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HomeMy WebLinkAboutBLDR-23-9989 k.,.► ;\c�cA ,..0,. 3-�.�..4,y UJpi l' -on le-L{t y- /k� ONE&TWO FAMILY ONLY-BUILDING PE W ri�c1 /1 Town of Yarmouth Building Department / or ittt 1146 Route 28,South Yarmouth,MA 02664-4492 / 508-398-2231 ext.1261 Fax 508-398-0836 '; Massachusetts State Building Code,780 CMR Building Perm it Application To Construct,Repair,Renovate Or Demolish \ a One-or Two-Family Dwelling i.A..7 Ai-Z S This Section For Official Use y Building Permit Number: ( •,DateA I r.\ SqAIS 4-Ls-13 Building Official(Print Name) ,.` a ignature ['APR VE6 t Wia23 SECTION 1:SITE INFORMATION 1.1 Pro a Address: 1.2 Assessors Map&Parcel N gl}DING DRTMj r q I�dfi_tlxrr)1 �drlv�. Y _ 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 Provided Required Provided Required Provided I.)111 0 IA- 014 1.)1A IS R 1J 1Fl- 1.6 Water Supply:(M.G.L c.40.454) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private 0 Zone:_ Outside Flood Zone? Municipal❑On site disposal system ❑ Check If yes❑ SECTION 2: PROPERTY OWNERSHIP' n• Record:ilone_a_ Ortit o Name(Print) Ci State,ZIP ti q l riLeuuorrl ,AllvP� _ _:K34 ,T� terru3DF ycheo-cw.. No.and Street Telephone Email dress SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building 0 Owner-Occupied 0 I Repairs(s) 0 Alteration(s) 0 Addition 0 w'Demolition ❑ Accessory Bldg.❑ Number of Units_ Other)4t Specify: r D i 1/t vi e Description of Proposed Work': U SECTION 4:ESTIMATED CONSTRUCTION COSTS. • Item Estimated Costs: (Labor and Materials) OfficiaCl7se Only 1.Building $ ,5(g 2'2 1. Building Permit Fee:$Kb Indicate how fee is determined: 2.Electrical $ tiI Standard City/Town Application Fee /��� 0 Total Project Costa(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical(HVAC) $ List: tYV.UV YYl O p 5.Mechanical(Fire p. .p-,, Q a,qi Suppression) $ Total All Fees:$ ' ��I p U Check No. Check Amount Cash Amount: 6.Total Project Cost: $ ]J ❑Paid in Full l9 Outstanding Balance Due: Q O SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) 'ks 1( ( ) g fh� t.o` t` 2 1 I�t J[i e LJ1 r t V Li 1,-. Number Expiration Date NameName of CSL Holder SN T p 1 n no I List CSL Type(see below) U No.and Street < `t�! Type Description uI v L� D Z 7 3 e U Unrestricted(Buildings up to 35,000 Cu.ft.) Cityl wn,State,ZIP R Restricted l&2 Family Dwelling M , Ivtasonry RC Roofing Covering WS Window and Siding 3�J � SF Solid Fuel Burning Appliances G I insulation Telephone Email ad ess D I Demolition 5 ' Registered Home AC2f hum eat Contractor(HIC) I Rej/ �`�p� // �� ""("C `'" ' ( iiii-- HIC Registration Number Ex trati n Date HI o an e r HIC Registrant N e C ups-\ — Lx Ii bf0 1/LJl/IC4J N an Street a^ ¢Q3Z y Email add ss City/Town,State,ZIP , I V �� p Tele hone SECTION 6:WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c.152.§ 25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the Issuance of the building perm' . Signed Affidavit Attached? Yes 0 No 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 Cat— to act on my behalf, in all matter elative to work authorized by this building permit application. �— 4110cdi- Print Oe(Elec tc Signatu Date SECTION 7b: OWNERt 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 e and accurate to the best of my knowledge and understanding. `'ii---30/- /77L%-. (1[14)3" Print Owner's or Authorized Agent Name Electronic •( Sib ature) Date NOTES: 1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration program or guaranty fund under M.G.L. c. 142A.Other important information on the HIC Program can be found at www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.aov/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 i Number of bathrooms Number of half/baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" §TOWN OF YARMOUTH 1146 Route 28, South Yarmouth, MA 02664 508-398-22311 ext.11261 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 I C� �I�l?( 1�r. (,rrninth . Work Address Is to be disposed of oat the following location: f l0 CSC1 U l 1'C, , I uu4 Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Ch. 111, §150A. (4110a- .. Sig ature of Application Date Permit No. ONE & TWO FAMILY ONLY- BUILDING PERMIT Town of Yarmouth Building Department r .. 1146 Route 28,South Yarmouth,MA 02664-4492 508-398-2231 ext. 1261 Fax 508-398-0836 1 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 E CEINCED Building Permit Number: BiD-23- OG c5Wate Applied: LAJR.21 2023 Building Official(Print Name) Signature . Date SECTION 1:SITE INFORMATION BUILDING 1)CPoRTN(ENT 1.1 Piperty Address:ua Del 1.2 Assessors Map&Parcel Num ers 1.1 a Is this JJan accepted street?yes , no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: 1 Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.G.L c.40,i54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public 0 Private 0 Zone: — Outside Flood Zone? Check if ycsD Municipal 0 On site disposal system 0 SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Rec d: NameRiN Print 3 ifteeA Ciry,S M/) CZi4 ti q I Dt )oo ` 1., ,SDf 7g 94/Z7 A. ag� r.ed2a.. No.and Street Telephone Email A ss SECTION 3:DESCRIPTION OF PROPOSED WORIC2(check all that apply) New Construction 0 I Existing Building Q Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0 Demolition 0 I Accessory Bldg.0 Number of Units Other li Specify: C (a,( GM Brief Description of Proposed Work2: Meta(e ea(i5 >Z_ J b�/thl l(v I ) W fvl--h i'1.e(,.J QL pcSJ2/Wt�1Trrn.p- SECTION 4:ESTIMATED CONSTRUCTION COSTS. Item Estimated Costs: (Labor and Materials) Official Use Only 1.Building $ f.11-5 I. Building Permit Fee:$ Indicate how fee is determined: Z.Electrical $ �Y ❑Standard City/Town Application Fee 3.Plumbing $ ❑Total Project Cost;(Item 6)x multiplier x /„50 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire . Suppression) $ Total All Fees:$ . 6.Total Project Cost: $ -7-7 2, Check No. Check Amount: Cash Amount: ❑Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTIONSERVICES ., 5.1 Construction Supervisor License (CSL) J ec�c�l�r� t ) 003 E' 10-1 "23 Name of CSL Holder License Number Expiration Date cg" DC )a r) D yQ/ .�'f-P1- J List CSL Type (see below) U No. and Street , JCS[ f Type Description M G.r{ o r) Y (32,1°?a Er Ti Unrestricted(Buildings up to 35,000 cu. ft.)City/Town, State, ZIP R Restricted 1&2 Family Dwelling M Masonry RC Roofing Covering WS Window and Siding G?Z� 1bcuk SF Solid Fuel Burning Appliances Telephone bf �� I Insulation mail address D � Demolition 5.2 Registered Home Improvement Contractor (IlIC) —._---_i Theodor 0/ ' �� 1- 1 . P1IC C� y e �Regis rar�t,j�iame ,/ MC Registration Number Expiration Date Al No and Street /I e hft4) �fi'1D/'� /�t tJ2 Uzo Email an rfts Citnown State, ZIP Telephone SECTION 6: WORKERS' COMPENSATION ENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152. § 25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the Issuance of the building permit. Signed Affidavit Attached? Yes El No 0 . SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES F DING PERMIT I, as Owner of the subject property, hereby authorize - 686 ‘ le to act on my behalf, in all matters relative to work gut prized by this building permit appyation. Ahdhlti Print Owner's Name(ElecPerT_____Ad„ c Signature) O Date SECTION 7b: OWNER1 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 ap lication is true and accura to the best of my knowledge and understanding. .....------- ti -Do Print wner's or Authorized Art. e ie o Signature) _ 0.5 Date NOTES: 1. An Owner who obtains a building permit to do his/her own work, or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC) Program), will not have access to the arbitration program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program can be found at www.mass.gov/oca Information on the Construction Supervisor License can be found at www.rnass.aov/dps 2. When substantial work is planned, provide the information below: Total floor area (sq. ft.) (including garage, finished basement/attics, decks or porch) Gross living area(sq. ft.) Habitable room count Number of fireplaces _ Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage" may be substituted for "Total Project Cost" §TOWN OF YARMOUTH 1146 Route 28, South Yarmouth, MA 02664 508-398-22311 ext.-1261 Fax 508-398-0836 Office of the Building 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_` ! / d le,W o d Work Address Is to be disposed of oat the following location: l(f/ L9(i//( a --- Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Ch. 111, §150A. Signature of Appli on Date Permit No. 3/( D} nweat\of o al e � Boarda A,Re +c as an Standards 7» 2 {\w#« uttres w »§ �, dote « , © k m«,A,ro2g mmm& a�S y #3�NO7 y y . a t, \ j . \ M ,A \«: \ { / \ . 2 ( mm . \ 6 ' * ® , _ __,2 •i;, `/,.,M,,,,,,r,,,/I.V.//.:a,. ,:.,,:.i., rl Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:individual Rgulstrgtjgp EXAlration ff 165792 11/18/2023 THEODORE J BAILEY THEODORE BAILEY 58 DELANO RD APT I £f (.-a6.!•r MARION,MA 02738 P _ __`__ Undersecretary / / The Commonwealth of Massachusetts a= t= Department offndustrialAccidents =t`�1= 1 Congress Street,Suite 100 _ f Boston,MA 02114-2017 4,,,,�, www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/OrganizatioMndividuap:, //2�?pdere t.//e y Address:_ City/State/Zip: era 11D11 IVA. o273f"Phone#: 33Y- 3„t 5�fS�7 Are you an employer?Check the appropriate box: �—`-- I, i are a employer with Type of project(required): ❑ employees Pali and/or part-time).* 2 tam a sole proprietor or partnership and have no employees working for me in 7. 0 New instruction y capacity.(No workers'comp.insurance requited.] 8• El Remodeling 3,D I erna homeowner doing all work myself(No workers'comp.insurance required.]t 9. ❑Demolition 4.❑I am a homeowner and will be hiring contractors to condom all work on my property.I will i0 El Building addition ensure that all contractors either have workers'compensation insurance or are sole proprietors with no employees. 11.❑Electrical repairs or additions 10 tam a general contractor and I have hired the sub-contractors listed on the attached sheet. 12'❑Plumbing repairs or additions These subcontractors have employees and have workers'comp.insurances 13.0 ROOF repalIS 6.❑we are a corporation and its officers have exercised their right of exemption per MGL a 14.�l pt}tgr �(.(.e 152,§I(4),and we have no employees.(No workers'comp.insurance required.] `r'e ',Any applicant that cheeks hoe Cl must also fill as the section below stowing their workers'compensation policy information KC(/1/ t Homeowners who submit this affidavit indicating they are doing all work end then hire outside contractors must submit a new affidavit indicating such tCantractors chat check this bax must attached an additional sheet showing the name of the rub-contractors and state whether or not those entities have employees.If the sub-contractors have employees,they must provide their workers'corny,policy number. I am an employer Uiai is providing workers'rompensation irrsaranco for my employees- Below is the policy and job site information. Insurance Company Name: Aer ksI1i re i. a,co al J Policy#or Self-ins.Liu.6: A./96'410?44,11i Expiration Date: Job Site Address: j City/SAttach a copy of the workers'compensation policy declaration page(showing the tpolicy 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$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of investigations of the DIA for insurance coverage verification. I do hereby cer i under the pains and penalties of rjury that the information provided above is true and correct. 'onature: ,mil. .2...------, y'n Olcaa 3 Date: Phone R: ,S j]$ 93,a gliq 7 Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License m • Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.CitylTown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone P: 414,2CoCERTIFICATE OF PROPERTY' INSURANCE D)ATE(MMIDDNYYY) /2022 THIS CERTIFICATE )S ISSUED AS A MATTER OF INFORMRTIO I ONLY AND CONFERS No RIGHTS UAOA! THE CERTIFICATEo6�o$R. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING HOLDER AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. POLICIES INSURER(S}, AUTHORIZED PRODUCER CONTACT NAME VHONE (844) 472-0967 FAX _ BIBERK -INttl; E•MAIL ---__ ...r� =I .�Lia.(2 ) 654-3613 A.O. Box 113247 PROD salessupport biberk.COM Stamford, CT 06911 PRODUCER ------__--._ ... INSURED 1---- INSIiRER(S)AFFORDING COVERAGE NAIC# INSURER A:Berkshire Hathaway Direct Insurance Compai 1238130 Theodore Bailey INSURER B 58 Delano Rd Apt 1 INSURER C: Marion, MA 02738-2011 —'� -INSURERR: -_''_`�`-"4 - - INSURER E: INSURER F:COVERAGES -—__ _.._.__.. CERTIFICATE NUMBER: LOCATION OF PREMISES/DESCRIPTION OF PROPERTY (Attach ACoRD 101,Additional Remarks Schedule,if more space is required) REVISION NUMBER: Location: 58 Delano Rd, apt 1 Marion, MA 02738-2011 Bldg #001: Carpentry - 7422101 THIS IS TO CERTIFY THAT THE POUCIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUEDS 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. 1NSR J - LTR R POLICY EFFECTIVE POLICY EXPIRATION COVERED PROPERTY i -- XPROPERTY DATE(MAR/DOmYY)l TYPE OF INSURANCE POLICY NUM DATE(MMlDL7JYYYY) LIMITS CAUSES OF LOSS DEDUCTIBLES BUILDING $ 0 ! BASIC BUILDING N9BP424491 04/28/2022 04/28/2023 I --! PERSONAL PROPERTY s - _._ 0_ 2 d i BROAD BUSINESINKt7ME -lK` * CONTENTS X SPECIAL �_..._._ _... $ EXTRA EXPENSE $ ' EARTHQUAKE RENTAL VALUE ... WIND Es-- BLANKET BUILDING $ n/a FLOOD AN PERS PROP �' /e -__... BLANKET BLDG&PP - s n/a $ INLAND MARINE TYPE OF POLICY $ CAUSES OF LOSS j + $ - $ NAMED PERILS l POLICY NUMBER l- J CRIME $ TYPE OF POLICY G $ BOILER&MACHINERY/ EQUIPMENT BREAKDOWN I $ SPECIAL CONDITIONS!OTHER COVERAGES (ACORD 101,Additiontai Remarks Schedule,may be attache/If more space Is required) - * ALS up to 12 months. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Theodore Bailey THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN 58 Deland Rd Apt 1 ACCORDANCE WITH THE POLICY PROVISIONS, Marion, MA 02738-2011 AUTHORIZED REPRESENTATIVE ACORD 24 (2016/03) The ACORD name and logo are registered marks of ACORD CORPORATION, All rights reserved. Commonwealth of Massachusetts 1 Division of Occupational Licensut8 Board of Building Regulations and Standards I Cons fonfS visor •s CS-100386 ..• ,pires:1 0101120 2 3 THEODORE*¢ ,1 'q 68 DELANO RD ;r a. . AO *, t MARION MA IQ • 1 ?YvOlJ.VaD3')J 1. Commissioner df,ta i..Eita i. 1 ti •F //,,.-;.;,..vfs e//; Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Individual Registration Expiration 165792 11/18/2023 THEODORE J BAILEY THEODORE BAILEY `� 58 DELANO RD APT 1 MARION,MA 02738 Undersecretary .%/ Yr•/IN/eemo i i/46 rr/4iid4riN Aie://' Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE Individual Registration gxoiration 165792 11/18/2023 THEODORE J BAILEY s THEODORE BAILEY 58 DELANO RD APT 1 ' MARION,MA 02738 Undersecretary iaY araee �_ . -\ I ne l.ommcenweuttn of tvtassacnuseus i=� Department oflndustrialAccidents _ Office of Investigations �;_+r`- Lafayette City Center 2 Avenue de Lafayette,Boston,MA 02111-1750 Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers A licant Information Please Print Le ibl Name(Busiaesa/Organizatiop/Individeal):Theodore Bailey Address:58 Delano Rd.APT 1 City/State/Zi :Marion Ma 02738 508-932-5447 Are you an employer?Check the appropriate box: Phone#: 1.❑I am a employer with 4.0 I am a general contractor and I Type of project(required): 2.1employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 1 I am a sole proprietor or partner- listed on the attached sheet. 7. El Remodeling ship and have no employees These sub-contractors have working for me in any capacity. employees and have workers' S' ❑Demolition [No workers'comp.insurance comp.insurance.t 9. El Building addition 3.❑required.] 5.0 We are a corporation and its 10.0 Electrical repairs or additions I am a homeowner doing all work officers have exercised their myself.[No workers'comp. right of exemption per MGL 11.0 Plumbing repairs or additions insurance required.]t c.152,§I(4),and we have no 12.0 Roof repairs 13.®Other Replace existing with new employees.[No workers' comp.insurance required.] "Any applicant that checks box gI must also fill out the section below showing their workers'compensation policy information, I.Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContmetors that check this box must attached an additional sheet showing the name of the subcontractors 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. Rio is the polity and Job site information. I' Insurance Company Name: 1�St Policy#or Self-ins.Lic.#:ji qaP y r1f—y y v --'-^—'-- Expiration Date: 0Z3 Job Site Address:• City/State/Zip:_ ' Attach a copy of the workers'compensation policy declaration page(showing the policy number andwxatirafion 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 ertify under the pains and penalties of perjury that the information provided above is true and correct. Si Lure: Ph n #: 508-932-5447 Date Official use only.Do not write in this area,to be completed by ctty or town official City or Town: Permit/License# Issuing Authority(check one): lOBoard of Health 20 Building Department 3 f City/Town Clerk 4.1 Electrical Inspector 5falumbing Inspector 6.DOther Contact Person: Phone#: AW D CERTIFICATE OF PROPERTY INSURANCE DATE(MMIDOIYYYY) 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 IA/C.No.Ex@ (A/C,Not: (203)654-3613 P.O. Box 113247 ADDRESS: salessupport@biberk.com PRODUCER ------- Stamford, CT 06911 CUSTOMER ID INSURED INSURER(,AFFORDING COVERAGE NAIC X INSURER A:Berkshire Hathaway Direct Insurance Compel 238130 Theodore Bailey INSURERS: 58 Delano Rd Apt 1 INSURERC: Marion, MA 02738-2011 INSURER D: -I 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 POUCIES 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 LTR DATE(MM/DD O/ /YYYY) DATE COVERED PROPERTY LIMITS X I PROPERTY BUILDING CAUSES OF LOSS DEDUCTIBLES S PERSONAL PROPERTY $ 0 BASIC BUILDING N9BP424491 04/28/2022 04/28/2023 BROAD 250 BUSINESS INCOME $ CONTENTS EXTRA EXPENSE S * X I SPECIAL RENTAL VALUE EARTHQUAKE S BLANKET BUILDING $ n/a MO FLOOD BLANKET PERS PROP $ n/a BLANKET BLDG&PP $ n/a S S INLAND MARINE TYPE OF POLICY S CAUSES OF LOSS S NAMED PERILS POLICY NUMBER -- _, S CRIME S S TYPE OF POLICY S I BOILER 3 MACHINERY I S EQUIPMENT BREAKDOWN S S S _ SPECIAL CONDITIONSI OTHER COVERAGES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) 5 * ALS up to 12 months. 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 eol ©1995-2015 ACORD CORPORATION. All rights reserved. ACORD 24(2016/03) The ACORD name and logo are registered marks of ACORD 1 Ali Bath Fitter Bridgewater Inc. 25 TURNPIKE ST. TYPE: Contract BAT H WEST BRIDGEWATER, MA, 02379 F I T T E R DATE: 2023-03-31 REF #:375-LFCU435P-RSE Te : 508-521-2700 508-588-4303 BFU375@bathfitter.corn CUSTOMER BILLING ADDRESS SERVICE ADDRESS Bianca Ortiz 9 Idlewood Drive. 9 Idlewood Drive. Yarmouth. Massachusetts. 02664 Yarmouth. Massachusetts. 02664 Andrew Perry 508-514-9427 T Email: aperry508(«'yahoo.com DESCRIPTION OTY PRICE Bathtub Over Bathtub / Standard White Right 1 INCLUDED Aristocrat (4-6') Drains : Bath Tub Pop-up stopper & Chrome 1 INCLUDED 4 overflow PLU 191. PLU386. PLU444 410 One Piece Seamless Wall ? Savona White 90IN OPEN X 1321N LGT WITH S 1 INCLUDED Subway Tile Pattern Ceilings ; Flat White 36IN X 60IN 1 INCLUDED Organizational Items ; Soap Dishes r White 1 INCLUDED Oxford Twin Soapdish Organizational Items Shelves t Bali • White 1 INCLUDED Shelf 25in x 5in .11° Faucets /Moen Tub & Shower Faucet Chrome ; 2.5 GPM Tub and Shower 1 INCLUDED Set ; Wynford M-Core Faucets : Moen Valves / M•Core Valve /' N/A N/A 1 INCLUDED rit66 U 140CIS/PLU0662 toilitti Doors & Curtains I Rods;Curved Chrome 6OIN 1 INCLUDED e. . .4 Bath Fitter Bridgewater Inc. 25 TURNPIKE ST. TYPE: Contract BATH WEST BRIDGEWATER, MA, 02379 FITTER DATE:2023-03-31 REF#:375-LFCU435P-RSE Tel:508-521-2700 508-588-4303 BFU375@bathfitter.com DESCRIPTION OP( PRICE Wall Repair Wall Repair 1 INCLUDED NOTES Sub Total $7.728.00 3-10 weeks to install date 9 IDLEWOOD DRIVE - -. YARMOUTH, MA. I _ 508-514-9427 +- - BATH FITTER SCOPE OF WORK EXISTING FLOOR PLAN UNCHANGED __ INSTALLING NEW BATHTUB LINER AND WALL LINER 1 1 r 1 i 1 _ ; I ; _ � _ i 1 i r _ - i i try A.....i_g Oc ,u 1 f ,r � - 1 1 , {i i 1 11 _ `� , 1 „V--.dC_ �� ` I c_, I V" c.:4Ji- ! , 1, } i i I i 1 L ' _ , ! j ! f 1 i i — _._ — — -- i_ti 0 , „ , , , , , , i ,_ , , -4---1 ' . i { i , ' _ 1 i 4 Y�, ,kypa ,� asy" � ' p < " i. _.',`' . - ...I, f. ii 1• M__ _ ,_ � •i r - 1 s 7z 41 i O .... Y I o t ' : : ' I.iwri _ _�. ._ 4. ' 1 air _ .- z ' 1' 1 -„ .. __. _._w.... I I 4 _ 7o rn o a al 0 go K as aLI--1 L L -4 ''[,4 I 1 I rn 73 I _ fyi . t i t I i , I � � �_ i 4 1 — 1 _ I I ( , 1 I 1 1 f t 1 i 1 � i 1 } ii i I 1 _ _� ! I I • I r. rr, ' •