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HomeMy WebLinkAboutBLDX-25-224- Dpcusign Envelope ID:C9F4DE2D-BBD2-4814-ADAD-113E439901B5 ONE & TWO FAMILY ONLY- BUILDING PERMIT Town of Yarmouth Building Department ,.pg Yak 1146 Route 28, South Yarmouth,MA 02664-4492 ;',gyp`= 508-398-2231 ext. 1261 Fax 508-398-0836 rO 14` Massachusetts State Building Code, 780 CMR Building Permit Application To Construct, Repair, Renovate Or Demolish ` '~41160teo...'�f a One-or Two-Family Dwelling • 611:01kSectio For Official Use Only Building Permit Number: `f Date Applied: Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map& Parcel Numbers 1.1a 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 1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public ID Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: Nicholas Lawrence Yarmouth MA 02675 Name(Print) City,State,ZIP 30 Dutchland Dr 1 (508)737-3441 nicholaslawrence19926yahoo.com No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) a Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed Work':Strip and re-roof entire house 1 layer 12sq SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $$6,795.00 1. Building Permit Fee:$ Indicate how fee is determined: ❑Standard City/Town Application Fee 2.Electrical $ ❑Total Project Cost'(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire Total All Fees:$ Suppression) Check No. Check Amount: Cash Amount: 6.Total Project Cost: $$6,795.00 ❑Paid in Full 0 Outstanding Balance Due: Dpcusign Envelope ID:C9F4DE2D-BBD2-4814-ADAD-113E439901B5 SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) cs-109085 2/9/27 Jarret Kazanjian License Number Expiration Date Name of CSL Holder List CSL Type(see below) u 23 Willow Ave No.and Street Type Description U Unrestricted(Buildings up to 35,000 cu.ft.) Dracut MA 01862 R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 978-375-8355 Innovativeroofingnh.ir@gmail.com I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 184808 04/14/26 Jarret Kazajian HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name 23 Willow Ave Innovativeroofingnhir@gmail.com g @gmail.com No.and Street Email address Dracut Ma 01862 978-375-8355 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 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 Jarret Kazanjiab ,te-a, ,gl>biny behalf,in all matters relative to work authorized by this building permit application. �,1 2/10/2025 Prtnnwner swine(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. /lam 2/10/25 Print Owner's or Auto'ized Agent's Na ► (El tropic 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.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/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" Docusign Envelope ID:C9F4DE2D-BBD2-4814-ADAD-113E439901B5 �44' TOWN OF YARMOUTH .<Off` YA�N`:. 6 `r �s Office of the Building Commissioner •° '�'•P 1146 Route 28, \� vSouth Yarmouth, MA 02664 Ry°Rek`E° y,` 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 to be conducted at.30 Dutchland Dr Yarmouth MA 02675 Work Address Resource Waste 270 Exeter Rd Epping nh 03042 Is to be disposed of at the following location: Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 1 1 1, §150A. A-w � 2/10/25 Sig ture of Apicant Date Permit No. Docusign Envelope ID:C9F4DE2D-BBD2-4814-ADAD-113E439901B5 Massachusetts Home Improvement Sample Contract This form satisfies all basic requirements of the states Home Improvement Contractor Law(MGL chapter 142A),but does not include standard language to protect homeowners. Seek legal advice if necessary. Any person planning home improvements should first obtain a copy of"a Massachusetts consumer guide to home improvement"before agreeing to any work on your residence.You may obtain a free copy by calling the Office of Consumer Affairs and Business Regulation's Consumer Information Hotline at 617-973-8787 or 1-888-283-3757. Homeowner Information Contractor Information Nicholas Lawrence Jarret Kazanjian/Innovative Roofing NH Name Company Name 30 Dutchland Dr Jarret Kazanjian Street Address(do not use a Post Office Box address) Contractor/Salesperson/Owner Name Yarmouth MA 02675 23 Willow Ave City/Town State Zip Code Business Address(must include a street address) (508) 737-3441 Dracut MA 01826 Daytime Phone Evening Phone City/Town State Zip Code 978-375-8355/603-999-88$5 Mailing Address(It different from above) Business Phone Federal Employer ID or S.S.Number ires Law requ that most ir home - Home vemeot Contractor Reg.Number Expiration date proverrreta contractor have a vas registration aucther 184808 04/14/2026 The Contractor agrees to do the following work for the Homeowner: (Describe in detail the work to completed,specifying the type,brand,and grade of materials to be used,use additional sheets if necessary.) Strip and re-roof entire house 1 layer 12sq Required Permits-The following building permits are required Proposed Start and Completion Schedule-The following schedule will and will be secured by the contractor as the homeowner's agent, be adhered to unless circumstances beyond the contractor's control arise (Owners who secure their own permits will be excluded from the Guaranty Fund provisions of 2/24/25 Date when contractor will begin contracted work. MGL chapter 142A.) 2/24/25 Date when contracted work will be substantially completed. Total Contract Price and Payment Schedule $6,795.00 The Contractor agrees to perform the work,furnish the material and labor specified above for the total sum of: (*) Payments will be made according to the following schedule: $0 upon signing contract(not to exceed 1/3 of the total contract price 4r the cost of special order items,whichever is greater) $0 by / / or upon completion of $0 by / / or upon completion of $0 upon completion of the contract. (Law forbids demanding full payment until contract is completed to both party's satisfaction) The following material/equipment must be special $ to be paid for ordered before the contracted work begins in order $ _ to be paid for to meet the completion schedule.(**) NOTES:(*)Including all finance charges(**)Law requires that any deposit or down-payment required by the contractor before work begins may not exceed the greater of(a)one-third of the total contract price or(b)the actual cost of any special equipment or custom made material which must be special ordered in advance to meet the completion schedule. Express Warranty-Is an express warranty being provided by the contractor? No Yes fall terms of the warranty must be attached to the contract) Subcontractors-The contractor agrees to be solely responsible for completion of the work described regardless of the actions of any third party/subcontractor utilized by the contractor. The contractor further agrees to be solely responsible for all payments to all subcontractors for materials and labor under this agreement Contract Acceptance-Upon signing,this document becomes a binding contract under law. Unless otherwise noted within this document,the contract shall not imply that any lien or other security interest has been placed on the residence. Review the following cautions and notices carefully before signing this contract. • Don't be pressured into signing the contract.Take time to read and fully understand it. Ask questions if something is unclear. • Make sure the contractor has a valid Home Improvement Contractor Registration. The law requires most home improvement contractors and subcontractors to be registered with the Director of Home Improvement Contractor Registration. You may inquire about contractor registration by writing to the Director at 10 Park Plaza,Room 5170,Boston,MA 02116 or by calling 617-973-8787 or 888-283-3757. • Does the contractor have insurance?Ask the Contractor for his insurance company information so that you can confirm coverage,or ask to see a copy of a"proof of insurance"document. • Know your rights and responsibilities. Read the Important hiformation on the reverse side of this form and get a copy of the Consumer Guide to the Home Improvement Contractor Law. You may cancel this agreement if it has been signed at a place other than the contractor's normal place of business,provided you notify the contractor in writing at his/her main office or branch office by ordinary mail posted,by telegram sent or by delivery,not later than midnight of the third business day following the signing of this agreement. See the attached notice of cancellation form for an explanation of this right. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES!!! Two identical copies of the contract must be completed and signed. One copy should go to the homeowner.The other copy should be kept by the contractor /'„\v' -�otiaiMPRITAnature Con s Signature C//llJ 2/10/2025 2/10/25 Date Date Docusign Envelope ID:C9F4DE2D-BBD2-4814-ADAD-113E439901 B5 Contractor Arbitration The Home Improvement Contractor Law provides homeowners with the right to initiate an arbitration action(as an alternative to court action)if they have a dispute with a contractor. The same right is not automatically afforded to a contractor,however. The contractor would have to resolve any dispute he/she has with a homeowner in court unless both parties agree to the optional clause provided below. This clause would give the contractor the same right to arbitration as is afforded to the homeowner by the Home Improvement Contractor Law. The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute concerning this contract,the contractor may submit the dispute to a private arbitration firm which has been approved by the Secretary of the Executive Office of Consumer Affairs and Business Regulation and the consumer shall be required to 1 1,9 such arbitration as provided In Massachusetts General Laws,chapter 142A. < Homeowners Signature Con ctor's Signatur �/ NOTICE:The signatures of the parties above apply only to the agreement of the parties to alternative dispute resolution initiated by the contractor. The homeowner may initiate alternative dispute resolution even where this section is not separately signed by the parties. Homeowner's Rights A homeowner's rights under the Home Improvement Contractor Law(MGL chapter 142A)and other consumer protection laws(i.e.MGL chapter 93A)may not be waived in any way,even by agreement. However,homeowners may be excluded from certain rights if the contractor they choose is not properly registered as prescribed by law. Homeowners who secure their own building permits are automatically excluded from all Guaranty Fund provisions of the Home Improvement Contractor Law. The contractor is responsible for completing the work as described,in a timely and workmanlike manner. Homeowners may be entitled to other specific legal rights if the contractor guarantees or provides an express warranty for workmanship or materials. In addition to guarantees or warranties provided by the contractor,all goods sold in Massachusetts carry an implied warranty of merchantability and fitness for a particular purpose. An enumeration of other matters on which the homeowner and contractor lawfully agree may be added to the terms of the contract as long as they do not restrict a homeowner's basic consumer rights. If you have questions about your consumer/homeowner rights,contact the Consumer Information Hotline(listed below). Execution of Contract The contract must be executed in duplicate and should not be signed until a copy of all exhibits and referenced documents have been attached. Parties are also advised not to sign the document until all blank sections have been filled in or marked as void,deleted,or not applicable. One original signed copy of the contract with attachments is to be given to the owner and the other kept by the contractor. Any modification to the original contract must be in writing and agreed to by both parties.Contracted work may not begin until both parties have received a fully executed copy of the contract,and the three day recission period has expired. Accelerated Payments A contractor may not demand payments in advance of the dates specified on the payment schedule in cases where the homeowner deems him/herself to be financially insecure. However,in instances where a contractor deems him/herself to be financially insecure,the contractor may require that the balance of funds not yet due be placed in a joint escrow account as a prerequisite to continuing the contracted work. Withdrawal of funds from said account would require the signatures of both parties. Additional Information If you need additional information about the Home Improvement Contractor Law or other consumer rights,or if you wish to obtain a free copy of"A Massachusetts Consumer Guide to Home Improvement,"contact: Consumer Information Hotline Office of Consumer Affairs and Business Regulation 501 Boylston St,Suite 5100,Boston,MA 02116 (617)973-8787 or 1-(888)2833757 If you want to verify the registration of a contractor or if you have questions or need additional information specifically about the contractor registration component of the Home Improvement Contractor Law,contact: Director of Home Improvement Contractor Registration Office of Consumer Affairs and Business Regulation 1000 Washington St,Room 710,Boston,MA 02118 617-973-8787,888-283-3757 or visit the HIC website at http://www.mass.gov/ocabr' Go online to view the status of a Home Improvement Contractor's Registration: http://db.state.ma.us/homeimprovement/licenseelist.asp For assistance with informal mediation of disputes or to register formal complaints against a business,call: Consumer Complaint Section Office of the Attorney General (617)727-8400 AND/OR Better Business Bureau (508)652-4800,(508)755-2548,(413)734-3114 D.ocusign Envelope ID:C9F4DE2D-BBD2-4814-ADAD-113E439901 B5 NOTICE OF CANCELLATION YOU MAY CANCEL THIS TRANSACTION, WITHOUT 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 CONTRACT OR SALE, AND ANY NEGOTIABLE INSTRUMENTS EXECUTED BY YOU WILL BE RETURNED WITHIN TEN BUSINESS DAYS FOLLOWING RECEIPT BY THE SELLER OF YOU 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 CONTRACT OR SALE; 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 CANCELLATION, YOU MAY RETAIN OR DESPOSE OF THE GOODS WITHOUT ANY FURTHER OBLIGATION. IF YOU FAIL 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 [Name of Seller],AT [Address of Seller's Place of Business]NOT LATER THAN MIDNIGHT OF (date). Signed by: 2/10/2025 I HEREBY CANCEL THEMAT ON. Date: Buyer's Signature;1 ;„02„,,,, dc2 . THE COMMONWEALTH OF MASSACHUSETT Office of Consumer Affairs & Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE: Individual Reghitration Explratigil 184808 04/14/2026 JARRET K;AZANJIAN t P,.- , , '''', .:..:.' ! ., JARRET KAZANJIAN L . A .... , , .,.,. .. f 0 e a , ',' ' } .' 23 WILLC3V'1�' AVE _ , f D fA CT' MA82� 4f M v Undersecretary o+,, «.� .,wa •mow vMwaru+r 1 Commonwealth of Massachusetts Construction Supervisor 11 Division of Occupational Licensure Unrestricted-Buildings of any use group which contain less than Board of Building Regulations and Standards 35,000 cubic feet(991 cubic meters)of enclosed space. Cons FHFQM4rvisor CS-109085 447 * 'cpires: 02/09/2027 JARRET R KAZANJIA 23 WILLOW AVE DRACUT MA D1826 'Ut Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. Commissioner z1 / Contact OPSI:(617)727-3200 or visit www.mass.gov/dpl/opsi ACc CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) t`.