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0044 WELLESLEY CIRCLE
irY4R� y S T� TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map— o?70 : .�p Parcel 4 Application Health Division Date Issued 'Conservation Division BUILDING bEPfie. Application Fee Planning Dept. �U� + �01� Permit Fee A)IT. tv Date Definitive Plan Approved b Planning Board Pp Y 9 L-E �^ Historic - OKH Preservation / Hyannis ✓i �,_ I �� U /I � '.� Project Street Address Village A IV/S Owner A Ivor f'oA Y /16 0ww o S Address Zlle!!eJlP C'AC/e A/ tea, Telephone .S*'d ,f 1,0/d "/d �6 0/ Permit Request �XiS�<r�, i y X �i 2 / eytOv Ylee f&A Div ee<X1ny , 1wli CIEQJq� del.41,p IV �it,A 4,yad a 100yV, 0/0,900J Square feet: 1 st floor: existing ftL proposed 0 2nd floor: existing O proposed Total new Zoning District P 'RB Flood Plain Groundwater Overlay AJ a ",Project Valuation /dl aoa Construction Type k1e00 4/14X8, 'Lot Size 4' 2 Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family M Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑Wo On Old King's Highway: ❑Yes C'K0 Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area(sq.ft.)' Basement Unfinished Area (sq.ft) Number of Baths: Full: existing f new ° Half: existing / new d Number of Bedrooms: 12 existing d new Total Room Count (not including baths): existing � new 0 First Floor Room Count y Heat Type and Fuel: CI'Gas ❑Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑Ao Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑/'existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: U existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ N110 If yes, site plan review# Current Use &J<WAUKA1 �'ir lE fi,49 lV Proposed Use _APPLICANT INFORMATION (BUILDER OR HOMEOWNER) �� ` ���� ��S�i/ ! Zve111161eA1eA-Zi1c_ 0 Name �� �/ 0oJ& llolq Telephone Number Address ° /JeuJ-60)k License # c. 44U%f10j,f Gwr Home Improvement Contractor# Worker's Compensation # C 5'T2rd ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO -Ke(J aJ o k 44VP ri!/ SIGNATURE DATE 4 46- 1 I/� i t; FOR OFFICIAL USE ONLY ! APPLICATION# r . _ DATE ISSUED MAP/PARCEL NO. ~ r r i I ADDRESS VILLAGE OWNER DATE OF INSPECTION: _FOUNDATION, FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL Y, PLUMBING: ROUGH FINAL f GAS: ROUGH FINAL k 4 FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. _ t I ®A CERTIFICATE OF LIABILITY INSURANCE DATE(MMMD"YYY) c�.�e;D 12 29 2015 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 endorsements). PRODUCER CONTACT NAME: ROGERS&GRAY INSURANCE AGENCY,INC. PHONE Fax A/C No Ext: AC' C No): 434 Route 134 E-MAIL ADDRESS: INSURERS)AFFORDING COVERAGE NAIC# South Dennis MA 02660 INSURERA: AmGUARD Insurance Company 2390 INSURED - - INSURER B: CAPIZZI HOME IMPROVEMENT INC INSURERC: 1645 NEWTOWN ROAD INSURERD: INSURER E: COTUIT MA 02635 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 ADDL SUBR POLICY NUMBER POLICY EFF MPOO ICY EXP LIMIT'S LTR GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED COMMERCIAL GENERAL LIABILITY PREMISES Ea oorunence $ CLAIMS-MADE OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: - PRODUCTS-COMPIOP AGG $ POLICY PRO-T r LOC $ AUTOMOBILE LIABILITY CEOM�BBIINd LI ED SINGLE MIT $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $HIRED AUTOS AUTOS Per accident $ UMBRELLA LIAB HOCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DIED I I RETENTION$ $ WORKERS COMPENSATION X� WC STATU- [ OTH- A AND EMPLOYERS'LIABILITY R2WC655250 12/25/2015 12/25/2016 T Y I --" E ANY PROPRIETORIPARTNER/EXECUTIVE YIN N NIA A E.L.EACH ACCIDENT - $ 1,OD0,000 OFFICER/MEMBER 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 Town Of Barnstable SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 200 Main Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Hyannis,MA 02601 AUTHORIZED �.��'�'""�'""+K�'R ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts v Department oflndustrialAccidents 1 Congress Street,Suite 100 Boston,MA.02114 2017 www.mass.gov/dta Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumben. TO N FILED'%=THE PERTVIITTMGAUTHORITY. AunlicsntInformation Please Print LeaFbiy Name(Business/orgmd ation&&vidual):CAPIZZI HOME IMPROVEMENT INC Address:1645 NEWTOWN ROAD City/State/Zip:COTUIT,MA 02635 Phone#:508;42M518 Are you an employer!Checicthe appropriate boa: Type of project(required), 1.2]1 am a employer with 40 employees(full and/or ps time).* 7. ❑Neva construction 2.❑I am a soie proprietor or pmwership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.o I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10[]Building addition krl I am a homeowner and will be hiring contractors to conduct all work on my property. I wilt ensure that all co�cat tors either have workers°compensation insurance or are sole 11.�Electrical repairs or additions proprietors with no employees. 12.[]Plumbing repairs or additions 5.Q 1 am a general contractor and I have hired the sub-conh�listed on the afxaChed d=L 13.C]R00f repairs These sub-contractors have employees and have workers'comp.insurance 6.Q We are a corporation and its of floors have exercised their right of exemption per MOL c. 14. er�� �OT�IBC� 152,§1(41 and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks boxt#1 tenet 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 awl tCont wtors that check this box must attached an additional sheet showing the name ofthe subcontractors and stale whether ornotthoseentrties have employees. Ifthesub-contsactorshweemplcyeestheymustprovkbdwir workers'comp.policy numb= I am an employer that is providing workers'compensation insurance for my earployees. Below is the policy and jOb site information Insurance Company Name.AmGUARD INSURANCE COMPANY Policy#or Self-ins.Lic.#:R2WC527200 Expiration Date:12/25/2016 Job Site Address: ill ul e lleile t Cade. City/state/Zip: 11 010) Attach a copy of the workers'compensation policy declaration page(showing the policy numb&and expiration date). Fatflure to secure coverage as required under MGL c.152,§25A is a criminal violation punishable by a fine up to$1,500.00 an Uor 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby ceMft andgi the As penalties ofper]'u that the information provided above is true and correct Signature: 7 D 6 4 12 1 1 l 6 Rhone#.508-428-9518 Official use only. Do not write in this area,to be completed by city or town offlcid 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#r (i �.%!ie (Aaur:rrc:rcacx�R/ n�>?�aJ.;czc/rue/Y.i •• I - office of Consumer Affairs&Business Regulation i OME IMPROVEMENT CONTRACTOR 1 i F7 Registration: 100740 Type: i License oc registration valid for indi*idol use only Expiratwn:�6J23J2018 Supplement Card before the expiration date. If found ireturn to: CAPIZZI HOME IMPROVEMENT;INC. Office of Consumer A1lairs and Busi>ess Regulation: r ' . 10 Park Plaza-Suite 5170 GARY GUSTAFSON Boston,iMi A 02116 1645 Newton Rd. t_ L Cotuit,MA 02635 Undersecretary i 1 f Not v l'rdAvithout signature j i ` I , f 0 ® I ts0 q+ 0 w' _ P, Al rA CCrrn'n lA i �— -� O 2 Qq o N c � G ME D t�ti O CD r CL tn C7 Cn f0 �° 0 I y Page 7 of 7 Capizzi Home Improvement Inc. Specifications and Estimates STATE OF MASSACHUSETTS LETTER OF AUTHORIZATION TO APPLE'FOR A BUILDING PERMIT /�1 Vd") ve lleSley I/WE, �t40401AV �Il�(r1 , OWN THE PROPERTY LOCATED AT IN 4yana S , 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: '' f..1t� ,4'' CU^� 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: a Town of Barnstable Building "4` � v; '�� ��' a�,. . cam • • r °':� x:l` ���• �. .��� '�,_,"i 8 " �v :�'* � ': � � ...4 E'�w i� �� 3..;�:: ,,,.i'�� 3. Post This Cad•So That rt is Ylslble FromoLhe;Street=A , roved lans;Mustbe Retained onJob andthis Card Must be Kept it tARN$TABI$ �. '�` ..,, r>. .,� " a 3 DPP a $ -✓ c ' x'.a s M Posted y UntilFinal InspectionHas Been Made F ,� moo, x- .