Loading...
HomeMy WebLinkAboutBld-23-004483 ONE & TWO FAMILY ONLY- BUILDING PERMIT Town of Yarmouth Building Department of Ni 1146 Route 28,South Yarmouth,MA 02664-4492 508-398-2231 ext. 1261 Fax 508-398-0836 Massachusetts State Building Code,780 CMR .o Building Permit Application To Construct,Repair, Renovate Or Demolish a One-or Two-Family Dwelling R E I V E p This S= n For Official Use Only S I �3-� 3 FEB 10 2023 Building Permit Number:{ ( Date Appli ' '(11-4 )'Crr°ft cJ c/ )"P 13 r --BUILDING DEPfikf Mkt _ _. Building Official(Print Name) store fc t L' - SECTION 1:SITE INFORMATION 1.1 Property Addre : 1.2 Assessors Map&Parcel Numbers 1.1 a Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: I 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required I Provided Required Provided Required Provided - i 1 1.6 Water Supply: (M.G.L c.40,154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public 0 Private 0 Zone: — Outside Flood Zone? Municipal 0 On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP` 2.1 Owner'of Record: �I'. � Nam (Prin City rate, IP 0 GI C BILMa—/S2-177 el(--4---16--as- othaths iliffh145 4 No. Street Telephone Email Address �Jr SECTION 3:DESCRIP N OF pROPOSED WORKS(check all that apply) New Construction 0 I Existing Building f Owner-Occupied 0 I Repairs(s) 0 Alteration(s) ,<ddition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: Bri"f TlP.rrinti nn of Proposed Work2: -- -1-0 c c w-e.K bra <<k�vt� SECTION 4:ESTIMATED CONSTRUCTION COSTS. • Item Estimated Costs: Official Use Only (Labor and Materials) . 1.Building $ �(�( 1. Building Permit Fee:$,_ Indicate how fee is determined: 2.Electrical $ i{Standard City/Town Application Fee 0 Total Project Cost3(Item 6)x multiplier x 3.Plumbing $ �_(� ( � 2. Other Fees: $ 4.Mechanical (HVAC) $ _ List: t 150 e ( '1430 5.Mechanical (Fire $ Suppression) Total All Fees:$ Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ a,q 4) 1 0 Paid in Full go Outstanding Balance Due: (- i SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) WPC1/?—g mtic, C`I.( 1 1 Licen a Number Expiration Date Name o SL Holder Q n ( t cr k'1 `& 96661- ' -1tList CSL Type(see below} UNo, d Street + ► l� Vv+ \ Type Description �lj (l,N6A ` /�j Ir U I Unrestricted(Buildings up to 35,000 Cu.ft.) City/Town,-- State,`''' ZIP U Z� lJ R Restricted 1&2 Family Dwelling M Masonry RC I Roofing Covering WS Window and Siding 3X }���j / SF Solid Fuel Burning Appliances —3 3 I! ok(�6 I Insulation Telephone mail address , !tM-. D Demolition 5.2 Registered Home Improvem nt Contractor(HIC) 1 i1S 4;0LnI, 0-�-& � Vieth HIC Registration Number Expiration DanzHICCo a R istrantName ll1116 rl o 14 1)ebal'hk px(NOte ikke@VI p(Cf,NA_ vd Str et • Email address City/Town,State,Lll' TeIephohe 1 JhV' 3-21 4. -ore SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(NI.G.L.c.152.§ 25C(6)) Workers Compensation Insurance affidavit must b completed and submitted with this application. Failure to provide this affidavit will result in the denial of the Issua a of the building permit. Signed Affidavit Attached? Yes No 0 . SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize to act on my behalf,in all matters relative to work authorized by this building permit a lication. atxy--iao)(- ct-o- Print Owner's Name(Electronic Signature) Date • SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accur a to the best o Qtowledge and undo dir -------;Prin Owner's or Authorized Agent's N tonic Signature) L9 NOTES: 1. An Owner who obtains a dine permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(ITIC)Program),will not have access to the arbitration program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at www.mass.sov/oca Information on the Construction Supervisor License can be found at www.mass.nov/dps 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch) Gross living area(sq.ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" §TOWN OF YARMOUTH 1146 Route 28, South Yarmouth, MA 02664 508-398-22311 ext.-1261 Fax 508-398-0836 Office of the Building Commissio f er BUILDING DEPARTMENT DEMOLITION DEBRIS DISPOSAL AFFIDAVIT Pursuant to M.G.L. Ch. 40, §54 and 780 CMR- Section 105.3.1. #4. I hereby certify that the debris resulting from the proposed work/demolition to be conducted at 3,c Qn,, I (40-- y v Work Address Is to be disposed of oat the following location: w Said disposal site shall be a licensed solid waste acility as e ined Ch. 111, §150A. 0-102-(g,2) nature of Application Date Permit No. The Commonwealth of Massachusetts Department of Industrial Accidents • 9 . '—'19 Office of Investigations 1 ;s r�1 Lafayette City Center 9/ 2 Avenue de Lafayette, Boston, MA 02111-1750 "`,,,, ,s, www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Long Roofing LLC/Long Baths LLC _ Address:300 Myles Standish Blvd City/State/Zip:Taunton MA 02780 Phone #:339-333-6118 Are you an employer? Check the appropriate box: Type of project(required): 1.0 I am a employer with 25 4. ❑ I am a general contractor and I 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. 7. ❑■ Remodeling ship and have no employees These sub-contractors have 8. E Demolition workingfor me in anycapacity. employees and have workers' p tY 9. ❑ Building addition [No workers' comp. insurance comp. insurance.t required.] 5. 0 We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.E Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13.n Other 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 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: Liberty Mutual Insurance Corporation Policy#or Self-ins. Lic. #:WC5-31 S-626143-013 Expiration Date:1/1/24 i � Job Site Address: 0/.5 n&Q I-- rift,City/State/Zip V 1,4- 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 ains and pena ' Vratilre-infoignationprovided a ove is true and correct. Signature: Date: / (/ 3 Phone#: -333-6118 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority(check one): I0Board of Health 20 Building Department 30City/Town Clerk 4.0 Electrical Inspector 51-1Plumbing Inspector 6.0Other Contact Person: Phone#: ® DATE(MM/DD/YYYY) ACc RD CERTIFICATE OF LIABILITY INSURANCE 1/8/2023 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). CONTACT PRODUCER ALLIANT INSURANCE SERVICES INC NAME: 16901 MELFORD BLVD STE 123 PHONE I BOWIE, MD 20715 {ENC,NL,Ext) sac r1o): ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: LM Insurance Corporation _ 33600 INSURED INSURER B: LONG ROOFING LLC DBA LONG HOME PRODUCTS INSURERC: LONG BATHS LLC INSURER D: 8530 CORRIDOR RD INSURER E: SAVAGE MD 20763 INSURER F: 1 COVERAGES CERTIFICATE NUMBER: 72387605 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. INSR 'lADDLSUBR - - _ --- - - _ - __POLICY EFF POLICY EXP — _ LIMITS LTR w TYPE OF INSURANCE INSD VD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) COMMERCIAL GENERAL LIABILITY 1 EACH OCCURRENCE $ _ DAMAGE TO RENTED CLAIMS-MADE I OCCUR ', PREMISES Ea occurrence) $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY I PRO- POLICY I LOC PRODUCTS-COMP/OP AGG $ OTHER: _— ' $ i AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO iBODILY INJURY(Per person) $ OWNED i SCHEDULED BODILY INJURY(Per accident) S AUTOS ONLY - AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY _; AUTOS ONLY (Per accident) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB H CLAIMS MADE AGGREGATE _ $ DED RETENTIONS S A 1 WORKERS COMPENSATION WC5-31S-626143-013 1/1/2023 1/1/2024 ✓ STATUTE I ERH AND EMPLOYERS'LIABILITY ANYPROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $1000000 OFFICER/MEMBEREXCLUDED? Y N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1000000 If yes,describe under l i I DESCRIPTION OF OPERATIONS below i E.L.DISEASE-POLICY LIMIT S 1000000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) WORKERS COMPENSATION INSURANCE COVERAGE APPLIES ONLY TO THE WORKERS COMPENSATION LAWS OF THE STATE OF MA. This certificate cancels and supersedes all previously issued certificates,only as they relate to workers compensation coverage. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of West Yarmouth, MA AUTHORIZED REPRESENTATIVE Jon Smith ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD 72387605 1 1-626143 1 23-24 WC- 1 n0270258 1 1/8/2023 5:11:08 PM (PST) 1 Page 1 of 1 ,..•..11 LONGFEN-04 DHARRIS A �Rv. CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 1/3/2023 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). PRODUCER License#0C36861 CONTACT Danielle Harris ,NAME: Lanham-Alliant Ins Svc Inc I(A FAX No): 16901 Melford Blvd Ste 123 PHONE Ext): - E-MAIL danielle.harris@alliant.com Bowie,MD 20715 ADDRESS_ • - — - INSURERJ AFFORDING COVERAGE NAIC# INSURER A:Everest Indemnity Insurance Company _ 10851 INSURED INSURER B:Commerce Insurance Company 34754 _ Long Roofing LLC dba Long Home Products INSURER C:Burlington Insurance Company _ 23620 300 Myles Standish Boulvard ' INSURER D: _ �_ Taunton,MA 02780 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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. INSR TYPE OF INSURANCE ADDLISUBRr W POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD VD (MM/DD/YYYYI (MM/DD/YYYY) A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR I l ICF4GL01198-221 12/31/2022 12/31/2023 DAMAGE TO RENTED 100,000 PREMISES(Ea occurrence) $ MED EXP(Any one person) $ _ PERSONAL BADVINJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY X JECT LOC I l l I IPRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: EBL AGGREGATE $ 2,000,000 B AUTOMOBILE LIABILITY Ea accciden INED SINGLE LIMIT $ 1,000,000 ANY AUTO BCDX02 1 12/31/2022 12/31/2023 BODILY INJURY(Per person) $ AUTOS ONLY XNED AUTOSULED BODILY INJURY(Per accident) $ HIRED NON-OWNED I PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY i (Per accident) $ I $ C UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 5,000,000 X EXCESS LIAB CLAIMS-MADE I600BE00525-03 12/31/2022 12/31/2023 AGGREGATE $ DED RETENTION$ Aggregate $ 5,000,000 WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER YIN ANYIPROPRIETOR EXRLNER/E ECUTIVE NIA E.L.EACH ACCIDENT $ OF(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of West Yarmouth, MA AUTHORIZED REPRESENTATIVE AM4'e gtat:5 ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD MA HIC#187510 Page 4 of 22 Long Roofing, LLC • 300 Myles Standish Blvd Taunton MA, LONG HOME 02780 (800)470-LONG • (240)473-1400 • LongRoofing.com PRODUCTS By Long Roofing, LLC William Coughlin ecbc44@aol.com Date:01/21/2023 25 Bennett ave 9144900885 Product Specialist: Veronica Swan west yarmouth MA 02673 The Buyer(s) listed above hereby jointly and severally agree to purchase the goods and/or services listed herein, in accordance with the prices and terms described in this "Agreement." Dumpster Required NO I confirm that the above information is accurate Are there electric lines within 3 feet of where LHP will be performing work? NO Preferred Method of Contact Phone Phone/Text/Email 9144900885 Total Purchase Price $12,761 Deposit with Order $1,300 Amount Due on Substantial Completion $0 Amount Financed $11,461 Form of Deposit Credit Card The Estimated Date of Commencement of the Work Is 6-8 Weeks The Estimated Completion Date Is 8-12 Weeks I am aware that the above dates are an ESTIMATE The Project Is Contingent Upon Obtaining Approved Financing, Permits THERE ARE NO ORAL AGREEMENTS Et/� Promotion Selected(Cannot be combined with other offers) Promotional Financing Customer Promotion Acknowledgment (r/L It is agreed and understood by and between the parties that this Agreement, constitutes the entire understanding between the parties, and there are no verbal understandings, changing or modifying any of the terms of this Agreement. Buyer(s) hereby acknowledge that Buyer(s) has read Agreement and has received a completed, signed and dated copy of this Agreement, including the two accompanying Notice of Cancellation forms, on the date first written above. Buyer(s) acknowledge that they were orally informed of their right to cancel this transaction. /1014.0.4 Veronica Swan William Coughlin 01/21/2023 01/21/2023 Date Date Page 4 of 4 Ima•e: 1.5 b , nstallatlon Inspection 9 l LONG BATHS stomor Name //2//C 4 Job M Dole_ ///'()v/11//,4/ PII Toch U Tub to Tub 662,t0 Shower U Shower to Shower U Shower to Tub U Walk In Tub _3=121111111 Tut Shower pf Watts floor Wes ewe.to qumMnO U Stool U f aa1 Pb t� �prywaA ..emenl U Pa. .Van U T o U wonMd In y Worn U`We U GrevnlP.a U Non U FmerGt.+. de UfioapMtt Utrarcet. UProp Water Shut Oaer U om« otn.r U O.W Oaf U Carpet U n..e.e .n U P.nl U ONv 0 oft, UOust CI Crewel,. UNone ( ' J B 0 MEASURE: Crown Mo.a:I y, weE J Y..U N o /-- _ E. [f .. Window: el..`N F fbabC... UYed No * C ettUn + ` O.o..CommWMM.Com r N. *0WlbfaaMPn ..ad O $el I Camp mpaTbva, Uc U e oam. W.. b.cMaw U Nono D E ez3 c 6)a_; Note.tolM N.IMNr. J'/Of/Q /iofV( Image: 1.6 . f j .:r o 'c ,‘ \ e to Nk tI 1 to Jv44, \v I L----- E n WY - leaptodigital.com 2.13.0 • • CornmonWealth of Massact use is Division of professional Licensure. Board of Building Regulations and Standards Consvirrfrvtsor j CS-115540 ' t ta, plres 12/291202 t: DAMES F COOS TE�LOV ri 1442.i . y ?0 N i4` 38 RARRIS FARM Re} - a ! - "" = sS r ' EAST BRIDGEI(VATERM 2333 Commissioner i es j � G a ,ei THE COMMONWEALTH OF MASSAUHUSh I 16 Office of Consumer Affairs and Business Regulation 1000 Washington=Street - Suite 710 Boston;-Masachusetts 0?118 Home ImproVement.Gontraetor=Registration ,, i1. l ' �-i / 2/ s a ii '':;� ..,„ 1 1 7. Type: Supplement Card LONG ROOFING LLC ` ' Registration: 187510 a ,� ;"` Expiration: 04/20/2023 D/B/A LONG HOME PRODUCTS ,- ,' .,, 14 8530 CORRIDOR RD, SUITE 200 ' ,-',',, , • ---r�. .,i+„,,,, SUITE 200 i, I Jt f� ,I SAVAGE, MD 20763 'i� 'W ° Update Address and Return Card. THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs&Business Regulation Registration valid for individual use only before the HOME IMPROVEMENT`CONTRACTOR expiration date. If found return to: TYRE:_SiaplArnent-Card Office Consumer Affairs and Business Regulation Registration- -Expiration 1000 a hington Street -Suite 710 187510 04/20/2023 Bos on, A 02118 .ONG ROOFING LLC, t. "' ,p , i , )/B/A LONG HOME PROD TS is if. TAMES COSTELLO y J `r t530 CORRIDOR RD,SUITE 2d0 �r,,04„4'rG.�u.Gt 4. / 11 UITE 3AVAGE, UndersecretaryNot valid without signature MD 20763 -�---� 9