State/Zip: Ef/y tla 0112
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 of criminal penalties ofd
fine 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 violator. Be advised that a copy of this statement maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do barely certify under the pain,a/nnld penalllieess ofperjury that the information provided abovepfs true and correct.
S' t .nA l .H'fIT.U/Z9-- _ Date:
Phone N: 413-552"0200
Oficial use only. Do not write in this area,to be completed by city or town official.
City or Town: Permfl/License ft
Issuing Authority(circle one):
I. Board of Health 2.Building Department 3.City?own Clerk 4.Electrical Inspector 5.Plumbing Inspector
b.Other
Contact Person: Phone H:
Cam annesetih of Massachusetts Constructed 8opuwaar
®: Olvislon of Professional Licensure Unrestricted•Buildings offset,us¢uup which certain
Board of Building Regulations and Standards lessthao 35,000 cubic lest(991 cubic nod"ofetcosed
Construction Supervisor ap+ce-
CSAD5175 Expires:09/29/2019 -
W67ALEY COUTURE
210 LATHROP14TREET
SOUTH HAOLEYMA 01075
Failure to possess a eunrd edhion of der Mas huwft
State Building Code bush for revocation of this teens.
For infwmttan aboat ties Sewrw
Cornmisslcner Call(617)7274M or VM wwwmsssgw/dpi
6rf)JAI iN0101(VC171lAaf'n/��trlur��ulelt�
s\ aa Office of Consumer Affairs and Business Regulation
10 Park Plaza- Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Type LLC
AMERICAN INSTALLATIONS,LLC. Registration: 175952
130 COLLEGE STREET SUITE 100 Ezpiratlon: 00/25/2018
SOUTH HADLEY,MA 01075
Update Andres and return card. Mark pawn for chugs.
SCA 10 kYIML 11 nAdd.— n o_wl rl Emp.oymnt J Loot Card
ur,
- - - CMoe of ConsumerAeain a 9uslneeeFpuation
HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only
TYPE:LLC before me expiration dine. nround return to:
Registration {xo1raffi,in Office of Cosunner Affairs and Business Regulation
175902 06/25=10 10 Park Name-3.1105170
AMERICAN INSTALLATIONS.LLC. Boeten,MA =116
WESLEY COUTURE
130 COI COLLEGE STREET SUITE 100 C� _
SOUTH HADLEY.MA 01075 Undereecretery' JWvalid without signature
A��® CERTIFICATE OF LIABILITY INSURANCE1 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,Aha 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 cerNBcate does not confer rights to the
certificate holder in lieu of such endorsemends).
PRODUCER RApE, Linda Poxera
Webber S Grinnell PHoxe (413)586-0111 a%C.
N4:"TU"efi-64
8 North Rin, Street n.RADRliss:lpou ra@aebberancigri nell.com
e1NSUESSR AFFORDING COVERAGE NAICp
Northampton ED. 01060 _ INSUMERAICESUPOLOPI Mutual casualty
INSURED INSURERBBerkshlre Hastlurenzy GDARD Ins. Co.
ADlarlcan Installations, LLC INSURERC:
Attn: Wes 6 Suzanne Couture INSURER.:
130 College Street, Suite 100 INSURERE:
South Bad16y MA 01075 L INSURER F:
COVERAGES CERTIFICATE NUMBERSIBE r Rap 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. NOTNATHSTANDMG ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO MICH 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 FO TOY NUMBERUE.-.1- FF,
MWIOOIYYY MPOUCVE%P UNITS
COMMERCIAL GENERAL LIP&MTY EACHCCCURRENOE S 1,000,000
A A E 500,000
A R CLAIMBMAOE El OCCUR PREMIE Eacmnenw
5D3535217 9/4/2017 9/4/2018 MED ESP(My ore palm) E 10,000
PERSONAL B AOV INJURY $ 1,000,000
GEN L AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE E 2,000,000
R POLICY jRj [:]LOC PRODUCTS.COMPOP AGO S 2,000,000
OTHER: E
AVTOMOMLE LIABILITY EBIN IN L L S 11000,000
ANY AUTO ROD I LY INJURY(Per SssEA $
A ALL OVMEDSCHEDULED
AUTOS x AUTOS 52353521] 9/4/201] 9/4/2018 TIDILY INJURY Pe,aulOeM) b
NON-0M D PROPERTY DAMAGE E
R FEEL AIDS y` AVi03 Po,aoaOml
PIP-B9sk $$ 5,000
R UMBRELu uAS OCCUR EACH OCCURRENCE S 1,000,000
A E%CESB MR CIAIMSMACE AGGREGATE S 1,000,000
DEO I X I RETENTION$ 10,000 ST353521] 9/4/2017 9/4/2018 f
WDRRERS COMPERSATWX PER OH
H-
AND EMPLOYERS'LIABILITY r STATUTE ER
YIN
ANY PROPRIETOSMARTHERE%ECUTIVE ❑ XIA E.L.EACH ACCIDENT $ 500,000
B NanEoryEI Xl�EXCLUDED? .609917
9/4/2017 9/4/2018 E.L.DI SEASE.EA EMPLOYEE S 500,000
Mye Eesm[elMm
DESCRIPTION OF OPERATIONS S oe EL DISEASE-POLICY LIMIT b 500.000
A Commercial Property SM535217 9/4/2011 9/4/2018 Estlucudn$1 WJ
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ADDED 101,AOENmel RemaMe Schedule,may 8e arrehW N mae space Is rtREMINI
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
EVidEUrE of I....... THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
Kevin Joyce/LMP
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