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HomeMy WebLinkAboutBld-20-002995 ' p�,YAR'r Office Use Only O}• r� H Ind,, i r Amount-- — bpa '•f �T",;` Permit expires 180 days from � '�'�lf jjjjt issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508)398-2231 Ext. 1261 CONSTRUCTION ADDRESS: ASSESSOR'S INFORMATION: Map: L j Parcel: C) OWNER: k/U(o{#JG 0- P4J( "P44.4),Li Ro LL)' `t atZAir z.rerpii /44- O 2d '1l NAME PRESENT ADDRESS TEL. # CONTRACTOR: 6419 (t9 f 1 A Jf kJ(I 1(4'y( �(1 e�ifauidl 24) Ga i ifi-i-, H11 10 -1, t/i 95 7-- /('� NAME CA,0 21 0/-1 enMAILING DDR SZi�v D 2lv 3i TEL.# �i+j- Z f �!rip ( /, �� I f` G O�Residential 0 Commercial Est.Cost of Construction$ id Cd d Home Improvement Contractor Lic.# ) CI'°I`t c' Construction Supervisor Lic.# C S U -i c d Workman's Compensation Insurance: (check one) I am the homeowner - I am the sole proprietor :;`/I have Worker's Compensation Insurance Insurance Company Name:A I 0 Anp A J Utt A t t Worker's Comp.Policy# WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove i.W t S ' .Eii,14 Lzo-i.eik1 Siding: #of Squares Replacement windows:# Replacement doors: # St el Roofing: #of Squares ( )Remove existing*(max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: ccpu �� jK/uerJTi1 L,-ie/'U,iii /4 4 Ail/aril/ -t 4 Location of Facility 1 declare under penalties of perjury 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 or r v • of my license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: Date: Owners Signature(or attachment) 417.44.` C°d. 4-U714a/2 7a," Date: Approved By: Date: Building ial esignee EMAIL AD SS: Zoning District: Historical District: - Yes No Flood Plain Zone: Yes No Water Resource Protection District: Within 100 ft.of Wetlands: Yes No Yes No Page 7 of 7 Capizzi Home Improvement Inc. Specifications and Estimates STATE OF MASSACHUSETTS LETTER OF AUTHORIZATION TO APPLY FOR A BUILDING PERMIT I/WE, , OWN THE PROPERTY LOCATED AT IN , 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. ( /7 7/9 I GIVE MY PERMISSION TO LESSEE TO APPLY FOR A BUILDING PERMIT IN ACCORDANCE WITH 780 CMR, THE MASSACHUSETTS STATE BUILDING CODE. rSIGNATURE OF OWNER: 6.11 , .- � L avio._ .d 1 dtic , 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: The Commonwealth of Massachusetts _IFIBI- 1, Department of Industrial Accidents _:e�= 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):Capizzi Home Improvement INC Address:1645 Newtown Road City/State/Zip:Cotuit, MA 02635 Phone#:508-428-9518 Are yoq an employer?Check the appropriate box: Type of project(required): l.12ram a employer with 40 employees(full and/or part-time).* 7. ❑New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 9. Demolition 3❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10❑Building addition ' JI am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11❑Electrical repairs or additions proprietors with no employees. 120Plumbing repairs or additions 50 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.ORoof repairs These sub-contractors have employees and have workers'comp.insurance.: 1.,.� �wu.�j I(�/N C 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 1 152,§1(4),and we have no employees.[No workers'comp.insurance required.] W C C '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:AmGuard Insurance Compnay Policy#or Self-ins.Lic.#:R2WC921272 Expiration Date:12/25/2019 .21 ?AW/J.te. RI) tit% •741.1;4.1otlr 1(Mq 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 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 fme of up to$250.00 a day against the violator. ' opy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verificati9n. I do hereby ce j nder a pains and penalties of perjuty that the information provided above is true and correct. Silisature: f " Date: 11 /Z///f Phone#:508-6 48-0269 Official use only. Do not write in this ,rea,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#: Conn wnw saltfi�of Division of PrefasslOveli - Board of Building Regulations ,ti Constr 11 CS-074640 fit. GARY GUSTAFSON ; 8 SHORT WAY SANDWICH MA 02583 .� - Cis 441-- - Commissioner • HONE IMPROVEMENT CONTRACTOR Ramon valid for individual use only TYPE:Supplement Caro Woes the expkMion dote. M found rstum to: Bseleastlen Ei&L1Yes Offos of Consumer Attains and Business Regulation -- 100740 06 22/2020 One Ashburton Piave- 1801 CAPIZZI HOME IMPROVEMENT,INC. Boston,MA 02108 GARY GUSTAFSON ,��. 1645 NEWTON RD. COTUIT,MA 00835 valid Without signature • ® DATE(MM/DD/YYYY) ACC o CERTIFICATE OF LIABILITY INSURANCE 12/14/2018 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 CONTNAME: Rogers Rogers and Gray Processing ROGERS&GRAY INSURANCE AGENCY INC PH No.Ext): (508)398-7980 FAX Na): E-MAIL mail ro ers ra com ADDDRDRESS: G� 9 9 Y• 434 ROUTE 134 INSURER(S)AFFORDING COVERAGE NAIC# SOUTH DENNIS MA 02660 INSURERA: AMGUARD INSURANCE CO 42390 INSURED INSURER B: CAPIZZI HOME IMPROVEMENT INC INSURERC: INSURER D: 1645 NEWTOWN ROAD INSURERE: COTUIT MA 02635 INSURERF: COVERAGES CERTIFICATE NUMBER: 348068 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. INSRLTTYPE OF INSURANCE INSD]NVD SUER POLICY NUMBER (MM/DD/YYYY) (MM LTR INSD /DD/YYYY) LIMITS COMMERCIAL GENERALLIABIUTY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POUCY PRO I JECT ILOC PRODUCTS-COMP/OPAGG $ OTHER: AUTOMOBILEUABIUTY COMBINED SINGLE LIMIT $ (Ea accident) _ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS _ AUTOS (Per accident) $ UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER Y 1 N E.L.EACH ACCIDENT $ 1,000,000 AOFFICER/MEMBER FICE /M MBR/EXCLUDED?ECUTIVE A (Mandatory in N/A NIA N/A R2WC921272 12/25/2018 12/25/2019 E.LDISEASE-EAEMPLOYEE $ 1,000,000 (Mandatory in NH) If yes,describe underPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF O N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is 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 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-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE MA 02601-0000 Daniel M.Cr ey,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 CAPIHOM-01 ;CROP ACORD® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) `-�-� 8/23/2019 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 have ADDITIONAL INSURED provisions or 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: RogersGray,Inc. 434 Rte 134 (A/c,No,EA):(800)553-1801 FAX p c,No):(877)816-2156 South Dennis,MA 02660 nIMt REss:mail@rogersgray.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Arbella Protection Insurance Company, Inc. 41360 INSURED INSURER B: INSURER C: Capizzi Home Improvement,Inc. 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 CONTRACT OR OTHER DOCUMENT WTH 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 ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD LIMITS /YYY1� (MM/DD/YYY1� - -- -- --A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR 8500067380 6/8/2019 6/8/2020 DAMAGE TO RENTED 500,000 PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 5,000 - - PERSONAL&ADV INJURY $ 1,000,000 GENt AGGREGATE UMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY X JE X LOC PRODUCTS-COMP/OP AGG $ 1,000,000 OTHER _ _ _ $ A AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 (Ea accident) ANY AUTO 1020064960 03 6/8/2019 6/8/2020 BODILY INJURY(Per person) $ OWNED SCHEDULED _ AUTOS ONLY X AUTOS BODILY INJURY(Per accident) $ X AUTOS ONLY X AUTOS ONLDY (Peer accident DAMAGE A X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 2,000,000 EXCESS UAB CLAIMS-MADE 4620081345 6/8/2019 6/8/2020 AGGREGATE $ 2,000,000 DED X RETENTION$ 10,000 $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Additional insured as respects general liability provided when required by written contract. WORK COMP CERTIFICATE TO BE ISSUED DIRECTLY BY THE CARRIER CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 7 ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved.