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0015 PIONEER PATH
�® NO. 1S21/3®RA �o�D �((�f�q`�'' I i e i k ^ .:� � ^ r^�lTn!?.__+F ng_��:r�.�[�.S ^�-.,..�:rss ... :.... .. - u..:,�.n..�...� t.•—��.+�. _..�.r�.!+-., ,. r+_..+�^_n ._ .—.r.+^�9'-R- 00 PJ . 3U�5`�S Town of Barnstable *Permit# d � Expires 6 months from issue date Regulatory Services Fee 3 fir, • snuvsnv�. �' Thomas F.Geiler,Director 4(-PRESS PERMIT cs� Building Division //�� �d'- Tom Perry,CBO, Building Commissioner JUL 11 2013 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 /� Fpx�NSTABLE EXPRESS PERNUT APPLICATION - RESIDE���l'A "NVY . ap/� ®p/Not Valid without Red X-Press Imprint Map/parcel Number �j Property Address / oNeed AWN W,?J-r 1301,Klril6le 104 [1(Residential Value of Work$ 411 000'101 Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address /V/44t t 1)7i?Z 1#p 04 Conlractor's Name G AK l7 y, Fd UPI y *4 Telephone Number C 01 ZZi wo me— rMeWd de Ak0 < Email:007 Y Home Improvement Contractor License#(if applicable) ` C� �/22/KdI�• Construction Supervisor's License#(if applicable) `� j9 7 yG yd ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor H �am the Homeowner V 1 have Worker's Compensation Insurancee Insurance Company Name Workman's Comp.Policy# V V C G 5W 1 0 sy 7 0/ Z 0/Z 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) ❑ e-side [Replacement Windows/doors/sliders.U-Value 3e (maximum.35)#of windows �o M-4it m e v id o Q — Ol4T�o�p q�A B #of doors: f � ova d�rl� ��ld�dsoy ❑ 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 Property Owner Letter of Permission. A copy of toe Home Improvement Contractors License&Construction Supervisors License is uir SIGNATURE• C:\Users\decollik\App ata Local lcrosoft\Windows\Temporaiy Internet Files\Content.Outlook\8R76BDVA\EXPRESS.doc Revised 061313 r Page 7 of 7 Capizzi Home Improvement Inc. Specifications and Estimates STATE OF MASSACHUSETTS LETTER OF AUTHORIZATION TO APPLY FOR A BUILDING PERMIT OWN THE PROPERTY LOCATED AT ✓�'o�y�ey IN 6aVA) �e , 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: JU 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: I RESPONSIBLE OFFICER TELEPHONE: . t i Unrestricted-Buildings of any use group which contain less than 35,000 cubic feet(991m)of enclosed space. Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supervisor Failure to possess a current edition of the Massachusetts License: CS-07.�.4640�I State Building Code is cause for revocation of this license. GARY GUSTAFSON For DPS licensing information visit: w,Nw.Mass.Gov/DPS g SHORT WAY _ SANDWICH MA=025 Expiration Commissioner 11/29/2014 Office of Consumer Affairs&Business Regulation Lieeltss or registration valid for Individnd use only OME IMPROVEMENT CONTRACTOR barbra the a*�tt°II date. If fozmd retm tv: :, ��ce of G'onsuiderAffaiFs sled Best ItegttWon Registration;406740 Tyw' 110 FarkPh=-SUM 5170 Expiration:^6t2 14 Supplement CAPIZZI HOME 1PQVEf1%JENTriNC. GARY GU STAFSON' -s;-;-; c;:• 1645 Newton Rd. ' Cotuit,MA 02635 Undersecretary ka •4P$f wut skusimm . 10.. '�.1:lfa:ngn5ftlya.tea _ ilnn.a Office oflnvestigations I Congress Street,Suite 100 Boston,MA 02114-2017 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/EIectricians/Plumbers Applicant Information PIease Print LegibIy Name(Business/Organ zatiowThdNidual):Capizzi Home Improvement Address:1645 Newtown Road City/State/Zip:Cotuit, MA-02648 Phone#:508-428-9518 Are you an employer? Check the appropriate box: 4 I am a Type of project(required): 1121.I am a employer with 40+ ❑ general contractor and I employees(full asid/orpart 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 8. ❑Demolition working for me in any capacity. employees and have workers' 9 Building [No workers' comp.insurance comp.insurance. 0 g addition required.] 5. ❑ We are a corporation and its IQ.❑Electrical repairs or additions J.❑ I am a homeowner doingall'work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL msurabce required.]t c. 152, §.1(4),and we have no 12.0 Roof repairs 'employees- [No workers' 13.[ Other -UJ111D 091 comp.insurance required.] 'Any appTcant that checks box#1 must also fill out the section below shov&g their workers'compensation policy infer tion�"fi Homeowgets w}pT submit this affidavit indicating they are doing all work.&W then hue outside contractors must sub mit�a new affidavit indicating such emplo ac6ors that check this box must attached an additiomal,sheet showingthe 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:.. 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 Company Policy.#or Self-ins.Lic.#:WCC5010 547012011Exp nation Date: 12/25/2013 Job Site Address:_ r/.on7 & PQ1# City/State/Zip: Attach a copy of the workers' compensation policy declaration page(shoydng the policy number and expiration date). Failure.to.secure coverage as required under Section 25A of MGL c. 152 can lead to the impositions 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 certify under the eaIns and enalties of erjury that the information provided above is true and correct .Si atuie: Date: 6-7 . o Z Phone#:508 . •8-9518 Of use only. Do not write in this area,to be completed by city or town of City or Town: Permit/License# Lssuing Authority(circle one): L Board of Health 2.Building Department 3.City/Town Clerk 4.EIectrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: W._: _ _��€�9;�_.. :-�. v•, d � - � v _. �� `,���� `t 4 �� V �. 'Y qr' .�;. a,w a •Yy�ac� � .. ... ..:-. � .. Yl� ,.___� 1 2 �( t 7 �_ �� ,,a �,...._ � �Kxv •..,f ��. � 1 �arm �- � }� J t I � "'" ,�a"`"'t �� .` .. �� }��' ;'ems . .CAS �' .�T• ,��, , LI CAPIHOM-01 CBENISCH AIift • CERTIFICATE OF LIABILITY INSURANCE DATE 6/12/20(MM/DDIYY13YY) 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 right's to the certificate holder in lieu of such endomement(s). PRODUCER NAME:CT Chris Benisch Rogers&Gray Ins.-Dennis Branch PHONE FAX 434 Rte 134 uuc.Ne.Em:(508)398-7980 A/c No):(877)816-2166 South Dennis,MA 02660 AIL ADDR ss:cbenisch@rogersgray.com INSURERiS)AFFORDING COVERAGE NAIC# INSURER A:Main Street America Assurance Co. INSURED INSURER B:Associated Employers Insurance Co. Capiai Home Improvement,Inc. INSURER C: Capiai Enterprises,Inc. INSURERD: 1645 Newtown Road 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. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSR WVD POLICY NUMBER LMM/DD/YYYY) (MMIDD/YYYY) GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TMENTE15 A X COMMERCIAL GENERAL LIABILITY MPB1075H 6/8/2013 6/6/2014 PREMISES(Ea occurrence) $ 500,000 CLAIMS-MADE Fx_1 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 JET LOC $ AUTOMOBILE LIABILITY COBINED SINGLE LIMIT Ea M accident $ A ANY AUTO MIM28044 6/8/2013 6/8/2014 BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED BODILY INJURY(Per accident) $ 500,000 AUTOS X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE AUTOS AUTOS PER ACCIDE X UMBRELLA LIAB OCCUR EACH OCCURRENCE S 5,000,000 A EXCESS LIAB HCLAIMS-MADE CUB1076H 6/8/2013 6/8/2014 AGGREGATE $ DED X RETENTION$ 10,000 $ 5,000,000 WORKERS COMPENSATION WC STATU- X OTH- AND EMPLOYERS'LIABILITY TORY LIMITS ER B ANY PROPRIETOR/PARTNERIEXECUTIVE Y/N WCC5010547012012 12/25/2012 12/25/2013 E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? a N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ 1,000,000 If yes,describe under d DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT I$ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,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 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD cF� Town of Barnstable *Permit Expires 6 onths from issue date ��' egulatory Services c Fee * aawszea MASS. Thomas F.Geiler,Director 16;y. �0 �Eo a PR 2 7 2012 Building Division 6p Tom Perry,CBO, Building Commissioner I� TOWNN ®� 200 Main Street,Hyannis,MA 02601 '• BTABLE www.town.barnstable.ma.us Office: 508-862-4038 Fax:508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY J Not Valid without Red X-Press Imprint Map/parcel Number 1017 Property Address s 1 ON-ee-V _P AT 44 W• 'B A-l2 N.J-%q,3 1,c 5]1Residential Value of Work Z/ C 0 d Minimum fee of$35.00 for work under$6000.00 E . Owner'sName&Address !Y N f Y `"' Z y �i 1 toNeev 'PqTU W $.4i2/1Jf,+4/,e_ M4 616(ff- Contractor's Name (�,4 P, G U J�V j ow Telephone Number Home Improvement Contractor License#(if applicable) UU 7 Construction Supervisor's License#(if applicable) —7 q G q U ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner [ZI have Worker's Compensation Insurance C Insurance Company Name S f U C I/a d C m�/G y�v.