HomeMy WebLinkAbout0058 MIDWAY DRIVE ..5� ��'w� fir. - - - -- _ - -
Town of Barnstable *Permit#a
Expires 6 months n issue dote—
-0 Regulatory Services Fee
MAM
t LE �j
9cb i63� ��� �� Thomas F.Geiler,Director ( r0
iOtfp Mph a � .
Building Division
Tom Perry,CBO, Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax:508-790-6230
EXPRESS PERNUT APPLICATION - RESIDENTIAL ONLY
s� / !� Not Valid without Red X-Press Imprint
Map/parcel Number4nw g
Property Address �4 ly/a y . �l�f U� �4 0243Z-"
[residential Value of Work/i 0®® Minimum fee of$35.00 for work under$6000.00
I1/�wc ,�•�d�e�f
Owner's Name&Address Y
�O u/g y �i�e e r�te��i%/e "�1 oa 4 3z
I
Contractor's Name lia J� � J/� "" Telephone Number
d o
Home Improvement Contractor License#(if applicable)
Construction Supervisor's License#(if applicable) CS '1 0 110`/I
� t :
l Workman's Compensation Insurance:
Check one:
❑ I am a sole proprietor '
El I am the Homeowner
I have Worker's Compensation Insurance`
Insurance Company Name
q J 0t i rye , kmrloye�i} 'Nda Nce co
Workman's Comp.Policy#
Copy of Insurance Compliance Certificate must accompany each permit.
Permit Reques (check box) /
Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to
4 wvwi?/I/ #If
❑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
*Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
***Note: Property Owner must sign Property Owner Letter of Permission.
copy of the Home I provement tractors License&Construction Supervisors License is
equi
SIGNATURE:
kk-
C:\Users\demllik\Aifr6t-a\i—.ocai\Microsoft\Windows\Temporary Internet Files\Content.06tlook\DDV87AAZ\EXPRESS.doc .
Revised 072110
dl
"
Department oflndustrialAccidents
Office oflnvestigations
I Congress Street,Suite 100
— " Boston,MA 02114-2017
www.mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Ele'ctricians/Plumbers
AP.Wicant Information PIease Print Legibly
Name(Business/organizadon/Individual):Capizzi Home Improvement
Address:1645 Newtown Road _z
City/State/Zip:Cotuit, MA-02648 508-428-9518 .
Phone#:
Are you an employer?Check the appropriate bog:
40+ 4. I am a e Type of project(required):
1.R1.I am a employer with ❑ general contractor and I
- 6< New
employees(full and/or part-time).* have hired the sub contractors 0. 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
8. Demolition
workingfor me in an capacity- employees and have y pacity. . workers'
9. Build'm additi
[No workers comp.insurance comp.insurance.$ 0 g on
required.] 5: 0 We are a corporation and its 10.0 Electrical repairs or additions
-3.fl I am a homeowner doin all work officers have exercised their
g 11.[]Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL
12.VRoof fepairs
insurance required.].t C. 152, §1(4),and we have no
_..... . . employees. : 13.0 Other... . .. . .[No workers
comp.insurance required.]
*Any applicant that ehecft box#1 must also fin out the section below shovAng their workers'.9 ompensation policy information's"
f Homenwaers who submit this affidavit indicating they are doing all worked then hire outside contractors mi:s-tsubmit anew affidavit indicating such.
$contractors that check this box must attached an additional sheet showingthe name of the soli-contractors and state whether or trot those entities have
employees. If the'sub-contractors have employees,they must provide thew wdrkers'comp,policy number: <
.: . an employer that is pruvzding workers'compensation insurance for my employees Below.is the policy and job site
information.
Insurance Company Name:Associated Employers Insurance Company
Policy.#or Self-ins.Lic.#:WCC5010 547012011 12/25/2012
Expiration:Date:
.Job Site Address: 10� City/State/Zip: Le&ei, 1118,
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
F'ailure.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 er the sins and pens 'w of perjury that the information provided above is true and correct
Si afore: JDate.
Phone#: 508-428-9518
Official use only. Do not write in this area,to be completed by city or town of
City or Town: PermitUcense#
Issuing Authority(circle one);
I:Board of Health 2.Building Department 3.City/Town Clerk -4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#•
... .... . .. age 7 0. 7..
Capizzi'Home Improvement Inc.
"Sp ecifications and Estimates
STATE OF MASSACHUSETTS
LETTER OF AUTHORIZATION,TO APPLE'FOR A BUILDING PERMIT
I, J�('�AKJ ITATS '7T ,OWN THE:PROPERTY LOCATED AT_ 0 wAl: bt
IN ct Nq RwlvL6 , MASSACHUSETTS.
I HAVE AUTHORIZED CAPIZZI HOME IMPROVEMENT TO ACT AS MY AGENT TO APPLY
FORA 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;
OWNE&'S:TELEPHONE:
i
LESSEE'S SIGNATURE::
LESSEE'S ADDRESS:
LESSEE'S TELEPHONE:_
APLLICANT'S SIGNATURE: '
APPLICANT'S ADDRESS: 1645 Newtown Rd:; Cotuit, IVIA_02635
APPLICANT'S TELEPHONE. �: 508=428-9518
: RESPONSIBLE OFFICER:;
RESPONSIBLE OFFICER ADDRESS:
RESPONSIBLE OFFICER TELEPHONE:
Client#:47298 CAPIHOM
FoArE
�exrDwrvvY)
ACORD. CERTIFICATE OF LIABILITY INSURANCE 12r26/2o12
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(les)must be endorsed.If SUBROGATION IS WAIVED,subject to
the terns 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 NAN7£AcT: Karen Walther -
Rogers&Gray Ins.-So.Dennis M2NE Ne.877-816-2156
434 Route 134 E- ML
Ess:
South Dennis,MA 02660-1601 INSURERISI AFFORDING COVERAGE NAICU
508 398 7980 BNSURERA:Main Street America Assurance C
INSURED INSURER B:Associated Employers Insurance
Capizzf Home Improvement,Inc.
CapbW Enterprises,In INSURER D:
c.
INSURER -
1645 Newtown Road
IDBURER E:
Cotuft,MA 02M
MSURERF:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LTTRR TYPE OF INSURANCE DL BR POLICY NUMBER �Y MMID EXP LIMnS
A GENERALLIABILm MPB1075H D610812012 0610812013 EACHoccuRRENcE $1000000
COMMERCIAL GEINER .Lua wy ems° emnrrDence 8500,00() -
CLARVIS-MADE 0 OCCUR HIED EXP OM are I>aism) $10,000
PERSONAL&ADv INMW $1,000,000
GENERAL AGGREGATE $ 000,000
GENI AGGREGATE LIMIT APPLIES PER: PwouaB-coumPAGG $2,000,000
POI..= JET LOC _ 8
A AUTOMOBILE LIABILITY M1M28044 610Sn012 06108/201 �a I�"®„ImN�u� $500,000
ANY AUTO
BODILY INJURY wPers an) $
ALL owNED X SCHEDULED BMILY INJURY(Per aodderd) $
AUTOS "JAM -
X HIRED AUTOS X ANUTOVDIED, PROPERTY DAMAGE $
ammmo
X Drive Oth Car $
A X UMBREL.LAuaB OCCUR CUS1076H 06MM012 06/08/201 EPzloccuRRENm s5,000,000
EXCESS LIAB CLAIMS-MADE AGGREGATE $5 000 000
r>ED XI RETENRON s10000 $
B WORKERS COMPERSAMON WCC5010547012012 I 2/25/2012 =512013 X :sraru- DTH-
AND EMPLOYERS'UM11 iY
j ANY PROPRIEfOIUPAInT16i1 Y/N - E.L.EACH ACCIDEKT $9 000 000
OFFICERWEMBER EXCLUDED? N I A
IMahhdaturyInNH) F1.DISEmE-EAEIdpLoYE$1,000,000
unEfer
Byes,ah>gah3eOFO - E,LnLSEASE-POLICYLlfdTr $1,000,000
DEscRnwTroN OFOPERAnare;nelan
DESCRUMON OF OPERATIONS I LOCATIONS(VEHICLE ACORD 101,AddWaaA Remarks Schedule.B mom space is required)
*'Workers Comp information
Included Officers or Proprietors
4
CERTIFICATE HOLDER CANCELLATION
Town Of Barnstable SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
200 Main Street ACCORDANCE WITH THE POLICY PROVISIONS.
Hyannis,MA 02601
AUTHORIM REPRESENTATIVE
0 198 •2010 ACORD CORPORATION.All rights reserved.
ACORD 25(2010105) 1 of 1 The ACORD name and logo are registered marlin of ACORD
11S918591M91856 TLC
a s achusviftsi -Deqartvnent of Pubhe Sa.1apy
Board of Suildunq Regu4abons and Stardards,
t8ALDEN AVE
Buzzards W
4 t5�4`:9.3353 'r i 14
` - 'Y°""`� VEnCe t+f L:O335i31m87'13III3trS do tsustriess xegwsuUil jultew a fir rt ,tsustuuu Yauu dtir MLUV UI Uza only
OME IMPROVEMENT CONTRACTOR before the expiration date. U found return to:
00"of Consumer Affairs and Bus.a=Regulatgat R?gistra#IonP &413 T3tFe' 10 Park 'loge-Suite 5170
Expi!m�=A_ 1A Supplement Card �
CAI�1ZZl H�NIE���-��, ._._.}, ��yy��..�� Boston,1VIA Q2116
F t -. �t V V. ..p'
JOHN STRUMS . a . i .�,......
1W Newton Rd.
Cotult,MA 02635 �:�'i t t•
Undersecrebry Dtut v d w1 oat signs re
77
pve��
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map Parcel Permit#
Health Division _ J� :. to Date Issued
Conservation Division Z Lrj 0, Application Fee
Tax Collector EXISTING Permit Fee h--c
SEPTIC SYSTEM
Treasurer /� l U LIMITED TO�_#OF BEDROOMS
Planning Dept.
Date Definitive Plan Approved by Planning Board
Historic-OKH Preservation/Hyannis
Project Street Address �� nr,(�,I VICE
Village dynd fy w 4 s
Owner W�2/'V Zi Sf Ass f-,%T Address ��� ZI%I ZLOL OA-1 V 6
Telephone O
Permit Request e/1 1 T C ll c! my R C el o j�_; L cS H?®L-L am,4,6
0 g rvec_y5
Square feet: 1 st floor: existing proposed 2nd floor: existing proposed ,Total new
Zoning District Flood Iain �Groundwater Overlay
Project Valuation , Co truction Type
Lot Size Grandfathered: ❑Yes ❑No If yes, attach supporting documentation.
Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(#units)
Age of Existing Structure Historic House: ❑Yes ❑No On Old King's Highway: ❑Yes ❑No
Basement Type: ❑ Full ❑Crawl ❑Walkout ❑Other
Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft)
Number of Baths: Full: existing new Half:existing new
Number of Bedrooms: existing new
Total Room Count(not including baths): existing new, First Floor Room Count
Heat Type and Fuel: ❑Gas ❑Oil ❑ Electric ❑Other
Central Air: ❑Yes O No Fireplaces: Existing New Existing wood/coal stove-. ❑.Yes ` ❑No
Detached garage:❑existing ❑new size Pool:❑existing ❑new size Barn:O existing ❑new size
Attached garage:❑existing O new size. Shed:❑existing ❑new size Other:
Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑
Commercial ❑Yes ❑ No if yes,site plan review#
Current Use Proposed Use
BUILDER INFORMATION
Name VJN19),N G,S TAR i Icy JV Telephone Number ���`J� 76
Address 2, A4 f A 6`r'r1/` g„�,�,( ✓ License# t t4 0 7 7
Home Improvement Contractor#
Worker's Compensation# ��� /�i O Y 6 3
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO �l71l mo I) �2 111 Nd
SIGNATURE DATE Z,2,
FOR OFFICIAL USE ONLY
PERMIT NO.
r "
DATE ISSUED
MAP/yPARCEL NO. ;
ADDRESS VILLAGE
OWNER r
DATE OF INSPECTION: p
FOUNDATION
FRAME A sr( +
INSULATION N j; �
FIREPLACE
m m
ELECTRICAL: ROUGH FINAL-'
p
PLUMBING: ROUGH FINAL
r3
GAS: ROUGH FINAL
FINAL BUILDING / '�'• /� rq �`O� '
�- u7
uz `
O
DATE CLOSED OUT • `
0
ASSOCIATION PLAN NO.
4 r
I
f
-71.�Oomrmea�wrea ✓G J as '
Boardof Bnildlog Regniations.aad Standards
HOME IIARROHEMENT CONTRACTQR
Re9ia�ration a29244 I''•
OilratUoni 7/30/2005
Prtvate:Corporation.
Whalen RestoraUonSeMceslnc
William.Whalen
22.Amedcan way GG-.• a,%
South Dennis,MA 02660
Administrator
1
a BO D O u LD u TiON .i
0' 928 �
f, E� a
x
a
a
mWlt. FI
t �
Town of Barnstable
Regulatory Services
sAxtvsrABLE, = Thomas F.Geller,Director
9 MA$&
1639 Building Division.
Tom Perry, Building Commissioner
200 Main Street, Hyannis,MA 02601
office: 508-862-4038 Fax: 508-790-6230
Property Owner Must Complete and Sign This Section If Using A:
Builder
as Owner of the subject property
hereby authorize \4 hg\Lx-\ S NO V4 nS to act on my behalf,
in all matters relative to work authorized bythis building permit application for(address of
job)
Signature of er Date
Print Name
�a:
The Commonwealth of Massachusetts
Department of Industrial Accidents
&?MCC a/10FOsti RMONs
_ t 600 Washington Street
Boston,Mass. 02111
Workers' Cam nsa tion Insurance Affidavit
name
location. I d \414-
city phone#
❑ I am a homeowner performing all work myself.
