25C-019 (4) 186 NORTH ST BP-2020-0153
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:25C-019 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-2020-0153
Proiect# JS-2020-000258
Est.Cost:$2500.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor. License:
Use Group: AMERICAN INSTALLATIONS LLC 106178
Lot Size(sq.ft.): 7 10 0.2 8 Owner: NOW MARY
Zoning: URB(100)/ Applicant. AMERICAN INSTALLATIONS LLC
AT. 186 NORTH ST
Applicant Address: Phone: Insurance:
130 COLLEGE ST (413) 552-0200 WC
SOUTH HADLEYMA01075 ISSUED ON:8/6/2019 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 SiLjnaturc:
FeeType: Date Paid: Amount:
Building 8/6/2019 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
RECEiVED
Dep
" AUG �fpon
N rtha pton
1 ng epa ment
212 M in St eet INSULATION
k
'!. OF BUILDING INSPF, 1
ORTHAMPTgco M. ton M 01060
ONLYphone 413-587-1240 Fax 413-587-1272
APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING ONLY
SECTION 1 -SITE INFORMATION INSULATION PERMIT
1.1 Property Address This section to be completed by office
184-186 North Street Map----6�� Lot 0 Iq Unit
Northampton,MA 01060 Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Mary Now 186 North Street,Northampton,MA 01060
Name(Print) Current Mailing Address:
See attached (413) 586-6455
Telephone
Signature
2.2 Authorized Agent:
American Installations 130 College Street Ste. 100, South Hadley,MA 01075
Name(Print) Current Mailing Address:
� (413)552-0200
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building $2,500.00 (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC) j/J
5. Fire Protection l J'
6. Total=(1 +2+3 +4+5) 2,500.00 Check Number
This Section For Official Use Only
Date
Building Permit Numb r: Issued:
Signature: l7- 7-U)q
Building Commissioner/Inspector of Buildings Date
pmductior, @ americaninstall ations.com
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 4-CONSTRUCTION SERVICES :t
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: Wesley K. Couture 106178
License Number
130 College Street Ste. 100, South Hadley MA 01075 912912019
Address Expiration Date
L)LUIA cau Lu— (413)552-0200
Signature J Telephone
9.Registered Home Improvement Contractor: Not Applicable ❑
American Installations 175982
Company Name Registration Number
130 College Street Ste. 100, South Hadley MA 01075 6126/2021
Address Expiration Date
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....... JX No...... ❑
Brief Description of Proposed Work NO TE: INS ULA TION ONL Y
Attic and basement 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
Print Name
7/29/2019
Signature of O er/Agent Date
I, Mary Now 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 7/29/2019
Signature of Owner Date
City of Northampton
r Massachusetts �v? �•. {�c
(�
DEPARTMENT OF BUILDING INSPECTIONS 7;
�e
exp jK212 Main Street •Municipal Building yJb,_ a
Northampton, 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:
184-186 North Street
(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)
tUPAL14
Signature oVPermit 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.
City of Northampton
N
Massachusetts
1 DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street a Municipal Building
Northampton, MA 01060 �SbJY' ji�1
\,y
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.L. Chapter 142A requires that the"reconstruction, alteration, renovation,repair, modernization, conversion,
improvement,removal, demolition, or construction of an addition to any pre-existing owner-occupied building containing
at least one but not more than four 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: 52,500.00
Address of Work: 184-186 North Street
Date of Permit Application: 7/29/2019
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 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:
7/29/2019 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:
119 waw V_ COWL&
Date Owner Narni and Signature
City of Northampton
f Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS 3,
212 Main Street • Municipal Building
�e+ Northampton, MA 01060
MANDATORY FOR HOUSES BUILT BEFORE 1945
Property Address: 184-186 North Street
Contractor
Name: American Installations
Address: 130 College Street Ste. 100
City, State: South Hadley MA
Phone: (413)552-0200
Property Owner
Name: Mary Now
Address: 186 North Street
City, State: Northampton, MA
1, Weslev K. Couturr (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
Date
7/29/2019
R VV V.�H r�4
� www.Americanlnstallations.com
BBB rRnnclvengr.
