17C-069 (3) 119 CHESTNUT ST BP-2019-1079
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map Block: 17C-069 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A)
Category: INSULATION BUILDING PERMIT
Permit# BP-2019-1079
Proiect0 JS-2019-001754
Est Cost, $3500.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO.-
Const.
O:Const Class: Contractor: License.
Use Group: AMERICAN INSTALLATIONS LLC 106178
Lot Size(sq. It.): 24001.56 Owner: MITCHELL PATRICIA&FRANK
Zoning: URB(I00)/ Applicant: AMERICAN INSTALLATIONS LLC
AT: 119 CHESTNUT ST
Applicant Address: Phone: Insurance:
130 COLLEGE ST (413) 552-0200 WC
SOUTH HADLEYMA01075 ISSUED ON.312912019 0:00.00
TOPERFORM THE FOLLOWING WORK:ATTIC 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: Q& 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 3/29/2019 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
Iq - )olb -to -71
Dap
City of Northampton
- Building Department '
212 Main Street
Room 100 {•✓ L.,INS[ ILA 7ON,,.
Northampton, MA 01060
phone 413-587-1240 Fax 413-587-1272 ONLY
APPLICATION FOR ILY DWELLING ONLY
SECTION I -SITE INFORM#ION ATION PERMIT
1.1 Property Address: MAR 29 2019 ^-.7This semon to be completed by office
119 Chestnut Street +per- Lot nrOq Unit
Florence, MA 01062 DEPT OF BUILDING INSPECTIONS one _ Overlay District
NORTHAMPION.VA_'1('.00
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
Mitchell. Patricia&Frank 119 Chestnut St. Northampton, MA 01062
Name(Piing current Mailing Address:
See attached (phomIa 2-0200
Telephone
Signature
2.2 Authorized Agent-
American Installations 130 College Street Ste. 100 South Hadley, MA 01075
Name(Prmp Current Mailing Address:
CmU t h 1 (413) 552-0200
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Oficial Use Only
completed bmiitapplicant
1. Building $3,500.00 (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total wit +2+3+4+6) $3500.00 Check Number 3 d7
This Section For Official Use On!
Dare
Building Permit Num Issued:
Signature: 4 3 Z9-201y
Building CommesionanInspector of Buildings Date
EMAIL ADDRESS(REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION e-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor. Nat Applicable ❑
Kamsof Lkagee Kglder: WesleyKCouture 106178
License Number
_130 College Street Ste. 100, South Hadley MA 01075 912912019
Address Expiration Dale
1 \�JQAs s V CbU MJ.. (413)552-0200
Slgneture Telephone
S.Registered Home fmorovemerit Contractor. Not Applicable ❑
American Installations 175982
Comoam Name Registration Number
130 College Street Ste, 100, South Hadley MA 01075 612612019
Address Expiration Date
cn7,�>L Telephone (413) 552-0200
SECTION 5-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....... -K No...... ❑
Brief Description of Proposed Work NOTE: INSULATION ONLY
Attic insulation and air sealing throughout.
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.
Wesley K.Couture
PMl Name
Cb 3/27/2019
Signalure of er/Agent Data
I, Mitchell, Patricia& Prank as Owner of the subject
property
hereby authonze American Installations
to act on my behalf,in all matters relative to work authorized by this building permit application.
See attached 3/27/2019
Signalure of O r Dale
City of Northampton
/ Massachusetts
\ I� L>212 I inS Street
B6r nxcp InsPBCTIng ?
312 Mnan Sttaat a Municipal Building
Moi[hemytan, 11A 01060
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and
subcontractors performing improvements or renovations on detached one to four family homes.Prior to
performing work on such homes,a contractor most be registered as a Home Improvement Contractor("HIC").
MG.L.Chapter 142A requires that the"reconstruction, ahere6on,renovation repair,modsmization, conversion,
improvement,removal,demolition,or construction of an addition to enypre-existing owner-occupied building containing
at least one but no more than Pour dwelling units....o to structures which are adjacent to such residence or building'be
done by registered contractors.
Note:Ifthe homeowner has contracted with a corporation or LLC,that entity must be registered
Type of Work: Insulation Est.Cost: S3,500.00
Address of Work: 119 Chestnut Street
Date of Permit Application: 3/27/2019
I hereby certify that:
Registration is not required for the following reason(s):
_Work excluded by law(explain):
—Job under$1,000.00
_Owner obtaining own permit(explain):
Building not owner-occupied
x Other(specify): Contractor pullinr permit for homeowma
OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED
CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT
ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND
UNDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK
PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION.
