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HomeMy WebLinkAbout0018 VANDERMINT LANE 11- 27-i3 P� Cape Save Inc. Toy'fv OF PARR TASK 7-D Huntington Avenue 2 13 South Yarmouth, MA 02664 . 31 Tel: 508-398-0398 Fax: 508-398-0399 11-25-13 Town of Barnstable Thomas Perry CBO Building Commissioner 200 Main St. Hyannis,MA 02601 RE: Building Permits Dear Mr. Perry,' This affidavit is to certify that all work completed for 18 Vandermint Lane.Hyannis has been inspected by a certified Building Performance Institute(BPI) Inspector. Ceiling: R-30 cellulose Basement: R-19 fiberglass in box sill All work performed meets or exceeds Federal and State Requirements. Sincerely, William McCluskey I � e. �p TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map On Parcel 0 6O Application # CJ� l Health Division Date:lssued Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH Preservation / Hyannis Project Street Address yi-J rm1int LoAt Village [ 4k4AIJ ` 4 Ownerinpr�� ►G((�'o Addresso4n1e, Telephone Permit Request f" RR-31D cAit k se -t-o hic- Ra d R -11 �+bets 6 ss, to 1-�e b use Mend b o& r;11 . P; seh pta n e Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation 30 8 0 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 Q Basement Finished Area (sq.ft.) Basement Unfinished Area (97 Number of Baths: Full: existing new Half: existing new i Number of Bedrooms: existing —new Total Room Count (not including baths): existing new First Floor Ro m Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other a ' 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 _41\10 If yes, site plan review # Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name Tele hone Number 5 9$ 39 p Address &AAIc6A &a. License # -__T C I Q&J4b f)r_ ^ V M 0 Home Improvement Contractor# lam' Worker's Compensation # SIP C 3 3 5 9 b 8 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO `Car�now� SIGNATURE DATE 11 /,3 FOR OFFICIAL USE ONLY ; s APPLICATION# DATE ISSUED MAP/PARCEL NO. z f ADDRESS VILLAGE F OWNER k DATE OF INSPECTION: FOUNDATION r. FRAME s INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL ` FINAL BUILDING DATE CLOSED OUT J ASSOCIATION PLAN NO. J_ %6 i�. Housing Assistance Corporation Cape Cod HOME OWNER WEATHERIZATION WORK PERMIT & FUEL RELEASE: PLEASE FILL OUT AND SIGN THIS FORM IF YOU ARE THE APPLICANT HOME OWNER. D L- 4 G Y t!H . /ti'/ 6 P 0 hereby consent to and agree that weatherization work may be done by the Weatherization Program of Housing Assistance Corporation (herein after referred as"Agency") on the property located at: _ t The weatherization work done will be based on programmatic priorities and availability of funding and it may include all or some of the following measures:. Weather-stripping &caulking of windows and doors, insulation of attics, sidewalls & basements, attic and other ventilation measures and possibly replacement of badly deteriorated windows. In consideration of the weatherization work to be done at my home I agree to the following; t. 1 give permission to the "Agency" its agents and employees to travel onto or across said property with such equipment and materials as may be necessary to perform weatherization work on said property. 2. The Housing Assistance Corporation 'reserves the right to inspect the fuel or utility bill for the weatherized unit on an ongoing basis for no more than five (5) years after the weatherization work is completed. I have read the-provisions o€this agreemen as listed and freely give my consent. Home Owner. {Signature) Date: / U ! r`.