17C-080 (7) 39 HIGH ST BP-2019-0931
GIs 0, COMMONWEALTH OF MASSACHUSETTS
Map-.Block: 17C-080 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-2019-0931
Project# JS-2019-001555
Est Cost:$2600.0
Fee $65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: AMERICAN INSTALLATIONS LLC 106178
Lot Size(sq. ft.): 7797.24 Owner: LOUGHREY KEDDIE
Zoning: URB(100)/ Applicant: AMERICAN INSTALLATIONS LLC
AT: 39 HIGH ST
Applicant Address: Phone: Insurance:
130 COLLEGE ST (413) 552-0200 WC
SOUTH HADLEYMA01075 ISSUED ON:3/5/2079 0:00:00
TO PERFORM THE FOLLOWING WORILATTIC 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 Stimulate:
FeeType: Date Paid: Amount:
Building 3/5/20190:00:00 565.00
212 Main Street,Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
Depamnent use only:
FEB 7_ 7 2019 Ci Of oroampton Status of Permit
B Idi Department Curb GurlDrhv"y Permit _
_ 12 Sin Street seweNSeppcAvanabARy
rTIV` R m 100 WalerlWen'Avanebllity.l:
ort ampton, MA 01060 Two setsMstmmrel'Plans
phone 413-567-1240 Fax 413-587-1272 porsi a Plena .
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION i-SITE INFORMATION
1.1 Property Address: This section to be completed
�byaMce
39 fligh Street Map—1-7('.-- Lot 4 a D -Unit
Florence, MA 01062 Zone overlay Distdet
Elm St Maui G CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
_Keddie Loughrey 39 High Street Florence, MA 01062
Name(Pdng C.M MaNig Address:
See attached T aphone
Signabe
2.2 Authorized Aoem:
American Installations 130 College St., Ste 100 South Hadlev, MA 01075
Name lPMq Cumxv MaBM AdMuor
�J)QX IA K i 413-552-0200
Slgm wra Telaplrttie
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Es1mated Cost(Dollars)to be Official Use Only
cmideted Iry permita cant
1. Building $2,600.00 (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from
3. Plumbing Sundng Permit Fee
4. Mechanical(HVAC)
5.Fire Protection
S. Total- 1 +2+3+4+5 $2,600.00 Check Number
This Section For Official Use Only
Building Permit Number. Data
Issued:
Signature: / 2- 27-201(7
Bladng Commkstonemnspector of BWWnga Data
Section 4. ZONING Ag Information Must lie Completed.Permit Can Be Denied Due To Inc nplete Information
Existing Proposed Required byZoniog
Tatscdumntobe fined in by
Building Depermeut
Lot Site
EM!Me �. _—( �
Setbacks front 0
Side L:= R:0 L:= R:=
Rear
Building Height O (J
Bldg.Square Footage
amanavu.b ,
#ofP Spaces
wlumn&I.aet®
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NOO DONT KNOW O YES O
IF YES,date Issued:I j
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW O YES O
IF YES: enter Book PageF and/or Document#IL 1
B. Does the site contain a brook, body of water or wetlands? NO O DONT IWOW 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:
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 dishab(deadng,grading.excavetm,or filing)over 1 acre or Is B part of a common plan
that vdfl disturb over 1 acre? YES O NO O
IF YES,then a Northampton Moon Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ I Replacement Windows ABeratlon(s) Roofing ❑
Or Doors O
Accessory Bldg. ❑ Demolition ❑ New Signs 0.7] Decks M Siding(01 Other[IN
Bdet DasaiPOO ofYoposed
Work: Attic and as
ement insulation and airsealing throughout
Alteration of exhi ft bedroom--Yes-No Adding new bedroom Yes No
Attached Narrative
Plans Attached Rog -Sheet Renovating unfinished basement _Yes No
_. _ .. . _.
Ga.NNraw house and or addilionto existing-housing complete the following,
e. lyse of building:One Family Two Famiy Other
b. Number of name in aeon family unit Number or Bathrooms
a Is there a garage atlzched? '
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
I. Method of testing? Fireplaces or Woodsmves Number of each_
g. Energy Conservation Compliance. Mosscheck Energy Compliance form attached?
h. Type of construction
1. isconstruWonwbhin100ftofvregends?_Yes _No. iswnsWCOmwgMn100yr. flwdplebr_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_ CitySewer_ Pdvatewaff_ Cbywater Supply_
SECTION To-OWNER AUTHORIZATION-TO HE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, Keddie Loughrey as Ownrofthe subject
properly
herebyeuthodze American Installations
to act on my behnif,in ail matters relative to work aWhodad by this building permit application.
See attached 2/20/2019
Slgmhre of Ovnwr Dam
I, American Installations asOvmer/Aubadud
Agent hereby declare that the statements and trdomation on the foregoing application are oue and accurate,to the best of my knowledge
and belief.
Signed underthe papa and penalties of perjury.
American Installations
Print�Name
�
-II.i.J:DSl".L1 �. ALtQ. 2/20/2019
Slgnalva M dAgent Dela
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor. Not Applicable ❑
Name of License Holder. Wesley K. Couture 106178
Uwme Number
130 College St., Ste 100 South Hadley,MA 01075 9/29/19
�pAd�dre�s,e��� lionden Date
1e1d122Ak3A K. 11'LUXL/U2. 413-552-0200
SlOnabrm Telaplane
9.Reaisnretl Nome imorovomerit Contract .. ... . 1. NolAppOceMe ❑
Wesley Couture - 175982
Company Name Registration Number
American Installations
Address; 6rpnauon 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,§26C(b])
Workers Compensation Insurance affidavit must be completed and submitted with this application.Failure to provide this affidavit will result
In the dental of the issuance of the building pemit.
S A0'unvl Attached Yes....... 11 NO...... ❑
11,Home Owner Exemption
The current exemption fm'lromeownes"wet arteuded to mclude4wpen-oeeuoled Dwelfines ofone(I) m lwo(2)families
and to allow such homeowner to engage an individual for him who does not possess a license,provided tbatthe owner acts
as saoervsor.CMR 780, Sixth Edition Section 1083.5.1.
Definition of Homeowner.Pasou(s)who owm a peace]oflend m which helshe resides or intends n reside,on which them
is,or is intended to be,a one or two fandly dwelling attached or detached structures accessary to such use aid/or farm
suuchaes.A Dermot who constructs mthan one house in a two-year period ah ll tot be catedidered a lasnemnae
Such%omeovmd'shall submitm the Building Oficial,on a form acceptable to the Building nh she Lhag be
responsible for all web workperfermed order the ballelize,permit
Asacting Coustwclionfiva icor Yom pressure On thejob site will be required from time n time,durngacl upon
completion ofthe work fm which this pumitis issued
Also be advised that with reference be Chapter 152(Workew'Compemaior) and Chapter 153(11abslityofbmployeste
Employees for injuries not resulting in Death)ofthe Massachusetts General laws Anaotated,You may be gable forp"Wev(s)
you him n perfo®work far you under this permit.
The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,Gtr of
Northampton Ordmanew,State and].owl Zomag laws and State ofMassschuseus General laws Anurrtanj
Howeawner 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: 39 High Street Florence MA 01062
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
2/20/2019 1, � V CAJDA k
Date Signature of Permit Applicant
City of Northampton
Massachusetts
z
OFFAR21ffirT OF Burzarm znWircF10R5 iS •Z+
212 /Yin Stzect • INniaipel suilc ing
Routh mp n, M 01060
Property Address: _39 High Street, Florence MA 01062
Contractor
Name: American Installations
Address: 130 College Street Ste. 100
City, State: South Hadley,MA
Phone: 43-552-0200
Property Owner
Name: Keddie Loughrey
Address: 39 High Street
City, State: Florence. MA 0106)
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 signature�'wV--
/ Calmp
ili,1y-
Date
2/20/2019
4#04www Amenunlnr5 lzd.n5.mm
7 • Licensed&Insured
qQW \ 1 MA0L M 106178
ATBrIC8r1Installations MA Regisfmfiow A 175981
130 Wge9rtA Sake IN.$WU Headline.MA 0105 Mee:1413)F5,not Fac(41315!s24202-lassuld:
SuppaSQNnnlonlnYdllalbnS.cOm
Loughrey,Keddie 2/5/2019
39 High Street wn Florence MA 01062
mmi a
1(413)325-782 keddieloughrey@gmail.com
Ina
AM 036 �0 19 MAS
sw,a Quantity Unit Unit Cost m Total
Air Sealing
AIRSEALING 8 man hour $ 85.00 $ 681
WEATHERSTRIP DOOR&ADD SWEEP 4 each $ 80.00 $ 320.00
Air Sealing $ 1,000.00
Air Sealing Incentive $ (1,000.00)
Air Selaing WK Balance $ -
Weathertzatlon
BASEMENT SILLS-R19 FG BATT 120 sett $ 1.95 $ 234.00
ATTIC FLAT-r OPEN R-30 CELLULOSE 420 sgft $ 1.44 $ 604.80
VENTILATION CHUTES 58 each $ 2.50 $ 145.00
ATTIC DAMMING-R-38 FIBERGLASS 90 sqft $ 2.05 $ 184.50
PULL-DOWN STAIR-THERMADOME,BUILT-UP 1 each $ 237.65 $ 237.65
BASEMENT-INSULATE BULKHEAD DOOR&INSULATE 1 each $ 110.00 $ 110.00
REMOVE INSULATION 114 $ 0.7S $ 10.50
Total Weatherization $ 1,526.45
Weatherization Incentive $ 1,136.96
Total Project $ 2,526A6
Total Utility Comminution $ 2,136.116
Total Curtomer Contribution $ 389A9
wAPFWIY'.Pmenzen InNlhYenS...11 nmmG[ne abra dar.homewne,Mna Spar wMmern'so semniv.
arear-randem.n. mauMand Ian'bammMne Neabs arga -A In aanNane wlea Ineabwa soeervtlbna.mallAwldnaaw
Suuars,waitlmn,m,in,mM1l conrM wlwaa auW heum.
A EPFANCE OF PROPOSAL:me above Wcou,seaerodons and TOTAL CONTRACT VALUE= $ 389.49
wnalaions are vanAinorvana.,e na,aW sages.
'Liwe
authorized w do wi sPaalR.d.Payment will be 1/3 down Prior Down Payment= $ 129.00 ® ckeck.
to Sortor wrok and belena due u,n fwmpktlon. "We BalanceDue Upon Completion= $ 260.49
�•�Loughrey,Keddie (J / 2/5/2019
R.Zamer 2/5/2019
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 15 BETWEEN AMERICAN INSTALLATIONS,LLC HEREINAFTER REFERRED TO AS"COMPANY",AND THE CUSTOMER(5)NAMED ON THE REVERSE SIDE,HEREINAFTER
REFERRED TO AS"CLIENT",AND WILL BE SUBJECT TO ALL APPROPRIATE LAWS,REGULATIONS MD 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 ATA RATE OF ONE AND ONE-HALF(1-1/21 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'FEB,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 HAVETHE RIGHTTO A LEIN ON THE PROPERTY.
3.THE COMPANY AGREES THAT WHEN DECAYS BECOME KNOWN TO THE COMPANY,THE COMPANY WILL ADVISE THE CLIENT AS SOON AS REASONABLE.
