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HomeMy WebLinkAboutBLDR-24-624 application ONE & TWO FAMILY ONLY- BUILDING PERMIT Town of Yarmouth Building Department of r 1146 Route 28, South Yarmouth,MA 02664-4492 508-398-2231 ext. 1261 Fax 508-398-0836 Massachusetts State Building Code,780 CMR o�e Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: 6L D -024— (0()-(1_ Date Applied: Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 As essors Map&Parcel Numbers U, C\ec,cf &'not_ (Ld 66 Rsct 6`I` 1.1 a Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: 1a,&A Zoning District Proposed Use Lot Area(sq ft) Frontage(ft 1.5 Building Setbacks(ft) RE C E E Front Yard Side Yards Rear Yand 0 I�� Required Provided Required Provided Required PF0 toed j UI DING DFPA'TMENT 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposhl Public rill, Private 0 Zone: — Outside Flood Zone? Municipal 0 On site disposal system t$ Check if yes SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'qf Record: Chonaler „ ilc-nu ktkez, Uses - yarwtod44 1-(A oa 6Z 3 Name(Print) City,State, IP CIQac1vv c nq-kki-E, ,L.M No.and Street Telephone Email Addre SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building❑ Owner-Occupied ❑ I Repairs(s) 0 Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other rir Specify: Brief Description of Proposed Work2: r A_wki • Pa7129 A ldA 1214V 'Nil it all e itS iYt9 SECTION 4: ESTIMATED CONSTRUCTION COSTS. fiinp r /1Jd , Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building $ ‘5 5-0 0,e p 1. Building Permit Fee:$ Indicate how fee is determined: 0 Standard City/Town Application Fee 2.Electrical $ s(� ` ❑Total Project Cost'(Item 6)x multiplier . x 3.Plumbing $ l?Q 4.. 8 0 2. Other Fees: $ 4.Mechanical (HVAC) $ List: egd,¢0 a-401 5.Mechanical (Fire Suppression) Total All Fees:$ Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ O,1 St o° 0 Paid in Full ❑Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) �,\ r� �5- �7yga$ tLtb ) il`t'( ,kA l,�Vlfl�L N.. License Number Expiration Date Name of CSL Holder %N`c List CSL Type(see below) \,J No.and Street Type Description a ``. ' 1� �f t U 11- Unrestricted(Buildings up to 35,000 Cu.ft.) FJ4KJo3 Yi" G R Restricted 1&2 Family Dwelling City/Town,State,ZIP Iv1 Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 1'' . l2-1€ y C� o 50 L '�Q W C/1(e'S tI i�►�1 Insulation Telephone �J Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) f( 'f\ J✓1 S fie' HIC Registration Number xpiration Date HIC Company Name or HIC a wtP1�Ca.• Registrant Name W b,erll4len 0 Itn!le,A5r4--7N s..ceri No.and Street Email address City/Town, State,ZIP Telephone SECTION 6:WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the Issuance of the building permit. Signed Affidavit Attached? Yes 40 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 JQ Q t,-(k,(1 1 k 4044, 1'0 r� to act on my behalf, in all matters relative to work authorize by this building permit application. Print Owner's Name(Electronic Signature) 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 application is true and accurate to the best of my knowledge and understanding. Print Owner's or Authorized Agent's Name(Electronic Signature) Date NOTES: 1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program can be found at www.mass.2ov/oca Information on the Construction Supervisor License can be found at www.mass.2ov/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" ONE or TWO FAMILY- BULDING PERMIT APPLICATION REGULATORY APPROVALS NOTICE Address of Proposed Work: (.,2C(east 6ro 0/C- b 5+ YAIt ,I:t.:i Scope of Proposed Work: ° k-er (\Ogle.r1 l:q-' i`S p1.0.5 �L v► ),\ bq-IL 0 ILA e&:54-1 ni Cr Date: i 2151,20.2 y Based on the scope of work described above, the applicant is required to obtain approval sign- offs from the following departments as checked-of below: Health Dept. —508-398-2231 ext. 1241 Conservation —508-398-2231 ext. 1288 Water Dept. —99 Buck Island Road, 508-771-7921 Old Kings HWY. Hist. Comm. — 508-398-22631 ext. 1292 Engineering Dept. —508-398-2231 ext. 1250 Fire Dept. — Kevin Huck/Matt Bearse, 96 Old Main Street, SY Note: Please call Fire Department for an appointment. 508-398-2212 Other Appropriate plans and/or application shall be provided to each departments checked-off above. Each of these regulatory authorities has their own requirements outside the jurisdiction of the Building Department. All applicable approvals shall be obtained prior to submitting a building permit application to the Building Dept. Thank you for your cooperation. Receipt Acknowledgement: UlAkiZ 5/026 Applicant's Signature Date Rev. March 2022 • TOWN OF YARMOUTH 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1261 Fax 508-398-0836 Office of the Building Commissioner BUILDING DEPARTMENT DEMOLITION DEBRIS DISPOSAL AFFIDAVIT Pursuant to M.G. L. Chapter 40, Section 54 and 780 CMR, Chapter 1, Section 111/5 I hereby certify that the debris resulting from the proposed work/demolition to be conducted at U Cie�..�bcwk \� , Work Address Is to be disposed of at the following location: D4J cYcp, Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 150A. a ( r 1a k,/ Signature of Applicant Date Permit No. The Commonwealth of Massachusetts Department of Industrial Accidents g 183— I Congress Street,Suite 100 u=�' , Boston,MA 02114-2017 �= www.rnass gov/din Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH l km PERMITTING AUTHORITY. Applicant Information _ Please Print Lesibly Name(Business/Organi7.stioa/Individual): i,tv!-1/4�--rJ R.es rvlt4-rick/ c erzv e.s /N C Address: 22 Amyl to v ' Y City/State/Zip: Sots 11-1 o ER/a I Si !n' D2t4O Phone#: 508 760 t 9 I I Are yaw an employer?Check the appropriate box: Type of project(required). I.r2 I am a employer with 2 7_employees(full andior part-time).* 7. []New construction 2.01 sin a sole proprietor or partnership and have no employees working forme in 8. Remodeling any capacity.[No workers'comp.insurance required.] 9. Demolition 30 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10[]Building addition 4.131 am a homeowner and will be hiring contractors to conduct:il work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.0I am a general contractor and I have hired the sub-contactors listed on the attached sheet l There sub-contractors have employers and have workers'comp.insurance t 13.DRoof repairs CD We are a corporation and its officers have exercised their right of exemption per MGL< 14. ]Other 152,§1(4),and we have no employees.[No workers'eotnp.insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. r Homeowners who submit this affidavit indicating they arc doing all work and then hire outside contractors must submits new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have employees. Ifthe sub-centractors have employees,they must provide their workers'camp.policy number. 1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job sire information. u-ssurance Company Name: ,UGC 6}MCr<i C, J frJS i,,reAftivc.E Policy#?or Self-ins.Lic.#: 6 S fO 2030 let! i3 C 8 $ 7 32i Expiration Date: 04,/0// Z S _ 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 S 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 S250.00 a day agairst 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 certify under the pains and penalties of perjury that the information provided above is true and correct. Sinnott:re: oLsy •� L Date: t 2 1 I n tl Phone#: ( 5e" 760 I 1// { 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#: [ _ __ .- ,' VI Restoration Services Inc. Fire,Smoke,Soot,Water Damage&Mold Remediation Services Cleaning • Deodorization • Reconstruction Specializing in Fire Restoration - All Work Guaranteed Access, Authorization and Direct Payment Request Form I (we) authorize WHALEN RESTORATION SERVICES to perform work at property located at �:, Lice r 8 rpot / . to repair damage caused by _ „ja--er on c{'i6/ma11 . As owner(s) of this property, I (we) understand that I (we) must authorize this work. I (we) hereby authorize WHALEN RESTORATION SERVICES to perform this work and accept responsibility for payment upon completion. I (we) authorize and direct my Insurance Company L� �dp►� Policy No. , to make payments directly to WHALEN RESTORATION SERVICES, Insurance Claim Specialists, for doing this work and to that extent I (we) assign the benefits applicable to this loss to WHALEN RESTORATION SERVICES. I (we) acknowledge receipt of a copy hereof: O'vA6S2-fOWNER l`�/ SIGNED i OWNER ALEN R OR P. SIGNED 22 American Way,South Dennis,MA 02660 Phone: (508)760-1911 • Fax: (508)760-9995 • 1-800-244-2598•E-Mail:restore@whalenrestorations.com Web Page: http://www.whalenrestorations.com OFFICE COPY A��® DATE(MM/DD/YYY)Y CO CERTIFICATE OF LIABILITY INSURANCE 12/3/2024 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 RogersGray,A Baldwin Risk Partner PHONE FAX 410 University Ave (A/c.No.Ext►:800-553-1801 (Afc,No):877-816-2156 Westwood MA 02090 ADRESS: mail@rogersgray.com INSURERS)AFFORDING COVERAGE NAIC aR License#:PC-514062 INSURER A:Union Insurance Company 25844 INSURED WHALRES-01 INSURER B:Acadia Insurance Company 31325 Whalen Restoration Services Inc 22 American Way INSURERC: South Dennis MA 02660 INSURERD: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:738996074 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. INTSRR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFYT POLICY EXYT LIMITS (MM/DDMlYY) (MMIDDlYYYY) A X COMMERCIAL GENERAL LIABILITY CPA558o718-10 4/1/2024 4/1/2025 EACH OCCURRENCE $1,000,000 CLAIMS-MADE X OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $300,000 MED EXP(My one person) $10,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY X Fire, X LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: $ A AUTOMOBILE LIABILITY MAA5580719-10 4/1/2024 4/1/2025 COMBINEDtSINGLE LIMIT $1,000,000 (Ea acciden ANY AUTO BODILY INJURY(Per person) $ OWNED X SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS X HIRED X NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) B X UMBRELLA LIAR X OCCUR CUA5580720-10 4/1/2024 4/1/2025 EACH OCCURRENCE $3,000,000 __ EXCESS LIAB CLAIMS-MADE AGGREGATE $3,000,000 _ DED X RETENTION$n $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBEREXCLUDED? NIA -- (Mandatory in NH) E.L.DISFARE-EA EMPLOYEE $ If yes,describe under — DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Workers Compensation Certificate to Follow Separately 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. Chandler and Kelly Barnatchez 26 Clear Brook Road West Yarmouth MA 02673 AUTHORIZED REPRESENTATIVE fe- ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD DATE(MM/DD/YYYY) Aco CERTIFICATE OF LIABILITY INSURANCE 12/03/2024 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 ACT Rogers and Gray Processing BALDWIN KRYSTYN SHERMAN PARTNERS LLC (A/C,No,EXU: (508)398-7980 (A/c No): E-MAIL mail ro ers ra ADDRESS: � s g v-com 4211 West Boy Scout Blvd Suite 800 INSURER(S)AFFORDING COVERAGE NAIC# Tampa FL 33607 INSURERA: ACE AMERICAN INSURANCE CO 22667 _ INSURED INSURER 8: WHALEN RESTORATION SERVICES INC INSURER C: INSURER D: 22 AMERICAN WAY INSURER E: SOUTH DENNIS MA 02660 INSURER F: COVERAGES CERTIFICATE NUMBER: 1069630 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. ILTRR ADDL TYPE OF INSURANCE INSD SUBR POLICY EFF POLICY EXP WVD POLICY NUMBER LIMITS (MM/DD/YYYY) (MM/DD/YYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCEDAMAGE TO $ _ CLAIMS-MADE 1 OCCUR PREMISES Ea occcurrence) $ _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 PER H PEATUTE ER AND EMPLOYERS'LIABILITY A OFFICER/MEMBER EXCLUDED?ECUTIVE N/A N/A N/A 6S62UB0W86857324 04/01/2024 04/01/2025 E.L.FACHACCIDENT $ 1,000,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Workers'Compensation benefits will be paid to Massachusetts employees only. Pursuant to Endorsement WC 20 03 06 B, no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires, or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage- Coverage Verification Search tool at www.mass.gov/Iwd/workers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION _ SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Chandler and Kelly Barnatchez ACCORDANCE WITH THE POLICY PROVISIONS. 26 Clear Brook Road AUTHORIZED REPRESENTATIVE West Yarmouth MA 02673 e Daniel M.Croy,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 Request for Taxpayer Give Form to the Form (Rev.October2018) Identification Number and Certification requester.Do not Department of the Treasury send to the IRS. internal Revenue Service O.Go to www.irs.gov/FormW9 for instructions and the latest information. 1 Name(as shown on your income tax return).Name is required on this line;do not leave this line blank. Whalen Restoration Services,Inc. 2 Business name/disregarded entity name,if different from above 3 Check appropriate box for federal tax classification of theperson whose name is entered on line 1.Check onlyone of the 4 Exemptions(codes apply onlyto P� PP Y m following seven boxes. certain entities,not individuals;see a instructions on page 3): o ❑ Individual/sole proprietor or 2 C Corporation ❑S Corporation ❑ Partnership ❑Trust/estate single member LLC Exempt payee code(if any) ao ❑ Limited liability company.Enter the tax classification(C=C corporation,S=S corporation,P=Partnership)► Note:Check the appropriate box in the line above for the tax classification of the single-member owner. Do not check Exemption from FATCA reporting LLC if the LLC is classified as a single-member LLC that is disregarded from the owner unless the owner of the LLC is ( any) U another LLC that is not disregarded from the owner for U.S.federal tax purposes.Otherwise,a single-member LLC that code if is disregarded from the owner should check the appropriate box for the tax classification of its owner. o ❑ Other(see instructions)► (Applies to accounts maintained outside Me us.) ar co 5 Address(number,street,and apt.or suite no.)See instructions. Requester's name and address(optional) cn 22 American Way 6 City,state,and ZIP code South Dennis,MA 02660 7 List account number(s)here(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 i Social security number backup withholding.For individuals,this is generally your social security number(SSN).However,for a resident alien,sole proprietor,or disregarded entity,see the instructions for Part I,later.For other - - entities,it is your employer identification number(EIN).If you do not have a number,see How to get a T7N,later. or Note:If the account is in more than one name,see the instructions for line 1.Also see What Name and Employer identification number Number To Give the Requester for guidelines on whose number to enter. 0 4 - 3 0 5 8 5 4 0 Part II Certification Under penalties of perjury,I certify that: 1.The number shown on this form is my correct taxpayer identification number(or I am waiting for a number to be issued to me);and 2.I am not 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 3.1 am a U.S.citizen or other U.S.person(defined below);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 failed to report all interest and dividends on your tax return.For real estate transactions,item 2 does not apply.For mortgage interest paid, acquisition or abandonment 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. Sign Signature of //.�� • Here U.S.person N. Date► J 157 roZ / General instruc to ✓✓ •Form 1099-DIV(dividends,including those from stocks or mutual funds) Section references are to the Internal Revenue Code unless otherwise •Form 1099-MISC(various types of income,prizes,awards,or gross noted. proceeds) Future developments.For the latest information about developments •Form 1099-B(stock or mutual fund sales and certain other related to Form W-9 and its instructions,such as legislation enacted transactions by brokers) after they were published,go to www.irs.gov/Fom1W9. •Form 1099-S(proceeds from real estate transactions) Purpose of Form •Form 1099-K(merchant card and third party network transactions) An individual or entity(Form W-9 requester)who is required to file an •Form 1098(home mortgage interest),1098-E(student loan interest), information return with the IRS must obtain your correct taxpayer 1098-T(tuition) identification number(TIN)which may be your social security number •Form 1099-C(canceled debt) (SSN),individual taxpayer identification number(ITN),adoption •Form 1099-A(acquisition or abandonment of secured property) taxpayer identification number(ATIN),or employer identification number (EIN),to report on an information return the amount paid to you,or other Use Form W-9 only if you are a U.S.person(including a resident amount reportable on an information return.Examples of information alien),to provide your correct TIN. returns include,but are not limited to,the following. If you do not return Form W-9 to the requester with a TIN,you might •Form 1099-INT(interest earned or paid) be subject to backup withholding.See What is backup withholding, later. Cat.No.10231X Form W-9(Rev.10-2018) THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration g to f— . A r'"/ Type: Corporation ..` Registration: 129244 WHALEN RESTORATION SERVICES INC. , Expiration: 07/29/2025 22 AMERICAN WAY SOUTH DENNIS, MA 02660 Update Address and Return Card. THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs&Business Regulation Registration valid for individual use only before the HOME IMPROVEMENT CONTRACTOR expiration date. If found return to: TYPE:Corporation Office of Consumer Affairs and Business Regulation Registration Expiration 1000 Washington Street -Suite 710 129244 07/29/2025 Boston,MA 02118 'HALEN RESTORATION SERVICES INC. ILLIAM WHALEN /) '.AMERICAN WAY �(0.-,,¢(a,/,644i,-l. )LITH DENNIS, MA 02660 Undersecretary Not valid without signature . J Co mmonwealth of Massachusetts Division of Occupational Licensura Board of Building Regulations and Standards Cont�arit�rvisor =s CS-074928 tt35:0811011024 fiLLkA#Wilittilk s ,� t2't POND SWEET ip aREWSTER Mk 2263: P Commissioner i er, i�,,tt.. -. ,4:4.Mt+`-- Consrutoil Supervisor Unaestrtcteti -Buildings of any use group which cones less than 35,000 cubic feet(9911 cubic meters)of encleoaed space. Failure to possess a cement edition of the/Mastachutaets, State Building Code Is cause for revocation of this license. For Information about this license Call(617)727-3200 or visit www.mass.govidpi Main Level 175„ ii- - Ii „k‘ •V,-, � VkN4� i tting 'oom a N r J �Oo 3�2'1'1K j Sitting c� i— „• Iw�: . ,,.:.. .Mu•_ (B10) lo' ea l f " �j. io'lo" ■ Uppersog grill : 14' w Ironed Bathroom sOr) :a r' ii A' � earBedroom : Piine• •t (�Upper •114Bltchen :II!� (B12) 1i1— 19'2" ,�R+Y Hallway "' 13'7" 2""I 1'2'2" •� 14'10" • /N r'9”—I I •„I T 3'1"f Living Room 2 5' I1''r Iir p:1)�Dining roo Ill1, 1) Front B:dro+, CIOPnt BedroomCc f Ling oom_MII•set (1) RI] iL 11'10" • • 17'4" • i 45'4„ ir Main Level BARNACHEZ_REP_EXTR-1 12/6/2024 Page: 8