Loading...
HomeMy WebLinkAboutBLD-23-006030 (/3/;Z3 0 11 Office Use Only OI c I. _ aH Amount D®,DO Mf n Af ft,�'+ e"""'". '�� Permit expires 180 days from issue date &-D —023 (e&ddO EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department RECEIVED 1146 Route 28 — South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 MAY 0 2 2023 CONSTRUCTION ADDRESS: 26 CAPTAIN CROCKER RD S YARMOUTH BUILDING DEPARTMENT By ASSESSOR'S INFORMATION: Map:68 Parcel:50 OWNER:LORRAINE CAMBRA 26 CAPTAIN CROCKER RD SOUTH YARMOUTH MA 02664 508-394-7741 NAME PRESENT ADDRESS TEL. # CONTRACTOR: JOHN STRUMSKI CAPIZZI HOME IMPROVEMENT INC 1645 NEWTOWN ROAD COTUIT MA 02635 508-428-9518 NAME MAILING ADDRESS TEL.# B Residential CICommercial Est.Cost of Construction$14,000 Home Improvement Contractor Lic.#100740 Construction Supervisor Lic.#CS-064817 Workman's Compensation Insurance: (check one) 12/25/2023 EXPIRATION DATE 0 I am the homeowner 0 I am the sole proprietor 9 I have Worker's Compensation Insurance Insurance Company Name: AMGUARD INS, COMPANY Worker's Comp.Policy#R2WC377754 WORK TO BE PERFORMED Tent El Duration Duration (Fire Retardant Certificate attached?) Wood Stove I i Siding: #of Squares 4 Replacement windows:#3 Replacement doors: #0 Roofing: #of Squares (❑)Remove existing*(max.2 layers) Insulation El I -1 Old Kings Highway/Historic Dist. Replacing like for like Pool fencing n *The debris will be disposed ofat: TOWN OF YARMOUTH LANDFILL AND DISPOSAL AREA Location of Facility I declare under penalties of per / 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 vocatio y license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: !/ i Date: 04/26/2023 Owners Signature(or attachment) Date: Approved By: � Date: Buildin c' designee) EMAIL RESS: - 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 (t4 07 it/a d 6 �� f(�c cv o-c k I/WE, L o V re; tY , OWN THE PROPERTY LOCATED AT iN , So yv1.14(4/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. 5Xj 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: L fJ - Yx _: 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 Office of Consumer Affap.,3 Business Regulation Registration valid for individual use only before the HOME IMPR• - CONTRACTOR expiration date. If found return to: TYP Office of Consumer Affairs and Business Regulation ,,,.;, 1000 Washington Street -Suite 710 ..474 Boston,MA 02118 CAPIZZI HOME IMP ,1 'i Y JOHN STRUMSKI ' wait, 1645 SANTUIT-NEWTOWN c,e,,,,,,ra, COTUIT,MA 02635 ` _ `: A Undersecretary Not vat without si furs N N _R 0 `.. NN `C C ,�vac . v.1gr(.o8� --,-,r,(.\-'1,..,., ''.':',..'.1:..,'-‘:.- ..' - 1 , ) � o . 4 .,. . co c ....,„.:. ,,, :, teaz 5 .,.. --- ,. .„.. .. „..'' ,....,- . -,131.- ..i. . -I, .,... , - --. ---- v 1 .' .t....... , .... ,. - tlett:: ,-.- ' .-..,,..., , ... 4W ''' 0 ,..--' OM V /y r ; d _..... IBC § .7) m () 4 0 ' 14-1''.‘,....".. ...::,.','_.i' ' iiii .,.. . V ® O t/1Z it, i ' E IM CC 44 0 ‘,... Z 0 0 it) i ov.0 i g �s §TOWN OF YARMOUTH 1146 Route 28, South Yarmouth, MA 02664 508-398-22311 ext.-1261 Fax 508-398-0836 Office of the Building Commissioner BUILDING DEPARTMENT DEMOLITION DEBRIS DISPOSAL AFFIDAVIT Pursuant to M.G.L. Ch. 40, §54 and 780 CMR- Section 105.3.1. #4. I hereby certify that the debris resulting from the proposed work/demolition to be conducted at 26 CAPTAIN CROCKER ROAD SOUTH YARMOUTH MA Work Address Is to be disposed of oat the following location: TOWN OF YARMOUTH LANDFILL AND DISPOSAL AREA Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Ch. 111, §150A. o'a 12.r] 2.3 Signature of Application Date Permit No. The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 w r X<• www mass gov/dia Workers'Compensation Insurance Affidavit: rs/Ele tricians/Pknnebers. TO BE FILED WITH THE PERMITTING AUTHORITY. Apalicatat Information Jleaae Print Lemit ly Name(Binirxs/O • tionllndividual): CAPI77I HOME IMPROVEMENT INC Address: 1645 NEWTOWN ROAD COTUIT MA 02635 City/State/Zip: Phone#: 508-428-9518 Are you an employer?Check the appropriate boa: T YPe proms(required): 1.0 I am:employer with4i employees(full and/or • �a^�) 9. 