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0008 HIGHLAND DRIVE
e y s CS)t61ilG= ; I . D Try Town of Barnstable *Permit# pExpires 6 months�om issue date r r Regulatory Services Fee r r + BARNSrABLE, r 16 9. �� Thomas F.Geiler,Director i0ren Mar" 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 ONLY4 O Not Valid without Red X-Press Imprint -Map/parcel Number / AN Property Address [Residential Value of Work$ I 3�0C'U t U a Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address 1' Contr 9tor'sName e�pf�?/ %�OdltL� any/dlldei9?PNT �A/C. Telephone Number vdh� T s ,�vmj/v -ad Home Improvement Contractor License#(if applicable) Email: Construction Supervisor's License#(if applicable)' CSC 0 6 yii7 XPRESS PF4?Anm' [/orkman's Compensation Insurance Check one: . ��T.._ 7 20�3 ❑ I am a sole proprietor a. El the Homeowner _ have Worker's Compensation Insurance TOWN OF BARNSTABLE Insurance Company Name 3SV(14fed FmIlo 7 ill 11yi li.4yie- 6 . Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping shingles)'All old shin les All construction debris will be taken g ) to Ve-roof(hurricane nailed)(not stripping. Going over existing layers of roof]e-side eplacement Windows/doors/sliders.U-Value °'� (maximum.35)#of windows. l4/,�e& 13V4 tuu � l �� �f� #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *Where required: Issuance of this permit does not exempt compliance with other town department regulations,'i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Propertv Owner Letter of Permission. ' A copy of tkg.Uome Improve _nt ontractors License&Construction Supervisors License is SIGNATUR> C:\Users\decollik a taxLocajWicrosoft\Windows\TfKporary Internet Files\Content.Outlook\8R76BDVAIEXPRESS.doc Revised 0613.13' Office of Investigations I Congress,Street,,Suite 100 Boston,MA 02114-2017 www.mass gov/dia Workers' Compensation Insurance A.ffdavit: Builders/Contractors/EIectricians/Plumbers Applicant Information Please Print I,egibIy Name(Business/Organizationdndividual):Capizzi Home lmprovement Address:1645 Newtown Road City/State/Zip:Cotuit, MA-02648 Phone#:508-428-9518 . Are you an employer?Check the appropriate bog: Type of project(required): 1.❑✓ I am a employer with 40+ 4• ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. El New construction 2.El 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' comp.insurance.$ 9. ❑Building addition [No workers' comp.insurance P• required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions officers have exercised their 3.El am a homeowner doing alT`vdork 1 1.El Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.[2/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 41 must also fill out the section below shov?mg their workers'rapensation policy infonnation�" fi Homeowners who submit this�_fidavit indicating they are doing all work.a. i then hire outside contractors must submit anew affida•;::indicating such, #Contractors that check this box must attached an additiopal 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 wdrkers'comp,policy number. I:am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:Associated Employers Insurance Company Policy.#or Self-ins.Lie.#:WCC5010 547012011 12/25/201 Y Expiration.Date: Job Site Address: U/ City/State/Zip: J11y4 AIAII� &A '®z fo 0/ 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 vp 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 DIA for insurance coverage verification. I do hereby certi un er the pains and penalties ofperjury that the information provided above is true and correct: Signature:ature: Date: - Zo/3 Phone#: 508-428-9518 Official use only. Do riot write in this area,to be completed by city or town official L6. or Town: PermitMeense# ng Authority(circle one): ard of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector her act Person: Phone#• :. .� f PfAW1,14 Safel"It i and - - CS>-lDf lk" ' ST � XEMN A �p s OWISM14 :: ,,,, .°t3ruee oz t,,a++tsaaeir +x�snr ;sa:un err cu�as,ua runs ccrr,iuuxviuw r+aa wru,,r G fs 'Ct1 TRAG Tt}R li re t it ex can: ta�H fb ietsii��tv ` Ofrl t of Cs��'Wcl earl . .y< TylmPark ka—Sift5I� ;. . CAP supanerst Gard , 1 tt11S , ` fiatttt _ so CAPIHOM-01 CBENISCH '`� R' CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) All. 6/1212013 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-NAN Chris Benisch Rog E-MAIL 8 Gray Ins.-Dennis Branch N 1:(508)398-7980 FAX nLcc South Not:(877)816-2156 4th Dennis,MA 02660 DRSS,cbenisch@rogersgray.com INSURER(S)AFFORDING COVERAGE NAIL Ir INSURER A:Main Street America Assurance Co. INSURED INSURER B:Associated Employers Insurance Co. Capiai Home Improvement,Inc. INSURERC: Capiai Enterprises,Inc. 1645 Newtown Road INSURER D Cotuit,MA 02635 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUER - POLICY EFF POLICY EXP LTR INSR WVD POLICYNUMBER MMID MM,'D LIMBS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY MPB1075H 6/8/2013 6/8/2014 PREMISES ea occurrence $ 500,000 CLAIMS-MADE IXI 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-COMPIOP AGG $ 2,000,000 POLICY PRO- JECT LOC I I $ AUTOMOBILE LIABILITYCOMBINED SINGLE LIMIT Ea aoddent $ A ANY AUTO M7 M28044 6/8/2013 6/8/2014 BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ 500,000 AUTOS X AUTOS NON-OX HIRED AUTOS X AUTOS ED PER ACCIDRPERTYDAM NT) $ AUTOS $ X UMBRELLA LIAB HOCCUR EACH OCCURRENCE $ 5,000,000 A EXCESS LIAB CLAIMS-MADE CUB1076H 6/8/2013 6/8/2014 AGGREGATE $ DED X RETENTION$ 10,000 $ 5,000,000 WORKERS COMPENSATION WCSTATU- X OTH- AND EMPLOYERS'LIABILITY TORY LIMITS ER B ANY PROPRIETORIPARTNERIEXECUTIVE YI N N/A CC5010547012012 12/25/2012 12/25/2013 E.L:EACH ACCIDENT $ 1,000,000 OFFICERIMEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION r SHOULD ANY OF THE ABOVE DESCRIBED POLICIE&'BE=CANCELLED BEFORE Town Of Barnstable THE EXPIRATION DATE THEREOF, NOTICE WIL6'^._BE DELIVERED IN 200 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. Hyannis,MA 02601-0000 AUTHOR®REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. J ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD Page 7 of 7 Capizzi Home Improvement Inc. Specifications and Estimates x STATE OF MASSACHUSETTS ` LETTER OF AUTHORIZATION TO APPLY FOR A BUILDING PERMIT WE, AMANDA LEIGH &PAT FRYE, OWN THE PROPERTY LOCATED AT 8 HIGHLAND DRIVE IN CENTERVILLE, 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: 8:HIGHLAND D IVE; CENTERVILLE, MA'. OWNER'S TELEPHONE: 50.8-778-5781 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: ~' RESP.ONSIBLE OFFICER TELEPHONE: TOWN OF BARNSTABLE.BUILDING PERMIT APPLICATION. Map lJ Parcel t�� Application �CPO Health Division =' Date Issued Conservation Division Application Fee cb Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH Preservation/Hyannis Project Street Address Village Owner0ft,k(IYZo ":1 �'�,)Y1 Address :fSz� C� Telephone \- Permit Request � �CL'��r� �L t�\ AszcU quare 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: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family(# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old Kin 's Highway: O;Yes ❑ No Basement Type: ❑ Full ❑Crawl ❑Walkout ❑Other } Basement Finished Area(sq.ft.) Basement Unfinished Area( ft) Number of Baths:, Full: existing new Half: existing Wiew> Number of Bedrooms: existing _new %wo rn 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# urrent Use a Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Nam G Telephone Number LA M ` "1-a, Address It dMf> ! �k License# ut�0�}� Home Improvement Contractor# 100__�S® Worker's Compensation # 53 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO 1 SIGNATURE 12 DATE H FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED t MAP/PARCEL N0: ADDRESS I VILLAGE ' OWNER DATE OF INSPECTION: FOUNDATION -FRAME w I►Iilk. INSULATION 1 :.FIREPLACE ELECTRICAL: ROUGH FINAL-, PLUMBING: ROUGH FINAL GAS ' u; ROUGH 'FINAL ! f FINAL BUILDING DATE CLOSED OUT t i l ASSOCIATION'PLAN NO. l � 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: Reglst19b:, 100740 Board of Building Regulations and Standards xp7r 3/2010 One Ashburton Place Rm 1301 FF tBoston,Ma.02108 g1112 plement Card CAPIZZI HOME M< I1�11 py N 1:. ARY GUSTAF U N=. Ion 1645 NewtRd. Cotud,MA 02635 -�� _ l turNiAdministrator , e Board of Building Regulations and Standards Construction Supervisor License License: CS 74640 B i rthdate: 11/29/1975 Expiration: 11/29/2008 Tr# 6430 Restrictlon: 00 GARY GUSTAFSON 8 SHORT WAY SANDWICH,MA 02563 Commissioner The Commonwealth of Massachusetts Department of Industrial Accidents W 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 Le ibl Name (Business/Organization/Individual): C8Piz 'M' mpr ��eyltnvun Road 'Address: Cotuit, MA 02635 r t al g 1, gon-262.5060 City/State/Zip: Phone.#: Are you an employer? Check the appropriate box: I Type of project(required):. 1 I am a employer with 4. ❑ I am a general contractor and I t employees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.17 I am a sole proprietor or partner- listed on the attached sheet. 7.V Remodeling ship and have no employees These sub-contractors have $. ❑ Demolition working for me in any capacity. employees and have workers' '• [No workers' comp. insurance comp. insurance.$ 9. ❑Building addition required.] 5. ❑ We are a corporation and its' 10.ElElectrical repairs or additions 3.1❑ I am a homeowner doingall work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No.workers' comp. right of exemption per MGL - insurance required.] t c. 152, §1(4), and we have no 12.E] Roof repairs 1 employees. [No workers' 13.❑ Other comp. insurance required.] *Ar%y 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: C1(o y)(\ roll cy#or Self-ins. Lic. #: 01 (� Expiration Date: - �3 Job Site Address: City/State/Zip: AttLch 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 finelup to$1,500.00 and/or one-year impr' onment, 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 violat Be adv'sed that a copy of this statement may be forwarded to the Office of Investi at-ions of the DI for insurance .overa e erification. — --I-do her-eby-cer-tify-u der-the-pains- d p alti -of perjury-that-the-infor-mation-pro...vided-abo-ve-is-true-and..co.r-r-ect.- Si nature: Date: Phone# Official use only. Do not write in this area, to be completed by city or town offccial City or Town: Permit/License# Issuing Authority(circle one): 1.IBoard of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.!Other Contact Person: Phone#: Client#: 47298 CAPIHOM _ j ACORD,. CERTIFICATE OF LIABILITY INSURANCE - osiizi2ooaYYY, PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Rogers &Gray Ins. -So. Dennis I ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 1434 Route 134 HOLDER,THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ! ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. � P.0. Box 1601 -- - i South Dennis, MA 02660-1601 j INSURERS AFFORDING COVERAGE NAIC# ) INSURED -- NSUREnA, NGM Insurance Company — Capizzi Home Improvement, Inc. INS,!RERa. American Home Assurance Capizzi Enterprises, Inc. I INsuR-P G 1645 Newtown Road ---- -- --- - --_ __—.--.� INSURER 0 Cotuit, MA 02635 ' — --- ------- —( INSURER E. COVERAGES "rHE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION CF ANY COINTRACT OR OTHER DOCUMENT WITH RESPECT TC WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TC AL'•_THE 1'ERIoS EX�.LUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE POLICY NUMBER I POLICY EFFECTIVE POLICY EXPIRATION j -" �^ LTR NSR I-_ DATE(MMIDO/YV) DATE(MMIDD!YYl LIMITS Q I GENERAL LIABILITY !MP61075H 06108108 '06/08/09 i I.Ac,oa:uRRE.NGE $1 OOO OOO I X COMMERCIAL GENERALt.iA.31L"" D�I:_AGE O RENTED S500 OOO FM!SES f4�2 rr n• ' 1 CLAIMS MADE E(OCCUR•' - I MEG iiXP(Any one parson) $1 O QOO i--' — j NERSO:NAL&AOV INJURY $1 OOO OOO _ I,GENERAL AGGREGATE. s2,000,000 EN'L AGGREGATE LIMIT APPLIES PER PRO — (PRvDi1C LS_COMP U /OP AGG $2 OOO OOO I - ---- — -- ---- POLICY�I JECT ' I "' AUTOMOBILE LIABILITY COMtLNED SINGLE LIME I< ! I ANY AU iO i(Ea accident), I AU..OWNED AUTOS I ESGUfi1 W_Li!4Y --i SCHEDULED AUTOS (?cr persc;n) I$ —I HIRED AUTOS _..._-----�---- �.OCUn.Y i.N,IUR}, I NON-OWNED AUTOS ;Per accneni) I$ p i PROPERTY CAPdAGF I GARAGE LIABILITY < � ----"-------�----- -- -- - (AU10 ONLY-EA ACCIDENT $ ANY AU(C THAN EA ACC $ — C.'IrIER All'.C,ONLY AGG 5 A EXCESS/UMBRELLA LIABILITY B 76H !06/08/08 06/08/09 -A CH OCCURRENCE _ $S OOO OQO X OCCUR ❑CCAiMS:\1n.DE i AGGREGATE _ $S 000 000 DEDUCTIBLE $ X RETENTION S 10000 $ — B WORKERS COMPENSATION AND ;WC6716562 T`:vC — 12/25/07 ;12/25/08 X .;.,;,RY STA 1MIT U- OTH- EMPLOYERS'LIABILITY 'f�— ANY PROPRIETOR!PARTNER/EXECU'FiVE - -_ EACH ACCIDENT- $SOO,000 OFFICER/MEMBER EXCLUDED? DISEASE-EA EMPLOYEE $500 000 If yes.describe under j i..:r___ r SPECIAL PROVISIONS below D!SEASE-POLiCY LIMIT $500,000 OTHER -`--'-----r— _ y 1 DESCRIPTION OF OPERATIONS I 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 __UL 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 6-2 NP I ZZ, ��- (�, )1" Page 1 of 1 WORK AUTHORIZATION# I ( Date: #80-0014011 Home Improvement a d C L#: 7454 1645 Newtown Road ;J egistration#: 100740 Cotuit, Massachusetts 02635 C� 508-428-9518 800-262-5060 F: 508-428-1547 P Established 1976. Serving the Cape for Over 30 Years Name: 6N/10�58 C L�(fff Job Address: Address. G ! City/Town: ._� City/Town: (/(,C�(�(,� Job Phone: State: Other Phone: LIP: u E-Mail: Estimator: Job Number: We hereby submit specifications and estimates for the following work: lam►' G C ko o'se — T/pl�s 67-0 aei�1 ` `Lv�G S � /IS Of Z� � :s I"Zs(::5) PGWcUbK ,� fi022 x off- � 7 viea07-3(f F>T. �C 1 � .3f Co U- e i o tc�co 11 r2-(?KS ) Z, �)00 L,�_ �c F 66umt 4wq ia1 k4 cc, Ue-1 Q 4-8 6 O� C_.AV ; Labor&Materials: $ LD NOTE: This work authorization will add additional time to your project. If acceptable,please sign both pages of work authorization and return the white copy to us. Please call if you have any questions.. Thank you. /,q Sincerely, JP��1 �� �v ' VC e CAPIZZI HOME IMPROVEMENT Accepted By Date: THIS PAGE IS PART OF AND IN (ONVORMANCE WITH PROPOSAL#: ti- 7 t, f�11 q( Town of Barnstable *Permit#_ (0 of ., Expires 6 months from issue date Regulatory Services _- Fee sr LE ' Thomas F.Geiler,Director - ' Building Division �� s oK (,1 S�oq Tom Perry,CBO, Building Commissioner d 200 Main Street,Hyannis,MA 02601 Www.town.bamstabl e.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXEItSS..PERIJa kPLICATION RESIDENTIAL ONLY �0 Not Va`Zid without Red X-Press Imprint Map/parcel Number - Property Address' , [ ;Residential Value of Work Minimum fee of$_2.5.00 for work under,$6000.00 Owner's Name&Address Contractor's Name l �� c 1c- 'x Telephone Number Home Improvement Contractor License#(if applicable) 0 Workman's Compensation Insurance Check one: ❑ I am a sole proprietor EI I am.the Homeowner >C I have Worker's Compensation Insurance Insurance Company Name �DC,� 1 . Workman's Comp:Policy#_ Copy,of Insurance Compliance Certificate must be on ile. Permit Request(check box) ARearoof(stripping old shingles) All construction debris will be.taken t\�any �Syti �-Re-roof(not stripping.Going over existing layers of roof) E _Re-side s [1 'Replacement Windows/doors/sliders.U-Value (maximum.44) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,Le Historic,Conservation,etc. ***Note. Property Owner must sign Property Owner Letter of Permission. copy of the Home Improvement Contractors License is required: SIGNATURE: Q:Forms-bu i l d i n g pe rm i tslexpres s R6vised'123107• Capizzi Home Improvement,Inc. Page 1 of 1 J Specifications&Estimates M Date: 1/ PROPOSAL FID#80-0014011 HomejCSL#: 7454 C : S5i Aa /aC Y�/�(��l Registration#: 100740 1645 Newtown Road,Cotuit,MA 02635 Pe t m f 508-428-9518 800-262-5060 F: 508-428-1547 Established 1976. Serving the Cape for 30 Years Name:fikU CD4__ L 0f (el,_ Job Address: Address: C � City/Town: 01 City/Town:: Job Phone: State: ce V'7 t G Other Phone. ZIP: V E-Mail: Estimator: Job Number: : We hereby submit specifications and estimates to furnish and install new commercial grade, .060 elck membrane,single-ply rubbtr roofinkssystem,black,from RPI,with 30-year warranty as follows: '� UK.T(sGt ■ Strip existing roo7mg and dispose of WIdebris. ■ Check all boarding. ■ Install aluminum drip edge on full perimeter or termination bar system on full perimeter as needed for application. ■ Apply new 1/2"retro board roof substrate underlayment with screw and deck plate fastening ' system. ■ Strip sidewall shingles in area of roof up'one-foot minimum from roofline for flashing of roof system to wall. ■ Install fully adhered E.P.D.M. roofing system. ■ Install new white cedar shingles as needed to finish. Re Ptac\e z s G 9 e _5 I Labor& Materials: _ _____i_$_ o� l NOTE: Touch-up pamtmg maybe required lnf�isct included in this proposal. . We look forward to wo king with you;please call if you have any questions. D6PQ st,;j 46 0" '_S (0 Sincerely, CAPIZZI HOME-I OVEMENT -TR t v L oq e a i— fuw Pmcc Accepted By: Date: t THIS PAGE IS PART OF AND IN CONFORMANCE WITH PROPOSAL#: 3a �' S r f i �Jf'7.E Q '^/ ✓�Gr�d�CJitt6¢C}b.:/ TOGY�rif��7�•t1L�LLL ��pp 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: f Board of Building Regulations and Standards Reglstr #j9N, 100740 One Ashburton Place Rm 1301 p�r_a snE�fQ 23/2010 Boston,Ma. 02108 z lement Card CAPIZZI HOME bARY GUSTAFSOty� =�'/a/ 1645 Newton Rd. Cotuit, MA 02635 — -- --- --.:__.. .._ Administrator No vali itho t nature 9. q),1a-m.w.ttt of Public ` afe(N -- — . Bo:zrtl fst'Btt ltla,to lZeitt+III tit3at:*, mil S:itnd arils - Construction Supervisor License 'License: CS 74640 Restricted:t0: 00 GARY GUSTAFSON: �- 8 SHORT WAY ys SANDWICH„MA 02563 E Pi .ai;uq: 11/29/2010 7755 r P The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 y www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl Name(Business/Organization/Individual): Address: ) City/State/Zip: Phone#:75 �G��g Are you an employer?Check the appropriate box: Type of project(required): I am a employer with SL'L-, _ 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time)." have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling These sub-contractors have g, ❑Demolition ship and have no employees 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 11.❑Plumbing repairs or additions right of exemption.per MGL 12. oof repairs myself. [No workers' comp. P insurance required.]t c. 152,§1(4),and we have no employees. [No workers' 1 Other comp.insurance required.] *Any applicant thatchecks 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. lContractors 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 subcontractors 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: C)CoYYI Policy#or Self-ins.Lic.#: Ck C:,kQ 1 Cd=Aca Expiration_Date: Job Site Address:��` �C t 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 S1,500.00 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 y against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investi ations of t e DIA foginsVEancc coverage verification. I do hereby certi Aunder ,,rplins and penalties of perjury that the information provided above is truce and correct S� e. Date:Phone# Official use only. Do not write in this area,to be completed by city or town offciaL 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#: Client#:47298 CAPIHOM ACORD,. CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) PRODUCER 12/30/08 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Rogers&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# INSURERA: NGM Insurance Company Capizzi-Home Improvement,Inc. INsuRERBi American Home Assurance Capizzi Enterprises,Inc. 1645 Newtown Road INSURER C: Cotuit, MA 02635 INSURERD: 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. S LTR NSR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION DATE MM/DD DATE MM/DD LIMITS A GENERAL LIABILITY MPB1075H 06/08/08 06/08/09 EACH OCCURRENCE $1 000 000 X COMMERCIAL GENERAL LIABILITY ORMA ET RENTED occurrence) $5O OOO CLAIMS MADE OCCUR MED EXP(Any one person) $5 OOO PERSONAL&ADV INJURY $1 OOO OOO GENERAL AGGREGATE $2 00O 000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRODUCTS-COMP/OP AGG s2,000,000 JERC LOC A AUTOMOBILE LIABILITY M1 M28044 06/08/08 06/08/09 COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $500,000 ALL OWNED AUTOS X SCHEDULED AUTOS BODILY INJURY (Per person) $ X HIRED AUTOS X NON-0 BODILY INJURY NON-OWNED (Per accident) $ X Drive Other Car PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY ANY AUTO AUTO ONLY-EA ACCIDENT $ OTHER THAN EA ACC $ AUTO ONLY: AGG $ A EXCESS/UMBRELLALIABILITY CUB1076H 06/08/08 F06/08/09 EACH OCCURRENCE $5 OOO OOO X OCCUR CLAIMS MADE AGGREGATE $5 000 000 RDEDUCTIBLE X RETENTION $10000 $ B WORKERS COMPENSATION AND WC6957000 12/25/08 12/25/09 X WC STATU- OTH- EMPLOYERS'LIABILITY T RY L MIT ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT s500,000 OFFICER/MEMBER EXCLUDED? If yes,describe under E.L.DISEASE-EA EMPLOYEE $500,000 SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT s500,000 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 1 n 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 KW © ACORD