HomeMy WebLinkAbout0103 LONG BEACH ROAD �o� ��� ���..;�� �
y ,�o
:; � 1
40
�IME r Town of Barnstable Permit.#
Expires 6 mon hs from issue dqo-
�T Regulatory. Services Fee i
* EMMSTABLE «
Richard V. Scali,Interim Director
i639. �e
Building Division: .
Tom Perry,CBO,Building Commissioner,
200 Main Street,Hyannis,MA 02601
www.town.barnstable.ma.us .
Office: 508-862-4038 Fax: 508-79076230
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
Not Valid without Red X-Press Imprint
Map/parcel Number
Property Address CJ,L( 7 (-f=
0 Residential Value of Work$ - A,j',00- -490 Minimum fee of$35.00 for work under$6000.00
Owner's Name&Address' lann4 M C, o,�rt��w` _. . 1 0 3 u�. .,.: .
�� A 4ti Ze
Contractor's Name'. ctiu s Telephone Number
s � 1
Home Improvement Contractor License#(if applicable) Email:
Construction Supervisor's License#(if applicable) ®
®Workman's Compensation Insurance
Check one: APR - 1 2014
I am a sole proprietor.
❑ I am the Homeowner
Fq I have Worker's Compensation Insurance M ®F BARN TABLE
Insurance Company Names q
Workman's Comp.Policy# C a-p"ap . 66C90 1�•.C�� 9
Copy of Insurance Compliance Certificate must accompany each permit.
Permit Request(check box)
Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to —m—"
❑.Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof)
❑ Re-side
❑ Replacement Windows/doors/sliders.U-Value (maximum.35)#of windows
#of doors:
❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with reds 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 Property Owner Letter of Permission.
A copy of the Home Improvement Contractors License&Construction Supervisors License is
,required.
SIGNATURE:
QAWPFILES\F uilding permit formsUORESS.doC
Revised 061313
The.Commonwealth of Massachusetts
Department oflndustrialAccidents
Y Office of Investigations
' 600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Elechicians/Plumbers
Applicant Information Please Print Legibly
Name(Business/OT nization/Individual): C�c//05
Address: Zo tuc,V:� ?= tt o
City/State/Zip: Phone#:
Are you an employer?Check the appropriate box: Type of project(required):
1. I am a employer with 1 _ 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 g: 0 Demolition
workingme in an aci employees and have workers'
for Y capacity.
�• in�rran�e•t 9. ❑Building addition
[No workers'Comp.insurance comp.
required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their I I.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.
$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: CA4D t A /
Policy#or Self-ins.Lic.#: �,(I , L0-Zo _000a.�Z -06' Expiration Date: 05'ld//f y
Job Site Address: 03 Cam.t, 4-0,�, I-O• City/State/Zip:l l�
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify der the pains and penalties perjury that the information provided above is true and correct
Signature:
Date: ! /
Phone
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association, corporation or other legal entity,or any two or more
of the foregoing engaged in'a joint enterprise,and including the legal 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-contractor(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
(Le.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 Commonialth of Massachusetts'.
Department of Industrial Accidents
office of fay.estigations
600 Washington Street.
Boston,MA 02111
Tel.#f 17-727-4900 ext 406 or 1-877-MASSAFE
Revised 4-24-07 Fax#617-727-7749.
W W W.M=.gov/dia
I
C
" 1 1
�ZFIE rqy� Town of Barnstable
Regulatory Services
Richard V.Scali,Interim Director
Building Division
Tom Perry,Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
Property Owner Must
Complete. and Sign This Section
If Using A Builder
I, �Ot'� *�►G�— �`l�y� ,as Owner of the subject property
hereby,authorize 6`tUi�C�- ^'� to act on my,behalf,
in all matters relative to work authorized by this building permit
(Addres of Job)
**Pool fences and alarms are the responsibility of the applicant. Pools .
are not to be filled or utilized before fence is installed and all final
inspections are performed and accepted.
Signatute of Owner tore of Applicant
Print Name Print Name
3 •
Date
4
Town of Barnstable :' -.
Regulatory Services
oFZi to�� Richard V.Scali,Interim Director
°-� Building.Division
a AARxcrARi F - Tom Perry,Building Commissioner
9� BUM
S ��� 200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6250
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 dwellings 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
Appinval 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 exempt
from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors); provided that if the homeowner
engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor."
Many homeowners who use this exemption are unaware that they are assuming the responsibilities'of a supervisor
(see Appendix Q,Rules&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 aware of his/her responsibilities,many communities require,as part of the
permit application,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.
Q.XWPFILES\FORMS\bm7ding permit for=MDMRESS.doc
Accrr& CERTIFICATE OF LIABILITY INSURANCE
1 2/1 61201 3
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
J 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 CONTA Ci
NAME: Berkley Assigned Risk Services
Leonard Insurance Agency Inc PHONE.I=n: 800 634 4589 FAX No.): 866 215-8118
683 Main St B E-MAIL
Osterville, MA 02655 ADDRESS: PolicySeMces@berkleyrisk.com
INSURERS AFFORDING COVERAGE NAIC#
INSURER A
INSURED
INSURER B:
Carlos Figueiroa
INSURER C:
dba: C N F Remodeling wstmER D:
20 Captain Noyes Rd 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 CO NDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR TYPE OF INSURANCE ADDLSUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS
LTR INSR WVD (.MM/DD/YYYY) (MM/DD/YYYY) -
GENERAL LIABILITY
AUTOMOBILE LIABILITY - $
WORKERS COMPENSATION - WC ST ATU- OTH-
AND EMPLOYERS' LIABILITY -Y/N - - TORY LIMITS ER ..
ANY PROPRIETOR/PARTNER/EXECUTIVE N E.L EACH ACCIDENT $ SOO,000
A OFFICE/MEMBER EXCLUDED? N/A ❑ WC-20-20-000092-06 05/01/2013 05/01/2014
(Mandatory in NH) . - - - E.L.DISEASE-EA EMPLOYEE $ SOO,000
If yes,describe under
DESCRIPTION OF OPERATIONSbelow - 500,000.
E.L.DISEASE-POLICY LIMIT
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) _
Coverage .:
Election Category Elect.Status Name State(s) All Entities/Locations.
Sole Proprietor Include -Carlos Figueiroa MA Figueiroa
20 Captain Noyes Rd South Yarmouth, MA 02664
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OFTHE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
w
_ T
Signature:
ACORD 25(M O/05) BRAC 3139
'. ..��e.�arrir��zoouoe�c/C/r,:c/�C�2crrpac�irtelY�1.: `- - ,j
Office of Consumer Affairs&'Business Regulation License,or rPg►stration valid for individul use a;:��
— pME IMPROVEMENT CONTRACTOR
before the.expiration date If,found return to:
Ixegistra;ion wt 53792 Type Office of('onsumer Affairs ai3d Business Regulation
irr 1/8/2015 D6A 10 PaYk Plaza 51.70
pi
Bostdn,MA 02116
I. C&F REMODELING;
CARLOS FIGUEIROA `k t
20 CAPTAIN NOYES'RD
i S.YARMOUTH; MA 02604 `,- U
Undersecretary Not valid without siggature ,,
*? Massachusetts-Department of Public Safety
Board of Building Regulations and Standards
Construction Supervisor fig;
License: CS-104107
CARLOS H FIGUEYROA
20 CAPTAIN NOYESRD�
SOUTH YARMOUTIIaMA 02164
)1.0% .: Expiration _
08/25/2015
Commissioner-
Town of Barnstable *Permit#
�P�QFSHE Tp��� Expires 6 niont isjro�n�e dale
" Regulatory Services Fee
fA�IJSTABLE,
y MASS. g Thomas F.Geiler,Director
1639.
�prEDMPt Building Division
Tom Perry, Building Commissioner
200 Main Street, Hyatuiis,MA 02601 r
_._ ...
Office: 508-862-4038 APR P 2004
Fax: 508-790-6230
EXPRESS PERMIT APPLIG IO - IRE,ESIDENTIAL ONL � �^ ,
Not Valid without Red X--Press Imprint Tod OF �A�`( F 1 .�
Map/parcel Numbef
Property Address 3 t
Value of Work 10205 0�
❑Residential .
Owner's Name&Address
/„ i C �� l Telephone Number
Contractor's Name 1 1/1 s `
Home Improvement Contractor License#(if applicable) ldo-ND
Construction Supervisor's License#(if applicable)
CSoS�o32
❑Workman's Compensation Insurance
Check one:
❑ I am a sole proprietor
❑ I am the Homeowner
[�Yl ave Worker's Compensation Insurance
�S Vr"
Insurance Company Name
e.2
Workman's Comp.Policy#
Permit Request(check box)
❑ Re-roof(stripping old shingles)
❑Re-roof(not stripping. Going over existing layers of roof)
❑ Re-side
eplacement Windows. U-Value (
maximum.44)
❑ Other(specify)
exempt compliance with other town department regulations,i.e.Historic,
*Where required: Issuance of this permit does not Conservation,etc.
Signature C
Q:Forms:expmtrg
"' raucur�rrrsor '_11�rs. I ne Nlcl;arthyCompanies FaxID:9789880038 To:Capizzi Home Improvement Inc Date:4/6/2004 01:59 PM Page:1 of 1
CORD CERTIFICATE OF LIABILITY INSURANCE OP ID DATE(MM/OD/YYYY)
PRODUCER CAPI Z—1 0 4/0 6/0 4
Norcross & Leighton Cape Loc. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATI
C.J.McCarthy Ins.Agency,Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
437 station Ave HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
So-Yarmouth MA 02664 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOV 1.
Phone:508-394-0946 Fax:508-760-1407 INSURERS AFFORDING COVERAGE INSURED NAIC#
INSURER A: National Grange Mutual Ins. Co
INSURER B: Guard Insurance Group
Cd i z Z i Home Improvement Inc. INSURER C:
16 5 Newtown Rd
COtuit MA 02635 INSURERD:
COVERAGES INSURER E:
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.
LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE('E
GENERAL LIABILITY m') 704
MWDD/t'Y) LIMITS
A X COMMERCIAL GENERAL LIABILITY MPS02733 EACH OCCURRENCE $1000000
04/O1/04 /01/05 PREMISES(Eaoccurence) $500000
CLAIMS MADE X❑OCCUR MED EXP(Any one person) $10000
PERSONAL&ADV INJURY $1000000
GENL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2000000
POLICY PRO- LOC PRODUCTS-COMP/OPAGG $2000000
JECTAUTOMOBILE LIABILITY
A ANY AUTO M9S02733 COMBINED SINGLE LIMIT $2S000O
01/31/04 01/31/05 (Ea accident)
ALL OWNED AUTOS
X SCHEDULED AUTOS BODILY INJURY $
X HIRED AUTOS (Per person)
X NON-OWNEDAUTOS BODILY INJURY
(Per accident) $
PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY
AUTO ONLY-EA ACCIDENT $
ANY AUTO
OTHER THAN EA ACC $
AUTO ONLY: - qGG $
EXCESSIUMBRELLA LIABILITY
EACH OCCURRENCE $1000000
A X OCCUR CLAIMSMADE CUS02733 04/01/04 04/01/05 AGGREGATE
DEDUCTIBLE
$
X RETENTION $�,0000 - $
WORKERS COMPENSATION AND
$
B EMPLOYERS'LIABILITY X TORY LIMITS ER
ANY PROPRIETOR/PARTNER/EXECUrIVE CAWC401043 01/01/04 01/01/05 E.L.EACH ACCIDENT $100000 \OFFICER/MEMBER EXCLUDED?
If yes.describe under E.L.DISEASE-EA EMPLOYEE $3.00000
SPECIAL PROVISIONS below
OTHER - E.L.DISEASE-POLICY LIMIT $500000
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
-----1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR
REPRESENTATIVES.
AUTHORIZED RESENTATIVE
ACORD 25(2001108) CORD ORP.RATION 198E
i
✓��s �onro,ra�r�uea�U o/:/f�.aeoac�waelta
�X
Board of Building Regulations and Standards
IiOME IMPROVEMENT CONTRACTOR
'���J'S•.�/� Registration: 100740
zr=�` Expiration: 6/23/2004
Type: Private Corporation
CAPIZZI HOME IMPROVEMENT,1
Tclomas Capizzi,jr.
1645 Newton Rd.
Coluil, 02635 Administrator
i • v
:.... 'R ✓/tC �09)r/IltO'Irl!/CIlG[IL 6�✓VGCLdd�GlUJP.�6
I
I BOARD OF BUILDING REGULATIONS
1
License: CONSTRUCTION SUPERVISOR
Number:GCS 057032
Birthaate-09721i11963
Ezplre§ 09/2l/2d05 i r.no: 7171.0
Restrict: 00
i TIHOMAS X CAPIZZI JR !�:
1645 NEWTOWN RD. � 1
COTUIT, MA 02635 Administrator
9
f. i
The Commonwealth of Massachusetts
Ueparlttreit[of Industrial it ccidettts
_- 600 Washington Street
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
uniti,
• !�.►�}
name: �"f i4�wtG� �a/��l Z'�I ^`rewi■• K
location: ?
city phone#
I am a homeowner performing all work myself.
I am a sole proprietor and have no one working in any capacity
I am an employer providing workers' compensation for my employees working on this job.
company name:
�A
3
phone
insuranceT u C*-- d ::-Jf t ef tic - policy
tom.,
❑ I am a sole proprietor,general contractor,or homeowner(circle one) and have hired the contractors listed below who h:,.:
the following workers'compensation polices:
comnanrname•
address
situ.-:: : ' : _
phone ft:.
tnsarantea o policY#'
company:name•
city. phone#•
insuranccco: policy#
Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to$1.500.00 andiu*
one years'imprisonment as well as civil penalties in the form of it STOP WORK ORDER and a fine of 5100.00 a day against me. 1 understand that a
copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
t do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature Date
n (�
Print namc� t[.Z,t�,.� -�� i'�L �� �1.. Phone#
oWcial use only do not write in this area to be completed by city or town official w
city or town: permit/license 1$ rlBuilding Department 4t;
C]Liccnsing board
0 check if immediate response is required []Selectmen's Office F,
Health Department`
contact person: phone#, nOther `
d
1
(rc ised 3/95 P1AI - - +
•. 1 I -, 1. 1 I I .
03/19/u3 l. WFJ) 09:39 FAX 6036279559 HAHVFY INbL15'I'RIE5 IIXANNI5 4PHSE Ir1JUl11
own
ENEnny 8WARpArtT NEtfil .„ IGOBDa�
TEST RESULTS
Harvey Manufactured Windows and Doors
U-Values in accordance with NFRC-100 • B."ed on re5idenlial sizes
• U- and R-Values are subject to change without notice • Whole window values
• Air infiltration results are subject to change without notice
All vinyl windows with Low-EIA19011 gUalify for the FNF_naY Smnr program throughout the U.S.'
Revised 1131103
Clear Insulated Luw=1: Low-F,/A,rgon° All-
U-VA1ue R-VAIge U-Valu01 R-Vatue U-V*1110 It-vIrto I"6111.1liun
�LtCIYL WIMp�a�rs. rfllilr
Classio Double Hung (Mechanical) 0.50 2.00 0.37 2.70 0.34 2.94 .0
Classic Doouble (-lung (Welded Sash) 0.60 200 0.36 2.78 0.33 3.03 .04
Classic Double I-lung(Welded Sash$ rarne) 0.49 2_04 0.36 2.78 0.33 3.03 .10
Classic Acoustical Double Hung STC40 0.23 4.35 0.18 5.56 U.17 5.88 .00
Signature Double,Huny (Mechanical) 0.50 ' 2.00 0-37 2.70 0.34• - 2.94 .04"
y ignature-Double-Fig-rig (vVetdednaas}r)- U.50 2.00 U.37 2.70 1 0.3 .94 .11
r
)Slimline Uouble Hung (Welded Sash) 0.51 1.95 U.38 2.63 0.34 ' .2.94 .08
Slimline Double Hung(Welded Sash R rame) 0_50 2_UU 0.38 2.63 0.35 2.86 .09
Slimline Single Hung (Welded Sash 1 rams) 0.50 2.00 0-38 2.63 0.35 2.86 .08
Vinyl Casement/Awning 0.47. 2.13 0_34 ;2.94 0.31 3.23 .01
Vinyl Casernent/Awning and Thermstl Pairml 0.31 3.23 0.25 4.00 0.24 4.17 .Ul
Vinyl Designer Shapes 0.49 2.04 0.34 2.94 0.30 3.33 -
Vinyl I lopper U 47 2.13 0.35 2.86 0.32 3.13 .08
Vlrtyl Plr:ture winrtow 0.46 2.17 0.31 3.23 0.28 3.57 .01
Vinyl Welded DeAdlite 0.50 9.00 0.34 2.94 0.31 3.23 --
Vinyl Roller- 2-Lite and 3 Lite U.50 2.00 0.36 2.78 0.33 3.0:3 .ue
(2-lile)
b'Iesl resull�,8rt basq(I on commwci.3l 51tRS
Temp.Clear Temp Low-6 'Temp,Argon
U-1'"Itic R-Value II-Value R•Volut U-VAlua RNAlu! Ir1lih rill!fill
rr,rvrr-
P.LL9JP_QQJA `
Harvey Solid Vinyl Patio Dour 0.49 2.04 0.40 Z.50 0.31 2.70 U9
Air itlflitratlon is in accordance with ASTM E283(U.025 mph.
*the use of tempered Low-E glass moy effect ENERGY SInR•quallflcatiun.in your region. ,
U-and R-Values are subject to change Wit!foul notice.
R
CAPIZZI HOME IMPROVEMENT INC . 2� ��
SPECIFICATIONS AND ESTIMATES PAGE 6 OF 6
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 INC.
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 CO
SIGNATURE OF OWNER:
OWNER'S ADDRESS:
OWNER'S TELEPHONE:
LESSEE'S SIGNATURE:
LESSEE'S ADDRESS:
LESSEE'S TELEPHONE:
APLLICANT'S SIGNATURE:
APPLICANT'S ADDRESS: 1645 NEWTOWN RD. , COTUIT, MA 02635
APPLICANT'S TELEPHONE: 5081428-9518
RESPONSIBLE OFFICER:
RESPONSIBLE OFFICER ADDRESS:
RESPONSIBLE OFFICER TELEPHONE:
I
ACCEPTED BY DATE
THIS PAGE IS" PART OF AND IN CONFORMANCE WITH PROPOSAL #
N
BGKU
S
C�
.. � -
Af , b 657 Main Street
- .. Unit 6
Route 28
out
September 23; 1999. West Yarmouth, MA
02673
Town of Barnstable;Buildiri
g Tel: 5o8-778-8919
Department Fax:5o8-778-8966
367 Main Street'
Hyannis,MA,02601,` 4
RE .' 103 Long Beach Road—:Do iriick.Gautrau property=House remodeling.- "
Expansion � L
Dear Mr:Crossen,
The purpose'of my letter,is to clarify my-previous conversations with you and
your staff,:pursuant:to the proposed addition to and the,remodehng of the Gautrau,.~,
property at`103"Long Beach:Rgad in Centerville _
''Based on my understanding of our:meeting, the;Gautraus'will'be able to construct
an-addition to their existing home,without vertically extending either'foundation to°
s' 100 year flood level provided'the;total value bf.improvements to the,house:does, :;
not exceed�50% of the market value m any calendar year
?' We further understand that the Town of'Bar'nstable assessors valuatiori or.a certified
real est ate appraisa1 can b' used to determine the house,value..,
"Because the'owners are in the perinI ing process for the protect as above captioned;
we ask that the;building-department advise at once if the information"provided m`this
letter does not accurately representyour understanding-of the state building code
reouirementsin_coastal•flood zones•pursuant to.expansions
Should you heed further cl nfication please call me at B'SC m Norwell at 78`1-659 7981
Sincerely,yours,' - F
Engineers
Norman W :Hayes Environmental
Project Director, t
Scientists
Associate
= GIS Consultants
cc. .Dominick: Judith Gautrau Landscape
`= Architects
103 Lorig:Beach Road• i_
`r
Centerville; MA' 026321
} Planners
s
" Surve or_