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Home My WebLink AboutBLD-19-000902 Y _ its Only J O%lir r, H: aAmmmt 60- n ' 5 Permit expires 180 days from .' -�.- issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department R E C r 1 t! E 1:) 1146 Route 28 South Yarmouth, MA 02664 1 AUG 15 2019 1 9q / (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: Ol l Ye tleyi'o0 L y / w y itto : o �fid z,+�'j—. T • ASSESSOR'S INFORMATION: ( T�'I 1 L Map: Parcel: OWNER: I1WLC� CQ / `E 7O l— NA/'1M,,E,, Cod ) /�,�,", (/ PRESENT ADDRESSATEL. # CONTRACTOR: A e C dRaw Ivnpvv. A -MI II SiPi u Yanw2 c �.s2r690/0 2 )1/Residential / N MAILING ADDRESS I TEL# 0 Residential 0 Commercial Est.Cost of Construction$ Z %aO. 0 0 /6,0112 Home Improvement Contractor Lic.# Construction Supervisor Lic.# /06-0P0 Workman's Compensation Insurance: (check one) , / 0 I am the homeowner 0 I am the sole pro etor WI have Worker's Compensation Insurance T/ Insurance Company Name: he/Yf (IC a / /�Worker's Comp.Policy# y 1/0/2 3 WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares t�,r,�� Replacement windows:# Replacement doors: # Roofing: #of Squares 2I ( V)Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing 'The debris will be disposed of at eh../`7 S, Demn1.5 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]w.. e d for secution under MG.L Ch.268,Section 1. Applicant's Signature: (//7D ox // // y Date: ! ✓r o Owners Signature(or attachment) Date: 071224.7 J Approved By: Date: 8//s-/x9 Buil ' ,Ofd (or designee) EMAIL AD SS: Zoning District Historical District 0 Yes 0 No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 0 No riA A CAPE COD ImprovementHome TM CAPE COD HOME IMPROVEMENT 27 MILL POND ROAD, WEST YARMOUTH MA 02673 (617) 710-1001, (508) 469-0102 CAPECODINC@GMAIL.COM, WWW.ROOFCAPECOD.COM, WWW.FACEBOOK.COM/CAPECODHOME PROPOSAL 07.22.201$ TO Tat(O R. MONICA LOCATION: 21 YELVERTON LN, WEST 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 SIX NAILS PER SHINGLE. • COLOR OF ROOF PENETRATIONS AND FLASHINGS TO BE CHOSEN BY OWNER. • INSTALLATION OF A SHINGLE-OVER RIDGE VENT AND SOFFIT-BUTTONS.VENT IN THIS AREA IS CAPE COD HOME IMPROVEMENT TM GUARANTEES THAT ALL COMPONENTS INSTALLED PROPERLY ' PLEASE FEEL FREE TO CALL CAPE COD HOME IMPROVEMENT TM WITH ANY QUESTIONS OR CONCERNS �,/,' PLEASE INITIAL THIS PAGE Mali • eii CAPECODHome 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 CONTINUOUS AND WILL PROVIDE MAXIMUM INTAKE VENTILATION FOR THE FULL ATTIC VENTILATION SYSTEM. • REPLACE ANY DAMAGE FASCIA-BOARDS OR RAKE-BOARDS AT AN ADDITIONAL 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. PTION 1 CERTA EED LANDMARK SHINGLES 50 YEARS NO - -ORATED TRANSFERABLE WARR LABOR AND MATERIAL . - • - 0.00 DUMPSTER: $550.06 TOTAL: '. = : 80.00 OPTION 2 `` D •• - CERTAINTEED LANDMARK SHINGLES 40 YEARS PRORATED WARRANTY(10 YEARS NON-PRORATED PERIOD) LABOR AND MATERIALS: $7,370.00 DUMPSTER: $550.00 . TOTAL: $7,920.00 J. r 6110*WE WILL MATCH OR OUTBID AN' -GITIMATE COMPETITOR* CAPE COD HOME IMPROVEMENT TM IS PROUD TO PRESENT YOU WITH SUPERIOR 10 YEAR WORKMANSHIP AND SERVICE WARRANTY.THIS WARRANTY IS IN ADDITION TO,BUT RUNS CONCURRENTLY WITH ANY MANUFACTURERS'WARRANTIES.IT COVERS ALL SERVICE CALLS RELATED TO WARRANTY REPLACEMENT AND/OR INSTALLATION ISSUES FOR THE FIRST TEN YEARS AFTER PRODUCT INSTALLATION CAPE COD HOME IMPROVEMENT TM GUARANTEES THAT ALL COMPONENTS INSTALLED PROPERLY 1/' PLEASE FEEL FREE TO CALL CAPE COD HOME IMPROVEMENT T" WITH ANY QUESTIONS OR CONCERNS PLEASE INITIAL THIS PAGE 4,1 • f f / ej CAPE rCOD CAPE COD HOME IMPROVEMENT TM 27 MILL POND ROAD, WEST YARMOUTH MA 02673 (617) 710-1001, (508) 469.0102 CAPECODINC@GMAIL.COM, WWW.ROOFCAPECOD.COM, WWW.FACEBOOK.COM/CAPECODHOME PAYMENT TERMS: 50%AT DEPOSIT; 50%UPON COMPLETION. JOB IS ESTIMATED TO COMMENCE APPROXIMATELY 2 TO 8 WEEKS AFTER DEPOSIT RECEIVED WORK IS SCHEDULED TO BE SUBSTANTIALLY COMPLETED IN APPROXIMATELY 1 TO 2 WEEKS. ANY WORK ABOVE AND BEYOND THE SPECIFICATIONS WILL BE PERFORMED AT 56.00$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 TM 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"4 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 WITH 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 ITEMS AGAINST WALLS SHOULD BE CONSIDERED FOR REMOVAL DURING ANY EXTERIOR SIDING JOBS,ADDITIONS,ETC.TO GUARD AGAINST DAMAGE.IN THE 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 TM IS NOT RESPONSIBLE FOR ANY DAMAGES IF SAID ITEMS REMAIN IN PLACE. CAPE COD HOME IMPROVEMENT T^' 15 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 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 NON-PAYMENT. a CAPE COD HOME IMPROVEMENT T"'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 �� CAPE COD 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 WE LOOK FORWARD TO WORKING WITH YOU: PLEASE CALL IF YOU HAVE ANY QUESTIONS. SINCERELY CAPE COD HOME IMPROVEMENT TM THIS CONTRACT NOT VALID UNLESS SIGNED BY ANATOLI "TONY" SIVITSKI ACCEPTED BY SIGN DATE ACCEPTED BY Mho S�O t3lC, abar1 SI a hitt: DATE (M( 14 I( !1 ACCEPTED BY (I choose Option 2) Monica Taylor SIGN rf"' t3/4ATE 08/14/2018 CAPE COD HOME IMPROVEMENT TM GUARANTEES THAT ALL COMPONENTS INSTALLED PROPERLY PLEASE FEEL FREE TO CALL CAPE COD HOME IMPROVEMENT" WITH ANY QUESTIONS OR CONCERNS PLEASE INITIAL THIS PAGE MT ACORLI a CERTIFICATE OF LIABILITY INSURANCEI DATE IMMvnrSTY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.ITHIS 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: H the certificate holder is en ADDITIONAL INSURED,the policy(lee)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require en endorsement A statement on this certificate does not confer rights to the endorsement(s). holder In lieu of such endoement(s). PPOWCER CONTACT NAME. Linda Sullivan DOWLING&O'NEIL INSURANCE AGENCY PHO_GwoNE pfll. (508)775-1620 AX F EMAIL IArC,Nal' 973 IYANNOUGH RD mks. Isulliven.tlolna com INSURER(S)AFFORDING COVERAGE MAI/ HYANNIS MA 02601 INSURER A AMGUARD INSURANCE CO 42390 INSURED INSURER e: CAPE COD HOME IMPROVEMENT INC INSURER C: INSURER 0' 27 MILL POND ROAD INSURER E: WEST YARMOUTH MA 02673 INSURER F- 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 POUCIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS INSR ADDLSUER _ LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER IMMID&YYYY) IMM'ODMYFF ROMSYYYP YI LIMITS COMMERCIAL GENERAL MOUSY EACH OCCURRENCE CLAIMS-MADE El OCCUR DAMAUE TO NeN LU PREMIFS IE occurrence) I MED EXP(Any ane person) $ N/A PERSONALS ADV INJURY _ f GENL AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ El jE�' POLICY f n LOC PRODUCTS-COMP/OP AGG 1 OTHER AUTOMOBILEWSLITY COMBINED SINGLE LIMIT $ ANY AUTO IEDmccdenU BODILY INJURY(Par Pevwnl S ALL OWNED —SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per ecaeenII $ HIRED AUTOS NONOWNED AUTOS wOPGq DAMAGE UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS WB CLAIMS-MADE N/A DED I I RETENTIONS AGGREGATE $ WORKERS COMPENSATION v f AND EMPLOYERS'LIABILITY VFN ^ISTATUTEI IERH A CFFICERAIEMANYPROPRIETBEXCLUCEDf CUTIVE WA WA WA EL EACH ACCIDENT 5 1.000,000 (Mendenory In NH) R244C940123 08/03/2018 08103/2019 IISlabs under EL DISEASE-EA EMPLOYEE$ 1,000,000 DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT f 1,000,000 N/A • DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD TOL AMRIpn fleme*s Bdr]ul may yMlaSS,ed N man eon Is 1pSrs) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 08 B.no authorization B 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 Venfication Search tool at www mass gov/Iwd/wohkers-compensationAnvestigationst CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DEUVERED IN Anatol'Sivitski ACCORDANCE WITH THE POUCY PROVISIONS. 222 Buck Island Road 8.8 AUTHORIZED REPRESENTATIVE West Yarmouth MA 02873 ` Dann iei l M.,Cr y,CPCU,Vice President–Residual Market–WCRIBMA ®1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD Commonwealth of Massachusetts II,fit' Division of Professional Licensure Board of Building Regulations and Standards • Constructio .�S1�ddfilisor Specialty 1 CSSL-106040 -1:.;" Ejspires : 05/14/2020 tU, ,,.. --: ANATOLI SIVITSKI . rr�� -` w 27 MILL POND-RD ;, s ,'' ' .:" WEST YARMOCI,T,H MA 026Sr3 � .`.. l , ani-ae Commissioner Cele The Commonwealth of Massachusetts • Department of Industrial Accidents `I P`L— !`t Office of Investigations • • =rte! 600 Washington Street tf "1 =r Boston,MA 02111 "�':-�_n� www.mass.gov/dia • Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information /� , Ito m Please Print Legibly Name(Business/Organization/Individual): (32pe Al FW l't/t.L 1{'Y/rad'emetelia Address: ° �1 �f 1'"hld !ed . City/State/Zip: V" •la, -0 CG '!Phone#: 307 7 6 9 0/0 Z Aree y u an employer?Check the appropriate box: • • Type of project(required): 1. `l� I am a employer with 7— 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet 7. 0 Remodeling ship and have no employees These sub-contractors have S. ❑Demolition working forme in any capacity. employees and have workers' 9 ❑Building addition No workers'comp.insurance comp.insurance.: required.] 5. ❑ We area corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing an work . officers have exercised their 11.0 Plumbing repairs or additions myself[No workers'comp. right of exemption per MOL Roof qu d]t c. 152,§1(4),andwehaveno 12.❑Other repairs f� insmancere13.ErOther WO / e employees. [No workers' comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing theft waiters'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 Iodinating 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 an:an employer that Is providing workers'compensation Insurance for my employees. Below is the policy and fob site information. ^ � / Insurance Company Name: �f yyfof / Policy#or Self-ins. +Liic.#: 9'90123 . Expiration Date:W x 06/03/19 Job Site Address:�S! I�v��N l City/State/Zip: t c 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 final 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 andIIcorrect. Signature: it'ki �t Date: od//T/l0 phone#: 3rnva7)'69 0/0 2 • Official use only. Do not write in this area,to be completed by city or town official City or Town: Perinit/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 indivifival,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 certificates)of insurance. Limited Liability Companies(ILC)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 pea-mit/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 maybe 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 obtninhng a license or permit not related to any business or commercial venture (i.e.a dog license or permit to bum 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.#617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 4-24-07 www macts.gov/dia ,�� Q �� aangit�r�cv-ea,%I i°-�i%Lamacitasea Office of Consumer Affairs and Business Regulation One Ashburton Place- Suite 1301 Boston, Massachusett's 02108 • Home Improvement Contractor Registration • Type: Corporation CAPE COD HOME IMPROVEMENT,INC. - - _ Registration: 168043 27 MILL POND RD • Expiration: 12/08/2018 WEST YARMOHTH.MA 02673 Update Address and Return Card. -,:o ; S 2O1A OF11. -. r'Trnsnsnc,nnrn/N.'7�''Jrlislitekthell, a • 011,cc of Consumer Affa,rs&Business Regulation HOME IMPROVEM ENT CONTRACTOR Registration valid for individual use only • TYPE:Ccencration before the expiration date. If found return to: Ffoaistratlon : Fxniratio0 Office of Consumer Affairs and Business Regulation '68043- - 12/0612018 10 Park Plaza-Sulu - • •. ;TIE CUO I IO`JE IMPROVEMENT,INC. Boston,MA r '- , ..SST YAPF.10_ I.WA 0 073 Undersecretary Not valid without signature