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EXPRESS BUILDING PERMIT APPLICA O C E I V E i°
TOWN OF YARMOUTH -
Yarmouth Building Department OCT 25 2018
1146 Route 28 BUIIDIN-�`,D"'ART
South Yarmouth,MA 02664 ay: _ MENT
(508) 398-2231 Ext. 1261
CONSTRUCTION ADDRESS: 6/ tAAe/y /lei Berri U thiry00r if otter
ASSESSOR'S INFORMATION:
Map:. I I,/ Parcel: J 1(
OWNER: Pa')/ de /l i✓t& 1)/fi Sio// i i/"L'&"aeon Sogent'le Ali /sryf
NAME PRESENT ADDRESS TEL # Email Address:
coNTRAcrot: Jahn f WeiNfi/ti (.v nh!NONe repraelia we— My' Vturfa w R. erradi#s 6 Ai fc
Vie
M` IUNGADDRESS mL#yet 4vli/y)mailAddress:
Residential V Commercial Est.Cost of Construction S i'" IPP •6 a -14-1-1-L evev.a
Home Improvement Contractor Lia# 10 c 7 y 0 Construction Supervisor Lie.# t:s 0 b y r/ N
Workman's Compensation Insurance: (check one)
I am the homeowner I am the sole proprietor have Worker's Compensation Insurance
Insurance Company Name: //IOU 4-0 `loll G eOrit it/ Worker's Comp.Policy# 2. WC 141 7 z/
WORK TO BE PERFORMED
Tent _ Duration // (Fire Retardant Certificate attached?) Wood Stove
/ Siding: #of Squares ' 6 _511 Replacement windows:# Replacement doors: it
Roofing: #of Squares ( )Remove existing*(max.2 layers) Insulation
Old Kings Highway/Historic Dist. ( )Replacing like for hie
t t ea:ern-pH 9.7/fail
I 'The debris will be disposed et at d tila // ti-PH/(lm' 14-.dgTit(
Location of Facility
I declare under penalties of.- : the statements herein contained are true and correct to the best of my knowledge and belief. I understand that any false answer(s)
will be just cause for denial ,. :tion of my license and for prosecution under MO.L Ct.268,Section I.
Applicant'sSi...t1! .A. t-//iae r' ri//rrld/t`/ldtDate: la//e/lr
owners SI ,.: t '. .,' ,: , �� - �i�(J�Y4iiii'" Debit
Approved B-L4%.."'IVDateo• 2 ?I
g.. ....g: rf` .(f'+guee) /
• Zoning District
historical District Yes No Flood Plain Zone: Yes No
Water Resource Protection District Within 100 ft.of Wetlands:
Yes No Yes No
The Commonwealth of Massachusetts
DepartmentoflndustrialAeddettts p~ '°
b� as Office of Investigations
ac r 600 Washington Street
, •_ Boston,MA 02111
r www.massgov/dia
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electrictans/Plnmbers
Applicant Information Please Print Legibly
Name(sus a : CAPI721 HOME IMPROVEMENT
Address: 1645 NEWIOWN ROAD
City/State/Zip: COTUIT MA 02635 Phone#: 508428-9518
Are you an employer?Check the appropriate box: Type of project(required):
1.✓ I am a employer with 40+ 4. I am a general contractor and I 6. New construction
employees(full and/or part-time).* have hired the anbactors
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
employees and have worker'
working for me in any capacity. t 9. Building addition
rrelworkers' insurance comp.
� corporation and its 10. Electrical repairs or additions
3. I am a homeowner doing all work v e officers have exercised their 11. Plumbing repair or additions
myself[No worker'comp. right of exemption per MGL 12. Roofrepairs
insurance required.]t , , c.152,§1(4),and we have no
employees. worker 13. Other -.5:121/;1/4
comp.insurance required.]
*Any applicant that checks box#1 most also fill out the secdon below showing theirworkin'compensation policy information.
t Homeowner who submit this affidavit Indicating they are doing all work and tea hire outside contractus mat submit a new affidavit indicating such.
:Contractors that check this box must attar an additional sheet showing the name ofthe subcontractor and state whether ornot those entities have
employees. If the sub-emtrecmrhave employees,they mast provide their workers'comp.pol pmmmbev. Btlowivtkepofieyafrdfobsite
I am an employer that is providing workers'compensation insurance for my employees
Information.
Insurance Company Name; AMGUARD INSURANCE COMPANY
�;_ .24ar it
Policy#or Self-ms.Lia.#:X3728 Expirationi_ ,
Job Site Address: Gi /94M 6th "y 4' City/State/Zip* yA/i/119oalaiOW/Yq
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
l'( Investigations of the DIA for insurance coverage verification.
I do hereby certify an, the pains and penalties ofperJnry that the information provided above Is true and correct
l/ > :Mr
. tG1 zc� iij
]'hone#: 5 tt '8-0269
Official use on5c Do not write in this area,to be completed by clay or town officiaL
City or Town: Permit/License ii
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrial Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
4
•
W. fb
SRO" CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDONYYII
v 12rz7rzon
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 bolder Is an ADDITIONAL INSURED,the policy(es)must be endorsed. If SUBROGATION IS WAIVED,subject to
the temp and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the
certificate holder In lieu of such endorsement(s). '
PRODUCER CONTACT
NAME; Rogers and Gray Processing
ROGERS&GRAY INSURANCE AGENCY INC PMONN E.n• (508)398-7980 WC.Nor.
ADDRESS: mall@rogersgrey.Dom
434 ROUTE 134 INSURER(s)AFFORDING COVERAGE NAILS
SOUTH DENNIS MA 02880 INSURER A I AMGUARD INSURANCE CO 42390
INSURED INSURER e: •
CAPIZZI HOME IMPROVEMENT INC INSURER C:
INSURER 0;
1645 NEWIOWN ROAD INSURER E:
COTUIT MA 02835 INSURER p;
COVERAGES CERTIFICATE NUMBER: 225553 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.
EFF POLICY EXP
ITRR TYPE OF INSURANCE AD* SLAM
Ma l POLICY NUMBER .IIMMADOF Ferl IMMNDIYYYYI UNITS
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $
RENTED
CLAIMS-MADE ❑OCCUR t PREMISES Es oc;ennce) S
MED EXP(Any ere pram) S -
N/A • ` PERSONAL AADV INJURY $
GENLAGGREGATE LIMITAPPLIES PER GENERALAGOREGATE $
POLICY❑,Ernef ❑LOC PRODUCTS-COMP/OP AGO $
_ OTHER: $
AUTOMOBLLEUABUTY COMBINED SINGLE LIMIT $
/Ea exJdent)
ANY AUTO BODILY INJURY(Per pan ,) $
• — ALL
OWNED SCHEDULED
AUN/A BODILY INJURY(Peracddet) $
_, — NONON-OWNED IPRO RTV DAMAGE I
HIRED AUTOS Autos Pa 4a+t
S
UMBRELLA LAS OCCLAR EACH OCCURRENCE $
—
EXCESS UAB CLAMS-MADE N/A AGGREGATE $
DED RETENTIONS DITµ. $
WORKERS COMPENSATION XI STATUTE FR
AND£PLOVERS'Lanny
A OFFICER/MEMBERIS CLUDEE D? WA WA WA R2WC883728 12/25/2017 12/25/2018 EL EACH ACCIDENT $ 1,000,000
(Mandatory In NIG E.L DISEASE-EA EMPLOYEE $ 1,000,000
NYw MaIW Oder
DESCRIP11QN OF OPERATIONS belay EL DISEASE-POLICY LIMIT $ 1,000,000
N/A
‘ DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule.may be attached If men apace M teethed)
Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 08 B,no authorization Is given to pay
claims for benefits to employees in states other than Massachusetts if the Insured hires,or has hired those employees outside of Massachusetts.
This certificate of insurance shows the policy in force on the date that this certificate was Issued(unless the expiration date on the above policy precedes the
Issue date of this certificate of Insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification
Search tool at www.mass.gov/Iwd/workers-compensatIoMnvestigatfonsL
f* CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Town of YarmouthACCORDANCE WITH THE POLICY PROVISIONS. •
1146 Mein Street Route 28 AUTHOR®REPRESENTATIVE
South Yarmouth MA 02884.0000 Daniel y,CPCU,Vice President–Residual Market–WCRIBMA
01988.2014ACORD-CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD 1
• .
SCA I O 20M-05117
/�'y4 r nUJtPNNx+>(�r fl Lar rNe��J
r tae ottEonsume lactri •Bowness egu on Registration valid for Individual use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return tc:
TYPE Supplement °431/.1.17...
ne of Consumer Affairs and Business Regulation
RMiati l� 0 12f One .burton Place-Suite 1501 /
100740PROA 02100
CAPIZ�HOME IMPROVEMENT,INC. �_
. j LJ ,imi
JACK STRUNSICI ir Not vat'• Without signature
1045 NEWTON RD. ---�—
COTUIT,MA 02635 Undersecretary
•
.
Construction Supervisor Coaunonwealthof Massachusetts
Unrestricted-Buildings of any use group which contain i�; Division oT Professional Licensure
less than 35,000 cubic feet(991 cubic meters)of enclosed Board of Building Regulations and Standards
space.• Construtti6If%i$pfrvisor
v
, CS-064817Expires:06/18/20
b
• - • JOHN T STRGMSKI •.r j
t0 ALDEN AV-El '
•
BUZZARDS 6AY�MA 02532 �v
Failum to possess a parent edition of the Massachusetts r)/S5':iP���,
State Building Code is cause for revocation of this license. -
For Information about this license , • 7 eL
0
•
•
3� � � TOWN OF YARMOUTH
r �?"•T 1146 ROUTE 28, SOUTH YARMOUTH, MA 02664-4451 REC1
Mi
Telephone(508)398-2231 Ext. 1292-Fax(508)398-0836
RECEIVED KING'S HIGHWAY HISTORIC DISTRICT COMMITT E OCT 2 2 2018 •
YARMOUTH
OCT 232018 APPLICATION FOR OLD KING'S HIGHWA1
CERTIFICATE OF EXEMPTION
SS TOWN CLERK
AppQ�dribinYiRAQ yTldiah0elfor the issuance of a Certificate of Exemption under Sections 6 and 7 of Chapter 470 of
Acts of 1973, as amended, for the proposed work as described below and on plans, drawings, or photographs
accompanying this application.
Type or print legibly:
Address of proposed work: 0 E4RI7 REp$GY✓y La Map/Lot# //fll7c
Cdp
y `
Owner(s): 140/ Dint pi/ fa ',flit .")/0n Phone
#: • rd -427 2 3
All applications must be submitted by owner or accompanied by letter from owner approving submittal of application.
Mailing address: 2 Z ti /,doi✓ 4 ve.ebE So.7tduife/ /f4 C 2/y)• Year built: 11 7V
Email: Preferred notification method: r/ Phone
Email •
c1c4n/ k 73oWD&i✓ •
Agent/Contractor: CO/22; I/o yE nip roae HERR/ .ZN6
Phone#:
Mailing Address: /4 V r /Lwouly 7?/) C o ru/:f! /1•4 •z G 3 C /1 H
Email:7eRN/.t 2 CA//y?j/,/OHCs • 4 OH Preferred notification method: Phone ✓ Email
Description of Proposed(Work(Additional pages may be attached if necessary):
Rep/nt. revue C/,edgeaRD wires Rae o/ ,P/Rn/& VE/047" CEOAen
(ow7Eav 4,4y !- G 17t114ees
EPaiit/r aEa/¢,ey pvv✓,/ Ar team-eF N/Ni .
_vim -etf!M . Moore.,� Al-'.29aTheo ) CA/itA/7lE - Co /o✓ o1. 'Mc it I ,"
?a,- Bl,ie,c o///aH"i 6'de ow <inn
Signed(Owner or agent) ,Gu/i Si-u/IL Date: /0 /20,
I > Owner/contractor/agent Is aware that a permit may be required from the Building Department.(Check other departments,also.)
> This certificate is good for one year from approval date or upon date of expiration of Building Permit,whichever date shall be later.
For Committee use only:
Date: bag- Approved _Approved with changes ___Denied_.
Amount 073 Reason for denial: • APPROVED
cat 3,3c2r OCT 2 2 2015
Rcvd by: 64/ .
t'ARMvUTH
OLD KING'S HIGHWAY
ff,,,
Date Signed/f)J Vs 9/ 0 Signed: .......
� �,
( rr APPLICATION#: 18—
Page 7 of 7
Capizzi Home Improvement Inc.
Specifications and Estimates
STATE OF MASSACHUSETTS
LETTER OF AUTHORIZATION TO APPLY FOR A BUILDING PERMIT
Pi "� , OWN THE PROPERTY LOCATED ATIS rl-e/ IN
ygte prr , MASSACHUSETTS. v.7
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 C 124-ejotifjegeP
E.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: