10-025 (3) 515 KENNEDY RD BP-2019-1440
GIs#: COMMONWEALTH OF MASSACHUSETTS
Block: 10-025 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A)
Categcrv: INSULATION BUILDING PERMIT
Permit# BP-2019-1440
Proiect# JS-2019-002326
Est.Cost:$1200.00
Fee:$65.00 PERMISSIONIS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: AMERICAN INSTALLATIONS LLC 106178
Lot Size(so. ft.): 105023.16 Owner: LAFOUNTAIN DAVID L&MICHELLE C DUFRESNE
Zoning: RR(1DBVWSP(100y Applicant. AMERICAN INSTALLATIONS LLC
AT: 515 KENNEDY RD
Applicant Address: Phone., Insurance:
130 COLLEGE ST (413) 552-0200 WC
SOUTH HADLEYMA01075 ISSUED ON.6/18120190:00:00
TO PERFORM THE FOLLOWING WORK:KNEEWALL 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 Occuimey signature:
FeeTvpe: Date Paid: Amount:
Building 6/18/20190:00:00 $65.00
212 Main Street,Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
Ia, l�3
RECEIVED
D "Puff
City of Northampton
Building Department JON S 2019
,/ A,• ,. 212 Main Street LA TION
Room 100 oePT ov Bus INC,INSPECTION
Northampton, MA 010 NonTUAnn toN.MA01060
phone 413-587-1240 Fax 413- - ONLY
APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING ONLY 3 —(
SECTION I-SITE INFORMATION INSULATION PERMIT
1.1 Prooeny Address: This section to be comp/leted by once
515 Kennedy Road Map _ Lot Q�J Unit
Leeds, MA 01053 Zone Overlay District
Ehn SL District CB Dishtct
SECTION 2-PROPERTY OWNERSHIPIAUTHORRED AGENT
2.1 Owner of Record:
Michelle&David LaFountain 515 Kennedy Road,Leeds,MA 01053
No.(Print) current waln9 Address:
See attached (4131 584-7726
Telephone
Signature
2.2 Authorized Agent
American Installations 130 College Street Ste. 100, South Hadley,MA 01075
Name(Prirg Cument Melling Addles:
W¢yQ S(.,- COASZTS (413)552-0200
Signature Ttlephaie
SECTION 3.ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building $1,200.00 (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction frau 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC) V b
5.Fire Protection
6. Total=(1+2+3+4+5) $1,200.00 Check Number 0
This Section For Official Use On
Date
Building Permit Num r Issued:
Signature: 4 z
(�/ O- 10.2()iy.
Building Commissimledlnspector of Buildings Dale
production @ americaninstallations.com
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 4-CONSTRUCTION SERVICES
8.1 Licensed Construction Suoerviser: v Not Applicable O
Planw of Li,e,,,Holder. Wesley K Couture 106178
Ligeree IkarWer
130 College Street Ste. 100, South Hadley MA 01075 912912019
Adheu E*afion Dale
(413)552-0200
SgreNe Telephone,
S.Registered Hone lmprovamant Contractor. Not Applicable ❑
American Installations 175982
Comoam Name Registration Number
130 College Street Ste. 100,South Hadley MA 01075 6126/2019
Atldneae Expiration Date
►*�k• Cu�19>M�� Telephone (413)552-0200
SECTION 6-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.O.L.c.162,g 25C(e))
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....... X No...... O
Brief Description of Proposed Work NOTE: INSULATION ONLY
Kneewall insulation and air sealing throughout.
I, American Installations- Wesley Couture .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
Phis Name
W -� 6/12/2019
SgnaWre of /Agem Date
I. LaFountain,Michelle&David 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 6/12/2019
Signalueef Ower Dale
City of Northampton
..... 4/`
Massachusetts
pla?"721ENT OF Inttulm InaFECTZOna
212 Nairn Street nunlcipel auil"ng
aarthamptan, ea 01060 'ry yl
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 must be registered as a Home Improvement Contractor("HIC").
M.G.G.Chapter 142A requires that the"reconstruction, alteration,renovation,repair,modemization,conversion,
improvement,removal, demolition,m conetmchon of an addition to anypre-exislog avneroccupied building containing
at least one but not more than tow dwelling units....w to structures which are adjacent to such residence or building"be
done by registered contractors.
Nate:If the homeowner has contracted mid,a corporation or LLC,that endU,must he registered
Type of Work: Insulation Est.Cost: $1,200.00
Address of Wmk: 515 Kennedy Road,Leeds 01053
Date of Permit Application: 6/12/2019
I hereby certify that:
Registration is not required fm the following remon(s):
_Wmk excluded by law(explain):
_
Job under$1,000.00
_Owner obtaining awn 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 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:
6/12/2019 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
_ , ss
Massachusetts a�
HOF HIOINO INHPHCTIONH
212 Mains eI
212 Nein ethos[ eWnvcxpal Builtli,y Vi tii. Cv
Nai[hemptan, MA OlOfiO
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:
515 Kennedy Road
(Please print house number and street 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)
V _ CsniJ .>r SLV2
a
Signature of 0 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.
nu aLn imass save e
xa PARTNER
Lon. 11
American Installations www.Amairanlnsbllatlmp.ram
130 UMe{e ShM Lae l�6mN Ndry�MAOWa[OIflR:NtASSLDAp Poe:Kt31557Dnt2 Finab suppnn�Amea[anlnaWladmi[an
Customer Name:Michelle UFountain
Email:Not provided
Phone:413-575-4279
Premise Address:515 Kennedy Rd,Northampton,MA 01053
Mailing Address:515 Kennedy Rd,Northampton,MA 01053
Protect to:3833177
Date:June 7,2019
Job Description
Measure Description Location Quantity Unit Total Cost Customer Cost
Air Sealing at Estimated 62.5 CFM50 Per Hour 2 hr $185.16 $0.00
Door Sweep (with AS hrs) Living Space 3 each $75.93 $0.00
Exterior Door Weather Stripping (with AS hrs) Living Space 3 each $90.21 $0.00
Door-T'Thermal Barrier Polyiso Living Space 1 each $90.44 $22.61
Kneewall Wall -2"Thermal Barrier Polyiso living Space 140 SF $669.20 $167.30
Project Total $1,110.94
Weatherization incentive ($569.73)
Air sealing incentive ($351.30)
Total Program Incentive -$921.03
Customer Total $189.91
.a.M :Mahan i2Mlada,LLC"I potl4e IM1etlO[e Yahtl M1unen+Mvaba/.Les eurYnoauby—N,
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bneba re Aar—i .I...altar..W
eLCEvrnaa[E Of vnnPKanL: Tr above phq ape[iF[xons aM [mdi[cns art TOTALCOmMC-VALUE-5 189.91
ua da[[arVaMa�e M[EYa[[M[ed.YouarcaNlmrissdNdowdA aSSR[ilkd.Ppnrtnt poam VaY'a'nt- 5 60.00
Jlhe Vf MYm pnd[o#aR WwM.Ytdbalarcedr upd�Complenm. falD
Banns Om Upon Catgle[bn= s 129.91
aB,eLme /�y � — ran, 617/2019
Page 1 of i
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THISAGREEMENT IS COMPOSED OF THIS PAGE AND THE REVERSE SIDE OF THIS PAGE AND SHALL BE CONSIDERED THE ENTREAGREEMENT OYTHE PARTIES INVOLVED. THIS
AGREEMENT IS BETWEEN AMERICAN INSTALLATIONS,LLC HEREINAFTER REFERNEDTO AS'COMPANY,ANDTHE CUSTOMER(S)NAMED ON THE REVERSE SIDE,HEREINAFTER
REFERRED TO A'CUENT`,AND WILL BE SUBJECT TO ALL APPROPRIATE LAWS,REGULATIONS AND ORDIRANCES OF 111E STATE OF MASSACHUSETTS OR CONNECTICUT
RESPECTIVELY,AS MUM ALL LOCMJURISDICIIONS.
THE FOLLOWINGTERMS AND CONDITIONSALSO APPLY
1. THISAGREEMENTISSUBIECTTO TIE APPROVALOF A MANAGER OF TIE COMPANY FOR THISAGREEMENTTO BE EFFECTIVE UNDERANYCCNDEWN.
1. SHOULD DEFAULT BE MACE IN THE PAYMENT OF THIS AGREEMENT,CHARGES SHALL BE ADDED FROM TIE DATE THEREOF AT A RATE OF ONE ANO ONE-HALF(1-I/2)
PERCENT PER MONTH.(M PER ANNUM)WITH A MINIMUM CHARGE OF 52.00 PER MONTH,MID IF PLACED IN THE HANDS OF AN ATTORNEY OR COLLECTION AGENCY
FOR COLLECTION,ALL ATEORNEYS'FEES,RPENSES AND COSTS OF COLLECTION SHALL BE PND BYTHE CLIENT. IN ADDITION,CUEM UNDERSTANDS THAT IN FAILING
TO PAYACCORDINGTOMF ABOVE TERMS,COMPANY MAY HAVETHE RIGHTTO A LON ON THE PROPERTY
3. THE CCAPANYAGREES TMTWHEN DELAYS BECOME KNOWN TOME COMPANY,THE COMPANYWUADVISE THECUENTASSOON A REASONABLE.
4. COMPANY AGREES THAT,NOTWITHSTANDING ANY AGREEMENT MR MATERIALS AND/OR LABOR BETWEEN COMPANY AND THIRD PARTY,COMPANY G RESPONSIBLE
TO CLIENT MR COMPLETION OF ALL WORK DESCRIBED INA TIMELY AND WORKMANLIKE MANNER.
S. ALL WARRANTIES FOO EQUIPMENT AND PRODUCTS SUPPLIED BY TIE COMPANY UNDER THIS AGREEMENT SHALL BE THOSE GIVEN BY THE MANUFACTURERS OF SUCH
EQUIPMENTAND PRODUCTS UNDER SUCH MANUFACTURER'S WARRANTIES,TIE CLIENT MAYBE REQUIRED REGISTER OR MAIL INA WARAI CARO OR OMER
EVIDENCE OF OWNERSHIP AND USE OF SUCH EWIPMENT AND/OR PRODUCTS IN ORDER TO ACTIVATE SUCH WARRANTIES.
6. THE QUOTATION ON THE PAGE HEREOF DOES NOT INCLUDE WENSES OR CHANGES MR BOND OR INSURANCE PREMIUMS OR COSTS BEYOND NORMAL INSURANCE
COVERAGE,ANN SUCH ADDITIONAL EXPENSES,PREMIUMS OR COST SHALL BE ADDED TO TIE TOTAL AGREEMENT AMOUNT.
T. THE COMPANY'S LABILITY MR CLAIMS ARISING OUT OF THIS AGREEMENT SHALL NOT EXCEED THE TOTALAGREEMENT PRICE EXCEPT TO ME EXTENT THOSE DAMAGES
ARE PROVEN M BE SOUK DUE TO ME OOMPANYS NEGLIGENCE.
8. WRING IDE DURATION OF TIE WORN,THE CLIENT'S HOMEOWNERS INSURANCE WI LL BE RESPONRBLE FOR ANY ANO ALL DAMAGES AS LONG AS WE COMPANY HAS
TAKEN THE APPROPRIATE ACTION TO PROTECT AREAS OF WORN.
9. THE COMPANY IS NOT RESPONSIBLE FOR PRE EXISTING OEFIOENCIES OR HAZARDOUS MATERIALS THAT MANIFEST THENEE LVES OURING ME CONSTRUCTION PROCESS.
E.G.WOOD MT,MO L,ASBESTOS,NAL POPS,DUCTWORK AND CONNECTIONS,PLUMBING AND VENT PIPES,DECKING DEFLECTOR,ETC.IFAPRE-EXISTIHIS DEFIQENCY
OR HAZARDOUS MATERIAL IS ENCOUNTERED PRIOR TO OR DURING CONSTRUCTION,AND COMPANY 15 NOTIFIED IN WRITING,COMPANY WILL TRY TO ASSIST CLIENT
WITHIN TIE COMPANYS MEANS AND CAPABILITIES TO CORRECT THE PROBLEMS)ON A TIME AND MATERIA BATHS, CLIENT AGREES THAT SUCH CONDITIONS ARE
CHAMOMILE BY ME COMPANY AN0 SHALL NOT BE CONSIDERED A VIOLATION OF ME AGREEMENT AND MAT DUE M THESE CONDITIONS THE OUMTION OF THE
WORK AND SCHEDULED DATE OF COMPLETION MAY DIFFER FROM THAT AGREED UPON,IF APFUCABLE,UNDER THIS AGREEMENT.
10. THE COMPANY IS NOT RESPONSIBLE,AND THE CLIENT AGREES i0 HOLD THE COMPANY HARMLESS,FOR MY PROBLEMS PND/OR DAMAGES,IHLCUOING BUT NOT
UNTIED TO MOLD GROWTH,ARISING FROM ME PERFORMANCE OF AIR SEALING WORK BY ME COMPANY AS A RESULT OF ANY KNOWN OR UNKNOWN MOISTURE
CONDITIONS.
11. THE COMPANY I5 NOT RESPONSIBLE MR,AND THE HENT AGREES TO HOW ME COMPANY HARMLESS,FOR ANY PROBLEMS AND/OR DAMAGES RELATING TO ICE
DAMMING THAT MAY ARISE WRING AND/OR AMR THE PERFORMANCE OF WORK BY THE COMPANY.
12. REPLACEMENT OF DETERIORATED DECKING,FASCIA WARDS,ROOF ACTS,VENTILATORS,FLASHING,METERS,NNSTS,INSULATION OR OTHER MATERIALS ARE NOT
INCLUDED UNLESS OTHERWISE NOTED HEREIN.
13. THE COMPANY WILL NOT BE RESPONSIBLE FOR THE SCRATCHING OR DENTING OF INTERIM WALLS ME CENNGS,FLOORS,TRIM,GUTTERS,WWNSPOUIS,EXISTING
SIDING AND WINDOWS,ODORS,OIL DROPLETS IN DRIVEWAYS,HAIRLINE FRACTIOUS M CONCRETE OR BLACKTOP DRIVES AND WALO,OR DAMAGE i0 PLANTS M
SHRUBBERY. IF EXCESSIVE DAMAGE IS CAUSED BY COMPANY,COMPANY WILL REPAIR OR REPLACE DAMAGED ARM ONLY AT COMPANYS EXPENSE.
14. THE COMPANY UNDER PROMSIONS OF CHAPTER I4ZAOF ME GENERAL UIWS IS REQUIRED TO APPY FOR ANO OBTAIN ALL CONSTRUCTION-RELATED PERMITS. THE
COMPANY SHALL NOT BE DEEMED RESPONSIBLE MR DELAYS IN THE WORK DESCRIBED IN THE AGREEMENT CAUSED BY REGULATORY PERMIT GRANTING OR
INSPECTIONAL AGENCIES,AUTHORTIES,OR INDIVIDUALS.
15. THIS AGREEMENT,INCLUDINGME PRM19ONS RELATING TO PRICEAND PAYMENTSCHEODU,CANNOT BE CHANGED OR ALTERED EXCEPTBYAWRITTEN STATEMENT
SIGNED BY BOTH THE COMPANY AND THE CLIENT.
16. ANY REPRESENTATIONS,STATEMENTS,OR OMER COMMUNICATION NOT WRITTEN ON THIS AGREEMENT ARE AGREED TO BE IMMATERIAL AND NOT RELIED ON BY
EITHER PARD,AND W NOT SURVIVE ME EXECUTION OF MIS AGREEMENT.
17. THE AGREEMENT CANNOT BE CANCELLED WITHOUT ME MUTUAL WR17EN CONSENT OF NOW PARTIES EKE"A5 OTHERWISE SET FORM HEREIN.
A THIS AGREEMENT,AND ANY WARMNTYS)PROVIDED HEREUNDER SHALL NOT BE ASSIGNED EKE"BY OR WITH THE WRITTEN PRMISSIW OF ME COMPANY.
19. IF THE CUENT FAILS TO PERFORM TES OBLIGATIONS HEREUNDER OR TERMINATES THIS AGREEMENT WITHOUT THE PRIOR WRITTEN CONSENT OF THE COMPANY,THE
WENT SHALL BE WHILE FOR DAMAGES FOR THE GREATER OF ME COMPANYS ACTUAL DAMAGES OR 25%OF ME AGREEMENT FOR RESTOCKING FEE.
20. ANY CHANGES TO MATERIALS BY THE CLIENT(BRAND,STYLE,COLOR,ETC.)AMR MID MATERNAL HAS BEEN DELIVERED OR IS IN ROUTE M THE WENT COULD RESULT
IN A 5%RE-STOCKING FEE BASED ON ME COST OF SAID MATER W5.
21. THIS AGREEMENT SHALL BE EFFECTIVE ONLY UPON In EXECUTION BY ALL PARTIES HERETO,PRIOR TO WHICH TIME ITSHALL BE DEEMED A PROPOSAL MECOMPANY
RESERVES ME RIGHT M REVME THIS PROPOSAL 90 DAYS FROM DATE R IS EXECUTED BY THE COMPANY IF IT 15 NOT EARLIER EXECUTED BY ME WENT AND THE
REQUIRED DOWN PAYMENT RECEIVED PRIOR TO THE EXPIRATION OF SUCH 90DAY PERIOD,AFTER 90 DAYS,AND IN THE EVENT COMPANY DOES NOT REVOKE ME
PRCWS44 COMPANY RESERVES ME RIGHT REVM ITS PRICE IN ACCORDANCE WITH NS COSTS IN EFFECT AT SUCH TIME.
22. IF ANY PROVISION OF MIS AGREEMENT SHOULD BE HELD TO BE INVALID OR UNENFORCMLE,ME VAUD"AND ENFORCEBIUTY OF THE REMAINING PROVISIONS OF
THIS AGREEMENT SHALL NOT BE AFFECTED THEREBY.
23. ARBITRATION:IN ME EVENT THE CLIENT AND COMPANY HAVE A DISPUTE REGARDING ANY OF THE TERMS,CONDITIONS,PROVISIONS,M PERFORMANCE OF MIS
AGREEMENT,THE PARTES AGREE TO PEACE THE MATTER INTO ARBITRATION BEFORE AN INDEPENDENT ARBITRATOR ASSIGNED BY THE AMERICAN ARBITRATION
ASSOCIATION TO RESOLVE THEIR DISPUTE.
24. ANY DISCOUNT,PROMOTION,REIMBURSEMENT,OR OMER PROGRAM THAT IS PART OF A STATE SPONSORED UTILITY PROGRAM(I.E.MASS MME-)(SUBJECT TO THE
AVAEABIUtt OF QUALIFYING STATE SPoNSERED PROGRAM AND WILL BE SUBJECT TO TERMIMTION IF THE STATE SPONSORED UTILITY PROGRAM IS DISCW NTINUED.
FURTHERMORE,ME TERMS AND CONDITIONS OF STATE SPONSORED UTILITY PROGRAM MAYBE ALTERED OR UPDATED PERIMIGLLY WITH OR WITHOUT NOTICE.
25. AMERICAN INSTALLER$,LLC IS NOT AN AGENT OF ANN'CATHY COMPAN'OF OMER VENDOR WORKING BY,THROUGH.OR UNDER ME MASS SAVE'ENERGY
PROGRAM.
26. CLIENT IS REPSON51BUE MR THE PAYMENTOF ANY ANDALL FEDERA45TATE OR LOCALTAXES THATAREAPPEJCABU TO THISAGREEMENT.
The Commonwealth ofMossacltuseha
Department of Industrial Accidents
Office of Investigations
wi 600 Washington Street
Boston,MA 02111
www.»utss gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Lee'bly
Name(BusmesslOrgani,auonitadividuxly American Installations,LLC
Address: 130 College Street,Suite 100
City/State/Zip: South Hadley,MA 01075 Phone#: 413-552-0200
Are you as employer?Check the appropriate box: Type of project(required):
L U I am a employer with 60 4. ❑ I not a general contractor and 1 6. ❑New construction
employees(full and/or part-time).' have hired the sub-contractors
2.❑ 1 am a sole proprietor in parmer- listed on the attached sheet 1 7. ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity, workers comp.insurance. 9. ❑ Building addition
[No workers'comp.insurance 5. ❑ Weare a corporation and its
required.[ officers have exercised their 10.E]Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑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.] I3.®Other Insulation
"Am applicant dnl cMcks box tll must also fill ora the section helow showing(heir wodees'compensotion Polivy informnion.
t Homeowwm who submit this.ffidnh mdkning meY arc duiag all wrork and dim him ouaide ccmimctmr must submil a rc aliMrvd wi icmmg such.
tContmdoa Ihm check U,rs loom moat mbNed an addnw.]sheet showing the nanrc of the autreomem:mrs aM then wmkcW comp.polity ofentation,
l am an employer that isproviding worhen'ronpemation imarance for my employees. Below is the policy and jnb site
Worm d—
Insurance Company Name: Guard Insurance Companies
Policy#or SelFire.. LLw.#: URWC609917 Expiration Date:) 09/04/2019
Job Sim Address' vt`5�0 a City/State/'Lip:
Attack a copy of the workers'compensation 61ity dechimtion page(showing the policy number and expiration date).
Failure in secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to 51,500.00 and/or one-year imprisonment,as well as civil penalties in the form ofa STOP WORK ORDER and a fine
of up to 5250.00 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 ceeofy ander the pains a/nfd penaf/des_of perjury that the Information providedabboove is trve and comate
Sin bLLr✓ 17111 L lL ( .9{lT.t//2.SL__ Dam, `�,!yll-I�
Phpne#: 61 413-55 -0200
Official use only. Do not write in IM area,to he compared by city or town ojjieiet
City or Town: Permit/Lkease#
Issuing Authority(circle one):
1.Board ofH"Ith 2. Building Department 3.Cityfruwn Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: phone#:
Commonwealth of Massachusetts Construction Supervisor
®f Oivisionof Professional Licensure Unrestricted-Buildings of any use group which contain
Board of Building Regulations and Standards less than 15,000 cubic fact(991 cubic meters)ofenclosed
Constr00rbn Supervisor space.
CS-106178 Expires: 09/292019
LOUTU
218 RE -
213 LATHRTHROSTREET
SOUTH HADLEY MA at 075
® Failure dings Code
is cause for revocation
Massachusetts
Stale Building Cade is cause for revocation of this license.
For information about this license
Commissioner Call(617(]2]3400 or visit www-mass.govidpl
r 4 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 piration: 175982
130 COLLEGE STREET SURE 100 Exxpiration: 0826/2019
SOUTH HADLEY,MA 01075
Update Address and return card. Mark reason fen charge.
scnl 6 NAOLtt
rl pdd,A ❑ce.=ter rl Ecroplplq{aDi r,(<431 Card
Office of CRnwmer Affairs a Basin.ROBula3Rn
-�+- {- HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only
"J. TYPE:LLC before Me expiration date. if bund return to:
.'` R i Registration Expiration Office of Consumer Affairs and Business Regulation
175932 W26M19 10 Park Placa-Suke6170
AMERICAN INSTALLATIONS,LLC, Boston,MA 02116
wESLEYCOUTURE
130 COLLEGE STREET SUITE 100
SOUTH FIADLEV,MA O1075 UrldefSBOfefary [valid without signature
AC` OROe CERTIFICATE OF LIABILITY INSURANCE 9/4/2018 18n
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIRCATE 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 INSURERS), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER
IMPORTANT: If the CaMfirme holder is an ADDITIONAL INSURED,the pollcy(Ms)MUM he ee0orse0. K SUBROGATION IS WAIVED,subject W
Me terms and condldons of me policy,c"m pmicles may raluire an endorsement A atatemenT on this cedificafe does not conlef rights To tlY
Certflcete holder In Ileo of luch eedoraemen e.
PROWCER COnieCi Linda PONYra
wabbe, E Grinnell vWNe (1131486-0111 j'p .pvue9-ue3
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Soath Badley M 01075 N9UR
COVERAGES CERTIFICATE NUM13EROK-ter Z m 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 REGUIROVENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THM
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES OESCRIBED HEREIN IS SUBJECT TO ALL THE TEAMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,
WOR TYPI OF IMBUYNC! YBEP YDV uses
COMYERCIY OENNMLIUWYIY O 1.000,000
A a c,NMSM1OEOCCIII a 300,000
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