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HomeMy WebLinkAbout0052 HOMEPORT DRIVE �: ��� i Kip zO' 24e� - 12lo i i Town of Barnstable *Permit# Q Expires 6 months from issue date Regulatory Services - Fee Thomas F.Geiler,Director • ` " �A, MIT Building Division .Tom Perry,CBO Building DE 7 ZUO� ry g Commissioner 200 Main Street,Hyannis,MA 02601 TOWN OF�Ap -I���� www.town.barnstable.ma.us Office_ 508-8�2°-4 �8 _ Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number&Q% - alp Property Address J C� Residential Value of Work�\Cm , Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address��� �),•X�_\I Contractor's Name �' �� 1_ \ I?? `'�11p � Telephone Number6' Q�1 , Home Improvement Contractor License#(if applicable) �. Workman's Compensation Insurance Check one: ❑ I am a sole proprietor. ❑ I am the Homeowner I have Worker's Compensation Insurance Insurance Company Name k)C�M Workman's Comp.Policy Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) ❑ Re-roof(stripping old shingles) .All construction debris will be taken to Re-roof(not stripping. Going over existing layers of roof) 'Re-side 1 Replacement Windows/doors/sliders.U-Value (maximum.44) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A co y of the Home Improvement Contractors License is required. SIGNATURE: Q:Fonns:buildingpermits/express Revised 123107 CAPIZZI HOME IMPROVEMENT INC. Page 7 of 7 SPECIFICATIONS AND ESTIMATES STATE OF MASSACHUSETTS LETTER OF AUTHORIZATION TO APPLY FOR A BUILDING PERMIT I, OWN THE PROPERTY LOCATED AT IN , MASSACHUSETTS. I HAVE AUTHORIZED CAPIZZI HOME IMPROVEMENT TO ACT AS MY AGENT TO APPLY FOR A BUILDING PERMIT IN ACCORDANCE WITH 780 CMR, THE MASSACHUSETTS STATE BUILDING CODE. I GIVE MY PERMISSION TO LESSEE TO APPLY FOR A BUILDING PERMIT IN ACCORDANCE WITH 780 CMR, THE MASSACHUSETTS STATE BUILDING CODE. SIGNATURE OF OWNER: LL OWNER'S ADDRESS: OWNER'S TELEPHONE.- LESSEE'S SIGNATURE: LESSEE'S ADDRESS: LESSEE'S TELEPHONE: APLLICANT'S SIGNATURE: APPLICANT'S ADDRESS: 1645 Newtown Rd., Cotuit, MA 02635 APPLICANT'S TELEPHONE: 508-428-9518 RESPONSIBLE OFFICER: RESPONSIBLE OFFICER ADDRESS: RESPONSIBLE OFFICER TELEPHONE: Client#: 47298 CAPIHOM ACORDrM CERTIFICATE OF LIABILITY INSURANCE 06112/2oo$YYY, 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.O. Box 1601 I iSouth Dennis, MA 02660-1601 _ INSURERS AFFORDING COVERAGE NAIC# —_ wsuREO NSURERA. NGM Insurance Company I Capizzi Home Improvement, Inc. INs:,RERa American.Home Assurance _ Capizzi Enterprises, Inc. NSJIREI c — 1645 Newtown Road ------- - -- -- i Cotuit, MA 02635 INSURER 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT?C'NHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO AL'_THE 7ERNIS EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY?.AID CLAIMS.. POLICY EFFECTIVE POLICY EXPIRATION LTR NSR TYPE OF INSURANCE POLICY NUMBER { DATE(MMIDD/YY) DATE.fMMIOD/YYI LIMITS A ! GENERAL LIABILITY MPB1075H 06108108 06f08109 ;--ACH OCC;oRRE.NCE $1 000 000 X COMMERCIAL GENERAL L ABti DAMAGE TO RENTED PREMISES Ea c rr n $500 OOO i CLAIMS MADE I X I OCCUR VIE,cXP(Any one person) $1 O Q00 OERSONAL&ADV INJURY $1 OOO 000 GENERAL.AGGREGATE s2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER PRGO:.IC tS-COMPlOP AGG $2,000,000 POLICY 7 IE� :_-:G ' -T i !AUTOMOBILE LIABILITY —OMB:NED SINGLE LIMI! j S 1 ~� ANY AUTO ;Ea acudenl) I I �l ALL OWNED AUTOS i BODn :N.U!ZY -T------ SCHEDULED AUTOS - •{P0,oerson; $ I I HIRED AUTOS -- -- f� _ I BOU.'r INJURY NON-OWNED AUTO., P;er acc,neni) I :PROi,FRTY DAMAGF i$ "ent GARAGE LIABILITY AJ-0 ONLY•EA ACCIDENT $ ANY AU'f 0 _ EA ACC $ rIE.R'I HAN A�;-O ONLY AGG $ A EXCESS/UMBRELLA LIABILITY CUB1 O76H L 06/08/08 06/08/09 AGH OCCURRENCE $5 000 000 X OCCUR CLAIMS MADE AGGHEGATE _ $S 000 000 ' ----- $ DEDUCTIBLE $ X I RETENTION $10000 - $ B WORKERS COMPENSATION AND - IWC6716562 12/25/07 ' 12/25/08 TX'-',,aYFELI OTH- EMPLOYERS'LIABILITY - I ITS ANY PROPRIETOR/PARTNER/EXECU''n,E -_ EACH ACCIDENT $500,000 OFFICER/MEMBER EXCLUDEO? DISEASE•EA EMPLOYEE $500,000 If yes,tlescnbe under t•= SPECIAL PROVISIONS below __ = DSEASE-POLICY LIMIT $500,000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS I 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 1 n DAYS WRITTEN ZOO 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. I AUTHORIZED REPRESENTATIVE - ACORD 25(2001/08)1 of 2 #S36540/M36539 KW © ACORD CORPORATION 1988 t 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 RegistrAtISPO;, 100740 One Ashburton Place Rm 1301 p�it'g "- 23/2010 Boston,Ma. 02108 1r/i lement Card c =�7Q AP - , PRIER 1'y=1. t CAPIZZI HOME.,, R.,E INj1 Tl I tARY GUSTAFS©ty=1yJ 1645 Newton Rd. Cotuit, MA 02635 Administrator i�o vali itho,Y nature Massachusetts- Dq),11111, of &t:tr?I apt'6uIi�I►.3 1ti: tlk'601's :""I s rlrp4� rril.ti OOrlstructlOn .SuPeNisOr 'License License; CB 74640 a it [ Re.sts•icted u;. 00 GARY GUSTAFSON X b SHORT WAY '- SANDWICH, MA U563 11/29/2010 . 7755 The Commonwealth of Massachusetts Department of Industrial Accidents u v Offtce of Investigations 600 Washington Street Boston, MA 02111 rvww.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Informatton UX • Please Print Legibly bl Name (Business/Organization/Indaidg64.5 Newtown Road Cotuit, MA 02.635 Address: jet 429-951811.800.262.5060 t City/State/Zip: Phone.#: . Are you an employer? Check the appropriate box: Type of project(required):. 1� I am a employer wife_ 4. ❑ 6.•I am a general contractor and I ❑ .New construction employees(full and/or part-time).* have hired the sub-contractors 2.El 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 tY• 9. ❑ Building addition [No workers' comp. insurance comp. insurance.$ F 10. Electrical re airs or additions required.] 5. We are a corporation and its ❑ P 3.❑ q ] officers have exercised their 11. Plumbing repairs or additions I am a homeowner doing all work � g p 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'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: Policy#or Self-ins. Lic.#: � ��nSlf�� Expiration Dafe: 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 may be forwarded to the Office of Investigations of the D4A for insurance coverage verification. -I do hereby-certify- nder--the pld-penalties of-perjury-that-the-infor-mation-pro,vided-above is true-and correct._ Signature:, Date: a _ Phone#: Official use only. Do not write in this area, to be completed by city or town official. City.or Town: Perm t/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#: