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0201 MEGAN ROAD
otoi�/IEsr�/ �Oa�L W r Town of Barnstable Building s Post This Card So That it is Visible From the Street-Approved Plans Must be Retained on Job and==this Card Must be Kept Mnsa Posted Until Final Inspection Has Been Made.`- �7�YY11 s639,p�� 1 mi ,Where -�ert to f,O ..,.�. ....�.,_:.-.�q d;' a h.B Building Occupied until a Final Inspection has been made Where a Certificate of Occupancy�s Required,such Bu�ldmg shall Not be Oc � -� �-_ F Permit No. B-19-216 Applicant Name: Roland Langevin Approvals Date Issued: 02/08/2019 Current Use: Structure Permit Type: Building-Insulation-Residential Expiration Date: 08/08/2019 Foundation: Location: 201 MEGAN ROAD, HYANNIS Map/Lot 291-240 Zoning District: RB Sheathing: t- Owner on Record: PETROVSKIY,VLADIMIR& PETROVSKAYA, Contractor Name: v ROLAND LANGEVIN Framing: 1 Address: 201 MEGAN ROAD Contractor License: CS-103861 2 HYANNIS, MA 02601 ( - Est. Project Cost: $4,176.00 Chimney: Description: air sealing,4" cellulose to walls,8" open R-36Cellulose to attic flat, Permit Fee: $85.00 ventilation chutes,vent fan bath thru roof, insulate bulkhead door, Insulation: Fee Paid`_ $85.00 seal and insulate attic hatch, R-38 fiberglass attic damming Final: Date: 2/8/2019 Project Review Req: Plumbing/Gas Rough Plumbing: Building Official Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized by'this permit is commenced within six months after issuance. All work authorized by this permit shall conform to the approved application and the approved construction documents for which this permit has been granted. Rough Gas: All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by-laws and codes. This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for.public inspection for the entire duration of the Final Gas: work until the completion of the same. ( , i Electrical The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided on this-permit. _ Minimum of Five Call Inspections Required for All Construction Work: Service: 1.Foundation or Footing ` Rough: 2.Sheathing Inspection .. m•N<• - — "'r 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Final: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection 5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough: 6.Insulation 7.Final Inspection before Occupancy Low Voltage Final: i Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health Work shall not proceed until the Inspector has approved the various stages of construction. Final: "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Fire Department Building plans are to be available on site Final: All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT Town of Barnstable *Permit#2�1 `D 6,5 1� Expires 6 months from issue date Regulatory Servi RE Fee anaxsenBMMAM S'� 059. Richard V.Scali,Director Building Divis � T 0 5 2015 Tom Perry,CBO,Building Comm"fs�ib BA /V 200 Main Street,Hyannis,MA 02601 �l/V STABLE www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY L1V` Not Valid without Red X-Press Imprint Map/parcel Number / Property Address DResidential Value of Work$ `�G G Mini fee fee of$35.00 for work under$6000.00 Owner's s Name Address �� Contractor's Name �G���L �Q.Z�Q r✓ (' ' Telephone Number r� -2— Home Improvement Contractor License#(if applicable) AP' Email: (fCZc_-a,(, Construction Supervisor's License#(if applicable) t/6 a 3q 3 OWorkman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner [►] I have Worker's Compensation Insurance Insurance Company Name rl CS"1 e,4 Workman's Comp.Policy# d--o 9-o o o) 03 �a Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) [j✓Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders.U-Value (maximum.32)#of windows #of doors: ❑ 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 requir i SIGNATURE: r C:\Users\Decollik\AppData\Local icrowf Win ows\Tempo t.etFiles\Content.Outlook\2PIOIDHR\EXPRESS.doc Revised 040215 �� QQ �T } BAIWffEpp � 3 9. Town of Barnstable Regulatory Services Richard V.Scali,Director Building Division Thomas Perry,CBO Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 . Property Owner Must Complete and Sign This Section If Using A Builder I ,as Owner of the subject property hereby authorize Z�'�c/ to act on my behalf, in all matters relative to work authorized by this building permit application for: (Address of Job) t s i� 5 N igna of Owner Date S � Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. C:\Users\Decollik\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\2PIOIDHR\EXPRESS.doc Revised 040215 U The ComniomwPeadth of Massachusetts -- Deparhumit of Indristraa Accidence Offwe of Investigations _ 600 Washington Street Boston,XA 02111 e mv.ma&Lgovldia Workers' Compensation Insurance Affidavit: BuUders/Conti-actorsXlectricians/Plu nbers ApipUcaut Information Please Print Lezibly Name(Baasiness(organization&dividuaq: eL,Q(k ae&0 Address: City/state/Zip: r�C�` ''® G'' P 1"'�� ]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 6. ❑New construction employees(full and/or part-time)-* have hired the sub-conbactors 2_❑ I am s sole proprietor or parffier- list ed on the attached sheet. 7. ❑Remodeling ship and have no employees These -contractors have g- ❑Demolition working for me in any capacity- employees and have woakers' 9. ❑Building addition [No workers'comp.insurance camp.insuranc e.I required-] 5. ❑ 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 of exemption per MGL 12_❑Roof repairs insurance required-]a c.152,§1(4� and we have no employees-[No workers' 13_❑Other4C-ZW comp.insurance require&] •Piny applicant that chedLs baz#1 mw also fill am the section below sbowing their arorkere oompensatitm policy information_ Hamear ms wbo submit this affidaruat m6catimg they ale daring all vat cad then/sire outside contractmas nest subzarit a new affidavit indicat ag each. h—cut ctus that check this bcK roast attached am additimnal sbeet showsmg the name of she sub-emummrs and state wheth a ma not those entatees have eanpha.fees. If the sub-cmataacton bare employees,they mast p mvide&w wmakers'amp.policy number. dam an eanpinyer that isproviding workers'conz mmation insurance for racy enrplojwes. Below is the,pelicy and job site inforaaaa om Insurance CompaaayName: C,- e'e, Policy.#or S ins.Lie.#: t9 U rTI 00-/-d 5V Q-� Expiration Date:— d +o �G Job Site Address: � 1 f^" G bra � CitylStatelZsp: b� Attach a copy of the workers'compensation.policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be farw arded to the Office of Investigations of the DIA for insurance coverage verification. - - - n e -- s of` " - — --f-- , n provided aborve is ®- correct I do Caere certi carder fire d natlaes that the in oruaatro b�ea 7/ Si Date: Phone Ojy cial use onty. Do not carte in this area,to be completed by city or town o,,icfat City or Town: PermitUcense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/rown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: I CERTIFICATE OF LIABILITY INSURANCE DA 5/12/2015 THIS CERTIFICATE IS ISSUED ASA 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: Berkle Assi ned Risk Services McShea Insurance A'C"�.NE E,a: 800 634-4589 FAX vc No.): 866 215-8118 1550 Falmouth Rd RT 28 Ste 2 E-MAIL ss: PolicyServices@berkleyrisk.com ADDRE Centerville,MA 026.32 INSURER AFFORDNG COVERAGE NAICa INSURER A INSURED INSURER B Richard Cazeault Jr INSURER C: 198 Five Comers Road INSURER o- Centerville,MA 02632 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 NUM BER MI POLICYE F POLICY EXP LIMITS -LTR INSR WVD MDO/YYY MM/DD/YYYY GENERAL LIABILITY AUTOMOBILE LIABILITY $ WORKERS COMPENSATION WC Si AT U- OTH- AND EMPLOYERS'LIABILITY WN _ TORY LIMITS ER ANY PROPRIETOR/PARTNERIEXECUTNE E.I.EACH ACCIDENT $ 500,000 A OFFICEIMEMBER EXCLUDED? N/A ❑ WC-20-20-003093-03 02/04/2015 02/04/2016 (Mandatory In NH)If yea,describe under E.L.DISEASE-EA EMPLOYEE $ 500,000 .. DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT IS 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,R more space is required) . Coverage Election Category Fled.Status Name State(s) All Entities/Locations Sole Proprietor Exclude Richard Cazeault Jr MA Cazeault Jr 198 Five Comers Road Centerville,MA 02632 CERTIFICATE HOLDER CANCELLATION SHOULDANYOFTHE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Sea Meadow village AUTHORIZED REPRESENTATIVE 720 Pitchers Way Hyannis,MA 02601 P Signature_ ACORD 25(2010/05) BRAC 3139 7 ,7. VdlYM :7fffm"f�r.� � „25..,,E :•_ • _ Office of ConsamerAffatrs,� License or registration valid.for individal ase;onfy HQIIAE fMPROVEiYIEIdT"COIVTRAC-.., bdore:tfie egpiration:date If foand return":to;' L RegLstratiort 1S8n07 J Expiration 3l812017 lrtd' Office of Consamer..�ffars andBusrae�s Regulation -;; = nrrduai lO ParIs P.aza-Ssarte 5170` RICHARD P.CAZEAtiLf'JR Boston; 02116 RICHARD CAZEAULfi 198 FIVE CORNERS RD „ 4 �. CENTERVILLE,-PAA d2S32 ,:.« .���,F`�'Y� �• f. Underse6ret2rt 1L'ot tialid�'thouegnat 1` i @ ppar mer'$.of r -q "+. s f " � 'CA1StrrrCtlt)1r'�UpEr4X59 :• - ee tee: C5-100393 RICHARD P CAZ$AUL1'iM.— 198 Five Corners Centerville MA 00632 Cotsr+is=ii�ne 02/0301r% Regulatory Services Prof Thomas F.Geiler,Director Building Division v$ 1MASS Tom Perry,Building Commissioner A ! s 200 Main Street, Hyannis,MA 02601 www.town.barmstable.mams Office: 508-862-4038 Fax: 508-790-6230 Approved: Permit#: :�;)O 130 ) U3 U HOME OCCUPATION REGISTRATION Date: 3' 1 Z�l2j Name: if'k Phone#: 08-1088-Sw4(o o k Address: tia,1 i5 M.4 oZfool. Village: �tir�1s✓Ti6te V(f n�� 5, S,,�n4keK�5 Name of Business: '3A61(1 a6-e Type of Business: 04�1'1{ Map/Lot: INTENT: It is the intent of dds section to allow die residents of the Town of Barnstable to operate a home occupation . Ridhin single family dwellings,subject to die provisions of Section 4-1.4 of die Zoning ordinance,prmided that the actiiaty shall not be discernible from outside die dwelling. there shall be no increase in noise or odor;no eisual alteration to die premises which would suggest any thing other than a residential use;no increase in traGc above normal res' ential voh mes; and no increase in air or groundwater pollution ' After registration with the Building Inspector, a customary home occupation shall be permitted as of riglh jecf to the follovdng conditions: t • The acti<aty is carried on by the permanent resident of a single family residential dwelling unfit;l cated«id�i�o l� that dvvelling unit. %� Such use occupies no more than 400 square feet of space. . There are no external alterations to die dwelling which are not customary in residential buildings and there;isP . no outside evidence of such use. No traffic will be generated in excess of normal residential volumes. o The use does not involve the production of offensive noise,vibration,smoke,dust or other particular matter, odors,electrical disturbance,heat,glare,humidity or other objectionable effects. Y There is no storage-or.use of toxic or ha7-lydous materials,or flammable or explosive materials,in excess.of normal household quantities. o Any need for parking generated by such use shall be met on the same lot containing the Customary Home Occupation,and not within the required front yard. . There is no exterior storage or display of materials or equipment. o There are no commercial veldcles.related to die Customary Home Occupation,odier than one van or one pick-up truck not to exceed one ton capacity, and one-trailer not to exceed20 feet in length and not to exceed 4 tires,parked on the same lot containing the Customary Home Occupation. e .No sign shall be displayed indicating the Customary Home Occupation. e If the Customary Home Occupation is listed or advertised as a business,the street address slz r1l not be included. • No person shall be employed in the Customary Home Occupation ivho is not a permanent resident of the dwelling unit. I,the undersigned;ha e r d and agree with the above restrictions for my home occupation I am registering. Applicant-_ Date: -/e- 2-61 Honieoc.doc Rev.QM YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L.-it does not give you permission to operate.) You must first obtain the necessary signatures on this form at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office, 1 st FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is required by law. DATE: $ S Zoi3 Fill in please: ME�N&IMl 009`09 ERR APPLICANT'S YOUR NAME/S: L4,fi I. SMse- BUSINESS YOUR HOME ADDRESS: to( MewaK Ad hC,u"641 A1.4 026001 jW ' TELEPHONE # Home Telephone Number 52;9(oSC- SIsH(o NAME OF CORPORATION: I 4cXJabl.1 Serv.Zx_S LLL. OA4., l2t/oad fGM—MSS NAME OF NEW BUSINESS TYPE OF BUSINESS ON/�4.e SlyK IS THIS A HOME OCCUPATION? X YES NO ADDRESS OF BUSINESS -. i5 Mk a2,bat MAP/PARCEL NUMBER a v"Z D [Assessing) When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200..Min_St. - (corner of Yarmouth Rd. &Main Street) to make sure you have the appropriate permits and licenses required to legally operate your bus,iness in this town. 1. BUILDING COMMISSIONER'S OFFICE //jj This individual has nformed oVhny permit rep4�e(rr 8%hB�RMIER �pj CCfjj Td@N MU FAILURE TO A J k� IONS. F , _ s a y � t rized Signatur D REGULATIONS. GL�. S4 Ce Y COMMENTS: © COMPLY MAY RESULT IN FINES. {./ -15 2. BOARD OF HEALTH This individual has been' r d of the permit re i ments tha p rtain to this type of business. Z�t.. 2hor1 ed Signature* COMMENTS: 3. CONSUMER AFFAIRS(LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature* COMMENTS: I4 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map- o291 Parcel 02 Q) Application v Health Division Date Issued Conservation Division Application Feg �L_ D Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/Hyannis Project Street Address 1 Village 4NA; s Owner "IJt MWINPCIA 461 Address aa/ u N/s Telephone O Permit )qu-,+ d W s' //"1 O Square feet: 1 st floor: existingl7 roposed 2nd floor: existing 14proposed Total new Zoning District oe e2 Flood Plain A/0 Groundwater Overlay yyyy�� Project Valu tion N Construction Type JJOQ/t G /,� /%/�1J , � Lot Size Grandfathered: ❑Yes XNo If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family (# units) Age of Existing Structure 7-q Historic House: ❑Yes I(No On Old King's Highway: ❑Yes ❑ No Basement Type: kull ❑ Crawl ❑Walkout ❑ Other Basement Finished Area(sq.ft.) 't7�� tl_ Basement Unfinished Area(sq.ft) �T IX— Number of Baths: Full: existing / new 6T Half: existing 0 new 0 Number of Bedrooms: TTexisting anew Total Room Count (not including baths): existing new First Floor oom Count Ks meti+ew)- x D i o �//S P ❑ Other oZ R UAA N Sh �iJC ti� Heat Type and Fuel: JGas ❑ Oil ❑ Electric O e Central Air: TAYes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage:AVAWC❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑4lb new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑YesNo If y s, site plan review# CC Current Use V Proposed Use ✓Ia7�1 -� APPLICANT INF (BUILDER OR OMEOWNER) 4,VO12. Name ,. _C// N Telephone Number Address �'j1 . License# aC&VJ& Home Improvement Contractor# 16&cJliv�e Worker's Compensation # ALL CO STRUCTION D B A5 RESULTING R M THIS PROJECT WILL BETAKEN TO '- /�Ge Ps SIGNATURE DATE lz' i 4P A • r ' FOR OFFICIAL USE ONLY . i As APPLICATION# ' DATE'ISSUED r MAP/PARCEL N0. , ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME r � } INSULATION F t 4 FIREPLACE - ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL Y GAS: ROUGH FINAL FINAL BUILDING - DATE CLOSED'OUT ASSOCIATION PLAN NO. ' f r , G. J. DOUGLAS MURPgy COUNSELOR AT LAW 243 South Street Lock-Drawer M Hyannis,Massachusetts 02601-1412 Telephone: 508-775-3116 . Facsimile: 508-775-37.20 Email:jd.murphy@verizon.net Please reply our File No. 17207 Hand Delivered April 12, 2011 Paul Roma,Building Inspector. Town of Barnstable 200'East Main Street Hyannis,MA 02601 Re: 201 Megan Road;Hyannis Dear Paul: Enclosed are the(I hope)necessary materials to"permit"the.widening of two doorways in the cellar of the above premises. My sister is scheduled for significant surgery Thursday and the closing is scheduled for Friday,so I am trying to assist my sister and her husband as much as I can: Please give me a call at 508-775-3116 (office) or 508 280-3116 (cell) if any questions or anything further is needed. Thank you for your assistance in this regard. mcerely,. J. ougl urph JDM/tlh Enclosures Town of Barnstaple THE Regulatory Services Thomas F. Geiler, Director B kMSrABLe, _ ' u Bildin _ �� g Division Tom Perry,Building Commissioner 200 Main Street, Hyannis, MA 02601 www.t6wn.barnstable.,ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: I Q JOB LOCATION: nu,mbbrrr s get villlaagee�t "HOMEOWNER": 'W'AMI)�j � ..+ '�`�• name a hone# work phone# CURRENT MALLFNG ADDRESS: CA a l�Z city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor, DEFINITION OF HOMEOWNER' Person(s)who owns a parcel of land on which he/she resides or intends to reside, on which there is,or is intended to be, a one or two-family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,bylaws,rules and regulations- The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply wi+,said procedures and requirements. Si ature 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 of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack ofawareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application, that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your.community. Q:forms:homeexempt i po IKE Tp� c R&RNSr"L& 6 Town of Barnstable 4 lEp µp`i Regulatory Services Thomas F. Geiler,Director Building Division Thomas Perry, CBO Building Commissioner 200 Main Street, Hyannis,MA 02601 'f ,. S www,town.barnstable.ma.us 0. ' Office. 508 862-4038 ', t ;, Fax: 508-790-6230 .i . i i - ,� P rape"rty'C?wner`Muat Complete an. I 'T1Rus"`'Section If Using A_Builder as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application for: (Address of Job) Signature of Owner Date Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. CA Use rs\decoIIik\AppData\Local\Microsoft\Windows\Temporary lntemet Files\Content.Outioc) iDDV87AAZ\EXPRESS.doc Revised 072110 S The Commonwealth of Massachusetts ' Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/plumbers Applicant Information l Please Print Le ibl Naive (Business/Organization/Individua r Address: �� City/State/Zip: C V) Phone #: Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 1 4. ❑ I am a general contractor and I * have hired the sub-contractors 6. ❑ New construction employees(full and/or part-time). � 2.❑ I am a sole proprietor or partner- -listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g. ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers'comp. insurance comp. insurance. - required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or-additions 3.91 am a homeowner doing all work officers have exercised their I LE] Plumbing repairs or additions myself. No workers' com right of exemption per MGL Y [ P• 12.❑ Roof repairs insurance required.] t c. 152,§1(4), and we have no employees. [No workers' 13.❑ Other comp. insurance required.] `Any applicant that checks box 91 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. lContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: , Policy#or Self-ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensatiea policy declaration pag&(showing the policy num-ber and expiration date). - Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil.penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage ye-ification. I do here certify under thpainand penalties of perjury that the information provided abo a is true.and correct. 1 /Si ature:c� / Date: Phone#: fl 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,.mainteriance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto A I not because of such employment be deemed to be an employer." i MGL chapter 152, §25C(6) also states that"every state or local licensing agency shall withhold the issuance or renewal of a license oi-.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 I ins urance coverage required." Additionally,MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary,supply sub-contractors)name(s),addresses) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other'than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should .be returned to the city or town that the application for the'perinit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the pernu till cense number which will be used as a reference number. In addition, an applicant that must submit multiple permit/liceiise applications in any given year,need only submit one affidavit indicating current policy information(if�iecessary) 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 yeu. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog 11cense,or permit to burn 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'saddreis,telephone and fax number: The Commonwealth of Massachusetts Department of.Industrial 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 4-24-07 www.mass.gov/dia ,� r A5 meal e I z lI cud2 � od PLO, gs � wu w a 0l Fr D �� ., - ._ � _. ' r. �. - - „ I ' .�i ._ �� - .. .r , O _..+9 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION LCO Co Map Parcel Application # Health Division Date Issued E^ Conservation Division " / Application Fee 0-0 Planning Dept. Permit Fee P62 0 Date Definitive Plan Approved by Planning Board Historic - OKH Preservation/Hyannis Project Street Address _ Gq v� I*e d 0__ Village Gc i S .2— a Owner a-✓' Address / n 1 ` Telephone 5-0 S ' Permit Request '�U ✓N Ct' 'e- te- - Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District C Flood Plain Al Groundwater Overlay c„ —D CD Project Valuation G Construction Type 'd �� � u Lot Size Grandfathered: ❑Yes " d If yes, attach s, pporting documpntation. Dwelling Type: Single Family Two Family ❑ Multi-Family (# units) Age of Existing Structure f! `r" Historic House: ❑Yes On Old Kin 's Hi hwaT ❑lEe ❑ No g 9 � 9 � 9 �` coCIO 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: 12I(Gas ❑ Oil ❑ Electric ❑Other Central Air: ❑Yes 1X"0 Fireplaces: Existing New Existing wood/coal stove: ❑Yes>(No Detached garage: ❑ existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: I Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name r ( U 7 en�D n Telephone Number S� /T 4 0 1 — Address L� �i'� D��PM Ch f License# Ile") 7 y0/9 �`� C, Home Improvement Contractor � 1�(2-/Z/ Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO L SIGNATURE l ' DATE �� 2-D D ,F } FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION r FIREPLACE ELECTRICAL: ROUGH FINAL ' PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING t DATE CLOSED OUT ASSOCIATION PLAN NO. r s ` f The Co«rrzd7 vt- n of Massachusetts D dustrial Accidents Of0waf-bivestigations ' d 600 hash ngton Street Boston,MA 02111 °'" °�° •� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LeLibly Name (Business/Organization/Individual): . Lax 0�"],} I . Address: —! � L�!k 0 City/State/Zip: Phone.#: ,'30t - Lo-S- �Cf S )e Are ou an employer? Check the ap r priate box: Type of project(required):. 1. a employer 4. I am a general contractor and I 6. ❑New construction employees(full and/or p rt-time).* have hired the sub-contractors 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, ❑Demolition working for me in any capacity. employees and have workers' # 9. ❑Building addition [No workers' comp.insurance comp.insurance. . required.] 5. ❑ We are a corporation and its' 10.[1 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 1 LE]Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.] t c. 152, §1(4),and we have no �,/ employees. [No workers' 1 . Qther 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. tContractors that check this box,must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.poficy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. 1 Insurance Company Name:_ j' !� Policy#or Self-ins. Lic.#:_ M-DF Expiration Dater 2- Job Site Address: r 0 a City/State/Zip: A X.In Attach a copy of the workers' co m nation policy declaration page(showing the policy num er and expiration date). .. i Failure to secure coverage as required under Section 25A of MOL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment;as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for ins ance coverage verification. I-do hexeby certify - -de tk rots and- analties a perjury-that-the-i7tfor-mation-prouided-abave-is-true-and-co.rr-ect. Si tune:. Date: Z) 2 D Phone#: Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Client#:47298 CAPIHOM ACORD. CERTIFICATE OF LIABILITY INSURANCE 01/05/10Dmrn 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 INSURERA: Nat'l Grange Mutual Insurance Co. Capizzi Home Improvement,Inc. INSURER B: ACE Property 8r Casualty Ins.Co. Capizzi Enterprises,Inc. INSURER C: 1645 Newtown Road INSURER D: Cotuit,MA 02635 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 IMMIDDIM LIMITS A GENERAL LIABILITY MPB1075H 06/08/09 06/08/10 EACH OCCURRENCE $1 000 000 X COMMERCIAL GENERAL LIABILITY PREMGETOERENTED $500 OOO CLAIMS MADE 51 OCCUR MED EXP(Any one person) $10 000 PERSONAL BADV INJURY $1 000 000 GENERAL AGGREGATE $2 000 000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG s2,000,000 POLICY JE a LOC A AUTOMOBILE LIABILITY M1 M28044 06/08/09 06/08/1 O COMBINED SINGLE LIMIT ANYAUTO (Ea accident) $500,000 ALL OWNED AUTOS BODILY INJURY $ X SCHEDULED AUTOS (Per person) X HIREDAUTOS BODILY INJURY $ X NON-OWNED AUTOS (Per accident) X Drive Other Car PROPERTYDAMAGE $ (Per accident) - GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO EA ACC $ OTHER THAN AUTO ONLY: AGG $ A EXCESSIUMBRELLA LIABILITY CUB1076H 06/08/09 06/08/10 EACH OCCURRENCE $5 000 000 X OCCUR CLAIMS MADE AGGREGATE $5 000 000 $ HDEDUCTIBLE X RETENTION $10 000 $ B WORKERS COMPENSATION AND NWCC45843208 12/25/09 12/25/10 X WC EMPLOYERS'LIABILITY T I LIMITS E ERR ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED?If yes,describe under E.L.DISEASE-EA EMPLOYEE $1 OOO,OOO ' SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $1 000,000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Carpentry CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Town Of Bourne DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 110 DAYS WRITTEN 24 Perry Avenue NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL Buzzards Bay,MA 02532 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 25(2001108)1 of 2 #S48109/M48107 KW 0 ACORD CORPORATION 1988 • a ' 6/72 lr �✓l as .. Board of Bu�ldin Re uletions and Standards g g License or registration valid for individ.ul.use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: f Board of Building 12egul:ltions and StAndards Reglstrat�o 100740.. One Ashburton Palace R"m 1301 l�1=-- ZkOlO 77� Boston,Ma 0210.8 Elm Plement Cara: CAPfZZI HOME��, GARY GUSIAFSn 1645`Newton Rd ) Cotult,MA 02635 Administrf or No vali. ttho• nature -- RbArtl,of $txilcla ;;lac ,utatt3tire..ill� �id43(3 1I115 Constructtot3 S,uprOF vtsor L�c? se incense CS 7�3640s. Restricted o: i00 a. mow. GARY GU$TAFSON 8 SHORT V1f1�Y SANDWICH MA 02563 e;.PIratinp;: 11/29/2010 C .fivaii..,tt t Y Tr. 7755 Page 7 of 7 CAPIZZI HOME RVIPROVEMENT INC. SPECIFICATIONS AND ESTIMATES STATE OF MASSACHUSETTS LETTER OF AUTHORIZATION TO APPLY FOR A BUILDING PERMIT OWN THE PROPERTY LOCATED AT IN rn dj�� , 