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0064 ANSEL HOWLAND ROAD
.: a .. TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map 7 Parcel Z J U w 6 ,,, OF Application # 2-a SV �7� Health Division Date Issued A. S Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board yea ^a Historic - OKH _ Preservation/ Hyannis Project Street Address Village Owner 40F2� 9 &k e yes da 9 Address Telephone oaf G 60 1,F475 Permit Request )#717G eAew ( ,0 2 Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District - Flood Plain Groundwater Overlay Project Valuation D�Construction Type /mod Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ,llo On Old King's Highway: ❑Yes ,W�No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site-plan review # Current Use Proposed Use APPLICANT INFORMATION - (BUILDER OR HOMEOWNER) Name ���� 4'�0d Telephone Number �� � f Z/34- ' Address,/_Y12�����,t� L'r /0 License #_�/�T�' 6 Home Improvement Contractor# Email Worker's Compensation # if/ ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE €�~ FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE �. OWNER ly :r DATE OF INSPECTION: FOUNDATION FRAME INSULATION f� FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. r CONTRACTOR . mass save �- PERMIT AUTHORIZATION FORM i - W,-'^ , owner.of the property located at: (Ow er's Nam , rinted) Y- i,4,5d, -A&J (Property Street Add ess) (Cityrrown); hereby authorize the Mass Save Home,Energy Services Program assigned Participating Contractor listed.below to act on my behalf and obtain"a building permit to perform insulation . and/or weatherization work.on my property. i Owner's Signa e 4 S F° ^ Date — . FOR CM OFFICE USE ONLY I Conservation Services:Group has assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: 'I CAP F. cop su -2 z Participating Contractor t�Da a - .. Rev.12132011 Mass a;lrusttt:, 00partment,of P.ublic.Safety. �-`..Board of Building Rt-gulations and Staridards Construction Supervisor License: CS-100988 HENRY E CASSI ' 8 SHED ROW � %'t WEST YARMOUTH � sB f i /r.�f.. Expiration• . Commissioner 11/1.1/2015 R Office of Consumer Affairs-and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home.Improvement Co' ,Tractor Registration Registration: 153567 Type: Private Corporation Expiration: 12/15/2016 Tr# 259188 CAPE COD INSULATION, INC =1 HENRY CASSIDY. 18 REARDON CIRCLE SO. YARMOUTH, MA 02664 Update Address and return card.Mark reason for change, scA r t5 20M•05n1 ❑ Address Renewal Employment Lost Card - ..... ..._. . ._ .. �e epai�ui�zai2cueall�a��/�/�cu�dac�cu�etlo ' Office of Consumer Affairs&Business Regulation License or registration valid for individul use only OME IMPROVEIV16ff ONTRACTOR before the expiration date: If found return to: egistratlon: .1 3567 Type: Office of Consumer Affairs,and.Business Regulation j xpiration: -;:1:2115%20:16 Private Corporation 10 Park Plaza-Suite 5170 t Boston,MA 02116 CAPE COD INS ULATI' N;.1NC•-'.- HENRY CASSIDY 18 REARDON CIRCLE g .r S0.YARMOUTH, MA 02664. Undersecretary N valid wi ut sign e THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINAL (S) mA , I / �C(�J L DATA :. CAPECOD-27 BDELAWRENCE: CERTIFICATE OF LIABILITY INSURANCE =DATE(MMIDD(YYYY) 5 TE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER,THIS DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES r1IIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN Tkf ISSUING INSURER(S),AUTHORIZED ,,,I TATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER, ANT; If the certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed, If SUBROGATION IS WAIVED,subject to f�icate holder In lieu of such endorsement(s),arms and conditions of the policy,certain policies may require an endorsement, •A state on this certificate does not confer rights to the DUCER CONTACT 43Oogers&Gray Insurance Agency,Inc. NAME` Rte 134 GONE ' FAX South Dennis,MA 02660 EMAIL A/C No):(877)816.2156 ADDRESS: INSURERS AFFORDING COVERAGE NAIC p INSURED INSURER A:Peerless Insurance Company-see LIBERTY MUTUAL INSURERS:ATLANTIC CHARTER INSURANCE GROUP Cape Cod Insulation, Inc, INSURERC: 18 Reardon Circle. INSURER 0: South Yarmouth,MA 02664 INSURER E; INSURER F: COVERAGES CERTIFICATE NUMBER; REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE,ISSUED OR'MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS.SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, INSR LTR TYPE OF INSURANCE POLICY EFF POLICY EXP LIMITS WDM POLICY NUMBER MMIDD6YY MMIDD/YY ` A X COMMERCIAL GENERAL LIABILITY 'EACH OCCURRENCE $ 1,000,000aCIAIMS•MADE OCCUR CBP8263063' 04101/2015 04I01/2016 PREMISES Ea occurrence $ 100,000 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 11000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POUCY PRO. a JECT LOCH OTHER: PROD UCTS-COMP/Op AGG S 2,000,000 ' AUTOMOBILE LIABILITY m Ee a81NED SINGLE LIMIT - $ ANY AUTO ALL OWNED SCHEDULED BODILY INJURY(Per person) $ AUTOS AUTOS HIREDAUTOS NON-OWNED BODILY INJURY(Per accident) $ PRO AUTOS Perr acc denIDAMAGE $ $ UMBRELLA LIAB OCCUR EXCESS LIAB EACH OCCURRENCE $ " CIAIMS•MADE AGGREGATE $ OOED RETENTION$ WORKERS COMPENSATION $ AND EMPLOYERS'LIABILITY PER OTH- YIN ANY PROPRIETOR/PARTNER/EXECUTIVE STATUTE ER B WCE00431904 0613012015 0613012016 OFFICERIMEMBEREXCLUDED? E N/A E.L.EACH ACCIDENT $ 1,000000(Mandatory In NH) If as,describe under -SCRIPTION OF OPERATIONS below E.L.DISEASE-fA EMPLOYEE $ 1,000,000 DE E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (ICORD 101,Additional Remarks Schedule,may be attached If more space Is requlrad) Workers Compensation includes Officers or Proprlbtors. Additional Insured status Is provided under the General Liability and Auto Liability when required by written contract or agreement with the Certificate Holder. CERTIFICATE HOLDER CANCELLATION {, SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Cape Cod Insulation,Inc THE EXPIRATION DATE THEREOF, NOTICE, WILL BE BE DELIVERED IN' 18 Reardon Circle ACCORDANCE WITH THE POLICY PROVISIONS, South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE ] -,AM417 ©1988.2014 ACORD CORPORATION, All rights reserved, .ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD - The Commonwealth of Massachusetts Department of Industrial Accidents, Office of Investigations :i 600.Washington Street f` Boston, MA 02111 www,mass.gov/dia orkers' Compensation Insurance Affidavit.'Builders/Contractors/Electricians/Plum bers licant Information Please Print Legibly Name (Business/OrganizationAndividual): �. FQ Address: j� � r City/State/Zip, �� �� �Ja � Phone #: Are you an employer? Check th appropriate.box: 'Type of project (required): �. P J 1, ,1 am a employer with 4,, ❑ I am a general contractor and 1 employees(full and/or part-time).* have hired the sub-contractors 6.,❑ New construction 2.❑ 1 am a sole proprietor or partner listed on the attached sheet. 7. ❑ Remodeling These sub-contractors have ship and have no employees ' ', 8., ❑ Demolition, ' working for me in any capacity. employees and haveworkers' 9. Building addition [No workers' comp, insurance comp, insurance.$ ❑ g required;] 5. 7 We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions ,m self o workers' right of exemption per MGL Y � comp. 12,7 Roof repairs' insurance required,] t ' c. 152, §1(4), and we have no y employees. [No workers' 13. Other - comp, insurance required,] *Any applicant that checks box 91'must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such, tContractors that check this box must attachbd 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 provlding workers'compensation insurance for my employees. Below is the policy,and job site-. information. ; Insurance Company Name; LK � -� VAy�. p :Y Policy # or Self-ins. Cie. #: Cit �' Expiration Date: - � - i Q ZG 3Z Job Site Address: � /s�� �N'�q�� �� ` City/State/Zip; �? , �2Altr�� 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 Aprisonment,,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 insurarLd. coverage verification. - I do hereby.certify d the pal an penalties of perjury`that the information provided above is true and correct. L / /Si nature: - Date: Phone#: 2 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 C� oFz r Town of Barnstable *Permit# Exp' 6 months m issue date yT Regulatory Services Fe RARN ESS 03q. Thomas F.'Geiler,Director A �AIFn Nw� )UN 9 �01 U U Building Drvislon om Perry,CBO, Building Commissioner SOWN OF SARNST4 00 . Main street,Hyannis,MA o2601 www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY l - Not Valid without Red X-Press Itnprint Map/parcel Number � Roa nProperty Address A15/ D C( fX �(fjt,�C 1,U I (-e . /t �9 2r_ 3 ;Z, Residential Value of Work �T" � t Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address Cc U C (�� V'e.. ( 1 ( ID r(1-_Yl X V 0 2—& 3 Contractor's Name Telephone Number �� Home Improvement Contractor License#(if applicable) 0 .y 740 Construction Supervisor's License#(if-applicable) `T T 0 orkman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# �.� Copy of Insurance Compliance Certificate must accompany each permit. r Permit 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 j #of doors Replacement Window�I ors/ liders.VU-Value / (maximum.44)#'of.windows *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. 'Note: Pr perry Own must sign Property Owner Leiter of Permission.. opy of t me Improvement Contractors License&Construction Supervisors License is re uire SIGNATURE:.. � - Q:\WPFILESTORMS\building permi fo \EXPRESS.doc :t Revised 090809 ✓tie TOoorvriaa�uveal�C o� a¢c�weel License or registration valid for individ;ul use only Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Board of Building Regulations and Standards RegistrAttP,N 100740 One Ashburton Place Rim 1301 =p�1 1 6 2312010 ��t_ra _ � Boston,Ma.02103 -__-' 7)lement Card . �< -Z MEL- -- pp CAPIZZI HOMEt�M' ►�1' N�1'� , tARY GUSTAFSOt 1645 Newton Cotult,MA 02635 Administrator No vali itho t' nature' Massachusetts- i)elyar=trtrlrtt #-public S,ai'et� -- — — f3_u:srd of Buildiva"i #ti arl.rtirrt: ar:S1 �t trtc#.rrc# �,- Construction Super=�iscr License License: CS 74640 Restricted to:. qq GARY ,GUSTAFSON 8 SHORT WAY r 'K SANDWICH, MA 02563 � �.