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HomeMy WebLinkAboutBld-20-002222 . .1)a., . , •,Y4 4ceeUse Only /�j� , • r , C -, 0 . .. . H '..Amount `Q6DMA7TACM [S[ �`°"°'"""Q cad Permit expires 180 days from {issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 C,l Sk13 South Yarmouth, MA 02664 I R I - (508) 398-2231 Ext. 1261 `?S; .n CONSTRUCTION ADDRESS: O`Of na/f e/r Rd, J . Vc24-n-'e-c7cbtI.._ ASSESSOR'S INFORMATION: �'/', ,-�p� Map: /� Parcel: �r�, ) ^ , OWNER: I`44 & i 1 Po _ is EA-was,� 2,0 C 9-Arlo' 6a0 a7 NAME y Q PRESENT ADDRESS TEL. # CONTRACTOR: hkv� of/ J/�I ea c Miii �ucf '/ hi. Yavt1W 372840690Noz. / NAME MAILING ADDRESS TEL.# Ni Residential 0 Commercial Est.Cost of Construction$ e/ Vrn o, 00 Home Improvement Contractor Lic.# 'Y 610 1 Construction Supervisor Lic.# '"f 06 € T 0 Workman's Compensation Insurance: (check one) ❑ I am the homeowner 0 I am the sole proprietor y I have Worker's Compensation Insurance Insurance Company Name: � (?U121 C/ Worker's Comp.Policy# t3gM6 2 WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares tom( (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: dot / 4 f ,. e�1 V/ y/ s 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 for pro -cution under M.G.L.Ch.268,Section 1. ,/ ,f Applicant's Signature: Date: "! o/! I1/9 Owners Signature(or attachment) 5 COlt. al4— Date: Approved By: c Cv f Date: la 'N--15 Building Official(or designee) EMAIL ADDRESS: Zoning District: Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes ❑ No The Commonwealth of Massachusetts Department oflndustrialAccidents • `; 1 Congress Street, Suite I00 • Boston, MA 02114-2017 r .•s www.mass.gov/dig \Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): &,,,te c[ `eo t. Address: c /f/ fOi'7c1 ,ed City/State/Zip: 1(hl'i 'j YU,0 cad,. Phone #: ff 9 6p Vl02 Are yop an employer?Check the appropriate box: Type of project(required): I. I am a employer with /V employees(full and/or part-time).* 7. ❑New construction 2.E I am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling any capacity. [No workers'comp. insurance required.] 3._I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. [1] Demolition 4.❑I am a homeowner and will be hiring contractors to conduct all work on mYP property.e I will 10 ❑ Building addition ensure that all contractors either have workers'compensation insurance or are sole 1 I.❑ Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 6.11 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. Roof repairs These sub-contractors have employees and have workers'comp. insurance.T �0� 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other 152,§1(4),and we have no employees. [No workers'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. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. � �1 / Insurance Company Name: V z i Policy 4 or Self-ins.Lic. #: e2,3 a6z- Expiration Date: 26 O 3/Z17 Job Site Address: AA Alievs ,Pc City/State/Zip: e. Yc ,ryvz,i, 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 andd penalties of perjury that the information provided above is true and Qcorrect. / Signature: � 7/ Date: /�/ a //9 Phone#: SPef II 69 d/ 0 2- 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 rr: • 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 Iicense 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 nnmber(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 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 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia • ' CAPE COD Home■ , 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. 1 2.201 9 TO MICHAEL PONTE LOCATION: 22 ANTLERS RD, SOUTH YARMOUTH WE HEREBY SUBMIT SPECIFICATIONS AND ESTIMATES FCIR MAIN COMPOSITION SHINGLE ROOF: • REMOVAL OF ALL EXISTING ROOFING AND FLASHING MEMBRANES TO THE PLYWOOD DECK SURFACE. • F-EPLAGEMENT OF ANY DAMAGED OR DETERIORATED PLYWOOD DECKING AT AN ADDITIONAL.i3OST. DECKING WILT.BE:. REPLACED IN W-IOL.E SHEETS ONLY IN ACCORDANCE WITH RECOMMENDATIONS BY BOTH THE NATIONAL. ROOFING CONTRACTORS ASSOCIATION(N RCA)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 INSTAL.L.ED IN Ali..VAL_LEYS 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 1 R INCHES TO PROVIDE PROTECTION AGAINST DAMAGE FROM ICE DAMS. INSTALLATION OF ONE LAYER OF ROOFING'JNDERLAYMENT ON DECK SURFACE NOT COVERED WITH ICE AND WATER PRO EC'ION MATERIAL. • INSTALLATION OF NEW,ARCHITECTURAL-STYLE ALGAE-RESISTANT CERTAINTEED SHiNGI_ES.SHINGLES IARI.L.BE:INSTALLED iN STRICT ACCORDANCE.:WITH THE MANUFACTURER'S SPECIFICATIONS AND SHAI...L.BF FASTENED :.!SING SIX NAM..-5 PEP SHINGLE. • COLOR OF ROOF PENETRATIONS AND FLASHINGS TO BE CHOSEN BY OWNER. • INSTALLATION OF'A.SHINGLE-OVER RIDGE.VENT.VENT IN THIS AREA IS CON'T iNUCIUS AND WILL.PROVIDE MAXIMUM INTAKE VENTILATION FOR THE FULL ATTIC VENTILATION SYSTEM. • REPLACE ANY DAMAGE FASCIA-BOARDS OR RARE-BOARDS AT AN ADDITIONAL COS I. • ALL GROUNDS TO BE CLEANED UP ON A DAILY BASIS.ALL BUSHES.SHRUBS.ANC'=LOWERSTO BE PROTECTED. HOMEOWNER IS ASKED TO SUPPLY ELECTRICAL POWE2 IF NEEDED. 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 fit PLEASE INITIAL THIS PAGE :��� { Jt-. CAPE COD Home I® 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 CERTAINTEED LANDMARK SHINGLES 4 STAR- 50 YEARS NON-PRORATED TRANSFERABLE WARRANTY A11 LABOR AND MATERIALS: $8,350.00 4.46 DUMPSTER: $450.00 ANGLES LIST COUPON: -$300.00 TOTAL: $8,500.00 CAPE.COD HOME IMPROVEMENT IS PROUD TO PRESENT YC.!WITH HJI ER'"R 1 0 YEAR WOI:I.MANSH)F'AND SERVICE VIARRAN THIS WARRANTY tS IN ADDITION TO.BUT RUNS CONCURRENTLY WITH ANY MANUFACTURERS'WARRAN lES_IT COVERS ALL SERVICE CALLS RELATED TO WARRANTY REPLACEMENT AND/OR INSTALLATION ISSUES FOR THE FIRST TEN YEARS AFTER PRODUCT INSTALLATION PAYMENT TERMS: 303 AT DE:POSIT. 30%AT START: 40'i, UPON COMPLETION. JOB IS ESTIMATED TO COMMENCE APPROXIMATELY 2 TO P WEEKS AFTER DEPOSIT RECEIVED WORK IS SCHEDUL.,ED TO BE SUBSTANTIALLY COMPL...F.TE:D IN APPROXIMAT'EL._Y 1 TO 1.WEEKS. ANY WORK ABOVE AND BEYOND THE SPECIFICATIONS WILL BE PERFORMED AT 56.00$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 WILL.PROV i DE UI.EANUP ON A CONTINUING BASIS AND ALL.DEBRIS N/ILJ...HE REMOVED FROM SF(F (PROFESSIONAL CLEANING DOESN'T INCLUDE).ALL PRODUCTS INSTALLED BY CAPE COD HOME IMPROVEMENT TM WILL BE TO MANUFACTURER SPECIFICATIONS.ALE WORK WILL BE PERFORMED BY INSURED PROFESSIONALS. ALL..MATERIAL.iS GUARANTEED F.ED TO HF.AS SPECIFIED.AND THE ABOVE.WORK-TO BE.PERFORMED IN ACCORDANCE WITH THE DRAWINGS AND/OR SPECIFICATIONS SUBMI I'I ED FOR ABOVE WORK AND COMPLETED IN A SUBSTANTIAL_WORKMANLIKE:MANNER. OWNER TO MOVE ALL PERSONAL OBJECTS,FURNITURE.ETC.FROM WORK AREA.ALE 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:EXF F'.CTED AND ANY ITEMS IN THE ATII `SHOUI....D BE REMOVED.CAPE COD HOME IMPROVEMENT TM IS NOT RESPONSIBLE FOR ANY DAMAGES IF SAID ITEMS REMAIN IN PLACE. 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 . J y '7 CAPE COD 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 CAPE COD HOME IMPROVEMENT IS NOT RESPONSIBLE.FOR ANY DAMAGES THAT"MAY OCCUR DURING CONS TRUCTION 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 CONSIRUCI-ION-REIATF D PERMITS OR DEAL_WITH LJNREGIS[ERE.IU CONTRACTORS MU_BE EXCLUDED FROM ACCESS TO'THE GUARANTY FUND.COS OFF COLLECTION,INCLUDING ATTORNEYS FEES WILL BE RECOVERABLE.IN THE EVENT OF NON-PAYMENT. WE LOOK FORWARD"10 WORKING WI IH YOU PI EASE CAL IF YOU HAVE ANY QUESTIONS. SINCERELY CAPE COD HOME IMPROVEMENT TM THIS CONTRACT NOT VALID UNLESS SIGNED BY ANATOL''TONY"SIVITSKI/ //a 7/€ , V17'CA'/76//,_, ' ACCEPTED BY a/t SIGN DATE JO / / / • ACCEPTED BY 0�a�til 1V'1cr-‘ G �'•a/ ' DATE V.' •IS CAPE COD HOME IMPROVEMENTT"'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 AC�® DATE(MM/DD/YYYY) ��. CERTIFICATE OF LIABILITY INSURANCE 06/04/2019 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 NAME ACT Linda Sullivan DOWLING &O'NEIL INSURANCE AGENCY PHONE Ext), (508)775-1620 FAX N,); _ADDRESS: Isullivan@doins.com 973 IYANNOUGH RD INSURER(S)AFFORDING COVERAGE NAIC# HYANNIS MA 02601 INSURERA: AMGUARD INSURANCE CO I 42390 INSURED INSURER B: CAPE COD HOME IMPROVEMENT INC INSURERC: INSURER D 27 MILL POND ROAD • INSURER E: WEST YARMOUTH MA 02673 INSURER F: COVERAGES CERTIFICATE NUMBER: 410125 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 IADDL'SUBRI POUCY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POUCY NUMBER (MMIDD/YYYY):(MM/DD/YYYY)L UMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCEDAMAGE TO RENTED ;CLAIMS-MADE OCCUR PREMISES Ea occurrence) $ MED EXP(Any one person) $ N/A ! PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ _ POLICY JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: • ,COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY I $ (Ea accident) ANY AUTO ; BODILY INJURY(Per person) $ ALL OWNED SCHEDULED N/A j BODILY INJURY(Per accident) $ AUTOS AUTOS I NON-OWNED I PROPERTY DAMAGE $ HIRED AUTOS 1 I AUTOS (Per accident) � $ UMBRELLA UAB OCCUR EACH OCCURRENCE $ __ EXCESS LAB $I 1 CLAIMS•MADE; N/A ;AGGREGATE DED - j RETENTION$ $ WORKERS COMPENSATION PER 1OTH- AND EMPLOYERS'LIABILITY X STATUTE , ER Y/N ANYPROPRIETOR/PARTNER/EXECUTIVE ' E.L.EACH ACCIDENT $ 1,000,000 A IOFFICER/MEMBEREXCLUDED? N/A',N/A N/A R2WCO23262 06/03/2019 106/03/2020 (Mandatory In NH) I E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 N/A DESCRIPTION OF OPERATIONS/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.gov/Iwd/workers-compensation/investigations/. I � CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Anatol; Sivitski 222 Buck Island Road 6-8 AUTHORIZED REPRESENTATIVE I West Yarmouth MA 02673 Daniel M.Crowley,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 ` r.y /i( r✓/fi , / t it , �.„dIr/ /./-//')/'/ ) Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Corporation CAPE COD HOME IMPROVEMENT, INC. Regis 12 27 MILL POND RD Expi ration:ration: 12//0 06//22 020 WEST YARMOUTH, MA 02673 Update Address and Return Card. Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Corporation before the expiration date. If found return to: feaistration• gxoiration Office of Consumer Affairs and Business Regulation 168043 12/06/2020 1000 Washington Street-Suite 710 CAPE COD HOME IMPROVEMENT,INC. Boston,MA 02118 ANATOLI SIVITSKI 27 MILL POND RD C WEST YARMOUTH,MA 02673 Undersecretary Not valid without signature „ E Commonwealth of Massachusetts ri Division of Professional is er . r Board � f BuildingReg Regulations ;in i s d { r fs LonstructiSupervisor • pec 1 l \ CSSL1O6O4O Exptres05 14 0 ANATOLI SIVITSKI m - 27 MILL POND RD 4 WEST YARMOUTH MA 02673 Commissioner C/1L 40,....----”