Loading...
BLD-22-007042 RECEIVED ONE & TWO FAMILY ONLY- BUILDING PERMIT JUN 03 2022 Town of Yarmouth Building Department 1146 Route 28, South Yarmouth,MA 02664-4492 BUI F,. TMEVT 508-398-2231 ext. 1261 Fax S - Br r� ,.r ��r - F 08 398-0836 , Massachusetts State Building Code,780 CMR Building Permit Application To Construct, Repair, Renovate Or Demolish .; a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: j21 b-'22—00'3C 2 Date Applied: Building Official(Print Name) ,r.ture Date SECTION 1:SITE INFORMATION 1.45 Sapertyil- ldLOor-//S G 1.2 Assessors Map&Parcel Numbers 1.1 a Is this an accepted street?yes X( 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 i 1.6 Water Supply: (1vi.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public 0 Private 0 Zone: — Outside Flood Zone? Check if yesl� Municipal 0 On site disposal system 0 SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: cca►►{{tQ Cc)4I 1 nine j MA j ®7�1 Name(Prilit) City,Satte,ZIP Z t4 ,,k 1,-; —0Telephone- 53z.� r' 'c c r'rrr :.c ' ,d1- No.and Street Ema Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building 0 I Owner-Occupied ❑ f Repairs(s) 0 Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other 'Specify: itzt ����-; - Brief Description of Proposed Work2:le jelQCe_. ejtiT►vi V$.►DuDer +- j) $ ►. {-ir _— c nem, 0.C-r k;e -.5VID ter-4-1.0cc11, S . -�r+A_. RECEIVED SECTION 4: ESTIMATED CONSTRUCTION COSTS. JUN 212022 Item Estimated Costs: � (Labor and Materials) Official Use Only gUILDINO DEPARTMENT I.Building $ -7 315 .dD 1. Building Permit Fee:$ ,1 O Indicate h�rv� tie .a r=ati `,- — ?.Electrical $ Standard City/Town Application Fee ❑Total Project Cost3 I.em 6)x multiplier x 3.Plumbing $ 1,g°a,° 2. Other Fees: $ ` 3.1.) 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire Suppression) $ Total All Fees:$ Check No. Check Amount: (ash 6.Total Project Cost: $ i, ? t °D 0 Paid in Full Outstanding Bal ce Due: 11' D-____..) WeJfice. Ma _ D f 1t SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) Name of CSL Holder License Number Expiration Date List CSL Type(see below) No.and Street Type 1 Description U I Unrestricted(Buildings up to 35,000 cu.ft.) City/Town,State,ZIP R Restricted 1,%2 Family Dwelling nI Masonry • RC j Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor CHIC) HIC Company Name or HIC Registrant Name HIC Registration Number Expiration Date No.and Street Email address City/Town, State,ZIP Telephone SECTION 6:WORKERS' COMPENSATION INSURANCE AFFIDAVIT(VI.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? 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 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 perjury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. 7K,Z-2. Print Owner's or Authorized Agent's Name(Electronic Signature) D to 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.cov/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 o. . ' -,�, B BUILDING DEPARTMENT �"rr "^TT^°^Er=�_'-4.'� 1146Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1261 ,n�5'w,c.�ILo.:c ti„ HOMEOWNER LICENSE EXEMPTION PLEASE PRINT: DATE: JOB LOCATION: d S S�.lt id„, e NAME STREET ADDRESS SECTION OF TOWN "HOMEOWNER" 213-895-838'5 NAME HOME PHONE WORK PHONE PRESENT MAILNG ADDRESS 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,provided 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 I 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 Ybi,94 (J) Zj APPROVAL OF BUILDING OFFICIAL INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent, which meets the requirements of MGL Ch.142. Yes 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. 7 Sign(7}',: t ' ��` Check one: ure of Owner oiOwner's Agent g Owner Anent h:horneownrlicexemp §TOWN OF YARMOUTH 1146 Route 28, South Yarmouth, MA 02664 508-398-22311 ext. 1261 Fax 508-398-0836 Office of the Building Commissio 4 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 075 \S JI i2,.KS uric. /& Work Address Is to be disposed of oat the following location: & ll'� Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Ch. 111, §150A. �C 5/28' L�ZZ Si to e of A 4 libation g PP Date Permit No. Bath Fitter Bridgewater Inc. 25 TURNPIKE ST, BATMTM WEST BRIDGEWATER,MA,02379 TYPE:Contract 7 T E DATE:2022-03-01 Tel:508-521-2700 Fax:508-588-4303 BFU375@bathfitter.com REF#:375-LOBCGS5G-MCO CUSTOMER Gayle Cody BILLING ADDRESS SERVICE ADDRESS 25 Salt Works Lane, 25 Salt Works Lane, Yarmouth,Massachusetts,02664 Yarmouth,Massachusetts,02664 Tel: 203-895-8385 Tel: Email: capecody@comcast.net DESCRIPTION Shower/FSSB/Rectangle White marble °TY PRICE 32IN X 60IN/Left Hand Drain 1 INCLUDED with Front Open Drains/Shower/Grate Brushed nickel PLU450,PLU452,PLU453 INCLUDED One Piece Seamless Wall/ White marble Rimini Mosaic Tile Pattern 841N X 132IN(83-3/81N X 1 INCLUDED 1311N) { Organizational Items/Corner White marble Shelf/Oxford Double Corner INCLUDED Shelf r0" ,,, Faucets/Moen Tub&Shower Brushed nickel/2.5 GPM Shower Faucet Set/Brantford INCLUDED Positemp Faucets/Moen Valves/ /N/A N_ sitemp Valve 2570/PLU182 N/A INCLUDED Wit u Off Faucets/Moen Hand Helds/ Brushed nickel/1 Shower .75 GPM Sh Fixed 4-Function Wall Bar INCLUDED Safety Options/Grab Bars/ Brushed stainless/16lN . , Knurled Grip 1 INCLUDED Safety Options/Grab Bars/ Brushed stainless/24lN Knurled Grip 1 INCLUDED Doors&Curtains/Rods/ Brushed nickel Curved 601N 1 INCLUDED Doors&Curtains/Rods/ Brushed nickel Straight 661N INCLUDED N/A 114 Bath Fitter Bridgewater Inc.("Bath Fitter'®")-Terms and Conditions—Massachusetts I. Cnntrac_ t Dngg_mg is. The contract documents consist of this agreement(the•'Agreement"),the attached Order,all written modifications dt'he Agreement or the during floornst laor iocen.Such h damages agar s could nc to the immediate work hear l rev ngoc or Order pursuant to Section h below,any required notices and any separate warrant duk of adj ce. tiles,Suchts could,include, the emoatlon,the placement or information provided by Bath Fitter*(collectively,'the Contract Documents"). exY crackingitn materials.er ah Fitter oceanst,be caused by responsible and these replacement es 2. Seose or Work Bath Fitter®agrees to provide all the labor and to do all the things should they appear.Moreover,in the case otbbah ner owal only installations,damages necessary for the proper installation and completion of the project set forth in flusher damage may occur to he existing bathtub or wall tiles; Bath Fittertt is not detail on the attached Order(he"Project"), responsible for minor damages,due to imperfections in any bathtub or wall tile that 3. Access.Owner agrees that Bath Fitter*shall have complete use of and access to the may result from the Bath Fitter}t; installation, and Owner remains responsible Project location during regular business hours,upon reasonable advance notice to to maintain the gout/silicone on existing walls.Should Bath Fitter*be required to Owner.Owner shall remove all obstacles such as furniture and appliances from the send a technician fora service call that Ls the result of inadequate maintenance.Owner installation area and Owner shall provide all heat and lighting for Bath Fitters to perform the