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20-006 (3) 508 SYLVESTER RD BP-2018-1227 GIS#: COMMONWEALTH OF MASSACHUSETTS MM-.Block:20-006 CITY OF NORTHAMPTON Lot-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Categorv� INSULATION BUILDING PERMIT Permit BP-2018-1227 Project# JS-2018-002190 Es[ Cost $3200.0 Fee:$65.00 PERMISSIONIS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: AMERICAN INSTALLATIONS LLC 106178 Lot Size(sp ft.): Owner: SWAN SARA&ZACHARY Zoning_ Applicant. AMERICAN INSTALLATIONS LLC AT: 508 SYLVESTER RD Applicant Address: Phone: Insurance: 130 COLLEGE ST (413) 552-0200 WC SOUTH HADLEYMA01075 ISSUED ON:512112018 0.00:00 TO PERFORM THE FOLLOWING WORK INSULATION 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: FeeTyoe- Date Paid: Amount: Building 5/21/20180:00:00 $65.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner � B - IH 6� Zvt su-la�rrn-� R EE C permit use only of Ddhampton Smarm of permitBW ding Department caro cpwdVeway ermtt MAY 18 2018 12 lu MnStreet sewer/septicAvagabil ty Ro m100 Wide dWeti'Availabllity . No mp n. MA 01060 rwu`sets ofSbudWml{?lens —__PERT 1 0 Fax 413-587-1272 plodel(e Plans ; nORTHAM TONMA01M OuterSpenily APPLICATION TO CONSTRUCT,ALTER,REPAIR RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 .SITE INFORMATION 6V 1-9- Ida 7 1.1 Property Address: This section to be completed office 508 Sylvester Road Map a O Lot I)o Lim Florence, MA 01062 Zone Overlay District IS.SL DRt O Ca District- SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 21 Owner of Record: Zachary &Sara Swan 508 Sylvester Road Florence,MA 01062 Name(Pont) CuJ4 f3)33ni-7652 See attached Telephone Signawe 2.2 Authorized Aaerd: American Installations 130 College St., Ste 100 South Hadley, MA 01075 Name(RW) - Coned Maaing Adkess: -- 413-552-0200 SgnaWre Telaphane SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed bpermit applicant 1. Building 3,200.00 (a)Building permit Fee 2 Elecbicel (b)Estimated Total Cost of Conswctlal from 3. Plumbing Building Permit Fee (' 4. Mechanical(HVAC) J 5.Fee Protection S. Total= 1 +2+3+4+ 3200.00 Check Number This Section For Otgelal Use Only Building Permit No Date Issued: Sig re: L BrddYg onemrepector of Buildings Date Section 4. ZONING AB Information Must Be Completed.Permit Can Be Denied Doe To Incomplete Irtornlatbn Existing Proposed Required by Zoning Thio column w be filled In by . rB—uBdivg Dquntmmt --� Lot Size ----_� —� J Frontage Sathacks F Side L:0 R:= L:= R:E= 0 i� Building Height Bldg.Square Footage Open SpamFootage I. avd #of Parking S Fill F— volume alomcov A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO Q DONT KNOW O YES Q IF YES,date issued: i IF YES: Was the pemdt recorded at the Registry of Deeds? NO O DONT KNOW O YES O IF YES: enter Book PageC and/or Document#L B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW O YES O IF YES,has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained O , Date Issued: C. Do any signs exist on the property? YES O NO O IF YES,describe size,type and location: [ —71 D. Are there any proposed changes to or additions of signs intended for the property? YES O NO O IF YES,describe size, type and location: I E. Will the construction activity disturb(clearing,gredkg,excavation,orifift)over 1 acre or Is it pert of a own is n plan that will disturb over 1 acre? YES O NO O IF YES,then a Northampton Stmt Water Management Permit from the DPW Is required. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ 1 Repkeament Windows Alteration(s) ❑ Roofing Or Doom 13 Accessory Bldg. ❑ Demolition ❑ New Signs 117] Decks [p Siding(ol Other[IYj Brief Dasoription of roposed Work Athc and basement insulation and air sealing throughout Alteration of eldsMlg bedroom_Yes_No Adding Crew bedroom Yes No Attached Namatwe Rerwvatlrg unfinished basement _Yes _No Plane Attached Rog -Sheat sa,if New and or addition to existing-housinci-complete the following, a. Use ofbulking:One Family Two FamilyOther b. Number of rooms in each family unitNumber of Bathrooms a Is Mere a garage attached? d. Proposed Square footage of raw wrstruction. Dimensions e. Number of stories? I. Method of heating? Fireplaces orWoodstaves Number of each_ g. Energy Conservation Compliance. Masschack Energy Compliance form attached? h. Type of construction I. Iswnstmcdm WfthiniOOlLofwelands?_Yes _No. IsconsWctionwifhln100yr. ffwdpkxn Yes_N0 J. Depth of basement or cellar floor below finished grade k. Wfll buDding conform to fire Bugling and Zoning mgulegons7 Yes_No. I. Septic Tank_ CitySewer_ Private well_ City water Supply_ SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, Zachary&Sara Swan as Owner of the subject property, hereby authorize American Installations to act on my behalf,in all maltem rotative to work authorized by this building permit application. See attached 5/12/2018 Slimawreof Owner Date I. American Installations .m Owner/Authorized Agent hereby declare that the statements and Information on the foregoing application am hue and accurate,to the best of my knowledge and belief. Signed under the pakls and pensNes or perjury. American Installations print Name 5/12/2018 S�neWacl AgaN Date SECTION 8-CONSTRUCTION SERVICES 81 Licensed Construction S umvl or: Not Appffcabie 13 Nemaotl.reenserioider: WesleyK. Couture 106178 License Number 130 College St., Ste 100 South Hadley, MA 01075 9129119 Address EgtiraUm pate 413-552-0200 Sisn"we Telephone 9.Registered Nome Improvement Contraetori Not Applicable ❑ Wesley Couture 175982 Company Name Registration Number American Installations Address F�gaire0on Date 130 College St., Ste 100 South Hadley, MA 01075 Telephone 413-552-0200 SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c.152,§25C(0)) Workers Compensation Insurance affidavit must be completed and submitted with this applicat on.Failure to provide this affidavk will result In the denial of the issuance more building it Signed AtfidavltAttachad Yes....... BI No...... ❑ 11. -Home Owner Eiemmdon The current exemption fm"homeowners"was extended to include owner-occupied Dwellings ofone(I) artwo(2)families and to allow such hna downer to engage m individual for hire who does not possess a license,provided thatthe owner sets as supervhor.CMR 780, Sixth Edition Section 108351. Definition of Homeowner:Person(a)who earn a parcel of lead on which he/she resides or intends W meide,on which them is,or is intended W be,a one or two family dweging,attached or detached structure;accessory W such use and/or femr structures.A person who consfiracts mom than am h in a two-year period SW not be considered ahomeowoer. Such"homeowner^shall submit W the Building Official,on a form acceptable W the Building Otfici ds that he/she shall be reannnsible for all=4 work performed odder the hufidinapermit. As acting Construction Suoervlsoryour presence onthejob she will be required from time W time,duriagand upon completion ofthe work