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HomeMy WebLinkAbout0044 SCREECHAM WAY 1� � _- --- _ _. 1, V J Town of Bitable = erni t� � vM Q Repflatory Sect Fee a a $ >6rq. Richard V Scab,Interim Director o ► ij S` I� o Tom Perry,CBO,Builtiin Commissioner � 3 2016 200 Mani Street Hyannis,MA 0?60�///V OF wtiquotivn.barnstable.ma.us p�/8 „� Office: 508-862-?038 ax:508 790-6230 ERMS LERMT AP'i, C-A-Z'ION - RESIDENTLAAL Mot Valid w thont Red X-Press hwfint Map/parcel Number_Q2 f 3 7 O Prope°rtAddress_�y .Si/�P��a�n 1 +� •� residential Value'of Work. lS 3 — i_Yfinimum fee of S3a00 for ork under$6000.00 , Owner's Name&Address� �fotfr ,c i ti ' cJ n e--ram r Contractor's Name- n al.�.uJ;r�r►�,5 / ?�;��, �n n i�,n i elephone NumberL�o 2Z k-C1 fCZ D Home Improvement Contractor License (if applicable) I?3? LS' Email: Construction'Supervisor's Licenses(if applicable)_©C 7 n- (5Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑-I•ani the Homeowner I have Worker's Compensation Insurance InstraneeCompanyName Worlartan's Comp.Policy trtilC q�.BD SB 3�S2 3 y CDPY of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shin?Ies) All construction debris K=itl betaken m ❑Re-roof(hurricane nailed)(not stripping. Going over: - existin4 layers of roof) LY'R eplacement Windotiystdoorslsliders.U Value . 3 C (maxtimum 35)01 of windows 2- of doors: - ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Eiictricai&Fire Permits required. "ubik Tequired- tsmame of ft pennft does not coat umme with other ttnvn department regulations,i.e.Historic,Conser Man,eta. r><Iote: PrWertYPMer mat sign Property Owner Letter of Permission. A copy 4 the Home Improvement Contractors License&Constmetion-Saperyisors Incense is � required. SIGNATUR& \M. Q AWPFILMF0RMSQr'u�M1M-,t fonnSWTRF.SS.doc _ Revised 061313 r�ewal. Ag rea me-,nt Dociu m en t a���I ill`II a Ii�t TIIelrllili� f i an 'n Atka f-owwA B.;,An1�r�ati v�Sn�tbc.Pn w`,f�w.Fn `r di �rlt and,P,ahricl��aliugiar. � I hlame +J�i lErn MAY?tnmyli iia'Ii srg etc cree[�oA''4. R11 N3607%M �1iT3 � i1 3�5 51 Uadl[Firinn MIDI �¢liilt ww:02633 . . �/{ viina5a� e� s eE,d�? 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Rriz mi@dLp 4l96a1Ci5!';41]4fS d1�4.rCit 4q i1 df9h Asnvlvl li>a_,gib�� Ib 4t 9li 51 444�, iLcl gym. 41� kd-k�a y;if r15 # iii i�ra lit4fls�Yii a ,` ' Elie'tca ate liii5ti' S c,t�"L�ii '+Vlatei�,5i:,#iri rlIrr' ia9e, PiEtPiCii��tdii`1 .uii1�b qi"ii uFill is, cie.ivic iSLfi,,+c3!!r� ti:4�a rri€el:rliit;' ' 'I 'I ! 0W,KI I Mi.IIriI it 1s tom%mo 111k Yb.I,I art fI'fsLLIkkl Ba,"I W 1 11titliI 111_k t.LIl15ic Mr 5-sit F:'07# -;1 201,E O T I T�9tRID, USI1t�[ SO i'#C ' [LEA S F1'I[I ' rat t1 + +Pb L=tICH VER: r�M IS '�,:A`�`R- EE. CFirr im. 1%10-11VED Nornc r,o rf o0iCULLK 10N FORM TO R AN r ��� rliiig-I _u rii�IGty�flgla0 �$in�tavry fl I, 1 o, e�,i &m m NotMIJUraii,l ,. ..�., - ors+ e4I . . n.a '. . a. .i ' �Ij,�I5ali4 rl ��PSi,�9 `n1 ��i€ I�gP P111 P ' d ilk;C rs��irl ;', hint tM14fi o a , Southern New England Windows d.b.a Renewal by Andersen of SINE f ass huse!`s-De anent of P_;3ic S2 ? I Boa-,a of EL7;iCi?.c=secpui 7s and S:anaa:^'..s ' { Canssmcm- 7i� _ Chartoa A Ga -r _ i J�sm Ex 0 r f CQ�1'53�55iC7=E' - I low Office of Consumer.A Mir-_'III I Bimmess Rt`—L' atiOn 10 Pafx Plan-S3glte 5170 Boson,Massacl3Osens 02116 Home lmprovemeiat Contra,=r Reci ` tiOn Reg-Ist2ticn= IM45 ; Type: Supplement Can: E:ziirAtion: 9/94lZD76 SOL'i HERN NEW ENGLAND WMDQr�JS i= ----------.------- DENNISON BRIAN 26 ALBION RD -- — LINCOLN,RI 02865 Upaam address wd rcmracrr&A4mt,.— r forcbmnge 77 6ddrr� `itmcwa7 -1£mPlc r LA-CArd V0,vii-9: scmrs Ar7nca 8 flmiors.Itt'uL�rive Lieansc yr rrrsaaavn sad fvr ivdiridu!vseRO-;E N r CON`rRACPDR before L eznrraftr�na7a l_rSvvnd rrsvry rv: 3�—orGmmmerAmmin`vd]3v�Regolvrioaore 773245 Eupiratlon: 97791207E �Supplenert am gosfnr:,Sr_A t!ii3E SOUTHERN N=_VN'ENG—vc WINDOWS LC. 1 RENEWAL BY AND92SDN DENNISON 9RIh-. ' 2E ALBION RD A `C L INCOLN.RI C2 m LFndersserclar? -Not valid�tboat srgnar°rs : `•:` ' Dep ent of 1ndustYii1Ac- z& -offl-ce Of -r y Borion,l&I 09114.2-017 o �ers' Compensation lus-arance &Ti Pint�igrMatio� please ,��a 1y NTame (Buuaesercirgmizationns-idividuall: SOI_l I HEERN NE11V ENG AND WINDOWS Ad&T•e.ss:26 Albion Rd City/State/Lp_Uncoln, RI 02865 Phone i.401 228-9800 Are you an employer. Check the appropriate box: Type of prgiect-(reqm6wed): = -employer20z- i_ I am a Qen contractor and I 1-C I ai-a wig � � � _ ct�on employees(hill and/or partme).`` have hired the sup-contractors �- t�[ew cons�a 2.(lE I an►_a sole"proprietor or parl4iepr- 7_ Rernodetin� listed on the ached sheet Q ship and leave no employees These sub-mntractors have S. D Demolition working Forme in an- capacity. employees and have workers' 9_ BttiIding addition (No workers"comp-insurance comp.insurance,.= 10_ Electrical repairs or additions requ?red-] 5- (� "We are a comoration and its Cj 3.01 I an a homeowner doing ail woric officers hen exercised their l I_0 Numbing repairs or additions njyseif_ L`Nlo vrorkars' comp. night of e:emption per MC-L 12Q Roof renairc insurance required-]t c. t 52. g t(4),&-d we have-no employees- (o wflr.rs 13_ ther (�l✓� G i comp. insurance requir�] re-� =any applicant&a-tchecks box-1 must also ffU out the section below showing their worker compensation Boliey information- Homeoviners who submit this affidavit mdim ig they am doiD--al?�vori-and iiea Kira outside con=ctars;awtsubmitanewaffidaeitin =Cont3etois that check this bon mast attached an additional sheet wo:-�rin`the aame of the sub-contractors and stalte vvlietiier ornot t{iose entities bane employees. If the sub-contractor have employees,they must provide th*217 workers'comp.poficy number- !am an emplayer�;�Fs py-ovM11k-�workers'comper=-Ion ir=si•ice for trey e�nplayees $3etoiv is the polzcV and job site arzforMa don. Insurance Company Flame:ARGONAUT INS. CO. _ Policy#or Self ins-Lic-9:WC 928058352394 Expiration Date.8/2112016 Jot}Site Address: - q Ll S c r e e c-1,et ")a. City/State/Zip: l r1U L I ' t✓� Attach a coley es the workers' compensation policy decla4i tion page(showin„the poHey number and exj >lrata®n datz� Failure to secure coverage as required under Section?SA-efGL c.152 can lead to the imposition of crlmmai penalties of a fine up to S 1,500.00 and/or one-pear 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 ofthis statement may be forwuded to the Office of Investigations of the DIA.foA insurance coverage verification. I do hereby cart ffy render fh ti in and penalties o1 perjury that the Mformeon provided above fs trace and correct. Y Signature. Date: - Z �- /•� Phoned 4012-989800 Official use only. Do not write aa€tfds arm to he completed by city or town ofrciffL Ciy oa Tmma ermitJl eense L9suing Authority(circle one): 1.Board of Hedth 2.braiding Department 3.City/Town Clerk 4.la lestfical Dspecwr .. 6.Other • SOUTNEW-01 SHETTYSHT� ' DATE(MMMWYYYY) ® CERTIFICATE OF UABIL6TY INSURANCE 811 9120 1FORMA 5 HIS THIS CERTIFICATE is ISSUED AS A MA OR NE GATIVELYTABBEND,ION LEXTEND OY AND R ALTER THE CQVERAGE AFFORDED BY 1 NO RIGHTS UPON THE CERTIFICATE �POLICIIES CERTIFICATE DOES N07 AFFlRMA BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED I REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: !f the Certificate holder is an ADDITIONAL INSURED,the policy{ies)must be endorsed. If SUBROGATION IS WAIVED,subied to i 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). CONTACT 1iNi11is Certificate Center I PRODUCER NAME 467-2378 1 Willis of New Jersey,Ine- A�,mod:(877)9�43 7378 ,No 888} { c/o 26 Century Blvd ADDRESS:cer fin .com P.O.Box 305191 NAIC t Nashville,TN 37230-5191 INSURER(5)AFFORDING COVERAGE INSURER A:Selective,Insurance Company of Southeast 39926 I = 21970 INSURED INSURER E:OIIieBeacon Insurance Company 1 1980 i I Southern New England Windows LLC INSURER C:Argonaut Insurance Company DBIA Renewal by Andersen INSURER D: '26 Albion Road INSURER E Lincoln,RI 02865 i INSUREk F: REVISION NUMBER: NUMBER- ER_ OL COVE. CERTIFICATE U i THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BEL01A'HAVE BEEN ISSUED T 0 THE INSURED NRMED ABOVE FOR THE POLIWFUCH CY PERT I CERTIFICATE NMAYNBE ISSUED OR MAY POERTAIIN,, THE INSURANCE AFFORDED OR CONDMON FBy THE POICC ES DESCRIBED HEREIN1S CONTRACT OR OT HER DOCUMENT SUBJECTTO AL �' kQ I FCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN FiEDUCS?BY PAID CLAIMS. II POLICY EFF I :PODGY EXF LIMITS I INSR A POLICY NUMBER i MB61DD.^.'YY'.') MIDDIYY'1 t LTn I TYPE OF uaSURANGE INSD.wvD ! i,DOD,0001 EACH QCCLIFtRENCE i` DO,Il�10� AX COMMERCIAL GENERAL UABIL^ 1 ` S 2029459 08M 0!2015 08/1012016 PRE ESES(Ez occurrences 1tt,U00I CLAIMS-MADE T OCCUR i i I j MED E)P.(Any om person) f= 1 I 1,DDC�,00fl' FERSONAL'fi AD\INJURY :$ 1 I I 3,DD0,0@DI S GENERAL AGGREGATE , jI-GGEEWLAGGREGATE:JMrtAPPL1E5P>~2 i j i PRODUCTS-COMP/OFAGG I:. J;DOD,pUO; PRO- I )( I LOG i ••• jj)POLICY IT JECT I__ 1 E c I I OTHER: I I COMBINED SINGLE LItyLT is ;,ODG,DDDt (Ez acddent) AUTOMOBILE LIABILITY ! ! ! S ti c c BODILY INJUF.Y{Pe'person) IIII A I X ANY AUTO lU 2DZSE5.. . ALL OWNED r i SCHEDULED I I I BODILY IALRY{Pe zr-.ident) 5 I I ALAS L__I I ! PROPERTY DAMAGE AUTOS j i I X I NON-OWN�'' , - {{Per accident! 1 X I HIRED AUTOS 1 ALM 05 I^I �� S.�OD,DDOI i f I EACH OCCURRENCE X I UMBRELLA UAE OCCUF. ,ODG,DDO� S 202945S ' :0,20 0811012D1 `:�; fc AGGREGA-E i AI 10ESS LIRE I CLAIh!S-MADE, D8r i ,1 S DED i RETENnONS ; I I OTH .I ! X f iTiE I ER !WORKERS COMPENSATION DD[.DDU` AND EMPLOYEIIr LIABiLnY Y iN! 1000006$028 i L81%112D15 O$12112D16 Fri EACF ACCIDENT ANY PROPRIETOR/PARTNERlFECUT1vE irk !N 1 A c 1,ODD,DDO OFFIEMBER EXCLUDED? E1_DISEASE-EA EMPLOYEE- �(M..C=InNH) 1,DDD,DDD` 1`yes.desa�E Mdar' I I E.L DISEASE-POLICY UtJf.f { DESCRIPnONOFOPERATIONS.befov.' ! - r D8•'6i12r? 5iDS12112016!See -ttached 1 ItNC8280583 2 SL C lWorkers Compensation I I DESCRIPTION ION- OF OPERA TIONS 1 LOCATIONS!VEHICLES(ACORD lrn,Additiona Rema*s ScheduiE,may be zMchec 1,more space I-required) I I ' CANCEL'ATlOiY CERTIFICATE HOLDER 1 f I SHOULC Ai l'or T,HE ABOVE DESCRIBED POLII WILL BE DELIVERED D� I THE EXPIR.L:TION DATE THEREOF, NSM- I ACCORDANCE WTH THE POLICY PRO\'1!§5'S. ! iAUTHOR=—REPRESENTATIVE I !Evidence of}nsuTance `<.rSg-2C?i¢fiCORD CORPOFc.ATt04\•. All rights t'ess-veC. -arks of A.GORL ACORD 25(2614/0 -he ;CORD narnee and loge are rec=.stereo SINE Town of Barnstable *Permit#Expires Regulatory Services Fee 6 months from issue date : ' MASS. 9'16 Richard V.Scali,Direc r �J 63 ♦0 QED MA'1 A Building Div o> �� Tom Perry,CBO,Building Commissioner 200 Main Street,Hyannis,MA 02 AI www.town.barnste I r O Office: 508-862-4038 OF BA Fax: 508-790-6230 !� EXPRESS PERMIT APPLICATION - RESIDEN °� _,XLY Not Valid without Red X-Press Imprint Map/parcel Number i�2L /00 Property Address "H J L 4 Ze`R A41 WA C afyi t- [Residential Value of Work$ f 6/ 0001 d d Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address 7,0LICI� -�- f AI,L SC,Aa'ttieV y s i2 ee tmrm Gojv,-�- , A-4 o z� G����r-f oil 3104 Contractor's Name ,t Telephone Number /„ L !t/Z ci4Yjt21 NUS lNl 1lrt �mi1 M ' , Home Improvement Contractor Lifense#(if applicable) / U77 4 Email: R y C C Q f i 21 t Acme , i o m Construction Supervisor's License#(if applicable) C 5 0 7 y i-7 0 0Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner [VI have Worker's Compensation Insurance Insurance Company Name T1 ln kll,91� Workman's Comp.Policy# 17 2'V 1✓ r,1710 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 e roof(hurricane nailed)(not strippping. Going over existing layers of roof) V.e-side W C 6 v il En-fii a (�sOl 0— Replacement Windows/doors/sliders.U-Value ' °' (maximum.32)#of windows #of doors: / ✓b/lq Or ❑ 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 of the Home.Improvement Contractors:License&Construction Supervisors License is eq eq d. j� �11✓ r Add 14 SIGNATURE: C:\Users\Decollik\AppData\Local\MicrosoR\Windows\Temporary Internet Files\Content.Outlook\2PIOIDHR\EXPRESS.doc Revised 040215 i Page 7 of 7 Capizzi Home Improvement Inc.: Specifications and Estimates STATE OF MASSACHUSETTS LETTER OF AUTHORIZATION TO APPLY FOR A BUILDING PERMIT WE, ERIC &PATRICIA SCHAEFER, OWN THE PROPERTY LOCATED AT 44 SCREECHEAM WAY IN COTUIT, 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: n. SIGNATURE OF OWNER: m OWNER'S ADDRESS: 27PRINCE.SS PINE:LANE,MILFORD MA 01757 OWNER'S TELEPHONE: (508)428-0956 - _. LESSEE'S SIGNATURE: LESSEE'S ADDRESS. LESSEE'S TELEPHONE: APLLICANT'S SIGNATURE: APPLICANT'S ADDRESS: 1645 Newtown Rd., Cotuit;MA,02635 APPLICANT.'S'TELEPHONE: 5087428-9518 RESPONSIBLE OFFICER: RESPONSIBLE OFFICER ADDRESS: - RESPONSIBLE OFFICER TELEPHONE: , "•S Massachusetts Department of Public Safety Board of Building Regulations and Standards Y 4)15�61 E:E.!3i11) 3tF i7�f 1!?l!1 _ License: CS-974640 �MIRI Q�NS7IA1AS(UN � O: ; ® i S Sint®L Ti WAY _. 1_ , ' Expiration B Commissionar > ® � 4 � � 42 N V - ;I AD ® 2 � .. .0 4 c O N 7 Z b0 (n G � u 0 � ti p'�C L) 9 - �d z O � A o Wiz. U w � 'M W...• Unre5iric`aod-Buildings of any use group which, a o, N � 3 8s uU r ,> contain less�35,000 cubic meet(991m )of > o : A °� o o enclosed space. o a,. - - a z I L 0 I n 0 O U) 0 a: ' 2 D o- a _ €ailure to,possess a current edition of the Massachusetts r v c<7 `° U State Building Code is cause for revocation of this license. For DPS Licensing information visit: vjwvj.Mass.Gov/DPS 7 The Commonwealth of Massachusetts Department of Industri'alAccidents 1 Congress Street;Suite 100 Boston,MA 02114-2017 www.massgov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electridans/Plumbers. TO BE FILED WITH THE PERMrrMG AUTHORM. ADDl a—=1nformation Please Print LeSlbly Name(ansfi=d0rga d=donlladividual):CAPIZZI HOME IMPROVEMENT INC Address:1645 NEWTOWN ROAD City/State/Zip:COTUIT,MA 02635 Phone#:508-428-9518 Are you an employer?Check the appropriate box: Type of project(required). 1.2/ I sm a employer with 40 employees(full and/orparirtime).* 7. ❑New Construction 2.QI am a sole proprietor or partnership and have no employees worldng forme in 8. Q Remodeling any capacity.[No workers'comp.insurance required.] 9. Q Demolition 3.Q I am a homeowner doing all work myself.1N0 workers'comp.insurance required.}t 10 Q Building addition 4.Q I am a homeowner and will be.hiring contractors to conduct all work on my property. I will ensure that au contractors erffiw have workers'compensation insurance or are sole 11.Q Electrical repairs or additions proprietons with no employees. 12.Q Plumbing repairs or additions S. I am a general contractor and I have hired the sub-contractors listed on the attached sheet These- c sub.•cout rs have employees andbave workers'comp.insurance-= 13.❑Roof repairs 14.ErUther 6.Qwe are a eorpomdon end its offieers have exercised their right ofw=4Xion perMGL c. 15%¢1(4),and we have no employees.[No workers'comp.insurance required.} � a 0 0 V i/to ej, °Airy applicant tbst checks box 01 must also fill outthe section below showing their workers'compensation policy inforumtion. t Homeowners who mbmit this affidavit indicating they are doing all work and an hire outside contractors must,&&a a new affidavit indicating such, tContmctors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or notthose entities have employees. if the sob�contcactors have employees;they mustprovide their workers'camp•policy nmmbm lam an employer that ispmWding workers'compensation insurance for my employees. Below Is thepolicy and job site tnformalion. Insurance Company Name:AmGUARD INSURANCE COMPANY Policy#or Self ins.Lic.#:R2WC527200 Expiration Date:12125/2016 Job Site Address: q q 5(,y re, t u &m Um City/State zip: c4IV Df%IV,# Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c.152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify ep ns and penaNtles ofperjury that the information provided above is true and wff&t Si Date: d(e`f d; Phone#.508-428-9518 a O fjwW use only. Do not write in this area,to be completed by city or town ojfklal City or Town: Permit/Liceuse# E ngAathorlty(cfrcle one): ard of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector ther tact Person: Phone#: Aco c CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDNYYY) F2/29/2015 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 CONTACT NAME: ROGERS&GRAY INSURANCE AGENCY, INC. PHONE FAX A/C No): 434 Route 134 E-MAIL ADDRESS: INSURERS AFFORDING COVERAGE NAIC# South Dennis MA 02660 INSURERA: AmGUARD Insurance Company 2390 INSURED INSURER B CAPIZZI HOME IMPROVEMENT INC INSURERC: 1645 NEWTOWN ROAD INSURERD: INSURER E: COTUIT MA 02635 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. ILTR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP INSR WVD POLICYNUMBER MMIDDNYW MM/DD LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAM GE TO RENTED PREMISES Ea occurrence $ CLAIMS-MADE OCCUR MED EXP(An one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per $ AUTOS AUTOS ( ) HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident UMBRELLA 1.1111 HOCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION STATU OTH- A AND EMPLOYERS'LIABILITY YIN R2WC655250 12/25/2015 12/25/2016 X WC - ANY PROPRIETOR/PARTNER/EXECUTIVE N/A E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? N❑ (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space is required) CERTIFICATE HOLDER CANCELLATION Town Of Barnstable SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 200 Main Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Hyannis, MA 02601 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) 1 The ACORD name and logo are registered marks of ACORD Town of Barnstable �t"E'grti Regulatory Services 'TO WA or- TAh�4' Richard V. Scali,Director OCT 7 ` MAQQ '� ` Building Division ' At n L6�T `�� jOtE16 9. Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 0260 i. www.town.barnstable.ma.usDi , Office: 508-862-4038 Fax: 508-790-6230 �.U�`� � PERMIT# � ' FEE: $35.00 SHED REGISTRATION RESIDENTIAL ONLY 200 square feet or less 4-4 cSe�ee c YLck �� Location of shed(address) Village Property owner's name Telephone number 13206 L � `2 1 Size of Shed Map/Parcel# /U - 27 - 614 Signs e Date Hyannis Main Street Waterfront Historic District? Old King's Highway Historic District Commission jurisdiction? If over 120 square feet,you must file with Old King's Highway Conservation Commission(signature is required) e _ Sign off hours for Conservation;.8:00-9:30&3:30-4:30 PLEASE NOTE: IF YOU ARE WITHIN THE JURISDICTION OF ANY OF THE ABOVE COMMISSIONS,THERE MAY BE A REVIEW PROCESS AND APPLICATION FEE. PLEASE SEE THE APPROPRIATE COMMISSION FOR DETAILS. THIS FORM MUST BE ACCOMPANIED BY A ' PLOT PLAN Q-forms-shedreg REV:040914 - TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Bad . 3 2 Map Parcel / ao<. N li i /3 � App cat o Health Division ' ` I` Date Issued 1 L Conservation Division Application Fee 91.�" Planning Dept. Permit Fee Ck 9.� Date Definitive Plan Approved by Planning Board OV h Historic - OKH _Preservation / Hyannis Project Street Address it S Cn e-eotAm W, `l C'o��l f 12M © zG 3 Village Owner ��/C !/ Address yy Sctat� �u� ko Telephone ��� Y G Co i / 1*4 0 3 f Permit Request > C 4d e_ gt egl,4 1W1 lip©c% 1%gl!0e me/y ' a 7 v 1✓ l2d� o eJ %lV,1Ti?!/ ly�?w %yeT✓ C'aoif eP oe�l�! C4�/�- � ,Uo c/14Nye To /_/aovoe/0 oe J-z11cT4111e o/ Ach-elv Square feet:.1 st floor: existing aproposed 2nd floor: existing 6 proposed d Total new Zoning District Flood Plain Groundwater Overlay Project Valuation / —Construction Type 1,1110, m-L Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family 2/ Two Family ❑ Multi-Family (#-units) Age of Existing Structure IM5' Historic House: ❑Yes ;�to On Old King's Highway: ❑Yes ❑Ncf_ Basement Type: ©'Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area(sq.ft.) Basement Unfinished Area(s,%f) 4. Number of Baths: Full: existing 2 new Q Half: existing 0` MOW ~ � C" Number of Bedrooms: existing _new Total Room Count (not including baths): existing new o First Floor Room Count w z:o Heat Type and Fuel: ❑ G W Oil ❑ Electric ❑ Other ' Central Air: ❑Yes 7 No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ullo Detached garage:rOxisting ❑ new size_Pool: ❑ existing .❑ new size Barn: ❑ existing ❑ new sizeAttached gara e: 9 existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Au orization ❑ Appeal # Recorded ❑ Commercial ❑Yes o If yes, site plan review # Current Use '��e �°�'�� J®lea r401)'I Proposed Use APPLICANT INFORMATION I/ A- Z(P Ildl j 1 g UILDER OR HOMEOWNER) l f�y S`f Name y 9`�� ��f/u I l/j^ Telephone Number S dress U et, f4Wl) Ujl t"� License # � S ' 6 -1 y 6 V c "_A d 2 Home Improvement Contractor# U ®-7 d Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO d LAJ M Odlr SIGNATURE DATE ! a `y 1 ' FOR OFFICIAL USE ONLY r APPLICATION# y DATE ISSUED MAP/PARCELNO. E x. ADDRESS VILLAGE OWNER s DATE OF INSPECTION: . =FOUNDATION k FRAME INSULATION FIREPLACE f ELECTRICAL: ROUGH FINAL vw PLUMBING: ROUGH FINAL GAS: ROUGH FINAL \C FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. - 1 Office of Investigations I Congress Street,Suite 100 Boston,MA 02114-2017 • www.massgov/dia 'workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information PIease Print LegibIy Name(Business/Organization/Individual):Capizzi Home Improvement Address:1645 Newtown Road City/State/Zip.Cotuit, MA-02648 Phone#:508-428-9518 . re you an employer?Check the appropriate box: 40+ 4. I am a Type of project(required): F., :❑✓ .I am a employer with_ ❑ 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, n Demolition working for mein any capacity. employees and have workers' o workers' com com insurance.t 9• ❑Building addition [N p.insurance p� required.] 3. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner dour all work officers have exercised their g 11.❑Plumbing repairs or additions myself. [No workers' comp- right of exemption per MGL insurance required.]t c. 152, §1(4),and we have no 12.