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HomeMy WebLinkAboutBld-23-005176 L/✓J I/a 3/L5, Pa 3) l Iz • . oF•-'.9,4 BUILDING PERMIT APPLICATION '-r APPLICATION TO CONSTRUCT, REPAIR, RENOVATE, CHANGE TH CUPANCY OF. '5O . .........5. y OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMI YRNE.LeNGE 1 V E D _ Town of-Yarmouth Building Department t'.-s4I••* 1146 Route 28 • Yarmouth, MA O9664-1.492 Tel: 508-398-2231 ext. 1261 Fax 508-398-0836 MAR 2 0 2023 Office Use Only Planning Board Information Assessors Department Informatit •BUILDING DEPARTMENT Permit No. d(�)-Z3-bb51�jate Plan Type Permit Fee $kV) Map nY ---- --__ Endorsement Date / Recording Date New Deposit Rec'd. $ 690,0 Date 3/241.4 Property Dimensions: CAC- L4 CI,3 Plan No. Net Due $ \�� Qit� Other Lot Area(sf) Frontage(ft) Lot Coverage 1. —This Section for Office Use Only Building Permit Number: Date Issued: Signature: -A ?--,i ? Certificate of Occupancy Building, dal Data is Is not required Section 1 - Site Information I 1.1 Property Address: r, 1.2 Zoning Information: 5 7 /i1cd7ZJc k 4.A i fy . Zoning District Proposed Use 1.3 Building Setbacks(ft) Front Yard I Side Yards Rear Yard Required Provided Required I Provided j Required 1 Provided 1.4 Water Supply(IM.Q.L c.40.S 54) 1 5 Flood Zone Information: Comments Public Private Zone: — SFE Section 2 - Property Ownership/Authorized Age 2.1 Owner of Record: Name(print) - �O / CY 3 , !r) A 4J, [`,4i' 67-' ' ' .=�. � � Mailing Address: a i t� f�,ii c �.�oF� Signature r 5E):P .F,I�<</ S �7y- yf7-,Ails; Tpiii'Liea / J—S,Cai�j' 9 Telephone Telephone / 2.2 Authorized Agent:1 Email Address: , - '75 4' ;-63",5 1/5 _ ),) l t'/ 'ail) /,)s NW/746 AM/ cl1er-/ Hams ( int) Mailing Address: a 3)._.f51`11 _4 ,,,i2 55/tA JCC614/31M5/4C 'Carl Si a re Telephone Fax I Email Address: , Section 3 - Construction Services 3.1 Lleens.d Construction Supervisor: Not Applicable i] l L /PC:�. /i ,( /t�)„,, �j / i C>r License Number / Addre4 z______`. l /J / N V� `lam � �'j ..(��s�j ! .' 7 1r-JPJ,1'" ram �_ Exp✓iration Date Sig ure Telephone Email Address: ?//�J�r.X/ S,4-e SS I '�.r ��' /��, �/rk ,CGS, y 3.2 Registered Home Improvement Contractor: Company Nam• I Not Applicable ❑ . __ C �itr ✓/qt %A'( I Address Registration Number 9./7 r,�-4C/✓, 7/%1 ),'Z- HY/1 /AL /y 4. 17 o/ /(MT/a I Signature,..""" �; Telephone �3: r� '�" �Expiztion C:tg L/�� Section 4-Workers' Compensation Insurance Affidavit (M,G.L c. 152 S 25C(6) d 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 `$' No Section 5- Professional Design and Construction Services-for Buildings and Structures Subject to Construction Control Pursuant to 780 CMR 116(containing more than 35,000 c.f. of enclosed space) Section 5.1 Registered Architect: Not Applicable Name (Registrant): Registration Number Address Expiration Date Signature Telephone Section 5.2 Registered Professional Engineer(sTi Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Section 5.3 General Contractor J ,f' � //aC /rV C Not Applicable ❑ Company Nam r.-� ./C)LAN i C.), Person Responsible for Construction 3/ 7 rm/ nt' ,'^/ .�;L. /v' 1/40/ Jf'S 4%/� Ode)/. Address /C'- �+r,?—Jr3? 9S �vs ......j . --____ Signature Telephone ' , Section 6 - Description of Proposed Work (check all applicable) New Construction ❑ I (for multiple family only) No.of Bedrooms (for multiple family only) No.of Bathrooms Existing Bldg- ❑ I Repair(s) If [ Alterations ❑ I Addition ❑ I Accessory Bldg. ❑ Type Demolition Other Specify: P fY: 1 Brief Description of Proposed Work: //- /(1'/rK i/1),5-4/ 64, / A24,10 /�y4A/k c c, igNi1?62 7;cod,^5". /�cxp /Y -':C c7 47,/(:X?_ 6.1/(7 AoAde 4 X orREAc Section 7- Use Group and Construction Type Building Use Group(Check as applicapable) Construction Type A ASSEMBLY ❑ A-1 ❑ ❑ A-2 ❑ A-3 ❑ 1 A B BUSINESS ❑ A-4 ❑ A-5 ❑ 1a ❑ 2A ❑ E EDUCATIONAL ❑ 2a ❑ F FACTORY ❑ r 1 ❑ F-2 ❑ 2C ❑ H HIGH HAZARD ❑ 3A ❑ I INSTITUTIONAL I ❑ I-1 D 1-2 ❑ 1-3 ❑ 3g ❑ l.A MERCHANTILE I ❑ ❑ 4 R RESIDENTIAL I R-1 ❑ R-2 ❑ R-3 ❑ SA ❑ S STORAGE l I ❑ S-1 ❑ S-2 ❑ ss D U UTILITY ❑ SPECIFY: M MIXED USE ❑ SPECIFY: _ S SPECIAL USE I ❑ SPECIFY: _ Complete this section if existing building undergoing renovations,additions and/or change in use.' Existing Use Group: Proposed Use Group: Existing Hazard Index 780 CMR 34 Proposed Hazard Index 780 CMR 34 Section 8 Building Height and Area I Building Area Existing(if applicable) Proposed Number of floors or stories include basement levels Floor Area per Floor(sf) Total Area All Floors (sf) Total Height (ft) [Section 9 - STRUCTURAL PEER REVIEW (780CMR 110 11) Independent Structural Engineering Structural Peer Review Required Yes No..-!... SECTION 10a OWNER AUTHORIZATION -TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, J' /3 /3/Vi I //-� oti.A,k , cG�'. "4i, � as Owner of the subject property hereby authorize LC 1//1 i/, '" //V`(. to act on ." /my behalf, in matters relative to work authorized by this building permit application. Signature Owner /� Date SECTION 1 0b OWNER)AUTHORIZED AGENT DECLARATION l' -r'1.4%At41/J/1C /'ld/< , as Owner/Authorized Agent hereby declare that the statements and information on the forgoing application are true and acurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. Print Name ....„ ....;`)/;e2 3 Sign re of Owner/Agent Date Section 11 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be completed by permit applicant 1.Building p- 2 60G.,00 a Electrical 3.Plumbing/Gas 4.Mechanical(l-1VAC) 5.Fire Protection 5.Total_(1+2+3+4+5) }�7j /f! c )/ 7.Total Square Ft.rim- new stones&a5ibxa) I u �•�C Check Below ❑ Conservation-Commission Filing (if applicable) ❑ Old Kings Highway&Historical Commission approval (if applicable) The Commonwealth of Massachusetts _ Department of Industrial Accidents ;;! Office ofInvestigations Lafayette City Center �' 2 Avenue de Lafayette, Boston,MA 02111-1750 -'` "" www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): t.,/(' k2 P J 5/C, . / G 1 a L _Y •Address: / 7 ,r- T,r-1 L-1€ City/State/Zip:__ '7`6,/a/7/7/5, 77', �, 2( O ` Phone #: ` ,5? -- 77/ - ;./. ` Are you in employer? Check the appropriate box: Type of project(required): 1.Li I am a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. 0 New construction 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling shipand have no employees These sub-contractors have S. 0 Demolition working for me in any capacity. employees and have workers' [No workers' co comp. insurance. 9 ❑Building addition comp. P required.] 5. ❑ We arc a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12 ❑Roof repairs insurance required.] t c. 152,§1(4),and we have no employees. [No workers' 13.0 Other j comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 1Contractors 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: /"/S G'7'2--/- .---_,_' 7;--iat cip 2-eS 0 r /12?55 /2 76/>7J a J:—T'i S Policy#or Self-ins. Lic. #: VW 7006,0 70 0€?,3,/9 Expiration Date: // / 424969.y Job Site Address: 97 Neptune Lane City/State/Zip:S. Yarmouth, MA. 02664 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 certfi sunder yhe pains and penalties of perjury that the information provided above is true and correct Si Mature Date: / 1° /v?C2 a' 5 Phone#: t -.; -.' / - = %/ t 7 I 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): 10Board of Health 20 Building Department 31:ICity/Town Clerk 4.0 Electrical Inspector 50Plumbing Inspector 6.0Other Contact Person: Phone#: §TOWN OF YARMOUTH 1146 Route 28, South Yarmouth, MA 02664 508-398-223!1 ext.-1261 Fax 508-398-0836 Office of the Building Commissioner 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 , 7 iiki ' t Work Address Is to be disposed of oat the following location: 3 LicCG, V /�!> c0 74/ 4671145, /WL 0'ate. Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Ch. 111, §150A. 5A-A 3 Signature of Application Date Permit No. IA ceansi deg Restoration Fire • Water• Soot•Mold 217 Thornton Drive,Hyannis,MA 0260i P.508-771-3 W/f.774-470-22 u wwtv.oc ArIssidoinc.coln DATE: 3/3/2023 Revised PROPOSAL SUBMITTED TO: JOB NUMBER:20220815 Riverview Resort Job Site: 37 Neptune Lane S Yarmouth,Ma 02664 same WE HEREBY PROPOSE TO FURNISH ANY MATERIAL(LISTED BELOW)AND LABOR, COMPLETE AS PROVIDED FOR IN THE SPECIFICATIONS BELOW. ALL MATERIAL IS WARRANTED TO BE FREE OF DEFECTS,AS SPECIFIED AND TO BE WITHIN ACCEPTABLE CONTEMPORARY QUALITY STANDARDS. ALL WORK IS TO BE COMPLETED IN A WORKMANSHIP-LIKE MANNER,ACCORDING TO STANDARD PRACTICES. MATERIAL COVERED UNDER THIS AGREEMENT AND DELIVERED TO THE JOB SI1'b ARE THE PROPERTY OF THE BUILDING OWNER UNLESS OTHER ARRANGEMENTS ARE MADE IN ADVANCE. OUR WORKERS ARE FULLY COVERED BY WORKERS' COMPENSATION LIABILITY INSURANCE.THIS PROPOSAL MAY BE WITHDRAWN BY US IF NOT ACCEPTED WITHIN TWENTY-ONE(21)DAYS. THIS PROPOSAL SUPERSEDES ANY AND ALL PREVIOUS OFFERS OR ESTIMATES TO PERFORM THIS WORK. NOTHING STATED IN THIS PROPOSAL IS MEANT TO IMPLY THAT THE COST OF COLLECTION OR DISPOSAL OF ANY HAZARDOUS WASTE IS INCLUDED IN THE CONTRACT PRICE. INFRASTRUCTURE COSTS (E.G. HEATING FUEL, ELECTRICITY, PLOWING,ETC.)REMAIN THE RESPONSIB[LITY OF THE OWNER AS A PART OF THIS AGREEMENT. WE HEREBY PROPOSE TO FURNISH MATERIAL(AS LISTED BELOW)AND LABOR- COMPLETE IN ACCORDANCE WITH SPECIFICATIONS BELOW, FOR THE SUM OF: $87,297.28 Eighty Seven Thousand,Two Hundred Ninety Seven AND 28/100 DOLLARS PLEASE INITIAL HERE ACCEPTING ALL TERMS AND CONDITIONS SET FORTH ABOVE:x ` ____ T—) PAYMENT TO BE MADE AS FOLLOWS: $30,000.00 Deposit upon signing,prior to commencement $30,000.00 Payable upon 50% completion S27,297.28 Payable upon substantial completion A FINANCE CHARGE WILL BE ADDED TO ALL ACCOUNTS THAT ARE PAST DUE ACCORDING TO THE TERMS OF THE PAYMENT SCHEDULE. THE RATE IS 11/2%PER MONTH COMPOUNDED MONTHLY(ANNUAL PERCENTAGE 19.56%). THERE WILL BE A$25.00 CHARGE FOR ANY CHECKS RETURNED TO US UNPAID. THE CUSTOMER AGREES TO PAY ALL REASONABLE COLLECTION COSTS INCLUDING ATTORNEY FEES. Proposed work: See attached scope—"Revised Exhibit A" i ,: Authorized by f Ocanside,Inc.lO Manager 8 gnaturg5 or Operations Mans ;i ... ` . - -) "_�•� -) rst1mator's Signature: -� Sign Print ACCEPTANCE OF PROPOSAL-the above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payment will be made as outlined above. DATE OF ACCEPTANCE: i/ z 3/o z 3 OWNER/AGENT SIGNATURE: ? OWNER/AGENT SIGNATURE BATE SIGNED PROPOSAL RCVD BY OCEANSIDE: PATE DEPOSIT RCVD BY QCEANSIDE: FOR OFFICE USE ONLY - -- -- FOR OFFICE jJSE ONLY PLEASE INITIAL HERE ACCEPTING ALL TERMS AND CONDITIONS SET FORTH ABOVE:x Commonwealth of Massachusetts {� Division of Occupational Licensure Board of Building Regulations and Standards ConstZn ISrvisor e ry CS-055571 .� I3,pires:09/17/2024 STEVEN M TESSIER 18 DEE BEE QIR MIDDLEBORO MA 02346 ;} i ' ld, `l (4.Lt'di1 l Commissioner dada >ri'. `GGvncDtq THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affaifrs and Business Regulation 1000 Washington Street-Suite 710 Bostorr Masachusettg118 Home Improvvme C ra registration ,Type: Supplement Card " 3�teistl ation: 100121 OCEANSIDE, INC. i 4p'itation: 06/08/2024 217 THORNTON DR mil• HYANNIS, MA 02601 >t A fj. C „ \� 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: TYPE:Supplement Card Office of Consumer Affairs and Business Regulation 139134111.11P12 Expiration 1000 Washington Street -Suite 710 100121 06/08/2024 Boston,MA 02118 OCEANSIDE,INC. STEVE TESSIERj))//./L‘ 217 THORNTON DR HYANNIS,MA 02601 Undersecretary Not valid without signature • ACGRD CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 01/04/2023 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 CONTACT Tina Reeves NAME: The Hilb Group New England,LLC PHONE (800)640-1620 FAX (A/C,No,Ext): (A/C,No): dba Dowling&O'Neil E-MAIL treeves©hilbgroup.com ADDRESS: 973 lyannough Road INSURER(S)AFFORDING COVERAGE NAIC# Hyannis MA 02601 INSURER A: Arbella Protection Insurance Co 41360 INSURED INSURER B: Colony Insurance Company 39993 Oceanside,Inc. INSURER C: 217 Thornton Drive INSURER D: INSURER E: Hyannis MA 02601 INSURER F: COVERAGES CERTIFICATE NUMBER: CL22122020988 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 ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD WVD (MMIDD/YYYY) (MM/DD/YYYY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,DAMAGE TO RENTED 000 CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ 100,000 MED EXP(Any one person) $ 5,000 A 8500066712 01/01/2023 01/01/2024 PERSONAL BADVINJURY $ 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $ 2,000,000 POLICY X JECT PRO LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ A OWNED X SCHEDULED 102006166607 01/01/2023 01/01/2024 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ X AUTOS ONLY X AUTOS ONLY (Per accident) X UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ 5,000,000 A EXCESS LIAB CLAIMS-MADE 462008968604 01/01/2023 01/01/2024 AGGREGATE $ 5,000,000 DED X RETENTION$ 10,000 $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ Pollution B CSP4223638 01/01/2023 01/01/2025 Aggregate $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Insurance coverage is limited to the terms,conditions,exclusions,other limitations and endorsements.Nothing contained in the certificate of insurance shall be deemed to have altered,waived,or extended the coverage provided by the policy provisions. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Oceanside Inc ACCORDANCE WITH THE POLICY PROVISIONS. 217 Thornton Drive AUTHORIZED REPRESENTATIVE Hyannis MA 02601 I ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD ♦ " AC.C)IKti CERTIFICATE OF LIABILITY INSURANCE DATE(IRYtpQ'VYYY) 01/0412023 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 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 CONTACT NAME Linda Sullivan DOWLING & O'NEIL INSURANCE AGENCY u o"r . (508)775-1620 FAx Apem en; lsuHivan ins.com poResa: _._973 IYANNOUGH RD B SURERIS)AFFORDING COVERAGE NAIC S HYANNIS MA 02601 INSURER A• AIM MUTUAL INS CO 33758 INSURED INSURER R OCEANSIDE INC INSURER C INSURER D 217 THORNTON DRIVE INSURER E HYANNIS MA 02601 INSURER F- COVERAGES CERTIFICATE NUMBER: 849163 REVISION NUMBER: HIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOC 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 1S SUBJECT TO ALL THE TERMS EXCLUSIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS MISR ER TYPE OF INSURANCE ADOI SUM POLICY EFF POLICY EXP LIMITS LTR tNSD WVO POLICY NUMBER IMIWDVYYYY) IMPAVVYYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S DAMAGE TO RENTED CLAIMS MADE OCCUR PREUISES tEa occurrercel . S MED EXP(Any one personl S WA PERSONA{.a ADV INJURY GENII AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE • POLICY JECT LOC PRC TS-COMPYOP AGG 3 OTHER AUTOMOBILE LIABILITY I COMBINED SINGLE UNIT $ tEa acuaent) ANY AUTO BODILY INJURY iPer perwr.; $ OWNED SCHEDULED AUTOS ONLY AUTOS N/A BODILY INJURY iPer acuoenh S HIRED NON-OWNED PROPERTY DAMAGE _—._..AUTOS ONLY . AUTOS ONLY {Per a6U0en1) 3 UMBRELLA LIAB OCCUR EACH OCCURRENCE - EXCESS LIAB CLAIMS-MADE NIA AGGREGATE S DELI RETENTION3 3 WORKERS COMPENSATION i X STATUTE OTH ER AND EMPLOYERS'LIABILITY i YIN ANYPROPRIE IOPA RTNERIXECUTIVE R' E L EACH ACCIDENT 3 1.000.000 A OFFICER+M£MBEREXCLUDED? NM NIA N/A WVC1 0060 1 9802 2 0 2 3A I01/01/2023 01/01/2024 (Mandatory we NH) I E.L.DISEASE-EA EMPLOYEE 3 1.000.000 I!yes.desuit*umber DESCRIPTION OF OPERATIONS below El DISEASE-POLICY LIMIT 3 1,000.000 N;A DESCRIPTION OF OPERATIONS 1 LOCATIONS/VEHICLES(ACORD 101.Additional Ranaras Schedule may be attached d more space is ragweed) Workers Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B.no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the Insured hires,or has hired those employees outside of Massachusetts This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass govftwdlworkers-compensatloniinvestigations'. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN Oceanside Inc ACCORDANCE WITH THE POLICY PROVISIONS 217 Thornton Drive AUTHORIZED REPRESENTATIVE Hyannis MA 02601 Daniel M.Crowley.CPCU.Vice President-Residual Market-WCRIBMA c 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD r><rst Floor _,_ tti c i Drywall and insulation repair in Rooms . 1-8 and 25. , Paint all rooms worked in and the lobby. Wa .ap: , 'iPLI- I--—,_— dama_ �`/ THE , -- r f Cl?P.,c'L iiPV6c. BUILT" 7. BATE: it Unit 1 Unit 2 Unit 3 6` ING OFFICIAL Unit 4 Unit 5 Unit 6 I, U I Unit 7 nit � _ •�B: B. �� -�� ' - e. lO ,' $ 1 , __-, G'---I 1"�I2'4" 1. r ■II � ' -11 J - �� Hallway 2 .� C MEW los-i l (l l ( (Rt4>s�IR, i ��, ru0o r I — 1, t o �' �s,,. BR 28 , I;nit 78 BR 27 Unit 27 Unit26 �``'` ��� +'_,..1_. i �BR 26 13R 2.5 - nit 25 i^ r 1 itio 28 B ' -atio 28':,tio 27 13 ' T _ISZ io 25 b Patio 25 W 20220815_REPAIRS First Floor 3/18/2023 Page: 1 T I Second Floor i/u6 / 96;j<`)fifiai/ 2.h,y-> Drywall and insulation repair in Rooms 29 - 36 and 47. Paint all rooms worked in. Repair glass in broken door. iI ,r ' u' ,z ,2 ,,, Patio 29 Patio 30 Patio 31 Patio 32 Patio 33 Patio 34 64 Patio 35 Patio 3 4'6" �'6 1'(i r Unit 29 Unit 30 Unit 31 Unit 32 Unit 33 Unit 34 Unit 35 Unit 36a 4'2'"'5'--w it'�i._5'_'.• r2'¶'-5'_..• f 2'r`--5,— T. 7, B.hroo 19 B ro o7oo 1 B rootirditoo 3 B ooBi ikoo 1 5 B;, roo ;c6 92'4" 6—i Repair oor Hallway 4'8" 7"Ty t1(��(��'' e�i(si� < ' -..-4'9" 7' 7' 4'9"-e-4 . •11 7,,--�r_m' �• r 1 r � 1 h iR WHO .y .. .' .,ilb - dcuiloBR B.11 �1;- T 7' . 8" g � Left .>��:«,� . . B+ h 48 B-: ► 7 �.44: 47 B .hroo 1�.7 r- - --, 1 —' F _• i • 11 � 1-7'4" _1 `I-- �r f-..-7'5"—' 1-7'4" T 7'4"—1 '"--7'5" I N Unit 49 �' IR ight BR. 49 t Left BR 49 Right BR 48'7" Unit 48 � eft BR 48 BR 47 Unit 47 ( '6" t do 49 )RBIs) Patio 49 Firatio 49 (LB do 48 (RBFF) Patio 48 F-atio 48 (LB do 47 (BR Patio 47 VI Second Floor 20220815_REPAIRS 3/18/2023 Page:2