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 CCORDANCE WITH 780 CMR,THE MASSACHUSETTS STATE BUILDING CODE. SIGNATURE OF OWNER: OWNER'S ADDRESS: OWNER'S TELEPHONE: LESSEE'S SIGNATURE: LESSEE'S ADDRESS: LESSEE'S TELEPHONE: APLLICANT'S SIGNATURE: APPLICANT'S ADDRESS: 1645 Newtown Rd., Cotuit, MA 02635 APPLICANT'S TELEPHONE: 508-428-9518 RESPONSIBLE OFFICER: RESPONSIBLE OFFICER ADDRESS: RESPONSIBLE OFFICER TELEPHONE: i Lop FILE# A1354 CLIENT: CENSUS TRAG7# 125 01AINER DEED;BOOK PAGE APPIJC Mr. PLAN BOOK PAGE LOT 24 ASSESSORS PLAN PLOT . MORTGAGE INSPECTION PLAN = SCALE: 1"=40' OF LAND LOCATED AT MARCH 29, 1996 201 MEGAN ROAD HYAHIUS, MASSA(HUSETTS vwul✓tLS LLN kAID..V NO Z 3 m N suaO �y 2 I ,5ry. . eo,o �.7OG.Teo'Tv P.c, . �Lt7ELID�L AV6. _ i M ..:.ZONING DETERMINATION THE LOCATION OF THE ORIGINAL _DWEL,IING SHOWN:HEREON EITHER WAS IN . COMPLIANCE WITH LQCA APPLICABLE ZONING BYLAWS IN .EFFECT WHEN CONSTRUCTED WITH RESPECT TO HORIZONTAL DIME'NSI ONAI REQUIREMENTS ONLY OR.IS EXSMPT FR0f VIOLATION ENFORCEMENT ACTION UNDER MASS. G.L. TITLE CHAP. 40A, SEC. 7, UNLESS OTHERWISE NOTE FROM PROPERTY OR.D OR SHOWN HEREON. A CONFIRMATORY INSTRUMENT SUR VII IS ADVISED WHEN STRUCIURES ARE Sr'i0Y7N TO BE ONE FOOT OR LESS F SETBACK LINES. REQUIRED ZONlR SU FLOOD DETERMINATION THE DWELLING SHOWN HERE DOES 90T FALL WITHIN A .SPECIAL FLOOD HAZARD ZONE.. AS DELINEATED ON MAP OF C0144UNITY # 250001 0005 C AS ZONE C -DATED 8/19/85 BY THE NATIONAL FLOOD INSQRANC CERTIFICATION I CERTIFY TO MURPHY_,& .MURPHY, P.C. ._.-@lbc'6 uc 3 a isurbep ca. tor. = SANDWICH CO-OPERATIVE BANK-&" IT5 = �ptt�eRt��oRa TITLE.INSURANCE COMPANY, THAT.THERE ARE NO VISIBLE ENCROACHMENTS OR AebJ 3lebtarb, 02745 �:C. EASEMENTS EXCEPT AS SHOWN AND THAT �Ak THIS PLAN WAS PREPARED UNDER MY 1-M-993-3302 'yy Oda IMMEDIATE SUPERVISION. -fax I-WO-993-3304 uR GENERAL NOTES:This mortgage f upectlon PkM was prepared for the above mentioned ctlent z " — Intended or represented to b®0 icstd Of ccdy as of d®tcdpilons,constn�ctlon or®sta i ppe►fY lfne auVey& No comers were Set It cannot be used for'pre bllsft fence,Hedge or d®esd klformailon and racy be sublact fo further outs, .t, m0 land as thaws Heron b based on cent fllrWmd fond owner or occ ao�mertts and rights of way NO re PMUty h extended to the tlsant tt�not attended to b®rec�rdad. -- L0 ✓V _ - -- - ------- ---- --J� Y_- : Z- c -_tea -- -- - - � �v ' - ' � r V i I _ 6-1 yp i A.- I f i 44 1 I FK; ' jv f � 1 ITT � .. `. - . � CAPRA r; / /L...L 0, .1......_. �✓ . - YRS - GA-)--V-88,?�Am 4,FD Co 67� To 6 a 4 Pe, /P . C' I �. TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map �. q / Parcel U Application # d Health Division Date Issued Z d Conservation Division Application Fee Planning Dept. Permit Fee. Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/Hyannis tI Project Street Address Village a Owner E[(�f�a Address 7 /> I 14-eQ , H:UL MLS Telephone C) I -- i 3 2 `7 d 2 b6/ Permit Request S �C� C' I n n us Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District C Flood Plain N Groundwater Overlay Project Valuation D 00 1 ODConstruction Type Lot Size 13 4 Grandfathered: ❑Yes )ELAlo If yes, attach supporting documentation. Dwelling Type: Single Family , Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes 66o On Old King's Highway: ❑Yes )4(No 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: hGas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes A No Fireplaces: Existing New Existing wood/coal stove: ❑Yes z9 No Detached garage: ❑ existing ❑ new size Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: ,Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ =0 ' Commercial ❑Yes JNo If yes, site plan review# Current Use Proposed Use ' w CD APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name v Ei✓1 Telephone Number Address �:C 1 ZZ�s 51 -ticense # b Il am(} 1,0 Home Improvement Contractor# �D 7 C2 3 S� Worker's Compensation # `T-1=C� l ;:2 iL-) ALL CONSTRUCTION DEBRIS S1JNG FROM THIS PROJECT WILL BETAKEN TO SIGNATURE DATE I oZ FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED s_ MAP/PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION v FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL } r GAS: ROUGH FINAL b FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. CAA I /11 FILE# A1354 CENSUS`TRACT* 125 CUEM: Ml DEEaBOOK OWNER: CLATMN PLAN BOOK' PAGE APPUCANr: PAGE LOT 29 .ASSESSORS RM PLOT MORTGAGE INSPECTION PLAN OF LAND LOCATED AT SCALE: 1"=40' MARCH 29, 1996 201 HWAN RDAD HYANNIS, MASsNMuSn S / eltj LL N 1GIJCYvV t4) Bo.o9� r4 N as c0 y�,Cl O W ,.70G.Fr0''r c, Rr—,A-r - � �r nTZi'blaL AVC. . M E C 3Ax, ZONING DMMINATIO THE LOCATION OF THE ORIGINAL -DWELLING SHOWN:HEREON EITHER WAS IN . COMPLIANCE WITH LOCA APPLICABLE ZONING BYLAWS IN .EFFECT WHEN CONSTRUCTED WITH RESPECT TO HORIZONTAL DIMENSIO NAI REQUIREMENTS ONLY OR_IS EXEMPT FROM VIOLATION ENFORCEMENT ACTION UNDER MASS- G.L. TITLE VII CHAP. 90A, SEC. 7, UNLESS OTHERWISE NOTED OR SHOWN HEREON. A CONFIRMATORY INSTRUMENT SUR VEI IS ADVISED WHEN STRUCTURES ARE SHOWN TO BE ONE FOOT OR LESS FROM PROPERTY OR REQUIRED ZONIN SETBACK LINES. ROOD DETERMINATION THE DWELLING SHOWN HERE DOES kT FALL WITHIN A SPECIAL FLOOD HAZARD ZONE.. AS DELINEATED ON MAP OF COMMUNITY # 250001 0005 C AS ZONE C -DATED 8/19/85 BY THE NATIONAL FLOOD INSURANC PROGRAM- CERTIRCATION I CERTIFY TO MURPHY-•& MURPHY, P.C. .eIbe:fitOne 3Canb&urbep(Co. SANDWICH CO-OPERATIVE BANK & ITS Gen�etbpOab TITLE INSURANCE COMPANY, THAT THERE p ARE NO VISIBLE ENCROACHMENTS OR hem-Aebferb,in 02745 EASEMENTS EXCEPT AS SHOWN AND THAT 1-800.893-3302 ' v. THIS PLAN WAS PREPARED UNDER MY 'y �ESSrO� IMMEDIATE SUPERVISION. -fax 1-600-993-3304 u9 GENERAL NOTES:This mortgage inspection plan was prepared for the above mentioned dlent my as of e r h riot Intended or represented to be a land or property one survey. No comer were act, it cannot be umd foi prelmling dried descrIptlons,constructlon or establishing fence,hedge or buodng onel, The land a ft m heron h bored on client WMed Information and may be subject to Amfhw out.Wea,tcWngs,easements and rights of way,.No MPMUIV is extended to the land owner or occiPont,It Is net Intended to be recorded, 70 , ^c Xe P %p _000.0000� At 7y - : - _ , 'k ADF_ VfW A as — — — — — �, : i . -CAPIZZI HOME RvIPROVEMENT INC. Page 7 of 7 SPECIFICATIONS AND ESTIMATES STATE OF MASSACHUSETTS LETTER OF AUTHORIZATION TO APPLY FOR A BUILDING PERMIT C / 4"— OWN THE PROPERTY LOCATED AT —2D.1 f ?�P a � IN °Gi L4 l 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 CCORDANCE WITH 780 CMR,'THE MASSACHUSETTS STATE BUILDING CODE. SIGNATURE OF OWNER: OWNER'S ADDRESS: "^^e OWNER'S TELEPHONE: LESSEE'S SIGNATURE: LESSEE'S ADDRESS: LESSEE'S TELEPHONE: APLLICANT'S SIGNATURE: APPLICANT'S ADDRESS: 1645 Newtown Rd., Cotuit, MA 02635 APPLICANT'S TELEPHONE: 508-428-9518 RESPONSIBLE OFFICER: RESPONSIBLE OFFICER ADDRESS: RESPONSIBLE OFFICER TELEPHONE: _ Board of Building Regulations and Standards License or registration valid for individ.ul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: rf'`L Board of Building Regulations and Standards Registrl4tip.A{ 100740 One Ashburton Place Rm 1301 _ORF 1an15Q.2312010 Boston;Ma.02108 pplement Card CAPIZZi HOME N111°� tARY GUSTAFS�Otr( — 1645 Newton Rd- ` `; F=� Cotuit, MA02635 {" -- 4CAdministrRtor 1Vo vali " nature :�ia.•.�:sel33i.5c.t#�- llv1><;r'tnYu t of pvh is safety -- — Bc<3rcl�l'6ctslili�i� tc<� fit'lls and standi ril:s Construction Supervisor License Lacs nSe: CS 74640 Resfril-ted to. 00 ;z GARY.GUSTAFSOt 8 SHORT WAY SANDWICH, NIA02563 T r_r� r 1'zi :• c�� �y i� c; ;;a?ir,• 1 1 129/20 1 0 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ' 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual):. ��? j �� - '�'1�✓� J _ -Address: � L�1ZYil� /'_r City/State/Zip: Phone.#:�Q(� Are ou an employer? Check the ap r priate box: Type of project(required):. 1. a employer with 4. 0 I am a general contractor and I employees(full and/or p -time).* have hired the sub-contractors 6. El 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 8. ❑Demolition working for me in any capacity. employees and have workers' 9. n [No workers'comp,insurance comp.insurance.$.� �Building addition required.] 5. ❑ 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 of exemption per MGL 12.❑ P Roof repairs ] insurance required. t ,c. 152, §1(4),and we have no employees. [No workers' 1j'` 9ther __ (� comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing4heir 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. TContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:_���1�{/� Policy#or Self-ins.Lic.#: fv7 c�/ _ :d�.. Expiration Date: 2 Job Site Address: City/State/Zip: ©/ Attach a copy of the workers' compensation policy declaration page(showing the policy numbe and expiration date). Failure,to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment;:as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for•ms=ance covers a verification. Ddo-hereby-c-dxtify - -der.-th ro an on..... o perjur-y-that-the-iitfor-mation-pro vided-abave—is-tr-ue-and-corr-ect Si ature: Date: U _ Phone#: s Official use only. Do not write rn t is area,to be completed by city or town offtciaL 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#: Client#:A7298 CAPIHOM ACORD- CERTIFICATE OF LIABILITY .INSURANCE 0DATE 1/05/10D�y) �. PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Rogers 8,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 INSURERA: Nat'l Grange Mutual Insurance Co. Capizzi Home Improvement,Inc. INSURERB: ACE Property&Casualty Ins.Co. Capizzi Enterprises,Inc.1645 Newtown Road INSURER C: 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 CONTRACTOR 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. S POLICY EFFECTIVE POLICY EXPIRATION LTR NS TYPE OF INSURANCE POLICY NUMBER DATE MM/DD DATE(MM/DDIM LIMITS A GENERAL LIABILITY MPB1075H 06/08/09 06/08/10 EACH OCCURRENCE $1 000 000 X COMMERCIAL GENERAL LIABILITY DRAMAGE EMISES ETORENTED a occurrence) $500 000 CLAIMS MADE 5�OCCUR MED EXP(Any one person) $10 000 PERSONAL&ADV INJURY $1 000 000 GENERAL AGGREGATE $2 00Q 000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG s2,000,000 POLICY PRO- LOC A AUTOMOBILE LIABILITY M7 M28044 06/08/09 06/08/10 COMBINED SINGLE LIMIT $500 ANY AUTO (Ea accident) ,000 ALL OWNED AUTOS BODILY INJURY $ X SCHEDULED AUTOS (Per person) X HIRED AUTOS BODILY INJURY X NON-OWNED AUTOS (Per accident) $ X Drive Other Car PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA.ACCIDENT $ ANY AUTO EA ACC $ OTHER THAN AUTO ONLY: AGG $ A EXCESS/UMBRELLA LIABILITY CUB1076H 06/08/09 06/08/10 EACH OCCURRENCE $5 000 000 X OCCUR CLAIMS MADE AGGREGATE $5 00Q 000 $ DEDUCTIBLE $ X RETENTION $10 000 $ B WORKERS COMPENSATION AND NWCC45843208 12/25/09 12/25/10 X I WC ST IMA'T OTH- EMPLOYERS'LIABILITYR ANY PROPRIETOR/PARTNER/EXECUTIVE E.L EACH ACCIDENT $1 000,000 OFFICERIMEMBER 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 IQ_ 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 ACORD 25(2001108)1 of 2 . #S48108/M48107 KW 0ACORD CORPORATION 1988 Town of Barnstable Permit# � � � Regulatory Services E 6monthsfromissuedate s Thomas F.Geiler,Director PERMIT Building Division ® 2 2009 Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us TOWN OF BRRNSTABLE Office: 508-8624038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number Property Address Z��0D \XResidential Value of Work Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address Contractor's Nam Z - Telephone Number _ l� Home Improvement Contractor License#(if applicable) o� `tU "XWorkman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ lam the Homeowner I have Worker's Compensation Insurance Insurance Company Name C Workman's Comp.Policy Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑ Re-roof(not stripping. Going over existing layers of roof) Re-side ❑ Replacement Windows/doors/sliders.U-Value (maximum.44) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. 'Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License is required. SIGNATURE: Q:Forms:bui ldi ngperm its/express Revised 123107 The Commonwealth of Massachusetts Department.of Industrial Accidents Office of Investigations ' 600 Washington Street e Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl Name(Business/Organization/Individual) Address:_,�D�A!s City/State/Zip Phone.#:,:,q) -LlAFN, Are you an employer? Check the appropriate box: Type of project(required):. 1. I am a.employer with�_ 4• ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2:❑ I am a sole proprietor or partner- listed on the attached sheet. 7. p p p ❑Remodeling ship and have no employees These sub-contractors have g, ❑Demolition workingfor me in an capacity. employees and have morkers' Y P tY• `[No workers' comp.insurance comp. insurance.$ 9. ❑Building addition required.] 5. ❑ We are a corporation and its' 10.❑ Electrical repairs or additions 3.0 I am a homeowner doingall work officers have exercised their 1 L❑Plumbing repairs or additions . myself. [No workers' comp: right of exemption per MGL R�er f repairs insurance required] t c. 152, §1(4),and we have noem .lo ees. �2.F, 3. O. p y [No.workers-._ .._ _ ,. . comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.'$Contractors that check this box must attached.an additional sheet showing the name of the sub-contractors and state whether or not those entities have .employees. If the sub-contractors have employees,-they must provide their workers'comp.policy number: I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site ' information. Insurance Company Name: C Policy#or Self-ins. Lic.#: Expiration Date: Job Site Addres. City/State/Zip: ad Attach a copy of the wor ers'co ensation policy declaration pag7e(showing the policy num er expiration date). Failure.to.secure covers as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 an or one-year imprisonment,.as well as civil penalties.in the form of a STOP WORK ORDER and.a fine of up to$250.00 a day' gainst the viol or. Be advised that a copy of this statement may be forwarded to the Office of Invest$ aeons of the IA for insura a covers a verification. I-do-heaeb dpenalties-ofperjur- that-the-information-pr.aWded-above-is-true-and-correct Si ature: G� r Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone# rR3 U. CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDNYYY) 12/30/08 ray Insurance Agency THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION 9 Y ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 34 HOLDER:THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 01 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, is,MA 02660-1601 INSURERS AFFORDING COVERAGE NAIC# � - Capizzi Home Improvement,Inc. INSURERA: NGM Insurance Company Capizzi Enterprises;Inc. INSURERB: American Home Assurance 1645 Newtown RoadINsuRER aOtuit, MA 02635 INSURERD: 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. S LTR NSR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION MM/DD DATE MMIDD LIMITS A GENERAL LIABILITY MPB1075H 06 DATE/08/08 O6/O8/O9 EACH OCCURRENCE X COMMERCIAL GENERAL LIABIUTY $1 OOO OOO DAMA EETO RENTED n s5O OOO CLAIMS MADE �OCCUR MED EXP(Any one person) $5 000 PERSONAL&ADV INJURY $1 000 000 GEN GENERAL AGGREGATE $2 000 000'L AGGREGATE LIMIT APPLIES PER: .� POLICY JE a LOG PRODUCTS-COMP/OP AGG $2 000 000 A- AUTOMOBILE LIABILITY M1 M28044 06/08/08 - 06/08/09 ANYAUTO COMBINED accident)SINGLE LIMIT $500,000 ALL OWNED AUTOS X SCHEDULED AUTOS BODILY INJURY $ (Per person) X HIREDAUTOS X NON-OWNED AUTOS BODILY INJURY $ (Per accident) X Drive Other Car PROPERTY DAMAGE $ (Per accident) - GARAGE LIABILITY ANY AUTO AUTO ONLY-EA ACCIDENT $ OTHER THAN EA ACC $ AUTO ONLY,. AGG $ A EXCESSNMBRELLA LIABILITY CUB1076H 06/08/08 06/08/09 EACH OCCURRENCE $5 000 000 X OCCUR �CLAIMS MADE ' AGGREGATE $5 000 000 DEDUCTIBLE $ X RETENTION $10000 $ B' WORKERS COMPENSATION_AND _ $ WC6957000 12/25/08 12/25/09 X WC ST T RY IM °TM EMPLOYERS'LIABILITY ' ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT . ESOO,000 OFFICER/MEMBER EXCLUDED? If yes,describe under- SPECIAL PROVISIONS below - E.L.DISEASE-EA EMPLOYEE $500,000 OTHER E.L.DISEASE-POLICY LIMIT $500,000 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 200 Main Street — Il— DAYS WRITTEN 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 ACORD 25(2001/08)1 of 2 *S40650/M40647 KW © ACORD CORPORATION 1988 a Board of Building Regulations and Standards License or registration valid for individul use only +TOMEIMPROVEMEN-TCOMfRAGTOR:, s before.the-expiration date;::IfTo tin d.:ceturn;to. . Board of Building Regulations and Standards Regis 100740 VpJea#igot�23/2010 One Ashburton Place 12m 1301 6{ -1- �_ 77) Boston,Ma.02108 ;r =?j�,:g`�pplement Card CAPIZZI HOME R . , !vI`Ir�Jll�� � .� � bARY GUSTAFSO 1645 Newton Rd. Cotuit, MA 02635 } Administrator 7ova itho. nature Massachusetts- llqm?-t?ni:r?t of Public uard of Builtlsst tie tll.)ti€isz. ?t?'1 i?ttle� ar[1s :Construction Supervisor License `License: CS 74640. Re-stiicted to; OQ. GARY GUSTAFSON � 8 SHORT WAY SANDWICH, MA 02563 c,.pit�1.i;l'<;; 11/29/2010 r;.. 7755 .. Page 7 of 7 CAPIZZI HOME IMPROVEMENT INC. SPECIFICATIONS AND ESTIMATES STATE OF MASSACHUSETTS LETTER OF AUTHORIZATION TO APPLY FOR A BUILDING PERMIT OWN THE PROPERTY LOCATED AT IN , 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 ACCORDANCE WITH 780 CMR, THE MASSACHUSETTS STATE BUILDING CODE. SIGNATURE OF OWNER: OWNER'S ADDRESS: 4a. OWNER'S TELEPHONE: LESSEE'S SIGNATURE: LESSEE'S ADDRESS: LESSEE'S TELEPHONE: APLLICANT'S SIGNATURE: APPLICANT'S ADDRESS: 1645 Newtown Rd., Cotuit,MA 02635 APPLICANT'S TELEPHONE: 508-428-9518 RESPONSIBLE OFFICER: RESPONSIBLE OFFICER ADDRESS: GFEI� EI,E 'AfO v � �,K Town of Barnstable *Permit# Uepires 6 months from issue date Regulatory Services Fee _�� BARNWrAeLE, w Thomas F.Geiler,Director q MASS. 1634• 0. Building Division FD µDt Tom Perry,CBO, Building Commissioner 200 Main Street, Hyannis, MA 02601 III v www.town.barnstable.ma.us r Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number, Property Addres�� c � �(C���_ c� � n [,Residential Value of Work\ V5�m Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address ��� i �\C) Contractor's Nam Q.j�� � ({���� �V�`} Telephone Numbelr -� « I Home Improvement Contractor License#(if applicable) p ❑Workman's Compensation Insurance SS PERMIT Check one: ❑ I am a sole proprietor 2�0� ❑ I am the Homeowner OCT d have Worker's Compensation Insurance Insurance Company Name��c�m • RNSTABLE Workman's Comp.Policy# 3�c d-11 -1), 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/doors/sliders.U-Value (maximum.44) *Where required`. Issuance ofthis 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 cop of the Home Improvement Contractors License is required. SIGNATURE: Q:Porms:buildingpennits/express Revised 123107 The Commonwealth of Massachusetts y ' Department of Industrial Accidents Office of Investigations ' a 600 Washington Street . Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): l� Address: City/State/Zip A ;``I�j CY) Q35 Phone.#.Sa-q&% qSl� Are you an employer? Check the appropriate box: Type of project(required):,. 1 V1 I am a employer with�— 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ❑ New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7.�Remodeling ship and have no employees These sub-contractors have g. ❑ Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance. $ 9. ❑ Building addition required.] 5. ❑ 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 of exemption per MGL l`a. Roof repairs insurance required.] t c. 152, §1(4), and we have no -' employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: (120 M Policy#or Self-ins.,Lic. #: (�(R�` ���a Expiration Date: Job Site Address:Cj�O �1 12� . City/State/Zip\A\jpht)j S Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day aga' t the violator. Be advised at a copy of this statement may be forwarded to the Office of Investigations of the D r insurance cove-rage verifi lion. I--do-her-eby-eer-tify-u -the-pains-an o- perjury-that-the-info-r-mation-provided-above-is-true-and-corr-ect. Signature: N Date: a. o% Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: • } JT �. 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: Reglstr L9tl:, 100740 Board of Building Regulations and Standards pTP�t1Q_!]� 23/2010 One Ashburton Place Rm 1301 rl� ry�77i lement Card Boston,Ma.02108 CAPIZZI HOME Ftj T� I b RY GUST AFSGD \._►�� 1645 Newton Rd. ;';i � �ti Cotuit,MA 02635 __.._. _.. __._ _.....__...._...___._....__. Administrator No vali itho..t ' nature om-rna-� o �cnu6el�d Board of Building Regulations and Standards Construction Supervisor License License: CS 74640 6 B i rthd ate: 11129!1975 Expiration: 11/29/2008 Tr# 6430 Restriction: 00 GARY GUSTAFSON 8 SHORT WAY SANDWICH,MA 02563 Commissioner Client#; 47298 CAPIHOM DATE ACORD,. CERTIFICATE OF LIABILITY INSURANCE 0 611 21200 8(MMIDDrYYYY) PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Rogers 8 Gray Ins. -So. Dennis ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 434 Route 134 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P. 0. Box 1601 South Dennis, MA 02660-1601 j INSURERS AFFORDING COVERAGE — NAIC#— — i INSURED INSURER A. NGM Insurance Company _--1 Capizzi Home Improvement, Inc.. j INSURER B. American Home Assurance Capizzi Enterprises, Inc. --- -- wsuRER:: 1645 Newtown Road INSURER D ----- - — —� L Cotuit, MA 02635 ---""- ! 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 CER-1 FiCATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL.THE 1 ERMS EX.I USiONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR --'I'"--�—' �PpOLIC�Y�EF—FEC—TIV'E i POLICY EXPIRATION! -� LTR NSR TYPE OF INSURANCE _� POLICY NUMBER----�I I DATE IMM/DD/YYI_ i „___---_--,-- LIMITS A I GENERAL LIABILITY !MPB1075H f�06108/08 106/08/09 t H )C.':�I RENCE 1,000,000 — r COMMERCIAL GENERAL, :.:TY ) 41GE 0 P )VTCL1 -- k AGE',1 (1 T rrenca) $5001000 CLAIMS MADE X oci;uR ec xP iAoy o e oerbo,i) +$10 000 ~°FRSUNAI ti ADu INJURY $1 000 000 GENERAL AGGREGATE I s2,000,000 I I GEN'1.AGGREGATE LIMIT APPLIES PER j I�PRODUCTS-COMP!CP AGO JIMO 000 j�POLICY n E' - —� r. ------.._._- --- — __. AUTOMOBILE LIABILITY COMB;NFD SINGIP.;.!Mr: I ANY AUTO 1 ! {Ea ar,denll i r' AL i..OWNED AUTOS - --__— i t301?•it INdi)'2't $ i SCHEDULED AUTOS F—I HIRED AUTOS i NON.OWNFD AUTOS I I _f?TY A4 AGE. ._ ._._..__.._ .-- — GARAGE LIABILITY _ O _1'_A ACCIDENT $ r ANY AUTO : lr_R i EA ACC r L,aN ----- I 1 4LiTI:ONLY AGG S EXCESS/UMBRLLA LIABILITY U f'.+ H CCNRENLA 61 $5 000,000_ X occuR n cLaiMs MADE A:,GIiEGAI E ---- $5,000,000--- I $ i DEDUCTIBLE i X RETENTION $1 OOOO $ _.T.WC ST.ATU- OTH- B WORKERS COMPENSATION AND WC6716562 ! 12/25/07 12/25108 X ;1� )R LIMITS— R EMPLOYERS'LIABILITY ANY PROPRIE'(DR/PARTNER/EXECUTIVE =ACIi ACCIDENT' $SOO,000 -- OFFICER/MEMBER EXCLUDED? E:. DISEASE-EA EMPLOYEE $500,000 If yes,describe under — — SPECIAL PROVISIONS below F..:. DISEASE-POLICY LIMIT I s500,000 OTHER --�----------'--- I i i DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES 1 EXCLUSIONS ADDED BY ENDORSEMENT I 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 1 n DAYS WRITTEN 200 Main Street NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO 00 SO SHALL Hyannis, MA 02601 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR (REPRESENTATIVES. _ AUTHORIZED REPRESENTATIVE ACORD 25(2001/08)1 of 2 #S36540/M36539 KW © ACORD CORPORATION 1988 Page 7 of 7 CAPIZZI HOME IMPROVEMENT INC. SPECIFICATIONS AND ESTIMATES STATE OF MASSACHUSETTS LETTER OF AUTHORIZATION TO APPLY FOR A BUILDING PERMIT I, ib"C'14 �����cAj OWN THE PROPERTY LOCATED AT -)--o l " IN KY01 C4 C-N , S 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: 271 v Si 3 6—q p w Veq`5 L`t-� IGNATURE: LESSEE'S ADDRESS: LESSEE'S TELEPHONE: APPLICANT'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: Assessor's map and lot number .......................................... /,2 7 ' ==-E"IC SYSTU-4 MUST BE -3...... IDS -MED !i.1 CC PUAINCE Sewage Permit number ..........�.(...... ............................... +, °i A T ,L ii STATE " S A�'x�i„RY CODE AND TOWN QyOf TN E T0�1 TOWN OF "A R LIE * SAWSTADLE, � t' mum A`. BmU LD N� INSPECTOR O'FD tlP'� F APPLICATION FOR PERMIT TO ...E "+ �� ... . .................................................................................. TYPE OF CONSTRUCTION ....... ...C-1.......? 4'F1�........................................................................ - A....... ...19/ TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location 40 / ��/ /�� e�/`i V e,41,L 141, :.................................... ..................................................................................... ................................ / o ,S/� ! r� �i� a7 Proposed Use ...............�.,. ....................f..../.. .......��.�. f ................................................. Zoning District .. ................................................................Fire District ............� !.....!....i:f......................................... Name of Owner .' .............Address !' f�'f'9/�.. S' ' J� i��f✓�'r' i Nameof Builder ....................................................................Address ....................'...........��................................................. Name of Architect ........�......... (� .. f' (� ..............................................Address .................. ............................................................ !� •'� Number of Rooms ...... ....................................................Foundation ... ..... ... .... �cL4........ Exterior ./e✓Q. ..................................Roofing ..... 45�?k�L.4................................................... Floors G.Q. ...........C .47. ...........Interior ....6 ......A.. . deg.�...�.............................. Heating ........r.. ..........�...................................................................... Fireplace .............k...................................................................Approximate Cost ..........2a,.Anx)................................ Definitive Plan Approved by Planning Board 19_ Z— Area Diagram of Lot and Building with Dimensions Fee 2 ...... .:Z. ................................. SUBJECT TO APPROVAL OF BOARD OF HEALTH 1, 0 A 3 -7 . z z- I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. N IArrName ... ...............�/��!�. .. .... ............... 5 Dacey, 'William E. No .....169 7 Permit for .......°.......stP�.......... single family..direllin .................. .................... Megan Road Locati ......... ......... ..................... Y?# 7,5.......................................... ' r �C'� ,,v r .�'i ,+'• r'} Owner ........William E. Dacey...................... { {' ' 4 it ,lr , a- - x J, , Y Type of Construction frame .......................................... t //�� ~•+yam Plot ............................ Lot ..............�4........... t Permit Granted .....Ba ,ch..26.......w. :.19 74 ,Date of Inspection . ........_.... �.- ,,_ ., Date Completed .. .. .. .. ... ... t PERMIT REFUSED _ ............................................................... 19 ...................................................................... ..... Approved ............. 19 ............................................................................... • A fi