® CDmgAOTOq Licensed&Insured
MA CSL#:106178
American Installations MARegistrorion#175981
130 College Street Suite 100,South Hadley,MA 01075 •Office:1413)552-0200 Faw(413)552-0202 • Email.support@Amerlcanlnstallatlons.com
Mary
3--6-19
184 NorthStreet North ampton Street MA 01060
(Add—, IenYl "';`1II�CI
(413)586-6455 riannalarkin@comcast.net
IH—I (c,lq (Emaiq
481585 19-0833-B
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Quantity Unit Unit Cost Total
Air Sealing
AIR SEALING 6 man hour $ 85.00 $ 510.00
Air Sealing $ 510.00
Air Sealing Incentive $ (510.00)
Air Selaing WX Balance $
Weatherization
ATTIC FLAT-6"OPEN R-22 CELLULOSE 656 sgft $ 1.32 $ 865.92
ATTIC DOOR-INSULATE&WS 1 each $ 110.00 $ 110.00
ATTIC DAMMING-R-38 FIBERGLASS 136 sqft $ 2.05 $ 278.80
Total Weatherization $ 1,254.72
Weatherization Incentive $ 1,129.25
Total Project $ 1,764.72
Total Utility Contribution $ 1,639.25
Total Customer Contribution $ 125.47
WARRANTY:American Installations,LLC will provide the above stated homeowner with a 1 year workmanship warranty.
American Installations,LLC hereby proposes to furnish all material and labor to complete the above scope of work in accordance with the above specifications and all local and state
building regulations for the Totai Contract Value as stated herein.
ACCEPTANCE OF PROPOSAL:The above prices,specifications and TOTAL CONTRACT VALUE_ $ 125.47
conditions are satisfactory and are hereby accepted. You are
authorized to do work as specified.Payment will be 1/3 down prior Down Payment= $ 50.00 ❑
to start of wor a d balance due upon Completion. D PAI
J Balance Due Upon Completion= $ 75.47 PAI
f J l
5�p�wure Dwe
Now,Mary 3/11/2019
PlopeHY OY+ne�(RImI Property O.ner ISynl Mie
Jason Bhajan 3/11/2019
Peprne�lal.e lD.nll Rep�e+emnl.e Synl Otle
THIS AGREEMENT IS COMPOSED OF THIS PAGE AND THE REVERSE NDE Of THIS PAGE AND SHALL BE CONSIDERED THE ENTIRE AGREEMENT BY THE PARTIES INVOLVED.THIS AGREEMENT IS BETWEEN AMERICAN INSTALLATIONS.LLC HER(IN—,LR
REFERAIII)TO AS'COMPANY,AND THE COSTOMERISI NAMED ABOVE,HEREINAFTER REFERRED To AS'CLIENT',AND WILL BE SOBIECT TO All APPAOPRIATE CAWS.AEG.1T—I AND OISDIHANCFS Of THE STATE Of MASSACNUSFITS OII
CONNECTICUT RESPECTIVELY,AS WELL AS ALL LOCAL IDRi5NCnONS
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 AS"COMPANY",AND THE CUSTOMER(S)NAMED ON THE REVERSE SIDE,HEREINAFTER
REFERRED TO AS"CLIENT",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 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 AT A RATE OF ONE AND ONE-HALF(1-1/2)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'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 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 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.
7.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 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 HAZARDOUS MATERIALS THAT MANIFEST THEMSELVES DURING THE CONSTRUCTION PROCESS E.G.
WOOD ROT, MOLD,ASBESTOS, NAIL POPS, DUCTWORK AND CONNECTIONS,PLUMBING AND VENT PIPES, DECKING DEFLECTION,ETC.IF A PRE-EXISTING DEFICIENCY OR
HAZARDOUS MATERIAL IS 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,INLCUOING 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 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,
14.THE COMPANY UNDER PROVISIONS OF CHAPTER 142A OF THE GENERAL LAWS IS REQUIRED TO APPLY FOR AND OBTAIN ALL CONSTRUCTION-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.
17.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 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 DELIVERED OR IS IN ROUTE TO THE CLIENT COULD RESULT IN A
5%RE-STOCKING FEE BASED ON THE COST OF SAID 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 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 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 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,
24.ANY DISCOUNT, PROMOTION,REIMBURSEMENT,OR OTHER PROGRAM THAT IS PART OF A STATE SPONSERED UTILITY PROGRAM(I E. 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 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.
-icensedet� mass save
MA C.9 p:1OF,1ZR PARTNEP
MA Rcgistranon p!/5997 American Installations www-Americaninstallations.com
130 College Street Suite 1D0,South Hadley,MA 01075•Office:(413)S52-07D0 raa:(413)552.0202•EmaiL support@Americaniestallat:ons.com
Customer Name:Mary Now
Email:Not provided
Phone:413-586-6455
Premise Address: 186 North St,Northampton,MA 01060
Mailing Address: 186 North St,Northampton,MA 01060
Project ID:3750407
Date:March 11,2019
Job Description
Measure Description Location Quantity Unit Total Cost Customer Cost
Air Sealing at Estimated 62.5 CFM50 Per Hour Living Space 2 hr $185.16 $0.00
Exterior Door Weather Stripping (with AS hrs) Living Space 3 each $90.21 $0.00
Door Sweep (with AS hrs) Living Space 3 each $75.93 $0.00
Rim Joist-6" Fiberglass Batting Living Space 136 SF $367.20 $36.72
Project Total $718.50
Weatherization incentive ($330.48)
Air sealing incentive ($351.30)
Total Program Incentive -$681.78
Customer Total $36.72
WARRANTY:American installations,LLC will provide the above stated homeowner with a 1-year worknunship warrarry.
American Installations,LLC hereby proposes to furnish all material and labor to complete the above scope of work in accordance with;he above specifications and all local and state
building regulations for the?0131 Contract Value as stated herein.
ACCEPTANCE OF PROPOSAL', The above prices, spedcations and condCions are TOTAL CONTRACT VALUE-S
satisfactory and are hereby accepted.You are authorised to do work as specified.Payment ment-5 O
will he 1/3 down prior t0 start of work,and balance due upon Completion. Down PayPAID
rt Balance Due Upon Completion= S
Signature
M!� I
K-1
(xDte
Property Owner(Print) (Sign; Page 1 of 1 Dale
Representative:(Print) (Sinn) Date
THIS Ac"ItI.IL rItC 1110SF:U:E'"s PAGE-U THE REITNSE SUL*THIS PAGE AhU 544EL BE CC.'IiIDENE3 THE C:AIIES I Ci SSU"FIS AGRlEMfrll BElY:EEN A!AERIt:.N INi'.E:i DChf,:SC M[REIVt�;Ep ru LRikO TO AS YCIAPAVI',
-DI.Ei ITCIWES(S)RA1.EU+EoVE.NERC RI tITRlfERflW IC AS'QIEMI',AMC W:EL 9E IUBJEC17UALLMPRCPRUIIe SAwi.RE3USA'IiC`15 mu o4ol `cEi Uf THES TA It of SSACM USO 75 CMCCMIE.IICU'RESKC11VESS,AS:'iEU AS A A LOCAL IURISDICTIChS
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 AS"COMPANY",AND THE CUSTOMER(S)NAMED ON THE REVERSE SIDE,HEREINAFTER
REFERRED TO AS"CLIENT", 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 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 AT A RATE OF ONE AND ONE-HALF(1-1/2)
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'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 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 IN A TIMELY AND WORKMANLIKE MANNER.
S. 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 A 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 PRE%"I%-15�yR COSTS BEYOND NORMAL INSURANCE
COVERAGE,ANY SUCH ADDITIONAL EXPENSES,PREMIUMS OR COST SHALL BE ADDED TO THE TOTAL AGREEMENT AMOUNT.
7. THE COMPANY'S LIABILITY FOR CLAIMS ARISING OUT OF THIS AGREEMENT SHALL NOT EXCEED THE TOTAL AGREEMENT PRICE EXCEPT TO THE EXTENTTHOSE DAMAGES
ARE PROVEN TO BE SOLEY 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 HAZARDOUS MATERIALS THAT MANIFEST THEMSELVES DURING THE CONSTRUCTION PROCESS.
E.G.WOOD ROT,MOLD,ASBESTOS,NAIL POPS,OUCTWORKAND CONNECTIONS,PLUMBING AND VENT PIPES,DECKING DEFLECTION,ETC.IF A PRE-EXISTING DEFICIENCY
OR HAZARDOUS MATERIAL IS 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 THISAGREEMENT.
10. THE COMPANY IS NOT RESPONSIBLE,AND THE CLIENT AGREES TO HOLD THE COMPANY HARMLESS,FOR ANY 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 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.
14. THE COMPANY UNDER PROVISIONS OF CHAPTER 142A OF THE GENERAL LAWS IS REQUIRED TO APPLY FOR AND OBTAIN ALL CONSTRUCTION-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
17. THIS AGREEMENT CANNOT BE CANCELLED WITHOUT THE MUTUAL WRITTEN CONSENT OF BOTH PARTIES EXCEPTAS OTHERWISE SET FORTH HEREIN.
18. THIS AGREEMENT,AND ANY WARRAN FY(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 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 DELIVERED OR IS IN ROUTE TO THE CLIENT COULD RESULT
IN A 5%RE-STOCKING FEE BASED ON THE COST OF SAID 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 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 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 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.
24. ANY DISCOUNT,PROMOTION,REIMBURSEMENT,OR OTHER PROGRAM THAT IS PART OF A STATE SPONSERED UTILITY PROGRAM(I.E.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 INSTALLERS,LLC 15 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
f Department of Industrial Accidents
I Congress Street, Suite 100
Boston,MA 02114-2017
www mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Business/Organization Name: 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: Business Type(required):
1.❑✓ I am a employer with 67 employees(full and/ 5. ❑Retail
or part-time).* 6. ❑Restaurant/Bar/Eating Establishment
2.❑ I am a sole proprietor or partnership and have no 7. ❑Office and/or Sales(incl.real estate,auto,etc.)
employees working for me in any capacity.
[No workers' comp. insurance required] g• E]Non-profit
3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment
their right of exemption per c. 152, §1(4),and we have 10.❑ Manufacturing
no employees. [No workers' comp. insurance required]** 11.❑ Health Care
4.❑ We are a non-profit organization,staffed by volunteers,
with no employees. [No workers' comp. insurance req.] 12.❑✓ Other Insulation
Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
**If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
organization should check box#1.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information.
Insurance Company Name: Guard Insurance Companies
Insurer's Address: P.O. Box A-H, 16 S. River Street
City/State/Zip: Wilkes-Barre, PA 18703-0020
Policy#or Self-ins. Lic.# AMWC994153 Expiration Date: 09/04/2019
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 penalties of a
tine up to$1,500.00 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 may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify,under the pains and penalties of perjury that the information provided above is true and correct.
Si nature: N Date:
Phone#: 413-55 -020
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3.City/Town Clerk 4. Licensing Board 5.Selectmen's Office
6.Other
Contact Person: Phone#:
www.mass.gov/dia
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 35,000 cubic feet(991 cubic meters)of enclosed
Construction Supervisor space.
CS-106178 Expires: 09/29/2019
WESLEY COUTURE
218 LATHROP STREET
SOUTH HADLEY MA 01075
11 Failure to possess a current edition of the Massachusetts
State Building Code is cause for revocation of this license.
J For information about this license
Commissioner Call(617)727-3200 or visit www.mass.gov/dpi
91-1
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston. Massachusetts 02116
Home Improvement Contractor Registration
Type: LLC
Registration: 175982
AMERICAN INSTALLATIONS, LLC. ( ' {
' "' � � Expiration: 06!26/2019
130 COLLEGE STREET SUITE 100 -1p
SOUTH HADLEY,MA 01075
w
31
Update Address and return card. Mark reason for change.
