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HomeMy WebLinkAbout0055 BUCKWOOD DRIVE 5� ���k�voo� ��-� Y� G _Z3 _jq � oFt ME►� TOvvn Of Barnstable rPernik# Expires 6 month om issue-date— " f Regulatory Services Fee /1 s�xsTnat.e. : Mnss.1639. $ Thomas F.Geiler,Director QED MA'S 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 PERMIT:APPLICATION :- RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number aya/V Property Address '�r �Ur;Ku► /VY a ne., [Residential Value of Work �o,(OOV Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address DA•/l//e4 J h? G %N,n4/4 - g's, v i jJlJ6 7/e Zs� fr n r7i i .dLt.4 G 26.d/ z 4-IV jl'yl C C O/{�12Q Gt< Telephone Number 5-Uq 1yq ��� Contractors Name /Ipw u. p Home Improvement Contractor License#.(if applicable) j1p O,f!7d v f Construction Supervisor's License#(if applicable) s U 7�a. ❑Workman's Compensation Insurance Check one: JUN 12 Za14 ❑ 1 am a sole proprietor ❑ I am the Homeowner [✓7 I have Worker's Compensation Insurance TO G. f l r�dn 10 ero OF BARNSTABLE o Insurance Company.Name �° y Workman's Comp.Policy# Uj u.7 r 6:j4r 6,ra Copy of Insurance Compliance Certificate must accompany each permit. Permit Req est(check box) aeeJU/gq /c ��iZT��%✓fPet1� �o G G I�JTvt'Z@ 640 �1.c [ 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) ❑ Re-side #of doors Replacement Windows/doors/sliders.U-Value (maximum.35)#of windows ❑ 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 the Home:Improvement Contractors License& nn«rrael on Supervisors License is required. SIGNATURE: : 04� 0� ao�y C:\Users\decollik\A pData\I oca icrosoft\Windows\Temporary Internet Files\Content.Outlook\QRE6ZUBN\ Revised 053012 Page 7 of 7 Capizzi Home Improvement Inc. Specifications and Estimates STATE OF MASSACHUSETTS _. . ... ... ... .. ... LETTER OF AUTHORIZATION TO APPLY FOR A BUILDDING PERMIT I, I ( j �c1(144 1 ;OWN THE PROPERTY LOCATED AT IN T r�rS , 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 BUILDINGt CODE. SIGNATLTRE 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: 508-4281-9515 RESPONSIBLE OFFICER: RESPONSIBLE OFFICER ADDRESS: RESPONSIBLE OFFICER TELEPHONE: i ;,rassachusetts -Department of Public Safety j Board of Building Regulations and Standards Y Construction Supervisor { License:CS-076261 %4JANIS MCC' ' ORMkCK 73 FEARING Hal WestWarehamma 0 Expiration, i l f13120115 i commissioner Office of Consumer Affairs�&Business Regulation License or registration valid for individul use only OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: ,;4 Office of Consumer Affairs and Business Regulation Registration:: 00740 Type: 10 Park Plaza-Suite 5170 Expiration fi%23121)14, Su lement Card Supplement Boston,MA 02116 CAPIZZI HOME'IMPROVEMENT INC. JAMES MCCORMACK= 1645 Newton Rd. Cotuit,MA 02635 - Undersecretary N.pfvalid without signature f I -_' ce of .zvestigadons JCongTess&reetsu& 100 Boston,HA 021-1 -2017 w-gW mass gov/dia Workers' Compensation Inmrance Affidavit:Builders/Contractors/Electiicians/Plumbers Applicant Information Please Print Ee�ibl� N2ffie(Business/Organiaation/Zndivzdual}:.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: 40� 4. I am a e Type of project(required): I am a employer with ❑ general contractor and I employees(full and/or part-time).* have hired the sub-contractors 5- ❑New construction 2.❑ I am a sole proprietor or artner listed on the attached sheet. 7. p p p. Q Remodeling ship and have no employees These sub-contractors have. g Q Demolition _ wozking forme in any capacity. employees and have workers' o--wor ers.,..ompssuranee e. - -.. . . _......_ - --- - requixed.] 5 ❑ We are a corporation and its 10.6 Electrical repairs or additions 3:[] I atn a homeowner loin all work officers have exercised their g I I-Ej Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGI, insurance required.]t c. 152;=§.1(4);and ire have no 12. oofrepir�. _ 'employees:LNo workers'� I I .Other comp.insurance req --------------- uired.] *Any aprAcant that che6h box#1 must also fill out the section below shov:5ng their workers'compensation polx y informations" T aor'eowners who submit this affidavit indicating they are 'c�`ii ag all work aW Bien Lure outside confractors must submit a new affidavit indicating such -TContragtors that check this box must attached an additional,sheet showjhglfiae name of the sub-contractors-and date whetfier or tot those entities have employees. If the sub-eontractors have employees,they mustprovide their workers'comp.,poli6y nutibei.; -':tiro•an employer that is providing workers compensation ins-urance for my employees, Below is the policy acid job site irfo.rz�ors. . Ln uratce Company Name:Associated Employers Insurance Company . _. _Policy.#or•Self-ins:Lic.#: :WCC5010 54:701201-f . _. _ . _ _ :ratian,D ��: ate: , Job Site Address: G 0 0 PD City/State/Zip: ti Attach a copy of the workers' &Ompensation policy declaration page(showing the policy number and expiratio)i date). FW. e.to'secure coverage as required under Section 25A of MGL c. 152 can Iead to the imposition of criminal penalties of a foie tip to$1;500.00 and/or one-year imprisonineiit,as well as civil penalties in the form of a STOP WORK ORDER and a flue 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: Z do hereby certify under the pains and penalties ofperjury that the information provided above.is true.and correct: .Si afore: Date: Phone#: 508- .28-9518 Official use oxly.. Do riot write in this area, to he completed by city or town official a . City or Taws: Permit/License# Issuing Authority(circle' one): I:Board ofIfealth 2.Building Department 3.City/Town.Clerk 4.Electrical Inspector 5.Plumbing inspector 6. Other Contact Person: . Phone#: CAPIHOM-01 APELL E(MM1DD CERTIFICATE OF LIABILITY INSURANCE DATE N/YYYV) 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 WANED,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 arc No Ext: Alc No):(877)816-2156 South Dennis,MA 02660 ED ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC S WSURERA:Main Street America Assurance Co. INSURED INSURER B:Associated Employers Insurance Co. 11104 Capiai Home Improvement,Inc. INSUPERC: Capizzi Enterprises,Inc. 1645 Newtown Road INSURER 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. DLITR TYPE OF INSURANCE ADDL SU POLICY NUMBER MMLJCY EFF IDDIYYYYJ MOLICY EXP LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 CLAIMS-MADE N OCCUR MPB1075H 06/0&2014 06/08/2015 pRMAGETORENTED. ce $ 500,00 MED EXP(Any one person) $ 10,00 PERSONAL&ADV INJURY $ 1,000,00 GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,00 POLICY a JECT Fx1 LOC PRODUCTS-COMP/OPAGG $ 2,000,0 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ a accident A ANY AUTO M1 M28044 06/08/2014 06/08/2015 BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED BODILY INJURY(Per accident) $ 500,00 AUTOS AUTOS X X NON-OWNED PROPERTY DAMAGE $ HIREDAUTOS AUTOS Peracddent $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,00 A EXCESS UAB CLAIMS-MADE CUB1076H 06/08/2014 06/08/2015 AGGREGATE $ DED I X I RETENTION$ 10,000 1Pers&Adv Inj $ 5,000,00 WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER B ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N CC50060105472013A 12/25/2013 12/25/2014 E.L.EACH ACCIDENT $ 1,000,00 OFFICERIMEMBER EXCLUDED? NIA (Mandatory in NH) E.L.DISEASE-EA EMPLOYEd$ 1,000,0(10 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMB I$ 1,000,00 DESCRIPTION OF OPERATIONS/LOCATIONS/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 AUTHOR093 REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 26(2014101) The ACORD name and logo are registered marks of ACORD