Loading...
HomeMy WebLinkAboutBLD-19-000903 Office Use Only O ,, '3 f Amount l.7 N „ A k".::::'"" :g Penait expires 180 days from 1 issue date bib- iq-WccU 3 EXPRESS BUILDING PERMIT APPLICATION R E C E ! V 6 1 : TOWN OF YARMOUTH Yarmouth Building Department I AUG15 2018 1146 Route 28 South Yarmouth, MA 02664 Bur ' /' (508) 398--223/1 Ext. 1261 y/ `3y -.� — _ r CONSTRUCTION ADDRESS: 7 / ��,/�'l9 RS S . y(,�j -nio Luz [t • ASSESSOR'S INFORMATION: • Map: / Parcel: OWNER: /VCULC4/ ail ey NAME ^^<7 /PRESENT ADDRESS fill/ �J /S TEL. # ' ' /l 'COONNTRACTOR: NG�'�"P Wl/ /Cowie _lily)MAIB:'ISaRES�S `/-�NCY if f W. ya noec iL V Residential ffJ/ ❑Commercial p /'� Est Cost of Construction$ �C'� 00. 00 Home Improvement Contractor Lia# 16O 0 Y 3 Construction Supervisor Lic.# 'l06 0 51c, Workman's Compensation Insurance: (check one) 0 I am the homeowner ❑ I amw ol the sole proprietor NKhave have Worker's Compensation Insurance Insurance Company Name: A „( V p C✓ Worker's Comp.Policy# % V0 2-3 WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacementlawindows:# Replacement doors: # Roofing: #of Squares .. 6.7-5--( 13 Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist ( )Replacing gg like for like Pool fencing l '[U s //)J/�',, t The debris will be disposed of at / Fie vrld 5 Location of Facility I declare under penalties of perjury that the statements herein contained are true and correct to the best of my knowledge and belief I understand that any false answer(s) will be just cause for denial or revocation of my license and fo prosecution under M.G.L.Ch.268,Section 1. ���////// p Applicant's Signature: Date: OS/fIJ/ i �y Owners Signature(or attachment) • r TO Date: �T�t7/j(p//d"/� Approved By: �-' Zit Date: Q /S>1 Bu' g•.�, (or d-ignee) EMAE. • s:re SS: / Zoning District Historical District ❑ Yes 0 No flood Plain Zone: 0 Yes ❑ No Water Resource Protection District Within 100 ft of Wetlands: 0 Yes 0 No 0 Yes 0 No • 1 CAPE coo Home ICAPE COD HOME IMPROVEMENT mprov D TM 27 MILL POND ROAD, WEST YARMOUTH MA 02673 (617)710.1001, (508)469-0102 CAPECODINC@CMAIL.COM, WWW.ROOFCAPECOD.COM, WWW.FACEBOOK.COM/CAPECODHOME PROPOSAL 06.08.2018 TO NANCY KELLEY LOCATION: 41 WILFIN RD, SOUTH YARMOUTH WE HEREBY SUBMIT SPECIFICATIONS AND ESTIMATES FOR MAIN COMPOSITION SHINGLE ROOF: • REMOVAL OF ALL EXISTING ROOFING AND FLASHING MEMBRANES TO THE PLYWOOD DECK SURFACE. • REPLACEMENT OF ANY DAMAGED OR DETERIORATED PLYWOOD DECKING AT AN ADDITIONAL COST.DECKING WILL BE REPLACED IN WHOLE SHEETS ONLY IN ACCORDANCE WITH RECOMMENDATIONS BY BOTH THE NATIONAL ROOFING CONTRACTORS ASSOCIATION(NRCA)AND THE AMERICAN PLYWOOD ASSOCIATION(APA).NEW DECKING SHALL BE APA RATED FOR STRUCTURAL USE.DECK FASTENING WILL MEET OR EXCEED LOCAL BUILDING CODE REQUIREMENTS. • • REPLACEMENT OF FOLLOWING FLASHING MATERIALS:STEP FLASHINGS,PIPE FLANGES,PERIMETER DRIP EDGE MATERIAL AND ALL SKYLIGHT FLASHING MATERIAL.ALL MATERIALS TO MEET OR EXCEED MANUFACTURER'S REQUIREMENTS. • ONE ROW OF ICE AND WATER PROTECTION MEMBRANE SHALL BE INSTALLED IN ALL VALLEYS AND AROUND THE CHIMNEY. • ONE ROW OF ICE AND WATER PROTECTION MEMBRANE SHALL BE INSTALLED ALONG ALL EAVES AND SHALL EXTEND PAST THE INTERIOR WALL LINE A MINIMUM OF 18 INCHES TO PROVIDE PROTECTION AGAINST DAMAGE FROM ICE DAMS. INSTALLATION OF ONE LAYER OF ROOFING UNDERLAYMENT ON DECK SURFACE NOT COVERED WITH ICE AND WATER PROTECTION MATERIAL. • INSTALLATION OF NEW.ARCHITECTURAL-STYLE ALGAE-RESISTANT CERTAINTEED SHINGLES.SHINGLES WILL BE INSTALLED IN STRICT ACCORDANCE WITH THE MANUFACTURER'S SPECIFICATIONS AND SHALL BE FASTENED USING EX NAILS PER SHINGLE. • COLOR OF ROOF PENETRATIONS AND FLASHINGS TO BE CHOSEN BY OWNER. • INSTALLATION OF A SHINGLE-OVER RIDGE VENT.VENT IN THIS AREA IS CONTINUOUS AND WILL PROVIDE MAXIMUM INTAKE VENTILATION FOR THE FULL ATTIC VENTILATION SYSTEM. • REPLACE ANY DAMAGE FASCIA-BOARDS OR RAKE-BOARDS AT AN ADDTONAL COST. • ALL GROUNDS TO BE CLEANED UP ON A DAILY BASIS.ALL BUSHES,SHRUBS.AND FLOWERS TO BE PROTECTED. HOMEOWNER IS ASKED TO SUPPLY ELECTRICAL POWER IF NEEDED. CAPE COD HOME IMPROVEMENT TM GUARANTEES HAT ALL COMPONENTS INSTALLED PROPERLY PLEASE FEEL FREE TO CALL CAPE COD HOME IMPROVEMENT"4 WRITANY QUESTIONS OR CONCERNS PLEASE INITIAL THIS PAGE '4 C • 4 ' otd CAPE COD Hom,impronm,nt CAPE COD HOME IMPROVEMENT TM 27 MILL POND ROAD,WEST YARMOUTH MA 02673 (617) 710.1001,(508)469-0102 CAPECODINC@GMAIL.COM, WWW.ROOFCAPECOD.COM, WWW.FACEBOOKCOM/CAPECODHOME CERTAINTEED LANDMARK SHINGLES LABOR AND MATERIALS: $3,450.00 EPDM RUBBER OR POLYUREA (POLYURETHANE) LABOR AND MATERIALS: $6,800.00 DUMPSTER;$450.00 TOTAL: $ 10,700.00 + ( 40o sio JS *WE WILL MATCH OR OUTBID ANY LEGITIMATE COMPETITOR" CAPE COD HOME IMPROVEMENTTM IS PROUD TO PRESENT YOU WITH SUPERIOR 10 YEAR WORKMANSHIP AND SERVICE WARRANTY.THIS WARRANTY IS IN ADDITION TO,BUT RUNS CONCURRENTLY WITH ANY MANUFACTURERS'WARRANTIES.IT COVERS ALL SERVICE CALLS RELATED TO WARRANTY REPLACEMENT AND/OR INSTALLATION ISSUES FOR THE FIRST TEN YEARS AFTER PRODUCT INSTALLATION PAYMENTTERMS: 50%AT DEPOSIT. Coco 50%UPON COMPLETION. JOB IS ESTIMATED TO COMMENCE APPROXIMATELY 2 TO 8 WEEKS AFTER DEPOSIT RECEIVED WORK IS SCHEDULED TO BE SUBSTANTIALLY COMPLETED IN APPROXIMATELY 1 TO 2 WEEKS. ANY WORK ABOVE AND BEYOND THE SPECIFICATIONS WILL BE PERFORMED AT 58.00$PER MAN HOUR PLUS MATERIALS OR PRICED ON REQUEST.ALL ADDITIONAL WORK.INCLUDING TRAVEL TIME AND LUMBERYARD RUNS,MOVING ALL PERSONAL OBJECTS.FURNITURE,ETC.FROM WORK AREA.WILL BE SUBJECT TO EXTRA CHARGE.IN THE EVENT OF ROT REPAIRS.ROOF REPAIRS OR ANY RELATED WORK REQUIRING IMMEDIATE ATTENTION,WE WILL PROCEED WITHOUT CUSTOMER APPROVAL. CAPE COD HOME IMPROVEMENT"WILL PROVIDE CLEANUP ON A CONTINUING BASIS AND ALL DEBRIS WILL BE REMOVED FROM SITE(PROFESSIONAL CLEANING DOESN'T INCLUDE).ALL PRODUCTS INSTALLED BY CAPE COD HOME IMPROVEMENT TM WILL BE TO MANUFACTURER SPECIFICATIONS.ALL WORK WILL BE PERFORMED BY INSURED PROFESSIONALS. ALL MATERIAL IS GUARANTEED TO BE AS SPECIFIED,AND THE ABOVE WORK TO BE PERFORMED IN ACCORDANCE WTR1 THE DRAWINGS AND/OR SPECIFICATIONS SUBMITTED FOR ABOVE WORK AND COMPLETED IN A SUBSTANTIAL WORKMANLIKE MANNER. OWNER TO MOVE ALL PERSONAL OBJECTS,FURNITURE,ETC.FROM WORK AREA.ALL RENS AGAINST WALLS SHOULD BE CONSIDERED FOR REMOVAL DURING ANY EXTERIOR SIDING JOBS,ADDITIONS,ETC.TO GUARD AGAINST DAMAGE.IN THE CAPE COD HOME IMPROVEMENT^'GUARANTEES THAT ALL COMPONENTS INSTALLED PROPERLY PLEASE FEEL FREE TO CALL CAPE COD HOME IMPROVEMENT TM WITH ANY QUESTIONS OR CONCERNS 71 Ii1 / � PLEASE INITIAL THIS PAGE y/7�� 1. Home cAPm°�on CAPE COD HOME IMPROVEMENT TM 27 MILL POND ROAD, WEST YARMOUTH MA 02673 (617) 710-1001, (508) 469-0102 CAPECODINC@GMAIL.COM, WWW.ROOFCAPECOD.COM, WWW.FACEBOOK.COM/CAPECODHOME CASE OF ANY ROOFING AND RIDGE VENTING,DUST AND DEBRIS SHOULD BE EXPECTED AND ANY ITEMS IN THE ATTIC SHOULD BE REMOVED.CAPE COD HOME IMPROVEMENT.IS NOT RESPONSIBLE FOR ANY DAMAGES IF SAID ITEMS REMAIN IN PLACE. CAPE COD HOME IMPROVEMENTTM IS NOT RESPONSIBLE FOR ANY DAMAGES THAT MAY OCCUR DURING CONSTRUCTION TO LANDSCAPING OR ANY FINISH GROUND WORK,PLANTINGS,ASPHALT OR STONE DRIVEWAY.ETC.FLOWERS AND SHRUBS AGAINST HOUSE MAY NEED TO BE REPAIRED OR REPLACED BY HOMEOWNER. ANY ALTERATION OR DEVIATION FROM ABOVE SPECIFICATIONS INVOLVING EXTRA COSTS WILL BE EXECUTED ONLY UPON WRITTEN ORDERS,AND WILL BECOME AN EXTRA CHARGE OVER AND ABOVE THE ESTIMATE.ALL AGREEMENTS CONTINGENT UPON STRIKES,ACCIDENTS OR DELAYS BEYOND OUR CONTROL OWNER TO CARRY FIRE,TORNADO AND OTHER NECESSARY INSURANCE UPON ABOVE WORK.WORKMEN'S COMPENSATION AND PUBLIC LIABILITY INSURANCE ON ABOVE WORK TO BE PLACED ON THE RESIDENCE AS A CONSEQUENCE OF THE CONTRACT.OWNER WHO SECURE THEIR OWN CONSTRUCTION- RELATED ONSTRUCTIONRELATED PERMITS OR DEAL WITH UNREGISTERED CONTRACTORS WILL BE EXCLUDED FROM ACCESS TO THE GUARANTY FUND.COSTS OFF COLLECTION,INCLUDING ATTORNEYS FEES WILL BE RECOVERABLE.IN THE EVENT OF NONPAYMENT. WE LOOK FORWARD TO WORKING WITH YOU: PLEASE CALL IF YOU HAVE ANY QUESTIONS. SINCERELY CAPE COD HOME IMPROVEMENT" THIS CONTRACT NOT VALID UNLESS SIGNED BY ANATOL!'TONY"SNTIBIO ACCEPTED BY p e� "" SIGN IA WOO �IJ..� 2-1—tit ACCEPTED BY °�1� k� '-^V` ,J ICA i SIS. C \iii .ATE ( Dg (() ACCEPTED BY SIGN DATE CAPE COD HOME IMPROVEMENT TM GUARANTEES THAT ALL COMPONENTS INSTALLED PROPERLY PLEASE FEEL FREE TO CALL CAPE COD HOME IMPROVEMENT T"WITH ANY QUESTIONS OR CONCERNS -- PLEASE INITIAL THIS PAGE Nide Ad Re: Replace Roofing Nancy Kelley <kelley.nancy45@yahoo.com> 7/17/201812:23 PM Gl To Anatoli Sivitski Copy Jerry Hertweck Hi,Tony, Olt let's sign a contract and do It the 3 rd week of August. Nancy and Jerry • • Sent from my Pad On Jul 17,2018,at 1:41 AM,Anatoli Sivitskl<capecodincAgmail.conp wrote: Hi Nancy and Jerry Yes,includes main roof with rubber m brane(not crag Yes,we'll take care of that section abo e the front door Cedar shingles on the cheeks going to cost$1,400 for both( aterials and installation) 3rd week of august sounds good! On Mon,Jul 16,2018 at 12:41 PM Nancy Kelley<Jcelley4nancy35.@yahoo.com>wrote: Hi,Tony, Thank you for the quote on replacing the roof at 41 Wilfin Sc South Yarmouth. We do have a couple of questions for you: We want to confirm that the estimate covers replacing the main root and that of the back porch,but not for the garage,and that it includes the rubber membrane on the low slope portion. Does the estimate include the cost to fix the problem we discussed by the front door? What is the cost of replacing the cedar shingles at the cheeks of the dormers? We are still interested in doing this project around the third week in August. Thank you, Nancy Kelley Jerry Hertweck Sent from my iPad On Jun 8,2018,at 10:38 PM,Anatoli Sivitski<capecodincAgmail.corq>wrote: Good evening Nancy It was very nice meeting you Please find attached files and don't hesitate to contact me if you have any questions or concerns Also please check out our work at links below and keep in mind that we'll match or outbid any legitimate competitor PS:if you'd like to replace siding on the sides of the dormer(pits attached) its going to cost Thank you Best regards / Ad Info Anatoli"Tony"Sivitski Cape Cod Home Improvement Tr" 27 Mill Pond rd,West Yarmouth MA 02673 ° Commonwealth of Massachusetts Division of Professional Licensure • Board of Building Regulations and Standards • Constructiota'daUtsor Specialty CSSL-106040 Expires : 05/14/2020 ,,• .. ANATOLI SIVITSKI rr;? -' A , 27 MILL POND-RD . ;, 1 � ' � ''� WEST YARMOUTH MA 02673 Commissioner CAL- C Rd A CERTIFICATE OF LIABILITY INSURANCE DATEIMWpNYYYY) �'- 08/15/2018 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(les)must 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), PROWLER CONNAMECr Linda Sullivan DOWLING&O'NEIL INSURANCE AGENCYPN°NE FAx .u-M N,�„ 508 7.751N,.. 77s-tezo I Na ADDRESS. Isullwan©IDdolns corn 973 IYANNOUGH RD INSURER(s)AFFORDING COVERAGE NAIL! HYANNIS MA 02601 INSURER A: AMGUARD INSURANCE CO 42390 INSURED INSURER B: CAPE COD HOME IMPROVEMENT INC INSURER C: INSURER D: 27 MILL POND ROAD INSURER!: WEST YARMOUTH MA 02673 INSURER IF COVERAGES CERTIFICATE NUMBER: 281511 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 BUBR LTR TYPE OF INSURANCE INET WVO POLICY NUMBER POLICY EFF MPOLICY INDW IMWDD'YYYYI IMMDDTyy YYYI LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE t CLAMS-MADE ❑OCCUR "DAMAGE TO RENTED PREMISES IES;bromine.) $ MED DIP(Any one person) 5 _ N/A PERSONAL!ADV INJURY $ GENT.AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE 5 H POLICY n PRO- II I� — _ JECT LOC PRODUCTS-COMP/OP AGO 5 OTHER AUTOMOBILE LIABILITY ;E'MBttIN„eDI$INGLE LIMIT t ANY AUTO BODILY INJURY(Pa Pence) $ ALL OWNED SCHEDULED AUTOS _AUTOS N/A BODILY INJURY(Per $$ HIRED AUTOS AUTOS NON-OWNED PROPERTY DAMAGE Autos t (Per accident) UMBRELLA MAS _OCCUR EACH OCCURRENCE EXCESS LIAB CLAIMS-MADE N/A AGGREGATE S DFD I IRETECOMPENSATIONWORKERS AND EMPLOYERS'DABIIITY YIN XI STATUTE I I ERN ANYPROPRIETORNARTNERIEXECUTNE E L EACH ACCIDENT A OFFICER/MEMBER EXCLUDED? W1 WA WA R2WC940123 05/03/2018 08/03/2019 t 1,000,000• (Mandatory In NH) E L DISEASE-EA EMPLOYEE $ 1,000,000 n yes ae«nBn Ma« DESCRIPTION OF OPERATIONS below EL DISEASE POLICY LIMIT 5 1,000,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional RNnerb sNMuls,may be maM,y E mot ewe lgSYea) 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/IwdMoAers-compensatloMnvestigattonst CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Anatol?Sivitski ACCORDANCE WITH THEPOLICY PROVISIONS. 222 Buck Island Road 6-8 AUTHORIZED REPRESENTATIVE West Yarmouth MA 02673 - Daniel M.CroWky CPCU,Vice President-Residual Market-WCRIBMA IS 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD r ik tThe Commonwealth of Massachusetts li, • =4=== Department of Industrial Accidents t' '—t`t _ `; Office of Investigations _ 600 Washington Street = I►_ - = 1'1= ' Boston,MA 02111 y �q -'r.. 1 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information ///'�',,, ��` /� /� h Please Print Legibly Name(Business/Organization/Individual): e-(2 c /LozAtt J>)I1PrOVQ�21 _ Address: o2% Mill /'V K. Rd / City/State/Zip: I✓ 1�Q/YG1.U3t MA Phone#: 577K I/60 0/0a Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. 0 1 am a general contractor and I 6. ❑New construction employees(full and/or part-time).' have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling ship and have no employees These sub-contractors have g, ❑Demolition working for me in any capacity. employees and have workers' 9 0 Building addition [No workers' comp.insurance comp.insurance.: required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work • officers have exercised their 11.❑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 employees. [No workers' 13.0 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. l am an employer that Is providing workers'compensation insurance for my employees. Below is the policy and job site information. 4u' rl Insurance Company Name: //l // Policy#or Self-ins.Lic.#: 94'O(23 Expiration Date: 06/0.31/2.2 1/1/// ,, ` / ' S. Y�- Job Site Address: �/ Yv j r ��^ City/State/Zip: 4 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 MOL 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. Ido hereby certify under the pains ayn�d pe allies of perjury that the information provided above is true an correct.0/v. Date: Oi//Jr 1Q Signature: (( Phone#: 508 416 90/02- Official o/D2Official 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#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." • An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel.#617-7274900 ext 406 or 1-877-MASSAFE Revised 4-24-07 Fax#617-727-7749 www.mass.gov/dna Q%e �pom/inouveau o/bgezoaac4aoel Office of Consumer Affairs and Business Regulation One Ashburton Place - Suite 1301 Boston, Massachusetts 02108 Home Improvement'Contiactor Registration r-r`*;�t'-, -- Type Corporation }� t:,\r:,,._ y z;J Registration: 166043 CAPE COD HOME IMPROVEMENT.INC. :- ?.!' tr __ u1 Expiration: 12/0W2018 27 MILL POND RD ' '- :11 t l WEST YARMOIdTH,MA 02673 ,j t-- - ti' �-`' j '. t;�\ -c::,.,TLk=/J/ \-,, ' << \n1yr.<.a ,wo/ _ i.- Update Address and Return Card, SCSI d N.MM11.005/177y �/ - -- te gwarkanin Office of Consumer Aftalrs&Business Regulation HOME IM PROVEM ENT CONTRACTOR Registration valid for Individual use only TYPELCcrooratlon before the expiration date. If found return to: Registration?.., Fxniratiort Office of Consumer Affairs and Business Regulation 182043-„----12/06/2018 10 Park Plaza-Sul • CARE COU 110%1E,IMPROVEMENT,INC. Boston,MA i C .. 1h� L.!!'i yi,.•4 ie i/ T ANATOLI SIVI I SKI '-'iI. R.CC af--- 27 MILL POND RD ' ` �� Not valid wit out s gnature WEST YAP.MOJTN,MA"02b79 Undersecretary .