HomeMy WebLinkAboutBLD-19-001492 O4..Y Office Use Only
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EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmouth, MA 02664
(508) 398-2231 Ext. 1261 ,
CONSTRUCTION ADDRESS: JVD WI(S D I t- awl.r kJ Va-v- w UI-C
ASSESSOR'S INFORMATION: •
Map:'•,{ Parcel:
OWNER ea ti VOly
NAME /�� / /�� �J'��,� PRESENT ADDRESS n I.' TEL # f"
CONTRACTOR &eo korpt -r`lir a!`u/(('� ft� W.Yarninni4, .021690I0e_
/ i/ 'MAILING ADDRESS TEL# p
D"Residential 0 Commercial-(680C(3 Est Cost of Construction S 1—p 00 a 0
Home Improvement Contractor Lie.# Construction Supervisor Lie.# Pea VO
Workman's Compensation Insurance: (check one)
0 I am the homeowner ❑ I am the//sole�proprietor 'W I have Worker's Compensation Insurance
Insurance Company Name: Am at0 j'! Worker's Comp.Policy# /1/012 3
•
WORK TO BE PERFORMED
Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove
Siding: #of Squares Replagement windows:# Replacement doors: #
Roofing: #of Squares /9.S ( )Remove existing* (man.2 layers) Insulation
Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing
'The debris will be disposed of at / > .e 'ut tS
Location of Facility
I declare under penalties of perjury that the statements herein contained are true and correct to the best of my lmowledge and belief. I understand that any false answer(s)
will be just cause for denial or revocation of my license for secution under M.G.L.Ch.268,Section 1. p
Applicant's Signature: Date:
Date: 0elotild
Owners Signature(or attachment) Date:
Approved By: •—91.-�, I Daze:
q•-•II'—l%.
Building Official(or designee) EMAIL ADDRESS:
Zoning District
Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes 0 No
Water Resource Protection District Within 100 R of Wetlands: '
0 Yes 0 No 0 Yes 0 No
•
The Commonwealth of Massachusetts
„..� Department of Industrial Accidents
Office of Investigations
i _; •' 600 Washington Street
Boston,MA 02111
www.mass.gov/din •
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information /�� /p �J` Please Print Legibly
Name(Business/organizalion/Individual)/ Cat e— COci `e0ft<t Trip
. Address: C21 q"�/w �1 t kW R� ,�1.
•
City/State/Zip: W. I.a�VW UAL-- Phone#: ,5 v!� f 6 9o/0 2
• . Are you an employer?Check the appropriate box • • Type of project(required): . •
1.❑ 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
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, 0 Demolition
working for me in any capacity. employees and have workers'
[No workers'comp.insurance comp.insurance.: 9. 0 Building addition
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.❑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.
!Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such.
=Contractors that chock 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 subcontractors 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. /7
/I �,il
Insurance Company Name: /MI (� / /
Policy#or Self ins.Lie.#A: I,/
CO
T23 Expiration Date:
� �/ 06/0.3/(9
Job Site Address: i t'" I 'wk. City/State/Zip: i/V. YQrIO&WL_
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 an en • ofperjury that the information provided above is true and correct
Signature: (//((lIJJ�� �-r� Date: /,9�HAM
J
Phone#: 05 2(69 woe—
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector,
6.Other
Contact Person: Phone#:
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 indivi l»R1,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 hot 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 toyour 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(LW)or Limited Liability Partnerships(I.IP)with no employees other than the
members or partners,are not required to cagy 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 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 hie 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=then
The Commonwealth of Massachusetts
- Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
Tel,#617-7274400 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 4-24-07 www,mass,gov/dia
•
•
APE
"•=m 'mCAPE COD HOME IMPROVEMENT TM 1
27 MILL POND ROAD,WEST YARMOUTH MA 02673
(617)710-1001,(508)469-0102
CAPECODINC@GMAILCOM. WWW.ROOFCAPECOD.COM, WWW.FACEBOOK.COM/CAPECODHOME
PROPOSAL
11 .07.2017
TO
JEFF
LOCATION: 56 WILSON RD,WEST YARMOUTH
WE HEREBY SUBMIT SPECIFICATIONS AND ESTIMATES FOR
MAIN COMPOSITION SIDING:
• REMOVAL OF EXISTING SIDING AND FLASHING MEMBRANES TO THE PLYWOOD DECK SURFACE.
- • REPLACEMENT OF ANY DAMAGED OR DETERIORATED PLYWOOD DECKING AT AN ADDITIONAL COST OF$40
PER FOUR FOOT BY EIGHT FOOT SHEET OF PLYWOOD NEEDED.DECKING WILL BE REPLACED IN WHOLE
SHEETS ONLY IN ACCORDANCE WITH RECOMMENDATIONS BY THE AMERICAN PLYWOOD ASSOCIATIOFh(APA).
NEW DECKING SHALL BE APA RATED FOR STRUCTURAL USE.DECK FASTENING WILL MEET OR EXCEED LOCAL
BUILDING CODE REQUIREMENTS.
• REPLACEMENT OF FLASHING MATERIALS.ALL MATERIALS TO MEET OR EXCEED MANUFACTURER'S
REQUIREMENTS.
• ONE ROW OF ICE AND WATER PROTECTION MEMBRANE SHALL BE INSTALLED ALONG ALL CHEEKS 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 SIDING UNDERLAYMENT ON DECK SURFACE NOT COVERED .
WITH ICE AND WATER PROTECTION MATERIAL
• INSTALLATION OF NEW SIDEWALL SHINGLES.SHINGLES WILL BE INSTALLED IN STRICT ACCORDANCE WITH
THE MANUFACTURER'S SPECIFICATIONS AND SHALL BE FASTENED USING AT LEAST TWO STAPLES PER
SHINGLE.
• USING STAINLESS STEEL NAILS WHERE NEEDED(LAST COURSES.LACED CORNERS.ETC.)
• COLOR AND OTHER DETAILS OF MATERIALS TO BE CHOSEN BY OWNER.
• INSTALLATION OF PVC TRIM BOARDS WITH CORTEX SCREWS.
. - • Au.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.
n ' CAPE COD Hone IMPROV WENT TM GUARANTEES THAT ALL COMPONENTS INSTALLED PROPERLY
PLEASE FEEL new TO CALL CAPE COD HOME IWRovEnaTM min ANT QUESTIONS OR CONCERN
PLEASE INITIAL THIS P G
•
PE COD
CAPE COD HOME IMPROVEMENT TM
27 MILL POND ROAD,WEST YARMOUTH MA 02673
(617)710`1001,(508)469-0102
CAPECODINCOGMAILCOM, WWW.ROOFCAPECOD.COM, WWW.FACEBOOK.COM/CAPECODHOME
BIDING (APPROX. 14 sol
LABOR AND M> Its: $4,900.00
TRIM (APPROX.850 LN FTI
LABOR AND M*rAt:S: $2,900.00
DUMPSTER: N/A
GRAND TOTAL: $7,800.00
- WE WILL MATCH OR OUTBID ANY LEGITIMATE COMPETITOR•
CAPE COD HOME IMPROVEMENT 1/4 IS PROUD TO PRESENT YOU WITH SUPERIOR IO 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;
50%UPON COMPLETION.
- - Y
ter, ���rc-s 4
r7", . .. PROYWBIfTTMOUARANTiiitTHAT ALL COMPONENTS INSTALLED MlM /'
�tLY ° , •
/IIQTo CALL CAPE COD HOME IPROvc4ENT m WITH ANT WESfloH{OR CONums91" INITIAL
/ /j
r PLEASE INI TIALTHIS PAGE I;��:J+�� ‘4,0
•
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CAPE COD ?
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"'Ca CAPE COD HOME IMPROVEMENT TM .f;
1 27 MILL POND ROAD,WEST'YARMOUTH MA 02673
(617)710.1001.(508)469-0102, fi'r`';
CAPECODINC@GMAIL.COM. WWW.ROOFCAPECOD.COM, WWW.FACEBOOK.COM/CAPECODHOME e4 +
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JOB IS ESTIMATED TO COMMENCE APPROXIMATELY 2 TO 8 WEEKS AFTER DEPOSIT RECEIVED t '0, t.
UNLESS OTHERWISE NOTED HERE: k':$1
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WORK IS SCHEDULED TO BE SUBSTANTIALLY COMPLETED IN APPROXIMATELY 1 TO 3 WEEKS. eri
it ttp
‘i- ANY WORK ABOVE AND BEYOND THE SPECIFICATIONS WILL BE PERFORMED AT 56.00$PER MAN »I. ".,
HOUR PWS MATERIALS OR PRICED ON REQUEST.Au..ADDITIONAL WORK,INCLUDING TRAVEL TIME p.,,, .
AND LUMBERYARD RUNS•MOVING ALL PERSONAL OBJECTS.FURNITURE.ETC.FROM WORK AREA. IR
WILL BE SUBJECT TO EXTRA CHARGE.IN THE EVENT OF ROT REPAIRS.ROOF REPAIRS OR ANY •h�
RELATED WORK REQUIRING IMMEDIATE ATTENTION,WE WILL PROCEED WITHOUT CUSTOMER .;
APPROVAL �r ,'-.
CAPE COD HOME IMPROVEMENT 1.1 WILL PROVIDE CLEANUP ON A CONTINUING BASIS AND ALL ^4°
DEBRIS WILL BE REMOVED FROM SITE(PROFESSIONAL CLEANING DOESN'T INCLUDE).ALL
PRODUCTS INSTALLED BY CAPE COD HOME IMPROVEMENT TM WILL BE TO MANUFACTURER
ISPECIFICATIONS.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 TM 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 +s&>II'
4
REPAIRED OR REPLACED BY HOMEOWNER. - x
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 Wilk a
ea-..4
OUR CONTROL OWNER TO CARRY FIRE,TORNADO AND OTHER NECESSARY INSURANCE UPON woe,Fr
CAPSCOOHOWL IMPROVIMIDM'asUUARAN ICEWTHAT A.U.COMPONENTS INSTALLED PROPERLY
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TO COD HOIMPROVEMENT Ir WRH ANT OUEITWNI OR LL
PLEASE IAL THIS PA`�y ,, Y' r, :
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•
•
WI!COD
..:Z' CAPE COD HOME IMPROVEMENT TM
27 MILL POND ROAD,WEST YARMOUTH MA 02673
(617)710-1001, (508)469-0102
CAPECODINC@GMAILCOM, WWW.ROOFCAPECOD.COM, WWW.FACEBOOK.COM/CAPECODHOME
ABOVE WORK.WORKMEN'S COMPENSATION AND PUBLJC LJABILITY 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.
WE LOOK FORWARD TO WORKING WITH YOU: PLEASE CALL IF YOU HAVE ANY QUESTIONS.
SINCERELY CAPE COD HOME IMPROVEMENT TM
THIS CONTRACT NOT VALID UNI FSG SIGNED BY .ANATOLI *TO NY" SIVITSKI
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ACCEPTED BY/ I'•GA+IN^" V M' -
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ACCEPTED BY \�It Jam' '' .S �`^ '
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"" 1 TOCACAPECOOHOIMPROYWOff"'yam ANY gunrooms oat CONCERNS 1;114
PLEASE INITIAL THIS PAG
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Commonwealth of Massachusetts
,` i Division of Professional Licensure
�� Board of Building Regulations and Standards
Construction:Si p r'visor Specialty
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CSSL-106040 - Epires : 05/14/2020
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ANATOLI SIVITSKI 7es.
27 MILL PONDJRD f `
WEST YARMOU,TiI-I MA .02673 !l
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alpir
Commissioner C2-
fe Wpaintnonrwec o/oI acct eoefS
Office of Consumer Affairs and Business Regulation
One Ashburton Place - Suite 1301
Boston, Massachusetts 02108
Home Improvement Contractor Registration .
Type Corporation
-:,. _- Registration: 168043
CAPE COD HOME IMPROVEMENT,INC. _ - Expiration: 12/06/2018
27 LIULLPOND RD tit ..,
WEST YARMOUTH,MA 02673 _ •
- Update Address and Return Card.
SCP i 4 tom n5n/
c) ,•(,nnn.•wwwnt%I�n`('/lctvr(Awor✓lu a
•
Orme of Consumer Atfaus&Business Regulation •
HOME IMPROVEM ENT CONTRACTOR Registration valid for Individual use only •
TYPE:Ccnc:ation before the expiration date. 8 found return to:
Noais:ration Expiration Office of Consumer Affairs and Business Regulation
1 o6Ci3- - 12/06/2018 10 Park Plaza-Suit •
• -t(E 0U:)I ic•dE IMPROVEMENT,INC. Boston,MA • • •
CT FMC ..is 1.
Yt Not valid without signature
..SCT •Ft.V.]J MA 02073 Undersecretary
ACCORD® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY)
06/15/2018
'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(ies)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).
PRODUCER CONTACT
NAME: Linda Sullivan
DOWLING & O'NEIL INSURANCE AGENCY O No EMI: (508)775-1620 i"c,N,):
ADDRESS: Isullivan@doins.com
973 IYANNOUGH RD INSURER(S)AFFORDING COVERAGE NAIC•
HYANNIS MA 02601 INSURER A: AMGUARD INSURANCE CO 42390
INSURED INSURER B:
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 POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR ADDL SUER POLICY EFF POLICY EXP
LTR TYPE OF INSURANCE MD wvn POLICY NUMBER IMMIDDIYYYY) (MMIDDfryYYI LIMITS
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $
-Naucdrrstkeareo
PREMISES
CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $
MED EXP(Any one person) $ .
N/A PERSONAL&ADV INJURY s
GENL AGGREGATE UMIT APPLIES PER. GENERAL AGGREGATE $
POLICY JECT LOC PRODUCTS•COMP/OP AGG $
OTHER s
AUTOMOBILE LLABIUTY COMBINEDSINGLE UMIT $
(Ea ac den0
ANY AUTO BODILY INJURY(Per person) $
ALL OWNED SCHEDULED
AUTOS AUTOS
N/A BODILY INJURY(Per accdent) $
,_
NON-OWNED DAMAGE $
HIRED AUTOS
AUTOSUTOS (Per accident)
$
UMBRELLA LIAR _ OCCUR EACH OCCURRENCE s
EXCESS LIAB CLAIMS-MADE N/A AGGREGATE S
DED RETENTION S _ $
WORKERS COMPENSATION
AND EMPLOYERS LIABILITY X STATUTEH
ER
ANYPROPRIETOR/PARTNER/EXECUTIVE YIN E.L EACH ACCIDENT S 1,000,000
A OFFICERAMEMBER EXCLUDED, WA WA N/A R2WC940123 06/03/2018 06/03/2019 -'
(Mandatory in NH) EL DISEASE•EA EMPLOYEE $ 1,000,000
II yes,describe under
DESCRIPTION OF OPERATIONS below EL DISEASE.POLICY LIMIT s 1,000,000
N/A
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space is required)
Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay
claims for benefits to employees in states other than Massachusetts if the Insured hires,or has hired those employees outside of Massachusetts.
This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the
Issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification
Search tool at www.mass.govllwd/workers-compensation(mvestigations/.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Anatoli Sivitski ACCORDANCE WITH THE POLICY PROVISIONS.
222 Buck Island Road 6-8
AUTHORIZED REPRESENTATIVE
West Yarmouth MA 02673 D el CCro, Je
y,CPCU,Vice President—Residual Market—WCRIBMA
@ 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACO RD name and logo are registered marks of ACORD