�� Permit R Whefe a5 Cert�fieate of Occu anc .> Re aired such Buildin"shall Notbe Occu ied;unt�l a F>Lnalji,nspection ihas beenmade . :�, �a.,... Permit No. B-16-1931 Applicant Name: MEDAIROS,ANTHONYJ Map/Lot:, 270-101-006 Date Issued: 07/14/2016 Current Use: Zoning District: RB Permit Type`. Shed-Residential-200 sf and under Expiration Date: 01/14/2017 Contractor Name: Location: 44WELLESLEY CIRCLE,HYANNIS Est Project Cost: $0.00 Contractor License: Owner on Record: MEDAIROS,ANTHONY Js Perrnit Fee $35.00 Address: 44 WELLESLEY CIR F,ee Pald~ � $35.00 .. .�.. ,., K_. HYANNIS, MA 02601 iz Date . . 7/14/2016 Description: 8'X10'SHED Project Review Reci : 8'X10'SHED ' ,gk Building Official This permit shall be deemed abandoned and invalid unless the work autho lied by this-permit is'�ommeed w t nchin slztrnonths after issuance. All work authorized by this permit shall conform to the approved application and ttie a proved`construction documents#Or which this permit has been granted. All construction,alterations and changes of use of any building and structures shall be in com'61"" ' ith the local�ioning by laws and codes. This permit shall be displayed in a location clearly visible from access reetlor road and shall be maintained open for public,inspection forthe entire duration of the work until the completion of the same. The Certificate of occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided on thistpermit. Minimum of Five Call Inspections Required for All Construction Work �� 1.Foundation or Footing 2.Sheathing Inspection , s xz 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed' h'` 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection " 5.Prior to Covering Structural Members(Frame Inspection) 6.Insulation ..' § 3 7.Final Inspection before Occupancy Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Work shall not proceed until the Inspector has approved the various stages of construction. "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Building plans are to be available on site All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT r Town.of Barnstable �TME' Regulatory Services Sc g . Richard V. ali,Director MASS. Building Division \NG Opp Tom Perry,Building Commissioner w\\.d 200 Main Street, Hyannis,MA o2601 www.town.barnstable.ma.us lo Office: 508-862-403 8 �J�IN ax: 508-790-6230 PERMIT# FEE: $35.00 SHED REGISTRATION RESIDENTIAL ONLY 200 square feet or less- Lfy Wt LL C:SLE y 2 CL-C 4 yA N Al is Location of shed(address) Village AM �oN y T. /V1LMi&o'f 5y�`3 7-10 , Property owner's name Telephone number Size of Shed Map/Parcel# 7/ Signature Date Hyannis Main Street Waterfront Historic District? ' N Old King's Highway Historic District Commission jurisdiction? N 0 You must file with Old King's Highway Conservation Commission(signature is required) ioops� Sign off hours for Conservation 8:00-9:30&3:30-4:30 PLEASE NOTE: IF YOU ARE WITHIN THE JURISDICTION OF ANY OF THE ABOVE COMMISSIONS,THERE MAY BE A REVIEW PROCESS AND APPLICATION FEE. PLEASE SEE THE APPROPRIATE COMMISSION FOR DETAILS. THIS FORM MUST BE ACCOMPANIED BY A PLOT PLAN Q-forms shedreg �1 L4I/Z0 @/COL,. C0Al REV:040914 1 - (L oT 7 wE�G 4 el t� 57To 33'/,9 99,7 g I a 32� 37'f v b s ' !�13 V S n, 3 n o� / ,00 0 SF /a4IM LCiT. w1p ry 33� 4�14� 3� t' tit 14 w � r p4l y 1 ��oTsl CERTIFIED PLOT PLAN r1l FIT �.,. - fie,,N4,7 't CERMY THAT THE Tl° C>,l >J T-- SHOWN' ON TM3 PLAN 111, LOCATIO r _ �#IST-ERE> RUtSTER 62- 0!t, THE: gR Nb AS CIvLL LANID cOmfflS TO TlEtdlg LA ENGINEER ` SU'RVEYOR OR.-:BY$: OF. *Alt 3TAl9LE ifA9A`e � ..�yt T12' MAIN' 'STR:E.ET yZ B H YA N 15, MASS. SiEE'!' ®F A E'ww E . LAND �UaYEYOR f SEE REVERSE SIDE FOR IMPORTANT INFORMATION Taxpayer Copy lift6rest`at tMe rate of 14%per annum will accrue THE COMMONWEALTH OF MASSACHUSETTS on overdue payments from due date until) Town of Barnstable Fiscal Year 2017 payment is made. BIII NO. 18756 Preliminary peal Estate Tax Bill PROPERTY DESCRIPTION TAX SUMMARY Preliminary Real.Estate Tax $702.76 44 WELLESLEY CIRCLE. HYRES $228.57 Special Assessments $0.00 Class Code 1010 TAXRES $460.38 Total Prelim.Tax/Spec.Assess. $702.76 Land Area 11326 SF CPA $13.81 1st Quarter.Due 8/1/2016 $351.38 Parcel ID, 270-101-006 Book/Page 10417 165 2nd Quarter.Due 11/2/2016 $351.38 Deed Date 10/15/1996 Make Checks Payable To:Town of Barnstable Assessed owner as of January 1;2016: Total Tax: $702.76 PO Box 742 MEDAIROS,ANTHONY J Reading, MA 01867-0405 SPECIAL ASSESSMENTS Collectors Offiew. 508 862-4054, MEDAIROS,ANTHONY J DESC AMOUNT INT 44 WELLESLEY CIR OFFICE HOURS HYANNIS MA 02601-2473 Monday-Friday 8:30 AM to 4:30 PM Total SpAs $0.00 f Town of Barnstable *Permit# Expires 6 months front issue dote Regulatory Services Fee • NA�• Thomas F.Geller,Director �M�h Building Division _ -PRESS PERMIT Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 APR 2 7 2012 www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERNUT APPLICATION - RESEDENTLWYMAF BARNSTABLE Not Valid without Red X-Press Imprint Map/parcel Number -7 Q 101 Property Address `'� el �r5 I Q-Y Ca, C [Residential Value of•Work 1%14 D Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address n 0 nil N e-j cur t`c)S W e_11es1 c1 C.r dle ✓1 A i.s m►4 Contractor's Name Sprinkle Home Improvement Telephone Number 508 775-1778 Ext. 10 103757 Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) CS 6643 XWorkman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner I have Worker's Compensation Insurance Insurance company Name Associated Industries of MA / A.I.M Mutual Insurance Co. workman's comp.Policy# AWC 7004943012012 Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) - ❑ Re-side #of doors /Replacement Windows oo sliders.U-Value (maximum.35)#of windows *Where required:required: Issuance.of this pemtit does not exempt compliance with other town department regulations;.i.e.Historic,Conservation,etc. Z�. Y ***Note: Property Owner must sign Property Owner Letter of Permission. A co o e Improvement Contractors License&Construction Supervisors License is req i SIGNATURE: ., >w C:\Users\decollik\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Oudook\DDV87AAZ\EXPRESS.doc Revised 072110 Town of Barnstable Regulatory Services v MAB& � Thomas F.Geiler,-Director Building Division Toba P.erry,:Building Commissioner 200 Main Street,Hyannis,MA 02ti01 wwwaown.bardstabl e.ma.us Office: 508-862 443$ Fax: 508=79M230 Propeirty Owner Must Complete and Sign-This Section If Using A Builder T, /4H n O N y S• M E N 12O S ,as Owner of the subject property herebyauthorize SPRINKLE HOME IMPROVEMENT,;INC. to act on my'behalf. in all utters relative to work:authonzecl bythis building pettnic application for 44 WC-U SLEY C X C Lc I HYAMNI f tAdd tss ofrobj; Signature of Owner Date Aty TW Uhl MLA 4-1 o Print Name If properlyOwner is applying for pemut please complete the Homeowners License Exempton. orm on the it side. Q:FORMS oVJNERARMISSION The Commonwealth of Massachusetts Print Form Department of Industrial Accidents Office of Investigations 1 Congress.Street, Suite 100 Boston, A" 02114-2017. www.mass.gov/dia. Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Sprinkle Home Improvement Address: 199 Barnstable Road , City/State/Zip: Hyannis, MA 02601 Phone #: 508 775-1778 Ext. 10 . Are you an employer?Check the appropriate boxy Type of project(required): 1.❑✓ I am a employer with 10-12 4. ❑ 1 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. ❑ Remodeling ship and have no employees These sub-contractors have g. ❑ Demolition workingfor me in an capacity. employees and have workers' ' y p ry' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.- required.] 5. ❑ We are a corporation.and its 1.0.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their l 1.❑ Plumbing repairs or additions myself. [Nomorkers' 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. 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 or not 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:, Associated Industries of MA.%A.I.M Mutual Insurance Co. Policy#or Self-ins. Lic.#: 7004943012012 Expiration Date: 01/01/2013 Job Site Address: y ►��IeSled Gi rcle- City/State/Zip: Is rMAA 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 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 thata copy of this statement may be forwarded to the Office of Investigations of the DIA for in sur erage verification. I do hereby ce!!, Apr A&Vrandpenalties ofperjury that the information provided above is true and correct Si ature: Date Phone#: 508 775-1778 Ext. 10 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#: 12/20/2011 9 : 35 : 33 AM 8740 ® 02/09 CERTIFICATE OF LIABILITY INSURANCE 1 DATE( WDD ii) Tale CERTIFICATE IS INSUID As A WWTQ or Isroamoros ONLY AND CoorERs so Riem" UPON TOO CERTI►ICA4m Noun&. TRB CERTIrICATE 00E8 NOT ArrIRMATIVELY OR NEGATIVELY AMUSED, NJ(TEND OR ALTER THE COVERAGE "rORZOW SY THE POLICIES BELOW. TNIS CzRTIFICATE Or INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN TM IRONING INSURNSI(B), AVTNORIZED REPREBXWMXVE OR PRODUCER, AND THE CERTIFICATE Rozam. - IMPORTANT: If the certificate holder is an ADDITIONAL INSVMM, the p011Cy(1e8) must be endorsed. If SVSR04RVXON IS WAIVED, sub-act to the tares and Conditions of the policy, certain policies may require an.andorsasent. A statement on this certificate does not Confer VI9bts to the certificate holder in liau of such ondorsoaant(a). .rasa. Bryden 6 Sullivan Ins Agency. .� Inc -(A/C. M.. Iwn): xw. a.oa 88 Falmouth Road Hyannis, Mh 02601 a)sleea Ir. sobs III air�saM ePSAaPs etc. Sprinkle t Inc p inkle Home nmm a. A.I.M. Mutual Insurance Co 33758 spr zmrcve®en IMIMs .: : 199 Barnstable Road Xl Hyannis, NX 02601 IMaws., zmmm ra COVERAGES CERTIPICAS'E NOMMiR: REVISION-NWWZR: Tali IN To CuRfm TasR'THE FOLICZEt or asURROMS LYi9ED MELOW RAVE asos To TRR 200112 W N ANOWN FOR TSM FO14=Fsaloo IsarcltsNO. ROEWrRR2RNDa0 ANY REQUI E1OT, TES ON COMMON.Or ANY OMMU AOs OR O'A NOCOINRPF WM RNiTNOF To� SOS CEMrXCATN IaY Me riven OR RAY Fla, TNN aSURANCE Ars"WED By TWO FOSMCM OQCiaED REaia IN susawr To ALL TNN TNSNR, RSCIASDONs AND CONDZTIONS or sOCN FOLzCINi. LDTs seen . mr saw 1NEE SfaOMIN RY ram CLAIMS. sr. FOyILY NUMBER Err ; POLICY NrT LIMITSs•• VWX or af01ANCe ItMUMMnTTn oT,alM/mra . 0011513AL LIASILITT seal OCCULBOrl. I f DO-.—OiRRAL LIADILITT snots »sTRa —� . r01IrgM..•e..a•ww) a_. � 130CLAne IeDI 0--NOW m IAq O•pI.•w) ! ' ❑ .Yf/YL A yv Ioom I O!❑t'L ASM90LTI LIMIT AFFLSIS■I: ��APORAATR t ❑rm.IcT ❑PRWICT❑IOC WINNOWT! COMM/O am a a . AOSOMOsm LZLSZLZ Y censa susu LIMIT - r 0— OIRID AUTOS FOIL! ZWVU (Nr a.--) I i - EIS MIDOLED AUTOS - - MOIL! TMTQ(P.r•.. t) a raaPMAT!Pis a MIM/D AV103OWN-OWID AUTOS (Nr woi.wq - M I ❑ r ---A LIAM OCC DM - la= ocNMYct a ❑IDCIMI LIAO ❑ --)MDt AassAAa • DID➢CTI ML! � I � WOE�f OOEWOiiTtOf - Tan Lum Y AND rsoYENi sIARIssTr M e7 YRUTIOR/PARIWERV C.L. IACI aamuT • 500,000 A EXECUTIVC OrrICERs Axe ® incl ❑ excl 7004943012012 01/01/2012 01/01/2013 I.L. MIU D AR -MLICT LDT I 500,000 I.L.'*ISM i -SA oeLO= 500,000 cemrs I WOMI"Ir t wenriass e)Lacmia6, - - WORKERS' COMPENSATION COVERAGE APPLIES TO MASSACHOSETTS EMPLOYEES i _ 1 CERTIFICATE,HOLDER CANCELLATION DROOP OP INSURANCE MOULD MY or in above Ommmm FOLnclss NN CANCILUM■eon mm € I , mZNATsos DATE TistRW, NOlICi WILL Ni DaIVOiE! IN ADoosDANCR WITH Tez FOLDCY PROVISIONS. - 5289 �l.n..lhU� 'Il. Il• t ..'i,l. t I':,Ir . / / Kr .trrl „1 liutlJul_ I. ui.0 ..n• ,,,,t ;n Office ofeoasumer.ffrfaln a mamsKeguanon :onstrucnon ±A, HOME IMPROVEMENT CONTRACTOR Registrations 103757 Type: 6643 I+.: Expiration: 7/9/2012 Private Corporahc Am WN& SPRINKLE HOME IMPROVEMENT. INC BRAD K SPRINKLE 190 LOTHROPS'LANE Brad Sprinkle W BARNSTABLE, MA 02668 199 PBarnstable Rd at- iyanni s MA 02601 1 adersecreur% 6004 I.icensr ur registration valid for individul use unh Failure to possess a current edition of the before the e%piratiun date. If found return to: Mxssachuutts State Building Code before oft•onsumer:Affairs and Business Regulation is cause for revocation of this license. 10 Par•6 Plaza-Suite 5170 lio.ton. %IA 02116 Referto: WWW.Mass.Gov/DPS Not %Aid without sign ur, to ..5. THE r Town of Barnstable *Permit 1S�- - Expires 6 in on o issued to + SARNSTAME, + vices Fee C MASS. Regulatory Ser i639• `0� Thomas P.Geiler,Director lE0 MA't A Building Division /} Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION RESIDENTIAL ONLY Not Valid.mitlzoutRedX-Presslmpririt _PR PERMIT vfap/parcel.Number 9_-® 10 1 o rl (n ` f,�h 'roperty Address � "\ JUN 3 0 2006 A ilk STABLE AResidential Value of Work Minimum fee of$25.00 for work under$6000.00 )wner's Name&Address V' el e e Qr oneractor's Name i � Telephone Numb [ome Improvement Contractor License#(if applicable)_ I 0®-9'4 0 onstruction Supervisor's License#(if applicable)_ ]Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner °�I have Worker's Compensation Insurance surance Company Name C� R orkman's Comp.Policy#_(2 QAQ C �� )py of Insurance Compliance Certificate must be on file. rmit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to Re-roof(not stripping. Going over existing layers of roof] ❑ Re-side Replacement Windows. U-Value 2_(o (maximurn q4) *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. Home Improvement Contractors License is required. nature ` )rms:expmtrg ise063004 Page 7 of 7 CAPIZZI HOME IMPROVEMENT INC. SPECIFICATIONS AND ESTIMATES STATE OF MASSACHUSETTS ' LETTER OF AUTHORIZATION TO APPLY FOR A BUILDING PERMIT I, OWN THE PROPERTY LOCATED AT IJCJC,� IN 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: 44 Wellesley Circle, Hyannis, MA 02601 OWNER'S TELEPHONE: 508-778-4785 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: Home Improvement Inc. I, Thomas Capizzi Jr., owner of Capizzi Home Improvement, hereby authorize Lisa Haworth, to sign on my behalf for permit applications filed through the town. Signed: Thomas apizzi, r. Date: r1ahaworth Date: 1645 Newtown Road Cotuit, MA 02635 (508) 428-9518 (800) 262-5060 FAX (508) 428-1547 Late: b/13/ZUUb TlMe: 8:4U AM TO: (9 9,1,b084281547 R8G 1a8. AgCy. Page: UU1 Client#:47298 CAPIHOM ACORD,. CERTIFICATE OF LIABILITY INSURANCE _ 06/13/�DIYYYY) PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Rogers&Gray Ins.Agency,Inc ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 434 Route 134 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.0. Box 1601 South Dennis,MA 02660-1601 INSURERS AFFORDING COVERAGE NAIC# fi INSURED INSURERA: National Grange Mutual Ins.Co. Capizzi Home Improvement,Inc. INSURER e: GUARD Insurance Group Capizzi Enterprises,Inc. INSURER c' 1645 Newtown Road Cotuit,MA 02635 INSURER D: INSURER E: COVERAGES I` 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 1 POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IN5K ADD TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LTR NS DATE MM/DD DATE MM/DD LIMITS A GENERAL LIABILITY MP010707 06/08/06 06/08/07 EACH OCCURRENCE $1 000 000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $500 000 CLAIMS MADE a OCCUR MED EXP(Any one person) $1 O 000 PERSONAL&ADV INJURY _ $1 000 000 GENERAL AGGREGATE $2 000 000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG s2,000,000 POLICY jE LOG A AUTOMOBILE LIABILITY M1010707 06/08/06 06/08/07 COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $500,000 ALL OWNED AUTOS " BODILY INJURY $ X SCHEDULED AUTOS (Per person) X HIREDAUTOS BODILY INJURY X NON-OWNED AUTOS (Per accident) $ X Drive Other Car PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO _ OTHER THAN EA ACC $ AUTO ONLY: AGG $ A EXCESSAIMBRELLALIABILITY CU010707 _ 06/08/06 06/08/07 EACH OCCURRENCE $5 000 000 X OCCUR CLAIMS MADE AGGREGATE s5,000,000 $ DEDUCTIBLE $ X RETENTION $10000 $ $ wolacERs COMPENSATION AND CAW C702365 12/25/05 12125I06 x we sTATU- OTH- EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTNE E.L.EACH ACCIDENT- $SOO,000 OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE s500,000 If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $500,000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT?SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLJGAT10N OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 25(2001/08)1 of 2 #M22681 MEE O ACORD CORPORATION 1988 "• .-�/yj♦: � Cljfrcr+ z,j 1t;�•rV"i1uliu»,c . of 114 tls!rin",, err �.•�,. ?7'19�)�?r7211+Sb:r; '�'�'x�rl�c�rs' C:c�zxt7�e�isa�.icix� z��r3 >,A.MO.,ivii: 3ualt3c:�a�;/C;r�7�� -arir��sll��c:c.�.ric?iaxas/ 'l�� z'xl:►c:z�; x .ax3 3n�'c3rx�aa��r>z1 "e. J."l )xt YiWy 1T?1C; {33usu3css�Ur arura�i.t>r��3jt�»+rdual)= Capin! Nome ImproveMent 19. c. pN nc hrn Rnnd 3dre;Ss: Cofult, MA 02G35 Tel Q289518118Q0.262-5t16� __. P13033c A employer?Chi ecl t.b e•apPropriai,e boa:_ • Type of proje+ct,(required): . I ana a exzTloyer _ 4_ E] I am a general contaagarand 1 . Ir-rrgpIoyeeS(flit andJorpaA-Yime).* have b.i---d f ie s��i-cont3ar�ors 6.' Ncw Constuc�ou am'a solc pop eiorozpa e3 bSb--d oz3 ii�e at(acl�ed sW l- T, ElRemodealg ship'and h2a 7e ho'employees These sub-coniaacion bz)e. 8. DeMGJl6Qn ' OTIO-ng for xae in any capac`xiy. V7ozlf,ers' comp_ans�a�ee. o WoT•kerS' . .. 9. � $ceding nddili A' . _ �- El we area corporaiion anal re�rzi ed] officers have exercised ibeir lfl•D El&trical mans o3-addi ons Z a a hoaneo�>ner doing all wozi. xihi o f exemption per h4CL 11-0 Ph E-ag xtpaks oz addidons z�yse No iorkers' cozap,,' c.1�2, {4),and xTel�aveo is anee�. tiirc t ". 12_E] Roofr-pains •� �. +eznplo3Tees_ �To z�To�ers' • comp_insazance rcxrlirecLJ 13_� Zex o icon:Yt�aYc3�ecssboa tmustalso fll auf�iieseoYion3ieloy+s7aoti g flae or3�ers'r ensaiioxipo3i4fomaaYiflA- orrn s bo t�ixis s�davit mdicati2g'al"Y are ding 0 r+ozliand tben.mire brr deoonixacaors zata submits ut-w sffidavii i 6aic� n sneer 1 ciz»IhaY-becl;tuts box m #tb ust se3 an addi'iions]sleet sii*or,+ Iztg$iersame"Off sib-Mata&loxs asd alie n+o exs'comp-p6lioy OZ3r3EliDn.'' . n�m;�lny�'r-tiza�is,�r-�rzdixzg��or�rs'c�rnpctzs�iarz�rzsut-r3rzce,�oarnp cx�.p�o•3��ns_ �8e�an��s x5�ie�rn �+��v�i szte ' • airz`io�z ac,e- Company N:mt. oz S el ios_I.ic. : C A C-7.0,a-3 l 1✓ ration l�aaie: c� � —.-'= -•-1=--- �iijTJStaieJZip: • a c7�py of Ze oxli exs', eoMPl2;as2 G)a poky dechfratto)a page�(s o g to policy*namtf--r a�ad expiration daie)_ io sec e CDVerage as reqr<ired.Xidex-Simon 25A of IAGL e_ 152 can lead t D the imp o siii©�of coal penalties of a $250- ; to 21,-00_ a..roz cine yew ziso e�i,as re as cis; T,�tiesia lh. form of a STOP-WORK. and a fine }0 a day abQaiust the olaioz. e advised that a t:opy oftius Sbt(--mmi;naay be forded to the Office of ' gaiions of fie Dl�for surance cocrezage�tex cat nx_ r,Pr N ZSP rxrzdeon t. . ; xre: /,/ _ v Date_ (�l-P 04 - Czrrl zrse'On Jz_ Do not rvri4e in taxis area,-Zo die Corzz,�Xe�ed Or wurrs Offiai+aL �'�xxx�t(�ecnse� • ivag.�-xxil�oxty (cix•el!e ox�ej: oaxd c►i Re.'AtIl Z.)3rxildiag Deparfuamt 3.�Ci:t.�yrr'Oliw Clerk q_ leca(xi 3acxspiLeir�x S-�']ix mbing Ix spector Cher tact 3Pex••soxx: ..._...__-•_-__....______ .. __._ _._.__... .-.-- -._ �';liokie�- Board of Building Regulations. and Standards One Ashburton Place - Room 1301 . Boston. Massachusetts 02108 Home Improvement-,Contractor Registration Registration: 100740 Type: Private Corporation _. Expiration: 6/23/2008 CAPIZZI HOME IMPROVEMENT,.INC:. Thomas Capizzi, jr. ' — - 1645 Newton Rd. — — Cotuit, MA 02635 Update Address and return card.Mark reason for change. Drys-CA1 w 50M-04/05-PC8698 Address Renewal Employment ❑ Lost Card 92e �anvr�wouuea o�/ aac�zuoeCta Board of Building Regulations and Standards ` License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: -= Registration: 100740 Board of Building Regulations and Standards Expiration ° 6/23/2008 One Ashburton Place Rm l•301• Type .,_.Private Corporation Boston,Ma.02108 CAPIZZI HOME IMPROVEMENT,INC. Thomas Capizzi jr,, �vlidwitiwuFsjgnature 1645 Newton Rd Cotuit, MA 02635 Ucputy Administrator 130ARD O BUILDING REGiJLA770NS License: CONSTRUCTION S j - i = Number,.CS• 057032 f ' ' Biri:bda'[e=,339/2511$63 i ReStriciec3-i0: j 6 l THOMAS X CAP L r�' s� 9645NEWTOWN COTUIT, MA 0263b ' uommissi6lier t WL TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map iV U oD arcel 1 of Permit# 99 , Health Division S?A fl�V 7 3 Date Issued Coftervation Division C 5 Application Fee Tax Collector Permit Fee Treasurer Planning Dept. CONNECTED SEWER ACCOUN Date Definitive Plan Approved by Planning Board W Historic-OKH Preservation/Hyannis Project Street Address WM>\,Wt l/ ��AOJIMS Village �. /y Ut,a V1 t� Owner K(V DM&NIVAJ�-_'t 0 S Address LN VV U— A0-Afi Telephone = Permit Request i/ Af 0 C..3 a :Sg Square feet: 1st floor: existing proposed 2nd floor: existing proposed Totalagew• r. Zoning District Flood Plain Groundwater Overlay 4 Project Valuation U 0 Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family a/ Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House: ❑Yes 340 On Old King's Highway:•ok❑Yes U7No 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 Other11�1 t Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes Cl 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 BUILDER INFORMATION Name ' / �"' .� Y "" Telephone Number t "", D UIb Address fVW tnl License# Home Improvement Contractor# �.0t1 Worker's Compensation# C- IN I I ALL N ONSTRUCi T'ION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE 1 ' DATE �� t� FOR OFFICIAL USE ONLY PERMIT NO. DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER f DATE OF INSPECTION: FOUNDATION FRAME 01C INSULATION Q lC 7 - f�--O r p 2 FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING t DATE CLOSED OUT ASSOCIATION PLAN NO. r-- MASheck COMPLIANCE REPORT I I Massachusetts Energy Code I Permit # I MAScheck Software Version 2.01 I L I I I Checked by/Date I ; CITY: Barnstable STATE: Massachusetts HDD: 6137 CONSTRUCTION TYPE: 1 or 2 Family, Detached HEATING SYSTEM TYPE: Other (Non-Electric Resistance) DATE: 12-13-2001 DATE OF PLANS: 4/4/05 TITLE: Medairos PROJECT INFORMATION: Basement room COMPANY INFORMATION: Capizzi Home Improvement COMPLIANCE: PASSES Required UA = 83 Your Home = 69 Area or Cavity Cont. Glazing/Door Perimeter R-Value R-Value aU-Value UA ------------------------------------------ CEILINGS 312 - 19".0 0.0 16 WALLS: Wood Frame, 16" O.C. 584 13.0 0.0 48 GLAZING: Windows or Doors 3 0.330 1 DOORS 18 0.210 4 ---------=--------------------------------------------------------------------- COMPLIANCE STATEMENT: The proposed building design described here is consistent with the building plans, specifications, and other calculations submitted with the permit application. The proposed building has been designed to meet the requirements of the Massachusetts Energy Code. The heating load for this building, and the cooling load if appropriate, has been determined using the applicable Standard Design Conditions found in the Code. The HVAC equip nt selected to heat or cool the building shall be no greater than 1 0 of the desi 1'ad as specified in- Sections 780CMR 1310 a 4.4. Builder/Designer Da MAScheck INSPECTION CHECKLIST Massachusetts Energy Code MAS .heck Software Version 2.01 Medairos DATE: 12-13-2001 Bldg. ] Dept I Use I I CEILINGS: [ J I 1. R-19 I Comments/Location I I WALLS: [ J I 1. Wood Frame, 16" O.C., R-13 i Comments/Location I I WINDOWS AND GLASS DOORS: [ ] I 1. U-value: 0.33 I For windows without labeled 0-values, describe features: I # Panes Frame Type Thermal Break? '[ ] Yes [ ] No I Comments/Location i I DOORS: [ ] I 1. U-value: 0.21 r I Comments/Location I I AIR LEAKAGE: [ l I Joints, penetrations, and all other 'such openings in the building I envelope that are sources of air leakage must be sealed. When I installed in the building envelope, recessed lighting fixtures I shall meet one of the following requirements: I 1. Type IC rated, manufactured with no penetrations between the I inside of the recessed fixture and ceiling cavity and sealed or ( gasketed to prevent air leakage into the unconditioned space: I 2. Type IC rated, in accordance with Standard ASTM E 283, with no I more than 2.0 cfm (0.944 L/s) air movement from the the I conditioned space to the ceiling cavity. The lighting fixture I shall have been tested at 75 PA or 1.57 lbs/ft2 pressure I difference and shall be labeled. I VAPOR RETARDER: [ ) I Required on the warm-in-winter side of all non-vented framed I ceilings, walls, and floors. I I MATERIALS IDENTIFICATION: ' [ ] I Materials and equipment must be identified so that compliance can . I be determined. Manufacturer manuals for all installed heating I and cooling equipment and service water heating equipment must be I provided. Insulation R-values'and glazing U-values must be clearly I marked on the building plans-,or specifications. I DUCT INSULATION: [ ] J Ducts shall .be insulated per Table" J4.4.7.1. I I ~ I DUCT CONSTRUCTION: [ ] I A11 accessible joints, seams, and connections of supply and return I ductwork located outside conditioned space, including stud bays or I joist cavities/spaces used to transport air, shall be sealed I using mastic and fibrous backing tape installed-according to the I manufacturer's installation instructions. Mesh tape may be I omitted where gaps are less than 1/8 inch. Duct tape is not I permitted. The HVAC system must provide a means for balancing I air and water systems. I I TEMPERATURE CONTROLS: [ ) I Thermostats are required for each separate HVAC system. A manual I or automatic means to partially restrict or shut off the heating I and/or cooling input to each zone or floor shall be provided. I HVAC EQUIPMENT SIZING: [ ] I Rated output capacity of the heating/cooling system is I not greater than 1250 of the design load as specified I in Sections 780CMR 1310 and J4.4. I [ l I SWIMMING POOLS: I All heated swimming pools must have an on/off heater switch and I require a cover unless over 200 of the heating energy is from I non-depletable sources. Pool pumps require a time clock. i [ ] I HVAC PIPING INSULATION: I HVAC piping conveying fluids above 120 F or chilled fluids I below 55 F must be insulated to the following levels (in.) : I PIPE SIZES (in.) I HEATING SYSTEMS: TEMP (F) 2" RUNOUTS 0-1" 1.25-2" 2.5-V' I Low pressure/temp. 201-250 1.0 1.5 1.5 2.0 I Low temperature 120-200 0.5 1.0 1.0 1.5 I Steam condensate any 1.0 1.0 1.5 2.0 I COOLING SYSTEMS: I Chilled water or 40-55 0.5 0.5 0.75 1.0 I' refrigerant below 40 1.0 1.0 1.5 1.5 [ l I CIRCULATING HOT WATER SYSTEMS: I Insulate circulating hot water pipes to the following levels (in.) : I PIPE SIZES (in.) I NON-CIRCULATING I CIRCULATING MAINS & RUNOUTS I HEATED WATER TEMP (F) : RUNOUTS. 0-l" I 0-1.25" 1.5-2.0" 2.0+" I 170-180 0.5 J 1.0 1.5 : 2.0 I 14.0-160 0.5 I 0.5 1.0 1.5 i 100-130 0.5 i 0.5 0.5 1.0 I ----NOTES TO FIELD (Building Department Use Only)---------------- ------ e • yam. , ,. _ � adz 33 CAPIZZI HOME IMPROVEMENT INC . SPECIFICATIONS AND ESTIMATES PAGE 6 OF 6 STATE OF MASSACHUSETTS LETTER OF AUTHORIZATION TO APPLY FOR A BUILDING PERMIT I, Lo"'Imo OWN THE PROPERTY LOCATED AT IN I'�l� 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: f � APLLICANT'S SIGNATURE: 00 0, ( . APPLICANT'S ADDRESS: 1645 NEWTOWN RD. , COTUIT, MA 02635 APPLICANT'S TELEPHONE: 5081428-9518 ' I RESPONSIBLE OFFICER: RESPONSIBLE OFFICER ADDRESS: RESPONSIBLE OFFICER TELEPHONE: l rJA ACCEPTED BY � DATE THIS PAGE IS ART OF AND IN ' CONFORMANCE WITH PROPOSAL # r „�„ - 91'A'z3JU-64U3 1-7Z4 11,UUUUUL r^I[C I � � IL i. �+i. eni:'�� •, 7;' ,�' ;. .' ( :.,�.., ��:';;:.: :.,I;i '.a''`• tii .fit^ ' .-4 •': ,r' �i :,� '„CR`T11�1 } ' t : ', ` S �, FRAN ,,•;f�:.i��. �.;.:;j .a �r,,,,.,�.,��;: PRCE OD -_-' _ �Tf.°s :",.,; ::��.�':},. :• ., ;��, tj ,,1�,'�^ < .. �• I HIS CERTIFIC,A7"E IS I$SUED AS A MATTFR�OF`INi_CU(WTION ON1-Y ATgU CONFERS' t4O RIGHTS UPON THL: CERTIFICATE 13f Mail, Ins t,Sulu Inc HOLDER.THIS CERI-IFICATE DOTS NOTiAMrNi), EXTEND OR 2ai Main M�taet,,420 �/1 ALI ER THE COVERAGE AFFORDED BY I HE,POLICIES BELOW FiPcJlbur�, MA01�?_p CUM_ 11, COMPANY A GRAiITF1S7TA E INSURANCE CO IPA) Y 1:;URED Rtswurt�e Marlapaments Inc 291 Main Stleel,SLtis g5 Ftt>vhburg, MA 01920 THIS is TO CER71f Y THAT 7HE POLICIES or INSURANCE UST D or-LOW HAVE 13EEN ISSUED TO THE INSURED NAt,7Cp ABOVE FOR I k,.. �,. THE POLIO'PERIOD INDICATED,NOT WITHSTANDING ANY REQUIPP-tvIENT,TERM DR CONDITION Of-ANY CONTRACT OR OTHER POLICIES E DI WIT.SCR;RESPJrGT TO WHICH THIS CERTIACATE MAY BE ISSUED OR MRY PERTAIN,THE INSURANCE AFFORDED THE " MAYA DESCRIBED HEREIN IS SLOJr-CT TO ALL THE-TERMS.EY.CLUSIONS AND CONDITIONS OF SUC#1 POLICIES.UMITS S14OWN MAY HAVE g�REDUCED BY PAID CLAIMS.' Tym 1401; of MPE14 ram votm NunteEt PDUCY Emry,mwc DATZ roucY rn�t Trora MCM MP�yiner iA9TtON ILRY 1i�PROPF�J� AR7N[ Sp�C lvE LtmITS fNCL O QotL jJ ..A •,. I�;a ••i x, Group 12262004 12J2v/2V05 STATUTORY L(NiiTB0477192 ,';'•1 i11}�"yK t''�•,.::,- , cn ACCIDENT 5 1dD,U tSMA=POLICY Lfwr 'S 5D0,0 E CRIPTIOIV OF OPl;RA77ot+Ii�/>`st•�ICL)QB/@Pt_"•GIAL til'?14Q5 3 1D0,0 RE:COVERS THE EMPLOI EES OF 771E NNvIED INSURED LEASED TQ:CAP'M HOMC IMPROVEMENTS INC,1645 NEWTON ROAD, OTUTT NSA vzea5. OFUMHOATE HOt pFR ANCELLATION ' CA,P127-1 HOME IMPROVEMENTS INC tHomt)WyOFIMPACOYMD"DetT15MPOLIG6SRTIIAK:R1 iOPGPORFym 1645 NEWTON ROAD D?l'PATION DAY M0;CE0T_,TM__tssUlNc coMPA TVa1-LarnmsM10R To MAIL32 COTUiT, MA 0263B DAYS wRrTr;N NOTiCE TO THE C5MFICATE HOLDM to Wg3 To THE LEFT,auT FAILURS 70 WIL SUCH NOTtce sHnLL mtr0=HD Otzu KMN on Lt",L(T or- ANY KIND UPON TM C(DMPANY,ITS AGENT'S ORREPrtmENTAT vn. AUTHORIZED REPRESENTATIVE g17 � _1/JCJ77?l ilA �. �fl . � l3<�ard �� 1.3u�� �n � }�c �u.l�� .)()J'js d Sta»c3arcis S One Ashlnij-103 } Jace 1301 t ''> 73oston_ Ma,s�apljusclls 0210 33c17t .,Ql tractor }' eo, �tTafi ,_ 1OD F7cpi Straliorl: 100740 l ype: Private Corporation CAPIZZI HOME IMPROVEMENT, INC. Expiration: 6i23/2006 Thomas Capizzi, jr. 1645 Nev�don Rd. COtUit, MA 02635 Update Address and return card.Mnrli reason for ci�anf Ej Addiess E] Rcne�ya) irmplo}'mcnt Lost C J1,c 'L�nr�rm•oruierll� o!'./f�.caoaa�icru+CY� Beard of Building;tcguhfiolu and Siandards Tka in License or registration valid fo3-individul use only HOME IMPRDVEMENT CD14TRACTOR beforethe expiration date. If found return to: r' Registration: 1fl07A0 Board of Dui)diug Rcgu)eiions and Standards >>' Expiration: 6123/2D06 One Ashburton Place 72m 1301 e Type: Private Corporation..' Boston,A42.02)08 CAPIZZI HOI✓E IMPROVEMENT,i y �llomas Capizzi,jr. n 1645 NeMon Rd. _ COluil, MA 02635 - Administrator Not va�,mviij)oul i-D n,•-,:+' <� :���� �+c»�rmr���r.rnt+all�. ��fl•rraaa:�•�uwell4 4 - _ r.v BOARD OF BUILDING REGULATIONS iU it4 License: CONSTRUCTION SUPERVISOR Number: CS 057032 B i rthd a te: 09/26/1963 Expires: 09/26/2005 Tr.no: 7171.0 Restricted: 00 THOMAS X CAPIZZI JR 1645 NEWTOWN RD — COTUIT, MA 02635 Administrator _ The Commonwealth of Massachusetts Department of Industrial Accidents mice Bf/trvgstfpffm 600 Washington Street Boston,Mass. 02111 Workers' Com ensation Insurance A.ffidayit-General Businesses S� ��vliyio.1=�°mh- .,t ro.+"ee•'Z^ •�. r•! 1 I 1 `n•,� " address' . state- a �C(1 work site location fa address' oblishmeat etor and one Business Type; 0 ail�Restaurant/Bar/Eat<ng I am a sole propri 0 05ce❑sales(including Real Estate,Autos etc.) wonting in any capacity. am an em to er with eiz 1 ees full& art time). ❑Other / / / //c /// n/fo/=/////y%/m%/P//�'/e�es worming on this job. . I am an employer Providing v{prker �• ,' , • ' aIIV.II 91ne7 t• „ E, -ate ,• i:: r COIII .,n ; ,wad•y:.. :+': ]hIV\ t is .T''•r :{s,, addr'ess, "` • :,'�r ,' ...h y 'y't ,M y. .,. 1, .;° bone#••• �(J,' ' :; ,(,T�.1��!.y/,. :,;:ti,. city: nsdrnnee.cad': :i '" ? ° / / %/•y workers' . I am a sole proprietor and have hired the independent contractors listed below who have the following compensation polices: . . +,::: . . 1 r :,•.', '1 "r:'ti'S i':•• _ IISlnp: ,< �i>;i.1:•,1..�: :',rr.:;•'.;n:.l'.'�i:;.�� +'• �"r,' '"C: rt•!:+: r 77777777. Cl •r, .t�•4.rc. ',a•.{i'1,.,;t�,,.:• :t.:; s• ', ' :,."•::" '� •;i' '11j•„i' s• ;' ', , r•« ,,r''.. .•4;„ �, ,,4?i+i?r::•-','�`,•.,•'Y .,.,r,; 011CV+# '.J•`.: ,/� �//I/��.����/ . . O /p/,% // // /// l .F,;•:1', ;; •,4;cj ,!'• i4'{ •.`::,•' • ,., r,: �:. :fit"•.`s,: •i,•n' .. ',:..t' r+i•.r' 'j, •i,, + . '''::' eom'an 'neared:: address: ' '• , '• . ' � •. .. .. '';�. " .:':.,,• 1 . . hone#' :',• . 'i..," ;• ,ti; 't.i,a a :t.' o71cY#. //� i'Tisiirence co; 21 WIN �/ y/ / // / Failure to secure coverage as require ctvd!order Section 25A of MGL 152of a ism-lead ORK o the and osimtdio Fine o ore f S um ee day s;aia?t�me' I-deFAfzud.tbat�r RD one years'imprisonment is well as ilpentesiti in the form forrmded to the Office of Investigations or the D1Afor coverage verification copy of this statement may be I do hereby certify and e .ains and p<enaftie of`er ury thab�the in or ation provided above is true ,d cor e �/, l Date 5iglature Phone# Prsnt name -•�•_,�-'�� ate- - .. - 0MIC121 use only do not!vrtte in this area to be completed by city or town afiidsl permit(licease# ❑Building Department wn: 0Licewingctme Board city or to ❑Seletmen's Office check if immediate response is required ❑Health Department phone; 00ther contaet person (tievbedSept=3) d 4 Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide the a of another no� under any ensation for tear employees. As quoted from the law'',an employee is defined as every person contract of hire,express or implied, oral or written. An employer is defined as an individual,partnership'association,corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer,or the receiver or trustee of an individual, partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more.than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter 152 section 25 also states that every state or local Ucensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the congnonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required. Additionally,neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority. Applicants Please fill in the workers' compensation affidavit completely,by checking the box that applies to your situation. Please supply,company name, address and phone numbers along with a certificate of insurance as all affidavits may be submitted to.the Department of industrial Accidents for confirmation of insurance coverage. .Also be sure to sign and date the affidavit. The affidavit shouldbe 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 require to obtain a worrs'ke compensationpolicy,please call the D.epartrnent at the number listed below. d City or Towns e sure•that the affidavit is complete and printed legibly. The Departmenthas provided a space at the bottom of the Pleaseb 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 perinit/license number which will be used as a reference number. The aff davits maybe retained to ' theDepartmentbYMulorFAXunless otherarraiOnontshavebeenmade. The Office of Investigations would like to thank you in.advance for you coop eration and should you have any questions, please do not hesitate to give us a call. ffi/m/"If 11 The Department's address,telephone and fax number The Commonwealth Of Massachusetts Department of industrial Accidents Office of lentesiigations 600 Washington Street Boston,Ma. 02111 fax#: (617)727-7749 phone#: (617) 7274900 ext.406 1 o�tME ,a� Town of Barnstable b . Regulatory Services BAwWABLE. Thomas F.Geiler,Director 4A 1659. p�� Building Division lfD MA'S Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 Fax: 508-790-6230 Office: 508-862-4038 � . 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 f 11 requirements. } I Estimated Cost Type of Work: l l "�O Address of Work: UU[ vvw Owner's Name: Date of Application: I hereby certify that: Registration is not required for the following reason(s): []Work excluded by law []Job Under$1,000 1nI 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 UNDERMGL c.142A. SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner: bD1�0 Contractor Nam Registration No. ate . OR Date Owner's Name Q:forms:homeaffidav L, Vd° iv" 4:7 �GV oFs�� Town of Barnstable *Permit# Expires 6 months from Issue date • = Regulatory Serviets Fee o?� snxxsrA= � WAM Thomas F.Geilery Director r Ea mPERMIT � Building Division Tom Perry, Building Commissioner J U L 12 2005 200 Main Street, Hyannis,MA 02601 �' Office: 508462-4038 TOWN OF BARNSTABLE Fax; 508-790-6234 " EXPRESS PERINM APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint dap/parcel Number LPIn iq.�S 'roperty Address Residential Value of Work Minimum fee of•$25.00 for work under$6000.00 'wner's Name&Address i Contractor_s_Name . I Telephone Number improvement Contractor License#(if applicable) �U�`'Cl1 ' Home Imp r�j Construction Supervisor's License#(if applicable) C� D"> (®�2:: [workman'.s Compensation Insurance Check one: I am a sole proprietor -4 ❑ am the Homeowner have worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# �41-1 Copy of Insurance Compliance Certificate must be on file. Permit Reques check box) //n Re-roof(stripping old shingles) All construction debris will be taken to A Re-roof not stripping. Going over existing layers of roof) ❑ Re-side [] Replacement Windows. U-Value (maximum.44) *Where required: issuance of this pccmit does not exempt compliance with other tows deputmeat regulation,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. Home Improvement Contractors License is required.- —Tyi Signature r ll - ' Q:Forms:expmtrg Revisc063004 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations z d 600 Washington Street Boston,MA 02111 �,M s�• www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate bog:. Type of project(required): 1. 1 am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction . employees(full and/or part-time).* have hired the sub-contractors 7 ❑ Remodeling 2.❑ I am a sole proprietor or partner- listed on the attached sheet ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.[3 Electrical repairs or additions required.] officers have exercised their right of exemption per MGL l l.0 Plumbing repairs or additions 3.❑ I am a homeowner doing all work mP P myself. [No workers' comp. c. 152, §1(4),and we have no 12.Z Roof repairs k t employees. [No workers'insurance required.] 13.❑ Other 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 tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. // D Insurance Company Name: 0 I I/l n I if �S �� ` Policy#or Self-ins.Lic.#: l ( J�k 1 Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensat' n 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 up to$1,500..00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under 'the pains and�p1 enalties of perju Iry that the information provided abovei is true and correct Signature: ` I l/ Ul r utiS 11A OIL 1 a/ Date / I I V J Phone#: 1 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#: Information and Instructions �. 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 chapter 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 compliance with the insurance to the contracting authority." ter have been resented g n' requirements of this chap P Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s), address(es)and phone number(s)along with their certificate(s) of insurance. Limited Liability 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 to 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: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 5-26-05 www.mass.gov/dia A-06 03:57PIr From-AIG 9j8�81fl-69U3 1-1'lg I,.UU21UU[ t-w Ic iice�--;;`` .,• C' . '•;:: XC PRODUCI_f1� •: ��3' -1 HIS CERTIFICATE IS ISSUED AS A MATTER Or- IN' aF,MAT1ON 1 ONLY AND CONFERS NO RIG14TS UPON THE CERTIFICATE 61 Mai�,�Ins t,Suit Inc HOLDER.THIS CERTIFICATE DOES NOT AMEND,Flt Main Stia 01420 �11 ALTER THE COVERAGE AFFORDED BY I HE POLICIES EXTEND BELOW FIPcJTbur�, MA0�42p COMPNVIES,A,FFORDING INSURANCE COMPANY AGRANITE STATE INSURANCE COMPANY IIaSURED RewLlrlue ivizrtagementc Inc 281 Main Street,SL<rte*5 Pfthburg, MA 01 q20 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW NAVE BEEN 1S5UED TO THE INSURED 1 •'• •FOR THE POLICY PERIOD INDICATED),NOT WITHSTANDING ANY REQUIREMENT.TERM OR CONDITION Or ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TOW HICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED THE POLICIES BESCFJSCRIBFD HEREIN IS SUTAJECT TO ALL THE TERMS.EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. OfRV3lIRANCr - PDL --NUMBER Mu CyOT-F Tltr6OATG POtJCY1SKYIRATTOt�DATTi A ORKBris COMPE1v8ATi01� . WD rMrjpYpZg L1A13IL Ty H�nROpR7E70TL Ltmrm �" C Group 12J252004 17J25/2U05 STATUTORYtIW8 7HE 0477192 se^Penn w MA ODQ.,ti.m Ofty, • cH ncclD�rrr 5 14D,0 CA-%C POUCY LrnAtT S 50a,D E ORIPTION OF OP�RAliotf�fl/F�Hrp�B1BP>rGIg1,1�a�tS S 100,0 RE:COWERS THE EMPLOYEES OF TTiE NAMED INSURED LEASED TO CAPIM HOME:IMPROVEMENT'S INC,1645 NEWTON ROAD. OTUrT MA OZW5. CERTIFICATE HOLDER ANCELLATION CAPIZZI HOME IMPROVEMENTS INC EHOULD ANY OF THEA]WE MacrtIilRD POLICIES A;CANC6iLi.40 p6POft�THE r 1645 NEWTON ROAD D(PPATION DATE TAU'E'OF'THE tssumc C0MF AnnrwrLLENDslkVroR TO MqU,3F COTUIT,'MA 02636 DA\S WRnEN NOTICE TD THE CffaWICATE HOLDER NAM®TO THE LEFT.BUT FAILURSTO MAIL SUCH NoTicl HAutnaroscNOOMMTIONORLKB,Lrrvor ANY KIND UPON'H*COMPANY,ITS Mt-NTS OR REPRESENTATIVES, AUTHORIZED REPRESENTATIVE . , g17— -G' roo'.4?T?��•f? �/('� � - O . c/!'�.(.1�4!lf1�C��l.�.C1e�:f.C�. )3<)ard )3u�J I1> > Jae �uJa ions and Standards, '• : .� One As] bu f0 ]� ' > oozn 1301 � Boston_ M.a.s.40-)usells 02108 b 11 C)17l C 1_1l]j)J OV eJ1]el�t (gip j T-a.CtOT Reg,}stray Ol) Registration: 100740 I ype: Private Corporation CAPIZZI HOME IMPROVEMENT, INC. Expiration: 6/23/2006 Thomas Capizzi, jr. 1645 Newton Rd. _ COtuit, MA 02635 Update Address and refurn card.A1ark reason for change // Address Renewal O Employment ❑ Lost Ca /-�� QQ !lJ�LZC� O��//�la46G7�/tfIAP�G• .. . Board of Building Regulations and Standards License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: 1-0074D \ Board of Building Regulations and Standards >' Expiration: G/23/2D06 One Ashburton Place Rm 1301 Type: Private Corporation BOsion,Ala.02108 CAPIZZI HOME IMPROVEMENT,I %Ornas Capizzi,jr. 1645 Newton Rd. _ COluit, MA 02635 - - Administrator Not va�,wifhovj fmr 1C!lJ:I!!,C•INLQC�O f '.0 BOARD OF BUILDING REGULATIONS (u License: CONSTRUCTION SUPERVISOR Number: CS 057032 Birthdate: 09/26/1963 Expires: 09/26/2005 Tr. no: 7171.0 Restricted: 00 ' .THOMAS X CAPIZZI JR 1645 NEWTOWN RD COTUIT, MA 02635 Administrator . t V UL-12-2005 TUE 10:56 AM JAF I Z/Z 11 FAX NO, i 8423154 7. P. 02 CAPT.Z'ZZ HODIE IYROVEIL"E1J'T INC. SYECZFICA?'l:tI:RS AND ESTIMATES PAGE b 02 `.; STATE OF fASSACITUSET'TS LETTER OF ADTHORI'LATIOR TO APPLY FOP, A BUILDING PE LT OWN THE BROPERTY 'LOCATED AT hL4S8ACt LSETT'S F h , I LAVE At?THORTzED- S,..&�I.'-!Z -If , -----•�---�---�-TO ,ACT AS MY AGENT TO APPLY FOP, A BUILDING FE MIT IN ACCORDANCE FTTB' 7801 C-MR, THE XASSAMSETTS STAtV BUILDING CODE. -�— LLS F: TO:APPLY FORA'BBILDING FEINT IN AC WT TEf ;$CD GNPC, 'Tlix tfASSAMUSETTS STATE BT1:l:LDlgG CODE. SIGUATURF OF OWNER: OWNER'S AIDDRE S S:. OkfiTER'S TELEPHONE: LESSEE'S SIGNATURE: LESSEE'S ADDRESS,. - - -- -----�--�- LESSEE'S TELEPHONE: - --- -- -- I API.LICAN`E'S SIGNATURE' APPLICANT'S ADDSESS: A��'PLICANT'S TELEP:IONE: 1.H.__��_...-� _ d- R?APONSISLE OFFICER: PESPONMLE OFFICER ADDRESS: �_-�-, - - - -- - --®-�---�- RISSPONSJBLE OFFICER TE,LEIITME:ACCEPTED 'By THIS PAGE IS tPfi T E7 IN CONF0R."I4NC in'iTFI. PROL'C�S�,L #. _ — "+ti.-.i. ,•✓ti-a..•.., i`.i .. �-„ Sw rw,:t..,. '1•.., f. jA r •``xi 7g,�e•h:.�€ s...s7:ab:s,_.....�y;'-. - '� a,.._. - .. GINAMMO: TOWN OF BARNSTABLE Permit No. -------27855----------- Building Inspector cash x Bond . OCCUPANCY PERMIT -------------- Issued to Capricorn Realty Trust Address'. lot #6 44 Wellesley Circle, Hyannis Wiring Inspector �� Inspection date ' Plumbing Inspector �ei -. Inspection dater j Gas Inspector Inspection date -f Ao4 A S /Engineering Departinentl'�� f/Y��. Inspection dateN Bo ra d of Health 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 AND IN ACCORDANCE WITH SECTION 119.0 OF THE MASSACHUSETTS STATE BUILDING CODE. Building Inspector § r r 4, TOWN OF BARNSTABLE BUILDING DEPARTMENT t ssaasxAIL t TOWN OFFICE BUILDING rqa . i619 HYANNIS, MASS. 02601 MEMO TO: Town Clerk FROM: Building Department C� SRC r' DATE: �1 � lc�k/ An Occupancy Permit has been issued for, the building authorized by Building Permit #.... !�.. ..../„z�J 4/» ... '�...... issued to .........., fU/� ,,...`� .....�. ._� c'�?� ..».........».».»....»».». Please release the performance bond. i Assessor's map and and lot number . . .......�a�/ THE • ' r� P� MIT NEED T'd EON-A16GT of T� Sewage Permit number ..:..t.........a..!!. . EWER. MUST'CONNECT TO TOWNS e BABBST House number ...................... .' ...................:..... 90 . Y� pp,i 263 63 q. �E'p AIPy Or. TOWN OF BARNSTABLE r- BUILDING INSPECTOR ' APPLICATION FOR PERMIT TO ..Cons. tru.ct....Si. n.gle...Famil. .y.' Dwellin. . g .... ........ ... .... .. .... ....... ........ .... .. ....... .... .......,.,.. .:,; .,........:..:.........:.... TYPE OF CONSTRUCTION .....WOOd Frame.......................................................... .................... r� Se tember 26 84 _..._ p ' 19..... TO,THE INSPECTOR OF BUILDINGS: The. undersigned hereby applies for a permit according to the following information:. Location .............................................................Lot # 6 Wellesley Circle, Hyannis, Mass. ... .... .. ProposedUse .................... ........ .... ........................ ........ .............................................. ........................ R. B. Hyannis ZoningDistrict . :.................................................................... Fire District .......................... ......... Name of Owner Capricorn Realty Trust Address .765• Falmouth Roads Hyannis, : Mays, ....... ..... .... .. ..... < Name of BuildFrranco Real,. Est.Dev.CO. iIncJkddress ..............Same....... ..... .... Name of Architect ..................................................................Address ...................................................... . ........... ...: Number of Rooms ......SaX...................................................Foundation I ........... . ..... Clapboard and�ox Shingles ............Roofing A spb.alt Exterior ' Floors CaY'pat Interior ..............!540.0 TA.0k..... F.W.A. ."'....�� PP� `.:Heating ..... ............................................................... Plumbing `I'I'►i4...... Fireplace None .Approximate. Cost �.. 000 00 (70 Definitive Plan Approved by Planning Board ___ _____________:__________19________. Area 1!.. .ft.t........... Diagram_ of Lot and Building with Dimensions Fee •..... SUBJECT TO APPROVAL OF BOARD OF HEALTH d � ' OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I I hereby agree.to conform to all the Rules and Regula ' s of the Town of Barnstable re arding.the above construction. E Na �..../!�12G1 ...........Px'tr 'Construction Supervisor's License ...0.009.8................... I I CAPRICORN REALTY TRUST No�.: 27855 Permit for ...One...S.t...r'......... <. {.. Single Famil Dwellin ..................................... .......................g......... n Lot 6! 44 Wellesle ircle Location .................. ...................................Y....�. `. ...........Hyanni S.................................... Owr. .......gA ricor �n Realty...Tr , ................. . Type of Construction ....F.1zAMe......................... ...... .,f................................... ................................ Plot" ....s....................... Lot ................................ Permit Granted ......Ua�r...a....................19 _ 85 r. Date of Inspection......................................1.9 v Vr Date Completed ................19 i7 v J CD� r C` z (L077) . WE-1-r-S'LEY C/Rc LS IB 99,78 � t 0 p 72 3 s o�h /o, n L /o q:y/ lx / S ETIS'Ar A- �O° o1:,,{ (4- CERTIFIED PLOT PLAN ;s y r!_I rw atx j IN '• r 1 i E / SCALE, / p DATE, r- E EE' B I CERTIFY THAT THE =o�yp�Tioi.Y a� CLIENT,^,.,.._.....,. SHOWN ON THIS PLAN 13 LOQAT94 t° f�i#TERED REGISTERF,.S t S NO, 82/ ON THE GROUND AS INDICATED Alit, m' CIVIL LAND :, , , �,! CONFORMS TO THE ZONlNo f.# 40 "" : :ENGINEER SURVEYOR DR.BY, OF DARNSTABLE, MASS. CN.SY$ ' 712- MAIN S T R E ET iA HYANHiS MASS. BMEETI,0F� E REG. LAND SURVEYON .- ".� -.r� _ r ...'� ..�M� � '] i✓.�.�1"`L''-r ti '..MfY�.���..,.�..yy„ Y� w � >. .,�.�'t,� F:' � 'N..,1 Assessor's map and lot number �.�/., 4. Sewage Permit number Z BJSBSTADLE. i House number '..............:........................... .....:....................... '°o MAt63 �o�0 aMPYM1 TOs�WN OF BARNSTABLE BUILDING INSPECTOR Construct Single Family Dwelling APPLICATION FOR PERMIT TO ..................................................................................:........................................... Wood Frame TYPEOF CONSTRUCTION ...............................................................................................:..................................... September 26, 8 .......19. 4... i TO THE INSPECTOR OF BUILDINGS: i The undersigned hereby applies for a permit according to the following information: Lot # 6 Wellesley Circles Hyannis, Mass. Location .............................................................................................................................................:..:...:.................................. I i ProposedUse .....................................................................................:.............................................................::........................ R. B. Hyannis i ZoningDistrict ........................................................................Fire District .............................................................................. Name of Owner Capricorn Realty Trust Address6-r Falmouth Road, Hyannis, Mass, Name of Build Franco Real . Est.Dev.Co. ,InC•Address Same ................................. ..............................:...:................................................. i Nameof Architect .........................................................:........Address ......".......................................... Numl3er of Rooms Si.X P.C, ...:. ......................................................Foundation ........... ....................................::..................:........ Clapboard and/or Shingles Exteror ....................Roofing ............. e............................ Floors .....Carpet Sheetrock ..................................................................... etrock ..... ...................................................... 1 Heating Gab — F•W.A. Plumbing ...........TWO — CO pP@r.......:.......: i ............................................. ....... ....Co ................. I None $40,000.00 i Fireplace ..................................................................................Approximate. Cost ........................................................... Definitive Plan Approved by Planning Board .________________________________19________. Area 0 6 B. ......f....t . Diagram, of Lot.and Building with Dimensions Fee SUBJECT TO.APPROVAL OF BOARD OF HEALTH l OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regul Lions of the Town of Barnstable regarding the above construction: Name ."......................... ����.....�Xe�.r.. Construction Supervisor's License ..0.0.09$9.................. CAPRICORN REALTY TRUST A=270-101 27855 No .................. Permit for ....pae...S,tpry......... Single Family.. ........... ........................ ................ location ..Lot...6.,rz:.....44...We-1.1e..5.)-ey...circle Hvannis .............................................................................. Owner ....g.ap.-K.iqqrn....Re.a-lty...Tr.us.t.... .. .. .... .... .. .... Type of Construction ...Er.aMe......................... ................................................................................ Plot ............................. Lot ................................. Permit Granted ..... P.f....................19 85 Date of Inspection ....................................19 Date Completed ......................................19 • C- a,y-O"IXIST, VPSTP<I�.y GcoS�'T ' $UtL_D OvT 7/a'r+- 12evge -01 r-OL,D Doop_ $1-DPED F,002 W1 SH06 -iLoe-te- IXI WOOD, 5T2JP -Jeuo Lt )j0I,ST. PL6 05E GAA-P-eT NO CAAPeT GLv5�T %-cook o2 /dEu� r�1l�t-i- NSW /1WNIA�G ,/ 1'D'MW• 3 rf 3�y"/trAX W I i!>'Ff l'fl`f F-I 5 7"OPF F ok t-- 64, .� �PAn?EL V Ru uh.rD + 3 �• 13 Gxr T I a"Fxrs \�A,1 \ 1 j SHE 7� �3 t MAx ouep SWPtD PLOdR UN7'IN1$H'Eo -- - 7y,"*- SLED 1NSlDE Exisr OP FcooR $ loll vly'r �trcrc ` p $ELxoRE ROG(. R,ET2/AA ooa 3 ax io Glk f o[ --— ax8 Pi llo O 1h Ft yr-ED Box&D Z G I aoc ` d 1.UM IJ a-?x8 J' ---- _ EA' - 4. W 5TJ£P A) _— -- 3DX66 $LOGe hRWNv New AA) :j" % 6 •NVATi&M-T' yoP- + n / agl(o V 1,. SlNOKE (oPhnlEl 9t v ir--y F F/zc- R-EQ. 57Dt y of ac-to Dl CUT7u O GU ITIt Eno 5 SwPE "' � � � sA*oi�E 5 OP�A> W/ �7pp FrT 5Tar25 ceoSS Sl-�7Tocl p a-v t t CeIr-Ito P t�i y �'UA 6N FLo02 /OL N� �1 GE may'= -a• tSFE GLr Arrg $-r tG c-7-7D 0 L[l�Wrj KC-� •g5�D 8 y CA-pIZL/ -11 �MOKt�`-Xa ' VE21Pr� L OLA770/U oA�s fT D777725 - re PA-,Jet- Mh-son, JT� —. U ERIF�f /1= 1415 DOO1 /� HeA7 FAL GlJjlGcf 4- OP- /A) F/A�1/5NtD >406 OAK- -rPEAD>- P2//Lt£17 OAK A*fLINvS S STL=P° UP lyre Prepared by Capizzi Home M ED//Lo5 To 3 UoZ 3 3 r Improvement for the use of CeP[rA Home Improvement=mFIOYces and subcontractors. Anyone using these scALE; // APPROVED BY: �'rawrr.•s sh ,, ;;eld verify all existing conditions, r=/ DRAWN By Jimen;l:•„s ,-onfrrmity,to Ioral and state building., DATE: H-y O S REVISED codes?a;,;L;:equecy of these drawings. Capizzi Home Imprn.eronn:.irsclaims any responsibilitytoranyandall 5NAkoN Atht-oAJE- =dj2SnAl 775-e, 7r/ prob:ems which arise from the use of these drawings by Anyone otherthnnemployees$ DRAWINGNVMBER subcomreaorsof F04' CAPrzzl PotAG LA--A1�epizz![form.?ImT:rovemerd.