+ Agent: (signature) g Date: HAC approved Weatherization Company : C`L C° ✓e All Cape Energy Cape Cod Insulation �Safficient Buildings,LLC Frontier Energy, Solutions,, Loh.r,84 Sons. .. • Resplutio.n Energy The Commonwealth of Massachusetts - Department of Industrial Accidents Office of Investigations I Congress Street, Suite 100 Boston,MA 02114-2017 www.mass.gov/dia � Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print_Le ibl Name (Business/Organization/Individual): Cape Save Inc. Address: 7D Huntington Ave City/State/Zip: South Yarmouth, MA 02664 Phone #: 508-398-0398 Are you an employer?Check the appropriate box: Type of project(required): 1. ✓0 I am a employer with I -)�_ — 4. ❑ I am a general contractor and 1 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. ❑ Remodeling ship and have no employees These sub-contractors have g. ❑ Demolition and have workers'employees working for me in any capacity. 9. Building addition [No workers' comp.insurance comp. insurance.+ required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions ,.❑ 1 am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL c. Roof repairs insurance required.] c. 152, §1(4), and we have no q ] r employees. [No workers' 13.❑✓ Other Insulation comp.insurance required.] Any applicant that checks box 91 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 or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. 1 ant an employer that is providing workers'compensation insurance for my employees. Below is the policy andjob site information. Insurance Company Name: Technology Insurance Company Policy#or Self-ins.Lic. #: TWC3353968 Expiration Date: 04/09/2014 Job Site Address: Lant° City/State/Zip: "Af%�S At tach a copy of the workers'compensation policy declaration page(showing the policy numb r and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. 1 do hereby certi under the eins and penalties ofperi ,that the in ortnation provided above is true and correct. Si gnat Date Phone#: 508-398-0398 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1. Board-of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: AC ®� DATE(MMIDDIYYYY) f � ._ CERTIFICATE OF LIABILITY INSURANCE 10/22/2013 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 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 endorsements. PRODUCER CONTACT NAME: Colleen Crowley Risk Strategies Company PHONE (781)986-4400 AC No:(781)963-4420 15 Pacella Park Drive Suite 240 INSURER(S)AFFORDING COVERAGE NAIC# Randolph MA 02368 INSURERA:Selective Ins. of America INSURED INSURERB:Safety Insurance Company 3618 Cape Save, Inc INSURER C:Technology Insurance Company 7 D Huntington Ave ►NSURERD: INSURER E: South Yarmouth MA 02664 INSURER F: COVERAGES CERTIFICATE NUMBER:CL13102268490 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 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 REDUCED BY PAID CLAIMS. rA TYPE OF INSURANCE ADDL SUBR AM POLICY NUMBER MMOf ICY EFF MPMI�D EXP LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence $ 100,000 CLAIMS-MADE �OCCUR 1994480 0/16/2013 0/16/2014 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN1_AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY X PRO X LOC $ AUTOMOBILE LIABILITY COMBINED Ea accident) L 1,000,000 ANY AUTO BODILY INJURY(Per person) $ 8 ALL OWNED SCHEDULED 208200 1/6/2013 1/6/2019 AUTOS X AUTOS BODILY INJURY(Per accident) $ X X NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Pera cident $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 A EXCESSLIAB CLAIMS-MADE AGGREGATE $ 1,000,000 DED RETENTION NIL 1994480 0/16/2013 0/16/2014 $ C WORKERS COMPENSATION Officers Included .for X ACSTATU- OTH- AND EMPLOYERS'LIABILITYTORY LIMITS ER ANY PROPRIEfORIPARTNERIF�ECUTIVE YIN rage E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? N❑ NIA (Mandatory in NH) 3353968 /9/2013 /9/2014 E.L.DISEASE-EA EMPLOYE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space Is required) Weatherization Specialists GL: Blnkt AI, Blnkt PNC, Blnkt WOS, Per Proj Agg, Per Loc Agg / GL Exclusions: Snow & Ice Removal/OCIP/Wrap Ups CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE chael Christian/CLC ;A- ACORD 25(2010/05) 0e 1988-2010 ACORD CORPORATION. All rights reserved. INS025(201005).01 The ACORD name and logo are registered marks of ACORD Yv • J � f U t Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supen-isorSpecialty- License: CSSL-102776 WILLIAM J MC C-LUSKEX.... 37 NAUSET ROAD West Yarmouth NIA 02673 �_y Expiration Commissioner 06/28/2015 jOffice of Consumer Affairs and eusness Regulation .10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 171380 Type: Corporation Expiration: 3/14/2014 Tr# 222184 CAPE SAVE INC. --_ WILLIAM McCLUSKEY 7-D HUNTINGTON AVENUE SOUTH YARMOUTH, MA 02664 Update Address and return card.Mark reason for change. Address n Renewal ❑ Employment Lost Card )PS-CAI 0 50M-04104-G101216 <- ✓lie License or registration valid for individul use ont \ Office of Consumer Affairs&Business Regulation g Y before the expiration date. If found return to: { 7t HOME IMPROVEMENT CONTRACTOR p (f— i-�Registration: :.171380 Type: Office of Consumer Affairs and Business Regulation ��; Expiration:,-=3/14/2014 Corporation 10 Park Plaza-Suite 5170 Boston,MA 02116 CAPE SAVE INC.;. WILLIAM McCLUSKEY 7-D HUNTINGTON AVENUE; g_ Q _ SOUTH YARMOUTH MA 02664" �— Undersecretary Not valid wit o Signa Town of Barnstable *Permit# Regulatory Services �ce 6,non rn u t s • 1ASNS1'ABI$ s 039. 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 APPLICAMN - RESIDENTIAL ONLY 57U 0 G t/ Not Valid without Red X-Press Imprint Map/parcel Number Property Address !l 6P �1#A)V p1f jXD Rf/- I-'4AI'P- 14 Y 4 M71 t r ❑Residential Valueof Work$ J� / ��� Minimum fee of$35.00 for work under$6000.00 �, Owner's Name&Address P 600144A) IUl 61Z d f- Vagyevwi;zlf�,4�e---, Hy ml., a2-4,-11 Contractor's Name d ohyj f 6(Mt1&1('6 Telephone Number rd/ C.� � z2� ��lJt� ��✓t �crvei�c��l� mac/°- J Home Improvement Contractor License# if applicable) /o o 7 V d Email: yRIP t 5L � Construction Supervisor's License#(if applicable) cr 0 yb�� X-PRESS PERMIT 10Workman's Compensation Insurance Check one: 0 C T 11 2013 . ❑ I am a sole proprietor ❑ I am the Homeowner ] I have Worker's Compensation Insurance TOWN�F STABLE Insurance Company Name d d D u f le(, f1�V je Z/ �"PW ` i tm AN`t Workman's Comp.Policy# W G G 7 01 ul Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side Replacement Windows/doors/sliders.U-Value �' (maximum.35)#of windows #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections 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 equired. SIGNATURE.. 4 110 a D l,� C:\Users\decollik ata ocal\Microsoft\Witidows Temporary Internet Files\Content.Outlook\8R76BDVA\EXPRESS.doc Revised 061313 I - �tsnw�s:r�ta�s• Wer6-rs'Cowpewad ii linwr2 xce,Affiud4 vit- env"1 l atx�Aac�+mtt 'ec ruciaal� Uo�mall �s Apiasi cant Information laleave yak IA45h.Ty Tl rx (�u i n��iost Yc :: C Ap,`x7-i 1401,19 2rrty�cv tJent� }- =ac. t l ct C vrug/J M.4 a zG 3J"' pbezke °:: Cl Me yvu an Mplow. t bea.the app Iniste Wit Twe.of rajett Fa 4, .a�meW casua for WA l: : '�0 1- ❑I b, El New��uetitu� e�tayc�(figtd€at t-t; eT� have,bkcA tie Ob-COW !eea 2.❑ I aou't.a We pmpaie or F-mlw- li on.-&e a-gibed Wit. ❑Rma&.l sg AMP aAd Mve.no emloyen 2bee,vab-cwtraeturt buic. $ [l Itea ahtion. waddag f w we iaa.aw CaPC4. ewpiwimad haverx° �Co cawp�i:ayuas: COMP. xcqui ) 5. ❑ VVe are a,coot at os.aed ita El Flecuical re,M or awlicw. 3,❑ I a,:a a hameww==fit,a1i of v bne exffrred tbw a I.❑Ru atiag tepma2 or addi boas a t�ccaUM, ri sot-e .iota.pff M a �� � � a,.❑Roaf''npt imunw-e realabetLI Y c.. 11,52,§tidal aid welawe so u�l dyy GUI ewplwjemi •atew' a3.0 p �a�np.ia�requw:e�Q,j `Ate it�rr t emallawi.A=43t 930fill Mv0* u-vx bebw tonal.I&IA wu&ew'ezyw R*bw Lvfmwgoix I; sxia: x fC4`s��s his 2MA®R A DIditUbfs At'Ve<l 08 eH WUit.Off ftM VM e C�stt3C'AU i,.IL—V 'It fao3ia zg �::. LCauar-ms amc d ecfi tag b.► ix m au+.Asa ihs&s*kwxtz dio ate M3eer tB;IaL:e em�I4:}>�. I�'tlse�ra�[�erxaarcaeT i�r�e cs�datieas,aetxy crnrrxaa:o'ait�ies�a �eulz�'aua�.�lie�ra .er., , EFAa&pmvidia g uty Ouwh ate. . t;b fbiieps iryv sued A s#d .e a dd S C 6M 4 n+pd,wy#or in•r.Lit..n: W c G S�° 1 B-�y-7--J�z / I,ii tier,Rste_Z l a a&V Job Site Adeh / �R�10E�lR/¢ l e a/a vitrymatemp., t 4 i�fii S .� o•Z a/ .Aral-i a,calmof tke: iaolvcy cfe Lvadcas.page(showbip tire dory trtwulM,Mul tffip(mdad daw). Fast ue,to vMwe Menge eS nvw"I sulee Secilco.ZA aMOL,c..152 c W,w tIw,impoeati m daildfA l Pftbltirg af:a :rxw,sap to sl w-cr,amvor me-yvv impeiuetittatew,as weGl u evil pezahWi iA Cbe:Av a►.of:a STIW WORK tilt.8M4 a,fim of up to Vskott a&,v a„t±pian tlae Viebtax. He advied vbat a cap :sf';iv saatewwt way be for%wJel to the Mice of Iir�e�igatia�o$t3ce,•��A�r%alai. ,:c:a��„�e:�ae4ifi¢�tisra.. . k dea h r Ne, dear baiiar.ani paim'^J 3bi(It iFa e far, sacra iota PMV&W a INM is&Ma GOA r. rnr Offle E nu seal Do ust iwke bra thb aae n,to Fah campbTM 4,ctt v sa smwe qffleM MY or Town: _ peri7afoucewt Iissin Audwft(dale:me): I.Ruazd of Ii,9th 2.Be,dbg Depaxl meat S. ;its 17(wn Clerk d•,Meru tcsa liuW-mtr FlUisbingbweew r tt,0t4er Cc of2aet persa" Mae M - -- - --- - ....... -- - - - - - - - - - 1 CAPIHOM-01 CBENISCH CERTIFICATE OF LIABILITY INSURANCE DAs(MMiDD 3) THIS`CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endomement(s). PRODUCER CONTACTMANE: Chris Benisch oge,B Gray Ins.-Dennis Branch 34 PHONa :(508)398-7980 ,No:(877)816-2156 South Dennis,MA 02660 ADD Lam:cbenisch@rogersgray.com INSURER(S)AFFORDING COVERAGE NAIL$ INSURER A:Main Street America Assurance Co. INSURED INSURER BAssociated Employers Insurance Co. Capiai Home Improvement,Inc. INSURERC: Capri Enterprises,Inc. 1645 Newtown Road INSURER D Cotuit,MA 02635 - INSURER E: . INSURER F: 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 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 REDUCED BY PAID CLAIMS. INSR TYPE W SURANCE DL SUBR POLICY EFF POLICY EXP LTR INSR WVD POLICY NUMBER MID MNID LIMBS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY MPB1075H - 68/2013 6/8/2014 PREMISES Ea occurrence $ 500,000 CLAIMS-MADE I Fvrl A I OCCUR MED EXP(Any one person) $ 10,000 PERSONAL SADVINJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 2,000,000 POLICY JE O- LOC $ AUTOMOBI E LIABILITY Ea accident) $ A ANY AUTO MIM28044 6/8/2013 6/8/2014 BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per acddent) $ 500,000 AUTOS X AUTOS ' X HIREDAUTOS X AUTOOSWNED PERA C DEAMAGE $ S X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 5,000,000 A EXCESS LIAB CLAIMS-MADE CUB1076H 6/8/2013 61812014. AGGREGATE $ DED I X I RETENTIONS 10,000 $ 5,000,000 WORKERS COMPENSATION WC STATU- X OTH- AND EMPLOYERS'LIABILITY TORY UMRS ER Y/N B ANY PROPRIETOR/PARTNERIEXECUTIVE N/A CC5010547012012 12/25/2012 12/25/2013 E-L-EACH ACCIDENT $ - 1,000,000 OFFICERIMFMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101.Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town Of Barnstable THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 200 Main Street Hyannis,MA 02601-0000 AUTHORIZED REPRESENTATIVE d ' ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD ;4 Board of"' Re P is a, 5za-1611?-d's. �4 'u iEi ".i F"�"Y'iT#.�' CS A ♦ k. <rof , ,S R1iVISKI arm T3wxardt t�ati-141� t}3�32 �t =, . s r1, 061$/2014 z VtIIcE 4f t pasumzr fsuafrs Gsc ssusiness xrgtuataun LECewe sir e+ tscrauuu vxuu tua.u+acxtuut una osuy OME llY f?R}1tEiV ENT CONTR'ACTO13 before.fhe expira€ari date. # return.tisP Office of Consumer Affairs and Btisut M_Regu o Re istrabi¢it} 0. T ype:op 1#i Park�'la*-'Suite 5170 = 1�. Supplement Card Bostoa,MA 02116 CAF'LZL!H3MEItl Mt�7G. JOHN SCRUMS �.�.�•-- �, 1645 Newrton Rd. Cotsfrl,NIA 02635 UTuderseerebry Not v d YPi out si i 3nre F• . FID#80-0014011 CSL#7454 HIC# 100740 Yf 508-428-9518 s 800-262-5060 (Toll Free) 508-428-1547(Fax) www.capizzihome.com Established in 1976 s • Work Authorization# 1 October 1,2013 _.. ....._ _....... .... Name: DEBORAH NIGRO Job Address 18 VANDERMINT LANE _..._.._.....__...................._......_._...................._...................._..............._._...... ...... .. . Address: : 18 VANDERMINT LANE City/Town: HYANNIS __ City/Town: HYANNIS Home Phone 508-775-4465 .... .. State: MA Cell Phone 1 w. . .._... _..... .. ..._.. ... ......__. ZIP: . 02601 Cell Phone 2 _..........................._..................._........_..............................................................................................._.....<..._..................................._........................................;............................_........................................_......................................... .......................... E-Mail 1: DEBORAH.NIGRO@YAHOO.COM Estimator: ROLAND GONZALEZ JACK STRUMSKI .. ,...... _.... ._.._ E-Mail .......... ............ .. ........ ........................._............... .............._ _.......... ............ _......:.............. .........._ ............... . We hereby submit specifications and estimates for the following: CREDITS AS FOLLOWS(OFF ORIGINAL AGREEMENT): 1. Credit off original agreement-not doing Harvey storm door on front. ..............................................................................._.............................................._.._._........................................... Labor&Materials: -$960.00 2. Credit off original agreement-not doing railing and screen work. f Labor&Materials: -$788.o0-, C Additional Work as Follows: Supply and install three [3] Great Lakes Bayshore white vinyl windows with Williamsburg colonial grids. Window to be gut job with new interior and exterior trim; no painting. .................................................................................................................................................................... Labor&Materials: : +$2,971.00 We look forward to working with you; please call if you have any questions. Sincerely, Jack Strumski(508) 648-9949 Capizzi Home Improvement Accepted B 7 /6 Date: O . THIS PAGE IS PART OF AND CONFORMANCE WITH PROPOSAL#34610 t WE Town of Barnstable C- r nit �'�`� 6 Expires 6 mont/rs m' e Regulatory Services Fee snnrrsrns�. II �1659. Thomas F.Geiler,Director Ep UAA'I Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number �U #60 Property Address If, V40Oefi Mi o f [Residential Value of Work$ 3�7oa! t9 d Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address Pe 6 M4,y NI 61(® !' I/A N 1)4fIX-I 1 GA/ A//4-NnV4s AJ4 0 zip/ Contractor's Name ./Vwld di-90 rkd 91 Telephone Number f i 22! N 6 rhe. Z m jr reef/ m4l Home Improvement Contractor License#(if applicable) ! G 0 7 Email: r'1L 7L0, X COm Construction Supervisor's License#(if applicable) T 1orkman's Compensation Insurance AUG 16 2013 Check one: ❑ I am a sole proprietor [�❑ I am the Homeowner . TOWN ®F BARNSTABLE I have Worker's Compensation Insurance ` Insurance Company Name Q J J o cilt�-ed- Workman's Comp.Policy# CC S 6 G S t 0 20 Copy of Insurance Compliance Certificate must accompany each permit. Permit Re Vest(check box) [ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to O�aJ 0� y�R/n0U7�� 4 6#r 64.fl,o sloe ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders.U-Value (maximum.35)#of windows #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections 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 wner Letter of Permission. A copy of the Hot roveme ontractors License&Construction Supervisors License is re fired. SIGNATURE: C:\Users\decolR\AppD ocal\Microsoft\Windows\Temporary Internet Files\Content.Outlook\8R76BDVA\EXPRESS.doc Revised 061313 } u 1 -- _ Boston,NIA 02114-2017 • www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information PIease Print I,e •bI Name(Business/oF nizaiipn/ludMdua1):Capizzi Home Improvement Address:164.5 Newiown Road City/State/Zip:Cotuit, MA-02648 Phone#:508-428=9518 Are you an employer?Check the appropriate box: Type of project(required): 1.❑✓ .I am a employer with 40+ 4• 0 I am a general contractor and I employees(full and/or part time).* have hired the sub-contractors 6, ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet: 7. El Remodeling ship and have no employees These sub-contractors have g, 0 Demolition working for me in any capacity. employees and have workers' No workers' comp.insurance comp:insurance.$ 9• Q Building addition required.] 5. E] We are a corporation and its 10.❑Electrical repairs or additions. 3.C] I am a homeowner doingall work officers-have exercised their [] g repairs or additions 11. Plumbing 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' 13.0 Other comp.inurance required.] *Any apVicaut flint cheeks box#1 must also fill out the section below shovring their workers'eompensa�on poly informations" fi ipoipeownets who submit this affidavit indicating.they are doing all work p then hire outside contractors must submit a new affidavit indicating such. -rContiagtors that check this,box must attached an additional 4cet showinatae name of the sub-contractors.and._-Ute whether or not those entities have employees. If the sub-eontiactois have employees,they must provide thew workers'co a nvmbea: �P•P .cy . .. < I:arit an employer that is providing 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 PC 12/25/201 Expiration Date: ,� �. Job Site Address: 2 City/State/Zip. y�lAIAII/ A4 D•Z 6 d1 Attach.a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). F ulure.to.secure coverage as required under Section 25A of MGL c. 152 can lead to.the imposition of criminal penalties of a fire 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 tip 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 certify and r)the .ai and b a�ties ofperjury that the information provided above is true and correct .Si ature: Phone#: 508-42 518 FF. only. Do not write in this area,to be completed by city or town official Town: Permit/License# hority(circle one): Health 2.Building Department 8.City/Town CIerk 4.Electrical Inspector 5 Plumbing Inspector son: Phone#• CAPIHOM-01 CBENISCH DATE(MMIDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 611212013 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. I IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WANED,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 NAME:CONTACT Chris Benisch Rogers&Gray Ins.-Dennis Branch PHONE 508 398-7980 No): 877 816-2156 434 Rte 134 A/c No EXt:( ) ): South Dennis,MA 02660 ADDE-MRESS:cbenisch@rogersgray.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Main Street America Assurance Co. INSURED INSURER B:Associated Employers Insurance CO. Capizzi Home Improvement,Inc. INSURER C: Capizzi Enterprises,Inc. 1645 Newtown Road INSURER D Cotuit,MA 02635 INSURER E: INSURER F: 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 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 REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADD L R POLICY EFF POLICY EXP LIMITS LTR INSR WVD POLICY NUMBER LM/DD MM/DD GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIA13ILFrY MPB1076H 6/8/2013 6/8/2014 DAMA E T RE D 500,000 PREMISE S Ea occurrence) $ CLAIMS-MADE OCCUR MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICYFI PRO- LOC $ JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ A ANY AUTO M1 M28044 6/8/2013 6/8/2014 BODILY INJURY(Per person) $ ALL OWNED Ix SCHEDULED BODILY INJURY(Per accident) $ 500�000 AUTOS AUTOSX HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS PER ACCIDENT) _ X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 6,000,000 A EXCESS LIAB CLAIMS-MADE CUB1076H 6/8/2013 6/8/2014 AGGREGATE $ DED I X I RETENTION$ 10,000 $ 5,000,000 WORKERS COMPENSATION WC STATU- X OTH- AND EMPLOYERS'LIABILITY TORY LIMITS ER B ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N I WCC5010547012012 12/25/2012 12/25/2013 E.L.EACH ACCIDENT $ 1,000,000 OFFICERIMEMBER EXCLUDED? N N/A ° (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 . i DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Barnstable THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 200 Main Street ACCORDANCE WITH THE POLICY PROVISIONS.. Hyannis,MA 02601-0000 AUTHORIZED REPRESENTATIVE Page 7 of 7 Capizzi Home Improvement Inc. Specifications and Estimates STATE OF MASSACHUSETTS. LETTER OF AUTHORIZATION TO APPLY FOR A BUILDING PERMIT I,_A)E6441+ N 16A0 , OWN THE PROPERTY LOCATED AT 1 Y VAS ;'iL ' ►.,Pl Lam, IN ttlOW-0 - ,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 FORA BUILDING PERMIT IN ACCORDANCE WITH 780 CMR; THE MASSACHUSETTS STATE BUILDING CODE. SIGNATURE OF OWNER: / ill G:" f 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: } it, a s ':Pdilg;`4F-nixi;<'t..sw'P :T. s"1.4Y. x36, rd,''s £ MI BuZzarclS BAv R l 06/1,812014 f E '°�-� utuca as t oasumcr Aua:ss nosiness xz wauun g 1,tCCus�yr rC,2Ytr-dELuit Ir2WU tut:jUjUVauut ana utuy OME IMP 1f�ji+i€1 i"Cf3NTF2ALI0 before the ration daf-, I€fanat�retui-n.ta ° z istraffon;r� Office of Consumer Affairs ind Business.Reguisfio `° e' 18 Park Pima-S�5170 bcp raft = 1 supplement Card >�• m��om ',. �"� $astan,MIk 02114 1-4 JOHN STRUMS D' 1645 NdMion Rd Uudersecxtfary Nat v d oat signora A f