17A-083 (7) 19 CAROLYN ST BP-2019-1433
GIS#: COMMONWEALTH OF MASSACHUSETTS
Mau:Block: 17A-083 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit Buntline DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: INSULATION BUILDING PERMIT
Permit# BP-2019-1433
Protect# JS-2019-002316
Est.Cost$5800.00
Fee:$65.00 PERMISSION IS HEREBY GRANTED TO.-
Const.
O.Const.Class: Contractor. License:
Use Group: AMERICAN INSTALLATIONS LLC 106178
Lot Size(sa. ft.): 10846.44 Owner. LIBBY JONATHAN
Zoning:RI(10o)/URA(loo)/wSP(lo0u Applicant: AMERICAN INSTALLATIONS LLC
AT: 19 CAROLYN ST
Applicant Address: Phone: Insurance.
130 COLLEGE ST (413) 552-0200 WC
SOUTH HADLEYMA01075 ISSUED ON.611812019 0.00.00
TO PERFORM THE FOLLOWING WORK.•WALL, KNEEWALL AND BASEMENT
INSULATION AND AIR SEALING THROUGHOUT
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
Driveway Find:
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 6/18/20190:00:00 S65.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
RECEIVED
City of Northampton
�.. Building Department
f 212 Main Street G i c N
Room 100
Northampton, MA 01060
phone 413.887-1240 Fax 413-587-1272 ONLY
APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING ONLY &t--(q - (5°33
SECTION I-SINFORMATION INSULATION PERMIT
ITE
1.1 Property Address! This section W be completed by office
19 Carolyn Street Map (]A' Lot 9083 Unt
Florence,MA 01062 zone Owday District
Elm St.Dlstrlet CS Dbmict
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Darner of Record:
Libby&Rome, Jonathan&JoAnne 19 Carolyn Street Florence, MA 01062
See attached D 774j 6 4 A44�5] :
Telephone
Sweetie,
22 Authorized Agent
American Installations 130 College Street Ste. 100, South Hadley,MA 01075
Name 1PIldg Caters MBOV Address:
�snAA,y CSA (413) 552-0200
3lpradae Tekehane
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by Permit applicant
1. Building $5,800.00 (a)Building Permit Fae
2. Electrical (b)Estimated Total Cost of
Construction fldn 8
3. Plumbing Building Permit Fee n r\^
OD
4. Mechanical(HVAC)
5.Fire Protection
S. Total=(1 +2+3+4+5) 5,800.00 Chaco Number
This Section For Official Use Only
Building Perot Nu r: Date
Issued:
Signabaw G- 18 -20,9
Gues,Cwnmissianemmlrector of Buildings Dale
product inn @ americaninstallations.com
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
Ft: �./IBJ N
i ��p
SECTION -COISTRUCTION ERVRES
8.1 Lice Coinannudion Survervisor. Not Applicable O
Name of License Hmdar-. tr,' � 1 % 106178
... __- '_ liranee Neneer
130 College Street Ste. 100,South Hadley MA 01075 9129/2019
Address ExPMlon Data
w10 w ,t y- �, (413)552-0200
Signature Telephone
9.Reablared Noma Immi amen Contractor. Not Applicable ❑
American Installations 175982
Comtism Name Registration Number
130 College Street Ste. 100, South Hadley MA 01075 6126/2019
Address LhQa
ess r1 Expiration Date
�Kl_& -Telephone-L4131 552-0200
SECTION 5-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e.162,6 2SC(S))
Workers Compensation Insurance affidavit must be completed and submitted with this applira8on.Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... Id No...... O
Brief Description of Proposed Work NOTE: INSULATION ONLY
Wall, kneewall and basement insulation and air scaling throughout.
I. Wesley K. Couture - American Installations as Owner/Authorized
Agent hereby dedere that the statements and information on the foregoing application ars true and accurate,to the beat of my knowledge
and belief.
Signed under the paina and penalties of perjury.
Wesley K.Couture
Print Name
W 1i A . COSI 6/8/2019
SgnaWreol gent Data
Libby&Romc, Jonathan&JoAnne as Owner of the subject
Property
hereby authorize American Installations
to ad on my behalf,in all matters relative to work authorized by this building permit application.
See attached 6/8/2019
Sgnaaee of Ower Data
City of Northampton
/ Massachusetts � S,
` 1 DEPARITRNT OF BCILDZHa IN3PSCSIONa
212 .in�\ rthN Man 1u11d1,y mertMyton, W 010 O30a0 3n�
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 few family homes. Prior to
performing work on such homes,a contractor most 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 orts but not nacre than Pour dwelling units....or to structures which are adjacent to such residence or building"be
done by registered contractors.
Note:If the homeowner has contracted mirk a corporation or LLC,that entity must be registered
Typeof Work: Insulation Est Cost. 55.80000
Address of Work: 19 Carolyn Street
Date of permit Application: 6/8/2019
I hereby codify that:
Registration is not required for the following reasan(s):
_Work excluded by law(explain):
_Job under S 1,000.00
_Owner obtaining own permit(explain):
Building not owns-occupied
_
x Other(sp=dy): Contractor pulliny 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.
Signedunder the penalties of perjury.
I hereby apply for a building pemdt as the agent of the owner:
6/8/2019 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:
Date Owner Name and Signature
City of Northampton
Massachuaetta
Ff
.4 r212 iEa1' or eozzoraa znspildi.'rs
1 313 Nnan 9tha p nMunleSpB1 BullGinq
NartLmpton, N.1 01060
Debris Disposal Affidavit
In accordance of the provisions of MGL c 40, 554, 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:
19 Carolyn Street
(Please print house number and street name)
Is to be disposed of at:
Waste Management oM England, Chicopee,MA 01020
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
\ (Company Name and Address)
4
2�,An1, t(. . -CJ6�1 p, 6/8/2019
Signature o rmit 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.
• mass save
n.nyd a nN,ed
` PARTNER
American Installations
13p WeSe5YM 5uirelal,5au161Yt11r,MA%%5�fM.:M1NSSi0SO1u:1113155D%DE�FmY'L ruppwiFMNk.nNaWAam
Customer Name:Jonathan Libby
Email:Not provided
Phone:774-644-4451
Premise Address: 19 Carolyn St,Northampton,MA 01062
Mailing Address:19 Carolyn SL Northampton.MA 01062
Project to:3832208
Date:June 5,2019
Job Description
Measure Description Location Quantlty Unit Total Cost Customer Cost
Air Sealing at Estimated 62.5 CFM50 Per Hour Living Space 2 hr $185.16 $0.00
Exterior Door Weather Stripping (with AS hrs) Living Space 3 each $90.21 $0.00
Door Sweep(with AS bra) Living Space 3 each $75.93 $0.00
Rim Joist- 6" Fiberglass Batting Living Space 4 SF $10.80 $2.70
Insulation Removal Living Space 200 SF $252.00 $252.00
Kneewall Slope - 6" Fiberglass Batting Living Space 423 SF $900.99 $225.25
Kneewall Slope - 2"Thermal Barrier Polyiso Living Space 423 SF $2,021.94 $505.49
Hatch - 2'Thermal Barrier Polyiso Living Space 1 each $46.28 $11.57
Sheathing Access Living Space 5 each $200.10 $50.02
Propavent Living Space 84 each $349.44 $87.36
Cut and Finish Access Living Space 1 each $124.53 $31.13
Walls - Vinyl-4" Dense Pack Cellulose Living Space 560 SF $1,484.00 $371.00
Project Total $5,741.38
Weatherization incentive ($3,853.56)
Air sealing incentive ($351.30)
Total Program Incentive -$4,204.86
Customer Total $1,536.52
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THGAGREEMENT IS COMPOSED OF THIS PAGEME)THE REVERSE SIDE OF THIS PAGE AHD SHALL BE CONSIDEREDTHE EN➢REAGREEMENDEV THE PARTIESINVOLVED. THIS
AGREEMENT IS BETWEENWAEMCAN INSTAl1ATON5,LLC HEREINAFTER REFERREDTO AS'COMPANW,ANOWE CUSTOMERS)NAMED ON THE REVERSE SIDE,HEREINAFTER
REFERRED TO AS'WEHT',AND WILL BE SUBIECT TO ALL APPROPRIATE LAWS,REGULATIONS AND ORDINANCES OF THE STATE OF MASSACHUSETTS OR CONNECTICUT
RESPECTIVELY,AS WELLASALLLOCALIURISDICTIONS.
THE FOLLOWING TERMSANDCONDITION5ALSOMPLY
1. THIS AGREEMENT IS SUBJECT TO WE APPROVAL OF A BLAMER OFTHE COMPANY FORTHISAGREEMENTTO BE EFFECTIVE UNDER ANYCONDITION.
2. SHOULD DEFAULT BE MADE IN THE P IAMEOF THISAGREEMEN,CHARGES SWILL BE ADDEO FROM THE DATE THEREOFATA RATE OF ONE AND ONE-HALF M-1/2)
PERCENTPER MONTH.(18%PER ANNOY)WITH A MINIMUM CHANGE OF$2.00 PER MONTH,AND IF PLACED IN THE HANDS DEAN ATTORNEYOR COLLECTN%J AGENCY
FOR COLLECTION,ALL A70RUM FEES,MENUS AND COSTS OF COLLECTION SHALL BE PND BY THE CLIENT. IN ADDITION,CLIENT UNDERSTANDS THAT IN FAILING
TOPAYACCOMING TO THE ABOVE TERMS,COMPANY MAY HAVE THE RIGHTY)A IFIN ON THE PROPERTY.
3. THE COMPANY AGREES THAT WHEN DELAYS BECOME KNOWN TO THE COMPANY,THE COMPANY WI LL ADVISE THE CLIENT AS SOON AS REASONABLE.
A. COMPANY AGREES THAT,NOTWITHSTANDING ANY AGREEMENT FOR MATERIALS AND/OR HAREM BETWEEN COMPANY AND THIRD PAM,COMPANY IS RESPONSIBLE
TO CLIENT FOR COMPLETION OF ALL WORK DESCRIBED INA TIMELY AND WORKMANLIKE MANNER.
5. ALL WARRANTIES FOR EQUIPMENT AND PRODUCTS SUPPLIED BY THE COMPANY UNDER THIS AGREEMENT SHALL BE THOSE GIVEN BY TIE MANUFACTURERS OF SUCH
EQUIPMENTAND PRODUCTS. UNDER SUCH MANUFACTURERS WARMMSES,THE CLIENT MAYBE REQUIRED REGISTER OR MNL INA WARRANTY URD OR OTHER
ENDENCE OF OWNERSHIP AND USE OF SUCH EQUIPMENT AND/OR PRODUCTS IN ORDER TO ACTNATE SUCH WARMMIES.
6. THE QUOTATION ON THE PAGE HEREOF DOES NOT INCLUDE EXPENSES OR CHARGES FDR BOND OR INSURANCE PREMIUMS OR COSTS BEYOND NORIML INSUMNCE
COVERAGE,ANY SUCH ADDITIONAL EXPENSES,PREMIUMS OR COST SHALL BE ADDED TO ME TOTAL AGREEMENT AMOUNT.
T. THE COMPANYS LIABILITY MR CLAIMS ARISING OUT OF THIS AGREEMENT SHALL NOT EXCEED ME TOTAL AGREEMENT PRICE EXCEPT TO ME EXTENT THOSE DAMAGES
ARE PROVEN TO BE SOLEY DUE TO THE COMPANY'S NEGUGENCE.
8. DURING THE DURATION OF THE WORK,THE NEHR 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. TIE COMPANY IS NOT RESPONSIBLE FOR PREEMSTING DEFICIENCIES OR HAOMEOU5 MATERIALS THAT MANIFEST THEMSELVES DURING THE CONSTRUCTION PROCESS.
E.G.W WO ROT,MOLD,ASBESTOS,NAIL ECK,DUCTWORK AND CONNECTIONS,PLUMBING AND VENT PIPES,DECKING DEFIEUR N,ETC.IFA PRE-EXISTING DEFICIENCY
OR HUUMOOUS MATERIAL 15 ENCOUNTERED PRIOR TO OR DURING CONSTRUCTION,AND COMPANY IS NOTIFIED IN WRITING,COMPANY WILL TRY TO MEET CLIENT
WITHIN THE COMPANY'S MENTI$AND CAPABILITIES TO CORRECT THE PROBLEMS)ON A TIME AND MATERIAL 84515. 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 DOORMEN OF THE
WORK AND SCHEDULED DATE OF CCMPLETgN MAY DIFFER FROM THAT AGREED UPON,IF APPLICABLE,UNDER THIS AGREEMENT.
10. THE COMPANY IS NOT RESPONSIBLE,AND THE WENT AGREES TO HOLD THE COMPANY HARMLESS,FOR ANY PROBLEMS PND/OR DAMAGES,INLCUDING BUT NOT
LIMITED TO MOLD GROWTH,ARISING FROM ME PERFORMANCE OF NR SEALING WORK BY THE COMPANY AS A RESULT OF ANY KNOWN OR UNKNOWN MOISTURE
CONDITIONS.
11. THE COMPANY IS NOT RESPONSIBLE FOR,AND ME WENT AGREES TO HOLO THE COMPANY HARMLESS,FOR ANY PROBLEMS AND/OR)MMERES RELATING TO ICE
DAMMING THAT MAY ARISE WRING AND/OR AFTER TIE PERFORMANCE OF WORK BY THE COMPANY.
12. REPLACEMENT OF DETERIORATED DECKING,FASCIA BOARDS ROOF JACKS,VENTILATORS,FLASHING,PATERS,JOISTS,INSUUTION OR OTHER MATERIALS ME NOT
INCLUDED UNLESS OTHERWISE NOTED HEREIN.
13. THE COMPANY WILL NOT BE RESPONSIBLE FOR THE SCRATCHING OR DEMING OF INTERIOR WALLS AND CEILINGS,HUGHES,TNM,GUTTERS,DOWNSPOUTS,EXEDNG
SIDING AND WINDOM,COORS.OIL DROPLETS IN DRIVEWAYS,HAIRLINE FRALNRES IN CONCRETE OR BLACKTOP DRIVES AND WALKS,OR DAMAGE TO PUNTS OR
SHRUBBERY. IF EXCESSIVE DAMAGE IS CAUSED OY COMPANY,COMPANY WILL REPAIR OR REPLACE DAMAGED ARU ONLY AT COMPAM'S EXPENSE.
14. THE COMPANY UNDER PROVISIONSOFCHAPTER IRA OF THE GENERAL LAWS IS REQUIRED M APPLY FOR AND OBTAIN ALL CONSTRUWONAEUTED PERMITS. THE
COMPANY SHALL NOT BE DEEMED RESPONSIBLE FOR DELAYS IN THE WORK DESCRIBED IN THE AGREEMENT CAUSED BY REGULATORY PERMIT GRANTING OR
INSPECTIONAL AGENCIES,AUTHORITIES,OR INDIVIDUALS.
15. THIS AGREEMENT,INCLUDING THE P M19ONS RELATING TO PRICE AND PAYMENT SCHEDULE,CANNOT BE C HANGED OR ALTERED EXCEPT BY A WRITTEN STATEMENT
SIGNED BY BOTH THE COMPANY AND ME 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 W NOT SURVIVE ME EXECUTION OF ME AGREEMENT.
17. THIS AGREEMENT CANNOT BE CANCELLED WITHOUT ME MUTUAL WRITTEN CONSENT OF BOTH PANTIES EXCEPT M OTHERWISE SET FORTH HEREIN.
18. THIS AGREEMENT,AND ANY WARMNTYE)PROVIDED HEREUNDER SHALL NOT BE ASSIGNED EXCEPT BY OR WITH THE WRITTEN PERMISSION OF THE COMPANY.
19. IF THE CLIENT FAILS TO PERFORM IR OBLIGATIONS HEREUNDER OR TERMINATES THUS AGREEMENT WITHOUT THE PRIOR WRITTEN CONSENT OF THE COMPANY,THE
HENT SHALL BE UUBLE FOR DAMAGES FOR WE GREATER OF TIE COMPANWS ACTUAL DAMAGES OR 25%OF THE AGREEMENT FOR RESTOCKING FEE.
20. ANY CHANGES M MATERVES BY THE CLIENT(BRAND,STYLE,COLOR,Ftt.)AFTER MW MATERIAL HAS BEEN DELIVERED OR IS IN ROUTE TO THE CLIENT MOLD RESULT
IN A 5%M-STOCNNG FEE BASED ON TIE COST OF MID MATEMAB.
21. THIS AGREEMENT SHALL BE EFFECTIVE ONLY UPON ITS EXECUTION BY ALL PARTIES HERETO,PRIOR TO WHICH TIME IT SHALL BE DEEMED A PROPOSAL THECOMPANY
RESERVES THE RIGHT TO REVOKE THIS PROPOSAL 9O DAYS FROM DATE IT IS EXECUMD BY THE COMPANY IF IT IS NOT EARUM EXECUTED BY THE WENT AND THE
REWIRED DOWN PAYMENT RECEIVED PRIOR TO THE EXPIRATION OF SUCH SO DAY PERKDO;AFTER 90 DAYS,AND IN THE EVENT COMPANY DOES NOT REVOKE ME
PROPOSAL COMPANY RESERVES THE FIGHT REVISE ITS PRICE IN ACCORDANCE WITH ITS COSTS IN EFFECT AT SUCH TME.
22. IF ANY PROVISION OF THIS AGREEMENT SHOULD BE HELD TO BE INVALID OR UNENNACABLE,WE VIWDFIY AND ENFORCEBILITY OF THE REMAINING PROVISIONS OF
THIS AGREEMENT SHALL NUT BE AFFECTED THEREBY.
23. ARRIIMTON:IN ME EVENT THE CLIENT AND COMPANY HAVE A DISPUTE REGARDING ANY OF THE TERM,CONDITIONS,PROMSIONR OR PERFORMANCE OF THIS
AGREEMENT,THE PARTES AGREE TO PLACE THE MATTER INTO ARBITRATION BEFORE AN INDEPENDENT ARBITRATOR ASSIGNED BY THE AMERICAN ARBITRATION
A OMPON TO RESOLVE THEIR DISPUTE.
24. ANY DISCOUNT,PROMOTION,REIMBURSEMENT,OR OWER PROGRAM THAT D PART OF A STATE SMNSERED UTILITY PROGRAM(I.E.MASS SIVE')IS SUBIECT TO THE
AVAILABILITY OF QUALIFYING STATE SPONSORED PROGRAM AND WILL BE SUBIECT TO TERMINATION IF THE STATE SPONSERED UTILITY PROGRAM IS DISCOUNTINUM.
FURTHERMORE,THE TERMS AND CONDITIONS OF STATE SPONSORED UTILITY PROGRAMS MAYBE ALTERED OR UPDATED PERIODICALLY WITH OR WITHOUT NOTICE,
25. AMERICAFI INSTALIERS,DEC IS NOT AN AGENT OF ANY UTILITY COMPANY OF OTHER VENDOR WOMENG BY,THROUGH,OR MGM THE MASS SAVE'ENERGY
PROGRAM.
26. WENT 6 MPSONSIBLE FOR THE PAYMENT OF ANY AND ALL FEDERAL STATE,OR LOCAL TAXES THAT ARE MPWABIE M THIS AGREEMENT.
The Commonweafth of Massactruseaa
Department of Industrial Accidents
Office of Investigations
wi 600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print LeEibly
Name(Busitcsn'Orgenhu aoNlodividowl: American Installations,LLC
Address: 130 College Street,Suite 100
City/State/Zip: South Hadley,MA 01075 Phone#: 413-552-0200
An you an employer?Check the appropriate box: Type of project(required)
I.9 1 am a employer with 60 _ 4. ❑ I am a general contractor and 1 6. []New construction
employees(full and/or part-time).• have hived the sub-enntraclors
2.E31 am a sole proprietor he partner- listed on the attached sheet.t T ❑ 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. insurance 5. ❑ We are a corporation and its
required.) officers;have exercised their 10.L]Electrical repairs or additiom
3.0 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.[3 Roof repairs
insurance required.]t employees.(No workers' 13.®Other Insulation
camp, insurance required.)
'Any applisanl aur chinks bas gl must also fill ouuho section below 4
showmlhcv worked cmmpcnsatra policyf n
ination.
t lomeawrcnwit submiubisefndarit mdi<af ing thcY use Jning all rod antl Ilua Girt omsidc mnrmaars ramisubmitamw vlixbril Iniceithgn¢b.
:Commctoo that check this box must altw.hetlan addiliceil Shoeubowing@enumcoflhesub-canaanmsaml their workers comp.poli,eifionmies
f am an employer thin is pmvWng workers'conpemation iruurance for my employees. Below u the polity and job site
ufoesmosen.
Insurance Company Name: Gturdlnsarance Companies
Policy dor Selfins.Lia k: RWC609917 Expiration Dote: 09/04/2019
Job Site Address: ICI l�Iat11701140 (SW[p4-- City/SatdZip: r aa2
Attach a copy of the washers'counpiallatio.porky dcelarafke page(showing the porky 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 STOP WORK ORDER and a line
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 ofthe DIA for insurance coverage verification.
/du hereby ceQrtify insider the pains an�dlemul/deJs of perjury lhm t.
she informadion provided above is true and correct
Signa lLYa2d/Jl.na Q (/,91f�/� _Dete:_L � It �1 G
� . _
Phone#: 61 At A-55 -0200 I•• 1'
Oficial we only. fid not write in this arra,in be coagrkled by city or town ofllelat
City or Town: Permit/License#
Issuing Authority(circle one):
I. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Penou: Plumb #:
Commonwealth of Massachusetts Construction Supervisor
Division of Profit essional Licensure Unrestricted-Buildings of any use group which contain
Board of Building Regulations aM Standards less than 36,000 cubic feet(991 cubic meltts)of enclosed
Const%pcion Supervisor space.
CS-106178 E;pires:09/29/2019
INS
21S L THROUTURE
219 LATHROP STREET
SOUTH HADLEY MA 01075
Failureto ilding Code
is cause for
ofthe of
liusetts
cense
Stale Building Oodenf cause for revocation o1 this license.
For 727-320ior about this license
Commissioner �
Call(617)]27-3200 or vied www.mass.gov/dpi
Office of Consumer Affairs and Business Regulation
10 Park Plaza- Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Type LLC
AMERICAN INSTALLATIONS,LLE C. R pration: 175982
130 COLLEGE STREET SURE 100 Eviration: O6/26/2019
SOUTH HADLEY,MA 01075
Update Address and ralurn card. Mark reason W things.
su o xauavn
0— Add— Cl R-- nEftio"Mart ❑!g9t S..ard
Mite Of consumer NlYn a Business Re,ulallan
HOME IM PROVEM ENT CONTRACTOR Registration valid for individual use only
TYPE:LLC before the eapiratron date. M found return to:
Redlstration E.piarld, Office of Consumer Affairs and Business Regulation
175982 06126=19 10 Park Raza-Suite 5170
AMERICAN INSTALLATIONS,LLC. Boston,MA 02116
WESLEY COUTURE
130 COLLEGE STREET SUITE 100
SOUTH HADLEY,MA 01075 and 1 u t valid without signature
---"I o
A`ORO CERTIFICATE OF LIABILITY INSURANCE °A9/4/" "
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 SEI WEEN THE ISSUING INSURER(S), AUTHOFIMD
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: It tlm carOOcate holder is an ADDITIONAL INSURED,the polloy(Irs)must DO endorsed. H SUBROGATION IS WAIVED,enb)ect W
Me terms and e°ndiHons of Me policy,canal p0ncles may repuire On endorsement A statement on 011e tam60ab does not confer rights to On,
certificate holder In lieu of such end a.
PROWCEP T I,Sd,a POYerY
Wehbar E Grinnell HMxE , (413)586-0111 FAl 1411..!.-cul
8 North King StrNt AYw 1DosareBeabbarudgr11me11.Cm
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Amari0se la"Allatiome, LLC 1anumetc:
ACCnt We. a He.. Couture IMOIeA O:
130 College Stlwet, Suite iDO can.c:
Soath Badley MA OIOTS 1esu F:
COVERAGES CERTIFICATENUMBER01exter ben 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. NOTWf111STANDND ANY RECUREIMNT.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.
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CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
84."-0 Of InHMiHIICe THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
RN
ACCORDANCE WTHE POLICY PNOVISIONS.
AUTIORRED REPRESENTATIVE
W Grinnell, CPCU, CIC �1_1G__ J Y,.�_-Pp
91986-2014 ACORD CORPIXUTION. Alf NgIHa reaeryetl.
ACORD 25(2010/01) The ACORD name and logo are registered merle of ACORD
INSOMD01301)