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HomeMy WebLinkAbout0127 HIGHLAND DRIVE .� W4t-A All n k � Y .;y tFr u".' ";s sm F�d �' w" Yk 'tr� :�' z F, r �. a � t n � K'� •f' .. f ,� el VIP s ,2 r y f ,.. . .�„ kr. ,.: .•. ." •..:." � u_ _i MSC � a. - ,v .. ,,�,: r S. t. .a . , r � 4 a d .a� n e.� 2 [ a!iY r, tF.. 'A�,'aE 4 .. - yr• f. .ry . �. A , •l ',. i1 w F . r Y 4 - .. r , - a G r • S � ;� � � � 6 ,t �.� 4f h r Sk 1 L ti n 1 - �b y .. r c r 4 � „.•f,xa s-:. •`fie.�,-" ��..rk; + 't .�" �" _ .s ° .. ' � F• :�4 T. H s , r T v N a ,•A y' ' �'cn. , �-z � •.r=� °- y. a a a f„ ' �rm�.� ..:� 5r..�. re`:.krkr r" •'y` �me y d f r F r a q « a. o � 4 s n � a n u , . y n r ,4 f N Y , a , r L r , .o Town of Barnstable "Permit# ^ow�� Fspires 6 months from issue dale Regulatory Services Fee BARN&TABLE. : Thomas F.Geiler, Director .v MASS - - �, Building Division - RMIT Tom Perry,CBO, Building Commissioner OCT ZOOS 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ilia.us �'Oi/VINT&0&/�t'sl\I"k8XPR S PERMIT APPLICATION RESIDENTIAL ONLY 508-790-62 i0 �V /� `�k'J(PR Not Valid without Red.Y-Press Inij)rint I►/i / � Map/parcel Number d l_JJ Property Address_--� �4J�.{f� )0 Residential Value of Work_ Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address IS14��, \er Contractor's Name C Telephone Nu Home Improvement Contractor License#(if applicable) �KWorkman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner I have Worker's Compensation Insurance Insurance Company NameJA C11 _ Workman's Comp. Policy# Copy of Insurance Compliance Certificate must be on file. Permit Request(check box)' XRe-roof(stripping old shingles) All construction debris will be taken to ❑ Re-roof(not stripping. Going over__existing layers of roof) ❑ Re-side _ ❑ Replacement Windows/doors/sliders. U-Value _(maximum .44) 'Where required: Issuance of this permit does not exempt compliance with other to\4'n department reeulations.i.e. Historic,Conservation,etc. *"Note: Property Owner must sign Property Owner Letter of Permission. JAAco y of the Home Improvement Contractors License is-required. SIGNATURE: }. Q:I-,ornns:hu i ld i ngpeinn i is/express Revised 123107 Page 7 of 7 CAPIZZI HOME IMPROVEMENT INC. SPECIFICATIONS AND ESTIMATES STATE OF MASSACHUSETTS LETTER OF AUTHORIZATION TO APPLY FOR A BUILDING PERMIT WE, TIMOTHY& HANMENG B. HAYES, OWN THE PROPERTY LOCATED AT 127 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: % 7 , _ OWNER'S ADDRESS: 127 HIGHLAND DRIVE, CENTERVILLE, MA 02632 OWNER'S TELEPHONE: 508-367-5858 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: s ,P� T 1° �X 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: "y ' Board of Building Regulations and Standards Registration.*, 100740 Explr�tlon 6�23l2010 One Ashburton Place Rm 1301 Boston,Ma.021.08 NType S`pplement Card CAP IZZI HOME 7J,MR-ROVEMENTIJ�I Ni RY GUSTAFSORy�Tq--4 - 1645 Newton Rd. Cotuit, MA 02635 ".., Administrator i ithofthatture ommareu a rxrrzuaell" Board of Building Regulations and Standards Construction Supervisor License License: CS 74640 B i rthdate: 11/29/1975 Expiration: 11/29/2008 Tr# 6430 "`. 6 Restriction: 00 GARY GUSTAFSON 8 SHORT WAY SANDWICH,MA 02563 Commissioner 5 Client#: 47298 CAPIHOM ACORDT. CERTIFICATE OF LIABILITY INSURANCE 06/12/2008 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Rogers&Gray Ins.-So. Dennis ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 434 Route 134 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P. O. Box 1601 South Dennis,MA 02660-1601 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: NGM Insurance Company Capizzi Home Improvement, Inc. INSURERB: 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 TERMS.EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. POLICY fFF ECTIVE POLICY EXPIRATION LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE MMIDD/YY DATE(MMIDD/YY LIMITS A GENERAL LIABILITY MPB1075H 06/08/08 06/0.8/09 EACH OCCURRENCE $1 000 000 �( COMMERCIAL GENERAL LIABILITY - I D, Is ES c rr TO RENTED P $500 000 F I.f,�t S (E i CLAIMS MADE 17X OCCUR i MED tXP(Any one person) $1 O OOO PERSONAL 8 ADV INJURY $1 000 000 GENERAL.AGGREGATE s2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: - I - PRODUCTS-COMP/OP AGG s2,000,000 POLICY PRO- LOC JECT AUTOMOBILE LIABILITY — COMBINED SINGLE LIMIT $ ANY AUTO - (Ea accident). ALL OWNED AUTOS - I BUDaY!NJURY $ .1 SCHEDULED AUTOS (Per person)� I - HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accldenl) ' GARAGE LIABILITY - AUl, O ONLY-EA ACCIDENT $ ANY AUTO Ol HER THAN EA ACC $ �. I AUTO ONLY' AGG $ A I EXCESS/UMBRELLA LIABILITY CUB1076H 106/08/08 06/08/09 EACH OCCuRRENCE $5,000000 X OCCUR ❑CLAIMS MADE I AGGREGATE s5,0001000 I � $$ DEDUCTIBLE $ X RETENTION $10000 - - $ B WORKERS COMPENSATION AND WC671 6562 12/25/07 i.12/25/08 )( TWC STATU• _EH EMPLOYERS'LIABILITY IMIT� ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $SOO,000� OFFICER/MEMBER EXCLUDED? El DISEASE-EA EMPLOYEE $500,000 If yes,describe under SPECIAL PROVISIONS below _ E.L.DISEASE-POLICY LIMIT s500,000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I 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 #S36540/M36539 KW © ACORD CORPORATION 1988 y The Commonwealth of Massachusetts Department of Industrial Accidents i W Office of Investigations W 600 Washington Street i °�,y SJey`eW Boston, MA 02111 i www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers ;Applicant Information, Please Print Legibly Caplzzl fin .nlprovemen lo Name (Business/Organization/Individual):_P64S PG_MWn RA—ad Address: Cotuit, MA 02635 City/State/Zip: Phone #: you an employer? Check the appropriate box: I am a employer wi general contractor and I Type of project(required):. th_ 4. ❑ I am a yemployees (full and/or part-time).* have hired the sub-contractors 6. ❑ New construction 2.!❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and:have no employees These sub-contractors have g. ❑ Demolition working for me in any capacity. employees and have workers' �o workers' com comp. insurance.# 9• ❑ Building addition comp. P• required.] 5. ❑ We are a corporation and its' 10.❑ Electrical repairs or additions 3.I❑ 1 am a homeowner doingall work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL - insurance required.] t c. 152, §1(4), and we have no 1 Roof repairs employees. [No workers' 13.0 Other comp, insurance required.] *An(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. Tcontractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:Qa(� Policy#or Self.ins. Lic. #:�9J(�(p� � Expiration Date: 0 i Job ISite Address:�i - 1�� City/State/Zi 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 vi ator. Be advised that a copy of this statement may be forwarded to the Office of Investi ations of the DIA for insur e covera e verification. -------I-dot hereby-ee-r--ti-- - rider-the-pa' s an alties-of pe-rju-ry-that-the-infor-mation-p.r-ovided-above-is-true-and-co.r-r-ect. Si nature: --- Date: IN 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.!Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.,'Other Contact Person: Phone#: I �p114E r Town of Barnstable *Permit# Expires 6 months from issue date s Regulatory Services Fee - OQ BMWSUBLE, g Y v� '""SS' Thomas F.Geiler.,Director i63q• ♦0 ArED1A°'`' Building Division Peter F.DiMatteo, Building Commissioner 367 Main Street, Hyannis,MA 02601`X-PRESS PER" . Office: 508-862-4038 /�� Fax: 508-790-6230 t 200� EXPRESS PERMIT APPLICATION Not Valid without Red X-Press Imprint TOWN OF BARNSTA1:. -1-- Map/parcel Number I RO Q S10 Property Address . c.v g Residential OR ❑Commercial Value of Work 6,300 Owner's Name&Address lye t�e:5 . Contractor's Name .41 h12W A/dik�is,-O Telephone Number Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) dworkman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑dam the Homeowner ,-,have Worker's Compensation,Insurance Insurance Company Name 2— ilel c y 161 Workman's Comp.Policy# tve, Permit Request(check box) �MO1 ❑ Re-roof o shi les) ❑ e-roo t stri il. ing o xisting layers of roof) �Re-side ❑ Replacement Windows. U-Value (maximum.44) 1. ❑ Other(specify) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. Signature V Q:Forms:expmtrg:rev-070601 r