Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
2423 IYANNOUGH RD/RTE 132
UPC 12543 iVo.53LOR . HASsiNcr, UN i r �t 40 o�VKWE Town of Barnstable *Permit# Expires 6 months from is a drlt_ Regulatory Services Fee snaxszaaM 9� MASS. mq Thomas F.Geder,Director / �f0 MP'I a Building Division 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 PERNIIT APPLICATION - RESIDENTIAL ONLY Map/parcel Number oZ 1/0 d Not Valid without Red X-Press Imprint Property Address 2 y °�3 :y u'Nn e-U bu •Rn, / 14 )3 1-- [Residential Value of Work -3 l Gbb Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address 1? c t-e yr P 1 K A ) j$' 51-0 Contractor's Name— j_j..N .54 V U M S'C l Telephone Number C N ?" Lz I '14 a ma U f/ 7 Y y' Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) �' S G 4 y d- 17 5(workman's Compensation Insurance XNPRESS PERMIT Check one: ❑ I am a sole proprietor SEp 2 2 2014 ❑ I am the Homeowner Yl have Worker's Compensation Insurance OF BARNSTABLE Insurance Company Name Cj 5 S U 11,4 ( hr4 Pei :Lip L c ,570yG 1 20jY'A Workman's Comp.Policy# ��/ � y' Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑,Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) M/Re-side ✓ br 14otw 1y4016 c4 40 .Thm& Jeeerlo 4 or .PiJ6"✓�'i0DM #of doors [Replacement Windows/doors/sliders.U-Value "d,3 X (maximum.35)#of windows Z. ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *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 Prop wner Letter of Permission. PaKM.iPcrosoft\Windovvs\Temporary py of the Home Improv ent C utractors License&`�'u:�astruction Supervisors License is SIGNATURE: C:\Users\decollik\A�Data imemet.—es\Content.0utlook\ 6ZUBNV>I T) �ti 4 4e Revised 053012 `7 t J. l� 1 The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations 1 Congress Street, Suite 100 Boston,MA 02114-2017 Y°V 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): 1.❑■ 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.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. VRemodeling ship and have no employees These sub-contractors have 8, ❑ Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.: 9. ❑ Building addition required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3:❑ I-am a homeowner-doing all work......••-.......—Officers.have.exercisedaheir,:.,..,_,,,„.,,,.,1.1:❑Plumbing.repairs or-additions...... •- •- myself. [No workers' comp. right of exemption per MGL 12. A Roof repairs insurance required.] t c. 152, §1(4),and we have no El �i11 Other ll�Q employees. [No workers' 13. comp. insurance required.] , *Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. 6,4,jemeAll 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. Insurance Company Name:Associated Employers Insurance Co. Policy#or Self-ins. Lic.. #:WCC50050105472013A Expiration Date: 12-25-2014 Job Site Address: / 'Z City/State/Zip: lifW 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 cer nder the pains and enalties of perjury that the information provided above is true and correct. Sil Date: 0 / L-2- 1 Y Phone#: 5 8-428-951 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#: A•, /^�^ CAPIHOM-01 APELL �4,CORp� DATE(MMIDDNYYY) CERTIFICATE OF LIABILITY INSURANCE F6/4/2014 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 NAME Rogers&Gray Insurance Agency,Inc. PHONE Fax 434 Rte 134 AIC No 6d: ac NI:(877)816-2156 South Dennis,MA 02660 -ADDRESS, INSURER(S)AFFORDING COVERAGE NAIC 9 INSURER A:Main Street America Assurance Co. INSURED INSuRERB:Associated Employers Insurance Co. 11104 Capiui Home Improvement,Inc. INSURER C: Capri Enterprises,Inc 1645 Newtown Road USURER D Cotuit,MA 02635 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. LTR TYPE OF INSURANCE ��SUBR POLICY NUMBER POLICY EFF POLICY EXP UNITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 DAMAGE TOR NTED CLAIMS-MADE a OCCUR MPB1075H 06/08/2014 06/08/2015 PREMISES a occurrence) $ 500,00 MED EXP(Any one person) $ 10,00 PERSONAL BADVINJURY $ 1,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,00 PRO- POLICY Fx_1 EECTT DO LOC PRODUCTS-COMP/OP AGG $ 2,000,00 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ a accident A ANY AUTO MIM28044 06/08/2014 06/08/2015 BODILY INJURY(Per person) $ ALL OWNED M SCHEDULED BODILY INJURY(Per accident) $ 50QQQAUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIREDAUTOSAUTOS Peracddent $ X UMBRELLA UAB X OCCUR EACH OCCURRENCE $ 5,000,00 A EXCESS LIAB CLAIMS-MADE CUB1076H 06/08/2014 06/08/2015 1 AGGREGATE $ DED I X I RETENTION$ 10,000 1Pers&Adv Inj $ 5,000,00 WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITY STATURE ER B ANY PROPRIETOR/PARTNERIEXECUTIVE Y/N CC50050105472013A 12/26/2013 12/25/2014 E.L EACH ACCIDENT $ 1,000,00 OFFICERIMEMBER EXCLUDED? N❑N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,00 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,00 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Barnstable THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 200 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. Hyannis,MA 02601-0000 AUTHORI2ED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD I �e�panuncaruueall�o��/`aaaccc%ccoetld ffice of Consumer Affairs&Business Regulation License or registration valid for individul use only ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation egistration: 100740 Type: 10 Park Plaza-Suite 5170 Expiration;_6/23/201'6 Supplement Card Boston,MA 02116 CAPIZZI HOME IMPROVEMENT-,INC. JOHN STRUMSKI 1645 Newton Rd. � — Cotuit, MA 02635 Undersecretary of valid without signature Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License: CS-064817 JOHN T STRUMSjd 18 ALDEN AWE Buzzards Bay Ma 02532� dddllilli Expiration Commissioner 06/18/2016 Va. 3 z Ygavrov j2 1 13 Z- �• 8AK1WZ461-e r Page 7 of 7 Capizzi Home Improvement Inc. Specifications and Estimates STATE OF MASSACHUSETTS LETTER OF AUTHORIZATION TO APPLY FOR A BUILDING PERMIT I, at �(! � i�� , OWN THE PROPERTY LOCATED AT z�2.3, IN /�C,Gj cil �. ,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: Cape Save Inc. 7-1) Huntington Avenue j South Yarmouth, MA 02664 Tel: 508-398-0398 Fax: 508-398-0399 7/23/12 Town of Barnstable Thomas Perry CBO - Building Commissioner 200 Main St. Hyannis,MA 02601 ti r RE: Building Permits Dear Mr. Perry, This affidavit is to certify that all work completed for 2423 Iyannough Road,West Barnstable has been inspected by a certified Building Performance Institute(BPI)Inspector. Ceiling: R-19 cellulose under decking& R-30 cellulose in open ceiling Walls:Attic stairwell walls R-13 cellulose& under stringers R-19 cellulose Floor: R-19 fiberglass blanket(approx. 920 sq ft) All work performed meets or exceeds Federal and State Requirements. Sincerely, N � i Q � William McCluskey r cry C3 tf� CO TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel 6 Application # Health Division Date Issued dX Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH Preservation/Hyannis Project Street Address 4 a.3 ?y a^n o 0.9h ilog,d Village W P-2+ B xQ5+4le, Owner Ktjb� P 1 k�,�'E 1 S Address p. Bar 1301 West �,Afh ►b`s Telephone 4 0 8 - 30.a. - �A 5 S Permit Request 30 and cellAlose +o k�ke �a►ss -6 40 60 sew d bo)c r se4l a- I c pl a rte �ha Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation 13.90 0 Construction Type Lot Size Grandfathered: ❑ Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family (# units) Age of Existing Structure t 9 b Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No 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 Number of Bedrooms: existing —new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil N Electric ❑ Other Central Air: ❑Yes ;1I 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 0 new size _Shed: ❑ existing ❑ new size _ Other: ® R P; ca Zoning Board of Appeals Authorization ❑ Appeal #_ Recorded ❑ C) - , Commercial ❑Yes A No If yes, site plan review # °, x� Current Use Proposed Use n r APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name , Willi 10.(V) 1'`C,C`%hS key Telephone Number 50 B -3 9 8 " 0318 Address '' �T1A,(1�In9")1 Nve, License # -tC I Q � o u 14 Home Improvement Contractor# I O U �T In1 Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO )(d rp O SIGNATURE DATE 5- - I r=: FOR OFFICIAL USE ONLY APPLICATION# F o r DATE ISSUED -: r MAP/PARCEL NO. ADDRESS VILLAGE. - OWNER 5 DATE OF INSPECTION: t,v..FOUNDATION [ FRAME INSULATION. FIREPLACE ELECTRICAL: ROUGH FINAL - `> PLUMBING: ROUGH FINAL GAS: . ROUGH FINAL -FINAL BUILDING C s DATE CLOSED,OUT ASSOCIATION.PLAN NO.' 7 t I i�ir` - r--,(': ��;'�:•r ?,l In Street t .r,t m s M.A 02 t 0 t ASSISI HOME OWNER aUEATHERIZATION WORK PERMIT &FUEL RELEASE: PLEASE FILL OUT AND SIGN THIS FORM IF YOU ARE THE APPLICANT I401VIE OWNER. I Ro M& PLi iA u a S hereby consent to and agree that weatherization work may be done by the Weatherization Program of Housing Assistance Corporation(herein after referred as "Agency") on the property located at: 7°AoCJ�j =#! The weatherization work done will be based on programmatic priorities and availability of funding and it may include all or some of the following measures- Weather-stripping &caulking of windows and doors,insulation of attics, sidewalls &basements, attic and other ventilation measures and possibly replacement of badly deteriorated windows.In consideration of the weatherization work to be done at my home I agree to the following: 1. I give permission to the "Agency" its agents and employees to travel onto or across said property with such equipment and materials as may be necessary to perform weatherization work on said property. 2. The Housing Assistance Corporation reserves the right to inspect the fuel or utility bill for the weatherized unit on an ongoing basis for no more than five (S) years after the weatherization work is completed. I have read the provisions of this agreement as listed and freely give my consent. Home Owner. Si ture. Date- Z-/ L,01 Agent: (signature) Date: Z C��`"' HAC approved Weatherization Company: C4 e eve All Cape Energy Building Performance Caliber Building&Remodeling Cape Cod Insulation Cape Save Frontier Energy Solutions Lohr&Sons Michael T.McMahon Niall Hopkins Builders Resolution Energy i CAPE) l,SAVE Weatherization 508-398-0398 August 2.2, 2010 To Whom It May Concern: William J. McCiuskey is an employee of Cape Save. He is authorized to negotiate contracts and building permits for our.company. Michael McCluskey Cape Save—Owner 919-593-5939 cell X Huntington.Avenue.,South Yarmouth, MA 026" i The Commonwealth of Massachusetts r' Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers A_nalicant Information ' Please Print Legibly Name(Business/Organization/Individual): /�1�,C14 ,�( ��.Z�vi�� ��1� � U Address: C, (�uo lni(-abnl &- �j City/State/Zip: ` t% maskTw A' 62,Ugone M - 3 g .3cejk Are you an employer?Check the appropriate box: Type of project(required): 1.®.I am a employer with ' ( 1— 4. [31 am a general contractor and 1 6. ❑New construction eloyees(full and/or part-time).* have hired the sub-contractors mp 2.Q I ant a sole proprietor or partner- listed on the attached sheet. 7. Q Remodeling ship and have no employees These sub-contractors have g, ❑ Demolition working for me in any capacity. employees and have workers'comp. Building addition [No workers' cotiup. insurance comp.insurance.: 5: ❑ We are a corporation and its 10.0 Electrical repairs or additions required.] .3.Q 1 am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions per MGL f right ig o exemption p myself.(No workers' comp. r 12.[D Roof h repairs{{ 11� insurance required.]+ c. 152, 1(4),and we have no Tt13�14T M 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. $Contractors that check this box must attached an additional sheet showing the nine 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: 1 P G h D 01 o Q- I -IDS tkmA o M a a(1 Y Policy#or Self-ins.Lie.#: _T W C 3 4, 9 4- I '7-d� Expiration Date: ] 0 a a`0 Job Site Address: cN 4 `i` n o uk � a City/State/Zip: �dM S'�AbI 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 finis 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 certify under the painsiLnd enafties erjury that the information provided above is true and correct. r Date: Signature: — Phone M - �9 FS- Official use only. Do not rtiri►e 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#: A .4 CERTIFICATE OF LIABILITY INSURANCE �0/20/2o'� 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 NAMEACT Shannon Sperrazza Risk Strategies Company PHONE (781)986-44O0 FAx (781)963-4420 AIC o: 15 Pacella Park Drive EpAIL .ssperrazza@risk-strategies.com Spite 240 INSURERS AFFORDING COVERAGE NAIC to Randolph MA 02368 INSURERA:Selective Insurance INSURED INSURERB:Safety Insurance Company 3618 Michael McCluskey, DBA: Cape Save INSURER C.TechnologyInsurance Company 7 C Huntington Ave INSURER D: INSURER E: South Yarmouth MA 02644 INSURER F: COVERAGES CERTIFICATE NUMBER:CL11102041451 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 ADDLSUSR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE POLICY NUMBER IMMIDDIYYYY11 IMMIDDIYYYY). GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 100,000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence) S A CLAIMS-MADE ❑X OCCUR CPPS1994480 0/16/2011 0/16/2012 MED EXP(Any one person) S 10,000 PERSONAL BADVINJURY $ -1,000,000 GENERAL AGGREGATE $ 2,000,000 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG S 2,000,0001 X POLICY PRO LOC $ AUTOMOBILE LIABILITY Ea accidentMBINED SINGLE LIMIT S 1,000,000 B ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED 6208200 1/6/2011 1/6/2012 BODILY INJURY(Per accident) $ AUTOS AUTOS X NO PROPERTY DAMAGE $ HIRED AUTOS AUTOS NON-OWNED X Per accident X Underinsured motorist BI split S 100000 300000 X UMBRELLA LIAB X OCCUR PPS1994480 0/16/2011 0/16/2012 EACH OCCURRENCE $ 1,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE S 1,000,000 RED I I RETENTION$ $ C WORKERS COMPENSATION Executive excluded X WC STATU- OTH- AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNERIEXECUTIVE YIN N from coverage E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDE07 � NIA 0/21/2011 0/21/2012 (Mandatory In NH) C3297972. E.L.DISEASE-EA EMPLOYE $ 500 000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,H more space Is required) Issued as evidence of insurance. National Grid Corporate Services LLC d/b/a National Grid, d/b/a Boston Gas Company, d/b/a Essex Gas Company, Action Inc., and Housing Assistance Corporation are listed as additional insureds as respects General Liability as required by written contract. CERTIFICATE HOLDER CANCELLATION (508)790-2425 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Housing Assistance Corp 484 Main Street Hyannis, MA 02601-3698 AUTHORIZED REPRESENTATIVE Michael Christian/SMS ACORD 26(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INsmmninnstni Tho ernan name anti Innn-pro roniefororl marlre of Armor i O ce o !Mnsi=er AaiVzind Busmess Regulation 10 Park Plaza - Suite 5170 � . Boston, Massachusetts 02116 Home Improverient'Contractor Registration _ Registration: 164432 = - ' Type: 'Supplement Card CAPE SAVE - __ Expiration: 10/6/2013 WILLIAM McCLUSKEY -- 8201 S. HOURD CT -_ CHAPEL HILL, NC 27516 = - ' Update Address and return card.Mark reason for change. )PS-CAI is 50AA-04100-G101216 L Address F1 Renewal Ej Employment Lost Card L\ Office of Consumer Affairs&Business Regulation License or registration valid for individul use only �-War, t$4HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Office of Consumer Affairs and Business Re ulation Registration:.164432 T g jype: 10 Park Plaza-Suite 5170 Expiratign'_10I6i2013 Supplement Card Boston,MA 02116 CAPE SAVE WILLIAM McCLUSICEYc.4_-=_ 7C HUNTING AVE: _ 49: S.YARMOUTH,MA 02664 Undersecretary Not valid without ' nature 9m"—Nl;t1-s.,;achw=-tt. Department of Public Safch Board of Buildim, Rc_!ulations and Standards Construction Supervisor Specialty License License: CS SL 102776 Restricted to. It , WILLIAM MC CLUSKY s 37 NAUSET ROAD WEST YARMOUTH, MA 02673 Expiration: 6/28/2013 (nnuuisvinncr Tm": 102776 � 3 a. C( ?-y Town of Barnstable *Permit#MMTASM Regulatory Services Fee Thomas F.Geiler,Director a� Building Division Tom Perry,CBO, Building-Commissioner X-PRESS PERMIT 200 Main Street,Hyannis,MA 02601 www.towmbarnstable.ma.us JAN 2 4 2012 Office: 508-862-4038 Fax:508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Lnprfht TOWN OF BARNSTABLE Map/parcel Number ce Property Address �14pd ` Q n n QV i2o� 2+e 1�2 Wes+ cry sto-YD :J [Residential Value of Work �z� Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address �� ► �w a�/ Contractor's Name 7:F- A4Qr nr,c�-r-. �,'��� LC C Telephone Number t!,Sda��—� Home Improvement Contractor License#(if applicable) (hl o;z 5 3(o Construction Supervisor's License#(if applicable) [;Workman's Compensation Insurance Check one: ❑ I am a sole proprietor I am the Homeowner I have Worker's Compensation Insurance Insurance Company Name No1+i e»o,1 Union F1 r e �n S u r&n C o Workman's Comp.Policy# N C-ab Q 4?0 6 0.1 Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going-over existing layers of roof) E�Re-side ❑ Replacement Windows/doors/sliders.U-Value #of doors (maximum.44)#of windows *Where required: Issuance of this pemrit does not exempt eompllance with other town department regulations,ie.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is required. SIGNATURE: • Q:\WPFILESTORWIruildingpermit forma\EURESS.d Revised 090809 • I 1 MINA The COnawnwyeaft ofmassaclhuseta De wtftW OflndnspWAcd� Office oflnve*afions 600 WashFVwfi Sj,,, 1 BosWn,M4 02111 j { Workers' mponsation v* d Applicant Inform bsa AMd � ConrctorsEeMrim 8ns/PIwabers ' f Name(sud"WOr, Please Print I, Address. S i , City/StatelZi Are ou sa em e'3 5 Phonte#: Sd�- y28 0 90? ji plover?Check the appropr�e boor I• a employer with T, 4 ❑I am a general and I TYFe of project(reggired); j ❑ p1 a eesSole(fnll and/or•part-tmte)* have hired the� 6. [�New const<u ion 2. I am a sole pttrprietor or jartnei- listed on the attached ship and have no employees These sub-co Wtors have ❑Remodeling i working for me in any capacity MPI and have workers' 8 ❑Demolition INo wa*=,comp-iastaance camp mace t 9. 0 Building addition 3.❑ Iam a requirecLI S.❑ we we a corporation and its 10.(]Electrical Mmi s or additions homeowner doigg a]I wark officers have exercised their myself[No woriM,cup. ri ft ofwon per M6L I1-❑Plumbing reps or additions insurance requfte&j t c 152,§I(4),and we have no 12-C]Roof repairs employees.[NO workers' 13.[]Other t`a'ePgH=that cb=bb=#ikmmmce rma;also su out&e ] abecJctftis b aot gtbey aye dofM au�asda d�.Mke a eMPf lfthes¢b�ntra�rs>rave�ay� �0II8me aft�e submit a� 7°di ng each. pmW&tftar v otkws coal po)iey number. G w � I mn�t���u per,f�tverk�s'coR Wormaffm bmff�f°rfiv MPS•Belo>D fa rJkepeliry mrd jnb sfie I Instaamce Company Name: +719U!C� ee n Policy#of SaIf-inn Ira# (N C 30 Job Site Address �7 / C,nnUv lj V / / I Attach a copy of&"e worllmrs'co`m -� `' ----- yet /Ztp: V PS� f'►'1S-kb/e Far'lure to secure cm Pommy declaration page(�W&g the Pow rrtcatber and expiration date). under Section 25A ofMQL c 112 can Iead to the*Mium of cnm x penalties ofa fine up to$I,S00.00 and/or one-y,;ar imps as well as aril!Pities is the form of a SIOP WORK ORDER and a fine i of vp do$250.00 a day against the violator. Be advised that s copy Invesdgations of the DIA for hmamre coverage verification. of this statsmeni may be forwarded to the Office of { In o on I do hereby c�tf r erfper,fatty t�� Pied above City 6true evn� i ay _.. use oaly. Do not Mite f z ft� . to be completed by efty or tow o °t or town: NrmwLicense# ! Isstung AathOr ity(cirde one): 1..Board of Health 2,B43ding Department 3. 6..Other City/Town Clerk 4� tkW>�etor S.Plumbing Inspector i Contact person: Photze#: I I I i AC R0� MSCON-01 MOSU `..� CERTIFICATE OF LIABILITY INSURANCE r 9126/2011 PRODUCER (508)676-0309 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION V veiros Insurance Agency,Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 375 Airport Road HOLDER THIS CERTIFICATE DOES NOT AMEND EXTEND OR Fall River,MA 02720 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC# INSURED Fraser Construction LLC INSURER A:WHOnal Union Fire Insurance Company P.O.Box IUS INSURERB. Cotult,MA 02635- INSURER G. INSURER D: INSURER E: COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR AWL MU TYPEOFINSURANCE POLICY NUMBER AfXPIRAM L ITS GENERAL LIABILITY EACH OCCURRENCE $ t MERCIAL GENERAL LIABILITY PREMI S CLAIMS MADE ❑OCCUR MED EXP(My one person S PERSONAL&ADVINJURY $ GENERAL AGGREGATE S GEML AGGREGATE LIMIT APPLIES PER PRODUCTS-COMPIOP AGO S 17 POLICY LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT .$ ANY AUTO (Ea�w) ALL OWNED AUTOS BODILY INJURY S SCHEDULED AUTOS (per Pam+) HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Per aocknQ S PROPERTY(emldenq DAMAGE S GARAGE LIABILITY AUTO ONLY-EA ACCIDENT S RANY AUTO OTHER THAN EA ACC S AUTO ONLY: AGG S EXCESS I UMBRELLA LNDiLITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE S S DEDUCTIBLE g RETENTION S S WORKERS COMPENSATION X WC STATU OTH AND BIDLOYERT LIABILITY YIN A ANY PRomErDRmARrNEwogcurrvE 30601 9126=11 9IM2012 EL EACH ACCIDENT S No, OFFICEI MEMBER EXCLUDED? 7 (MMULMM In NM) E.L.DISEASE-EA EMPLOYEE S W010 If y69,desalDe Sider SPECIAL PROVISIONS below E.L.DISEASE-POLICY UMIT $ 6fl0, OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT SPECIAL PROVI91ONS CERTIFICATE HOLDER CANCELLATION SHOULDANYOFTHEABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Fraser Cormbuction,LLC DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAR 30 DAYS WRITTEN PO BOX 1845 NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE To Do So SMALL Cotult,MA 02635- IMPOSE NO OBLIGATION OR LIABILITY OF ANY IOND UPON THE INSURER,ITS AGENTS OR REPRESENTATTUES. AUTHORIZED REPRESENTATIVE ACORD 26(2009101) 01988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD I Office of Consumer Affairs and VUSness Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Congctor Registration ............___. Registration: 112536 �? Type: DBA Expiration: 3/2 312 0 1 3 Tr# 209024 FRASER CONSTRUCTION CO. DEAN FRASER P.O. BOX 1845 COTUIT, MA 02635 Update Address and return card.Mark reason for change. Address Renewal 0 Employment Lost Card DPS-CAI 0 5OM-04/04-GIO11216 ,,/�� 0fC ce Al mer a`.N�B Mess ss1z"eguta on License or registration.valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: E 12536 Type: Office of Consumer Affairs and Business Regulation Expiration: 3/23A013 DBA to Park Plaza-Suite 5170 Boston,MA 02116 YFRCONSTRWTION-CO. n DEAN FRASER v 104 TWINN VIEW LANE � E FALMOUTH,MA s36 Undersecretary of va ut si re 02 r i Kassac6usetts-bep.trt-ment of Public's. Board of Building Regulations and Standards C.&Iattuotfon Supervisor License License: CS 97668 DEA44: R " 3.k 7E EAST FALMI 62536 �i�-�► �yj Expiration: S/7/2013 Conunissioitar Tr#: 16892 - h Fraser Construction, LLC. P.O. Box 1845, Cotuit, MA. 02635 Email: fraser_construction@verizon.net www.fraserroofing.com Phone 1-508-428-2292 & FAX 1-508-428-0123 DATE: November 15, 2011 PHONE: 550-690-5332 NAME: Robert Plikaitis MAIL ADDRESS: P ® Box 230 ®Vest Barnstable MA O2658 JOB ADDRESS: 2423 Iyanough RD Rte 132 ®Vest Barnstable O2668 RE: Gutters, siding, tram, and windows 1. Gutters- Front amain only: Includes white aluminum downspout. PRICE- $2,495.00 Initial D, Add $175.00 per downpout for 3" round copper. Initial 2. Partial White Cedar Siding- Front Main only- PRICE- $2,175.00 Initial C AVZ 3. Front Door Trim--MX replace Rot PRICE- $225.00 Initial . 'Ccaz- 4. Threshold- TIME & MATERIAL Initial � S. Andersen 400 Series New Construction Windows double hung Low E- 4 glass with sash. Colonial 3w 2h fine light grilles between glass, white screen. PRICE- $1,025.00 each Initial Same unit with removable grilles interior- PRICE- $985.00 each Initial Note: All windows include new interior trim to match and exterior PVC trim applied with cortex hidden fastening system. Storm windows removed and saved for paint. NO MONEY DOWN - NO Payment at the start or part way thru Payments accepted are: CASH- CHECK-MASTERCARD- VISA -AMERICAN EXPRESS * Any payments not made within 30 days of completion will be charged 1.5 %for every 30 days the payment is late. Any deviation or alteration from above specification will be executed upon written orders and will become an extra charge over and above the estimate. All agreements contingent upon strikes, accidents or delays are beyond our control. Owner should carry fire, tornado and other necessary insurance upon the above work. We, if not accepted within thirty days may withdraw this proposal. FRASER CONSTRUCTION, LLC: Carries Workman's Compensation and Public Liability Insurance on the above work, certificate available upon request. DATE OF ACCEPTANCE: //• ��• �ii Homeowner Fraser Co s uction, LLC Town of Barnstable *Permit# Fee 6 nwntbsfrom tssu Regulatory Services e e anttxsreai.E. KAM Thomas F.Geiler,Director 9 039• MAC A � Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax:508-790-6230 EXPRESS PERMrr APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number 2 J 6 y L - Property Address a2 Roo�e- 3 ;I— W.. 9.42N J-r413 /e Residential Value of Work l Z 00 ° it 0 Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address R o b e y+ P 1_t k k14't Y p, 13CoX Z-3o Wrj -r *A-iv✓,4r31e- h?A G 0z641- Contractor's Name ire ti� ' 5�V V m SKI• Telephone Number s if Home Improvement Contractor License#(if applicable) I Gy-7 j y q Construction Supervisor's License#(if applicable) 12W/0rkman's Compensation Insurance Check one: XvP-� E S S PERMIT ❑ I am a sole proprietor ❑ I am the Homeowner [�tI have Worker's Compensation Insurance Insurance Company Name A e e Pl er.e v.j (4- C4dV4-Lf y TOWN OF BARNSTABLE W&Ianan's Comp.Policy# IV G( q Sa y 3) de Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to V b cu,"A, ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) �d f /' ❑ Re-side T� #of doors //�/74 4 If S/2,e- d Replacement Windows/doors/sliders.U-Value 3 3 (maximum.35)#of windows e v cr4Pte h? Q✓ e XiJTIti �] ✓V IN �- ¢ blSe = Vl L 4-7-ee .+L NaT We,o j •Where required: Issuance of this perihit does not exempt compliance . other town department regulations,i.e.Historic,Conservation,etc. b o - ***Note: groperty Owner must sign Property Owner Letter of Permission. copy of the Home Improvement Contractors License&Construction Supervisors License is required. _5 SIGNATURE: C:\Users\decolliklAppffocal\Mcrosoft\Windows\Temporaiy ocal\Microsoft\Windows\Temporary Internet Files\Content.0utlook\DDV87AAZ\EXPRESS.doc Revised 072110 v rw vviwiicvrcwcwccra Y vrusuuwarow'cwu Office of Consumer Affairs&Business Regulation License or registration valid for individul use only 'HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Office of Consumer Affairs and:Besin:ess Regulation Registration:,l'A 00740 Type: 10 Park Plaza-Suite 5170 Expiratiori6/23/2012 Supplement Card Boston MA 02116 CAPIZZI HOME'IMPROVEMENT;.INC. JACK STRUNSKI: --: 1645 Newton Rd. Cotuit, MA 02635 Undersecretary Not valid without signature I 'lassachusetts- Department of Public Safeti- Board of Buildincy Regulations and Standards Construction.Supervisor License license: Cs 64817 :JOHN.T_ : ky; S'.RUMSKI: ` .:.PO BOX 861_` BUZZARDS2AYn-MA 02532 Expiration: 6/18/2012 _ (°fimiw5ione ' Tr#: 10573 • i i Page 7 of 7 CAPIZZI HOME H PROVEMENT INC. SPECIFICATIONS AND ESTIMATES STATE OF MASSACHUSETTS LETTER OF AUTHORIZATION TO APPLY FOR A BUILDING PERMIT llw— OWN THE PROPERTY LOCATED AT IN � �1°/ , 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: �-- LABOR BUDGET FORM + P �� ` � ITEM BUDGET BATE/NAME, HOURS bOLLARS NOTES TD Tb ;Go TOTALS: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Buiilders/Contr-actors/Electricians/Plumbers Apulicant Information Please Print Leeibly Name(Business/Organization/Individual): /"�-• �-T f yZl �o b e. . rnjp t-7 tJe6'►'e?-J4 7tv(. Address: N e l lj—hq u;j 12 Tv City/State/Zip: C o+u a+t MA 014-35s' Phone#: Are you an employer?Check the appropriate box: [�F 1. am a employer with 40 4- 4. E] I am a general contractor and I Type of project(required): employees(full andlorpnrt-time). t have hired-the sub-contractors b. ❑�Zmodeling construction 2.Q 1 am a sole proprietor or partner- listed on the attached sheet. 7. ship and have no employees These sub-contractors have g. Q Demolition working for me in any capacity. employees and have workers' [No workers'comp,insurance comp.insnrance.I 9. [)Building addition required,] 5. Q We are a corporation and its 1013 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I l.❑Plumbing repairs or-additions myself.(No workers'comp. right of exemption per MGL 12.Q Roof repairs insurance required.]t c. 152,§1(4),and we have no i3.❑Other employees.[No workers' comp.insurance required.] 'Any applicant that checks box ql must also fill out the section below showing their workers'compensation policy information t Homeowuets who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractots that checkthis box must attached an additional sheet showing the na=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. 1 am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information.Insurance Company Name: A C V 0 Pe R-r Y tf 10 C A Sty L y 5 8 Ll 3�!?� Policy#or Self-ins.Lic.#: � � CC / Expiration Date: i �• � �g � �O 1'7 Job site Address:. 02� a-3 4- 1 3 2 l �y Q 14 U v�/I> City/State/Zip: W -8,42N • hid 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 no to S.000.0 and/orone-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 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 under the pains and penal ' f perjury that the information provided above is true and correct Sifiature: Date: ® � /0 20// Phone#: Okf ial use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issaing Authority(circle one): is Bosrd of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Photte#: Oil Client#:47298 CAPIHOM ATE(MMIDDNY) -AG'ORDrw' CERTIFICATE OF LIABILITY INSURANCE D01/04/20111 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 terns 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). NT PRODUCER NAME, Karen Walther Rogers&Gray Ins.-So.Dennis PHONE 508 398-7980 FAX 434 Route 134 E-MAIL�"� A/C,No ADDRESS: waltherka@rogersgray.com P.O.BOX 1601 PRODUCER South Dennis,MA 02660-1601 CUSTOMER ID#: INSURER(S)AFFORDING COVERAGE NAIC# INSURED Capiui Home Improvement,Inc. INSURER A:National Grange Insurance Co. Capiai Enterprises,Inc. INSURERB:ACE Property&Casualty Ins.Co 1645 Newtown Road INSURER C: Cotuit,MA 02635 INSURER D: 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 TYPE OF INSURANCE DL UBR POLICY EFF POLICY EXP S POLICY NUMBER MM/DDIYYYY) (MMIDDIYYM LIMITS A GENERAL LIABILITY MPB1075H 06/08/2010 06/08/2011 EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO PREMISES Ea occurrence) $500 OOO CLAIMS-MADE Fil 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 PR4 LOC $ A AUTOMOBILE LIABILITY BPO10786 06/08/201 O 06/08/2011 COMBINED SINGLE LIMIT (Ea accident) $500 000 A ANY AUTO M1 M28044 /08/2010 06/08/2011 BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ X SCHEDULED AUTOS PROPERTY DAMAGE $ X HIRED AUTOS (Per accident) X NON-OWNED AUTOS U1 $250/500,000 X Drive Other Car U2 $250/500,000 A UMBRELLA UAB X OCCUR CUB1076H 06/08/2010 06/08/2011 EACH OCCURRENCE s5,000,000 EXCESS LIAR CLAIMS-MADE AGGREGATE s5,000,000 DEDUCTIBLE $ X RETENTION 10000 $ B WORKERS COMPENSATION NWCC45843208 12/25/2010 12/25/2011 X TO YLIMIT FORTH AND EMPLOYERS'LIABILrY ANY PROPRIETOR/PARTNER/EXECUTIVEY/N E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? NIA (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 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space Is required) Workers Comp Information Included Officers or Proprietors CERTIFICATE HOLDER CANCELLATION 10 Da s for Non-Pa ment 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 0198 -2009 ACORD CORPORATION.All rights reserved. ACORD 25(2009/09) 1 of 1 The ACORD name and logo are registered marks of ACORD #S61971/M61970 MEE Town of Barnstable *Permit l0 0614aa. Expires 6 months from issue date Regulatory Services -Fee ����, Co f Thomas.F.Geiler,Director Q` Building Division 64v:- 39 Tom Perry,CBO, Building Commissioner p►c �L�io 200 Main Street,Hyannis,MA 02601 aa www.town.bamstable.ma.us Office: 508-86$1d38 AI Fax: 508-790-6230 ,( ERNHT APPLICATION - RESIDENTIAL ONLY ION + ,., Not Valid without Red X-Press Imprint Map/parcel Number t Property Address a Y C SCR. We.1 I JGl f�yt.rj E&tesidential Value of Work I of I 5 Minimum fee of$25.00 for work under$'6000.00 Owner's Name&Address 1?n�1 Pw<GLi� p o UB USG oQ 30 Contractor's Name F� GL-� �LLu-� z-c�� Telephone Number0 9 Home Improvement Contractor License#(if applicable) ' 2 S 3�P Construction Supervisor's License#(if applicable) C � �o �p 9 �orkman's Compensation Insurance � � �U� � Checl one: ❑ I am a sole proprietor ❑ I am the Homeowner 3,I have Worker's Compensation Insurance Insurance Company Name T -CL Workman's Comp.Policy# _ _ L(_ 1 0 3 q T ,5S b -b .9 Copy of Insurance Compliance Certificate must be on file. Pernut Request(check box) 9-Re-ro f(strip ' old hingqes) All constru onbe taken to ��� P V&Q ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders. U-Value (maximum.44) *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 Improvement Contractors License is required. SIGNATURE: Q.Fo=:expmtrg Revise061306 �� 1 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ' 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/Individual): 'FA g_,L� L�l , L LG Address: �1? 0 1 X 19 Y_j City/State/Zip: C�j MA- ba63s Phone #: 569 Ya,? Are you an employer?Check the appropriate box: Type of project(required): I Z-1 am a employer with _ 4. ❑ I am a general contractor and I 6. El New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition workingfor me in an capacity. employees and have workers' y p �'• 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 I LE] 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.❑ 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. =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. Insurance Company Name: 2 O 6-Z-L y 8 0 t41 5S� "®� !,Expiration Date:- o : Q RW, AB. Policy#or Self-ins. Lic.#• - "� /'rl .___ . Job Site Address: -�. ">�[ City/State/Zip: )'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 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 certi he nd pe lties ofperjury that the information provided above is true and correct _ Si mature: Date: Phone#: �4 Yoe a oC 7A Official use only. Do not write in this area, to be completed by city or town official. City or Town: PermittLicense# 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#: RightFax C2-2 9/29/2009 5 : 35: 22 AM PAGE 2/002 Fax Server ACORD. CERT CATS OF WSURANCE DATE(MM=\YY) 09-29-09 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE WISE&QUINN INS AGCY IN HOLDER- THIS CERTIFICATE DOES MOT AMEND,EXTEND OR 449 PLEASANT ST ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. COMPANIES AFFORDING COVERAGE BROCKTON,MA 02301 COMPANY 24WCB A HARTTORD GROW INSURED COMPANY B - FRASER CONSTRUCTION LLC COMPANY P.O.BOX 1845 C COTUIT,MA 02635 COMPANY D COVERAGE THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUEDTO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT,TERtM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN.THE INSURANCE AFFORDED BYTHE POLICIES DESCRIBED HEREIN tS SUBJECTTO ALLTHETER?&%E)(CLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CO POLICY EFF POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER DATE(MMIDOWY) DATE LIMITS GENERAL LIABILITY OENERATS-COM IOP $ COMMERCIAL GENERAL PRODUCTS COMP/OP AGO. $ CLAIMS MADE OCCUR. PERSONAL&&ADV.INJURY $ OWNER'S&&CONTRACTOR'S PROT. EACH OCCURRENCE $ FIRE DAMAGE(Any one fire) $ MED.EXPENSE(Any one person) $ AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT $ ALL OWNED AUTOS BODILY INJURY(Per Person) $ SCHEDULE AUTOS BODILY INJURY(Per Accident) $ HIRED AUTOS PROPERTY DAMAGE $ NON-OWNED AUTOS GARADE LIABILITY ANY AUTOS AUTO ONLY-EA ACCIDENT $ OTHER THAN AUTO ONLY: EACH ACCIDENT $ AGREGATE $ EXCESS LIABILTY EACH OCCURRENCE $ UMBRELLA FORM OTHER THAN UMBRELLA FORM AGGREGATE $ WORKER'S COMPENSATION AND A EMPOLVER'S LIABILITY UB-034IM556-09 09-26-09 09-26-10 STATUTORY LIMITS X THE PROPRIETOR/ EACH ACCIDENT $ 500,000 PARTNERS/EXECUTIVE INCL DISEASE-POLICY LIMIT $ 500,000 OFFICERS ARE: X EXCL DISEASE-EACH EMPLOYEE $ 500,000 OTHER DESCRIPTION OF OPERATIONSILOCATIONSNEHICLESIRESTRICTIONS!SPECIAL ITEMS THIS REPLACES ANY PRIOR CER-TIFICATE ISSUED TO MM CERTffICATE HOLDER AFFECfINO WORICHRS COMP COV BRAOIl CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE FRASII2 CONSTRUCTION LLC EXPIRATION DATE THEREOF,THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TOTHE LEFT,BUT PO BOX 1845 FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NOOBUGATIONOR LIABILITY OF ANY HIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES COTUIT,MA 02635 AUTHORIZED REPRESENTATIVE ACORD 25-5(3/93) Raman Ayer v r' ✓fte V/Q779reo/ziA/ecccr/a a '/�2 �rd�'Cli '' � � hoard of Building Regulations and Standards; • �Construction Stiperviso�•License License� o 97668 Birthd5W. 6/7/1957 v M. ,Expir n 6/7/.201:1 Tr# 97668 •: Restore$ion 00 DEAN FRASER 104 TWINN'VIEW LANE, ' �"� " � EAST•FALMOUTH,MA 02536 C"oinmssioner= i f ��e �amvrreoozruea,���ac�z�ael�d -� �• • Board of Building Regulations and Standards License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Regist�at�i h.; 112536 Board of Building Regulations and Standards L'�Cp� b On V2312011 Tr# 281021 One Ashburton Place Rm 1301 Type: DM Boston,Ma.02108 FRASER CONSTRUCTION C.O. DEAN FRASER 104 TWINN VIEW 14[dE � E FALMOUTH,MA 02536 y Administrator Not re Boar lW- g4ea4 4raniaYrsea One Ashburton Place m Room 1301 Boston. Massachusetts 02108 Home Improvement-Cbntractor Registration Registration: 112536 Type: DBA Expiration: 3/23/2011 Tr# 281021 FRASER CONSTRUCTION CO. DEAN FRASER P.O. BOX 1845 COTUIT, MA 02635 Update Address and return card.Marls reason for change. Address Renewal Employment Lost Card Al 0 40M-08/OB-DBSIJFORMCA108212008 El a k! Fraser Construction LLC CONSTRUCTION P.O. Box 1845, Cotuit MA. 02635 Email: fraser construction@verizon.net "will www.frasei-roofing.com FAX 1-508-428-0123 508-428-2292 420 MCL#112536 CS#97668 RE-ROOFING PROPOSAL, PARTIAL DATE: November 2, 2009 ►1 a3 PHONE: 508-771-2029 NAME: Joseph & Jane Sauro MAIL ADDRESS: same JOB ADDRESS: 1324 Craigville Bech Rd Centerville, MA02632 FRASER CONSTRUCTION hereby proposes to perform the following services in a neat and professional like manner and in accordance with the manufacturer's specifications and local building code. -Remove and Haul away all of the old roofing material (2 layers) -Re-nail all plywood sheathing as needed. Supply and Install - CERTAINTEED XT AR-25: 25 - Year Warranty, 5 Year Sure Start Protection, CLASS A FIRE RATED, ALGAE Resistant, Extra Heavy Weight, Self- Sealing, 3-Tab, Fiberglass Based Asphalt Shingle with New England's Exclusive COPPERXERAMIC Stones with a Full 10 Year Warranty against ALG Containment. Color: Slate Blend to match PRICE- $2,195 Ini al South facing only i Supply & Install - CertainTeed Winter - Guard: (ice & water shield) Waterproof Underlayment System (3ft. on eves and valleys, 18" on rakes, walls, and skylights) Supple & Install- Roofer's Select Underlayment Paper (as recommended by CertainTeed) Supply & Install - (Soffit Venting) Hick's Ventilated Drip Edge or 8" Aluminum Drip Edge with existing soffit vents Supply & Install -Aluminum & Neoprene Soil Pipe Flashing Supply & Install- Ridge Vent - Shingle Vent II (as recommended by CertainTeed) Clean & Remove - Debris from work area daily. (2) OPTIONS RUBBER ROOFING SUPPLY & INSTALL - .060 EPDM Rubber Roofing OVER 'Ya" FIBERBOARD SUPPLY & INSTALL - .32 White Aluminum Termination Rubber Roofing on 2 low pitched sections South & East facing PRICE- $3,375 Initial Rubber Roofing on South facing section, surrounding ey PRICE- $1,475 In WHITE CEDAR SIDE WALL Remove & replace white cedar shingles above East facing rubber PRICE- $795 Initial All structural or carpentry repair work will be billed at time & al we ill out at $60 per man hour --"*Ini .ial ' � wE ' ONEY DOWN- NO Payment at the start or part way thru Payments accepted are: CASH - CHECK- MASTERCARD -VISA-AMERICAN EXPRESS *Any payments not made within 30 days of completion will be charged 1.5 %for every 30 days the payment is late. Possi a -After the shingles �e ed from the plywood to make sure ul ti against the plywood sh aSgpreventing ventilation from the o d e. If it is, ventilation panelsinstalled by-, removm ywood sheathing, ins g the panels, turning plywood over en re-installing the plywood. If nee this would be ch as an a at the rate of$6.00 per panel including Materials or. There are 6 P e s per sheet of plywood. Possible Extra -Any rotted or otherwise deteriorated trim boards, plywood sheathing, lead flashing, or other carpentry needing replacement will be done and charged for as an extra at the rate of$60.00 per hour, plus 15% mark-up materials FRASER CONSTRUCTION Warranties the labor for 12 years FRASER CONSTRUCTION Warranties the shingles against Blow-Offs for 10 years. - CERTAINTEED Warranties the shingles and labor 100% through the Sure Start Warranty duration. CERTAINTEED Warranties the shingles to be ALGAE resistant for the duration of the _= Sure Start Warranty depending on the shingle that was purchased. L s Any deviation or alteration from above specification will be executed upon written orders and will become an extra charge over and above the estimate. All agreements contingent upon strikes, accidents or delays are beyond our control. Owner should carry fire, tornado and other necessary insurance upon the above work. We, if not accepted within thirty days may withdraw this proposal. FRASER CONSTRUCTION, LLC: Carries Workman's Compensation and Public Liability Insurance on the above work, certificate available upon request. f� f DATE OF ACCEPTANCE: 1 • �-1' b j ,., omeowner Fraser Construction, LLC Town of Barnstable �W#/?405)53 Expires 6 mont s f) t e date Regulatory Services Fee • snatvsTnsi.e. 9cb 163 S. Thomas F.Geiler,Director 9. Building Division 8� Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-8624038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTL4L ONLY Not Valid without Red X-Press Imprint Map/parcel Number L 0 Property Address �Residential Value'of Work 14�S 0 Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address l - Contractor's Name 6-O ( )S �_fsu�y� �{- �' l , �_ ./ 1 �- Telephone Number.4or-412-F,_9 / Home Improvement Contractor License#(if applicable) r L Construction Supervisor's License#(if applicable) ig R E S S P IT _ Workman's Compensation Insurance OCT 2 6 2009 Check one: ❑ I am a sole proprietor TOWN OF BARNSTABLE []..I am the Homeowner have Worker's Compensation Insurance Insurance Company Name Uz c`-� Workman's Comp.Policy# V' Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ;P-e -P vas ❑ Re-roof(stripping old shingles) All construction debris will be taken.to ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side #of doors Oeplacement Window doors/ liders.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,efc. �� ***Note: Pr 40wnst sign Property Owrier Letter.of Permission. e Improvement Contractors License&Construction Supervisors License is re SIGNATURE: Q:\WPFILES\FORM3\building permi fo \EXPRESS.doc Revised 090809 Board of Building Regulations and Standards License or registration valid for individ;ul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: �f Board of Building Regulations and Standards Reglstrp.tjQ[t; 100740 One Ashburton Place Rm 1301 _p�41 TFlIt�23/2010 _�• _,—_: Boston,Ma.02108 . plement Card CAP1221 HOME NARY GUSTAFSOty:��-{,=a,� • v\ . = r• 1645 Newton Rd. ; Fe i � „� Y. Cotuit, MA 02635 Administrator 1Yo vali itho. ' " nnture :Oia.:�aehasitts I)i:Ita1-1111ent of Public Salc1l • Bo:trtl ol•Btfiidin"_ Reoulation and Standards _ Construction Supervisor License License: CS 74640 Restricted.to: s .,ei Ui e. GAR Y GUSTAFSON }� 8 SHORT WAY SANDWICH, MA 02563 Expiration: 1 1 129/201 0 The Commonwealth of Massachusetts Depariment of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LeLyibly Name(Business/Organization/Individual): . Law a:z 4�� Address: City/State/Zip: Phone.#: Are-you an employer? Check the ap r priate box: Type of project(required):. 1. a employer with 4. ❑ I am a general contractor and I employees(full and/or p rt-time). * have hired the sub-contractors 6. ❑New construction 2.❑ I am a'sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have $, .❑Demolition working for me in any capacity. employees;and have workers' � • 9. ❑Building addition [No workers' comp. insurance comp. insurance. . required.] 5. ❑ We are a corporation and its' 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13.$dQther"19tA_dL R comp. insurance required.] (J 'Any applicant that checks box#1 must also fill out the section below showing;their workers'compensation policy Kiformation. t Homeowners who submit this affidavit indicating they are doing all work and_then hire outside contractors must submit a new affidavit indicating such. 2Contractors that check this box must attached an additional sheet showing the name of the subcontractors 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: _Vat -L&LX Z =t L16 Policy#or Self-ins. Lic.#: V4 G 6 9 6 .,T.0 Expiration Date: Job Site Address: d— n City/State/Zip: . Attach a copy of the workers' compensation policy declarafi'on page(showing the policy numbe and expiration I e). 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 ins ance coverage verification. I-do-her-oby-c-er-tify j th ins-and- enaltia&af-psrjur-that-the-infor-or -pr-avided-above-llis tr-ue-anp-correct. Signature: Date: Phone M 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 M ACORD. CERTIFICATE OF: LIABILITY INSURANCE 05/07/09D�» PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION I Rogers 8:Gray Ins.-So. Dennis ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 434 Route 134 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P. O.Box 1601 South Dennis, MA 02660-1601 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: National Grange Mutual Insurance Co. Capiai Home Improvement,Inc. _ INSURER B: NATIONAL UNION FIRE INS. Capiai Enterprises, Inc. y INSURER C: 1645 Newtown Road INSURER D: Cotuit,MA 02635 INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED t6 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LTR NSR DATE MM/DD DATE(MMIDDIM LIMITS A GENERAL LIABILITY MPB1075H 06/08109 06108110 EACH OCCURRENCE $1 000 000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO R PREMISES(EaoED xrren $SOO OOO CLAIMS MADE 51 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/013 AGG $2 000 000 POLICY X JJECTT LOC A AUTOMOBILE LIABILITY BP010786 06/08/09 06108/1 O COMBINED SINGLE LIMIT ANY AUTO :(Ea accident) $500,000 f ALL OWNED AUTOS BODILY INJURY person) $ (Per erson X SCHEDULED AUTOS I X 'HIRED AUTOS BODILY INJURY $ X NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ A EXCESS/UMBRELLA LIABILITY CUB1076H 06/08/09 06/08/10 EACH OCCURRENCE $5 000 000 X OCCUR CLAIMS MADE AGGREGATE $5 000 000 $ DEDUCTIBLE - $ X RETENTION $10000 c $ B WORKERS COMPENSATION AND WC006957000 12/25/08 12/25/09 X WC STATUMIT- OTH- EEL EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $1 000 000 OFFICER/MEMBEREXCLUDED9 E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under SPECIAL PROVISIONS below J E.L.DISEASE-POLICY LIMIT $1 000 000 OTHER Z I DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Carpentry CERTIFICATE HOLDER :.CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Town Of Barnstable DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 1fl DAYS WRITTEN 200 Main Street NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL Hyannis,MA 02601 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATTVES. .AUTHORIZED REPRESENTATIVE ACORD 25(2001/08)1 of 2 #S43470/M43449 KW 0 ACORD CORPORATION 1988 i CAPIZZI HOME RAPROVEMENT INC. Page 7 of 7 SPECIFICATIONS AND ESTIMATES STATE OF MASSACHUSETTS LETTER OF AUTHORIZATION TO APPLY FOR A BUILDING PERMIT h Po 6P6 OWN THE PROPERTY LOCATED AT -P 2 . Zyct•-ram y 5 All IN_ fir- MASSACHUSETTS. I 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 IN7ACCO-11DANCE WITH 780 CMR,THE MASSACHUSETTS STATE BUILDING CODE. SIGNATURE OF OWNER: OWNER'S ADDRESS: i OWNER'S TELEPHONE: LESSEE'S SIGNATURE: LESSEE'S ADDRESS: LESSEE'S TELEPHONE: APLLICANT'S SIGNATURE: i APPLICANT'S ADDRESS: 1645 Newtown Rd., Cotuit,MA 02635 i APPLICANT'S TELEPHONE: 508-428-9518 RESPONSIBLE OFFICER: RESPONSIBLE OFFICER ADDRESS: RESPONSIBLE OFFICER TELEPHONE: i i r iKE ` own ®f Barnstable *Permit # � � Q Expires 6 nronflrs jroui issue dale T BARNSTABLE, Regulatory Services >i�o Thomas F. Geiler, Director °1f0 A Building Division {� OTom Perry, CBO, Building Commissioner 200 Main Street, Hyannis, MA 02601 www.town.barnstab Ie.ma.LIS Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY l� Not Valid without Red X-Press Imprint Map/parcel Number ' r " Property Address Z Z 3 ll-iA�puC 14- Rt> %AVEST —15A 0-baST-4 fR-L4--- MA ®ZA-6 9 dResidential Value of Work 4 z1'C->a Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address eai5G3r,`( A, 'FL_% K4 t-rt S 2 4 2 3 e y�,��e�-s t�d� v\I MA 021-6 Z Contractor's Name Telephone Number Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable)❑Workman's Compensation Insurance -PRESS PERa�'°fin®T Check one: ❑ I am a sole proprietor JUL 2 9 Z009 ZI am the Homeowner ❑ I have Worker's Compensation Insurance - OWN OF BARNSTA1111- Insurance Company Name Workman's Comp. Policy# Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑ Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ✓[f Replacement Windows. U-ValueO ° 30 (maximum .44) *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. Home Improvement Contractors License& Construct Supervisors License is required. SIGNATURE: QAWPFILES\FORMS\Express\EXPRESSPERM IT.DOC Revisc060109 \, The Commonwealth of Massachusetts Department oflndustrial Accidents Office of Investigations a 600 Washington Street Boston, MA 02.11.1 :�•`� lvwjv.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print]Legibly Naive (Business/Organization/Individual): JEA P L l KA I T l ,S Address: 2,1f 2 3 I YAP-4nuq, H P—P ity/State/Zip:(N 1342N STA(3t.0 M4 Phone.#: SM • 3462•Z2S.r Are you an employer? Check the appropriate bog: Type of project(required}: 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-tim.e).* have hired the sub-contractors Elemployees am a sole proprietor or partner listed on the attached sheet. T. ❑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 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 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. lContractors 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 andjob site information. Insurance Company Name: Policy#or Self-ins.Lic.M 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 tip 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 ftir insurance coverage verification I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Si>7nature Date: 7•Z�j..O� _ Phone#: EDr5 36 2 2Z.S'S Official use only. Do not write in this area, to be completed by city or town offccial 'City or Town: Pern-it/License # Issuing Authority(circle one): 1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6. Other Information end ��s �° �� ®ls 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 ffi stee 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 commonwealth nor any of its political subdivisions shall . enter into any contract for,the performance of public work until acceptable evidence of compliance«zth 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-con6actor(s)narne(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 quired to carry workers' compensation insurance. If an LLC or LLP does have members or partners, are not re 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, additio ,an applicant that must submit multiple pernut/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 t be filled out each applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit mus year.Where a home owner or citizen is obtaining a license or permit not related to any business of commercial venture (i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. T he Office of Investigations would Lke 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 Iudustri.al Accidents Of-flee of Investigations. 600 Washington Street Boston, MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Fax# 617-727n7749 Revised 11-22-06 www.mass.gov/dia 'A 1 IKEr, Town of Barnstable BARNSTABLERegulatory Services , ?&A %. • Thomas F. Geiler,Director 9FD u a Building Division 0 Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-62 Property Owner Must Comiplete and Sign This Section A If Usin Bui der T, 20 tzT /a . �t_t��� tT i S , as Owner of the subject property hereby authorize 3:1\4 Qt-C� to act on my behalf, in all matters relative to work a rued by this building permit application for. 2. 23 ti v c-� cz a w'$Acmes—rA 3cC— IA4 (Addres of job) 1 . 7-z4 •o �- Signature of er Date Print e If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. or Town .of Barnstable Yt•+e t�y� lRegutatoYy Services Thomas F. Geiler,Director P 16.19. Building Division Tom Perry,Building Commissioner 200 Mairi=Street—Hy�is;M 02-601 vrww.toyvn.b arnstable.ma.us Office: S09-862-4039 Fax: 508-790-6230 HOhl: OWNER LICENSE EXEMPTION Please Print DATE.- JOB LOCATION: 2-4423 1y�•���`-+ TCP K)U. TAoL-rQ NAA number s tract village "HOMFAWNER": crt'T PLL1.icA t T t s SdFs•3�,?• 2ZSS $b$.36 2.8 3oo name hoe phone# work phone# m CURRENT MAMING ADDRESS: 70 f20K 2-10 - Lv tZvczA Y3L MA 02�8 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. DEFD'iMON 01?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 Tpwn of Barastable.Building Department ruin in,um inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signaux,of Homeowner 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 perfomring 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 hamcowner engages a person(s)for hire to do such work, that such Horrieowna 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&Rcgulations'for Licensing Construction Supervisors,Section 2.15) This lack of awareness ofkn results in serious problems,particularly when the homeowner hires unlicensed persons )n 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 bomcowner is fully aware of his/hcr mspmnbilitirs,many communities require,as part of the permit application, that the homeowner certify that he/she undmtEmds the mspoiuibilitiu of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a fotrn/ccrtifi cation.for use in your community.