38D-030 (6) 292 SOUTH ST-2ND FLOOR BP-2020-0223
GIS#: COMMONWEALTH OF MASSACHUSETTS
Ma :Block: 38D-030 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-2020-0223
Project# J$-2020-000368
Est.Cost:$1310.00
Fee:$65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: AMERICAN INSTALLATIONS LLC 106178
Lot Size(sq. ft.): 10715.76 Owner. KERRIGAN KATHERINE
Zoning: URB(100)/ Applicant. AMERICAN INSTALLATIONS LLC
AT: 292 SOUTH ST - 2ND FLOOR
Applicant Address: Phone: Insurance:
130 COLLEGE ST (413) 552-0200 WC
SOUTH HADLEYMA01075 ISSUED ON.8/22/2019 0.00.00
TO PERFORM THE FOLLOWING WORK.-WALL 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:
FeeType: Date Paid: Amount:
Building 8/22/2019 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
16
Iq-221-� �, ao-ate 3
Dep
OR
"j�orth mpton
;y Building'Dep rtment
U� eet
2 20 412 Main tr
Room oo INSULATION
ri�:r pton, A 01060
06'11e 4, 1,240 ax 413-587-1272
ONLY,,,,, :*, 4
APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING ONLY
SECTION 1 -SITE INFORMATION INS ULA TION PERMIT
1.1 Property Address This section to be commp)leted by office
Map /� Lot v �� Unit
292 South Street 2nd floor
Zone Overlay District
Elm St.District CB District !
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Katherine Kerrigan 292 South Street 2nd flr
Name(Print) Cu ent ailin Address:
See attached 1369 0778
Telephone
Signature
2.2 Authorized Agent:
American Installations 130 Collette Street Ste. 100, South Hadley, MA 01075
Name(Print) Current Mailing Address:
(�p� Q 1 , , �� m (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 (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature: 74 -21-Z)9
Building Commissioner/inspector of Buildings Date
production @ americaninstallations.com
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 4-CONSTRUCTION SERVICES
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
(A )W 14 4 � � (413)552-0200
Sig—nature T Telephone
9.Registered Home Improvement Contractor: Not Applicable ❑
American Installations 175982
Company Name Registration Number
130 College Street Ste. 100, South Hadley MA 01075 612612021
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....... JV No...... ❑
Brief Description of Proposed Work NOTE: INSULATION ONLY
Wall 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
K. C('Sl.l �,c 8/17/2019
Signature of 0 er/Agent Date
I. , 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 8/17/2019
Signature of Owner Date
s
City of Northampton
Massachusetts _
DEPARTMENT OF BUILDING INSPECTIONS ?` m
r
212 Main Street • Municipal Building J6 cam
Northampton, MA 01060 r�jY••�,,j��1
_-
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: 1310.00
Address of Work: 292 South Street 2nd tlr
Date of Permit Application: 8/17/2019
I hereby certify that:
Registration is not required for the following reason(s):
_Work excluded by law(explain):
_Job under S 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:
8/17/2019 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:
8/17/2019 WDA.I . K. C(,uTAA A,
Date Owner Name And Signature
City of Northampton
• ' Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS
r 212 Main Street *municipal Building
Northampton, MA 01060 ss� '•• \,�0
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:
292 South Street 2nd flr
(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)
(A�&bAj
V,. CCA-AW
of Permit Applicant or Owner Date
If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the
Building Department as to the location where the debris will be disposed.
City of Northampton
S
q;
Massachusetts
y
dt DEPARTMENT OF BUILDING INSPECTIONS 9j
212 Main Street • Municipal Building ��,.• S�
Northampton, MA 01060
MANDATORY FOR HOUSES BUILT BEFORE 1945
Property Address: 292 South Street 2nd t1r
Contractor
Name: American Installations
Address: 130 College Street Ste. 100
City, State: South Hadley MA
Phone: (413) 552-0200
Property Owner
Name: Katherine Kerrigan
Address: 292 South Street 2nd flr
City, State: Northampton, MA 01060
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.
Contractor signature
L.Ai,Q A k. CCR,4,'A J
Date 8/17/2019
www.Americanlnstallations.com
T
BBB NM/IOFAEa10, • Licensed&Insured
EMi �"
MA CSL p:106178
American Installations MA Registration of 175982
130 College Street Suite 100,South fladley,MA 01075 Office:(413)S52-0200 Fax:(413)552-0202 Email:support@Americaninstallations.com
Kerrigan,Katherine 8/2/2019
p.,a (—L
IOn.q
292 South Street Northampton MA 01060
I..-" (Obi
a.,vl u.n
413-695-0778 cchandless@comcast.net
Pmmel ISN1 IL•ull
487 180
19-2271-A
IS•e Ipl IbO Fl —
Quantity Unit Unit Cost Total
Air Sealing
AIR SEALING 13 Iman hour 1 $ 85.00 1$ 255.00
DOOR SWEEP 6 leach $ 25.00 $ 150.00
WEATHERSTRIP DOOR 6 leach $ 58.00 $ 348.00
Air Sealing $ 753.00
Air Sealing Incentive $ (753.00)
Air Selaing WX Balance $
Weatherization
BASEMENT SILLS-R19 FG BATT 151 sqft $ 1.95 $ 294.45
CRAWLSPACE-6MIL GROUND COVER 40 sqft $ 0.77 $ 30.80
COMMON WALL-2"RIGID BOARD 60 sqft $ 3.85 $ 231.00
Total Weatherization $ 556.25
Weatherization Incentive $ 500.63
Total Project $ 1,309.25
Total Utility Contribution $ 1,253.63_
Total Customer Contribution $ 55.63
WARRANTY:American Installatlam,ILC will provide the abovestated homeowner with a 1 year wo[kmanship warranty.
American Installations,LLC hereby Proposes to furnish ail material and labor to complete the above scope of work in accordance with the above specifications and all local and Stale building
regulations for the Total Contract Value as stated herein.
ACCEPTANCE OF PROPOSAL:The above prices,specifications and TOTAL CONTRACT VALUE= $ 55.63
conditions are satisfactory and are hereby accepted.You are
authorized to do work as specified.Payment will be 1/3 down prior to Down Payment= $ 18.00 ❑
start of work,and balance due upon Completion. PAIL --
�� 0, Balance Due Upon Completion= $ 37.63
Co r t n n e C K cC
Timothy Wheeler Timothy Wheeler 8-2-2019
e.y..enN..1NT,n --------_.-- +n.r,•nNelAeO —.__-._— ale----
I HIS AGMEMEN11scovAOSED a THIS FAOf AND INI AT"AN s"Or IN'S PA ANO SNAIL of CO RID THIF SN1140HAFFMENIaY THE FAMS 100OLVfO.[HI5 AOMFMffn IS nIWE IN AAE[RKAN HISTA TH(NS,uc NE111114R
RENRRtU IO AS'COMrnm-,ANO INE CUSIDME NN MAMIC AIiDVl.HFREINNIFR NFERMO IO AS'[Df Nl',ANO mil N SUNtCt IO All AOFIIpFRuIE UYVS,IIfD1AAT10NS AND ORpNANCF50r INF StAiF or MnSSAOIUSfrtSOR
CONNFCIICUI RFSIfCIrvHY,AS Wfll AS ntl IIXAI IUNSDICIIONS.
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 TIiIS AGREEMENT,CHARGES SHALL BE ADDED FROM THE DATE THEREOF AT A RATE OF ONE AND ONE-HALF(1-1/2)PERCENT PER MONTH.
119%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 T1IE 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 CLIENTAS SOON AS REASONABLE.
4,COMPANY AGREES THAT,NOTWITHSTANDING ANY AGREEMENT FOR MATERIALS AND/OR LABOR BETWEEN COMPANY AND THIRD PARTY,COMPANY 15 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 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.
B.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 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,INCCUDING 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 15 NOT RESPONSIBLE FOR,AND THE CLIENT AGREES TO HOLD THE COMPANY HARMLESS,FOR ANY PROBLEMS ANO/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 Hf REIN.
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.
]A,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 AGENOES,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 PANTIES
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 SPONSEF ED 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 15 REPSONSIBLE FOR THE PAYMENT OF ANY AND ALL FEDERAL,STATE,OR LOCAL TAXES THAT ARE APPLICABLE TO THIS AGREEMENT.
The C'ommotnvealt/t of Massachusetts
lowDepartment of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.ntass.goti/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print I egibiv
Name (Business/organization/Individual):-,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):
1.!.� I am a employer with 60 4. E] I am a general contractor and l 6.'
[:] New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.t r-1 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. ❑ We are a corporation and its
required] officers have exercised their 10.F1 Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGI. 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.] 13. Other Insulation _
*Any applicant that checks box n1 must also till out the section below showing their workers'compensation policy information.
t I lomeowners who submit this affidavit indicating they arc doing all work and then hire outside contractors must submit a new affidavit indicating such.
`Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
I am an employer ilia(is provitling)vorkers'compensation insurance for my employees. Below is the policy acrd job site
iti formation.
Insurance Company Name: Guard Insurance Companies
Policy#or Self-ins. (Laic.#:CURWC609917 ( Expiration Date: 09/04/2019 `\ '1
Job Site Address: L-I� )� `� {�(,� V City/State/Zip: Nhr ba(DP1 n) OIC LPV
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
fine 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 andpenalties of perjury that the information provitted above is true and correct.
Si nature:
Phone#: 413-55 -0200
Official use only. Do not write in this area,to be completed by city or town official
t
City or Town:-Permit/License#
issuing Authority(circle one):
i 1. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
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 Supervisorspace.
CS-106178 Expires: 09/29/2019
-x
WESLEY COUTURE
218 LATHROP STREET
SOUTH HADLEY MA 01075
`�` Failure to possess a current edition of the Massachusetts
Y State Building Code is cause for revocation of this license.
! r For information about this license
Commissioner Call(617)727-3200 or visit www.mass.gov/dpi
VW/X a W a a/(-7-)/&"I'j a�
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
tt —, Type: LLC
{ - - Registration: 175982
AMERICAN INSTALLATIONS, LLC. . , Expiration: 06/26/2019
130 COLLEGE STREET SUITE 100 Ir 1 41
SOUTH HADLEY, MA 01075
V�
4`1!k 4np.
1 Update Address and return card. Mark reason for change.
SCA 1 201,4-05/11 r-1 A-ILl;a--- El rl.Emp-layment Q Lost Ca rd
� �!�- rt wxsrarnrr.�rrh/✓r� �r,xfliii;�l/:
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
Ac" CERTIFICATE OF LIABILITY INSURANCE DATE(MWDD/YYYY)
�i. 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 NAME: Linda Powers
Webber & Grinnell (NAME: .Exit, (413)586-0111 FAX (413)586-6481
8 North King Street E-MAIL 1powerB@webberandgrinnell.com
ADDRESS:
__ INSURER(S)AFFORDING COVERAGE NAIC ti
Northampton MA 01060 INsuaERA:�loyers Mutual Casualty
0000 --- ---0600-- --- -
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 MA 01075 1 INSURER F: _
COVERAGES CERTIFICATE NUMBER:Master 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.
INSR - -DL SUER POLICY EFF POLICY EXP T
LTR TYPE OF INSURANCE POLICY NUMBER MM/DDNYYV M D YYY LIMITS
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
A X CLAIMS-MADE F OCCUR DAMAGE TO RENTED 500,000
PREMISES(Ea occurrence) $
5D3535217 9/4/2018 9/4/2019 MED EXP(Any one person) $ 10,000
PERSONAL 8 ADV INJURY IS 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000
X POLICY❑JECT 7 LOC PRODUCTS-COMP/OP AGG $ 2,000,000
OTHER: $
AUTOMOBILE LIABILITY EOMaBINdEDISINGLE LIMIT $ 11000,000
A ANY AUTO BUDILY INJURY(Per person) $
ALL OWNED X SCHEDULED 523535217 9/4/2018 9/4/2019 BODILY INJURY Per accident) $
AUTOS AUTOS
X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $
AUTOS
7[ Coll S2.000 X comp S2,W0 plP_Baslc $ 8,000
X UMBRELLA UAB OCCUR EACH OCCURRENCE $ 1,000,000
A EXCESS UAB CLAIMS-MADE AGGREGATE $ 1,000,000
DED I X RETENTIONS ID,0001 15J3535217 9/4/2018 9/4/2019 $
WORKERS COMPENSATION PER OTH-
AND EMPLOYERS'LIABILITY Y/N T FR
ANY PROPR'.ETOR/PARTNERlEXECUTIVE E.L.EACH ACCIDENT $ 500,000
OFFICER/MEMBER EXCLUDED? ❑Ill
B
(Mandatory In NH) URMC609917 9/4/2018 9/4/2019 E.L.DISEASE- EMPLOYE $ _ _ 500,000
It yes,describe under - - - - -
DESCRIPTION OF OPERATIONS belowE.L.DISEASE-POLICY LIMIT $ 500,000
A Commercial Property SJL3535217 9/4/2018 9/4/2019 I deductible$1.000
DESCRIPTION OF OPERATIONS 1 LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if 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 ��~-
01988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD
INS025,zo1�o1 I