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HomeMy WebLinkAbout0640 POPONESSETT ROAD I lima Town Town of Barnstable *Permit-m i/I�JVV// y�' �� Expires months Regulatory Services Fee W from iss date v 6ss.i639. Thomas F.Geiler,Director p�� Fp Building Division q�j Jr? 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 Q D�� Not Valid without Red X-Press Imprint Map/parcel Number Property Address l0 / 0 Po p 0 Al e 5S eW 81) C 61-y6 [X2esidential Value of Work$ 2°7 ` Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address J,14 AJ 8 a11 (Q Vp C°�.yl_4 mA L Contractor's Name G 4iz y 6 Ur/jkA .�J U Ia. Telephone Number �a Ya,4 Y 5-/ G�'�1221 �u� Z(rIqUUll�n2�Nf 2Nt, - Home Improvement ontractor License#(if applicable) j b fj:7 Y p Email: P-etg"j 4 O_ C4e1*17l.b Dine [Orw Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance X®PRESS PERMIT Check one: ❑ I am a sole proprietor S E P 18 2013 ❑ I am the Homeowner 06 have Worker's Compensation Insurance Insurance Company Name 4 J t lA f P ct ��'1Z j0�a�ell L A LE Workman's Comp.Policy# 'W C G I O s i10 a o 11 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 ' ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side ao o Replacement Windows/doors/sliders.U-Value 9%ee✓ (maximum.35)#of windows 64 dew elu P #of doors: ! -7 heKm4 f eas- ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. , *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: -Property Owner must sign Property Owner Letter of Permission. A copy f the Home Improvement Contractors License&Construction Supervisors License is it d. SIGNATURE: ' C:\Users\decollik\AppD cal rosoft\Windows\Temporary Internet Files\Content.Outlook\8R76BDVA\EXPRESS.doc Revised 061313 Office oflnvestigations I Congress Street,Suite l00 ' - Boston,GYM 02114-2017 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information PIease Print Le bIv Name(Business/Organizadon/fndividuai):Capizzi Home Improvement Address:1645 Newtown Road City/State/Zip:Cofuit, MA 02648 Phone#:508-428-9518 re you an employer?Check the appropriate box: 7A! : 1.[✓ .I am a employer with`l•0+ 4. ❑ I am a general contractor and Ir7. ype of project(required): employees(full and/or part-time).* have hired the sub-contractors , ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 0 Remodeling ship and have no employees These sub-contractors have g EJ Demolition working for me in any capacity. employees and have workers' No workers•' comp.insurance comp:ins_urance.1 9. []Building addition required.] 5. El We are a corporation and its 10.❑Electrical repairs or additions 3.C] I am,a homeowner doing all work _ officers have exercised their E. Plumbing repairs or additions mself.y [No workers comp. right of exemption per MGL insurance required]fi a 152, §.1(4),and we.have no 12:[�Roofrepatrs: employees. [No workers' 13:[ Other_ W l ii y .o uJ COMP.insurance required.] 00 d *A11Y,aP14cant that che6ft box#1 must also fill out the section below shov4ng their workers'compensation pol::y information\`fi hFonpeowaers who submit this affidavit indicating they are doing all work,a hen hire outside contractors must submit a new affidavit indicating such. Contrar�tors that check this box must attached an additional Sheet showinatae employees. If the sub name of the sub-contractors and V fate whether or not those entities have ntractors have employees,they must provide their workers'comp,policy number. I a n an employer that is providing workers'co Wensation insurance for my employees, Below is the policy and job site information. Insurance Company Name:Associated Employers Insurance Company Policy.#of Self-ins.Lic.#.WCC5010 547012011 Expiration Date: 12/2512013 Job Site Address: G o ° cN,J eJ . City/State/Zip:_ � / f 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 tip 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 t ains a nalties ofperjury that the information provided above is true and correct .Si ature: 0 Date: Phone#: 5 -428-95 $ ` ---------------- Official use only. Do not write an this area,to be completed by city or town official City or`Tbwn: Permt/License# 7ssning Authority(circle one): 1:Board of Health 2.Building Department 3.City/Town CIerk 4.Electrical Inspector 5.PIumbing Inspector 6.Other Contact Person: Phone#: . CAPIHOM-01 CBENISCH CERTIFICATE OF LIABILITY INSURANCE DATD/YYYY) 61121212/2013 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 endomement(s). PRODUCER CONTACT Chris Benisch NAME: Rogers&Gray Ins.-Dennis Branch PHONE FAX 434 Rte 134 A/C No EXt:(508)398-7980 A/c,No):(877)816-2156 South Dennis,MA 02660 ADDRESS:cbenisch@rogersgray.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Main.Street America Assurance Co. INSURED INSURER B:Associated Employers Insurance Co. Capizzi Home Improvement,Inc. INSURER C: Capizzi Enterprises,Inc. INSURER D: 1645 Newtown Road COtult,MA 02635 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSR WVD POLICY NUMBER MMIDDNYYY MMIDD GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY MPB1075H 6/8/2013 6/8/2014 DAM-AGE TO PREMISES Ea occurrence $ 5009000 CLAIMS-MADE Fx—]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-COMPIOPAGG $ 2,000,000 POLICY JR O- LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea..dent $ A ANY AUTO MIM28044 6/8/2013 6/8/2014 BODILY INJURY(Per person) $ AUTOS Ix SCHEDULEDBODILYINJURY(Peraccident) $ 500,000 AUTOS AUTOSXHIREDAUTOS NON-OWNED - PER ACCIDENTIPR PERTYGE $ .. ., $ X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 5,000,000 A EXCESS LIAB CLAIMS-MADE CUB1076H .618/2013 6/8/2014 AGGREGATE $ DED I X I RETENTION$ 10,000 $ 5,000,000 WORKERS COMPENSATION WC STATU- I X OTH- AND EMPLOYERS•LIABILITY TORY LIMITS ER _ B ANY PROPRIETORIPARTNER/EXECUnVE YIN N WCC5010547012012 12/25/2012 12/25/2013 E.L-EACH ACCIDENT $ 1,000,000 OFFICERIMEMBER 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 $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) - CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Barnstable THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 200 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. Hyannis,MA 02601-0000 AUTHORIZED REPRESENTATIVE @ 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD Unrestricted-Buildings of any use group which contain less than 35,000 cubic feet(9911n )of enclosed space. Massachusetts -Department.of Public Safety Board of Building Regulations and Standards Construction Supervisor Failure to possess a current edition of the Massachusetts License: CS-07�4640�� State Building Code is cause for revocation of this license. GARy GUSTAFS(jrT For DPS licensing information visit: www.Mass.Gov/DPS $SHORT WAY + SANDWICH MA=025 �.•�+.,.JJ ' '! �s��` Expiration Commissioner 11/29/2014 ✓fie �anvinoozcuea�x o�./�aaaac�ivaea ! Office of Consumer Affairs&Business Regblation 14cme or t•�fton valid for 1adz�idnti we only OME IMPROVEMENT CONTRACTOR 'before the e�fp t n date, Ifhzmd retinm to: 10ffice of Caasirnler,�.ffidrs>�DusinesS RAplation Registration;'=:f00740 Type, Ii1�QgrCPl& € e$I7$ . Expire{ions 62A12014 Supplement osfa 3i i16• 1 CAPIZZI HOME:MP-R01%EM NT;INC. ' GARY GUSTAFSON is-<:I 1645 Newton Rd. •` ' :: , Cotuit,MA 02635 +ftttntr�s Undersecretary L , _. Page 7 of 7 Capizzi Home Improvement Inc. Specifications and Estimates_ ` STATE OF MASSACHUSETTS LETTER OF AUTHORIZATION TO APPL�VTOR A BUILDING PERMIT I, IA OWN THE PROPERTY LOCATED AT 6� IN < ;MASSACHUSETTS.: , I HAVE AUTHORIZED. CAPIZZI HOME IMPROVEMENT TO ACT AS MY:AGENT_TO APPLY FOR A BUILDING PERMIT IN ACCORDANCE WITH 180 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 BUILD. G CODE: _ SIGNATURE OF OWNER:-. I�Tir a OWNER'S ADDRESS. OWNER'S TELEPHONE: LESSEE'S SIGNATURE: r z•, 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: w , RESPONSIBLE.OFFICER ADDRESS: . RESPONSIBLE OFFICER TELEPHONE: r a To of J�arnstable tv C�`-f 2 Z u �o�rt+r r *Permit# Expires 6 monlhsfronr issue date ,. Regulatory Services +' BARVSTABLE Fee G y pnss. Thomas F. Getler, Director Building Division Tom Perry, CBO; 'Building.Commissioner- ©gg 200 Main Street, Hyannis, MA 02601 F� www.town.barnstab le.m a,us Office: 508-862-4038 Fax 508 790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Nol Valid tvilhoul Red X-Press Trpprin! Map/parcel Nurnber a Property Ad codress . � �� " i� •TV'��--•4 ,. ❑ Residential Value of Work. ao© 1+V-0. a Mtnimu.m fee of$35.00 for work under$6000.U0 Owner's N am e Address Contractor's Narne14,� �� Telephone Number p �.7 . . Home Improvement Contractor License#(if, pplicable) Construction Supervisor's License# (if applicable) ._ �z'' t f �+• r' ❑Workman's Compensation.Insurance ` IT. Check one: I am a sole proprietor F . AI�C k2�1a ❑ I am the Homeowner , ❑ I have Worker's Compensation Insurances � T®WN,OF BARNS.rABLE' ' Insurance Company Name r Workman's Comp.'Po7icy# Copy of Insurance Compliance Certificate must accompany,each:permi#.. Permit Request (check box)A Re-roof(hurncane nailed) (stripping old shingles),All construction debris will be taken fo D � Re-roof hurricane nailed PP g•p d �° ❑ ( )(not stri in Goin over existing layers of roof) ❑ Re-side ti #of doors Replacement Windows/doors%sliders..0 Value (maximum :35)# of windows " . *tivhere.lequired: Issuance of this permit does not exempt compliance with other tom department regulations,i"e:.Histonc,Conservation,etc , ***Note: Property Owner must sign Property O}vner.FLetter of Permission; A copy of the Home Improvement Contractors.Licen"se & re ui re ,Construction Supervisors License is t� AGNATURE: - :\WPFILMFORMS\building permit forms\EXPRESS.doC evised 072110. ai The Coin»tornrealth of-Massachusetts r! - - - Department of Industrial Accidernts F--.{. Office of Innvestigations I , 600 Washington Street - Boston, M4. 02111 a --3 f'L'3b'Yt'.n11aSS.g01�,✓(�la NVorl{ers' Compensation Insurance Affida-v1t: Builder:s/Cont.2 a'idol-&/Electllciins/P1:11mbers Aplr hcant Information Please Print LegibIN Name (Business/Organi.?ationgndividerai).- W Seil VZ Acf&ess:T p city/state/zip: Phone 8' Z 5-- -2 Z_Y Are you an employer?Check the appropriate boa.: F[JRemodeling ect(required): L❑ I'am a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time)_ have hired:the sub--contractors nstniction 2.. I am a sole proprietor or partner-- - . listed on the attached sheet. ship and have no 10 ees These sub-contractors have p � y tion ;working :for me in any capacity- employees and Have lworkers' '[No workers' comp.insurance comp_insurance. I 9. ❑:Building addition ❑required] 5. We are.a corporation.and its 10.0 Electrical repairs or.additions 3.❑ 1 ant a homeo-vimer doing all work atf.cers have exercised their 11.0 Plumbing repairs or additions myself [No workers'comp, right of exemption per NTGL 12.0 Roof repairs insurance required]T c. 152, l(4),.and.we have no employees. [No Workers' 11 E] Other comp.insurance required.] 'Any applicant that clh,ecls box#1.must also fill out the section below showing their workers'compensation policy infornaatian. f Homeowners who submit this.affdzvit indecating they are doing all'woA and then hire outside,contractors n=submit a new affidavit indicating such- ICGnvactors that check this box must snacbed an sdditional sheet sbo.wing the:name of the sub-contractors gad state whether or not those entities have employees. If the sub-conuactors1ave employees,they.must provide their wurkus'comp.policy number. I am�u+'1r:p1�o,I�er tlrrrt is pro��rdirrg traarkars':corrrperrsnlon iusrrrrrrrce for vrcy ertrpla�=eas. :Belorr is this pr�Licy�nrtrl,jn,b sits irforniaticrit Insurance Company Name.- Policy 9 or Self-iris.Lic. E:xpirationDate: Job Site Address- City/Stat&r. Attach a copy of the workers'compensation policy declaration page(shorting the policy number and expiration date). Failure to secure coverage as required under Section 25A of NfGL 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'�VORR 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 Once of Investigations of the DIA for insurance coverage verification, y I do hereby cer rrrtder the parrs arrd pelrr blos gfpei jiity that#lie ir:foritrRtran prm�irled a.bo v is trine alid correct. Signature Date: Phone#: o�cial►ise only. Do pot ti'rite in flris area,to be coniplete+d'by city or totor of ciaL City or To-"7r: Permit/License# Issuing Authoiit3'(circle one): 1.Board of Health 2.Building Department 3, G`ity/rown Clerk 4,Electrical Inspector 5:'Plumbii>g Inspector 6.Other Contact Person: Phone#, 6 OF THE Thy BARNSTAHLE, Town of Barnstable �lFD Mp2t A - Regulatory Services Thomas F. Geiler, Director Building Division Thomas Perry, CBO Building Commissioner , 200 Main Street, Hyannis, MA 02601 www.townXarnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and-Sign This Section If Using.A-Builder as`Owner of the subject property hereby authorize r ��m ' �>�UI 0, Co to act on my behalf, in all matters relative to work authorized by.this building permit application for: (Address of Job) AL Signature o£ wner Date . Print Name . If Property Owner is applying for,permit, please complete the Homeowners License Exemption Forrn on'the reverse side. QAWPFILESIFORMSIbuilding permit formsTXPRESS.doc Revised 072110 5 P�olTgt�� Town of Barnstable ' Regulatory Services � �^�JASS. Thomas F. Geiler, Director �j� b79. A 1m Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis, MA 02601 www.town.barnstable.ma.us Office: 548-862-4038 Fax: 508-790-6230 -----------------------_-___ HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER" name -home phone# work phone# CURRENT MAILNG ADDRESS: city/town state zip code The current exenption 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 tliat'he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic{feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1 -Licensing ofconstruction 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 I amend and adopt su:h a form/certification for use in your community. QAWPFILES\FORMS\building permit forms\EXPRESS.doc Revised 072110 I Eby iV1it"achusetts- Department of Public Safct. Board of Building Regulations and Standard Construction Supervisor License License:'CS 52649 Restricted to: 1 G WALTER A SLABODEN i 10 SALT RIVER RD E FALMOUTH, MA 02534 Expiration: 11/11/2010 ('ununissiuncr Tr#: 6178 Office ofCo me' �rEs 3�c$ ine�egu HOME IMPROVEMENT CONTRACTOR ' Registration: <-,101668 Type: Expiration: t;6/26%2012 DBA. SERVICES COMPANY ' WEr Walter Slaboden 1 k ' r 10 SALT RIVER ( FALMOUTH, MA 02536.` Undersecretary 1 r License or registration valid for mdividul use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 10 Park Plaza-Suite 5170 Boston,MA 02116 of valid without signature �? t ,i . i Cr TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map 666 Parcel 1 . Permit# YY�QS Health Division Date Issued Conservation Division Fee �✓r Z Tax Collector N1, ( I Treasurer a_ -e-e . � Planning Dept. Date Definitive Plan Approved by Planning Board Historic-OKH Preservation/Hyannis Project Street Address tv* Pout)a e sSe 5-r Village �(9'�'�-1`� Owner Oki, [� � Address �/it,ut'U( f �(� Telephone 'WA Ou Permit Request Lc)CS 6;S*b 1061(0 t a Sa ok.5 s e S i ze D1 Vtrn 4L W`. I,cJtA'JbQttIS (�.SLtrnt' StZ 3b sl$ 3[`� �(0 33S�g��x �l�f�I Square feet: 1st floor: existing proposed 2nd floor: existing proposed Total new Valuation `QT� � ' Zoning District Flood Plain Groundwater Overlay Construction Type (.k Lot Size Grandfathered: ❑Yes W-Pdo' If yes, attach supporting documentation. Dwelling Type: Single Family O--ol"Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House: ❑Yes On Old King's Highway: ❑Yes Q-W Basement Type: ❑ Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing new Total Room Count(not including baths): existing new .First Floor Room Count Heat Type and Fuel: ❑Gas ❑Oil ❑ Electric ❑Other Central Air: ❑Yes ❑No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑No Detached garage:0 existing ❑new size Pool:0 existing 0 new size Barn:0 existing ❑new size Attached garage:0 existing 0 new size Shed: 0 existing ❑new size Other: Zoning Board of Appeals Authorization 0 Appeal# Recorded O Commercial ❑Yes U-Moo� If yes, site plan review# Current Use Proposed Use BUILDER INFORMATION Name- eigf;7-7,f � .r= of Telephone Number Address f(o S License# Z3 �fsTru`t�MA j.4k 3 5 Home Improvement Contractor# 10074 o Worker's Compensation# 1AJ qq(�10/S- ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE �p,P,�.r.���l —DATE �a FOR OFFICIAL USE•ONLY - PERMIT NO. - - DATE ISSUED • MAP/PARCEL NO. .. 7 p 7 ADDRESS �g VILLAGE t ;R. OWNERel : DATE OF INSPECTIO FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. _ '3 d � r• = The Town of Barnstable 9s — Department of Health Safety and Environmental Services Building Division 367 Main Street,Hyannis MA 02601 Office: 508-862-4038 Ralph Crossen Fax: 508-790-6230 Building Commissioner Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW `• SUPPLEMENT TO PERMIT APPLICATION , MGL c. 142A requires that the"reconstruction,alterations,renovation,repair,modernization,conversion, improvement,removal,.demolition,or construction of an addition to any pre-existing owner-occupied building containing at least one'but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors,with certain exceptions,along with other requirements. F Type of Work: S Estimated Cost s� Address of Work: 6((() &p n a 1 eSS IAT-6-.i 11 Owner's Name: -> �.�► Date of Application: 9-Lat n?) I hereby certify that: Registration is not required for the following reason(s): Work excluded by law Job Under S 1,000 Building not owner-occupied Owner pulling own permit i Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A. SIGNED UNDER PENALTIES OF PERJURY 1 I hereby apply for a permit as the agent of the owner. D /�2�ny /C _ l DD'� Date Co tractor Name Registration No. f-�or�e OR Date Owner's Name A� q:forms:Affidav The Commonwealth of Massachusetts Department of Industrial Accidents --" Office oflnlvesUgnfoos - 600 Washington Street Boston,Mass. 02111 Workers' Compensation Insurance Affidavit ,7,.t,.7, � Qty— one I am a homeown�perforrnigall work myself. I am a sole proprietor and have no one working in any capacity K.I am an employer providing workers' compensation for my employees working on this job. company name.• O q P/ r� /0"14CMC- r situ;_ CQ l fit-1 , Q�if03 phone# (Jd 95/x insurance co, E�T��}'1� � �J�S �Q- poli # I am a sole proprietor,general contractor,or homeowner(circle one) and have hired the contractors listed below who hu, the following workers'compensation polices: comnaav name: address;. city::;.:-:.. phone#- tnsarttnce co:..; policy# comnanymame adc#ress.. city: phone# nsarancrco. policy# Failure to secure coverage as required under Section 25A of MCL 152 can lead to the imposition of criminal penalties of a fine up to S1.500.00 andio one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of S100.00 a day against me. I understand that copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Signature Ow pJ Date Print name EMI2 I C%>L 0- ,41 PAS 777 Cfl�C.a' r.Phone# I .mod / '7`��— 9S� [check only do not write in this area to be completed by city or town official n: permit/license# f�Building Department 0Liccnsing Board immediate res onse is re uired p q oSelectmen's Office0liealth Departmentson: phone#; nOther l" (revised 1195 P1A) 671- = HOME INPROVENENT CONTRACTOR ^ / /�aaaaclu�e..lta ��I t Registration: 1 p Y BOARD.OF BUILDING REGULATIONS 100740 ERVExpira N;SURI$OR License: I"Type: I s Privat � 057032CorPoratio CAPIZZI " HONE I k NPROVENENI; '' � Ezpi�@s 09/26/2001 ' Tr.no: '5742 ADMINTR oR 1645aNewton1Rd1, Sr. Restriced)To:. 00 Coluit + KA 02635 THOMAS X CAPIZZI JR - 280 PERCIVAL D.R. W BARN STABLE, MA 0261i8 Administrator ,5., i ,. ,� - I I ��: ✓�LC 1�Jd17L/7L0�/2(lMQGI� o�a.���2��^JiN TION BOARD OF BUILD1 SUPE EGUVISORS ` % License: CONSTRUCTION DEPARTMENT OF PUBLIC SAFETY.' : Number: CS 007454 R �r CONSTRUCTION SUPERVISOR LICENSE h Number.:' Expires; lj REStttctnd TOf 00: Restricted To: 00 .. I THOMAS CAPIZZI FREOERIt K V RgSCH III. - :i, I 1645 NEWTOWN RD er 0r 1060'B OURNItAO COTUIT, MA 02635 Administrator W PLYMOUTH, MA 02360 I �