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HomeMy WebLinkAbout0014 MARSH LANEF ' 7 �cpS Town of Barnstable *Permit# Expires 6 mont s from issue date Regulatory Services Fee 7 Y =nnxsrnBr.E * 9 Mass,639. 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 PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number 3 7.14 of 3 Property s MA Addres . V1 PY h esidential Value of Work I-la G Minimum fee of$35.00 for Work under$6000.00' Owner's Name&Addressc l(t i yls Contractor's Name /�,���z r7 4.TC,(n y�a Telephone Number Home Improvement Contractor License#(if applicable) Construction Supervisor's License#_(if applicable) IT ❑Workman's Compensation Insurance Check.one:. . ❑,I am a sole proprietor N�� 2.6 2012 ❑ I Ja M. the Homeowner I have Worker's Compensation Insurance Insurance Company Name TOWN OF BARNSTABLE Workman's Comp.,Policy# GGG/ Ti Kr l 1 C s / Copy of Insurance Compliance Certificate must accompany each permit. .Permit Reques eck box) e-roof(hurricane nailed)(stripping pld.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 mar(ed with red S.andinspections 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&Construction Supervisors License is required. SIGNATURE: y C:\Users\decollik\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\QRE6ZUBN\EXPRESS.doc Revised 053012 I The Comynonweralth of Massa djusetts Deparhnent of Ladrrstrfral Accidents Office of Im estigations 600 Washington.Street Boston,MA 02111 n4vfv.Yn as&gvv1dada Workers' Compensation Insurance Affidavit: Builders/ContractorsJ'EIectcaciaIIs/Plumbers Applicant Information Please Print Legibly Name(Busmesslorgauizationllndivida i)- �f r�11r r /Y�21.ra tares Address: City/State/Zip: t ,5�v' ,� G Z( 3 I Phone 47 S CY Sjm/ 63 7>' Are you employer?Check the appropriate boa:: Type of project F ro'am a eneral contractor and I (required): 1. am a employer with Z-- ❑ I g 6_ ❑New construction employees(fall and/or p -rim _ have hired the sub-contacts 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7- ❑Remodeling ship and have no employees These sub-contractors have >i_ ❑Demolition working for me in any capacity. employees and have workers' 9_ ❑Building addition [No worlms'comp.insurance comp_insurance-1 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.] •Aay applicant that checks boa#1 mast also fill out the section below showing their wwkers'compeosatiou pnlicq iufarM3t®arL .Homeowners who submit this affidavit indicating they are doing all wcA and rhea hire outside contractors guest submit a new affidavit indicating such lContractors that check this box must attached au addition al sheet slrowa the name of die sub-ccutraeWis and state whether at act those entities have employees. If the mb-contra€tors bhave Employees,they mug provide their warkwO comp.policy aw nber. I ate an employer that is pm4dirrg workers'compensrttiou inmirance for rrry employees. Below is thepolicy and job site iiaforffrrrlia�b Insurance Company Aflame: pG�, �� J Onc,, / Policy 4 or Self-ins-Lic.9: 6&1 E-4 ft 110 t / Expiration Date: Fob Site Address: l C� (n�r S 4 L t� City/State/Zip: 1� c s 01-t Attach a copy of the workers'compensation policy dectaration page(shoring 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-yinff 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.forwuded to the Office of Investigations of the DIA for insurance coverage verification_ I do hereby certify wader the pirins and peuahfes of pellity that the inforinaton pro ded rabmw is brae and correct Signature: Date: 1/ /4:b L Phone#: ti_GSr Y y(.-(3 7 offleial use oufy Do not write in this area,to be completed by city or town official -- City or Town: PermitUcense# 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#: " f Nlussachuxetts.- Department of Public Safety : :~ Board of Building Regulations and Standard. icense- License: CS 99258; MICHAEL-HUTCHINSON,- - PO BOX 534 BREWSTER, MA 02631 . Expiration: 12/25=13 {'�nuni .iunrr Tr#: 7285 t.-Q Office of Consumer Affairs&B stness Regulation HOME IMPROVEMENT CONTRACTOR Registration:,�U8330 Type_ Expiration 3k 642013, DBA HUTCHINSON ROQFPA- ,w", MICHAEL HUTCHINSW 26 MAURY LANE BREWSTER:MA.0201 ' =4 Undersecretary r � valid for md►vidul.use only re rstration 1f fo. ieturn toy or, g date: °IId 1,►cense iration a ulat►on. before thc.exp er Affairs and Business R g e C.onsum t ;; Off►ce of Suite 5170 " 10 FarkYlaza- - Boston,MA 02116 without signature Not yalid r �TME A • snxxsTnsM MAW Town of Barnstable Regulatory Services Thomas F.Geiler,Director Building Division Thomas Perry,CBO Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I, il �; 1/ (,i ,as Owner of the subject property hereby authorize di��� � �1 Z 54:4/ to act on my behalf, in all matters relative to work authorized by this building permit application for: i ,s (Address of Job w I e of Own Ur Date Print&ame If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. C:\Users\decollik\AppData\Local\Microsoft\Windows\Temporary Intemet Files\Content.Outlook\QRE6ZUBN\EXPRESS.doc Revised 053012 CERTIFICATE OF LIABILITY INSURANCE DA o`417/20 �' THIS CERTIFICATE IS ISSUED AS A HATTER OF INFORMATION ONLY AND CONFERS BO 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 - I9SURANCE DOES NOT COHSTITUTE: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 - - Miller McCartin am` PNmiE' '. PA: dba Dowling & O'Neil Ins Agcy ('�`"Be. n`t'° E-IUIL - 973 Iyannough Road ADDRESS: PRODUCER Hyannis, MA 02601 CUSTOMER ID'° Imv=(S) AarORDING-CUvU&pE ®IC R INSURED IRSORER A: A.I M. Mutual Insurance Co - 33758 Michael Hutchinson' . CENSURER e: dba Hutchinson Roofing INSURED C: P 0 Box 534 LSD, D: Brewster, MA 02631 INSIIRER E: INSURER r: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN.ISSUED TO THE INSURED NPHED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIR@gNT, 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 REDO® BY PAID CLAnIS. - POLICY NUMBER" POLICY Err POLICY EXP LIMITS - TYPE OF INSURANCE nan■nY■r� mrmnYTr� GENERAL LIABILITY - - EACH OCCMRANCE 11capILRCIAL GENERAL LIABILITY DAMAGE TO arareD i PRaiifxstea.eceaaenee) ❑❑CW IMS MADE - ❑OCCUR DEW ESP (A^Y a _ PERSONAL L ADD IRUURT . GENERAL AGGREGATE i GER'L AGGREGATE LIMIT.APPLIES ER: - -0—�LOC - ❑ PRODUCTS- CDIM/DP:AGE i Pm1ICZ - - -- .. - AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ❑ANY AUTO _ - ` lea aDofdentl S. -i BODILY INJVRY(per-pervam) i ALL OIRLD ADIOS - - - ❑SCHEDULED ABIOS BODILY INJURE(Per awident) nNIRED AUTOS PROPERTY DAIDI CE 1pa ee A—t) i 5R011-OWRED AUTOS .. 4 [1UMUE1,LA LIAB 1:1 OCCUR - BACK OCCURRENCE i EJEICLSS LIAB a.CLAIIS MADE - - AGGREGATE i FIDEDUCTIRLL i WORKERS COMPENSATION - ® R sTara- oyU_ AND EZELOYEES LIABILITY - TUR Smx. .ICE - THE PROPRIETOR/PARTNERS/ - EXECUTIVE OFFICERS ARE .. ti.L. EACH i<ccrDENr.. i. 00,000 I A E.L. DISEASE-POLICY LIMIT Soo,000 ® incl excl 6006598012012 {. O1/15/2012 Ol/15%2013- E.L.DISEASE-EYaRn°uaE i 100,000 COMMENTS DESCRIPTION Or OPERATIONS OR LOCATIONS: MICHAEL HUTCHINSON. IS COVERED BY THE WORKERS' COMPENSATION POLICY J CERTIFICATE HOLDER CANCELLATION WHALEN RESTORATION SERVICE_ SHOULD.ANY OF THE ABOVE DESCRIBED POLic=s BE CANCELLED BEFORE THE . EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED ICE ACCORDANCE WITH.THE 22 AMERICAN WAY - POLICY PROVISIONS.. SOUTH DENNIS, MA 02660 AUTHOR IXCv IMPReaaTATIM 9037 FTHET��yn TOWN OF BARNSTABLE Z BA"ST"LE. i " 0 b 9 BUILDING INSPECTOR �'p MPY a• , APPLICATION FOR PERMIT TO . iv1...P. ©P7 e.......... TYPE OF CONSTRUCTION .........(aQ�.....T. 715?1 d....... /. ? ..., ... ........r, ..!tied �.......... ...........��.�Y............................, TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to thhe� following information: location .�Valr`.�f/...2(�.`1.a.... ......4 N -S...... �Ir! .6,0S/ d 60 . ....... ............................................. J L ProposedUse 11/G L;,e...... ................................................................................................................................. ZoningDistrict .......1.5A.........................................................Fire District ... ..!............................................................. Name of Owner l'��e/"�.. c..rQl7612.................Address ./..vl CiY�tP� �� C01�1O✓'��li Di7�fG2 . .................. Name of Builder ...54?lf. ...5A .(w r c.fir?......Addressy COd/<O/ D_ fsJ� A/ 0� 0l� Name of Architect�o��f.�itry l!Y. .ls' .....1J..�l!Y!�.:�li:'.�1...:��..�. .... ./�.............................Address Numberof Rooms ...............................................................:..Foundation ..................................... Exterior .............................................Roofing .1� aCl ....5' /./.1��1 ..........,........................... Floors ... Vaod....................................................Interior .assz�/:":..... �7hlf.....Ge�G9Q�......................... �` CP /'J Qf / Heating 1.1�C.... .....Q..... .........f'............................,i....Plumbing ..L gyp. �f"... G/ .e....."........ ..:, Cf J, Fireplace ......................................................................Approximate Cost ....... ; J ........................ Difinitive Plan Approved by Planning Board --------------------------------19-------- . / 02 7 < s Diagram of Lot and Building with Dimensions THE POSEDNhO .. SAIVIT ME OF AND DARY WATER SUPP t' LG', : . r`G ;� ; LY, SEWAGE DISPOSAL RAINAGE IS HEREBY LD - 70UVN OOF�AR NSTABLE, �- BOARD OF HEALTH A LICENSED INSTALLER MUST OBTAIN SEWAGE PERMIT. AND INSTALL SYSTEM. hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. ,.,,,4- ,//G.61,A. ... .............. kJohnson, Albert D. 311971. 12358 1 1/2 story, ................. Permit for .................................... single family dwelling .......................................................................... Location Marsh Ln. (off Gosnold St. ) .............. ......................................... .........................Hyannis...................................................... Owner ..........Albert D. Johnson ........................................................ Type of Construction ............... rpqnf!................ ........... Plot Pe��..... Lot ......................... t Permit Granted ..................may 6......................19 69� y" 4 Date of Inspection .... ..........19 Date Completed ....... 19�114�11t. 114...... 4)'cf- 40*,eA 7-b C—' ft P r—e7-.'6AJ 2/- r7/ PERMIT REFUSED ................................................................ 19 ............. 4 ................................................................................ ............................................................................... Approved ................................................. 19 ....................................................................... ........ kr ............................................................................... i • r � I I i_ Iw i _1. _ t I' ` �- ' - i__LI_ ' !_! I I !J_L_ 4-4 I 1 I ! ! '_ r I !. f ! i . + .._I_ _! { +�'+'1' i� t+I'tir4ti"lllllt'`j{ !-.I_-T.�_._ - - r _.7 { - _.. 1_ f _ ! i )�!_ III ; o I_ + I..__ I- ~ t ! LIIj III'4 t 1 UJIL', -I-� I i J I {- L -� t i I_�.i- -.I� _LJ. )_ !_ r 1,. it it I I -I I I - ! ! I' I -!-Ir- I�J�t -1 4.-.I L, :� �IIt,! it, -� _ q I- - - OuSf�I _ _ �I_ 0.. I �-,!�-I_i I I -i -; I -1:1.' _-I=�-- I-I-;_- _I- i- ! {- (_ 1_I I ._1J_ _ ?. I I. - II I I f I1 I � I-!i- -�--! I I I I ! I_j_ I i � I I I -�- i I`1 I r i-I I " I I I 1 I iJ+ I I• 1 i-% ! ! iL1=1 _L� J (.I l-1_ 7 I--� �� _I_L _� _I 1_i -�� I _ _ t 1 I� ! 1 �__Li-I-i -I i i'i i �L I l_L ! i_i ., _Lj__ i ! + I L!E I I ±_;_ I ! I ! I J I 1 .• I-- T-+ , ;_I-I , -L- f- 1_I-� ) -•-r-I_���-- L __I _,_ 4_:! L---I_._± � :_ ! i ! � -I� I I I ,-�1.i ice- -I !- i ��,• ,-! !, IJ i �-_- � ! �� i ��I -� H �-- I_ -t- - ! - I -I-' r , �. THE PROPOSED METHOD OF PRO ,� II �v r SANITA-RY--WA-T-ER-SU.P_PLY,_SEWAGE DISPOSAL AND DRAINAGE IS HEREBY r�:�vER� �� TOWN ,OF BARNSTABLE, � r BQARD .OF HEALTH. NSTALLE-R -MUST- OBTAIN SEWAGE A LICENSED 1 I PERMIT: AND INSTALL SYSTEM. t �oFtHe Tqy Town of Barnstable *Permit#7 �a ,xP p Expires 6 months front Issue date CO snxr�sTnet>;, ' Regulatory Services Fee t y nsass. $ cb 019. Thomas F.Geller,Director A'EDM1°r� Building Division �� Tom Perry, Building Commissioner PERMIT. 200 Maui Street, Hyannis,MA 02601 SEP 2 ?004 Faxi Office: 508-860 2 438 TOWN OF BARNST�CE v EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY B l Not Valid without Red X Press Imprint Map/parcel Number Property Address 1 l I�V� VI lA0,In 1�Residential Value of Work 4 l/y�6, Owner's Name&Address kwd 47bwt , 0 61'1'16 Contractor's NameMM Telephone Number pg. q� Home Improvement Contractor License#(if applicable)/Q ® -7 r i' 7 Construction Supervisor's 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 t. A ULI Workman's Comp.Policy# Permit Request(check box) ❑ Re-roof(stripping old shingles) ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side w -Value maximum.44 �� r�""�p� ✓ '"' . cplacement Wmdo s. U ( ) P Other(specify) '(� 7? �' t►` 1 `�W o `a" ' *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. Signature Loam � ,o Q:Forms:expmtrg Reviscd121901 - S CAPIZZI HOME IMPROVEMENT INC. SPECIFICATIONS AND ESTIMATES PAGE 6 OF 6 STATE OF MASSACHUSETTS LETTER OF AUTHORIZATION TO APPLY FOR A BUILDING PERMIT I, k �G OWN THE PROPERTY LOCATED AT�_� ��L 1,�11 1 IiC i IN A MASSACHUSETTS. I HAVE AUTHORIZED CAPIZZI HOME IMPROVEMENT INC. 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: 5081428-9518 RESPONSIBLE OFFICER: RESPONSIBLE OFFICER ADDRESS: RESPONSIBLE OFFICER TELEPHONE: ACCEPTED BY ` DATE THIS PAGE IS ART OF AND IN CONFO ANCE WITH PROPOSAL # I -- The Common wealth of Massach"sells __ 6 Department of Industrial Accidents Ulllce ollnivesftadoos 600 Washington Street Boston,Mass. 02111 Workers' Compensation Insurance Affidavit a C.Q r location: c1ly phone# 1 am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity 1 am an employer providing workers' compensation for my employees working on this job. a v +: . Alk �c.� phone 1111 of I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who h:,,:. the following workers' compensation polices: comfy name: - address: phone++ insuranceso:.: policy N Nor— <>: . comoanymame: - dd city phone., insuranceco: policy!! ° Failure to secure coverage as required under Section 25A of MGL 152 can lead to the im osition of criminal �p penalties of a fine up to Sl•500.00 andru, one years'imprisonment as well as civil penalties in the form or STOP WORK ORDER and a fine orS100.00 a day against me. I understand that a COPY of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. 1 do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Signature.S Uate •. -rl=t * Pont name ` - ''• '�- �t Phone .. rccheck only, do not write in this area to be completed by city or town official n: permit/license q —Building Department h• 0Licensing Board 1 immediate response is required ,Selectmen'sOfftcc r�Heaiih Departmentrson• phone N. rlOther (revised V95 P)AI w From:Maurabeth Chilson CIC At The McCarthy Companies FaXID:9789880038 To:Capizzi Home improvement Date:12/1 W1UU 1 14 It rrv1 rode. r�• OM AC-0-8-0- CERTIFICATE OF LIABILITY INSURANCE DATE2/1DDI/0 CAVIL 1 12 10 03 PRODUCER THIS CERTIFICATE 13 ISSUED AS A MATTER OF INFORMATION Norcross i Leighton Cape LOCI. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE C.J.140Carthy Ins.Agency,Inc. HOLDER,THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 437 Station Ave ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. So.Yarmouth ba 02664 phone:509-394-0946 r":508-160-1407 INSURERS AFFORDING COVERAGE NAlCN NSURTRI INSURER A: National Grange Mutual In Co INSURER B: Safety Insurance ColDpany Cap :Ei HMOTf>prove"Ut Inc. INSURERC: Guard insurance Gronp 1646it Newtown t w26G3RL5da� 14SURERD: cotuINSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOT Wm1STPNDING 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 H a- AVE BEEN REDUCED BY PAID aMS. POIX LTR TYPE OF NSURANCE POLICY NUMBER DATE('IWD DATE LamEACHoccuaREl>cE 11000000 , GENERALLUINATY A X Ca&ERC1AL GENERAL LIABILITY HFS02733 04/01/03 04/01/04 PREMISES(Eeoccvrsnce 1500000 CLAIMS MADE XD OCCUR MED EXP(Any one person) f 10000 PERSONAL 8 ADV INJURY i 1000000RAL GENE AGGREGATE f 2000000 GE RL AGGREGATE LIMIT APPLIES PER: PRoDUcrs-CoMProPAGG $2000000 POLICY PRO- LOC JECT AUTOMOBILE LJ11BS-ITY COMBINED SINGLE LIMIT i g ANY AUTO 1601064. 04/01/03 04/01/04 lEaecelaert) ALL OWNED AUTOS s BODILY INJURY 11000000 (Perpenon) X SCHEDULED AUTOS X HARED AUTOS r BODILY INJURY f 1000000 (Per ecndert) - X N014OWNED AUTOS PROPERTY DAMAGE f 500000 (Perecaderd) CARAOEUABILITY AUTOONLY-EAACCIDENT f ANY AUTO OTHER THAN EA ACC S y AUTO OILY' AGG i EXCESSAAOMLALUdlILM EACH OCCURRENCE f OCCUR CLAIMS MADE AGGREGATE f i f DEDUCTIBLE RETENTION f _ ' IN011H COMBrSATION AND - X TORY LIMITS ER C r�IP,.%,KFJRsrcLTATIM.mr CANC401043 01/01/04 01/01/05 E.L.EACH ACCIDENT $100000 ANY PROPRETOPJPART1ER*XECUTIVE OFFICEIM EMBEREXCLUDED7 E.L.DISEASE-EA EMPLOYEE 1100000 It yes.dembe wider i E.L.DISEASE POLICY LIMIT 1500000 SPECIAL PROVISIONS below OTHER DESCRIPTION OPERA I OCATI W I CLEe l EXCLU610NS ADDED BY ENDORSEMIEW/SPECIAL rKOVivIONS CERTIFICATE HOLDER ti CANCELLATION ------1 fHOULD ANY OF THE ABOVE DESCRIBED POLICES BE CANCELLED BEFORE THE EXPMATION DATE TIEREOF,THE ISSUMO NSURER WILL ENDEAVOR TO MAIL 10 DAYS YVWREN NOTICE TO THE CERTMICATS HOLDER NAMED TO THE LIST,BUT FAILURE TO DO 80 SNALL • - r IMPOSE No OBLIGATION OR LIABILITY OF ANY"D UPON THE INSURER RS AGENTS OR REPRESENTATIVES. A TNDRI7ED R-eREIAHATIVS ACORD 25(2001/09) CORD CJORPORATION 1998- E \ B oar o iz1l g ' �ulaon�sand stand arU One Ashburton Place-Room 1.301 Boston.-Mu shusetts 02108 Home Improvement tt`actor Relation _ Registration: 10074D - Type: Private Corporation :�cairation: 6,=005 CAP1771 HOME 11APRoVEMENTJ C. .':=: Thomas Capizzi, jr. _ - 164-5 Newton Rd. Cotult, IVIA 02535 'Update Address and return card.Mark reason for change. Address = Renewal ; Lrnplovment .Los Gard - ✓rie'�io�xo.�auuea�li: a�✓�iaao¢cvi� � - • , " Board ofBuildine Reguiatidns and Standards License or reguistration valid for individul use o6h° g HCM:IMPROVEMENT CON 7PLACTOR before the expiration date. I`found return to: Regisration: 10;f40 Board ofBuilditig Regulations and Standards = One Ashburton?lace Rim_ ~ �:pi25or.: 6_3,2DOE Boston,Ma. 0a08 = TVpe: Privait C or?Oration CAz=:HOME "ncmas '-aP .j'. Nemor K�. - Cotut,IVLL.M-5 .dzninisr ator Not valid without signature • _ I ey.. . �. ��4, VNJJlfMIONlIIPd��O�t/TCliddlY�!/.QEQ� f 130ARD OF BUILDINO REGULATIONS Llcense: CONSTRUCTION SUPERVISOR ,. .. Number GS 057032 • Birtlidate: 6 912 611963 R �''•-• _._... _ Explres: 09/2Ei/2005 Tr.no: 7171.0 Restricted: 60, 1 HOMAS X CAPIZZ_I JR j 1645 NEWTOWN RUe b /.. - ; COTUIT, MA 02635 AdmNttstrator 4 :tee The Commonwealili of11fass"husetts ,. I Department of Industrial Accidents c � _ ._� � 0/fiCBo/Inyesbgaliens 600 Washington Street Boston,Mass. 02111 Workers' Compensation Insurance Affidavit pArne: I4Jcation- f' n of i am a h eowner performin-,all work myself. ❑ I am a sole proprietor and have no one working in any capacity ❑ I am aft employer providing workers'compensation for my emplovees working on this job. Ompany. lame. iiflflresa: •. . . :. .. . city rion insurapee co: policy# I am a sole proprietor.general contractor,or homeowner(circle one)and have hired the contractors listed below who have the following,workers' compensation polices: ramD4ny acme: . insiirarice co.' w; tpmtiany name: .. .. � ,, . . ... . . . :. � . ... .. —• addrecs- cih•• .. QUIP,. .. Failure to secure coverage as required ouder Section 25A of MG1.152 eau lead to the imposilioa of criminal penalties o[a flue up to$t,.500.00 and!or sac years'imprisotuaeat as w•dl a9 dviI prnatdcs is tLe form of a STOP WORK ORI)EI2 sad a Ime of�100.00 a day against me. [understand tltac a copy oC Ibis statement play be forwarded to the ptiia of Javcstigatinnv of lue[)lA far coverage verification. I do!t iehy certify&nder the pains and Qe sitter of�rerjrtry that the informatiat provided above is tram and correct. Signature atc l Print numc Phcnc Ccheck only do not write in this area to he completed by city or tows otficiml : pertniUliceaac M r'tBuilding Department �1,ieensiog Board mmediate response is require) pSelecttntn's Ofrec QHealth nepariaient on• phone0; -Other J frevk cd cros rJM 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 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 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 be an employer. MGL chapter 152 section 25 also states that every state.or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business 6r 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 pub)is work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority. 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 al] 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. City or Towns Please be sure that the affidavit is complete and printed legibly. 'De 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 retumed to the Department by mail or FAX unless other arrangetnents have been made. The 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. The Department's address,telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents Office of 1>1fUew"OnS 600 Washington street Bostoa.Ma. 02111 fax 4: (617)727-7749. phone#: (617) 727-4900 ext,406,409 or 375 w-., TOWN OF BARNSTABLE BUILDING DEPARTMENT HOMEOWNER LICENSE EXEMPTION Please print. DATE JOB LOCATION "Number Street address S ction of town "HOMEOWNER" . Name Home phone Work phone-. PRESENT MAILING ADDRESS City town State Zip co The current exemption for "homeowners" was extended to include owner-occu. dwellings of six units or less and to allow such homeowners to engage an dividual for hire who does not possess a license, provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER: Person(sT who owns a parcel of land on which he/she resides or intends to side, on which there is, or is intended to be, a one to six family dwellii attached or detached structures accessory to such use and/or farm structu: A person who constructs more than one home in a two-year period shall not considered a homeowner. Such "homeowner" shall submit to the Building Oft on a form acgeptable to the Building Official, that he/she shall be resnor for all such work performed under the building permit. . (Section 109.1.1) The undersigned "homeowner" assumes ..responsibility for compliance with the Building Code -and other applicable codes, by-laws, rules and regulations. The undersigned "homeowner" certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requireme: and that he/she will comp with said procedures and requirements. HOMEOWNER'S SIGNATURE APPROVAL OF BUILDING OFFICIAL Note: Three family dwellings 35, 000 cubic feet, or larger, will be require to comply with State.-Building....Code, Section 127. 0, Construction Control. HOME OWNER'S EXEMPTION The code state that: "Any Home Owner performing work for whwicha buiic Permit is required shall be exempt from the provisions of:%,this• section (Section 109. 1.1 - Licensing of Construction Supervisors) ; provided tha Home Owner engages a persons) for hire to do such work, that such Home shall act as supervisor. " Many Home Owners who use this exemption are unaware that they are assua the responsibilities of a supervisor (see Appendix Q, Rules and Regulat for .licensing Construction Supervisors,, Section 2.15) . This lack of au often results in serious' problems, particularly when the Home Owner hir unlicensed persons. In this case our Board cannot proceed against the inlicensed person as it would with licensed Supervisor. The Home"Owner as. supervisor ,-is ultimately. kesponsible. �. .,. To ensure that the Home Owner is fully aware of his/her responsibilitie communities require, as part of the permit application, that the Home 'O certify that he/she understands the responsibilities of a supervisor. + last page of this issue is a form currently used by several towns. You care to amend and adopt such a form/certification for use in your commu: .ioat , ;. °PYRE tp� The Town of Barnstable » IARNSTABM - 9� .MASS. �e� Department of Health Safety and Environmental Services ArEo 59. Building Division 367 Main Street,Hyannis MA 02601 Office: 508-790-6227 Ralph Crossen Fax: 508-790-6230 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. Type of Work: Est.Cost Address of Work: Owner's Name GaLoc�� Date of Permit Application: I hereby certify that: Registration is not required for the following reason(s): Work excluded by law Job under$1,000. __Building not owner-occupied Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH 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 hereby apply for a permit as the agent of the owner: Date Contractor Name Registration No. OR Date Owner's Name ` �. Erigireering Dept. (3rd floor) Map 3,:;� Parcel �' Permit# / � r-2 lJ House# 1 (4 ei� Date Issu �-7 .Fee �5 ` �1 ` r 19 BARNSTABLE. TOWN OF BARNSTABLE Building P it AP lication Proje t ddress !dam- dE I I Village Owner Address Telephone —3 Permit Request First Floor square feet Second Floor square feet Construction Type Estimated Project Cost $ ` d Zoning District Flood Plain Water Protection Lot Size Grandfathered ❑Yes ❑No Dwelling Type: Single Family UXTwo Family ❑ Multi-Family(#units) Age of Existing Structure 1 Historic House ❑Yes ❑No On Old King's Highway ❑Yes ❑No Basement Type: 24rull ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) r� Number of Baths: Full: Existing 4, New Half: Existing New No.of Bedrooms: Existing New V Total Room Count(not including baths): Existin New First Floor Room Count Heat Type and Fuel: ❑Gas ❑Oil lectric ❑Other Central Air ❑Yes LSO Fireplaces: Existing New Existing wood/coal stove ❑YesaKo Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size) 7one hed(size) ❑Barn(size) ❑Shed(size) ❑Other(size) Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes, site plan review# Current Use Proposed Use Builder Information Name / Telephone Number Address License# Home Improvement Contractor# 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 SIGNATURE WT DA TE, 7 BUILDING PERMIT DENIED FOR TH OLLOWING REASON(S) 7 � , I L � � f r . r.<.Ae 4vt� A1."4Mi ev,rmro.,,r .< �anw..,r. ",yiTN IR�g•t'.�•�• J 4YI.•,pPl.."7.', �•�"'^-MNn. - �'• w. '.v:.u3hKlMCwe2l ee+.er•w wv\..sn...K.. (J'1f���/�!� d -I-I LJy_' 1 iLi —I - - ^' I tj --- — _ — — ' {- ... - - .i --ltL - - L., Til _( ! :I - I i4_ t-- _.�_ �, t I ! ! ' + -___ ! i t , '-.a •,: i. { ( � ' 1- : - -; )1 (- --f f i� I j ! i i j 1 i ! I i + Lt ! ' ! ", i i 1 .1 1 � I 1 I ( ! ! I I f 1� � , 1 I ! I I_ J i! -- I ! I 1 LL�i i ! - ! •t 1 ! t 1 , ! ! �- - - j--j 1 i j ! ! t _- 1 f f i I i I � i: 77, t 001 ,001 �_L i {{ I �-� — II J ! � I _•1 1 ! I t :!_ I � ! J_ � t I _ i It Mir it I ,i it 77 : N;, :- 1 It _ t I , _ 1 xa !c i xIt it ' ! F I I I : !-i ! i - i 7_ i i ! I I i � 1 ! ! I I ! I I 1 i ! ( I I ! , I i ! i ! ! t 1 I I� _ I I�i I 1 t + L ( -- +-=-• t �_t I_?! •_ [ i-iImo_! i_= L ! ._i I I ! 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