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HomeMy WebLinkAbout0039 TOWER HILL ROAD (34) c� j. 4 t �: q i �. 4 �. �' i 5 i 09 71 t i' k k_ is 't ��..q�:..�.!.��......... Application number i �► � ".D ©Fee........... ..... . ... ........................................... Building Inspectors Initials.... . �,►sg. �g► 14AR 2 2 2019 CC]] �. ..... . Date Issued...-..l�.-I ..1.. all. TOWN O� SARNSlABL� .... ..... Map/Parcel.........1.1.3-1110...........D.............. TOWN OF BARNSTABLE EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WIND O W S/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMATION Address of Project: 3 9 /0 We kO,�td y n l L1516r V d ie—, NUMBER STREET VILLAGE Owner's Name: If en Phone Number IVIA Email Address: JU 1A Cell Phone Number Project cost$ 8 S' Check one Residential ✓ Commercial OWNER'S AUTHORIZATION As owner of the above property I hereby authorize ?at4,t T C 6 Z ea l c.j4 to make application for a building permit in accordance with 780 CMR Owner Signature: �� �l-�e.� Date: g TYPE OF WORK © Siding 0 Windows (no header change)# © Insulation/Weatherization ors (no header change)# Commercial Doors require an inspector's review [PrRoof(not applying more than 1 layer of shingles) Construction Debris will be going to l CONTRACTOR'S INFORMATION ^/ Contractor's name Paul U Col ze,_Gz.CI-/Y Home Improvement Contractors Registration(if applicable)# �(`� / (attach copy) Construction Supervisor's License# 0 5 —/Og MS 7— (attach copy) Email of Contractor O�rl Ce @ CGc Zia y/�- C dy`-` Phone number ALL PROPERTIES THAT HAVE STRUCTURES OVER 75 YEARS OLD OR IF THE SUBJECT PROPERTY.IS IN j A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. I APPLICATION NUMBER......................................................!.... *For Tents Only* Date Tent(s)will be erected Removed on number of tents total Does the tent have sides? Yes No " (If yes please attach floor plan with exits marked) Dimensions of each Tent X X X Additional tent dimensions can be attached on a separate piece of paper. Purpose of Event Check one: this event is a: for profit non-profit event Check one: Food served Yes No Flame Spread Sheet of each tent must be attached. Provide a site plan with the location(s)of each'tent Fuel source being used LP tank 20 lbs. or> Yes No , if yes, a gas permit is required. Natural Gas Yes No ,if yes, a gas permit is required. If food is being served at your event please obtain a Health Department approval between the hours of 8:00am-9:30 am or 3:30 pm-4.30pm. Commercial events may require Fire Department approval. *WOOD/COAL/PELLET STOVES Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from combustibles: front back left side right side HOMEOWNER'S LICENSE EXEMPTION Homeowner's Name: Telephone Number Cell or Work number I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures, specific inspections and documentation required by 780 CMR and the Town of Barnstable. i Signature Date APPLICANT'S SIGNATURE Signature Date a h,.9 All permit applications are subject to a building official's approval prior to issuance. i I I Property Owner Must Complete & Sign This Form If Using a Roofer / Builder. (Print) _ Devin Witter , as Owner / Agent of the subject property hereby authorizes Paul J. Cazeault & Sons Roofing Inc. to act on my behalf, in all matters relative to work authorized by this building permit application for. Address of Job 39 Tower Hill Rd, Osterville MA Signature of Owner Mailing Address of Owner 1046 Main St. Suite 11 Osterville, MA 02655 Telephone # 508-agn-mgg Date 3/21/2019 i i Please return this form to Paul J. Cazeault Roofing along with your signed contract. It is needed for us to obtain the building permit required by your town to complete your roofing project fax#508-420-4555 office@cazeault.com "a F C DATE(R4R§/DDI"YYY) CERTIFICATE 16 :I €`[- 11/07/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORfOATiON ONLY A14D 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 endorsernent(s). PRODUCER CONTACT N A IV.E Linda Sullivan DOWLING & O'NEIL INSURANCE AGENCY PHON o E I. (508)775-1620 aIc.I4o: ADDRESS: Iullivan@doins.com 973 IYANNOUGH RD INSURER(S)AFFORDING COVERAGE LAIC R HYANNIS MA 02601 INSURER A: LM INS CORP 33600 INSURED INSURER B PAUL J CAZEAULT& SONS INC INSURERC: INSURER D: 1031 MAIN ST INSURER E: :::::] OSTERVILLE MA 02655 INSURER F: _ COVERAGES CERTIFICATE NUMBER: 334821 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 I 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 TYPE OF INSURANCE ADDL SUBR) r POLICY EFF POLICY EY.P LIMITS LTR M POLICY NUMBER NiMID D/YYYYI Mlu/DDIYYYY' COMMERCIAL GE14ERAL LIABILITY EACH OCCURRENCE S CLAIMS-MADE OCCUR DAMAG E I(REI4TED PREN4IS� Ea occurrence S MED EXP(Any one person) S N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIK41T APPLIES PER: GENERAL AGGREGATE S PEC LOC PRODUCTS-COMP/OP AGG S POLICY❑ OTHER: I I I I S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S Ea accident ANY AUTO BODILY INJURY(Per person) S ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per accident) S NON-OWNED PROPERTY DAMAGE S HIRED AUTOS AUTOS Per accident S UMBRELLA LIAB OCCUR EACH OCCURRENCE S EXCESS LIAR HCLAIMS-MADE N/A AGGREGATE S DED I I RETENTIONS \\// S WORKERS COMPENSATION h STATUTE E PER ORH AND ENIPLOYERS'LIABILITY A OFFICER/MEMBER EXCLUDED?ANYPROPRIETOR]PARTNERIEXECUTIVE NIA N/A NIA WC531S386670028 08/10/2018 08/10/2019 E.L.EACHACCIDEIJT S 1,000,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE S 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT I S 1,000,000 N/A DESCRIPTION OF OPERATIONS I 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 vm-A,.mass.gov/lwd/v,,orkei-s-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Great Quality General Contracting Inc ACCORDANCE WITH THE POLICY PROVISIONS. 1099 Main Street AUTHORIZED REPRESENTATIVE r"'l (( �L•Cf� Marshfield I MA 02050 Daniel M.CroQ,ey,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 i M31 f0l813' AAA 0125;5� 2i;!(i J. .. ri � iirYrlioyl :it�"'l f li`i il;,It+ll+ t trt Wort L aNit of h~;'assaeltu.efts Division of Rrolessiatial Licenswe Bcmi 1 of WIdin+g Reguiations and Slartdaids Cana�; f��itlip}rviscr i - . RUSSE P IA RR3JitrtfST-r—MAX � , 12 ;. ( G�'E�311FrEGPaalQn4'6 � �. 7 ,r.,7'e..f�T�,�'�`"�i,.O r.r %�'., F1 .i t.til'' �i.•� �/ ��fi. O'(Ce of Cp�g+,3t•�'dSjurner€ff JY��i�and �t usiness 7�'�'.eg iiuo qon '10190 11n�1 ashingl-'On S3—retit>. a�1..9i3.'���.. 71 D H 'aoJ•l"ie Improveme h- .Contracior 1 ecii,iraticn ype: Corporation, Registration: 103714 t AUL J.CAiERUL l&SONS, INC. Registration: 07/08/2020 1031 MAIN STREET - OS T ERVILLE, 111JA 02655 Upda'ie Address and Re urrs Card. SCA 1 C= EGt:.1-GE417 Oi�;ce of Consume.,a�iairs�3usiness Renulalion , HI 0J 11=i I'll PRG1f_ill=NT C 0 N T RACTGP Pegistra%ion valid ior's9-i-Pubid:iai use only TVPz.;Corporation before the expiration?ate. if found retu n.o: Regisc£3�i7:7 ,=x li,atiori Office of Conss;i-ner!AWs ffs and Bess tress R egu a-ion 07/00/2_020 . 1000 Washington Sa ae'-Su Re 7 4) )L T- IPAUL J CAZES > "i 18 RUSSELL CAZEAULT: `p C �� -- "� ;f /i'^ 1031 MAIN STREET; �� i OSTEP.VILLE,NIA 02oa"5 - _^- % ' Net valid L'1>aa aA:id 51�137 aa:l4fm Undersecretary (G L8) -t 177 w)a s: (5-0 ,11 25`_55 . r l.ine f:f: /5 Oi? ..1-t 1_11 �w 1 1• 1 �lt_{v,'�+ The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street,Suite 100 Boston,MA 02114-2017 www rnass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly n Name (Business/Organization/Individual): -V(/ J C AZ C^—(f liT f S =<"F1 S J /V Address: r'U f /1-(fl--r /1 J City/State/Zip: O S Q�12 V i 1—t L Phone#: ` `�2- Are you an employer?Check the appropriate box: Type of project(required): 1. I aiii a employer with employees(full and/or part-tune)." 7. New construction 1 am a sole proprietor or partnership and have no employees working for the in $. E]Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition. 3.Q I am a homeowner doing all work myself[No v.orkers'comp.insurance required.]f 10 Q Building addition 4.❑1 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 I L FJ Electrical repairs or additions proprietors with no employees. 12.FJ Plumbing repairs or additions 5.a 1 am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0 Roof repairs / These sub-contractors have employees and have workers'comp.insurance.- n1�tN 6. We are a corporation and its officers have exercised their right of exemption per MGL c. i4 J2.0ther Uo 152,§1(4),and we have no employees.[No workers'comp.insurance required.] 'Any applicant that checks box#i must also fill out the section below showing their workers'compensation policy information. Homeowners 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 trust 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. Ian.,an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: —, -j Vu 0 i L)A C_ Policy#or Self-ins.Lic.#: IN CS -3 1 .S U 6 00 Expiration Date:T1j Job Site Address: 14Ili R0 V0 7 /ycity/State/Zip: OS VILL�� 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 viol ation•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 certi under the pains and penalties ofpei jtr►y that the in ormation provided above is hwe and correct Signature: / Date: 02 / Phone 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#: 7 - ' TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION�,� Map 'I q Parcel . �d Q a Application # Z 7'� � Health Division Date Issued 7 S= 17 Conservation Division Application Fee Planning Dept.. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH Preservation/Hyannis n Project Street Address 3 7. 'fo We gt// RD U"V., /Y Village Owner 61!'Erg(/ 64 AAgy Address 3 y 1�041,e Xlj UN/ -1 / p !� Telephone II - 3 3 7d�l y Permit Request t �4 ce. Ai!l?OOW./ I-riq1;6t11z, B h�fxdtF- oZ - Li V/�t y /T OU Al CO 1 ,.4,J J 6 vev T a eD/?0017 a /260 . t 6 .ram ,,,_# E LIT/4t. Square feet: 1 st floor: existing proposed d 2nd floor: existing ' 0 proposed D Total new "1l'Q Zoning District S>L! U15 Flood Plain Groundwater Overlay gQ Project Valuation d6c�Construction Type W OOa t/lAtfA, Lot Size '�l� Cu^�n -0 Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family A/ Two Family ❑ Multi-Family(# units) Age of Existing Structure 1 9 7 5 Historic House: ❑Yes g g YNo On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other p1A Basement Finished Area(sq.ft.) 4 Basement Unfinished Area(sq.ft) Number of Baths: Full: existing new 0 Half: existing d new Number of Bedrooms: existing Q new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil Electric ❑ Other Central Air: O Yes ❑ No Fireplaces: Existing 6 New Existing wood/coal stove: ❑Yes ❑ No t Detached garage: ❑existing ❑ new size_Pool: ❑existing ❑ new size _ Barn: ❑existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑existing ❑ new size _ Other: ® W z c Zoning Board of Ap�ppeals Authoriz tion ❑ Appeal # Recorded ❑ O c 6�n oo 0 00 Commercial aiYes ❑ No If yes, site plan review# X N Current Use f�k �� �.4Ki / Proposed Use o rn cc� 7-i r- APPLICANT INFORMATION (BUILDER OR HOMEOWNER) - Name 1,044/ Telephone Number Address � /l/'� OuJ14 W11 License # (f_C7 - ®i a 'Ue�l 84 026 Home Improvement Contractor# /047W Email � � � � '. = d =<er's Compensation # ALL ONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE 6 0 1 2.9-/ /7 FOR OFFICIAL USE ONLY APPLICATION # DATE ISSUED MAP/PARCEL NO. a ADDRESS - VILLAGE OWNER 1 DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL. ,GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT A ASSOCIATION PLAN NO. .` I Page 7 of 7 Capizzi Home Improvement Inc. Specifications and Estimates STATE OF MASSACHUSETTS LETTER OF AUTHORIZATION TO APPLY FOR A BUILDING PERMIT PIN lye UWE,j5 h,(� ��i1ity , OWN THE PROPERTY LOCATED AT 3� 7o welt Ma P IN 0 S lif j2VW,,tK. , 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: 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: <•� r:'l/rr. �a»rurnrrnscvr�l�c�n/laurtr.� .Massachusetts Department of Public SafetyCeOfQ,'QIISUIIIEE�fjAjpS�'r�usjilEyRB�u(AQIOI Board-of Building Regulations and Standards OME IMPROVEMENT CONTRACTOR License: CS-0648117 Construction Supervisor ReMsb'atlon: 100740 1YP , Expiration: 6/23/2018 Supplemen JOHN T STRUMSKI ` CAPIZZI HOME IMPROVEMENT, INC. 18 ALDEN AVE BUZZARDS BAY MA 02632 JOHN STRUMSKI 1645 Newton Rd. Cotuit,MA 02635 / Underaeeretaq Expiration: Commissioner 06118/2018: r- Led-B aiflci� s of any use group which is&W 35,000 cubic melt Q991ma off Pam . Xess a curtent?editlan of Me Aftssachusetlts Code 14 cause for r evocalton of this Devise. ngTn`rorrnatlonvisn: NNM.Nl2ss.00VJ0P5 License or registrgdon valid for indMilaal nse only before the exPfratim dale. Yf found reWm to: Office Of Consumer Affairs and Business 10 Park Plaza-Salte S170 Ji miafion Boston,iA 02116 A' Not bout sigaatgre - � 7 ® DATE(MM/DD/YYl'Y) A6 v CERTIFICATE OF LIABILITY INSURANCEF12/30/2016 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). CONT PRODUCER NAM EACT Rogers and Gray Processing FAX ROGERS& GRAY INSURANCE AGENCY INC JAIC,PHON oExth 508 398-7980 A/C No: E-MAIL ADDRESS: mail@rogersgray.com 434 ROUTE 134 INSURERS AFFORDING COVERAGE NAIC# SOUTH DENNIS MA 02660 INSURERA: AMGUARD INSURANCE CO 42390 INSURED INSURER B: CAPIZZI HOME IMPROVEMENT INC INSURERC: INSURER D: 1645 NEWTOWN ROAD INSURERE: COTUIT MA 02635 1 INSURER F: COVERAGES CERTIFICATE NUMBER: 114654 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 ADDLISUBRTYPE OF INSURANCE INSD WVD POLICYNUMBER POLICY EFF POLICY EXP LTR MM/DDIYYYY MM/DD/YYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE F1 OCCUR PREMISES(Ea occurrence) $ MED EXP(Any oneperson) $ N/A PERSONAL&ADV INJURY $ M'OTHER: LAGGREGATELIMITAPPLIESPER: GENERALAGGREGATE $ POLICY❑JECOT- LOCPRODUCTS-COMP/OPAGG $ 1 $ AUTOMOBILE LIABILITY C0 'idINED SINGLE LIMIT $ Ea accent ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS N/A BODILY INJURY(Per accident) $ AUTOSNON-OWNED PROPERTY DAMAGE $ HIRED Al1TOS AUTOS Per acc dent UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS LIAR HCLAIMS-MADE N/A AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION X I STATUTE OERH AND EMPLOYERS'LIABILITY ANYPROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $ 1,000,000 A OFFICERIMEMBEREXCLUDED? N/A N/A NIA R2WC775326 12/25/2016 12/25/2017 (Mandatory in NH) 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 I 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 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/lwdtworkers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION 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 AUTHORIZED REPRESENTATIVE Hyannis MA 02601 DanielCr ey,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 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 U9 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): CAPIZZI HOME IMPROVEMENT INC Address: 1645 NEWTOWN ROAD City/State/Zip: COTUIT , MA 02635 Phone#: 508-428-9518 Are you an employer?Check the appropriate box: Type of project(required): L I am a employer with 40+ 4. I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. New construction 2. 1 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' 9. Building addition [No workers'comp.insurance comp.insurance$ required.] 5. We are a corporation and its 10. Electrical repairs or additions 3. 1 am a homeowner doing all work officers have exercised their 11. 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 Llli'171�vw employees. [No workers' 13. Other 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. tContractors 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: AMGUARD INSURANCE COMPANY Policy#or Self-ins.Lic.#: R2WC775326 L Expiration Date: 12/25/2017 Job Site Address: y �GIJ Py ul// �(J ��1 T l U 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 lender 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 herebyOr!�t dpains and penalties of perjury that the information provided above/is true and correct. Si ature: Date: Phone#: 508-428-9518 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#: THE VILLAGE SQUARE NORTH CONDOMINIUMS 1046 Main St Suite 1 I Telephone:508-420-0299 Osterville,MA 02655 Fax:508420-0789 June 21,2017 To Whom It May Concern, This is to inform you that 1,Devin Witter,excercising my power as Property Manager of Village Square North Condominiums,39 Tower Hill Road,Osterville MA,and as Agent of the Board of Trustees of said property hereby give permission to Capizzi Home Improvements to undergo the window replacement project that they have proposed at Unit 14D per their agreement with owner Eileen Geary. If you have any questions feel free to contact me. Sincerely, Devin Witter CMCA,AMS First Property Management