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HomeMy WebLinkAboutBLDC-24-73- • Or "44 Town of Yarmouth Building Department y 1146 Route 28 South Yarmouth,MA 02664 508-398-2231 Ext.1261 Fax 508-398-0836 Building Permit Application for any Building other than a One-or Two-Famil welling (This Section For Official Use Only) Building Permit Number: Date Applied: Building Official`/J J//5 % � SE ION 1:LOC ION No.and Street City/Town ` Zip Code Oa4 6!'( Name of Building(if applicable) Asses ors Map# Block#and/or Lot# SECTION 2:PROPOSED WORK Edition of MA State Code used If N w Construction check here 0 or check all that apply in the two rows below Existing Building d7 Repair'Alteration Addition 0 Demolition 0 (Please fill out and submit Appendix 2) Change of Use 0 Change of Occupancy 0 Other 0 Specify: Are building plans and/or construction documents being supplied as part of this permit application? ___ h Is an Independent Structural Engineering Peer Review required? ++ Ye ❑ No 0 Brief Description of Proposed Work: XTe,QI d e_ t Lo vS "1"O .-- (i✓ 1 � SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) 0 Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) 3 Total Area(sq.ft.)and Total Height(ft.) a"' [S`s��.csc Sl 0-7 r ctaas SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1 0 A-2 0 Nightclub 0 A-3 0 A-4 0 A-5 0 B: Business Mr E: Educational 0 F: Factory F-1 0 F2 0 H: High Hazard H-1 0 H-2 0 H-3 0 H-4 0 H-5 0 I: Institutional I-1 0 I-2 0 I-3 0 I-4 0 M: Mercantile 0 R: Residential R-10 R-2 0 R-3 0 R-4 0 S: Storage S-1 0 S-2 0 U: Utility 0 Special Use 0 and please describe below: Special Use Description: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA CI IB CI IIA 0 IIBO IIIA ❑ IIIB 0 IV CI VA 0 VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit Debris Removal: f,,/ A trench will not be Licensed Disposal Site 0 Public Check if outside Flood Zone Indicate municipal 0 Private 0 or identify Zone: or on-site system required 0 or trench or specify: permit is enclosed 0 Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process: Not Applicable 0 Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed 0 Yes 0 or No 0 Yes 0 No 0 SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: Does the building contain a Sprinkler System? Special Stipulations: Design Occupant Load per Floor and Assembly space: ' SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner (o LID ,3A.z., s r 2. 'k I iJ P.z.o,�.�, 6s e.-2.- � 6_O "'4 c_(y - �' £ A—<2 .,6.d Name(Print) No.and itreet City/Town Zip Property Owner Contact Information: rv1 I p `7 Z erfy-12-4" 0 ^t 1 Tic�— Title Telephone No.(business) Telephone No. (cell) e-mail addrep�j �,,.,L.Q , ,I-- If applicable,the property owner hereby authorizes: `�-- c 4.A. Aie__ 1-4-1 ( -14i-t& li ba_ 5r il''ik'L .44. i41,+4- Q 1_4,44 Name Street Address City/Town State Zip to apply for and act on the property owner's behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 1) If a building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control,then check here O. Otherwise provide construction control forms(see section 107 in the code)as required. 10.1 Registered Professional Responsible for Construction Control(the professional coordinating document submittals) Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor ('l 4'L.- Re•IAN1 Coirlipany Nacfi . V\02.tA .5 co e_cs- Name of Pexs n Responsible for Construction License No. and� f Applicable 7 a"`/ �w ��--- S 41 V nii to .41.71' '_ill " ,026 'q Street Address City/T6wn tate Zip 0 1 { <cW 776 �766 gi,si.e.i. (0) htI- ��- cp-,____ Telephone No.(business) Telephone No.(cell) e-maiaddress SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§25C(6)) A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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. Is a signed Affidavit submitted with this application? Yes 0 No 0 SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materi Office Use Only 1.Building $ K AVc /)L l 46posit Received$ 60,09 Date 3 ,y 2.Electrical $ ' 3.Plumbing $ Permit Fee$ , G d 4.Mechanical (HVAC) $ (� /, 5.Mechanical (Other) $ Net Due$ 9 `v 6.Total Cost $ k Make check payable to Town of Yarmouth SECT ON 13:SIGNATURE OF BUILDING PERMIT APPLICANT 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. • 3 / Al (41d - ? 9.,w4i -- F2A Please print and sign name Title Telephone No. Date I47 $12,944, ...1.0b it- se 41,E A' ,] !Ly s 1 L941...7 rl•,.,,,.r Street Address City/Town State Zip `Email Address l ` Municipal Inspector to fill out this section upon application approval: Name Date I j 3:2 Registered Home Improvement Contractor 1 . Cove y Nsms P Not Applicable ❑ • Address Registration Number Expiation Date Signature Telephone • Section 4-Workers'Compensation Insurance Affidavit(M,G.L c.152 S 25C(6) Workers Compensation Insurance:affidavit must be completed and submitted with this application. Failure to provide thisaffidavit will result in the denial of the'issuance of the building permit. ' Signed Affidavit Attached Yes ... No Section 5- Professional Design and Construction Services-for Buildings and Structures Subject •: - to,Constnlction Corgi►Pursuant to 780 CMR 116(containing more than 35,000 c.f.of enclosed space) 'Section 5.1 Registered Architect 1t \ , `1-ot.L61 ET A. rt T�S, (N C. Hams (Registrant's r , 2"� W L AVI- 7. V '(Uwtw Nol Applicable Ol Registrallo Nu e 1 958 302 aes 3 Expiration Datee Telephone Section 5.2 Registered P essional`Engineer(s) Pn� Sir�,i,essva, . • � , esponsibility, Hams 1.V1CAC.1.9 ./7'�-L�►1 �f�M1� m^ Z` Area M R Addre Regfstralon Number 5 0 8-3+z5-abaz -ID s1)141f Z 2.4 signature:,: 43 Telephone Expiraton Data Hautns Area of Responsibility Address Registration Number Signature Telephone: Expiration Data Nsnns Area of Responsibility Address Registration Number Signature Telephone Expiration Date Hams Area of Responsibility Address Registration Number Signature Telephone Expiration Date Section 5:3 General Contractor Not Applicable ❑ Company.Name :. Person Responsible for Construction • Address signature,. Telephone • g a�, TOWN OF YARMOUTH `z o ao'a Office of the BuildingCommissioner �; =�EF 1146 Route 28, South Yarmouth, MA 02664 °RA`E 508-398-2231 ext. 1260 Fax 508-398-0836 DEMOLITION DEBRIS DISPOSAL APPLICATION Pursuant to M.G.L. c.40 §54 and 780 CMR Section 105.3.1 #4. I hereby certify that the debris resulting from the proposed work/demolition t be conducted at. le- Work Address Is to bedisposed of at the following location: L w� 1 / f[Ad ( Said disposal site shall •e a licensed solid waste facility as defined ry M.G.L. Chapter 111, §150A. illi IV i 'ram �` ��__ g 1�& oq �Z Sigre of App ican Date Permit No. i' 1111111 ll 111 1 1111111' `lillll 0 f 0 / r AR 71 e m "D D Z 1111111► 141111111 1111111' ; `1111111 b RECEIVED CUSTOM .6 PRRDK,�_.WARD.�Nti nuN 2 8 2014 archi LP, UPHAET ROOF�rND�6_ PVC 19,142, _ E.6 PVC BUILDING DEPARTMENT 399.1391,311 SOUTH YARMOUTH . __ � i == _ _ N.. D.03 �N. .. .;` .. le,ISO.•RIB] ■■ / .. IIDtl lta• Sm ' H ER MI[wHIRCR ggpp�� .<UM III N .N.. aIr h~ YARMOUTH ��.�J �1E I I Pill - I SE I - CEDAR IUPRESLOM a SHINGLE SIDWf = 0�0 0�0 RELIVING 1 ._,N.._... 1.� _ t COMRMUMTY X 71PIC CUPOLA - � gq22��22NN 1 ST ET �L _ PROPOSED LEFT/WEST ELEVATION A fT 4 . . S Q T uflii FRANKER f V —HORIZONTAL SWING.YAWLROAD - t _- 1.'-_-_ _V-.. -� PROJECT/120323 ®NT II ippliV XAT nr.g %�a\� as milmmmA aillillik. hill la IiiiiiillyE REOSTRAI" :M i�� ���� ������ � 4-- a a-- - - Ir4 r _-_ IL-i_--. -FN. L.-AL. -r-. .Y3- ----. --_ PROPOSED NORTH/REAR ELEVATION PROPOSED FRONT/SOUTH ELEVATION REVISIONS DATE: RfnSiONs: s r w-wr _ t TJ ITIr i , -- - -- � . ISSUED FOR. PERSIIIING DATE: 06.26.2023 � � �' � �� PRO AL. -- PROJECT TRITE wTA E� ■� _.-� - UNLESS OTHEFNASE NOTED .--. ''�'i ' SHEET NO. , __ F� J H A.3 YTYPICAL DORMER u Y IIINIIIIIi�IIII IliiililiilllliViililliiIl'lilliilii�liliiliililiii �• ` �� JV TOTAL NUMBER O SHEETS WALL.4'y__ IN SET: wH u MN mnuiV TNT SLOP I-' PROPOSED RIGHT/EAST ELEVATION IQ 0 3 -Y ) 'v 3 kk $ N e a ! s ha _al g Wk 7 ! ' gA g Z - 3 - v i m D r \ 1 x 7g4� Z 1 OV 1 FS far i m 4 q :N z o m v � S o o ' xi „^ O He Jn M U1.11 bd l' . 1 ei y, t m ' I D r 4 | I { \\ 2 | ° | y ; . 41 /y | i. i ° 1 . � � g _ § Ai / z [ I i e , / \ q ' ' 7 /` _ `! � \ �` � : m fl M / ; / % \ z [ | | , \ / [ < ; ; ` ^ ' , Z.! ;\ ! § \ . ; ! :- ! ! r ) i \ | | j f — - — § O| ! ; om « . `� �m § l ) - > VI . c U: 1 - ® %l \` GP }® ( @ IH{ !i;rd13> ® a Li: O� ` 4 IJtiIW § m | «_ § § ` . . 0 TYPICAL WALL NOTES = Itkilc I 4 — TJ RIM JOIST u.Nlab inlercrBnignn ewers R-.TO FIBERGLASS INSULATION FLOOR FRAMING PLAN SCAM FAR .. .w Aaa.wMM.aaw.r.RI.M..NMI R,•IW. s/BpFDF'CoAa€ASV.a E. Irs. A ImEIJmBW'J P.T.SILL (7207m-TECO w./gs�u 4Asflt imy>m.stm9oTANonARW DnuF�iiwGs ` TnxRcrsc ggpp- R_, 1Y OUOUTH 1 rl. } O TYPICAL SILL DETAIL RELIVINGN w > ETI.f2u�2mNN5 YT III + S'ppp7 A EEL T TYPICAL WALL NOTES II 14 S 13RpGLT enT iii•IrCCALN. III B COMPACTED 0000 p,. FRANK BAKER A z•RIpD B R•yOppLA��}}D Itas km GOO REABAARRS CONE. 1I Yn AA EXISTING P 6 ILIALS MW.. bL1 �� o FOUNDATION MO KEBABS COMi. -- rwiwod,m,j jja55..NEvwo«AL 60IWL, 1 I s.. OPINED.MN OP VS -t— E BOT OP f000TRnpp e{. •"E 'I }� • III -e.. - .s o,ssr w<ue,uemr v.. _.�, OSLAB ON GRADE DETAIL 4•RIpD NS kL'�IW iZpE1TTEl BELOWMSLLAB ARWNOP RENSIONS i + ENTIRE PEMUCTERN�IfOUNDAl10x, DATE: RENSIONS'. --- UNWL LCNE�ELnAS L ttAMEO)OAv SIRENDIN SE wREO CEO PRaPE'v I— — CV �2'NO�RIZSk]B�aEAT A-W,iY.t ..IE-. _ a[_a vr.i- f0•CONC.WALL --- > 1 e W-CPACIED FILL� ISSUED FOR: PERUITBNC y. GATE: ILIA NI oaf r/y MWNU BA,oPEtidcs____ _i vI:RETMOFA FOUNDATION PLAN PROJECT RUE Ja,M--,-P- »/RERAN,CON,—---- -r1-_• � . UNLESS OTHERWISE NOTED. X I' ioOTimaNPROPAa A A ET N0. E nDNOO Bo:L r A.O -LI TOTAL NUMBER OF SHEETS IN SET: OTYPICAL WFOUNDATION DETAIL 1 fi • a I I <<m a 0 I -f 1 w 11L_!_!1!iH H I , / CO - ,;° - CO C % C K I ' K I U —1 J ID eP 0 CO cn U) m m o 9D 9C 0 H O o Z A gm Mil ik Z I 1 @ 110'111N—WP Ilth @ D °gym �� eD Dd___ • CO I C 0 F� 00 h I ; H m C �� C _ . 1 I k�€ V � _ g k.NN„ae 1.1Ilia 1ilai '" v A ; Zrn C 15 1 it i i is Project No: Initital Construction Control Document 170323 To be submitted with the building permit application by a Registered Design Professional • r' for work per the 9th edition of the Massachusetts State Building Code, 780 CMR, Section 107 Project Title: Wise Living Date: 06.26.2024 Property Address: 834 Route 28,South Yarmouth,MA Project: Check(x)one or both as applicable: New construction X Existing Construction Project description: Exterior additions to existing building I,Erik Robert Tolley, MA Registration Number:10730 Expiration date: August 31,2023, am a registered design professional,and I have prepared or directly supervised the preparation of all design plans,computations and specifications concerning: XX Entire Project Architectural Structural Mechanical Fire Protection Electrical Other: for the above named project and that to the best of my knowledge,information,and belief such plans,computations and specifications meet the applicable provisions of the Massachusetts State Building Code,(780 CMR),and accepted engineering practices for the proposed project.I understand and agree that I(or my designee)shall perform the necessary professional services and be present on the construction site on a regular and periodic basis to: 1.Review,for conformance to this code and the design concept,shop drawings,samples and other submittals by the contractor in accordance with the requirements of the construction documents. 2.Perform the duties for registered design professionals in 780 CMR Chapter 17,as applicable. 3.Be present at intervals appropriate to the stage of construction to become generally familiar with the progress and quality of the work and to determine if the work is being performed in a manner consistent with the approved construction documents and this code.The contractor is responsible for the performance of the work in accordance with the contract documents and shall be exclusively responsible for its construction means,methods,sequences,performance,warranties,and procedures,and for construction safety. Nothing in this document relieves the contractor of its responsibility regarding the provisions of 780 CMR 107. When required by the building official,I shall submit field/progress reports(see item 3.)together with pertinent comments,in a form acceptable to the building official. Upon completion of the work,I shall submit to the building official a'Final Construction Control Document'. Nothing in this document relieves the contractor of its responsibility regarding the provisions of 780 CMR 107 or 521 CMR. Afi Enter in the space to the right a"wet"or 5oE RT 4yil�or c;* electronic signature and seal: T . D4 et- W No.10730 < v.' d _ r1 OF Till, Phone number: 508.362.8883 Email: Erik@ERTArchitects.com Building Official Use Only Building Official Name: Permit No.: Date: Version 06_11 2013-mod 08_21_2013 tvp Commonwealth of Massachusetts kfit Division of Occupational Licensure Board of Building a uIations and Standards Cons fon 5 rvisor .f. CS-060855 ti R.tpires. 11/22/2024 MICHAEL A HHEALY 72 OLD MAIIWST '° SOUTH YARM¢UTH MA 02664 .;. • • AC�® DATE(MM/DD/YYTY) CERTIFICATE OF LIABILITY INSURANCE 06/26/2024 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 KimberlyFitzgerald NAME: 9 MARSHALL K LOVELETTE INSURANCE AGENCY INC WC.No.Ext): (508)775-4559 (A/C,No): E-MAIL kim@loveletteins.com ADDRESS: 396 MAIN ST INSURER(S)AFFORDING COVERAGE NAIC# WEST YARMOUTH MA 02673 INSURER A: HARTFORD UNDERWRITERS INS CO 30104 INSURED INSURER B HEALY BROTHERS CONSTRUCTION INC INSURER C: INSURER D: 72 OLD MAIN ST INSURER E: SOUTH YARMOUTH MA 02664 INSURER F: COVERAGES CERTIFICATE NUMBER: 1021867 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 AWL SUBR POLICY EFF POLICY EXP LTR INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED N/A 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 N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X STATUTE ERH AND EMPLOYERS'LIABILRY A OFF C E.L.EACH ACCIDENT $ 100,000 ER/MEMB REXC UDED ECUTIVE N/A NIA N/A 6S60UB0W65672423 08/19/2023 08/1 9/2024 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B, no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage- Coverage Verification Search tool at www.mass.gov/lwd/workers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Wise Living.com 822 RTE 28 AUTHORIZED REPRESENTATIVE South Yarmouth MA 02664 Daniel M.Cro y,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD ACC:PR EP® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) 06/26/2024 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 Marshall K.Lovelette Marshall K Lovelette Insurance Agency Inc PHONE FAX 396 Main St INC.No,E_xth (508)775-4559 (A/C,No): West Yamouth,MA 02673 ADDRESS: marshall@loveletteins.com INSURER(S)AFFORDING COVERAGE NAIC# INSURERA: Nautilus Insurance Co 17370J INSURED Healy Brothers Construction,Inc. INSURER B 72 Old Main Street INSURER C: South Yarmouth,MA 02664 INSURER D: 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 SUBR POLICY LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DDIYYT POLICY EXP Y) (MM YY/DD/Y () LIMITS A COMMERCIAL GENERAL LIABILITY NN1637497 01/09/2024 01/09/2025 EACH OCCURRENCE $ 1,000,000 DAMAGE TO CLAIMS-MADE t/ OCCUR PREMISES(EaENTED occurrence) $ 100,000 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY PRO- 1,000,000 JECT LOC PRODUCTS-COMP/OP AGG $ 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 OTH- AND EMPLOYERS'LIABILITY STATUTE ER Y/N ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBEREXCLUDED? N I A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space I.required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Wise Living at Yarmouth LLC ACCORDANCE WITH THE POLICY PROVISIONS. 822 Route 28 South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of Industrial Accidents _=' 1='� Office of Investigations = 1, a La ette City° Lafayette Center 2 Avenue de Lafayette, Boston,MA 02111-1750 www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contrac rs/Electric' ns/Plumbers Applicant Information P as Print egibly Name (Business/Organizat o ndividual): L. Address: ) l/�/(, c t . . �— " • City/State/Zip: Phone #: Are you an employer? Check the appropriate box: Type of project(required): 1.ifrt am a employer with 4. ❑ I am a general contractor and I * have hired the sub-contractors �' New❑ construction employees (full and/or pare).* 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. EzRemodeling ship and have no employees These sub-contractors have 8. ❑ Demolition workingfor me in anycapacity. employees and have workers' 9. [' Building addition [No workers' comp. insurance comp. insurance.+ required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions officers have exercised their 11. Plumbingrepairs or additions 3.❑ I am a homeowner doing all work 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.❑ Other comp. insurance required.] *Any applicant that checks box#t must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins. Lic. #: Expiration Date: 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 viol. : . :• advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insura e cover:ge verification. do hereby cert:, under e pa' a • !ties of perjury that the information provided above is true and correct. Signature: Date: Phone#: / 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 30City/Town Clerk 4.0 Electrical Inspector 50Plumbing Inspector 6.0Other Contact Person: Phone#: