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HomeMy WebLinkAbout0478 OLD TOWN ROAD I §§i . TOVIN OF ;,£ NSTA ALE CAPE COD INSULATION 9171 NOV -2 P"1 : g9 I c7] ' FIBERGLASS SEAMLESS SPRATFOAM SUSPENDED wi*a..x,e.-:.,c-�:•.Nrt- „rp.::Jzmm„ BAT GUTTERS INSULATION CEILINGS v.A.y 1-800-696-6611 DTVY S7 Town of Barnstable Regulatory Services Building Division 200 Main St Hyannis, MA 02601 Date: �) f Dear Building Inspector i Please accept this Affidavit as documentation that Cape Cod Insulation, Inc. performed & j. completed the insulation and weatherization work at the property listed below. Cape Cod Insulation did.this in accordance to the specifications listed on the building permit ` application. All work has been inspected by a certified Building Performance Institute (BPI) inspector. All work preformed meets or exceeds Federal & State Requirements. Property Owner Property Address Village t :%NAA ?--ArARNv 1471 ol& +u0 YkO0% Insulation Installed: Fiberglass Cellulose R-Value Restricted Unrestricted "I Ceilings 00 I Slopes ( ) ( ) ( ) ( ) ( ) 1 Floors/A ,.v> Walls X) ( ) Sincerely f W s' y Jr, P sident n lation, nc. d s TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION �00 _ l Map _-~ Parcel Applica ion # Health Division y J' Date Issued Conservation Division pp A lication Planning Dept. � . �. .j Permit Fee -- Date Definitive Plan Approved by Planning Board Historic OKH _ Preservation/ Hyannis Project Street Address L �$ & "163 VJ Village C e rJ A-� v •A Owner Address W7T (D c&40W.-I 0- Telephone 501— 725.- S$S01 Permit Request L U:r_4,1-�ztk�Sc3� 1 �u�Sy ��� -yo '1; Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation 14030-11 Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ 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: ❑ Gas . ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# - - - Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) CAP-e— Cc�c�TN��A��01J Name tActjN C'_ASSt ay Telephone Number Address License #_ l 0 TTT yv\v4. (7`a 6d1 Home Improvement Contractor# L 53 G Worker's Compensation # LA)C 0 Sa.S 0 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO SIGNATURE DATE 7 �/ t j < FOR OFFICIAL USE ONLY t APPLICATION# DATE.ISSUED , MARL PARCEL NO. ADDRESS VILLAGE . t . f OWNER - ` DATE OF INSPECTION: f f; FOUNDATIION,i t . FRAME � INSULATION- ! FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS ,mat' ROUGH FINAL t -, 'FINAL BUILDING R DATE CLOSED OUT " ASSOCIATION PLAN NO. j R 460 West Main Street - BOUS I NG Hyannis, MA 02601-3698 S S I S TANCE ENERGY & HOME REPAIR - .. . - T (508) 790-7106 F (508) 790- CORPORATION 2425 HOME OWNER WEATHERIZATION WORK PERMIT& FUEL RELEASE: PLEASE FILL OUT AND SIGN THISFORM IF YOU ARE THEAPPLI CAN T HOMEOWNER. �0i I !�IA� I D n�6�l_-0 hereby consent to and agree that weatherization work may be done by the Weatherization Program of H ousi ng Assistance Corporation ( herein after ref red as"Agency") on the property located at: aon rb-S 1Z p I Theweatherization work donewill be based on programmatic priorities and availability of funding and it may include all or some of the following measures: Weather-stripping& hulking of windows and doors~ insulation of attics, sidewalls& basements, attic and other ventilation measures and possibly replacement of badly deteriorated windows. In consideration of the weatherization work to be done at my home ! agreeto thefollowing: j s o I give permission to the"Agency" its agents and employees to travel onto or across said property with such equipment and materials as may be nary to perform weatherization work on said property. ! I have read the provisions of this agreement as listed and freely give my consent. Home Owner: (Signature) Date Agent: (signature) Date: _ lo Ca (M oqh&tip p ark at4 hOn'zed 12?j C F \'�i�s-fstx�-ttr(iF 14��F�M1�fS`J l W svnrl_perrait micase. 1822010.doc rI11Ik:: d:bU PM To: Hank @ 9,15087785735 Rogers 6 Cray Ins. Page: 002 r Client4:4597 CCINSUL ACO U. CERTIFICATE OF LI BILITY INSURANCE DATE27/20IYYYY) 0712712010 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($),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 Margaret Rogers$Gray Ins. -So. Dennis NAME: g' Young PHONE 508-760-4602 FAX 434 Route 134 A c,No,Exll ac No EMAIL -P.0. Box 1601 ADDRESS: orou — South Dennis, MA 02660-1601 CUSTOMER11) — INSURER(S)AFFORDING COVERAGE NAIC U INSURES Cape Cod Insulation Inc INSURER A:Peerless Insurance 455 Yarmouth Road INSURERB:Ohio Casualty Insurance Company wSURERC:Atlantic Charter Insurance Hyannis, MA 02601 INSURER DCommerce Insurance Company 34754 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 CERT:FICATE 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. TR TYPE OF INSURANCE NSR VD POLICY NUMBER MM%OD,YEFF POLICY EXP YYYY LIMBS AGENERAL LIABILITY YyyI CBP8263063 04101/2010 04/0112011 EACH OCCURRENCE $1 400 000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO R-N E f��y� PREMISES Ea ocr-nrronro $100 ODO CLAIM)",MADE t OCCUR MED EXP(Any ono pomon) $5,000 ( PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $2 000,000 GENT.AGORC:GATI=.UMI"f APPLIES PER:LOCPRODUCTS-COMP/OP AGG $2 000,000 PRO- $ D AUTOMOBILE LIABILITY 10MMBCKVMK 04101/2010 04101/2011 COMBINED SINGLE LIMIT ANY AU1-0 (Eaacadonl) $1000;000 — At l GWIV['D All[Clt; BODILY INJURY(Parpersan) $ _ X SCIIFUULL D All I OS BODILY INJURY(Par ar-cidenl) $ PROPERTY DAMAGE X HIRED AUI'MS (Per accident) $ X NUN OWNED AUTOS $ — - $ B UMBRELLA LIAB X OCCUR MEYAPP397725 0611712010 04/01/2011 EACH OCCURRENCE $1 000 000 Excess uAs CLAIMS-MADE AGGREGATE $1 000 000 DEDUCTIBLE $ X RF.IFNr1ON • 10000 $ C WORKERS COMPENSATION AND EMPLOYERS'LIABILfTLITY WCA00525901 6/3012010 06/30/2011 X WC STAIU: OTI-1- LI RY I -- _ ANY PROPRIL:'IOR/l"ARTN Y/NMEXECUTIVE E.L.EACH ACCIDENT $SOO,000 OFFICERIMENIBI-R EXCLUOED7 N, NIA (Mandalory in NH) E.L.DISEASE-EA EMPLOYEE $500 0000 II yes,dusalbo undur -------- OESCRIr'I[ON OF OP FRA I IONS below E.L.DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space is requkad) - `,Workers Comp Information" Included Officers or Proprietors (See Attached Descriptions) CERTIFICATE HOLDER CANCELLATION 10 Days for Non-Payment SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Housing Assistance Corp. ACCORDANCE WITH THE POLICY PROVISIONS. 484 West Main Street Hyannis, MA 02601 AUTHORIZED REPRESENTATIVE 01988-2009 ACORD CORPORATION.All rights reserved. ACORD 25(2009/09) 1 of 2 The ACORD name and logo are registered marks of ACORD AS54814/M53353 MEY <1 Massachusetts- Department of Public Safe`tN Board ofBuildirig Regulations and Standards . x` Construction Supervisor License License:'CS- 100988 Res acted to: 00 'HENRY, CASSIDY ; . q_ 8 SHED ROW ° ~ r� M WEST YARMOLITH,'MA 02673 Ex,pir'etion: 11/11/2011" Ojai+i�isianrr Tr#: 100988 4: iw e Bea n ulaalonAan anAars One Ashburton Place - Room 1301 I. Boston, Massachusetts 02108 Home Improvement Contractor Registration Registration: 153567 i Type: Private Corporation ! 3 r,L Expiration: 12/15/2010 Tr# 278247 CAPE COD INSULATION, INC M =, HENRY CASSIDY 455 YARMOUTH RD. HYAN N I S, MA 02601 Update Address and return card.Mark reason for change. Address Renewal Employment Lost Card IS-CAI 0 50M-07/07-PC8490 BO '� ` ° �� � License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: 153567 Board of Building Regulations and Standards Expiratio ',12/15/2010 Tr# 278247 One Ashburton Place Rm 1301 n Boston,Ma.02108 ,`:Type Private Corporation CAPE COD INSULATI0'N INC y : }�i ; HENRY CASSIDY. ;'"`,_ _ 455 YARMOUTH RD.. '' Z a HYANNIS,MA 02601` r*<'= ' Administrator t id wi ut ignature c . I t i The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations I' 600`Washington Street Boston, MA 02111 yy www;rnass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electl-icians/Plumbers Applicant Information Please Print Legibly Name (Business/Organizationnndividual): CA (LQ d rAJ 01 ens -L/) C - Address: r Cr City/State/Zip: CC Phone #: �0 7 7 ��' ' ILI Are you an employer? Check th appropriate box: Type of project (required): 1. 1 am a employer with_ 4. ❑ I am a general contractor and I — 6. ❑ New construction ei�iployees(full and/or part-time). have hired the sub-contractors.. . 2-El I am a sole proprietor-or partner- listed on the attached sheet. 7. Re mod cling 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 10.0 Electrical repairs or additions 3.❑ 1 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 13.❑ Othe - employees. [No workers' r���b.���n q t:t o1 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 arc 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, am an employer that is providing worlters' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: r_ c /i•-' .eA _n=;eniCe - Policy#or Self-ins. Lic. #; (.A,)( , 7_579 O Expiration Date; Job Site Address: City/State/Zip: Attach it 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 forwarded to the Office of Investigations of the DIA for insurance coverage verification. I.do hereby certify to e pa' and penalties of perjury that the information provided above is trice and!correct. / ) Signature.: _T [f : Date: _ .Phone#: S O Official use only. Do not K)rite in this area, to be completed by city or loom officiaL City or Town; Permit/License# Issuing Authority (circle one); I. Board of Health 2. Building Department 3, Cite/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6, Other Contact Person; Phone#: �S l e �� rq Town of Barnstable *Permit# O Expires 6 months from issue date Regulatory Services Fees = BARN s?ABLE. 9cb ,Miss Thomas F.Geiler,Director / �fD MA'I �P I ;?jEFSS, Building Division CBO, Building Commissioner lU� 1 9 2 m Street,Hyannis,MA 02601 �7-0W/ 2(��Q www.town.bamstable.ma.us Office: 508-862-40 PP Sq Fax: 508-790-6230 EXPRES�Pn� PLICATION - RESIDENTIAL NLY o Valid without Red X-Press Imprint Map/parcel Number //5-6 Property Address q e 0 TO 5 , Residential Value of Work Minimum fee of for work under$6000.00 Owner's Name&Address I ti /L o /,u w, y 6 �U)� AYeqn1?(,_S,1Am v�(6/ ' ( Telephone Number Name , 1 c Home Improvement Contractor License#(if applicable) l) 7 Construction Supervisor's License#(if applicable) 7 �� ❑Workman's Compensation Insurance '"heck one: I'am a sole proprietor the Homeowner have Worker's Compensation Insurance Insurance Company Name /(O f f� ct.l (09• Workman's Comp.Policy# /V 57- j rJ Copy of Insurance Compliance Certificate must accompany each permit. 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 p ( ) #of doors d ©� e lacement Windows/doors/sliders.U-Value maximum.44 #of windows�,_ {� hv� 5*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 t e Home Improvement Contractors License&Construction Supervisors License is require � ' SIGNATURE: C:\Users\decollik\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\4STGU5QO\EXPRESS.doc Revised 090809 The Commonwealth of Massachusetts Department of Industrial Accidents " Office of Investigations 000 Washington Street 9 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): Z-L-1 "� N P V Address: RD CL City/State/Zip: Phone.#: Are you an employer? Check the appropriate box: Type of project(required):. :./"/e a employer with * 4. ❑ I am a general contractor and I mployees(full and/or artti- me). * 'have hired the sub-contractors 6. ❑New construction ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees x These sub-contractors have 8. ❑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.❑ 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' 13� ther W d A comp. insurance required.] / r C-e 4,L *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:_ /v �a-� e- U Policy#or Self-ins. Lic. #: N W l� �S U`T 3 Expiration Date: Job Site Address:_-Y70 ® Id t yY)-' Dt. City/State/Zip: o Attach a copy of the workers' compensation policy declaration page(showing the policy nu er and expi ation 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I-do-hereby-ser-t, ies-of-perjury-that-the-infor-mation-pr-ovided-above-is-true-anti-carr-ect. Signature: Date: 0 Phone#: Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Office of Consumer Affairs&B siness Regulation License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration:_;.�.;1,00740 Type: Office of Consumer Affairs and Business Regulation Expiration: .U231,2012 Private Corporation 10 Park Plaza-Suite 5170 Boston,MA 02116 CA IZZI HOME I,IV[ ROfE�1[E #T1(C. C_ ifs 72 Thomas Capizzi, r 1645 ',X Newton Rd. i Cotuit, MA 02635 Undersecretary Not valid �ouignat re of Public sai'm A' W':':cl 1i# ttlitaii3!„{ Re fliitions and Standard's CenstructiOn SUPer:riscr License License: CS 74640 Restricted to; 09 e s ; GARY GUSTAFSON 8$HORT WAY rry ` SANDVVI.CH, MA 02563 ter: rim_ �y ?c� 11/29/2010 Cuiit!di3.'a+Ffa .i.rl,; 7755 . Client#:47298 CAPIHOM ACORM CERTIFICATE OF LIABILITY INSURANCE DATE MMIDDNYYY) 06/04/2010 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,NTAC Karen A Walther,CISR Rogers&Gray Ins.-So.Dennis PHONE 508-760-4630 508-258-2230 434 Route 134 ac,No,Ext: (a/c,No): P.O.Box 1601 ADDRESS: waltherka@rogersgray.com CUSTOMER ID#: South Dennis,MA 02660-1601 INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURERA:National Grange Insurance Co. Capizzi Home Improvement,Inc. INSURER B:ACE Property&Casualty Ins.Co Capizzi Enterprises,Inc. 1645 Newtown Road INSURERC: Cotult,MA 02635 INSURERD: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDLSUBR1 POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER MM/DD MM/DD LIMITS A GENERAL LIABILITY MPB1075H 06/08/2010 06/08/2011 EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGET PREMISES Ea occurrence $500,000 CLAIMS-MADE 51 OCCUR MED EXP(Any one person) $10,000 I PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 POLICY PRO-- LOC $ jECT A AUTOMOBILE LIABILITY M1 M28044 06/08/2010 06/08/2011 COMBINED SINGLE LIMIT ANY AUTO (Ea accident) .$5OO OOO BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ X SCHEDULED AUTOS PROPERTY DAMAGE $ X HIRED AUTOS (Per accident) X NON-OWNED AUTOS Uninsured $250000/500000 Underinsured $250000/500000 A X UMBRELLA LIAB X OCCUR CUB1076H 06/08/2010 06/08/2011 EACH OCCURRENCE $5 000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $5,000,000 DEDUCTIBLE $ X RETENTION $ 10000 $ B WORKERS COMPENSATION YIN NWCC45843208 12/25/2009 12/25/201 X WC STATU- OTH- AND EMPLOYERS'LIABILITY T RY LIMITS E ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? ❑N N/A i(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If es,describe under (DESCRIPTION OF OPERATIONS below -T E.L.DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) Carpentry CERTIFICATE HOLDER CANCELLATION 10 Days for Non-Payment SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Town of Barnstable ACCORDANCE WITH THE POLICY PROVISIONS. 200 Main Street Hyannis,MA 02601 AUTHORIZED REPRESENTATIVE ©198 -2009 ACORD CORPORATION.All rights reserved. ACORD 25(2009/09) 1 of 1 The ACORD name and logo are registered marks of ACORD #S52549/M52541 KW -77 Page 7 of 7 CAPIZZI HOME IMPROVEMENT INC. SPECIFICATIONS AND ESTIMATES STATE OF MASSACHUSETTS LETTER OF AUTHORIZATION TO APPLY FOR A BUILDING PERMIT I, Linda Romano & OWN THE PROPERTY LOCATED AT 468 Old Town Rd IN Hyannis, 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 OW NER: OWNER'S ADDRESS: �� �rZ.,,v 1 OWNER'S TELEPHONE: LESSEE'S SIGNATURE: LESSEE'S ADDRESS: i LESSEE'S TELEPHONE: I APLLICANT'S SIGNATURE: APPLICANT'S ADDRESS: 1645 Newtown Rd. Cotait MA 02, 635 APPLICANT'S TELEPHONE: 508-428-9518 i RESPONSIBLE OFFICER: RESPONSIBLE OFFICER ADDRESS: RESPONSIBLE OFFICER TELEPHONE: i i Town of Barnstable *Permit# 2�fa OCR I °(ram Expires 6 monthsJrom issue date Regulatory Services Fee 3� sextvsresrs. * _ - itrass Thomas F.Geiler,Director 0.19 ,•� X-PRESS PERMIT pTED M°� Building Division Tom Perry,CBO, Building Commissioner O C T .1 9 2012 200 Main Street;H annis'MA 02601 y www.town.barnstable.ma.us Office: 508-862-4038 . TQ � I�H�N ABLE EXPRE SS PERMIT APPLICATION - RESIDENTIAL CSNL Not Valid without Red X-Press Imprint Map/parcel Number Lj`6 L-0�1 5 Property Address 0 I / L 1:/1 14 l�l �� n✓�1 c-0 esidential Value of Work 1 00f Minimum fee of$35.00 for work under$6000.00 L l < n-� Owner's Name&Address 0 t 20)rvl - Contractor's Name Telephone Number Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) . ❑Workman's Compensation Insurance Check one: am a sole proprietor hP am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side #of doors .35 #of windows I ❑ Replacement Windows/doors/sliders.U-Value (maximum ) ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *Where required: Is 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 8c Construction Supervisors License is re q fired . SIGNATURE; i The Comm nnivealth of Massachusetts 13gwhnent oflndustriil Accidentr Office of Investigations 600 Washington Street Boston,H4 02111 wnm.rr at mgvv/din Workers' Compensatian Insurance Affidav& Budddersi+Contractors/ElectiL-ic ans/Phunbers Applicant Information Flease Friut I:{'gibly Name(Business 0%mization�vidoal): �11 t, oync,� Address: 2 Ci /SState! 1 X A J1 1.S Wl�" .�7i(� OJ Phone#- Al$1-1 Il a 5 Are you an employer?Check the appropriate box:: Type of project(required) 1.❑ I am a employer with 4- ❑ I am,a generatcontractor and 3 : have:hir�ed the sorb-�co�ntractars 6- ❑New oonsi�xct%ora employees(full and/or pact-lime). ?. Remodeliaa 2.❑ I am a sole proprietor or partner- listed an the attached sheet ❑ g step.and ha ve no employees These sub-contractors have g ❑Deutolition employees and have worleers' working for`.me i n any capacity. 9. ❑Building.additiotZ JNo.wodmrs'comp.insurance comp-msurance 5. ❑ We are a corporation and its la.❑Electri aI repairs or additions Auired.] 3_ I am a homeowner doing all work right officers haveexercised IG 1 I_❑Plumbing repairs or additions myself: [No workers'camp- right of e:semgtiort per Iw1GL 12.❑Roof repairs insurance required.]r c. 152, §1(4),and we have no to 13.❑Other employees.yt:es. oworkers'jN camp.insurance required.] *Any apphcant that checks box#1:must also fill one the section belowshmnn.g their workers'compensat Len policy information_ I Homeowners who submit this affidavit indicating they are doing aUwed sad dum hue outside contractors mast submit a new affidavit indicating such tfonincmrs that check this boa must attached an additiond sheet showing the name of the sub-convectors and stare whether or not those endues have ereployees. If the sub-cantmamrs have employees,they mist provide their workers,comp.policy number. I am an emplayer that is provi ng workers'congm sad0n inmrance for it:Y atnplhytesx Below is thePoUt`and job site infbrmahon. Insurance Company Name: Poky-or.Self=ins.Lic.# Expiration Date: Job Site Address: City/Btatseizip: A tack a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 157 can lead to the imposition of criminal penalties of a fine up to$I,500.OG and/r one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250-DO a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of ha;estigatio ns of the DIA for insurance coverage vec tit ati I do he"by cis.lt& the pains and peratfias ofped-u y that the infornzatian provided ab"e is hw and rorred Si /►ire: Bate: 0 L '+ Phone#: _ a official use only. Do not rwMe in this arena,to be completed by cad or tin oficiat City or Town: PermitUceme# !suing Authority(circle tune): 1..Board.of Heah t Bndng Department 3.City/Town Clerk d.Electrical l nspec r 5.Plumbing Inspector S..O�ther Contact Person: Phone#: . of THE r� Q� ti lnRxsTnaLE. 9� "� ,�� Town of Barnstable ATED AM,t A Regulatory Services Thomas F. Geiler,'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 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 ti Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on,the reverse side. ; QAWPFILES\FORMS\building permit forms\EXPRESS.doc _Revise__A701_l0 ._ _ _� oFIKKE Town of Barnstable Regulatory Services s ; BARN T^BLE Thomas F. Geiler,Director: 9�A1 Ten ,, Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office:. 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: (,�✓) t� j'� ,Q ^�-,^ JOB LOCATION: l l u l0��l ' /Vw /�n iL� tkAq number street village "HOMEOWNER": l.�►.✓1�r�C, �V1�1(iln/,7 � '��>'1��1� ���--1 01���'t name home phone# work phone# CURRENT MAILING ADDRESS: I- C)IJL city/ton 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 F 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. Aperson 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 nd.require ents and that he/she will comply with said procedures and requirements. Signature 4FHomeowner 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 of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible.' To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. Q:\WPFILES\FORMS\building permit formsTXPRESS.doc