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HomeMy WebLinkAbout0017 PONTIAC STREET 7 7 Town of Barnstable 7 R�EC PTr 200 Main Street, Hyannis MA 02601 508-862-4038 Application for Building Permit Application No: B-17-1968 Date Recieved:. 6/22/2017 Job Location: 17 UNIT 7 PONTIAC STREET,HYANNIS Permit For: Building-Siding/Windows/Roof/Doors Contractor's Name: STEPHEN T DICKINSON State Lic. No: CS-081843 Address: MERRIMAC, MA 01860 Applicant Phone: (508)676-6820 (Home)Owner's Name: PERILLO,MARIA R Phone: (508)243-0411 (Home)Owner's Address: 212 PATRIOT WAY, CENTERVILLE,MA 02632 Work Description: replacement of 2 window a �� J Total Value Of Work To Be Performed: $2,929.00 t� ram, Structure Size: 0.00 0.00 0.00 Width Depth Total Area I hereby swear and attest that I will require proof of workers'compensation insurance for every contractor,subcontractor,or other worker before he/she engages in work on the above property in accordance with the Workers' Compensation Act(Chapter 568). I understand that pursuant to 31-275 C.G.S.,officers of a corporation and partners in a partnership may elect to be excluded from coverage by filing a waiver with the appropriate District Office;and that a sole proprietor of a business is not required to have coverage unless he files his intent to accept coverage. I hereby certify that I am the owner of the property which is the subject of this application or the authorized agent of the property owner and have been authorized to make this application. I understand that when a permit is issued,it is a permit to proceed and grants no right to violate the Massachusetts State Building Code or any other code,ordinance or statute,regardless of what might be shown or omitted on the submitted plans and specifications. All information contained within is true and accurate to the best of my knowledge and belief. All permits approved are subject to inspections performed by a representative of this office. Requests for inspections must be made at least 24 hours in advance. Signed: Stephen Dickinson 6/22/2017 (508)676-6820 Applicant Date Telephone No. Estimated Construction Costs/Permit Fees Total Project Cost ; t $2,929.00 Date Paid Amount Paid Check#or CC# Pay Type Total Permit Fee: $35.00 6/22/2017 $35.00 XXXX-XXXX-XXXX- Credit Card 7597 .......................................................................................................................................................................................................................................................................................................... Total Permit Fee Paid: $35.00 MBE 011610 - -- r Assessor's map and lot number ?�, .., _ -� ' I ` e ^ ,_......... .....:...................? I E Tp�♦ Sewage Permit number —?I BABHnSBTa LE, i House number ........................................................................f 'oo MAO& 0� TOWN OF BARNSTABLE BUILDING INSPECTOR ` APPLICATION FOR PERMIT TO .. ) ? ,.......... •,+!•l.?®!SC 1,t1 R;3,•M••c....................................... TYPE OF CONSTRUCTION ..:: ' r :F_. y ............................ ...............19. TO -THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: - Location 1-�is_�._ . ,.-�.�.:::.��...�.....:......: '....� ....................:............ ................................... Proposed Use `�r.�.: fvC �` 1? 10?� �r�� / i. rv�. ........... .ff .� ,.%. ........................................ .............. .......................................... ZoningDistrict ...........................................:............................Fire District .............................................................................. Name of Owner ..............Address.!. c:?fJ.�. '.. T.....r ... . .r . _Name of Builder ........Address � 11 't!.. 3.I tT t Nameof Architect ............... ..................................................Address .................................................................................... t3? .��.............Foundation � Number of Rooms ....................................:.............. ....................... ..................................... Exierior � f/' !l "!t�.F .........................................Roofing ... �5�'r!.•'r i Floors ........i...............................................................Interior ................... ........:................................................................ Plumbing Heating - r_.� r-17 Z rs�' � �','! .,.................................................................... c Fireplace ....&) ............................................Approximate Cost .. c ••; ....................., Definitive Plan Approved by Planning Board ________________________________19________. Area ..........................................41 t . / ..�...,. . Diagram of Lot and Building with Dimensions Fee .. SUBJECT TO APPROVAL OF BOARD OF HEALTH ' �frr I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name .I/................................11'. Lt + f:......................................... Sullivan, Danie.-l'-*- ' "A7--269-711- GO 22725 condomini�40T No.................. Permit for .................................... 9 Units ............................................................................... Location ...........17 Pontiac Street ..................................................... ......................... ...................................... Owner ............Daniel .Sullivan ...................................................... Type of Construction ...... M. .ry................ ...................................... . ................................. Plot ............................ Lot ................................ December 3 80 Permit Granted ..... ...........i.........19 Date of Inspection ......................./...........19 Date Completed ......................................19 PERMIT REFUSED .................. ...................... .. 19 ... . . ..... .. . . .. . ......... .... ...... .... ....... ....... ........ ................... .. ...........................I ................. ... ............ . . ... ....... ..... ........ .......... .................. ...... . .............. ................................ Approved .................... 19 Assessor's map and lot number Co.:.9..... 1..�p.../,� gyp%7H E SEPTIC SYSTEM MUST SE Q ~ Sewage Permit numberSTALLED IN COMPI.IAI�I� (� WITH TITLE t 9 BARNSTABLE, MABa 0 House number .... ��...........'................R.............................. ENVIROA11'�IE TAL COD ��� °°,0�i639- 'Fp'ypY a TOWN: ,OF . BAR _ X1Trc-"' �' S ` .- BUILDING INSPECTOR { � APPLICATION FOR PERMIT TO ... r 5 .................................... TYPE OF CONSTRUCTION <..... �r �............................................................... it .... . ............................ l//............... TO -THE-INSPECTOR-OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ... :.. ...........fed ....��' .Y...l .. ........................:................................................... Proposed Use �.1 d liNe �8 �.: ®!tiJ N/.v! ..............��.. e .,l.! ........................................ ..................... ZoningDistrict `........................................................................Fire District ........................................ ..................................... Name of ..............Address/.?#... ®lJ Y.°��. �..... Name of Builder ( I..e�Z.L.... lG�� J �........Address�7.....�r'v%iS%-�i- ..S .. �!.... Nameof Architect ...Address.................... . ....................................... .................................................................................... w Number of Rooms ...... .... ..G:........... Foundation ?..V !�.�.�....`..��C Z'g�� 4 �� G Exlerior .�.R1�.�..(f.��........�. .....Roofing ..:............................................ ........................................................................ �� .Interior �� �-�`g�r!Floors 6.................................................................................. . HeatingF....t-.lz. �16�(I ...................... .........Plumbing.................. .............. ....... . . ............................................. Fireplace ....Ak ..................................Approximate Cost Definitive Plan Approved by Planning Board ________________________-------1 9--------. Are -/ _ D& Diagram of Lot and Building with Dimensions Fee SUBJECT TO APPROVAL OF BOARD OF HEALTH i/ I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above . construction. _ Na me ....................... I Sullivan, Daniel iNa 22725 Permit for .,, Condominium 9 Units - ................. ...........................................`............. Location ......... _ _ e 1.7..Pontiac. ...Street. . ..... .. ............. . ...... . .... A Hyannis...:........ _ - - ';r Owner ............Daniel Sullivan.................... Type of Construction ry ......... ............................................................ Plot ...................... Lot ................................ December 3' 80 Permit Granted .......................................19 Date of Inspection ..................... 3 Date Completed ...............................19 . s ;. 'PERMIT REFUSED - ... ... 19 ii�i ... �_ ........... .. ...... .................. iZ ........ ....`} ................................... . ................... '• i ............ '. ....`................. ................. ........... ................................................................ `' �` �/•� - i R Ap ro�yed ......G! ...................�.. ..... 19 t --w- C/. l .... .... ..... . - -- '0A „•'""'• TOWN OF BARNSTABLE Permit No. -------2272f `o e Building Inspector 1 s:un.n Cash OpA OCCUPANCY PERMIT -- — Bond x`<0�$k1 t "No building nor structure shall be erected, and no land, building or structure shall be used for a new, different, changed, or enlarged use without a Building Permit therefor first having been obtained from the Building Inspector. No building shall be occupied until a certificate of occupancy has been issued by the Building Inspector." Issued to Daniel Sullivan Address 17 Pmtiar, st7rpot_ %mrnic IJ TIT I Wiring Inspector Inspection date Plumbing Insp,,ector ` ! Inspection date Gas Inspector - Inspection date Engineering Departmentf� �.ir `t J �1� ( -_� Inspection date THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN REQUIREMENTS. jno h ................ 19.........._ .............. J� 0 Building Inspeeto k- 1 jr w�M;` .e TOWN OF BARNSTABLE Permit No. Building Inspector cash OCCUPANCY PERMIT Bond "No building nor structure shall be erected, and no land, building or structure shall be used for a new, different, changed, or enlarged use without a Building Permit therefor first having been obtained from the Building Inspector. No building shall be occupied until a certificate of occupancy has been issued by the Building Inspector." Issued to Daniel Sullivan Address 17 Pontiac Street, Hyallriis WIT 2 Wiring Inspector �r� Inspection date Plumbing Inspector . .. Inspection date^ Gas Inspector C Inspection date Engineering Department ?xtfa ,(t � ��1./-.�.�C ,P .Inspection date THIS PERMIT WILL NOT BE VALID,, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN REQUIREMENTS'. ..... ............. 19 ! f �� Building�Inspeto , r TOWN OF BARNSTABLE 22725 Permit No. ------------- -- saa�rr.0 BU]lildIIg ZY1SpeCtOr Cash ___-- �`°"`+~ OCCUPANCY PERMIT Bond No building nor structure shall be erected, and no land, building or structure shall be used for a new, different, changed, or enlarged use without a Building Permit therefor first having been obtained from the Building Inspector. No building shall be occupied until a certificate of occupancy has been issued by the Building Inspector." Daniel Sullivan Issued to Address 17 Pontiac Street Hyarmis UWr 3 Wiring Inspector , a 6 Inspection date Plumbing Inspector-�� Inspection dateM p,, Gas Inspector 4 w "�t Inspection date a j Inspection date Engineering Department P pe ( � f THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN REQUIREMENTS.. �..�f 19� .....................�, M» » » ��» »� »� »� - Building Inspector-----,' \l f ry. y TOWN OF BARNSTABLE Permit No. _------,22725 _ Building Inspector swrru Cash '- OCCUPANCY PERMIT Bona No building nor structure shall be erected, and no land, building or structure shall be used for a new, different, changed, or enlarged use without a Building Permit therefor first having been obtained from the Building Inspector. No building shall be occupied until a certificate of occupancy has been issued by the Building Inspector." 4ja Issued to Darti.e2 St:llivan Address 17 Pontiac Stet. Hvan?is TUT 4 Wiring Inspector � Inspection date Plumbing Easpectoi/` ' Inspection dateA � Gas Inspector v _y �, Inspection date Engineering Department "GZe"C:t!t� �� Inspection dateAt THIS PERMIT WILL NOT BE VALID; AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN REQUIREMENTS. . ' !!! 19 � f )�-Building Inspector TOWN OF BARNSTABLE Permit No. Building Inspector Cash wa i �O t679• `� �d OCCUPANCY PERMIT Bond _ No building nor structure shall be erected, and no land, building or structure shall be used for a new, different, changed, or enlarged use without a Building Permit therefor first having been obtained from the Building Inspector. No building shall be occupied until a certificate of occupancy has been issued by the Building Inspector." Daniel Sullivan Issued Ito Address 17 Pontiac Street, ymmis MT 5 r Wiring Inspector `'� / ,+ - Inspection date /!:/ s� eems. r_ Plumbing Inspector � J( Inspection date r,.4 Gas Inspector �� r Inspection date Engineering Department Inspection date THIS PERMIT WILL NOT BE VALID,/.AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN REQUIREMENTS. 1�4 A ..........� . ................ is_ � ,��� . /` �BBuiiding Inspector-- TOWN OF BARNSTABLE Permit No. _-------22725 t SAUSTAu. Building Inspector cash --------_----- 0�0 YPY��P OCCUPANCY PERMIT Bond No building nor structure shall be erected, and no land, building or structure shall be used for a new, different, changed, or enlarged use without a Building Permit therefor first having been obtained from the Building Inspector. No building shall be occupied until a certificate of occupancy has been issued by the Building Inspector." Issued to Address Sullivan Address 27 Pontiac Stet Hyannis UNIT b a Wiring Inspector Inspection date z•:.•''�.�i-�.. Plumbing Inspector ,....- Inspection date Gas Inspector ���/ Inspection date l r Engineering Department /s 'r Inspection date t, THIS PERMIT WILL NOT BE VALID,r AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN REQUIREMENTS. �- � . ............ ............... .........................;/'It ......... 19... . ..Building Inspe for .... _ w s� TOWN OF BARNSTABLE Permit No. ----.---22725 -- s,e�n.m B111lddIlg Inspector Cash ----------- nua A,eya. ,re Y Z' OCCUPANCY PERMIT Bond No building nor structure shall be erected, and no land, building or structure shall be used for a new, different, changed, or enlarged use without a Building Permit therefor first having been obtained from the Building Inspector. No building shall be occupied until a certificate of occupancy has been issued by the Building Inspector." '" Daniel Sullivan Issued to Address 17 Pontiac Street, Hyamis UNIT 7 Wiring Inspector Inspection date Plumbing hLspec�t�or � � ^�*� Inspection date/y, 4 -; Gas Inspector t? Cj� f � Inspection date Engineering Department Inspection date r, THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN REQUIREMENTS. L5 � .. ............. 1991 .... f � ��yBuilding Inspee��_ TOWN OF BARNSTABLE Permit No. _________22725 Building Inspector saunw Cash oO�,639* OCCUPANCY PERMIT Bond "No building nor structure shall be erected, and no land, building or structure shall be used for a new, different, changed, or enlarged use without a Building Permit therefor first having been obtained from the Building Inspector. No building shall be occupied until a certificate of occupancy has been issued by the Building Inspector." Issued to Daniel Sullivan Address 17 prvnt.i.nr Rtlw—t. TNAMri_s III T 8 Wiring Inspector Inspection date ' Plumbing Inspector �� ,�( Inspection date „? 9 r Gas Inspector J f ;r� / "� Inspection date / Engineering Department - �l¢� � Z J t � l { � Inspection date THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN REQUIREMENT'S. I9 ............... ii%2 .... C �Building Inspector 22725 F A NSTABLE�„ . TOWN 0 B R Permit No. _________—_ . {»STAU Building Inspector cash __—�— rua �!• 00�0 YPY!�P OCCUPANCY PERMIT Bond No building nor structure shall be erected, and no land, building or structure shall be used for a new, different, changed, or enlarged use without a Building Permit therefor first having been obtained from the Building Inspector. No building shall be occupied until a . certificate of occupancy has been issued by the Building Inspector." Daniel Sullivan Issued to � Address 17 Pontiac Street, HyamiB UNIT 9 Wiring Inspector --- Inspection date Plumbing Iaspector Inspection date Gas Inspector Inspection date Engineering Department �� )v�,� �. Inspection dated ' Q THIS PERMIT WIL T BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN REQUIREMENTS. V `f-Bu'lding�Inspector ,r _w TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map to Parcel (L TITfYiN OF B RNSTABLE Application # Z 6150 /&0& Health Division Date Issued - Conservation Division - Application Fee Dept; - 35 Planning p Permit Fee' Date Definitive Plan Approved by Planning.Board Historic - OKH _ Preservation/ Hyannis Project Street Address � )AL S Village S — Owner j9:7, ,����. Address Telephone 370 263 762 A d a d-S7 3 1'�93 c Permit Request A1,L A Atd 71 Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District. Flood Plain Groundwater Overlay Project .Valuation Construction.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 ❑ 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 Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name Telephone Number Address License # Home Improvement Contractor# /0% Email C2 Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO I � SIGNATURE DATE A" FOR OFFICIAL USE ONLY APPLICATION# I . /".. DATE ISSUED MAP/PARCEL N0. ADDRESS I VILLAGE :sl OWNER ' DATE OF INSPECTION: M FOUNDATION FRAME '•'` L INSULATION _ FIREPLACE i ELECTRICAL: ROUGH { FINAL ti PLUMBING: ROUGH FINAL GAS: ROUGH FINAL f' FINAL BUILDING t`, 4 DATE CLOSED OUT ASSOCIATION PLAN NO. woo Ay _ t r A 4 �w ��tAF f + 1isF 3 ,1�, sa as,ltit , ie - , ' 1 �� ` irk ai }�,f4111.ad�i�IL'.CC}F�da�itfi�'i31lri YTzd.C�.�F�24[I�JC�'�.��d�`R�t�f ..ad�.- r ^�.•�v s r v PHI Ile_ t. , to 1 III RAM The Coznmmrweah*o,f Massachzwetts Department gf1ndzirsdria1Acdd Office o fir"m*adow IF. 600 Wad*vlon&reet Boston,CIA 02HI mVmmamgvP/frill Workers' CumpBIISaf an.Insurance Affidavit:BuilderS/C�II ers ArmFi;ant IIYZt18tfnn Please Print Addre:�2r3 �� 1,19�� Are you an employer?Che&the appropriate box ' Type of project(require4_ L❑ I am a employer with 4. ❑I am a general confractor and I 6. New employees(fan anrr Vor pie)* have hired the wb comtractar 2. lam a sole proprietar orpartner- Iced on the attached sheet 7- ❑Remodermg slip and have no employees Theses sub-contractors have g-. Demolition wodting for me in any capacity_ employees and have workers' [No nos'camp.iiestrsaace Camp_„'mince 1 �_ ❑Building adtiiiion regoired.] 5_ ❑ We are a oorgoratim and its 10. Eteclriral repairs or additions; 3. I am a homeovmer doing all vark officers have esscsed their 1L0 Plumbing repairs or eedsfrhoas myself o workers' of a mmigion pff MGL insurancerequired-]Toanzp. c.M§1(4).andwehaveav �f employees-[No wodoe ❑Ether/N3fA �L-rH/Es Camp-insurance, -] '/t �' S •AnyW5C=datCbedmbcmRamstalsofMo=lheswdanbe7mdwvmzgtFw-swastmec=p parkyiaf oa I s who sub das stl�ft they gm daing sll weak sad rhenium outsi&coutrecto[s— sa mit a new afdaelt indite s¢d. ICam 1. that che&tbft boar mast attache@ m additional sheet sbming the umne of the sdp ca�smd state vdudm arnottbose eafifthne employees.Ift]m bsve a p1uyee%theYams'p=vide ter wmimecmmp•polity awnbea: I am an euepr Heat is proerieiirrg workers'caesperesafime iresnenxce fvr ercp empla,}�ee� Betaev is�tleepertiey and jab site in foreaaaOiL Iasuranm CompanyName: Policy t or Self-in&Lic. ExpindoQDate: Job Ste.Address: City/StaftOWT. Attach a copy of the workers'compensationpoiicy duration page(showing the policy,mrmber and expiration date}. Failure to secure coverage as required under Section.25A of MQ.r—152 can lead to the imposition of criaeseat penalties of a fine up to$I,SQa QO and/or one-yearimpassonmenk as well as civil penalties in the forme of a STOP VMM ORDERand a Eme of up to$250.00 a day against the violator. Be advised that a copy of this statement nmy.be forwarded to the Office of Investigations ofthe DIA.for insurance coverage v on. I rlo Hereby the pidpolaWm f urti ie in,fors prm idol abmv is bns and e r m t Sitrreatnce_ ° Date- Phone; D D O.rWial&W only. Do not ethreta in this area, be eannpteted by taty ortas o,&&L City or Town: Permif .&ease 0 Issuing Aaflsority(drcle one): L Board of Health I Baff Img Department 3.Cityfrown Clerk 4.Electrical Inspector S.Phunbing Inspeeimr 6.Oth�er Office of Consumer Affairs&Business Regulation (� HOME IMPROVEMENT CONTRACTOR Registration -, '124954 Type: Expiration 9117/2--017 Individual Arthur J. LaFranchise Arthur LaFranchise1 a 23 CenterBoard Lane`i:;,; '- S.Yarmouth,MA 02664 Undersecretary L r / i Town of Barnstable *Permit ado oft ram,, t# a'd 7l Expires 6 mont from issue date Regulatory Services Fee BARVSTABLE, Thomas F.Geiler,Director ` Building Division AIEn� A Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY }} fi r� Not Valid without Red X-Press Imprint - Map/parcel Number cad (4P .I y� Property Address Residential Value of Work , � Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address' 7A �,16z—A.4)< Contractor's Name d { 4-5 %X A---Sd/J Telephone Number `C770 Home Improvement Contractor License#(if applicable) XWorkman's Compensation Insurance Check one: ❑ I am a sole proprietor -PRESS PERMIT ❑ I am the Homeowner I have Worker's Compensation Insurraance AUG 12 2008 Insurance Company Name TOWN OF BARNSTABL.E Workman's Comp.Policy# Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be to 0 Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side Replacement Windows% ors liders.U-Value (maximum.44) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property.Owner Letter of Permission. A'co of the Home Improvement Contractors License is r SIGNATURE,: — -... . Q:Forms:buildingpermits/express Revised 123107 I The Commonwealth of Massachusetts Department of Industrial Accidents u Office of Investigations d 600 Washington Street Boston,MA 02111' www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lefibly. Name(Business/Organization U&vidual):D(Z,nm_ =4 Address' City/State/Zip: Phone.#: Are.you an employer? Check the appropriate box: .Type of project(required):, 1• employer 4. [� I am a general contractor and I '�I am a mp yer with �_ 6. ❑New construction . employees(full and/or part-time).* have hired the sub-contractors 2. I am a'sole proprietor or partner- listed on the-attached sheet. 7.4 Remodeling ship and have no employees These sub-contractors have g• []Demolition workin for me in an capacity. employees and have workers' g y p ty 9. ❑Building addition [No workers' comp,insurance comp. insurance•# 5. [ We are a corporation and its 10.7$lectrical repairs or additions required.] 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 12.7 Roof repairs insurance.required]t c. 152, §1(4), and we have no 13.[] Other employees. [No workers' 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, $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether ornot 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: (\Q)V\ Policy#or Self-ins.Lic.M J,CpS(DQ Expiration Date: Job Site Address:�� 1�� ��` City/State/Zip \Tr ini�,'Nk CSC I 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 tip to$1,500.00 and/or one-year.imprisonment,as well as civil penalties in the form of a STOP WORK,ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of th I)IA for insurance coverage verification. I do hereby certify der the a' sand penalties of perjury that the information provided above is true and correct. Si afore: Date: Phone# � Lyl� S Official use only. Do nat write in this area, to be completed by.city or town official. City or Town: Termit/License# Issuing Authority(circle one): J.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone..#: Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. 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 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, §25C(6)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,MGL ehapter..152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall `enter into any contract for,the performance of public work until acceptable evidence of compl ance 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 Liabiliy 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 is required. Be advised 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 regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all-locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be 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 io any business or commercial venture (i.e. a dog license or permit to burn 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.. Thy Commonwealth ofMassa&usetts Departmmt of Industrial Accidents Office of Investigations 600 Washington Street Boston,.MA 02111 TeL ##617-727-4900 ext 40b or 1-877-MASSAFE Fax##G17-727»7749 Revised 11-22-06 www.mass..gov/dia Client#: 47298 CAPIHOM ACORDTM CERTIFICATE OF LIABILITY INSURANCE 06112/2008 Y' PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Rogers&Gray Ins.So. Dennis ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 434 Route 134 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 e: American Home Assurance r Ca Izzi Enterprises,Inc. p p INSURER C: 1645 Newtown Road INSURER 0: Cotult,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 LIMITS LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE MM/DDIYY DATE MM/DDlYY A GENERAL LIABILITY MPB1075H 06/08/08 06/08/09 EACH OCCURRENCE $1 000 000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $500 OOO- li PR ISES E occurrence) CLAIMS MADE F 7X OCCUR MED EXP(Any one person) $1 O 000 PERSONAL&ADV INJURY $1 OOO OOO GENERAL AGGREGATE s2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG s2,000,000 POLICY PROECT LOC J 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 $5 000 000 DEDUCTIBLE $ X RETENTION $10000 $ B WORKERS COMPENSATION AND WC6716562 12/25/07 12/25/08 X we LIMITU-FJ O ER EMPLOYERS'LIABILITY E.L.EACH ACCIDENT $500,000 ANY PROPRIETORIPARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? E.L.DISEASE.EA EMPLOYEE s500,000 yes,describe under S E.L.DISEASE-POLICY LIMIT $50O OOO SPECIAL PROVISIONS below r OTHER DESCRIPTION OF OPERATIONS I 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 If) 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 © ACORD CORPORATION 1988 Find a Licensee Page 1 of 1 VVef>s!ir:of the Executive Office of Public Safely and Security(FOPS) Public Safety Mass.Gov Home ^A,;•;�,n•;Hno,F� Agencies State Online Services EOPSS Home - State Age c Department of Public Safety Licensee Lookup The list is current as of Thursday, August 07, 2008. You can,search/fitter the licensee list by any of the criteria below. License Businesses Individuals Select a License Type Home Improvement Contractor„ i Search by License.Number-100740 I Search Select a License Type Home Improvement Contractor i i Search by Business Name Search by Contact Last Name First I I Search by City Zip Code j Search - I Select a License Type.,Select One I Search by Last Name First' ' i. Search by City Zip Code Search j Search Results LICENSE TYPE BUSINESS NAME CONTACT NAME LICENSE RESTRICTION ADDRESS Home Improvement Capizzi Home Improvement, Capizzi, Jr., 100740 1645 Newton Rd. Cotuit, Contractor Inc. Thomas 02635 http://db.state.ma.us/dps/licenseelist.asp 8/12/2008 Page 7 of 7 CAPIZZI HOME IMPROVEMENT INC. SPECIFICATIONS AND ESTIMATES STATE OF MASSACHUSETTS LETTER OF AUTHORIZATION TO APPLY FOR A BUILDING PERMIT 1, � OWN THE PROPERTY LOCATED AT �' /���-� ��� 5 `� Ui it k-7 IN 2"40VA '/ - , 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: _ I ' tHE T Town of Barnstable *Permit# Expire months front issue date rszABr�, ; Regulatory Services Fe Muss. Thomas F.Geller,Director �AIEo N9. Building Division x PR, Tom Perry, Building Commissioner ' :Ss 200.Main Street, Hyannis,MA 02601 JUN 8 ?004 7' Office: 508-862-4038 - � 7.Ow Fax: 508-790-6230 N EXPRESS PERMIT APPLICATION - RESIDENTIAL ONFBA&/VSSA N Not Valid without Red X-Press Imprint ��E Map/parcel Number 06 Property Address � Value of Work 4t I q'a-moo Residential ®� Owner's Name&Address C�o2—t S Contractor's Name lYl rti(Gy� Telephone Number W*"8.3 6'6 l S� Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) - ho n.Insurance an sC Compensation❑V'Jorkm P Check one: [] I am a sole proprietor I am the Homeowner I have Worker's Compensation.Insurance Insurance Company Name � � ! Worlanan's Comp.Policy# Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) lRe-roof(stripping old shingles) All construction debris will betaken ❑Re-roof(not stripping. Going over existing layers of roof) (] Re-side Replacement Windows. U-Value (maximum.44) *Where required: Lssuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: opeiprovernent wner must sign Property Owner Letter of Permission. Owner Contractors License is required. Signature Q:Forms:expmtrg Revise053003 PJ'Irt;f�f�I11iftlria 1Rebafzitians and.Stan�isr;�s . HOME lrApRbVvmjWElVT Op ► cTOR Rego it �o s 36206 004 AXvi.dual ARf CS 1/ia RlaVy 11Tf1F.'((aj.ro � N1 _ n0 i A�rninistrat�r N I r Town of Barnstable Regulatory Services $ Thomas F.Geller,Dtreetor . ,� Building Divisfon !o ?om ferry, $s�llding Cornu�l�etoner 200 Main street, Hyannis,MA 02601 �yyrrv.to rvn.b ara�table.xna.us Fax. 5ob»790-6230 pff'ice: 5p8-862AO38 property ()wrier Must Complete and Sign This Section If Using A Builder as Owner of the subject property t On m half, to act y be hereby authorize in ah r,I tter3 relative to work authorized by&i s building permit application for. (Address of Jo ) Date Signature of Owner r ------------- Print Name