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29-391 (3) BP-2023-0505 69 BROOKWOOD DR COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 29-391-001 CITY OF NORTHAMPTON Permit: Alts Renovations Repair PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit# BP-2023-0505 PERMISSION IS HEREBY GRANTED TO: Project# BULKHEAD 2023 Contractor: License: Est. Cost: 5595 MR HOME CSL103401 Const.Class: Exp.Date: 03/19/2025 Use Group: Owner: BACHAND RONALD K Lot Size (sq.ft.) Zoning: WSP Applicant: MR HOME Applicant Address Phone: Insurance: 74 CISLAK DR (413)222-5368 UB003R873577 LUDLOW, MA 01056 ISSUED ON: 04/25/2023 TO PERFORM THE FOLLOWING WORK: CONVERT WINDOW TO BULKHEAD POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Service: Meter: Footings: Rough: Rough: House # Foundation: Final: Final: Final: Rough Frame: Gas: Fire Department Driveway Final: Fireplace/Chimney: Rough: Oil: Insulation: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: 1 ' Fees Paid: $65.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner ft f \ ,/,' /----------......„......,....,.&--,.....-------N, , The Commonwealth of Massa use 't1°19 R .f° Board of Building Regulations amid St ds �'o j IF PALITY `� Massachusetts State Building Code,7§0A 4'0� SE Building Permit Application To Construct,Repair, Renova4e`0r° r* ' a Revi ed Mar 2011 One-or Two-Family Dwelling �N Mq nFcrio This Section For Official Use Only Building Permit Number: �.3` L5 06 Date Applied: Ktrv„„ rZ'S5 if/ y-2 5-24!)2.75 Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Prope dd ess: 1.2 Assessors Map&Parcel Numbers 6 ,e/PIA6Virlf/d0'D /OIL , i 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 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public 0 Private 0 Zone: _ Outside Flood Zone? Municipal 0 On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: eQG'i1/,9/2 EAG//,i1.v 0 A/oiz aAJ/' Name(Print) City,State,ZIP (9 Enm64'11-2A/Md 4w 27(r Id'✓3 No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building 0 Owner-Occupied ❑ Repairs(s) 0 Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed Work': ni d J,VI te' 19 i 14Jkf&&, 1O ,b,6' , .6./ ,2,%'i4a fi'G dA.IiY j 9//ji[/,i. 12`J'1' QQr A/,,gJ4 f 7'2;✓I 4/z2 AY O ,e;14,/ .i'///4 ,A�'dit o"T /j4,zy'� r. SECTION 4:ESTTh4 TED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ 1. Building Permit Fe $ Indicate how fee is determined: ❑ Standard City/To Application Fee 2.Electrical $ ❑Total Project Cost3 tem 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fees: /,�� r Check No. heck Amount: (,� 6. Total Project Cost: $ g-J 9Jr ❑ Paid in Full 0 Outstanding Balance Due: J r City of Northampton , 7�4 jr} .�.. �. $NS�.".,_�Si' Massachusetts f� _ '`� /t • ti t 4'" DEPARTMENT OF BUILDING INSPECTIONS . 212 Main Street a Municipal Building `3iy. $ 1v4ItAg Northampton, MA 01060 Ps',,. �, �',°Sy PROCEDURE FOR OBTAINING A BUILDING PERMIT FOR WINDOWS, DOORS, ROOFS,RENOVATIONS,ROOF MOUNTED SOLAR, ETC. 1. Building Permit Application signed by legal owner and filled out by owner or authorized agent. 2. One set of plans and specifications of proposed work(Digital and hard copy). 3. Construction Debris Affidavit filled out and signed by applicant. 4. Worker's Compensation Insurance Affidavit filled out and signed by applicant. 5. Contractors must supply a copy CSL, HIC, and proof of Liability Insurance. 6. Energy Conservation Compliance Certificate (new/replacement windows). 7. Home owner's License Exemption Form (if applicable). 8. Note any Special Permit requirements(if applicable). 9. Energy Code—all new construction (Gut/Rehab) requires a HERS Rater Affidavit 10. Please provide the appropriate fee in the form of a check made payable to: The City of Northampton. SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) jn 7 yOl 7,/n,,zf /4,f))14/l ,1,,(4I )LO/V(°/ License Number Expiration Date Name of CSL Holder / 7 >/ / List CSL Type(see below) No.and Street �[ Type Description / ,/1 nrestricted(Buildings up to 35,000 cu. tt.) •L Z� / v/i i Restricted 1&2 Family Dwelling City/Town,State,,ZIP / Masonry RC Roofing Covering WS I Window and Siding 174 r(('' ,�! SF Solid Fuel Burning Appliances 7� �j J J� �X r�JP�� /1�� Insulation Telephone mail addre D Demolition 5.2 Registered Hyrum Improvement Contractor(HIC)' 7 yn 9?/� !•� "ill -NAV�J I-IC Registrationgi fNumber / Expirationa Date HIC Company Name or IIIC,Registrant Name �,/ No.and Street A/ ,��2�/Ilx ///�A /,�21/ ,0/f 4/ & l�,/ mail address City/Town,State,ZIIPI� /„ !(S 7Telelephoonne SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 25C(6)) Workers Compensation Insurance affidavit m st be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the Is ance of the building permit. Signed Affidavit Attached? Yes No .0 SECTION 7a:OWNE AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize to act on my behalf,in all matters relative to work authorized by this building permit application. Print Owner's Name(Electronic Signature) Date SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the st of my knowledge and understanding. /lam '4/V ��!/ r 5'o Print Owner's or Authorized Agent's Name(Electronic ign e 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" A. The (ommonovenith of Afassoehusetts Department of industrial Accidents .....t, 1,=. 1 Congress Street,Suite 100 k ,7 r -t-5--- Boston, A1,-1 0211.1-2017 4 www.moss.gor/dia Workers'Compensation Insurance Aflidat it:BuildersiCont.rattorsfEketricians/Plumbers. It)at:1-11..ED WITH'I III PLIC111-1-11:st;All'HORITV. APHriellitt Information Please Print Leribh Name Wits incss'Organtzn t ton;Individual V.: Address: . .._ . City/State/Zip: Phone .kre y on an employer?t'heck the Appropriate box: Type of project(required): . I am a employer with 16 __,ensployccs,(full=ctot part-titrwi,' 7. 0 Neu. construction _a I am a auk prupnctor in pornientop and bat.III/employees wiirking lilt me in S. Remodeling, any tmpacity.No workers'comp..insurance required I 9. Demolition .q::::1 I Am a hornoownin ihnng all work myself.[Nu woritas`comp.3lIzAJMIliZt mown/A* I 0 0 Building,addition I.Cal am a humeowItaa=ay/ill bc tirrinv contrardins to conduct ull work on my property I will otsure that all contractors either have workers'compensation insurance cc are sole I I.CD Electrical repairs or additions proprietors with nu employees, 12_0 Plumbing repairs or additions 3.0 I am a eenerai contractor and I he.c hued the sub-contractun.listed On the athichexl sheet. 130 Roof repairs These sub-contracton.have imployccs Ars,/bee VitItital'k'usrip.Insurance.; I 4.n Other ist]th'e are a oorpccation and its officers Mo.c exercised th•err nen of cierription per MGT.c 152.§1(1),and wc have no crisplot.ecs.[No workers'comp.insiaanec requrrodi 'Any appticiatt that ehecics box al most also fill mar the section below show in thin(winker"'emimensation pokey imlocmatton. t Homeowners.veho%thaw this aflukwi Truncating they are doing all work and then hue<outside camtractues mast submit a new aft-Want!indicating such. :Contractors that cheek this box must attacheil an additional sheet show ing the name of the stils-conuactors arul stab:.411Clikt or nut thuac entities hike ernployees If the sub-contractors have cirrploycel.they must provide their workers'conip.policy number . „ . . I urn an employer that is providing os.orkers'compensation Insurance for my employees. Below is the policy and job,site Information. Insurance Company Name'. T/Z4 Ye2/rej:LZ____.ZAZ________________ Policy#or Self-ins. Lie. #:. ,Zita:?,eflo?21„,? Expiration Date. 9 - ' . - .ld--„? .7 Job Site Address-. 41.fidl- /2/2o-(//1-14/ * pvi, City'StatelZip: /2.1,/fn/1 AA) Attach a copy of the workers'compensation polky declaration page(showing the policy number and tspiration date). Failure to secure coverage as required under MGL c. 152., §25A i' Li Criminal violation punishable En a fine up to$1.500.00 muter one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a line 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 certtlr under the pains and aides of p rjury that the t nfOrntanon provided above Is true and correct._ Signature: Date.: y,,? 7 .y Phonc t: 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.Cityrfown Clerk 4.Electrical Inspector 5. Plumbing Inspector G.Other Contact Person: Phone#: - — — City of Northampton „finsr,4 Massachusetts DEPARTMENT OF BUILDING INSPECTIONSZ. 212 Main Street • Municipal Building Northampton, MA 01060 S'py Y CONSTRUCTION DEBRIS AFFIDAVIT (FOR ALL DEMOLITION AND RENOVATION PROJECTS) In accordance of the provisions of MGL c 40, S54, a condition of Building Permit Number is that all debris resulting from this work shall be disposed of in a properly licensed waste disposal facility, as defined by MGL c 111, S 150A. The debris will be disposed of in: Location of Facility: r 0_ 1 79' The debris will be transported by: Name of Hauler: /\•4tp-71/0/1' C _ ) Signature of Applicant: 4/;74 Date: 5/.-2 City of Northampton y[:LCl,rd. Massachusetts t a • DEPARTMENT OF BUILDING INSPECTIONS ., `�> 212 Main Street • Municipal Building '��,. s� Northampton, MA 01060 „`- HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT I, (insert full legal name), born (insert month, day,year), hereby depose and state the following: 1. I am seeking a building permit pursuant to the homeowners'exemption to the permit requirements of the Massachusetts State Building Code, codified at 780 CMR 110.R5.1.3.1, in connection with a project or work on a parcel of land to which I hold legal title. 2. 1 am not engaged in, and the project or work for which I am seeking the aforementioned homeowners' exemption, does not involve the field erection of manufactured buildings constructed in accordance with 780 CMR 110.R3. 3. I qualify under the State Building Code's definition of"homeowner"as defined at 780 CMR 110.R5.1.2: Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one-or two-family dwelling, attached or detached structures accessory to such use and/or farm structures.A person who constructs more than one home in a two-year period shall not be considered a home owner. 4. I do not hold a valid Massachusetts construction supervision license and, except to the extent that I qualify for and will abide by the Massachusetts State Building Code's requirements for the supervision of the project or work on my parcel, I am not engaged in construction supervision in connection with any project or work involving construction, reconstruction, alteration, repair, removal or demolition involving any activity regulated by any provision of the Massachusetts State Building Code. 5. If I engage any other person or persons for hire in connection with the aforementioned project or work on my parcel,I acknowledge that I am required to and will act as the supervisor for said project or work. Signed under the pains and penalties of perjury on this day of ,20_. (Signature) .r'. .--o%0 01- kfak *- PROPOSAL/AGREEMENT —� 1f:'il MA Lic.# 147560 j ice; ` ' wwwsnr-home.net CT Lic#613751 '� office.mr.horne@gmaiLcom Pli 6 6 f t5 19 n b Dumaine Street, Wilbraham, MA 01095 t t£ `f {413)222-5368 , , _- C '� ' cn VD,L4 .,,,.. C.h e {8GO) 627-5610 ,--- Date Proposed To Be Dine "' Windsor Locks,CT -+T.;.• '. y / j Submitted To: Phone Numhers: .49.,A/A EX,6.74',l/jam' `? &/ Cell: Street: ,/ /� City,State and Zip Code: 47„ Email: Notes: j WORK TO B1;DONE cOI.OR: '02 ,e4/lf; A , r� /i .� t-e-,1//,i9Q /ret2. r_? f l GUTTERS: ak-r•- 1.�rer, bi r J/4/. e4,, e . ,5,4 tie. ,,.7'�` DOWNSPOUTS: / e4/A-4 l/A4 /-- -67,e/./ver",, 2 MITERS: 1. /5z eie. ne? !/h,2'OsQ,4d.t /X4n„/.. I IANDCUT MITERS: ,r1_'4 28 /.4.rr RIP/REMOVE: ~ 2 GUTTER GUARD: -_- ---e0 i? srfrQ ,,/�1" ,84, A4'/t • (4:77:5) `� /- '.I , 1/4 r L"{i (Pei/ "f 4 i//( L' • , -,/‘ ./1 ( ' ' ., '"_:_V . . ,-" - . : 7.--';:---;I.2 7 fr - ! --7),- . S7s4,,R-f://' I Please Check Diagram Carefully and Sign Below Totat Cost For Above Specified Work Includes Material And Labor: S _ 1/3 Down Required to Hook Work and Balance Ls Due llpon Completion fAcceptance of Proposal-'flee above prices.speciti ationcand conditions are satisfictory and hereby accepted You are authorized to do the work v.specified. Pad went will be nutde as outline above. Mu,our caned this transaction without penalty or obligation t Whin three business dins. Date of :Acceptance: Completed E P Y r^ i f ` Customer Signature Authorized Signature / .� _�? -' --� Permit Pack • Certificate of Insurance : Valid Until 09/25/2023 (Ideal Insurance Agency, Inc.) • CSL License : Valid Until 09/19/2025 (CSFA-103401) • Ma Home Improvement Contractor License : Valid Until 01/29/2025 (REG# 194368) • W-9 ACC DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 4/19/2023 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 Dowd Agencies, LLC PHONE 14 Bobala Rd tkc,No,Ext):413-538-7444 FAX ,Not:413-536-6020 Holyoke MA 01040 a DRESS: INSURER(S)AFFORDING COVERAGE NAIC License#:BR-1201657 INSURER A:Travelers Casualty and Surety Company 19038 INSURED MRHOMEO-01 INSURER B:Arbella Protection Insurance Company 41360 Mr. Home, Inc 6 Dumaine Street INSURERC: Wilbraham MA 01095 INSURERD: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:1060812005 REVISION NUMBER: [HIS 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 ADDL SUBR POLICY EFF POLICY EXP W LIMITS LTR INSD VD POLICY NUMBER (MM/DD/YYYY) (MMIDDIYYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES Ea occ urence),_ $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ B AUTOMOBILE LIABILITY 1020126484 2/11/2023 2/11/2024 COMBINED SINGLE LIMIT $ (Ea acciden@ ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $100,000 AUTOS ONLY AUTOS ONLY (Per accident) $ UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ A WORKERS COMPENSATION UB3R873577 9/25/2022 9/25/2023 X STATUTE OTH- ER AND EMPLOYERS'LIABILITY Y/N - ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $500,000 OFFICER/MEMBEREXCLUDED? NIA (Mandatory in NH) El DISEASE-EA EMPLOYEE $500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS 1 LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule.may be attached if more space Is required) Home Improvement 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. For Insureds Record AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD • Commonwealth of Massachusetts / Division of Occupational Licensure Board of Building R ulations and Standards Construction it*1 &2 Family CSFA-103401 Ares 03/19/2025 WILLIAM H NEEP Y 74 CISLAK DRIVE w LUDLOW MA11060 7 1 i . Commissioner da , `17Ftmc.Qca,„ THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs and Business Regulation 1000 Washington Strwt - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration =' , : ;" ' Type: Corporation MR HOME, INC. ° Registration: 194368 "" E piration: 01/29/2025 74 CISLAK DRIVE ; Imaginings—�---- • sommimman:�-m--- LUDLOW, MA 01056 1 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 194368 01/29/2025 Boston,MA 02118 MR HOME,INC. W I ILLIAM H. SWEENEY°� _--. 6 DUMAINE STREET i_ WILBRAHAM,MA 01095 Undersecretary Not valid without signature Request for Taxpayer Give Form to the Form W11119 (Rev.October 2018) Identification Number and Certification requester. Do not Department of the Treasury send to the IRS. Internal Revenue Service ►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. V\17 I t \ t ;tiers 2 Business name/disregarded entity name,if different Mom above m 3 Check appropriate box for federal tax classification of the person whose name is entered on line 1.Check only one of the 4 Exemptions(codes apply only to c following seven boxes. certain entities,not individuals;see Q. instructions on page 3): S ❑ IndividuaVsole proprietor or 0 C Corporation al S Corporation ❑ Partnership ❑ Trust/estate ai single-member LLC c Exempt payee code(if any) ❑ Limited liability company.Enter the tax classification(C=C corporation,S=S corporation,P=Partnership)► c 2 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 code if an c another LLC that is not disregarded from the owner for U.S.federal tax purposes.Otherwise,a single-member LLC that ( y) Is disregarded from the owner should check the appropriate box for the tax classification of its owner. ❑ Other(see instructions)► (Applies to accounts maintained outside the U.S.) y 5 Address.(number,street,and apt.or suite no.)See instructions. Requester's name and address(optional) 8 L.,' l ) trn&.‘c e ‘-�v ce_A- 8 City,state,and ZIP cycle 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 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 TIN, 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. — 7 9 `y n 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.I 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 + i �� '�/ Here U.S.person► fr ` � �f� Date► ,j� t X l�r .7 General Instructions ��"V�� • 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/FormW9. • 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(ITIN),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)