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HomeMy WebLinkAbout0017 ORR'S AVENUE fl�ENUE Town.of Barnstable j cg 35 tres6 nvvraM Regulatory Services. Fee Thomas Geiler,Director Buiildi :g D isic n Tom Perry,CBot .Building Commhsioner 200 Main Stet,Hyannis,.MA 02601. WWWADWn.batnstable ma.us . office:. 509-862-4038 Fax:509-790-6230 LXPRESS PER1�2I'' APPLICATION - RESIDENTIAL ONLY N&Valid ivithc zd Red J- ;lnVrjnt Map4wml Number S o o G 3 Property Address 6 rl" S �U���,r �9fv�rrrf _ , ,_,/Residential Value ofWo ,L� ��(�'(� Minlmnrn fee of$35.00 for vvarlt under S6000.00 Owner's Name&Address L 14 !)A Fie 141 Contractor's Name G G vJ�'Q d c�a { Telephone Number S6� �d� 9-5"/10 Home linprovement Contractor LicWe#(if applicable) C f I yk i/° Construction•Supervisor's License g #(if applicable) . - 11 4worktnan's CoTnpensation Insurance „ Check one; 0 C T 2 011 [j I am a sole proprietor I am the Hozneo'wmer -oWN OF BARNSTABLE I have Worker's.Cotiipensatian Insurance Insurance Company Name �C� �<1dU9/� � �y���� �/✓�/. �o�f�'4d/y Workmen's Comp.Polio NUl C-GgS'�32af, Copy of Insurance Compliaate CcrtifiCate must accompany each peruziL 1'crcnrt Request fleck box)' Re-roof(hurricane nailed)(stripping old shingles) All construction debris wilt be taken;to Re-roof(hurricane nailed}(ni stripping. Going over existizig layers aafroa [ Re=side �Iell� ill" y df�Ge ��rt�j�e 11alVe _ .. #of doors (.V�. Rcplacern�zt Wind6wv dao (niWdmutn..35),#of*kdovr q. rWf requited Z ee oPtlr�c;permit does not eser com�x[ia=with other town deparmxg regulatitos,ie.I ISW Ac,Cossawdon,etc. « *Note:. F'ro petty O er must sign,Pxvaperty Owner getter of Per?rnnission. .A► ogy o„ Home Improvement Contractors License 4t Construction Supervisors Licex►se is SIGNA'i'i1 .. C_�Ustxalcle 11 sA Aata f uu3oc ST ozzu :InterimiFiles�C�tczit-" okADDV87AAZWMRESSdDC. Revised 0721.10 f The Commonwealth ofMassachusetts 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): Address: 16145 Nero;own 'k p City/State/Zip: Phone#: r00(' elw-y.rle Are you an employer?Check the appropriate bog: Type of project(required'" I.a am a employer with . LIa 4. 0 I am a general contractor and I employees(full and/or part-time). s have hired the sub-contractors 6. 0 New construction 2.❑ I am a sole proprietor orpartner- listed on the attached sheet. 7. 0 Remodeling ship and have no employees These sub-contractors have g; F Demolition workingfor me in an capacity. employees and have workers' Y P tY• 9. 0 Building addition [No workers'.comp.insurance comp.insurance.Z required.] 5. E We are a corporation and its 10.E Electrical repairs or additions 3.❑ I am a homeowner doing all work ` officers have exercised their 1 L[]Plumbing repairs or additions myself.[No.workers'comp. right of exemption per MGL 2.V00ther of repairs insurance required.]t c. 152,§1(4),and we have.no employees. [No workers' 13. comp.insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information: t Homeowner:who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors edrat check this Wi must attached'an additional sheet showing the name of the subcontractors and state whethei 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 isproviding.workers'compensadon insurance for my employees. Below is thepollcy and..job site information. Insurance Company Name: p.Y /o T y ¢ ✓ �Z/'. VA-1 t//19 N!� g32G licy#or Self-ins.Lic.#: N2� G I- s� Po Expiration Date: ► a S" 1 i i 7 d pef 'fUell�°� �y4�r�« � Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine 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 insuranceAverage verification.. I do hereby certify un the i and penalties of perjury that the information provided above is true and correct Signature: Date: f®�WROl� Phone#: 3-0 �l a J s,i� Offl clal 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 F D TE(MMDD YY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND;EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed.If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Karen Walther Rogers&Gray Ins.-So.Dennis PHONE FAX JC No Ext:508-760-4630 (AJC,No): 508-258-2230 434 Route 134 E-MAIL ers ra waltherka ro com P.0.BOX 1601 PRODUCER @ g g Y CUSTOMER ID#: South Dennis,MA 02660-1601 INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A:National Grange Insurance Co. Capizzi Home Improvement,Inc. INSURER B:ACE Property&Casualty Ins.Co Capizzi Enterprises,Inc. INSURERC: 1645 Newtown Road Cotuit,MA 02635 INSURER D: 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 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDLSUBRI - - POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER MM/DD MMIDD LIMITS A GENERAL LIABILITY MPB1075H 06/08/2011 06/08/2012 EACH OCCURRENCE $1 00O 000 X COMMERCIAL GENERAL LIABILITY - DAMAGE TO RENTED PREMISES Ea occunence $5OO OOO CLAIMS-MADE 1 I OCCUR MED EXP(Any one person) $10,000 PERSONAL BADVINJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OPAGG $2,000,000 POLICY PRO-J'CT F LOC. $ .A AUTOMOBILE LIABILITY - M1 M28044 06/08/2011 06/08/2012 COMBINED SINGLE LIMIT (Ea accident) $F':00 000- ANY AUTO `fi _ 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 $ X Drive Other Car $ A UMBRELLA LIAB X OCCUR CUB1076H 06/0812611 06/W/2012 EACH OCCURRENCE- $5 000 000 EXCESS LIAB CLAIMS-MADE - - AGGREGATE s5,000,000 DEDUCTIBLE $ X RETENTION 10000 $ B WORKERS COMPENSATION NWCC45843208 12/25/2010 12/25/2011 X WC STATU- OTH- AND.EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVEY/N E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED?. 51 NIA (Mandatory in NH) - E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under - DESCRIPTION OF OPERATIONS below - E.L.DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space is required) Additional insured status is provided under the general liability when required by a written contract with the certificate holder CERTIFICATE HOLDER CANCELLATION 10 Days for Non-Pa ment 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 c AUTHORIZED REPRESENTATIVE ©198 -2009 ACORD CORPORATION.All rights reserved. ACORD 25(2009109) 1 of 1 The ACORD name and logo are registered marks of ACORD #S67537/M67480 MEE �� �"� :..i�.e'L?tss:.�xza�.�ealcli �✓szaa,.�r,Jecr�..ttd Ofsce of Consumer FSM-irs&Business Regulation License or registration valid for individui use onto Oi;, [f iPr C�43r1IEil 'C{3 iTFt C E} before the.expiration date. if found ret�rn to: r G,. Office of Consumer Affairs and Business Regulation _. Registration` G,740 Tyke: IQ Parki'taza-Suite 5170 Exp Era s� 7 uppPemaot Cad Boston,i4IA.02116 Crkl izzi HOME� � I<�Ft�r�l�Ci. " .. b^s,s GARY GUS t S� Coffuit,KAA 02635 _�� ' iinsie>secretary ttTo id without si-nature Nttc f Public Safet% i � � (If Duiltlra;�,e�,�ul.�ti:�tt��tn��tartcitzr Construction SupervlsOr �icer��e:. License: CS 7460Fa, GARY GUSTAFSON 8 SHORT WAY SANE) IC 1,MA 02563 Exgisaiion: 1 R191 2 Tr.-- 7058 ' I Page 7 of 7 CAPIZZI HOME IMPROVEMENT INC. SPECIFICATIONS AND ESTIMATES STATE OF MASSACHUSETTS LETTER OF AUTHORIZATION TO APPLY FOR A BUILDING PERMIT A/ evo4o ) OWN THE PROPERTY LOCATED AT 11 0 r'IrS 4i.j.e nu.4 IN 14 j&,vivo , , MASSACHUSETTS. I HAVE AUTHORIZED CAPIZZI HOME IMPROVEMENT JO ACT AS MY AGENT TO APPLY FOR A BUILDING PERMIT IN ACCORDANCE WITH 780 CMR, THE MASSACHUSETTS STATE BUILDING CODE. I GIVE MY PERMISSION TO LESSEE TO APPLY FOR A BUILDING PERMIT IN ACCORDANCE WITH 780 CMR, THE MASSACHUSETTS STATE BUILDING CODE. SIGNATURE OF OWNER: OWNER'S ADDRESS: OWNER'S TELEPHONE: LESSEE'S SIGNATURE: LESSEE'S ADDRESS: LESSEE'S TELEPHONE: APLLICANT'S SIGNATURE: APPLICANT'S ADDRESS: 1645 Newtown Rd., Cotuit, MA 02635 APPLICANT'S TELEPHONE: 508-428-9518 RESPONSIBLE OFFICER: RESPONSIBLE OFFICER ADDRESS: RESPONSIBLE OFFICER TELEPHONE: