28-056 (2) 125 SYLVESTER RD BP-2019-0911
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map-.Block:28-056 CITY OF NORTHAMPTON'
Lot-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cateeorv: INSULATION BUILDING PERMIT
Permit# BP-2019-0911
Proiect# JS-2019-001529
Est Cost: $6579.00
Fe : $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: AMERICAN INSTALLATIONS LLC 106178
Lot Size(sp. it): 655578.00 Owner. RANNEY DOUGLAS C
Zonine: Applicant: AMERICAN INSTALLATIONS LLC
AT.- 125 SYLVESTER RD
ApplicantAddress: Phone: Insurance:
130 COLLEGE ST (413) 552-0200 WC
SOUTH HADLEYMA01075 ISSUED ON.212212019 0:00:00
TO PERFORM THE FOLLOWING WORKATTIC, WALLAND 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 q Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Qi1: 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 2/22/20190:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax:(413)5874272
Louis Hasbrouck—Building Commissioner
REC r Department use Dny
City of Northampton slams ofPmmit.
uilding Department CurbewDriveway,Permit
FEB 2 1 2019 212 Main Street Bawer i5epacAvailability
Room 100 WataYAVell Availability.
E N hampton, MA 01060 Two Sate of5lrudtuml plans
nE�NAM�1oN!MAPayl e 4 587-1240 Fax 413-587-1272 PlduSlfe Plans
OMerSpecify
APPLICATION TO CONSTRUCT,ALTER REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY WELLING
SECTIONI -SITE INFORMATION ��—�q ^
1.1 ProoerivAddress: This section to be completed�by office
Map �' Lot nit.
125 Sylvester Road
Zona Overlay District
EIm at Dtabiot. CS Dbbid
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of RecoM:
Douglas Ranney 125 Sylvester Road
Name(PdnQ Com"'u" Addreec:
(413) 584-5150
See attached Telephsna
Sigmaum
7-2 Authorised Agent:
American Installations 130 College St., Ste 100 South Hadley, MA 01075
Nam1e1(RM) - Cunent Mating Aadiess:
_lAyly(r„� ,V 413-552-0200
S19nam�— Teephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building 6579.00 (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from
3. Plumbing Building PermR Fee
4. Medrerdcal(HVAC) r rr S, O O
5.Fire Protection �e
S. Total=(1+2+3+4+5) 6579.00 Check Number
This Section For Official Use Only
Date
Building Permit Number. Issued:
Signature: 2- 2Z- Zoiq
BOOS CommhslonedimpedN of Buildings Date
i
Section 4. ZONING Ml lydormatbn Must Be Completed.Permit Can Be Denied Due To lnrom ete 14ormattnn
Existing Proposed Required yZoidng (', a.
T -eiu wtefilw iby
saitnea nj' *
Lot Sin
Frontage
Setbacks Front p p O
Side L-.= r--= L:r R=
gearr-
Building Height L_1 O
Bldg.Square Footage %
Open Space Footage % r
(W—mime ft&paved u L�
#of Perkin $ = r
FBI: --
wlame&I.ocefim)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW Q YES Q
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 PageF and/or Document if 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: F-
D.
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:
E. Will the construction activity disturb(clearing,grading,excavegon,orfiling)over i acre or is it pad of a common plan
that Will dtsNm over l acre? YES O NO O
IF YES,then a Northampton Storm Water Management Permit from the DPN is mqulred.
SECTION 5.DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacementwinckws Alterations) Roofing ❑
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs M Decks Ip Shing][?] Other]i't
Brief Desai ooff Pmpps ed
Work AthcWnall anA basement insulation and air sealing throughout
AlterationofextsWgbedroom_Yes_No Adding raw bedroom Yes No
Attached Narrative Renovating unfimahed basement —Yes No
Plena Attached Rall -Sheet
sa.It New house and or addition to existing houshrim complete the following,
e. Use of bugding:One Famity Two Family Ot her
b. Number of rooms in each family uNt Number of Bathrooms
u Is there a garage attached?
d. Proposed Square footage of new cocebuctioh. Dimemloms
e. Numberofstodes?
f. Method of besting? Fireplaces or Woodsloves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
I. Is constmtllon within lOO fL of wetlands?_Yes —No. Is construction vAthln 100 yr. floodplain Yes_No
]. Depth of basement or cellar floor below finished grade
k Will building conform to the Building end Zoning regulations? Yes_No.
L Septic Tank_ qty Sewer_ Private well_ City water Supply_
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1• as Owner of the subject
property
herebyauthor¢e American Installations
to act on my behalf,In all matters relathre to work autirorbed by this building pemdt application.
See attached
SlOmeureefosmar Date 2/15/2019
I, American Installations .as Oaner/Authortzed
Agent hereby declare that the statements and Information on the foregoing application are ting and accurate,to Ore best of my knowledge
and beflef.
Signed under the pales and penalties of perjury.
American Installations
Pdm Name ��pp /�t��..yy��...�
IIA 14 , txlA.tdlA1 �
gnetee riAgent Data 2/15/50L9
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Nam.&ILLmeattaida, WesleyKCouture 106178
U..Number
130 College St., Ste 100 South Hadley, MA 01075 9129119
�Address Expiration Data
tgi+S._A�ut - �d1LuC3 413-552-0200
Stpnalure Telephone
9.Registered Home Improvement Contractor: _ NolApplicable
Wesley Couture 175982
Compamr Name Registration Number
American Installations 6126119
Address Expiration Date
130 College SL, Sic 100 South Hadley, MA 01075 Telephone 413-552-0200
SECTION 10.WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L e.int,§2SC(6))
Workers Compensation Insurance affidavit most be completed and submitted with this application.Failure to provide the affidavit will result
In firs dental of the issuance of the building permit.
Slgned AiOdavitAlladred Yes.._.. 11 No...... ❑
11. =Home Owner Exemotion
The current exemption for"homeowvers"was extended to include Owner-occupied Dwellings ofone(1) or two(2)families
and to allow such bons owner to engage an individual for hire who does act possess a license,provided that the owner acts
as supervises.CMR 780, SIM Edition Section 10835.1.
Definition of Homeowner.Person(s)who own a pared ofland on which he/she resides or intends m residS on which there
is,or is intended to be,a one or Iwo family dwelling,attached or detached structures secessnry to such use M&or farm
structures.A Dennis who constructsm than one home in a two-year tied shag not be considered a homeowner.
Such"homeowaer"shall submit to the Building Oficial,nn a form acceptable to the Building OBrcial,thethe/she ehaD be
resoendble for all suet work performed under the buildine permit
As soft Construction Supervisor your presence an thejob site will be required from time to them during and upon
completion ofthe work for which this permit is issued.
Also be advised that with refereuoe to Chapter 152(Workers'Compensation) ead Chapter 153(Liability ofEmployersto
Employees for injuries act resulting in Death)ofthe Messachuseds General laws Annotated,you maybe Debts forperson(s)
you hire to perform work for you under this permit
The undersigned"homeowner"certifies and assnntes responsibilityfor compliance with the State Building Code,City of
Northampton Ordinances,State and Ictal Zoning Laws and State ofllassacbusetts General Laws Annotated.
Homeowner Signature see attached
City of Northampton
Massachusetts �rl `kms
s
DEPART W OF asira:Ne zNspX=Offs
212 Win atm Wnicipal BuilAinq V1J" pC
aortbay,W., M 01060 n�
Property Address: 125 Sylvester Road
Contractor
Name: American Installations
Address: 130 College Street Ste. I00
City, State: South Hadley, MA
Phone: 43-552-0200
Property Owner
Name: Douglas Ranney
Address: 125 Sylvester Road
City, State: Florence, MA 01062
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.
Contracto`r ignature
�914.1.\
Date
2/15/2019
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: 125 Sylvester Road
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 Wesley Couture
2/15/2019 1. " k abZ N
Date Signature of Permit Applicant
AIM
mass save
�ameaa oven • PARTNER
Aii L
ma d',od-"o°° ". American Installations www.Americarnstaeaeons.com
I.ad,,,a,.sid.us,Soup Asi MP ULWS•ani—Na>I.,..0 fin:1X31.10},• si a YPaul®AAAiLo--Aed. --,—
Customer Name:Doug Ranney
Email:Not provided
Phone:413-584-5150
Premise Address: 125 Sylvester Rd,Northampton.MA 01062
Project to:3456976
Date:Aug.22,2018
Job Description
Measure Description Quantity Unit Total Cost Customer Cost
Air Sealing at Estimated 62.5 CFM50 Per Hour 4 hr $370.32 $0.00
Exterior Door Weather Stripping (with AS hrs) 3 each $90.21 $0.00
Door Sweep (with AS hrs) 3 each $75.93 $0.00
Rim Joist-6" Fiberglass Batting 70 SF $189.00 $47.25
Kneewall Slope -6" Fiberglass Batting 500 SF $1,065.00 $266.25
Kneewall Slope-2" Thermal Barrier Polyiso 500 SF $2,390.00 $59250
Kneewall Gable Wall -3" Fiberglass Rating 40 SF $76.40 $19.10
Kneewall Gable - 2"Thermal Barrier Polyiso 40 SF $191.20 $47.80
Attic Slope-6" Dense Pack Cellulose 436 SF $1,229.52 $307.38
Attic Floor- 12"Open Blow Cellulose 400 SF $816.00 $204.00
Damming 16 each $38.24 $9.56
Hatch -2" Thermal Barrier Polyiso 1 each $46.28 $11.57
Project Total $6,578.10
Weatherization incentive ($4,531.23)
Air sealing Incentive ($536.46)
Total Program Incentive -$5,067.69
Customer Total $1,510.41
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THIS AGREEMENT IS COMPOSED OF THIS PAGE AND INE 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(5)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 Pd-LOCAL JURISDICTIONS.
TH E FOLLOWING TERMS AND CONDITIONS ABC APPLY
1. THIS AGREEMENT IS SUBJECT TO ME 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 ADDE D FROM TIE DATE THEREOF AT A RATE OF ONE AND ONE-HALF(1-1/2)
PERCENT PER MONTH,118%PER ANNUM)WITH A MINIMUM CHARGE OF$3 W PER MONTH,AND IF PLACED IN THE HANDS OF AN ATTORNEY OR COLLECTION AGENCY
FOR COLLECTION,ALL A70RNHV 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 LOIN ON THE PROPERTY
3. THE COMPANY AGREES THAT WHEN DELAYS BECOME KNOWN TO ME COMPANY,THE COMPANY WILL ADVISE THE CLIENT AS WON AS REASONABLE.
<. 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 ATIMELY AND WORKMANLIKE MANNER.
S. ALL WARRANTIES FOR EQUIPMENT AND PRODUCTS SUPPLED BY THE COMPANY UNDER THIS AGREEMENT SHALL BE THOSE GIVEN BY THE MANUFACTUR ERS OF SUCH
EQUIPMENT AND PRODUCTS UNDER SUCH MANUFACTUREWS WARRANTIES,THE CLIENT MAY BE REQUIRED TO REGISTER OR MAIL IN A WARRANTY CARD OR OMER
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.
J. THECOMPPNYS LIABILITY FOR CLAIMS ARISING OUT OF THIS AGREEMENT SHALL NOT EXCEED THE TOTAL AGREEMENT PRICE EXCEPT TO THE EXT ENT THOSE DAMAGES
ARE PROVEN TO BE SOUCY DUE TO THE COMPANY'S NEGLIGENCE.
8. DURING THE DURATION OF ME 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 FOR PREEXISTING DEFICIENCIES OR HAEAROOUS MATERIALS THAT MANIFEST THEMSELVES DURING THE CONSTRUCTION PROCESS.
EG,WOOD ROT,MOLD,ASBESTOS,NAIL POPS,DUCTWORK AND CONNECTIONS,PLUMBING AND VENT PIPES,DECKING DETECTION,ETC.IFA PRE-E%ISTNG DEFICIENCY
OR HAZARDOUS MATERIAL IS ENCOUNTERED PRIOR TO OR DURING CONSTRUCTION,AND COMPANY 15 NOTIFIED IN WRITING,COMPANY WILL TRY TO ASSIST CLIENT
WITHIN THE COMPANY'S MEANS AND CAPABILITIES TO CORRECT ME PROBLEM)$)ON A TIME AND MATERIAL BASIS. CLIENT AGREES THAT SUCH CONDITIONS ARE
UNAVOIDABLE BY ME 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 LS NOT RESPONSIBLE,AND THE CLIENT AGREES TO HOLD ME COMPANY HARMLESS,FOR ANY PROBLEMS AND/OR DAMAGES,(NUMBING BUT NOT
LIMITED TO MOW 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 HOLO 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 JACIS,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 15 CAUSED BY COMPANY,COMPANY WILL REPAIR OR REPLACE DAMAGED AREA ONLY AT COMPANY'S EXPENSE.
34. THE COMPANY UNDER PROVISIONS OF CHAPTER I42A OF THE GENERAL LAWS IS REQUIRED TO APPLY FOR AND OBTAIN ALL CONSTRUCTIONRELATED PERMITS THE
COMPANY SHALL NOT BE DEEMED RESPONSIBLE MR DELAYS IN THE WORK DESCRIBED IN THIS AGREEMENT CAUSED BY REGULATORY PERMIT GRANTING OR
INSPECTIONAL AGENCIES,AUTHORITIES,OR INDIVIOUALS.
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 WRITTEN ON THIS AGREEMENT ARE AGREED TO BE IMMATERIAL AND NOT RELIED ON SY
EITHER PARTY,AND DO NOT SURNVE ME 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 WR17EN PERMISSION OF THE COMPANY.
19. IF THE CLIENT FAILS TO PERFORM ITS 00LIGATIONS HEREUNDER OR TERMINATES THIS AGREEMENT WITHOUT THE PRIOR WRITTEN CONSENT OF THE COMPANY,THE
COUNT SHALL BE UABLE 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,SME,COLOR,ETC.)AFTER SAID MATERIAL HAS BEEN DELIVERED OR IS IN ROME M THE CLIENT COULD RESULT
IN A 5%RESTOCKING 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 15 EXECUTED BY THE COMPANY IF IT IS NOT EARLIER EXECUTED BY THE CLIENT AND ME
REQUIRED DOWN PAYMENT RECEIVED PRIOR TO THE EXPIRATION OF SUCH W DAY PERIOD;AFTER 90 DAYS,AND IN THE EVENT COMPANY DOES NOT REVOKE THE
PROPOSA4 COMPANY RESERVES THE RIGHT TO RENSE 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 UNENFORCMLE,THE VAUDITI 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,PRONSION5F 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(IF MASS SAVE-)IS SUBJECT TO THE
AVAILABILITY OF QUALIFYING STATE SPONSORED PROGRAM AND WILL BE SUBJECT TO TERMINATION IF ME STATE SPONSERED UTILITY PROGRAM 15 DISCOUNTINUM.
FURTHERMORE,THE TERMS AND CONDITIONS OF STATE SPONSERED UTILITY PROGRAMS MAY BE ALTERED OR UPDATED PERIODICALLY WITH OR WITHOUT NOTICE,
25. AMERICAN INSTALLERS,DEC IS NOT AN AGENT OF ANY UTIUTY COMPANY OF OTHER VENDOR WORKING BY,MRWCH,OR UNDER THE MASS SAVE'ENERGY
PROGRAM.
26. CLIENT IS REPSONSIBLE FOR THE PAYMENTOF ANY AND ALL FEDERAL,STATE,OR LOCALTAXESMATARE APPLICABLE TOTHIS AGREEMENT.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations,
wi 600 Washington Street
Boston,MA 02111
www.mass.gox/Jia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Letdbly
Name(Buslneadorgummoordlndlvidua0: American Installations,LLC
Address: 130 College Street,Suite 100
City/State/Zip: South Hadley,MA 01075 Phone 11: 413-552-0200
Are you an employer?Check the appropriate box: Type of project(required):
1.U 1 am o employer with 60 _ 4. ❑ I am a general contractor and 1 6. ❑ New construction
employees(full and/or part-lime)! have hired the sub-contractors
2.C:1I am a sole proprietor or partner- listed on the attached sheet.2 7. Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity, workers'comp. insurance. 9. ❑ Building addition
[No workers'comp. insumnee 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑ Electrical repairs or additions
1❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions
myself.[No workers'comp. c. 152,§1(4),and we have no 12.❑ Roof repairs
insurance required.]f employees.[No workers'
comp.insurance required.] 13.®Other-_Insulation
•Any applicant thin checks bort al mug els.fill.1 the swlien below,hawing their worker'compensation policy info,mnion.
t I lome.ons who mmnit this eRdovil indicating may ora doing all work act mm hire.uHW cammmooi mml submit o new alrxhrit lodiwting such.
:Comrucwrs Dal chink on,box mint gnehed en eddilionei sheet showing Inc Immo ol'IM sutrcamraauxs and In.,wwketi comp.policy idiom,mion.
I am an employer that is providing workers'comperp'mlon insurance far my eagdoyeee. Below is the policy and job sae
inform ion.
Insurance Company Name: Guard Insurance Companies
Policy#or Self--ins. Lic.#: UR,W1_C(609917 Expiration Date: 09/04/2019 y�
Job Site Address: IZS !SU *,9 �r�j City/State/Zip:Np� PA
l ]vA OIDLL'L
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 S 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 5250.00 a day against the violator. Be advised that a copy of this statement maybe Forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
t do herehy ceenify under the pains anndpenal/Fiefs ojperjltry That the information provided above is true and correct
S'gn�kC]�t✓LA/h.n.a lL ( 'AiLT.L(12A�. Date' ZII-III I
Phone# 61 413-5510200
Of}7cial use only. Do not write in this area,to be contuhned by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.Citylfown Clerk 4.Electrical inspector S.Plumbing Inspector
6.Other
Contact Person' Phone#-
Cotnnweatth of Massachusetts Construction superv�
m
®� Division of Professional Licensure UnrsMutetl-auederps of any use tRoOp which contain
Board of Building Regulations and Stanuards Was than 50,000 cubic feet(891 curse orders)of enclosed
Construction Supervisor spat°'
CS-108178 E3pires:09/292019
WESLEY COUTURE
218 LATHROF14TREET "4}
SOUTH HAOLEYMA 01070
Faguse supossess•eunanf edleao of the Massachusetts
n
Side B011mrp Code Is cause,tions abuse
mof SO eunae.
Information ahau use,tlesss
Commissioner Call(817)7274200 or Wt[wwwmess.govltlpl
If lllyylftiff/Pllf J? Q fn�ll5:1(CfY7TG1l
1 �
Office of Consumer Affairs and Business Regulation
10 Park Plaza- Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Type LLC
AMERICAN INSTALLATIONS,U.C. Registration: 175902
0&2&12019
130 COLLEGE STREET SUITE 100
SOUTH HADLEY,MA 01075
U,hune Mcluess and ratum card. Mark reason for change.
SCAT o WMu0e 1 I-14dt4 nP.—I.RE,*yuan1 T,met CErd
OMka of Consnxr MlatnA WBinaeeRpulatlon
HOME IMPROVEMENT CONTRACTOR RpMlretlon vend hR lydiWduat us only
TYPE:LLC radon the w0radoo dais. If bund ratum W:
.' aBialreflon Elmilxdon OMca of Consumer Affairs and Sadness Regulation
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Z&AMERICAN INSTALLATIONS,I.I.C. 9oeton,MA 02118
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