---- 04/02/2024 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 Jessica Krauklin NAME: Core Benefits Group Inc (PHONE C N,Ext): (603)329-4933 FAX A C,No): (603)329-4924 2 Village Green Road E-MAIL JKrauklin©mycoreinsurance.com ADDRESS: Suite Al INSURER(S)AFFORDING COVERAGE NAIC# Hampstead NH 03841 INSURERA: The Burlington Insurance Company INSURED INSURER B: Merchants Mutual Insurance Company 23329 Innovative Roofing NH LLC INSURER C: Technology Insurance Co 41 Dutton Rd INSURER D: INSURER E: Pelham NH 03076 INSURER F: COVERAGES CERTIFICATE NUMBER: 24-25 Master Cert 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 EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) UNITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE RENTED CLAIMS-MADE X OCCUR PREMISESOoccurrence)(Ea $ 50,000 MED EXP(Any one person) $ 5,000 A 807BG11288 04/01/2024 04/01/2025 PERSONAL&ADVINJURY $ 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY X PR0. LOC PRODUCTS-COMP/OP AGG $ 2,000,000 JECT OTHER: $ AUTOMOBILE UABIUTY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) X ANY AUTO BODILY INJURY(Per person) $ B OWNED SCHEDULED CAPI080330 10/28/2023 10/28/2024 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS_ HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 2,000,- 000 A EXCESS LIAB CLAIMS-MADE 8076E09764 04/01/2024 04/01/2025 AGGREGATE $ 2,000,000 DED RETENTION$ $ WORKERS COMPENSATION vl PER OTH- 3A State:NH AND EMPLOYERS'LIABILITY Y/N ^I STATUTE ER , , C ANY PROPRIETOR/PARTNER/EXECUTIVE Y N/A TARNH1034139-04 04/03/2024 04/03/2025 E.L.EACH ACCIDENT $ 1 000 000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1,000,000 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) Daniel Robinson,Boyd Foulds and Jarret Kazanjian are excluded from Worker's Compensation coverage. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN "`FOR INFORMATION ONLY"' ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 26(2016/03) The ACORD name and logo are registered marks of ACORD ACC RD® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 04/02/2024 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 Jessica Krauklin NAME: Core Benefits Group Inc PH NN Ext): (603)329-4933 jA/X,No): (603)329-4924 (A/2 Village Green Road E-MAIL JKrauklin@mycoreinsurance.com ADDRESS: Suite Al INSURERS)AFFORDING COVERAGE NAIC# Hampstead NH 03841 INSURERA: The Burlington Insurance Company INSURED INSURER B: Merchants Mutual Insurance Company 23329 Innovative Roofing NH LLC INSURER C: Technology Insurance Co 41 Dutton Rd INSURER D: INSURER E: Pelham NH 03076 INSURER F: COVERAGES CERTIFICATE NUMBER: 24-25 Master Cert 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 EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MMIDD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ 50,000 MED EXP(Any one person) $ 5,000 A 807BG11288 04/01/2024 04/01/2025 PERSONAL&ADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY X JECOT- LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) X ANY AUTO BODILY INJURY(Per person) $ B OWNED SCHEDULED CAPI080330 10/28/2023 10/28/2024 BODILY INJURY(Per accident) $ AUTOS ONLY _ AUTOS HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY _ AUTOS ONLY (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 2,000,000 A EXCESS UAB CLAIMS-MADE 8076E09764 04/01/2024 04/01/2025 AGGREGATE $ 2,000,000 DED RETENTION$ $ WORKERS COMPENSATION X STATUTE EOTH 3A State:NH AND EMPLOYERS'LIABILITY Y/N C ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACHACCIDENT $ , , 1000000 OFFICER/MEMBER EXCLUDED? Y N/A TARNH1034139-04 04/03/2024 04/03/2025 (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 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) Daniel Robinson,Boyd Foulds and Jarret Kazanjian are excluded from Worker's Compensation coverage. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ***FOR INFORMATION ONLY*** ACCORDANCE WITH THE POLICY PROVISIONS. 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 9. -_ Office of Investigations a44l_tt 64i Lafayette City Center _. , 2 Avenue de Lafayette, Boston,MA 02111-1750 to, www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Innovative Roofing NH Jarret Kazanjian Address:7 Kristen Dr City/State/Zip:Derry, NH 03038 Phone #:978-375-8355 Are you an employer? Check the appropriate box: Type of project(required): 1.El I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction listed on the attached sheet. 7. ElRemodeling 2.0 I am a sole proprietor or partner- ship and have no employees These sub-contractors have 8. ElDemolition workingfor me in anycapacity. employees and have workers' P ty. 9. ❑ Building addition [No workers' comp. insurance comp. insurance.: required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ 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 12.0 Roof repairs insurance required.] t c. 152, §1(4), and we have no Roof employees. [No workers' 13.❑� 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. :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. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:Technology Insurance Co Policy#or Self-ins. Lic. #:TARNH1034139-04 Expiration Date:4/3/25 Job Site Address: 30 Dutchland Dr City/State/Zip:Yarmouth MA 02675 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 that the information provided above is true and correct. • Signature: Jarret Kazanjian / a ja4 yzadL Date: 2/13/25 Phone#: 978-375-8355 �a 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): 1❑Board of Health 20 Building Department 30City/Town Clerk 4.0 Electrical Inspector 5.1=1Plumbing Inspector 6.0Other Contact Person: Phone#: