28-075 (4) 255 SYLVESTER RD BP-2019-0861
GIs#: COMMONWEALTH OF MASSACHUSETTS
M .Block: 28-075 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-2019-0861
Project# JS-2019-001431
Est.Cost: $5600.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor., License:
Use Groin AMERICAN INSTALLATIONS LLC 106178
Lot Size(sa.ft.): 80019.72 Owner. PREMO DAVID A&CLAIRE A
Zoning: Applicant. AMERICAN INSTALLATIONS LLC
AT: 255 SYLVESTER RD
Applicant Address: Phone: Insurance:
130 COLLEGE ST (413) 552-0200 WC
SOUTH HADLEYMA01075 ISSUED ON:2/5/2019 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 Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
FeeType: Date Paid: Amount:
Building 2/5/2019 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
Ns U C.6�Ti0/t'/�
.epartment;use Drily:
City f Northampton Status of Permit
FEB - 4 2019 uild ng Department curb Cut/Dnveway Permit
21 Main Street Sewer/Septtc•Availabihfy
c,F�T or rui��wc�r,sPECTioNs Dom 100 Water/1NellAvailabihty
NORTHAMPTON,MA 0106 pton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 PIoUSite Plan's . . . _
Other;$pecify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION 6 (,;?'-/9"- 4qo/
1.1 Property Address:
This section to be Completed by office
i
255 Sylvester Road Map Lot 0 , Unit.
Florence MA 01062 Zone Overlay District
Elm St District CS District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
David&Clair Premo 255 Sylvester Road,Florence MA 01062
Name(Print) Current Mailing Address:
(413) 584-7797
See attached Telephone
Signature
2.2 Authorized Agent:
American Installations 130 College St., Ste 100 South Hadley, MA 01075
Name(Print) Current Mailing Address:
\ � - • C Vti 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 5,600.00 (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
S.Fire Protection
6. Total=(1+2+3+4+5) 5,600.00 Check Number
This Section For Official Use Only
Date
Building Permit Numb r. 1
Issued:
I /-----'
Signature: 4 Z-y-
Building Commissionerlinspector of Buildings Date
R
Section 4. ZONING Ali 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 F���i
Frontage
Setbacks Front
Side L:Q R:= L= R:Q Q __
Rear I �
Building Height —� Q
Bldg.Square Footage %
Open Space Footage % �---•�
(Lot area minus bldg&paved
addn
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW O YES Q
IF YES,date issued:,
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW O YES O
IF YES: enter BookPage�� and/or Document#1
B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW O YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained O , Date Issued:
C. Do any signs exist on the property? YES O NO O
IF YES,describe size,type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES O NO O
IF YES, describe size, type and location: l
E. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES O NO O
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
f
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing
Or Doors 171
Accessory Bldg. ❑ Demolition ❑ New Signs 101 Decks [O Siding[p] Other I&
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 Roll -Sheet
6a.If New house andoraddition.to exist ing°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.
I. 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, David&Clair Premo 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 1/31/2019
Signature of Owner Date
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
V- C�V' 1/31/2019
Signature of r/Agent Date
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
\ K.. d 413-552-0200
Signature ' Telephone
9.Registered Home lmarovement Contractors 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 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 budding permit.
Signed Affidavit Attached Yes....... IN No...... ❑
11. .=^Home Owner:Exemption
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 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 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 hermit.
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
f
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: 255 Sylvester Road
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
1/31/2019 u-' Caau/�
Date Signature of Permit Applicant
t
mass save
Licensed u inwred PARTNER
MA GSf s;1 t.Y,178
MARtOiUaonon&1759V American Installations www•Arnericaninstallations.com
130 Collate Skeet SWU 100,Swtb ltadlav,MA OWS-Office:(413)SS2.0200 rax:(413)SSI-020Z•Email snpporidKmarksnMsbENad"Leom
Customer Name:David Premo
Email:Not provided
Phone:413-584-7797
Premise Address:255 Sylvester Rd,Northampton,MA 01062
Project ID:3622905
Date:Dec.28,2018
Job Description
Air Sealing at Estimated 62.5 CFM50 Per Hour Living Space 18 hr $1,666.44 $0.00
Attic Floor-4"Open Blow Cellulose Living Space 2136 SF $3,161.28 $790.32
Hatch-2"Thermal Barrier Polyiso Living Space-,...2_...__ each $92.56 $23.14-
Damming Living Space 280 each $669.20 $167.30
Project Total $5,589.48
Weatherization incentive ($2,942.28)
Air sealing incentive ($1,666.44)
Total Program Incentive -$4,608.72
Customer Total $980.76
WARPANTY.American installations,LLC 41 provide the above stated homeowner with a 1-year worknrnship warramv.
American instaNations,LLC hereby proposes to Hanish all material and labor to complete the above scope*11 work in accordance with the above spedfications and all local and state
btik3ns m1dadons for the TOW Contract value as stated herein.
ACCEPTANCE OF PROPOSAL: The above perces, spedfications and conditions are TOTAL CONTRACT VALUE-S 980.76
satisfactory and are hereby accepted.Youere auMoriced to do work as specified.Payment Down Payment"S 200.00 13
will be 10 down prior to start of work,and balance due upon Completion.
PAID
Balance thEc Upon Completion• S 780.76
ssenoturo David Premo(Jan 1,2019) oate 12-28-18
property Owner(Pdntl Premo,David&Clair 1SIRM Page 1 of 1 Dat
, I a
Representative:(print) iasonBhaian (Sig„) D 12-28-18
1H1 AeREEMEMI D COWOSm OF IMS PAGE AMD TME RESDgE ADE of IMS IAOEAMO SMALL N COMSWEND TIEEMSNE AOMMEW t1 IHE AMUES pWQtFD IMS AOOEEMEMI it IETW EOM AMENCAM IMSTA LAIR]MS,LLC MIeIMSTU NEFFSLNED 10 A&TOMAAMH,
AhOTMt COSI W4M%l MUM AIM MI MMI01 NnERME010AS'QRMI',AMO WILL aE SUEIECT IOALL APFROPRNIE LAWS.R@USATx111 AA00R01MAwQS OF THE SIAM W MASSAOMUSITIS ON COMMECIR:Ut MAAILINlLY,ASWELL AS ALL LOCAL)UM9 CnOM1.
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 CUSTOMERS)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 TH E 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 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 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 EXTENTTHOSE 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,RAFTERS101STS 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 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 15 IN ROUTE TO THE CLIENT COULD RESULT
IN A S%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.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www.mass.gov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Let±<iibly
Name(Business/Organization/individual): 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):
1.51 l am a employer with 60 4. ❑ 1 am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.El am a sole proprietor or partner- listed on the attached sheet.I ❑ 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. ElWe are a corporation and its
required.] officers have exercised their 10.El Electrical repairs or additions
3_❑ I am a homeowner doing all work right of exemption per MGL 1 l.❑ Plumbing repairs or additions
myself.[No workers'comp. c. 152,§1(4),and we have no 12.❑ Roof repairs
insurance required.]t employees. [No workers'
comp.insurance required.] 13.®Other Insulation
'Any applicant that checks box 111 must also rill 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 job site
information.
Insurance Company Name: Guard Insurance Companies
Policy#or Self-ins. Lic.#: URWC609917 Expiration Date: 09/04/2019
Job SiteAddress: .25`5 SU)V,0 (bbd City/State/Zip: FIQV,AI�O k nl�v2
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$1,500.00 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#: 413-55 -0200
Oficial use only. Do not write in this area,to be completed by city or town offreiaL
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#:
Commonwealth of Massachusetts Construction Supervisor
Division of Professional Licensure Unrestricted-Buildings of any use group which contain
�f Board of Building Regulations and Standards less than 55,000 cubic feet(991 cubic meters)of enclosed
Construction Supervisor
space.
CS-106178 Upires:09/29/2019
WESLEY COU rURE
218 LATHROP=OTREET.
SOUTH HADLEY MA 011075
' Failure to possess a current edition of the Massachusetts
State Building Code is cause for revocation of this tkense.
For infomntion about this license
Commissioner Call(617)727-3200 or visit www.mass.gov1dpl
rt
n� fl-jyl,yyljt�UF'C�' yl t� n���Gf2 Zs :1el
1
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 E>q�iration: 06/26/2019
SOUTH HADLEY,MA 01075
Update Address and return card. Mark reason for change.
SCA 1 0 20M-05111 n Add-;,e—a n o�..,.,f_O_E.010nylneni_O I oat Cerd
� r-��c�rtttitr�xttkvrl/f r�' �taJNrr•�uN�r1
Office of Consumer Atkin&business Regulation
7� HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only
TYPE:LLC before the expiration date. If found return to:
�I
E321ration Office of Consumer Affairs and Business Regulation
175882 06/26/2019 10 Park Plaza-Suite 5170
AMERICAN INSTALLATIONS,LLC. Boston,MA 02116
WESLEY COUTURE
130 COLLEGE STREET SUITE 100
SOUTH HADLEY,MA 01075 Undersecretary^ valid without signature
ACORU- DATE(MMRDonyYY)
` CO CERTIFICATE OF LIABILITY INSURANCE 9i4i2018
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 pollcy(les)must be endorsed. If SUBROGATION IS WANED,subject to
the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder In lieu of such endorsement(*).
PRODUCER Linda Powers
Webber & Grinnell PHONE (413)586-0111 FRx (413)5e6-44e1
B North Ring Street AO-MAIL DFUMS.ipowersQwebberandgrinnoll.cow
INSUREAM AFFORDING COVERAGE Northampton MR. 01060 INSURERA: 1 rs Mutual Casualt:BINSURED NaURERsarkshire Hathawa GUARD Ins.EHN
American Installations, LLC INSURER C-
Attnt Was a Susanne Couture INSURERD-
130 College Street, Suite 100 INSURER E:
South Hadley MA 01075 INSURER P.
COVERAGES CERTIFICATE NUMBER:Master ZzV 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.
TYPE OF INSURANCE Lam
COMMERCIAL GENERAL LIAELRY EACH OCCURRENCE $ 1,000,000
A X CLAIMS-MADE �OCCUR S 500,000
5D3535217 9/4/201$ 9/4/2019 MED EXp CAny one faun $ 10,000
PERSONAL 6 ADV INJURY S 1,000,000
GENL AGGREGATE LIMIT APPLIES PER: GENERAL AGGR83ATE $ 2,000,000
X POLICY F]J� F-1 LAC PRODUCT'S.COMPAP AGG S 2,000,000
O $
AUTOMOBILE LABILITY $ 1.000,000'
A ANY AUTO ODDLY INJURY(Per POMM) S
ALL�D X E�AD 523535217 9/4/2015 9/4/2019 BODILY S� AC.
X HIRED AUTOS X NIJTD PROPERTY DAMAGE S
X con$2000 X ecm $2,0D0 plp.11mic $ 8,000
X UMBRELLA Lh OCCUR EACH OCCURRENCE _- S 11000,000
A EXCESS LIAe --HCLAVAS-MADE AGGREGATE $ 1.000,000
DIED I X 503535217 9/4/2015 9/4/2019 $
WORKERS COMPENSATION y
AND EMPLOYERS'LIABILITY ANY PROPRIETORRARTNERIEXECUTNE Y�N/A
EL EACH ACCIDENT $ 500,000
8 OFRCERyin N EXCLUDED? 071110609917 9/4/2018 9/4/2019
(Marrdabry H) E.L.DISEASE-EA EMPLOYEE S 500,000
It s Osecdbe under
E.L.DISEASE-POLICY UNIT I$ 500,000
A Ccenaraial Property 5A3535217 9/4/2018 9/4/2019 dedw"SIADO
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACDRD 101,Additml Remarks 8che&q*may be amadrd N more apace k nquN,rl)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Evidence of insurance THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE ,/J1
W Grinnell, CPCU, CIC ��
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INS025(201401)