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HomeMy WebLinkAbout0025 WESTON CIRCLE o��G�.�S'JDs2 ��� � _� .� r .�+ Town of Barnstable *Permit # Q„ Expires 6 months jr issue to , Regulatory Services Fee Jx snuvsrnste. , 9 1639. �� Thomas F.Geiler,Director f0 MA'I s . 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 Property Address 2 S We—S-�o C I/zc fe— 6 h n i J� iW,4 ,(jZ w/G [/Residential Value of Work ��.5"(/o t Ud Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address 1qA 12t2 ' C1`Zr l x Contractor's �Z/ //tJtn e Syr oae- /w PN/ Telephone Number I'VAt C�/��zZi Td Home Improvement Contractor License#(if applicable) /0 U7 y 0 �0�2-4 Construction Supervisor's License#(if applicable) C 5 -r7o 3 Z %14/;?—O// QWorkman's Compensation InsuranceVi Check one: ❑ I a a sole proprietornvi ; !a } Elam the Homeowner EirI have Worker's Compensation Insurance " `�i tEr OFF t; -%y�i�I S -�-i�-I I ',.J`I-,,l l�l L<%t' �tl''11.F,Q�i G'.A f'Z i"3 Insurance Company Name 14 ( -. 'Pilo p-e ct T I ct vt U C 4 . U R L h C'o mr.-q/3.y Workman's Comp.Policy# A) )t) C G f}S-S q 3.7 G Copy of Insurance Compliance Certificate must accompany each permit Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will betaken to (�—e�Ui�« !ZU El Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) f ff/Vo6u,- /I -,M? ❑ Re-side" ✓O Tgii7l (00-C z4je, e q LUko i-e #of doors ❑ Replacement Windows/doors/sliders.U-Value (maximum.35)#of windows *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the.Home Improvement Contractors License&Construction Supervisors License is required. SIGNATURE: C:\Users\decollik\AppData\Local\Microsoft\Windows\Temporary Intemet Files\Content.0utlook\DDV87AAZ\EXPRESS.doc Revised 072110 oF�rq� + mxxsTABLE+' MAR& Town of Barnstable prfD MA'I� - Regulatory Services Thomas F.Geiler,Director Building Division Thomas Perry,CBO Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 ` . Fax: 508-790-6230 Property Owner Must Complete and.Sign.This Section If Using A Builder I M AXY. L 4 N e ;as Owner of the subject property hereby authorize �! f'd°pye h?P.✓� to act on my behalf, in all matters relative to work authorized by this building permit application for: 1c1lTa� L'irLe l� lryQ�rZ<✓ /�1a d2 iol (Address of Job) Signature of Owner IKA Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. C:\Users\decollik\AppData\LocalWicrosoft\Windows\Temporary Intemet Files\Content.Outlook\DDV87AAZ\EXPRESS.doc Revised 072110 ` Office of Consumer Affairs&B siness Regulation License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration;.;.a, l � . 100740 Type: Office of Consumer'Affairs and Business Regulation c= Expiration: 612372012 Private Corporation 10 Park Plaza-Suite 5170 Boston,MA 02116 >;APIZZI HOME INi(?ROVENfE-N ,,7NC. Thomas Capizzi,jr. 1645 Newton Rd: Cotuit,MA 02635 = Undersecretary Not valid out srgnat re Massachusetts- Depai-tmegt of Public Safct) Board of Building Mcgplations and Standards Construction Supervisor License License: CS 57032 Restricted.to: 00 THOMAS.X.CAPIZZI.JR 1645 NEWTQWN RD COTU IT, MA.0263.5 -- - � � Expiration: 9/26/2011 ('unm,issioner Tr#: 4113 Client#-.47298 CAPIHOM ACORU. CERTIFICATE OF LIABILITY INSURANCE DATE IY TE(MMDD Y) 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 endorsement(s). PRODUCER - - CONTACT Karen Walther NAME: Rogers&Gray Ins.-So. Dennis PHONE 508 398-7980 FAX (A/C, /C No Ext: :- A/C,No 434 Route 134 E-MAIL ADDRESS: waltherka@rogersgray.com P.O.BOX 1601 PRODUC IR CUSTOMER ID#: South Dennis, MA 02660-1601 INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A:National Grange Insurance Co. - Capizzi Home Improvement,Inc: INSURER B:ACE Property$Casualty Ins.Co Capizzi Enterprises,Inc. 1645 Newtown Road INSURER C: -Cotuit, MA 02635 - INSURER D: - INSURER E: - - INSURERF: - - 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. LT R TYPE OF INSURANCE DDL UBR - POLICY EFF- POLICY EXP LTR NSR D. POLICY NUMBER MM/DD MM/DD - - LIMITS A GENERAL LIABILITY MPB1075H 06/08/2010 06/08/2011,EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY AMAGE TO RENTED PREMISES Ea occurrence $SOO,pOO. CLAIMS-MADE a OCCUR MED EXP(Any one person) $10,000 PERSONAL&ADV INJURY $1,000,000 ` - GENERAL AGGREGATE $2,000,000_ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 POLICY JECTPRO- LC -. - $ - A AUTOMOBILE LIABILITY BPOI0786 06/08/2010 06/08/201 1 COMBINED SINGLE LIMIT $ A ANY AUTO M1 M28044 06/08/2010 06/08/2011 (Ea accident) 500000BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ X SCHEDULED AUTOS - _ PROPERTY DAMAGE $ X HIRED AUTOS - - (Per accident) X NON-OWNED AUTOS U1 - $250/500,000 - X Drive Other Car U2 $2501500,000 A UMBRELLA LIAR IV occuR CUB1076H 06/08/2010.06/08/2011 EACH OCCURRENCE s5,000,000_ EXCESS LIAB CLAIMS-MADE - .. AGGREGATE $5 000,000 DEDUCTIBLE $ X RETENTION $ 10000 - - $ B WORKERS COMPENSATION NWCC45843208 12/25/2010 12/25/2011 X WC sTAru- 0TH- AND EMPLOYERS'LIABILITY _ YIN ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $1,000,000 OFFICERIMEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,0009000If . DEes,describe under SCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/.VEHICLES(Attach ACORD.101,Additional Remarks Schedule,if more space is required) - - Workers Comp Information Included Officers or Proprietors CERTIFICATE HOLDER CANCELLATION 10 Days for Non-Payment SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Town Of Barnstable ACCORDANCE WITH THE POLICY PROVISIONS. 200 Main Street Hyannis,MA 02601 AUTHORIZED REPRESENTATIVE ©198 -2009 ACORD CORPORATION.All rights reserved. ACORD 25(2009/09) 1 of 1 The ACORD name and logo are registered marks of ACORD #S61971/M61970 MEE The Commonwealth of Massachusetts -.Department oflndustrialAccidents Office of Investigations ' 600 Washington`Street Boston, M 02111 wivw.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applic. ant Information Please Print Le ibly Name(Business/Organization/Individual): Address: City/State/Zip: l_ 7�7/� f / D�4 3 5- Phone A ,-( op' Ylef '9 Are you an employer? Check the appropriate box: Type of project(required):. 1 I am a employer with � 4• ❑ I am a general contractor and I / employees (full and/or part-time);* have hired the stab-contractors. 6• ❑New construction 2.❑ I am a•sole proprietor.or partner- listed on the attached sheet. 7. ❑Remodeling shipand have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. employees and.have workers' P com insurance.$ 9: El Building addition. [No workers'comp.insurance required.] 5• ❑ We are a corporation and its' WTI Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their l l.❑Plumbing repairs or additions . myself. [No workers'comp: right of exemption per MGL 12 ❑Roof repairs insurance required.] t c. 152, §1(4),and we have no 13.[Other i'l yUl1 C 6�e✓u a employees. [No workers' S comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy infom�ation. . t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. cContaactors that check this box must attached an additional sheet h t showing the name of the subcontractors 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-an-Name: �' c a 'op.e fury c Policy#or Self-ins, Lic:#:/�[.�ee- 3 j17) Expiration Date: �'�"�� /.2 e 11 Job Site Address: 'ZS Wes 767k te City/State/Zip: yg,144-� �9Q 0Z6aj 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 that a copy of this statement may be forwarded to the Office of: _ Investigations of the DIA for insurance coverage verification = Ido-her-eby-c-er-tif-y-under-titepains andpenalties-ofpe-r-jurjLthat-th�-info;r-tnation-pr-ovider-above-is-tr-ue-and-cor-r-ecz Si store'. Date: 1�.� m 0// Phone#: LYV 00 C{Z Sl(p official use only. Do not write in this area,to be completed by city or town offzciaL City'or Town: Permit/License# Issuing Authority(circle one):_ 1.Board of Health 2.Building Department 3. City/Town Clerk 4.EIectrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: TOWN OF,IIIARNSTABLE-BUILDING PERMIT APPLICATION :Parcel"," �:,�A [ h 3rl5b:�L76 Map pplicatio Health'Division Date Issued go o, JiO Conservation Division Application Fee it - Planning Dept. Perm Fee Date Definitive Plan Approved by Planning Board f P Historic - OKR Preservation Hyannis 'Cia Project Street Address S±n4yA 1.10 04n Village 7 Q 1 s Owner Address V Telephone -7=f 6JP4 Permit Request Square feet: 1 st floor: existing—proposed 2nd floor: existing—proposed Total new Zoning District Flood Plain Groundwater;Overlay Project Valuation Construction Type Lot Size Grandfathered: J Yes LJ No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family LJ Multi-Family(# units) Age of Existing Structure Historic House: J Yes PAo On Old King's Highway: U Yes LJ No Basement Type: Eli Full 0 Crawl LJ Walkout J Other Basement Finished Area(sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing newexisting new Number of Bedrooms: existing —new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: LJ Gas 0 Oil J Electric LJ Other Central Air: Ll Yes L1 No Fireplaces: Existing New Existing wood/coal stove: LJ Yes Q No .QDetached garage: LJ existing J new size—Pool: Ll existing J new size Barn: Ll existing LJ new size— Attached garage: U existing Unew size —Shed: J existing Ll new size Other: C3 Zoning Board of Appeals Authorization Ll Appeal # Recorded Ll �i Commercial Q Yes -E No If yes, site plan review# Current Use Proposed Use 5i APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name CO-40fl2i 4,�4 -:�,'.0fAVe1*70,6heIephone Number E0r_`1Xr:791S_701)1_ Address License (6)::J2JZJZ (-e 3J Home Improvement Contractor# QQ 7 �L Worker's Compensation # W o In ALL CONSTRUCTION DEB :3LT<1,NGFROM THIS PRO C T WILL BE TAKEN TO ,, SIGNATURE DATE 60 FOR OFFICIAL USE ONLY a .. APPLICATION# ..- � DATE ISSUED ,I MAP/PARCEL NO. R i ADDRESS VILLAGE OWNER j DATE OF INSPECTION: FOUNDATION FRAME ti r . INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL 4 FINAL BUILDING f 4 , DATE CLOSED OUT ASSOCIATION PLAN NO. p The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations' ' 600 Washington Street Boston, MA 02111 a4 �� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LeLribly Name(Busines&10rganization/Individual): bbovI-2-4 4­6_1�_�_ _ YA kesz 00 Z_-.-4t Address: P, L4 �( 14 A(7 City/State/Zip: Phone.#: S-0 L_`W_r `9 S f t Are you an employer? Check they appropriate box: Type of project(required): 1. I am a employer with j�rf,� r • 4. I am a general contractor and I . --/-+< 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2. 1 I am a sole proprietor or'partner-' listed on the-attached sheet. T. . Re odeling ship and have no employees These sub-contractors have g.' Demolition working for me in any capacity. employees and have workers' 9. 0 Building addition " [No workers'.comp.•insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have eicercised their I LE]Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 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 state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. lam an employer that isproviding workers'compensation insurance for my employees. Below is thepolicy andjob site information. Insurance Company Name: �/ Policy#or Self-ins. Lic.#: / C o V Q C- d Expiration Date: Job Site Address: S Vl C rC. �- _ Ci /State/Zi s0.4 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine tip to$1,50D.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 Mnvesti ations of the DMA for' urance coverage verification. I do hereby certW and t ai enalties of perjury that the information provided above is true and correct Si ature• Date: oZ �-�Phone — 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#: r 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 tiustee of an individual,parinership,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 oron 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 with-hold 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 requirements of this chapter have been presented to the contracting authority." Applicants Please:fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary,supply sub-contractors)name(s),addresses)and_phone number(s)along with their certificates)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- . • . •... - -A - --�--,._...... ...I_ T..�AA;4:n„ r.—licant Please be sure to fill in the per,univ icense number which will oc us—as a Lctctcu�,11. ui . 1LL uu.. -,a.._rr- — - 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 markedtr 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 fo any business or commercial venture (i.e. a dog license of permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would hike 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 Indust-id Accidents Office of Tnvestigatian& 600 Washington Street Boston,MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Fax# 617-727=770 Revised 11-22-06 www.mass.govldia I� • ��ie •[Oo-n�nomsuea� a�./�aaaczc�aiceeaa Board of Building Regulations and Standards License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration(late. If found return to; Board of Building Regulations and Standards Reglstrptj;Qb_; 100740 One Ashburton Place Rm 1301 Tra a =Q23/2010 Boston,Ma. 02103 - 4pplement Card51 CAPIZZI HOME� . �?�V.. !V?! 11p1 tARY GISTAF,9(D;, 1645 Newton Rd. `: y:;'ice `� ,H ` 41,17 Cotuit,MA 02635 ....t_..)•. � •. -.- ...__.,......Administrator ith ._t...._..nature • :_... ..._ . vw �i;r.a;►c'hu�ct.t Di'rarf+nirtt of Publiv 5al'CtN -- - I3u:tr'd {)t 13usi(lln.t, Regulations and Statotl:ll`d-N Construction Supervisor license License: CS 74640 Restricted to: 00 GARY .G:USTAFSON 8 SHORT WAY SANDWICH, MA 02563 1 1/291201 0 t ,nrFni.,i trot r. Irk; 7755 I- I 1 _ � CAPIZZI HOME IMPROVEMENT INC. Page 7 of 7 SPECIFICATIONS AND ESTMATES STATE OF MASSACHUSETTS LETTER OF AUTHORIZATION TO APPLY FOR A BUILDING PERMIT I,MARY LANE, OWN THE PROPERTY LOCATED AT 25;WESTON CIRCLE IN HYANNIS, 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 ACCO ANCE WITH 780 CMR,THE MASSACHUSETTS STATE BUILDING CODE. SIGNATURE OF OWNER: OWNER'S ADDRESS: 25 WESTON CIRCLE,HYANNIS,MA 02601 OWNER'S TELEPHONE: 508-775-5921 LESSEE'S SIGNATURE: LESSEE'S ADDRESS: LESSEE'S TELEPHONE: APLLICANT'S SIGNATURE: i2 APPLICANT'S ADDRESS: 1645 Newtown Rd., Cotuit,MA 02635 APPLICANT'S TELEPHONE: 508-428-9518 RESPONSIBLE OFFICER: RESPONSIBLE OFFICER ADDRESS: RESPONSIBLE OFFICER TELEPHONE: r— /� Client#:47298 CAPIHOM ACORD- CERTIFICATE OF LIABILITY INSURANCE 5107/M/DDIYYY1� 05/07109 PRODUCER THIS'CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Rogers&Gray Ins.-So.Dennis ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 434 Route 134 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR P.O.Box 1601 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. South Dennis,MA 02660-1601 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: National Grange Mutual Insurance Co. Capi�i Home Improvement,Inc. INSURERe: NATIONAL UNION FIRE INS. Capizzi Enterprises,Inc. INSURER-C: 1645 Newtown Road INSURER D: Cotuit,MA 02635 INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWRMAY HAVE BEEN REDUCED BY PAID CLAIMS. SR ADD1POLICY EFFECTIVE POLICY EXPIRATION LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE MMIDD/YY DATE(MM/DDIM LIMITS A GENERAL LIABILITY MPB1075H 06/08/09 06/08/10 EACH OCCURRENCE $1,000,000 N:_71M MERCIAL GENERAL LIABILITY DAMAGE TMISESER o"cu° ce $500 000 CLAIMS MADE a OCCUR MED EXP(Any one person) $10 000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $2 000 000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2 000 000 POLICY X PRO - A LOC A AUTOMOBILE LIABILITY BPO10786 06/08/09 06/0811 O COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $500,000 ALL OWNED AUTOS BODILY INJURY $ X SCHEDULED AUTOS (Per person) X HIRED AUTOS BODILY INJURY $ X NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO EA ACC $ OTHER THAN AUTO ONLY: AGG $ A EXCESS/UMBRELLA LIABILITY CUB1076H 06/08/09 06/08/10 EACH OCCURRENCE s5,000,000 X OCCUR CLAIMS MADE AGGREGATE $5 000 000 DEDUCTIBLE $ X RETENTION $10000 $ B WORKERS COMPENSATION AND WC006957000 12/25/08 12/25/09 X WC STATU- OTH- C EMPLOYERS'LIABILITY E.L.EACH ACCIDENT $1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Carpentry CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Town of Barnstable DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL In DAYS WRITTEN 200 Main Street NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL Hyannis, MA 02601 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE r ACORD 25(2001/08)1 of 2 #S43470/M43449 KW 0 ACORD CORPORATION 1988 OMEN OMEN MEMNON OEM ONE 00 MENEM mom MENEM ME 0 0 mi MENEM MEMEMMEMEMEMN 0 ■■■■■■■ ■■■■■■■■■ MENEMMEMNON ....... ..........NONE . . .. ....... ��iiiii �iiiieiiii�iiiii ii■ ii�i�io■i EMMEMEN mommommommoommoom mom NEEMEM No No 0 ME moommom mommmom Elm mm�mmmm MONSOON! ommom immoommomm 0 No MEN ....... .... �, r � _ - � -� - _ _ �:_ _ r - - � i - � - �' _ _ _{ _ - r - � - - _ - - - r ;� fi ' � _ _ - - - 1�-- - - -, - - - + - �-'' - - - I - I IIi - - -. 4 oEzxs r0 �':Cl U �x I1S�`17 (E *Permit# O Regulatory ti��T�I Cl 1. Er s 6 r onllr.r n r.r.rrrr.rlrir� ces 1 nnxx n r. , ES PERITromas F. Geiler, Director v rryss � 39. Building; Division 'rfo;Mai/ AUG 2 5 2008 / Pom Perry, CBO, Building Commissioner in Street, Hyannis, MA G2EU1 TOWN OF BARNSTAB�:t ''`�1a �•���r.tc�n�.barnstahle ma us Office: 509-862-4038 Fax: 508-`790 6230 FA MESS .PE10111' A.PPUCATION - RESIDCNTIA.L ONLY -_- No! �.'a(id,+,iLhn,rr Red,V_P,C,'V 1,1pl-iret -- Map/Parcel Number a�..`. . ..._ _ t ✓. ... _.-.-..-. ii r� ^^,, Pro1..erly Addres's`Y J. W ..-..��� �:\ .. y. .11Ois.'WA �.. ..._._ _._. .... Zraidc:ntir l Vah.,e of`Vorka5�'� Minirnnnr fee of$25.00 for work under $0000.00 Ownc.r's Namc r . Addreis �N1awv. �t�y� ` 1 Flume IntProve.rrten( Contractor (:teen>:e: H 'Alorkman's Compencr„lien liisurancc. Check one: I and a soli;proprietor I am the Ffnmeowner f?lave Worke.r's Compencalirm fn.surancr fnsuran.ce Company Name Workman's Comp• Policy,li ' '�S _� --....._... Copy of Insurance Compliance (-'ertificatc nm,st he nu lil::. Permit Request (check box) ire-roof(strippino nld shingles) All (7onsirllction debris %:aill he taken to Re-roof(not stripping. Going over existing lavers of lm,A) ❑ Re-side Replacement 1 'indows!doors.,/sliders. li Value- (rnaxi,num .44) *Where required: Issuance of this pcnnir does tint exempt cornplianec wish other lean department regulatiom,i.e. Historic,Conservation,etc. ***Note: Property Owner nnist sign Property Owner Letter of'Permission.. A cop), of the .Home Improvement Contractors License is required. SIGNATURE: ,1 0:\',�,i'i=?LES�,�OR1viSr;buildir:e nermi; fnnns`,�?;F4F':C d-c The Commonwealth of Massachusetts Department of Industrial Accidents " Office of Investigations e 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information `\_ Please Print Legibly Name(Business/Organization/Individual): (1 QS�Z2, l J�`(1 ad z t k Address: City/state/Zip:7137t "ato Phone.#: Are you an employer?Check the appropriate bog: Type of project(required): 1.® I am a employer 4. ❑ I am a general contractor and I � Yer with� 6. El New construction . employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. remodeling ship and have no employees These sub-contractors have gig, ❑ Demolition workingfor me in an capacity. employees and have workers' Y P tY• 9. F-1 Building addition [No workers'comp.insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work .officers have exercised their I LE] Plumbing repairs or additions 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.❑ 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: Policy#or Self-ins.Lic.M r @, Lq— Qr---s c`A Expiration Date: 1Q Job Site Address: �� (�,� C`Q City/State/Zip: 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 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 penalties ofperjury that the information provided above is true and correct Signature: Date: Phone#: 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 representative's 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 requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation.and, if necessary,supply sub-contractors)name(s),addresses) 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. # 617-72.7-4000 ext 406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 11-22-06 www.rnass.gov/dia 4ite Boar o ui m e la-ions an g gu tan ar s One Ashburton Place - Room 1301 UVBoston, Ma&chusietts 02108 Constructionsor License License. CS: 57032 Restriction: 00 y z Birthdate: 9/26/1963 . tq w W Expiration: .9/26/2009 Tr# 3801 THOMAS X CAPIZZI JR 1645 NEWTOWN RD , - -- COTUIT, MA 02635 K k ov4� sV s Update Address and return card.Mark reason'for change DP�AI 0 50M-W✓os-Pc8dso 0 Address n Renewal E] Lost Card . ham. �/.e.;Poomr�nrnuoeao;.o�./Cfaaaac/�uaelld Board of$uilding i�egulatiohx and_Standards jg- Construction::Supervisor t Icense: I > Liofi CS 57032 s t K e BirthBat 9.,26/1%3 §. �¢2009 Tr# 3801 ` 1 THOMAS X"CAP 3 1645 NEVVTOWN.. COTUIT,MA 02635 Commissioner i /ze -G'o�rvnonueald o�,/�,veaacluaeQa 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: Registr�j,io 1: 100740 Board of Building Regulations and Standards E�cPira#on j23/2010 Tr# 267955 One Ashburton Place Rm 1301 ' e`i. Boston,Ma.02108 Type Pnvate.Corporation CAPIZZI HOME IMPR.VEME 4'11,INC. Thomas Capizzi,jr,` i 0a 1645 Newton Rd. Cotuit,MA 02635 "' Administrator Not valid without signatu e 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 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 ACCORD CE WITH 780 CMR, THE MASSACHUSETTS STATE BUILDING CODE. SIGNATURE OF OWNER: OWNER'S ADDRESS: OWNER'S TELEPHONE: LESSEE'S SIGNATURE: LESSEE'S ADDRESS: LESSEE'S TELEPHONE: APLLICANT'S SIGNATURE: APPLICANT'S ADDRESS: 1645 Newtown Rd., Cotuit, MA 02635 APPLICANT'S TELEPHONE: 508-428-9518 RESPONSIBLE OFFICER: RESPONSIBLE OFFICER ADDRESS: RESPONSIBLE OFFICER TELEPHONE: r t Client*47298 CAPIHOM ACORDTM CERTIFICATE OF LIABILITY INSURANCE osi;2/2008 Y' PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Rogers 8,Gray Ins.So. Dennis ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 434 Route 134 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.0.Box 1601 South Dennis, MA 02660-1601 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: NGM Insurance Company Capizzi Home Improvement, Inc. INSURER e: American Home Assurance r Ca izzi Enterprises, Inc.P p :INSURER C: 1645 Newtown Road INSURER D: Cotuit,MA 02635 INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE.BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSRDD POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE MMIDD/YY DATE MMIDD/YY A GENERAL LIABILITY MPB1075H 06/08/08 06/08109 EACH OCCURRENCE $1 00O 000 X COMMERCIAL GENERAL LIABILITY PREDAMAGE MIS D RENTrED $500 000 CLAIMS MADE �7x OCCUR MED EXP(Any one person) $1 O 000 PERSONAL&ADV INJURY $1 00O 000 GENERAL AGGREGATE s2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG s2,000,000 POLICY PRO LOC JECT AUTOMOBILE LIABILITY - COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) $ HIRED AUTOS BODILY INJURY (Per accident) $ NON-OWNED AUTOS PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ A EXCESS/UMBRELLA LIABILITY CUB1076H 06/08/08 06/08/09 EACH OCCURRENCE s5,000,000 X OCCUR 7 CLAIMS MADE AGGREGATE $5 000 000 DEDUCTIBLE $ X RETENTION $10000 $ B WORKERS COMPENSATION AND WC6716562 12/25/07 12/25/08 X TOCLIM T- OTH- STAT ER EMPLOYERS'LIABILITY E.L.EACH ACCIDENT s500,000 ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? E.L,DISEASE-EA EMPLOYEE $500,000 If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $500,000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Carpentry CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Town of Barnstable DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL (I DAYS WRITTEN 200 Main Street NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL Hyannis, MA 02601 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 25(2001/08)1 of 2 #S36540/M36539 KW © ACORD CORPORATION 1988 Y ,�an •yam Y j r�'� �-4 S r�F',F' _ TOWN OF BARNSTABLE BUILDING PERMIT:APPLICATION; Map Parcel Application Health Division. Date Issued Conservation Division Application Tee Tax Collector Permit Fee Treasurer Planning Dept. Date Definitive Plan Approved by Planning Board Historic-OKH Preservation/Hyannis Project Street Address Village /4'VA A/AJ✓S Owner 4A 4 4�-_, "A V Address Telephone .fig �7;72!F Permit Request IV -bb (d)i e_ l,(, A L.L. Tp r1a257_ ,_GObP, $ATE id A4.0 y -A k)J Square feet: 1 st floor:existing q g 2nd floor:existing proposed Taal new Zoning District Flood Plain Groundwater Overlay c w Project Valuation DDD - °Construction Type Lot Size Grandfathered: ❑Yes ❑No If yes, attach supporting documAn tion. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(#units) X m Age of Existing Structure Historic House: ❑Yes ❑No On Old King's Highway: 0 Yes ❑No Basement Type: ❑Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full:existing new Half:existing new Number of Bedrooms: existing new Total Room Count(not including baths):existing new First Floor Room Count Heat Type and Fuel: ❑Gas ❑Oil ❑ Electric ❑Other Central Air: ❑Yes ❑No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑No Detached garage:❑existing ❑new size Pool:❑existing ❑new size Barn:❑existing ❑new size Attached garage:❑existing ❑new size Shed:❑existing ❑new size Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes, site plan review# Current Use Proposed Use BUILDER INFORMATION Name y 4 t467-4/CSd/) Telephone Number 1-1!9-09 Address C �Z�-� T/lit C JAI License# Z-6 / l•���w/� _;�?61VJb Home Improvement Contractor# Z l C0 GW 7— IYA 4:036 Worker's Compensation# ALL CONSTRUCTION`DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO 64/J_�S,Wl<: ,Iv- SIGNATURE DATE ����'/Ol 7 ` FOR OFFICIAL USE ONLY R APPLICATION# Y DATE ISSUED MAP/PARCEL NO. F. . ADDRESS VILLAGE t OWNER DATE F INS PECTION: SPECTION: FOUNDATION 5 ' FRAME -� -p INSULATION FIREPLACE R ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL `.t GAS: ROUGH FINAL t FINAL BUILDING r DATE CLOSED OUT ASSOCIATION PLAN NO. r - The Commonwealth of Massachusetts Department of Industrial Accidents . Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia " Workers' Compensation Insurance Affidavit: Builders/Contractors/Eleclease Print umbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address: City/State/Zip: C07k-1 T; .,:2,:'; 35 Phone#: Are you an employer?Check the appropriate box: Type of project(required): i 4. I am a general contractor and I 1.� I am a employer with 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g. Demofition working for me in any capacity. employees and have workers' 9 Building addition [No workers'comp.insurance comp.insurance.= required.] 5. We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I I.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption.per MGL 12.0 Roof repairs insurance required.]t c. 152, §1(4),and we have no q employees. [No workers' 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. tContractots 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. �� � �� -/ nssurancance Company Name: l �f Policy#or Self-ins.Lic.#: ! �- ` Expiration Date: Job Site Address: City/State/Zip: 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 advis d that a copy of this statement may be forwarded to the Office of Investigations of the D for insurance covers e v ification. 1 do hereby certify der the pains and p n I ' so rjury that the information provided above is true/and correct. Si ature: Date: �� ��< — Phone#: OJficia/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#: Date: 10/4/2007 Time: 12:26 PM TO: f4 9,1,508 420 0318 R&G Ins. Agcy. Page: 001 Client#:47298 CAPIHOM •ACCRD. CERTIFICATE OF LIABILITY INSURANCE 081320 7 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Rogers&Gray Ins.-So. Dennis ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 434 Route 134 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR P.0.Box 1601 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. South Dennis,MA 02660-1601 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURERA: National Grange Mutual Ins.Co. Capizzi Home Improvement,Inc. INSURER B: American Home Assurance Capizzi Enterprises,Inc. INSURER c: 1645 Newtown Road INSURER D: COtLIIt,MA 02635 INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECTTO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. POLICY EFFECTIVE POLICY EXPIRATION LTR INSR1 TYPE OF INSURANCE POLICY NUMBER . DATE MM/DD DATE MM/DD LIMITS A GENERAL LIABILITY MP010707, 06/08/07 06/08/08 EACH OCCURRENCE $1 000 000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED MISS o ce $500,000 CLAIMS MADE a OCCUR MED EXP(Any one person) $1 O OOO PERSONAL&ADV INJURY $1 OOO 000 GENERAL AGGREGATE s2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: - - PRODUCTS-COMP/OP AGG $2 000 000 POLICY PRO- JECT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) $ GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO EA ACC $ OTHER THAN AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ DEDUCTIBLE RETENTION $ $ B WORKERS COMPENSATION AND WC1764953 12/25/06 12/25/07 WC STATU- OTH- EMPLOYERS'LIABILTTY - FR ANY PROPRIETORIPARTNERIEXECl1TNE E.L.EACH ACCIDENT $500,000 OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $500,000 Syes,AL PROVISIONS below describe under E.L.DISEASE-POLICY LIMIT $500,000 SPECI OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES!EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS **Supplemental Name** First Supplemental Name applies to all policies-Capizzi Home Improvement Inc&Thomas Capizzi,Jr.` Policy#MP010707-:Thomas Capizzi,Jr. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Town of Barnstable DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 1Q_ DAYS WRITTEN 200 Main Street NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT F_AR-URE TO DO SO SHALL Hyannis,MA 02601 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. ' AUTHORIZED REPRESENTATIVE ACORD 25(2001/08)1. of 2 #S30375/M30374 DD ©ACORD CORPORATION 1988 f , ✓1ze �a}rvnzoozulea� r�'✓�a�aac>lu�ee%ta - 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: Board of Building Regulations and Standards s Registration: 100740•Expi ration:. 6/23/2008 One Ashburton Place Rm 1301 Boston,Ma.02108 Type:!:Supplement Card CAP1=1 HOME IMPROVEMENT, I dARY GUSTAFSON 1645 Newton Rd. Cotuit MA 02635 Administrator t valid with t sig tore _62 e Board of Building Regula ions and Standards One Ashburton Place - Room -1301 Boston. Massachusetts U21 U� a 4 4 Homg Improvement Contractor Registration .: --'. . "- - Type: Supplement Card Expiration: .6/2 3/2008 CAR HOMP 1-MPR_VEMFNT, ANC' GARY GUSTAFSON 1645 Newton Rd. COtU lt, MA 02635 Update Address and return card.Mark reason for change. _.. Ej Address Renewal Employment fJ Lost Card ✓�ce t�amvriio rucea�C� c��Jri�aaaacr�u efZa " &oard.ofBuilding_Regu_1.bons and Standards Cons_f'ucfionrtr- yuor�Li¢ense���- a � ` ` �' � � z �� y f� c 'a r'bs-`3'•- ° S ^^: t u .s ah�1 AY r �- F �„�,z t K y,. c t i ��,�'ct v.t^ v�t .3. ''�,."'..,51"' "-``r4 L -t n.1 `'gs"r �'b d Sri _`�._ R. f..-u•3`. f .;_,,- "c 'tT,X.>'-C�' � 'ate-F x,x _ st +' v £ : v license%C '7 w YT t�f_ l p {,✓_{`�y.f,.•J'.Yil iS� i:CM+ ••f'.P'^.Y^� ups �-' Mo. 11 "ate it , 4,• B . .-0 . - y{-- ,y11( .n qni T.v.Yz€ iC St �3 , v § , f f �x:� ht 1 a:'ciu y.. x +.'i ,h,,� k ai E,i -�.2r , g 1 s� v y. iu r✓kw `' '' a'•"s� H c r �s r s :'1 a v� -'�ri•r�z-wsl�.t:: '� P fa 1f/2 20 8 , 6 ct a y k4 E �, taw i cct -.;e::�j'. r'.y, -''Sa�f":'.ly��.9'4L' �•+'tV'_r�i�".terry i' V'P�aay„-Q,3�:��:tr_rZ„A4 r N c�'� �✓` .��: �c yy,,h •,.iv �?E=�fi v rtt-•;� � sr k � .d, -".;ynx"�i €' i'p"•s�' f -.!; ''•?.w: '� _ -;y;..'a�.+�•�t ,v.Si`-t1`� 2� °4.Si� .;,a a'a 4_r, ,g.,'� ��a;h't ar y,r �udapr' 'k � , 6testFictt fl0 ,� _.f; r7..i.c�*'9li-�' �J k ,y�• t a -.✓•y r Lv� r"3+ ,SC, ,n� a- � -F P �?� �t i.� � �� ..-, � .�`YMy�r �" �' -��t�� 1.�.. "•g$�,�,-1€ �*� ����ac;��a ��� b. .1�"�: •k�.r; �� � �` ,� .f i � � nn��������� -w*.3xtR�..•.(, �� >> ) ri- r� 4 yh�t'-�f �y�`�}�w'�?'R'i'-�x 4 "�: �r �IE'�'')�-`` ..� �"�', '':' : ;.,..GARY GUSTAFSON ^+ 8'SHORT WAY_. %:; ,-.. _ 7 SANDWICH,MA 02563 Commissioner. • , 4 Kti - '�-"*� ^•eie„«a� '. C$.)sr�d�..���`�..aee'.�J,a�.:;�'«`'':t�' a7`+,a�� .��Y �'�e-�•" �' #'•:.: �`���: h 1' 3 i na :. { - _. _....2�... ...... _ K .. .. QK fi S, H r •� r f y o m a { t 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 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 ACCORD CE WITH 780 CMR, THE MASSACHUSETTS STATE BUILDING CODE. SIGNATURE OF OWNER: OWNER'S ADDRESS: OWNER'S TELEPHONE: LESSEE'S SIGNATURE: LESSEE'S ADDRESS: LESSEE'S TELEPHONE: APLLICANT'S SIGNATURE: APPLICANT'S ADDRESS: 1645.Newtown Rd., Cotuit, MA 02635 APPLICANT'S TELEPHONE: 508-428-9518 RESPONSIBLE OFFICER: RESPONSIBLE OFFICER ADDRESS: RESPONSIBLE OFFICER TELEPHONE: ����( �" permNo --------- TOWN OF BARNSTABLE' � 7� B ding Inspe for ,wea r t AUSTAU Cas OCCUPANCY PERMIT Bond -___ -1_►--- -_ Issued to Ca:przcorn ":Rem y, T iIg't Address A l25 West:Ori Clrcle; kly Ilnis Wiring Inspector r Inspection date Plumbing Ease ctor � � / _/ Inspection date : ,- Gas Inspector ( T f o Inspection date r X Engineering•Department ^/ALA/LiJ yJ�i'rYi� Inspection.date-- — Board of Health. +;u'n �` �/ — Inspection date THIS 'PERMIT WILL NOT BE VALID, AND THI:,,,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. 'f ...... .... ............................................ li Building'Inspector ` Assessor's map and lot number .rLl..:...1.. '.• ` v "" TN E y Sewage Permit number .................................. L Z EAHBSTADLL House number /// r'�......�. ................................................ 90O M679 9� p MA i Av TOWN OF BARNSTABLE - BUILDING INSPECTOR APPLICATION FOR PERMIT TO .OnStruct Sin91e T ajy. Dwelli,n .... TYPE OF CONSTRUCTION ......woad Frame . .................................................................................................................... �.. .... �...............19........ r TO THE INSPECTOR OF BUILDINGS: The lundersigned hereby applies for a permit according to the following information: Location ..•..:.LO .. ... .......j.! `4.. `'. .. '''.. :�..° U.j. ` -....... V ..: ............................................. ProposedUse ............................................................................................................................................................................. I+ Zoning District ........... )NaMis ..............................................................Fire District ......;,....................................................................... - Name of Owner .CaRri c orn Realty .Trust Address •6.5 Falmouth Road, Hyarunis ................... ........... Name of Builder'FranCo Real Estate Dev. Co ddress .' (a l~'Ia MOI.I ;l h R�r,? c Ntr�r�r�l el.............. ........................................................ �J(ll<Y Nameof Architect ..................................................................Address .................................................................................... Number of Rooms S ...•..........................Foundation ...P."C .....•..ix............................ .•.................................................................. Exterior Clapboard ariC3,�Or 3hin�18s ...Roofing .Asphalt s £les........................................ ............. Floors Carpet Sheetrack ............ ...........................................................................................................................Interior ................................. r Heating G3S .{a PlumbingTwo� o C(?� per ..................... : ............... ............................... �.40,.000.00 } Fireplace ...None...............................................................................Approximate Cost .............. ............. ........... Definitive Plan Approved by Planning Board ------------------- - a,.+...ft....... - -------19-------. Area :- �� i Diagram of Lot and .Building with Dimensions Fee !........1............ SUBJECT TO APPROVAL OF BOARD OF HEALTH r 1 1 � 1 4 C} s OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name J� pc� FCAPRICORN REALTY TRUST A=271-188 31,t�.7 4 9 One Story No . ....... Permit for .................................... Single Family Dwelling ....................................................................... Location ...Lqt... Q.irq.je ...............byaxlai..5............................................. Owner ...QARKig.Qrn...RQA!t;Y Trust,,.,, ..... Type of Construction .....FXAMe........................ ....................................................................... Plot ............................ Lot ................................ Permit Granted .....January 24........19 83 ....................... Date of Inspection ....................................19 Date Completed ......................................19 ©�dj` 2 Assessor.'s map and lot number /.'/ .f.: .:k a ®® THE SeWa' Permit number .....lf. .. ... ... ...... . ....... -� 'yAt {►11� �v, o� r 46i BABB9TOD • House number `.'7�....:� �.... ........................................r .. . 90o L `.e �; L. �r 4 R' 0 MAY A,. + TOWN. - .0F BAk ' A LE BUILDING , INSPECTOR �IAPPLICATION FOR PERMIT,TO .Construe Single Famil�r Dwelling ... _ TYPE OF'CONSTRUCTION ......Wood Frame K ` .. .3 ..............19........ TO THE INSPECTOR OF BUILDINGS: The undersigned hereby appiiesh for a p rmit according to the following information: . Location . Lot # .��.. min �4 r.� H annis MA... :.....:.......:.. y ...x...... . ....s. .. ProposedUse ...................................... ...... ............... . ................................................ ...................................... Zoning District R. .................... ..........Fire District, ..Hyannis..... Name of owner ..Capricorn' Realty Trust Address 765...Falmouth Road; Hyannis Name of Builder'Franco Real Estate Dev. Co,address•..7.653-almouth...Raad,....HY..armis.....................I•nc . Name of Architect ............................................... :....:.........:Address .................................... Six Foundation ...P.C. r Number of Rooms ............. ........ .................... ................................................................... Exterior Clapboard andor• shingles•,•••••• Roofing Asphalt shingles Floors Carpet Sheetrock .. ..:.................... Interior .... . ...... ..... Heating Gas.......F W:•.A:°.. ....... ....... ......... ..............Plumbing ..TWO........Co er.......................... .............. Fireplace ...None .......:...:...Approximate Cost,....��P A 000.00 ••.•.••• ••• Definitive Plan Approved by Planning Board ____________- _________19________ Area _. ...... ...:..5.�1.....ft....... Diagram of Lot and Building with Dimensions' Fee .... SUBJECT TO APPROVAL OF.BOARD OF HEALTH OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS e hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name .. ... ... ..... ... . ......:: � ✓�- ;�'APRICORN: REALTY TRUST 2�4749 One Story No ...:............ Permit for .................................... i Single Family Dwelling e ...................................................................... k ?i Lot #8, 25 Weston .Circle Location ............................................. .................. - - Hyannis...:.................a..... _ Capricorn Realty Trust - r` Owner � .... ........................................................... ` Frame .* ion :................................ Type�of Coo fiuct ...................................................:............................. r Plot' ....................... Lot ................................. ~ - _ Permit Gra ted .•January•_24......_••.•19 83 Date`�o't` nspection .......:. .. .. .;:.......19 ( c + Date''Completed :... 7.�, t�' .......19 Ilia.�' LdT -� � a _ V\l�sro�1 LE_: . 10 40' *wAcTE- , WAS/ Q x . -7 s, F. La-r" 1 v � JEE F-- I. F. CERTIFIED PLOT PLAN 0 OF LOT 8. VJESTC�a-i G i QGt�' a't 1-��(Q►J tJ 1 S s H IN ft 874�0 C � 1s t1FE QI8TEN . U �No su���y $GALE= ► 'Sa DATE : of/os 63 ELDREDGE ENGINEERING co-TN CLIENT. I CERTIFY THAT THE Four ��A-noi.! EGISTERED REGISTERED SHOWN ON THIS PLAN IS LOCATED JOB NO. 8 i 2c5 ON THE GROUND AS INDICATED AND CIVIL I LAND CONFORMS TO THE Z NING LAWS ENGINEER SURVEYOR DR.BY J'�'E' OF , M SS. 712 MAIN ST. CH.BYE —�- HYANNIS, MASS, GREET 1 OF -1 DATE G. LAND SURVEYOR