BP-20-280 i
10 HAYWARD RD ! BP-2020-0280
GIS#: I COMMONWEALTH OF _V ASSACHUSETTS
Mdp:Block: 16B-058 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building. DO NOT HAVE ACCESS TO THE GUARANTYUND (MGL c.142A)
ry
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Cate o : INSULATION BUILDING
PERMIT
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Permit# BP-2020-0280
Project# JS-2020-000472
Est.Cost: $7339.00
Fee:$65.00 PERMISSION IS HEREBY GRAN D TO.-
Const.
O.Const.Class: Contractor: License:
Use Group: i AMERICAN INSTALLATIONS LLC 106178
Lot Size(sq. ft.): 14374.80 Owner: LEARY LISA H
zoning_URB(100)/ Applicant: AMERICAN INSTALLATIONS LLC
AT. 10 HAYWARD RD
Applicant Address: ! Phone: Insurance:
130 COLLEGE ST (413) 552-0200 WC
SOUTH HADLEYMA01075 ISSUED ON.91412019 0:00:00
TO PERFORM THE FOLLOWING WORK:ATTIC, KNEEWALL 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# Fondation:
Driveway Final:
Final: Final:
Ro; gh Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: . Oil: In ulation:
Final: Smoke: Final:
� II
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 9/4/2019 0:00:00 $65.00
1212 Main Street,Phone(413)587-1240,Fax:(41'3)587-1272
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Louis Hasbrouck—Building Commissioner
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SEP City of rtha pton F �,'�-y',.F� � �� ;
3 .1din. Dep rtment
ain treeE
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5 TON r pto MA'01060
P �8 X124 -Fax 4.13-587-1272 amp,
a.Li i Y•,qY 1 2'�t, ar F n� > 'Yr
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APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING ONLY
SECTION 1 -SITE INFORMATION INSULA TION PERMIT
1.1 Property Address: This sc}tion to#be complet by office
Map "' Lot I.... Unit
10 Hayward Road
Zone Overlay District
Elm St District I CB District .
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1.Owner of Record:
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Lisa Leary 10 Hayward Road
Name(Print) C}�4r�t)M I g 8Stds. i
See attached Telephone U
Signature
2.2 Authorized Accent:
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American Installations . 130 College Street Ste. 100, South Hadley, MA 01075
Name(Print) Current Mailing Address:
)Old 1A 4 K C64 IbAg (413)552-0200 I.
Signature j Telephone .
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
com leted by permit applicant
1. Building 7339.00 (a)Building Permit Fee ,I
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2. Electrical (b)Estimated Total Cost of
Construction from(%j
3. Plumbing Building Permit Fee
.. $
'4. Mechanical(HVAC)
5. Fire Protection i
6. Total=.(1 +2+3+4+5) 7339.00 Check Number
This Section For Official Use Only
Building Permit Num er: Date
Issued:
, 7
Signature:
Building Commissioner/inspector or Buildings I Date
production @ americaninstallationi.com
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EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
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SECTION 4-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: Wesley K Couture t 106178
License Number
130 College Street Ste. 100, South Hadley MA 01075 `'9/29%2019
Address 'Expiration Date
V. CFl� 1�d (413)552-0200
Signature J Telephone
9:Re4istered Home trnoovement Contractors ,... Not Applicable ❑
American Installations 175982
Company Name Registration Number
130 College Street Ste. 100, South Hadley MA 01075 6/26/20211 `X
Address Expiration Date
Telephone (413)552-0200
SECTION 5-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.1:52,§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....... X No...... ❑ r�,g / p
Brief Description of Proposed ID�Ssti9
Work OTE: LATI®,N ONL Pv
Attic, kneewall 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
CMA,-6/Lk 8/17/2019
Signature of Ower/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
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City of Northampton _
yS�5 ^u"SCj
. .• =2µ`i.. Massachusetts
s %t
'£ ` x` DEPARTMENT OF BOIZDING INSPECTIONS
212 Main Street • Municipal Building vti� pa.
` ,' Northampton, MA 01060 'r�'Nty�j,1a.
AFFIDAVIT
Home Improvement Contractor Law
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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 ownerI ccupied building containing
at least one but not more than four dwelling units....or to structures which are adjacent to s ch residence or building"be'
done by-registered contractors.
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Note:If the homeowner has contracted will:a corporation or LLC,that entity musta registered
Type of Work: Insulation I Est.Cost: 739.00
Address of Work: 10 Hayward Road Florence,MA 01062
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$1,000.',00
Owner obtaining own permit(explain): I.
Building not owner-occupied
x Other(specify): Contractor pulling permit for homeowner
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OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED
CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT
ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND
UNDER M.G.L.Chapter 1421 SUCH OWNERS ALSO ASSUME THE RESPONSIBI{ITES FOR ALL WORK
PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION.
Signed under the penalties of;perjury
I hereby apply for a buildingpermit as the agent of the owner:
8/17/2019 I American Installations 175982
Date Contractor Name HIC Registration No.
OR:
Notwithstanding the above notice, I hereby apply for a building permit as the owner of the above property:
.8/17/2019
Date Owner Narhe and Signature
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City of Northampton
Massachusetts : .,• •.;c�
DEPAR2MNT OF BUILDING INSPECTIONS a;
t « 212 Main Street •Municipal Building �J$ 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:
10 Hayward 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)
1 )UjUA . Cc�,tU.e.
Signature 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.
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City of Northampton
Massachusetts
.� ��,•.; �• : H3 ice.
DEPARTMENT OF BDZbDZNG ZNSPECTZONS y iy
'' bt •O.
212 Main Street'• Municipal. Building
fE N'orthamp'ton, MA 01060
MANDATORY FOR HOUSES BUILT BEFORE 1945
Property Address: 10 Heyward Road 1
Contractor
Name: American In tallations
Address: 130 College Street Ste. 100
City,.State: South Hadlely MA i
Phone: (413)552-0200
Property Owner
Name: Lisa Leary
Address: 10 Hayward Road
City, State: Florence,MA 01062
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I, 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.
Contract r signature
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Date 8/17/2019
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MA Rrg[srrrrror,oti5,gyj American i)'1Staiiations www_Amiiricaninstallations.com
130 Collere Streel Suite 10(1,South HadleV,MA 01075•Office:(413)552.0200 rax:(413)552.0202•Emaie•support@ArnericanlnstallaGons,com
Customer Name:Lisa Leary
Email:Not provided
Phone:413-586-8016
Premise Address:10 Hayward Rd,No I hampton,MA 01062
Mailing Address:10 Hayward Rd,Nort ampton,MA 01062
Project ID:3853392
Date:July 11,2019
Job Description
es pi
t Loeatlon.` Qusntrty 'Unit TotalCost Customer Cost
L..: ... _
Air Sealing at Estimated 62.5 CFM50 Per Hour 12 hr $1 110.96 $0.00
l ---.._......,._... ....__w._.,.__.__w.__......_....._
Polyethylene(with AS hrs) 200 SF 196.00 $0.00
Rim Joist-6" Fiberglass Batfing^ ,��'•'"�
............
- ..... �-•������ '"���� _ .......
Vapor arrier 6 ml Po eth en
117 SF $315.90 $78.97
Insulation Removal 204 SF 257.04 257.04
Open Wall-2"Thermal Barrier Polyiso 214 SF $1J,022.92 $255.73
. ._._...._.._........._......-......-......................._...._...........,...._-..._,.........._ _...,.:..,.........:.:... .....,.__._._......__.........._..........._.................._..........
Kneewall Gable Wall-3"Fiberglass Batting Living Space 57 SF $364.81 $91.20
134
-
.......... .......
.;. .......................;.....__...,............._........_...__..._...... .:._..._....__,...-...___... ._...:.._...._..__.............,..............._..,. __. _......,..... .....
Attic Floor-7"Open Blow Cellulose 1120 SF $1,881.60 $470.42
_....,...,.:...:._.... ......_.._.,".............._....._...... . ............................._,.........._.-_.__...._.. ._,._,......____....,...__................. _..:..:__......................,_......._.........
Hatch-2"Thermal Barrier Polyiso Living Space 1........._ each $46.28 $11.57
Door`2"Thermal Barrier Polyiso Living Space 2 each 180 88 $45.22
Propavent Living Space 17 each J$70.72 $17.68
Kneewall Slope-6"Fiberglass Batting LivingSpace 185 SF 394.05 $98.51
_................ ..,-....................._.............,... .............._........._..........._......................._......_...................._............_..._....,..... .....-.... ...._.._............................._.......-............................_...
Kneewall Slope-2"Thermal Barrier Polyiso Living Space 197 SF $941,66 $235,41
m.._-..._,....._......._...... _...,..._�_...... ........_.._.._.........
............._......:..__._....__........._......._..1_... __...,_.... ...
Kneewall Gable-2"Thermal'Barrier Polyiso Living Space 57 SF 272.46 $68.11
Exterior Door Weather Stripping(with AS hrs) Living Space 4 each $120.28 $0.00
....._....._....._.._..__....-......._.. _.._....._...._._......:........,..,_..._.__............................._......_.....__. ..._:......._.....,...-........._...,_.,...• ..
Door Sweep(with AS hrs) Living Space 4. each $101.24 $0.00
Damming................. ._ _....._......._................_....... ....... .........Living Space.... 26 $62,14
each _..,.....__......_.__.._.._......._...._.... .
$15.54
WARRANTY:American:rK Wllations,LLC will provide the above stated homeowner with a 1-year workmanship warranty.
American Installations,LLC hereby proposes to fu Inish all nutedal and labor to complete the above scope of work in accordance with the atbove specificationsand oil local and stare
building reStAntirns for the 1 otal Contract Value as stated herein.
ACCEPTANCE OF PROPOSAL: The abnuc prices, sf7eti:icalions arrd conditions arc TOTALCONTRACVALUE-S �
satisfactory and are hereby accepted.Youare asrhoriredto dowod,as specified.Payment 0� C< /. �{465.13
Kill be 1:3 down prior to start&work,andball -c dire upon ComplE:ion: Down Payr.7ent:S _--12
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PAID
Valance one Upon Completion-- ' 930.27
Signature �l Dain 12,1
Property Owner(Print) ! t✓lf (Sion) L;X fd ' Date
Representative:(Print) (sign) Date
':M,J4aGtrJJSI'.SW:fPpSN'L'{1M1ISPi4:aM1G':NGlIE�JIa!!tie[.Irq'1`4CE%M1�SNY_S Ct ttT!17CN!-J IMEGIrL:e4i�LLr:ENr11T1nk[:hly l\LYilta ilnSFbSt:\'tYfn SEII/LW h�N:ttNIY'tp:y{II.M.!lCFW6Tli1r:JI h:IWi[u1U:5'Y:R1'•:NS'.
aN07�t(u310KCt{S)aAUt0-2UL''E NtPLM1AFi!xi!lCYXIG?aAS'GIEN7',:M1L"mifir WHIC770AS:AP:NOPww7El?WS,AE310SA:1ONST 00KCIVLlrE%of 7F MIEOS 1JAU-rhilin 109 cohNEVICJT 911•ECUtV.41 twLL:aaLL 4rat
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MA RN'hrrrnnmp fT.'987 American Instal latici is WWW-Amerkaninstall2tions.com ,
130 College Street Suite 100,South Hadley,MA 01075•Office:(413)552.0200:rali:(413)SS2-0202.• EmoiL•support@Ametiennlnstallations.com
Customer Name:Lisa Leary
Email:Not provided
Phone:413-586-8016
Premise Address:10 Hayward Rd,Northampton,MA 01062
Mailing Address:10 Hayward Rd,Northampton,MA 01062
Project ID:3853392
-- _ Date:-July-1-1,-2019 --Project-Total— - $7,338:94'
Weatherization incentive ($4,165.06)
Pre-Weatherization barrier incentive ($250.00)
Air sealing incentive ($1,528.48)
Total Program Incentive -$5,943.54
Customer Total $1,395.40
WARRANTY:Anerican installations,LLC will provide the above stated hor towner with a 1-year workmanship voarranty.
American Installations,LLC hereby proposes to furnish all material and labor to complete the above scope a,work in accordance with the above specifications and all local and state
building regulations for the Total Contract.value as stated herein. 1
ACCEPTANCE OF PROPOSAL: The abase prices, specirications and conditions are TOTAL CONTRACT VALUE=S u ( ,i
satisfactary and are hereby accepted.You are authorized to do work as specilied Payment 65,13
will be 1.43 down prior to start of work,and balance due upon Compte"on. Down Payment
ta� PAID
Balance Dole Upon Completion=S �]UUC �y�� 9 ,27.
Sig aturc Isa Leary(Aug r •.9) . �I� j_ /or
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Property Owner(Point) L[ .Srf L Page / ..
�tSignl Dale
Representative:(Print, (Sign)_ Dale
1 H"611,E MhI is G/V.PMU Lw IMS 1.1W GNU INE NtAKIF WE LC rHio'•etrv1U 14A L ht LL•.1SIJtAtJ,Y,t tail•!Pi�tLYL!It at7Y.!L•:N I.L`C1�o,Z1tU IKY=4Ntt54V1:3 GtlYikis••'AkalLii/1N�ri:13'Ik:NS,LLl'NlNiW:PIA 7nIM/!'Ula%t'CJ/JX.N,'�
arm T�[:JS,OLIE:tSY MUM A"AlE-NEFL 411 nN Fii_NPELTO go,"nitMY,:ao wAL BE iUd;Ur MAU aoK.;L',7CL:1P1L XiSJUiONS AA aFWVSVECS 0'7nE:7:IE UtWASSLWORM U CONNI:T: Tw`LSpELT,IMU KLLL Stt4 LL;,:t.UN1?.VIJNS
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The Cam»toff.tveaXth:of ltlrissaclausetts
1?epartrrrent'of 1ndustrk1 Acccdern&
Office-ofLrvg1igat ons '
6Q0 Warslii±ttgton Sh eet'
' Bostor:;l►Zl,02I X 1 �
Workers' Coanlietisation Insurance Affidav><t _builders%Contractors/1Ciectrtcians/JPluanbeas
Applicant Iiifvirtua'tion. ;Please Plr>aat ,egil5
Name'(Business%Organiiacionllntiv�iitialjE' American Installations,LLC
Address:_ 130 College Street,Suite 100
CityNState/Zip South Hadley,MA 01075 Phone# 413-55M200
0200
Are yot,an employee?G6eck•tlte approprr-tc.box _ _Type tifprolcc(t6._gd ritd)'�
xI am'a eiriployer with 60 I 4'Q 1 am a general congactor anal[ } b ❑INew corastructtom
ll atim
nd/or part
employees(fue),* have hued the sub contractors
;2 ❑ ,I:am a sole proprietor orpartner hsted;on the attached sheet # ❑Remodeling.
ship anal Iiave nti.employees These sub contractors have 8 r�Demolition;
working,for mein any..capacity: workers, comp insurance,, [j B;u'ilding addition
M6 workers.".comp:insurance 5.,[] We are a corporahori.and its.
requireda; officers havd,exer6ised their.. 10 D,Electrical repairs or.additions.
` 3 ❑;;I'am a homeownet.dong all`work' right of exemption per,MGL, i 1 ❑:;Plumbing repairs fir additions! .
myself(No Workers crimp c.1-52' l{q);and we have:no.
12 Q Roof repairs,
insurance;regtiired.)a " employees:,[No workers''
-_.
comp:.insurance requfe d.] 13 (Other Insulation_
J*Any applicant tliat checks boa,91 must also ill!out the section below sho iiii their workers'compensation policy"inforinatton
I lgmeowncrs Who.siibmit this aftidavii indicating they are doing 5ltwoik'and_then hire outside contractors most submits a neW allidavit indicating such:,.
=Cun'faclois that'check this box,must.afiactied an additional sheet showing the name 0Pllia siilr-sontractors'an -thcit workers comp;-lioliey inforxnalion.:
I'am ara eitirployei that rs.provi�ling.workers'cotirperrsation urscrrairce for»ry entployeec:: Below is rise pnlrcy mid job site.
irr or»iatroir. - - � _
`Insurance'Gompany.Name: Guard Insurance,Com anies
URWC609917
;Policy,#.or SeIF ins Lic;' :. _ ,, i Expiration Dat 09/0472019
•Job Site Address.• ��L�IM/I.I�I�[ go l�tlq. City/Stafe%Ztp ��. W V 1O U2–
;Attach a copy of the.wor&ars mpensation.policy.dMaration-page(showiugthe policy nuiober and'expiration tiara)_. .
Failure to-secure coverage as required under Section 25 1 of MGL•c 152 can lmR6 the irriposit�on 'f erhninal peniltres of,a
—,fine up to-$1-500;00'at>dJor one=yeaiimprisonrnent;as well as.crv.ii penaltiep in the form.of a STOP WQR7C ORDER ana a fine— -- -
of up to$250.00 a day againsi'tlie,violator•: 'Be advised ihai'a copy of this sta"tetnent may,,lie forwarded to thz'Office_of.
�. .Investigations of the DIA for insurance coverage ver=ification.
-1 do hereby certijy�ut:de's the paiirs-ond penuhies.f per' i/iaf rite irrfornrat pn provided trbove isartre atzd Correct.-
Siiiiiature,:
Phone'#: 413-55 -0200
Offcial rise only.. Do•noi write in this area,'to-be completed by city or town ojfciaC.'.
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City or Town: .^ Peimit/License#1 .
I Issuing Authority(6rcle.cine):
h.Board,of Health; 2.13uilding Department a.City/Town Clerk 4.Electrical inspector 5.Plumbing his
pectoi
6_.Other
I - r
Contact Person: Phone#-
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Commonwealth of Massachusetts Construction Supervisor
btvision of Professional Licensure.
Unrestricted Buddings;of any use group which contain;
Board,of Budding.Regulations and Standards' lesstWM 35 000,cubic feet(991 cubicmetersj of.enclosed;
rt apace:
Corsis -
CS406178 —.,f Opfres:09129'/20.19;}:
_ ._.
WESLEY COWURE ! '
218:LATHROPr8TREET, zz
SOUTH HADL'-EY'MA'101075
y r"3 I } )Failuie io possss a ecurrenteditiori"ofthe Massachusetts,
- - •--- --_-' State.Buildmg Code�s cause'for revocation of this`fi_cense;;
For,information about.this license _
'Commissioner'
taiii(617)727,3200_:or visit`www mass govldp_I
4
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-_•_ ,� Office;of Consumer Affairs and Business'Regulatiori
=' 10 Park tPlaza' Suite.,_17Q
,Boston, Massachusetts' A2116�
HOm9:t'mproveme6vC6ntract6r,:Registration
5
Type LLC;
___ ;�� �,.,_,_ { R09istratlon; 1175982'
AMERICAN INSlALLAT:IONS;LLC Iratlon i 06/26%2079.
130 COLLEGE STREET"SUITE 100 �` y' �' `�`�- �`
SOUTH HAQ1 MA`01075
S 1 74
°,_ ,tom Update Address and return card_ 'Mark reason'for changer
SCA t 20MS05/11 rn c'• n:R1eno rjl ri mplo �tQ.11t I-1 1.OSt CarC�_.
;2 ._..
�+ �T t�c»a�raTtiir«Hall(r f C'i`1�irs3u�/ruieftd �- --
\ Office of Consum"erAffafrs&Business Regulation
(� HOME IMPROVEMENT CONTAACTOR'. Registration valid for individual use nig.
TYPE._LLG. before the expiration date if found rgfurrto:
Registration) 'Expiration Wide of Consumer AffairsaiN'Busm6Ss Regula#lori;
175982 ,06/26/2019 10 Park Plaza;-Sude 51.70:
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Bo
h I ' I ston,'MA "
APnERICAN INSTALLATIONS;LLC: 02116_
WESLEY COUTURE'' CGQ -
130 COLLEGE STREET Sl!(TE:1 q0 f
SOUTH'HADLEY,MA 01075, 'U valid Witho-tit slg(toUrre
ndersecretary
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. coRv. CERTIFICATE'OF LIABILITY INSURANCE °nrE(MWp°""""`
. . 974/2018
THIS:CERTIFICATE IS fSSUED AS':A MATTER OF INFORMATION ONLY AND`CONFERS Np-RIGHTS,UPON THE;CERTIFICATE HOLDER,THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY;AMEND; IXTENDi OR;ALTERS THE COVERAGE AFFORDED BY THE POLICIES;
BRLOW THIS CERTIFICATE SOF INSORA M DOES'NOT CONSTITU_TEA CONTRAC I BETWEEN,THE:ISSUING'INSURERS}; AUTHORIZED!
REPRESENTATIVE OR PRODUCER;AND TFjE CERTIFICATE HOLDER.
IMPORTANT if,the certificate holder is an ADDITIONAL INSURED the.;poht y(Ies)must`be endorsed If,,'SUBRQGATION IS-WAIVED,Subject to
the terms,and coniiit,ons of the policy,certain poltcles may reguire�an endorsement:,A'statement on this�certificate does:not confer'rlghts to th_of
i ceittficate Ii'I&-lWIIC of such ehdorsement(s
- -
I PRODUCER
_-.-' - - - CONTACT
NAME k'�1IIC�a{ POWerS
W@17I19T"Sd'Gnirinell-: PHONE '`_ (4�13)586 �O11�a -FAC_-"e _(413)586;6461..
{ :8:i North,Ria- Street l ;
i EMAIL "'
g ADDRE s: poweFISL eblieranclgrinnell coni '
INSURERS'AFFORDING COVERAGE' _ NAIC 0-
} North M8 (010;60} INsuRERa. 1" ss'Mntuall'Casua'lt
Bm�tOI1.,
.�.. .._.
INsuRER s.Berkre-%Mat haway. GDARD Ins a,Co:'
- .
Amer1 caa Installation`s,z LLC;' ..
INSURER C e
� Attn Wes &,Suzanne+Cotature' I - '
130 College St=eet,Y(Suite ,S00 INSURERO
INSURER E•.
South, Hadl'ey,:. M!► jto10.75% -.. _
w,
INSURER F
COVERAGES1.
;CERTIFICATE NUMBER Master Exp 9 2019 REVISION NUMBEREI
'THIS IST.O CERTIFY THAT THE POLICIES OF INSURANCE-LISTED'BELOW HAVE BEEN'ISSUED TO THE'INSURED;NAMED;ABOVE FOR''THE POLICY PERIOD'"
I I INDICATED.:,NOTWITHSTANDING-ANY REQUIREMENT;TERM OR CONDITION,OF ANY CONTRACTOR.OTHER DOCUMENT:WITH:RESPECT'-TO WHICH.THIS,
CERTIFICATE MAY BE ISSUED,OR MAY PERTAIN,THE:INSURANCE AFFORDED BY THE,P,OLICIES DESCRIBED-HEREIN.IS_SUBJECT{TO 9LL'THETERMSj
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES LIMITS_SHOW1.MAY HAVE'BEEN REDUCED:BY PAID CLAIMSr _ T
INSR. - ADOL SUBR 'POLICY EFF,•POLICY EXP
y ITR: _ TYPE OF INSURANCE..- .. - POLICY NUMBER 'MMIDD/YYYY MM DD YYY ,. LIMITSi
i ;-- 1- COMMERCIAL GENERAL LIABILITY ; - - u ' �_ - - EAC $i Y 00,000
:-. '- • H.00CURRENCE r .....
A, $ CDAMAGERELAIMS_MADE a OCCUR i ,'.PRE1d SES Ea ocNc ErrenEe Si 500 000.
�.. _
9/4y2018: 974/.2019" 20'-000.
t :. . - ED EXF.Any one person t
• - + i � 'PERSONAL&ADV INJURY� $ 1 000,000-'
431 I ; PER f 14 GENERAL,AGGREGATE,
. o.- 00ENLAGGREGATECMlTAPPLIE
x t PRO
POLICY JECT ElWcPRODUCTS-COMP/OP'AGG '6100
0
i �•
'AUTOMOBILE LABIUTYI '` � ' ...I .- .. -_•_ . ...:_. .. ;- •-- ,._-... ;COMBINED SINGLELIMIT
2 000';0
I r` accident'— $ 1;000,000
�A � ANYAIJTOa i � C BODILY INJURY(Perperson) $I
ALL OWNED „SCHEDULED.`
AUTOS '-" X AUTOS 523535217, 9/4/2018 j+9/A%2019 BODILY INJURY(Per,accident). Al_
INON-OWNED �� } :,PROPERTY DAMAGE -' -
; X' HIRED'A_UTOS $' AUTOS" r I rP id t
Coll$2;000 X compS2000 PIP-Basil8,000:.
__X UMBRELLA UAB OCCUR
`EACHOCCUflRENCE $. 1,000"000
I i A EXCESS UAB _, ..CLAIM8-MADE, I I AGGREGATE $ 1 000 000
r.DED' X .RETENTIONS' +10`000' -. SJ3535217:_ - _ 9/4/2018
... L. $Y
I WORKERS COMPENSATION - - - K; P ATl1TE; ETH-
'
AND FJHPLOYERS LIABIUTYt ,_ _- -
—
ANYPERIMEMTORIPARTNERIEXECUTIVEI YIN E.GEACHACCIDENTi $I 500•;000.'.
i OFFlCERIMEMBER EXCLUDED?i'~- �'N/A' 7 ._
. $ (Mandatory In NH).:-""` DRWd60991T 9/4/2.018 1 49/412019 ELDISEASE'EA EMPLOYE $; 560"000
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DfysCdeA -under-. .
_ .__
RIPTIONOFOPERATION§below, LIDIA _ P
0' 000iE L
ciai, 9/4/2019 deducble$1,000A-, 901y .
i
j -DESCRIPTION'OF OPERATIONS/LOCATIONS/VEHICLES_,(ACORD:101.Additional Reipaiks$ct edule may be attached if-more space is regoiretl)! f
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SHOULD ANY-OF THE-ABOVE DESCRIBED POLICIES'BE;CANCELLED'SEFORE
Evi delnce df Tasur'auce
THE.;EXPIRATION ;DATE' THEREOF' NOTICE WILL' 'BE' DELIVERED'. IN
ACCORDANCE_.WITH THE'POLICY PROVISIONS:
AUTHORRED:REPRESENTAIWE `
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p 1088-2014 ACO RD:CORPORATION; All rights reserved:
ACORD:25',(26
logo"are registeredmasks of ECORD
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