HomeMy WebLinkAbout0008 TOWNHOUSE TERRACE 4acl
8
TOWN OF BARNSTABLE BUILD NG PERMIT APPLICATION
_-0
Map Parcel Permit# ' CP 3 7 5-3
Health Division 0 Date Issued /o--L--
Conservation Division ' "'
Fee
Tax CollectorL — —4 oZ/ % ' �p 2
_ _ Ny
�nir
Treasurer °� ENc o �A SEA
Planning Dept. CONSTF NGD �'R�IK THE
� CTl0I1� �BIO$TO
Date Definitive Plan Approved by Planning Board a '
Historic-OKH Preservation/Hyannisd�' � .
Project Street Address y L,,n,h 5 Q_ 0,00is
ZIA.
Village I' S
Owner LC.&i2r-d CICA;akt. k' ) Address JCLtM__
Telephone °1J' Y/ (12
,-Permit Request ('
V Ct M _ W
Square feet: 1st floor: existing proposed 2nd floor: existing proposed Total new
VValuatioA '1506 . Zoning District Flood Plain Groundwater Overlay
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 newer c1 r
Number of Bedrooms: existing new C
Total Room Count(not including baths): existing new First Floor Room Count
_e
9, zi)
Heat Type and Fuel: ❑Gas ❑Oil ❑Electric ❑Other _J
Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal sto e: ❑liO,
Detached garage:O existing Cl new size Pool: 0 existing ❑new size Barn:O exist' size
Attached garage:0 existing 0 new size Shed:0 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 '— :;AnQrQVtflL4J Telephone Number
Address J d License# r S 06 70 F3a
Y IL6., Ua1 36— Home Improvement Contractor# 100 7YO
Worker's Compensation# o�(�(X7
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE 7 A40A4 DATE
FOR OFFICIAL USE ONLY
PERMIT NO.
DATE ISSUED
MAP/PARCEL NO..
i
ADDRESS VILLAGE
OWNER '
DATE OF INSPECTION:
FOUNDATION
iY ► r
FRAME
INSULATION 6 O* `
FIREPLACE
ELECTRICAL: ROUGH FINAL +
PLUMBING: ROUGH FINAL
GAS: ROUGH; �' FINAL
r FINAL BUILDING ' y
DATE CLOSED OUT *-
ASSOCIATION PLAN NO.
�"^' _'r'�wa'c�:.F-^..ti�v.' a�...:M� _.:. a„,,,.,.et.-r� n...� � , ..:.�W +> .. ... , .. V+F�Ti7Lc•'J"'�ir�+'y*'.�i.ie"'aM•vw}''-sue-,......-,..,.,,.wn
`oF.HEr � The Town of Barnstable
o�
G : 9ARN87Aa�E. Department of Health Safety and Environmental Services
MASS
�Fo,r,Ay• Building Division
367 Main Street,Hyannis,MA 02601
Office: 508-790-6227 Ralph Crossen
Fax: 508-790-6230 Building Commissioner
Inspection Correction Notice
Type of Inspection {
Location q'_�O- to "AWa S.® Q, � Permit Number
Owner Builder f Cez 1-"-)6
r
One notice to remain on jobsite, one notice on file in Building Department.
The following items need correcting:
C4 Ji
1•''Y"ir". A..,� ntY.n P .. Ste" -
Please call: 508-862'-4038 fr re-inspection.
Inspected by (I V
Date 1 0) 1 ,l '2
. . °: The Town of Barnstable
..eaNsrns�e. •
Department of Health Safety and Environmental Services
'�En rvt" Building Division
367 Main Street, Hyannis MA 02601
Office: 508-862-4038 Ralph Crossen
Fax: 508-790-6230 Building Commissioner
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.
v
VIType of Work: -t Lr► l CiMI Estimated Cost 4 Cb.
Address of Work: �( I.l dl ADU.S e_
Owner's Name: l C/,a- /11—
Date of Application: a—
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 Co' N e Registration No.
CAP 1 u 0 M 2tuPjcOvEN�EuY
OR
Date Owner's Name
q:fbmis:Affidav
The Commonwealth of Massachusetts
Department of Industrial Accidents
_ Ol!%Ce O/l/IYestlynfODS
600 Washington Street
f Boston Mass. 02 111
Workers' Compensation Insurance Affidavit
location
city GQ n1M/l phone#
I am a h6eowner performing all work myself.
I am a sole proprietor and have no one working in any capacity
am an employer providing workers' compensation for my employees working on this job.
company name• J_ �l �� t / M(' '17/ V.,C jy1 M-1
address:. Al
r L � �}
situ: �'12, �-- ���L '�J phone th 15 CQ—/_/J dG — L5_IF
Ct✓ o i. a5o
I am a sole propricYor,general contractor, or homeowner(circle one) and have hired the contractors listed below who
the following workers' compensation polices:
company name:
address:
rih" phone#•
insuranceco. oli #
1:4mpany namr
addrem:;:
cttr phone#•
ii surance co. policy#
Failure to secure coverage as required under Section 25A of NIGL 152 can lead to the imposition of criminal penalties of a fine up to 51,500.00 andi,-
one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of S100.00 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.
do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature Date
Print name 0 ril a S ! Z- Phone# �C !V-2k- 9 /Y
7check
do not write in this area to be completed by city or town official
permit/license# nFtuilding Department l
0Licensing Board
ediate response is require) OSdectmen's Office, f'
Health Department
phone#; -Other
Om,i d 3/95 PIA)
/ie �omvnwouaea�i o�,./f/laaaac�u�aelta
-- Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
11_ Registration: 100740
Expiration: 6/23/2004
Type: Private Corporation
CAPIZZI HOME IMPROVEMENT,I
%omas Capizzi,jr.
1645 Newton Rd. �
Cotuit,MA 02635 Administrator
omvma�r o
BOARD OF BUILDING REGULATIONS
.'License: CONSTRUCTION SUPERVISOR
i; Number: CS 057032
Birthdate: 09/26/1963
Expires:09/26/2003 Tr.no: 5790
Restricted.: 00
THOMAS X CAPIZZI JR
280 PERCIVAL DR ( ...�
W BARNSTAKE, MA 02668 Administrator
TAW 3s 2 lb(ears--0 �t Frossil FnX6
prsseripttrs p�eks;te fer6"sad Tww
t3laang . A 8 Ctiiin� FloorR
CII vslue� WJLUPfaff
Ar=f(V,) U-values R-t�1ue� R R�yatust
Psd ° Ent to D I
6
3 i 11 19 10 . 6 Nar1
0.4� 30 19 19 10 V AFM
g IZY: 0.5Z 13 19 ,3 13 23 ri LA
Tv ' 03 6
ts
a.46 ?VA
v � wA
0. 4 31 11 6 ZS AAFFVV
151/. E
19 i9 10 Norrnsi
jy 1S'/, 03Z 30 WA ?UA
13 25
19VA
go AFUS
:. Y 1 E'i. ' 0.42 3:. 10 6
3j 13 1g 6 40 AFVE
0:41 14 10
a 50 30 19
AA 1 8.. '
DRESS OF PROPERTY:
2, SQUARE FOOTAGE OF ALL 'ERIOR WALLS:
3, SQUARE FOOTAGE OF ALL GLAZING:
4, 0/4 GLAZING AREA M DNIDED BY#2):
SELECT PACKAGE(Q AA-sea chart above): ;
OTHER MORE INVOLVED METHODS OF D
ETERMD4ING ENERGY•REQUI EMEN'rS
NOTE:
ARE AVAILABLE. ASK US FOR THIS INFORMATIOI`Z•
BUILDING INSPECTOR APPROVAL:
NO:
YES:
gdorms•f980303a �
Footnoie's to Table-J5.Z.ib:*
I Glazing area is the ratio of the area of the glazing assemblies (including sliding-glass•doors,sdkylhe �s, d
basement windows if located in walls that encloseo canditi�on�ed sazp��a be �X�l ded frorcut tl�e u value requirement.
area. expresspd as a percentage. Up to 1/o f the glazing g
Far example;3 fr of 'must be tested and documented by the manufacturer in accordance with
decorative glass may be excluded from a building design with.300 of lazing area.
= After January I, 14de glazing U-values'mu
the National' Fenestration Rating Council (NFRC) test procedure, er' �'fr0m Table 11.5.3a U-values arc Far
whole urtits:'center-of-glass U-values cannot be tiled.
The ceiling R-values do not assume a raised or oversized truss COLLStiuctloa. If the'insulation achieves the full
insulation thickness• over the exterior walls without compression; R 30 irtsulatinn may be substituted for R-3 S
es �c sum Of caviry
insulation and ME insulation may be substituted forR=49 insulation. CaT R��g use be pla d between
insulation plus insulating sheathing (if.used). F°r.vcntilatrd ceilings,.
the coriditioned space and'tiie ventilated portion of the roof- sh�ng (if used). Do not include
Wall R-values represent the sum cf the wall cavity.insulation plus insulating
exterior siding, structural sheathing, and interior'drywslL For example, art R-19 regturrment.could be met aITHER
by R-19 cavil}% insulation'OR R-13'cavity lnstliat3on plus M insulating &eathWg- Wall � et
q p.
1 to
wood=frame or mass (concrete,masonry,log)wall.eonst Cdrins,but do not apply to metal4ratne construction.
•''Ihe floor•;requircments`apply to,floors*over unconditioned spat= (such as unconditioned crawlspaces,basements,
or garages):•Floors'o er;cutside air rt list meet the ceiling requirements• de must
`TI-c entire opaque portion of any individual basement wall witfi aa'avezage,depth less than 5doors of coow nditioned
elect,. the same R-valuc requirement-as above-grade walls. Windows and sliding glass
basements must be included with the other glazing. Basement doors must meet the door U-value requirement
d-scribed in Note b.
'The R-value requirements arc for unheated slabs,Add an additional R Z for heated slabs.
If the building utilizes clettric resistance healing use compliance approarh 3; , r 5.the if you
men with to stalthe lm l m r
than one piece.of heating equipment or.more than one piece of cooling equipment,t, eq p
efficiency must meet or exceed the efficiency required by the selected package-
For'Heating-Degree Day requirements of the closest city ortown see Table 35.2-1a.
l�lOTES:
a) Glazing areas and U-values are maxim acceptable.levels.Insulation R-values are minimum acceptable levels.
um
R-value requirements are for insulation only and do nqt include structural eommpp nent Door U-vaIues must be tested
b) Opaque doors in the building envelope must have a U-value no cad= or taken from the door U-Value
and documented by the manufacrurer in.accordance with the NFFR�p f r door is not available, include the
ass and an a eta ,
' contains 1 gig.
in Table 11.5.3b. If a door g door.'
glass area of the door with your windows and use the opaque door U-value to determine compliance of the
One door may be excluded from this regi irement'(i.c,may have a U-value greater than 0.35).
c) If a ceiling,wall, floor,basement wall,slab-edge,or crawl spacz wall component value is two
than or equal or more areas tth
o
different insulation levels, the component complies if the arcs-weighted rag
the R-value requirement for that component. Glazing or door components comply if the area-weighted average U-
value of all windows or doors is less than or equal to the U-value requirement(0,35 for doors),.'
43
780 CMR: STATE BOARD OF BUILDING REGULATIONS AND STANDARDS
THE MASSACHUSEITS STATE BUILDING CODE
FIGURE 3606.2.3b
FRAMING DETAILS
CUT PLATE T1 FD STAOOPIR JOINTS 4"OR C /
WITII 24 OAOF. USE SPLICE PLATES
ST M ANGLE OR SFl 7110 CMR 36061.3.3
EQUIVALENT
SIMILE OR
DOUBLE TOP
PLATE
FIRESTOP
AROUND PIPE
HEADER-SEE
TABLE 3606.2.E
WALL STUDS r K STlmc
SEE 780 CMR 3606.2.3' pR TRIMMERS
t7
� m
O
0
m 0
_FLOOR
SUBFLOOR — JOISTS
�u run FOUNDATION
-- ------------ t 'RIPPLE ,
WALL SEE
___-- ------ 780 CM
3606.2.9
ANCHORROLTSEMBEDDED _ -------
-------------- -----
IN FOUNDATION 60'O.C. t-------------------------------
MAXIMUM
FO DATION
WALL STUDS
t CORNER AND PARTITION POSTS
I-BY 4-DIAGONAL
BRACELET INfU STUDS —
Non::A third stud and/or anchor partition
intersection backing studs may be omitted through
the use of wood backup cleats,metal drywall clips
Apply approved shoe g n plates
and exterior walls wish I" or other approved devices that will serve as an
by to braces to into studs end plates end extending from adequate backing for the facing materials
bottom plate to lop platy
See 780 CMR 3606.2.9.
For SI: 1 inch=25.4 mm, I foot=204.8 mill.
TABLE 3606.2.6
AIA.XIAIUM SPANS FOR HEADERS LOCATED OVER OPENINGS IN WALLS
IIEAUERS IN BEARING WALLS2 HEAVERS IN
WALLS NOT
SIZE OF HEADERI'2 SUPPORTING
Supporting Roof Only One Story Above Two Slories Above FLOORS OR ROOFS
2-2 x 4 4
2-2 x 6 6 4
2-2x8 8 6 10
2-2xl0 10 8 6 12
2-2 x l2 12 10 8 16
For SI: I inch=25.4 nun, I fool 304.8 nun.
1. Nominal four-inch thick single headers may be substituted for double members.
2. Spans are based on No.2 Grade Lumber with ten-foot tributary floor and roof loads.
1 •
h
534 780 CMR-Sixth Edition 12/12/97 (Effective 8/28/97)
780 CMR: STATE BOARD 01'13U1LDIIJG REM LA77UNS AND STANDARDS
TI IE MASSACI IUSETfS STATE BUILDINU CODE
FIGURE,3606.2.3b
FRAMING DETAILS
Cur rLA7E 11ED 5 tAOOPR 101N1S 1"OR
Wl I it 21 OA(IF USE SrIJCE rtA1 FS
S IFEI ANOLE OR SEE 710 CMA 36061.3.)
F.QUIVALENr
S0101B OR
bothil.F,rUF
Fill"
ff
II
FIRESlor —�
AROUND PIPF
Lllr rER-SF
TA IE 3606. 6
WALL STUDS --► 3At S1UOS. —
SGr.7A0CMA3606.2.3' �jA IMMER
0 Q
J
O O
in v.
FLOOR
Sunrr0`011 ss —Joists
roUNDATION
Clurrl.E ,
I -- -- 780 MSEE .
Teo 36o6.2.8
--- - - - t --- 2.tI
ANCIIORnOLISrhmEDDED _
IN routiVATION 6'0'O.C. r_------------------------------
MAXIMUM roll DA1101
WALL STUDS
CORNER AND rARTITION rOS I S
1 � I'ttY 4"UTAt101JAL - -
/ ORACELEIINIOSMI-IS
1
NOTE:A lbird stud and/or anchor pail ition
intersection backing studs may be omitted thtough
the use of wood backup cleats,metal drywall clips
ArPIY^PProvcd she g or brace exterior walis%villa I" or otber a proved devices that will serve as Rn
by•t"bracts let into studs and plates and extending born adequate backing for lire facing materials
bottom plate to top plate.
See 780 CMR 3606.2.9.
For SI: I inch=25.4 min, 1 foot=204.8 nun.
TA11LE 3606.2.6
p,1A,X1MUN1 SPANS FOR HEA_DEMS LOCATED OVER 01'ENINCS IN WALLS
IIF,ADERS IN
[WAVERS IN HEARING WALLS WALLS NOT
SIZE OF HEADERI'J -- SIJI'I'ORTINC
SuppolMIR Itoo(Only One Story Above Two Stories Above FLOURS Olt ROOFS
2-2 x 4 4
2-2 x 6 6 4 10
2-2 x 8 8 6 6 12
2-2x10 10 1U 8 IG
2-2x12 12
For SI: 1 inch=25.4 nnn, I fool 304.8 nun.
t I. Nominal four-inch thick single headers . be substituted for double members.
e 2. Spans are based on No.2 grade Lumber with Ian-li,ot li ibutnry floor and roof loads.
r
h
I �
r
534
78U CMR Sixth Edition (Effective 8/28/97)
Town of Barnstable *Permit# ? 2 7
&pines 6 months from issue date
ssr� Regulatory Services Fees` d-T7
9 1659. ,0� Thomas F.Geiler,Director
ED 1A°` Building Division
Elbert C Ulshoeffer,Jr. Building Commissioner o
367 Main Street, Hyannis,MA 02601w -PRESS PEI
Office: 508-862-4038 �t Z 1 2001
Fax: 508-790-6230
EXPRESS PERMIT APPLICATION TOWN OF BARNSTABLE
Not Valid without Red X-Press Imprint I�
Map/parcel Number �p` 0 Y
j2(,
Property Address lauk-) iNQU5&_ (,G$__ � 1
LrC n n l S
Residential OR ❑Commercial Value of Work /& c5--
Owner's Name&Address 1 r Ial 4k .
Contractor's Name f Zit elephone Number02
Home Improvement Contractor License#(if applicable) 2L/Q
Construction Supervisor's License#(if applicable) C7�
MWdkmanIs Compensation Insurance
Check one:
17 ,
I am a sole proprietor
❑ I OM the Homeowner
9116ave Worker's Compensation Insurance
Insurance Company Name urlc,/ /7YYlY-x-1 caA
Workman's Comp.Policy# (/j (' l�Z ]- Q�fo -UZ
Permit Request(check box)
❑ Re-roof(stripping old shingles)
❑.Re-roof(not stripping. Going over , existing layers of r000
❑ Re-side
L-41acement Windows. U-Value (maximum.44)
❑ Other(specify)
*Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
Signature
expmtrg
Town of Barnstable *Permit
�FZHE Tp� Expires 6 uiontbs froo,issue date
0
b T
Regulatory Services " Fee
(J(J
i 1ARDI5'rABLE,
y MASS. $ Thomas F.Geiler,Director
�p 1659• A`0
lfo r+tpr Building Division
Tom Perry, Building Commissioner ® p
200 Main Street, Hyannis,MA 02601 pRESS PERIM
Office: 508-862-4038 SEP 0 4 2003
Fax: 508-790-6230
EXPRESS PERMIT APPLICATION - RE LXSIDENTIAL_Q F SARNSTABLF-
Not Valid without Red.Y Press Imprint
Map/parcel Number
Z�UIDqoC� "
Property Address -row
�( e Value of Work 3
�'6Cy Residential '
Owner's Name&Address
Tbw
Telephone Number
?Contractor's Name T `�
,zi `Home Improvement.Contractor License#(if applicable)
Construction Supervisor's License#(if applicable)
❑Workman's Compensation Insurance
Check one:
❑ I am a,sole proprietor
am the Homeowner
IAd I have Worker's Compensation insurance
^ w
Insurance Company Name Pwcwc�
Workman's Comp.Policy#
�A, ), ,(4, lU� �
Permit Request(check box) -
❑ Re-roof(stripping old shingles)
❑Re-roof(not stripping. Going over existing layers of roof)
❑ Re-side e ,%
Replacement Windows. U-Value (maximum� .
.44)
❑ Other(specify)
*Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
qk_,60� C4��
Signature
Q:Forms:expmtrg
1 l.I. ' , I 1
03i19/07. WF) 09:.19 FAX 6036279559 RARVEY INDUSTRIES HYA.NNIS W'H5E 1d]ou1
ENERGY BTHR
F'�:a ,,, IGo9DOt
TEST RESULTS
Harvey Manufactured Windows and Doors
- U-Values in accordatice with NFRC-100 • Based on residential sizes
• U- and R-Values are subject to change without notice •Whole window values
Air infiltration rusuits are subject to change without notice
All vinyl windows with Low-FiArgo11 qualify fOr the ENERGY STAG"program throughout tile U.S.'
Revised 1131103
Clear Ir►eu1310 Luw�E Low-F,/Argun* Ali-
U-Vetere !t-VAlne U-V�lue 1t-V,►lue 11-vnluo It-V.Iuo Inlihralinn
VINYL WIMOQVNS
Classio Double Flung (Mechanical) 0.50 2.00 0.37 2.70 0.34 2.94 •G8
Classic Double Flung (Welded Sash) 0.50 2.00 0.36 2.78 0.33 3.03 .04
Classic Double Hung(Welded Sash t3 rarne) 0.49 2.04 0.36 2.78 0.33 3.03 .10
Classic Acoustical Double Hung STC40 0.23 4.35 0.18 5,56 0,17 5.88 .09
o0 Signature Double Hung (Mechanical) 0.50 2.00 0.37 2.70 0.34•;'. 2.94 .04"
ignature Double flung (Welded Sash)- U.50 2.00 0.37 2.70 0.34., 2,94 .11'
Slimline Uouble Hung (Welded Sash) 0.51 1,96 U,36 2,63 0.34 2.94 •08
Slimline Double Hung(Welded Sash & rame) 0.50 2.00 0.38 2.63 0.35 2.86 •09
Slimline Single Hung (Welded Sash $ rarne) 0.50 2.00 0.38 2.63 0.35 2.86 .03
Vinyl Casement/Awning 0.47 2.13 0.34 2.94 0.31 3.23 .01
Vinyl Ca.sernent/Awning and Thermal Panel 0.31 3.23 0.25 4.00 0,24 4.17 .01
Vinyl Desi.1 Shapes 0.4.9 2.04 0.34 2.94 0.30 3.33 -
Vinylllopper 0.47 2.13 0.35 2.86 0.32 3.13 .08
Vlrtyl Picture Winnow 0.46 2.17 0.31 3.23 0.28 ., 3.57 .01
Vinyl Welded Dear_Ilile 0.50 2.00 0.34 2.94 0,31 _ 3.23 --
Vinyl F2aller- ?_Lite enri 3 Lite 0,50 2.00 0.36 2_78 0.3$ 3.03 u9
(241a)
1'7esl resup;,PrC batitid on cunim4rcial 5I2M',
•iell►p.Clear Tlenip Low-Pt Temp,Argon :fir
U-V14Ipe R-Villue 0-Value R-Voluc U-Valuc ANA"* Ihlihr:ginn
rfovir'
eAT101LU J3
Harvey Solid Virtyl Patio Door 0.49 2.04 0,40 2,50 0.37 '2_70 .09
Air itlfiltratlorl is in accordance with AS-I-M E283@.)25 mph.
"the use of tempered Low-9 glass may effect ENERGY STAR°quallfication in your region_
U-and R-Valuea are subject to change wiltrrlut notice_
The Cornmouwealth of Massachusetts
Department of industrial Accidents
Office of Investigations
600 Washington Street
Boston,ViA 02111
Workers' Compensation insurance Affidavit
Applicant Information: PLEASE PRINT
U1N1 QS U) (YI
LOCATION
CITY ST.�TE ZIP CODE PEiO-E
O I am a homeowner performing all work myself.
O I am a sole proprietor and have no one working in any capacity.
O lam an employer providing workers' compensation for my employees working on this job.
'c Name ( l ` ►U 1-oy/ 1'0 `e 1'l
Company
Address (� S ' Je -b lc)
State rr�� Zip Code 1 Z�3 S Phone T ��b ( 2 d —
Ciry�U �U1 � 2
(i u CA W CU 10 g 3 Expiration Date
Insurance Co. VrQ vi Policy R
O I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have the
following workers' compensation policies-
Company Name
Address
City
State Zip Code Phone T
Insurance Co.
Policy K Expiration Date
Company Name
Address
City
State Zip Code Phone^A
Insurance Ca
Policy 4 Expiration Date
as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to
Failure to secure coverage
Failure
to and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of 5100.00 a
f this statement may be forwarded to the Office of Investigations of the DIA for coverage
day against me. I understand that a copy o
verification.
I do hereby certify under the pains and penalties of perju�ryythat the information provided above is true and correct.
Date
Signature �` }
. Print name
^rhUY1/ICLS ��Q 1Z-?mil ��`r • Phone ff"
Official use only-do not write in this area-to be completed by city or town of icial
permidlicense X Cl Building Depamnent
ClLicensing Board
City or town
O Selectmen's 06ee
O Health Departz=t
O Other
O check if immediate response is required
Phone
Contact person
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Hoard of Building Regulations r,nd Standards
1 IIOME IMPROVEMENT CONTRACTOR
��;,�-,•.r� Reylslrallon: 100740 - it
ram`. Explrallon: 6/23/2004
Type: Prlvale.Corporalion ,
CAPIZZI 140ME IMPROVEMENT,I
Tromas Capizzi,Jr.
1645 Newton Rd. ��
Coluil,MA 02635 Administrator
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130ARb Or DU1LDING REGULATIONS
n 1 Llcese: CONSIRUCTION SUPERVISOR
Number: CS 057037_Dlrthdalo: 09/26/1963
EXp nlres: 09/26/2003 Tr. o: 5790
Restrlctod: 00
7I IOMAS X CAPI7_ZI JR _
7.13U Pfal(,IVAI_UIZ (�....,.� —7i/Vrrte/
W DARNSTADLE, MA 02660 Adminisiralor
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ACORD_ CERTIFICATE OF LIABILITY INSURANC pppp °""`""""°°""'
�2L-1 03/26 03
PRODUCER THIS CERTIFICATIR It IifUED AS ORMATI
Nororoas L Leighton Cape Loc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
C.J.McCarthy ins.Agency,Inc. HOLDER.THIS CERTIFICATZ DOES NOT AMEND,EXTEND OR
437 Station Ave ALTER THE CoVERAOE AFFORDED BY THE POLICIES BELOW.
So.Yarn►outh HA 02664 INSURERS AFFORDING COVERA09
Phone: 508-394-0946 rax:508-760-1407
INSURED INSURER A: National Orange Mutual Inn. C6
94SURE3R N: Nafety Insurance C •i><
1 6v5rzi Homo Im ve proment Inc. INSURER Guard Insurance groRp
Got5ui euk 'Ol IN9UR R Dr.
INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE SEEN 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 16 SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LMTS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
IN TYPE OF INSURANCE POLICY NUTMER T M Y —MMELIMITS
oENERAL LIABILITY EACH OCCURRENCE f 1000000
A J( COMMERCIAL GENERAL LIABILITY MPS02733 04/01/03 04/01/04 PRE DAMAGE(Any oMNis) f 300000
CLAIMS MADE a OCCUR MED EXP(Any ons pmun) s 10000
PERSONAL a Agri INJURY f 1000000
OENERAL AGGREGATE $2000000
OWL AGGREGATE LIMIT APPLIES PER: PRowcm.COMP/OPAm $2000000
P E D OLICY LOC
AUTONOWLE LIABIUTY COMBINED SINGLE LIMIT f
H ANY AUTO 1601064 04/01/03 04/01/04 memi& m
ALL OWNED AVTOS BODILY RLIURY 11000000
X SCHEMILED AUTOS, (P-Pn)
X HIRED AUTOS BODILY INJURY $1000000
L-1 X NONaWNFD AUTOS .eew�np
PROPERTYDAMAGE 1500000
pew moldwo
GARAOELWILITY AVTO ONLY.EAACCIDENT 1
ANY AUTO p7}1�q T1UW SA AM s
I�IJTO ONLY: AGO i
EXCESO LIANUTY EACH OCCURRENCE i
OCCUR CLAIMS MADE A00RE0A7E f
DEDUCTIBLE i
RETENTION s s
woRKERS COMPENSATION AND X
C EMPLOYERVLIANILITY CAWC401043 01/01/03 O1/01/04 E.L.FACNACCIDENT f 100000
LL.DISCASK.FA EMPLOYEO i 100000
LL.DISEASE.POLICY LIMIT s 500000
OTHER
DESCRIPTION OF OMATIONKOCATIONSIMM E OLU ONS ADDED BY ENDORSEMENTISPECIAL PROYISION6
CERTIFICATE HOLDER IN I ADDITIONAL INSURED;INSURER LETTER: CANCELLATION
SHOULD ANY OP THE ABOVB DESCRIBED POLWICS EE OANCEILED BEFORE THE EXPIRATION
DATE THEREOF,TNK IIIUIND INSURER WILL ENDEAVOR TO MAR 11Z_DAYS WRITTEN
NOTICE TO THE CELTIPICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO 60 SHALL
` IMPOSE No ODUGATION OR UAAILITY OF ANY KIND UPON THE INSURER.ITS AGENTS OR
REPRESENTATIVES.
AUTHORIZED 6ENTAT '
ACORD 25-5(r197) OACORD COMDORATION tat
CAPIZZI HOME IMPROVEMENT INC.
SPECIFICATIONS AND ESTIMATES PAGE 6 OF 6
STATE OF MASSACHUSETTS
LETTER OF AUTHORIZATION TO APPLY FOR A BUILDING PERMIT
I, �is
OWN THE PROPERTY LOCATED AT 5 I r)u-vtf2 f4 c,-� T`e evm c-e
IN MASSACHUSETTS.
I HAVE AUTHORIZED
TO ACT AS MY AGENT TO APPLY tOR A BUILDING PERMIT IN ACCOIfANCE WITH 7 0 CMR,
THE MASSACHUSTTS STATE BUILDING CODE.
I GIVE MY PREMISSION TO
LESSEE TO APPLY FOR A BUILDING PERMIT IN ACCORDANCE WITH 780 CMR, THE
MASSACHUSETTS STATE BUILDING CODE.
,.JA� '-'- I k
SIGNATURE OF OWNER: `L
OWNER'S ADDRESS:
OWNER'S TELEPHONE: J-0 �7 �" D
LESSEE'S SIGNATURE:
LESSEE'S ADDRESS:
I
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 PART OF AND IN CONFORMANCE WITH PROPOSAL #
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