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Home My WebLink About0112 CEDARWOOD ROAD J �� I.n �' e.. ra - �`r 1A. - - - - oFINKE Town of Barnstable *Permit# Expires 6 mo s jrom issue dat�� 7 Regulatory Services Fee ansivsrnet.e, v� 039. `0� Thomas F.Geiler,Director �fD MA't a Building Divisions v Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERAUT APPLICATION - RESIDENTIAL ONLY t Not Valid without Red X-Press Imprint Map/parcel Number 0 ( 9 k`t3 Property Address a C e G�(�O y ' , Co `I y 1 da �9 3� esidential Value of Work 3, 000 Minimum fee of$o"O for work under$6000.00 Owner's Name&Address rvq 0 rm.ci n 6 o- o Contractor's Name 00�� l �' ✓lilp ,�� , Telephone Number Home Improvement Contractor License#(if applicable) /(,6) Construction Supervisor's License#(if applicable) 4. (� ❑Workman's Compensation Insurance -PEC-SS PERMIT Check one: ❑ I am a sole proprietor O < ❑ I am the Homeowner E .I-have Worker's Compensation Insurance L ( VVN OF BARNSTABj E Insurance Company Name �,,�T 16,4 aj Workman's Comp.Policy# A.)(j L' C Lf Copy of Insurance Compliance Certificate must accompany each permit. Permit RnRe-roof check box (stripping old shingles) All construction debris will be taken to �(�f y y�V\ �GL/1 S '1[-0 r1 ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side #of doors ❑ Replacement Windows/doors/sliders.U-Value (maximum.44)#of windows 'Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner m sign Property Owner Letter of Permission. A copy of the me Improvement Contractors License&Construction Supervisors License is re aired SIGNATURE: C:\Users\decollik\AppData\Local\M crosoft\Windows\Tempormy Internet Files\Content.Outlook\4STGU5QO\E)PRESS.doc Revised 090809 The Commonwealth of Massachusetts Department of Industrial Accidents 0, ice of lnvestigations ' d 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information ' ' Please Print Legibly Name(Business/Organization/Individtial): . - V t ZL I �-�'D m-� Zlh,d Y'a /K`( 11 fi •Address: ,� /V-e iLl RUCL D�— City/State/Zip: 6 /)'l/¢ . 3�� Phone.#: 37 CY ' Axe you an employer? Check the appropriate T&X: Type of project(required):, 1. a employer with 1 4. ❑f I am a general contractor and I 6. ❑New construction employees(full and/or art-time).* have hired the sub-contractors ❑ I am a sole proprietor or partner- listed on the' -attached sheet. 7. ❑Remodeling ship and have no employees :These sub-contractors have g_ ❑Demolition working for me in any capacity. :employees and have workers' o workers' co comp. insurance.$, 9• ❑Building addition [N comp.insurance P• 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 11.0 Plumbing repairs or additions myself. [No workers' comp_ right of exemption per MGL insurance required.]t c. 152, §1(4),and we have no 12. of repo uS or r s kRA 13.2TOther buW-Ue � employees. [No workers' � .� comp. insurance required.] (� 1� ro'� C 2�0. *Any applicant that checks box#1 must also fill out the section below showing•rttieir workers'compensation policy information. t Homeowners who submit this affidavit indicating.they are doing all work and then hire outside contractors must submit anew affidavit indicating such. $Contractors that check this box must attached an additional she0t showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must providt 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: /f/ 6�1�4��►` U �f L.CJ Policy#or Self-ins. Lic.#: N Expiration Date: ?�}� Job Site Address: �c ? .)O63 City/State/Zip: C0+0l' Attach a copy of the workers' compensation poliey 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 maybe forwarded to the Office of Invesdizations of the DIA for ' urance coverage verification. -Mo-hemb a fi y e fy-u ids and-panaltie�f pexjr�ry thatha in{ormatioa�provideabove is txu�and carrec Si afore: Date: Z/7 Phone#: �7 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 3s City/Town CIerk 4.Electrical Inspector 5.Plumbing Inspector .6.Other Contact Person: Phone#: Client#:47298 CAPIHOM ACOROTM CERTIFICATE OF LIABILITY INSURANCE O6 DATE 0 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 Karen A Walther CISR NAME: Rogers&Gray Ins.-So.Dennis PHONE 508-760-4630 508-258-2230 434 Route 134 A/c No,Ext: ac,No ADDRESS: waltherka@rogersgray.com P.O.Box 1601 South Dennis,MA 02660-1601 CUSTOMER ID#: INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A:National Grange Insurance Co. Capizzi Home Improvement,Inc. ACE Pro a &Casual Ins.Co Capizzi Enterprises,Inc. INSURERB: P rtY Casualty 1645 Newtown Road INSURERC: Cotuit, MA 02635 INSURERD: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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 kDDLsUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE NSR WVD POLICY NUMBER MM/DD/YYYY) IMMIDDIYYYYI LIMITS A GENERAL LIABILITY. MPB1075H 06/08/2010 06/08/2011 EACH OCCURRENCE $1,000,000 DAmAG X COMMERCIAL GENERAL LIABILITY PREMISES Ea ocarrrence $500,000 CLAIMS-MADE a OCCUR MED EXP(Any one person) $10,000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 POLICY PRO- LOC $ A AUTOMOBILE LIABILITY M1 M28044 06/08/2010 06/08/2011 COMBINED SINGLE LIMIT (Ea accident) $500 000 ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ X SCHEDULED AUTOS PROPERTY DAMAGE $ X HIRED AUTOS (Per accident) X NON-OWNEDAUTOS Uninsured $250000/500000 Underinsured $250000/500000 A X UMBRELLA LIAB X OCCUR CUB1076H 06/08/2010 06/08/2011 EACH OCCURRENCE s5,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $S 000,000 DEDUCTIBLE $ X RETENTION $ 10000 $ B WORKERS COMPENSATION NWCC45843208 12/25/2009 12/25/201 X WC STL MI ETH AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNERIEXECUTIVEF-N N/A E.L.EACH ACCIDENT $1,000,000 (Mandatory OFFICER/MEMBER NH) EXCLUDED? E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 _T DESCRIPTION OF OPERATIONS LOCATIONS VEHICLES(Attach ACORDAdditional101, Remarks Schedule,if more space is required) Carpentry CERTIFICATE HOLDER CANCELLATION 10 Days for Non-Payment SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Town of Barnstable ACCORDANCE WITH THE POLICY PROVISIONS. 200 Main Street Hyannis,MA 02601 AUTHORIZED REPRESENTATIVE ©198 -2009 ACORD CORPORATION.All rights reserved. ACORD 25(2009/09) 1 of 1 The ACORD name and logo are registered marks of ACORD #S52549/M52541 KW �/ze '[�om�mor,.caec>��i o�✓�adaac�icceet�a Office of Consumer Affairs&Business Regulation License or registration valid for individul use only jOME IMPROVEMENT`CONTRACTOR before the expiration date. If found return to: f% ,. Office of Consumer Affairs and Business Regulation Reg istration''4"0p740 Type: 10 Park Plaza-Suite 5170 Expj�inn=--ORTA i Supplement Card Boston,MA 02116 CAPIZZI HOME'lUP—Q- El%--.�.�f1NC. J V_1 +�. -�, GARY GUSTAFS©"_ •�`= i-�:; .. 1645 Newton Cotuit,MA 02635 Undersecretary No id without signature N.LLss achusetts- 1)vp artnivnt of Public SaI•et) Board Of Building Regulations and S.audaril:s Construction Supervisor License License: CS 74640 Restricted to: Q.9 ji. 7� GARY',G.USTAFSON. , 8 SHORT WAy SANDWICH, MA 02563T - Enpirati.7n: 11/29/2010 C tt�i��i,sin:�a Tr.'; 7755 f Page 7 of 7 + CAPIZZI HOME IMPROVEMENT INC. SPECIFICATIONS AND ESTIMATES STATE OF MASSACHUSETTS LETTER OF AUTHORIZATION TO APPLY FOR A BUILDING PERMIT I,NORMAN SLOAN, OWN THE PROPERTY LOCATED AT 112 CEDARWOOD ROAD.IN COTUIT, MASSACHUSETTS. I HAVE AUTHORIZED CAPIZZI HOME IMPROVEMENT TO ACT AS MY AGENT TO APPLY FOR A BUILDING PERMIT IN ACCORDANCE WITH 780 CMR, THE MASSACHUSETTS STATE BUILDING CODE. I GIVE MY PERMISSION TO LESSEE TO APPLY FOR A BUILDING PERMIT IN ACCORDANCE WITH 780 CMR,THE MASSACHUSETTS STATE BUILDING CODE. SIGNATURE OF OWNER: OWNER'S ADDRESS: 112 CEDARWOOD ROAD, COTUIT, MA 02635 OWNER'S TELEPHONE: LESSEE'S SIGNATURE: LESSEE'S ADDRESS: LESSEE'S TELEPHONE: APLLICANT'S SIGNATURE: APPLICANT'S ADDRESS: 1645 Newtown Rd., Cotuit, MA 02635 APPLICANT'S TELEPHONE: 508-428-9518 RESPONSIBLE OFFICER: RESPONSIBLE OFFICER ADDRESS: RESPONSIBLE OFFICER TELEPHONE: