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HomeMy WebLinkAboutBld-20-003906 v Og-Y- Office Use Only • Permit#Amount 6 V 001",1 . '3 ,' HATT n CS ' \°'°°°ac°°P �a' ] (� Permit expires 180 days from -- ;: 13 VD✓ u jtJ t�(�o to issuet date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 Ce4 9R- South Yarmouth, MA 02664 � (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: j6 CZ�"'' �rr' . r►' ' t,e , ASSESSOR'S INFORMATION: f p ,Map: / ��.+ J- Parcel: OWNER: NAME Art 1-e u /4 C e4°7S . ) Vav14 Q L. # Q /�, / �M y CONTRACTOR: I����� 1, U 114/5 a PRESENT ! �' go A. i V►' ctAt b � SU$%q0/0z- NAME MAILING ADDRESS 0 Residential ❑Commercial Est.Cost of Construction$ 2.0 0. 0 U Home Improvement Contractor Lic.# (6.i•Gqf/ Construction Supervisor Lic.# 106 0'V27 Workman's Compensation Insurance: (check one) , ❑ I am the homeowner 0 I am the sole proprietor Ef I have Worker's Compensation Insurance Insurance Company Name: , Gu.QAEI Worker's Comp.Policy# 02 3 46 2_ WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares 40 ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: CA,//, Own 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 licens p ose 'on under M.G.L.Ch.268,Section 1. J Applicant's Signature: Date: O//'%ii/ Owners Signature(or attachment) Date: Approved By: Date: cial(or designee) EMAIL ADDRESS: Zoning District: Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 0 No The Commonwealth of Massachusetts .y Department of Industrial Accidents 1 Congress Street, Suite 100 7.1 _T•i= Boston, MA 02114-2017 tot 5�•`''4 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information PIease Print LezibIy Name (Business/Organization/Individual): e Co I 1.6004, //7'1/0/'�JV Address: o /-(,Q,/ /oti� 4d l' City/State/Zip: W YQ4'(� �° - Phone #: Srd 6'Q0/f7 Are yo an employer?Check the appropriate box: Type of project(required): l. I am a employer with 'ti(/ employees(full and/or part-time).* 7. ❑New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in g. ❑ Remodeling any capacity.[No workers'comp.insurance required.] 3. I am a homeowner doing all work myself 9. ❑ Demolition ❑ y [No workers'comp.insurance required.]` I am a homeowner and will be hiring contractors to conduct all work on my10 ❑ Building addition 4. ❑ property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑ Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑ '.of repairs These sub-contractors have employees and have workers'comp. insurance.$ /6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other j;OQ ` GJ 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. r Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 1Contractors 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. / Insurance Company Name: ,4M1G�(� .Q/Y ( Policy#or Self-ins.Lic.#: 02326 2 Expiration Date: O6 0.3 20 ?�C) Job Site Address: - 6' ateete44-e7 /& City/State/Zip: (/I - 62M7,O ` _ Attach a copy of the workers' compensation peclaration page(showing the policy number and expiration date). P 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 trueand correct. Signature: I129 Date: 0///I/7/040 0 Phone#: . VI '6q t3/2_ • 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 4: CAPE COD How ':': ; 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 10.03.2019 TO ARI LEW LOCATION: 1 6 CHECKERBERRY 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(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 REQUIREMENT'S. • 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 BF 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 1 8 I NCHES 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 5JA NAILS PER SHINGLE. • COLOR OF ROOF PENETRATIONS AND FLASHINGS TO BE CHOSEN BY OWNER. • INSTALLATION OF A SHINGLE-OVER RIDGE VENT.VENT IN THIS AREA IS 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. CAPE COD HOME IMPROVEMENT T"GUARANTEES THAT ALL COMPONENTS INSTALLED