23D-039 64 RIVERSIDE DR BP-2019-1460
GIS#: COMMONWEALTH OF MASSACHUSETTS
Mao:Block:23D-039 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-2019-1460
Proiect# JS-2019-002368
Est.Cost:$2900.00
Fee:$65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor. License:
Use Group: AMERICAN INSTALLATIONS LLC 106178
Lot Simian.B.l: 6969.60 Owner: BEAUVAIS VERA
zoning: URB(100) Applicant: AMERICAN INSTALLATIONS LLC
AT: 64 RIVERSIDE DR
Applicant Address: Phone: Insurance:
130 COLLEGE ST (413) 552-0200 WC
SOUTH HADLEYMA01075 ISSUED ON.6,2112019 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:
FeeTvpe: Date Paid: Amount
Building 6/21/20190:00:00 $65.00
212 Main Street,Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
i
1
I
RECEIVED
"a Pat?City of Nort amp on JUfl 2 201
Building De rtm nt
212 MaIn Room DO pEpT OF IWROwGINSFF TION) SOLATION
Northampton, THAMCTON.MAP
phone 413.587-1240 Fax 41&587-1272 ONLY
APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING ONLY P I ct i /
L/teo
SECTION I-SITE INFORMarION INSULATION PERMIT
1.1 Property Address'. This section to be completed by officeMap L/ D Lot QM Unit
64 Riverside Drive
Zone Owday Dlatrict
Elm SL District CB DYbkI_
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Ownar of Record:
Vera Beauvais 64 Riverside Drive Florence,MA 01062
See attached CMI�� :
Telephone
Signal".
2.2 Authorized Aaent:
American Installations 130 Collere Street Ste. 100,South Hadley,MA 01075
None(Pralp Curve Mang Addeo:
y (413)552-0200
34Naaa Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building 2900.00 (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from B
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5.Fire Protection
5. Total=(1 +2+3.4+5) 2900.00 Check Number (�
This Section For Official Use Only
Building Permit Number. Data
Issued:
Signature GZO-zag
Buldng Canmaeio nedlnpect rof Buildings Das
production @ annericaninstallations.cont
EMAIL ADDRESS(REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
t
SECTION a-CONSTRUCTION SERVICES {
8.1 Licensed Conetnrction Suaervlor. Not Applicable 0
Name of uwnse Holder: Wesley K. Couture 106178
Uorm,Number
130 College Street Ste. 100, South Hadley MA 01075 912912019
Address Expiration Dal
\ . ( 6N 11 0. (413)552-0200
siplttn rakrohom
S.Reulbred Noma k praimment Contractor. Not Applicable 0
American Installations 175982
Comoerw Name Registration Number
130 College Street Ste. 100,South Hadley MA 01075 6126/2019
Address Expiration Dal
k . �i9A�AaM1 siphons !4137551-0200
SECTION 5-WORIO=RS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e.152,9 26C(ej)
Workers Compensation Insurance affidavit must be completed and submttld with this application.Failure l provide this affidavit will result
in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... X No...... 0
Brief Description of Proposed Work NOTE: INSULATION ONLY
Attic and basement insulation and air sealing throughout.
1, American Installations- Wesley Couture .as Owner/Autho!zed
Agent hereby declare that the statements and information on the foregoing application are We and accurate,to the best of my knowledge
and belief..
Signed under the pains and penalties of perjury.
Wesley K. Couture
Pdn\\Namer1
\1J 3AC1.An �-. CHS \y.y,a 6/17/2019
Signature of Dimx pwd Dale
I, as Owner of the subject
property
hereby authorize American Installations
W act on my behalf,in all matters relative 0 work authorized by this building permit application.
See attached 1, 1 ''Illy
Signature of ower Date
City of Northampton
Nassachusetts
L
[212 Min
OF o B@ LDIMMunicipal
al BuilTIOBS
Pt_ 313 Min atcnn,t " rYM 011 Lu11Gl,y
' porthuppon, w. 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 must be registered as a Home Improvement Contractor("RIC").
M.G.L.Chapter 142A requires that the"reconstruction, alteration,renovation,repair, modernization,conversion,
improvement,removal, demolition, or construction of an addition to any pre-existing owneroccupied building containing
at least one but not more than for 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 endly must be registered
Type of Work: Insulation Est.Cost:
Address of Work 64 Riverside Drive Florence,MA 01062
Date of Permit Application: 6/17/2019
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 call permit(explain):
_Building not owner-occupied
z Other(specify): Contractor pulling permit for homeowner
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:
6/17/2019 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
6/17/2019
Date Owner Name and Signature
City of Northampton
�
Massachusetts 3
t 4Y1/I 's
.1 tpw
DCPAR M OF BDILDL12a IBSPSCSIOBB O �_/
,.;Tit, . 212 Mi. at •14n1aiW1 anildinq p
,.y NorUi,epCe/,. MA 01060
Debris Disposal Affidavit
In accordance of the provisions M 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:
64 Riverside Drive Florence,MA 01062
(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 kKation of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
\ (Company Name and Address)
WAS),. ), \\) Cm&iu\), �1�`�
Signature o rmit Applicant or Owner Dat `
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.
--- City of Northampton
Massachusetts a
La9ARTlSMl OF BUILDING INSTVO IONS
ttes
212 Win at a Mnici"I Building
Nor" ten, M 01060 M'NJ�1J
MANDATORY FOR HOUSES BUILT BEFORE 1945
Property Address: 64 liirerside Drive Florence,MA 01062
Contractor
Name: American Installations
Address: 130 College Street Ste. 100
City, State: South Hadley MA
Phone: (413) 552-0200
Property Owner
Name: Vera Beauvais
Address: 64 Riverside Drive
City, State: Florence,MA 01062
1, Wesley K. Couture (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.
Cc t clot signature
Date
6/17/2019
,
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Bearab,Vera 6/11/2019
64 Riverside Or M Florence MA 01062
413.320.8500
495939 .. 1� 19-1746
1..n
Quantity Unit UnNCost u.. Total
Ai SwBry
AIR SEALING 8 manhour $ 85.00 $ 680.00
DOORSWEEP 2 eaEh
WEATHERSTRIP DOOR 2 jeacti is 58A0 15 116,00
Air Sealing $ III
Air Sealinglncentlye $ (846.00)
Air Selaing W%Balance $ -
WeatMMtlws
FINISHED CEILING ACCESS 1 each $ 135.00 $ 135.00
ATTICFLAT-9'OPENR-33CEUULOSE 860scift 1.50 $ 1,296.00
ATTIC DAMMING-R-39 FIBERGIA55 94Soft 2.05 Is 192.70
NEED RIDGE VENT 2 each $ 110.75 $ 221.50
VENTILATION CHUTES 57 each $ 2.50 $ 142.50
Taal Wealherizatim $ 1,987.70
Weatherization Incentive $ 1,490.78
Total Project 5 2,833.70
Total Utility Contribution $ 2376.78
Tatal Customer Cuntriblrtbn $ 496.93
W MMMY:.Yryaan InYlYlbm.11C wYM pvN.IM.Evn f nn0 Mmww wah.l P'vbruMp wrnnry.
am.Mn Im ..,LLC MMYpgq..Ep Mmlri.1mmMI.M m,,b.c,.rM.Wn¢eM of vr..rtmr0.nn xIM IM Wz.maim.,..11-1 pw Waar.
111-1 M IM r W.I cmE.d v.Ir..MH hmin.
AcCIPTAxcE OF rRorosu:llW.line price•.w..wunwnane TOTAL CONTRACTVALUE= $ 496.93
.onertmm.rc imitmory.M..hereer.—om.rouse
.whmaea to aox rt a mcrfiea.Pa,m At wal M V3 mm i to Down Payment= $ iw.w ® 415-zov
m,rw won.aria Ml.m ew opal fnlnpleNon. PAn
�Balance Due Upon Completion= $ 336.93
wx.. Beauvais,Ven - s' �i^� `— — ntl 6/11/2019
C.Dragori 6/11/2019
THIS AGREEMENT IS COMPOSED OF THIS PAGE AND TIE REV E16E SLOE OF THIS PAGE AND MALLBE Cp61 DERED THE EMI RE AGREEMENT BY TIE PANTIES INVOLVED.MS FGREMEM IS
BETWEEN AMERICAN INSLAWTIOM,LLL HEREINAFTER REFERRED TOM'COMPA TI AHDTHE CUSTOMEMSI NAMED ON TIE REVERSE SIC(HEREINAFTER REFE%RW TO A"NEXT,AND
WILL BE WSIIECT TO ALL APPROPRIATE LAWS,REGULATIONS AND ORDINANCE50F THE FATE OF MASSACHUSETTS OR CONNECTICUT RESPECTIVELY,AS WEU MALL LOCAL JUMDICTIX6.
THE FOLLOWING TERMS AND CONDITIONS AASO APPLY
1.TRIS AGREEMENT IS SUBJECT M THE APPROVAL OF A MANAGER OF ME COMPANY FOR TITS AGREEMENT TO BE EFFECTVE UNDER ANY COMMIOX.
3,SHOULD DEFAULT BE MADE IN THE PAYMENT OF MIS AGREEMENT,CHARGESS U BE ADDED FROM ME COTE MEMOS AT A MT:OF ONE AND CHI(El/B)PERCENT PER MOWN.
JIM PER ANNUM)WITH A MINIMUM CURIE OF S3.W PER MONTH,AND IF PLACED IN ME HANDS OF AN ATTORNEY OR COMMON AGENCY FOR COLLECTION ALL ATTORNEYS,FEES,
OPENED AND COMES CE CCUECTpN SIMLL SE PAID BY ME NEM.IN ADDITION.MO.UNDERSTANDS THAT IN IMMUNE TO PAY ACCORDING TO THE AWE TERMS,COMPANY MAY
HAVE ME RIGHT TO A MO ON ME PROPERTY.
ME COM PAM AGREES THAT WHEN DELAYS BECOME KNOWN TO ME COMPANY,ME COMPAM WILL ADVISE THE CULT AS MEW AS REASONABLE.
1,COMPANY AGREES THAT,NOTWTMTANOING AM AGREEMENT FOR MATERIALS AND/OR LABOR BETWEEN COMPANY AND THEM PART,COMPANY 6 RESPOINBIE M CLIENT FOR
COMPLETION OF ALL WORK DESCRIBED IN A TIMELY AND WORKMANLIKE MANNER.
S.ALL WARMMIES FOR EWIFMEM AND PROCACTS SUPPLIED BY THE COMPANY UNDER NIS AGREEMENT SHALL BE THOSE GIVEN BY THE MANUFACTURERS OF SUCH EW IPNEM AND
PRODUCTS.UNDER SUCH MANUFACTURER'S WARMTH U THE NEM MAYBE REW IMDTO REGISTERM MMl INA WARRANTY CARO OR OWER EVIDENCE OF OWXfMHIPAND USE O
SUNEWIPMEMAND/MNIOWRSINO ERTOARIVAnWCHWAMP ES.
fi.MEWOTATCNONMEPOLEHFAEOFDOESIMTINCLU MIX E500.OWKESFMAO INSUMHCE WEMMMSORCW15 BEIOID NORMAL INSURANCE COYEPAGE,AMSVOI
ADE COMAIXSLIABLPREMIV MSIICOFNG OUT AOMD TOMFIOTAAGLNOTETAEDTHE
].ME C OLETO S LIABIMY FOR CLAIMS ARISING Wi OF THIS AGREEMENT SPALL HOT OCEEDME TOTAL AGREEMENT PRICE EXCEPTTOME FKTfMiXOSE DAMAGES ARE PRWENTO BE
SOLIV
B.AFRIMEL THE W RATION OF ME WORK,ONE CIIEMS M0AE0WHE0.5 INSURANCE WILL BE!RESPONSIBLE FOR AM AND AL DAMAGES/S LONG AS ME COMPANY HAS TAREV Mf
APE C MIMUM IS
T RUMMRRMUR OF WORK.
9.ME ,ASBESTOS,
IS NOLLMAE, BU WR PRAND C N DENEONCERS, OR HALM WHO E T III D CIDE MANIFEST TEM56VE5 WANG ME CWSTRVLTOH PHAZARD US WO^A ROI,
MOD,ASBESTOS, RTPOS gKG CONS ANDCWMND COM PWM&NG AND VNWRPB,CEQINGY WILL TOA FTGIFA ENTRE WITINGHIN
HE COMPANY'S
MEMES AND
IS
ENCOUNTERED E MOB.OR WRING TIME AND MAT AND COMPANY IS TOURED IN AT SUCH COMPANY WILL EMYTO
ENA ASSIST WENT WTHIN THE COMPANY$MGH$ANO UPMRED A
TO COPPER ME PAGREEMEN ON A TIME UE MATERIAL BA515,NEM AGREES TOUTS E DIRK A ON5 ARE UNAVA E OF BY THE COMPANY AND SPALL NOT A CONSIDERED A
VIOLATION OF U DE AGREEMENTANDMEN THAT DUE TOMFSE COIOTNWSTXf DURATION OF ME WCPA AND SCXMUIEO DATE Of COMPLETION MAY RARER FROM TUT AGREED UMN.If
APPNCABIE,VHOERMUAGREFAFM
10.THE COMPANY IS HOT RESPONSIBLE,AND ME CLAW AGREED M IKKD ME CCMGNY XMMIE{5,FOR ANY PROBLEM$ANO/OI DMIAGES,INCl10NG BM NET UMTED i0 MOLD
GROWTH,ARISING FROM THE PERFORMANCE OF MR SOLING WORK BY ME COMPANY AS ARESULT OF ANY KNOWN OR UNKNOWN MOISTURE CONDITION&/
ll.THE COMPANY IS NOT RESPONSIBLE FOR AND ME CLIENT AGREES TO HOLD ME COMPANY HARMLESS,FOR AM PROBLEMS AND/OR MMAGB BELONG TO ICE DAMMING THAT MAY
ARISE DURING AHD/M AFTER ME PERFORMANCE OF WORK BY ME MMEMW.
12.REPLACEMENT OF DETERIORATES OWNG,FAS U,BOARDS,ROCf LACKS,VENTILATORS FVSNING,MITERS,WISP,INSULATION OR OMG MATERIALS AM NOT INCLUDED UNLESS
OOERMSE NOTED HEREIN.
11.ME COMPANY WILL HT BE FISMIL ISIE EOR ME SCRAMMING OR DAM ON O NONCOM WAILS AND CERN SS,FLOCAS,TRIM,GUTTER DOMNSPHEI MEETING SIDING AND
WINDOWS,WOKS,MORWLER IN DRIVEWAYS,HAIRLINE FRACTURES IN CO CIRMOR BLARTO ORIVESAHD WAYS,OR DAMAGE i0 PLAMSOR SHWBBEW.IF EXCESSIVE OAfMGE 15
CAUSED BVWMPAW,COMPANY WILL REPAIR OR REPLACE DAMAGED AREA NLY ATCOMPANYS EXPENSE.
14L THE COMPANY UNDER PROVISIONS OF CHOLER U]A OF ME GENERAL LAWS N REWIRED TO APPLY FORAM OBTAIN ALL CONFRURIOHREGTED PERMITS.THE COMPANY SHALL NOT
M MEWED REASONABLE EOR DELAYS IN THE WORK.DESCRIBED IN THIS ASSESSMENT CAUSED BY REGULATORY PERMIT MEANING OR IWEOIONAL AGENCIES,AUTHORITIES.OR
NONNY US.
B.NIS M INIMUM.INCWONG THE PROVISIONS REGTHGM PRICEAMD PAYMEM$CIEWIF,CANNOT BE OMNGEDOR ALTERED EXCEPT BYAWMTEN FAI COSIGNED BY BOO ME
COMPANY AND ME MEW.
16.ANY REPRESENTATIONS,STATEMENTS,OR BM OR COMMUHIGTON NOT WRITTEN ON THIS AGREEMENT ARE AGREED TO BE IMUMMA.AND NOT AFUED ON BY SEM IS PARTY,AND DO
NOT WWNE ME EXECUTION OF THIS AG RE EVENT.
17.THIS AGREEMENT GHNT BE CANCELLED W NDI ME MUTUAL WRIFEN CONSENT OF BOM PATES Dan M OTHERWISE SET FORM HEREIN.
IA MRS AGREEMENT,AND ANY WMUMETHS)REMOVED HEREU NOER SHALL RACE ME ASSIGNED Dan BY OR WTM ME WETTISH FORMISGON O ME COMPANY
1B,IF ME WENT FARE i0 PERFORM ITS M" M HTEUNOR M TERMINATE THIS XAEEMEM WITHOUT ME PRIOR WAREN CONSENT O ME COMPANY,ME WENT SHALL.ME
LIABLE FOR DAMMED FOR ME GREATER OF ME OCAR A ES ACTUAL DAMAGES DR$5%0FME AGREEMENT FOR RESTOCKING FEE.
30.ANY CHANGES TO MATERIALS BY ME CLIENT)BAND.STYLE,C0L04 EIC)APER SAID MATERIAL HAS BEEN DELIVERED OR IS IN RARE TO ME NEM CAM RESULT IN A5%RE-STOCKING
FEE USED ON THE COST O SAID MATERIALS
21.THIS AGREEMENT SIWL L EFFECTIVE ONLY UPON ITS IXENTION BY ALL GLIB HERETO,PRpR TO WHICH TIME IT SHALL BE DENIED A PROPOGI,ME COMPANY RESERVES ME RIGHT
M REVOKE THIS PR0gML SO DAYS FROM DATE ITN DEOREO BY THE COMPANY IF TU NOT EALIER EXENRD BY ME NEM AID ME REWIRED COVEN!PAYMENT RECEIVED PMOLM
ME EXPRATON Of SUCH SO DAY PERIOD,AFTER SO DAYS,AND IN ME EVENT COMMISSARY DOS NOT REVENUE ME HANSOM.COMPANY RESERVES ME RIGA M REWSE TR MILE IN
ACCORDANCE WIN ITS COSTS IN EFFECT AT GLI TIME.
33.IF AM PROVISION OF MIS AGREEMENT SHOULD BE HEIR TO BE INVALID OR UNENFORGBLE,ME VALIDITY AND ENFORCEBILR'OF ME REMAINING PROVISIONS OF MI5 AGREEMENT
SHALL NOT BE AFFECTED THEREBY.
33.ARETRATCN:I N ME NEW ME DIEM AND COMPANY HAVE A DISPUTE REGNONG ANY OF THE TE RMS.CWDMCN S.PROVISIONS,W PERFORMANCE OF THI S AGREE MEM,THE SABRES
AGREE TO RACE ME MATER IMO ARBITRATION BFIME AN I XOPEHOMR MUWNUMR ASSIGNED BY THE AM ERICAN ARMMTW ASSO MON i0 RESOLVE M FIR pSRRE.
IC.ANY OUCW Ni,PROAMDX,REIMBURSEMENT,OR OTHER PROGRAM THAT IS PARI O A FATE SPONSORED UNITY PROGRAM D.E MASS SA I M SUBJECT TO ME AVMIANUO OF
QUALIFYING STATE SHONSERED PROGRAM AND WILL BE SUBJECT TO TERMINATOR IF THE STATE SPONSGM MILK PROGRAM IS DISCOLNTNUM,FURTHERMORE ME TERMS AND
CONDEEMS OF STATE SPOMELD UOLITY PROGRAMS MAY BE ALTERED OR UPDATED PERIWICALLY WITH OR WTNOUT NOTICE,
IS.AMERICANIHSTNIERLLLCTHOIMAGEMOAYUTUTYCOMPAM OMERVENWRWMIMBY,THROWN,ORUNORMEMA VESEMG PROGRAM.
36.NERALS REVYM91E Fg1THE PAYMEW 0..DALL FMERAL,STATE,M IOCALTMESTHATME APLIGBIE T0TH6 AKWW,
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Inivaligations
600 Washington Street
Boston,MA 02111
www.rnunstgov/dia
Workers' Compensation Insurance Affidavit: Builders!Contractors/Electricians/Plumbers
Applicant Information Please Print Letubly
Name(Bminexi-'aganicaeoNlndividaaq: American Installations,LLC
Address: 130 College Stmt,Suite 100
City/State/Zip: South Hadley,MA 01075 Phone#: 413-552-0200
An you an employer?Cheek the appropriate box: Type of project(required):
1.N 1 sm o employer with 60 4. ❑ 1 am a general contractor and 1 6. ❑New construction
employees(full and/or pan-time).• 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 subcontractors have S. ❑ Demolition
working far mein anv capacity. workers'comp.insurance. 9. E] Building addition
(No workers tamp.insurance 5. ❑ We are a corporation and its
required.] oDicers have exercised their Ill Electrical repairs a additions
3.❑ 1 am s homeowner doing all work right of exemption per MGI. I I.❑ Plumbing repairs or additions
myself.[No workers'comp. c. 152,§i(4),and we have no 12.❑ Roof repairs
insurance required. t employees.[No workers' 13.[N OtherInsulatlOn
comp. insurance required.]
"applicml Nuchce box Yl mustalrorillWIme amn hel.flowing their workercnmpnnsarion palmy intommion.
I Itameownem who sultana this nmdevit rdicating they me hunts all nark and then him outside camg
aors must submit n new altiJavit malwa ing such.
:C'omnclor act]check Nis box mmt aaached un add..io..at shcet slwwing the at.of the mt-.mantas and their wmkcha'comp,policy..fa malm.
l um an employer that u providing workers'enmpemodon imumnee far my employees Below is the policy and job site
informa(ion.
Insurance Company Name: Guard Insurance Companies
Policy dor Self-ins.L11i1c1,h: URWC60,9^917t� Grp _ Expiration Date: 09/04/20199 y� /� (`
Job Site Addaces: A R]�S�(le [ )Y l7\. City/State/Lip: FI�rP.n T, IVIA-L MUZ
Attach a copy of the workers'compensation policy declaration page(showing the policy number and exaltation date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the impontion of criminal penalties of a
litre up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form ofa STOP WORK ORDER and a lira
of up to 5250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded w the Once of
Investigations of the DIA for insurance coverage verification.
I do hereby c7erdfy-u�nd�er the puim a/n/�d�penal(irs rof�perjury that the information pmvlided above is true and carred
S (nLA//lirkk � l A1TLl.W(�- __Date:
Phone q: 413-552"0200
Offfeial me only. Do not write in this one,to be completed by city or town official
City or Town: Permit/License k
Issuing Authority(circle ane):
1.Board of Health 2. Building Department 3.Cityrrown Clerk 4.Electrical inspector S. Plumbing Inspector
6.Other
Contact Person: Phone a:
I
Commonwealth of Massachusetts Construction Supervisor
Division of Professional Licensure Unrestricted-Buildings of any use group which contain
Board of Building Regulations and Standards less than 36,000 cubic feet(991 cubic melers)of enclosed
Construction Supervisor space.
CS-106178 Expires:0912912019 -
WESLEY COLLTUHE
218 LATXRORS7ftEET
SOUTH HAOLEI A 01075
)a Failure to possess a current edition of the Massachusetts
Stale Building Cade is cause for revoratlon of this license.
41, For intoan tioabout this license
CpnnISSI8n8f n
Call(6 17)727-3200 or visit v rhasz,govldpl
Office of Consumer Affairs and Business Regulation
1000 Washington Street- Suite 710
Boston, Massachusetts 02118
Home Improvement Contractor Registration
Type: LLC
AMERICAN INSTALLATIONS,LLC. Registration. 175982Expirabon: 06/2&2021
130 COLLEGE STREET BUTTE 100
SOUTH HAOLEV,MA 01075
Updam Address and Return Cad.
Scw, G xml.1w
.//.. Y.nv..n n..i.A//. "/. .'/..........
A-,
OMn M consurns,Maim 6 Business Regulation
HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only
TYPE:LLC before the saturation dam. IF found remm to:
Redstrat'on E.oireuo" r)Rce of Consumer Affairs and Business Regulation
175902 OBY1812021 1000 Washington Street -Suite 710
AMERICAN INSTALLATIONS,LLC. Bcaton,MA 02118
WESLEYCOUTURE
130 COLLEGE STREET SUITE 100
SOUTH HADLEY,MA 01075Untlersecretary Wit valid without signature
--N
AC40R& CERTIFICATE OF LIABILITY INSURANCE
1 9/4/2018
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY ANID CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGA1TVEL.Y MEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POUCHES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETIIIIEEN THE ISSUING INSUREFKS). JULTHIORRIMI
REPREEIENTAnVE OR PRODUCER,AND THE CERTIFICATE MILDER
IMPORTANT: If The ounificale holder Is an ADDITIONAL INSURED,Me,pdIcy(Ies)MUM be enclorusi. If SUBROGATION IS WAINED,subject W
Me IN=And comilliOne of Me pi,licy,cerIMn oliclas MAY ne,use an emo� A slaidernment On Has ceriffiCalm,does not conler ngm to Me
conifficate holder In lieu of such endonseerengs).
..00UCEN HONT
A,,ACT Lin" Posaar.
Webber A Grinnell jltt� ms-..
8 North King street M��ndrixrmmll.ccm
wousawass..... wac.
Nortbamptan m 01060 UA1M.�11a1%F1QorI IdUt.1 CIIIIIII
INUM. oxwuara.�IISUIIUL. Raviluremy � MON. Co.
Amenticaus InarallotitFeg, HSU`NNC
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