Signed under the penalties of perjury.
I hereby apply for a building permit as the agent of the owner:
3/27/2019 American Installations 175982
Date Contractor Name HIC Registration No.
OR:
Notwithstanding the above notice,I hereby apply for a building permit as the owner of the above property:
Date Owner Name and Signature
City of Northampton
Massachusetts
i\< bN OF BO INSPECTIONS
212 Min StoMnicipal auilding
xoxth® tan,
V �p
MA 01060
Debris 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.
The debris from construction work being performed at:
119 Chestnut Street
(Please print house number and street name)
Is to be disposed of at:
Waste Management o(New F,ngland, Chicopee, MA 01020
(Please pant name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
Signature of Permit Applicant or Owner Date
If, for any reason,the debris will not be disposed of as indicated, the Applicant or Owner shall notify the
Building Department as to the location where the debris will be disposed.
,
mass save
!1*41 PARTNER
Mary.::Iran
a Ae4mmnm.x3pssaz American Installations www.AmevicaninsUlistions.com
130CNkaepro.vuiv10ASwMNJer MA.U7I •Oaire'.tollsrriossrn'.(a1MausaR• EmYI tupWIMmnkenlnatllNYmasmm
Customer Name:Patricia Mitchell
Email:pjmitche11610@gmail.com
Phone:413-695-1420
Premise Address:119 Chestnut St,Nodhamptoa,MA 01062
Mailing Address: 119 Chestnut Sp Northampton,MA 01062
Project ID:3773216
Dale:March 25,2019
Job Description
Measure Description Location Quantity Unit - Total Cost Customer Cost
Air Sealing at Estimated 62.5 CFM50 Per Hour Living Space 12 hr $1,110.96 $0.00
Exterior Door Weather Stripping (with AS hrs) Living Space 2 each $60.14 $0.00
Door Sweep (with AS hrs) Living Space 2 each $50.62 $0.00
Rim Joist-6" Fiberglass Batting Living Space 70 SF $189.00 $47.25
Insulation Removal Living Space 25 SF $31.50 $31.50
Attic Floor-6"Open Blow Cellulose Living Space 1176 SF $1,905.12 $476.28
Hatch - 2"Thermal Barrier Polyiso Living Space 1 each $46.28 $11.57
Damming 12 each $28.68 $7.17
Project Total $3,422.30
Weatherization Incentive ($1,626.81)
Air sealing incentive ($1,221.72)
Total Program Incentive -$2,848.53
Customer Total $573.77
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THIS AGREEMENT IS COMPOSED OF THIS PAGE PND 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-CCMPANW,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 WE STATE OF MASSACHUSETTS OR CONNECTICUT
RESPECTIVELY,AS WELLAS ALL LOCAL JURISDICTIONS.
THE FOLLOWING TERMS AND CON0IMONS ALSO APPLY
1. THISAGREEMENT ISSUBIERTO THE APPROVALOF A MANAGER OPINE COMPANY MATHIS AGREEMENTTO BE EFFECTNE UNDER ANYCONDITION.
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(11/2)
PERCENT PER MONTH.(18%PER ANNUM)WITH A MINIMUM CHARGE OF$2.00 PER MONTH,AND IF PLACED IN THE HMDSOF 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 LOIN 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 INATIMELY AND WORKMANLIKE MANNER.
S. ALL WARRANTIES FOR EQUIPMENT AND PRODUCTS SUPPLIED BY THE COMPANY UNDER THIS AGREEMENT SHALL BE THOSE GIVEN BY THE MANUFACTJR ERS OF SUCH
EQUIPMENTAND PRODUCTS. UNDER SUCH MANUFACTURER'S WARRANTIES,THE CLIENT MAYBE REQUIRED TO REGISTER OR MAIL INA WARRANTY CARD OR OTHER
EVIDENCE OF OWNERSHIP AND USE OF SUCH EQUIPMENT AND/OR PRODUCTS IN ORDER TO ACTIVATE SUCH WARRANTIES.
6, WE QUOTATION ON THE PAGE HEREOF DOES NOT INCLUDE EXPENSES OR CHARGES MR BOND OR INSURANCE PREMIUMS OR COSTS BEYOND NORMAL INSURANCE
COVERAGE,ANY SUCH ADDITIONAL EXPENSES,PREMIUMS OR COST SHALL BE ADDED TO THE TOTAL AGREEMENT AMOUNT.
J. THE COMPPNYS LIABILITY FOR CLAIMS ARISING OUT OF THIS AGREEMENT SHALL NOT EXCEED THE TOTAL AGREEMENT PRICE EXCEPT TO WE EXT ENTTHOSE DAMAGES
ARE PROVEN TO RE SULLY DUE TO THE COMPANY'S NEGLIGENCE.
0, DURING THE DURATION OF THE WORK,THE CLIENTS HOMEOWNERS INSURANCE WILL BE RESPONSIBLE FOR ANY AND ALL DAMAGES AS LONG AS THE COMPANY HAS
TAKEN THE APPROPRIATE ACTION TO PROTECT AREAS OF WORK.
9. THE COMPANY IS NOT RESPONSIBLE FOR PREEXISTING 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 APES.DECKING DEFLECTION,ETC IF A PREEXISTING DEFICIENCY
OR HAZARDOUS MATERIAL IS ENCOUNTERED PRIOR M OR DURING CONSTRUCTION,AND COMPANY IS NOTIFIED IN WRITING,COMPANY WILL TRY TO ASSIST CLIENT
WITHIN THE COMPARY'S MEANS AND CAPABILITIES TO CORRECT THE PROBLEM(5)ON A TIME AND MATERIAL W IS. CUENT AGREES THAT SUCH CONDITIONS ARE
UNAVOIDABLE BY WE COMPANY AND SHALL NOT BE CONSIDERED A VIOLATION OF THE AGREEMENT AND MAT 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 CUENT AGREES TO HOLD THE COMPANY HARMLESS,FOR MY 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 COUNGS FLOORS,TRIM,GUTTERS,DOWNSPOUTS,EXISTING
SIDING AND WINDOWS,MORS,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.
14. THE COMPANY UNDER PROVISIONS OF CHAPTER 142A OF THE GENERAL LAVE IS REQUIRED TO APPLY FOR AND OBTAIN ALLCONSTRUCTIOWRELATED 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,STATEMENT$OR OTHER COMMUNICATION NOT WWRER ON THIS AGREEMENT ARE AGREED TO BE IMMATERIAL AND NOT RELIED ON BY
EITHER PARTY,AND DO NOT SURVIVE WE EXECUTION OF THIS AGREEMENT.
12, THIS AGREEMENT CANNOT BE CANCELLED WITHOUT THE MUTUAL WRITTEN CONSENT OF DOTH 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 WR17EN PERMISSION OF WE COMPANY.
19. IF THE HENT FABS TO PERFORM ITS OBLIGATIONS HEREUNDER OR TERMINATES THIS AGREEMENT WITHOUT THE PRIOR WRITTEN CONSENT OF THE COMPANY,THE
CUENT 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 ROM TO THE CLIENT COULD RESULT
IN A 5%RE FEE BASED ON WE COST OF SAID MATERIALS.
21, THIS AGREEMENT SHALL BE EFFECTIVE ONLY UPON ITS EXECUTION BY ALL PARTIES HEREID,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 WE CLIENT AND THE
REQUIRED DOWN PAYMENT RECEIVED PRIOR TO THE EXPIRATION OF SUCH AD 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 ENFORCEABILITY OF THE REMAINING PROVISIONS OF
THUS 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 SPONSORED UTILITY PROGRAM QE 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 INSTAQER9,LLC IS NOT AN AGENT OF ANY UTILITY COMPANY OF OTHER VENDOR WORKING BY,THROUGH,OR UNDER THE MASS SAV'ENERGY
PROGRAM.
26. CLIENT 15 REPSONSIBLE FOR THE PAYMENT OF ANY AND ALL FEDERAL STATE,OR LOCAL TAXES MATARE APPLICABLE TO THISAGREEMENT.
The Commonwealth ofMassachusens
Department of Industrial Accidents
Ojjice of Investigations
US 600 Washington Street
Boston,MA 02/11
www.mass.gov/din
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibiv
Name (pasiavot!0reanlmtionilnaividua1): American Installations,LLC
Address: 130 College Street,Suite 100
City/State/Zip: South Hadley,MA 01075 Phone if 413-552-0200
Are you an employer?Check the appropriate bee.
I am o employer with 60 4. 1_1 I zm a general eonlractmand I 6. [] New construction
employees(full and,or parbtimc).' have hired the sub-comracmrs
2.❑ 1 am a sale proprietor or partner- listed nn the attached sheet t 7- ❑ Remodeling
ship and have no employees TI,cse subcontractors have 8- ❑ Demolition
working for no, in any ci ip., workers'comp. insurance. g F] Building addition
[No workeri comp. insurance 5. F-] Wearca corporation and its
required officers have acercised(heir
10.❑ Electrical repairs or additions
3.U I am a homeowner doing all work right of exemption per MGL I I.L.] Plumbing repairs or additions 1,
myself[No workers'comp- c 152 §1(4),and we have no 1 12.❑ R apairs
insurance required.]' nplovew. IN,)worker,'
17.r,]Other Insulation
comp insurance required --—--'Anyvpwt-vh ince,baa HId-i atmalloutrhe.1-1k,maid helowsok aing,acid rover workers'eompa,a,.wonol,ddola-11
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Cnnmdorsrhm chuck@rs hos mol anacM1rA:m'addilional soca showing the nano aflbe mbcam,vnor mW their worken'mmp.mobs. inrormvlion
I am nn employer that is providing workers'compensation inturance for my employees. Below is tire policy mrd jab site
infurmmloa
Insurance Cumpary Name: Guard Insurance Companies_,
Policy a or Self-ins Ltc k URWC609917 Expiration Date: 09/04/2019
Job Site Address: l.A Q,�`l)'� L I City Stine/Zip.jib6tn-(f (}�/Yaj2
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Pai!ure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
f:5-' ytoS1 5,00J rAxd.lbye; r-ps-n.wro, .a uraroCydy- hies it the fun of s S FOP WORK ORDER nlinc
of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to die Office of
Investigations ofthe DIA for insurance coverage verification.
Ids,hereby certify..it,,deforms a/nfd penalties of perjury that me information provided above is true and correct.
Si nature: vq / (�-�(�(.(J�_ _ Date:
Phone u: U 413-552-0200
Official use ont. Do not write to this area,to be completed by cry or town official
City or Town: Permit/License N III
Issuing Authority(circle one):
I. Board of liealth 2. Building Department 3.City/town Clerk 4. Electrical Inspector S. Plumbing Inspector
6.Other
Contact Person: Phone It.
Commonwealth of Massachusetts Comtruction Supervisor
®� Division of Professional Licensure Unrestricted-Buildings of any use group xTich contain
Board of Building Regulations and Standards fess than 35.000 cubic feet(991 cubic matters)W enclosed
Construction Supervisor space'
CS-106178 Expires:09/29/2019
WESLEY COUTURE
216 LATHROF6TREET 't1
SOUTH 14ADLEY MA 01076
Failure t0 possess a curtest eddmn W Me Massachusets
State auditing Code is cause for re rocedon oldies Ifcense.
For infomWn a
iabout Mis license
Commissioner Cali(61T)72-1200 or visit www.n ass•.govldpl
IY - �'�1e ((ir�j�rjjtn�tlt/F�rrt'�yz r�JC�iGCrrJ:icrrf,tfln��1
' " Office of Consumer Affairs and Business Regulation
10 Park Plaza- Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Type: LLC
AMERICAN INSTALLATIONS,LLC. Registration: 175982
130 COLLEGE STREET SUITE 100 Elryiration: 0828/2019
SOUTH HADLEY,MA 01075
update Address and return card. Mark reason for change.
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- 1759n2 06/2fi/2019 10 Park Plaza-SufR 5170
rAMERICAN INSTALLATIONS,LLC. Boston,MA 02116
WESLEY COUTURE
130 COLLEGE STREET SUITE 100
SOUTH HAOLEV,MA .1 015 Undersecretary �—N6t valid without signature
AV O® CERTIFICATE OF LIABILITY INSURANCE DA,/;,W,°D18°
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: H Me ceNBcate holler Is an ADDITIONAL INSURED,the policy(les)must be emforsed. N SUBROGATION IS WAIVED,subject to
Me terms small rondlBons of Me pocky,cermin policies may require an endomerowt. A stammem An MIB ceNfieate does not confer dghm to Me
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130 College Street, Suite 100 INSURER E.
South Badley Be 01075 ( SURER IF
COVERAGES CERTIFICATE NUMBERlaaster EDRD 9-3019 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 MY 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 CC4IDITCNS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,
TYPEOFMBURANCE P011CY NUYBER PoD YP£F Pd�Y EIJ Lmns
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GENU AGGREGATE LIMIT APPLIES PER: GFNEMUG.RAGAPF E 31000,000
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