Loading...
HomeMy WebLinkAboutBLD-22-006967 ONE & TWO FAMILY ONLY- BUILDING PERMIT Town of Yarmouth Building Department 1146 Route 28,South Yarmouth,MA 02664-4492 508-398-2231 ext. 1261 Fax 508-398-0836 1-4. ''i Massachusetts State Building Code,780 CMR � ..4e Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling RECEIVED This Section For Official Use Only / r�!. EA Building Permit Number: (� n -� '�)l)tli Q try 7 Date Applied: 1� AO ��c.- ‘ } � N xiiii BUILDING DEPARTMENT Building Official(Print Name) \� Signature ey' D ((� SECTION 1:SITE INFORMATION • 1. Pferithdilkenl ` 1.2 Assessors Map&Parcel Numbers 1.1 a Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 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 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone? Municipal 0 On site disposal system 0 Public 0 Private 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' /� /� �nu ig_obtORZikrik.111 vimS a r, kOkAt I f,1 - .. `� IN. (Pr'n City,At te,Z „y� fre-i ,CA,C-6(AY(L irr_ty\tecur,d,,o ( No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED�WORK(chall that apply) New Construction 0 I Existing Buildi Owner-Occupied ❑`''Repairs(s) Alteration(s) 0 I Addition 0 Demolition ❑ I Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description f Pro ose Wox 1ok,�y nu jo6b/Aty' r U,r 0"r) r ,c- Slit,f fOU l'I ^' Gti - (VCC t Sr. w6 fiL 0 Y CIOSECTION 4:ESTIMATED CONSTRUCTION COSTS. - Estimated Costs: Official Use Only Item (Labor dls) 1.Building $ 1. Building Permit Fee:$ ) O _Indicate how fee is determined: i 0 Standard City/Town Application Fee 2.Electrical $ ❑Total Project Costa(Item 6)x multiplier x . 3.Plumbing $ 2. Other Fees: $ .,. CI,6 42,Fr 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Total All Fees:$ Suppression) d Check No. Check Amount: Cash Amount: \'sc)-' L 1� 6.Total Project Cost: $ , U CI Paid in Full 0 Outstanding Balance Due: // _ �\r"a\ SECTION 5: CONSTRUCTION SERVICES 5.1 Co ruction Supervisor License(CSL) t i ol/ 3 0 a 4 ImP l n p Q-'S License Number Ex ration ate e of CSL Ho er ( (4 GIB,, y,�k� List CSL Type(see below) No.an treet / Type Description S (tutUL \()Pk., 03 ci3O�J U R Unrestricted(Buildings up to 35,000 cu.ft.) 00o Restricted 1(%2 Family Dwelling City/Town,State,ZIP M Masonry a Oir pt 1 /49 N ices (} �rr , RC Roofing Covering K YI N 1 ► �' WS Window and Siding —F u i • ( G I --( (/v y, SF Solid Fuel Burning Appliances I Insulation Telephone Email address D ! Demolition 5.2 Registered Home Iniproveunent Contractor(HIC) d i c Qq /:s l `eLu r ro • )n 1 U V e j IIIC R gsstration Number Ex iratt Date IIC om• • ame or,' Registrant N e 0.1p ' t i ( co arr se as►ic cv1 , o. tre OiL mail address ` n ate ( 7/1'4c,33, 4Il G� City/Town,State,ZIP Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT I.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 Issu ce of the building permit. Signed Affidavit Attached? Yes No 0 SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIESrr FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize 1 Jev-onole-5 ic) to act on my b half,in all matters relative to work authorized by this building permit application. b. ,i( crn,CW 6,_ t _., S') 'DY lnt 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 accurate to the best of my knowledge and understanding. it S •)3-a� Print Owners or Authorized Agent's Name(Electronic Signature) Date NOTES: I. 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 IIIC Program can be found at www.mass.aov/oca Information on the Construction Supervisor License can be found at www.mass.eov/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 508-398-2231 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 ti A671°°4i) Wo Address p Is to be disposed of oat the following location: Ra-VoA)\ (0-t)(IA\l/e.Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Ch. 111, §150A. •► of Application Date ,,ture pp Permit No. r L e / Page 1 of 11 CT Reg#0605216 Y/C(MA Reg#146589 RI Reg#26463 HOME SOLUTIONS 26 Cedar St Woburn, MA 01801 800-242-9974 Federal ID #20-2625129 Luxury Contract Customer Information Robert Desmarais (508) 965-8972 0 Date:04/27/2022 48 Village Brook Rd reneandrose@gmail.com Rep: Joshua Moss South Yarmouth MA 02664 Office# 800-242-9974 Location Agreement NEWPRO hereby agrees that it will, for the consideration hereinafter mentioned, furnish all labor and material necessary to install the goods purchased by Owner in accordance with the terms described on the following pages of this agreement (collectively, this "Agreement") at the premises located at: 48 Village Brook Rd South Yarmouth MA 02664 Custom Shower Details Package: Tub to Shower(Custom Acrylic/Spray Foam) Wall Color: White Size- Drain: 59"L x 30"W- Right Wall Style: Smooth Base Color: White Walls To Ceiling: Yes Threshold: Single Fixtures 3.7" QTY 1 Chrome Align Shower Trim&Valve Moen Multi Function Hand Shower w/Slide Bar&Elbow QTY 1 Chrome Moen QTY 1 Chrome 5' Straight Shower Rod QTY 1 Chrome 18" Grab Bar Liquid Accents QTY 1 Chrome 24" Grab Bar Liquid Accents QTY 1 Gray Metal Teak Seat Moen Accessories QTY 2 White Single Tier Corner Shelf Smooth QTY 1 White Window Kit(51"x 6") Smooth Luxury Labor This space intentionally left blank Page 2 of 11 Remove Cast Iron or Steel Tub QTY 1 Tub will NOT be removed in one piece Wall Repair(As Needed) QTY 3 Installation & Promotion Details Newpro will remove any demoed or installation debris from the property in relation to this contract. All promotions were applied at the time of purchase and can not be combined with any future offers. Discounts Senior Discount Applied Veteran Discount Applied Payment Total Price: $15,400 Deposit: $0 Due Upon Completion: $15,400 Payment Method: Finance Estimated Start&Completion Estimated Start: 14 to 16 weeks Estimated Completion: 1 to 3 days r Customer understands they will be contacted to set a firm installation date once all product is received. State MA Year Home was Built 1970 LSWP NO This space intentionally left bla Page 3 of 11 Renovate Right Pamphlet Receipt Robert Desmarais 48 Village Brook Rd South Yarmouth MA 02664 Your family's health and safety is our top priority! I hereby acknowledge receipt of the pamphlet, "Renovate Right." This pamphlet informs me of the potential risk of lead hazard exposure from renovation activity to be performed in my home. I confirm that I have received this pamphlet before any work began on my home. ,4-21t/4°1' AtS-4-v4- Robert Desmarais 04/27/2022 Date Residential Exemption Clearance Form ENVIRONMENTAL PROTECTION AGENCY RENOVATION, REPAIR, AND PAINTING RULE Robert Desmarais 48 Village Brook Rd South Yarmouth MA 02664 The type and scope of the planned remodeling project is described further herein. On behalf of Newpro, the undersigned individual hereby states that the following exemption from the Renovation, Repair, and Painting Rule is applicable to the planned remodeling project: Work Performed on Paint-Free Surface.To exempt the work area as paint-free, BOTH of the following must be completed: On behalf of Newpro, the undersigned individual has personally examined the specific areas upon which the remodeling work will be performed, as well as any adjacent or adjoining areas(interior and exterior)that are expected to be impacted by the remodeling work. Upon such examination the undersigned has determined that there is no painted surface that will be disturbed, damaged, or otherwise affected or impacted by the planned remodeling project; AND By initialing after this line, the undersigned states that to the best of his and/or her knowledge, the areas upon which the planned remodeling project will be performed do not appear to contain any painted surfaces that will be disturbed, damaged, or otherwise affected or impacted by the planned remodeling project. Customer Initials NEWPRO Representative: I certify under penalty of law that the above information is true and complete to the best of my knowledge as of the date first written above. Joshua Moss 04/27/2022 Date This space uitentiorta "9 z +.g n Page 1 of 10 CREATE A 5 STAR EXPERIENCE FOR EVERY CUSTOMER ASK FOR A REVIEW" HOME SOLUTIONS Luxury Work Order Customer Information Robert Desmarais (508) 965-8972 Q Date:04/27/2022 48 Village Brook Rd reneandrose@gmail.com Rep: Joshua Moss South Yarmouth MA 02664 Rep# 800-242-9974 Bathroom 1 Details None Package Includes Selected Base, 3 Walls, 1 Corner Trim, Floor Repair if needed Shower Measurements Package Tub to Shower(Custom Acrylic/Spray Foam) Wall Color White Size - Drain 59 L x 30"W- Right Wall Style Smooth Threshold Single Walls to Ceiling - Room Height Yes- 89 Base Color White Left Side Wall Width 60 Opening Length x Existing Base Width 59 x 30' Left Surround Width 32 Trim Skirt YES Right Side Wall Width 60 Right Surround Width 32 Fixtures Align 3.7" Shower Trim&Valve QTY 1 Chrome MT 2192-C Moen Multi Function Hand Shower w/Slide Bar&Elbow QTY 1 Chrome MHS-3667EP-C Moen 5'Straight Shower Rod QTY 1 Chrome SRS-60-C 18" Grab Bar QTY 1 Chrome LAGB-18-C Liquid Accents QTY 1 Chrome 24"Grab Bar LAGB-24-C Liquid Accents Teak Seat QTY 1 Gray Metal MOE-DN7110 Moen Accessories Single Tier Corner Shelf Smooth QTY 2 White CC-ST W Window Kit(51"x 6") Smooth QTY 1 White WK-W Luxury Page 2 of 10 Labor Remove Cast Iron or Steel Tub QTY 1 Tub will NOT be removed in one piece Wall Repair(As Needed) QTY 3 Installation Instructions Left Wall Wall Repair- 18" Grab Bar-Teak Seat Back Wall Wall Repair- 24" Grab Bar-Window Kit Right Wall Wall Repair- Valve- Shower Fixture- Drop Ell Pre-install Checklist Variance Required NO Property Type Single Family Parking Options Large Driveway Fixture Install Handheld w/Drop Ell (No Shower Head) Curtain Rod or Glass Doors to be Installed Straight Curtain Rod Bath Location 1st Floor Existing Base Type Cast Iron/Steel Existing Walls Tile Is there access behind wet wall or below base? YES Below Base Ceiling Panel/Soffit NO Window Within Wet Area YES -Window Kit Ordered Wainscoting/Accessories NO Second Full Bath NO Additional Items to be Installed None Are there any existing problems with the plumbing? NO This space intentionally left- Page 3 of 10 image: 1.i .,,," • Page 10of10 Ima•e: ,8 1111 11 I s- A 1 s� j3 9 I1114 u ; sus _ t ��r . 4 . II. Commonwealth of Massa .4 Division of Occupational Licensure 1j Board of Building Res ulations and Standards ' ,r le Cons by ton 61/2 rvisor - fe. __ ...._... CS-110763 .....,' 6c.pires: 05/05/2024 JEFFREY C(*INORS :411 64 OLD FIELD RI) , SOUTH BERWJCK ME 03908 .'* ' -0.. ::. ,, ,. - * -- -, ....... t0' v LIV(1.-11. e-- Commissioner ,/4,aid21 K. Flandz . li L cCS L CO al U re c co -13 Q) N C C E O O N 00 N N R C Qco p 3 O (13 _ LO Q O O QCCO c6 � cLac� = � mtiL. c Q ZS O Ov) 00 (qO W 3 w C sP — toN Q'' a� L �C � N � •= -akao LLcaOL ++♦A O 4- O 00'Oa) L- > % u) C)oC� }' � p o °' Oca :1:21:cptc COU Y � o � c v, L a) o Q �2 E cow a) wx2O , mNv E , 00acom U ' E ., mE N� a) `— 0 O = _O \ a) O • R IX up U U m0 cU pN 1 c O , O y p fC N Z •L O C Z UO Q ' Oo N- auI • O CO ots H LZ 0- , W U O n aoJ Q EC .QZ w_ >cj 2co 0 pct 3°' Oui � co' zaWm ixa •N � F w E)U a � o z wNQ 2H 0 o Z � of 0 wcco2 Q 0 0 QwD 2Um w UFO Z EEN � AFRO® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) , THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS U IS/30/2021 CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BYA THE POLICIES DER. I 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 Melissa Pflug The Hilb Group of New England PHONE (508)366-6161 FAX 120 Turnpike Rd.Ste 300 (A/C,No,Ext1: 1(A/C,No): E-MAIL Melissap@mackintire.com ADDRESS: p@ SOUthbOrOU h INSURER(S)AFFORDING COVERAGE 9 MA 01772 INsuRERA: Employers Mutual Casualty Co 21415 INSURED 21415 INSURER B: Newpro Operating LLC INSURER C: 26 Cedar St. INSURER D: INSURER E: Woburn MA 01801 INSURER F: COVERAGES CERTIFICATE NUMBER: 21-22 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 AUUL SUER LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MMIDD/YEYYY POLICY EXP) X COMMERCIAL GENERAL LIABILITY ) (MMIDDIYYYY LIMITS EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR DAMAGE TO RENTED 500,000 PREMISES(Ea occurrence) $ A MED EXP(Any one person) $ 10,000 6D15090 12/31/2021 12/31/2022 1000,000 PERSONAL&ADV INJURY $ , GEN'L AGGREGATE LIMIT APPLIES PER: $ 3, , POLICY n jECOT LOC GENERAL AGGREGATE 000 000 1 PRODUCTS-COMP/OPAGG $ 2.000,000 OTHER. EMPLOYEE BENEFITS $ 1,000,000 AUTOMOBILE LIABILITY SOMBINE8 SINGLE LIMN.• ANY AUTO (Ea accident) $ 1,000,000 OWNED BODILY INJURY(Per person) $ A AUTOS ONLY X SCHEDULED 6Z15090 12/31/2021 12/31/2022 BODILY INJURY(Per accident) $ X HIRED NON-OWNED AUTOS ONLY X AUTOS ONLY PROPERTY DAMAGE $ (Per accident) X UMBRELLA LIAR Uninsured motorist BI $ 250,000 OCCUR EACH OCCURRENCE $ 5,000,000 6J15090 12/31/2021 12/31/2022 5 A EXCESS LIAB CLAIMS-MADE AGGREGATE $ ,000,000 _ DED I XI RETENTION$ 0 $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY X ;MUTE YIN STATUTE I ER A OFFICER/MEMBER EXCLUDED? N N/A E.L.EACH ACCIDENT 500,000 (Mandatory in NH) $ If yes,desc be under E.L.DISEASE-EA EMPLOYEE $ 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ SOC OOO DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Contractor/Carpentry/Siding Install 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. AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD A 03/14/12022 Y) CERTIFICATE OF LIABILITY INSURANCE DATE( 022 ' 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 Aon Risk Services,Inc of Florida NAME: Aon Risk Services,Inc of Florida 1001 Brickell Bay Drive,Suite#1100 PHONE FAX Miami,FL 33131-4937 (A/C,No,Ext):800-743-8130 (A/C,No):800-522-7514 EMAIL ADDRESS: ADP.COI.Center©Aon.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: New Hampshire Ins Co 23841 INSURED ADP TotalSource CO XXII,Inc INSURER B 5800 Windward Parkway INSURER C: Alpharetta,GA 30005 ALTERNATE EMPLOYER INSURER D: Newpro Operating LLC 26 Cedar St, INSURER E Woburn,MA 01801 INSURER F: COVERAGES CERTIFICATE NUMBER:3841567 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. LIMITS SHOWN ARE AS REQUESTED. INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSR WVD (MMIDD/YYYY) (MMIDDIYYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PROJECT LOC PRODUCTS-COMP/OP AGG $ OTHER $ COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY (Ea accident) $ -ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED _AUTOS ONLY AUTOS BODILY INJURY(Per accident)_ $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY _AUTOS ONLY (Per accident) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEC RETENTION$ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N X STATUTE ER A ANY PROPRIETOR/PARTNER/EXECUTIVE WCO24266477 MA 03/13/2022 07/01/2022 E.L.EACH ACCIDENT $ 2,000,000 OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 2,000,000 if yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 2,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) All worksite employees working for NEWPRO OPERATING LLC,paid under ADP TOTALSOURCE,INC.'s payroll,are covered under the above stated policy. NEWPRO OPERATING LLC is an alternate employer under this policy. CERTIFICATE HOLDER CANCELLATION Newpro Operating LLC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 26CedarSt THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Woburn,MA 01801 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE (toR,R.k 5etvice.6, 4nc of capticia ©1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD ir n'r' 0 'Sjl 2 r`)e�le !o L_ ette Boston, f a g2 11-_75/ ``'a„ J, jr ipass vida 77,W,-NIT• ka:r59 1~0 M pensation ii n e FA mfav : ldp_c Cora r ^torS I4 1Iet'PcR n i lr'f tI De ss 5 _Trot i n off` ation Please Feat LeRIE ,,' anae (Business/Organi7afion/-individual): NEWPRO OPERATING LLC .ddress:26 CEDAR ST it!% tat& ip:WOBURN, MA 01801 phone =: 781-933-4100 - you_:, e1ni 10yer? Check the appropriate box: ,(required): e 1., Tyne of�={����� tae.�.az:3�e�f. 7 i am a employer with 20 4. D I am a general contractor and I - - _ employees (full and/or part-time).* nave hired the sub-contractors 6. ❑New constrac on 1 am a sole proprietor or partner- listed on.the attached sheet. 7. F4r•emodeling These hese sub-contractors have ship and have no employees 8. Demolition employees and have workers' ',coric'ing for me in any capacity. o I ( comp.insurance.= Building addition o workers' comp. insurance _ 5. 1= We are a corporation and its '0.❑Electrical repairs or additions _equi,:ee.1 Li i a,;, a homeowner doing all work Off have exercised their i l.(_j Plumbing repairs or additions myself. [No workers' comp_ right of exemption per£v1GL- j 12.0 Roof repairs insurance reauired.l ' C. 152, §l( ),mid we have no employees. {No workers h•1 iher come.insurance required.] .nv applicant that checks box-I must also fill out the section below showing their workers'cornensation policy information. omeowuers who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. ontractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have anloyees. If the sub-contractors have employees,they must provide their workers'comp.policy number. Csran er.?uzoyer that is providing workers'eDE.2Da.72.9f'31:2 u ma's?li-'rc:Th;• employees.e 'is the policy rl isu aYnce Company l�ame: — NEW HAMPSHIRE INSURANCE CO olic g.or Self ins. Lie.„ W 02426647 7Ml I-0`j%0�= Y Expiration Date: V 1 ` CA"' `',Y/\ob Site�ddress:"1 � 6ot City/State/Zip:� lr I tW 41'\ VIL---(31)*0 _ �oe3y the workers' compensation 7ol_c� declaration ge{crno - r number and - te: 1 "':� �aa..��.. �•T_�'the�t�aarS _���_ �-"7%+c'L3=�a__�. 'ailure to secure coverage as required under Section 25P of MOL c. 152 can lead to the imposition of criminal penalties of a me up to$1,500.00 and/or one-year imprisonment, as well as civil ii penalties in the form of a STOP WORK ORDER and a fine iup to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of ovestigations of the DLA for insurance coverage verification. =o hereby ee5ii cj z IJd ._ th -n i�rl'7!.J{p laah-ee of perhzrj'that x c 7i2a-✓Y`s=J•.fi-ida rrc.':0vo is tr C. / �41 (�(n/ r L-'L the G Z! i O `and!'�a—,0 i enatare4`/ /t` u Date: o hone= 81-933 i 00 '",J drat rise only. Do riot write in this area,to be'O22Epi r'by city ri��'21 try i°f1fJ_ Oi�?CcCL City 'i'ovat; ?ermit/ eh ic s..¢,1Se i Issuing Author ity(check one): D3oard of Health 2U Building g Department 3 U r^a 1e_ _i tr; I =—� a �L ?il�Is ;.' "_��_ _Ca_ S €czl3r 9sha� 1 !!nsper or 6.1 !Other I Contact eTJvn. =]' e# i! �Ua ¢