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Home My WebLink AboutBLD-19-002315 r:'Office Use Only F'Y -1ever • i Permit# ,.'F ! O 3 r� .66 c4 Permit expires 180 days from - issue date S"o f. C - 1,/ F-;- EXPRESS BUILDING PERMIT APPLICATION I r--------7- - ----7 �) TOWN OF YARMOUTH OCT 1 8 2018 I. Yarmouth Building Department 1146 Route 28 14' u,-F: - jr South Yarmouth,MA 02664 (_ .---. --_-- pp A,,'_p(�508)) 398-22331•Ext. 12616 �/ CONSTRUCTION ADDRESS: ooc. fitt ✓✓l.cwt Ave., `arn40Ce t'e- 114'4 ASSESSOR'S INFORMATION: • Map: Parcel: OWNER: 7oe_ Dl//Jai NAME /J� [� PRESENT ADDRESS ,/l, TEL. # CONTRACTOR Pe -onieJmpave ,02 ' U%//'on?dR4liv. Varkuwcz / N MAILING ADDRESS TEL##�- &'Residential 0 Commercial tp `' Est Cost of Construction 7 >,;00. Q0 Home Improvement Contractor Lic.# I'VO O Y 3 Construction Supervisor Lic.# -060v0 Workman's Compensation Insurance: (check one) l/ 0 I am the homeowner 0 I am the sole proprietorn�� /�❑ I have Worker's Compensation Insurance Insurance Company Name: /'ry1� V f t alvd Worker's Comp.Policy# 9110/23 WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares p Replacement windows:# 'Replacement doors: # Roofing: #of Squares ,3p ( VI/Remove existing* (max.2 layers) Insulation y Old Kings Highway/Historic Dist. (Replacing like for like Pool fencing ca,ifsjD/1 a� ,t i 'The debris will be disposed of at //C�/ vfv 5 Location of Fahity • I declare under penalties of perjury that the statements herein contained are true and correct to the best of my Imowledge and belief I understand that any false answer(s) will be just cause for denial or revocation of my license and, sec ' n under M.G.L.Ch.268,Section 1. / Applicant's Signature: �G,� Date: /0 i0/'f Owners Signature(or attachment) t2L g/a, Date: Approved By: �-4.- Date: 1°.-.18.-tr.' . Building Official(or design EMAIL ADDRESS: Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: ❑ Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands:. ' 0 Yes 0 No 0 Yes 0 No =-4:--•.7 The Commonwealth ofMassachusetts ' 1" a= t Department o .�,=it i=. p flrsdustrialAccidents ==ems 1 Congress Street, Suite 100 _' f_ a Boston, MA 02114-2017 �e.;,,.o www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILEI)WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): [?,,rry� Iod /-�we_JTmprvV� Address: l /Ltit A5a1c Jed., �/, Ya - uiC City/State/Zip: 00/69-3 Phone #: svg4F6 90/02 vAreyop an employer?Cheek t e appropriate box: Type of project(required): I. am a employer with employees(full and/or part-time).* 7. 0 New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling • any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself[No workers'comp.insurance required.]? 9. ❑Demolition 4.❑I am a homeowner and will be hiring contactors to conduct all work on my property. I will 10 Q Building addition ensure that all contactors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the ached sheet These sub-contractors have employees and have workers'comp.insurance.? 13. 12.50f repair �t 6.0 We are a corporation and im officers have exercised their right of exemption per MGL c. 14. Other PO OO/ 152,§1(4),and we have no employees. [No workers'camp.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 contactors must submit a new affidavit indicating such. ?Contractors that check this box must attached an additional sheet showing the name of the sub-contactors 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 providlne workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Ain OttoArd Policy#or Self-ins.Lic.#: 9 vo 123 Expiration Date: 06/0.09/ ot Job Site Address: o(_ILCQWelf att41 !l(ce, City/State/Zip: Van,/OWN 4/V Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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.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 Sienature: iteg Date: ID/la/It/ Phone: ((// 506IP690/OZ 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. EIectrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: ,is . • 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 ajoint 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 contact for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contacting 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 advisedThat this affidavit may be submitted to the Department of Industrial • Accident for confirmation of insurance coverage. Also be sure to sign and date the affidavit The affidavit should be retuned 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 Officals 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 bum leaves etc.) said person is NOT required to complete this affidavit The Department's address,telephone and fax number. The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 r• ' Boston, MA 02114-2017 Tel. # 617-7274900 ext. 7406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 02-23-15 www.mass.gov/dia A • WI E COD P 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 PROPOSAL 08.30.2018 TO JOE DILLON LOCATION: 22 MERCHANT AVE, YARMOUTH PORT 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 18INCHES 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 SHINGLEOVER RIDGE VENT.VENT IN THIS AREA IS CONTINUOUS AND WILL flA CAPE COD HOME IMPROVEMENT".GUARANTEES THAT ALL COMPONENTS INSTALLED PROPERLY PLEASE FEEL FREE TO CALL CAPE COD HOME IMPROVEMENTTM WITH ANY QUESTIONS OR CONCERNS PLEASE INITIAL THIS PAGE di (▪ eissi-wsk • CAPE COD H•"`' 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 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. OPTION 1 CERTAINTEED LANDMARK SHINGLES 50 YEARS NON-PRORATED TRANSFERABLE WARRANTY LABOR AND MATERIALS; $15,350.00 DuMPSTER: $950.00 TOTAL: $ 16,300.00 OPTION 2 CERTAINTEED LANDMARK SHINGLES 40 YEARS PRORATED WARRANTY(10 YEARS NON-PRORATED PERIOD) LABOR AND MATERIALS: $14,350.00 DUMPSTER: $950.00 TOTAL: $ 15,300.00 *WE WILL,MATCH 0- • • a • - LEGITIMATE COMPETITOR* CAPE COD HOME IMPROVEMENT IS PROUD TO PRESENT YOU WITH SUPERIOR 1 0 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 TT"GUARANTEES THAT ALL COMPONENTS INSTALLED PROPERLY -■ PLEASE FEEL FREE TO CALL CAPE COD HOME IMPROVEMENT TT" WITH ANY QUESTIONS OR CONCERNS /f PLEASE INITIAL THIS PAGE n. J w • ilk 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 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.ALLADDITIONAL 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 WITH THE DRAWINGS AND/OR SPECIFICATIONS SUBMITTED FOR ABOVE WORK AND COMPLETED IN A SUBSTANTIAL WORKMANUKE 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 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 PUBUC UABWTY 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. CAPE COD HOME IMPROVEM ENT TM GUARANTEES THAT ALL.COMPONENTS INSTALLED PROPERLY PLEASE FEEL FREE TO CALL CAPE COD HOME IMPROVEMENT TM WITH ANY QUESTIONS OR CONCERNS �I PLEASE INITIAL THIS PAGE • E COD P 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 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 UNLESS SIGNED BY ANATOLI"TONY"SMTSKI ACCEPTED BY ---JoS 704 0--/Z-, SIG a DATE //d C /f ACCEPTED BY I I • -1:11: Si S 41 DATE D ACCEPTED BY SIGN DATE CAPE COD HOME IMPROVEMENT"GUARANTEES THAT ALL COMPONENTS INSTALLED PROPERLY ^ PLEASE FEEL FREE TO CALL CAPE COD HOME IMPROVEMENT Th. WITH ANY QUESTIONS OR CONCERNS PLEASE INITIAL THIS PAGE Q w Ac Ro CERTIFICATE OF LIABILITY INSURANCE DATE (M5rzo ems) 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). PRODUCER CONTANAME CT Linda Sullivan DOWLING&O'NEIL INSURANCE AGENCY (A/C Eat (508)775-1620 PAX E-MAIL ADDRESS: lsullivan 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 D: 27 MILL POND ROAD INSURER E: WEST YARMOUTH MA 02673 INSURERF: 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 POUCY 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 AD VW.i0e POLICY EFF POLICY EXP LTR TYPE OF INSURANCE IN SD WVD POLICY NUMBER (MMIDD/YYYY) (MMIDDFYYYY) LIMAS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE f CLAIMSMADE OCCUR PREAETOlaEccES— RAtISISESjEaoceurrcncel f MED EXP(Any one person) $ N/A PERSONAL f ADV INJURY $ GM AGGREGATE OMIT APPLIES PER: GENERAL AGGREGATE $ POLICY n32-1- LOC PRODUCTS•COMP/OP AGG f _ OTHER: f AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) f ALL OVrNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per accdent) $ _ NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS Per accident) S UMBRELLA LIAR OCCUR EACH OCCURRENCE E _ EXCESS LIAR ]J CLAIMS-MADE N/A AGGREGATE S DED RETENTIONS E WORKERS COMPENSATION XII PER OTH- AND EMPLOYERS'LIABILITY A ^t STATUTE E@_ A Of CERRAEMBBEREXC UDED PO�VE NIA WA WA R2V 940123 06/03/2018 06/03/2019 E.L.EACH ACCIDENT $ 1,000,000 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE E 1,000,000 If yes,describe under DtSCRIPTION OF OPERATIONS below E.L.DISEASE•POLICY LIMIT S 1,000,000 N/A DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached X 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.gov/Iwd/workers-compensationAnvestigations/. 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 Daniel M..Cr Cro y,CPCU,Vice President—Residual Market—WCRIBMA 01988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACO RD name and logo are registered marks of ACORD r . . Commonwealth of Massachusetts is e =L Ir i Division of Professional Licensure Board of Building Regulations and Standards • Construction,�-;Sp'Wrvisor .Specialty Y� CSS L -106040 ,--• Ejp i res : 05/ 14/2020 ANATOLI SIVITSKI en? 27 MILL PONIYRD }F ; ` - t .�; . WEST YARMOUTH MA" 02673 ,��. t I `� e )1cV+1L I 1 o. C,lis laSses Commissioner C9n e WO/nntalUelea4i o/o/l oad ufle Office of Consumer Affairs and Business Regulation One Ashburton Place- Suite 1301 Boston, Massachusetts 02108 Home Improvement Contractor Registration Type: corporation CAPE COD HOME IMPROVEMENT.INC. R Expiration: 1280W12201S 27 MILL POND RD t 4 r Expiration: 12/O W EST YARMOyTH.MA 02673 - • Update Address and Return Card. .<A1 4 t O5117 r_'R< ;.s.YnroH,irrn//.4<,[?I4m10nGIAua<A • • Oil of Consumer ACahs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only TYPE:Cancration before the expiration date. lt found return to: 8oeis:ration ;-: Fxniratioq Office of Consumer Affairs and Business Regulation '6eC43- - - 12'06%2018 10 Park Plaza-Suit • '.rE coi l lO'll lMPl7OVCMENT,INC. Boston,MA • gAt T OLI S VI :KI \ACCem T YAP MO-nt.MA 021.373 undersecretary Not valid wit outs gnature