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Home My WebLink About0377 SEA VIEW AVENUE 77 � F, 0 t •5I IL :r $4,900,000 " ++ Osterville #Rms 13 Bedrms 4 . 1 FuliBaths 5 1/2 Baths 1 Style CONTEMP `kk WatAcc BEACH Built 1996APPRORI r z 'LolSize 1.33 u S FI "3 20W Addr 377 SEA VIEW TR C1406 Subdiv �'..,' ', ., Map/Par,32 •y: MI Beath`BEACHFRT, BchOwnar PRIVATE, TotalAssmt t• 1799900 Taxes 24065 19� Heat/Cool 'CNTRL AC,NAT GAS,HOT AIR,3 ZONE" W atr%Sever/Utll 'PRV S W R,TW N W TR,GAS,ELECTRIC,TELEP� IntFeat ATCSTOR.HU•ELDRY,HU•WASHR,PANTRY,WET8 Equlli/App "REFRIGER,DISHWSHR.CNTRLVAC,COMPACTM Bsmt Y "FULL,W.FP : Lead N, LIM N .� Ga '6iRNTRYOPENERY' Dock N" Rem A newly constructed waterfront home on over an acre of privacy in an esl neighborhood with 210 feet on Nantucket I,'t�' v Sound.Superior level of craflma 2ship and attention 16 detail.,", 4 Owner'ACKLAND Shw-CALLOFC•c„' j LstOff"KINLIN GROVER GMAC REAL E'%Ph-=(508)'426-1i30, Ls PAUL GROVER Ph 508 428.410 Dir OMain St.Osterviile to W ianno Ave.to end,right onto Sear View Ave,on f i O v V a I I t. I' t.' i r. Parcel ), Permit# 5"/ ?Q S/0/ 6 Conservation Office(4th floor)(8:30-9:30/1:00-2:00) S G Date Issued Board of Health(3rd floor)(8:15 -9:30/1:00-4:45) Fee Engineering Dept. (3rd floor) House# Q� Planning Dept.(1st floor/School Admin. Bldg.) SEPTIC SyU iSW INSTALLED �,De nif P Approved b Planning Board 10�.,e c�(. , 19 ��r.E j QRT '�10 1R®NMEN CCU ! l� TOWN OF BARNSTAB �z�� P Building/Permit Application ' Project Street Address 3 Vic Village Fvs Owner Address a\ SO NNUOk Telephone — � Permit Request 12n, 1F Y\ \, 0 Y12J� C� i First Floor square feet Second Floor square feet Estimated Project Cost $ , ]�3CD. on Zoning District — Flood Plain Water Protection Lot Size S S Grandfathered ? Zoning Board of Appeals Authorization Recorded Current Use ��\�2��c1� Proposed Use&_S�&A �-A Construction Type (,J00('s _ Commercial Residential�5 Dwelling Type: Single Family Two Family Multi-Family Age of Existing Structure N/ Basement Type: Finished Historic House A. Unfinished Old King's Highway Number of Baths ` '—YLLDL-�No.of Bedrooms Total Room Count(not including baths) ` First Floor (O Heat Type and Fuel GAS Cenkral Air (/�S Fireplaces �UIS Garage: Detached Other Detached Structures: Pool TVD Attached Barn I�p None Sheds Other Builder Information Name Telephone Numb , � 89 n� Address t _ License# �- Home Improvement Contractor# Worker's Compensation# NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. f' ALL CONST U,% N DEBRIS LTING. OM THIS PROJECT WILL BE TAKEN TO A '-''SIGNATU D BUILDING ER NIED FOR THE FOLLO SON(S) FOR OFFICIAL USE ONLY PIRMIT NO. DTE ISSUED r , 1 P/PARCEL NO. LESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION J `7J� FRAME• INSULATION 0 FIREPLACE -e� 4:Sf ELECTRICAL:'• ROUGH , FINAL _ PLUMBING: ROUGH FINAL f M e GAS: ROuH-4" FINAL - FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. ' � �� I � 7 �� 1 �. �� -, , � �� -� TOWN OF BARNSTABLE CERTIFICATE OF OCCUPANCY PARCEL-ID 138 .032 GEOBASE ID 7315 ADD) ESS ' 377 SEA VIEW AVENUE AVENUE PHONE (508)42.8-8908 y OSTERVILLE, MA ZIP 02655- LOT BLOCK LOT SIZE DBA"' DEVELOPMENT DISTRICT CO i PERMIT 19871 DESCRIPTION SINGLE FAMILY DWELLING (PMT.#15180) ' PERMIT TYPE BC00 TITLE CERTIFICATE OF OCCUPANCY , CONTRACTORS: Department of Health, Safety ; ARCHITECTS: and Environmental Services TOTAL FEES: BOND $.00 Ox CONSTRUCTION COSTS $.00 756 CERTIFICATE OF OCCUPANCY * HAItNSTABLE, . MASS. OWNER SEA VIEW AVENUE TRUST, ERIN ACKLAND, TRUSTEE 1639. ADDRESS ED MA'S 121 SOUTH BAY ROAD BUILDxN D r�' OSTERVILLE, M� BY DATE ISSUED 12/10/1996 EXPIRATION DATE 'Lila Department of Health, Safet3 and Environmental Services MAS& BUILDING DIVISION BY -.. THIS PERMIT CONVEYS NO RIGHT TO OCCUPY ANY STREET,ALLEY OR SIDEWALK OR ANY PART THEREOF, EITHER TEMPORARILY OR PERMANENTLY.EN- CROACHMENTS ON PUBLIC PROPERTY,NOT SPECIFICALLY PERMITTED UNDER THE BUILDING CODE,MUST BE APPROVED BY THE JURISDICTION.STREET OR ALLEY GRADES AS WELL AS DEPTH AND LOCATION OF PUBLIC SEWERS MAY BE OBTAINED FROM THE DEPARTMENT OF PUBLIC WORKS.THE ISSUANCE OF THIS PERMIT DOES NOT RELEASE THE APPLICANT FROM THE CONDITIONS OF ANY APPLICABLE SUBDIVISION RESTRICTIONS. MINIMUM OF FOUR CALL INSPECTIONS REQUIRED FOR ALL CONSTRUCTION WORK: APPROVED PLANS MUST BE RETAINED ON JOB AND WHERE APPLICABLE, SEPARATE 1.FOUNDATIONS OR FOOTINGS THIS CARD KEPT POSTED UNTIL FINAL INSPECTION PERMITS ARE REQUIRED FOR 2. PRIOR TO COVERING STRUCTURAL MEMBERS HAS BEEN MADE.WHERE A CERTIFICATE OF OCCU- ELECTRICAL,PLUMBING AND MECH- (READY TO LATH). PANCY IS REQUIRED,SUCH BUILDING SHALL NOT BE ANICAL INSTALLATIONS. 3.INSULATION. OCCUPIED UNTIL FINAL INSPECTION HAS BEEN MADE. 4.FINAL INSPECTION BEFORE OCCUPANCY. . POSTTHIS CARD SO IT IS VISIBLE FROM STREET BUILDING INSPECTION APPROVALS PLUMBING INSPECTION APPROVALS ELECTRICAL INSPECTION APPROVALS 1 � Q,�-(f,-/0 -f'� �� 1.,+c I��PI�, 1 .�G- 2�Y��o ✓ 3..sa�.�.� 1 g HEATING INSPECTION APPROVALS G RING PARTME 2 (' BOARD OKHEALTH OTHER: SITE PLAN REVIEW APPROVAL WORK SHALL NOT PROCEED UNTIL PERMIT WILL BECOME NULLA p VOID IF CON- INSPECTIONS INDICATED ON THIS E THE INSPECTOR HAS APPROVED THE STRUCTION WORK IS NOT STARTED WITHIN SIX CARD CAN BE ARRANGED FOR BY VARIOUS STAGES OF CONSTRUC- MONTHS OF DATE THE PERMIT IS ISSUED AS TELEPHONE OR WRITTEN NOTIFICA- TION. NOTED ABOVE. TION. ''yy 1 j i Map Parcel Permit# I Yo2 7;- ' DEmo / Conservation Office(4th floor)(8:30- 9:30/1:00-2:00)�W��1�R�cgb or.)4.�( Date Issued �,2/ — 9 S, Board'of Health(3rd floor)(8:15 -9:30/1:00-4:45) Feeo�s. Engineering Dept. (3rd floor) House# ��`��' BIKE DIV *-7 U TO BARNSTABLE&.V Building Permit Ap lictionoje dress Vico�o Vill i Owner Address 1 lA Telephone Permit Request Z)�yy\c � � C. First Floor L.XcqQLWuare feet Second Floor square feet Estimated Project Cost $ �,(J d l/�l Zoning District Flood Plain Water Protection Lot Size `s�� e,L, F Grandfathered ? Zoning Board of Anneals Authorization Recorded Current Use �� 2�U� LC�� Proposed Use Sl j�o Construction Type Commercial `s Residential Dwelling Type: Single Family e Two Family Multi-Family Age of Existing Structure Basement Type: Finished Historic House A- Unfinished Old King's Highway N/ Number of Baths No. of Bedrooms 4- Total Room Count(not including baths) First Floor + Heat Type and Fuel C:>C.,S Central Air Fireplaces I e S Garage: Detached Other Detached Structures: Pool Attached e�S Barn None Sheds Other Builder Information pp Q Name �� Telephone Number Address License# Home Improvement Contractor# Worker's Compensation# NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ` ALL CONSTRU_ 10 D1�BRIS RE LILTING OM��S��JECT WILL BE TAKEN TO SIGNATURE ATE BUILDIN PE IED FOR THE ING REASONS) FOR OFFICIAL USE ONLY P MIT NO. D TE ISSUED M P/PARCEL NO. l ADDRESS VILLAGE OWNER ; DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE' ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. o _ o White's path COLONIAL, South Yarmouth,MA02664 508-394-9851 G A S C 0 M P A N Y Fax:508-394-2564 May 20, 1996 RE: : 377 Seaview Avenue - Osterville ACCT: 64-03-5270-1 TO WHOM IT MAY CONCERN.: This letter is to confirm that the gas service at-.the above address has been cut off at the street. Sincerely, COLONIAL GAS. COMPANY Cape Cod Division Jayne Starck Distribution Department r z Centerville-Osterville-Marstons Mills Water Department P.O. BOX 369 - 1138 MAIN STREET OSTERVILLE, MASSACHUSETTS 02655 °sy 2 � � OFFICE OF u WATER BOARD OF WATER COMMISSIONERS �, DEPT. v WATER SUPERINTENDENT 9ASTONs TEL.No. 508-428-6691 FAX No. 508-428-3508 May 21, 1996 Town of Barnstable Building Inspector RE: 377 Sea View Ave., Osterville To whom it may concern: Please be advised that the water service at the above mentioned address, 377 Sea View Ave., in Osterville, has been disconnected on this day. The meter #3712 has been pulled from the premises and there is no service available to this property. If you have any further questions please do not hesitate to call our office. Very truly yours, y G�� Gary Oakley, Foreman for Donald F. Rugg, Superintendent sjn I � Commonwealth Electric Company COMflectric Cranberry Highway Wareham, Massachusetts 02571 Telephone (508)291-0950 484 Willow St Hyannis, Ma 02601 May 20, 1996 Town of Barnstable Building Inspectors Office Main St. Hyannis, Ma 02601 To whom it may concern: This letter is to inform you that the electric service and meter at 377 Seaview Ave in Wianno was removed 5/20/96. This was done at the request of Dr. Michael Ackland, the new owner of this property, for the purpose of demolition. Should you have any questions please feel free_ to contact me at 790-1721 X5781. Very truly yours, -9��J' Judith A. Webb Customer Service Rep Hyannis .................. ...................... .............................. ......................................... ............................. ........ .............. .......................................... ..... ............................................ ....................................... .... ..................... ...... ...................... ..........: .............. .................. ........ .......... SSUE DATE(MMMD/YY) ............ ......... Q............ . .......... T : !AXE .. ..... .... ..... ....... .... . .......................... ............................%............................................. ....... . ...................................................... .................................... . .......... ........ .. ............ . .......................... ............ .................. ..................... ................................... .......-...................................... ................................ ............... ............. ....... ............. 10/96 05 . PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE The Fair Insurance Agency, Inc DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE P.O. Box 430 619 Main Street POLICIES BELOW. Centerville, Ma 02632 COMPANIES AFFORDING COVERAGE (5 0 8) 775-3131 COMPANY A LETTER LUMBERMENS MUTUAL COMPANY B INSURED LETTER ohn Aalto Backhoe, Service COMPANY c 150 Walnut Street LETTER COMPANY D Marstons Mills MA 02648 LETTER :(508) 428-9595 COMPANY E LETTER ......................... . ............................................................................................................... ........................ ........................... . .........................................................................................:::***,::::"*",:::::: i-"%.--,-,.-,--.-,i:................ ........... ......... ......... ..... ..................... .....................::: ::: :: .......... ... ..... ......... ............................................ .......... ......... .......................................................................... ........................................ ...... ..... ........ ..... .... ................. .......................... . .... ......... . .... .......... ................................... . ........................................... .............. . .. . . ........: . .................... 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 DOCLINIENT W:TH RESPECT TO WH!CH TH!S 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. CO TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR DATE(MMMD/YY) DATE(MM/DD/YY) GENERAL LIABILITY GENERAL AGGREGATE S N COMMERCIAL GENERAL LIABILITY PRODUCTS-COMP/OP AGG. $ CLAIMS MADE OCCUR.F PERSONAL&ADV.INJURY S D OWNER'S&CONTRACTORS PROT. EACH OCCURRENCE $ FIRE DAMAGE(Any one fire) S MED.EXPENSE(Anyoneperson) S AUTOMOBILE LIABILITY COMBINED SINGLE S ANY AUTO LIMIT ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Per accideno S. GARAGE LIABILITY PROPERTY DAMAGE $ EXCESS LIABILITY EACH OCCURRENCE S UMBRELLA FORM AGGREGATE $ OTHER THAN UMBRELLA FORM WORKER'S COMPENSATION X STATUTORY LIMITS 33-13YO036220n AND V �06/09/15 �06/09/96 EACH ACC;DENT IS100000 EMPLOYERS'LIABILITY DISEASE-POUCY LIMIT IS500000 DISEASE-EACH EMPLOYEE IS100000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/SPECIAL ITEMS ........................ ......... .... .... .................. ................. ............ ............ ........................ ........ ........ ............ .. ...... ......................... . " .......................... ......... ......... ................ 01..... ........ ... .................. ... . ...... ........... .................. ...... x ..... ...................... ............... ....... .................. ............... .0 ............. ...... ........ ... ... ... ............ .... ... ... . ............. . X ... ...... ................ . ........ ......... ...... .............. ........ .......................... ......... ..... ............................................................ r. Adkland SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO 121 S . Bay Road MAIL 15 DAY6 WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR sterville MA 02655 LIABILITY OF ANY KIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ........ ..................... ............................ ............. ........................ ................................. r • TOWN OF BARNSTABLE BUILDING DEPARTMENT HOMEOWNER LICENSE EXEMPTION Please print. DATE JOB. LOCATION 7 ycJ " o � o � Number ess Section of town "HOMEOWNER" S,= OC' - (P�0 Name Home phone Work phone - PRESENT MAILING ADDRESS City town State Zip code The current exemption for "homeowners" was extended to include owner-occupied dwellings of six units or less and to allow such homeowners to engage an in-dividual for hire who does not possess a license, provided that the owner acts as supervisor DEFINITION OF HOMEOWNER: Persons) who owns a parcel of land on which he/she resides or intends to re- side, on which there is, or is intended to be, a one to six family dwelling, attached or detached structures accessory to such use and/or farm structures.A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner"- shall submit to the Building Official on a form acceptable to the Building Official, that he/she shall be responsible for all such work performed under the buildinq permit. (Section 109. 1. 1) The undersigned "homeowner" assumes .responsibility for compliance with the Stat Building Code and other applicable codes, by-laws, rules and regulations. The undersigned "homeowner" certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. HOMEOWNER'S SIGNATURE J . APPROVAL OF BUILDING OFFICIAL Note: 'Three family dwellings 35, 000 cubic feet, or larger, will be required to comply with State Building Code Section 127. 0, Construction Control. HOME OWNER'S EXEMPTION The code state that: "Any Home Owner performing work for which a building permit is required shall be exempt from the provisions of this section (Section 109. 1. 1 - Licensing of Construction Supervisors) ; provided that ifHome Owner engages a person O s) for hire to do such work, that such Home wner shall act as supervisor. " 1 + Many Home Owners who use this exemption are unaware that they are assuming the responsibilities of a supervisor (see Appendix Q, Rules and Regulations for . licensing .Construction Supervisors,Section 2. 15) . This lack of awarenes often results in serious problems, particularly when the Home Owner hires unlicensed persons. In this case our Board cannot proceed against the inlicensed person as it would with licensed Supervisor. The Home ""wrier actin as supervisor is ultimately responsible. To ensure that the Home Owner is fully aware of his/her responsibilities, man communities require, as part of the permit application, that the Home Owner certify that he/she understands the responsibilities of a supervisor. On the last page of this issue is a form currently used by several towns. 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G_iYPI..If.uILllmw . \ � L 6 p curbY LAa..#ryYr.d.p.Ny l0• Pr.vW•b r.Nfw.n,b.».N I s.s. ��e�'�i U D D�p h.•I.mf.er and lDr.s 9rlla.lb.pl.0 Ai t y .r.• L.r n.1 ti nLdV.(f.w4flm w.lh i te d ty C♦1/s•fr.e rNf.aw ro.M,a.m.,m..I t•o•ue, i p° DMfNrvE T'PL 1 e .e•P.e..d.mcr.f.f..nn, pvld'mq maa#ion ,'-W.,'-N.I'P.vr./wn✓.f.f..1Ly w/s/rb r.br.p.aN w.nb.ne G.blm f.M.»-1[•..'O`.�oi. •b fvmd9p 4wi e s,•..s w/6..•6 L.r.EW. ryNe,un b.r l.pd4f.ns.•90•(NP, DO.r.w4flm 70.bl.b Elr.D'V .�•[R A NIA,'.9lCI,IA,'.91CL O _/� - �[ /J� [a0.rr.IF ` The Conununll'calth of Massathusetn Lt:l: tllaoi; Department of Industrial Accidents �: . '%•:�' 6111111 irslungtun Street - -�' Burton.Mam. 02111 �•' Workers' Compensation Insurance.ARtlavit YQ ieSV T'1 i Q. Iry�1 - 1 am a homeowner performing all work myself. 1 am a sole proprietor and have no one working in any capacity am an employer providing workers' compensation formy employees working on this 'ob. kv umv, _-T r kks 2 � • cih•: (nskcr /c N-, I Ml n a_1U S•lam nhnne#* y — LO� c t ' 1 am a sole proprietor,general contractor,of ;�meowne► ,;irde one)and have hived the contractors listed below who have ' 'the following workers' compensation polices: cmmMInt•name! - - address: may nhone rt: ineuronw.. Miley d L^+•;:. '•"°:,•T.:�.- — ' _. rssre-rs.•saws-n'rr+i'^�•�R"'•F�rSC.�y�=• -- 'TJVEF�J�RI��RZ:�•T��A'.".�!'�..1_fd�4'3?S!�.�.'•'r�•�� ctimnanv name• - address: - city nhone#: insur•t ice co, "alley 0 Attach additional"sheet if t;ee 7 z-, . •.t��-�-:'±''- '• ''R =�`►`'' :' •" �i':+ Failure to secure coverace as required under Section SA of 51GL 152 can lead to the imposition of criminai penalties of a fine op to$1.500.00 and/or One years'imprisonment as well as cn it penalties in the forte of a STOP NVORK ORDER and a fine of SI00.00 a day against me. 1 understaad that a COPY of this statement may be forwarded to the alike of Investigations of the D1A for corerage veriBeation. ' !do hereby cmify uraler die pains and penalties of perjure that the information presided above is true and sonnet: Signature 4-LL-L� 1-P_L4,S Tom; Date 15 WI CL\,! 19 qi (o Print nun. �K I r /T C�,k L-A a Phone# S� — �� `g 7 Gg otncial use only do not write is this area to be completed by city or town of icial city or town: permit/license# "Building Department 01.1cenaing Board'- check if immediate response is required OSeleetmea's office Clliesith Department contact person: phone#; "Other Information and instructions .� 1. Massachusetts General Laws chapter I52 section 25 requires all employers to provide workers' compensation for their employees: As quoted from the "law",an emplgree is defined as every person in the service of another under any contract of hire, express or implied, oral or written. An cmplover is defined as an individual, partnership.association, corporation or other :,-gal entity, or any two or more the forc�:oin engaged in a joint enterprise,and including the legal representatives of a deceased employer, or the receiver or trustee of an individual , partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling!rouse of another who employs persons to do maintenance,construction or repair work on such dwelling hou or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter 1'52 section 25 also states that every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant.who has not produced acceptable evidence of compliance with the insurance coverage required. Additionally. neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter In been presented to the contracting authority. tF-77'77- 1�1�.5t:t� 'f /. • :i11i .1:1 ''y'.i- - .w.. -• iI1•�' •YEA L.•Y"•-•'y !• Applicants 1 �, Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and supplying-company names, address and phone numbers as all affidavits may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the"law"or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. .,,�R.sw-,..o•.•ew! i.::l,:- .rim.. .r.1Y.•Y.'•:.. y; .„,•-..✓ _,"...Aff S r: �!9:-• -".,s. •i . ... . - .�;. _. ,. r��y',-. ..1'�. ..� .:-:n.�:�::w,..:':�_ (N.i'f.� T•r.t.0i !!.:f�.F'!�f`"' �+.. '��!iR!'.rti '�+•"• City or Towns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Plea, be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned tc the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any questionF please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents Office of investigations 600 Washington Street — Boston,Ma. 02111 fax#: (617) 727-7749 phone #: (617) 7274900 ext. 406, 409 or 375 i 1ut T Dowling O'Neil Insurancea Agency, Inc. 222 West Main Street P.O.Box 1990 Hyannis,Massachusetts 02601-1990 Tel.(508)77575-1620 Fax(508)778-1218 i May 15, 1996 377 Seaview Avenue Trust, Erin Ackland Trustee 121 South Bay Road Osterville, MA 02655 Dear Ms Ackland: This letter will acknowledge that we have received and sent your completed workers compensation application and payment to the Massachusetts Workers Compensation Assigned Risk Pool. We expect coverage to be effective 24 hours after the Pool receives your application foregoing any problems with the application. Sincerely, Dowling & 0 ' Neil surance Sharon K. Hawkins, CIC Vice President SKH/262888 MASSACHUSETTS WORKERS' COMPENSATION ASSIGNED RISK POOL APPLICATION FOR WORKERS'COMPENSATION INSURANCE _�i_MIL TO' The Workers'Compensation Rating&Inspection Bureau of Massachusetts P.O.Box 9006 Boston, MA 02206 (617) 439-9030 IMPORTANT This application must be typed or printed and filed in duplicate with the Bureau. An original bbfold form must be used. A separate application must be filed for each legal entity. Enclose check made payable to: The Massachusetts Workers'Compensation Assigned Risk Pool (MWCARP). Coverage will be tentatively bound provided that,upon review,Bureau Staff finds that the application was satisfactorily completed. The earliest date coverage can be bound is at 12:01 A.M.the day after the application and deposit premium are received in the office of the Bureau. Under no circumstance will coverage be bound if:payment or deposit premium does not accompany the application;the declination requirements are not met;there is a record of coverage in force for the entity making application;or,the applicant Is in default of premium for prior workers'compensation coverage. The undersigned employer is unable to purchase workers'compensation and employers'liability insurance in the voluntary market and hereby applies for such insurance in the Massachusetts Assigned Risk Pool and expressly represents that such insurance is sought in good faith. Requested I. GENERAL INFORMATION Effective Date: 1. 37�1 a V} �U, ��r e n Q ru. E: ;n NAME OF EMPLOYER (Name of sole proprietor,gene I partners)or rustee(s)must be given with theltrade name of the business.) 