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HomeMy WebLinkAbout0911 MAIN STREET (COTUIT) / �i� ��! • `� :F ��h'?'a ,,.�„�µ,.es,.r..,.,.,-. � � .'F�. �, .., y:.�. �.+. ,� ,�.�n .. � t�• � ,,. �'. ,.r,_ ..r :...� �.v. �.,P..-i.:�tit"�:xa,++sss�ttyl�r� �,.ua YY M Town of Barnstable *Permit 4-0 Expires 6 months from issue date ' Regulatory Services , FeeMANsrABM ey,5"� ��p�- M Thomas F.Geiler,Director ► '° Building Division Tom Perry,CBO, Building Commissioner \S 1 v 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number O�� Property Address �u X I ` ChA t l Residential Value of Work Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address Enful, Contractor's Name IAA a6kw MtAlephone Number42 -cas Home Improvement Contractor License#(if applicable) l 0© _Iq Construction Supervisor's License#(if applicable) 04O ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor AUG 3 0 2007 I am the Homeowner TOW j� EIARf`JS�A��� I have Worker's Compensation Insurance EV Off' =, Insuranc Company Name Workman's Comp.Policy# � G Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) )Re-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement 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 Proper Owner Letter of Permission. Home Improvement Contractors Li ense is required. SIGNATURE: �P. Q:Forms:expmtrg Revise071405 ;G 2 f HomIe Improvement "I, Gary Gustafson, Produ_ctionmanager Of`Capizz Home Irripfovement, hereby authorize Lisa Haworth, to sign on iiiy behalf for permit apphcatioils filed through theaowl:' x..x ' Signed. - - o�-Z9 Gary Gjtstafso Date: 1645 Newtown Road Cotuit, MA 02635 (508) 428-9518 (800) 262-5060 FAX (508) 428-1547 ` . . Fa �.f CAPIZZ-1 I4tiME TMPROVEMtNT INC. h µ STA.' S OF M-ASSA WCHUS , l A TO:A fM A U;bM PEW OWN TM. � �L F . MAHU . y _ j�T W . TO APPLYFOR, CODE, I Gv P� Q 0 APIs u STATU SIG--N FlO 0 Ny ......... pA � ' '1N ",� SIG CK : Y xv a 3 LESSEE Q� F .M i ij- m� in , � yj^dy ^}Y ON 6 . 4 k LICAN, um r � , ES PIRIB . y roil, r s e i r .?t,. Cliant#:47298 CAPIHOM ACORD, CER1'iFlG�4TE OF LIABILITY INSURANCE DATE(MN(DD/YYYY) PRODUCER 01/09/07 V Rogars,&Gray Ins, Agency,lnc. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLYAND CONFERS NO RIGHTS UPON THE CERTIFICATE 434 Routs 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 INSURED INSURERS AFFORDING COVERAGE NAIC# Capizzi Home ImprOVement,Inc. INSURER.0 National Grange Mutual Ins, Co. Capizzl Enterprises, Inc. INSURER a: American International Gr 1 W Newtown Road INSURER C: Catuit, MA 02635 INSURER D; COVERAGES HJsuRERE . THE POLICIES OF INSURANCE LISTED BELOW HA`,G BEEN ISSUED TO THE INSURED NAMED ABO'JE FOR.THE POLICY PERIOD INDICATED.NOTNITHSTANOING 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 POLICES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, 7V! EOFINSURANCE POLICY EFFECTIVE POLICY EXPIRATION POLICYNUb18ER T I Y AT MI IY 'LIMITS ABILITY MP010707 06/08/06 06/08/07 : EACH OCCURRENCE $1 000,004 RCIAL GENERAL LIABILITY DAMAGE TO RENTED I CLAIr4S tAAOE 0 OCCUR P ,s $500 000 .MED EXF(Any one pmonj $1 O OOO . PERSONAL d ADS/INJURY $1 000 000 - GENERAL AGGREGATE $2,0000.00 GEN'L AGGREGATE UMI7 APPLIES PER: . POLICY ECOT LOC _ - - PRODUCTS.CONPlOPAGO $2,000000- AUTOMOBIL'cLIABILITY - - ANYAUTG - - - COMBINED SINGLE LIMIT $ iEa accident) ALL OWNED ALTOS SCHEDULED AUTOS BODILY INJURY - $ (Per person) _ HIRED AUKS NON-OWNED AUTOS - BODILY INJURY $ (Per acc d_ra) PROPERTY DA?04t•E - (PeraccdeA) _ $ GARAGE LIABILITY ANY AUTO - AUTO ONLY-EA ACCIDENT $. - � - OTHER THAN - EA ACC $ - . AUTO ONLY:- - AGG $ -XCESSIU M BFELL A LIABILITY I - - EACH OCCURRENCE` OCCURI $CLAMS MA - .. - AGGREGATE - $ ir1 DEDUCTIBLE - RETENTION B WORKERS COMPENSATION AND- 1764953 - S $ EMPLOYERS'LIABILITY 12125106 12/25/07 TO AI U,;,_ OTF- -Pry PR - OPRIETO fWA T ft NEt3(EXEC LIT V t E OfFiCERIMETABEREXCLUDED% � - _ - - E.L.EACH ACCIDENT $500,000 If yea,dascrbe under - - -SPECIAL PROVISIONS te'cr E.L.DISEASE•FA EMPLOYEE $500,000 - _ OTHER - E.L.DISEASE•POLICY mirr 3500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES/p(CLU6{ONS ADDED BY ENOORSE(itJvT l SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION - SHOULD ANY OFTHE 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 UABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. - - AUTHORIZED REPRESENTATIVE ACORD 25(2001108)1 of 2 #26435 4 ' 0MW 0 ACORD CORPORATION 1988 r i ne t-ommonweturn of lvcassacnusetts Department of Industrial Accidents �. Office of Investigktions 600 Washington Street �f Boston, M 02111 www mass:gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organizationdndividual): Address: 3-645. Newtown. R.Dad City/State/Zip: Tel. 428 9518180D 262-5060 - one#: , i4re .on an employer?Check the-appropriate bog: Type of project(required): I am a erriployer wrth s 4- [} I,am a general contractor and I employees 6idl and/or part time).* have}ired,tii S6—*contractors ❑ ]Vevr consfiuciion .6. 2.0 I ain a.sole proprietor or partner- hsted on tile.attaeTied sheet $. 7 D gemodeling ship anti have no employees !h6se sub=contractors have 8. .E jDemolition tiv or3Qng.forme in any cap achy. workers'-co rnsiirance. o workers' co. 9. [{Building addition [N MP.insurance 5: Q We are a coaporahonand its .• . , • . y. required:) officers have egerced'tlieir lo• Electnral repairs or additions 3.0 I.an'-a h.ome-owiler doing.alt work lVitbf exemption pei MGi 11.Q PIumbirig repairs or additions myself jTo worke ':coiilp. c 152,§1(4,and wehaveno Roo 12[ insurance requiiecl I t •:empoyees {No workers' comp; sztrancez 13:0 Other- * Y gPP� t 41 Maust also fill but-tile section below showing 211eir workeis'ooxripensafionohcyo�ation t Homeowners who submi#ffiis affidavit mdi"catmg$eyare doing aII work and:ffien hire outside contiactors.uiust submit anew efisdavit mdcatg suclL g ontractors ffiat efieck flusbog must BYtached an Oulu sheet shovv�n fhe:nauie offlie sab contractors cud flies:workeis cou�i policymformatibn f nm an employer that isproviriing workers'compensafian rresur=ee for my Employees $etory is the policy mz�I joi7i site cnformatcor� f t I.nstreance: 30mpapy Nam,P^� 1prf ,,! � i�r (� ✓1 ��p S j Policy#or.Self--ins. Lrc. Exp : ion Date. I S Job Site Address;. City/StatelZip: attach a Copyof the workers _compensation policy declaration page(showing the,.poiicy uuinber and expiration date): a'iliire to.secdre coverage as required antler Section 25A of M*GL c 152.cui lead to the imposition:of criminal penalties of a me.up to$1,500_GO.aud/orone-year imprisonment as well as civil penalties in the fozm of a STOP WORK flRDE 2.and.a..fine iflip to$254 ao a= .:.. _ _ _. w Y�gainst#heoiator. Be advised that"a copy,of tills statement may be forwarded to the Office of nvestigations o f the;DJA for'mi suran e coverage verrlicahon do hereby ce .` under theaires arzd pencrltces of pe ' ry thatIze in-,formation provide above is Ice i�ecf r 1.. .attire: Date: 'hone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/Licease# Xssuing Authority(circle one): 1. Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical inspe 6. Other ctor 5. Plumbing Inspector Contact..Per on:_....__......_....__.._..._..._..:....._ one rr.#......:: _ ----------------._.......-------.... __.. h r - � 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: Registration: 100740 Board of Building Regulations and Standards Expiration:.`6/23/2008 One Ashburton Place Rm 1301 Type:.:Supplement Card.. Boston,Ma.02108 CAPIZZI HOME IMPROVEMENT; t;A Y GUSTAFSON 1645 Newton Rd. ` Cotuit, MA 02635 Administrator t valid with . t si tune g Board of Building Regula ions and Standards One Ashburton Place - Room 1301 ..Boston Massachusetts 021 08 r � Home Improvement Contractor Registration - TYPe: Supplement Card Expiration: 6/23/2008 Q-APIzI HQME IMPROVEMENT, INC' GARY GUSTAFSON 1 645 Newton Rd. Cotuit, MA 02635 Update Address and return card.Mark reason for change. _.. Address 0 Renewal ❑ Employment I� Lost Card ✓lie 'tDarrumriru�erzlClc �����czaaczo�uselZs _ ard:ofBuild- g Re--slg d standards '�GonStrUCilo�.�SlINIrv,1 HL a S6��i �,�-• '§�� �`' '''�`"*�,�`'Z'°��' �, •�,� yK - tvH- ,i' s ". a. ,. '::;LICen$24�C74640 :ear• s WR r z � r �` - ya �;'� 0 ,�..: '= `+•k3a f� ,. yk, R 'u s 'X�'" s- s HF a .a. '-T` n .r L ax' i ry„''-�rF _ _: @stElCtl� �Ud-�-'� '- "-,.3b"' �-a�.F,-i a i# `' -t'•F 3 u - �, -r'a`i:, ate- -."r��" 7 - y�P $Lsur - s Y' 5:W _.:. ..G RY GUSTAFSON } 8:SHORT WAY '. ? x' SANDWICH MA 02563 Commissioner _ 1 V TV u V1 AJill AL►OLccLIiG "rernutiF g � O•� Expires 6 m'onty�"m lasue date r Aare, i Regulatory Services Fee KAM �cb %639. �� Thomas F.Geller,Director m (J, Building Division Tom Perry, ]Building Commissioner 200 Main Street, Hyannis,MA 02601 A- P RESS PERMIT Office: 508-862-4038 AUG - 2.2005 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAR® F BARNSTABLE Not Valid without Red X PressImprint dap/parcel Number 'roperty Address N)tA 1 .1 Residential Value of Work /Minimum fee of•$25.00 for work under$6000.00 3wner's Name&Address Contractor's Name Tpamm, Telephone Number fU• �0 ��J t Home Improvement Confractor License#(if applicable) _ Construction Supervisor's License#(if applicable) ' Aworkman's Compensation Insurance Check one: ❑ I am a sole proprietor ; ❑ am the Homeowner �I have Worker's Co nation Insurance "A~ Insurance Company Name _ tv Workman's Comp.Policy# Copy of Insurance Compliance Certificate must be on file. ` Permit Request(check box) Ln m ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) ❑ e-side Replacement Windows. U-Value (maximum.44) *Where required: Issuance of thispermit does not exempt compliance with other town departrleat regulations,i.e.Historic.Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. Home Improvement Contractors License is required. Signature Q:Fwzns:expmtrg Revin063004 PlyGem Lifestyles windows reflect a commitment ass Comparison-Center of Glass: W-Factor ::a Glass Comparison.LTotal Unit U=Factor... to making your home a comfortable oasis year Single Glatt single t la round. Clear lnruGtted Gluts 7/8''o fi thickness y Clear lnrulated Glav>7/8 overaU th:cknesr Hard-Coat(p);;vAtic)Lour•E iraulaied /au rg r $ Hard Coat(pyroliric)'LourE iwulaie__Aw,, The Benefits of LOW-Emissivity saACoat(spurier)Lou;Einsularedglaa 4 Sofs-Coat(sprirtn)LowEmsulittedglau 2 J. (LOW-E) Glass Systems HiR+PlurSoftCoat(sputtff),' Hi'R+PlurSoft-Coat'(sputter)LourE' Less Transfer Of Heat ,s: iizsulatedglaufilledwith"argongac 4 {:i.Lu redglau�fl&dunt/iargongas Hi R+Plus' and Maxuus`" lass systems detect M�usSo�Coat'(4,u�r)Lort-E� g Y e =-inrulateil lass Qed with om as to MaxutaSoft-:Coat mr)LowE and block radiant heat-keeping it in your home Maxuui7GSofHcoxr r; dg4tcrfilled with argongar during the winter, and out of your home during k g g Y y7 ,ruularc rYhtxrtru7.GSofr-Coax(tpurur), (rputrer)Low-E Insulated: ; the summer. We fill our insulated glass units with -filied unrh -._ Low Einnrlaadglaufil�d , arg. g with aibrort gar At heavier than air inert argon gas which is about I "1111110 f ,t 40% denser than air' to resist the transfer of s heat. The result is increased energy efficiency and decreased utility expenses. ,The In'the UF—"heg,raa,'hx rn;-L-d„rr L. uarue,f ibeini�ne�R.Y&9 ofnc�uFocro. � -s Tl;�lo�er h�u Fa�ar dx gnaar dK inrn/cdo»ial rs R=ual�e-udo,,,,xu(R=U(�ojdie U-F---. f ., :< Ceneer ofg4w fartorr calculated per Wjndo 51 r&tion software(LBNL-Law ce Berkky N ho4-d labmtu_).� NFRC Fnumm�'on Rdtr'rsg Coon it)PKM glau g op"M ToralUnu Fac7an dernrnr l00(Natianal an eonf+ed w NFRC 700 Hi R>Plssr nreeu dl EI E GYST4R nqu rnu Reduced Condensation w �. -.,'�.... v...,. . ... -. _ _ _ _.. With Hi R+Plus and Maxuus glass systems, window condensation is virtually eliminated. Choose your level of comfort Windows worthy of an industry leader ENERGY STAR products for the next 15 You can maintain higher interior humidity- years, our national energy bill would be increasing comfort while reducing utility bills. ■� Features one lite of soft ENERGY STAR Window Program is a voluntary . reduced by approximately $100 billion. The Enhanced Sound Control ■ i R+P lu5 coat, 7/8" single-surface partnership between the U.S. Department of reduction in carbon dioxide emissions would Combined with the noise absorbing qualities of s r s T E M s multilayer vacuum-depo- Energy and participating window manufacturers. be equivalent to reducing gasoline consump- multi-chambered vinyl frames and R-Core insula- sition Low-E insulated ENERGY STAR performance requirements are tai- tion by 120 billion gallons, taking 17 million lion,Hi R+Plus and Maxuus glass systems reduce glass unit with argon gas. Argon gas is 40% lored to fit the energy needs of the country's differ- cars off the road, or preserving 142 million exterior noise up to 300% better than single pane denser than air` which means more energy ent regions - from northern states to southern acres of trees for the next 15 years." windows. efficiency for your home. states.Your investment in ENERGY STAR windows will pay for itself over time,and then the savings is PlyGem Lifestyles windows ... good for you, Reduced Photochemical Damage "Figure courtesy of Linde Gas. Inc. money in the bank every year! good for your home and good for the ;:Damage to furnishings, carpets and draperies environment. results from a photochemical process influenced Combines two lites of You'll be doing your part to help the environment. I)y: the level of visible light,the intensity of heat, MM UUS° Low-E glass and an In fact, if all households and businesses bought he strength of infrared radiation, and the amount insulation chamber of of ultra-violet radiation. A Low-E coating's trans- argon gas. The 7/8" mission level of these factors is known as the dual-surface multilayer vacuum-deposition _ Damage Weighted Transmission. The table Low-E glass units with argon gas makes �a~A�o�oelow com ares the dama e blockin these windows near) five times more energy p g g qualities Y . of Hi R+Plus and Maxuus 7.6 glass systems, efficient than single pane glass. r r x Is a triple pane assembly Damage WelghtedTransmisslon kt McI�ZUUS"combining two lites of a c, a• * Glua's Srsre,n multilayered vacuum- : d• J - Insulanng Gnus Type Damage Tranrinrsswn deposition Low-E glass71 I "$4% with an interior glass substrate which provides two Hf Rt insulating chambers of argon gas. The result is Maxuus 76 , t�.>k A//o z nearly six times more energy efficient than single Northern South/Central Mostly Heating Heating&Cooling 'trz� s ..... pane A�tG glass. North/central Southern tJamage:lY/aghudTmnrnttvton nrearnrrr the mnourrtafdarnagmg• „ - Heating&Cooling Mostly Cooling u veknptyr that wdl part rhrmgl:agiazang Tbe.fownrthe number the l ighn iht prorernon Figum ca�urteryofPPG Itidwtrut ' v r . STAR qualification is based on NFRC certified product ratings. gures'courtr.4y of Linde Gas,Inc. CAPIZZI HOME IMPROVEMENT INC . Y SPECIFICATIONS AND ESTIMATES PAGE 6 OF 6 STATE OF MASSACHUSETTS LETTER OF AUTHORIZATION TO APPLY FOR A BUILDING PERMIT I, jolt- , �G V)"ov OWN THE PROPERTY LOCATED AT ` IA7aN,- �rT" IN Co�-y r 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: lti, OWNER'S ADDRESS: Sa440 OWNER'S TELEPHONE: 1 �' Z- 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: ACCEPTED BY DATE THIS PAGE IS PART OF AND IN CONFORMANCE WITH PROPOSAL # Jl� z j.A .Board o uil mg Regula ons and Standards -' One Ashburton Place - Room 1301 Boston_ Massachusetts 02108 Home Improvement-Qgtractor Registration ? - Registration: 100740 Type: Private Corporation Expiration: 6/23/2006 CAPIZZI HOME IMPROVEMENT,'INC.' Thomas Capizzi, jr: 1645 Newton Rd. Cotuit, MA 02635 Update Address and return card.Mark reason for change. Address Renewal ❑ Employment Lost Card Board of Building Regulations and Standards License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Board of Building Regulations and Standards Registration: 10D740 z One Ashburton Place Rm 1301 Expiration: 6/23/20D6 ` Boston,Ma.02108• • Type: Private Corporation CAPIZZI HOME IMPROVEMENT,I- %omas Capizzi,jr. 1645 Newton Rd. GG -i Cotuit,MA 02635 -. Administrator Not valid with r • � ✓/ae �omircc�uoea�� o�✓u'�Cia:rpc�iccaet7a , BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR - r - - Number:-CS 057032 Birthdate 09/26/1963 Expires 09/26/2005 Tr.no: 7171.0 ..._ Restricted 00 -------- - THOMAS-X'CAPIZZl JR 1645 NEWTOWN RD COTUIT, MA 02635 Administrator . a SOWn U " tr►tt 30 f Barnstable Per # ag 4 IUW&u d mowhrfhoe,Lrsue dote awstxtrrwtauc i Regulatory Services Fee nwN' p Thomas F.Geiler,Director ° Building Division Tom Perry, Building Commissione 200 Main Street, Hyannis,MA 0260X PRESS PERMIT Office; 508-862-4038 NOV 2�03 Fax: 508-790-6230 EXPRESS PERNUT APPLICATION - RESMENTUL ONLY Not-Vdtd without Re dX-Prasrmprinf UVVN UF BARNSTABLE Map%parcal Numbcr `.3 Property Addresa 9t pj ti 3 T, n To i 7- Value ofWorOl �csidcntial ga. Owacr's'Nauz 8t:Address�apv-k L=— -E—SL)dd P c - 8" S 023 Contractor's Name G�J J �4-Z-� l+ `� ��► Tclephono Number L 0� ��"1\1 Home.Improvement Contractor License t#(if applicable) �U3-7 I Construction Supervisor's License# if applicable) oWerkmau's Compensation Insurance r Check one: ❑ I am a sole proprietor ❑ I am the Homeowner (�I have Workor's Compensation Insurance Insurance Company Name 1�ra.v e�42 f75 workrnan's comp.Policy a -1Pj L)6-q as x Q 5 3 - 502- Permit Request(chock box) Re-roof(stripping old shingles) All construction debris will be taken to _ Y1� Q.Re-roof(not stepping. Going over existing layers of root) ❑ Re-side ❑ Replacement Windows. U-Value (maximum ,WOther(specify) Y'� /�S77rU dt�1`D/1) Q�Z *Where required: issuance of ads partmt does not cx=pt corrtpliancc with other tow daputlient regulations,i.e.Histork,Conservation,ctr. Signature Q:Forcne:ex�tntrg Revisedt21901 TP '4r)t1.4 nc7anc i onr rr. 7 T-r r 7nn7 inn ,n r t PROPERTY OWNER MUST COMPLETE AND SIGN THIS SECTION IF USING A BUILDER / ROOFER (Please return this form to Cazeau,lt Roofers with your signed proposal/contract) 1, 2r erg �Ccs dd e r , as Owner of the subject J property Hereby authorize Paul J. Ca:zeault & Sons Roofin To act on my behalf, in all matters relative to work authorized by this building Permit application for (address of Job) -All M01A) S i �3 Sign ture of Owner 1e Scudder Print Name , DATE(MWOOIYY) Ate- CERTIFICATE OF LIABILITY INSURANCE PRODUCER THIS CERTIFICATE 13 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Mc Shea Insurance AgenCy, Inc. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 749 Main street, Suite#H ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Osterville, Na. 02655 INSURERB AFFORDING COVERAGE. INSURED paul J Cazoault & Sons Roofing Inc. INSURER k Western eritaQ.e n®• Co• _ INsTER akvA er»s Indemnity_ co of Ti 1 1031 Main Street INSURER C" Osterville- Na 02655 INSUAERD: INSUHFR 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 13E 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. LT POU Y EfFECTNE POLICY EXPIRATION UMRB - - TYPE OF INSURANCE POLICY NUMBER TE MW E MM/OD/Y CENERALLIABILITY LGENEFIAL NCE ;Sl,.00.. I X COMMERCIAL VtNFRAL LIABILITY Any one Bra) $ .I CLAIMS MADE �.I OCCUR MEEXon Person) 1 S A SCP0467325 04/30/03 04/30/04 VINJURY ill,_000 fGATE_��,�OO GEN'L AGGREOAIIt LIMIT APPLIES PER". PRODUCTS-COMP/OP AC.G 1 S I GOO.GOO. POLICY .vHO: LOC JECT AUTOMOBILE LIABILITY COMBINED 41NOlE LIMIT $ ANY AUTO (Ee acud9m) ALL OWNED AUTOS _ FIODILV INJURY S - (Per SCHEDULED AV PBT.on)10S � � _ HIRED AUTOS - DODILYINJURV S NON-OW NEO AUT09 (Par acc dent) FHOPEATY DAMAGE S (Per eccldem) GARAGE LIABILITY AUTO ONLY.EA ACCIDENT S ANY AUTO EA ACC S OTHER THAN .._. ... AUTO ONLY: AGG S EXCESS LIABILITY EACH OCCURRENCE S OCCUR l I CLAIMS MADE AGGREGATE S OFOUCTIDLE - $ HE(FNTION S $ WORKERS COMPENSATION AND X TN RY LIMITS ER EMPLOYERS'LIABILITY 7PJV8-922X653-502 O8/10/03 08/10/04 E.L EACH ACCIDENT I$ 8 - E.L.DISEASE•EA EMPLOYEE S .p0 El DISEASE•POI ICY LIMIT S OTHER DE9CRIPTION OF OPE RAT IONSILOCATIONSIVEHICLESIEXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER ADDITIONAL INSURED:INSURER LETTER: CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUINO INSURER WILL ENDEAVOR TO MAIL la-DAYS WRITTEN NOTICE TO THE CERTIFICATE MOLDER NAMED TO THE LEFT,BUT FAILURE TO.DO SO SHALL IMPOSE NO OBLWATION OR LIABIOTY.OF ANY KIND l ON TH 1 9, E INSURER,ITS ADEN79 OR REPRESENTA r AUTHORIZED R RE T i ACORD 25-S(7/97) o ACORD CORPORATION 1988 THE FOLLOWING IS/ARE THE .BEST IMAGESTROM POOR QUALITY ORIGINALS) DATA i i� _`), ✓�l� �C�YLQ�/?2�1G'f�Tii; 1. c-- - r,{ �� Board of 13L1iIdin(, Re,1ula ions and Standards One Ashburton Place - Room 1301. Boston. MassachL[SettS 02108 Home Improvement ,�ontractor Registrat.ioil Registration: 103714 Type: Private Corporation Expiration: 7/9/2004 PAUL J. CAZEAULT & SONS, INC. Paul Cazeault P.O. Box 2781 Orleans, MA 02653 Update Address and rclurn Carl. N1arlc reason for changc. Address I i RenewA Employment Lost t':u d /L//Lp.LCU...��� Il�/../(-�IdJU.�'�UA•f.'�,�J s Board of Building Regulations and Standards ,�� � License or registration valid for iudiyitlul use onlN HOME IMPROVEMENT CONTRACTOR before the expiration date. If found rcfuro to: Board of Bi ilding Regulations and Standards Registration: 103714 On( Ashburton Place Rio 1301 Expiration: 7/9/2004 139sion, Nia.02108 Type: Private Corporation PAUL J.CAZEAULT&SONS, INC. Paul Cazeault 22 Giddiah Rd. (�_� � I ;'lY ✓fie {�omvnza>uuea . a�✓lar/tuae�l4 Orleans, MA 02653 Administrator Pduij BOARD OF BUILDING REGULATIONS 1, License: CONSTRUCTION SUPERVISOR l ;! f Number:..CS,. 026325 r Birthdate,10/20/1959 N Expires: 10/20/2005 Tr.no: 8603.0 f Restricted:' 00 PAUL J CAZEAUCT. e _ 1031 MAIN ST OSTERVILLE, MA 02655 Administrator Board of Building egulations One Ashburton Prace, Rm 1301 Boston, Ma 02108-1618 License: CONSTRUCTION SUPERVISOR LICENSE ti Birthdate: 10/20/1959 Number: CS 026325 Expires: 10/20/2005::r� Restricted To: 00 PAULJ CAZEAULT 1031 MAIN ST OSTERVILLE, MA 02655 Tr.no: 8603.0 Keep top for receipt and change of address notification.