PROPERLY PLEASE FEEL FREE TO CALL CAPE COD HOME IMPROVEMENT r" WITH ANY QUESTIONS OR CONCERNS AL PLEASE INITIAL THIS PAGE CAPE CAPE COD HOME IMPROVEMENT Homc Lnproveinrnt 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 /wI F N R00 I G. Option 1 CERTAINTEED LANDMARK SHINGLES �� \ 5 STAR- 50 YEARS NON-PRORATED TRANSFERABLE WARRANTY LABOR AND MATERIALS: $3,750.00 �\ PSTER: $450.00 TOTAL: $4,200.00 ROOFING. Option 2 CERTAINTEED LANDMARK SHINGLES 3 STAR- 20 YEARS WARRANTY LABOR AND MATERIALS: $3, 150.00 DUMPSTER: $450.00 TOTAL: $3,600.00 Lifetime Limited 3-STAR 4-STAR 5-STAR Warranty Shingles Protection Protection Protection Coverage 20 years 50 years* 50 years** Materials & Labor ✓ ✓ ✓ Tear-off ✓ ✓ ✓ Disposal ✓ ✓ Workmanship �. . *WE WILL MATCH OR OUTBID ANY LEGITIMATE COMPETITOR* CAPE COD HOME IMPROVEMENT TM GUARANTEES THAT ALL COMPONENTS INSTALLED PROPERLY PLEASE FEEL FREE TO CALL CAPE COD HOME IMPROVEMENT TM WITH ANY QUESTIONS OR CONCERNS PLEASE INITIAL THIS PAGE __. Home Improvement COD CAPE COD HOME IMPROVEMENT TM 27 MILL POND ROAD, WEST YARMOUTH MA 02673 (617) 710-1001, (508) 469-0102 CAPECODINC@GMAIL.COM, WWW.ROOFCAPECOD.COM, WWW.FACEBOOK.COM/CAPECODHOME CAPE COD HOME IMPROVEMENT TM IS PROUD TO PRESENT YOU WITH SUPERIOR 1 0 YEAR WORKMANSHIP AND SERVICE WARRANTY. THIS WARRANTY IS IN ADDITION TO, BUT RUNS CONCURRENTLY WITH ANY MANUFACTURERS' WARRANTIES. IT COVERS ALL SERVICE CALLS RELATED TO WARRANTY REPLACEMENT AND/OR INSTALLATION ISSUES FOR THE FIRST TEN YEARS AFTER PRODUCT INSTALLATION PAYMENTTERMS: 30%AT DEPOSIT: 30%AT START: 40%UPON COMPLETION. JOB IS ESTIMATED TO COMMENCE APPROXIMATELY 2 TO 8 WEEKS AFTER DEPOSIT RECEIVED WORK IS SCHEDULED TO BE SUBSTANTIALLY COMPLE.I tD IN APPROXIMATELY 1 TO 2 WEEKS. ANY WORK ABOVE AND BEYOND THE SPECIFICATIONS WILL.BE PERFORMED AT 56.00$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 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"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"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__ CAPE COD Home Improvement 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 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 UABIUTY 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 UNLESS SIGNED BY ANATOU"TONY"SIVITSK1 1 ,ll"'/ ACCEPTED BY f __ SIGN U DATE L VI 1 ACCEPTED BY SIGN ' "� DATE I b / I 1 G 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 AC0 CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 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 I CONTACT L NAME: Linda Sullivan DOWLING &O'NEIL INSURANCE AGENCY I. PHONE t,. (508)775-1620 FAX E-MAIL isuilivan AO4RPSS, Qt7doin5.COm 973 IYANNOUGH RD INSURER(S)AFFORDING COVERAGE -. _ NAIC HYANNIS MA C2601 (INSURER A_ AMGUARD INSURANCE CO 42390 iNSURED I INSURER B: CAPE COD HOME IMPROVEMENT INC 1 INSURER C_ _ '.�INSURER D 27 MILL POND ROAD 1 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. I INSR ADDL SUER POLICY EFF POLICY EXPLIMITS LTR TYPE OFINSURANCE INS]) POLICY NUMBER (MM(DD/YYW M/{ (MDpJYYYYI COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES(Ea occurrence] -_$ __— MED EXP(Any one person) $ —......- __ N/A PERSONAL 8 ADV INJURY IT$ GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATEPR - POLICY ___...JECT LCC PRODUCTS-COMP/OP AGG $ OTHER- AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Lea eCGQ nt ANY AUTO BODILY INJURY(Per person) ,$ A:LCWNED �SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per accident),$ -.-._ : ,.._--- r.1RED AUTOS PROPERTY DAMAGE $ ._._ AUTOS _LPer accident_ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ LIED RETENTIONS $ WORKERS COMPENSATION X PER QTH- AND EMPLOYERS'LIABILITY �,/N __ STATUTE ER ANYPROPRIETORIPARTNER/EXECUTIVE EL EACH ACCIDENT S 1,000,000 A OFFICERuMEMBEREXCLUDED' I N/AI N/A N/A R2WCO23262 06/03/2019 06/0312020 --- - - — --- (Mandatory in NH) E.L.DISEASE•EA EMPLOYEE S 1,000,000 if es oescnbe cnEer ---_ ..� DESCRIPT,ON OF OPERATIONS below E.L.DISEASE-POL CY LIMIT $ 1,000,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS/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 fired those employees outside of Massachusetts. Tnis 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 'ssue date of this certificate of insurance). The status of this coverage can ce monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/lwd/workers-compensation/investigationsi. CERTIFICATE HOLDER CANCELLATION 1 � 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.Crowley,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reservet7. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD f 1111)( i) 1 n! t:4 • BOarl: B - ti (A11) (1 n. 5 1, r S- - 1.:SSL - 10604t7) 'St ANATOLI SIVITSKI 27 MILL POND RD MST YARMOUTH MA 02673 C/4" `)�Z�l� (9Om,/m2O/2CltP d1(f 07,-)4-(lell4P1i41- Office of Consumer Affairs and Business Regulation 1000 Washington Street- Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Corporation Registration: 168043 CAPE COD HOME IMPROVEMENT,INC. Expiration: 12/06/2020 27 MILL POND RD WEST YARMOUTH,MA 02673 Update Address and Return Card. SCA 1 O 20M-05/17 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: Jteoistration. . Expiration Office of Consumer Affairs and Business Regulation 16804.3 12/06/2020 1000 Washington Street-Suite 710 CAPE COD HOME IMPROVEMENT,INC. Boston,MA 02118 ANATOL!SIVITSKI P-Ccart 27 MILL POND RD U NOb811d without signature WEST YARMOUTH,MA 02673 Undersecretary AC R CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) 06/04/2019 1 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 Linda ndo Sullivan DOWLING &O'NEIL INSURANCE AGENCY ?g°NN y,l. (508)775-1620 • FA,N,u E-MAIL I slivn doins.com • :ADDRESS:_. ula � ( 9731YANNOUGH RD _t INSURER IC S)AFFORDING COVERAGE NAM ' �YANNIS MA 02601 -- _ _ I INSURER A; AMGUARD INSURANCE CO 42390 INSURED __ __.. .._ 1 INSURER B: { CAPE COD HOME IMPROVEMENT INC I INSURER c: (INSURER D; 27 MILL POND ROAD , SURERE_ WEST YARMOUTH MA 02673 I 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. I(NSF _.--'ADDL SUBR I LTR TYPE OF INSURANCE POLICY EFFYY' POLICY EXP , INSD WW1 POLICY NUMBER (MMIDD/YYVYI fMM/DOlYYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED —T.. _.- CLA,MS-MADE OCCUR PREMISES(Ea occurrence) _.$ MED EXP(Any one person $ • NiA PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER' GENERAL AGGREGATE $ POLICY PRO- , JECT :GC PRODUCTS-COMP/OPAGG $ OTHER- $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ,I __(,Ea accident) NY AUTO BODILY WJURY(Per person] $ ' AU .AUTOS L OWNED SCHEDULED AUTOS N/A BODILY INJURY Per accident) $ __. NON-OWNED PROPERTY DAMAGE - _ SIRED AUTOS _ .AUTOSUTOS yPer accident)._ --_ $ _. $ UMBRELLA LIAB OCCUR .._._-. EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ •$ WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILfTY Y/N _ STATUTE ER - ANYPROPRIETOR/PARTNER/EXECUTIVE -j EL EACH ACCIDENT $ 1,000,000 A OFFICER'MEMBEREXCLUDEDI 'N/A; N/A N/A R2WCO23262 06/03/2019 06/03/2020(Man ---"----- ---- "" -- d'(yes nl in describefuo EL_DISEASE-EA EMPLOYEE$ 1,000,000 er DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLCY 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. Tnis 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 `ssue date of this certificate of insurance). The status of this coverage can ce monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/Iwd/workers-compensation./investigationsr. CERTIFICATE HOLDER CANCELLATION I SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Anatoli Sivitski i ACCORDANCE WITH THE POLICY PROVISIONS. 222 Buck Island Road 6-8 AUTHORIZED REPRESENTATIVE West Yarmouth MA 02673 Daniel M.Crowley,CPCU,Vice President—Residual Market—WCRIBMA I ©1988-2014 ACORD CORPORATION. All rights reserves. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD