Loading...
HomeMy WebLinkAbout0062 CROCKERS NECK ROAD 6,z r^la�i,f +��, `?n �. ii INSULAT ON, I I4f401g5S 5[q M1135 SP4gT IOgM fU5PfN0L0 Bglf} OU LLI4f IRSUI'L[ION'.u.¢{61/1NUS�Ay�_ 1-800-696l'6641N Town of Barnstable Regulatory Services Building Division 200 Main St Hyannis, MA 02601 Date: Dear Building Inspector Please accept this Affidavit as documentation that Cape Cod Insulation, Inc. performed & completed the insulation and weatherization work at the property listed below. Cape Cod Insulation did this in accordance to the specifications listed on the building permit application. All work has been inspected by a certified Building Performance Institute '(BPI) inspector. All work preformed meets or exceeds Federal & State Requirements. Property Owner Property Address Village Insulation Installed: Fiberglass Cellulose R-Value Restricted Unrestricted Ceilings ( ) ( ) ( ) ( ) ( ) Slopes ( ( ) ( ) ( ) ( ) Floors Walls GN�re�� CVOr !� Fwr)rOr,41 Sincerely VHry E ssi r, President Ins ation, Inc. TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map J Parcel ® � Application Health Division Date Issued S i Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis Project Street Address Village _ Aui k Owner C�� ��f,� ���'� Address Telephone �"7J ,� .44 / Permit Request IyA l 1zi Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation oU144 z9 Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family „ I Two Family ❑ Multi-Family(# units) Age of Existing Structure Historic House: ❑Yes ANo On Old King's Highway: ❑Yes >No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other _ Basement Finished Area (sq.ft.) Basement Unfinished AreaCD (sgft) Number of Baths: Full: existing new Half: existing CD -new Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Room Counter c- c� Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name Csh"v C;d C��S��, r� Telephone Number it ZY2 91 f I/-- Addressf ��� (�/�� License # D to � Home Improvement Contractor# Email Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE t - i FOR OFFICIAL USE.ONLY APPLICATION# DATE ISSUED MAP/PARCEL NO. ,t ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION a FRAME INSULATION FIREPLACE ,s ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. 4 t r r A mass save caarRacnoR PERMIT AUTHORIZATION FORM I, CATHERINE L:LOGAN ,owner of the property located at: (Owner's Name,printed) 62 Crocker Neck Rd BARNSTABLE (Property Street Address) (City) hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed below to act on my behalf and obtain a building permit to perform insulation and/or weatherization work on my property. X . Owner's Signature . d-ei T Date FOR CSG OFFICE USE ONLY Conservation Services Group has assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: CAPE �00 Participating Contractor_ Date T CI�rO • - Did For office use only Rev.12132011 ;. 7 he Commonwealth of Massachusetts Department of Industrial Accidents , t Office of Investigations I> 600 Washington Street , Boston, MA 02111 www,mass.gov/dia Workers' Compensation Insurance Affidavit: Build ers/Contractors/Electricians/PIumbet-S Applicant Information PIease Print Y,e�ibl', Name (Business/Organizadonflndividual): -� a, C/100, Address: 10 avG'l 6l/l & City/State/Zi :eT ` AV �/l/l,b�( ���� Phone#: Are you an employer? Cheek he appropriate bor.: - 1. I am a employer with 4; ® I am'a general contractor and I Type of project(required): employees (full and/or part-time).* have hired the sub-contractors . 6. 0 New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. [] Remodeling ship and have no employees These sub-contractors have g,'[] Demolition working for me in any capacity, employees and have workers' [No workers' comp. insurance comp. insurance.t 9. LL[� Building addition required;] We are a corporation and its 10.© Electrical repairs or adr{;ror:_, 3.❑ I am a homeowner doing all work officers have exercised_ their . ( 1.[� Plumbing repairs or adeitot myself. [No workers' comp., right of exemption per MGL insurance required.] t c. 152, §1(4), and we have no 1,1qRbof repairs 3a.❑ I am a homeowner acting as a employees. [No workers' 13. Other general contmctor(refer, to 44) — - --� -------- comp.'insurance required-]. Any applicant that checks box#1 must also fill out the section below showing their workers'co satiou` li t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors mustsub�new affidavit indicating such. tContracton that check this boz must attached an additional'sbeet showing the name of the sub contzactom and state whether or not those entities hxvc 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 information. my employees. Below u the policy a�rd jubeY,r� -- ( , r� Insurance Company Name: 'C� � Policy#or Self-ins. Lic. #:__L�O / -2.I Expiration Date: Job Site Address: e /__Y ?ityy/,9/_tat/e/Zip:_,1" Attach s copy of the workers' compensation policy declaration page (showing the policy number and expiration date). s Failure to secure coverage as r g equired.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 fin of up to$250.'00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi , un the pains and penalties of perjury that the information provided above is true and correct ^ ^ S 1 a � Date: ° Phone 9- Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/Liceuse # a Issuing Authority (circle one): I. Board of Health 2. Building Department 3. Cityrrow❑ Clerk 4. Electrical Inspector 5.'Plumbing Inspector I 6. Other Contact Person: Phone #: From:Rogers&Gray InsuiaFax: To: +16087786736 Fax: +16087785.735 Page 2 of 2 03/30/2015 10:04 Afvt •��� ` r CAPECOD-217 ,BDEUAWRk NCE CERTIFICATE OF LIABILITY INSURANCE DAT130/2 15 ' 3130/'1.015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. 1:HIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER•THE COVERAGE AFFORDED BY THE POl_ICIF:E; BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZE:() 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, Subjeci 10 j the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer fights to the certificate holder in lieu of such endorsement(s).' PRODUCER - ^CONY CT _ ------ --- NAME: Rogers&Gray Insurance Agency,Inc: r PHONE 434 Rte 134 rarc No Exn Fax• South Dennis, MA02660 arc No: (877)816 7."156 EMAIL ,. - - ---5 --'- • - ADDRESS: - - ` - 'INSURER(S)AFFOROINGCOVERAGE - HAIC INSURER A:Peerless Insurance Company-.see LIBERTY MUTUAL - INSURED y - "INSURER B:SAFETY INSURANCE COMPANY 394 54- ' Cape Cod Insulation,Inc. INSURER c:Endurance American Specialty Ins. Co. _I 18 Reardon Circle South Yarmouth, MA 02664 w R suRERD:ATLANTIC CHARTER INSURANCE GROUP I s -INSURER E 114SURER 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 PE:EiIC:G ^` INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF'ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO W� ilC1 i I ;IS i CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THc TER1,AS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INS LTR - - _ POL EFF PO ICY P - ------TYPE OF INSURANCE - �- POLICY NUMBER..- MMIDDNYYY MM/DD/YYYY _. LIMITS _ A X COMMERCIAL GENERAL LIABILITY - - - -------------_-- EACH OCCURRENCE y, 1,000 OOQ t CLAIMS-MADE a,OCCUR - CBP8263063 04/01/2015 04/01/2016 11TE ----- 1p0,�(")Qt.PREMISES Ea occun'ence MED EXP(Any one person) —— 5,000. - PERSONAL&ADVINJURY i - 1,000 OOCi, GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE X POLICY a PECT LOr_ ---- - PRODUCTS c COMP/OP AGG S' 2,000,000, OTHER: g AUTOMOBILE LIABILITY - —COMBINE D SINGLE LIMIT 1,.... G Ea accident B ANY AUTO TBD 04/01/2015 04/01/2016 BODILY INJURY(Per person) 1 1 ALL OVNVED X SCHEDULED AUTOS AUTOS `BODILY INJURY(Per acci(ent) .5 X NON-OWNED X HIREDAUTOS AUTOS - PROPERTY(DAMAGE q ' Per accident X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 2,000 0001 C EXCESS LIAB CLAIMS-MADE EXC10006635000 - 04/01/201504/01/20.16 AGGREGATE g DED I X I RETENTION$ 10,000 Aggregate 2,UOU 0001 WORKERS COMPENSATION •, PER OTH- -- AND EMPLOYERS'LIABILITY STATUTE ER _ f D OFFI ANY CERIMEMBER/EXCLUDED�ECUTIVE Y] N/A WCE00431900 06I30/2014 06/30/2015 E.L,EACHAcaDENT $ 1,OOr)DUu (MandatoryinNH) � -- - -• If yes,describe under - - - E.L.DISEASE-EA EMPLOYEE% 1,000,000- DESCRIPTION OF OPERATIONS below' E.L.DISEASE-POLICY LIMIT $ 1,000,00Q. DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if more space is required) - — Workers Compensation includes Officers or Proprietors. Additional Insured status is provided under the General Liability and Auto Liability Wien required by written contract or agreement with the Certificate Holder. i CERTIFICATE HOLDER -'-- -- • CANCELLATION - SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED LifT OR Cape Cod Insulation,Inc, THE EXPIRATION DATE THEREOF, NOTICE WILL BE' DELIVER[:[).Iti 18 Reardon Circle ACCORDANCE WITH THE POLICY PROVISIONS.. South Yarmouth, MA 02664 .' AUTHORIZED REPRESENTATIVE -- -- �� ©1.988-2014 ACORD CORPORATION: All rights i(,soi vecl. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD ell . Office of Consumer Affairs and Business Regulation ` 10 Park Plaza - Suite 5170 Boston, Massachusetts 02.1 lb Home Improvement Contractor Registration Registration: 153567 Type.: Private Corporation Expiration: 12/15/2016 TrA 259188 CAPE COD INSULATION, INC HENRY CASSIDY 18 R E A R D O N CIRCLE _...----._--------.--__._.-- _ SO. YARMO.UTH, MA 02664 Update Andress and return card. Mark reason for c:htui c. (� Address .,Renewal ❑ Employment F_j L:o C,1rd SCA 1 :i 20M-05/11 - - - V/ie�oarao�ic�racrrcrr.�C�p�C�/fla��ac�ulelri ' ter\ Office of Consumer Affairs& Business Regulation, License or registration.valid for indiviciui use only .. before the expiration date. If found return to: HOME IMPROVEMENT CONTRACTOR �— registration: 153567 Type: Office of Consumei Affairs and Business Regulation ?,_! /= 10 Park Plaza -Suite 5170 Private C�Q��;Explration: .12/15/201.6 i ale _ Boston, NIA 02116 CAPE COD INSULATION, INC HENRY CASSIDY 18 REARDON CIRCLE gam= -6s i v SO.YARMOUTH, MA 02664 llndcrsecretary N� valid wi }�i1 sign e T Massslchusel s " B'eparlment of,'�' lublic Safely �. 8o1ard of BulldiiicJ Regulations g s and Sfandarcls " Cun.etructlnnSuhcriiscir License: CS-100988., H2NRY E CASSIDY jk 8 sHEDRowW> ST.YAR 0TI-H t;, �� '� Expiration Comnaissioner 11/11/2015 . 5 DIME► Town of Barnstable *Permit dOIN&J3P Expires 6 months from issue date Regulatory Services Fee 3;=' • BAMRN ner e, � 11 MASS.. ��� - . Thomas F.Geiler,Director AlED h1Ar A Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint' Map/parcel Number Property Address 2. C ij 0 C//Pt,S Ne C/C Rp t'O-IU.4, M.4 Residential Value of Work y� Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address C jz-eviNG 0�^/,✓ oCf)I-Q �, M4 d x( 9,v Contractor's Name 3 0 hsV S-1 vu l�vl S Aft Telephone Number 5W Home Improvement Contractor License#(if applicable) 1 n.17 / 0 Construction Supervisor's License#(if applicable) C 5; 7 [/Workman's Compensation Insurance ��,,,��_ } Check one: X-PRESS PERMIT ❑ I am a sole proprietor I am the Homeowner m A 2 [ YI have Worker's Compensation Insurance i.l 1 �¢ Cce �eel-t q C 4V 1144 1 OWN CIF 13ARNSTABLE Insurance Company Name �/ Workman's Comp.Policy# Alty C G 41. fr 3 .Z Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) j ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) 4/urx,,,? 7r-1;7t c ovex4je, Gh Yp-ev r�a/cPo,j��„�«a��t', l�c�vr�e✓�vr� ; y s��f� 0 Re-side Uyle eao ,X heer.e /Vegt t�riveuJsy � Ateil CPU.-y #of doors ❑ Replacement Windows/doors/sliders.U-Value (maximum.35)#of windows 'Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. opy of the Home Improvement Contractors License&Construction Supervisors License is quire SIGNATURE: C:\Users\decollMAppD roca l\Microsoft\WindowsUemporary Internet Files\Content.Outlook\DDV87AAZ\EXPRESS.doc Revised 072110 ulau;o.t'uusu,nerniiairs&business xegmanon License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Office of Consumer Affairs and:Besiness Regulation Registration:i::1..... Type: 10 Park Plaza-Suite 5170 •* ' ` Expiration _612312012 . Su leinent Card PP Boston,MA 02116 CAPIZZI HOME IMPROVEMENT-INC. JACK STRUNSKI: > 1645 Newton Rd. �� — Cotuit, MA 02635 Undersecretary Not valid without signature iINlassachusetts Department of Public S:ifet, Board of Buildin-,Rey *ulations and Standards Construction Supervisor License License: CS 64817 ..JOHN T FSTRUMSKI ;{ PO BOX BUZZARDS BAY,<MA 02532 Expiration: 6/18/2012 _ Contrnistiiurier- Tr#: 10573 • i • j i Client#:47298 CAPIHOM ACORD. CERTIFICATE OF LIABILITY INSURANCE DATE(M 2o1;m) 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 - NAME:CONTACT Karen Walther Rogers&Gray Ins.-So.Dennis PHONE 508 398-7980 F 434 Route 134 F-MCANL Fps: A/c,No P.O.Box 1601 ADDRESS: waltherka@rogersgray.com PRODUCER CUSTOMER ID#: - - - South Dennis,MA 02660-1601 INSURER(S)AFFORDING COVERAGE NAIL# INSURED INSURER A:National Grange Insurance Co. Capiai Home Improvement,Inca INSURER B:ACE Property&Casualty Ins.Co Capiai Enterprises,Inc.. - - - INSURER C: - 1645 Newtown Road Cotuit,MA 02635 INSURERD 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 DL UBR - -- POLICY EFF POLICY EXP L .POLICY NUMBER MMIDDNYM (MMIDOfYYYYl LIMITS - A GENERAL LIABILITY MPB1075H 06/08/2010 06/08/2011 EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED - PREMISES Ea occunence s500,000 CLAIMS-MADE 51 OCCUR - MED EXP(Any one person) $10,000 - PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: - - - PRODUCTS-COMP/OP AGG $2,000,000 POLICY JFQT PRO LOC $ A AUTOMOBILE LIABILITY - BPO10786 06/08/2010 06/08/2011 COMBINED SINGLE LIMIT A' ANY AUTO M1M28044 06/08/2010 06/08/2011 (Ea accident) $500 000 BODILY INJURY(Per person) $ ALL OWNED AUTOS - - BODILY INJURY(Per accident) $ - X SCHEDULED AUTOS PROPERTY DAMAGE X HIRED AUTOS (Per accident) $ ' X NON-OWNED AUTOS U1 $2501500,000 X1 Drive Other Car U2 $250/500,000 A UMBRELLA LIAB X OCCUR CUB1076H 06/08/2010 06/08/2011 EACH OCCURRENCE s5,000,000 EXCESS LIAB CLAIMS-MADE - AGGREGATE s5,000,000 - DEDUCTIBLE $ X RETENTION 10000 - $ B WORKERS COMPENSATION NWCC45843208 12/25/2010 12/25/2011 X WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N - ANY PROPRIETORIPARTNER/EXECUTIVE - - E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? ❑ NIA - ,(Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under - - DESCRIPTION OF OPERATIONS below - E.L.DISEASE-POLICY LIMIT 1$1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) - - Workers Comp Information Included Officers or Proprietors CERTIFICATE HOLDER CANCELLATION 10 Da Vs for Non-Pa ment SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Town of Barnstable ACCORDANCE WITH THE POLICY PROVISIONS. 200 Main Street Hyannis,MA 02601 AUTHORIZED REPRESENTATIVE 0198 -2009 ACORD CORPORATION.All rights reserved. ACORD 25(2009/09) 1 of 1 The ACORD name and logo are registered marks of ACORD #S61971/M61970 MEE Page 7 of 7 CAPIZZI HOME INTROVEMENT INC. SPECIFICATIONS AND ESTIMATES STATE OF MASSACHUSETTS LETTER OF AUTHORIZATION TO APPLY FOR A BUILDING PERMIT OWN THE PROPERTY LOCATED AT 2 C/f 0` kett S Alec K Rq IN C©-�vlv , MASSACHUSETTS. / J I HAVE AUTHORIZED CAPIZZI HOME IMPROVEMENT TO ACT AS MY AGENT TO APPLY FOR A BUILDING PERMIT IN ACCORDANCE WITH 780 CMR, THE MASSACHUSETTS STATE BUILDING CODE. I GIVE MY PERMISSION TO LESSEE TO APPLY FOR A BUILDING PERMIT IN ACCORDANCE WITH 780 CMR, THE MASSACHUSETTS STATE BUILDING CODE. SIGNATURE OF OWNER: OWNER'S ADDRESS: OWNER'S TELEPHONE: 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: le x5 RESPONSIBLE OFFICER ADDRESS: RESPONSIBLE OFFICER TELEPHONE: The Commonwealth of Massachuse& Department of Industrial Accidents Ogee of Investigations 600 Washington Street Boston,MA 02111 www mangov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant.Information Please Print LePibly Name(BusineWOrganizati(3nRndividual): n i 22P w o nle .-L me t-v iJ-etine'^j Zv Address: 4 S� A t ujah uj p, IZ p City/State/Zip: C o-4-v i♦i M q 6205' Phone#: 3 0J�- Y.Z t q 51191 Are you an employer?Check the appropriate box: Type of project(required): 1. am a employer with 40 -4- 4. ❑ 1 am a general contractor and I 6. []New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ 1 am a sole ro oetor or partner- listed on the attached sheet. 7. ❑Remodeling P P. ship and have no employees These sub-contractors have g: 0 Demolition working for are in any capacity. employees and have workers' o workers'co coin insuraace.i 4. C]Building addition [N comp. P•. required.] 5. ❑ 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 l.❑Plumbing repairs or additions myself..(No workers'cote. right of exemption per MGL 12.❑�oof repairs insurance required.]t c. 152,§1(4),and we have no j3.. ther�dl rYt !a dC/l it ? employees.[No workers' f comp.insurance required.] d 6 k 'Any applicant that checks box el must also fill out the sectica 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 mitre of the subcontractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. 1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. n Insurance Company Name: C�' C''v t lip C+4 S u4 L4 y CC. q5� q 3Zt�� Policy#or Self-ins.Lie.#; Expiration Date: i J 011 Job site Address: A CiZ D ClL-P✓ Neck 1?N City/State/Zip: �o:Fy. 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 S250.00 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 under the pains and penalti f perjury that the information provided above is true and correct Sianature: s--� Date: G Phone#: U SO a2 cl 518 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.Braiding Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing In . 6.Other Contact Person: Phone#:` Assessor's map and lot number ......U:a .........................Q � n f 11 V j .:`^�'�-.ter L ypi THE t0 Sewage PermFtUn'umbe ..1�. /.,. (. .. '?� �l` �j 1 J B9Hd9TL8L i ,House number - r�9 'FO YPY d� TOWN OR BARNS{TABLE BUILDING INSPECTOR . , APPLICATION FOR PERMIT TO ......4.0D..M Q..EXri.5 ..INCL...TAF,T,.+.I,a,A T........................................................ TYPEOF CONSTRUCTION .............ACCa1.)...FRAN............................................................................................. ......... ..z ... ..3. gRq.19........ TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location .........62...Qropke.r...Rf'ak.;Road..!�A1v It.Xa.e........... ProposedUse ....Emily..x'cvm............................................................................................................................................ ZoningDistrict ..RZI...............................................................Fire District .otu t............................................................ Name of Owner ......Address ...62... rackex:.. P:f-k'...f''�..C?ad.......Ont,v_J.t. asse + Name of Builder' .Qharle.s... ...Ra,T bI.J.a......................Address .. I.��.�..I ewt,QwX,3,.R��.�.R...�O�t��� Nameof Architect ....... .On.?.................................................Address ........../A.a................................................................. Number of Rooms .......... ................ ..................................Foundation ....................................... Exierior ...: 1 tG„CG,C ..S f�,Xl �4. ............................Roofing .....ftp I�„Sr17 T1fZ1,G',5.............................�..... Floors (r'1X"Kjet1.......................................................Interior ..... x'vWAll...... ...................................................... Heating ......k{A „we ...................................................Plumbing ...N=A.................................................................... Fireplace .......N.n .............................................................. ........Approximate Cost ............................................. Definitive Plan Approved by Planning Board -----------_______-----------19_______. Area ...M...P .,. £t.p........... Diagram of Lot and Building with Dimensions Fee .... 0, 00 SUBJECT TO APPROVAL OF BOARD OF HEALTH � c 1 f p�1 1 p; s 1 3 ` 71 a. OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. j 'Ivz I I ` Name .. .:� . .�� ..,d.. ...... SCUDDER, EDSON & PRISCILLA A=020-095 No A.112.Q.. Permit for ..Build...Addition ...........Single...Family. . ...Dwelling ............... .. .... ....... .. Location 62 Crocker>'Neck Road ................................................................ Cotuit ............................................................................... Owner ...Edson....&....Priscilla...Scudder ..... ....... . .... .. .... .. .... .. .. ............ Type of Construction ...Frame.......................... ............................................................................... Plot ............................ Lot ................................ Permit Granted ........ .........19 89 Date of Inspection ....................................19 Date Completed ......................................19 AD f _ Assessor's map and lot Qumber ...:...U,a... ....... .,: `L FTNEr g �vnc SYSTEM anu c c� Selvage Permit" mb1r .. .. �. INSLJ�6�f�lr� douse number ...............................�ia.. ... . BASd9T118L rnas Op •63q. \� ON a` TOWN ! OF BARNSTABLE BUILDING *. INSPECTOR APPLICATION FOR PERMIT TO ?...................................... TYPEOF CONSTRUCTION ...............WQQ.]p.. E....'.:.................. ...................................................................... .........kU9=t.....3,1. �.19........ TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location .........62...Cro.cXe ...Re k...Road..QQ.Uit...�a.•........... f !2 ProposedUse JI .F=Uy....r.QQM.. ............ ................................................. ................................................................. Zoning District ..REq:............:.................................................Fire District &.0tilis............................................................. Name of Owner E .Son...&1?risci.11a..Seudd-r......Address ...62...Cracker... eak.-Road.,....C.otu].a,.—Mass. Name of Builder" .Gharle.S...Z.r.H8Xb1 r1......................Address ...1.7.2.6...�.�19►t.QY9xJ..�Qr�da...ri.Q�kl7.ta...�a�S• Name of Architect .......Rorie.................................................Address ..........IV&a.............................................I.................. Number of Rooms ..........I. .....................................................Foundation ... ....................................... Exterior ....Malte...cedar...OXIX191 S............................Roofing .....:AS.Phall...ghingl?5..................................... Floors .............rrarpeting....................... ............. ...Interior ......L)r�mu............................................................ HeatingHSJ ..!Ka .eX .....:...:..:.........:............................Plumbing ...None.................................................................... Fireplace .......lY. ..........Approximate Cost ...2IO.QQ CD Definitive Plan Approved by Planning Board -----------____—-------____19---_--- Area ....2$8...S.q.•:...ft.a.......... Diagram of Lot and Building with Dimensions Fee ....$5Qr QO......................... SUBJECT TO APPROVAL OF BOARD OF HEALTH y � 1 OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above /a construction. a � l ..me .. .. .. �� Na ................................ SCUDDER, EDSON & PRISCILLA _ 33.1205 BUILD ADDITION No .... ........... Permit for ....... ........................... _ Sin le Famil Dwellin - ............g.....................X.....................�.............. Location ....62 Croc. . kery.Neck. .... ........ Road ±�= F .. ..... .. .. .......... ..... .... .......... otuit `i ................................................... ................ _i Ci; t'� ..t'.,, - i•S - - $ Owner ..Edson & Priscilla Scudder _ Type of Construction .......................................... s. .......................................................... Plot r .. ..................... Lot `;a n - w Atl tlSt r Permit Granted �. ....:: r..::.....:19, 8 9 ' Date of Inspection .......Y: .......... ......19 Date Completed .... j. ,................... ..... .... 19 U C) 7-3 r 1 C> t: 0. VS t a � Assessor's Office(1st floor) Map Parcel ermit#- Conservation Office 4,th floor 8:30-9:30/1:00 2:00 - Date Issued —� ( )( _) Board of Health(3rd floor)(8:15 -9:30/1:00-4:45) i ~. Fee . Lti Engineering Dept.(3rd floor)• House# t lie Planning Dept. (1st floor/School Admin. Bldg.) Definiti Pln A app ved by Planning Board 19 a - rfD MAy� TOWN OF,BARNSTABLE' Buildin Permit Application UProjec et Address Village Y � � fJ'6 3-S "Owner Address �-, Telephone Permit Request '�C e�JF 0,gKzjy2 i ,First Floor square feet Second Floor square feet Estimated Project Cost $ , e9aO Zoning District Flood Plain Water Protection Lot Size Grandfathered ? Zoning Board of Appeals Authorization Recorded Current Use Proposed Use Construction Type Ge_l00,t> Commercial Residential Dwelling Type: Single Family Two Family Multi-Family Age of Existing Structure Basement Type: Finished Historic House /1/6 Unfinished Old King's Highway ,/4 Number of Baths No. of Bedrooms Total Room Count(not including baths) First Floor Heat Type and Fuel Central Air Fireplaces Garage: Detached Other Detached Structures: Pool Attached Barn None Sheds Other Builder Information Name dle a /= Telephone Number Address /�y,�/4;?, iw "d�� �j?T/> License# Home Improvement Contractor# %:�,07PIp Worker's Compensation# D8 elAle i l NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE BUILDING PERMIT DENIED FOR THE FOLLOWING REASON(S) r FOR OFFICIAL USE ONLY , PERMIT NO. l V f DATE ISSUED t MAP/PARCEL NO. . i ADDRESS } VILLAGE OWNER , DATE OF INSPECTION: FOUNDATION E ► a _ FRAME = i _ f ra _; • y i .. i INSULATION � z ► y _ _ FIREPLACE ' t ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL _GAS: ROUGH FINAL F FINAL BUILDING r r r i i DATE CLOSED OUT ASSOCIATION PLAN NO. ;h„ t The Commonwealth of Massachusetts Department of Indus&ial Accidents .. Oflliao/ler�stlOstliis - 600 Washington Street Boston,Mass. 02111 Workers' Compensation Insurance Affidavit Iotritiorl: ' /A yS' /_ o.i7� 7— �� gol 2 phone 0 1 am a homeowner performing all work myself. ' I am a sole proprietor_-d have no one working in any capacity �m an employer pro%iding workers' compensation for my employees working on this job. comnanv name: address: city- phone#- insurance co. =-Z-7,—,— 4�� po i y it I am a sole proprietor. general contractor,or homeowner(circle one) and have hired the contractors listed below who hay e the followins worker_ compensation polices: comoanv name- Address: city: j1hone tt• insurance co. policy# company name: address: city- phone ff• mail; .10MR ' insnrancs_co. poBev# • a Failure to secure coverage as required under Section 25A of MGL 152 as lead to the imposition of eriasfaai penalties of a flat up to S1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a.STOP WORK ORDER and a flue of S100.00 a day against me. I anderstaad that a copy of this statement may be forwarded to the Once of investigations of the DIA for coverage verification. 1 do hereby cerrify rand rb " 'ns and pep es ojpe ury drat the injormadon provided above it&ue and correct 11010 Signature. ,tin. ' _� - Print name _ ��I/ Phone 9 official use only _do not write in_this area to be completed by city or town official city or town: _ permitAicense 0 riBuilding Department C3Ucensing Board 0 check if is amediate response is required cSeleetmea's Otllee (SOS} ❑Health Department- conta�t person• phone iF Other . Irev.sed 3.15 PJA1 _ ; -,per .. :_.. .. _ . . _. .. _i . . ...__._�_. . -•--•'- -'--- � . . -- -- -.. ._. , l \ ✓/Z6 -(/419�)?OILGJP.QGUZ 0 0 Zl6GP. d I I , HOME IMPROVEMENT CONTRACTORS REGISTRATION oard of Building Regulations and Standards One Ashburton Place Room .1301 -Boston, Massachusetts :021.08 i I . I 'HOME IMPROVEMENT CONTRACTOR I -------- - -------------------------- -Registration 100740 Expiration 06/23/96 r Type — PRIVATE CORPORATION I HOME IMPROVEMENT CONTRACTOR..., I i.Stelstratlea 1O014O I .Capizzi Home -Improvement , Inc . i TYPO -'..PRIVATE CORPORATION- . Thomas -Capizzi , Sr . i -ENpirstion 06/23/96 1645 Newton Rd. Cotuit MA 02635., i Capizzi Nome Improvement, Inc ' Thous Capizzi, Sr. r G� �o W 6y" Newton-Rd. I Am*asT=m .Cotult NA 01635 t - Restricted To: 10 DEF)ARTMENT 1EPARiNENT IF /UBLIC SAFETY ONE ASHBU(: r CONSTRUCTION SUPERVISOR LICENSE I 10 - goat BOSTON, Rider: . Expires: 16 - 1 8 ? Wily Roles CONSTRUCTION SUPERVISOR LICENSE Restricted To: 10 Number: Expires: - �.4z-e- - 1AVID N IEBB Restricted lu: uO ; w<-'.!:--.. r.:.`;:: :; COMWK*Ma 100 PION H011OY RO t, E fALNOUTN, 0 11536 . . . rf•' �rtt� rah.' THOMAS``:X CAPIZZI JR 280 PERCIYAL DR c �t�•9`„-� ; 'W BARN.STABLE, MA O266E3 \ �-_ . : The Town of Barnstable M P Department of Health Safety and Environmental Services, Building Division 367 Main Street,Hyaaais MA 02601 Ralph Crosses O 508-790�Z27 Big Coamissionc: F= 508-775-3344 For office use only - Permit no. Date AFFIDAVIT HOME rWROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the-reconstruction,alterations,renovation,repair;modernization,=ierdon, ed improvement,.mmotial, demolition. or construction of as addition to'any pm building which t building containing at least one but not more than four dwelling units or to strucwres to such residence or building be done by registered contractors.with certain cc=pdons, along with other raluir,cments- T of Work: .Est Cost o©-0 Address of Work: C�e ex7e ale Owner.Name: Date of Permit Application: 3 Zd I hereby certify that: Registration is not required for the following rrason(s): Work cmduded by law Job under SI,000 Building not owner-died Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PR DEALING FOR APPLICABLE HOME NE FLANE E ACCESS TO ME ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c 142A SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the Dynes: Date Contractor narat Registration No. OR ' Owner's name