Project.During the installation,Bath Fitter®shall properlywill be invoiced at the current service rates. remnants and scrap material relating to the Project.If a defect isallgedi disposeither 17. patients may varout the y.Bath wallsub, or r,cannot guarantee the workmanship or product,immediate notification must be made and Bath Fittenik 'Marbled colors or an most be allowed ready access in order to assess and/or make any repair of the alleged Ill. Baths Fitter*the color to Suspendatters oorkTermina( Limitation accessories, ftt defects. Filter*;is not responsible for legal encumbrances,building/zoning code violations, 4. Existing Plumbing.ft is expressly understood by the parties that neither Bath Fitter*nor any Bath Fitter*employee,agent or subcontractor is a licensed architect lend paintng or structural deficiencies,t s,or the discovery ry of or removal of asbestos.mold, or professional engineer.Bath Fitter*is not responsible far inspecting,servicing,ct lead or other hazardous or toxic substances s or materials.If Owner breaches the Contract Documents.terminate or if Bath Finero discovers any ofthe above,Bath Fittcrx:may modifying your existing plumbing fixtures and facilities. Because the existing immediately terminate the Contract Documents without further obligation to Owner plumbing at the Pmject location may be old,corroded,or in need or repair or breachr,in it entire discretion,discontinue a work un the Project pending replacement,Bath Fitterl4 cannot he responsible for damage to the chrome finish, agrees applicable1al Pe g Proper cure ofthc blocked drains or plumbing below or behind the tub,including shut-off valves,or for correction by properly qualified firms at Owner's expense. any damage caused by faulty plumbing.Bath Filter recommends replacing old by Baths Fitterbleh o ugh the Bath udatr//t thc costs of time oftermination, lus as. ny other amounts services provided d fixtures when installing a new wall system. under applicable law. 5. Contract Price.Owner agrees to pay Bath Fitter*the amount set forth on the IF REASON FITTER•R•IS UNABLE TO COMPLETE THE PROJECT FOR ANY attached Order,unless otherwise mutually agreed upon between the panics hereto by UNRELATED TO OWNER,BATH FITTEPO S LIABILITY SHALL virtue of a written change order. BE LIMBED TO A REFUND OF OWNER'S DEPOSIT. BATH FNC FOR h. Change Orders. Any alteration or deviation from the above contractual CANNOT BE HELD RESPONSIBLE FOR CLAIMS OF INCONVENIENCE OR specifications that results in a revision of the contract price will be executed only ANY OTHER HARM. upon the parties entering in to a written change order detailing such changes and the Iv' C partyforcntial Damages.Bach Finer*will not be batik to the Owner or any third resulting change to the contract price.Each change order shall become part of the for special,indirect.COnsegcential,exemplary or punitive damages or costs Contract Documents.All work shall be perhnned under the same terms and haarising knowleout of dge related damages es ctortheandwheaetDoc or sucheveiti es accosts conditions as specified herein unless mutually agreed in uniting, have knowledge of such damages or costs and whether or not such damages or costs are foreseeable. 7. Method of Payment The method of payment of the contract price shall be as set 20 forth in the attached Order.Immediately upon completion of the Project,the Owner Warranty.The only warranty offered on the material you purchased in accordance wagrees to pay to Bath Fitterk�the balance of the total agreed upon price,less the initial substance the Contract Documents is the manufacturer's warranty.For silicone or any like deposit.If payment is not made,all discounts will be reversed and an adjusted invoice joints/seats a 12-month warranty front installation date is offered.The will be sent to Owner.Owner shall indemnify and reimburse Bath Fitter*for all above warranties are not transferable and are for your personal benefit only.The reasonable costs of collection associated with late payment or nonpayment including warranties offered in relation allo this Agreement and the remedies set forth therein but not limited to reasonable attorneys'fees.A late charge of 1 Me per month shall are exclusive and in lieu of other warranties,remedies and conditions,all sets,whether be added to all overdue balances(nominal annual percentage rate of ISM).There oral,written,stardory,express or implied.Bath Filter disclaims all statutory and will be a 525.00 fee for any retumad check. implied warranties,including without limitation,legal warranties of quality and R. Payment Options.garb Fittetu otibrx third party financing for qualified buyers.If fitness for a particular purpose and warranties against hidden or Intent defects.Bath you choose to finance your purchase and your application is approved,a third partyFitter limits c the number and remedies of such warranties to the duration of the finance contract will prevail and may provide for a different month) payment warranties contained therein. amount and team than shown in the Contract Documents.The option of financing 21. Integration and SevernhIlt�. The Contract Documents contain the entire may only be selected at the time you place your order. agreement between the parties herew and supersede all prior oral or written 9. permits Owner shall famish and pay for,at their own expense,taxes, understandings,Should any part of the Contract Documents for any reason be found _ Pelicrmits inclOuster furnish limitation.pay,local, t and municipal se,axs and licemite and invalid,such a determination shalt not affect the validity of any remaining portion of required by law or any applicable regulations to perform the work in accordance with withit Contracteach Documeng,If me t shallha and this Agreement are in any way inconsistent these Contract Documents. You hereby agree to defend,indemnify and hold Bath 22. each other,this and Agreement Re govern. Fitter harmless,of front and against any claims,liability,suits,damages,expenses, governed a Law accordance ccDispute anc Resolution The Contract to of Mass shall be s. costs(including reasonable attorney fees),fines and penalties attributable toyour For any and s discoed in other mate with n laws of the State out r or related to For any claims,rctdispute other breh in controversyyprovision arising of Fi related to failure to comply with the above obligation.In all instances where Bath Fitter would determine,in its discretion,it would provide any of the abovemenlioned pemtits or these t dispute attoaDocuments, the breach ofn any hin thereof p drb may licenses, it will note you Director the the Of to a privatearbitration firm which has beengl approvedi by the administrative costs will b added la he contract price. Bah Fitterit cannot be held and of the l be r of Consumerosu mit Business n as provided e in MGL, responsible for any permit related delays. and Owner 4shall be required to submit to such arbitration as provided n MGL, 10. Chapter 142A.The non-prevailing party in the arbitration shall pay the prevailing Win Although Bath Fitter*makes every effort to do so,Bath Fitter*cannot party's reasonable attomey fees,costs,and expenses. guarantee that your installation will be completed in one day.In addition,on occasion Bath Fitter®will be forced to postpone die start date of a project whether due t '-4�''yJ3'()tT'13;()3;31EST scheduling conflicts,labor or material shortages.It is Bath Fitter*policy to notify -�F�� the customer as soon as any change is known.You will be informed of the reason For ..e,.. Ot the delay and the revised installation date.If she installationis delayed or takes more - Date — Owttar`s Signature —than one day,Bath Fitters,cannot be held responsible for any reimbursement, :022-03-0IT12:02:466S'I' discount,or any other type of compensation to you for claims of inconvenience or ' t/r,..n,,_s:, .. _any other harm.Unnecessary delays experienced by our technician caused by Owner i—q--, a22413-Or, will result in an additional charge. Bath FitterlD Signature _ —• — ------ 1 I. NOTI OF t's+ n rAngs. Dale TRANSACTION AT ANY TIME PRIOR THE OWNER W NERIiMT AYF THE THIRD TI lls 23. Use of E-m u r r mar Fand s ><aFrom pro time to time,wish Bath Fitter*(or any of its thud party strategic partners and service provides)may wish to contact you at the BUSINESS DAY AFTER TIIE DATE OF THIS AGREEMENT, BATIT e-mail address set forth on the attached Order,You hereby authorize Both Fitter* BUSINESS PRODUCTS WILL BE CUSTOM MADE FOR YOU,BATH BECAUSEFI BAT (or any of its third party strategic CANNOT REFUND YOUR DEPOSIT AFTER THE CANCELLATION PERIOD to communicate with you for thenwars and service providers)to use your email FITIEHAS EXPIRED. b purpose of improving IIath products. research and marketing,including obtaining your feedback and conducting customer 12. ITO\I' OI ICtr research and satisfaction surveys. I ATtON,YOU MAY CANCEL TIIIS AGREEMENT IF IT IIaS BEEN SIGNED BY A PARTY TI IERETO AT A PLACE OTHER THAN AN '�I agree with the use army e-mafl for these u ADDRESS OF THE SELLER, WHICH MAY BE HIS,MAIN OFFICE OR 74' 1=k!!5•Massachusetts law• purposes BRANCH THEREOF,PROVIDED YOU NOTIFY THE SELLER IN grants lien rights t builders.Any construction contractor, AT Ills MAIN OFFICE OR BRANCI!BY ORDINARY MAIL POSTED.BY subcontractor.tradesman material dischargedlr ho is not paid can record a lien on TELEGRAM SENT OR BY DELIVERY,NOT LATERthe property being THAN MIDNIGHT OF become a security like a mortgage on the byr payment.this mechanics'Tien will THE THIRD BUSINESS DAY FOLLOWING THE SIGNING OF THIS ii ocontractorsra to Y AGREEMENT.SEE THE ATTACHED NOTICE OF CANCELLATION FORM 25. 5 a tram.All u and subcontractors must be registered by the OCADR, and any inquiries about a contractor or subcontractor relating to a registration should FOR AN EXPLANATION OF THIS RIGHT, 13. Farce date ire be directed to OCABR. �.Bath Fitters,shall not be held liable for any loss,damage or delay Do not sign this Agreement if there are any blank spaces. in connection with this agreement due to delays in transportation of materials, I understand and agree to the terms and conditions above,including without ,.:accidents,theft fire,labor disputes,insurrection,acts of God,or any other cause t beyond Bath Fitter®'s control. Contract the terms of the attached Order dated �a22-03-0t and all other 14. Removal of R Documents of same date xhdnr,fljihiegg.Bath Fitter is not responsible for the removal and/or Yarmu t°reinstallation of fixtures,including electrical fixtures.Bath Fitter will not remove Dated at Massachusetts nu the list and/or reinstall anyofg 20 day of March doors.In the event that the doors will no longextures, r including. Bath Fhoutrncannot be held responsible for any reimbursement,discount,or any other type of compensation to 20�2- 3."t?1 ,2-.�2:32 ES T you for replacement of hese fixtures. t. 15. 214Lt1.Mold occurs naturally in almost all indoor environments.Molds Signature of Property )homes throwP Y Owmcr or Dut•Authorized by mperpy.(hvncr 6h doorways,windows and a variety of other.ways.A Bath Fitter* Daps Cody installation may include the removal of wet,loose,defective,discolored or odorous Name of Property paper or Duly Authorized b Pro rt surfaces and the washing of remaining surfaces with a household bleach solution. Yo Pe>Owner fPkaye/rrlrorJ Bath Ftltcnffi 25 Sao Works taco. and its representatives make no warranty or representation of any kind, ^AO11tn'Massachusetts,ozsea express or implied.regarding the presence or absence of mold,or regarding the effectiveness of any biocide designed for reducing the presence,effect or growth of mold,and make no warranty or representation with respect to,and cannotAddress of Pmpetty patter or Duly Authorized b Pro responsible for,the be held Oath FitlurandgowatorInc. Y Property Owner installation. presence of mold in your home subsequent to the Bath Fiucru; / �j��j:G. humuse' If during he installation phase.Bath Fitters,is required to perforate ( -- 1 02:4�>, _ repairs to existing walls•additional charges will apply at the current service rates. NamPer: Mario of Consultant Ma v Conde • 314 NATIBAT-01 AJIMENEZ ,4�oRo /Y CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDYYY) 12/21/2021 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 NAME: Johnson,Kendall&Johnson,Inc. PHONE 109 Pheasant Run (A/c,No,E:t):(215)968-4741 Newtown,PA 18940 ADDRE info '•c (A/c,No):(215)968-0973 ADDRESS: �j kj• Om INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Hartford Fire Insurance Co. 19682 INSURED INSURER B:Zurich American Insurance Co. _ 16535 BATH FITTER BRIDGEWATER,dba Bath Fitter INSURER C:Arch Insurance Company 11150 25 Turnpike St. INSURER D: West Bridgewater,MA 02379 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 'ADDL SUER POLICY EFF POLICY EXP - - _ LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS A I X COMMERCIAL GENERAL LIABILITY I EACH OCCURRENCE $ 2,000,000 CLAIMS-MADE i X I OCCUR 39UEEEB1605 6/30/2021 6/30/2022 DAMAGE TO RENTED I 300,000 PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY PRO- JECT J LOC 1 j PRODUCTS-COMP/OP AGG $ 2,000,000 l OTHER: $ B AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 _(-Ea accident) $ X ANY AUTO BAP4845884-02 6/30/2021 6/30/2022 BODILY INJURY OWNED SCHEDULED (Per person) $ AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ AUTOS ONLY NON-OWNED ONLY PROPERTY DAMAGE (Per accident) $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE I$ EXCESS LIAB i CLAIMS-MADE AGGREGATE $ DED j j RETENTION$ C WORKERS COMPENSATION $ AND EMPLOYERS'LIABILITY X STATUTE J OTH- ER ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N ZAWCI5806603 1/1/2022 1/1/2023 1,000,000 OFFICER/MEMBER EXCLUDED N/A E.L.EACH ACCIDENT $ ? N (Mandatory in NH) _ If yes,describe under E.L.DISEASE-EA EMPLOYEE $ 1,000,000 DESCRIPTION OF OPERATIONS below 1,000,000 E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) BFU 375-Bath Fitter Bridgewater,Inc.dba Bath Fitter,25 Turnpike St.West Bridgewater MA 02379 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE To whom it may concern. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) 9The ACORD name and logo are registered marks of A ACORD015 CORPORATION. All rights reserved. CORD The Commonwealth of Massachusetts Department of Industrial Accidents -9 ,,k, o tw Office of Investigations avms• moor mom immor l"� Lafayette City Center c w� ,mimr � 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): Bath Fitter Bridgewater Address:25 Turnpike Street City/State/Zip:West Bridgewater Ma 02379 Phone #:508-521-2700 Are you an employer? Check the appropriate box: Type of project(required): 1.❑■ I am a employer with 25 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ❑ New construction 2.❑ I am a sole proprietor or partner listed on the attached sheet. 7. 0 Remodeling shipand have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance. # 9. ❑ Building addition required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.0 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.❑ Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13.0 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. 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:Arch Insurance Company Policy#or Self-ins. Lic. #:ZAWC15806603 Expiration Date:1/1/2023 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 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 th t e inform ion provided above is true and correct. Si nature: • ate: 1/1/2022 Phone#: 508-521-2700 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): 11:1Board of Health 20 Building Department 31:City/Town Clerk 4.0 Electrical Inspector 5EIPlumbing Inspector 6.0Other Contact Person: Phone#: M (Nil $ 0 Co HZIC % / o Z / ? / I \2O ® @ o m O alX \ / $ % 0 c \ / / _ ƒ g J m w ? � -I m b \ ( ®2 § g C 3> 1 m ca # -0oiT.i Q3mT \ \ £ - -0 -I H » > � 2 2 . 0 / 1m e m / z J n m 2 2 N)& < SGQ (0 O / x \o . > m - / - � -l ; m xS C o - > � f e = 2/ > D 0 ¥ 0 « mi c m CD § k w - I O 2 ® w Z o — O 0 2 — o G _ 0' O O = R O O 7 73 c O O 3 % ? ua) 00k7 ƒ CD SD� 0 P < 0 � - r)is n a) o § � � k n w Z > Eo % ƒ R c m o 5 = x < �� § � / R 1)tzt a co a CO@CDE7 O m ' § � » ' -' - J � I X � c, 5' - £ - m . — = � 2 ' < 2 _ 3 m o .• CSC / C• Cn x _. Cn _ £ a / E 13a � co k7i ) c _. k� CD a) S. = a = \ . 0 CID 'El. $ \ K £ o �CD co / a � m ? 0• ƒ CD ? 30 • U) K5@2 = = 0 o a N) _ 70 co = n % Ti &I-3e (CI ,Z6“ e5; it --rt)16 (;(16 0 24" 4 4P fift-;4-3 06( NOTICE OF CANCELLATION FORM FOR HOME SOLICITATION SALE 2022-03-01 Date of Transaction: Ref St: 375-LO8CGS5G-MCO 2022-03-01 Date this contract is signed: Ref#: 375-L08CGS5G-MCO You may cancel this transaction,without any penalty or obligation,within three business days from the above date. If you cancel,any property traded in,any payments made by you under the agreement,and any negotiable instrument executed by you will be returned within ten business days following receipt by the seller of your cancellation notice, and any security interest arising out of the transaction will be cancelled. If you cancel,you must make available to the seller at your residence,in substantially as good condition as when received,any goods delivered to you under this agreement;or you may,If you wish,comply with the instructions of the seller regarding the return shipment of the goods at the seller's expense and risk. If you do make the goods available to the seller and the seller does not pick them up within twenty days of the date of your notice of cancellation,you may retain or dispose of the goods without any further obligation.If you fall to make the goods available to the seller,or if you agree to return the goods to the seller and fail to do so,then you remain liable for performance of all obligations under the contract. To cancel this transaction,mail or deliver a signed and dated copy of this cancellation notice or any other written notice,or send a telegram,to: Bath Fitter Bridgewater Inc. 25 TURNPIKE ST, WEST BRIDGEWATER,MA, 02379 Not later than midnight of 2022-03-04 I hereby cancel this transaction. Date: Signature of Property Owner or Duly Authorized by Property Owner: 4/4 Bath Fitter Bridgewater Inc. 25 TURNPIKE ST, TYPE:Contract BAT I WEST BRIDGEWATER,MA,02379 • DATE:2022-03.01 FITTER REF#:375-L08CGS5G-MCO Tel Fax:508-588-4303 BFU375@bathfitter.com DESCRIPTION OTT PRICE Faucets/Delta Plumbing Brushed nickel/N/A Shower 1 INCLUDED Accessories/Drop Elbow Permit 1 INCLUDED Relocate Drain 1 INCLUDED Remove Existing Tub and Wall 1 INCLUDED Wall Preparation 1 INCLUDED Wall Repair Wall repair 1 INCLUDED Plumber Additional plumbing 1 INCLUDED Non-, --�— —_ -_ Sub Total $9,280.00 Customer would like install in 1st week of August(preferred 8/4) TOTAL% $9,280.00 Deposit/Payment I $1,000.00 Balance due on completion I $8,280.00 /Balance Financed I Cash I understand that Oath Fitter and Its representatives are not sweat led to advise moon mold detection or clean-up.I have been offered a slip-resistant coating as an option for an additional cost.The following (attached)terms and conditions establish any rights and obligations under this agreement,Including those provided for by the applicable consumer protection legislation.Estimate valid for 30 days. (' kit0�2h2L9,31501M02_4 " 2022 02:29EST Mario Conde Signature of Property Owner or Duly Authorized by Property Owner Bath Fitter Bridgewater Inc. 214 Bath Fitter Bridgewater Inc. 25 TURNPIKE ST, TYPE:Contract BATH WEST BRIDGEWATER,MA,02379 F I T T E Re DATE:2022-03-01 REF#:375-LO8CGS5G-MCO Tel:508-521-2700 Fax:508-588-4303 BFU375@bathfitter.com DESCRIPTION OTY PRICE Faucets/Delta Plumbing Brushed nickel/N/A Shower 1 INCLUDED Accessories/Drop Elbow Permit 1 INCLUDED Relocate Drain 1 INCLUDED Remove Existing Tub and Wall T INCLUDED -------------- Wall Preparation 1 INCLUDED Wall Repair Wall repair t INCLUDED Plumber Additional plumbing 1 INCLUDED NOTES Sub Total 89.280•00 Customer would like install in 1st week of August(preferred 8/4) TOTAL $8r280.00 Deposit/Payment $1,000.00 Balance due on completion $8,280.00 /Balance Financed Cash I understand that Bath Fitter and its representatives are not qualified to advise me on mold detection or clean-up.I have been offered a slip-resistant coating as an option for an additional cost.The following (attached)terms and conditions establish my rights and obligations under this agreement,including those provided for by the applicable consumer protection legislation.Estimate valid for 30 days. ( 2-0 301 2022 .02:29EST Mario Conde Signature of Property Owner or Duly Authorized by Property Owner Bath Fitter Bridgewater Inc. Bath Fitter Bridgewater Inc.