for which this permit is issued. Also be advised that with refeteace W Chapter 152(Workers'Compensation) and Chapter 153(Liability offmrployers to Employees for injuries not resulting in DeaOr)of the Massachusetts Genial Laws A®otated,you may be liable forperaon(s) you hire W perfonnwork for you under this permit The undersigned"homeowner"certifies and measures responsibility for co aphanes with the State Building Code.City of Northampton Ordinances,State and Local Zoning Laws and State ofMassachusetb General Laws Annotated Homeowner Signature City of Northampton 212 Main Street, Northampton, MA 01060 Solid Waste 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. Address of the work: 508 Sylvester Road, Florence MA 01062 The debris will be transported by: American Installations The debris will be received by: Waste Management of N.E. - Chicopee Building permit number: Name of Permit Applicant W,•ta� U'rt'),< 5/12/2018 kz"Ae V— QGV.�.. Date Signature of Permit Applicant • mass save PARTNER MP GY,r:161J8 M.[4pkfmumlll59Bt American Installations svww.Amadu^msMlatlms.Lom vpLaYPnwts:trfm.soin xraLr,ru arms.omY:ILislssaamorv.laslssLmm.un.i[yyenMm.tsmMura.n.[om Customer Name:Zachary Swan Email:Not provided Phone:413-335-7652 Premlae Address:508 Sylvester Rd,Northampton,MA 01062 Project to:3405460 Date:April 26,2018 Job Description Insulation Removal 68 SF $85.68 $85.68 Rim Joist-6" Fiberglass Batting 136 SF $367.20 $91.80 Attic Floor- 12"Open Blow Cellulose 816 SF $1,664.64 $416.16 Damming 18 each $43.02 $10.75 Bath Fan Hose 1 each $26.20 $6.55 Hatch-2"Thermal Barrier Polyiso 1 each $46.28 $11.57 Door-2"Thermal Barrier Polyiso 1 each $90.44 $22.61 Exterior Door Weather Stripping (with AS hrs) 1 each $30.07 $0.00 Door Sweep(with AS hrs) 1 each $25.31 $0.00 Air Sealing at Estimated 62.5 CFM50 Per Hour 8 hr $740.64 $0.00 -- Project Total $3119.48 - Weatherization incentive ($1,678.34) Air sealing incentive ($796.02) Total Program Incentive -$2,474.36 Customer Total $645.12 wAAaAYrv:ama[an Iw+NNm[,uc.at.oYae Ne Nouacame xm<wrM.wxn a r.w.+vsimnnlo.+[.nr Ma[lun InuiaETt LL[IweErp[pplLyplvry'NYI n.maal«tl INV N WnglateJe Mrcuglof[a4 N«[MaaMe MNtlwabre fpatihNM3aMaY total anastam NMS rt«la6«a M tl«ietY Co W eR V aM.of f Geo MM ACCEVTAYCE or enoeosm: Ter Yo[e oma wa[s[Ylwi. arc! rc r L ao TOTALCONTRAvvAwE=s 645.12 +aE[M1Mr«ia«envNr«eamY vwartammYmatDtlovaYa Yxlflea,>«'e.etep«, t.e20000p cc rix useowaa«<e c.ner.en,aGeam2ea..w,m mMNm. vAlo aa«ee omupenrurryLRbn- s 445.12 vLw«e \/Imm eea«Iv oxmlvant Zachary Swan vMt �p7,3 l mm 4-26-18 ae«ermmn[ealmml B.Zaer Ivml T/ `� aam 4-26-t8 m aa,n[at,o L-�® M«�..�a r, o.B oa..wt.,•.we�:opt.[.®..[.. �U,w.�o wa�am. :.yo- w[ :wT w'�,am�[..tl u" .[ a� THIS AGREEMENT IS COMPOSED OF THIS PAGE AND THE REVERSE SIDE OF THIS PAGE AND SHALL BE CONSIDERED THE ENTRE AGREEMENT BY THE PARTIES INVOLVED. THIS AGREEMENT IS BETWEEN AMERICAN INSTALLATIONS,LLC HEREINAFTER REFERRED TOM"COMPANY',AND THE CUSTOMERO 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 THE AGREEMENT TO BE EFFECTIVE UNDER ANY COND91ON. 2, SHOULD DEFAULT BE MADE IN THE PAYMENT OF THIS AGREEMENT,CHARGES SHALL BE ADOE D FROM THE DATE TH EREOF AT A BATE OF ONE AND ONE-HALF(1-1/2U PERCENT PER MONTH.(18%PER ANNUM)WITH A MINIMUM CHARGE OF$2.00 PER MONTE,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 IDA LEIN ON THE PROPERTY 3. THE COMPANY AGREES THAT WHEN DELAYS BECOME KNOWN TO THE COMPANY,THE COMPANY WI LL ADVISE THE CUENT AS SOON AS REASONABLE. 4. COMPANY AGREES THAT,NOTWITHSTANDING ANY AGREEMENT FOR MATERIALS AND/OR LABOR BETWEEN COMPANY AND THIRD PAM,COMPANY 15 RESPONSIBLE TO CLIENT FOR COMPLETION OF ALL WORK DESCRIBED IN ATIMELY 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 MANUFACTURERS WARRANTIES,THE CUM 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 I INSURANCE COVERAGE,ANY SUCH ADDITIONAL EXPENSES,PREMIUMS OR COST SHALL BE ADDED TO THE TOTALAGRFEMENTMMOUNT ]. THE COMPANYS 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 SOIFY DUE TO THE COMPANY'S NEGLIGENCE, 8. DURING THE DURATION OF THE WORK,THE CLIENTS HOMEOWNERS INSURANCE WILL BE RESPONSIBLE FOR ANY AND ALL DAMAGES AS LONG AS ME COMPANY HAS TAKEN THE APPROPRIATE ACTION TO PROTECT AREAS OF WORK 9. THE COMPANY IS NOT RESPONSIBLE FDR PREEXISTING DEFICIENCIES OR HAZARDOUS MATERIALS THAT MANIFEST THEMSELVES DURING THE CONSTRUCTION PROCESS, EG,WOOD ROT,MOLD,ASBESTOS,NAIL POPS,DUCTWORK AND CONNECTIONS,PLUMBING AND VENT PIPES,DECKING DEFLECTION,ETC.IF APRE-EX191NG DEFICIENCY OR HAZARDOUS MATERIAL IS ENCOUNTERED PRIOR TO OR DURING CONSTRUCTION,AND COMPANY IS NOTIFIED M 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 Am UNAVOIDABLE BY THE COMPANY AND SHALL NOT BE CONSIDERED A VIOLATION OF THE AGREEMENT AND THAT DUE TO THESE CONDITIONS THE DURATION GF 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 MY PROBLEMS AND/OR DAMAGES,MOLDING BUT NOT LIMITED TO MOLD GROWTH,ARISING FROM THE PERFORMANCE OF AIR SEAUNG 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 HON THE COMPANY HARMLESS,FOR ANY PROBLEMS AND/OR DAMAGES REIATING 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 SCRATCH NG OR DENTING OF INTERIOR WALLS AND CEILINGS PUMPS,TRIM,GUTTERS,DOWNSPOUTS,EXISTING SIDING AND WINDOWS MORS 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$EXPENSE, 3A THE COMPANY UNDER PROVISIONS OF CHAPTER 142A OF THE GENERAL LAWS 15 REQUIRED TO APPLY FOR AND OBTAIN ALL CONSTRUCTIONRELATED PERMITS THE COMPANY SHALL NOT BE DEEMED RESPONSIBLE FOR BELAYS 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 C HANGED OR ALTERED EXCEPT BY A WRITTEN STATEMENT SIGNED BY BOTH THE COMPANY AND THE CLIENT. 16, ANY REPRESENTATIONS STATEMENTS,OR OTHER COMMUNICATION NOT WR17EN ON THIS AGREEMENT ARE AGREED TO BE IMMATERIAL AND NOT RELIED ON BY EITHER PART/,AND DO NOT SURVIVE THE EXECUTION OF THIS AGREEMENT. 12. THIS AGREEMENT CANNOT BE CANCELLED WITHOUT THE MI ITHAI.WRITTEN CONSENT OF ROAN PARTIES EXCEPT AS OTHERWISE SET FORTH HEREIN. 10. THIS AGREEMENT,AND ANY WARRANTY(S)PROVIDED HEREUNDER SHALL NOT BE ASSIGNED EXERT 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'SACTUAL DAMAGES OR 25%OF THE AGREEMENT FOR RESTOCKING FEE. 20. ANY CHANGES TO MATERIALS BY THE CLIENT(BRAND,STYLE,COLOR,FTC,)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 MATERIAE, 21. THIS AGREEMENT SHALL BE EFFECTIVE ONLY UPON ITS EXECUTION BY ALL PARTIES HERETO,PRIOR TO WHICH TIME IT SHALL BE DEEMED A PRO POSAL THE COMPANY RESERVES THE RIGHT TO REVOKE MIS PROPOSAL 90 DAYS FROM DAZE IT IS EXECUTED BY THE COMPANY IF IT IS NOT EARLIER EXECUTED BY THE CLIENT AND THE REQUIRED MAN PAYMENT RECEIVED PRIOR TO THE EXPIRATION OF SUCH AD 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 0E INVALID OR UNENFORC40LE,THE VAUD"AND ENFORCEDILITY 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 PEACE 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 SPONSORED UTILITY PROGRAM I.E.MASS SAVE')IS SUBJECT M THE AVAILABILITY OF QUALIFYING STATE SPONSERED PROGRAM AND WILL BE SUBJECT TO TERMINATION IF THE STATE SPONSERED UTILITY PRMMM IS DMOUNTINUED, FURTHERMORE,THE TERMS AND CONDITIONS OF STATE SPONSERED UTILITY PROGRAMS MAY BE ALTERED OR UPDATED PERIODICALLY WITH OR WITHOUT NOTICE. 25. AMENCAN 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 6 REPSONSIBLE FOR THE PAYMENTOF ANYAND ALL FEDERAL,STATE,OR LOCALTAXES THAT ARE APPLICABLE TO THLSAGREEMENT The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,ALA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers _Applicant Information Please Print Legibly Name(Basiucsssorga,i a nneinavidual : American Installations,LLC Address: 130 College Street,Suite 100 --- City/State/Zip: South Hadley,MA 01075 _ Phone d: 413-552-0200 Are you an employer?Check the appropriate box: Type ofproject(required): I.tA1 am a employer with 46 _ 4. ❑ I am a general mnhactor and 1 6, Q New construction employees(full and/or part-time)." have hired the sub-contractors Remodelin 2. I am a sole proprietor or partner- listed on the attached sheet.t ❑ g ship and have no employees These sub-contractors have &. El Demolition working for me in any capacity. workers'comp. insurance. 9. ❑Building addition i thio workers'comp,insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.[-] Electricalrepairsor additions 3.C: 1 am a homeowner doing all work right of exemption per MGL I i.[]PVmbing repairs or additions myself. ]No workers'comp. a 152,§1(4)and we have no1 12.E] Roof repairs insuranceaired, t employees. [No workers' req I;.N Other Insulation comp. insurance required.] - -nny eppllam dutehecks box tll mud oleo fill om the scgien below showing lM1eir workers'wmpensmion polity infomution. t rinnrcuwncn wFm sahmir chis Mrdavn indsaeing Nry arc ening alt,mr::and aav haooanida eunuurws muse submit a aew ati#wa a,aii,miag suer. :Cenirenars 22292 chock Iprs box mw�mxM1N an adailionel Shed sM�wing ne name of Ne subcanrrnaon and rM1ett wwkur,r comp,polity into�mnion. t am an emptuyer tkm is prorddtag workers'ca+rvpr+nsatian insaraace formy earpJoyees Sete.is the palfcy andjebsire infornraltem Insurance Company Name: Guardlnsurance Companies Policy q m SelFin, LLieh.N:_ AMWC897387 v Expiration Date::- 09/09/2018 Job Sire Address: )t10,__.),.lot At.✓ I`O� City/Stete/Zip: I ./l�l [�r 01�J�p2 Attach a copy of the warken'eompensatioa policy declaration Page(showing'be policy number and expiration date)- Failure ate)- Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a tiro up to S 1,500.00 andtor cru-year,imprisonment,as well as civil penalties in the to=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 somement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. too here unify under the pains and penatder of perjury that Ike inforwhidon provided above is true and correct Si t n : ,.— Deto: -. Pph{ane H: 41200 Ojlir'at useanfy. Bu mu wrtle fa this arra,to ke rnaptetrd ky e"'ar lawa aJfictat City or Town: P'sonk/Licease#� Issuing Authority(circle one): I. Board of Health 2.Building Department 3.Cityrrown Clerk a.Electrical Inspector d.Plumbing Inspector 6.Other Contact Person: Phone 0 : Commonwealth of Massachusetts Construction Supervisor Division of Professional Licensure Unrestricted-Buildings o/any use,lineup which contain a` Boats of Building Regulations and Standards less Mean 35,000 comic least(991 culAc meters)ofeadosed Construction Supervisor fie. CS-106178 E;pires:09/29/2019 WESLEY COUTURE 21S LATHROVgTREET SOUTH HADLEY MA 01078 Fate.to possess a current am.of Me Massactluselts state Building Code is"use for rinroeMbn of MIS Rcen re. (^/a�w. Fos TV-32M Mo or Ahad Mis Oewlq Commissioner Cao(817) Ns0 wwwmssgv/dpl ;�� n�fte lPa7yt7ytnjttt�eTr�lft a�JC��J1a�f1t7Je��:1 Office of Consumer Affairs and Business Regulation 10 Park Plaza- Suite 5170 Boston, Massachusetts 02116 Home improvement Contractor Registration Type: LLC AMERICAN INSTALLATIONS,LLC. Regisxiration165982 130 COLLEGE STREET SUITE 100 EExpiration:: 08/28/2019 SOUTH HADLEY.MA 01075 Update Address and return card. Mak reason tax dung. scAl 3 mmuvll n A40-c=- ❑Re--Y 1 I_I Efflooyment ❑(AStCend O6keof Consumer Affaire&Bseeees Ragelstan HOMEIMPROVEMENTCONTRACTOR Registration valid far iMivitlual use only TYPE:LLC Mfere Me"nation We. N bund rearm to: x`y J.•;- aWleureien ExomaBon Office of Consumer Affairs ard!Business Regulation 175982 06126/2019 to Park Flaw-SUR051T0 AMERICAN INSTALLATIONS,LLC. Boston,MA 02116 WESLEY COUTURE 130 COLLEGE STREET SUITE 100 SOUTH HADLEY,MA 01075 Undersecretaly e*valid without signature A CERTIFICATE OF LIABILITY INSURANCE DATE(MWDW " 8/14/2017 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: N the certigcele holder is an ADDITIONAL INSURED,the pollcy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the Policy,certain Policies may require an andorsemem. A statement on this certificate does not confer rights to the certificate holder in lieu of such endomement(s). PRODUCER NAME: Linda POw¢xa Behber 6 Grinnell PMINE (413)586-0111 Faz xo:ums96-64.1 8 North Ring Street A urzRFssapowers@wehherandgrl nell.Com INSURIERVI AFFORDING COVERAGE XAICX Northampton 6A 01060 INSUAERAZSyFlerS Nutual Casualty INSURED IXSURERBBerkehire Hathaway BOARD Ins. Co. American Installations, LLC mSUNERc: Attn: Wes 6 Suzanne Couture INSURER D: 130 College Street, Suite 100 INSURERE: South Hadley l9A 01075 INSURER F: COVERAGES CERTIFICATE NUMBERMeatar Exp 9-2018 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. /NSR I TYPE OF INSURANCE POLICY NUMBER MMID POLICYEFF MP POLICY UPR LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 11000,000 A A CIAIMSJ]AOE �OCCUR PREM/ E Eeouvnenw $ 500,000 SD3535217 9/1/2017 9/1/2018 MEDE%P(Anyone PweW) 11 10,000 PERSONAL 6 ADV INJURY 1$ 1,000,000 GEHL AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,000 A POLICY ] ECT OL. PRODUCTSCOMRADEAGO $ 2,000,000 OTHER. $ MO AUTOBILE LIABILITY SaockeU $ 1,000,000 A ANY AUTO BODILY INJURY(Far(Bmon) $ ALL OSWED AUTOJLEO X G5x353521] 9/4/2011 9/4/2038 BODILY INJURY(PerardenO S NONOVRIED PROPERTYDAMA E `t HIRED Au]os '4 AUTOS Feramdere) $ PIFLUNC S 8,000 A UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 11000,000 A EXCESS NAB CIAIMSMAOE AGGREGATE S 1,000,000 DED X I RETENTION$ 10 000 SJ3535217 9/4/2017 9/4/2018 S WORKERS COMPENSATION PER DTH. AND EMPLOYERS'WBIOTY x BTATUTE Be ANY OFF/CERMEIMT RExOWo oE�,IYECUTIVE YO NIA EL EACH ACCIDENT S 500,000 B (MnWrory In MR) GUNC6099I0 9/4/201] 9/4/2018 E.L.DISEASE CA EMPLOYE $ 500,000 y a.,.uMer OEBORIPTIONOF OPERATIONS EeeA EL OISEASE-POLICY LIMIT $ 500,000 A Commercial Property 5A3535217 9/4/20ll 9/4/2018 dMotllEk$?0]0 DESCRIPTION OF OPERATIONS/LOCATIONS VEHICLES(ACORD 101,AddRlmtl WIMMM SCNedule,may be Maohed If mom spaceN reWRe01 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 Kevin Joyce/LMP 3*z A� ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD INS0251aT1nnn