� Al J 1`0 Workman's Comp.Policy# Q Q 13 Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ce&:,4 itii/& TVVF s41- lei 3Y J f tJa tie— `iJ/vi feit /4,/f [� Re-roof(hurricane nailed)(stripping olg shingles) All construction debris will be taken to .e ivv`e-e 0 J4/VP U4 ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) Ar ❑ Re-side #of doors [Replacement Windows/doors/sliders.U-Value ' 3 0 (maximum.35)#of windows *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is requ ed SIGNATURE C:\Users\decollik\AppData cal icrosoft\Windows\TemporaryIntemet Files\Content.Outlook\DDV87AAZ\FMRESS.doc Revised 072110 4 Capizzi Home Improvement Inc. Page 7 of 7 Specifications and Estimates STATE OF MASSACHUSETTS LETTER OF AUTHORIZATION TO APPLY FOR A BUILDING PERMIT I,NANCY MRZYGLOD, OWN THE PROPERTY LOCATED AT 12 PIONEER PATH IN WEST BARNSTABLE, 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: r OWNER'S ADDRESS: 12 PIONEER PATH IN WEST BARNSTABLE, MA 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: ram, The Commonwealth of Massachusetts Department of Industrial Accidents - -- Office of Investigations 600 Washington Street ...aY Boston,lllA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): C A P j 6 0115 TM e U-e /71& ,f i A C Address: Cp a IV 21y-J-0:,.. go City/State/Zip: C 6+10. ; � ; 0 i `-Phone#: Are you an employer? Check the appropriate box: Type of project(required): I am a employer with q 6 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. [2 Remodeling ship and have no employees These sub-contractors have g• ❑ Demolition wotking 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 3.0: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. 1[S/Roof repairs insurance required.] t c. 152, §1(4), and we have no f�C employees. [No workers' 13. Other y�lic�.� comp. insurance required.] *Any applicant tha*'cliecks box#1 must also fill out the section below showing their workers'compensation policy informa'.ign. 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 atfached'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 v"vloyees. Below is the policy and job site information. _ Insurance Company Name: _4 51©f 14 Tf d r/A1�/v ices- ��,/-5,' Policy#or Self-ins.Laic:#: a o 1-3 0 1 3z Expiration Date: Job Site Address: 5 p i wf-ey p d•T a VV ' 6 49-1V . City/State/Zip: W• 8 Ar ,W,1 r"�4 t31 a 11fy 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 ci vil 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 unde he "ns and penalties ofperjury that the information provided above is true and correct. Si nature: Date: Phone#: 5,(V �/ Cl 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#: ufaa r/✓v�atiar 40 tlffrce of Coca ser.A emirs s�Husiness R oc Iafivn Licam or rea.Mmtion vaUd for individul use only OME IMPROVEMENT CONTRACTOR before the.expiration date. If found retarrn to. Offia of CbmnnW hffalrs AnZ Business Rep on- Regfs mn 40 Types 10 zark Plaza-Suite 5170 _ ExotraSupplement Card i ost4u,IYTA-07116 CAPIM BONE 1... GARY GUSTAFSY. I W- I-tawton Rd, CoftA MA 026i5 • .. l�nsierseere�rg a ; 'd witlxaut si77S�e �� lRt�+:tisrcl�u tts- Depat" arcnt'If Public 521feil Board 4 Building Rrgulatisins and Sts��tl�rtl+ „► CIonstruction Supervisor License License', Cs 7 GARY GUSTAFSON S SHORT WAY [0"cK MA 02563 Tk% 70a"Il i Client#:47298 CAPIHOM ACORD. CERTIFICATE OF LIABILITY INSURANCE FDATE(MM/DDIYYYY) 12/28/2011 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY.AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT-CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed.If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Karen A Walther,CISR Rogers&Gray Ins.-So.Dennis PHONE 508.760.4630 FAX AIC No Ext: ac No): 877.816.2156 434 Route 134 E-MAIL ADDRESS: South Dennis,MA 02660-1601 INSURER(S)AFFORDING COVERAGE NAIC# 508 398-7980 INSURER A:National Grange Insurance Co. INSURED INSURER B:Associated Employers Insurance Capizzi Home Improvement,Inc. CNA I Companies Capizzi Enterprises,Inc. INSURER C: Insurance om P 1645 Newtown Road INSURER D: Cotult,MA 02635 INSURERE: 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 ADDL SUBR POLICY EFF POLICY E-XP LIMITS LTR I SR WVD POLICY NUMBER MM/DD IY MM/DDYYY A GENERAL LIABILITY MPB1075H 6/08/2011 06/08/2012 EACH OCCURRENCE $1 000000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea occurrence $5O0 000 CLAIMS-MADE a OCCUR MED EXP(Any one person) $10 000 PERSONAL&ADV INJURY $1 000,000 GENERAL AGGREGATE . $_2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS---COMP/OP AGG $2j000,000 POLICY I zga LOC $ A AUTOMOBILE LIABILITY M1 M28044 6/08/20.11 06/08/201 COMBINED Ea accide t $:SINGLE LIMIT 500,000 1 ANY AUTO' 11 BODILY INJURY(Per person) $ ALL OWNED Ix SCHEDULED BODILY INJURY(Per accident)' $ AUTOS AUTOSNON-OWNED PROPERTY DAMAGE X HIRED AUTOS AUTOS Per accident $ A X UMBRELLALIAB x OCCUR CUB1076H 6/08/2011 66/08/2012 EACH OCCURRENCE s5,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $5 000 000 DED I X RETENTION$$10 000 $ B WORKERS COMPENSATION QQ130221321 12/25/2011 12/25/201 X WO STATU- OTH- AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE YIN E.L.EACH ACCIDENT $1 000 000 OFFICER/MEMBER EXCLUDED? F N I A (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 C Surety Bond 70011667 11/28/2011 11/28/2012 $25,000 DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) - Carpentry. CERTIFICATE HOLDER CANCELLATION Town Of Barnstable SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 200 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. Hyannis,MA 02601 AUTHORIZED REPRESENTATIVE 6 ©198 -2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 1. The ACORD name and logo are registered marks of ACORD #S75543/M75539 KW OFIKE rp,. Town of Barnstable ' *Permit# 1383 Expires 6 months from issue dat Regulatory Services Fee _ BARNSTABLE Thomas F.Geiler,Director ` MASS. ►639. Building Division O g 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 PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number Xa �F e5` Property Address Residential Value of Work t�j �O. 00 Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address NXAle, L ! /v 104/6N 86-oe t4X 7W Contractor's Name BAR y 614 s rx�&soX) Telephone Number Home Improvement Contractor License#(if applicable) MWorkpensation Insurance Check one: - S PERMIT ❑ I am a sole proprietor ❑ I am the Homeowner MAR 14 2008 I have Worker's Compensation Insurance 'J Insurance Company Name J ���s. �" �7 TOWN OF BARNSTABLE Workman's Comp.Policy Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) Re-side ❑ Replacement Windows/doors/sliders.U-Value (maximum.44) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission., A copy of the Home Improvement Contractors License is requir d. SIGNATURE: '' c Q:Forms:bui I dingperm its/express Revised 123107 EE sr Page 7 of 7 CAPVM HOW IMPROVEMENT INC. .; SPECOCATIONS AND ESTIMATES STATE OF MASSACHUSETTS LETTER OF AUTHORIZATION TO APPLY FOR A BUILDING PERMIT I,NANCY MRZYGLOD,OWN THE PROPERTY LOCATED AT 15 PIONEER PATH IN WEST ;rt: T BARNSTABLE,.MASSACHUSETTS. I HAVE AUTHORIZED CAPIZZI HOME IMPROVEMENT TO ACT AS MY AGENT TO APPLY FOR A BUILDING PERMIT IN ACCORDANCE WITH 780 CMR,THE MASSACHUSETTS STATE BUILDING CODE. I GIVE MY$ERMISSION TO LESSEE TO APPLY FORA BI7 ING PERMIT IN ACCORDANCE WITH 780 CMR,THE MASSACHUSETTS STATE BUILDING CODE. SIGNATURE OF OWNER: JU OWNER'S ADDRESS: 15 PIONEER PATH,WEST BARNSTABLE OWNER'S TELEPHONE: 508-420-3743 LESSEE'S SIGNAL: LESSEE'S ADDRESS;` u LES:SEE'S:TEI;EIIONE: AP:LLICAN'T'.:5.SIGNAT'L�RE: . API? ,ICANT'S.ADDRESS 1C45 Newtowxi.Rd.,Cohnt;:MA2635. APP.LICANT`S MEPHON : 50$-4?&9518 -RE O Vlb)MR k ' RESPONSIBLE EX ADDRESS-. REP4NIBLE OFFICER TELBPHOIVE _.. : A z. dp �..:K' u„ r,..�. •f :. + ..FF''. "k- S 56ro a?vf �' d 'ya-#�.ic.' R! t'a.,.; i tidy.' W.-UN" a y t ...:..... !!tea. `x �# ....d,.w2�. ',3' ..xitiYe�k. �,.��±e_ "�M '�� w'v35'+'.. i9Nf.! '•.r °nn1 ..,:: 4i.,ui., ,A 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/El please Print m it Applicant Information bly Name(Business/Organization/Individual): Ca 1zzi Home 1645 Newtown improvement Inc. Address: Cotuit, MA 02635 Tel. 428.951811.800-262 City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): 4. I am a general contractor and I l I am a employer with have hired the sub-contractors 6. ❑New construction employees(full and/or part-time).2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have S. DemoLtion working for me in any capacity. employees and have workers' 9 Building addition o workers'comp.insurance comp. insurance.t 5. ❑ We are a corporation and its 10.❑Electrical repairs or required.) officers have exercised their 11.❑Plumbing repairs or additions 3.❑ I am a homeowner doing all work right of exemption-per MGL myself.[No workers'comp. rig 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. tContractors 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 subcontractors 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. Q Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expirat::.. Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties. . fine up to S1,500.00 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 pains and penald ry that the information provided above is true and correct ��— Date: �.� Signature, Phone#: Uffieial 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#: _.-.. i Client#:47298 CAPIHOM ACORDT, CERTIFICATE OF LIABILITY INSURANCE DATE(MWODNYYY) 12/26/2007 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Rogers&Gray Ins.-So. Dennis ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 434 Route 134 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR P.O. Box 1601 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. South Dennis,MA 02660-1601 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURERA: NGM Insurance Company Capizzi Home Improvement,Inc. INSURER s: American Home Assurance Capizzi Enterprises, Inc. 1645 Newtown Road INSURER C: Cotult,MA 02635 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. LTR INSRE TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION DATE MM/DD/VV DATE MM/DD/YY LIMITS A GENERAL LIABILITY MP010707 06/08/07 06/08/08 EACH OCCURRENCE $ 1 000 OOO NCOM MERCIAL GENERAL LIABILITY DAMAGE TO RENTED $SOO OOO CLAIMS MADE D OCCUR MED EXP(Any one person) $1 Q QQQ PERSONAL S ADV INJURY $1 000 000 GENERAL AGGREGATE s2,000.000 GEN'L AGGREGATE LIMIT APPLIES PER: PROOUCTS.COMP/OP AGG s2 000 000 POLICY PROJECT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ _ ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE UABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ B WORKERS COMPENSATION AND WC1764953 12/25/07 12/25/08 WC STATU- OTH- ORyEMPLOYERS'LIABILITYLIMIT ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $SQQ QQQ OFFICER/MEMBER EXCLUDED? E. If yes,describe under L.DISEASE•EA EMPLOYEE $500,000 SPECIAL PROVISIONS below ' E.L.DISEASE-POLICY LIMIT 1 s500,000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Corporate officers are included in Workers Compensation coverage. 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 ,,Q_ 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 REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 25(2001/08) 1 of 2 #S33206/M33205 KW © ACORD CORPORATION 1988 i ✓21noann�z�u��ea� n�/f�avoar�uael�a �\ 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: 11 Board of Building Regulations and Standards =. Registration: 100740 One Ashburton Place Rm 1301 Expiration: 6/23/2008 Boston,Ma.02108 Type: Supplement Card CAPIZZI HOME IMPROVEMENT,I t RY GUSTAFSON 1645 Newton Rd. Cotuit,MA 02635 Administrator t valid with t Sig tune h Board of Building Regula ions and Standards One Ashburton Place - Room 1301 Boston, Massachusetts 02108 Home Improvement Contractor.Registration Registration: 100740 Type: Supplement Card Expiration: 6/23/2008 CAPIZZI HOME IMPROVEMENT, INC.. GARY GUSTAFSON 1645 Newton Rd. Cotuit, MA 02635 Update Address and return card.Mark reason for change. nc Address ❑ Renewal Employment Lost Card ✓fie T�a�rLrrzorw�eo� of�•��avaru.•iivaP,/ta . Board of Building Regulations and Standards Construction Supervisor License License: CS 74640 Expiration: 11/29/2008 Tr# 6430 Restriction: 00 GARY GUSTAFSON 8 SHORT WAY �— SANDWICH,MA 02563 Commissioner • i `"ETOis Town of Barnstable *I'crmit # Y00fO031/0 Expires 6 moiahss from issue date + ]BARNSTABLE, : Regulatory Services Fee py 7 00 9$A rli. ESS PERMIThomas F.Geiler,Director rFD MAt a• JAN 1 8 2008 ' Building Division A l�(`N1/[�/11FVfM� Tom Perry, Building Commissioner �,)) TOWN OF BARNSTABLto Main Street, Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press7rnprint Map/parcel Number X 5?Y z9 Property Address �� P]Residential Value of Work : l DOQ, Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address /t✓'0/�L �(���� ���°i�iiji 4-41 Contractor's Name 6m if 4:�5 Telephone Number—,- QW �e ��Ile Home Improvement Contractor License#(if applicable) ' 2 �6 Construction Supervisor's License#(if applicable) l�4�)_ �;v Workman's Compensation Insurance Check one: ❑ I ant a sole proprietor ❑ I am the Homeowner I have Worker's Compensation Insurance Insurance Corrq)any NameD� 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 root) Re-side �af/�,e2,YlZ7 ❑ Replacement Windows. 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. H me Iiprovement Contractors License is required. :igna :Forms:expmtrg evise063004 , ,per The Commonwealth of Massachusetts �\ Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Ut 1 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers aplZZI Home Impfoyem , Please Print Le ibl Applicant Information ewtown.Ro �41 Road Name(Business/Organization/individual): Tel. 428 9518��.i;,80D� 6� .5060 Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): ❑ 1,�I am a employer with� 4. I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors listed on the attached sheet. 7. ❑Remodeling 2.❑ I am a sole proprietor or partner- These sub-contractors have g. ❑DemoLtion ship and have no employees employees and have workers' working for me in any capacity. comp.insurance.t 9. ❑ Building addition [No workers'comp.insurance 10. Electrical repairs or a: required.) t: qu 5• ❑ We are a corporation and its p 3.❑ I a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions right of myself. [No workers' comp. exemption-per12. Roof repairs insurance required.]t c. 152, §1(4),anddMGL we we have no ❑ employees. [No workers' 13.❑Other comp.insurance required.] •My 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 am 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 subcontractors 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. /� o $ L� �� - Insurance Company Name: +� _ Policy#or Self-ins. Lic. #: / /42 Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expirat::.. Failure to secure coverage as required tinder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties 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. 1 do hereby eertW under the pains and penald ry that the information provided above is true and correct �-- —=------- Date: — Si ature: Phone#: cial 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#: _..... Client#:47298 CAPIHOM ACORD,. CERTIFICATE OF LIABILITY INSURANCET—jDjT2E6/2007fYY ) PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Rogers&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.0.Box 1601 South Dennis, MA 02660-1601 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: NGM Insurance Company Capizzi Home Improvement, Inc. INSURER B: American Home Assurance Capizzi Enterprises,Inc. INSURER C: 1645 Newtown Road INSURER D: Cotuit,MA 02635 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. POLICY EFFECTIVE POLICY EXPIRATION LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE MM/DD/YY DATE MM/DD/YY LIMITS A GENERAL LIABILITY MP010707 06/08/07 06/08/08 EACH OCCURRENCE $1 000 000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO R MISES(E.ENTED $500 000 CLAIMS MADE Fx�OCCUR MED EXP(Any one person) $10 000 PERSONAL&ADV INJURY $1 000 000 GENERAL AGGREGATE s2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG s2,000,000 POLICY PRO- ECT LOC J AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Per accident) $ PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ TATUB WORKERS COMPENSATION AND WC1764953 12/25/07 12/25/0$ WC SLIMIT OTH- ER EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $SOO,000 OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE s500,000 If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT s500,000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Corporate officers are included in Workers Compensation coverage. 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 1n 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 REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 25(2001/08)1 of 2 #S33206/M33205 KW 0 ACORD CORPORATION 1988 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: Board of Building Regulations and Standards — = Registration: 100740 One Ashburton Place Rm 1301 Expiration: 6/23/2008 Boston,Ma.02108 Type: Supplement Card CAPIZZI HOME IMPROVEMENT,I UARY GUSTAFSON - 1645 Newton Rd. Cotuit,MA 02635 Administrator t valid with t Sig ture r Board of Building Regula ions and Standards One Ashburton Place - Room 1301 Boston. Massachusetts 02108 Home Improvement Contractor.Registration Registration: 100740 Type: Supplement Card Expiration: 6/23/2008 CAPIZZI HOME IMPROVEMENT, INC.. . GARY GUSTAFSON 1645 Newton Rd. Cotult, MA 02635 Update Address'and return card.Mark reason for change. Address Renewal Employment Lost Card IBoard of Building Regulations and Standards Construction Supervisor License License: CS 74640 I { Expiration: 11/29/2008 Tr# 6430 i Restriction: 00 GARY GUSTAFSON I 8 SHORT WAY SANDWICH,MA 02563 Commissioner I Page 7 of 7 CAPIZZt HOME IMPROVEMENT INC. SPECIFICATIONS AND ESTIMATES STATE OF MASSACHUSETTS LETTER OF AUTHORIZATION TO APPLY FOR A BUILDING PERMIT 1, NANCY MRZYGLOD,OWN THE PROPERTY LOCATED AT 15 PIONEER PATH IN WEST BARNSTABLE, MASSACHUSETTS. 12 , 7 I HAVE AUTHORIZED CAPIZZI HOME IMPROVEN4 ENT TO ACT ASM-Y 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 INITH 790 CMR,THE MASSACHUSETTS STATE BUILDING CODE. SIGNATURE OF OWNER. -ju OWNER'S ADDRESS: 1.5 PIONEER PATH, INVEST BARNSTABLE OWNER'S TELEPHONE: 508-420-3743 LESSEE'S SIGNATURE. LESSEE'S ADDRESS: LESSEE'S TELEPFIONE: A.PLLICANT'S SIGNATURE: APPLICANT'S ADDRESS: 1645 Newtown Rd., Cotuit,MA 02635 -S TELEPHONE: ...kPPLICANT' E 508-428-9518 RESPONSTBLE OFFr RESPONSIBLE DBLE QFFIQER ADDRESS: RESPONSIBLE OFFICER TELEPHONE: t TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map es g Parcel 1 . as / Application i s dogz I 0 Health Division Date Issued Conservation Division 'Application Fe > V Tax Collector Permit Fee r Treasurer `y Planning Dept. Date Definitive Plan Approved-by Planning Board -fir Historic-OKH Preservation/Hyannis Project Street Address I�O A)r—_8,0e_ �v�s �Ja k1U S� —LE Village v Owner ti�4��y � ! Address Telephone Permit Request J�E�1Dll sQ/V!� F—A44CZ—_ g5X/s7_/AA* 6 C /ylE � �.E/�tOU� �. -.?��o@S' zr" L�OG✓`.0 �� -,�1�D to/�.� LC�S � quare feet: 1 st floor:existing proposed 2nd floor:existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuatio ��D0• as 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 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 ❑ Electric ❑Other Central Air: ❑Yes ❑No Fireplaces: Existing I New Existing wood/coal stove: ❑Yes ❑ No Detached garage:❑existing ❑new size Pool:❑existing ❑new size Barn:❑existing ❑new size Attached garage:❑existing ❑new size Shed:❑existing ❑new size Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes, site plan review# Current Use Proposed Use BUILDER INFORMATION Name 44kq Telephone Number-,vD9 19 Address Lx1�/ License# Home Improvement Contractor# Worker's Compensation# Z29W 1.6=F ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE � � DATE /4 j FOR OFFICIAL USE ONLY F' APPLICATION# DATE ISSUED . MAP/PARCEL NO. ADDRESS } - VILLAGE OWNER - DATE OF INSPECTION: FOUNDATION FRAME INSULATION ' s FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING:. ROUGH ". FINAL a GAS: ROUGH FINAL ' FINAL BUILDING f N-1. r. DATE CLOSED OUT.: ' k= ASSOCIATION PLAN NO. �t I Client#:47298 CAPIHOM ACORD- CERTIFICATE OF LIABILITY INSURANCE 2/26/MIDD/YYYY) 12/26/2007 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Rogers&Gray Ins.-So.Dennis ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 434 Route 134 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O.Box 1601 South Dennis,MA 02660-1601 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: NGM Insurance Company Capiui Home Improvement,Inc. INSURER B: American Home Assurance Capiui Enterprises,Inc. INSURER C: 1645 Newtown Road INSURER D: Cotuit,MA 02635 INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICYPERIOD 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. POLICY EFFECTIVE POLICY EXPIRATION LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE MM/DD DATE MM/DD LIMITS _ A GENERAL LIABILITY MP010707 06/08/07 06/08/08 EACH OCCURRENCE $1 000 000 X COMMERCIAL GENERAL LIABILITY DAMAGEEMLW TO RtF z.ENTED $SOO OOO CLAIMS MADE �OCCUR MED EXP(Any one person) $1 O 000 PERSONAL&ADV INJURY $1 00O 000 GENERAL AGGREGATE s2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG s2,000,000 POLICY PRO JECT 7 LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO EA ACC $ OTHER THAN AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ B WORKERS COMPENSATION AND WC1764953 12/25/07 12/25/08 TWORYSTATULIMITj I I OTH- EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $SOO,000 OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE s500,000 If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $500,000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Corporate officers are included in Workers Compensation coverage. 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 10 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 REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 25(2001/08)1 of 2 #S33206/M33205 KW © ACORD CORPORATION 1988 i Q� SEPTIC Q\ A SYSTEM FROM SBUI SEX. SHED ���,��� E .POOL OEX. SHED EX. DWEWNG 6 REMOVE PROP. EX.STAIRS REBUILD /� STEPS & DECK EX.DECK & STEPS IN PLACE . MAP 128, PARCEL 17 #15 PIONEER PATH SEPTIC'SYSTEM PLOTTED BARNSTABLE, MA FROM AS-BUILT ON FILE AT TOWN HEALTH DEPT. CERTIFIED PLOT - PLAN MRZYGLOD RESIDENCE I CERTIFY THAT THE IMPROVEMENTS SHOWN OF M #15 PIONEER PATH HAVE BEEN LOCATED WITH AN INSTRUMENT � Ass90 BARNSTABLE, MA SURVEY. y� DATE: DEC. 2a 2007 DRAWN: RBS ROBB JOB #: E00795 c SYKES ; SCALE:1"=20' DWG. CPP No. 35418 EASTBOUND LAND SURVEYING, INC. P.0. BOX 442 ROBB SYKES, RLS. DATE FORESTDALE, MA 02644 508-477-4511 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/Eleclease Print umbers Applicant Information Please,Pprint Legibly Name(Business/Organization/individual): d,,4JPf. Address: City/State/Zip: Are you an employer?Check the appropriate boa: Type of project(required): 1;21 I am a employer with 4. ❑ I am a general contractor and I 6. ❑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 g, ❑DemoLi.tion working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers'comp.insurance comp.insurance.t 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 I.❑Plumbing repairs or additions myself.[No workers'comp. right of exemption.per MGL 12.❑Roof repairs insurance required.]t c. 152,§1(4),and we have no 13.❑Other employees. [No workers' comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 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'corM.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: � � �� Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to S 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 coveLd6e verification. I do hereby certi under the pains nd Wallies f perjury that the information provided'above is true and correct Si ature Date: / �� D — Phone Official use only. Do not rite in this area,to be completed by city or town official. City or Town: Permit/License# i 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#: i Date: 10/4/2007 Time: 12:26 PM To: @ 9,1,508-420-0318 R&G Ins. Agcy. Page: 001 Client#:47298 CAPIHOM ACORD. CERTIFICATE OF LIABILITY INSURANCE 08/13,07"' PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Rogers&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.0.Box 1601 South Dennis, MA 02660-1601 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: National Grange Mutual Ins.Co. Capizzi Home Improvement,Inc. INSURERS: American Home Assurance Capizzi Enterprises,Inc. INSURERC: 1645 Newtown Road INSURER0: Cotuit,MA 02635 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. TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LTR NSR DATE MM/DD DATE MM/DD LIMITS A GENERAL LIABILITY MP010707 06/08/07 06/08/08 EACH OCCURRENCE $1 000 000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RSESjE.ENTED $500 000 PREMCLAIMS MADE a OCCUR MED EXP(Any one person) $1 D 000 PERSONAL&ADV INJURY $1 DUD 000 GENERAL AGGREGATE s2,000,000 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG s2,000,000 POLICY PRO JECT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per acddent) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ B WORKERS COMPENSATION AND WC1764953 12/25/06 12/25/07 1 AC s"ATU- OTH- EMPLOYERS'LIABILITY ANY PROPRIETORIPARTNERIEXECUTNE E.L.EACH ACCIDENT $5OO O00 OFFICERIMEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE s500,000 If yes,descr be under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT s500,000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS *"Supplemental Name** First Supplemental Name applies to all policies-Capizzi Home Improvement Inc&Thomas Capizzi,Jr. Policy#MP010707-:Thomas Capizzi,Jr. 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 In 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 REPRESENTATIVES. AUTHORIZED REPRESENTATIVE F pw^ ACORD 25(2001/08)1 of 2 #S30375/M30374 DD ® ACORD CORPORATION 1988 i 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: \ Board of Building Regulations and Standards Registration.`_�:00740 Expirraton=6123/2008 One Ashburton Place Rm 1301 �i> " ;:r� Boston Ma.02108 - Type:Supplement Card ' NO:- = CAPIZZI HOME IMPROV,EMENT?I p�!� f 4i=tSE'��I,l tARY GUSTAFSON 1645 Newton Rd. Cotuit,MA 02635 Administrator t valid with t sig ture fi Board of Building Regula ions and Standards One Ashburton Place - Room 1301 Boston, Massachusetts 02108 Home Improvement,03ontractor.Registration Registration: 100740 Type: Supplement Card Expiration: 6/23/2008 CAPIZZI HOME IMPROVEMENT , , '. = GARY GUSTAFSON ? "j = 1645 Newton Rd. Cotuit, MA 02635 ''�:?`,;. -�- �r ar Update Address'and return card.Mark reason for change. )PS-CAI 0 5OM-04/05-PC8698 ❑ Address Renewal Employment Lost Card f , , ' �.�•��..I J .,� .�.fM:�l i•:{��•t (Q%.��.(yY��r'_ r I, .,l 3' .' • r_ .11,'. `i�, ,A �.i,_rl I ,..n. .i'. �• •1 t l�, `� •''t 1��.�ff•:{�(�TI: 1. 4 I � I IVY I r 4 i S ! I ! ! 4, kNIko IN F- t i . � : •� C'9o0. 4 �' i � � �i � � � j � � 1 I I li I 1 y. I NA k r6 IN t, I .. Jr...,......_.._ 1 -- ...... .... \ __ I "; � � r 4 ", , t w ��ti k_ 1;^ �i� 3 . r � �d � ' �ks �� "x. ��1 µ. t ti Y�E !:', 5�' .. ���� �� .. ....._ #N .. ... _ k: �I��pm �N�� r � i k4 o ��� �; �V �. <?eF e x -�" �� ` ��� s�"_ � ,�sr �A� &� �;;. . �s; �:> k� +�. is }�j., Y, 1: �: �_ Page 7 of 7 CAPIZZI HOME IMPROVEMENT INC. SPECIFICATIONS AND ESTIMATES STATE OF MASSACHUSETTS LETTER OF AUTHORIZATION TO APPLY FOR A BUILDING PERMIT I,NANCY MRZYGLOD, OWN THE PROPERTY LOCATED AT 15 PIONEER PATH IN WEST BARNSTABLE, MASSACHUSETTS. A2 S-o `7 I HAVE AUTHORIZED CAPIZZI HOME IMPROVEMENT JO 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: Ju OWNER'S ADDRESS: 15 PIONEER PATH, WEST BARNSTABLE OWNER'S TELEPHONE: 508-420-3743 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: f t Assessor's Office(1st floor) Map Lot b 00/ elMermit# Ll'-! lv ' Conservation Office(4th floor) %�-J 9G' � �fte.Issued — ► $ —9 Board of Health(3rd floor)(8:30-9:30/,1:00-2:00) Engineering Dept.(3rd floor) House#1 �J + `�_ ,�� ® A NWABIE • - 19 � AB& ` TOWN OF BARNSTABLE _ Building Pe 't Ap lication �® Project S reet ddre Village Axe V VW t Owner ��' ,��/��/, Address �� /�/� Telephone~Permit Request ]yfl/ o /o }�/� S� �J Total 1 Story Area(include 1 story garages&decks) square feet Total 2 Story Area(total of 1st&2nd stories) square feet Estimated Project Cost $ Zoning District Flood Plain Water Protection Lot Size Grandfathered ? Zoning Board of Appeals Authorization Recorded Current Use Proposed Use Construction Type > Commercial Residential Dwelling Type: Single Family Two Family Multi-Family Age of Existing Structure Basement Type: Finished Historic House Unfinished Old King's Highway Number of Baths No.of Bedrooms Total Room Count(not including baths) First Floor Heat Type and Fuel Central Air Fireplaces Garage: Detached. Other Detached Structures: Pool Attached Barn None Sheds Other Builder Information Name 6,", ��� Telephone Number Address G � !� / License# 963, Home Improvement Contractor# 1060 Worker's Compensation# NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE4 DATE / ` 6 �,� BUILDING PERMIT DENIED FOR THE FOLLOWING REASON(S) FOR OFFICIAL USE ONLY PEKtMIT N DATE ISSUED l MAP/PARCEL NO. ADDRESS VILLAGE r OWNER - ' DATE OF INSPECTI N: , FOUNDATION ' r FRAME INSULATION r ~ FIREPLACE] r r J ELECTRICAL: ROUGH FINAL , PLUMBING: ROUGH FINAL GAS: ROUGH FINAL j FINAL BUILDING', DATE CLOSED OUT ASSOCIATION PLAN NO. The Conunon►+'ealth of Afassachusetts Department of Industrial Accidents 600 H•ashinrton Street Boston,Muss. 02111 Workers' Compensation Insurance Affidavit _...— ._.,m_..-w _.. �RpJ�ant tormation• Please PRiNTlee�jy s,;�_ � � -_ ""�' ' / s natne�_;L1� L► d1-� �tUuoS�j loci ion 10 loe fP 7-080 02121;-t6' may. r o Kz"ni l c �5� 1+hone# %2L—es,: 2 I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity —_ I am an employer providing workers' compensation for my employees working on this job. company name: address: city: phone#• insurance co. Policy# �...:.'�`.''�......,.sS ,. ". .•nr�•"..y'fay',,*!�'�sYtn34�'�y,�.fJ'•"... .....;'ems'^':�f;�ar,sw,.. _ .k:�_ .tea. ��:'"r'*....;�4.rre,,..+.• 1 am a sole-proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have the following workers' compensation polices: company name address: city: phone#: insurance co. Policy a.a.•raar r a watm -ts oc .mnan,y name: address city: phone#• insurance co. Policy# Afiae_h'additional'shceEifneeessa _ ': f{'�-•+rr, -�' ' R ^^� - •� �:- ._._.�',u`;vta ' .�a.a:�+Y• -�'s. �.. =� �.,.r. , iYnc'..`siun`. Failure to secure coverage as required under Section 25A of 111GL 152 can lead to the imposition of criminal penalties of a fine up to 51.500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of S100.00 a day against me. 1 understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do herehr certify and•r the,pains and A tallies of perjury that the information provided above is true and brrect Signature Date �6 Print name Pt(-yi/1%y� �E'�✓U S�f Phone# Eialtu7e only do not write in this area to be completed by city or town official: permit/license# 708uilding DepartmentLicensing Board immediate response is required OSelectmen's Office�licalth Ucpartmcntson: phone#; r101hcr .4.--wR (revised 3;95 PIA) L 1 Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the "law", an empinree is defined as every person in the service ofanother under any contract of hire, express or implied, oral or written. An enip/ot,er 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 trustee of an individual , partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to bean employer. MGL chapter 152 section 25 also states that even,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. 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 with the insurance requirements of this chapter have been presented to the contracting authority. `7,7�. - ,..:..•, ..: ._. .: .. .. ..: .. ...- ��'. .. .. ,�1 �•v.:iir .fib ..(: Applicants Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and supplying company names, address and phone numbers as all affidavits 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. .. :.. ..... ..,:.., .. v,'lsGff�r r.,.d. Sti �•.fi�w Mn!" �i �y City or Towns 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. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. Tile Office of Investigations would like to thank you in advance for you cooperation and should you have any questions, please do not hesitate to give us a call. '.!-v+�+.s!. rw,v�aa..�s�r��e TT*! 'TT�!" 17 A.. •:.v. �,..`�'cTv Ten�^�►?!^awM?wf. r' The Department's address, telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,Ma. 02111 fax#: (617) 727-7749 phone #: (617) 727-4900 ext. 406, 409 or 375 _ `.: • • . v 1 I • I i" I I i 1 • • : I I I I I 1 ! i ; ` 1 - ! I I a a N ,� Af,• CY , , ' v . �b •a� os �•� •r�, tt L � p � I M • ' � y K N J c,• � • .a C ,' � Y S , • T 73•Z� ?�'•2oN �bZ S ' T i . I I • i I i I I • i i The Town of Barnstable KPALg Department of Health Safety and Environmental Services 1°'16,39. `e BuiIding Division 367 Main Strut,Hyannis MA 02601 Ralph Crosson Office: 508-790-6227 Biding Commissio Fare 508 775-33" For office use only Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the"reconstruction,alterations,renovation,repai4 modernization,conversion, improvement,removal, demolition. or construction of an addition to nay pm-cdsting owner ooccgn building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors,with certain elmepptions, along with other tequirzmeats. Type of Work: .9 Est.Cost Address of Work: N— ORner.Name: �J A x Z'�"Io Date of Permit Application: l� I hereby certify that: Registration is not required for the following reason(s): Work excluded by law Job under 51,000 Building not owner-oocupied puftg own peraut Notice is hereby given that: CONTRACTORS W ONERS PULLING THEIR OWN PERMIT OR DEALING WTIHUNREGi3'fERED FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the age o estra ow Date Contractor frame Regi non No. OR ^.p Owner's name _.•• ° (Jp�i �r:�lt6 TDO07LllLO4C!/JCw..!"'O�`�-" ��• ulei�� DEPARTMENT OF PUBLIC SAFETY CONS.iRULTION.,SUPERVISOR LICENSE Naaber -- Expires: ?,Restrictedio� 00 RICNAR0 T SEHOSKI 10 PEEP TOAD RD CENTERVILL, MA .02632 ow,L.•�`.- !Nt'S �tl.�' IpLMMMM�OMW GILQyy� CtiONTRA'CTOt• F;.. PRO: .r .,y�r._,-,... UAL ,?, a F.�81� 9rVla�le 0�263 / z.. , ADMINISTRATOR ? to f��Jr�•r T 'Assessor's office (1st floor): d/ d 1� �. �7 1C SYSTEM M'"" E To Assessor's map and lot number..�,,.�� ....���.".........7• �-�' .. �♦ Board of Health (3rd floor): Q / ��..�YA'LLE® IN CO25P Sewage Permit number ....%.. ...l... � VM TITLE Z BAH199TODLL, • Engineering Department (3rd floor): 11 ,C1 L ENVIRONMENTAL C® 1 � House number ............................�+ ...5...!Y.l.............. TOWN REG9JLATIO 0 YpY 6�9 Definitive Plan Approved by Planning Board �N/ �SSeiLRS -- APPLICATIONS PROCESSED 8:30-9:30 A.M. and 1:00-2:0 P. . only'�23�87 Y I/�a TOWN OF BARNSTABL BUILDING INSPECTOR APPLICATION FOR PERMIT TO �` ....�. f. .•�� ....f. ...........................•.• TYPE OF CONSTRUCTION .1r.�.�0..,��....... ... .. . . . f.... ...................................................................... ' I ... . ................ 76 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit .according to the following information: 1 jr Location ..... ...?--�....... ...P .. ./.. �7r ... ��Z3 ........................... Proposed Use .....1 ..... � ..................................... Zoning District .......:.F—P.......................................:...........Fire District ........... ill � ............... Name of Owner ........ ......Address . .. . VZ �t•,••c�r. ,.. 1 Name of Builder .. . G/ Name- of Architect ..... .... ..Address l .`/' 1! .�d ../ �� ..�''( .............. Number of Rooms .....�......................................................Foundation . :Iv................. .� Exterior ..� tPJ{ ...~ .Ll� ..................Roofing ... WZ�7-7.0J. Floors QomC41PIC .. .. . . .............Interior .....)/?Yq. ..16Ir!................................................. Heating A....... j �...�`L,�...........................Plumbing ...:.. .`.7........:........................................ Fireplace ..........., ................................... ....Approximate Cost tootzl??:.5�................................. .... Area .......................................... Diagram of Lot and Building with Dimensions Fee P 32 50 ol i 5 OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name ......... ..... . ... .............................. 7-19 Construction Supervisor's License .Ql ..���.......:..... No ................. Permit for .................................... ......................................................................... Location ..... .......................................................... ............................................................................... Owner .................................................................. Type of,'Construction .......................................... .............Iz............................................................... Plot ......-.*.,.................... Lot ................................. Permit Granted ...................................19 J Date of Inspectiofi a 9 Date-Completed .....................................1,9 The Town of Barnstable o�TMf Permit# Massachusetts Date IIARMABM �e S SOLID FUEL STOVE PERMIT +� Fee d0 This constitutes an official stove permit after inspection and approval by the building inspector. Owner Telephone no. ��(� — �� Ll 3 Address of Pro e rty—g— ��Z� 7 P Village Location and Stove Type 000 1 A-9� Date: 1- 21 -"I.S Building Inspector The solid fuel burning stove at the above location passed: failed: inspection. n r/ Assessor's Office 1st floor Ma /4 Lot < (i Permit# 7 7 Conservation Office Oth floor, . Y~ 1SJ Date Issued Board of Health Ord floor ASLI,eclllk 1� Feu Z,.Oeec0 f� Engineering Dept. Ord floor) House# ,<S—jqJ.f• � Planning Dept. (1st floor/School Admin.Bldg.): NAM ..� Definitive Plan Approved by Planning Board 19 t6IW _ o uud (Applications processed 8:30-9:30 a.m.& 1:00-2:00 p.m.) L TOWN OF BARNSTABLE Building Permit Application Proiect Street Address /6- EE" PIT-,l D&O Lo7- 7 Village IV ST/41!3 t- Fire District 60 :1 RH,e/V 5 64g- Owner 1114,u e_!z 1v R v �-Be>! Address / to/ /V E'er f! 7— Tcicphonc �-5 6 ip 3 7 3 Permit Re uest: �- ST' /7 -:T—Aj RU uo GJi m 1 A/ �oL Zoning District Flood Plain Water Protection Lot Size d Grandfathered Zoning Board of Appeals Authorization Recorded Current Use Proposed Use Construction Type Existing Information Dwelling Type: Single Family Two family Multi-family Age of structure Basement type 1 Lu C.0 Historic House Finished !� Old Kings Highway Unfinished Number of Baths a No. of Bedrooms Total Room Count(not including baths) 40 First Floor Heat Type and Fuel © /L T 164 rC4Central Air Fireplaces 3 Garage: Detached Other Detached Structures: Pool Attached 1/ Barn None Sheds Other Builder Information Name ( • 6 F Af0 5 Ael• Telephone number iJ O S— 4f� 8— 7 Address 16 ��1=P �/9 /�1 License# 0 0 4 io S- 0_,,r-7/V 7_CR U r l I i 0 X(. 3 2 Home Improvement Contractor# 164, O O Worker's Com iisation # NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN (AS BUILT) SHOWING EXISTING, AS WELL AS i° PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO L r a r Project Cost /'S<� 0 O 0 Fee SIGNATURE DATE BUILDING PERMIT DENIED FOR THE FOLLOWING REASON(S) BPERM T • 4/10/9 5 }�—► FOR OFFICE USE ONLY 128.017.001 ADDRESS 15 Pioneer Path (Lot 17) VILLAGEW. Barnstable Nancy Mryzglod'.• - OWNER DATE OF INSPECTION: FOUNDATION ' i FRAME INSULATION FIREPLACE , ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL ` FINAL BUILDING: DATE CLOSED OUT: ASSOCIATE PLAN NO. d V � . HOME 11viPRi.!`, 1E_MEN'1" 1O1� Board of Building c;ar, Standards'. One Ashburton Place — Roorn 1301 Boston ,";Hassachusetts 02108 �iOME�,I PRQVENIENT CONS TOR $ Lr �i i. --------- ;Keg�lstr-atiop'�106009 xpiration,:07/21/96�r a � sR w� �� pp�s� ..zY /✓ 4e n- �'.,,a.• t.: ,; lOOMNlrO�[Ltl�(t e�w 'd.::d.�tt67ead Type 'INDIVIDUAL ` ~ - �"� :-,._ i a. - r{ ' SHONE IMPROVEMENT.bNTRACT-- Ar >n5 a ' } - _ t a -r'Syt .re s Y tzatlom-J.06009 1'A '�l� t 'N* tr k0 .r �.t a }fin•■..,�1,{.1 P_ Richard T -Senos i ^`� Ezpitation 07/21/96 10 Peep Toad Rdr ., �; Cenl rv111e,M'A 632 .v, 2.L -Jf,4••° r.F i .r � � ``." + 4�a ate{ zy- f �ct�eed�T SeDOSkI r �, y, ♦- YFt i ^ r}, f SY+a�4'� .PY :�'.}— 5',ak g`� �1',9 J '['SR+t,•J c+ >Z P is { i-f. "s y�' C�M I.O�_• s `su.�.w; t I 0202 i ✓ice — _ DEPARTMENT OF PUBLIC SAFETY Restricted to: 00 _ CONSTRUCTION SUPERVISOR LICENSE 00 - None (rIJure to P .....acrrn Number: Moasectucatt.StareAsWdlEXplrs: IG - I S 2 family NOSES of tills llcb++.a. Restricted To: 00 EICNARO T SENCISKi 1ENP aO EP,Viil MA 626:"! r I T -s�wvsr�. The Town of Barnstable . 'A �0S Department of Health Safety and Environmental Services Building Division 367 Main Street,Hyannis MA 02601 Office: 508-790-6227 Ralph Crosscn Fax: 508-775-3344 Building Commissioner For office use only Permit no. Date , AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the"reconstruction,alterations,renovation,repair,modernization,conversion, improvement, removal, demolition, or construction of an addition to any pre-existing owner occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors,with certain exceptions,along with other requirements. T of Work: U V �vU fst Type � f u Address of Work: /y d,e 0 Owner Name: �/Ll 0 v Date of Permit Application: Ll A I herebv ccrtifv that: Registration is not required for the following reason(s): Work excluded by law Job under S1,000 Building not owner-o=ipied Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITTI UNREGISTERED CONTRACTORS .FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A SIGNED UNDER PENALTIES OF PERJURY I hcrcby apply for a permit as the agent of the ow er: �e a.5 00 Date Contractor name Registration No. OR Datc Owner's name C,ommonwea& of Vamac4uJetb S2ePartment o1 JnJujtria[- cciJ..b 0 600 VVai4ington Street James J.Campbell 1 oiton, Madiacliuietti 02f f f Commissioner Workers' Cpmpensation Insurance Affidavit (licensee/permiccee) with a principal place of business at: (Gcy/Sace/;4) do hereby certify under the pains and penalties of perjury, that: () 1 am an employer providing workers' compensation coverage for my employees working on this job. Insurance Company Policy Number ( I am a sole proprietor and have no one working for me in any capacity. () I am a sole proprietor, general contractor or homeowner (circle one) and have hired the contractors listed below who have the following workers' compensation policies: Contractor Insurance Company/Policy Number Contractor Insurance Company/Policy Number Contractor Insurance Company/Policy Number () I am a homeowner performing all the work myself. I understand that a copy of this statement will be forwarded to the Office of Investigations of the DIA for coverage verification and that failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties consisting of a fine of up to S 1,500.00 and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER/and a fine of S 100.00 a day against me. Signed thi day of 19 r Li nsee/Permittee Building Department Licensing Board Selectmens Office Health Department (� TO VERIFY COVERAGE INFORMATION CALL: 617-727-4900 X403, 404, 405, .409; .375 - ,(•i�t , �� ♦mow .. r r: _+.. . .w � , •..` a,[ �•,.si lY •Mluaa,r✓711 y�� O . .a/ a.r••a.•.. r .,....t.t• t1.aw w :cxw.w. a.S:,i.4._Y !3 ' sarw r '.•s&...e[: wl'1L,vck.Y J ,....a. •rDi(Jk ',1�'r'Si4.. tFi;J4��tM(kR `SdV��. TYt•r,.o�.±t•t:•ti: :f+"♦"er.•�" • 5..dtT�s 7.� .f. T•rTea�%w?1M' 3!�'2+.'A r f "ltva:ira i.\ r� 'Cx7 `2� GOR�A3 '�� ` Yv�'a. O C`7 �� v(O a t�. r--✓-��+- -� r d. — i f --- a.: �..t ,- r ; �t �' sue- .._, 1 � :; t2�� .a-stn4+ r �. .,, .-+ �+"' :.•s►�.a.�D ,n,. ( a, �;.a, '-�sxu:•�p � "��� ! ' d::,"''' .-t.^:r�"-+ aa',�....�cTLY �iit+stia ':r.-� _ _ t .. ,o,,. j r...,.�.:..'rr' � .apt ...s�.•�`",'. ��?^� ' .t�,a.. 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TOWN C-F BARNSTABLE, MASSACHUSETTS BUILDING PERMIT `A-t2$--017.001 r DATE September Ll` 19 88 PERMIT NONQ e 228 APPLICANT Owner ADDRESS r owner (N0.) (STREET) (CONTR'S LICENSE) PERMIT TO guild dormer (_) STORY Single family awL:lling NNUMBERN OF G UNITS 1 (TYPE OF IMPROVEMENT) NO. (PROPOSED USE) l+►t.?�L11 apt/i l lca �7Fa�+ R n�+t ti+7�, DiJ^C rv�,.� cs I b SAY le ZONING AT (LOCATION) /� p �J�'�J�A•fw� DISTRICT BETWEEN V// "C ( AND (CROSS STREET) (CROSS STREET) SUBDIVISION LOT BLOCK SIO E r I. r BUILDING IS TO BE / FT. WIDE BY FT. LONG BY F.T. IN HEIGHT. AND SHALL CONFORM IN CONSTRUCTION TO TYPE USE GROUP BASEMENT WALLS OR FOUNDATION ~) 1 (TYPE) 5 REMARKS: Na' oewage: AREA OR No area change 12,000 PERMIT s 50.00 VOLUME ESTIMATED COST $ FEE (CUBIC/SQUARE FEET) William G. Zissulis OWNER .. `.4 1/14 VbLUrV!!.Le—ii it, DU 11t;V 9Dle C� i3Cl BUILDING DEPT. j{ffj / JAY j /H ADDRESS •- -• - - R. BY THIS PERMIT CONVEYS NO RIGHT TO OCCUPY ANY STREET, ALLEY O fSID WALK OR ANY PART THEREOF. EITHER TEMPORARI Y OR ® PERMANENTLY. ENCROACHMENTS ON PUBL.IC,PROPERTY, NOT �RECIFIQQA L���Y PERMITTED UNDER THE BUILDING CODE, MUST BE AP- PROVED BY THE JURISDICTION. STREET OR ALLEY GRADES AS WELL AS'�fdrEPTH AND LOCATION OF PUBLIC SEWERS MAY,BE OBTAINED FROM THE DEPARTMENT OF PUBLIC WORKS. THE ISSUANCE�OF TFjiIS PERMIT DOES NOT RELEASE THE APPLICANT,FROM THE CONDITIONS OF ANY APPLICABLE SUBDIVISION RESTRICTIONS. \ 1\ MINIMUM OF THREE CALL APPROVED PLANS MUST ESE R AINED ON JOB AND THIS WHERE APPLICABLE SEPARATE . INSPECTIONS REQUIRED FOR CARD KEPT POSTED UN��IL AL INSPECTION HAS BEEN PERMITS ARE REQUIRED FOR ALL CONSTRUCTION WORK: ELECTRICAL; PLUMBING AND 1. FOUNDATIONS OR FOOTINGS. MADE. WHERE A C� RTIFICATE OF OCCUPANCY IS RE- MECHANICAL INSTALLATIONS. 2. PRIOR TO COVERING STRUCTURAL QUIRED,SUCH BUILD �S�ALL NOT BE OCCUPIED UNTIL MEMBERS(READY TO LATH). FINACINSPECTNN H S EN MADE. 3. FINAL INSPECTION BEFORE I \ ` .. OCCUPANCY. POST THIS CARD DSO I�T IS VISIBLE FROM STREET BUILDING INSPECTION APPROVALS I PLUMBING IN/S/P�ECTION APPROVALS ELECTRICAL INSPECTION APPROVALS 2 2 2 3 HEATING INSPECTION APPROVALS ENGINEERING DEPARTMENT - OTHER BOARD OF HEALTH WORK SHALL NOT PROCEED UNTIL THE INSPEC- PERMIT 'W!LL BECOME NULL AND VOID IF CONST.RUCTION„INSPECTIONS-INDICATED ON THIS CARD CAN BE —TOR HAS APPROVED THE'VARIODUS-STAGES OF —WORK-IS NOT STARTED WITHIN SIX MONTHS OF DATE THE ARRANGED FOR BY TELEPHONE OR WRITTEN CONSTRUCTION. PERMIT iS ISSUED AS NOTED ABOVE. NOTIFICATION. J BUILDING PERMIT BUILDING DEPARTMENT HOMEOWNER LICENSE EXEMPTION � ••.L ;b�'?a • i Please print. dATE � ;.; � � , . , :. ' 2i>, ' •� `yF `FCC `;fiSQI'� 'ti ri JOB •• ` 4 ,I •LOCATION UCf n ` u lli �,,t S7d I4 I �rr�y' Street a ress I "HOM[OWNER" ection Of'°town 'AA ��` T� a • ame 106 . • ' om �1 /6• ���,�, �,i 'r'tcAt�v�y���t=i '! e p PRESENT MAILING ADDRESS or P.one , a i Y la rtyY Al Lvtxs �FiiL 3 r ", I ity town ...: ...: to ..�.: ►• �. ,n f r��f f9 �s.���� ' The current to 1 .>;'t ! ;t:;.afr ' exemption for P co e well of'six' units or homeowners was extended to inchude-'owner-ro'�f ?n ivi ua for hire, who does not possess a ccupiQdc. : . .« t. . to a 11 ow such homeowners to��.en a e, any I n •' = acts ery 9 < ` , j as sup isor. (State Building Code Pr°Vided that the owner Perso'nTION OF HOMEOWNER: (s'J who owns a � -- } side,. parcel of land on ►vl�ich he/she resiM1de 53 ed .which there is or is intended to be f attached or Or structures access s or Intend A person who a one to 'six fa* to, re L , - considered accessory to such use and/or farmys�ructures. constructs more than one home in a homeowner, a two-year < 5 on a.. form acceptable Such homeowner." Year period shal'.1. not- be-" for all such work to the Building shall submit to ,the B r: s ; f. performed under the0bui'Ida�' that he/she shallibelresPonsibl�s :.:::r-;: . `:`-: '.' BuiIdine Undersigned "homeowner" assumesg permi ection c -'n= { f x• 9 ode and other applicable responsibility for Pplicable codes, b compliance with-the The Undersigned " y-laws, rules and regulations.. Barnstable Bui1din homeowner" certifies that h+and that he/she wiII comply minimum inspectioni�e understands the �04Fn of . comply with said Procedures and requirements procedures and requirements.-..HOMEOWNER'S SIGNATURE ' APPROVAL •- .. �'�:...��� ,� OF BUILDING OFFICIAL Note: ' Three famil x dwell ' .to Comply with StateBuilding s 35,000 cubic feet,"• or lar er : .•.. ;: Code Section eet 127.0 g will be required Construction Control . I i-- .. ..............._..._............. Th HOME OWNER 'S EXEMPTION e Code state that . Permit Is Any Home Owner (Section required shall PC"-forming work for 109. 1 , 1 be exempt from the wh'Ich Home — Licensing of Construction a buI'Iding::;'', Owner en.gag' provlsl.ons_of , this section sha I i 9 gesr a persons) for h l re to dos�rpery lsors) ;, act as supervisor, such.;,;work, Y such Hom Many Hem that e'3 Owners ; e Owners who V� the responsibllitleSuse tfi.Is. exempt,lon are for Llcensln °f a SUP tinawa're that ' g Construct Ion pery l sor (see q they. .are Of re Supery I sors' ppend I x 0, results, In serious Sectl'ori 2, 75 RUles :and`Regp*I 10ns unlicensed problems, particularl ) " ' This lack of Unlicensed AeCson's. In this case „awareness Y when the. _Home Owneri h'�1 as. sU person as It would with licensed SBoar.d' cannot pervisor Is Ultimate pe'rvl proceed against I.Y. res sor.. Th'a Home .Owner:. To ensure that the p°nslble, COMMUnjt'les. re Home Owner Is fully aware Of his/her Certifyquire, as part. of the permit respons•IbII;it=l..es.'<'m' h that he/she understands the responslbllltle last page of ppl icat Ion • th . , , a y'; ;: .. this 1 at: the`:home-'-..,Qwne:r. ;s •: .. Care to amend ssUe Is .a form current I s Of a ,supervisor c' and adopt such Y used by several .towns,..: ;•; On the a form/ce r t I f I ca t I on for r:. Use In 1' ciy 4;`-. . Your common f%* ",'' . �t _ h 7, ®/ SEPTIC SYSTEM MUST BE Assessor;, office Ost floor): �pF TeE / n �,, 2 Assessor's map and lot number ...�07..... �,1 .-"......./ �i (' ' Q Board of Health (3rd floor): SS-ewage Permit number ....... fa. ENV1 � ,,%L CODE Ai 01 L Basa9TODLL, Engineering Department (3rd floor): TOWN REGULATIONS Y4°s � House number oe,i63I Definitive Plan Approved by Planning Board ________________________________19-------- . APPLICATIONS PROCESSED 8:30-9:30 A.M. and 1:00-2:00 P.M. only TOWN OF . BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO U/L � I�.. ............ . .............................................. . ....................... TYPE OF CONSTRUCTION `.'��.�!�C„�.... ..�L� �`^v' .................... ..... ............ .... ............................................................. .................. 2�..................19.A..y . TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the followingfollowiing information: /:/ /� A ' Location ..�./..1Y..(/..5.1.�1.�(illLo......0.!.. r�.�. iGa L........1\.�i ... ........Y.V. . fit" /v.s.�........................ Proposed Use ....... �......l.J.(.:.a.40.P.H..'LS........................................................:. ZoningDistrict ........................................................................Fire District .............................................................................. Name of Owner 14-A-111.4M.... Z.r.Ss.4 Address ....01Y...afff ..W...j..1arn-.SI.Glle.... . Name of Builder Address ............ � ^� .'�'r i.Ct ........................... Name of Architect ..�j�Q:f..vj....... .�.11`S.................................Address ................... ,...� K,'e.Q ...... ?.G...•................ Numberof Rooms .........a...1...................................................Foundation .............................................................................. Exlerior .....0.Ct.R.d.....ct°dze..sh.,t, )e-s&....CTAP.LR<w...Roofing ........�sp.I'1Lc� ......................................................... Floors ...1. �� Livad...k d ...L tJ-(..t..(.r.).6X....(ge..Interior ..........S.�ee...410 ,IC................................................ Heating ... ... I.....Ck4SC'-&0.4(.:,'/...............Plumbing .......l...Y..���... .... jo. Fireplace .' ............................................Approximate Cost ..... � �. Area !..'..0....... 14.. 7�?L7.. Diagram of Lot and Building with Dimensions Fee OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name ........ .. r..... Construction Supervisor's License ...... r1.e/............... ZISSULIS, WILLIAM G. �Z 0/ `tqd ..32 .. Permit for ..B,uild Dormer ................ r" T Sin.le Family dwelling ............. ...................... ................................... 1714 Osterville-West Barnstable Road 3 Location .................................................... West Barnstable ............................................................................... Owner William G. Zissulis } 2 ............................................................. Frame `- Type of Construction .......................................... ? ..... ...................................................................... Plot ............................ Lot ................................ Permit Granted - September 21 , 88 ...........................19 Date of��nspection ....................................19 - P=Dote CompjVted ......................................19 ti 1y4--b `7• 00 Assessor's office (1st floor): Assessor's map and lot number lwk-le/7.-OQId,k , T"E>o� ...........,..... Board of Health (3rd floor): •Sewage Permit number .......9 .-/c. . .�.,, 7..................... Z 21AUSTODLE, i Engineering Department (3rd floor): rasa Hou'se�number O YP-4 �0 Definitive Plan Approved by Planning Board ________________________________19-------- . APPLICATIONS PROCESSED 8:30-9:30 A.M. and 1:00-2:00, P.M. only TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO �,+� J Z. .......... .....C7.. ........................ . ............................................ TYPE OF CONSTRUCTION `.."'........ ......................... ........... . ............................................................. ................... ................... TO THE INSPECTOR OF BUILDINGS: The undersigned�Uhereby applies for a permit according to the following information: Location ..f. �1... s. P..�!�!. d°.....�!.�.!... ..T y1 "s. 1 , IVC1 W/.���J.s _ ProposedUse ............... !. !.�1..! ...cr... .1.......�2 ............................................................................................ Zoning District ........................................................................Fire District Name of Owner .�r,!!..!.t.(�,.W`1.....�';..t... /S St.�1./.5.......Address ..... �f G� jj � ........ ti•.a�.n.....c._.(P.......... Name of Builder �.�Go. �� _.... ... . .>. ............... ....Address ........... Name of Architect ...(_o.C.n !- C17 ......�?.�.1�$.................................Address ...................(A.),... .f.!' ��.7..�?...... ...:............... Number of Rooms ............ oZ'......................................................(FounJdation .............................................................................. • � I T/lir7 I Exlerior .....f. .C�ori�.:.. 'P.. 14r...C',hirr, lr,:S�n ....C�u�h. l. ...Roofing ........AS.n.I�.G..f ......................................................... 1 J Floors !7e mt 1-A r:.0 �...?e..`!�.6. ..1..:�'<�.'..7;...1..:.�C:.��...�u�',��` Interior .......... ,N.?.P.%.1..'d ................................................ S..... Heatin 1� .to...:>U...Ol.......(b!!R ..<4oq!✓i/............. / V,t/ y�r g � � (•,.......� � Plumbing ............ .............. �;•. ............................. Fireplace .......................... �w ..............Approximate Cost ......�.. ( . ..I� ......./.a.............. Area L.'.®....... .. '?,�.... Diagram of Lot and Building with Dimensions Fee ................ ...""'............. OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name .. � / _ ��r:f.... ./.�1.. ........... Construction Supervisor's License ............. .. ,,?ISSULIS, WILLIAM G. A=128-017. 001 , No .3 2. 8�.°,Permit for .Bui.ld..Dormer... a r .._.S ngle.,.Fami1Y .Dwelling,, , Rio Irer Location ! `" le-West Barnstable Rd ...........................TP.s ..Ba n$,tabale............. Owner .....:Will ,am..G......Zissulis Type of Construction ...........Frame.................. ............................................................................... Plot ............................ Lot ................................ Permit Granted .......Septc...21.............19 88 Date of Inspection ................................ Date Completed ......................................19 - r . .• 6r J r � 1 N® ��� ,41wr 0 TOWN OF BARNSTABLE Permit No..., 33853 • BUILDING DEPARTMENT t """ I TOWN OFFICE BUILDING Cash .Y� s�v �����►+'" HYANNIS,MASS.02601 Bond X...' �° � CERTIFICATE OF USE AND OCCUPANCY Issued to Greenbrier Corp. Address Lot #20, 15 Pioneer Path Hest Barnstable, Mass. I � USE GROUP FIRE GRADING OCCUPANCY LOAD THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN REQUIREMENTS AND.IN ACCORDANCE WITH SECTION 119.0 OF THE MASSACHUSETTS STATE BUILDING CODE. ?/ November 3 0, g 0 ....................... 19................. Building Inspector I