12C-079 (4) Akw R CERTIFICATE 4F LIABILITY INSURANCE °499J420`4/ ois18
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), AUTHORMEO
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(lee)must be endorsed. If SUBROGATION IS WANED,subject to
the terms and conditions of the policy,certain policies may require an aidorsemeft A statemert on this certificate does not confer rights to the
certificate holder In lieu of such a.
PRODUCER Linda Powers
Webber & Grinnell PHONE (413)586-0111 IF ,(413)594-6481
go-
ii North King street E41AILADDRM.1povaire webberandgrinnell.coat
INSII AFFORDING COVERAGE MAIC 4
MortbanVton MR 01060 INSURERA:Mpoloyorn itutual Casualty
INSURED muRERe:Berkshire Sathaxa GQP,RD Ins. Co.
American installations, LLC INSUIERC:
Attn: Ines & Susanne Couture INSURER
130 College Street, quite 100 INSURER E:
South Hadley MR 01075 MIMM F:
COVERAGES CERTIFICATE NUMBER:riaster Xxv 9-2019 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.
ADDL SUM
TYPE OF INSURANCE Y WJMUR Y EFP LIW,S
COMMERCIAL 004ERAL LIABILITY
EACH OCCURRENCE $ 1,000,000
A. .7 CLAIMS-MADE 7 OCCUR PREMISES(En ocaiffenco) $ 500,000
SD3535217 9/4/2010 9/4/3019 MED EXP am raan $ 10,000
PERSONAL&ADV INJURY 6 11000,000
GENL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 1,000,000
POLICY a J CT D LOC PRODUCTS-OOMPXW AGO $ 2,000,000
OTHER: $
AUTOMOBILE LIABILITY NGLE LIMIT
tFa e $ 1.000,000
ANY AUTO BODILY INJURY(Per pemon) $ —
A(LL�ED X ASUr�LED 583535217 9/4/2018 9/4/2019 BODILY INJURY(Per accdwM $
X HIRED AUTOS = NONALIT-OWNED PROPERTY F 1DAMAGE $
x Cd1$2,000 E comp$2,000 ptp-sasic $ 8,000
X UMBRELLA UAB EACH OCCURRENCE $ 11000,000
A EXCESS LIAB CtA01S-MADE
AGGREGATE 8 1,000,000
- CEO
* 1 SJ3335217 9/4/2018 9/4/2019 $
WORKERS COMPENSATION 8
AND EMPL0YM$`LIABILITY
ANY PROPRIETOFbPARTNERIEXECUTIVE YIN E.L.EACH ACCIDENT 3 500,000
OFFICERIMEMSER EXCLUDED? F-�MIA
8 _._.
(MwwaEwy)n NH) OR 609917 9/4/2018 9/4/2019 E.L.DISEASE-EA EMPLOYE $ 500,000
If es, eacflba dudder .—.--...
RATIONSOf E.L.DISEASE-POLICY LIMIT. $ 500,09-0-
A
00 0 0A Coommireial Pra"rty SA3535217 9/4/2018 9/4/2019 deduc"$1,000
DESCRIPTION OF OPERATKMiS I LOCATIM J VEHICLES(ACORD 101,A"donal R69wfb adwdula,may be oftd l M mare apac6 u requNed)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
EZridowe of Imuran= THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
W Grinnell, CPCU, CIC
O 1986-2014 ACORD CORPORATION. All rights reserved.
ACORD 28(2014/01) The ACORD name and logo are registered marks of ACORD
INS025(2ouoz)
t Commonwealth of Massachusetts Construction Supervisor
1V Division of Professional Licensure Unwed-Buildings of any use group which contain
Board of Building Regulations and Standards less than 35,000 cubic feet(991 cubic meters)of enclosed
Constrtldibn Supervisor
space-
CS-106178 Upires:09/29/2019
WESLEY COUTURE -
218 LATHROF-STREET
SOUTH HADLE`Y--MA 01075
Failure to possess a current edition of the Massachusetts
State Buil ivig Code is cause for revocation of this sense.
For infarmatbn about this license
Commissioner Cap(617)727.3200 ar visit www.rrtassgov/dpl
,� ����� ��f�Hyl yyt 1�jt fl,�'.C2'���Z� tz�C�i l��C�`1:.1���2,u:1P��1•
Office of Consumer Affairs and Business Regulation
p _ 10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Type: LLC
AMERICAN INSTALLATIONS,LLC. Registration: 175982
130 COLLEGE STREET SUITE 100 Expiration: 06/26/2019
SOUTH HADLEY,MA 01075
Update Address and return card. Mark reason for change.
