10B-072 (5) 30 WATER ST BP-2019-0600
GIs#: COMMONWEALTH OF MASSACHUSETTS
MU-Block: 10B-072 CITY OF NORTHAMPTON
LPA:-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-2019-0600
Project# &2019-000969
Eat..Cot;09M
Fee: .00 PERMISSION IS HEREBY GRANTED TO:
Qgng.QMs: Contractor: .license:
Use Group: AMERICAN INSTALLATIONS LLC 106178
Lot Si a(sq.ft.): 12066.12 Owner: GREENS JASQN&.LEANNE
zonjng:!IRB(100)/ Applicant: AMERICAN INSTALLATIONS LLC
AT.- 30 WATER ST
Applicant Address: Phone: Insurance:
130 COLLEGE ST (413)552-0200 WC
SOUTH HADLEYMA01075 ISSUED ON:1111412018 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:
Bough Frame:
Gas: Flee` e a amen, Fireplace/Chimney:
Rough: 9,1.1; Insulation:
Final: oke; Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Cegificall of OccU anC I nature:
FeehRe: _ Date Paid: Amount:
Building 11/14/20180:00:00 $65.00
212 Main Street,Phone(413)51174240,Fax;(413)587-1272
Louis Hasbrouck—Building Commissioner
Department;use only
ity 4 f Northampton Status of Permiti.
N O V 1 3 2018 uild rig Department curb Cut/Driveway Permit
212 Main Street SeW6dSeptIc AvarlabiUty
R .oom 100 WaterNllell Availability
DEPT OF 6UILDING INSPECT it*tha pton, MA 01060 Two Sets of Stnictural Plans
NORTHAh17,TON MA 010 0
-1240 Fax 413-587-1272 Plotlsite"Plans
Other SPedfy
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATIONA lq—(100
1.1 Properly Address:
This section to be completed by office
� '
30 Water Street, Leeds MA 01053 h
Map Lot � /� Unit.
Zone Overlay District
Elm SL District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Tason &Leanne Greene 30 Water Street, Leeds MA 01053
Name(Print) Current Mailin Address:
See attached Telephone 5$�4-1987
Signature
2.2 Authorized Agent:
American Installations 130 College St., Ste 100 South Hadley, MA 01075
Name(Print) Current Mailing Address:
y- 1/t.t 413-552-0200
Signature j Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building 2,500.00 (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from,(6)
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5.Fire Protection
6. Total= 1+2+374 4+5) 2,500.00 Check Number
This Section For Official Use Only
Building Permit Number. Date
Issued:
Signature: l
Building Commissioner/Inspector of Buildings Date
Section 4. ZONING All Information Must Be Completed.Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L:= R:= L:= K-= �� {
Rear
Building Height
Bldg.Square Footage C� "a
Open Space Footage I ' % r—�
(Lot arca minus bldg 8c paved
adds
#of Parking Spaces �-
Fill: .�� --
volume&Location) — i'
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW Q YES 0
IF YES,date issued:f
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW O YES O
IF YES: enter Book I I
Page�� and/or Document#i_
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 0 , Date Issued:
C. Do any signs exist on the property? YES O NO O
IF YES,describe size,type and location: 4 _�
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: l
E. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO O
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors 1]
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [Q Siding[O] Other[E&
Brief Description of Proposed
Work: Attic and basement insulation and air sealing throughout
Alteration of e)asting bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Pians Attached Roll -Sheet
6a.It New house and'or adc ition_to existing°housing..comalete the:foliowing:
a. Use of building:One Family Two Family Other
b. Number of rooms In each family unit: Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
i. is construction within 100 ft.of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No
J. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No.
I. Septic Tank City Sewer Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, Jason &Leanne Greene ,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 10/3/2018
Signature of Owner Date
I, American Installations 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.
American Installations
Print Name
v, lle 10/3/2018
Signature of Own /Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: Wesley K. Couture 106178
License Number
_130 College St., Ste 100 South Hadley, MA 01075 9/29/19
Address Expiration Date
\� �, C&Jaa 413-552-0200
Signature Telephone
.9Registered Home Imorovemerit Contractors _. __ _ ' . Not Applicable ❑
Wesley Couture 175982
Company Name Registration Number
American Installations 6/26/19
Address Expiration 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(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....... IN No...... ❑
Home Uwner.Egejg tioii
4
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)families
and to allow such homeowner to engage an individual for hire who does not possess a.license,provided that the owner acts
as supervisor.CMR 780, Sixth Edition Section 1083.5.1.
Definition of Homeowner:Person(s)who own a parcel of land on which he/she resides or intends to reside,on which there
is,or is intended to be,a one or two family dwelling,attached or detached structures accessory to such use and/or farm
structures.A person who constructs more than one home In a two year period shall not be considered a homeowner.
Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official,that helshe shall be
responsible for all such work performed under the bulldine hermit
As acting Construction Supervisor your presence on the job site will be required from time to time,during and upon
completion of the work for which this permit is issued.
Also be advised that with reference to Chapter 152(Workers'Compensation) and Chapter 153(Liability of Employers to
Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,you may be liable for person(s)
you hire to perform work for you under this permit.
The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of
Northampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
City of Northampton
SSS•'"'� SSC
Massachusetts
yF �
� DEPARTMENT OF BVILDING INSPECTIONS
212 Main Street • Munici al Building
Northampton, ML 01060
Property Address: 30 Water Street,Leeds MA 01053
Contractor
Name: American Installations
Address: 130 College Street Ste. 100
City, State: _South Hadley, MA
Phone: 43-552-0200
Property Owner
Name: Jason &Leanne Greene
Address: 30 Water Street
City, State: Leeds MA 01053
I, American Installations (contractor)attest and affirm that the building I intend to
insulate does not have any open air(knob and tube)wiring in the spaces to be insulated and that I have
provided the property owner with a copy of this affidavit.
Contractor signature
Date
10/3/2018
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: 30 Water Street, Leeds MA 01053
The debris will be transported by: American Installations
The debris will be received by: Waste Management of New England
Building permit number:
Name of Permit Applicant American Installations - Wesley Couture
10/3/2018
Date Signature of Permit Applicant
www.Americanlnstallations.com
B�, FtLarEsarEaEa
' • Licensed&Insured
MA CSL#:106178
American Installations MA Registration#175982
130 College Street Suite 100,South Hadley,MA 01075•Office:(413)552-0200 Fax:(413)552-0202• Email:support@Americanlnstallations.com
Greene,Jason and Leanne 9/7/2018
lust' (F-) (Date)
30 Water St. Leeds MA 01053
lAmress) (ChY) (State) (Zip)
413.584.1987
(Nome) (Cell) (Email)
469807 18-2658
Isne IDl
(Jeb hl
Quantity Unit Unit Cost Total
Air Sealing
AIR SEALING 10 Iman hour 1 $ 85.00 1 $ 850.00
Air Sealing $ 850.00
Air Sealing Incentive $ (850.00)
Air Selaing WX Balance $ -
Weatherization
ATTIC HATCH-SEAL&INSULATE 1 each $ 60.00 $ 60.00
ATTIC DAMMING-R-38 FIBERGLASS 98 sqft $ 2.05 $ 200.90
KNEEWALL-2"RIGID BOARD 177 sqft $ 3.85 $ 681.45
VENTILATION CHUTES 33 each $ 2.50 $ 82.50
ATTIC FLAT-10"OPEN R-37 CELLULOSE 400 sqft $ 1.56 $ 624.00
Total Weatherization $ 1,648.85
Weatherization Incentive $ 1,236.64
Total Project $ 2,498.85
Total Utility Contribution $ 2,086.64
Total Customer Contribution $ 412.21
WARRANTY:American Installations,LLC will provide the above stated homeowner with a 2 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_ $ 412.21
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= $ 130.00 6 9-7-2018
start of work,and balance due upon Completion. PAID
Balance Due Upon Completion= $ 282.21
Slrnatmt Date
Jason Greene
9/7/2018
PropertyD—(Pnm) Property syn) D—
C.Dragovich 9/7/2018
RepnseetatW(Print( Represematwe(Sign) Date
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 ABOVE,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.
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 CUSTOMERS)NAMED ON THE REVERSE SIDE,HEREINAFTER REFERRED TO AS"CLIENT",AND
WILL BE SUBJECT TO ALL APPROPRIATE LAWS,REGULATIONS AND ORDINANCES OF THE STATE OF MASSACHUSETTS OR CONNECTICUT RESPECTIVELY,AS WELL AS ALL LOCAL JURISDICTIONS.
THE FOLLOWING TERMS AND CONDITIONS ALSO APPLY
1.THIS AGREEMENT IS SUBJECT TO THE APPROVAL OF A MANAGER OF THE COMPANY FOR THIS AGREEMENT TO BE EFFECTIVE UNDER ANY CONDITION.
2.SHOULD DEFAULT BE MADE IN THE PAYMENT OF THIS AGREEMENT,CHARGES SHALL BE ADDED FROM THE DATE THEREOF AT A RATE OF ONE AND ONE-HALF(1-1/2)PERCENT PER MONTH.
(18%PER ANNUM)WITH A MINIMUM CHARGE OF$2.00 PER MONTH,AND IF PLACED IN THE HANDS OF AN ATTORNEY OR COLLECTION AGENCY FOR COLLECTION,ALL ATTORNEYS'FEES,
EXPENSES AND COSTS OF COLLECTION SHALL BE PAID BY THE CLIENT.IN ADDITION,CLIENT UNDERSTANDS THAT IN FAILING TO PAY ACCORDING TO THE ABOVE TERMS,COMPANY MAY
HAVE THE RIGHTTO A LEIN ON THE PROPERTY.
3.THE COMPANY AGREES THAT WHEN DELAYS BECOME KNOWN TO THE COMPANY,THE COMPANY WILL ADVISE THE CLIENT AS SOON AS REASONABLE.
4.COMPANY AGREES THAT, NOTWITHSTANDING ANY AGREEMENT FOR MATERIALS AND/OR LABOR BETWEEN COMPANY AND THIRD PARTY,COMPANY IS RESPONSIBLE TO CLIENT FOR
COMPLETION OF ALL WORK DESCRIBED IN A TIMELY AND WORKMANLIKE MANNER.
5.ALL WARRANTIES FOR EQUIPMENT AND PRODUCTS SUPPLIED BY THE COMPANY UNDER THIS AGREEMENT SHALL BE THOSE GIVEN BY THE MANUFACTURERS OF SUCH EQUIPMENT AND
PRODUCTS.UNDER SUCH MANUFACTURER'S WARRANTIES,THE CLIENT MAY BE REQUIRED TO REGISTER OR MAIL IN A WARRANTY CARD OR OTHER EVIDENCE OF OWNERSHIP AND USE OF
SUCH EQUIPMENT AND/OR PRODUCTS IN ORDER TO ACTIVATE SUCH WARRANTIES.
6.THE QUOTATION ON THE PAGE HEREOF DOES NOT INCLUDE EXPENSES OR CHARGES FOR BOND OR INSURANCE PREMIUMS OR COSTS BEYOND NORMAL INSURANCE COVERAGE,ANY SUCH
ADDITIONAL EXPENSES,PREMIUMS OR COST SHALL BE ADDED TO THE TOTAL AGREEMENT AMOUNT.
7.THE COMPANY'S LIABILITY FOR CLAIMS ARISING OUT OF THIS AGREEMENT SHALL NOT EXCEED THE TOTAL AGREEMENT PRICE EXCEPT TO THE EXTENT THOSE DAMAGES ARE PROVEN TO BE
SOLEY DUE TO THE COMPANY'S NEGLIGENCE.
8.DURING THE DURATION OF THE WORK,THE CLIENT'S HOMEOWNERS INSURANCE WILL BE RESPONSIBLE FOR ANY AND ALL DAMAGES AS LONG AS THE COMPANY HAS TAKEN THE
APPROPRIATE ACTION TO PROTECT AREAS OF WORK.
9.THE COMPANY IS NOT RESPONSIBLE FOR PREEXISTING DEFICIENCIES OR HAZARDOUS MATERIALS THAT MANIFEST THEMSELVES DURING THE CONSTRUCTION PROCESS.E.G.WOOD ROT,
MOLD,ASBESTOS,NAIL POPS,DUCTWORK AND CONNECTIONS,PLUMBING AND VENT PIPES,DECKING DEFLECTION,ETC.IF A PRE-EXISTING DEFICIENCY OR HAZARDOUS MATERIAL IS
ENCOUNTERED PRIOR TO OR DURING CONSTRUCTION,AND COMPANY IS NOTIFIED IN WRITING,COMPANY WILL TRY TO ASSIST CLIENT WITHIN THE COMPANY'S MEANS AND CAPABILITIES
TO CORRECT THE PROBLEM(S)ON A TIME AND MATERIAL BASIS.CLIENT AGREES THAT SUCH CONDITIONS ARE UNAVOIDABLE BY THE COMPANY AND SHALL NOT BE CONSIDERED A
VIOLATION OF THE AGREEMENT AND THAT DUE TO THESE CONDITIONS THE DURATION OF THE WORK AND SCHEDULED DATE OF COMPLETION MAY DIFFER FROM THAT AGREED UPON,IF
APPLICABLE,UNDER THIS AGREEMENT.
10.THE COMPANY IS NOT RESPONSIBLE,AND THE CLIENT AGREES TO HOLD THE COMPANY HARMLESS,FOR ANY PROBLEMS AND/OR DAMAGES,INLCUDING BUT NOT LIMITED TO MOLD
GROWTH,ARISING FROM THE PERFORMANCE OF AIR SEALING WORK BY THE COMPANY AS A RESULT OF ANY KNOWN OR UNKNOWN MOISTURE CONDITIONS.
11.THE COMPANY IS NOT RESPONSIBLE FOR,AND THE CLIENT AGREES TO HOLD THE COMPANY HARMLESS,FOR ANY PROBLEMS AND/OR DAMAGES RELATING TO ICE DAMMING THAT MAY
ARISE DURING AND/OR AFTER THE PERFORMANCE OF WORK BY THE COMPANY.
12.REPLACEMENT OF DETERIORATED DECKING,FASCIA BOARDS,ROOF JACKS,VENTILATORS,FLASHING,RAFTERS,JOISTS, INSULATION OR OTHER MATERIALS ARE NOT INCLUDED UNLESS
OTHERWISE NOTED HEREIN.
13.THE COMPANY WILL NOT BE RESPONSIBLE FOR THE SCRATCHING OR DENTING OF INTERIOR WALLS AND CEILINGS, FLOORS,TRIM,GUTTERS, DOWNSPOUTS, EXISTING SIDING AND
WINDOWS,DOORS,OIL DROPLETS IN DRIVEWAYS,HAIRLINE FRACTURES IN CONCRETE OR BLACKTOP DRIVES AND WALKS,OR DAMAGE TO PLANTS OR SHRUBBERY.IF EXCESSIVE DAMAGE IS
CAUSED BY COMPANY,COMPANY WILL REPAIR OR REPLACE DAMAGED AREA ONLY AT COMPANY'S EXPENSE.
14.THE COMPANY UNDER PROVISIONS OF CHAPTER 142A OF THE GENERAL LAWS IS REQUIRED TO APPLY FOR AND OBTAIN ALL CONSTRUCTION-RELATED PERMITS.THE COMPANY SHALL NOT
BE DEEMED RESPONSIBLE FOR DELAYS IN THE WORK DESCRIBED IN THIS AGREEMENT CAUSED BY REGULATORY PERMIT GRANTING OR INSPECTIONAL AGENCIES,AUTHORITIES,OR
INDIVIDUALS.
15.THIS AGREEMENT,INCLUDING THE PROVISIONS RELATING TO PRICE AND PAYMENT SCHEDULE,CANNOT BE CHANGED OR ALTERED EXCEPT BY A WRITTEN STATEMENT SIGNED BY BOTH THE
COMPANY AND THE CLIENT.
16.ANY REPRESENTATIONS,STATEMENTS,OR OTHER COMMUNICATION NOT WRITTEN ON THIS AGREEMENT ARE AGREED TO BE IMMATERIAL AND NOT RELIED ON BY EITHER PARTY,AND DO
NOT SURVIVE THE EXECUTION OF THIS AGREEMENT.
17.THIS AGREEMENT CANNOT BE CANCELLED WITHOUT THE MUTUAL WRITTEN CONSENT OF BOTH PARTIES EXCEPT AS OTHERWISE SET FORTH HEREIN.
18.THIS AGREEMENT,AND ANY WARRANTY(S)PROVIDED HEREUNDER SHALL NOT BE ASSIGNED EXCEPT BY OR WITH THE WRITTEN PERMISSION OF THE COMPANY.
19.IF THE CLIENT FAILS TO PERFORM ITS OBLIGATIONS HEREUNDER OR TERMINATES THIS AGREEMENT WITHOUT THE PRIOR WRITTEN CONSENT OF THE COMPANY,THE CLIENT SHALL BE
LIABLE FOR DAMAGES FOR THE GREATER OF THE COMPANY'S ACTUAL DAMAGES OR 25%OF THE AGREEMENT FOR RESTOCKING FEE.
20.ANY CHANGES TO MATERIALS BY THE CLIENT(BRAND,STYLE,COLOR,ETC.)AFTER SAID MATERIAL HAS BEEN DELIVERED OR IS IN ROUTE TO THE CLIENT COULD RESULT IN A 5%RE-STOCKING
FEE BASED ON THE COST OF SAID MATERIALS.
21.THIS AGREEMENT SHALL BE EFFECTIVE ONLY UPON ITS EXECUTION BY ALL PARTIES HERETO,PRIOR TO WHICH TIME IT SHALL BE DEEMED A PROPOSAL.THE COMPANY RESERVES THE RIGHT
TO REVOKE THIS PROPOSAL 90 DAYS FROM DATE IT IS EXECUTED BY THE COMPANY IF IT IS NOT EARLIER EXECUTED BY THE CLIENT AND THE REQUIRED DOWN PAYMENT RECEIVED PRIOR TO
THE EXPIRATION OF SUCH 90 DAY PERIOD;AFTER 90 DAYS,AND IN THE EVENT COMPANY DOES NOT REVOKE THE PROPOSAL,COMPANY RESERVES THE RIGHT TO REVISE ITS PRICE IN
ACCORDANCE WITH ITS COSTS IN EFFECT AT SUCH TIME.
22.IF ANY PROVISION OF THIS AGREEMENT SHOULD BE HELD TO BE INVALID OR UNENFORCABLE,THE VALIDITY AND ENFORCEBILITY OF THE REMAINING PROVISIONS OF THIS AGREEMENT
SHALL NOT BE AFFECTED THEREBY.
23.ARBITRATION:IN THE EVENT THE CLIENT AND COMPANY HAVE A DISPUTE REGARDING ANY OF THE TERMS,CONDITIONS,PROVISIONS,OR PERFORMANCE OF THIS AGREEMENT,THE PARTIES
AGREE TO PLACE THE MATTER INTO ARBITRATION BEFORE AN INDEPENDENT ARBITRATOR ASSIGNED BY THE AMERICAN ARBITRATION ASSOCIATION TO RESOLVE THEIR DISPUTE.
24.ANY DISCOUNT,PROMOTION,REIMBURSEMENT,OR OTHER PROGRAM THAT IS PART OF A STATE SPONSERED UTILITY PROGRAM(I.E.MASS SAVE®)IS SUBJECT TO THE AVAILABILITY OF
QUALIFYING STATE SPONSERED PROGRAM AND WILL BE SUBJECT TO TERMINATION IF THE STATE SPONSERED UTILITY PROGRAM IS DISCOUNTINUED.FURTHERMORE,THE TERMS AND
CONDITIONS OF STATE SPONSERED UTILITY PROGRAMS MAY BE ALTERED OR UPDATED PERIODICALLY WITH OR WITHOUT NOTICE.
25.AMERICAN INSTALLERS,LLC IS NOT AN AGENT OF ANY UTILITY COMPANY OF OTHER VENDOR WORKING BY,THROUGH,OR UNDER THE MASS SAVE-ENERGY PROGRAM.
26.CLIENT IS REPSONSIBLE FOR THE PAYMENT OF ANY AND ALL FEDERAL,STATE,OR LOCAL TAXES THAT ARE APPLICABLE TO THIS AGREEMENT.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organizationlindividuap: 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.LI I am a employer with 60 4. ❑ I am a general contractor and 1 6. New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet.i 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
'comp.working for me in any capacity. workersP• insurance. 9. ❑ Building addition �
[No workers'comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their !0.❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGI, 1 1.[_] Plumbing repairs or additions fI
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 ftl must also fit out the section below showing their workers'compensation policy information.
t I lomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new atlidavit indicating such.
,Contractors that check this box must attached an additional sheet showing the name of the subcontractor.and their workers'comp.policy information.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:_ Guard Insurance Companies _ ^
Policy#or Self-ins. Lic.#: URWC609917ii _ Expiration Date: 09/04/2019 T
.fob Site Address: ��)Y�i)t"` 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 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 and penalties of perjury that the information provided above is true and correct
Si nature: Date: At
Phone#: 413-55f-0200
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
ConstructionSupervisor space.
CS-106178 EjEpires:09/29/2019
WESLEY COUTURE
218 LATHROP%STREET
SOUTH HADLEY MA 01075
Failure to possess a current edition of the Massachusetts
State Building Code is cause for revocation of this license.
For information about this license
Commissioner Call(617)727-3200 or visit www.mass.govldpl
_4
Office
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. Registration: 175982
130 COLLEGE STREET SUITE 100 Expiration: 06/26/2019
SOUTH HADLEY,MA 01075
Update Address and return card. Mark reason for change.
SCA 1 C: 20M-05/11 I-1 j,��l�e+`n_c I,�I Rsyn_ev.el n Fnt�IQ�-eBf. �!4s#(;srd.
Office of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only
rt 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 COLLEGE STREET SUITE 100
SOUTH HADLEY,MA 01075 Undersecretary valid without Signature
ACOROe DATE(MMIDDJYYYY)
CERTIFICATE OF LIABILITY INSURANCE 914i2018
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(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 NAMEA Linda Powers
Webber & Grinnell PHONE -FAX (413)586-6481
8 North King Street E-MAIL .lpowersewebberandgrinnell.com
INSURE AFFORDING COVERAGE NAIC i
Northampton MA 01060 I1NSURERA:1WWlC1Y8r8 Mutual Casualty
INSURED INSURERB:Berkshire Hathaway GUARD IIIA. Co.
American Installations, LLC INSURERC:
Attn: Was & Suzanne Couture INSURER D:
130 College Street, Suite 100 INSURER E:
South Hadley MA 01075 INSURER F:
COVERAGES CERTIFICATE NUMBERXaster 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.
-LTR TYPE OF INSURANCE AD POLICY
POLICY NUMBER POLICY EFF POLICY EXP ONYYYI LIMITS
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 11000,000
DAMAGE YUROM
A X CLAIMS-MADE F1 OCCUR PREMIS Me occurrence) $ 500,000
5x3535217 9/4/2018 9/4/2019 MED EXP(Any oneperson) $ 10,000
PERSONAL&ADV INJURY $ 1,000,000
GENL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000
X POLICY ECT
� F�LOC PRODUCTS-COMPIOP AGG $ 2,000,000
OTHER: $
AUTOMOBILE LIABILITY ,BcicloO LE NGLIMIT $ 11000,000
ANY AUTO BODILY INJURY(Per person) $
A ALL OWNED SCHEDUL.EO (Per accident) $
AUTOS X AUTOS 523535217 9/4/2018 9/4/2019 BODILY INJURY
ED
PROPERTY DAMAGE $
X HIRED AUTOS X AUTOS (Per acckWM
x Coll$2.00D X comp$2,ODO PIP-Basic $ 81000
X UMBRELLA UABOCCUR EACH OCCURRENCE $ 1,000,000
A EXCESS LIAB HCLAIMS-MADE AGGREGATE $ 1,000,000
DFS I X I RETENTION 10 000 I ISJ3535217 9/4/2018 9/4/2019 $
WORKERS COMPENSATION xPER OTH
AND EMPLOYERS'LIABILITY Y/N
ANY PROPRIETORIPARTNERIEXECUTIVE E.L.EACH ACCIDENT $ 500,000
OFFICEMMEMBER EXCLUDED? NIA
A
B
(Mandatory in NH) UIIWC609917 9/4/2018 9/4/2019 E.L.DISEASE-FA EMPLOYEE $ 500,000
It yyes,describe under
DESCFlIPfl0OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 500,000
A Commercial Property SA3535217 9/4/2018 9/4/2019 deduc(ible$1,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Addidorral Remarks Schedule,may be efteched 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 �f
W Grinnell, CPCU, CIC
®1986-2014 ACORD CORPORATION. All fights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
INS026(201401)