[] oofxepairs: . / employees: [No workers' 1316ther IV/#OP/� comp.insurance required.] *Any app.!cant that cheer box#1 must also fill out the section below shoving their workers'compensation polE�y infornution�"' fi Homeowners*11 submit this affidavit indicating they are doing all work.anr_i then hire check #Contia ors outside contractors must submit'a new affidavit indicating such that box must attached an additional Sheet showingothe name of the sub-contractors and,state whether or pot those entities have employees. If the sub-eontractors have employees,they must provide their workers'comp,polioy Milo I:am an employeration. that is providing workers'compensation insurance for my employees Below is the policy and job site inform Insurance Company Name:Associated Employers Insurance Company Policy.#or Self-ins.Lic.#:WCC5010 547012011 " Expiration.Date: 12/251201; Job Site Address: `� t_ —City/State/Zip- 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify nder th pains and p n ties of perjury that the in provided above is true and correct.' Si ature: � Date: Phone#: 508-428-951$ 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): I:Board of Health 2.Building Department 3.City/Town CIerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: I CAPIHOM-01 CBENISCH ACVRO" DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 6/12/2013 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 endorsement(s). PRODUCER NAME CT Chris Benisch MR eRrss&Gray Ins.-Dennis Branch PHONE 508 398-7980 FAA( 443344 Avc No E,d:( ) ac No:(877)816-2166 South Dennis,MA 02660 of DRILESS:cbenisch@rogersgray.com INSURERS)AFFORDING COVERAGE NAIL d INSURER A:Main Street America Assurance Co. INSURED INSURERB:Associated Employers Insurance Co. Capizzi Home Improvement,Inc. INSURER C: Capizzi Enterprises,Inc. INSURERD: 1645 Newtown Road Cotu it,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. I�TRR TYPE OF INSURANCE INSR SWVD POLICY NUMBER MIDDY E� MM/DD LICY EXP LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY MPB1075H 6/8/2013 6/8/2014 WA,E-TO REN D ocane ES Ea nce $ 500,000 CLAIMS-MADE a 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-COMPIOP AGG $ 1 2,000,000 POLICY PRO- LOC $ AUTOMOBILE LIABILITY - - COMBINED SINGLE LIMIT = - - Ea accident $ A ANY AUTO MIM28044 6/8/2013 6/8/2014 BODILY INJURY(Per person) $ ALL AUTOS X AUTOS BODILY INJURY(Per accident) $ 500,000 X HIRED AUTOS X NON-OWNED - PROPERTY DAMAGE $ AUTOS PER ACCIDENT X UMBRELLA LIAB OCCUR - EACH OCCURRENCE $ 5,000,000 A EXCESS LIAB CLAIMS-MADE CUB1076H 6/8/2013 6/8/2014 AGGREGATE - $ DED I X I RETENTION$ 10,000 1 $ 5,000,000 WORKERS COMPENSATION T WC STATU- X OTH- - AND EMPLOYERS'LIABILITY TORY LIMITS ER B ANY PROPRIEfORWARTNER/EXECUTIVEY/N CCSO10547012012 12/25/2012 12/25/2013 E.L.EACH ACCIDENT $ ' 1,000,000 OFFICER/MEMBER EXCLUDED? ® N/A - - (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/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 YYILL BE DELIVERED IN 200 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. Hyannis,MA 02601-ONO AUTHORIZED REPRESENTATIVE _ ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD Page 7 of 7. ' Capizzi Home Improvement Inc: Specifications and Estimates STATE.OF MASSACHUSETTS - LETTER OF:AUTHORIZATION TO APPLY FOR A BUILDING PERMIT WE, ERIC &PATRICIA SCHAEFER;OWN THE PROPERTY LOCATED AT 44 SCREECHAM WAY IN COTUIT, MASSACHUSETTS r 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 I LESSEE TO APPLY FOR A BUILDING PERMIT IN ACCORDANCEWITH 780 CMR; THE MASSACHUSETTS STATE BUILDING CODE. SIGNATURE OF OWNER: r y— .�-c� �C �n � �,-_ -�1 E lo OWNER'S ADDRESS: 44:SCREECHAM WAY, COTUIT, IVIA:02635 f: OWNER'S TELEPHONE. 508-428-0956: . r - LESSEE'S SIGNATURE:.'': LESSEE'S ADDRESS. LESSEE'S TELEPHONE:: . .y a_ APLLICANT'S SIGNATURE: APPLICANT. S ADDRESS:. x >1645Newtown Rd., Cotuit, MA.02635 APPLICANT'S TELEPHONE: 508=428-9518 , RESPONSIBLE OFFICER-" RESPONSIBLE OFFICER ADDRESS: - .. RESPONSIBLE OFFICER TELEPHONE: ' 6. Unrestricted-Buildings of any use group which contain less than 35,000 cubic feet(991m)of enclosed space. Massachusetts -Department of Public Safety �f Board of Building Regulations and Standards Construction Supervisor Failure to possess a current edition of the Massachusetts License: CS-074640 State Building Code is cause for revocation of this license. GARY GUSTAFSON For DPS Licensing information visit: www.Mass.Gov/DPS g SHORT WAY SANDWICH MA=025 1 J.�w•+�J/e ►• ,� �u�� Expiration Commissioner 11/29/2014 �1e �omvmazureall�x o��/�aaae�u�eet!a � - . Officmom e of Consumer Affairs&Business Regulation 14cause or registration Yard for ladhitdtl usa only OME IMPROVEMENT CONTRACTOR bum the e*ht zt€an date. Iffbtnd Few to. iQffice of CaasttlnerAHhira salt Budm6sll Refit htfm Registration '.::1'06740 Type; 11��`st'1cI'la -Sate5'170 - Expiratig g`123 2014 Supplement 11 CAPIZZI HOME lF►�OVEM�NT,INC. r! GARY GUSTAFSON__..,,.•, _.., .:- 1645 Newton Rd. Cotuit,MA 02635 Undersecretary . . .. �gq... 'Li,!rncttn�seesatPa I e , AF At r �aY:: :N } -t. y - • j t ',x, ° ,r$ ,ate - s..;; t,�„ a - „t�^g -. ` r'- �.^ •J' .�++ .y— -�^•- "4 �y.��..� u 4� r w_ a� �. .,1 al+tdra T< °�E5~ ii�x �` � F s,�'Y M R�_ ._ .m r awr.... `. re • ^'�#' 1• :M ur, .ic+pr:is+r +w,.k wk sis„w�: +*Yt w',.J` i+ 1 '� � �"� e. Ito lop V, 0I Iwo i.. �alln �k ,„'r % �.;, i F z ' `}. e .v". ' xi � 1 4 I IV NOW e { Im AOL ._./.. ate. �#> --WIN All K 40 r -44 pm„� yw�, :.. '„ ..:se' _ �d 'A`g 4 Al01, a y" •.+. m'y `;`"a# > rf �'.r.'��a�aa ... rya !! + t ..V � � � �� 'r •-p�' �•?; '�^:. ..� ,. ' Y m'�`"`:+ °,"��,��... y �., .fie -�' '�`" .�. '� ""t��w`'.,t �'> ;, *ti z '''s� ar: � .. ..f ay� "���- w" rr.,ac�� ,�,• ,..- p«� .*� w, ,« s`s�x.wu~ ,�w.;:,�„�:.«,��,w' �� ,w,;�;�,:...< � = rl�cr�; 5 , ., ",. rs. a ••TO �... .. Ott �F 7.8 d1.. 1#4 Oak 4�- PR 17,i vivo a , TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map �-' Parcel.-.",. ) 4j,.�— 601 'Application# Health`DivisionDate Issued Conservation Division Application Fee Planning.Dept: Permit Fee 0 Date Definitive Plan Approved by Planning Board Historic - OKH Preservation/ Hyannis ' Project Street Address `7 E G r '�E' ch Ct Village ' G-D L-U➢ Owner G �� G -h(d�- r Address / 7 Telephone C5 Permit Request �,( n ✓-P�c} � - Cam- -r 1 Square feet: 1 st floor: existing proposed _2nd floor: existing proposed Total new Zoning District Flood P ain'' Groundwater Overlay >rlProject Valuation ® +' Construction Type Lot Size Grandfathered: ❑Yes 0 No If yes, attach supporting documentation. l� DwellingType: Single Family .❑ Two Family ❑ Multi-Family(# units) fT ge of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No asement Type: ❑ Full ❑ Crawl ❑Walkout ❑Other asement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) umber of Baths: Full: existing new Half: existing new umber of Bedrooms: /T existing A Total Room Count (not including baths): existing / new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑Oil .❑-Electric ❑Other ►= Central Air: ❑Yes ❑ No ;-Fi"replaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size—Pool: ❑ existing ❑ new size_ Barn: ❑ existing ❑ new size_ Attached garag.e:"Olexisting ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ --� o Commercial,-O Yes ❑ No If yes, site plan review# % Current,Use Proposed Use APPLICANT INFORMATION ' (BUILDER OR HOMEOWNER) Name l4� �- ,V?)16PAj2#elephone Number � n �eu� 1 -) Address /T/If J �a,��) License# � `7" (Q T1 Cnz h-P a t , ILIA 1 14 3, Home Improvement Contractor# Worker's Compensation # W C ALL CONSTll ICTION DEBRIS RESULTING FROM THIS P OJECT WI L BE TAKEN TO E ., - aol $ I SIGNATURE DATE FOR OFFICIAL USE ONLY { APPLICATION# DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER f 9 s • h DATE OF INSPECTION: FOUNDATION FRAME ��R�� 4©P�o PfNe-k AA.-- INSULATION r r FIREPLACE i r I ELECTRICAL: ROUGH FINAL 1, PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT r , ASSOCIATION PLAN NO. The Commonwealth of Afassachusetts Department of Industrial Accidents Office of Investigations' ' 600 Washington Street Boston, MA 02111 �4 =� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/individual): Address: �_ f 1 P/r A) 1fl City/State/Zip: ('-�(� Phone.#: ® Are you an employer? Check the appropriate box: Type of project(required): 1 I am a employer with • 4. I am a general contractor and I . employees(full and/or p -timel.* have hired the sub-contractors 6. ❑New construction 2.0 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 working for me in any capacity. employees and have workers' 9 0 Building addition [No workers'-comp.•insurance comp. insurance.$ required.] 5. 0 We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers' comp. right df exemption per MGL 12.0 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. XContractors 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_cmployees,they must provide their workers'comp.policy number. Iam an employer that isproviding workers'compensation insurance for my employees. Below is the policy andjob site information. Insurance Company Name: DY) (9 Y �+�vW I 6 Policy#or Self-ins. Lic.M IA/ Expiration Dater D B i r-� Roo Job Site Address• rrx �S�r City/State/Zip: ' f Attach a copy of the workers'compensation policy declaration page(showing the policy n mb r and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the'imposition of crimirial 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'• urance coverage verification. I do hereby certify r t pains and penalde of perjury that the information provided above is true and correct Siznafore: J Date: _ Phone#: 7 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 corupiiance vzth 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, it necessary,supply sub-cont=actor(s)name(s),address(es)andphone 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 Departraent at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Offirials 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 n r I_ T_ .AA:fi a nr �n nnl;,-gnt Please be sure to fill in the permivacense number which will oc mod as a re,o��u����uu.��.• �u u..u•u..., --- rr---- 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 fo any business or commercial venture (i.e. a dog license of 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 Commonwealth of Massachusetts Department of Industri 1 Accidents Office of Investigations, 600 Washington Street Boston,MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Fax# 617-727=7749 Revised 11-22-06 ' www.mass.gov/dia NOON ■ - >. . ■■■ ■MEMEEME■■NOON■■ ■ MEN■■ ■EMEM■MEM ■ MEMNON sl MMEMMMMMMMMMII ■■NNE■■■ NOON ■ ■ , ■■■■■■■ ■■■■NI ■■■■■■■■ -!i NONE ■■NON■ %�-� .�. :>���''i _�. -�■ .■E. !' . �. ■ONE■ ■NEEM■ IMIS MENEMNei ■ ■ENNEN ■NENNEEM■■■M■EME■E ■ ■ ■■Illo'm ■ENNE■ ■E■■MEM■NEM■E■■ ■I ME ■ ■■■M■■M ■ENN■■ ■■■■■■■■■■■■■■■ ■r10 ■ ■■■NENN ■EN■M■ ■ENME■M■■NEE■EME ■■ ■■ NONE■■■ MENNE■ ■NNEMEMM■MEMMEME ■■ ■■ ■NEE■■■ ■EON■■ M■EM■OME■■■M■EMMMM No ■■ OEM■■■■ ■ENE■■ NOON ■ ■E■■E■ ■■ ■NNE■■ ■ NN ■■M■E■ ■■ ■ENE■■ ■■■■■■■■■■■■■■■■■■ MEMON M■■NNN■ ■NEE■■ ■ ,ME■■O■■■OM■■MEMNMEMM■■ENEIMMEM M MENNE■ vNNNNNNNNNN■NNNN■ NOON■■■ M■NEM■ MENEM■EM ■E■NEN ■■ENE■■■ ■EON■■■ MEMME■ ■■■■■■■ MOMEMEE■ ■OMMEM■■MMEMEME■■ M■NEON ■■NEM■■ NNNN■■■■■■■■■■N■E■EMN NONE E■■■■■ M■■N■■■■■■■■■■■NOON NONENN ■EN■■N ■EN MINE■ ■ENNE■ ■M■EM■■■NNEE■ ■■ ONE■ �■ ■■ ■E■NEN ■NNEEM■E■M■EM ME ON M NONE ■MEE No ■■ ■■■EM■■OMEMNN ■■ ■■ ■■■N No ■■ ■ loommMENNE■ ■■ NONEO� ■N MEMOME■E■ E■MNM■EEM■■ ■■■ NIEMEN ■E■MUMMEME ■ ■ ■■■■■NNE rm...Imlill ■■ 0 ■■ENNNNNNNONNMMEMEE■■■■■■ E®E NOON J i i i i i i j Client#:47298 CAPIHOM ACORD- CERTIFICATE OF LIABILITY INSURANCE DATE( M1 DAY) 09 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Rogers&Gray Ins.-So.Dennis ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 434 Route 134 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR P.O. Box 1601 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. , South Dennis, MA 02660-1601 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: National Grange Mutual Insurance Co. Capizzi Home Improvement, Inc. INSURERB: NATIONAL UNION FIRE INS. Capizzi Enterprises, Inc. INSURER C: 1645 Newtown Road Cotuit, MA 02635 INSURER D: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED.BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. SR ADD' POLICY EFFECTIVE POLICY EXPIRATION LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE MM/DD DATE MM/DD/YY LIMITS A GENERAL LIABILITY MPB1075H 06/08109 06/08/10 EACH OCCURRENCE $1,000,000 N�_CO]M MERCIAL GENERAL LIABILITY DAMAGE TOPREMISES a NToccU e ce $500 OOO 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 s2,000,000 POLICY 7X jE 0 LOC A AUTOMOBILE LIABILITY BPO10786 06/08/09 06/08/10 COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $500,000 ALL OWNED AUTOS BODILY INJURY $ X SCHEDULED AUTOS (Per person) X HIRED AUTOS BODILY INJURY $ X NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO EA ACC $ G OTHER THAN AUTO ONLY: AGG $ A EXCESS/UMBRELLALIABILITY CUB1076H 06/08/09 06/08/10 EACH OCCURRENCE $5 000 000 X OCCUR CLAIMS MADE AGGREGATE s5,000,000 $ DEDUCTIBLE $ X RETENTION $10000 $ B WORKERS COMPENSATION AND WC006957000 12/25/08 ` 12/25/09 X WC STATU- ER EMPLOYERS'LIABILITY E.L.EACH ACCIDENT $1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE POLICY LIMIT $1,000,000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Carpentry CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Town of Barnstable DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 1n DAYS WRITTEN 200 Main Street NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL Hyannis,MA 02601 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE r ACORD 25(2001108)1 of 2 #S43470/M43449 KW 0 ACORD'CORPORATION 1988 92. '(Ooorvrrt1—lia o�✓ aaa u�zueetta Board of Building Regulations and Standaeds License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: , hoard of Building Regulations and Standards Reglstt);Qt�; 100740 One Ashburton Place Rm 1301 p1Fi�lien=_@ 23/2010 Boston,Ma.02108 �llement Card CAPIZZI HOME M tARY GUSTAFS\t 1645 Newton Rd. IX.r _ Cotuit,MA 02635 __ ._._ .._...._.. .._ _... ..._ . Administrator 70- va ic itho.t nature ,,�. >C:t.�.,;tchu�.ctt•- 1)i:liartrttt�tit t�f I'.ttlylic 5.afet� . -- --- —. BOA111 41! litliitlest, 12c ;t+latiun .trael t tnd.ai'tls .. Constructicn Supervisor License License: Cs 74640 ` hA a Restricted to; 00 i GARY .GUSTAFSON � a 8 SHORT WAY SANDWICH, MA 02563i' E,x17tr+ti sa: 41/29/2010 'Tr : 7755 Page 7 of 7 CAPIZZI HOME RAPROVEMENT INC.: SPECIFICATIONS AND ESTIMATES STATE OF MASSACHUSETTS LETTER OF AUTHORIZATION TO APPLY FOR A BUILDING PERMIT WE,ERIC&PAT SCHAEFFER, OWN THE PROPERTY'LOCATED AT 44 SCREECHAM WAY IN COTUIT,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: OWNER'S ADDRESS: OWNER'S TELEPHONE: ; LESSEE'S SIGNATURE: ` LESSEE'S ADDRESS: LESSEE'S TELEPHONE: APLLICANT'S SIGNATURE: APPLICANT'SADDRESS: . 1645 Newtown Rd.,Cotuit,MA 02635 APPL-ICANT'S TELEPHONE: 508-428-9518 RESPONSIBLE OFFICER: RESPONSIBLE OFFICER ADDRESS: RESPONSIBLE OFFICER TELEPHONE: L v • �> TOWN OF BARNSTABLE Permit No. _27831 _ i " Building Inspector �� cash +eio D OCCUPANCY PERMIT Bond Issued to 0. E. Schaefer Address Lot 13, 44 Screecham Way, Cotuit Wiring Inspector � Inspection date 1�.�....�� Plumbing Inspector Inspection date Gas Inspector i Inspection date Engineering Department Inspection date 44 Board of Health Inspection date THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN REQUIREMENTS AND IN ACCORDANCE WITH SECTION 119.0 OF THE MASSACHUSETTS STATE BUILDING CODE. ............................. ....., ..... .. _......................_..................................._... Building Inspector i •ti TOWN OF BARNSTABLE BUILDING DEPARTMENT Z DAH37T : TOWN OFFICE BUILDING rua HYANNIS, MASS: 02601 MEMO TO: Town Clerk FROM: Building Department DATE: x An Occupancy Permit has been issued for the building authorized by BuildingPermit #...................rr..'�.:7�3. ...................... ....................................................... ..........._....................... .......... a issuedto :G.. ?. % 1 ............................................................................._......................................._......_.. Please release the performance bond Assessor's map;and lot number ........... ...... .:....... .....' p .' o6 THE TO r Sewage Permit. numberK"S R k. ::......... g yyqQ AHB9 E, i 1..� B TODL House number ... ................/.5 .......C -.. ......... f MeO [ Y rr. SEPTIC '�0 MPr°r� TOWN. OF BA�RNST�' wE �' Ro"ENT'AL x CODE AND N RGUATIIBUILDING R r APPLICATIONFOR PERMIT TO ............:.. ..... l ........ .... ................................................:........ TYPE OF CONSTRUCTION ...................... . .. . ..... .......;... ���'°'� e............................................... TO THE INSPECTOR OF BUILDINGS: The undersigned her by applies for a permit ding to the.following information: Location ................. P�....1 .... ProposedUse ..... . ....... ......_.. ......................................... ....... ............ .. .... ....... .... ... . ... Zoning District ..Fire District :.�� ........ ..... . Name of Owner ... ' .�. �.... .Address .... y.q................................. .�� ASAName of Builder . ... ,. ..... ............... Address ... ... (. .... .......................................... Nameof Architect ............... .... `. .........................Address .................................................................................... Number. of Rooms ............. ..............................................:...Foundation ....... .................................................. �. Roofing .....f..''...... . .............................................. Exterior ......... ................. ......... ....................... Floors ....... .. ............. ..... ...... ........................Interior .......................................... Heating ........ �.L...................... . •....................................Plumbing .......................���r......................... Fireplace .. ........... ...'.lr' ,.-.................................. .....Approximate Cost .......... ."�a... ...`................-. )7 Definitive Plan Approved by Planning Board ---------! __ _ ____19 , v Area -'�.0 ............. Diagram of Lot and Building with Dimensions. Fee ....4 7r.... . ........ .... .. SUBJECT TO APPROVAL OF BOARD OF HEALTH /S� 9 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. .� � Name ............................ .................. ............................... Construction Supervisor's, License ...10.L... ./.. 0 ,,-HAEFER, 0. E. -i7 3 3 7' 1x, Story No ..... Permit for ..................................... Single Family Dwelling ....................... ...............................................Location Cot it� Fg Lot .,,13, .44 5creechdm Way Lot , ................ Owner ...... . S ................E.........chaefer.................................... Type of Construction ................................................................................. Plot .............................. Lot ................................. Permit'Granted ............May...If................19 85 Date of Inspection. .................19 Date Completed ...�eU.r.�.l.... X:3.............19 P, Assessor's map and lot number ..................... THE 41 Sewage Permit number ................. ............... SARNSTLBLE, House number ..4.Y....�ke. A. ........ NAG& 039. 1411 am -f LT TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO .................................................. ..........CF� ...... ........................................................ ... ... .. .......V........................................................................... TYPE OF CONSTRUCTION .......... . ... ...................... ...... 01 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: A Location ...... ...........................7.......... ..................... ....... ......... 7 ProposedUse ........ ...........................................................;..................................................................... .. � �, Zoning District ............ ... ..............�=... ........... . ..........Fire District ......... ...............e...................... ec-.Name of Owner ........... i.. ..!..... ....Address .......7q...2... ...tie...�,/ /4u ..� /I .......................................... Name of Builder .................. ............... .... ...Address ... Nameof Architect ............. ................................Address .................................................................................... Numberof Rooms ............e............................................Foundation ....... ............................................... Exierior ..........o�, Aez ......Roofing . .......... ......... .. ....... ,...............................Interior .......................6.................1, Floors .............. .....I ... ........ ............ Heating ........ .................. .......................Plumbing .............. Fireplace ................. ?.................................................Approximate. Cost .......... .......;P-n................................ Definitive Plan Approved by Planning Board -------- ---------19 Area .... ................ Diagram of Lot and Building with Dimensions Fee ............... ........... SUBJECT TO APPROVAL OF BOARD OF HEALTH /S� 9kk -- 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 construction. Name .................................................................................. Construction Supery iSor's License ... Y SCHAEFER, O. E. 27837 1 z Story No ................. Permit for .................................... Single Family Dwelling ....... ............................................................... Location .......Lot 13, 44.. Screecham. Way -Cotuit Owner ...... ....E�...Schaefer.................... Type of Construction ....F....rame...................... ........... ................................................................................ Plot ........................... Lot ................................ Permit Granted ...May. ...3........................19 85 Date of Inspection ....................................19 t> Date Completed .....19 s � -2- 5 f 1 - e � t I : : I I 2 I I , ` i 41 � I I I r 1 I I I I I , , I i ... I ; 11.3 Q? I I ' I ` I ( 'aj I f I I I - r— -- � 1 , .. � ..'r" , "r VV�rL..J.11�.'d�•�".A. _ _ ILL'I I 4 . 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