("Bath Fitter®")-Terms and Conditions—Massachusetts I. Contract Documents. The contract documents consist of this agreement (the Wall,floor or ceiling damages in or adjacent to the immediate work area may occur "Agreement'),the:attached Order.all written modifications of the Agreement or the during installation.Such damages could include,without limitation,the loosening or Order•pursuant to Section 6 below.any required notices and any separate warranty cracking of adjacent tiles,paints or joints.caused by the removal and replacement of inforiation provided by Bath Fitters(collectively. the Contract Documents"). existing materials.Bath Fitter k:cannot be held responsible for these damages 2. $egyc of W'orlt. Bath Fitters agrees to provide all the labor and to do all the things should they appear.Moreover,in the case of bath liner or wall only installations. necessary for the proper installation and completion of the project set forth in thither damage may occur to the existing bathtub or wall tiles; Bath Fitters is not detail on the attached Order ithe"Project"). responsible for minor damages,due to imperfections in any bathtub or wall tile that and r 3. ,Access,Ownee agrees that Bath Fitters shall have complete use ofaccess to the may result from the Bath Finery installation, and Owner remains responsible Project loch during regular business hours,upon reasonable advance notice to to maintain the grout/silicone on existing walls.Should Bath Fitters.be required to send a technician fora service call that is the result of inadequate maintenance.Owner Owner.Owner shall remove all obstacles such as tbmiture and appliances from the installation arca and Owner shall provide all heat and lighting tar Bath Fitters-to will be invoiced at the current service rates. perform the Project.During the installation.Bath Fitters shall properly dispose of 17. Colors.Marbled colors or patterns may vary.Bath Fitters cannot guarantee the remnants and scrap material relating to the Project.If a defect is alleged in either consistency of the color patters throughout the tub,walls or accessories. workmanship or product,immediate nmitication must be made and Bath Fitters must be allowed ready access in order to assess amd'or make any repair of the alleged 18 Rath Fitter*Right to Suspend or Terminate:Limitation of liability Bath defects. Fitters,is not responsible for legal encumbrances,buildingrioning code violations, 4. Existing Plumbing.It is expressly understood by the parties that neither Bath Plumbing or structural deficiencies,orthe discovery oforremoval of asbestos,mold, FitterB nor any Bath Fitters employee,agent or subcontractor is a licensed architect lead paint or other hazardous or toxic substances or materials.If Owner breaches the Contract Documents,or if Bath Fitter*discovers any of the above.Bath Fitter!,may or professional engineer.Bath Fitters-is not responsible for inspecting,servicing,or immediately terminate the Contract Documents without further obligation to Owner modifying your existing plumbing ((stares and facilities. Because the existing or,in its entire discretion,discontinue work on the Project pending proper cure of the plumbing at the Project location may be old,corroded,or in need of repair or breach and/or applicable correction by properly qualified limns at Owner's expense. replacement,Bath Fitters cannot be responsible for damage to the chrome finish. Owner agrees to pay Bath Fitters the costs of materials,labor and services provided blocked drains or plumbing below or behind the tub.including shut-off valves.or for by Bath Hoerr.throughlhedactinco(temminatinn,plusanymheramountsallowed any damage caused by faulty plumbing.Bath Fitter recommends replacing old under applicable law. fixtures when installing a new wail system, IF BATH FITTERS IS UNABLE TO COMPLETE THE PROJECT FOR ANY 5. Contract Price.Owner agrees to pay Bath Enteric the amount set forth on the REASON UNRELATED TO OWNER.BATII FITTERS'S LIABILITY SHALL attached Order,unless otherwise mutually agreed upon between the parties hereto by BE LIMITED TO A REFUND OF OWNER'S DEPOSIT. BATI I FITTER a; virtue of a written change order. CANNOT BE I IELD RESPONSIBLE FOR CLAIMS OF INCONVENIENCE OR 6. Change Orders. Any alteration or deviation from the above contractual ANY OTHER IIARM. specifications that results in a revision of the contract price will be executed only 19. Consequential Damages.Bath Fitters will not be liable to the Owner or any third upon the parties entering in to a written change order detailing such changes and the pony for special,indirect,consequential,exemplary or punitive damages or costs resulting change to the contract price.Each change order shall become part of the arising out of or related to the Project or these Contract Documents,even tithe parties Contract Documents. All work shall be performed under the same terms and have knowledge of such damages or costs and whether or not such damages or costs conditions as specified herein unless mutually agreed in writing. are foreseeable. 7. Method of Payment.The method of payment of the contract price shall be as set 20. Warranty,The only warranty offered on the material you purchased in accordance flak in the attached Order.Immediately upon completion of the Project,the Owner with the Contact Documents is the manufacturer's warranty.For silicone or any like agrees to pay to Bath Filters the balance oldie total agreed upon price,less the initial substance joints seals a 12-month warranty from installation date is offered.The deposit.If payment is not made.all discounts will be reversed and an adjusted invoice above warranties are not transferable and are for your personal benefit only.The will be sent to Owner.Owner shall indemnify and reimburse Bath Fitters. Ibr all warranties offered in relation to this Agreement and the remedies set forth therein reasonable costs of collection associated with late payment or nonpayment including are exclusive and in lieu of all other warranties,remedies and conditions.whether but not limited to reasonable attorneys'fees.A late charge of I'i°u per month shall oral,svriiten,statutory•,express or implied.Bath Fitter disclaims all statutory and be added to all overdue balances(nominal annual percentage rate of 18°%).There implied warranties,including without limitation.legal warranties of quality and will be a S25 00 fee for any returned check. fitness for a particular purpose and warranties against hidden or latent defects,Bath 8. Payment Onions.Bath Fitters-offers third party financing for qualified buyers.If Fitter.limis the duration and remedies of such warranties to the duration of the you choose to finance your purchase and your application is approved,a third party warranties contained therein. finance contract will prevail and may provide for a different monthly payment 21. Integration and Severabilih'. The Contract Documents cocain the entire amount and tern than shown in the Contract Documents.The option of financing agreement between the parties here' and supersede all prior oral or written may only be selected at the time you place your order. understandings.Should any part of the Contract Documents for any reason be found 9. Permits Owner shall furnish and pay for,at their own expense,laves,permits and invalid,such a determination shall not affect the validity of any remaining portion of licenses,including without limitation,local and municipal permits and licenses, the Contract Documents.I f the Order and this Agreement arc in any way inconsistent required by law or any applicable regulations to perforni the work in accordance with with each other.this Agreement shall govern. these Contract Documents. You hereby agree to defend.indemnify and hold Bath 22. Applicable Law and Dispute Resnhutinn.TIme Contract Documents shall be Fitter harmless,of,front and against any claims,liability,suits,damages,expenses, governed and construed in accordance with the laws of the State of Massachusetts. costs(including reasonable attorney fees),fines and penalties attributable to your For any claims,dispute or other natter in controversy arising out of or related to failure to comply with the above obligation.In all instances where Bath Fitter would these Contract Documents.or the breach of any provision thereof Bath Fitters may determine,in its discretion,it would provide any of the abovenentioned permits or subunit the dispute to a private arbitration firm which has been approved by the licenses, it will notify you and the permitrlicese fee including reasonable Director of the Office of Consumer Affairs and Business Regulation("OCABR"l administrative costs will be added to the contract price Bath Fitters cannot be held and Owner shall be required to subunit to such arbitration as provided in MGL. responsible for any permit related delays. Chapter h42A.The non-prevailing party in the arbitration shall pay the prevailing It. Delays.Although Bath Fitterty makes every chat to do so,Bath Fiuerk cannot parry's reasonable attorney fees.costs,and expenses. guarantee that your installation will be completed in one day.In addition,on occasion 2t>_•*2:rJ3-B IT;2;42:3 I L S T Bath Fitters will be forced to postpone the start date of a project whether due to scheduling conflicts labor or material shortages.It is Bath Fitters policy to notify a ' 2022.03.0t the customer as soon as any change is knsn n.You will be inibrmed of the reason for 'r's "" -- ._...._. ._. Owner's 2-014urc Date the ddayand the rca•isedinstallation date.It the installation is delayed or takes more 'n`2-tm.-ulll.':ii'>ItrPS`I' than one day,Bath Fitters cannot he held responsible for any reimbursement, / _ discount,or any other type of compensation to you far claims of inconvenience or '' ��' 2022.03-01 any other harm.Unnecessary delays experienced by our technician caused by Owner B tth Fitters Signature Date will result in an additional charge. 23. Use of E-mail for Customer Feedback.From time to time,Bath Fitters(or any of I I. NOTICE OF CANCELLATION. THE OWNER MAY CANCEL THIS its third man strategic partners and service providers)may wish to contact you at the TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD(ism) party s 6 P DUSINESS DAY AFTER TI IE DATE OF THIS AGREEMENT.BECAUSE BATH e-mail address set forth on the attached Order.You hereby authorize Bath Filers FITTER�n PRODUCTS WILL BE CUSTOM MADE FOR YOU,BATII FITTER'S (or any of itsc third party strategic partners and improvingoe providers)ft use your ears. CANNOT REFUND YOUR DEPOSIT AFTER TilE CANCELLATION PERIOD to communicate amid as with you for the purpose of feedbcBath Filtertin pnducfer IIAS EXPIRED, services and narketine,including obtaining your feedback and conducting customer research and satisfaction surveys. 12. HOME SOLICITATION.YOU MAY CANCEL TI IIS AGREEMENT IF IT 11AS ✓ I agree with the use of my e-mail for these purposes BEEN SIGNED BY A PARTY THERETO AT A PLACE OTHER TI IAN AN 24, Liens,Massachusetts law grants lien rights to builders.Any construction contractor. ADDRESS OF THE SELLER, WIIICII MAY BE IBIS MAIN OFFICE OR subcontractor.tradesman or material supplier who is not paid can record a lien on BRANCIl THEREOF,PROVIDED YOU NOTIFY TIIE SELLER IN WRITING the property being improved.If not discharged by iaynment,this mechanics'lien will AT HIS MAIN OFFICE OR BRANCH BY ORDINARY MAIL POSTED,BY become a security like a mortgage on the property. TELEGRAM SENT OR BY DELIVERY.NOT LATER TI IAN MIDNIGHT OF 25. Registration.All contractors and subcontractors must be registered by the OCABR, THE THIRD BUSINESS DAY FOLLOWING THE SIGNING OF THIS and any inquiries about a contractor or subcontractor relating to a registration should AGREEMENT.SEE TIIE ATTACIIED NOTICE OF CANCELLATION FORM be directed to OCADR. FOR AN EXPLANATION OF THIS RIGHT. Do not sign this Agreement if there are any blank spares, 13. Force Maleure.Bath Fitters shall not be held liable for any loss.damage or delay I understand and agree to the terms and conditions above,Includin without in connection with this agreement due'to delays in transportation of materials, 1f 2022 accidents,theft.tire,labor disputes,insurrection,acts of God.or any other cause o3Ot limitation the terms of the attached Order dated and all other beyond Bath FitterS's control. Contract Documents of same date. 14. Removal of Existing Fixtures.Bath Fitter is not responsible for the removal and/or Dated at yam"Oitt' ,Massachusetts on the otst toy'of March reinstallation of fixtures,including electrical fixtures.Bath Fitter will not remove2822 and;or reinstall any of your existing fixtures,including,without!invitation,shower -y 02^y�Q 3..O t4.,2:02.32 LL:J S G r^ doors.In the event that the doors will no longer fit,Bath Fitters cannot be held - -1 responsible for any reimbursement,discount.or any other type of compensation to you for replacement of these fixtures. Signature of Property Owner or Duly Authorized by Property Owner IS. Mold.Mold occurs naturally in almost all indoor environments.Mold spores enter Gayle Cody homes through doorways,windows and a variety of other ways.A Bath Fitters. Name of Property Owner or Duly Authorized by Property Owner(Please Print) installation may include the removal of wet,loose,detective,discolored or odorous 25 Salt Works Lane. surfaces and the washing of remaining surfaces with a household bleach solution. Yarmouth.Massachusetts,02664 Bath Fitters and its representatives make no warranty or representation of any kind. express or implied•regarding the presence or absence of mold,or regarding the Address of Property Owner or Duly Authorized by Property Owner effectiveness of any biocide designed for reducing the presence,effect or growth of Bath Fitter Breigewater Inc. mold.and make no warranty or representation with respect to.and cannot be held responsible for,the presence of mold in your home subsequent to the Bath Fitters: 7 f 1'y. 2 ,i r installation. �, itift( �dlU-- '"r` - Per: \ t.__.. 16, )nstallation.IE during the installation phase,Bath Fillers is required to perform Name of Consultant repairs to existing walls,additional charges will apply at the current service rates. Mare Condo §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 &5 .5J-J &o,-/GCS .Z 4,oe Work Address Is to be disposed of oat the following location: c25 S .r-riei, p. 577 /i) 3,74,0416.- Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Ch. 111, §150A. "AA Ji / z.L_ Signature of Application 4 Date Permit No. SECTION S: CONSTRUCTION SERVICES tim Construction Supervisor License(CSL) eodore4A CS- I DO384) Name of CSL Holder License Number Expitatio Date ,J k _� 1 List CSL Type(see below) No.and Street /�� r(�w Type Description ity/Town, � /'�4A. Da73r • U Unrestricted(Buildings up to 35,000 Cu. ft.) State,ZIP R Restricted I&2 Family Dwelling n1 Masonry RC Roofing Covering WS Window and Siding Qt/d� ��� C� SF Solid Fuel Burning Appliances Telephone)a_ST 7 C o1nSi-nAL jrQ I Insulation mail address i l V C.Cofk D Demolition Registered Home Improvement Contractor(HIC) 2 ) 171 e_C•cio '1 ;\ i k e-79 a E a3 ��Corn an 'Name or FIN Registrant Name HIC Registration Number Expiration Date N . dStreet - I `� �tt�.ColnS11(14..C{ionQ `1Vim• wn UUQ od,73F� ,Sd$-93o?•Sy'�'� Email address W K., 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. Failute this affidavit will result in the denial of the Issuance of the building permit. p E IV E D Signed Affidavit Attached? Yes — - 0 No . 0 SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN JUN 2 7 202 OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT _ By I,as Owner of the subject property,hereby authorizele BUILDING D=PARTMENT to act on my behalf, in all matters relative to work authorized by this building pei'rfiit application. K� ate Print Owners arm(E ectronic ature °?'� d'"t SECTION 7b: OWNERI OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of peijury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. Sledthre:4-604.: Print Owner's or Authorized t s Name El /� av I (Electronic Si Y gnature / 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.eov/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.) garage,(including finished basement/attics,decks or porch) Gross living area(sq.ft.) Number of fireplaces Habitable room count Number of bathrooms Number of bedrooms Type of heating system Number of half/baths Type of cooling system Number of decks/porches Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" A`ORD® CERTIFICATE OF PROPERTY INSURANCE DATE(MM/DD/YYYY) 06/08/2022 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. PRODUCER CONTACT NAME: PHONE (844) 472-0967 FAX (A/C,No,Ext): (A/c,No): (203) 654-3613 BIBERK ADDRESS: salessupport@biberk.com P.O. Box 113247 PRODUCER Stamford, CT 06911 CUSTOMER ID: _. INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURERA:Berkshire Hathaway Direct Insurance Compal 238130 INSURER B: Theodore Bailey INSURERC: 58 Delano Rd Apt 1 Marion, MA 02738-2011 INSURERD: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: LOCATION OF PREMISES/DESCRIPTION OF PROPERTY (Attach ACORD 101,Additional Remarks Schedule,if more space is required) Location: 58 Delano Rd, apt 1 Marion, MA 02738-2011 Bldg #001: Carpentry - 7422101 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 POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION COVERED PROPERTY LIMITS LTR, DATE(MM/DD/WYY) DATE(MM/DD/YYYY) X PROPERTY BUILDING $ _ 0 CAUSES OF LOSS DEDUCTIBLES PERSONAL PROPERTY j BASIC 250 ING N9BP424491 04/28/2022 04/28/2023 IIBUSINESSINCOME $ 0* BROAD CONTENTS EXTRA EXPENSE * X SPECIAL RENTAL VALUE EARTHQUAKE BLANKET BUILDING $ n/a WIND BLANKET PERS PROP $ n/a FLOOD BLANKET BLDG&PP $ n/a ■ $ $ INLAND MARINE TYPE OF POLICY $ CAUSES OF LOSS ■ NAMED PERILS POLICY NUMBER ■ $ CRIME I $ $ TYPE OF POLICY $ $ BOILER&MACHINERY/ EQUIPMENT BREAKDOWN $ $ , $ I $ SPECIAL CONDITIONS/OTHER COVERAGES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) * ALS up to 12 months. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Theodore Bailey ACCORDANCE WITH THE POLICY PROVISIONS. 58 Delano Rd Apt 1 Marion, MA 02738-2011 AUTHORIZED REPRESENTATIVE ,:::fl ©1995-2015 ACORD CORPORATION. All rights reserved. ACORD 24(2016/03) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Departmnt of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 s�•''� www.mass.°ov/dia \Y orkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): W[idDff Address: ,Tir-i pj p Al 404- / `JJ City/State/Zip: aa,ryon Darsp- Phone #: 5DSO-9'302-54 47 Are you an employer?Check the appropriate box: Type of project(required): [I am a employer with employees(full and/or part-time).* 2.k1 am a sole proprietor or partnership and have no employees working for me in 7 ❑New construction any capacity.[No workers'comp. insurance required.] [ Remodeling 3.[I am a homeowner doing all work myself. [No workers'comp. insurance required.]t g C Demolition 4.[I 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.[ Electrical repairs or additions proprietors with no employees. 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 12.0 Plumbing repairs or additions These sub-contractors have employees and have workers'comp. insurance.t 13.[Roof repairs 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.ROtl]e '��e c 5.�.; e� 152,§1(4),and we have no employees. [No workers'comp. insurance required.] IAA*" nth 'nJ *Any applicant that checks box 41 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: g—ZI Policy#or Self-ins.Lic.#: 9$941a4�q % Expiration Date: 44)02 t/c gg 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 forwafdedto the Office of Investigations of the DIA for insurance coverage verification. I do hereby cer 'y under the pains and penalties of perjury that the information provided above is true and correct. Signature: , Date: �Z Phone Y: 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#: A�� ® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 06/08/2022 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 CONTACT NAME: BIBERK PHONE 844-472-0967 FAX 203-654-3613 P.O. BOX 113247 (A/C,No,Ext): (A/C,No): E-MAIL customerservice@biBERK.com Stamford, CT 06911 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIL# INSURER A: Berkshire Hathaway Direct Insurance Company 10391 T eRoESore Bailey INSURER B: INSURER C: 58 Delano Rd Apt 1 INSURERD: Marion, MA 02738-2011 INSURERS: 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 IADDL SUBR ' POLICY EFF POLICY EXP LTR ,INSD WVD POLICY NUMBER (MM!DD/YYYY) (MM/DD/YYYY) LIMITS X 1 COMMERCIAL GENERAL LIABILITY I EACH OCCURRENCE $ 1,000,000 X DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ 50,000 A N9BP424491 1 04/28/2022 04/28/2023 MED EXP(Any one person) 1$ 5,000 --I PERSONAL&ADV INJURY $ Included GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY PRO- JECT LOC i PRODUCTS-COMP/OPAGG $ 2,000,000 X OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ' ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident $ AUTOS ONLY n AUTOS )�. HIRED „ NON-OWNED PROPERTY DAMAGE AUTOS ONLY I AUTOS ONLY (Per accident) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATIONI PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBEREXCLUDED? NIA - (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ Professional Liability (Errors & Per Occurrence/ Omissions): Claims-Made 1 Aggregate DESCRIPTION OF OPERATIONS/LOCATIONS I 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 Theodore Bailey THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 58 Delano Rd Apt 1 Marion, MA 02738-2011 AUTHORIZED REPRESENTATIVE 6 ----- ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Commonwealth of Massachusetts 1l` Division of Occupational Licensure Board of Building Re ulations and Standards Const t+otirS O9rvisor CS-10C386 spires: 10/01/2023 THEODORE 4 BAILEY 58 DELANO RD APT 1 MARION MA 0:11738 Commissioner da, Cvn�itra G' Komin my2l Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Individual Registration Expiration 165792 11/18/2023 THEODORE J BAILEY THEODORE BAILEY 7) 58 DELANO RD APT 1 j n�f�.('� .$n: MARION,MA 02738 Undersecretary • • ( . 1Jec V ® DATE(202/YYYY) AC `..,►, CERTIFICATE OF LIABILITY INSURANCE 03/03/2022 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT,BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: BIBERK PHONE 844 472 0967 FAX 203 654 3613 P.O. BOX 113247 (A/C,No,Extl: (A/C,No): Stamford, CT 06911 E-MAIL customerservice@biBERK.com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# ,SS pp INSURERA: Berkshire Hathaway Direct Insurance Company 10391— I neotlore Bailey INSURER B: INSURER C: 58 Delano Rd INSURER D: apt 1 INSURERE: Marion, MA 02738-2011 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPEOF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF 'i POLICY EXP LIMITS LTR INSD_WVD (MMIDD/YYYY)'.(MM/DD!YYYY) X COMMERCIAL GENERAL LIABILITY I EACH OCCURRENCE I$ 1,000,000 DAMAGE TO RENTE ____ CLAIMS-MADE X OCCUR PREMISES(Ea occcur ence) $ 50,000 A i N9BP274877 04/28/2021 04/28/2022 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ Included GEN'L AGGREGATE LIMIT APPLIES PER: I GENERAL AGGREGATE $ 2,000,000 POLICY JECT LOC I PRODUCTS-COMP/OPAGG $ 2,000,000 X OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER 1 OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBEREXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ _ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ Professional Liability (Errors & Per Occurrence/ Omissions): Claims-Made Aggregate 1 DESCRIPTION OF OPERATIONS I LOCATIONS I 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 Theodore Bailey THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 58 Delano Rd Apt 1 Marion, Ma 02738 AUTHORIZED REPRESENTATIVE n Marion, MA 02738t _, 6`J= ' -- ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD a,. y .9 Request for Taxpayer Glare Fortr,to the (Rev.October 2018) Identification Number and Certification requester.Do not ogoartment eternal Revenue Service le the Treasury Go to the IRS. t3o to www.lrs.gov/Ferny/for Mstnict)ons and the latest information. 1 Name(as shown on your income tax return).Name Is required on this fine;do not leave this tine blank. Theodore Bailey 2 Business name/disregarded entity name,if different from above ---------- - a� f following seven box 3 �box for federal tax classification of the person whose name is entered on line 1.Check only one of the 4 Exemptions(codes apply only to y certain entities,not individuals;see g Q Int ual/sole proprietor or 0 C Corporation ❑$Co tienInstmrCtions on page 3): rpord ❑ Partnership 0 Trust/estate singb marker LLC Exempt payee code(1t any) t f3 0 Limited iabtity company.Enter the tax classification(C--C corporation.S--S corporation,P.-Partnership)► Note_Check the appropriate brae In the tine above for the tax dassIficatIon of the single-member owner. Do not check Exemption from FATCA reporting 1 LLC it the LLC is classified as a single-member LLC that is disregarded from the owner unless the owner of the LLC is a. c another LLC that is not disregarded from the owner for U.S.federal tax purposes,Otherwise,a single-member LLC that e of any) is disregarded from the owner should check the appropriate box for the fax classification of its owner. ❑ Other(see instructions)► Aiwa.ro•wig ,-,a,.d cwad•m•US.) 5 Address(number,street,and apt.or suite no.)See Instructions. Requester's name and address(optional) A 58 Delano Rd Apti 6 City,state,and Z]P code Marion,MA 02738 7 t.tst account number(s)haze(optional) Part I Taxpayer Identification Number(TIN) Enter your TIN in the appropriate box.The TIN provided must match the name given on line 1 to avoid E Social security number _...__..___.1 barcioas e withholding.For individuals,this is generally your social security number(SSN).However,for ares proprietor, or disregarded entity,see the Instructions for Peri I,later.For other 0 0 1 - 6 0 -1111 1 0 ent es,it is your employer Identification number(EIN).If you do not have a number,see How to get a 17ht later. or Note K the account is in more than one name,see the instructions for line 1.Also see What Name and 1 Employer lda+itilfceiion number 1 htmbar To Give the Requester for guidelines on whose number to enter. -1 I I I Fart II Certification Under penalties of perjury,I certify that: 1_The number shown on this form is my correct taxpayer Identification number(or 1 em waiting for a number to be issued to me):and subject to backup withholding because:(a)I am exempt from backup withholding,or(b)I have not been notified by the internal Revenue Service(IRS)that I am subject to backup withholding as a result of a failure to report all interest or dividends,or(c)the IRS has notified me that I am no longer subject to backup withholding;and 3.I am a U.S.citizen or other U.S.person(deftnew);and 4.The FATCA code(s)entered on this form(if any)indicating that i am exempt from FATCA reporting is correct. Certification instructions.You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have faded to report al interest and dividends on your tax return.For real estate transactions,tern 2 does not apply.For mortgage interest paid. aa7uiaa ion or abandonmerrt of secured property,cancellation of debt,contributions to an individual retirement arrangement(IRA),and generally,payments other than interest and dividends,you are not required to sign the certification,but you must provide your correct TIN.See the instructions for Part Ii,later. f Sign i� Signature of 4 , U.S. ► �/t ^ i Person /(i I Date! 1:,,,Cf �i v� Genera! instructions •Form t 099-all(dividends,including those from stocks or mutual fSection references are to the Internal Revenue Code unless otherwise •uFos) noted, •Form 1099-MISC(various prizes,awards,or gross types of income, proceeds) F .developments.For the latest Information about developments •Form 1099-B(stock or mutual fund sales and certain other meted to Form W-9 and its Instructions,such as legislation enacted she(they were published,go to www.irs.gov/FormiN9, transactions by brokers) p, „ ofForm •Form 1099-S(proceeds from real estate transactions) P `w Foy •Form 1099-tc(merchant card and third party network transactions) A,:=evaded or entity(Form W-9 requester)who is required to fits an •Form 1098(home mortgage interest),1098-E(student loan interest), ritaa,raEioe return with the IRS must obtain your correct taxpayer 1098-T(tuition) ioentrscation number(TIN)which may be your social security number •Form 1099-C(canceled debt) ISSet•dial taxpayer identification number(ITer adoption •Form 1099 A(acquisition abandonment of secured property) Myer identification number(ATiN),or employer identification number p party) 434,to report on an information return the amount paid to you,or other Use Form W-9 only if you area U.S.person(including a resident amount reportable on an information return.Exam es of information alien),to provide your correct TIN. returns include,but are not limited to,the fotowind.ap If you do notnetum Form W-9 to the requester with a TIN,you might •Form 10994NT(interest earned or paid) be subject to backup withholding.See What is backup withholding, later. • Cat,No.10231X Form W-9(Rev.10-2018) r _. _ ok.office.com/mail/inbox/id/AAQkAGFIZDFM1p4LTNjMTItNDY3MCO5MTrizLWM2NzAzMm.IhMeendn5/seannncn0«1 Qw ocU.......r,o,.,-. .,..