CORPORATION 1988 Town of Barnstable *Permit# oyo��Sd2 Expires 6 months j om isp�date Regulatory Services Fee akMh-rABM : Thomas F.Geiler,Directorn"l _ k �uildin Division �" g � 9rlS1Q8 it�Perry,CBO, Building Commissioner SEP 12 2008 206 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us '� Fax:_508-790-6230 Office_: 508� h_C) ,9AR EXPRE 4 IT APPLICATION RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number Property Address` � \A � 0 z?tzi eAk tKResidential Value of Work s Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address Tna �' A Contractor's NameC,Q k?' ,t `"�anV, i,\'�M(;'xi\ Telephone Number`_L A%-q j Home Improvement Contractor License#(if applicable) ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# �1`_�SIC� Copy of Insurance Compliance Certificate must be on file. Permit Request(check box)Re-roof(stripping old shingles) All construction debriswill be taken toNO� ❑ Re-roof(not stripping. Going over existing layers of roof) Re-side )91 Replacement Windows/doors/sliders.U-Value ,3 (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. A copy of the Home Improvement Contractors License is required. SIGNATURE:. Q:Fonns:bu ildingpermits/express Revised 123107 j Y • 1 .. _ , III ✓fee �om rrwouuea`l� a�/�aaaczc�uraeL%'a 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: d111 `� Board of Building Regulations and Standards - Registrattgn 100740• One Ashburton Place Rm 1301 TxpJratlgn 6'�23/2010 rj(Tiylpe S�pplement Card Boston,Ma.02108 r CAPIZZI HOME J�MPRRR�VEME�I TI5I P ARY GUSTAFSON 1645 Newton Rd.` �`w ` ' ` Cotuit MA02635 { . 5.� -,_--..- Administrator No vali itho t nature Board of Building Regulations and Stindards Construction Supervisor License License: CS 74640 Birthdate: 11/29/1975 Expiration: 11/29/2008 Tr# 6430 Restriction: 00 GARY GUSTAFSON 8 SHORT WAY SANDWICH,MA 02563 Commissioner Client#: 47298 CAPIHOM ACORDTM CERTIFICATE OF LIABILITY INSURANCE 0611212008 Y' PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Rogers&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 B: American Home Assurance 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 I ERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. POLICY EFFECTIVE POLICY EXPIRATION LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE MMIDDIYY DATE MMID D/VYI LIMITS A GENERAL LIABILITY IMPB1075H 06/08/08 106/08/09 cH OCCURRENCE $1 000 000 X COMMERCIAL GENERAL UABIL'TY I - DAMAGE TO RENTED �'R MISES E occ rr n $500 000 CLAIMS MADE a OCCUR - �VE—D EXP(Any one person) $1 Q 000 I PERSONAL A ADV INJURY $1 OQO 000 FGLr 'NERAi-AGGREGATE s2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER:i I PRODUCTS-COMPIOP AGG s2,000,000 POLICY JE� LOC I — I11 I -------- ------- — AUTOMOBILE LIABILITY I COMBINED SINGLE-LIMIT. ANY AUTO I(Ea accident) I$' F— ALL.OWNED AUTOS i I I BODILY INJURY (Per person) $ -I SCHEDULED AUTOS HIRED AUTOS I ! I j �BODILY IN.iURY $ NON-OWNED AUTOS i ! (orr aranenl) I I _ PROPERTY DAMAGE I I !(Per accident) $ GARAGE LIABILITY L AU1"0 ONLY-EA ACCIDENT $ ANY AUTO ( I I OTHER'i HAN EA ACC $ AUTO ONLY: AGG $ A EXCESS/UMBRELLA LIABILITY CUB1076H 06/08108 106/08/09 EACH OCCURRENCE s5,000,000 X OCCUR CLAIMS MADE i - AGGREGATE $5 O0O 000 $ DEDUCTIBLE i $ - X RETENTION $1 OOOO _ I _ $ B WORKERS COMPENSATION AND I WC671 6562 1 2/25107 12125108 ��( IeNC S1 JM OTH- TFIR EMPLOYERS'LIABILITY - E.L.EACH ACCIDENT $500,000 ANY PROPRIETORIPARTNER/EXECUTIVE I OFFICER/MEMBER EXCLUDED? I E.L.DISEASE-EA EMPLOYEE s500,000 If yes,tlescribe untler i SPECIAL PROVISIONS Delow _ E.L.DISEASE-POLICY LIMIT $� 500,000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES 1 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 _1n_ 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.(2001108)1 Of 2 #S36540IM36539 KW © ACORD CORPORATION 1988 f Page 7 of 7 CAPIZZI HOME IMPROVEMENT INC. SPECIFICATIONS AND ESTIMATES STATE OF MASSACHUSETTS LETTER OF AUTHORIZATION TO APPLY FOR A BUILDING PERMIT I, AMANDA LEIGH, OWN THE PROPERTY LOCATED AT 8 HIGHLAND DRIVE IN CENTERVILLE, 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: L OWNER'S ADDRESS: 8 HIGHLAND DRIVE, 9TERVILLE, MASSACHUSETTS OWNER'S TELEPHONE: 508-778-5781 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: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, AfA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Build ers/Contractors/EIectricians/Plumbers Applicant Information Please Print LeZibly Name (Business/Organizat-ion/Individual)(,' � ��C>V Address:\i c,��� City/State/Zipo� ( r�.-,`( `,&jo?,S Phone.#::f�41 %_qS1% 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-tim.e).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g, ❑Demolition workingfor me in an capacity. employee's 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.El am a homeowner doing all work officers have exercised their 11.❑ 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. [N6 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 anew 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 Insurance Company Name: O co'fn Policy#or Self-ins. Lic.#: (e���Lgs(p� Expiration Date: rob Site Address•�1c� � _�(� City/State/Zip:���T� ��`C R 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 yerification. I do hereby certify under e pains and pen o perjury that the information provided ab ve is true and correct Si ature: 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 J 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 th e e 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 tha 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: Tate Commonweakth of(Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-490.0 ext 406 or 1-877-NIASSAFE Fax# 617-727-7749 Revised 11-22-06 www.rnass.-gov/dia r oFt�r� Town of Barnstable *Permit# 6?( 5� 1. (, Expires 6 onth�sfrom issue date f Regulatory Services Pee ,�. Thomas F. Geller, Director Q. PERMIT Building Division rid�y SEP 1 2 2008 Tom Perry, CBO, Building Commissioner 200 Main Street, Hyannis, MA 02601 TOWN OF BARNSTABLE www.town.barnstable.ma.us Office: 508-862-4038 Fax: 5087790-6230 .EXPRESS PERMIT APPLICATION RESIDENTIAL ONLY Not Valid wizliout Red X-Press Imprint Map/parcel Number / C) U /c., ( � Property Address � VRcsidential Value of ork 4 (�(� Minimum fee of$25.00 for work under$6000.00 Owner's Name & Address 144 , 111 1i1 � Tele hone Numb er7 �7 _2&� Contractor's Name ;� /y�ZQ ?/>.i,.�'� p Home Improvement Contractor License#(if applicable) 7C .1 �j ❑Workman's Compensation Insurance Chec -one: PI am a sole proprietor ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp. Policy# j C 00 S� U� Copy of Insurance Compliance Certificate must be on file.. Permit Request (check box) Q--Re-roof(stepping old shingles) All construction debris will be taken toinpnd � ��•` ❑ Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders. 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. A copy of the Rome Improvement Contractors License is required. SIGNATURE: Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc Rcvisc020108 • ✓fie C�oznareomuseaf,Cfi o��a-aa¢c�iccGeC�a '� ' Board of Building Regulations and Standards License or registration valid for individul use only C HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: . Board of Building Regulations and Standards Registration:, 121596 One Ashburton Place Rm.1301- -7 Expiration 5%24/2010 Tit 268467 t - Boston,Ma.02108 ,Type Indjividual d M I C H A E L J.ARONNE 1� (.y1r i MICHAEL ARON`E 34 CIRCUIT RD NORTH ' WEST YARMOUTH,Mk02673 Administrator 1 Not valid without signature + 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/EIectricians/Plllmbers Applicant Information Please Print LegriblY Nara0 (Business]OrganizaEonllndMfival):� City/State/ZipLd-,, Phone-4.- `Z 2 3 Are you an employer? heck the appropriate bolo: Type of proj ect(required): 1.❑ T am a employer with 4. I am a generaliroat[acttor and I 6. ❑New construction employees(hill.and/or part-time).* havo hired thecontractors Z U'l am asole proprietoror partner- � on the aed sheet 7. Rsmodeling ship and have no employees These soh-contractors have 9. Demolition working for ton ia say capacity. employees and have workers' 9. ❑Building addition [No workers' comp.-insrtranre comp.incrrrance rbgtured ] 5. F1 WC are a corporation and its 10.❑�Elcctrical repairs or additions 3.❑ I am a homeowner doing all work officers bave.cxcrcised their It.F]Plumbing repairs or additions myself- [No workers' comp. right of exemption per MCrL 12 ❑Roof repairs inM=c,C regnired.l 152, §1(4),and we have no employees. [No workers" 13.❑ Other comp.insurance required.] *Any zpplicant that chxkc box#1 must also fill out the section belaw showing their—k='comp=wE.an poficy infwTmtiort t Homcowrmt who submit this af5davitin&M6ng trey arc doing all worlcand then hire outside contractors must submit anew affiLvitindimfiog such. tCanb actors that ebxk this box oust attached an additional sheet showing the name of the sub-aotraetnrs and stain whether or not thost entities have employees. If the sub-contraebars have employees,they must provi a their works='cutup.policy number. I am an employer that is providing workers'compensation insurance for my employees Below is the policy and jab site information. Incnrance Company Namt: Policy#or Sc1f-ins.Lic.#: C /� ©0- e�Url a Expiration Date: / Job Site Address: t ( city/5t,&Zip: Attach a copy of thewor rs' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required tmdcr Section 25A of MGL c. 152 can lead to the imposition of erimirial penalties of a fine tip to S 1,500.00 and/or one-year bnprisonment;as wrU as civil penalties in the form of a STOP WORK ORDER and a fi of up to S250.00 a day against the violator. Be advised iftat a copy of this statrmcrit tray be f6 Warded to the Offico of IuyestiKations of the DIA for immnanco coyerag o verification. Ida hereby certify under the auus•and penalties of perjury that the information provided above is true and correc.G Si c: Date: Phone O facial use only. Do not write in this area, tb be compl&ted by city or town ofjx!aL City or Town: Permit/License# 1=dng Authority(circle one): 1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6. Other .r,--41..-4 VI.-- Phone �of1NE7, Town of Barnstable Rego atolry Services NSTA 77 MASSgIE Thomas F. Geiler,Director q'`iED �a`m Building Division Tom perry, Building Commissioner 200 Main Street, Hyannis, MA 02601 www.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-623 0 Property Owner Must Complete and Sign This Section If-Using A Builder i" as Owner of the subject property . hereby authorize to act on my behalf, in ah.matters relati e to work authorized by this building permit application for: A4� Address of ob) i3 oy gn o wne ot Print ame If Property Owner is applying for permit please complete the Homeowners License Exemption Form on th:e reverse side. Town of Barnstable �op SHE Tp�� Regulatory Services - ----- Thomas F. Geiler,Director ri BAssrwUX. ' MAss. Building Division pTED `�r` Tom Perry,Building Commissioner . 200 Main Street, Hyannis, MA 02601 Rrww.town.b arnstabl e.ma.us 0ffi-_e: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER': name home phone# work phone# CURRENT MAILING ADDRESS: city/town state zip code The current.exemption for"homeowners"was extended to include owner-occupied dwellinjgq of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s) who owns a parcel of land on'which he/she resides or intends to reside, on which there is,or is intended to be, a one or two-family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner"shall submit to the Building Official on a form acceptable to the Building Official, that he/she shall be responsible for all such work performed under the building?permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department :minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the. State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be cxcmpt from the provisions of this section(Section 109.l.I-Licensing of construction Supervisors);provided that if the homeowner engages a parson(s)for hire to do such -Rork,that such Homeowner shall act as supervisor." Many homeowners who use this exemption aie unaware that they are assuming the responsibilities of a supervisor(see Appendix Q. Zules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons_ In this case,our Board cannot proceed against the unlicensed person as it would With a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aw of his/her responsibilities,many communities require,as part of the permit application, are that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. �oFt►ie roy, Town of Barnstable er t# aDa� a�5d5 . re monUos from issue date BARNSTABLE, z Regulatory Services Fee o2MASS 9$.0 1639. ,0� Thomas F.Geiler,Director lFD MAt A p-?/o7 Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION RESIDENTIAL ONLY /\ Not Valid without Red X-Press)Imprint G tp/parcel Number I -I© I y B _ )perty Address Residential Value of Work � � Minimum fee of$.25.00 for work under$6000.00 mer's Name&Address I A2 atractor's Name at'►p I ZZ 1 140rGe _S1PrUu'e,me4alephone Number gZW —qG me Improvement Contractor License#(if applicable) I O c)—+4 V istruction Supervisor's License#(if applicable) C) 0 'J Workman's Compensation Insurance X-PRESS PERMIT Check one: 0 I am a sole proprietor JAN 2 9 2007 I am the Homeowner TOWN OF Eif����TA�LE I have Worker's Compensation Insurance trance Company Name_?- We S rkman's Comp.Policy# Iy of Insurance Compliance Certificate must be on file. rut Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will betaken to ._, (]Re-roof(not stripping. Going over existing layers of roof) —' F3 n Re-side r c1 Replacement Windows. 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. �A Ho a Improvement Contractors 'nse s required. nature ak A G;)e� rms:expmtrg ;e063004 l i Page 7 of 7 CAPIZZI HOME IMPROVEMENT INC. SPECIFICATIONS AND ESTIMATES STATE OF MASSACHUSETTS LETTER OF AUTHORIZATION TO APPLY FOR A BUILDING PERMIT OWN THE PROPERTY LOCATED AT MQh4 c,_*i o � IN MASSACHUSETTS. I HAVE AUTHORIZED. CAPIZZI HOME IMPROVEMENT TO ACT AS MY AGENT TO APPLY FOR A BUILDING PERMIT IN ACCORDANCE WITH 780 CMR, THE MASSACHUSETTS STATE BUILDING CODE. I GIVE MY PERMISSION TO LESSEE TO APPLY FOR A BUILDING PERMIT IN ACCORDANCE WITH 780 CMR, THE MASSACHUSETTS STATE BUILDING CODE. 1 i SIGNATURE OF OWNER: �_6_x ' i OWNER'S ADDRESS: OWNER'S TELEPHONE: i LESSEE'S SIGNATURE: LESSEE'S ADDRESS: f LESSEE'S TELEPHONE: i APLLICANT'S SIGNATURE: kf4I I APPLICANT'S ADDRESS: 1645 wtown Rd., Cotuit, MA 02635 APPLICANT'S TELEPHONE: 508-428-9518 RESPONSIBLE OFFICER: RESPONSIBLE OFFICER ADDRESS: RESPONSIBLE OFFICER TELEPHONE: • Client#:4T298 CAPIHOM ACQRD,w CERTIFICATE OF LIABILITY INSURANCE DATE.( oilo777DIYYYYI g 5 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION • Rogers$Gray Ins.Agency,Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 434 Route 134 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR P.0.Box 1601 ALTER THE COVERAGE AFFORDED BYTHE POLICIES BELOW. South Dennis,MA 02660-1601 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A; National Grange Mutual Ins.Co. Captrsi Home Improvement,Inc. INSURER ls: American Ilrtemational Gr Caplzzl Enterprises,Inc. 1645 Newtown Road INSURER c Cotuit,MA 02635 _.._ INSURER r `.: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 DOCUNENT 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: LTR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE. POLICY EXPIRA71ON - -- 'LIMITS - Q GENERAL LIABILITY MP.010707 06108/06 06/08/07 EACH OCCURRENCE $1 000.060 X COMMERCIAL GENERAL LIABILITY � � � - � DAMAGE TO RENTED $PjOO.00II� • C AIMS MADE.5 OCCUR - PREMISES -a 0cm- IAED EXP(Any one person) .. $1 O OOO PERSMAL EADV INJURY s1'000,000 . - GENERAL AGGRECATE -$2 OOO O00 GENT AGGREGATE LIMIT APPLIES PER; PRODUCTS=CONPMF AGG $2,000 000 POLICY. ' PRO• , JECT LOCH. AUTOMOBILE LIABILITY - .. - .. -X-MBWEDSINGLE LIMIT AfVY AUTO iF-aceldent) $ .ALL OftED ALTOS - - BODILY INJURY . SCIiEDULEDAUT05 {Pei,pereon) $ HIRED AUTOS - .. NON-OWNED AUTOS _ BODILY INJURY $'. (Peramddot) _ - PROPERTY DAMLAGE (I-er accderd) GARAGE LIABILITY AUTO ONLY•EA ACCIDENT $� ANY AUTO _ OTHER PMAN :EA ACC .. AUTO ONLY: G. g,.. EXCESSAJMBRELLA LIABILITY EACH OCCURRENCE OCCUR CLAIMS MADE AGGREGATE •« :-c.$ :-.. _. e ._..... ,vr. �..:. DF:OUCTIBLE- .$ RETENTI3N $ - B WORKERS COMPENSATION AND 1764953 12t251D6 1212510T T(YC STAMTU• OTH• - ; EMPLOYERS'LIABILITY - - ANY PROPRIETOR)PARTNER!EXECUTIVEE.L.EACH ACCIDENT "�: $500 OOO CfFlCdembs underSER EXCLUDED? E.L.DISEASE+EJI EMPLOYEE $500,060 Ityea,.descr ha-under LPROVISIONStocw OTHER E.L.DISEASE.POLICY LIMIT $500.000 I .. ... OTHER _. _ '' DESCRP71ON OF OPERATIONS'I LOCATIONS!VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT!SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE,CANCELLED BEFORE THE EXPaA rioN DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR 70.MAL .7 n . DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT.BUT FAILURE TO DO SO SHALL_ IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,iTS AGENTS OR REPRESENTATIVES. - -AUTHOPJZEDREPRESENTATIVE.--"--...._..._... '--_.,..,,,,__- •.,..,.,,,__.»_�,�._�...�_._.__:. ACORD 25(2001108)1 of 2 #26435_,__ DMW-®ACORD CORPORATION.1988 �. i. � v V V'/�,I tij�;��V'/GL4%'r✓��Y�l fir V �/ („ij���/� Y- Board of Building Regulations axed Standards One Ashbuxtoxx Place - Roo-nl 1301 Boston. Massachusetts 02108 Home Improvement Contractor Registration Registration: i oom Type: Private Corporation CAPIZZI .HOME IMPROVEMENT, -INC. Expiration: 6/23/2008 Thomas :Capizzi,Jr. t 1646 Newton Rd. Cotu it, MA 02635 Update Address and return card.Mark reason for change. DPS CA1 0 60M 04/0&�'C8B99 Address E] Renewal 0 pmpIoyment Lost Card ✓lzs'{vo�iao�acu� o��aaa/u,�Qefth r I I bard of Bviiding Regulations and Standards Lleense or registration valid for IndividuI use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: `Registration: 100T40 Board of 13uilding Regulations and Standards Expiration' gj2812008 One Ashburtbn PIace Rm 13of Type: Private Corporation Boston,Mg.02108 CAPIZZI WOME IMPROVEMENT,INC. Thomas Capiazi,jr. 1645 Newton Rd. Cotuit, MA 02635 Deputy Administrator Not valid ivitllout signature IL aI.rY 1 BOARD OF SUILDINe 1. 60fise:'Cb S � N i 1J IRl JCfiION 8 f Nurn4 6S 057032 t Ott a;';J 963 irj', 667 Hbm S 1646 N W7`0 Go TUIT, MA Met r., ._.- -� 1 ne uommonweturn v lnassaenusetts Depaiinent of Industrial accidents Office of Inveshgahons 1 QShtng on 'tiPt't .t BOSton� Q wwwrnassgovr`dia Workers'Coiripensaflon Insurance Affidavit u tiers/Contractors/Electncians/Plumbers a APO eant_Iniformiation Please'Pi nt Le bly Name tBnsmess/Organ�zation/Indzvidual 1F45 I�levuto� � Tel 428 9518 800 262 5060 CitylState/Zipone e ou an employer?Check the appropriate box. y a Type of project(regmred): I ain a employer with 4 [] I am a general contractor and I :. n employees MM andlor dart inne).* have hued tine sn -contractors 6 (�New consiractio f asole proprietor or partner- :lasted on the attached sheet 0 Remodeling shp and have nD.employees These sub-coDitraciors"laav $ D Demolition;. - �vo�rmg b" ' m any capacity. worlceis'comp nas�arance 9 ❑ Bidding addition {I�o workers'coax� insurance 5 We area corporation and its.. regured] a officxrs3iave eaercased their 10 Electrical moans or additions 3 I am a licimeownet dorrig all wntk rrghtofexe tronper.MGI 11 [ Plumbmgrepaus of addit3ioiis "Wself To workers' co c 152, 1�{4),and wel ave no 1� Roofiepaars ` misorance regnrred]# employees` io workers' 43. tOther: ' msurancce IeQalt 3 *may applicant that clieel�boa:#r must also fiTi ont#he section below�oiviug 8�erc wor]cers'compensatron pc>trcy mfomratron t Homeowners who ailmvt 8ns affidavit md#cdn they ate dome sti woricand 8ren lore otrtsde contractors mast submit a new:s�idavit citc ug such tContractors 8�at check Hns box must sltached an addrtyoriid sheet showing 8ie�mne-of#iteusub contractors end lbes wor7cers' `` 7rc info on I am an employer°that zsrovuiing workers'roerisatioi:rnsurariceor►►i3'employees $elo�v�s flre policyrnrd�olri srtee Ins�ance Company Name ► _ Policy#or,Self uas Lie: E xp on Date. Job Site Address Cad _. .__v /StateiZrp - - - - Attach acopy of the workers'compel%lion,poli�ey,declaration page:{s6owrng the pglacg nombeT:and ear atron date). Far�iue to secure coverage as reglllred binder Section 25A of.MGL c 152 can 1ead:to the rnposrtion of eiunmai:penaties of a fine,tp to$1,500 OU and/or one-year mipnsoriDiient,as well as crvr penalties m the loran of a STOP WORD ORDE$Andzdfi=__.. .._. of p to-$230 90 r ay against a�rroiator Se advised that a'copj►;of ties stateindnt.may be forwarded to the=O ce'of Invesfrgatrons ofthe DiA for incuance coverage venficiion "`"� - t do hereby untie tlse pains andpen�lties o,f p tlzat#he�n�formai�on.proviried ubov -is true and correct S--<� tare: _� � _ - _ ' Date: - O,f ictal use Drily Do not write in`this area,to be completed by city or town official City or"Town - - Permit(License# _Issuing Authoa•ity 1.Board of Health Z.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact.Peroon _ _ ----------