❑ I am a sol. Prietor and have no one workiz in ca achy
am an em to roviding workers'compensation far rQy employees working on this job.
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❑ I am a sole proprietor, general contractor, or homeowner(circle one)and have hired the contractors listed below who
have
themPfollowin workers' co ensation polices: :r•::•,•;:::::.::
::::::::.::::::::::::::i:::::.:.:::::.::::::.:::::::.::.:::::::::::..:::::.:.:::::.:.,..::::::::::::.:.t....:.::r.,,:•r.......:::..:
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is f�.::;:;�%;::;;i i:';?i}iY.::t;};ij}y:;:ii::::::{::>.;:�:::::i><i�Y:;:;:�:i�::i:;i}iiii:{�:4:��'r:.L:•:;:4?i::.i:i.:�:}:3Y�iY!ySiL::iY::i :•i:::.;.:•iy;.>;':;•>;i:::{.::..;};.�v.;.;:i{`i::ii:w.:;?::i:.i:i;iiS:i•}:i;v:•i:;v{:::is iii:;;ii::iii:i:i:4ii�:'r,':<:;..:.;y:i>..:ryy}v:b::::.::':i{^;:e.v;:;
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�•�ruiarauce
FaittQe to seca�e coverage a+required mmder Section 25A of MGL 15Z can lead to the imposition of criminal penalties of a fine up to$1,300.00 and/or
one yes,imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a Sae of 5100.00 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.
I do hereby certify under the pains and penalties of perjury that the information provided above is trisp mid correct
signature �.( .�/�-4 Date
Print name w 14 L 1✓�n9 ire��'! L C A- - Phone# 5-CV -;710
official use only do not write in this area to be completed by city or town official
city or town: permit/license# []Building Department
❑Licensing Board
❑checkif immediate response is required ❑Selectmen's Office
❑Health Department
contact person: phone#; ❑Other
(rd"d 9/95 PLC
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 or 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 public 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
company names, address and phone numbers along with a certificate of insurance as all affidavits may be
x, supplying
submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and
li:. 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. 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 regarding the applicant. Please
be sure to fill in the Piimk icense number which will be used as a reference number. The affidavits may be returned to
the Department by mail or FAX unless other arrangements 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.
'�Departznesrt's address,telephone and fax number:
The Commonwealth Of Massachusetts
Department of Industrial Accidents
Office of Investlgatlons
600 Washington Street
Boston, Ma. 02111
fax#: (617) 727-7749
phone#: (617) 727-4900 ext. 406, 409 or 375
16. .
WHALEN RESTORATION SERVICES INC.
22 AMERICANWAY
SOUTH DENNIS MA 02660
(508)760-1911 FAX(508)760-9995
MA LIC#CS-074928 HIC REG# 129244
Complete Fire,Smoke,Soot,Water&Mold Remediation Service
Main Level
531811
14' 5" 61611 17' 6" 131711
C = _
�Avya -
BR2 T 1 Kitchen u
CC
Y VVV
k",
15' 11" 33' S GARAGE M �\
� . O
N N
N T1 101211 _ _
� �' Q LIVING N
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' 7 T
8' 5" 17' 11"
211411 32' 4"
BASSETTCLN 12/09/2004 Page: 1
WHALEN RESTORATION SERVICES INC.
:q
22 AMERICANWAY
SOUTH DENNIS MA 02660
(508)760-1911 FAX(508)760-9995
MA LIC#CS-074928 HIC REG# 129244
Complete Fire,Smoke, Soot, Water&Mold Remediation Service
Basement
40
391 411
r
f A
Basement M
Basement
:,r r
BASSETTCLN 12/09/2004 Page: 2
FRIEDLINE&CARTER ADJUSTMENT, INC.
436 Main Street, P. O. Box 338
Hyannis, Massachusetts 02601
gel. (508) 771-3232
TO: /FAX (508) 790-2344
Building Commissioner or Inspector of Buildings
( ) Board of Health or Board of Selectmen
O Fire Department
TOWN OF Centerville
TOWN HALL
, MA
RE: Insured: ASSETT, Nancy
Property Addr 58 Midway Drive
Policy Number: H09915018
Type of Loss: Fire
Date of Loss: 10/6/2004
File#: 100593
Claim has been made involving loss, damage or destruction of the above captioned
property,which may either exceed $1,000.00 or cause Mass. General Laws, Chapter 143,
Section 6 to be applicable. If any notice under MGL, Ch. 139, Sec. 3B is appropriate,
please direct it to the attention of this writer and include a reference to the captioned
insured, location, policy number, date of loss and file number.
On this date, I caused copies of this notice to be sent,to the persons named above at the
addresses indicated above by First Class Mail.
N. LAGUE
Adjuster
10/7/2004