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EXPRESS BUILDING PERMIT APPLIC• I
TOWN OF YARMOUTH RECEIVED
Yarmouth Building Department
1146Route 28 AUG 28 2018
South Yarmouth,MA 02664
(508)398-2231 Ext. 1261 BUlI' rot
CONSTRUCTION ADDRESS: 30 Nkr�C
ure¢ a wlSf yA•{/Qen/ BY ASSESSOR'S INFORMATION:
// Map: 417 Parcel:
OWNER -K,lli? Asti la It/4u✓Lr 1 V. a ref
nr1v Ay, it ` '3
NAME PRESENT ADDRESS / TEL a f tin
coNnucrost: 1du f�d u u pi (itp/Z2,'Agit Z t7t !'t y!rdt it c nyr raced
NAME MAILING ADDRESS Sifly`ffyy TEL* c.tu/ l /q,; 026yr
Residential ✓ Commercial Cost ofConstruction$ �o/do. od
Home Improvement Contractor Ile.# 007 ye Construction Supervisor Lie.# OIY9//7
Workman's Compensation Insusmzce: (check one)
I am the homeowner /tam the sole proprietor I have Worker's Compensation Insurance
Insurance Company Name: A It/ 60,00 2 u1. Col yi worts comp wucy✓r Z w e P63725"
WORK TO`BE PERFORMEDE
❑Tent (care RenMs.r..`na...«.+.rws
en
❑Wood Stove__ pp_
ve Sa
gafkun� eotSytara - flod/? £a4' false EA*
/ --a Replacement doer a Rrolsee vrtodows:e
(3riieaaaE :ars ' AI SHED L4VO/'Ls(k Atlfrittfil ewslame
()Stripping old shingles* ()going over____Inyeas of exhibit roof 0 Old Kings laghway/HIstoric Distda
Roofing/Siding(Like for Lite)
.The debts wig xdisposedWat/liellla(/ff/ Ind4%/ 4dlf/ddraii�l,7'
taea loa of Facilityl
/ I dec ander rookies or prior!Nat the uatement herein contained re rose and coma to the tett ofmy lmovtedaeant bad.. [understand that any false answer(s)
just awe for denWi itvtntiou of my Ikense and(or pmsecudoe under MGI.Ci.26L SSoo L
(9.k ✓tvu�rslr. Cfr f MOH,-
get Ill"fall.2',va �„ errniier
Owners Signature(or Madmen AfReot Dna:.
wt Approved B,: Date
BW «Boat(a,ddesi8nee)
Zoning District
Historical District Yes No Flood Plain Zone Yes No
Water Resource Protection District Within 100 It of Wetlands
Yes No Yes No
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W�,I-,� Ctrs agall /i..vl uir/.t Regi valid for individual use Only
ROME IMTM OVEYS �MROR helorothe e�ha�n date. g tourd return to:
�Ca�daClorr Office of consumer Affairs and Business Regrdation
Reala0 One . Place-Suite 1901 SIOr100740 HOMEIMPROVEMEtin,INC. atJACK STRUNlI
CBCT NEWTON 26 .Not vat i• Without signature
COTUR,MA 026335 Undersecretary
•
Construction Supervisor - Commonwealth of
Unrestricted-Buildings of any use group which contain ®/ Division of of Massachusetts Licensure
less than 35,000 cubic feet(981 cubic meters)of enclosed sPaest Board of Building Regulations and Standards
Con striAtiorf tapervisor
CS-064817 E Aires:06(18(2021
u
JOHN T STRUMSW - ` F. g
19 ALDEN AVE-,
.
BUZZARDS RAT?'
ti2532 • i '
possess a current edition of Massachusetts
Failure to . ' 3 -
State Buildingthis `�rg:33L
• Code is cause for revocation of icense. s
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For information abort this license L p-
'
Page 7 of 7
Capizzi Home Improvement Inc.
Specifications and Estimates
STATE OF MASSACHUSETTS
/ LE ITER OF AUTHORIZATION TO APPLY FOR A BUILDING PERMIT
A Ai
I/WE, Ole u(! ' d , OWN THE PROPERTY LOCATED AT SCJ lauSe7� IN
tileri4't / ,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: 17<2 0
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:
• e, a
•
ACa° CERTIFICATE OF LIABILITY INSURANCE DATE
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(es)must be endorsed If SUBROGATION IS WAIVED,subject to
the terms and cond)tIons of the policy,certain policies may require en endorsement. A statement on this certificate does not confer rights to the
certificate holder In lieu of such endorsemeM(s).
PRODUCER CONTACT
NACT . Rogers and Gray Processing
ROGERS&GRAY INSURANCE AGENCY INC PHONE
Exp. (508)398-7980 I AX
FA/C.NM:
E-MAIL
ADDRESS: mall@rogersgray-COrll
434 ROUTE 134 INSURERS)AFFORDING COVERAGE RAIC0
SOUTH DENNIS MA 02660 INSURER A: AMGUARD INSURANCE CO 42390
INSURED INSURERS; '
•
CAPIZZI HOME IMPROVEMENT INC INSURER C:
INSURER 0: '
1645NEWTOWNROAD INSURER E: "
COTUIT MA 02835 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 POUCIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR ADDL.SUER POLICY EFF PCL.CY ECP
TYPE OF INSURANCE LIMITS
LTR INcn YAm %POLICY NUMBER MI IMMNDOr1YYM
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $
CLAIMS-MADE [IICCCUR - PREMISESSO(ERs o NTE
$
— . MED EXP(Any onepwscn) 5
_
N/A PERSONAL&ADV INJURY $
GENL AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $
POUCY-JECar ❑LOC PRODUCTS-COMP/OP AGO $
OTHER: $
AUTOMOBILELIABIIJTY (Ea accident) F UMI r $
ANY AUTO BODILY INJURY(Perperson) $
- �OOWNED —_ AUTOS N/A N/A BODILY INJURY(PPeracddent) $
PROPERTY
• HIRED AUTOS _AUTOS NON-OWNED
(Por accident)DAMAGE
$ _
S
UMBRELLA UAB _ OCCUR EACH OCCURRENCE $
EXCESS LIAR CLAIMS-MADE N/A AGGREGATE 3
DED I RETENTIONS $
WORKERS COMPENSATION
AND EMPLOYERS UABRJTY X STATUTE ERµ _
A OFF10ERR//eIREABER EXCJ IIDEE EE�ECUINE wA N/A N/A R2WC883728 12252017 12252018 EL EACH ACCIDENT $ 1,000,000
(Mandatory In NH) EL DISEASE•EA EMPLOYEE $ 1,000,000
Myyes desWbeu,der
DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT 5 1,000,000
N/A
DESCRIPTOR OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Addbane'Remarks Schedule,may be rattled If men WWI Is rpulrsd)
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.govilwd/workers-compenaeOonilnvestIgasons/. ,
Is CERTIFICATE HOLDER CANCELLATION
,` 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.
1148 Main Street Route 28 •
AUTHORIZEDREPRESENTATIVE
South Yarmouth MA 02664-0000 D
I ant M,Cr y,CPCU,Vice President—Residual Market—WCRIBMA
01988.2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD