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10D-004 A� DATE(rwwonrrr) GERTlFICATE OF LIABILITY lNSURANGE 9/4/2018 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 this cartifEcats holler Is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION M WAIVED,Subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate doers not confer rights to the c"ficats holder in lieu of such endor a. PRODUCER Linda Powers Webber i Grinnell =HE (413)586-0111 P'� 44i3)SS4-nasi 8 North fling Street •MAIL ,ipoworsiluebberandgrimsell.con INSURERISI AFFORDING COVERAGE MAIC e Xortbanpton KA 01060 BISU RA: 1 rs NUtual Casyslt INSURED INSURER B.Berkwhire, Hatbaway GUARD Ins. Co. American Installations, LLC INSURER C: nttnl ire$ i Susanno Couture BISURERO; 130 College Street, suite 100 INSURERa: south Radley Nil 01075 MURN F.- COVERAGES CERTIFICATE NUMBERXaster 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 REOUIREMENT,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. LTR LTR AKWL Pw TYPE OF INSURANCE r LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 11000,000 A x CLAIMS MADE ❑OCCUR DAMAGETO $ 500,000 SD3535217 9/412018 9/4/2019 MED EXp am non $ 10,000 PERSONAL.d ADV INJURY $ 11000,000 GEN1.AGGREGATE LIMIT APPLIES PER: GENERAL.AGGREGATE S 2,000,000 x POLICY❑29 F�LOC PRODUCTS-COMPIDP AGG $ 2,000,000 $ AUTOMOBILE LIABILITY 3 11000,000 ANY AUTO BODILY INJURY(Per pomm) $ OWNED Z s�SCHEDULED 583535217 9/4/2018 9/4/2019 BODILY $ALA NON40hVNED PROPERTY DAMAGE $ x HIRED AUTOS x AUTOS -- Z OwSZ000 x CwvS2,000 PIP- $ 8,000 X UMBRELLA UAB OCCUR EACH OCCURRENCE 1,000,000 A EXCESS UAB CLA -MADE AGGREGATE $ 1.000,000 DED I X I RETENTIONS io.000 533535217 9/4/2018 9/4/2019 WORKERS COMPENSATION x AND EMPLOYERS'LI ABI ITY '—'— IN ANY PROPRIETORMARTNERIEXECUTNE r❑N/A ILL EACH ACCIDENT $ 500,000 B OFE EXCLUDED? X809917 9/4/2018 9/4/2019 - pknmm In 1114) E.L DISEASE-EA EMPLOYEE S 500,000 If d llre under PTICN OF OPERATKM below L DOME- UNIT 3 500,000 1A ccauwraial vropez+-y 5A3533217 9/4/2018 9/4/2019 d9WCWS*$1,0DD DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES(ACORD 101,AdNBond Renwft 8o"ft way be aftelod I mon epme is regWr4m CERTIFICATE"OLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Bvidenco of insurance THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE n W Grinnell, CPCU, CICS ®1588-2014 ACORD CORPORATION. All rights reserved- ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD INS025(201401) Commonwealth of Massachusetts Construction Supervisor Division of Professional Licensure Unrestricted-Buildings of any use group which contain Board of Building Regulations and Standards less than 56,000 cubic feet(981 cubic meters)of enclosed Constructibn Supervisor space. CS-106178 4pires:09/29/2019 WESLEY COUTURE . 218 LATHROP%STREET SOUTH HADLEY-MA 01075 Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this Ncense. For information about this license Commissioner Call(617)727-3200 or visit www.mass.gov/dpi .. �'� Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Type: LLC Registration: 175982 AMERICAN INSTALLATIONS,LLC. Expiration: 06/26/2019 130 COLLEGE STREET SUITE 100 SOUTH HADLEY,MA 01075 SCA 1 CJ 20M-05/11 Update Address and return card. Mark reason for change. _ n A&L-a-e 0 Employment.0 mss#rare . r��s'�I-JJIINlyNINVl��n!��TtIJNI!'/lIIII'�li office of Consumer Affairs 6 Business Regulation V-"t, HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:LLC before the expiration data. If found return to:Rgol"ion ExpirationOffice of Consumer Affair and Business Regulation ` 175982 06/26/2019 10 Park Plata-Suite 5170 AMERICAN INSTALLATIONS,LI C. Boston,MA 02116 WESLEY COUTURE `,Q„ 130 COLLEGE STREET SUITE 100 U —/:ZZL -' SOUTH HADLEY,MA 01075 Undersecretary valid without signature The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations wi 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Busincss/OrganirtttioNtndividual): 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): 1.0 I am a employer with 60 4. ❑ I am a general contractor and 1 6. ❑ New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.t 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 officers have exercised their !4.❑ Electrical repairs or additions required.] 3.F1 am a homeowner doing all work right of exemption per MGL 1 1.❑ 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' 131A Other. Insulation comp. insurance required.] 'Any applicant that checks box#1 must also rill out the section below showing their workers'compensation policy information. t l-lomeowners who submit this affidavit indicating they are doing all work and them hire outside contractors must submit a new at3`idavit 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. _ 1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Guard Insurance Companies Policy#or Self-ins. Lic.#: URWC66009917 Expiration Date: 09/04/20n19 Job Site Address: LV kf � UkA City/State/Zip: Q rQ{ �t tv{UL055 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 of a fine up to$1,500.0-0 an for one-year impr'tsooneent,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.44 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 hereby certify under the pains and pens/ties of perjury that the information provided above is true and correct. 5i ntr : Dat : Phonq#: 413-552(-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.Cityrrown 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(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. 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 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. 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. 11.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 SURVIVE THE 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%RE-STOCKING FEE BASED ON THE COST OF SAID MATERIALS. 21.THIS AGREEMENT SHALL BE EFFECTIVE ONLY UPON ITS EXECUTION BY ALL PARTIES HERETO, PRIOR TO WHICH TIME IT SHALL BE DEEMED A 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 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 EVENT THE CLIENT AND COMPANY HAVE A DISPUTE REGARDING ANY OF THE TERMS, CONDITIONS, PROVISIONS, OR PERFORMANCE OF THIS AGREEMENT, THE PARTIES AGREE TO PLACE THE MATTER INTO ARBITRATION BEFORE AN INDEPENDENT ARBITRATOR ASSIGNED BY THE AMERICAN ARBITRATION ASSOCIATION TO RESOLVE THEIR DISPUTE. 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.Americanlnstallations.com BBB. Licensed&Insured _ • MA CSL#.*106178 American Installations MA Registrotion#175982 130 College Street Suite 100,South Hadley,MA 01075 •Office:(413)552-0200 Fax:(413)552-0202• Email:support@Americanlnstallations.com Dolen,Ana 11/12/2018 (L-) (Flirt) (0xe) 67 Water Street Leeds MA 01053 (Ad*—) (CRY) IS—) (ZIPI (413)695-7548 Limai_2000@yahoo.com (Hama) (C.E) (EM,Ie 476 416 18-3263 ISR.ID) (Job.) Quantity Unit Unit Cost Total Air Sealing AIR SEALING 8 man hour $ 85.00 $ 680.00 WEATHERSTRIP DOOR&ADD SWEEP 2 leach $ 80.00 $ 160.00 Air Sealing $ 840.00 Air Sealing Incentive $ (840.00) Air Selaing WX Balance $ Weatherization CRAWLSPACE WALL R10 RIGID BOARD 92 leach $ 4.05 $ 372.60 ATTIC FLAT-10"OPEN R-37 CELLULOSE 528 sqft $ 1.56 $ 823.68 VENTILATION CHUTES 40 each $ 2.50 $ 100.00 ATTIC DAMMING-R-38 FIBERGLASS 60 sqft $ 2.05 $ 123.00 ATTIC HATCH-SEAL&INSULATE 1 each $ 60.00 $ 60.00 Total Weatherization $ 1,479.28 Weatherization Incentive $ 1,109.46 Total Project $ 2,319.28 Total Utility Contribution $ 1,949.46 Total Customer Contribution $ 369.82 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= $ 369.82 conditions are satisfactory and are hereby accepted.You are authorized to do work as specified.Payment will be 1/3 down prior Down Payment= $ 123.00 El cc to start of work,and balance due upon Completion. PAID Balance Due Upon Completion= $ 246.82 vBnxure Dxe Dolen,Ana 11/12/2018 P,.P"Ow.IPHYU Property owner ISIPd ° B.Zamer 3. Z-a*"r 11/12/2018 Rro,aamxrve(Pnml It"I(San) Dxe 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'COMPANW,AND THE OUSTOMER(S)NAMED ABOVE,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. 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: 67 Water Street 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 11/23/2018 Date Signature of Permit Applicant City of Northampton Massachusetts X. DEPARTMNT OF BVIZDXNG INSPECTIONS 222 Main Street 0 Municipal Building Nortba MIL 01060 Property Address: 67 Water Street Contractor Name: American Installations Address: 130 College Street Ste, 100 City, State: South Hadley, MA Phone: 43-552-0200 Property Owner Name: Ana Dolen Address: 67 Water Street City, State: Leeds, MA 01053 1, 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 nature o Qin V- Date 11/23/2018 SECTION 8-CONSTRUCTION SERVICES 8.1 licensed Construction Supervisor. Not Applicable ❑ Name ofUc seHoldeer: Wesley K. Couture 106178 License Number _130 Colleke St., Ste 100 South Hadley,MA 01075 9129119 Address Expiration Date UU-PaA4 .C1 413-552-0200 SignaturTelephone 9.Registered Hoene ininrovement Conti�actori ._ _. Not Applicable ❑ Wesley Couture 175982 -Company Name Registration Number American Installations 6126119 Address Expiration Date 130 College St., Ste 100 South Hadley, MA 01075 Telephone 413-552-0200 SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(6)) 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...... ❑ U... Home Owner ftob*Ofion The current exemption for"homeowners"was extended to include Owner-occupied Dwellines of one(1) or two(2)families 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 780, Sixth Edition Section 1083.5.1. 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 an/or farm structures.A versa 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 bufldine 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 persons) you hire to perform work for youunder 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 see attached SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing Or Doors E3 Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [Q Siding[L7] Other[IYQ Brief Description of Proposed Work: Attic and basement insulation and air sealing throughout Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roil -Sheet 6a._If New house andor addition to exlsting°housing.complete 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 i• 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 Signature of Owner Data 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 �► Q1kll4 V-.- C�� , Signature of r/Agent Date S Section 4. ZONING Alt Information Must Be Completed.Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning Ibis column to be filled in by Building Depmhocat Lot Size Frontage Setbacks Fmat A& L-= R= L.= R Rear Building Height Bldg.Square Footage Open Space Footage % (Lot area minus bldg&paved p"king) #of Paidrig Spaces Fill: (Volume&Locatioull A. Has a Special Permit/Variance/Finding ever been issued for/on the site? 140 0 DONT 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 W YES: enter Book Page arid/or Document#! 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: I I 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 common 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. Usv (J47 Department use only RECEIVED Ci of Northampton Status of Perriirt Bu ding Department Curb Cut/Dnveway Permit 12 Main Street Sewer/Septic Availability N O V 2 q 2018 Room 100 Water/Well Availability; ort ampton, MA 01060 Two Sets of StructuralPlans s: 3-5117-1240 Fax 413-587-1272 PIoUSite Plans DEPT.OF BUILDING INSPECTIONS OtherSpedfy, NORTHAMPTON,MA 01060 APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1-SITE INFORMATION1.1 Property Address: This sectionto be co*mplO'tpd by office Map P Y Lot o / Unit. 67 Water Street Zone Overlay District Elm SL District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Ana Dolen 67 Wa ter Street Name(Print) C rrenta�1in pp,dd�� s: 4136956-754 See attached Telephone Signature 2.2 Authorized Agent: American Installations 130 College St., Ste 100 South Hadley, MA 01075 Name(Print) Current Mailing Address: i V— �. 413-552-0200 Signature J Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building 2320.00 (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) (.l' 5.Fire Protection 6. Total= 1 +2+3+4+5) 2320.00 Check Number This Section For Official Use Only Date Building Permit Number. Issued: Signature: Building Commlesionerflnspector of Buildings Date 67 WATER ST BP-2019-0645 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: IOD-004 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-2019-0645 Project# JS-2019-001054 Est.Cost: $2320.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: AMERICAN INSTALLATIONS LLC 106178 Lot Size(sq.ft.): 6446.88 Owner: DOLEN ANA Zoning. URB(100)/ Applicant: AMERICAN INSTALLATIONS LLC AT. 67 WATER ST Applicant Address: Phone: Insurance: 130 COLLEGE ST (413) 552-0200 WC SOUTH HADLEYMA01075 ISSUED ON:11/30/2018 0:00:00 TO PERFORM THE FOLLOWING WORK.-ATTIC 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 Deaartment 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 Sisnature: FeeType: Date Paid: Amount: Building 11/30/2018 0:00:00 $65.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner