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Home My WebLink AboutBLD-19-3679 • OF,Yt Office Use Only /*•.:0 .t 'tr0 Pemtit# 0 air,'8 c Amount 5D-" N , h ' Pi \""av d' Pemtit expires 180 days from issue date &b-IQr-tb3607 f EXPRESS BUILDING PERMIT APPLICAT 'ON:: C�_E p TOWN OF YARMOUTH Yarmouth Building Department .--DEC 18 20181 1146 Route 28 South Yarmouth, MA 02664 II itr; ,, . ,rte /,./ (508)398--2231 Ext. 1261 l� fav Pvi� r ' r CONSTRUCTION ADDRESS: 1'Z Lieh, Rea 411 / ' ma ii ASSESSOR'S INFORMATION: Map: illi' /Parcel: / / �1 rel [ OWNER: Dov✓4Nv i 10 64a14 6 gAiz1 7tep6e✓vcc LI Y4✓NUul riai 3 6 a PO ii? NAME /PRESENT ADDRE S Na TEL. # CONTRACTOR: Car r 6114411 ea elin; florae TNfAil/e yl v/,.27A/C, rot &Yt 0 2 6 S NAME MAILING ADDRESS TEL.# /6,VC Motown go c erfath 10 a Z b 3 z 9lesidential 0 Commercial Est.Cost of Construction$ VO/000. CO Home Improvement Contractor Lic.# l 0 07 y o Construction Supervisor Lic.# 0-7.14 40 Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor Caiave Worker's Compensation Insurance AH tuna-. _Levi. Cal/AN' R 2 (,vc d`37av Insurance Company Name: Worker's Comp.Policy# WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # 114No'y4✓t., 62n-1 To •Y.trcw .eccipet Roofing: #of Squares at ( ✓)Remove existing*(max.2 layers) Insulation VPI�r�ld Kings Highway/Historic Dist. (Y)'keplacing like for like Pool fencing *The debris will be disposed of at f t'euu 0 r 7'�- "+"UC/TH C41t/D fi=r'I f Location of Facility I declare under penalties of perju that 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 r f my license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: Date: i 2i I/ d //, Owners Signal or attachment) Date: '�j /�/� Approved By: d ' Date: /_1 —/ .., Building"/1° 1C. 4d gnee) E . ADDRESS: Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes U No Water Resource Protection District: Within 100 ft.of Wetlands: ❑ Yes 0 No 0 Yes 0 No The Commonwealth of Massachusetts t�"1"-• or=At Department of Industrial Accidents •r _cunt- a 1 Congress Street,Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): CA pi 1:2; )401-1 e tilt YAJt 464 Address: 11.'1C 1J-euikowut "Ru City/State/Zip: Co-tui}-/ /I* Phone#: 3'OeV 2+9 c/r Are you an employer?Check the appropriate box: Type of project(required): 1.❑I am a employer with employees(full and/or part-time).* 7. 0 New construction 2.01 am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself(No workers'comp.insurance required.]t 9. ❑Demolition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. twill 10 0 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.I Roof repairs These sub-contractors have employees and have workers'comp.insurance. 6.0 We are a corporation and its officers have exercised their right of exemption per MGL e. 14.❑Other 152,61(4),and we have no employees.[No workers'comp.insurance required.] !Any applicant that rherlrs 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 contactors 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's providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: 1Miami r-7:-/11/- e.0/9t'Rd y We.16 371-1 / Policy#or Self-ins.Lic.#: Expiration Date: /171 j/—a/ Job Site Address: opo . ie. y deLAiry efr City/State/Zip: ,�itrust/Trf�ar - Attach a copy of the workers'compensation policy declaration page(showing the policy nu er and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement ma be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do her•.y - %s rider the pains a. .enalties of perjury that the information provided above is true and correct. Signature: / Date: /2-//r/// Phone#. fat oVia yyvc 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.Numbing Inspector 6.Other Contact Person: Phone#: 'd ACCFRO CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDA'WY) 12/2712017 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(les)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). ' PRODUCER CONTACT NAME: Rogers and Gray Processing ROGERS&GRAY INSURANCE AGENCY INC PbUHOO"N Ern: (508)3984980 FAX,Nal; E-MAIL mail ro ers r8 ADDRESS: 9 9 Y•com 434 ROUTE 134 INSURER(8)AFFOROINGCOVERAGE NAICI SOUTH DENNIS MA 02660 INSURER A: AMGUARD INSURANCE CO 42390 INSURED INSURER B: • CAPIZZI HOME IMPROVEMENT INC INSURER c: INSURER D: 1645 NEWTOWN ROAD INSURER!: COTUIT MA 02635 INSURER F: 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. INSRTTYPE OF MSURANCE INSD WAeBn, POLICY NUMBER IMR M,DCU/YYYYI (MMY EFF M POLICY LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS-MADE nOCCUR EACH OCCURRENCE S DAMAGE TO RENTED —PREMISES(Ea°mamma) $ MED EXP(My one person) $ N/A PERSONAL IL ADV INJURY $ — GEN.AGGREGATE UNIT APPLIES PER GENERAL AGGREGATE $ 1 POLICY 0 JECT 0 LOC PRODUCTS-COMP/OP AGG f OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ IEa accident) ANY AUTO BODILY INJURY(Per person) $ — ALL OWNED SCHEDULED N/A BODILY INJURY(Per accident) $ AUTOS AUTOS ON -OVr1JED aPROPERTY S • _ HIRED AUTOS _ AUTOS S — UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS UAB , CWMS-MADE N/A AGGREGATE $ DEO RETENTION$ �7 $ WORKERS COMPENSATION X 8 RME FRH AND EMPLOYERS'LIABILITY A AOFYICERKIEMBOWPOACRLUDED? curlve Yl WA NIA R2WC883728 12/25/2017 12/25/2018 EL EACH ACCIDENT $ 1,000,000 (Mandatory In NH) I I 'E.L DISEASE-EA EMPLOYEE $ 1,000,000 DyeEySeee,descIPTIO10e OFN toOPERATIONS below ELast DISEASE-POLICY LIMIT $ 1,000,000 I N/A e3 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLE-8(ACORD 101,Additional Remarks Schedule.may be attached I more space G required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization Is given to pay Balms 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/lwdhvorkers-compensatlorVinvestlgatlonsl. 'w; CERTIFICATE HOLDER CANCELLATION tv SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Main Street Route 28 AUTHORIZED REPRESEN TATNE C South Yarmouth MA 02664-0000 Daniel M.Cr. y,CPCU,Vice President—Residual Market—WCRIBMA ®1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD r Ar , • • artment of Public Safety \` Massachusetts Dep - Board of Building Regulatlona and Standards License:CS-074640 isor Construction Supe , GARY GUSTAFSON Lov _ ,8 SHORT WAY SANDWICH MA 02563 • l l'Zy /2o /CefGPd Expiratio / i la lvzerz R� if osto r J �.+�w /nmOnrtM,,�� n n'l�J.fae/rtgu Offiu HOME IMPROVEMENT Ngula0on IMPROVEMENT CONTRACTOR Registration valid for Individual use onlyTYPE:Supplement Card before the expiration date. If found return to: Registration Fxnlratbrt Office of Consumer Affairs and Business Regulation 100740'"` 06/22/2020 One Ashburton Place-Su - 1301 CAPIZZI HOME IMPROVEMENT,INC. Boston,MA 02108 GARY GUSTAFSON - 1845NEWTON RD / o valid without signature COTUIT,MA 02635 - • - Undersecretary 6 4 LGta11S tea • • Licensee Details • Demographic Information •4 . Full Name: GARY GUSTAFSON caner Name: License Address Information City: SANDWICH ' State: MA Zipcode: 02563 Country: United States License Information License No: CS-074640 License Type: Construction Supervisor Profession: Building Licenses Date of Last Renewal: 11/5/2018 Issue Date: Expiration Date: 11/29/2020 License Status: Active Today's Date: 11/17/2018 k. SecondaryLicense Type: Doing Business As: Status Change Reason: License Renewal Prerequisite Information • No Prerequisite Information • • 'ittp://elicense.chs.state.ma.usNerification/Details.aspx?agency_id=1&license_id=26359... 11/17/2018 Page 7 of 7 Capizzi Home Improvement Inc. Specifications and Estimates STATE OF MASSACHUSETTS LETTER OF AUTHORIZATION TO APPLY FOR A BUILDING PERMIT WE,DONALD AND JANET GAULAND, OWN THE PROPERTY LOCATED AT 62 EARLY RED BERRY LANE IN YARMOUTHPORT, 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. ///a2/F I GIVE MY PERMISSION TO LESSEE TO APPLY FOR A BUILDING PERMIT IN ACCORDANCE WITH 780 CMR, THE MASSACHUSETTS STATE BUILDING CODE. I SIGNATURE OF OWNER: XJ .—.c i 41, 6/ / 4 i t/ / OWNER'S ADDRESS: 62 /Y RED BERRY LANE, YAC,' OUTH PO Ij OWNER'S TELEPHONE: (508) 362-8086 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: