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38B-148 (3)
47 COLUMBUS AVE BP-2020-1021 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:38B- 148 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-2020-1021 Proiect# JS-2020-001723 Est.Cost: $2679.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: AMERICAN INSTALLATIONS LLC 106178 Lot Size(sq. ft.): 5749.92 Owner: WOODS KARA Zoning: URB(100)/ Applicant: AMERICAN INSTALLATIONS LLC AT. 47 COLUMBUS AVE Applicant Address: Phone: Insurance: 130 COLLEGE ST (413) 552-0200 WC SOUTH HADLEYMA01075 ISSUED ON:3/13/2020 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: FeeType: Date Paid: Amount: Building 3/13/2020 0:00:00 $65.00 212 Main Street, Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner IR-� 21� ........ I I Lz V—/ Dep cr�7;�r City of Northampton F *y Building Department 212 Main Street MAP INSULATION oom 0 Northampton, MA 01060 :vR." t phone 413-587-1240 Fax 413-587-127 " APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING ONLY SECTION 1 -SITE INFORMATION INSULATION PERMIT This section to be completed by office 1.1 Property Address: Map err' Lot Unit 47 Columbus Avenue Zone Overlay District Elm St.District Gia District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: 47 Columbus Avenue Name(Print) Curr% ajU A ffjj : See attached Telephone j��ttii bb 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 ermitapplicant 1. Building 2679.00 (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=0 +2+3+4+5) 2679.00 Check Number This Section For Official Use Only Building Permit Number: �n� O Date O� Issued: Signature: Q 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 9/29/2021 Address Expiration Date (413)552-0200 Signature Telephone 9.Registered Home Improvement Contractor: Not Applicable ❑ American Installations 175982 Company Name Registration Number 130 College Street Ste. 100, South Hadley MA 01075 6/26/2021 Address Expiration Date Telephone (113)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....... .W No...... ❑ Brief Description of Proposed Work NOTE: INSULATION ONLY:]- Attic NLYAttic 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 3/5/20 Signature of Own r/Agent Date 1. 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 3/5/20 Signature of Owner Date City of Northampton ;p ✓''F Massachusetts ( w DEPARTMENT OF BUILDING INSPECTIONS ?` • 'z m 212 Main Street • Municipal Building „. Northampton, MA 01060 sbJY^ \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: 2679.00 Address of Work: 47 Columbus Avenue Date of Permit Application: 3/5/20 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: 3/5/20 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: 3/5/20 k �JdEJA L, CCLAYU Date Owner NameAnd Signature City of Northampton Massachusetts DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street •Municipal Building 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: 47 Columbus Avenue (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: American Installations (Company Name and Address) 2 1jj J'i , le- L 2rj!&— Signature of Pe it 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 _... r Massachusetts DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building Northampton, MA 01060 MANDATORY FOR HOUSES BUILT BEFORE 1945 Property Address: 47 Columbus Avenue Contractor Name: American Installations Address: 130 College Street Ste. 100 City, State: South Hadley MA Phone: (413) 552-0200 Property Owner Kara Wood Name: Address: 47 Columbus Avenue City, State: Northampton,MA 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 ` t/ Date 3/5/20 r ` www.Americanlnstallations.com BBB �+ = Licensed&Insured ratingmass save MA CSL J1:106178 J !101fl PARTNER MA Registration#175982 American Installations 130 college Street Suite 100,South Hadley.MA 01075• Office:(4131 552-0200 Fax:(413)552-0202 • Email:SuDDort@Americaninstallations.com Kara Wood 47 Columbus AV Northampton MA 01060 ry D 305.778-6117 vvwood720PRmail.com Inim,rvl IxConuarvl IEmaip 494603 19-3726 (St.IDI floe RI Quantity Unit Unit Cost Total Air Sealing AIR SEALING 4 man hour $ 85.00 $ 340.00 WEATHERSTRIP DOOR 2 each $ 58.00 $ 116.00 DOOR SWEEP 3 each $ 25.00 $ 75.00 Total Air Sealing Value $ 531.00 Utility Air Sealing Incentive S (531.00) Weatherization BASEMENT-INSULATE BULKHEAD DOOR&INSULATE 1 each $ 110.00 $ 110.00 ATTIC FLAT-5"FLOORED R-16 DENSE CELLULOSE 900 sqft $ 1.75 $ 1,575.00 ATTIC DOOR-INSULATE&WS 1 each $ 110.00 $ 110.00 ATTIC FLAT-7"OPEN R-26 CELLULOSE 100 sqft $ 1.38 $ 138.00 VENTILATION CHUTES 20 each $ 2.50 $ 50.00 ATTIC DAMMING-R-38 FIBERGLASS 20 sqft $ 2.05 $ 41.00 18"X 24"WOOD GABLE VENT 1 each $ 123.50 $ 123.50 Total Weatherization Value $ 2,147.50 Utility Weatherization Incentive $ (1,610.63) Total Project Value $ 2,678.50 Utility Weatherization/Air Sealing;Incentive $ (2,141.63) Weatherization Balance $ 536.88 Total Customer Contribution $ 536.88 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 Total Contract Value as stated herein. ACCEPTANCE OF PROPOSAL:The above prices,specifications and TOTAL CONTRACT VALUE= $ 536.88 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= 5 178.00 ❑ start of work,and balance due upon Completion. PAID Balance Due Upon Completion= $ 358.88 Ka W an 9.2020712/18/2019 Srnatw< ate Kara Wood 12/18/2019 I..tY owns(Print) P,oP..tY wnRr(sr�1 car. Lukasz Socha 12/18/2019 R.Pres.n-(Print) R.Preaem,Rv.IvRnl ate THIS AGREEMENT IS COMPOSED OF THIS PAGE AND THE REVERSE SIDE OF THIS PAGE AND SHALL BE CONSIDEREDTHE ENTIRE AGREEMENT BY THE PARTIES INVOLVED.THISAGREEMENT IS BETWEEN AMERICAN INSTALLATIONS,LLC HEREINAFTER REFERRED TOAS-COMPANY-,ANDTHE CUSTOMER(S)NAMED ABOVE,HEREINAFTER REFERRED TO AS-CUENr,AND WILL BE SUB(ECT TO ALL APPROPRIATE LAWS,REGULATIONS ANDORDINANCES OF THE STATE OF MASSACHUSETTS OR CONNECTICUT RESPECTIVELY, AS WELL AS ALL LOCAL JURISDICTIONS. 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 HE REINAFTERREFERREDTOAS"COMPANY",AND THE CUSTOMERS)NAMED ON THE REVERSE SIDE,HE REINAFTERREFERREDTOAS"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 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 EXCEPTTO 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 WILLTRY 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,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 DRIVESAND WALKS,OR DAMAGETO PLANTS ORSHRUBBERY.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 WITHOUTTHE 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 CHANGESTO MATERIALS BYTHE CLIENT(BRAND,STYLE,COLOR,ETC.)AFTER SAID MATERIAL HAS BEEN DELIVERED OR IS IN ROUTE TO THE CLIENTCOULD 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,PRIORTO 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 EVENTTHE CLIENT AND COMPANY HAVE A DISPUTE REGARDING ANY OF THE TERMS,CONDITIONS,PROVISIONS,OR PERFORMANCE OF THISAGREEMENT,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. 27.THE CLIENT CONSENTS TO USING AN ELECTRONIC SIGNATURE TO SIGN THIS AGREEMENT AND BE LEGALLY BOUND TO THE CLIENT'S ACCEPTANCE OF THE AGREEMENT.BY ELECTRONICALLY SIGNING THE AGREEMENT,THE CLIENT ALSO CONSENTS TO ENTERING INTO THIS AGREEMENT IN ELECTRONIC FORM.tHE CLIENT ACKNOWLEDGES THATTHE CLIENT'S ELECTRONIC SIGNATURE WILL HAVE THE SAME LEGAL FORCE AND EFFECT AS A HANDWRITTEN SIGNATURE. The Commonwealth of Massachusetts 4 Department of Industrial Accidents a 1 Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly 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 70 employees(full and/or part-time).* 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. E]Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.Q I am a homeowner doing all work myself.[No workers'comp.insurance required.]f 10 EJ Building addition 4.❑1 am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11. Electrical repairs or additions proprietors with no employees. 12. Plumbing repairs or additions 5.a I am a general contractor and I have hired the sub-contractors listed on the attached sheet. j 3.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.[ 6.r_J we are a corporation and its officers have exercised their right of exemption per MGL c. 14.QX Other Insulation 152,§1(4),and we have no employees.(No workers'comp.insurance required.) *Any applicant that checks box tl t must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are 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 state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees Below is thepolicy andjob site information. Insurance Company Name: Berkshire Hathaway GUARD Policy#or Self-ins.Lic.#: AMWC049875 _ — Expiration Date: 09/04/2020 Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.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 I Signature: Date: Phone#: 413-552-U00 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.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 Supervisor space. CS-1061'R Expires: 09 WESLEY COUTURE 139 PACKARDVILLE ROAD PELHAM MA 01002 Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. CommissionerFor information about this license "-- - Call (617) 7273200 or visit www.mass.gov/dpi 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: 175982 130 COLLEGE STREET SUITE 100 Expiration: 06/26/2021 SOUTH HADLEY, MA 01075 Update Address and Return Card. SCA 1 0 2OM-05/1? 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 06/26/2021 1000 Washington Street -Suite 710 AMERICAN INSTALLATIONS.LLC. Boston,MA 02113 COUTURE 130 COL 130 COLLEGE STREET SUITE 100 SOUTH HADLEY,MA 01075 Undersecretary Nit valid without signature f A�I� CERTIFICATE OF LIABILITY INSURANCE FDATE(MMIDDNYYY) 8/28/2019 THIS CERTIFICATE IS ISSUED ASA 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(les)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 WN IAGT NAME: Linda Powers Webber & Grinnell PHONE (Q13)586-0111 FAX A/C NO: (413)586-6481 8 North King Street E-MAIL ADDRESS: 1powers@webberandgrinnell.com INSURERS AFFORDING COVERAGE NAIC# Northampton MA 01060 INSURERA:Em lO ers Mutual Casualty INSURED INSURER B:Berkshire Hathaway GUARD Ins. Co. American installations, LLC INSURERC: Attn: Wes & Suzanne Couture INSURER D: 130 College Street, Suite 100 INSURERE: South Hadley MA 01075 INSURER F: COVERAGES CERTIFICATE NUMBER:Master Exp 9-2020 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 ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER MMIDDNYYY MMIDD/YYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 500,000 A X CLAIMS-MADE OCCUR PREMISES Ea occurrence $ 5D3535217 9/4/2019 9/4/2020 MED EXP(Any one person) $ 10,000 PERSONAL 8 ADV INJURY $ 1,000,000 GENIAGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE $ 2,000,000 X PRO POLICY PRO- JECT f LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY EOMaBINEDtSINGLE LIMIT $ 1,000,000 A ANYAUTO BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED 523535217 9/4/2019 9/4/2020 BODILY INJURY Per accident $ AUTOS AUTOS ( ) X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE AUTOS Per accident $ X Coll$2,000 X comp$2,000 PIP-Basic $ 8,000 X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 1,000,000 AEXCESS LIAR CLAIMS-MADE AGGREGATE $ 1,000,000 DED I X I RETENTION$ 10,000 5J3535217 9/4/2019 9/4/2020 $ WORKERS COMPENSATION . PER OTH- AND EMPLOYERS'LIABILITY YIN TAT T ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? ❑NIA B (Mandatory in NH) AMWC994153 9/4/2019 9/4/2020 E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 A Business Personal Property 5x3535217 9/4/2019 9/4/2020 tletluctible$1,Goo 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS I 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 �/ 1 W Grinnell, CPCU, CIC ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025(201401)