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HomeMy WebLinkAboutBLD-22-007481 ONE & TWO FAMILY ONLY- BUILDING PERMIT Town of Yarmouth Building Department 1146 Route 28,South Yarmouth,MA 02664-4492 1114 .'-= 508-398-2231 ext. 1261 Fax 508-398-0836 Massachusetts State Building Code,780 CMR ale Building Permit Application To Construct, Repair, Renovate Or Demolish _ a One-or Two-Family Dwelling This Section For Official Use Only (T E C E I V ED Building Permit Number: (3(b).-.-()D7 It Rl Date Applied: i 13- a, JUN 27 2022 Building Official(Print Name) . afore Date _�. ----— SECTION 1:SITE INFORMATION BUILDINU BEPARTM NT ar ------ -. 1.1 Property Address: 1.2 sess s Map& arcel Numbers ` CO moRohuct 1.1a Is this an accepted street?yes no Map Num er Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: e '# (ChS Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) ��T 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required I Provided Required Provided Required Provided I 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public Private 0 Zone: _ Outside ood�Zone• Municipal❑ On site disposal systempf--, Check if ye�Eil SECTION 2: PROPERTY O WNERSEIP` 2.1 Owner'of Record: CAR L Os O k a r-Ro bar) 1 i'`vtv N - Fl x- - ? --2,_ Name(Print) City,State,ZIP 7 G 55" 0r,U16 iq e3 r re 2_ - 5b e ?00 -2 8 5 3 A oa-s r2oI ,o W16.twsT No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORD'(check all that apply) New Construction 0 Existing Buildin Owner-Occupied ❑ 1 Repairs(s) 0 Alteration(s) ❑ Addition 0 Demolition 0 Accessory Bldg. 0 j Num er of Units ether 61 Specify:: Brief Description of Proposed Work2: V1 eL) • f w' �. Cez\ts- - -3'�Ti-i-it -As►s,I4`- `-914fr'k-c- 003-e-rs--e dVe-�eipIto-t-c�_ . r., . /4->50•.. -Dr 5.v,.44d( QA ' F/oo,as {.4C( .z. 01) pop_ i N i--e i v._—E K(-e 0-ii)(Z W 4.IZS - i N S t Pi - b R y 0 4 t( - G Il'i y&7 SECTION 4:ESTIMATED CONSTRUCTION COSTS. Item Estimated Costs: Official Use Only (Labor and Materials) I.Building $ %5-00a,— I. Building Permit Fee:4 5-0 Indicate how fee is determined: 41 Standard City/Town Application Fee 2.Electrical $ 35069 69 ❑Total Project Costa(Item 6) multiplier x (J,k 3.Plumbing $ 2t�DO'� 2. Other Fees: $�e Y 1a `�f(' 4.Mechanical (HVAC) $ List C/ 11/ 5.Mechanical (Fire $ Total All Fees:$ , D Suppression) i i Check No. Check Amount: Cash un: \ Z6.Total Project Cost: $ l� ❑Paid in Full 41 Outstanding Balanc Due:.i` /l\0�`L4 1 SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) 6011( G,041Ie/j � — o ���- -�� -� License Number Expiration Date Name of CSL Holds; ,/ y [ Z /'�1W.. s7 List CSL Type(see below) (�/ ` No.and Street Type Description gie r/ j yl p 4-- 2)2 , % t Unrestricted(Buildings up to 35,000 Cu.ft.) l R Restricted t&.2 Family Dwelling City/Town,State,ZIP M Masonry .x t/i, (>4,f/Q4w_soe,�ne_,c RC I Roofing Covering `, r�,� WS Window and Siding �� � /,� SF Solid Fuel Burning Appliances 77 7 I Insulation Telephone Email address D j Demolition 5.2 Re istered Home Improvement Contractor CHIC) W HIC Company Name or HIC Registrant Name HIC Registration Number Expiration Date LL kwt�<LL z-(AIL) V.) t� flbfrr/s et:et ae(e..lit e'3/2,.cof 1�..S C set No.and Stre Email address . aAtiA p , -t s ah 0 0 ye101( City/Town,State,ZIP Telephone SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6)) 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? es No Cl . SECTION a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize / 0 ift.42 ) i ,0C to act on my behalf,in all matters relative to work authorized by this building permit application. 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 per jury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. /0 fWit,e 2-Z.-- Print Owner's or Authorized Agent's Name(Electronic Signature) Date NOTES: 1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)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.gov/oca Information on the Construction Supervisor License can be found at www.mass.aovldps 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (•i S Z (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 Z Number of half/baths -- Type of heating system CO - 40 t v.:ir(€RZ. Number of decks/porches Type of cooling system tte/Fr Ft.VAT . Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" i ne uummunweunn of iviussucnuseit Department of Industrial Accidents 9 'f Office of Investigations 4 J� j Lafayette City Center :' . :�<%� 2 Avenue de Lafayette, Boston,MA 02111-1750 41 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): WHALEN RESTORATION SERVICES INC Address: 22 AMERICAN WAY City/State/Zip: SOUTH DENNIS, MA 02660 Phone #: 508-760-1911 Are you an employer? Check the appropriate box: Type of project(required): 1.❑l 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. ❑ Demolition working for me in any capacity. employees and have workers' 9. [1] Building addition [No workers' comp. insurance comp. insurance.+ required.] 5. ❑ We are a corporation and its 10.0 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 12.0 Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other comp. insurance required.] *My 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: ACE AMERICAN INSURANCE COM NAIC#22667 Policy#or Self-ins. Lic. #: 6S62UB5B89454222 Expiration Date:04/04/2023 Job Site Address: ci ILO'�' Pit(V e.-'- City/State/Zip: S - k.RADbt.k- out . 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 pains and penalties of'perjury that the information provided above is true and correct. Signature: �c_~�._ Date: /) 'J� . 2' - Phone#: n L( t(Yc'7 L` f`3 9— 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): 1❑Board of Health 2❑Building Department 31:City/Town Clerk 4.0 Electrical Inspector 5DPlumbing Inspector 6.0Other Contact Person: Phone#: ONE or TWO FAMILY— BULDING PERMIT APPLICATION REGULATORY APPROVALS NOTICE Address of Proposed Work: C't z 1./m/i-6 V;(7eatvi-4( - Scope of Proposed Work: '����t,� . (p A(S — Usi,t Y 4t1—Dif- -Moog_ 4 e/rneou .,/' NU-we/A< tl-ec•�2s t 8+, Date: /0/1/1/ 0147,- • Based on the scope of work described above,the applicant is required to obtain approval sign- offs from the following departments as checked-of below: Health Dept.—508-398-2231 ext. 1241 Conservation—508-398-2231 ext. 1288 Water Dept. —99 Buck Island Road, 508-771-7921 Old Kings HWY. Hist. Comm. —508-398-22631 ext. 1292 Engineering Dept.—508-398-2231 ext. 1250 Fire Dept.—Kevin Huck/Scott Smith, 96 Old Main Street, SY Note: Please call Fire Department for an appointment. 508-398-2212 Other Appropriate plans and/or application shall be provided to each departments checked-off above. Each of these regulatory authorities has their own requirements outside the jurisdiction of the Building Department. All applicable approvals shall be obtained prior to submitting a building permit application to the Building Dept. Thank you for your cooperation. Receipt Acknowledgement: Applicant's Signature Date Rev. Jan. 2019 df d TOWN OF YA OUT I BUILDINGDEPARTMENT �'p w.r��tR«,, a .1146 Route 28, South Yarmouth,MA 02664 508-398-2231 ext. 1261 HOMEOWNER LICENSE EXEMPTION PLEASE PRINT: DA'1'h: (� JOB LOCATION: q w.®g o ,►� 4 l7 iu\c �(.4*( df flew cftiL__ - NAME STREET ADDRESS SECTION OF TOWN "HOMEOWNER" (J/ /0c/65726)i _579& 760— 2-253 NAME HOME PHONE WORK PHONE PRESENT MAILING ADDRESS 74) s—5 47`v')/5ill�'S r jQ/tr - 8✓z4 �ti 11)s% PI/ CITY OR TOWN STATE ZIP CODE The current exemption for `Homeowner' was extended to include owner—occupied dwellings of one or two units and to allow such homeowners to engage an individual for hire who does not possess a license,urovided that such homeowner shall act as supervisor. (State Building Code Section 110 R5.1.3.1) Definition of Homeowner: Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is or is intended to be, a one or two family attached or detached structure assessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner;such"homeowner"shall submit to the building official,on a form acceptable to the building official,that he/she shall be responsible for all such work performed under the building permit. (Section 110 R5.1.3.1) The undersigned `homeowner' assumes responsibility for compliance with the State Building Code and other applicable codes,by-laws, rules and regulations. The undersigned 'homeowner' certifies that he/ she understands the Town of Yarmouth Building Department minimum inspection procedures and requirements and that he / she will comply with said procedures and requirements. HOMEOWNER"S SIGNATURE `e- 1)1L.- APPROVAL OF BUILDING OFFICIAL INSURANCE COVERAGE: I have a current 'ability insurance policy or its substantial equivalent, which meets the requirements of MGL Ch.142. Ye No If you have checked ves, please indicate the type coverage by checking the appropriate box. A liability insurance policy Other type of indemnity Bond OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws and that my signature on this permit application waives this requirement. � -- Check one: Signature of Owner or Owner's Agent Owner gent h:homeownriicexemp §TOWN OF YARMOUTH 1146 Route 289 South Yarmouth, MA 02664 508-398-2231 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 ifitOtNi w(r' P/tftie- Work Address in location: YibitiOl4-A___ AYe)-51fil Is to be disposed of oat the following Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Ch. 111, §150A. / !i IAA V�•� III 111 Date Signature of Application Permit No. Specializing in Fire Restoration—All Work Guaranteed Access,Authorization and Direct Payment Request Form I(we)authorize WHALEN RESTORATION SERVICES to perform work as per estimate at property located at 9 Morning Drive.South Yarmouth,MA 02664 to repair damage caused by Water/Burst Pipe on 2/4/2022. As owner(s)ofthis property,I(we)understand that I(we)mist atdhoriee this work.I(we)hereby authorize WHALEN RESTORATION SERVICES to performthis work and accept responslbrlity for payment upon completion I(we)authorize and direct my Insularxe Company,,to Hake payments directly to WHALEN RESTORATION SERVICES,Insurance Claim Specialists,for doing this work and to that extent I(we)assign the benefits applicable to the loss to WHALEN RESTORATION SERVICES. I(we)acknowledge receipt of a copy hereof a �IDATE SIGNED 11-717 Z-0 2-2- S NED DAT WHALEN RESTORATION REP. -...,,, WHALRES-01 DKULICK A�Rim CERTIFICATE OF LIABILITY INSURANCE DAT6/9/2022 ) 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#1780862 CONTACT ONT CT HUB International New England ONNo,Ext):(508 945-0446 FAX )945-9136 265 Orleans Road (A/C, ) (A/C,No):(508 North Chatham,MA 02650 E-MAILSS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Acadia Insurance Company 31325 INSURED INSURER B: Whalen Restoration Services Inc. INSURER C: 22 American Way INSURER D: South Dennis,MA 02660 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 ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD,WVD (MMIDDIYYYYI IMM/DDIYYYYI A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR CPA 5427058-12 4/1/2022 4/1/2023 DAMAGE TO RENTED 100,000 PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ A AUTOMOBILE LIABILITY (EOMBINED a accident)SINGLE LIMIT $ 1,000,000 ANY AUTO MAA 5427059-10 4/1/2022 4/1/2023 BODILY INJURY(Per person) $ OWNED X SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS X AUTOS ONLY X AUUTOS ONEYY (PROPERTYr cidtDAMAGE $ $ A X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 EXCESS LIAB CLAIMS-MADE 5427060-12 4/1/2022 4/1/2023 AGGREGATE $ 1,000,000 DED X RETENTION$ 10,000 $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN 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 $ DESCRIPTION OF OPERATIONS/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 Carl Rockstroh ACCORDANCE WITH THE POLICY PROVISIONS. _ 9 Morning Drive South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE i 9-$,V-- -A4-3-1 I ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All r The ACORD name and logo are registered marks of ACORD 'ORE CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 06/09/2022 HIS 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 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 CONTNAME:ACT Cheryl Woodside HUB INTERNATIONAL NEW ENGLAND LLC la/c°."No.E:t): (978)661-6678 FAX (A/C,No): E-MAIL ADDRESS: cheryl.woodside@hubinternational.com 600 LONGWATER DRIVE INSURER(S)AFFORDING COVERAGE NAIC# NORWELL MA 02061 INSURER A: ACE AMERICAN INSURANCE CO 22667 INSURED INSURER B: WHALEN RESTORATION SERVICES INC INSURERC: INSURER D: 22 AMERICAN WAY INSURER E: SOUTH DENNIS MA 02660 INSURERF: COVERAGES CERTIFICATE NUMBER: 783118 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 EFF POLICY EXP W LIMITS LTR INSD VD POLICY NUMBER (MM/DD/YYYY) (MMIDD/YYYYI COMMERCIAL GENERAL LIABILITY EACH OCCURRENCEDAMAGE TO RENTE $ CLAIMS-MADE OCCUR PREMISES(Ea occur ence) $ MED EXP(Any one person) $ N/A PERSONAL&ADVINJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS N/A BODILY INJURY(Per accident) $ AUTOS NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS (Per accident) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY ANYPROPRIETOR/PARTNER/EXECUTIVE Y/N X STATUTE ER E.L.EACH ACCIDENT $ 1,000,000 A OFFICER/MEMBEREXCLUDED? N/A N/A N/A 6S62UB5B89454222 04/01/2022 04/01/2023 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) 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.gov/Iwd/workers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Carl Rockstroh ACCORDANCE WITH THE POLICY PROVISIONS. 9 Morning Drive AUTHORIZED REPRESENTATIVE South Yarmouth MA 02664 Daniel M.Cr y,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD Commonwealth of Massachusetts 1 : Division of Professional Licensure Board of Building Regulations and Standards • ,Su; CS-074928 Expires:08/10/2022 WILLIAM WHALEN 122 POND STREET BREWSTER MA 02631 Commissioner due. Office of Consumer Affairs and Business Regulation 1000 Washington Street- Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Corporation WHALEN RESTORATION SERVICES INC. Registration: 129244 22 AMERICAN WAY Expiration: 07/29/2023 SOUTH DENNIS,MA 02660 Update Address and Return Card. Office of Consumer Affairs&Business Reaulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Corporation before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation 129244 07/29/2023 1000 Washington Street -Suite 710 WHALEN RESTORATION SERVICES INC. Boston,MA 02118 WILLIAM WHALEN 22 AMERICAN WAY SOUTH :>— SOUTH DENNIS,MA 02660 Not valid without signature Undersecretary • cco _ FA o :' �; ,) 0• \' • 41 , ; r- J • 5 ' r,:. r. --a (...----, ifr----61 3"------4-T ;' .L4,/5„ `G f�tl 8' 1„ �1� t 6'8 W 11'5„ 1 — ET vg„ - - T _ 1� o0 ° 7, „ T I __ N — I.) 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