A.COMPANY AGREES THAT,NOTWITHSTANDING ANY AGREEMENT FOR MATERIALS AND/OR LABOR BETWEEN COMPANY AND THIRD PARTY,COMPANY IS RESPON98LE TO
CUENT FOP 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 MAY BE REQUIRED TO REGISTER OR MAIL IN A WARRANTY CARD OR OTHER
EVIDENCE OF OWNERSHIP AND USE OF SUCH EQUIPMENTAND/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.
T.THE COMPANYS LIABIUTY FOR CLAIMS ARISING OUT OF THIS AGREEMENT SHALL NOT EXCEED THE TOTAL AGREEMENT PRICE EXCEPT TO THE EXTENT THOSE DAMAGES ARE
PROVEN TO BE SOUCY 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 HPIARDCUS MATERIALS THAT MANIFEST THEMSELVES DURING THE CONSTRUCTION PROCESS.E.G.
WOOD ROT,MOW,ASBESTOS NAIL POPS,DUCTWORK AND CONNECTIONS,PLUMBING AND VENT PIPES, DECKING DEFLECTION,ETC.IF A PRE-EXISTING DEFICIENCY OR
HAZARDOUS MATERIAL 15 ENCOUNTERED PRIOR TO OR DURING CONSTRUCTION,AND COMPANY 15 NOTIFIED IN WRITING,COMPANY WILL TRY TO ASSIST CUENT WITHIN
THE COMPANYS MEANS AND CAPABILITIES TO CORRECT THE PFOBLEMIS)ON ATIME 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 15 NOT RESPONSIBLE,AND THE CLIENT AGREES TO HOLD THE COMPANY HARMLESS,FOR ANY PROBLEMS AND/OR DAMAGES,INCOMING BUT NOT LIMITED
TO MOLD GROWTH,ARISING FROM THE PERFORMANCE OF AIR SPACING WORK BY THE COMPANY AS A RESULT OF ANY KNOWN OR UNKNOWN MOISTURE CONDITIONS.
11.THE COMPANY IS NOT RESPONSIBLE FOR,AND THE CUENT AGREES TO HOLD THE COMPANY HARMLESS,FOR ANY PROBLEMS AND/OR DAMAGES RELATING TO ICE DAMMING
THAT MAY ANNE DURING AND/OR AFTER THE PERFORMANCE OF WORK BY THE COMPANY.
12,REPLACEMENT OF DETERIORATED DECKING, FASCIA BOARDS, ROOF JACKS, VENTILATORS RUSHING, 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 COMPANYS EXPENSE.
10.THE COMPANY UNDER PROVISIONS OF CHAPTER 102A OF THE GENERAL LAM IS REQUIRED TO APPLY FOR AND OBTAIN ALL CONSTRUCTION-REIATED 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 INDIVIDUAL.
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 REUED ON BY EITHER
PARTS,AND DO NOT SURVIVE THE EXECUTION OF THIS AGREEMENT.
12.THIS AGREEMENT CANNOT BE CANCELLED WITHOUT THE MUTUAL WRITTEN CONSENT OF BOTH PARTIES EXCEPT AS OTHERWISE SET FORTH HEREIN.
18.THIS AGREEMENT,AND ANY WARRANTUS)PROVIDED HEREUNDER SHALL NOT BE ASSIGNED EXCEPT BY OR WITH THE WRITTEN PERMISSION OF THE COMPANY.
19. IF THE CUENT 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 DELWERED OR IS IN ROUTE TO THE CLIENT COULD RESULT IN A
5%RE-STOCKING FEE BASED ON THE COST OF MID 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 PROMML 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 PROMML,
COMPANY RESERVE THE RIGHT TO REVISE ITS PRICE IN ACCORDANCE WITH IT$COSTS IN EFFECT AT SUCH TIME,
22. IF ANY PROVISION OF THIS AGREEMENT SHOULD BE HEIR TO BE INVALID OR ON ENFORCABIE,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.
