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HomeMy WebLinkAboutBLD-19-1050 Jr. ' ;.irr.i2 I F S 1 t RH i :•: 3 F T (4.1--ti Office Use Only etrlit0 f YRli ..•• N..:',::- :APAfIIi1':Ml ,.ii- S� r; i_l Pemti49'f.ir.:: f ww LOr Li?IL ',t7: - r�j^.�5 -.rtt.it Pm/ r.L" rEET i7Ri.i),1Sirir:: l:.in iAmount �t5 ^ wj0 Permit expires ISO days from !issue date . EXPRESS SHED PERMIT APPLICATIONrR E C E 1 V E t t TOWN OF YARMOUTII I Yarmouth Building Department AUG 21 2018 J 1146 Route 28 ��,� South Yarmouth, MA 02664 3' ,_1 "tom���UNT � (508) 398-2231 Ext. 1261 � L./CONSTRUCTION CONSTRUCTION ADDRESS: -` C 1 R C V t 7 Q CI WEST `l 2 h1 CIV S E ASSESSOR'S INFORMATION: Map: Parcel: OWNER: In QS sQ VQ1% `e EI S Sam2 502. S eki 14 k 12 NAME PRESENT ADDRESS TEL # coraRAcroR:\AlbW1t 16Y2xWbS ZZC - 300 COx1/4)%t\ TLYT O'N IAV 3.200 NAME MAILING ADDRESS TEL.# s'k^iC 2 C 104 G I g 46593 lJ Residential 0 Commercial Est.Cost of Construction$ Z• 3 t 3 , 1'I Home Improvement Contractor Lie.#_ 14 CM_J 3 _aQaitstruction Supervisor Lie.# CS I 0? 1_Lt C Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor 0 I have Worker's Compensation insurance t,---Insurance Company Name: 4 Cb 0 Worker's Comp.Policy# STIED INFORMATION New _ Size L Q x tr IC x H 1' Corner Lot: Yes Nov . Per Town of Yarmouth Zoning By-Law Sec 203.5 E: Side and rear setbacks for accessory buildings less them 150 square feet and single story, shall be 6 feet in all districts, but in no case built closer than 12 feet to any other building. • Replace existing* N% Size L x W x H "The debris will be disposed of at Location of Facility I declare wider penalties of perjury that the statements herein contained are nue and correct to the best of ray knowledge and belief. I understand that any false answens) will be just cause for denial or revocation of my license and for prosecution under M.O.L.Ch.263.Section 1 Applicant's Signature: Date: p+ Owners Signature(or attar I e.\U Date: C) 7 Z` 1 lL Q Q Approved By: V C / Date: �/ -/�" Ming' /al(or designee) EM ADDRESS: Zoning District: - _._...._..�_�_— Historical District: 1 Yes 11 No Flood Plain Zone: !" Yes f: No 1 Water Resource Protection District: Within 100 ft.of Wetlands:*** 0 Yes C No II Yes r' No • ***Note:Conservation review required if within 100 ft.of Wetlands 9/13 ...eru ..,mac. ✓ • The Commonwealth of Massachusetts 51' Department oflndustrialAccidents ( Ertel 1 Congress Street,Suite 100 I WI Boston, MA 02114-2017 www.mass.gov/dia ✓ Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): to P.e kA 13. eE\ S • Address C-1 ecu V T WO City/State/Zip: DJ W\o k-Yv�\ - 0 Phone#: 5 OR ac L¢. Z • Are yo an employer?Check the appropriate box: Type of project(required): I.Iam a employer with employees(full and/or part-time).* 7. 0 New construction • 2.0 1 am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 3.0 l am a homeowner doing all work myself[No workers'comp.insurance required.]t 9. C]Demolition 4.T, am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 ❑Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. • 12.❑Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.; 6.❑We are a corporation and its officers have exercised their right bf exemption per MGL c. 14.❑Other 152,31(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box q I must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verifi tion. I do hereby c r y nd th pain nd penalties of perjury that the information provided ab ye is t ue and correct. � Q Signature; tJ4 Date: Phone g: 5O< ' GZ{ U.11- 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#: ,/i ' r. . • • A • PLOT PLAN .r• , FOR LOT S Indicate location of garage or accessory building Additions with dashed lines Sewerage disposal (cesspool) 6130 Well r I I _ _ _ I (lot ft. rear) I Abuttor's 1 'fl' —' — — Name to I Abettor' Lot 0I Name Lot M Co I :f this is a REAR YARD 6- arner lot, ft. If this vrite in name I corner street• I write II f 3, � • �� name of II 0 • 4other ,o street. 4 4 : SIDE YARD • HOUSE SIDE YARD d--- --ET. <1.1 up • •• • • • I g• • . •• ••• • SET BACK ' 4,' ft. : Sj H30 (lot ft. f ontage) / / 4 E ► t� cu lT en (NAME OF STREET) / • \ Information / Supplied by 'ARK NORTH POINT _ i .. tib_=. • sjp1A0310MWALA* WWII MAPS Mutat-1191 fl3 ajVsgY1v Lt8.1 ao POP In 0061•12/119 CPI 11 ILD YWY'towoB PAS 50114111%009 m110411go PSLIo alUsPixsY1F1 w1tO lusgramba Illimilitietftit to Spptiatmanuoa710 Rem am0 el malral los sossI° X11. arra mi pm at;Oar taw kook°all 4a amob Ls'DaR sot map las'aop'adocs rot sp mum.i apt Rapp a aso PID'+a aapdparp MPG au lamp Mi apldmoa a probal Ilk:A.erad pm(as sat ma a tiaasa ao somasM p'P s al) .aroma ppmumma ae a_1 1 Lm a PDa'Y'S wad ao"mat■IDJ.iargD al amp soars 5 t one'aM 7's+a'srav R"'srlla'plp'nm Y +aaugsSWUM NM asp la as si WIMP PIM oPIP ps ilelsnpdde .g1aPPImudRLm nal SLAPRt4j".,--nPaine 4isPtlio maia9aiSAW agPptaw Y.Ina aDLtf'a).__$7-upggt;.*Pa pp. ,1onIldd'ap•PwITYAnt am.afanP4(1..— -ih aoPasalia MIDd Maw tap"!Pg NOM!as proomAtra,aa mat mall as aq ssopsppdd'a monsp ad mainline warm Pim PR) neallddswaWPM y '-gagatoanVaoaP"'RM aMaagarssanligmndlculWIaearRrima arsoRdd'aPPapas ootnaamaaosaapd,suazpsalilo'c fano aganleo INa1mei sip myna Mals ml+s9*PP aids!MIAs , iosoost it Intl mope Pm wit=elF' 1,11P POI era Mali • 'PPM aaV.a.AND a mq;ape ppm nom*Ma'Dtips et p. fi amassap a'dqud'Q Mt ipads'.q %mod aspw'dmoa Aram Iamp Nprat asaotpaoaalasp tapaalanmom*In aim sat ppm gelapl'DYParr • p n'aand'a ap 1ss'9sM3310 tarts!s'aslt mo'mad Ra asp agaapdds aP pip tars Lap op a pow sq PID'g'IlaiST ItaIR v sqt am Pas sip a tars R 4Y visaa.3 asse'gis a'1"mglaw fl PswaPtsa_ PPMDPsi,P aasgndsp Ra a Pa'Ia4D'sq Lam*Ws PRI n9a PaMP"DB ?Maw s!Lgpd e'n.tol3aa .asj smop in ao STI aril sr a-paodmw mama Lasa a maim as la (lads ssgsam asp la" o antslima w"Ps Grn)swans Lagpg'I mon a UFO a assdaro alllg'17 u.n watt's] M(')'tsgpaa As,RN"hoop Waal sand p'(npsagi''(')sarso(')aa'DDGD n ir-'La tam Aslas mamas at a Lldd'MI meat nl t'I;asga Lq*mad=papaw aopuaadmoti magma ap pop sand Winn"Y .4it 'gas trp'ogsa'sv a; --'d ruq.aq aad'gs MUD aaaniaba' ' ' 1 salmi eamntimmajo swamp a at web=pm pm map.nm'gsd sql asp maw La or rum !tans a'DAl4Pg'r Ira sip Ase ass Rguaaemmw saga arglsli•a s'(Lbtii'UI maw two LsrDsplPPY ,?DapsbaMaus.asaaat'Rtins aardia cpssa'PI'.mada 'psapeM1saMINMpagdds Ass asp ansa n Ma op$f Sem pupa*amowapagso ai.aspendasowapopIo'w'a aanal aDiirmapR'bads=4'aartF (a'a4'LaaaMPRPaWssl'(9bcrf tut MOM DK ,vuteldma a'sq a Pam'-P sq swslcjdma pap sr mac tpgr asp 1oasRsrddr Asngsq s apoasd Ms so s smog temsnn was so>i'raa satin s mpantiaos amoisamm op a mad WO=eqa ammo p!stag PSEtisap map p'dawr wasps 4im'ga moppet eta pm spamp'd'nip wasp masa 1.s*slag meet tgflMPop muse agyseam retold=Warm'lsaspit air aarmameaI --,a4'pppipoiapSalsasalnar MOW JD DMAmso'Ltpm o datespy lrotoaow ,,paorboa .. . ."''d}g'wsnd lerso►!PD!*e«s'pew av .vaW aii so pm tapir s sa ud_a 's'lggo puma Ae'spun nwoseio.at' 'Ras!wad Lae,a pram u Wain s Mara'lsp a rug vsnI1&oa rip asp arp'm'dmw Amapa*"pad co rand =if' bat LCs aad'gs sari pausal) • 1 3 suop3nx}sui put uofUULIoJui • _� The Commonwealth of Massachusetts ,„= Department oflndustrialAccidents —_L _ " 11a 1 Congress Street,Suite 100 • 44 Boston,MA 02114-2017 .MO' www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual):HOME BRANDS Address:300 CONSTITUTION AVENUE City/State/Zip:PORTSMOUTH NH 03801 Phone#:603-868-1300 Are you an employer?Check the appropriate box: Type of project(required): 1.I 1 am a employer with 25 employees(full and/or part-time).• 7. ✓❑New construction 2.0 lam a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.0 1 am a homeowner doing all work myself.[No workers'comp.insurance required.]t 4.0 1 am a homeowner and will be hiring contractors to conduct all work on my property. I will 10❑Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.0 1 am a general contractor and I have hired the sub-contractors listed on the attached sheet. ]3.0 ROOFre ails These sub-contractors have employees and have workers'comp.insurance.: SHEDS INSTALL 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Othei 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have employees. If the subcontractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:LOCKTON Policy#or Self-ins.Lic.#:22WBEL9729 Expiration Date: 11/01/18 Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. D__w Mwr_o_ GIto- Oi4n nxam.uve...cw.,. s . Signature: m` °va^" Date: Phone#:603-868-1300 EXT 44605 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#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the Issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia C/Ae eo- mmo'im /lea/a o �ciflas racA uaellJ Office of Consumer Affairs and Business Regulation One Ashburton Place - Suite 1301 Boston, Massachusetts 02108 Home Improvement Contractor Registration Type: Corporation Registration: 146930 HOME BRANDS,LLC. Expiration: 0513012019 300 CONSTITUTION AVE STE 200 PORTSMOUTH,NH 03801 • Update Address and Return Card. SCA1 A 20A405n7 r%/r l'ornnr.-n„vn//A re'(in.uii/.,,.J/ -Office of Consumer Affairs a Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only TYPE:Corporation before the expiration date. If found return to: Realstr- 1011 Expiration Office of Consumer Affairs and Business Regulation 146930 - -05/30.2019 10 Park Plaza•Suite 5170 HOME BRANDS,LLC. Boston,MA 02116 • CHAD BUTSON e-CC(1e 300 CONSTITUTION AVE STE 200 PORTSMOUTH,NH 03801 Undersecretary Not valid without signature ACORD ki...—i 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(ies)must have ADDITIONAL INSURED provisions or 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). ONTACT PRODUCER Lockton Companies NAME: 3280 Peachtree Road NE,Suite#250 PHONN FAX Eel. X.Nor Atlanta GA 30305 EMAIL (404)460-3600 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC S INSURER A:Twin City Fire Insurance Company 29459 INSURED Home Brands,LLC INSURER B:Trumbull Insurance Company 27120 1432013 300 Constitution Ave.,Suite 200 INSURER C:Commerce and Industry Insurance Company 19410 Portsmouth NH 03801 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 14580298 REVISION NUMBER: XXXXXXX THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSR WVD POLICY NUMBER IMM/DDT/YYY) (MM/DD/YYYY) A X COMMERCIAL GENERAL LIABILITY N N 22ECS OF6721 11/1/2017 11/IR018 EACH OCCURRENCE S 1,000,000 CLAIMS-MADEDAMAGE TO RENTED CLAIM X OCCUR PREMISES(Ea occurrence) S 1,000,000 MED EXP(Any one person) S XXXXXXX — PERSONALS ACV INJURY S 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2,000,000 XPOLICY u jE7 fl LOC I PRODUCTS-COMP/OP AGG S 2,000,000 OTHER' $ B AUTOMOBILE LIABILITY N N 22UENNL9044 11/1/2017 11/1/2018 COMBINED SINGLE LIMIT $ _ COMBINED dent) 1,000,000 X ANY AUTO BODILY INJURY(Per person) $ XXXXXXX OWNED SCHEDULED BODILY INJURY(Per aaident) $ AUTOS ONLY _ AUTOS XXXXXXX _ HIRED NON-OWNED PROPERTY DAMAGE $ XXXXXXX _ AUTOS ONLY _ AUTOS ONLY (Per ecadent) _ SXXXXXXX C X UMBRELLALIAa X OCCUR N N 8E025881327 11/1/2017 11/1/2018 EACH OCCURRENCE S 25.000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE S 25,000,000 DED RETENTIONS S XXXXXXX WORKERS COMPENSATION , PER OTH- A AND EMPLOYERS'LIABILITY VIN N 22WB EL9729 11/1/2017 11/1/2018 Al STATUTE ER ANY OFFICEOPRIETER/PARTNDEDXECUTIVE E N/A E L.EACH ACCIDENT S 1,000,000 (Mandatory In NH) E L.DISEASE•EA EMPLOYEE S 1,000,000 R yea.describe under DESCRIPTION OF OPERATIONS below EL.DISEASE-POLICY LIMIT S L000.000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD tet.Additional Remarks Schedule,may be attached R mon space Is required) CERTIFICATE HOLDER CANCELLATION 14580298 Town Of Yarmouth SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 1146 Route 28 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN South Yarmouth MA 02664 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENT I ©1988.20 ACORD CORPll rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD 1 Massachusetts - Department of 'Liblic Safety Board of Building Regulations and Standards Comtrutlion upen Hnr License! CS-108446 s. .t MICIiAELFRITZ= • l Via.:: P.O.BOX 1013 S -.w----"\ts Rye NI1 03870 7 'r + Comrmssroner 12/03/2018 1 • i h ' #+ '� mo i` f`T r .z w' r n (4.+` '�:'_y K�'y ' , £ two. I 'yl jl .sc{(S#r'A` MI' t "?)rte i ! /�--, wflak S• �`'c ^+/ BRna.� iI SO' Oat .-- Its_ ttA 16 a,e) L.tslaiil:m I it. .1s (wasZZD 9wr..- t T- Vd _ ?anoIeisure• rCONTRACTOR LICENSING i 7/LGS VP .GTi ant + • ` - Michael/. . • •i ✓CQ,2.T/CIX.L^63flVll�A71IJE'.Cf�ULCi//'P//l//l�i \ Arm-arm revairenzartAr • 4. Mass. Construction Supervisor License-12 Hour Continuing Education(CS-9800) { 1 } April 11201$ .6-LEISURE" CONTRACTOR LICENSING. LLC • �` .•�. ," - 4 PROSPECT COURT, KINGSTON, MA 02364 2h; " DATE OP COURSE COMPLETION ' �'a'i I COURSE COORDINATOR' � 1 i 35 h1Yrica Ave no 1013 JAMES VENETO �� f : . . Rye,New Hampshire 03870 COORDINATOR LICENSE NUMBER: • .. 9•ADDRESS OP PARTICIPANTHE-195440 : ' t m5iV4775Cacomcast net CERTIPIC ATE NUMBER: C \K; y'"p• EMAIL OF PARTICIPANT 15705604181162331 1 �, IA' CS-108446 ' "'•it COORDINATOR)) SIGGNATURE: y y AI, 14 LICENSE NUMBER 1 -;a :(n4;:I V rt' S}1 , I" myp'5 'turn-- l `$,�}�' 4. .- h�F .:tin t)'f=ARIA '�(1`:•. ) . r`. _;^•1424PA haj-' n.-- .s . Y� lditk.. tit .. i x tn- C d +� ,. . . i.\ ,.•. v+ a I t r5y .. -.,.�* 1 j.i.:'-r7r- 'tu - if '- d =f� .+d& 'Irl - _ e`{ v,-1•.1- -; i'1 Si,wl. 't`. 1.