0 New construction 2131 am a sole proprietor or partnership and have no employees yees working for me in 8. (3 Remodeling any capacity.(No workers'comp.insurance r 3.01 am a homeowner doing all work myself(No workers'comp.insurance required.)t 9. Demolition 4.01 am a homeowner and will be hiring contractors to conduct all.welt es 1[)Q Building addition ensure Mar all contractors either have workers'ca will proprietors with no employees. otnpemsatian issuance or are sole 11.0 Electrical ai repairs or additions 5.0 tam a general contactor and 1 have hired the ors listed on the attached sheet 12.0 Plumbing repairs or additions These sub-contractors have employees and have workers'comp.ioswaace.t 13.QRoof repairs 6.Q We are a corporative and Its offices have exercised their right of exemption per MGL c. 14.QOther 152,§1(4),and we have no employees.(No workers'comp.iawraece required.) 'Any applicant that checks box tt I must also fill out tbi section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating are doing Wreak and then hire outside contractors must submit a new affidavit indicating such. tContrsetors 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 subcontractors have employees,they totne provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy wed job site information. Insurance company Name: AMGUAr D iNSiiRANCE COMPANY Policy#or Self-ins.Lic.t1: R2VVC377754 Expiration Date: 12/25:2023 Job Site Address: 2 4 CA PI 1 C R O C k eon 12� City/State/Zip: 5 R ie s►-t otrr at 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 S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cerp[yennder the pains arid penalties a perjury that the inforwsation provided above is true and correct. Signattve: _ Date: y 1z G12>2 phoze tt: 508-648-0269 —Official use only. Do not write in this area,to be completed by city or town official r v City or Town: Permit/License b 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 k: ACED® CERTIFICATE OF LIABILITY INSURANCE DATE(MNVDD/YYYY) iliiii..'---- 12/22/2022 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: Mary Beresford BALDWIN KRYSTYN SHERMAN PARTNERS LLC PHONEto.mil_ (508)760-4604 Fa,No): E-klAE ADDRESS: mary.beresford@rogersgray.com 4211 West Boy Scout Blvd Suite 800 INSURER(S)AFFORDING COVERAGE NAIC to Tampa FL 33607 INSURER A: AMGUARD INSURANCE CO 42390 INSURED INSURER B: CAPIZZI HOME IMPROVEMENT INC INSURER C: INSURER D: — I 1645 NEWTOWN ROAD INSURER E: COTUIT MA 02635 INSURER F: COVERAGES CERTIFICATE NUMBER: 846346 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. INSRLTMI TYPE OF INSURANCE ADOL SUER POLICY POLICY EXP LTR INSD WVD POLICY NUMBER (MDD/YYTYYY) IMMIDD/Y)fYYI LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY I$ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE I$ POLICY I jE a LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ _(Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS N/A BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY $ (Per accideMk--- _-- _ UMBRELLA LIAB I OCCUR EACH OCCURRENCE $ EXCESS LIAR (CLAIMS-MADE N/A AGGREGATE I$ DED RETENTION$ $ WORKERS COMPENSATION v PER I OTH- Y!N AND EMPLOYERS'LIABILITY STATUTE i ER FANYPROPRIETORJPARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 A IOFFICER/MEMBEREXCLUDED7 NIA NIA N/A R2WC377754 12/25/2022 12/25/2023 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 i If yes,describe under -- DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 N/A ( I 1 DESCRIPTION OF OPERATIONS/LOCATIONS I 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 Town Of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 AUTHORIZED REPRESENTATIVE t, Yarmouth i MA 02664 CC Daniel M.Cr**,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD