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Home My WebLink About0205 BUCKWOOD DRIVE i Town of Barnstable Permit# Expires 6nwnths fr m issue date Regulatory Services Fee rinxivsraslX v MASS'za3� Thomas F.Geiler,Director � �� 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 PERAHT APPLICATION RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number Property Address a N Al yGIeUJI P O,Vl vt 11 ^A,11J l?4 0;100/ Jd� Residential : Value of Work IUd Minimum fee of$35.00 for work.under$6000.00 Owner's Name&Address C Contractor's Name ✓ W 2ol� Telephone Number r ,�l 22iGvUve I/ll-P�fl� laU��0 Home Improvement contractor License (if applicable) Construction Supervisor's License#(if applicable) XPRESSS PERMIT `gWorkman's Compensation Insurance APR 29 2013 • Check one: r' ❑ I am a sole proprietor ' ❑ I am the Homeowner TOWN OF BARNSTABLE [ I have Worker's Compensation Insurance Insurance Company Name 11J✓UU.¢1V l0 e'e! "L/lJJ- t 041,0 Workman's Comp.Policy# W C C -f 0/ .rV 0!Z 01 2 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) (PIRe-side (Jl#Y4C -IlU l�V f #of doors ❑ Replacement Windows/doors/sliders.U-Value (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. copy of the Home provement tractors License&Construction Supervisors License is equ' SIGNATURE: C:\Users\decollik\A ta\I.ocallMicrosoft\Windows\Temporary Internet Files\Content Oudook\DDV87AAZ\EXPRESS.doc Revised 072110 . Arse k,urrerrcursweall" UJ 1V�t(dJmac•nuseli4 (. '�`''uggm Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston,M4 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual):Capizzi Home Improvement Address:1645 Newtown Road City/State/Zip:Cotuit, MA-02648 Phone#:508-428-9518 . 7Are you an employer?Check the appropriate box: Type of project(required): 1 0✓ I am a employer with 40+ 4. [] I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. []Remodeling shipand have no employees These sub-contractors have 8. 0 Demolition working for me in any capacity. employees and have workers' insurance.$ 9: []Building addition NO workers' comp.insurance • comp. required.] 5. We are a corporation and its 10.❑Electrical repairs or additions 3..0 I an a homeowner doing all`work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.]t c. 152, §1(4), and we have no employees. [No workers' . 13. Other 011ylNt comp.insurance required.] *Any applican i that checks box#1 must also fill out the section below shovfmg their workers'compensation policy in brmati.n\ t Homeowners who submit this affidavit indicating they are doing all work.W then hire outside contractors must submit a new affidavit indicating such. tContractors that check ons box must attached an additional sheet showing.tae name of the sub-contractors and state c�hether or not those entities have employees. lithe sub-contractors have employees,they must provide their workers'comp,policy number. Earn 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 w Policy#or Self-ins.Lie.#WCC5010 547012011 Expiration.Date: 12/25/2012. Job Site Address: �'�" City/State/Zip: ��/y/✓ ' '��Z Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure.to secure coverage as required under,Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cert�un r e ' s penalties ofperjury that the information provided above is true and correct Signature: Phone#. 508-428-9518 ; Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1:Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Client#:47298 CAPIHOM DATEYYYYY) ACORD. CERTIFICATE OF LIABILITY INSURANCE 12126/2012 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 certi icate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed.If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may requim an endorsement A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER CONTACT Karen Walther Rogers&Gray Ins.-So.Dennis NIa Nc.377-816-2156 434 Route 134 E-MD South Dennis,MA 02660-1609 INSURERS APFoRDING COVERAGE NAiC 4 508 398 7980 INSURER A:Main Street America Assurance C INSURED INSURER D:Associated Employers Insurance Capizzi Home Improvement,Inc. INSURER C: Caphczi Enterpnses,Inc. INSURER D 16455 Newtown Road INSURER E Cotuit,MA 02635 : ' 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBACT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. L RR TYPE OF INSURANCE DL BR POLICY NUMBER MWD LIGYEFF MPMIDDY EXP LIMITS A GENERAL LIABILITY MPB1075H D610812012 06108/201 p-EACH ocTcuRRE►xE $1 000 000 X COMMERCIAL GISNERAL LIABILITY F'fU�E SESO aa�racr� $500,000 CLAtMS4AADE'�OCCUR $10,000 PERSONAL&ADV IMBIRY $1,000,000 GENERAL AGGREGATE s2,000,000 GENt AGGREGATE LBM APPLIES PM PRODUCTS-COMPIDPAGG $2,000,000 _ POLICY PO- FLOC $ A AUTOMOBILE LIABILITY MIM28044 D610812012 06/08/209 EolAs tm'-LE' s500,000 TWOMth OBODILYIN.IURYawpersm) $ ED X SCHEDULED - BODILY IM URY(Peracddent) $ AUTOS OS X pNojOWNED �...�- $X Caz $ A X uMBRELLA LI B HoccuR CUB1076H DrafOS12012 0610812013 EA ui occuRRENcE $5 000 000 EXCESS LIAB CLAIMS-MADE AGGREGATE $5,000,000 DED I X1 RETENrms10000 $ B WORKERS COMPENSATION WCC5010547012012 1212512012 12/25/209 X V!c STATU- oTH- AND EMPLOYERS'LIABILITY ANYPROPRIEIOWP pI YIN EL EACH ACCIDENT $1000000 OFT-ICERIMEMBEREXCLUDED7 N NIA (Mandatory In NH) E.L.DISEASE-EAEMPLOYEE$1,000,000 uyes.destx®re undo- - E,L.DISEASE-POI U'V UMFT s9,000,000 DESCR�TIOAI OF OPERAnONS De1ow DESCRIPITON OF OPERATLONS I LOCATIONS!VEHICLES(Mitch ACORD 101.AddWaaaf RemadLs Sdtedtde,if more space Is required) *'Workers Comp Information'* Included Officers or Proprietors 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 2 200 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. Hyannis,MA 02601 AUTHORIZED REPRESENTATIVE ®196 -2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010105) 1 of 1 The ACORD name and logo are registered marks of ACORD #S918591MM1856 TLH I 4� ' Page 7"of 7 Capizzi Home'Improvement Inc. Specifications and Estimates STATE OF MASSACHUSETTS LETTER OF AUTHORIZATION TO APPLE'FOR A BUILDING PERMIT r� fc�l�� `'�`� , OWN THE PROPERTY LOCATED AT IN / I ya&1 2 , 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 DE. SIGNATURE OF OWNER: -J- e-7- 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 0263.5 APPLICANT'S TELEPHONE: 508-428-9518 RESPONSIBLE OFFICER: RESPONSIBLE OFFICER ADDRESS: RESPONSIBLE OFFICER TELEPHONE: Ma�ssach s is -Depal n-'ent qt Pulobc Sat fil Bawd of Suikdmg RegWat:ons:end Sta-d Lv_—ep CS-0 7 " JW14 T SMUMSJ i 18 A DEN aim e -0- kmee ox t:t=merAna=,&3sumess xegwauun JUICA "or rCgtsu~3uou vauu rvr Anucrtuut ubo uauy OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Office of Consumer Affairs and Bus ess R uiatio l. Ree is-tra#Ion:;—p TYPO: 10 Park PlAp-Suite 5170 ExpimfM ' A' Supplement Card Boston,WfA 02116 CAPIZZi H6MEi ; NC. t JOHN STRtJIttfS 1645 Newt Rd. C otul..ma�yy,MA�,�d/��j� 2,.� •• �^'�� ' Q2635 '••�+"-v;mot y; undersecretary iYot v et�i oat Signature > Town of Barnstable *Permit# Expires 6 months from issue date DEC _ 3 2009 Regulatory Services Fee F BARNST ABLE Thomas F.Geiler,Director TOWN Building Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number Property Address - Jos ( ) u c k w0o b b A, 6 j,]1Y /U /_5 esidential Value of Work 7 0V/" Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address Al v .20.S 8 u c1c L.)0 D 6 P" J) 15 Contractor's Name prq � Telephone Number �D� S66`-33 Home Improvement Contractor License#(if applicable) 6 oil Z 1 r Construction Supervisor's License#(if applicable) 1Y& ❑Workman's Compensation Insurance Check one: R1 am a sole proprietor ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) e-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,Conservadon,.etc. ***Note. Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvemen Contractors License is required. SIGNATURE: Q:Forms:expmtrg Revise061306 ✓!ie Pomnwncrea&! "�/�aaaacl�uaelta r License or registration valid for individul use only Office of Consumer Affairs&Business Regulation before the expiration date. If found return to: HOME IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Business Regulation i Registration'" ,119766 10 Park Plaza-Suite 5170 Expiration W_8128/2011 Tr# 288419 Boston,MA 02116 "— _4 Type -l "iidual . I } WEBB CRAFT DSIGNi. DAVID WEBB tit I,`f 17 ACADEMY LN� ----- FALMOUTH,MA 02540_= ' Undersecretary Not valid without signature 1 i I 1 Massachusetts.-Departm h ent of Public Sufe i Board of Vubkdin,T.Regulutions and Stxn r duds COnstructiofSupervisor License iU,JAdense: CS �46189 ReMri'cted to: 00 DAVID H WEBB 17 ACADEMY LN FALMOUTH, MA 02540 Expiration: 10/2912010 ('ununisiuner Trt#: 5826 j { The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations . 600 Washington Street Boston,MA 02111 , www.m ass.gov/dia Workers' Compensation Insurance.Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): •Address: / /� �i►� y L/lyv City/State/Zip: pqy_�771 M#ol- ne Phone.#: �8�-4 Ski ' 3 3- Are you an employer? Check the appropriate box- -Type of project(required) 1.ET am a employer with 4. am a general contractor and I 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 s and have no employees These sub-contractors have �P8. ❑Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp.insurance comp,insurance. • $ required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions •3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 12•0 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 warkers'cornpensation 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. lContracton that check this box must attached an additionalshect showing the name of the sub-contractors and state whether ornot those entitics have employees. If the sub-contactors have employees,they must providb their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic•#: p / Expiration Date:: / Job Site Address:# OZ D S R UCICG opA Jb/C• City/State/Zip /�`� f X Attach a copy of the workers' compensation policy declaration page(showing the policy numLer and expiration date),. Failure,to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine tip to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification Ido hereby ce ,nder th/e�painns•andpenaltiiess erjure that the information provided above is true and correct: Simature: C /Vin G^/ �'- ate• Z c�• Phone#: d �G '.—_3 3,z 0fftcial use only. Do not write in this area,'tb 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 CIerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person, Phone#: ' Ott'1HE I of.B , : Town Barnstable, Regulatory Services + BARNVABLE, • y buss. $ Thomas F. Geiler,Director �'•TFD Mph A1� Building Division, Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstabk.ma.us Office: 508-862-403$ Fax: 508-790-6230 Property Owner Must Complete and Sign This Section if Using A]Builder PA-TRiQui14 Al(,F&,4 , as Owner of the subject property. herebyauthorizeb, W r�-m to act on my behalf, in all matters relative to,work authorized bythis building permit application for: . A VA VA 5 (Address of Job) J /- 3 1) Signa4 o e D e P l y I./Q Pent Name QTORMS:OWNERPERMIS SION � J V1f4RCERS'`CQ�VIPENSATIONAt11D EIVIPLOYERS LIABIL� 1f11� 11F # iCj PULI+CYr tnf ormatlo ' 'la° s n„Pge ► 4 a'I Atlantic Charter Insurance Company VDAC NCCI Co. No.:29211 Policy Number: WCV00730203 1. INSURED: Prior Policy Number: WCV00730202 Tyndall Roofing, LLC Producer: 30 Jillian's Way Fredericks Insurance Agency, Marston Mills, MA 02648 Federal ID Number:204616445 Inc. Risk ID Number: 1046 Main Street Business Type: Limited Liability Osterville, MA 02655 SIC:9999 NONCLASSIFIABLE ESTABLISHMENTS Other Named Insured: Other Work Places: See WCE107 2. POLICY PERIOD: The Policy Period Is From: 7/11/2009 To 7/11/2010 12:01 A.M. Standard Time at The Insured Mailing Address 3. COVERAGES A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 100,000: each accident Bodily Injury by Disease $ 500,000 policy limit Bodily Injury by Disease $ 100,000 each employee C. Other States Insured: Part Three of the policy applies to the states, if any, listed here: COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06A All states except Monopolistic State Fund States D. This policy includes these endorsements and schedules: See WCE105 4. COVERAGES: The premium for this policy will be determined by our Manual of Rules, Classifications, Rates & Rating Plans. All information required below is subject to verification and change by audit. Code Premium Basis Total Rate Per Estimated Classifications No Estimated Annual $100 of Annual Remuneration Remuneration Premium See WC 00 00 01 Minimum Premium: Deposit Premium.- $500 $1,284 Interim Adjustment: Annually Servicing Office: Total Estimated Premium $1,217 25 New Chardon Street Surcharge(s) 67 Boston, MA 02114-4721 _ Total Premium and Surch rge(s $1,284 � Issue Date 06/22/2009 Countersigned By: Date JUN 2 2 ZD .--— _ _ 9 Copyright 1987 National Council on Compensation Insurance Form: 100m