12C-104 (5) 35 RICK Lilt BP-2019-1302
GIs#: _ _ COMMONWEALTH OF MASSACHUSETTS
Miggfli ck; 12C- l04 CITY OF NORTHAMPTON
Lot.-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Categqly INSULATION BUILDING PERMIT
Permit# BP-2019-1302
Proieet# JS-2019A02100
Est Cost $280Q,00
E@o;$65,0 PERMISSION IS HEREBY GRANTED TO:
Const Class: Contractor: License:
Use Group: AMERICAN INSTALLATIONS LLC 908178
Lot Siu(w.R.): 10018.80 Owner: MOULTON RALPH R&GLORIA I
Zoning•RI(100)/URA(100)1WSP(100)/ Applicant: AMERICAN INSTALLATIONS LLC
AT: 35 RICK DR
ApolicantAddress: Phone: (nsarance:
130 COLLEGE ST (413)552-NOO WC
SOUTH HADLEYMA01075 ISSUED ON:511712919 0:00100
TO PERFORM THE FOLLOWING WORK:ATTIC INSULATION &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; Sorelae: Motes
Footmen
Rough; Roughs House k Foundatlow
Driveway Finale
Final: Final;
Rough Frame;
Gaala grt„t g t Fireplace/Chimney;
Rough; M lasulatioul
Final: Smoke: Final;
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate pf Occupancy Sisnatu
Feeltug; Date Paid: Amoaat:
Building 5/17/20190;00;00 $65.00
212 Main$tree[,Phone(413),587,Q,10,Fax;(413)587,1272
Louis Hasbrouck—Building Commissioner
IC,-I�ql
City of Northam on -
Building De art end '� ���
212 MainPstr t SAY ) 5 rtiq
- Room 100
Northampton, MA 01080rrr or rwi Dwr °RckloNB
phone 413-687-1240 Fax'413 5 -r' TSI ro •.'-,5 ONLY
APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING ONLY
SECTION I-SITE INFORMATION INSULATION PERMIT ep l9-iia
1.1 Property Address: �This section to be completed by office
Map_{Qy�_ Lot f 0 V Unit
35 Rick Drive
Florence,MA 01062 Zone O"day District
Elm at Disalct Ca District
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
Chris Moulton 35 Rick Drive Florence, MA 01062
Name(Print) Current Mailing Address:
See attached (4141 SRfi-0x;16
elephone
Signature
2.2 Authorized Aaent:
American Installations 130 ColleZe Street Ste, 100, South Hadley, MA 01075
7N (PrinV.g Curren Mailing Address:
� � . � (413) 552-0200
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Oficial Use Only
completed blmitapplicant
1. Building $2,800.00 (a)Building Peraut Fee
2. Electrical (b)Estimated Total Cost of
Construction from 8
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1+2+3+4+5J $2,800.00 Check Number
This Section For Official Use Only
Date
Building Permit Num r: Issued.
Signature'
Building Commisslonedlospector of BuilEings Date
EMAIL ADDRESS(REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 4-CONSTRUCTION SERVICES
8.1 IJcenseel Construction Supervisor; Not Applicable ❑
Nameof Llcanse Holder: Wesley K. Couture 106178
License Number
130 College Street Ste. 100, South Hadley MA 01075 912912019
Add... Expiration Date
1 (413)552-0200
Slgnat�u'r'ed Telephone
9.Registered Home Improvement Contractor: Not Applicable ❑
American Installations 175982
Company Name Registration Number
130 College Street Ste. 100, South Hadley MA 01075 612612019
Address
�[ Expiration Data
WXJak¢A.x k . A Telephone (413)552-0200
SECTION 5-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(S))
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....... 10 No...... ❑
Brief Description of Proposed Work NOTE: INSULATIONONL Y
Attic insulation and air sealing throughout.
I, Wesley K. Couture -American Installations as Owner/Authonzed
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
Print Name
PO� �-- CA]A�.V��A.- 5/11/2019
SigwWrec
I er/Agent Data
Gloria Moulton as Owner of the subject
properly
hereby authonze American Installations
to act on my behalf,in all matters relative to work authorized by this building permit application.
See attached 5/11/2019
Signature of Owner Date
City of Northampton
f
Massachusetts tia�' t 'fir
G 0212 vleaxs•Street
aarz Ici als ITroas o \\\
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Nei[hampton, !p 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. Nor to
performing work on such homes,a contractor must be registered as a Home Improvement Contractor("HIC").
M.G.L.Chapter 142A requires that the"reconstruction,aeration, renovation,repair, modernization,conversion,
Improvement removal,demolition,or construction of an addition to any pre-existing ownerbccupied building containing
at least one but not mom than Pour dwelling units....or to structures which are adjacent to such residence or building'be
done by registered contractors.
Note.If the homeowner has contracted with a corporation or LLC,that entity must be registered
Type of Work: Insulation Est.Cost: $2,800.00
Address of Work: 35 a„k Dr'
Date of Permit Application: 5/11/2019
1 hereby certify that:
Registration is not required for the following reason(s):
_Work excluded by law(explain):
_lob under$1,000.00
_Owner obtaining own permit (explain):
Building not owner-occupied
x Other(specify): Contractor pulling permit for homeowner
OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED
CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE ROME 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 RESPONSIBH.ITES FOR ALL WORK
PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION.
Signed under the penalties of perjury:
I hereby apply fm a building permit as the agent of the owner:
5/11/2019 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
..5 C
/ •?' ' Massachusetts d 4
OEPARTIN,NT OF BOILOZ NS KCTIONS
t: t •Wau
013 Win 3niei 1 llding
111\\VV�YYI///
�., Northampton, Nr, 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:
35 Rick Drive
(Please print house number and sheet name)
Is to be disposed of at:
Waste Management of New England, Chicopee, MA 01020
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
DOL) V- QU–JA-I " 5/1112019
Signatureo�Permit Applicant r 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.
e \� www.Nne.lv'.nlnn.Lan —,
6196 1I%�\ o Licensed OL &insured\ MA fSNa061 78
American Installations MAge9istmfionpl 75982
ssg cdkce men asre sal sous xsalev.MAmms. aaa:Hsy sszaxop Fa:HSN ssxazox. anll'aNppm.Qmm�imlmblhmmwn
Moulton,Gloria 5/3/2019
3l
35 Rick Drive Ary Florence MA 01062
4133206343 M gloria.mouaon@gmail.mm mN
=n
483398 Nn 19-1391
n.n quantity Unit Unit Cost Total
A rSeagng
pIq SEALING1 10 Iman hour $ 85.00 $ 850.00
Air Sealing $ 850.00
Air Sealing Incentive $ (850.00)
Air Selaing W%Balance $ -
Weetb,rumon
BASEMENT SILLS-R39 FG BATT 98 sqk $ 1.95 $ 191.10
ATTICFIAT-4"OPEN R-14CELLULOSE 996 sqk $ 1.20 $ 1,195.20
VENTILATION CHUTES 58 each $ 2.50 $ 145.00
ATTIC DAMMING-R-38FIBERGLASS 104 sqk $ 2.05 $ 213.20
ATTICFLAT-R-I9 UNFACEDFIBERGVaSS 120 sqk $ 1.60 $ 192.0
Total Weatherizxtion $ 1,936.50
Weatherization Incentive $ 1,452.38
TRIAL project $ 2.286.50
Total Utility Contribution $ 2,302.38
Total Customer Contribution $ 484.13
WARFANn'.Amennnn ,um..ucwn Wwe.tMaFnw ualad bmwxro,wan,LW,wm4-SaaP w„nnry
m1-fk th.TNaay ,n- mmmm,nI.umi.nauw.mcomPNa.m.,enswem.meson n,.m.mne.wan<M.nm.aP«mormna.na 41 mi.nasuro
ewia.r,.rvunnnso.m.TMI mnmv.me,,.mr n.,.m.
ACCEPTANCE or PROPOSAL:Te aeue prKKs,speclAaa'nos and TOTAL CONTRACT VALUE= $ 484.13
enndnlon:are aansbRory amase h...n.—,ea.I.—r.
aumodiedsodowerkaaap.Oned.wymeotwln del/36owopraur Down payment= $ 16100
to Ad olwod,and W Nnee tlue ulpn Compinlon.
Balance Due Upon Completion= $ 323.13 Far
5/3/2019
5/3/2019
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 IS BETWEEN AMERICAN INSTALLATIONS,LLC HEREINAFTER REFERRED TO A5'COMPANW,AND THE CUSTOMER(S)NAMED ON THE REVERSE SIDE,HEREINAFTER
REFERRED TO AS'CUENY,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 15 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(1-1/2)PERCENT
PER MONTH. (18%PER ANNUM) WITH A MINIMUM CHARGE OF$2.09 PER MONTH,AND IF PLACED IN THE HANDS OF AN ATTORNEY OR COLLECION 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 OJENT AS ATON AS REASONABLE.
0.COMPANY AGREES THAT,NOTWITHSTANDING ANY AGREEMENT FOR MATERIALS AND/OR LIBOR BETWEEN COMPANY AND THIRD PARTY,COMPANY IS RESPONSIBLE TO
CUENT 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.
J.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 CLIENTS HOMEOWNERS INSURANCE WILL BE RE9P0NSI BLE 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 WRING THE CONSTRUCTION PROCESS.E.G.
WOOD ROT,MOLD,ASBESTOS,NAIL POPS,DUCTWORK AND CONNECTIONS,PLUMBING AND VENT PIPES,DECKING DEFLECTION, ETC.IF A PREEXISTING DEFICIENCY OR
HA2ARW US MATERIAL 15 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,MOLDING BUT NOT LIMITED
TO MOLD GROWTH,ARISING FROM THE PERFORMANCE OF AIR SEALING WORK BY THE COMPMY ASA 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, HOOF 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.
1E.THE COMPANY UNDER PROVISIONS OF CHAPTER 1@A OF THE GENERAL LAWS IS REQUIRED TO APPLY FOR AND OBTAIN ALL CONSTRURION 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.
IT 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 OBUGATIONS 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 CUENT IBRANM STYLE,COLOR,ETC)AFTER MID 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 MATERIAE.
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 WES 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.
20.ANY DISCOUNT,PROMOTION,REIMBURSEMENT,OR OTHER PROGRAM THAT IS PART OF A STATE SPONSEREO UTILITY PROGRAM )LE.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 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,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
wi 600 Washington Street
Boston, MA 02111
www.nwss.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legible
Name (Busirees0rgam,xdon/lpolviduah: 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):
I J 1 am a employer with 60 4. ❑ I am a general contractor and 1 6 ❑ New construction
employees(full and/or pan-time).' have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.1 2. ❑ Remodeling
ship and have no employees These sub-convectors have 8. ❑ Demolition
working for me in ane capacm, workers'comp. insurance. 9. ❑ Building addition
(No workers' comp. insurance 5. ❑ We are a corporation and its l
Electrical repairs or additions
required.) officers have exercised their 10
10 I am a homeowner doing all work right of exemption per MGL I L[] Plumbing repairs or additions
myself [No workers'comp- a 152,§I(4),and we have no 12,❑ Roof repairs
insurance re uired. t employees. lNo orkers'
9 wI3.! Other Insulation
mmp. insurance required.] - - —
hlny
applicant that c lecks box XI must also fill om tM1u x tion below showia5 tM1cir woden"mmpensmpn WIicY information.
'I lomcuwncn who submit tFis amJavit intlicaing tM1cy am Juin6 all work entl thw him omsiJa cnnvacmrs muv submit a now amJavit indicating such.
Conlmclars rim v'hak Nrs box mmt anachetl an aJdilipnal short showing tM1e nam<pI rM subcummdms and rhea worlun'comp.policy infomution.
I am an employer that is propiding workers'compemadan imuranee for my employees Below is the policy and joh site
informalion.
Insurance Company Name: Guard Insurance Companies
917
URWC609
Policy N or SeIF-ins. Lie N, Expiration Date: 09/04/2019
lob Site Address: 'fes" - �� _— �— City/State/%ip_-4E an(f_—�kn/k 6kb(A
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 penahies of a
Fine up to 81,500.00 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 maybe forwarded to the Office of
Investigations of DIA for insurance coverage veriBcalion.
f no hereby cyenn'ifyunder the pains a/nd penal/deess totperjury that the information provided above is true and correct
$urraa> a dA M"/IiriA n�I
a l .lf'W�/ f-- Date: _5�1
z 61
Phone x: 413-55 -0200 1
Official use only. Do not write in this area,to he completed by city or town official
City or Town: Permil/Lieense p
Issuing Authority(circle one):
I. Board of Health 2.Building Department 3.Cityrrown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone q:
Commonwealth of Massachusetts Construction supervisor
®f Division of Professional Licensure Unresekted-Buildings of any use group which contain
Board of Building Regulations and Standards less Uses 36,000 cubic feet(991 cubic traders)of enclosed
Construction Supervisor spam'
CS-106178 IE;pires: 09/2912019 -
WESLEY COUTURE -
218 LATHROP-STREET t}
SOUTH HADLEY'MA 01076 rs
PaOere b possess a current Odom oitlue Massachusetts
n State BuiMngCodefscausebr tthis cc orchis 8crose.
r`A�
For InfomMlbn about tlla 4cerrse
Commissioner �/'"- / Ca111617t 7274206 or visO www.ranargoddpl
.a r%�ea>njrttxttrcTrlf a /CiG'�rrtutcttlefS
Office of Consumer Affairs and Business Regulation
10 Park Plaza- Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Type. LLC
AMERICAN INSTALLATIONS,LLQ Re ton: 175982
130 COLLEGE STREET SUITE 100 Exxpirpiraation: 08/26/2019
SOUTH HADLEY,MA 01075
Update Address and return card. Mark reason for Change.
scni G zumnsu nAd&�- 71R-rra.m n Employment I.
O61 OPrd
Office of Consumer NM1in a Bus...P".1"on
HOME IMPROVEMENT CONTRACTOR Regisurd.velld for individual..only
yyyy�� TYPE:LLC before Me expiration doe. 6 bund return to:
` Amy RealShaHnn E.01rad G(BGY of Consumer Affairs and sanu nes Regulation
_YY 1]5982 06126/2019 10 Park Rana-Suite 5170
AMERICAN INSTALLATIONS,LLC. Soabn,MA U116
WESLEY COUTURE
130 COLLEGE STREET SUITE 100 :, y
SOUTH HADLEY,MA 01075 Undersecretary / t valid without signature
A�d CERTIFICATE OF LIABILITY INSURANCE
9/4/2038
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THUS
CERTIFICATE DOES NOT AFFIRIMATR/ELY 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 DISURER(5), AUTHOWZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
I IPORTANT: H the eeMlleeM holder Is an ADDITIONAL INSURED,the Wicy(ks)must Oe arldersed. H SUBROGATION IS WAIVED,subles M
Me Lerma and tolklNons of Me polity,exleln policies may raisers an eMwvement. A sftMw vnt On MIs terMtale does See coots rights M Me
comficak baker in lieu of such an c.
PROWCER Linda P..
Webber A Ori.11 P110DDe (413)596-0111 .Musa..Ful
a North Sins Street .lpovreragwebberavderivnell.com
INSYAr, 3APORDWOCOYBRAOe XLICF
Northampton Y 01060 INSURER: 3 a INtuel Casuelt
IINSURED ran.9:SBrAaO.L. Hathavrey GUARD Ina. CO.
Ameriesa Inatelletiona, LLC IMmeRG:
Attn[ We0 6 Sursme Cwtura IMJIERD:
130 College Street, Suits IDU INSYPEE:
South Hedley SA 03075 FIVII.F.
COVERAGES CERTIFICATE NUMBER:Neeter Hrp 9-2019 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED PROVE FOR THE POUR PERIOD
INDICATED. NOTWITHSTANDING MY REQUIREMENT.TERM OR CONMON OF ANY CONTRACT OR OTHER DOCUMENT WDIA 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.
05 WSR ryPe OF amUM11LE YvadaR 7914/201M.
POIILY RP LOADS
cwMEmu oWlEAI UAMury EPcxowWgantE a 11000,000
A E CIA1.MADE ❑000M1 9 500,000
5035]5317 9/4/ EXP E 10,000
ADV INJURY 8 1,000,000
GENL AGGREGATE UMRGENFAI.LAG3RE[igTE E a,000,0O0
E1JEM O� PROWLR-COvPgPAD3 ] ],000,000
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CERTIFICATE HOLDER CANCELLATION
$HmKD AWY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
BYIQYDCe OP IuesranCO THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
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4)1988-2014 ACORD CORPORATION. All rights reserved.
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