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Town of Barnstable Peres 6 #
aggoo
pFt Tpt�, Expires 6 mon hs from ' date
Regulatory Services Fee
+ BARNSrABLE,
y MA-SQ. Thomas F.Geiler,Director
�p .t63y39 p10 .
�f0
. Building Division
Tom Perry,CBO; Building Commissioner
200 Main Street,Hyannis,MA 02601
www.to wn.b arns t ab l e.ma.u s
Office: 508-86274038
Fax: 508-790-6230
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
y� Not Valid without Red X-Press Imprint
Map/parcel Number y 3
Property Address
Residential Value of Work cv d Minimum fee of$25.00 for work under$6000.00
Owner's Name&Address
Contractor's Name --� Ci,rebud�Telephone Number �j Q "8 13 ��d
Home Improvement Contractor License#(if applicable) 7 -7—7 7AL4
Construction Supervisor's License#(if applicable) /� ��g—og
❑Workman's Compensation Insurance nP S PERMIT
Check one:
I am a sole proprietor O C T t 9 2009
❑ I am the Homeowner
❑ .I have Worker's Compensation Insurance
\ TOWN OF BARNSTABLE
Insurance Company Name
\ Workman's Comp.Policy#
Copy of Insurance Compliance Certificate must accompany each permit.
Permit Request(check box)
❑ Re-roof(stripping old shingles) All construction debris will betaken to
❑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 must sign Property Owner Letter of Permission.
A copy of the Home tmprovement Contractors License&Construction Supervisors License ir"
required.
SIGNAT G
Q:\WPFILES\FORMS\building permit fonns\EXPRESS.doc
Revised 090809 -
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office oflnvestigations
600 Washington Street
F Boston, MA 02111
wi<vw.mass.gov/dia
Wd'rkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information IPlease Print Legibly
Name (Business/Organization/Individual): 2105,L,�
Address:
City/State/Zip: Phone #: � �
Are you an employer? Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2.J?fam a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. employees and have workers' 9. ❑ Building addition
[No workers' comp. insurance comp, insurance.
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 1 I.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.] t c. 152, §1(4),and we have no
employees. [No workers' 13.A Other .S ( `
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing thcir workers'compensation policy information.
t Homcowners who,submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whcthcr or not those cntities 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:
Policy#or Self-ins. Lic.#: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy 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 may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby cert' under the pains and penalties of perjury that the information provided above is true and correct.
Signature.. Date: 1611 6
Phone#:
Official itse 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 S. Plumbing Inspector
6. Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an eyrrployee 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.9 lari•individual,partnership, association, corporation or other legal entity,or any two or more
of the foregoing engaged in a j'cint 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 conunonwealth 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-contractors)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 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 nu:umber. In addition,an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating currentr ;
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 ,R
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 burn leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call. `
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
- 600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 4-.24-07
www.mass.gov/dia
�YHEr Town of Barnstable
Regulatory Services
s^ MLA&S Bi>r Thomas F. Geiler,Director.
039.�Eo�.,► Building Division
Tom Perry,Building Commissioner
200 Main Street,Hyannis,MA 02601 .
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
Property Owner Must
Complete and Sign This Section
If Usine A Builder
� l
I )Cs , as Owner of the subject property
hereby authorize 4�ni W,oQ- to act on my behalf,
in all matters relative to work authorized by this building permit application for.
(Address of Job)
k '
tore of er Date
n t Name
If Property Owner is applying for permit please complete the
Homeowners License.Exemption Form on the reverse side.
t,
Q:FORMS:OWNER.PERMISSION
r
4
oft►,E r�
Town of Barnstable
Regulatory Services
Thomas F. Geiler,Director
BARNStABLE,
Mass.
039. ,m� Building Division
p�fD � Tom Perry,Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION
Please Print
DATE:
JOB LOCATION: W t ! r 7Y �K,
number street village
"HOMEOWNER": C�auY►+ _ Yv�.
name G 171 �7v1 I� ome phone# C�p% work phone#
CURRENT MAILING ADDRESS:_*,S �CQcv
city/town state zip code
The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and
to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as
supervisor.
DEFINITION OF HOMEOWNER
Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to
be, a one or two-family dwelling,attached or detached structures accessory to such use and/or farm structures. A
person who constructs more than one home in a two-year period shall not be considered a homeowner. Such
"homeowner"shall submit to the Building Official on a form acceptable to the Building Official, that he/she shall be
responsible for all such work performed under the building permit. (Section 109:1.1)
The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other
applicable codes,bylaws,rules and regulations.
The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department
mum inspection procedures and requirements and that he/she will comply with said procedures and
re irements. .
i
nature opAimeoWner
Approval of Building Official
Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the
State Building Code Section 127.0 Construction Control.
HOMEOWNER'S EXEMPTION
The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions
of this section(Section 109.1.1 -Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such
work,that such Homeowner shall act as supervisor."
Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q,
Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly
when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed
Supervisor. The homeowner acting as Supervisor is ultimately responsible.
To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,
responsibilities of a Supervisor. On the last page of this issue is a form currently used by
that the homeowner certify that he./she understands the
several towns. You may care t amend and adopt such a form/certification for use in your community.
Q:\WPFILES\FORMS\bomeexempt.DOC
1
,,pper� ✓�ie -Uanvnarnauie� o�✓/�ca�aacfeuaP,�Q
Z\ Board of Building Regulatio sand Standards License or registration valid for individul use only
HOME IMPROVEMENT.CONTRACTOR before the expiration date. If found return to:
Board of Building Regulations and Standards
Registry ion;\152773 One Ashburton Place Rm 1301 (I
Expiration: 8/2010 Tr# 275598 : Boston,Ma.02108 ;
_Type DBA? .I
i
J GROUP t; I
DANIEL WOOD
-t q
38 EVELYN CIRCLE', Not valid without signature
CENTERVILLE,MA 02632 Administrator
13o'�r f�u-M•c�inr g i"onbranarils
"' Constructiori SupervisorLicense
License CS 62822
>, ExpicaUoh
3728/2010 Tr# 22125
@StfIG: :-
I- -
__DANIEL C�,WOOD -
38 EVELYN Cfi2
CENTERVILLE,,MA62632 '''ye~ Commissioner
r
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION -
Map bJ Parcel dS f Permit# 00 k�p (p
n - Date Issued
Fee q, 63
Tom
Tax Collector
Treasurer
Date Definitive Plan Approved by Planning Board ,
Histe4g_ - OKH. -P se ✓ tie /#ya nis r
-`r
,Project Street Address in![h*c- �R�'Ue,
Village TY aessTIw S /1'AtS ! '
`Owner �Sf�'F! OA Vl wt_43 Address go rjy el- ) Ave.MR RMAkc
Telephone 5' F3�40 y5i
Permit Request -,-r-/w_f_ � 1�1G� R>PRS'=( l �e�J� �d/y2W&kS(SVee She)- [,u Ifi1_C,,--,- ,3J47,JCLE
Sib i Af 6j L. 54 9 � RoL s S; • o" 7S
RCPL• Sl1 ec3B elk ill 14 h,4G/1 2'4 AAln PA t 34 alff6,0-rh ie-44 5P 1 M4 i—?n2z b envsr
Square feet: 1 st floor: existing proposed 2nd floor:existing proposed Total new
Estimated Project Cost b'0.. Zoning District Flood Plain Groundwater Overlay
Construction Type 05T)
Lot Size Grandfathered: ❑Yes 910 If yes, attach supporting documentation.
Dwelling Type: Single Family l3 Two Family ❑ Multi-Family(#units)
Age of Existing Structure Historic House: ❑Yes EVo On Old King's Highway: ❑Yes O44o
Basement Type: U Full ❑Crawl ❑Walkout ❑Other
Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft)
Number of Baths: Full: existing new Half:existing new
Number of Bedrooms: existing new
Total Room Count(not including baths): existing new First Floor Room Count
Heat Type and Fuel: ❑Gas' ❑Oil ❑ Electric ❑Other
Central Air: ❑Yes ❑No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑No
Detached garage:❑existing ❑new size Pool:❑existing ❑new size Barn:❑existing ❑new size
Attached garage:❑existing ❑new size Shed:❑existing ❑new size Other:
Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑
Commercial ❑Yes UK If yes, site plan review# ,
Current Use Proposed Use
BUILDER INFORMATION
Name C �l�-�� %7'� 1i� �'/E• Telephone Number '' g
Address /O�Al�1WW 12:0 License# CSU
Home Improvement Contractor'# 14617`O
Worker's Compensation#
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE � � DATE _ 9/cR/q l
L FOR OFFICIAL USE ONLY
PERMIT NO. . !
DATE ISSUED
MAP/PARCEL NO.
ADDRESS VILLAGE, ! -
OWNER _
DATE OF INSPECTION,., I
FOUNDATION
FRAME "
INSULATION
FIREPLACE
ELECTRICAL: ROUGH FINAL '
PLUMBING: ROUGH FINAL
GAS: ROUGH FINAL ;
FINAL BUILDING, r�'
DATE CLOSED OUT
ASSOCIATION PLAN NO. ' !
t
mr ' Window & Door Prime Products Page_..._—of
1-rAAV E� "
N IANOrder Form Harvey Industries, Inc. • 725 Huse Road Manchester, NIA 03103-2339
Dealer Name /aAl�l Z Z 7�7Ul�l /fit Stop Via Delivery Fie uest Dale Ordered
_L_____ —�=-- -�� Account A — _ 'i
U Warehouse Truck U Standard l Z�
Address —._ U Factory Direct U Special Cust.P.O. •'
U Factory Pickup ��� � /
! U Pick up at Age
Job Name l�] ___I�$�_••-- _ ���- L ordered by
(Delivery Area)' /�,��/�,
Window Speclflcstlons: bNerior Exterior Glazing: �Sc_'� _ Day/Dow
T , Size• Col Coke— U Quar— plan U DH Angie: Flankers: Wall Depth: Veneer
Inyl I �ng LV61ille L1,411te ow-E U Fun U CsUr U710' U I'5' U 4 9/16' STD Interlor.
U Wood I U Ruck 0 Almond U Almond U Low-E Argon U None
U Center DH U 300 U I'9' O Other O Oak
O Atumlrxtm ' O TTT U Bronze U Med.Bronze U Obscure U Center PW U 450 U 2V* O Birch
U Stock U Pine O Dark Bronze U Special Temp. Grids: U Mttlti-point lock U Z4'
Sas ype: U Catalog Size O Oak Freye! U Other U Colonial In-Glass —
ochanical O Oaktone eplacemeni U Colonial Snap-In — (A of Iltes)
U Welded I U Nail Fin U Diamond In-Glass COMMENTS:
. .
. : C VDHMEN=
--�3 I ` ' r _ --
i
tk
Vinyl Patio Doors
_ Colonial
Q!!a—ity -Size Style Gtlds Glazing Color
El Standard
- --— - — - U Low-E
r U Argon
--- —----- U Bevelled
Wall
DW1h Hardware Prep
— --.___�.._._•.—._.. _ ---- ---- wood o orris o MuMpolM LockkV
U Slaw"s nystnrrr Indrxbs ctu om
�DDeeaddbc* Steel Wheels PoRshed brass handle
— Customer Signal ere:
J
-- - The Commonwealth of Massachusetts
Department of Industrial Accidents
600 Washington Sired
Boston,Mass 02111
Workers' Comiensation Insurance davit
can nCn1IIt1Dt .:•%. ri R /. y / r //�//• f '.
e:
ocation: ' AIV-44
city / 1?tl:(.�aS� mil, �u 1�0. - f � phone N
❑ I am a homeowner performing all work myself.
❑ 1 am a sole proDrietor and have no one workin in any ca acity
Mllmloel=4eliC / � rear.
I am an employer providing workers•compensation for my employees working on this job.
tempany anme: NPir2i
address: 16T--r / le&jwwAl
city: Co ZU/]' tool to 3S phone#: V Og) �1.t8- 9SA8
insurance ca. P elicvtY WC �s� i
/.11lr,/.!!!G/!i,
❑ I am a sole proprietor,general contractor, or homeowner(circle one)and have hired the contractors listed below who
have .
the follm ing workers' compensation polices:
company name•
address:
city phone fa
insurance co. ..,
-
eomnanv name- :.. :•• :....:..
address:
nsurs"Ce CO. olicv#
00///%%%
Finaure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penaltles of a Ane up to S 1.500.00 and/or
one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a Me of$100.00 a day against me. I understand that a
copy of this statement may he forwarded to the OMce of Investigations of the DIA for coverage vtsiIIntion
I do hereby terrify under the pairw and penalties perjury that the information provided abow is urn,and correct.
Print name die Ed 1Jc*.� t�. GSA s e H /�+• Phaae tT �r�S�9 S S
COch
ly do not write is this area to be completed by city or town otIlda]
pennitAlcense 0 ❑Building Department
_ ❑Lkensmg Board
medLte tYspome b required - —--— - --- Sclectmm's Orrice - -
❑Health Department
n: phone 0.. - 00ther
_ ....
(rcwea d�95 PJi
pro
' The Town of Barnstable
9Q�M�0 Department of Health Safety and Environmental Services
` � . Building Division
367 Main Street,Hyannis MA 02601
Ralph Crossen
Office: 508-790-6227 Building Commissioner
Fax: 508-790-6230
For office use only
Permit no.
Date AFFIDAVIT
HOME IMPROVEMENT CONTRACTOR LAW
SUPPLEMENT TO PERMIT APPLICATION
MGL c. 142A requires that the "reconstruction, alterations, renovation, repair, modernization,
conversion, improvement, removal, demolition, or construction of an addition to- any pre-existing
owner occupied building containing at least one but not more than four dwelling units or to
structures which are adjacent to such residence or building be done by registered contractors, with
certain exceptions,along with other requirements.
Est. Cost
Type of Work:
Address of Work:
Owner's Name
Date of Permit Ap ication:
I hereby certify that:
Registration is not required for the following reason(s):
_Work excluded by law
Job under S1,000. !
_Building not owner-occupied
Owner pulling own permit
Notice is hereby given that:
OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED
HOME IMPROVEMENT WORK DO
CONTRACTORS FOR APPLICABLE GZAM OR GUARANTY FUND UNDER MGLO 142�A�
ACCESS TO THE ARBITRATION
SIGNED UNDER PENALTIES OF PERJURY
I hereby permit apply for a pmit as the agent of the owner: O
�� 0 7
Contractor Name Registration No.
Date -
05-4 erg P
OR
_ __ nwnersYarne� _
,
TP. LdDUJ)tdI1G/e�� O` -'('GCIJJ(dC�IIJP,C�J
:iiN�.�rC.'IDIi ;IlY� 1'.JC�•. -'t_I:';�
Number:
°T/t�� o>«alaF�✓ll.�t.I�aa `sestric`?G ?o: 3h
HOME IMPROVEMENT CONTRACTOR x /THi+MAS • CAPI•'_ii
Registration 100740 '64' NEWTOWN RD
Type - PRIVATE CORPORATION
Expiration 06/23/00 -
CAPIZZI HOME IMPROVEMENT, INC
as Capizzi, Sr.
ADMINISTRATOR 45 Newton Rd.
Cotuit MA 02635
)
----------- ✓sae �!a)Jz)Jtd)ztaea� o���l/I,aJJa.�•�rlJetld
DEPARTMENT OF PUBLIC SAFETY
' 7 CONSTRUC-T-ION SUPERVISOR LICENSE
' a Number: Expires:
Restr-icted lo: 88
THOMAS X CAPIZZI JR
'286 PERCIVAL OR
—3- _W BARNSTABLE, NA 02668
.. ✓fie '�anralra')vuetz��• a��-llizd�n�uw./,lJ
_ s OEPARTMENT OF PUBLIC SAFETY
CONSTRUCTION SUPERVISOR LICENSE
Number: xpires:
/ Restricted To: a0
_ FREDERICK V RASC6 III
�'�""4/ p -"•:060 6OURNE RD
PtYNOUN. NA 0?360
Engineering Dept.(3rd floor) Map Parcel ermit# 9 q o 4
House# - Date Issue 9 ° /
Board of Health(3rd floor)(8:15 =9:30/1:00-4:30) Fee
Conservation Office(4ih floor)(8:30- 9:30/1:00-2:00) _
Planning Dept.(1st floor/School Admin. Bldg.) �tae►q
giree
Approved by Planning Board 19 -. ;
RARNSTMA
ABLE.
TOWN OF-BARNSTABLE
Building Permit Application
Prddress /�G/y/G/s>/l✓�rnly�� '/;-J11/�.�
Village Owner /�,�/f/�Y�d l� /� /rJ Address �J /. w� A� ,Y 7�l
7 ,
Telephone 7 ZEE` d :Q1,
Permit Request .5'Tiei,a-Y,- `/7,'5p,", &i' 7' �i ✓ ✓�6,./�' t/stJ>�i� ,S`�®/��
D1d/�� —�,�ilriHl�/r�z1S' ,�u��� .I/dWT' �'��c.�9� •�f�r✓i�� �'� s�U�� i il/
of Al V,-,04 xpo49
,First Floor square feet Second Floor square feet
Construction Type
Estimated Project Cost $ ott -O
Zoning District Flood Plain Water Protection
Lot Size Grandfathered ❑Yes ❑No
Dwelling Type: Single Family Cd' Two Family ❑ Multi-Family(#units)
Age of Existing Structure Historic House ❑Yes W1410" On Old King's Highway ❑Yes 01f,0
Basement Type: ❑Full ❑Crawl ❑Walkout ❑Other
Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft)
Number of Baths: Full: Existing New Half: Existing New
No.of Bedrooms: Existing New
Total Room Count(not including baths):Existing New First Floor Room Count
Heat Type and Fuel: ❑Gas ❑Oil ❑Electric ❑Other
Central Air ❑Yes ❑No Fireplaces: Existing New Existing wood/coal stove ❑Yes ❑No
Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size)
❑Attached(size) ❑Barn(size)
❑None ❑Shed(size)
❑Other(size)
Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑
Commercial ❑Yes ®'No If yes, site plan review#
Current Use Proposed Use
&,ZzBuilder Information
Name z,!2 / Telephone Number �1.e—
Address /G%����r�%C.r7 Lam'I—�j, License# 6S� 32
'' 1212 j m-o- Home Improvement Contractor# ;/bd 74/163
Worker's Compensation#M/mod I$l�J 93 W
NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS
PROPOSED STRUCTURES ON THE LOT.
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE DATE -'—Jy-
BUILDING PERMIT DENIED FOR,THE FOLLOWING REASON(S)
FOR OFFICIAL USE ONLY �^ '
PERMIT NO. �� Y
DATE ISSUED '
MAP/PARCEL NO.
ADDRESS• i VILLAGE
OWNER
DATE OF INSPECTION: r
t
FOUNDATION
FRAME a
. INSULATION _
FIREPLACE b
ELECTRICAL: ROUGH FINAL —
PLUMBING: ROUGH FINAL F
GAS: ROUGH FINAL —
FINAL BUILDING
DATE CLOSED OUT
ASSOCIATION PLAN NO.
.. • .. •ice .
OME .IMPROVEMENT CONTRACTORS REGISTRATION
'Board, of Building Regulations and Standards
One Ashburton Place - Room 1301
:Boston, Massachusetts 02108 j
• I
HOME IMPROVEMENT CONTRACTOR -L-------------------------- -------
Registration 100740 Expiration 06/23/98
OL
,Type — PRIVATE CORPORATION
HOME IMPROVEMENT CONTRACTOR
Registration 100740
CAPIZZI HOME IMPROVEMENT, INC. Type - PRIVATE CORPORATION
Thomas Capizzi , Sr . Expiration 06/23/98
1645 Newton Rd . i
Cotuit MA 02635 CAPIZZI HOME IMPROVEMENT, INC
Thopas Capizzi, Sr.
&T1445 Newton Rd.
ADMINISTRATOR Cotuit MA 02635
------------
DEPARTMENT ,
ONE A314BUR
OST
•kUG.��ON .SUPERVISOR LICENSE
{rt' %IExpires: .
, .�X *��
�S�X��GA�PIZ�I:F.JR�••' ':� .
2NS'1` SLt,, A`'02660
l 7Ry. e T
r krt•'•'�;�� . . ���\ fir= .
dig �
The Commonwealth of Massachusetts
Z Department of Industrial Accidents
011lce011" sllisdaws
600 Washington Street
Boston,Mass 02111
Workers' Compensation Insurance Affidavit
A ,
n m Ci LBr
location*
ciry ��% Z� phone# ZI- 24 Jr/ 7
CD I am a homeowner performing all work myself.
I am a sole proprietor and have no one working in any capacity
I am' an employer prop idins workers• compensation for my employees working on this job.
cornl2any name:
address:
city phone#-
insurance co �� T zzk �/ policy#
I am a sole proprietor. general contractor. or homeowner(circle one) and have hired the contractors listed below who have
the following workers* compensation polices:
company name-,
address:
ci phone#:
policy
insuranceco.
#
company name:
ctty phone#•
pofiev#
msurance co,
RIMS ti
failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of erimitW penalties of a floe up to 53,500.00 and/or
one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a line of S100.00 a day against me. I understand that a
copy or this statement may be forwarded to the Once of Investigations of the DIA for coverage veriGatioa.
t do hereby certify under the pains an enaN of perjury that the information provided above is true and correct
Signature _/ ate 9—lo—ge
Print name /� CST Phone `
s official use onlc do not w rite in this area to be completed by city or town oMcial
city or town YARMODT$ _ permittlicense# riBuilding Department
�Lfcensing Board
check if immediate response is required 261 QSelectmea's Once
�Healtb Department
~phone#;
tact person (508) 399-2231 ext. nOther
con —- —
(re.'ised 3:95 PIA) - '
The Town of Barnstable.:
>� es
Department of Health Safety and Environmental Servl .
Building Division
. Ma .
367 Main Street,HY=nis MA 02601
Ralph C==
Office: 3o8-79o-6227 Bnadrag C=mission
Fax 509-775-3344
For office use only . .
Permit no.
AFFIDAVIT
]ROME MOROVEMENT CONTRACTOR LAW
SUPLEMENT TO PERMIT APPLICATION
MGL c 142A requires that.the"reconstrnaron,alterations;renovation,repair; °IIi.
improvement,.rema%%L demolition. or aonstruaraa of an addition to'anY a�vaer Occupied
building containing at least one but not more than four dwelling units Or to wtufch are
to such residence or building be done by registered coatracx M with artain C=qvjoM along with other
requir= t
=1S' r
Type of Work /' jL &22 . Est.Cost ! -4 � —
Address of Work:
OvMcr.Name:
Date of Permit Application:
I hereby certify that: i
j.
Registration is not required for the following rtason(s):
Work ecduded by law
Job trader SI.000
_Building not awne -=Pied
Owns pulling own permit
Notice is hereby given that:
OWNERS PULLING THEIR OWN PERMIT OR D WORK DSO NOT t7R�EG�CONTRACTORS
TO
. FOR APPLICABLE HOME IMPROVEMENT
ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c 142A
SIGNED UNDER PENALTIES OF PERIt1RY
I hereby apply for a permit as the agent of the owner:
el ,
R No.
Date e
OR `