SCA 1 u 20M,-OS'll
E-mpjoyment_CLost(^.ard
, ����r rmn�=uf✓+e��l���^�?✓crtkr��teu^ft;
"- Office of Consumer Affairs&Business Regulation
' HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only
TYPE: LLC before the expiration date. if found return to:
Registration Expiration Office of Consumer Affairs and Business Regulation
175982 06/26/2019 10 Park Plaza-Suite 5170
AMERICAN INSTALLATIONS.LLC. Boston.MA 02116
WESLEY COUTURE
130 COLLEGE STREET SUITE 100
SOUTH HADLEY,MA 01075 Undersecretary valid without signature
ACo CERTIFICATE OF LIABILITY INSURANCE DATE(MM,DD/YYYY)
�.� 9/4/2018
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: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER CONTACT Linda Powers
NAME:
Webber & GrinnellPHONE (413)586-0111 FAX (413)586-6481
8 North King Street EAIL - �wersera 1 0webb
A-MDR ndgrinnell.coim
INSURERS AFFORDING COVERAGE NAIC of
Northampton _ MA 01060 INSURER A: 1 rs Nutual Ca6ualt
INSURED INSURER B:Berkshire Hathaway GUARD Ins. Co.
American Installations, LLC INSURERC:
Attn: Wes & Suzanne Couture INSURER D:
130 College Street, Suite 100 INSURER E:
South Hadley NA 01075 INSURER F
COVERAGES CERTIFICATE NUMBER:Naster Exp 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 REQUIREMENT,TERM OR CONDITION OF ANY 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 CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INTSRR _ TYPE OF INSURANCE ADDL USA INSn POLK:Y NUMBER MM/DDJYYYY MPOLICY EXPyyay — —-- LIMITS
COMMERCIAL GENERAL LIABILn'Y EACH OCCURRENCE $ 1,000,000
A Z CLAIMS-MADE u OCCUR I DAMA E TO RENTED 500,000
PREMISES Ea occurrence $
SD3535217 9/4/2018 9/4/2019 MED EXP(Any one person) $ 101000
PERSONAL 8 ADV INJURY S 11000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000
% POLICY 1-1JECT F-1 LOC PRODUCTS-COMP/OP AGG $ 2,000,000
OTHER: $
AUTOMOBILE LIABILITY COMBINEDent SINGLE LIMIT $ 11000,000
E accid
A ANY AUTO BODILY INJURY(Per person) $
ALL OWNED 1xx
SCHEDULED SZ3535217 9/4/2018 9/4/2019 BODILY INJURY(Per accident) $
AUTOS AUTOS
NON-OWNED PROPERTY DAMAGE $
% HIRED AUTOS AUTOS (Pier wcKlent)Coll 52,000 comp 52,000 PIP-Basic $ 8,000
% UMBRELLA UA8 OCCUR EACH OCCURRENCE $ 1,000,000
A EXCESS LIAB HCLAIMS-MADE AGGREGATE $ 1,000,000
DED I % I RETENTIONS 10.000 SJ3535217 9/4/2018 9/4/2019 $
WORKERS COMPENSATIONZ PER OTH-
i AND EMPLOYERS'LIABILITY Y/N A R
ANY PROPR.'ETOR/PARTNERrEXECUTiVEI E.L EACH ACCIDENT $ 500,000
B OFFICERWEMBER EXCLUDED? ❑N/A'.
(Mandatory In NH) URM609917 9/4/2018 9/4-/2019 E.L DISEASE-EA EMPLOYEE $ 500,000
If yes,describe under 1 ----------- --
DESCRIPTION OF OPERATIObelow I E.L
NS .DISEASE-POLICY LIMIT $ 500.000
A Caaararcial Property 15JL3535227 9/4/2018 9/4/2019 deductlble$1,000
i
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule.may he attached it more space is required)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Evidence of Insurance THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
'w Grinnell, CPCU, CIC
®1988-2014 ACORD CORPORATION. All rWft rle"r4sd.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
INS025 i201401>