+ 11/29/2010 . The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ' d 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly P Name(Business/Organization/Individual): . t L Z�( /� Address: /�/�G�fDGJ✓I City/State/Zip: fV J �;AA .(�uo'3 Phone.#: L � Are you an employer? Check the appropriate box: Type of project(required):. l. am a employer with d 4. ❑ I am a general contractor and I eP4jmployees(full and/or art-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 working for me in any capacity. employees and have workers' [No workers' comp.insurance comp.insurance. #' 9. ❑Building addition 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 11.0 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. xContractors 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. j CC) . Insurance Company Name: f 4via�� 6—/ Sv /l 0 if Policy#or Self-ins. Lic.#:_ Z-q d Expiration Date: l Z Z 0 Job Site Address: A r City/State/Zip: Ill ll e, a�3 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 imprisonments 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,certi pains am pgnaltias of p8xjury-that-the-4afar--mation-pravided-a v is-tr-ue-and-corr-ect. / _ Si afore: U Date: Z-� �� Phone#: � r 2 r J Q Official use only. Do not write in this area,tb 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 CIerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other 11 Contact Person: Phone#: Client#:47298 CAPIHOM' ATE(MMIDDNYYY) ACORD. CERTIFICATE OF LIABILITY INSURANCE D06104/2010 !HIS 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 A Walther CISR NAME: Rogers 8r Gray Ins. -So.Dennis PHONE 508-760-4630 FAX 508-258-2230 434 Route 134 E-MAIL Ext: (Alt,No): ADDRESS: waltherka@rogersgray.com P.0. Box 1601 PRODUCER CUSTOMER ID#: South Dennis, MA 02660-1601 INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A:National Grange Insurance Co. Capizzi Home Improvement, Inc. Capizzi Enterprises, Inc. INSURER B:ACE Property&Casualty Ins.Co INSURER C: 1645 Newtown Road INSURER D Cotuit, MA 02635 .INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDLSUBR POLICY EFF POLICY EXP LT TYPE OF INSURANCE NS D POLICY NUMBER MM/DD MMIDD LIMITS A GENERAL LIABILITY MPB1075H 06/08/2010 06/08/2011 EACH OCCURRENCE $1,000 000 DAMAGE To X COMMERCIAL GENERAL LIABILITY PREMISES E'ENa oceu ante s500,000 CLAIMS-MADE 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 PRO- LOC $ A AUTOMOBILE LIABILITY M1 M28O44 06/08/2010 06/08/2011 COMBINED SINGLE LIMIT $ (Ea accident) 500,000 ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ X SCHEDULED AUTOS PROPERTY DAMAGE $ X HIRED AUTOS (Per accident) X NON-OWNED AUTOS Uninsured $250000/500000 Underinsured $250000/500000 A X UMBRELLA LIAB X OCCUR CUB1076H 06/08/2010 06/08/2011 EACH OCCURRENCE $51000 000 EXCESS LIAB CLAIMS-MADE AGGREGATE $5,000,000 DEDUCTIBLE $ IX RETENTION 10000 $ B WORKERS COMPENSATION NWCC45843208 12/25/2009 12/25/2010 X I WC is I OTH- AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? f N] NIA (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,OOO DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) Carpentry 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 Bourne. ACCORDANCE WITH THE POLICY PROVISIONS. 24 Perry Avenue ' Buzzards Bay,MA 02532 AUTHORIZED REPRESENTATIVE i 0198 -2009 ACORD CORPORATION.All rights reserved. ACORD 25(2009/09) 1 of 1 The ACORD name and logo are registered marks of ACORD #S52550/M52541 KW Page 7 of 7 CAPIZZI HOME DAPROVEIVIENT INC. SPECIFICATIONS AND ESTIMATES STATE OF MASSACHUSETTS LETTER OF AUTHORIZATION TO APPLY FOR A BUILDING PERMIT OWN THE PROPERTY LOCATED AT k7 S l IN '+t f I/ i e ,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: 41 . 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: 1 Town of Barnstable *Permit# r 176Yeec-'J ►* OF THE Tp� __. �P� 0 Expires 6 nt ntl rom'site dale y Regulatory Services Fee + BARNSTABLE, « v MASS. ThomasF. Ceiler, Director i639 ATFD MPS A Building Division Tom Perry, CBO,-Building Commissioner 200 Main Street, Hyannis, MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint ti1apr'parcel Number Property Address "IgResidential Value of Work Minimum fee of$25.00 for work under$6000.00 Owner's Name & Address`- �J\ Contractor's Name Z-, Telephone Numbe 1 Ionic Improvement Contractor License#(if applicable) `QC�� Construction Supervisor's License # (if applicable)_ ���� ❑Workman's Compensation Insurance Check one: X-PRESSPERMIT ❑ I am a sole proprietor ❑ I am the Homeowner MAY 2009 I have Worker's Compensation Insurance Insurance Company Name � � ®F BARNSTABLE Workman's Comp. Policy # Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑ Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side Replacement ' oors s . U-Value (maximum .44) *Where required: Issuance of this permit does not exempt compliance.with other town department regulations,i.e.Historic,Conservation,etc. 'Note: Property Owner must sign Property Owner Letter of Permission. copy f the Home Improvement Contractors License is required. slctinTultF: r� ____ i r..\kPFI11s\FMMs\building permit forms\EXPRESS.doc Revised 100608 r The Commonwealth of Massachusetts y� Department of Industrial Accidents Office of Investigations 600 Washington Street . Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address: V A City/State/Zip��M 9 Phone.#: 506-9ffi%-9�— Fd Are you an employer?Check the appropriate box: Type of project(required):. L&I am a employer with(S r)� 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling ship and have no employees These sub-contractors have S. ❑Demolition workingfor me in an capacity. employees and have workers' Y p tY• 9. ❑Building addition [No workers' comp. insurance comp. insurance.$ 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 1 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 to ee&. o workers' _ . 13;❑ Other ,erne Y �. ., - 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-contractori 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_ Sl �,py Policy#or Self-i Ins.\\L11ic.#:_�QWCES 7(VV o Expiration Date. Job Site Address:U t ; \QU� \ City/State/Zip8- K," _ � 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 maybe forwarded to the Office of Investigations of the IA forAnsurance coverage verification. Ldo-hereby-serti- rider-t - ns-and-penalties-qf-parju-ry-that-the-information-pravidedabove.-is-true-and-cor-r-ect. Si afore: 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#: f a 7 Board of Building Regulations and Standards License or registration valid for individul use only 1.30ME"IMPROV(=MENT`EONFRkGT-OR-j= _---- �•--before=#heexpird�tion_elaae. "If found rctur.n o ..,.., -�..; _ Reglstr !-Ab, 100740 Board of Building Regulations and Standards pdra iT One Ashburton Place Rm 1301 —M 23/2010 71 Boston,Ma. 02108� PIement Card —_ - � R• CAPIZZI HOME E=,• dARY GUSTAFSD 1645 Newton Rd. Cotuit, MA02635 —' 4itho Administrator No vali " nature Di,p artmv.11t of Puliiic' '- VBoard of Buildi a. and 4tandill-d's ,l.` Construction Supervisor License License: CS 74640 Restricted to: QO ' s GARY GUSTAFSON �''� , 8 SHORT.WAY �e SANDWICH, MA 02.563 SFr,f•';-- z..,... 11/29/2010 ,,i n „sci it 7755 Client#:47298 CAPIHOM ACORD- CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDNWY) PRODUCER 12/30/08 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ,Roger's- &Gray Insurance Agency 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 INSURED NAIC# Capizzi Home Improvement, Inc. INSURER A: NGM Insurance Company Capizzi Enterprises,Inc. INSURER B: American Home Assurance 1645 Newtown Road INSURER C: COtuit,MA 02635 INSURER D; 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 DESCR POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED IBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH I SR D BY PAID CLAIMS. LTR NSR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION DATE MM/DD DATE 01MIDDIM LIMITS A GENERAL LIABILITY MPB1075H 06/08/08 66/08/09 EACH OCCURRENCE $1000000 X COMMERCIAL GENERAL LIABILITY DAMAGE AGE TO11,ES aE I occu D nee $50 0O0 CLAIMS MADE OCCUR MED EXP(Any one person) $5 000 PERSONAL&ADV INJURY $1 000 000 GENERAL AGGREGATE $2 000.000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2 000 OOO POLICY JECT PRI LOC A AUTOMOBILE LIABILITY M1 M28044 06/08/08 06/08/09 ANY AUTO COMBINED SINGLE LIMIT $500,000 (Ea accident) ALL OWNED AUTOS :.-,,,. ::..::... .. .: ,,..,. BODILYINJURY .' X SCHEDULED AUTOS (Per person) $ .. X HIRED AUTOS X NON-OWNED AUTOS BODILY INJURY $ (Per accident) X -Drive Other Car _..._ PROPERTY DAMAGE _.. (Per accident) $ _. GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO ' OTHER THAN EA ACC $ AGG $ A EXCESSIUMBRELLA LIABILITY CUB1076H 06/08/08 06/08/09 EACH OCCURRENCE $5 000 000 X OCCUR CLAIMS MADE AGGREGATE $5 OOO OOO DEDUCTIBLE X RETENTION $10000 $ B WORKERS COMPENSATION AND WC6957000. WC STATU- OTH- $ EMPLOYERS uasam 12/25/08 12/25/09 X ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $500�000 OFFICER/MEMBER EXCLUDED? If yes,describe under E.L.DISEASE-EA EMPLOYEE s500,000 SPECIAL PROVISIONS below OTHER E.L.DISEASE-POLICY LIMIT s500,000 e 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 10 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 #S40650/M40647 E(yy 0ACORD CORPORATION 1988 ' 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 CORDANCE WITH 780 CMR, THE MASSACHUSETTS STATE BUILDING CODE. v-v?I, SIGNATURE OF OWNER: OWNER'S ADDRESS: OWNER'S TELEPHONE: LESSEE'S SIGNATURE: LESSEE'S ADDRESS: LESSEE'S TELEPHONE: APLLICANT'S SIGNATURE: APPLICANT'S ADDRESS: 1 5 Newtown Rd., Cotuit, MA 02635 APPLICANT'S TELEPHONE: 508-428-9518 RESPONSIBLE OFFICER: RESPONSIBLE OFFICER ADDRESS: RESPONSIBLE OFFICER TELEPHONE: t� L TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel 64 pp �y A lication#�00 `6 _ 05r ., Health Division Date Issued. / Conservation Division Application Fee / Tax Collector Permit Fee / Treasurer ���`3l°7 Planning Dept. d Date Definitive Plan Approved by Planning Board Historic-OKH Preservation/Hyannis Project Street Address Village Owner 0oU Address 1,1�2. \�Ow) A np Telephone 3 Permit Request "rA y.;2 O a_�c �Gw1 LV 1C1 ioGW l� 1'1 01 C-VUR.2 U Yl IA: WC) S 1 E>-2 Square feet: 1st floor:existing proposed 2nd floor:existing proposed I Total newer. Zoning District Flood Plain Groundwater Overlay 1 -, Project Valuation Construction Type cD i '> Lot Size Grandfathered: ❑Yes ❑No If yes, attach supportigdocumentdtion. Dwelling Type: Single Family Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House: ❑Yes \XNo On Old King's Highway: ❑Yes )q`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 AL horization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes, site plan review# Current Use Proposed Use V��., -LV-,, UILDER INFORMATION I Name C �-��1 �l�S' �'FSa� Telephone Number 4210� C'fS� L U A ress 1 Uq License# --i'tu"i 0 o�LA l Y1yN r Home Improvement Contractor# 40 Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATUR ^ DATE l FOR OFFICIAL USE ONLY APPLICATION# ATE ISSUED MAP/PARCELNO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION ' FRAME INSULATION FIREPLACE i ELECTRICAL: ROUGH FINAL I PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT t t 7" ASSOCIATION PLAN NO. S -\ The Commonwealth of Massachusetts ./ Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia ffidavit: Builders/Contractors/Electricians/Plumbers Workers' Compensation Insurance A 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.❑ I am a employer with 4. ❑ I am a general contractor and I employees(full and/or parttime).* have hired the sub-contractors 6. El 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 8. ❑Demolition workingfor me in an capacity. employees and have workers' Y P tY• �. 9. El Building addition [No workers' comp.insurance comp.insurance. required.] 5. We are a corporation and its ME]Electrical repairs or additions 11. airs or additions 3.❑ I am a homeowner doing.all work officers have exercised their right of exemption per MGL ❑Plumbing repairsP � myself. [No workers comp. P P 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. Iam an employer that is providing workers'compensation insurance for my employees. Below is.the policy and job site information. r� Insurance Company Name: [ f "i, f Policy#or Self-ins.Lic.#: 1 7L Q�-( s2s Expiration Date: Job Site Address: l q AU,--�I �A0w�And klU J 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#rtifv and r the pains-anndpe`nalties ofperjury that the information provided above is true and correct Si aZ4 V v ` Date: Phone#: Official use only. Do not write in this area,to be completed by city or town o jlciab City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town CIerk 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 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-eonti-actor(s)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 bum 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 11-22.06 www.mass.govldia E ray 'own of Barnstable Regulatory Servvides BAM. nBM ' Thomas F.Geiler,Director T Mnss. 16.19• Building Division MA'S p b Tom Perry,Building Commissioner 200 Main Street, Hyatmis,MA 02601 office : 509-862-4038 Fax; 508-790-6230 Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAB' SUPPLEMENT TO PERMIT APPLICATION MGL c.142A requires that the"reconstruction, alteiations,renovation,repair,modernization,conversion, 'improvement,removal, demolition,or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors,with certain exceptions, along with other requirements. \ Type of Work: C3 Uw Estimated Cost t\� Address of Work: LQ�-1 �U&S'e-, 1A U,01 CLW\0 "4' - Owner's Nam: :P CJ�--�- G_ Date of Application: Io_T© T I hereby certify that: Registration is not required for the following reason(s): Work excluded by law ❑lob Under$1,000 QBuilding not owner-occupied []Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR 0WN PERMIT 0R DEAL,IN G WITH UNREGISTERED. CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c.142A. SIGNED UNDER PENALTIES.OF PEPJURY I hereby apply far a permit as the agent of the owner: CA Date Contractor Name RegistrationN0. OR Date Owner's Name Q:f=1shcmezMdav Tame jm=v tcuummou pseseriptivm Pae&mgd far flee ead TYraF'am •Rsai3matisl BaM;IL.3p BMW wilt wall l:'Pals • 11'1AXfMUhg . A'Q8fIR3Il1V.[ tCilaung Glazing Ceiling Wall Fiver Bsxrnsa! Slab 'Heating/Coolfng Viall F.q�dpmesd Effideae �I(°A) U-valae= R-YADW ' R-value' R-YWuLA . P=I ge '.!'IGI to 63�G Heailag I3egrtr Dnra' a R Y� � , Nl 12%. O 40 58 I3 I9 10 a izos 12% 00.52 30 I8 13 10. S 3dotrnsl R ,6 . .•937�'UE ' S . I2'!n p.50 31 I3 19 10 I5�° 036 31 13 29 NIA NIA. 3dormaf' ,�. v .�'f0?Sf131 ' IP/0 0.44 31 19 19 l0 �r 15% 0.44 31 13 21 NIA, NIA 83 AFITB �y 133'. am 19 19 10 U ACTS • ,� . 11°fa 033 31 • 13 2 NIA P1/A Normal 0,42 31 19 23 NIA NlA 1+c=zl 2; I1°fo 0,4z 33. 13 19 Id g 90 AFUE I g®�° t130. 30 19 19 I0 . . SO AF LTa+ ADpRESS OFPROFERTY" SQUARE FOOTAGE OF ALL.EXIM- OR,MALLS; 3, SQUARE FOOTAGE Ole ALL GLAZING: ' 4 % bLAZINO ARRA 03 DIVIDED BY42), �. SBLECT PACKAGE(Q AA see chart above),' ; NO OT'HE•R MIRE DWOLVED�THODS OF DE iMiG E3 ERGY REQ S ARE,AVAILABLE. AM.TJS FOR T'E S I�TFORYvIATION, E�i1,Di TG L TSPECTOR AMOVAL.' . q-g�rau-f cG303� . Ciianti:.44729.3 ACOR CERTIFICATE OF LIABILITY INBl1IANCE j JA1_ N:�:mfYYvv} 0,i09107 I AS A RCC3t;8� THIS C=RTIFICIT=IS=-J_, :,1 P Gray Ins. Agency,lric. A-ER O;Ni=O. 41...tT IOv �3 i t�CUt9" 13 a 1 CON;c;�s N z.G iTS U`CN`HE C=<TI,ICa E i N v L__c,i.i riS c , C. i I;IC, EDO=S NO AMEND,�=1 ,4D 0 P. O. Box 16r ALT= T==C0VG JL CS LOW SeLn 13^liS, •2oer-1CU rA — �`I f fJ ' I+ I INSURED II N SU S A F 0 Ro JNG Cot, AG EI _ I NAIC l.dplZZl fIOR1e In1�r7Ysmeni,Inc. 41:4S�REr.?: Na ienal Gi¢nSB I•iU=`_dl ins, G_. - , Cagt7zI B'ntarprisss, Inc. 'INSi-RER 3: iimariGan Intfima:ionai GY. I 1645 Newtown;Roar! NsJRER G: Cot 11`, MA 02635 t�suRE. D: I INSURER CC�RAGES - 7N=FCLICcS Oc Ii IS ryAyCE LS-0 BELOW;_(A?S 8==V ISSUE TC 7:iE INS UPEO,-qvl ED ASC; =Ct?i PGUC(?=ZIC?NDIC :J,IVO i f/1 i riS7�.iVJ(}VG ANY R=QUfRAc 7, I'-_RFA C^t^CNDf ICyv ^ANY CGN rJ CT OR O T c?OGCJNS\T YJIi RES?E'^i?Q YJ IiCH THIS Cc;� r _ c MAY ERT.�IN,T�=INSURANCE Ar,-CRti_r,3Y TEE POLICIES 6=SCRISSJ H6RE6V IS SU'iJ Ci 70 A!7HE TARP 1S.=XCLUSIGI�S ANC CQVO('SSU OOSUCH POLICES.Ea AGGREGATE l.n„175 S'aCh1!MAY 144.E 9c Y R�'�UCEO'R AiC ClAIh1S. INo..4VIJt; LT.4 I7fC TY?E OF;NSURANCE ?OLICY iVU138ER PCLICY=FPaCTDl= 'POUCY EX?IRATION 1 A79 IM^J./D lYY? AT='S1D1/D !YY? I 'LIMITS A I j Gcic2aLClA81Lf(Y IMP010707 0E(08rL6 i 0Ei'08;a7 �l I. _,r_tt oL:.GUR.RP.ncE000,00C IX c'RCIALGZNF-RALLIR31LR'( Ofi ;:GE TO Rci;T=D 11 CL1`IMS rAACE u bI CCCUR PFEUSFS tag -^r-rre, �(P(Anv cne ae�scn; isi Q,flflQ .• 1 PERSONAL d ADV NXRY '31,flflfl 00Q I ', - GENc';aLAGGi`-GATc. S2,Ofl0 OQG� -j�:Etl'L AGGr^c=G:i-E WAIT APPLIES rt?. I PCLrcY JECT i PRODUCTS•cc"P/CPAGO t2,000,000 JECT CO-G II AU i0XO21LE LIA8IL.ITY ANY AUTO I SM8?NED SINGLE LIMIT ; I ;EL.ccidert} ALL OvWIED LTOS I SCHEDULED AUTOS BODILY RJJURY u NON-OWNED AUTOS BODILY INJURYI i I I j^.IRA^E WY AU 70 Lt 31L1TY I � I ALTO 0\LY•E IC6E?JT! : I I S , i �Trc�I�Vti . OJ � I� IAU7o onL.: iI acc'3 ;ICESSIU Pa.3P--LL,i CU311JTY DCCURR�.\3EZ I I Dcc!R CL4!NS MAD-- . i IAOGREGAi❑ �3 a 13 B ricRtcE3scorrt?s eATIaN AND T S 12/25iT36 i22o/07 STATI eTH LIh37LITY'- "" '�` w ; Ya r t-TGR1 In,lfT ,� AI,}PC?OPRET'�R,pA 4-NE4eeXEGL71V _ ^r....N.. .;�. -.'' ��.L.cCCN OFFiC�/1 ,t16ER c^}.'CCLOFL:" ._.I`"' .z if yam,dais u der _ _ .- E.L.DIScASc-_4 c ArL,—EE $500 0CPRCUISICNS - T 071-(ER I=!r%ISEASE FOL.CY U::IIT I Ssiux 4x - Ot SCRh;Mr10r 7o= - � - s - -� CERrnCAT=HOLDER CA,YCcLL r AT,ON :. sHCULD A,4Y or'fti_AaCVE?ESCR:B_D.=0L10.cS SE C JELLtD F—,.RE i4E Ex?FA�!CN IO T li Z ly_ISa UIY tvSU R= W!L 40 40R iO V�L in Days z k-A �'s. �, S O.,.3 r-' °'� } ' ].ay4.7� ..-,� y ;,`S 474TATIY 3:- ast;. „+ ,#iv` z � t„`c:'n3_;:4�P-30 2 0R >R,_ YIA. .f - ` A t ne c,ommonwerurrI of�iassacnusetts Department o Indusiriral_ A P f ccidents '.., Office oflnvestz,,v ons , 600 Washington Street Boston, llf4 fl 2111 � � w3^1x!mass g ov/dia Workers' Compensation Insurance Affdavzt: Bidlders/Contractors/ .lectricians/Pluxztbers .ppNeaut lnformatioD Please Print Legibly NaM' (Bnsn�ss/Org i7 tionfindiv diial): 1 'rl is n�i}iu Addr,-ss: 15 Nevitown load City/Slate/ZI TeL �?8 95i8.� &DO 26I 5�16D P Pfi0ne 17 e ou an employer? Check the-appropriate bog: Type of projeet(regilu ed): I am a employer wig, 4. Q I azn a ge�.eraj contractor and I e : Io: ees �iE and/or art time . -�-z hiied.tbe sub contractors 6 Q Neer coi7sfiictiorz 1 ,Y . ( P 2.0 I a i a.sGle:.ro rletor or ar�.er- Lsrted on tb.e a€Fached sheet-1 7. Q Reinodelinb�I ;P P ship and ll�l rz ao employees 1 hese sub=contractor Have 8 Q Deraoittion :` tiv(i m formeui any capacity. Rork= baij ,insivaace. 9. [Q Binding addition [No workers' co. p_ msttrance 5. QYe are a.'orpozation agd its rI o£�ces Iiiave eercied#izeiz I0.Q Electrical izpairs or additions 3 [ I a all61eowner doing ail work ngbt�f ewe ptioa per MCTL 1 I Q I'Iz biag repair or additions -� m3eltTo�uffes� Y— c i5�, � �uw� eito .1� Raofrepags msosance r T Q. equar emg7oy J S carp nirranc - _ennl 13 Q E7tner y e�phc t t Tied,cox L m also EU bc� e s cUon'oeiow.s'�owia ge�wo�{air oo„ rn� ono alic. rorr�ioa Homeowners who secs�dsv�t iiid csimo i r�e ase.dcs g an wbrs and 1 or�Cz an-Zc orstist si min s newa rt aca o ontraczr �nxk thrs bba msst che3 s sxch :. - an,-dQlZOn�SCeet SIlOW^d .,.e n -:e of 1,e s;!can�ectcr ?d des wq�„1 coni polcy� zorty .. - ....- ... gin cnx em Ioyerr3rzr isprovu irgrvorrers'compen�arzon.iizsurizrcre )my z jo " - . y my geese�ozv is the olio irnd-�� szfe forrrzarzon 1 iA hcy rr or Self ips LIo E troi `Da P -0' x � Srte Address d - �,. .-^_ - �� ,:�. � �. - � 4 � � •� � �-�<�_ �� -� r ,.. .� �• � City7State/Zip •. `3c:� a copy of the zvorker�5 compensation policy declaration page(scoFvingfhe_policy I�nmber and e�p�rafxau date). hire to secure ca�erage as required cadet Section 25�ofN1CL c. 352 c can lead to the?position of -� ;na3 pezialties ofa :._ ra 1, 00.0'0 and/or one-yearimnz?sonmen as 1velI as civ l:p enalties ine form ofa pc)p wO �flBR.aiid a_ ie C r e visor a_acopyo sTatem ;sligauons oftu,, for Insures Q y to me 1 �, en�nla .beforwar�ed O'�ice �` .. Dh ce cov�ia��v.eii�icon her z�y ce under thepains vzdpeririliies ofperjyry that tT e infor.raiion provided above is true and col i eci R attire: � Date: - MI � cal useronly-�Do notryv�iztezn t3zrs nrea�to�e com��e`d `��"�-'� y s � -¢ p y or t0}vIi OffL�CLdI ` E & + r z',,�. s^s. t,,��` E-a'hyxy„,S. ( $x x s' JJ ;f�' �a -a�s"' C' �-n.,• r +a- ,+"- .�'{"' 'Y^-�.s ^• ' ac.,. 'E: ,^. Ta,x'". •4 ivV Mcl 05 g �erMIM1CeIlSe 1I141a llfhOrlty�CIrCle.dZle� ONCE s� � sue' ' x�3I sl1r« d of i� h7Bua11IgDepaztmen 3"41Cit�MOP Llzrlti E�fical-Inspector *P"Iumblu` Ins ector; r x �f�ler :"_. p. w - _ 8' Board of Building Regulations and Standards' License or registration valid for individul use only - HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Board of Building Regulations and Standards Expiration 6/23/20008 .. Registration: 1007 One Ashburton Place Rm 1301 . " � Boston,Ma.02108 r. TYPe. Supplement Card. m CAPIZZI HOME IMPROVEMENT;I CHARY GUSTAFSON 1645 Newton Rd. Cotuit MA 02635 Administrator t valid with t sig ture Board of Building Regula ions and Standards One Ashburton Place - Room 130.1 Boston Massachusetts 021 U� �. � Home Improvement Contractor Registration �. �` k 3���- � �. , �- Type: Supplement Card Expiration: 6/23/2008 SAPI77I H9ME I-MPROVEMENT, INC' GARY GUSTAFSON = 1645 Newton Rd: COtU lf, MA 02635 Update Address and return card.Mark reason for change. _ _.. Address Renewal Employment (E] Lost Card - Board.otBuild rg Reg lations and Standards _ Cons uct�to Sup- rV o_Li`cense� FF. g� r Llce�nse CS 74640 � q � z "3 �, �. �� �aK-e- i"^ fii�s �, rs'st 8irthdate. i1/2911975 . �Ez irabon., Tr# 6430 t �� � � P..� 11/29/2008 31 Al llml t� GARY. GU$TAFSON - _ _ ` IWO 8 SHORT WAY SANDWICH, MA025o"3 om _ y t Cmissioner i r Page 7 of 7 CAPIZZI HOME IMPROVEMENT INC. SPECIFICATIONS AND ESTIMATES STATE OF MASSACHUSETTS LETTER OF AUTHORIZATION TO APPLY FOR A BUILDING PERMIT ck ova( ), OWN THE PROPER TY LOCATED AT 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 BI7ILD11VG CODE I GIVE MY PERMISSION TO LESSEE' TO APPLY FOR A.BUILDING PERMIT IN ACCORDANCE WITH 780 CMR; THE NIASSACHUSETTS SIGNATURE OF-OWNER(S) � - `. OWNER'S ADDRESS: OWNER'S TELEPHONE: LESSEE'S SIGNATURE: �,LESSEEES ADDRESS�. � .i LESSEE'S TF,I EPHONE: - APLLICANT'S SIGNATURE: ti S: 1645 Newtown Rd.; Cotuit, MA 02635 APPLICANT'S TELEPHONE: 508-428-9518 RESPONSIBLE OFFICER: RESPONSIBLE OFFICER ADDRESS: - W... G 21 Home Improvement L.Gary Gustafkh'Production manages ,- Capizzi Home Improvement, Hereby authorize Lisa Haworth, to sgn=oii my Behalf for permit applications fled through the town; s 5 }` 'Signed Gary GidstafsoK Date: NS -- _ _ __ __ .Date: 1645 Newtown Road Cotuit, MA 02635 (508) 428-9518 (800) 262-5060 . FAX (508) 428-1547 HA / / OR A A Vf- Z-Y /,s 7-//V G 0 W , C FXX7 ,6 ILLS , I FI ; i i w s o oL s 1� c lR Z- _ ti it E Town of Barnstable *Permit# F ��,, �•o Expires 6 months from issue date M 00 E„R,,,STABt,E : Regulatory Services Fee Mom. $ Thomas F.Geiler,Director 039. �0 1h Building Division Elbert C Ulshoeffer,Jr. Building Commissioner 367 Main Street, Hyannis,MA 02601w MAR 2 6 2 Office: 508-862-4038 002 Fax: 508-790-6230 T®wN OF BgRdt► EXPRESS PERMIT APPLICATION ST-AELE J a, Not Valid without Red X-Press Imprint Map/parcel Number / / a a3 0 Property Address 6,61 IM L �L'�v� ' �rEEy1� LU Ef Residential OR ❑Commercial Value of Work 9� Owner's Name&Address y Contractor's Name /FQcge-eT P104600 Telephone Number Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor �'! ❑ the Homeowner Er I have Worker's Compensation Insurance Insurance Company Name v ei Cf{ ZN 1 . 7j_'jq/�F V_ Workman's Comp.Policy# G ?S 8 g" r� Permit Request(check box) Re-roof(stripping old shingles) ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side . ❑ Replacement Windows. U-Value (maximum.44) ❑ Other(specify) *Where required: Issuance of this permit does not exempt compliance with other town department regulations.i.e.Historic.Conservation.etc. Signature expmtrg TOWN OF BARNSTABLE Permit No. -----------______------ Building Inspector t►urran Cash OCCUPANCY PERMIT Bond ---------- --No building building nor structure shall be erected, and no land, building or structure shall be used for a new, different, changed, or enlarged use without a Building Permit therefor first having been obtained from the Building Inspector. No building shall be occupied until a certificate of occupancy has been issued by the Building Inspector." Issued to Address Wiring Inspector Inspection date Plumbing Inspector Inspection date Gas Inspector Inspection date Engineering Department Inspection date THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN REQUIREMENTS. ............................... 19...... _ ............................................................................................._......._........_ Building Inspector I tt,y�l'�� �L�1V111_`r — 3 13DtZfJOdK ,.i f 1 jij- � I11if t.i0' (a42r:s"4GE F�?�ZI•{.1�ER_ i' - } � �,t " ( �1 �.1�, 111 ° ;'.,1 b�dtLY �t..p�c✓ lto �c;3.�: .`3�0 �.pv :..lt 1 �.M. � I ;�-t 't'tc��: 7' t� 30:� i5c ; ".• i 5�4:P.D it t , 1 I PO�bI `l�oo121f2 J IT t C/A -1..• 'E-Q i 70 iC lj�:. Z S-.i, .� p� ,. t x� lf� Yet-y� ] —1 t d -� I .. -:� �� � 'l � t �-• 6U..�'C> PAD.' I 1 Sz'�T N j _ +is *-' _._ _' , '1,,.,�. _.. 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SYSTEM MUST t,zA" asa House number ................................. ...... .......... ............. M -ALLED INC M 16 INST 0 PLIA WITH INTO 5 TOWN OF BXR; N", � -rwE BUILDING INSPECTOR . 711 APPLICATION FOR PERMIT TO .....)WO*401.......................... ..........................I-,....................................... TYPEOF CONSTRUCTION ....... ........................................................ ................................ ............ ..........................19.11 TO THE INSPECTOR OF BUILDINGS:t The undersigned hereby applies for a permit according to 'the following iaformation: av ..... 0............... ..... ................ Location .................... .....C'?.....0... ......X. ProposedUse ... ....................................................................................................................................... Zoning District .................... .......................Fire District ....... .... ............ 1A.............. .. Name of Owner .....Y..:..... ........................Address ............. N Name of Builder ....................................................................Address .................. ................................................................. Nameof Architect ..................................................................Address ................ ............................................................ Number of Rooms ....... ........................................................Foundation .......... Exterior ............Roofing ......Exlei ...... ..... ..... ................................ ........... Floors ..........qvnl...............................................................Interior ................. ........................ ..........r .... ........t.,... g ........Heating . . . ......................................•............ ........I .............Plumbin ................................ Fireplace ..... 7P...........................................Approximate Cost .... . ... . 0 ......................................... Definitive Plan Approved by Planning Board ------------------------I--------19--------- Area ....ZP..7211................ Diagram of Lot and.Building with. Dimensions 175 Fee ............. /& ........................... SUBJECT TO APPROVAL OF BOARD OF HEALTH I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable egarding the above construction. Nam ... ........................ ' � . , . . 23720 One Story - Single Family Dwelling ----.^------..'�---.----.----- , Location .Lot_#.2.0_..64_Aoo*iI_Bowla.nd .Rd, Centerville ----.----------.-----------. . ^ . ' � Alan ,Small Owner .................................................................. . ' Frame Type 6f Construction .......................................... ' / ' ............ _..�-------------,------. ~ ^ ' ' \ . ` . Plot .............................. Lot ................................ ' - ^ ` December 22, 81 Permit Granted -------------]9 � : ` ' � Date of Inspection ----------_—]A - - - ' ^ ~..e ' ' PERMIT REFUSED ^ . . ~ .............................. ----------.. lg / _ � . -------------------------' ^ . ^--,~--------.--~--------.--- —.---------...'.~._--~--...---.. ` . ` ~ / . -----..---^----...-.--~--.—... . ' -- - Approved' lg � —��-------------' .................. ...................................................... ^ . ---------.—.,---.--..,—.—.....^