20.ANY DISCOUNT, PROMOTION,REIMBURSEMENT,OR OTHER PROGRAM THAT IS PART OF A STATE SPONSERED UTILITY PROGRAM(LE. MASS SAVE-)IS SUBJECT TO THE
AVAILABHIry 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 SPONSORED 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.CUENT 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
wi 600 Washington Street
Boston,MA 01777
www.massgovldia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Eleetricians/Plumben
Applicant Information Please Print Legibly
Name(Busimvs/organimlionnndividual): American Installations,LLC
Address: 130 College Street,Suite 100
City/State/Zip: South Hadley,MA 01075 Phone 4: 413-552-0200
Are you an employer?Cheek the appropriate box: Type ofproject(required):
1.[x] 1 am a employer with 60 4. ❑ I am a geneml contractor and 1 6. ❑ New construction
employees(full and/or parr-lime).' have hired the subcontractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.t 7. ❑ Remodeling
ship and have no employees These sub-comm tors have S. ❑ 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 10.El Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repairs or additions
myself [No workers'comp. c. 152,§1(4),and we have no 12.❑ Roof repairs
insurance required.]I employees. [No workers'
comp.insurance required.] 13.N Other Insulation
'Any awlium Out checks bon al muu also fill om she sehirii below,h.wina their workaneun er"twe policy whirmalion
t I lomeowncm wM10 submit This drdevih imlkoling awry orc JoinB ell wok ad Nut M1im omsNc canuacrors muss submit a nm alixbvil bJlraling such.
•Cantra<lors Thal eMxk NIS box muss aaeshm an adEildmi sheet showing IM1c name of Ih:wbcommmors end shun workeli comp.policy iefomhmhm.
1 am an employer that is paviding workers'rompensadon insurance for my employem Below is the policy and job site
information.
Insurance Company Name: Guard Insurance Companies
Policy#or Self-ins. Lie g: URWC600991117 Expiration Date: 09/04/2019
Job Site Address: n L71Yr I Ciry/StaWZiP:.% Pjrf C`m�'L IM
Attach a copy of the workers' mpensation policy declaration page(showing the policy number and expintbm date). 4]d(2
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fire up to$1,500.00 and/or one-year imprisonment,as well"civil penalties in the form of 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.
1 do hereby certify under the palm annnd penal[iees�s of perjury Ileal the Information provided above is the and comet
S' t : ( ,.fhlA.Cll25�— Date
Phone k: 413-55 -020
QhMal use only. Do not write in this area,to be completed by city or town ojJictat
City or Town: Permit/License a
Issuing Authority(eircle one):
1. Board of Health 2.Building Department 3.City/Town Clerk 4. Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone a:
Commonwealth of Massachusetts Cmea uclnen SupervWr
19" Division of Professional Lcensure DmstrMW-8u�ings of any up group wldeh wmahn
Boardof Building Regulations and Standards b"thsn 96'000 CUW teet(991 eWlc mefef8f ofenelosed
Construction Supe"isor Spam
CS-106178 El:pires:09/29/2019
WESLEYCOU URE
218 LATHRo79TREET
SOUTH HADLEY-MA 01075
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Office of Consumer Affairs and Business Regulation
10 Park Plaza- Suite 5170
Boston, Massachusetts 02116
Home improvement Contractor Registration
. Type: LLC
175982
AMERICAN INSTALLATIONS,LLQ RegleOa =on: 06M6
130 COLLEGE STREET SU ITE 100 Et�iradon: 08/28/2019
SOUTH HADLEY,MA 01075
Updee Address and rahun card. Mark reason for change.
MA1 o x M6 11 ❑Add.�s n Rye...el n EMOrialent CnrA
OMp of Conesess Aeeke a seelneee Reae4tlon
R
HOs1EUIPROVEMENTCONTRACTOR apbtMbn vtlblar lrghbu4 un qtly
TYPE:LLC bfors the saplrsdon".. H found rehrm to:
>' Registration Expiration OMC&ofCousumar Affairs end Business Regulation
y3 .`a 175M 0528/2019 10 Park SUR.5190
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