SCAt Gt 20M-05/11
� '"��c1`r-rxrrrrirrr�,rrll�r+f'"��rsxrr�rrx•!!s
Office of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only
i TYPE:LLC before the expiration date. ff found return to:
z ) R2gisjE4L Ex Ira ation Office of Consumer Affairs and Business Regulation
V t > 17 $2 06/26/2019 10 Park Plaza-Sufte 5178
AMERICAN INSTALLATIONS,LLC. Boston,MA 02116
WESLEY COUTURE �,Q C
)�Z/-
130 COLLEGE STREET SUITE 100
SOUTH HADLEY,MA 01075 Undersecretary valid without signature
The Commonwealth of Massachusetts
E5E5EEE3 D2 Department of Industrial Accidents
Office of Investigations
wi 600 Washington Street
Boston,MA 02111
www.mass.govldia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
APplicant Information Please Print Legibly
Name(Business/orgmiratiovJlndividual): American Installations,LLC
Address: 130 College Street,Suite 100
City/State/Zip: South Hadley,MA 01075 Phone#: 413-552-0200
Are you an employer?Check the appropriate box: Type of project(required):
1.❑x i am a employer with 60 _ 4. [11 am a general contractor and t b. E]New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner-
listed on the attached sheet.t 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 10.E] Electrical repairs or auditions
required.] officers have exercised their
3.❑ I am a homeowner doing all work right of exemption per MGI I t.F1 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.N Other Insulation
comp.insurance required.]
*Any applicant that checks box#1 must also tilt out the section below showing their workers'compensation policy information.
t i lomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
*Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers"comp.policy information.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and jab site
information.
Insurance Company Name: Guard Insurance Companies
Policy#or Self-ins. Lic...#: URWC609917 Expiration Date: 09/04/2019
Job Site Address:---.0
{1 t Yx iak City/State/Zip: FJLa!= _ MA= GJC&-Z-
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 MGI.c. 152 can lead to the imposition of criminal penalties of a
tine 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct
Signature: Date:
Phone#: 413-55f-0200
Oficial use only. Do not write in this area:to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
THIS AGREEMENT IS COMPOSED OF THIS PAGE AND THE REVERSE SIDE OF THIS PAGE AND SHALL BE CONSIDERED THE ENTIRE AGREEMENT BY THE PARTIES INVOLVED.THIS AGREEMENT IS
BETWEEN AMERICAN INSTALLATIONS,LLC HEREINAFTER REFERRED TO AS"COMPANY",AND THE CUSTOMER($)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.
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 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 WILL ADVISE THE CLIENT AS SOON AS REASONABLE.
4.COMPANY AGREES THAT, NOTWITHSTANDING ANY AGREEMENT FOR MATERIALS AND/OR LABOR BETWEEN COMPANY AND THIRD PARTY,COMPANY IS RESPONSIBLE TO CLIENT FOR
COMPLETION OF ALL WORK DESCRIBED IN A TIMELY 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 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 ORDERTO 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 ADDEDTOTHE TOTAL AGREEMENT AMOUNT.
7.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
SOLEY 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 IS NOTIFIED IN WRITING,COMPANY WILL TRY TO ASSIST CLIENT WITHIN THE COMPANY'S MEANS AND CAPABILITIES
TO CORRECT THE PROBLEM(S)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.
ll.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 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,GUTTERS, DOWNSPOUTS,EXISTING SIDING AND
WINDOWS,DOORS,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 COMPANY'S EXPENSE.
14.THE COMPANY UNDER PROVISIONS OF CHAPTER 142A 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 SURVIVETHE EXECUTION OF THIS AGREEMENT.
17.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 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 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%RESTOCKING
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 PROPOSAL.THE COMPANY RESERVES THE RIGHT
TO REVOKE THIS PROPOSAL 90 DAYS FROM DATE IT 15 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 90 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.
22.IF ANY PROVISION OF THIS AGREEMENT SHOULD BE HELD TO BE INVALID OR UNENFORCABLE,THE VALIDITY AND ENFORCEBILITY OF THE REMAINING PROVISIONS OF THIS AGREEMENT
SHALL NOT BE AFFECTED THEREBY.
23.ARBITRATION:IN THE EVENTTHE 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.
24.ANY DISCOUNT,PROMOTION,REIMBURSEMENT,OR OTHER PROGRAM THAT IS PART OF A STATE SPONSERED UTILITY PROGRAM(I.E.MASS SAVE®)IS SUBJECT TO THE AVAILABILITY OF
QUALIFYING STATE SPONSERED 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 IS REPSONSIBLE FOR THE PAYMENT OF ANY AND ALL FEDERAL,STATE,OR LOCAL TAXES THAT ARE APPLICABLE TO THIS AGREEMENT.
www.Amtrkaninstailatians.com
.! Licensed&Insured
MA CSL Al106178
American Installations MA Registration#175982
130 College Street Suite 100,South Hadley,MA 01075•Office:(413)552.0200 Fax:(413)552-0202•Email:support@Amerkantnstallations.com
IO I��I
Young,Maureen 10/22/2018
-0 (Fiat) (Drte)
20 Marc Circle Florence MA 01062
(AWH,N) {Gley! (State) (ZW
413.320.8025 holly@delaprealestate.com
436803 17-0416
(zxeJDl Hob rl
Quantity Unit Unit Cost Total
Air Sealing
AIR SEALING 12 man hour $ 85.00 $ 1,020.00
Air Sealing $ 1,020.00
Air Sealing Incentive $ (1,020.00)
Air Selaing WX Balance $ -
Weatherization
BASEMENT SILLS-R19 FG BATT 52 5 ft $ 1.95 $ 101.40
ATTIC HATCH-SEAL&INSULATE 1 each $ 60.00 $ 60,00
ATTIC FLAT-7"OPEN R-26 CELLULOSE 960 sgft $ 1.38 $ 1,324.80
INSULATED BATH EXHAUST HOSE 1 each $ 60.00 $ 60.00
ATTIC DAMMING-R-38 FIBERGLASS 38 sqft $ 2.05 $ 77.90
VENTILATION CHUTES 63 each $ 2.50 $ 15750
REMOVE INSULATION 52 s ft $ 0.75 $ 39.00
Total Weatherization $ 1,820.60
Weatherization Incentive $ 1,336.20
Total Project $ 2,840.60
Total Utility Contribution $ 2,356.20
Total Customer Contribution $ 484.40
WARRANTY:American Installations,LLC will provide the above stated homeowner with a 2 year workmanship warranty.
American Installations,LLC hereby proposes to furnish all material and labor to complete the above scope of work in accordance with the above specifications and all local and state building
regulations for the Total Contract Value as stated herein.
ACCEPTANCE OF PROPOSAL:The above prices,specifications and TOTAL CONTRACT VALUE= $ 484.40
conditions are satisfactory and are hereby accepted.You are
authorized to do work as specified.Payment wilt be 1/3 down prior to Down Payment= $ 160.00 ® 14/22/2018
start of work,and balance due upon Completion. PAID
Balance Due Upon Completion= $ 324.40
$lanrture Dote
Young,Maureen �.?IL yDL!lLQ� 10/22/2018
Property--(PH.) P -- (f Drte
Craig Dragovich Craig Qragovich 10/22/2018
RePr HL.1 e(—') R,Pmwnt,tw(Sirn) Date
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 CUSTOMER(S)NAMED ABOVE,HEREINAFTER REFERRED TO AS-CUENT',AND WILL BE SUBJECT TO ALL APPROPRIATE LAWS,REGULATIONS AND ORDINANCES OF THE STATE OF MASSACHUSETTS OR CDNNECTIa)T
RESPECTIVELY,AS WELL AS All LOCALJUR1501CTi0NS
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 Marc Circle
The debris will be transported by: American Installations
The debris will be received by: Waste Management of New England
Building permit number:
Name of Permit Applicant Wesley Couture
10/27/2018
Date Signature of Permit Applicant
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor. Not Applicable ❑
Name of License Holder-. Wesley K. Couture 106178
License Number
_130 College St., Ste 100 South Hadley, MA 01075 9/29/19
Address Expiration Date
AAAA.
1 A + '- V—.. CISH uUl.. 413-552-0200
Signature - Tdaphone
9.Rep{stared Home irrtnroretne�st Ccntractcsr Not Applicable ❑
_Wesley Couture 175982
Company Name Registration Number
American Installations –6/26/19
Address Expiration Date
130 College St., Ste 100 South Hadley, MA 01075 Telephone413-552-0200
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.162,§25C(8))
Workers Compensation insurance affidavit must be completed and submitted with this application.Failure to provide this affidavit will result
In the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... IN No...... ❑
11 . Home Owner Exelmiution
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)families
and to allow such homeowner to engage an individual for him who does not possess a license,provided that the owner acts
as supervisor.CMR 780, Sixth Edition Section 1083 51
Definition of Homeowner:Person(s)who own a parcel of land on which he/she resides or intends to reside,on which there
is,or 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 home in a two-year period shall not be considered a homeowner.
Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official,that he/she shall be
responsible for all such work Performed under the building permit.
As acting Construction Supervisor your presence on the job site will be required from time to time,during and upon
completion of the work for which this permit is issued.
Also be advised that with reference to Chapter 152(Workers'Compensation) and Chapter 153(Liability of Employers to
Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,you may be liable for person(s)
you hire to perform work for you under this permit
The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of
Northampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicabie)
New House ❑ Addition ❑ Replacement Windows Ai#era#ion{s) ❑ Roofing ❑
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [Q Siding[p] Other[&
Brief Description of Proposed
Work: Attic and basement insulation and air seali�throughout
Alteration of exdsOng bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa.if New house andbr addition_to existnia housinq,.comatete the-following:
a. Use of building:One Family Two Family Other
b. Number of rooms in each family unit Number of Bathrooms
c. is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. 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 100 ft.of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No.
1. Septic Tank City Sewer Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, Young,Maureen as Owner of the subject
property
hereby authorize American Installations
to act on my behalf,In all matters relative to work authorized by this building permit application.
See attached 10/27/2018
Signature of Owner tate
I. American Installations .as Owner/Authorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
American Installations
Print Name
k, 10/27/2018
Signature of Owng0gent Data
Section 4. ZONING All Information Must Be Completed.Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L:= R-= L:= R.,=
Rear
Building Height 1771
Bldg.Square Footage 010
Open Space Footage %
(Lot am minus bldg&paved
Peking)
#of P2Lid�n Spaces L--�
Fill: IF
(Volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DON'T KNOW 0 YES 0
IF YES,date issued:1 i
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book i PageL
and/or Document#i I I
B. Does the site contain a brook,body of water or wetlands? NO 0 DONT KNOW 0 YES 0
IF YES,has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO 0
IF YES, describe size,type and location:
E. Will the construction activity disturb{clearing,grading,excavation,or filling)over I acre or Is it part of a cornmon plan
that will disturb over I acre? YES 0 NO 0
IF YES,then a Northampton Storm Water Management Permit from the DPW Is required.
De artm`ent use`onl
P Y
City of Northampton status of Perrr►►t
_ . - -c uilding Department Cuib CutlDhveway Perr►it
E C E 1 V G Q 212 Main Street SewerlSep6c Availabil►ty
Roam 100 w4birMlelt Availab(fiity
N rthamptan, MA 01060 Two Sets of Structural Pians
a Cj 3 1 20an 41 587-1240 Fax 413-587-1272'RiPlotlSite Pians
OkF►er Specify a
HEFT oF1�6A NST UCT,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
20 Marc Cirlce, Florence MA 01062 Map 11 LotnqqUnit.
Zone Overlay District
Elm St.District CS District
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record•
Maureen Young 20 Marc Circle,Florence MA 01062
Name(Print) Current Maffing Address:
(413) 320-8025
See attached Telephone
Signature
2.2 Authorized Agent:
American Installations 130 College St., Ste 100 South Hadley, MA 01075
Name(Print) Current Malling Address:
\,\IaL.XA k, C,cs�aw�✓ 413-552-0200
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building $2,900.00 (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Constriction from 6
3. Plumbing Building Permit Fee j
j Q
4. Mechanical(MVAC)
S.Fire Protection
6. Total=(1+2+3+4+6) $2,900.00 Check Number
This Section For Official Use Only
Building Permit Number. Issued:
Sfignature• t t (, {F�
Building Commtesionedinspector of Buildings Data
20 MARC CIR BP-2019-0537
GIs#: COMMONWEALTH OF MASSACHUSETTS
MV.BloSk: 12C-079 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: INSULATION BUILDING PERMIT
Permit# BP-2019-0537
Proiect# JS-2019-000867
Est.Cost:$2900.00
Fee:$65.00 PERMISSION IS HEREBY GRANTED TO
const,class: Contractor: License:
Use Group: AMERICAN INSTALLATIONS LLC 106178
Lot Size(sq.ft.): 20037.60 Owner: YOUNG MAUREEN
Zoning: RI(100)/URA(100Z/wsP(100)/ Applicant: AMERICAN INSTALLATIONS LLC
AT: 20 MARC CIR
Applinant Address: Phone: Insurance:
130 COLLEGE ST (413) 552-0200 wc
SOUTH HADLEYMA01075 ISSUED ON.1117120180:00.-00
TO PERFORM THE FOLLOWING WORK.-ATTIC AND BASEMENT INS 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.. Eirs Itbe artment 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 Occypancy Si nature:
Fellype: Date Paid: Awognt.,-
Building 11/7/2018 0:00,00 $65,00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner