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0057 CANTERBURY CIRCLE
�7 C���u Gar- TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION 70(o Map Parcel Application # < Health Division Date Issued Conservation Division Application Fee JV Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Q i Historic - OKH _ Preservation /Hyannis Project Street Address 59 c N-ru 2'T-- oZ Y Ci Ic_t 6 Village Owner J ACp R IC yF-'t�U Address q(o AN LN O Telephone 1 q-qU,V — Co O I Li L)t ST- )2o x`P�c)(z y MA C)d )-S Permit Request JNSUOA""OYJ * (-) ir2 Se- A L-i N& -- 1X kQ 5QV-r CrsLitUWStF jN E)C'rj41V2 WPLLS 501�Fl-T vetT� 'T_P IzMA-`�orAj5 Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation ®5 "� Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(# units) F Age of Existing Structure Historic House: ❑Yes ❑ No On Old King s'Highway,-jO Yet ❑ No Y«� i Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ t Other Basement Finished Area (sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: existing new Half: existing neyv Number of Bedrooms: existing _new CD 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 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 I.!se Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name 5TeV61IJ C- W la t-rty Telephone Number Address License # 5 D 3 Ul N3 Sel�)AST)A tJ —b (Z- 10 Home Improvement Contractor# 1 (0 Worker's Compensation # LI H q L� ? Fs Ll LI ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO f SIGNATURE DATE i FOR OFFICIAL USE ONLY 1 APPLICATION# '"'' DATE ISSUED X ` MAP)PARCELNO. ADDRESS. VILLAGE a i� OWNER DATE OF INSPECTION: ,�FOUNDATIONJ. ., i FRAME ',INSULATION., } FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL f ' GAS: r= E ;:ti ROUGH > 4 FINAL s i -.DATE. CLOSED OUT ASSOCIATION PLAN NO. 5 _ 1 `~ The Commonwealth of Massach usetts ` Department of Industrial Accidents ' Office of Investigations, 600 Washington Street, Boston,MA 02111 www mass.gov/dia Workers' Compensation.Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): 45 FF 101 J 'T D(J l t-D l 7fG S l L C e Address: 8 cTAN SE e A S-'1 F3 N 3>21 V57 Uu i7- Jp t City/State/Zip: SA N D LJI,C f-i, MA OaS(0 3 phone #: 50 9"SS S'— 1 f 1b ' Are you an employer? Check the appropriate box: Type of project(required): 1.9 I am a employer with 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 " ship and have no employees These sub-contractors have g. Demolition working for me in any capacity. employees and have workers' comp.insurance.$ 9. ❑Building addition [No workers' comp.insurance P• required.] 5• E] We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doingall work officers have exercised their 1 1.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL insurance required.] t c. 152, §1(4);and we have no 12.❑Roof repairs employees. [No workers' 13:[Y 'Other 3'NS uL-ATi 0 tA comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have _ employees. If the sub-contractors have employees,they must provide their workers'comp,policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information.Insurance Company Name: .A GRD U p , Policy#or Self-ins. Lic. #: Expiration Date: 3-O?"op.0/a 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$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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification._. I do hereby certify under the pains and/penalties of perrytha the information provided above is true and correct Signature: C / Date: Phone# !^ �b'k 0 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/'I'own Clerk'4.Electrical Inspector 5. Plumbing Inspector,. ^ 6.Other Contact Person: Phone#: i " A CERTIFICATE OF LIABILITY INSURANCEF9/14/,2011O IDD/YYYY) 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 D CONTACT avid Crawford NAME:Eldredge 6 Lumpkin Insurance Agency, Inc. PHONE FAX (508)945-0393 IAOC N .(508)945-4048 697 Main Street L .david@elinsurance.com INSURER S AFFORDING COVERAGE NAIC II Chatham MA 02633 INSURERANational Grange Mutual Ins Co 14788 INSURED INSURER B:Commerce Grou - IG001 Caliber Building and Remodeling LLC, ' INSURERCP,ce American Ins. Co. - eARWC 22667 Efficient Buildings, LLC. INSURER0: 8 Jan Sebastian Drive #10 INSURERE: Sandwich MA 02563 INSURERF: COVERAGES CERTIFICATE NUMBER:Housing Assistance Corp 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 PF 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. ILTR TYPE OF INSURANCE POLICY NUMBER �MM POLICY POLICY D1,YYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY - - PREMISES A - N occurrence) $ 500,000 A CLAIMS-MADE a OCCUR 27360 /.15/2011 /15/2012 MED EXP.(Any one person) $ 10,000 PERSONALBADVINJURY $ - 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: • PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY r PRO LOC $ AUTOMOBILE LIABILITY EaMeB NEE SINGLE LIMIT 11000,000 ANY AUTO - BODILY INJURY(Per person) $ B ALL OWNED SCHEDULED BNVCS /16/2011 /16/2012 AUTOS X AUTOS -BODILY INJURY(Per accident) $ _ NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS _ - Par' $ X-1 UMBRELLA LIAR OCCUR EACH OCCURRENCE $ 1,000,000 A EXCESS LIAR CLAIMS-MADE - AGGREGATE $ 1,000,000 DED I I RETENTION$ 27360 - /15/2011 /15/2012 $ C I WORKERS COMPENSATION _ WC.STATU- OTH- fAND EMPLOYERS'LIABILITY Y/N # - - - I ER PROPRIETOR/PARTNER/EXECUTIVE❑ - E.L.EACH ACCIDENT $ C7FiCERIMEMBER EXCLUDED? N I A 494P844 /2/2011 /2/2012 500,000 (Mandatory in NH) - E.L..DISEASE-EA EMPLOYE $ 500,000 '_eC deswoe under RIPTION OF OPERATIONS below - E.L.DISEASE POLICY LIMIT $ 566,000 f 7 . 0ESCPffrnC N OF OPERATIONS I LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule If more space Is required) _a.-pertry. In conjunction with the Weatherization Assistance Program, the following entities are named as motional Insureds for Liability coverage under Pol-#MP027360: National_ Grid Corporate .Services LLC DBA satonal Grid, Action Inc., Colonial Gas Co. 6 NSTAR-Electric. CERTIFICATE HOLDER CANCELLATION a,"r SHOULD ANY OF THE ABOVE bESCRIBED POLICIES BE CANCELLED BEFORE THE' EXPIRATION DATE THEREOF; NOTNCE,WILL BE DELIVERED IN ACCORDANCE MTH THE POLICY PROVISIONS. Housing Assistance Corporation Att: Ruth Bechtold (` t- AUTHORi�REPRESENTATIVE 460 West Main St. - Hyannis, MA 02601 d t avidrCrawford/ELDDCl 9"''""�� C t. x. =. ORD 25(2010105) ©1988-2010 ACORD CORPORATION. All rights reserved.. :R-'�ii5 :"•'n=:n, - TAs A.f:tl mama 2nA liven.2ra ronralowii mnrirc of Ar:nPn Nlassactfusetts- Dcpadtmcnt of Public Safcti Boartkof Building Regulatii>n-.and�'Standards'. Construction Supervisor License ` License: CS 95038 Restricted to: 00 STEVEN WHITE 147 RIDGEWOOD AVENUE, HYANNIS, MA 02601' -Expiration: 228M12 ('AAiuni�+irnt•r Tr#: ,19311. r _ - ' �— /fe Loin.»eoouuPa`��o ✓�faaaa�Cuaelta ; License or registration valid for individul use only Office of Consumer Affairs&B smess Regulation �!, HOME IMPROVEMENT CONTRACTOR before the expiration date.If found return to: R esbation: 1 ggg4q `Type: Office of Consumer Affairs and Business Regulation eg. axx� - 10 Park Plaza=Suite 5170 Expiration: WW2013 LLC Boston,MA 62I16 Er" LLC. Act x r z STEV"-' C�� i - t S ': '•'+" •= - Undersecretary Not valid without signature # Y 4 ": } t }fie xrr z „ -y s . vy:41 > �,_S•"^hAiw'� .+ `� "jP g, q :".ar-a' �S M�.r s •s.;r .. z �, . v -•, �, �mg{�m.� ,M^5 yc� p.�,4..die, t - • - , a CALIBER Building & Remodeling', LLC r 147 Ridgewood Ave. Hyannis, MA 02601 508-430-4005 fax: 508-430-4006 r Proposal Date: 9/26/10. Customer. Jacob & Sofia Kordun Home #: Street: 57 Canterbury Circle Cell #: 617-448-6074 City/State/Zip: Hyannis, MA 02601 Email: jacobkor@gmail.com Contractor will hereby perform the following.weatherization measures as outlined in Cape Light Compact Energy Audit performed by Rise Engineering: • Perform up to 10.hours Air`Sealing including weatherstrip front door $660.00 • Install Class 1 cellulose of 1140 sq. ft. of exterior walls $1,653.00 • Install cover over whole house fan (thermodome) $200.00 • Install insulated exhaust hose/roof flapper assy to existing bath fans $200.00 • Install (10) 4" X 16" aluminum soffit vents $170.00 • Air seal with foam and install R-19 fiberglass insulation to rim joist $167.20 Total Balance Due when work completed: $3,050.20 . Caliber Building & Remodeling will apply all eligible rebates to this invoice. Customer responsible for net amount of$25% of insulating measures when work is completed. Air Sealing portion is provided free to customer by Cape Light Compact. Balance Due from Customer: $597.56 \ Remainder Due from Cape Light Compact: Acceptance of Proposal As stated in the above specification. The costs, materials, and specifications are satisfactory and are hereby accepted. I authorize the contractor to perform the work as specified and payments will be a as summarized above. Customer Date: ?.GIt,0 Signature: Customer - Date: L '.�.. Signature: www.socrates.com. Page 1 of 1 PKt 13-2•Rev.05/04 I w l Efficient Buildings, LLC r October 31, 2011 Town of Barnstable Attn: Thomas Perry, CBO 200 Main Street Hyannis, MA 02601 re: 57 Canterbury Circle, Hyannis, MA 02601 Dear Mr. Perry: This affidavit is to certify that all work completed at 57 Canterbury Circle, Hyannis, MA 02601, has been inspected by a certified Building Performance Institute (BPI) inspector. Work included air sealing, and installation of 928 sq. ft. Class 1 cellulose in exterior walls. All work performed meets or exceeds Federal and State requirements.-,, Sincerely, /teve . White Owner/Managing Member Efficient Buildings, LLC ? 8 Jan Sebastian Drive, Unit 10,"Sandwich, MA 02563 Tel: 508-888-1110 Fax: 508-888-1109 �oFrru row Town of Ba-rmsta bl'e ' 4 t# ti ' ' O F-rpires 6 r r1/r ro re .. ;, 'Reg111atory,,�elwices Fee 1619• �b Thomas F. Gciler, Director a Buildin g Dlvision - Ta m Perry, CBO, Building Commissioner 200 Main Street, Hyannis; MA 02601 www.town.barnstable.ma.us r Office: 508-862-4038 Fax 508-790-6230 EXPRESS PERMIT•APPLICATION RESIDENTIAL ONLY Nnl!Valid wilhoul Red X-Press Irrrprinl Map/parcel Nurnber Property Address eResidential Value of Work ` t 0 0 C—D Minimum fee:of$35,00 forworli uncler$6000.00 Owner's Nam e & Address 3gep10 Go� � aZ Q�r2v' Contractor's Narne Telephone Number Home Improvement Contractor.License.#.(if applicable) Construction Supervisor's License#(if applicable) s g5 CS 3 ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor PRESS. PERMIT . ❑ I am the Homeowner I F Q I have.Worker's Compensation Insurance Insurance Company Name �e f,� TO1/VN OF BARNSTABLE, Workman's Comp. Policy Copy of Insurance Compliance Certificate.must accompany each permit. Permit Request (check box) ❑ Re-roof(hurricane nailed) (stripping old shingles) All constructiondebris will be taken to ❑ Re-roof(hurricane nailed) (riot stripping. 'Going over `existing layers of roofl Re-side ❑ Replacement Windows/doors/sliders: U Value #.ofdoors g (maximum .35)#of windows o *Where required: Issuance of this permit does not exempt compliance with other,town department regulations,i.e.Historic,Conservation,etc. 13 ***Note:.. Property Owner must sign Property Owner Letter of:I'ermission. copy of the Home Impro.Vement Contractors License & Construction Supervisors License is uired. SIGNATURE; ?AWPFILESTORMSIbuildingpermit forms\EXPRESS.doc Zevised 072110 _. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations, 600 Washington Street ' Boston, MA 02111 www.rnass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information / � Please Print Legibly Name(Business/Organization/Individual) LS�lttot2 _Utv 6� c _-C_ty_ ULC_ Address: /}7 t caa oo v2 City/State/Zip: o Phone.#: 'oZ-� ` Are you an employer?Check the appropriate box: Type of project(required): 1.[h 1 am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees full and/or -time .* have hired the sub-contractors ( P ) 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• ❑Demolition workingfor me in an capacity. employees and have workers' Y P h'• 9. ❑Building addition [No workers'comp.insurance comp:insurance.$ required.] 5. ❑ We are a corporationand 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:❑Ro f repairs insurance required.] t F c. 152, §1(4),artd we have no employees..[No workers' 13. Other +e-�comp:insurance required.] *Any applicant_that checks box#1 must also b fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. ;Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state_ whether or not those entities have employees. If the sub-contractors have employees,they,must provide their workers'comp:policy number.- I am an employer that is providing workers'compensation insurance for my employees. Below is the policy andjob site information. _ Insurance Company Name: ����'l S Policy#or Self-ins. Lic. #: f!jt��: . d� 57f1(Q S Expiration Date: Job Site Address: S n a d1r City/State/Zip: 66c/in.1S MA b aka l Attach a copy of the workers' coMpensatio4 policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine. of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi r the pains and penalties.of perjury that the information provided above is true and correct Signafore: Date: O Phone#: 5-0$-,-;2 Official use only. Do not write in this area,,to be completed by city"or.toww 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 m: . Contact Person: Phone#: Informatron-and Ins-tr-uctro-ns-------- - Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. li Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied, oral or written." . An employer is defined as"an individual,partnership,association,corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a decease emp Dyer,-or a--- — receiver or trustee of an individual,partnership, association or other legal entity,employing employees. However the owner of a�dwellmg house having riot.more than three apartments and who.resides therein,or the occupant of the dwelling house of another who etnp'1`o�ys person"s to'do main ena�nce;ticonstruet'on or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,, tat§25C(6)also,ses that `every state or local licensing agency 1hall withhold the issuance or renewal of a license'or permit to operate a business or to construct bi il'dings1hAe com-l-gmwealth1or any applicant who has not produced acceptable evidence of compliance with the insurance coverage`'required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its pol'iti�al 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." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary,supply sub-contractor(s)name(s),_address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees .'a:policy issequired. Beradvised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete'and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you'r6garding the applicant. Please be sure t'6;fill'in the permit/license number which will be used as'a refe dnc.e number In aNition,an applicant that must submit multiple permit/license applications in any given year,need only submithne affidavit indicating current policy;iaforrriatidn hf necessary):and under"Job Site Address" the applicar4"kould write',`all locatlon5 in (city or town)."..A copy of the affidavit that has been officially stamped or marked by the city or town maybe provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone,and fax number: „T1ie Commonwealth of Massachusetts Department of Industrial Accidents - office of Investigations 600 Washington Street Boston, MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Fax# 617-727-7749 . Revised 11-22-06 www.mass.gov/dia as owner(s) of the subject property at: hereby authorize Steve White of Caliber Building And Remodeling, LLC (contractor) to act on my behalf in all matters relative to the building permit application. signature er date signature of owner date Massachusetts- Department of Public Safety Board of Buildim, Rc uulations and Standards Construction Supervisor License License: CS 95038 Restricted to: 00 STEVEN WHITE 147 RIDGEWOOD AVENUE HYANNIS, MA 02601 Expiration: 212&M12 (' mmisi'ncr Tr--: 19311 ✓lie 7°an2meaittaealDc o� �ao6ac�utae ZX Board of Mdiing Regaiation§and Standards HOME IMPROVEMENT CONTRACTOR ReO .,. 154359 _?'18/2011 Tr# 280764 T L'0 Liability,Corporation CALIBER BUILDS G Rl DELING.LLC. STEVEN WHITE 147 RIDGEWOOD/lam .,G..,Q.....` HYANNIS,MA 02601 Administrator License or registration valid for iudlMdul use only before the eapiradon date. If found return to: Board of BoiCdift RePla#ions and Standards One Ashburton-P1aee Rm 1301 Boston,Ma.02168 ANot"' w without signature i ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) 09/15/2010 PRODUCER S08.94S.0393 FAX 508.945.4048 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Eldredge & Lumpki n Ins. Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 697 Main Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Chatham, MA 02633 INSURERS AFFORDING COVERAGE NAIC# INSURED Caliber Building and Remodeling LLC INSURERA National Grange Mutual Ins Co 14788 INSURER B: Commerce Group` CIG001 147 Ridgewood Ave INsuRERc: Granite State Ins. Co.-ARWC 13102 H annis, MA 02601 —-- - y INSURER D: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR DD'l, TYPE OF INSURANCE POLICY NUMBER POLJCY EFFECTIVE POLICY EXPIRATION LTR NSRD 'DATE MM/DD/YYYY DATE MMlDDM/YY LIMITS I GENERAL LIABILITY MP0273601 09/15/2010 09/15/2011 ,EACH OCCURRENCE $ 11000 Q0 X COMMERCIAL GENERAL LIABILITY ,PDAMASES(Ea ocarrence) $ 500,000 I CLAIMS MADE OCCUR MED EXP(Any one person) $ 10,000 A PERSONAL 6 ADV INJURY $ 11000,000 GENERAL AGGREGATE $ - 2,000,00 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS•COMP/OP AGG $ 2,000,00 POLICY PRO- i -- JECT LOC AUTOMOBILE LIABILITY BBNVCS 02/16/2010 02/16/2011 1 COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ 11000,000 ALL OWNED AUTOS [BODILY INJURYBX SCHEDULED AUTOS er 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 D CLAIMS MADE AGGREGATE $ -- $ I I DEDUCTIBLE $ RETENTION $ WORKERS COMPENSATION WC74ZS405 03/02/2010 03/02/2011 TORY LIMITS ER AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ C OFFICER/MEMBER EXCLUDED? SOO,OOO (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ S00,00 Des.describe under _... SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS arpentry CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL � DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL Town of Barnstable IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR Attention: Building Department REPRESENTATIVES. 200 Main Street AUTHORIZED REPRESENTATIVE Hy nnis, MA 02601 Alan R. Lon Presiden ACORD 25(2009101) ©1988-2009 ACORD CORPO ION. All rights reserved. The ACORD name and logo are registered marks of ACORD o 1 KME � Town of Barnstable *Permit# , v(? 6 o Regulator Services empires 6 mon[lrsfrom issue date ��6 o F y ee 1 RARN6TABLE,�t)IThomas F.Geiler,Director mass. i63 , 3 1 « Building Division ®F� Tom Perry,CBO, Building Commissioner P �R/VS7--Aj3 200 Main Street, Hyannis,MA 02601 LE 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 ;f y � &I Property Address ;j -7 /?r l l r- UYt/ XResidential Value of lWork, Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address Contractor's Name Telephone Number ` Home Improvement Contractor License#(if applicable) orkman's Compensation Insurance Check one: ❑ 1 am a sole proprietor ❑ I am the Homeowner I have Worker's Compensation Insurance Insurance Company Name G' 2. CW 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 i ❑ Re-roof(not stripping. Going over existing layers of roof) r V[�Re- icementVindowsoors/sliders. e -�•—�l✓//rv� 7Tl�1 y.� r3 / (� /ace�e.,lt 1 eAr" ro-e {!Ak LUPC-VL Mcw �C�.�� 10. �fC.4rsv[ ❑ Rep U-Value (maximum .44) / *Where required: Issuance ofthis permit does not exemptcomphance with other town department regulations,i.e.Historic,Conservation,etc, ***Note: Property Owner must sign Property Owner Letter of Permission. } A copy of the Home Improvement Contractors License is required. f SIGNATURE: Q:Forms:build ingperm its/express Revised 123107 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street V Boston,MA 02111 www.mass.gov/dia Workers' Compensation.Insurance Affi ftjlji�Vf a f�;g �igts/Electricians/Ptumbers Applicant Information ,6;5 (,ie�a�te�Nn Bead Please Print Legibly Name(Business/Organization/Individual): Cotuit, MA 02635 e• 4 518 I 1-800.262-5060 Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate box. Type of project(required): l N I am a employer with %3 4. ❑ I 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 ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. employees and have workers' co insurance.t 9• ❑Building addition [No workers'comp,insurance comp. required.] 5• ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers'comp. right of exemption.per MGL 12.❑Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.❑Other comp.insurance required.] '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 are doing all work and then hire outside contractors must submit a new affidavit indicating such. (Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the 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,L ' information. Insurance Company Name: Policy#or Self-ins.Lic.#: /7 617'-!j L, 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 Invest/ anon of the DIA for insurance coverage verification. I do hereby certify under the pains an i ry that the information provided above is true and correct Si atu e: Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Client#:47298 CAPIHOM ACORDTM CERTIFICATE OF LIABILITY INSURANCE ToD6A,12/2008 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Rogers 8r 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 EFFECT/YIVE POLICY EXPIRATION LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE MMIDDY DATE MM/DD/YY LIMITS A GENERAL LIABILITY MPB1075H 06/08/08 06/08/09 EACH OCCURRENCE $1 000 000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea o $500 000 CLAIMS MADE FXI OCCUR MED EXP(Any one person) $1 O 000 PERSONAL&ADV INJURY $1 000 000 GENERAL AGGREGATE s2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000 000 POLICY PRO- JECT 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 $ A EXCESS/UMBRELLA LIABILITY CUB1076H 06/08/08 06/08/09 EACH OCCURRENCE $5 000 000 X OCCUR CLAIMS MADE AGGREGATE $5 OOO OOO RDEDUCTIBLE $ X RETENTION $10000 $. B WORKERS COMPENSATION AND WC6716562 12/25/07 12/25/08 X OR STATUS OTH- EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $SOO,000 OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $500,000 If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $500,000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Carpentry CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Town of Barnstable DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL _I 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 #S36540/M36539 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: Registr.`atioii:, 100740 Board of Building Regulations and Standards Expirafyon_ /23/2010 Tr# 267955 One Ashburton Place Rm 1301 Corporation Boston,Ma.02108 • - k„!���v�te CAPIZZI HOME Fly1R] �7EFIIENTANC. Ya r:' Thomas Capizzi,lr_'�.�—�— 1645 Newton Rd. ��1 '• Cotuit,MA 02635 Administrator Not valid without signature / y - _62 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 CAPI=I HOME IMPROVEMENT, INC.. GARY GUSTAFSON 1645 Newton Rd. COtU It, MA 02635 - Update Address and return card.Mark reason for change. - - Address R Renewal Employment Lost Card J� L�007?iY12092UJCQLUL 4��� UdP.�.�b P , Board of Building Regulations and Standards Construction Supervisor License License: CS 74640 Birthdate: 11/29/1975 Expiration: 11/29/2008 Tr#�6430 -- '`"':> Restriction: 00. GARY GUSTAFSON l 8 SHON-f WAY � • SANDWICH,MA 02563 Commissioner Page 7 of 7 CAPIZZI HOME IMPROVEMENT INC. SPECIFICATIONS AND ESTIMATES STATE OF MASSACHUSETTS LETTER OF AUTHORIZATION TO APPLY FOR A BUILDING PERMIT I, j l'o r 60 OWN THE PROPERTY LOCATED AT IN N y�( �k 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 CODE. SIGNATURE OF OWNER: OWNER'S ADDRESS: OWNER'S TELEPHONE: LESSEE'S SIGNATURE: LESSEE'S ADDRESS: LESSEE'S TELEPHONE: APLLICANT'S SIGNATURE: APPLICANT'S ADDRESS: 1645 Newtown Rd., Cotuit, MA 02635 APPLICANT'S TELEPHONE: 508-428-9518 RESPONSIBLE OFFICER: RESPONSIBLE OFFICER ADDRESS: RESPONSIBLE OFFICER TELEPHONE: �pFE rti Town of Barnstable *Permit o �IT Expires 6 moudlisJrom issue date X'P MASS' � Regulatory Services Fee 1 9 7 Thomas F.Geiler,Director D p Building Division T�— TOWN O� ggRNSTABLE Tomi Perry, Building Comn*sioner 200 Main Street, Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - ,RESIDENTIAL ONLY Not Valid H1ftkout Iced X-Press Imprint Map/parcel Number 9 Property Address -5-7_ C�I J'J",e—4,6 �U C Residential Value of Work , SLR, Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address ,�X✓� d �/� iq VAS AIX Contractor's Name 44X!-J 6 u67,4,,' , 6.j Telephone Number Horns Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) KIWorloman's Compensation Insurance Check one: ' ❑ I am a sole proprietor - ❑ I am the Homeowner. ER I have Worker's.Compensation Insurance asurance Company Name Vorkman's Comp.Policy# ;7%p •opy of Insurance Compliance Certificate must be on file. emlit Request(check box) El Re-roof(stripping old shingles) All constr ctionidebris will be taken to ❑Re-roof(not stripping. Going over existing layers of root) ❑ Re-side 7/2rr ,�1 �N� �//U,6,0u)S NV -A Replacement Windows. U-Value ( , . (rnaXlIllur11.44) *Wbere required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. Home Improvement Contractors License is required. I nature )n-ns:expmtrg se063004 �,�Pf`?�• n� .k.•sue r � .�. P. a.. � � �'� �.�',;`. r, .���; S'f��t� F-'d��.��' q,.td�',��,k�gmY9��:•. .iy�# � r, & ,a`E`. rl ,Y-,s,* � kx���ri:�¢d � Wtl . , �< Emig :* ^,r,.i k,!i I AND d+n' + ',+:s,�- Sw�L'' .a'd `tt � f>, y.�t' r,SP 1a r s E s%'t✓ s r , e _ 0 omit �r a ' d � $d�t'��t"»m�'+:.��o�S a����r�� �•�µa rr t -rP... e ' f` kf.1 .�'�> t� ��� T� 3i� �r E A Y v` d rA K a r µ.' `� " 4 t ,.;r• }` p.�°r'°! � �p ,v t/1 r E� gid �2 i.'tn •:t' z � ,''.�� f r�a` stx� 'fW r c s ei �S�,,a3-� fy < SEW i'j d r- ;fi r ,i, Y Alt: ^ trs ar it a # w d� r ... M..N Una ,..-.. ^'- § 3 s Fun y `z _ bT'�rs� !yx:.. T M�IAA .. ';' PS f i €. y. .l�p" p. su a E��< d:, S.✓ `�+° ," i,,.t ,,.,�41 :. ,� t A AP _"` ,4 f !l.. '�.'. ..»$`•'' f rr 't - .r; rr,. tG:� g tR f"aMENWas 'a r,.v�. f ..,.•;.rr 3r ; ,;d F..;i& < ,xs ,ka # � "'; ':: .X. .ro^r pan ^ „ _ 'r }� ,ram- •,C , T c: s�A }'x +„ �`$:�1" � �.: <�,.;�. �•°<- a`� r'�" ..:,, .rr,.s';.: s F,�'' .,� ^,5 ��"'�� ":� .:f�:i ^ �V all t;7 i„„t,3°'vP 1;: `P .�s s W. " +t" Y"�` ,�:.:. k r r t t' ,✓ a s.,r1a.�. "' 4 's': '� "d c,,, . .t too, # .f h'� °sr r k .x a.2'r'" ,.,,.. .a..Pj .: '.r "t d r f r ,r — ..::,Y. - -? i LS ,xN,- i ,� :^,s.,'. +`d`p; sa ^s ,$ xs p t q}, l " `i'p "` r-' C �::�5 ,.. .v P r �: �., x":d fy S.< `�.f,.3 l� ;.,p §.+sF a:t, £ :ya�� �d f,g-•, \• ff� t.. ,,�" �4„y. ti � q ._ „y�' id" d."s£ .tx a:♦. ' t! a ,x ;.,a§ . ^ tt .' .^4 fs ,:d::.:. f ..,' .-�". Yi i+ a" � p ,s � wc�% „r " t-S"P. r'' SON P ^E er°..^. 'k ! rv`d'� k P, � > t,. f� a$, y` 1`r� us - *�, '} lA '«. .:m, :sw�z,^:s�� _, 4N a. i�- s °� to a ' r'' .^"1� '� �� 9� AW . r` + rs � tv .w,` e�'"4°TJ s `` .. a' a`!' �€ 4y 4 k e Pn�;•'v� NIP Eiji � t,g� 1 y✓''a�= k.'�-'P" .. , .� ' ai" ,-i x�+F-r ,rr a 0 `''�* a•> P t q Pr p' "s�.n 3 - sssM :s '• 3 .t3 p fw r. B fE:a�. , a ,dw a 0 `,r g�n'� ; Page 7 of 7 CAPIZZI HOME IMPROVEMENT INC. SPECIFICATIONS AND ESTIMATES STATE OF MASSACHUSETTS LETTER OF AUTHORIZATION TO APPLY FOR A BUILDING PERMIT I, �I C&.c--a � OWN THE PROPERTY LOCATED AT 1i IN �.f ,F , MASSACHUSETTS. I HAVE AUTHORIZED CAPIZZI HOME IMPROVEMENT TO ACT AS MY AGENT TO APPLY FOR A BUILDING PERMIT IN ACCORDANCE WITH 780 CMR, THE MASSACHUSETTS STATE BUILDING CODE. I GIVE MY PERMISSION TO LESSEE TO APPLY FOR A BUILDING PERMIT IN ACCORDANCE WITH 780 CMR, THE MASSACHUSETTS STATE BUILDING CODE. SIGNATURE OF OWNER: OWNER'S ADDRESS: OWNER'S TELEPHONE: LESSEE'S SIGNATURE: LESSEE'S ADDRESS: LESSEE'S TELEPHONE: APLLICANT'S SIGNATURE: APPLICANT'S ADDRESS: 1645 Newtown Rd., Cotuit, MA 02635 APPLICANT'S TELEPHONE: 508-428-9518 RESPONSIBLE OFFICER: RESPONSIBLE OFFICER ADDRESS: RESPONSIBLE-OFFICER TELEPHONE: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leafty Name(Business/Organization/Individual): rae1771 Hntna ImnrnVPMen4 Inr 1645 Newtown Road Address: Cetbtit, M�! 8�6�� Tel.428.9518 jk80Be2�2-5060 City/State/Zip: 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 a" 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 8, ❑Demolition working for me in any capacity. employees and have workers' g ❑Building addition [No workers'comp.insurance comp.insurance.t required.] S. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I LEI 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 e employees.[No workers' 13.❑Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'con> mmtion policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew afdevit 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. lam an employer that is providing workers'compensation insurance for my employee& Below is the policy and job site information. G Insurance Company Name:�a /�96 tF r-�" � �/Q4 7'J r�J Policy#or Self-ins.Lie.#: f ti dl g?•6. 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 coverage verification. I do hereby certify under the pains andpenaldes of perjury that the information provided above is true and correct Si ature: p '! Date: Phone Uffuurl use only. Do not write in this area,to be completed by city or town offieiaL 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#: 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: 6/212008, Boston,Ma.02108 Type: Supplement Card CAPIZZI HOME IMPROVEMENT,I Ui RY GUSTAFSON - 1645 Newton Rd. Cotuit,MA 02635 Administrator t valid with t Sig tore Board of Building Regula ions and Standards One Ashburton Place Room 1301 Boston. Massachusetts 02108 Home Improvement Contractor.Registration Registration: 100740 Type:, Supplem ent Card Expiration:x 6/23/2008 CAPIZZI HOME IMPROVEMENT, INC GARY GUSTAFSON - 1645 Newton Rd. COtu lt, MA 02635 . Update Address and return card:Mark reason for change. Address Renewal Employment . Lost Card _ - pp �/ze i�a�r�irixa�zcueall� a�:�t/�aaa¢c?uaP,�Xa :" = Board of Building Regulations and Standards Construction Supervisor License License: CS, 74640. I Birthdate: 11/29/1975 Expiration: 11/29/2008 Tr# 6430 ; `. Restriction: 00 GARY GUSTAFSON I 8 SHORT WAY SANDWICH,MA 02563 Commissioner I zx - a � = � rF n 7 glo y - - a•�r..d 3�:.�3mM�,Sewn. ' k+a'•%.''� d' ,,_-. Date: 10/4/2007 Time: 12:26 PM To: t4 9,1,508-420-0318 R&G Ins. Agcy. Page: 001 Client#:47298 CAPIHOM ACOR& CERTIFICATE OF LIABILITY INSURANCE 08T13�;Y) 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.0.Box 1601 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. South Dennis,MA 02660-1601 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: National Grange Mutual Ins.Co. Capizzi Home Improvement,Inc. INSURER American Home Assurance Capizzi Enterprises,Inc. INSURERC: 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 INSRI TYPE OF INSURANCE POLICY NUMBER DATE MMMD DATE MMIDD/YY LIMITS A GENERAL LIABILITY MP010707 06/08/07 06/08/08 EACH OCCURRENCE $1 000 000 X COMMERCIAL GENERAL LIABILITY DAMAGE ETO RENTED S(Fa occurrence, $5OO OOO CLAIMS MADE a OCCUR PREMISMED EXP(Anyone person) $1 O 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 POLICYF_j PRO- JECT LOG 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 LIABUJTY AUTO ONLY-EA ACCIDENT $ ANY AUTO EA ACC $ OTHER THAN AUTO ONLY: AGG $ EXCESSIUMBRELLALIABILITY.' EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION $ $ B WORKERS COMPENSATION AND WC1764953 12/25/06 12/25/07 TWO CSLTATU jMrr OTH- EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACHACCIDENT $500,000 OFFICER/MEMBER EXCLUDED?If E.L.DISEASE-EA EMPLOYEE $SOO OOO SPECIAL AL PROVISIONS ISIO E.L.DISEASE-POLICY LIMIT $500 000 SPECIAL PROVISIONS below 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 DAYS WRITTEN 200 Main Street NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO 00 So SHALL Hyannis,MA 02601 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 25(2001108)1 of 2 #S303751M30374 DD ®ACORD CORPORATION 1988 APIZ4Z, HOME IMPROVEMENT I,Gary Gustafson, Production Manager of Capizzi Home Improvement,Inc.,hereby authorize Jan Donnelly to sign on my behalf for permit applications filed through the town. Signed: O7 Gary Gus fs4 ate n Donnelly - Date 1645 Newtown Road, Cotuit, Massachusetts 02635 • Tel. (508) 428-9518 Toll Free (800) 262-5060 Fax. (508) 428-1547 • Email: chi@capecod.net Website: www.capizzihome.com 2 fie? b�PyOFTHET��y� TOWN OF BARNSTABLB i EARNSTOHL p� "b 9 BUILDING INSPECTOR 'Fp M a APPLICATION FOR PERMIT TO .. ........ TYPE OF CONSTRUCTION ............... :......... �/.. .................................................... .........c . `-...Z...........19.2;—; TO THE INSPECTOR OF BUILDING : The undersigned hereby applies fo a per it according to the following information: Location .......... ..L. .. (�. ..�i�R'��-mod• . ...... � �'� ... Proposed Use :C'.-C.. . .- ...... ZoningDistrict ........................................................................Fire District .............................................................................. Name of Owner `. Address , Name of Builder ... ¢P:�...Address ......................... '..................... Nameof Architect ......... ..........:...........................Address ........, .....--:..................................................... Number of Rooms .................. .............................Foundation .........: �5��t!L.. .: ...........,.............. Exterior .....W..�a ..:: ...Roofing ........, 7 �-z, A, ... Floors ... ............................Interior ......... .�,,-. .. ................................ . Heating .....g .`' •.. �� � ...Plumbing .................. .. . 1.�1/la—....'a�� �............ Fireplace ...........-Approximate Cost Definitive Plan Approved by Planning Board -----------__________________19 Diagram of Lot and Building with Dimensions / .�,__ SUBJECT TO APPROVAL OF BOARD OF HEALTH f E /\ Lu X LtJ (9 OL U) m Z a, `\ Ln 000 ZQ � LJ.1 � W < Q .5 to LL0 - i Fr Li. Ld, O to l`o � ! ocn ¢ ) Z � w 0 in = a. Ld C) a- cam. I— 4iji =�-1----Q-Q 0U LU .F 4 tY W H w'� Q VL. Lt1 C� Q �� P I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name .�.. .... ........ Cedar Acres Realty Trust No ...15328 Permit for ........one story........ single family duelling ............. .............................................................. Locatioo Q Canterbury Oircle ................................................................ Hyannis _ _ ............................................................................... Owner Cedar Acres Realty trust f Type of Construction frame .......................................... Plot ............................ Lot ...........15.................. Permit Granted .......August 4...............19 72 Date of Inspection .............. ......I.... .........19 Date Completed ..'3 ...... ... ... ........19 PERMIT REFUSED ................................................................ 19 ............................................................................... ................................................................................ t i Approved ................................................ 19 ............................................................................... ...............................................................................