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The Commonwealth of Massachusetts .Department of Industrial Accidents `mil= 0.1 1 congress Street,Suite 100 ='»t�- Boston, MA 02114-2017 At,..�� www.mass.govldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: in 943 city/State/Z.T. e ; : o�qq -/ t P �1 S � cp3� Phone ,l/O T 4-��3 j C Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with employees(full and/or part-time).* 7. D New construction 2(E I am a sole proprietor or partnership and have no employees working for me in 8. fl Remodeling any capacity.[No workers'comp insurance required.] 9. ❑Demolition 3. I am a homeowner doing all work myself[No workers'comp.insurance required.)t ,l 10 ❑ Building addition 4 0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.[]Electrical repairs or additions roprietors with no employees. 12.D Plumbing repairs or additions. 5 I am a general contractor and I have hired the sub-contractors listed on the airached sheet.X 13 These sub-contractors have employees and have workers'comp.insurance.'* oof repairs ��,y 14.i Other 6.i0 s e are a corporation and its officers have exercised their right of exemption per MGL c � 152,;1(4),and we have no employees. No workers'comp insurance required.] j 4 *Any applicant that checks box.11 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they ate doing ail work and then hire outside contractors must submit a new at;oavii indicating such. Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or net those entities have employees. lithe sub-contractors 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. r Insurance Company Name: C7u (k e �3 Policy 4 or Self-ins. Lic.:;:_ — — -_ _ __ Expiration Date: ______ Job Site Address: 1,03 Q-/0,1 4e rD i ' .S. V Attach a copy of the workers' compensation policy declaration page(showing the policy num&er 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 S250.00 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 an penalties of rjury that the information provided above is true and correct. Signature: l�%%� rAe Date: Gil13119 Phone/: -*I-Co 1-143 Official use only. Do not write in this area,to be completed bycity or town official .�• � f.>� City or Town: Permit/License t# _ Issuing Authority(circle one): I.Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other s Contact Person: __ Phone#: ACCMEP CERTIFICATE OF LIABILITY INSURANCE DATE(NMIDOIYYYY) 03/19/19 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 °ONg 'E^`T NM ; PAUL SCHLEGEL Phoenix Ins LLC PHONE Exit 781-436-3024 FAz �(AID Nok 781336-5754 WYMAN STREET T M 02072 A CERTIFICATE@PhoenixInsuranceLLC.com CERTIFICATE@PhnixlnsuranceLLC.com STOUGHINSURER(S)AFFORDING COVERAGE NAIL N INSURER A: A.I.M.Mutual Insurance Company INSURED INSURER B: TELAMON INSURANCE LEWIS SM CONSTRUCTION INC INSURER C: 34 MARKET ST INSURER BROCKTON,MA 02301 D: INSURER E: T ,INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTEY 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, EXCLUSIONSAND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LLTTRR TYPE OF INSURANCE INS°OVD POLICY NUMBER (NNIDDIYYYY) (MMI)OIYYYY) UNITS X COMMERCIAL GENERAL UABM.rY EACH OCCURRENCE $ 1,000 000 (CLAIMS-MADE nX OCCUR MMAGE TO RENTED PREMISES(Ea 000areece) $ 100,000 MED EXP(Any are Neesan) $ 5,000 A TBD043325 PERSONAL&AIN INJURY $ 1,000.000 GENT_AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000.000 POLICY❑TEE8ii [1 LOC PRODUCTS-CDMP/OP AGO $ 2,000.000 OTTER $ AUTOMOBILE LIABILITY COMBINED SINGLE UMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ — CANNED AONLY TSCI .ED BODILY INJURY(Per a ncdent) $ HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY .._ AUTOS ONLY (Per accident) $ UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED I I RETENTIONS $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'UABIUTY YIN I STATUTE 1 'ER ANY PROPRIETORIPARTNERIDCECUTNE EL EACH ACCIDENT $ 1,000.000 B OFFICER/MEMBEROCCLUDED? NIA VWC10060236932019A 03/12/19 03/12/20 (Mandatory ki NH) E.L.DISEASE-EA EMPLOYEE $ 1,000.000 If yes,desate ender DESCRIPTION OF OPERATIONS below E.L.DIRFSSE-POLICYUNIT $ 1,000.000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(WORD 101,Additional Remarks Schedule,may be attached 3 more space is required) FOR OPERATIONS COVERED ON INSURED'S POLICIES. HYTECH ROOFING SOLUTIONS IS LISTED AS AN ADDITIONAL INSURED. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF TIE ABOVE DESCRIBED POLICIES BE CANCELLED ED BEFORE TIE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN HYTECH ROOFING SOLUTIONS ACCORDANCE WMTH THE POLICY PROVISIONS. 12 BALDWIN RD DENNIS MA 02638 AUTHORIZED REPRESENTATIVE HYTECH ROOFING SOLUTIONS , OLMA ELLIS ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD atoie (6520~itoluveahg ?atezeidadadein Office of Consumer Affairs and Business Regulation One Ashburton Place - Suite 1301 Boston, Massachusetts 02108 Home Improvement Contractor Registration Types LLC HYTECH ROOFING SOLUTIONS LLC. Registration: 184383 12 BALDWIN RD Expiration 0110412020 DENNIS,MA 02638 Update Address and Return Card. SCA 1 C 20M-05/17 ee oili xaautoal//orCiftewerckaells Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:LLC before the Registration Expiration expiration date. If found return to: Office of Consumer Affairs and Business Regulation 184383 01/04/2020 10 Park Plaza-Suite 5170 HYTECH ROOFING SOLUTIONS LLC. Boston,MA 02116 PATRICK CLIFFORD /00,L-rf . !L 12 BALDWIN RD DENNIS,MA 02638 Uruefsecretary Not valid without signature Commonwealth of Massachusetts Division of Professional LicensureBoard of Building Regulations and Standards Constr uction SUper-visor Specialty CSSL-105951 Expires:06/02/2020 `' ea PATRICK CLEFORD .- " 12 BALDWIN ROAD ' DENNIS MA 02638 _ Commissioner itti�r I aft l l 5Øi!u7757%73 12 Baldwin Rd. Dennis, MA 02638 ROOF REPLACEMENT PROPOSAL Date: September 11, 2019 Customer: NAME: I Doug Walker TEL: 774 212 0459 STREET: 103 Quartermaster Row CELL: a _ CITY: South Yarmouth,MA. EMAIL: dougc.walker(c.comcast.net HyTech Roofing Solutions hereby proposes to perform the following services in a neat and professional manner and in accordance with the manufacturer's specifications and local building codes. Remove and Haul Away All of the Old Roofing Shingles from the Roof Deck Area of the House. Inspect and Re-Nail Any loose or popped plywood or boards on the Entire Roof Deck Area of the House Supply and Install CERTAINTEED LANDMARK LIFETIME WARRANTY, 10 YEAR SURE START PROTECTION,CLASS A FIRE RATED,COPPER) CERAMIC STONES for 10 YEARS PROTECTION AGAINST ALGAE CONTAMINENT,235 POUND, EXTRA HEAVY WEIGHT, 130 MPH WIND WARRANTY,CATEGORY III HURRICANE, STORM II URICANE NAILED (6 NAILS PER SHINGLE),MULTI-LAYERED,LAMINATED ARCHITECTURAL STYLE, FIBERGLASS BASED ASPHALT SHINGLES.MAX-DEFF COLOR: Wadbered Wow 1 rr01.: 01 tile Of tile il00, ;-1 ;":1ZE RATED, COPPER/ "Q """lruCTION AGAINST "''FNT, 235 POUND. EX_ERA HEAVY WEIGHT, 130 MPH WIND WARRANTY, CATEGORN: HURRICANE. STORM /IIURICANE 'NAILED (6 NAILS PER SHINGLE)„ MUL FI-LAYERED, LAVE-INA1ED ARcnrrEcTuRAL sra,t, FIBERGLASS BASED ASPHALT SHINGLES. MAX-DEFF COLOR: Weathered Wood 1 Suppl. and Install HICKS VEN'FILATED ti [MINI'M DRIP EDGE on the entire roof eaves of the house Supply and Install 8- WHITE ALUYIINUM DRIP EDGE, on the entire g,ahle end rakes of the roof. Supply and Install CERTAINTEED WINTER-GUARD ( Ice & Water Shield ) WATERPROOF UNDER!, tkIrMENT SYSTEM 3 feet coverage on the entire roof eaves and valleys and on top of Soil Pipes& Vents. Under Step }lashings, and running up the walls of the Chimney. Supply and Install CERTAINTEED ROOE-RUNNER SN NTHETIC UNDERLAYMENT PAPER on the entire roof deck area as required per warranty specifications. Supply and Install CFR FAINTEED SWIFT START adhesive asphalt starter strips on all eses and Rakes with a ¶ inch overhang Supply tmd CERTAINTEED FILTER RIDGE (SHINGLE VENT II) ridge vent on the entire ridge area of the roof using the 3" hand nailing method. Supply and Install CERTAINTEED HIP AND RIDGE CAPS on the entire ridge/hip area of the roof using the 3" hand nailing method Supply and Install ALUMINUM & NEOPRI.:NE SOIL PIPE FLASHINGS Clean and Ren10%c Debris from the ‘%ork area after the job is complete TOTAL ROOF 1 NV ESTM ENT: S10,800.00 Discount: -$8,900.00 Balance: $1,900.00 POSSIBLE EXTRA CARPENTRY: Any rotted or otherwise deteriorated trim boards, plywood sheathing, missing metal flashing,side walling or any other carpentry needing replacement will be done and charged for as an Extra: materials plus labor at the rate of S 60.00 per hour. PAYMENT SCHEDULE: A deposit of one half is due at the signing of this roof proposal and the final payment for the balance is due immediately upon completion. WORK SCHEDULE: All roof work is normally scheduled for completion within 30 days of acceptance and receipt of deposit providing the materials are available. Please Make Checks Payable to: HyTech h ®ofi b Solutions HyTech Roofing Solutions Warranties the Shingles and Labor for 20 years. CER'1'AI\TEED Warranties the shingles and labor 100% for the First 10 wears and the Shingles your I.WETIME if the shingles becomes defective_ CERTAIN`I:'EED Warrants the Shingles up to a CATEGORY HI HURRICANE-I30 MPH WIND WARRANTY. CERTAINTEED Warrants the Shingles to be Algae Resistant. HyTech Roofing Solutions Carries Workmran's Compensation Lind Public liability Insurance on the above tt°cork Handles all permitting and planning involved with the above proposed work TOTAL INVESTMENT. ss UCH (With All Selected Options DATE OF ACCOTANCE: 9 11 2 C31 CI ACCEPTED BY: SUBMITTED BY: D o; '% 'tikes Patrick Clifford — Alex Y'as avets flO . 1OWN ER (Business Owners) MA CSL license 105951 MA I Ii license 1 X4 31';. 4 l • ADDITIONAL OPTIONS: Supply and Install New AZEK maintenance free PVC trim boards replacing all of the rake boards around the house. All new trim is to be installed using the CORTEX scree and plug invisible fastening system. ADDITIONAL INVESTMENT: S3,900.00 Supply and Install . E "Daintenance free PVC trim hoards acing all of the Fascia boards'ar trnt.,the house. All 4m i Tin is be installed using the CORTEX screw and sible fastening sr stem. : DDI 'I ' L INVESTMENT:NT: S2,200.00 Supply and instal a seamless gutters replacing tters and downspouts arouid he tir e. New gutters are to be installed using hidden hangers-mg i'.as ems. t 'ff&AL INVESTMENT: St 580.00 3