2. 1.4 C L S fl — _n O ern I CwuLs ❑ PENDING FEDERAL EMPLOYERS (IDENTIFICATION NUMBER f pending,attach a copy of the IRS application.) 3. MAILING ADDRESS r Street I City State Zip Phone 4. MASSACHUSETTS LOCATION Number Street City State Zip Phone 5. I OTHER MASS.LOCATIONS Number Street City State Zip Phone (Attach separate sheet if necessary.) 6. � rY _ LOCATION OF RECORDS Number Street City State Zip Phone 7. LEGAL STATUS ❑ Sole Proprietor ❑ Partnership Trust ❑ Limited Partnership , ❑ Corporation ❑ Other(explain) 11. CORPORATE INFORMATION List the Name,Duties,Percentage of Ownership and Annual Salary of each officer listed in the Corporate Articles of Organization. NAME DUTIES %OWNERSHIP SALARY President Treasurer Clerk NOTE: Corporate officers cannot elect to be excluded from coverage in Massachusetts. See the Massachusetts Rate Pages for corporate officer maximum/ minimum payroll limitations. Sole proprietors and partners cannot elect to be covered in Massachusetts. III. INSURANCE COMPANIES WHO REFUSED TO WRITE VOLUNTARY COVERAGE According to Massachusetts General Law,Chapter 152,Section 65A,an employer may obtain workers'compensation coverage through the Massachusetts Workers'Compensation Assigned Risk Pool if they have been rejected by two companies licensed to write workers' compensation insurance in the Commonwealth of Massachusetts. 1. Attach two letters of declination from insurance companies who have declined to write voluntary coverage. The letters must be submitted on original letterhead; they must not be dated more than sbcty(60)days prior to submission; they must have original signatures; and,they must be signed by carrier personnel authorized to bind coverage. NOTE: If you are currently insured in the voluntary market,one of the declinations must be from your present carrier. A copy of the cancellation or nonrenewal must be attached to the application. 2. Have you received any offers of voluntary coverage? (Include multi-line or retrospective rating terms.) ❑ YES X NO I IV. INSURANCE RECORD YES NO Has the applicant previously had Massachusetts workers'compensation insurance? 2. If YES,complete the following for the most recent three years: INSURANCE COMPANY POLICY NUMBER POLICY PERIOD PREMIUM 3. If NO,complete: New Business ❑Self Insured ❑Other(explain): 4. Former Self Insurers are subject to the Premium Determination Endorsement-Former Self Insurers-1.An audit must be completed before coverage can be bound. Refer to the Procedures Manual for details. If self insured within the last twelve months,provide the termination date: 5. Is there any unpaid workers'compensation premium due from you or any other commonly owned or managed enterprise? If YES,provide the entity name,balance and policy number(s)below. If the premium is being disputed,attach an explanation for Bureau consideration. If an arrangement for payment has been made,attach a copy of the signed agreement. 6. Is the employer in bankruptcy? If YES,attach a copy of the approved bankruptcy filing. 7. Does this entity or any commonly managed or owned entity have operations in states other than Mass.? If YES,attach a list of employer names,states,carriers and interstate or Intrastate ID numbers. 8. Has there been a name change within the last five years? ` 9. Has there been a merger or consolidation within the last five years? X 10. Has there been a sale,transfer or conveyance of ownership interest within the last five years? 11. Did the applicant purchase or otherwise acquire the physical assets of another entity whose operations they took over within the last five years? 12. Have the owners or officers ever had ownership interest in any other entity,either currently or previously existing? COMPLETE AN ERM FORM AND ATTACH TO THIS APPLICATION IF THE ANSWER TO 7,8,9, 10, 11 OR 12 IS YES. V. BUSINESS OF EMPLOYER 1. Does the applicant supply employees to other businesses? If YES,complete and attach the supplemental YES NO application,Side A,and refer to the Procedures Manual for instructions. 2. Does the applicant regularly have employees supplied to them from other businesses? If YES,complete and attach the supplemental application,Side B, and refer to the Procedures Manual for instructions. 3. Mass.law provides that you,the employer,are liable for injury of employees of uninsured subcontractors. Premium will be charged in the absence of a certificate of insurance from subcontractors. Is it anticipated that subcontract labor will be utilized during the policy tern? If YES,estimate payrolls made to subcontractors without certificates of Insurance. $ Transfer this amount to Section VI and identify by classification of work performed. 4. Do you use independent contractors? If YES,you must maintain documentation which supports that they are,in fact,independent contractors. If such documentation is not available,or if the designated carrier finds evidence of an employment relationship, X then premium may be charged as if the individuals were employees. l V. BUSIN,ES4 OF EMPLOYER (continued) 5. Completely describe all operations of the employer by location. Also,completely describe any changes that have taken place concerning the business of the employer or the nature of the operations Attach a separate sheet if necessary. AW, — RAS i illc , l VI. MASSACHUSETTS CLASSIFICATIONS, PAYROLLS, AND PREMIUM CALCULATIONS Payrolls of corporate officers must be included. Attach the four most recently filed Form 941's or DET Form Vs. Payrolls and classifications on the application will be corn red to odor audits and II records submitted. Describe the Duties of the Employees by Location Class Number of Total Rate Premium Code Employees Remuneration Car * r� ►� uC_ y�3 �� Ger�t.l 1� �� z) �c$ CLy l Clerical NOC 8810 3 /I L l l Outside Sales 8742 Drivers,NOC 7380 4 Employers'Liability I TOTAL PREMIUM 1 " Experience Rating( )or Merit Rating( ) " Massachusetts Construction Credit( ) R Loss Constant STANDARD"PREMIUM Deductible Credit( ) VII. DEPOSIT REQUIRED : * ARAP( ) 1. . Installment Options ""* Insurance Charge( 10% ) Estimated Installment Minimum Additional Expense Constant Premium Basis Deposit Payments l� Under Annually 100% none TOTAL ESTIMATED ANNUAL PREMIUM $5,000 t-n , tiwrx 11??14-K),LVI \- At least Semi- 75% one DIA Assessment(3 .� %)of Standard Premium $5,000 Annually _ At least Quarterly 50% three TOTAL EST.ANNUAL PREMIUM AND DIA ASSESSMENT �/3 $10,000 At least Monthly 25% nine DEPOSIT PREMIUM i $25,000 2. Enclosed is check number in the amount of$ made payable to the Massachusetts Workers'Compensation Assigned Risk Pool(MWCARP). A single check must- a submitted. Any binding of coverage is based on the assumption that the check is negotiable. If the check is non-negotiable,the assignment will be rescinded. 3. Is the premium being financed? ❑ YES >q NO If YES,then 100%of the Total Estimated Annual Premium and Massachusetts DIA Assessment must be sent with the application along with a signed copy of the finance agreement. " If applicable. Refer to the Mass. es of the Basic Manual for Workers'Compensation and Em pages pe p"rs'Liability Insurance for details. w•w Applies only to Former Self Insurers. Refer to the Procedures Manual for details. N1111. APPLICANT'S STATEMENT ' The undersigned hereby certifies that he/she has read and understands the statement in this application. Furthermore,in consideration of the issuance of the policy of insurance,he/she also certifies that the statements made in this application are true and agrees: 1. To maintain a complete record of all policy transactions In such form as the insurance company may reasonably require and that all such records will be available to the company at the designated address. 2. To comply substantially with all laws,orders,rules and regulations in force and effect made by the public authorities relating to the welfare,health and safety of employees. 3. To comply with all reasonable recommendations made by the insurance company relating to the welfare, health and safety of employees. This insurance is being provided through the MASSACHUSETTS WORKERS'COMPENSATION ASSIGNED RISK POOL,and not through the voluntary market. NOTICE: MASSACHUSETTS GENERAL LAW,CHAPTER 162,SECTION 14(3)PROVIDES: "Notwithstanding any provision of section one hundred and eleven A of chapter two hundred and sixty-six to the contrary,any person who knowingly makes any false or misleading statement, representation or submission or knowingly assists, abets, solicits or conspires in the making of any false or misleading statement,representation or submission,or knowingly conceals or fails to disclose knowledge of the occurrence of any event affecting the payment,coverage or other benefit for the purpose of obtaining or denying any payment, coverage or other benefit under this chapter; and any person or employer who knowingly misclassifies employees or engages in deceptive employee leasing practices for the purpose of avoiding full payment of insurance premiums...shall be punished by imprisonment in the state prison for not more than five years or by imprisonment In jail for not less than six months nor more than two and one-half years or by a fine of not less than one thousand nor more than ten thousand dollars, or by both such fine and Imprisonment." _ Q 3 77 S�cw;e,J�ve C tYuS�` l�- 1 �,� 1.Lz- cCP—� (Business Name of Employer) Date SIgnature and Title(Sole Proprietor,General Partner,Corporate Officer or Trustee) IX. AGENCY INFORMATION AND PRODUCER STATEMENT The producer hereby certifies that the information provided,including premium information,is true to the best of histher knowledge and belief. AGENCY �� `'L1�V C1`� V IV C 1 L .LtS S��'�t�t CE AG�i Nc-T 0!I D � 19�- Naame(Printed)) Agency Federal Identification Number ,^� ADDRESS 1 uVX 113G i3 P YPiv�4S H A , 60) 5b --rs-I�O�V Street 1 City 4e p Code ^� Telephone PRODUCER F��'` f`' �Alti'�..LhSJ ,v� !u � Ci ! %+ Name(Printed) Signature ate Agency License Number MASSACHUSETTS WORKERS'COMPENSATION ASSIGNED RISK POOL RULES AND PROCEDURES PLEASE READ CAREFULLY 1. Applications will not be accepted by FAX machine. 2. An additional or replacement entity cannot be endorsed onto an existing assigned risk policy as a named insured unless an application and check are submitted and coverage is assigned by the Bureau. Refer to the Procedures Manual for instructions. 3. The Pool is able to provide coverage only for Massachusetts employees. If an employer has operations in any state other than Massachusetts,or commences operations in such state after policy inception,application for coverage for those operations must be made to the appropriate Bureau or other agency administering the Residual Market in that state,if voluntary coverage is not available. 4. If voluntary coverage has been cancelled or nonrenewed at the insured's request,the insured Is not eligible for assigned risk coverage. The insured-or their agent must replace coverage in the voluntary market. 5. When a Pool policy has been cancelled twice for non-payment of premium or at the request of the finance company,the employer must reapply to the Pool for subsequent coverage after all outstanding balances have been paid. 6. Applications for joint ventures must include a copy of the joint venture agreement. 7. Payrolls and classifications are subject to review by Bureau Staff and may be changed. 8. The Waiver of Our Rights to Recover from Others Endorsement,WC000313,is available to employers who require the endorsement by contract. Refer to the Procedures Manual for details. 9. Agents are not agents of the Mass.Workers'Compensation Assigned Risk Pool and cannot issue Certificates of Insurance. 10. If you have any questions about the rules governing the Massachusetts Workers'Compensation Assigned Risk Pool,refer to the Procedures Manual. If additional information is required,contact the Workers'Compensation Rating&Inspection Bureau of Mass. at(617)439-9030 or write to either P.O.Box 9005,Boston,MA 02205 or 101 Arch Street,Boston,MA 02110. EDmoN 11-95 .. , TOWN OF BARNSTABLE BUILDING DEPARTMENT • HOMEOWNER LICENSE EXEMPTION Please prin DATE {o JOB LOCATION Number Street address Section of town "HOMEOWNER" Name Home phone Work phone - - PRESENT MAILING ADDRESS e-r V Kk City town State Zip code The current exemption for "homeowners" was extended to include owner-occupiE dwellings of six units or less and to allow such homeowners to engage an in- dividual for hire who does not possess a license, provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER: Person (sj who owns a parcel of land on which he/she resides or intends to re side, on which there is , or is intended to be, a one to six family dwelling, attached or detached structures accessory to such use and/or farm structures A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner" shall submit to the Building Offic on •a form acce-ptable to the Building Official, that he/she shall be responsi for all such work performed under the building permit. (Section 109. 1. 1) The undersigned "homeowner" assumes . responsibility for compliance with the S-, Building Code and other applicable codes, by-laws, rules and regulations. The undersigned "homeowner" certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirement; and that he/she will com with said roc ur and requirements. HOMEOWNER'S SIGNATURE ' APPROVAL OF BUILDING OFFI AL Note: Three family dwellings 35 , 000 cubic feet, or larger, will be required : to comply with State Building Code Section 127. 0, Construction Control. C• c� HOME OWNER'S EXEMPTION The code state that: "Any Home Owner performing work for which a ,building permit is required shall be exempt from the provisions of this section (Section 109. 1 . 1 - Licensing of Construction Supervisors) ; provided that if Home Owner engages a person (s) for hire to do such work, that such Home Owne shall act as supervisor. " Many Home Owners who use - this exemption are unaware that they are assuming the responsibilities of a supervisor (see Appendix Q, Rules and Regulations for . licensing Construction Supervisors, Section 2. 15) . This lack of awarene often results in serious problems, particularly when -the Home Owner hires unlicensed persons. In this case our Board cannot proceed against the inlicensed person as it would with licensed Supervisor. The Home ''Owner acti as supervisor is ultimately responsible. ;. To ensure that the Home Owner is fully aware of his/her responsibilities, ma communities require, as part of the permit application, that the Home Owner ' certify that he/she understands the responsibilities of a supervisor. On th. last page of this issue is a form currently used by several towns. You may care to amend and adopt such a form/certification for use in your community. j v Engineering Dept.(3rd floor) Map 0 Parcel ®cam Permit# OV 4b House# - 2-7 - - Date Iss v-Board of Health(3rd flo or)-(8:15 -9:30/1:00-4:30) — dP5 6 Fee xonservation Office.(4th floor)(8:30-9:30/1:00-2 00) ,s= Ir- Planning Dept.(1st floor/School Admin. Bldg.) IMF rq Definitive Plan Approved by Planning Board 19 ; B 1 RARNSTARLE. TOWN OF!BARNSTABLEF° 'y'�� Building Permit Application Project Street Addres I - (� Village 5 Owner of a Address Telephone Permit'Request 2-C: 6q/6_4�) I First Floor square feet Second Floor square feet Construction Type Estimated Project Cost $ Od Zoning District Flood Plain Water Protection Lot Size Grandfathered ❑Yes ❑No Dwelling Type: Single Family Two Family ❑ Multi-Family(#units) Age of Existing Structure �owV44�'Historic House ❑Yes *0 On Old King's Highway ❑Yes ❑No Basement Type: ❑Full ❑Crawl alkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: Existing New Half: Existing New No. of Bedrooms: Existing New Total Room Count(not including baths): Existing New First Floor Room Count Heat Type and Fuel: Gas ❑Oil ❑Electric ❑Other Central Air ❑Yes ❑No Fireplaces: Existing New Existing wood/coal stove ❑Yes ❑No Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size) ❑Attached(size) ❑Barn(size) ❑None ❑Shed(size) ❑Other(size) e Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes, site plan review# - Current Use Proposed Use Builder Information Name Telephone Number — N>� n Address ' License# (^ C,.,, r�Co 'I-_�7 P Home Improvement Contractor# Worker's Compensation# - NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTVO D RIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE BUILDING PE IT NIED FOR THE FOLLOWING REASON(S) FOR OFFICIAL USE ONLY PERMIT NO. DATE ISSUED i MAP/PARCEL NO. ADDRESS VILLAGE' OWNER DATE OF INSPECTION: e ' FOUNDATION FRAME I INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL' PLUMBING: ROUGH ; FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ' ASSOCIATION PLAN NO. �7 °F WE ray,. . .11/ The Town of Barnstable ; a�uvsrna�, • Department of Health Safety and Environmental Services A'Eo ' Building Division 367 Main Street,Hyannis MA 02601 Office: 508-790-6227 Ralph Crossen Fax: 508-790-6230 Building Commissioner 0 For office use only Permit no. , Date L AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the "reconstruction, alterations, renovation, repair, modernization, conversion, improvement, removal, demolition, or construction of an addition to any pre-existing owner occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors, with certain exceptions,along with other requirements. Type of Work: �::)2C.,4``k, Est.Cost Address of Work: — 1, Owner's Name 10f" - " CA W C Date of Permit Application: Or) I hereby certify that: Registration is not required for the following reason(s): Work excluded by law Job under$1,000. Building not owner-occupied Owner pulling own permit Notice is hereby given that! OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A SIGNED.UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner:, 2-1 . r, 1�O 2 � Date Contractor Nam Registration No. OR Date Owner's Name The Cummunllrcalth of Atfrssachuscttt w j `• Department of Industrial Acciticnfs office-9/lnyest/gatlons 600 !i'a,'l,ia�rnn Starer 4�• �:`��.; ,�: Bmvwn. Mau. (12111 Workers' Compensation Insurance Affidavit c Phone 171 1 am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity T• —+•pri �..�.-,«......nr...cr.-+mow-,7r++-�'�- _ �..s.....—..►.`...,.,,,_�=_. I m an mplover providing workers compensation for my employees working on this job. cnmtinev n• rne- tdtlrccc- city phone#• incurince cn nolicv# lhe m•a sole proprietor. general contractor. or homeo�yner(circle one) and have hired the contractors listed below who n following w compensation polices: folio n_ workers* comp CmmnIny n-nine: atirlrccc• city. nhnnc#- incurincc rn nnlicy N .�... � •t ri.- Y�".^.. .�.�_ .�..�.• _ r -- ----r�.��,L.T•r1.rw�. r• •Tt;'L - ��1-•S r—� cmmP.lny n•tmc- addresc- rity• nhnnc#• it�.cunnc ce - Police•# Attach additional sheet if necessary �_..; __,:-:..y.:L:.:i' :•• ... ..-,.: .:_ .A- Failure to secure*covernac as required under 5eetion 3A of A1GL I53 can lead to the imposition of criminal penalties of a tine up to 51.500.00 andiu. vnc ry can'imprisonment as well as civil •es in the form of a STOP WORK ORDER and a fine of 5100.00 a day against me. 1 understand that.: cop)•of this state c t may be carded the t- of Investigations of the DIA for coverage verification. i rio/iercht•ccrtij t •r r t tt ai ' peryurr that the information prorided above is true u d come . Date Signature \ \ Print name V� \ r- Phone# P. �oRciai use only do not write in this area to be completed by city or town official permit/license# rllluilding Department city or town: - Licensing Board check if immediate response is required C3Jelcetmen•s()Rice* t.. I: rllteatth Department �� •• r Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation employees. As quoted f Qom the 61a%%*-. all e»lphtree is defined as every person in the service of another under contract of hire, express or implied. oral or written. An emp/in•er is defined as an individual, partnership, association. corporation or other legal entit% or any two the foregoing cnanued in a joint enterprise,and including the legal representatives of a deceased employer, or rccciver or trustee of an individual . partnership. association or other legal entity, employing employees. How owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of t d%%?cllin-, house of another who employs persons to do maintenance, construction or repair wort: on such d�vel: or on the ;,,rounds or building appurtenant thereto shall not because of such employment be deemed to be an er. MGL chapter 152 section 25 also states that even•state or local licensing agency shall withhold the issuanc renewal of a license or permit to operate a business or to construct buildings in the commomi-ealth for st applicant who has not produced acceptable evidence of compliance with the insurance coverage required Additionally. neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this cl: been presented to the contracting authority. Applicants Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situatio: supplying company narnes. address and phone numbers as all affidavits may be submitted to the Department of Industrial Accidents for confirmation of insurance covemae. Also be sure to sign and date the affidavit• 17. affidavit should be returned to the cit%' or town that the application for the permit or license is being requested. not the Department of Industrial Accidents. Should You have any questions regarding the "law"or if you are re to obtain a workers' compensation policy. please call the Department at the number listed below. Cin• or •ro„•ns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bo: the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applican be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be rest the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for;you cooperation and should you have any qt please do not hesitate to. `,isle us a call. Tlie Departinerif s address. telephone and fax number. The Commonwealth Of Massachusetts =+ Department of Industrial Accidents Office at Investigations 600 Washington Strcet Boston. Ma. 02111 - t>y !•'.,.'1' ": •r;t lit; I l�'i.i t'I<S f�:'�tt.;l . �, :y' r.iru•:• rlr:;ITl�lI1 1: .. t't e��1.�y f?!'i5�;1' ;;?rt I"1,°•I'.. .HC.11.1U>., ''f.'f' 0;�.'1 C)ft HOME I r°I;'I?tlk,f Mo.:N I r,,,r.!1 t?�;1."! 1`:'..•ii :.. .i'.:I ii:l'I I :.'l.'iar ,11 f'yat.iil :il iiiil ...i!i.• ,. '?b: . 1A4,(omx mtKscv{m v�(4Jr�i 'OMF. IMPROVEMENT CONIRA! `ration I OS? ' i7 •r. ": �I, 1=iF'1 •.'; it � I'j I•%[1P - iNQi4i;;llai r t;r; ri...'F,IIt IOHN T. 4LEkICH' 336 TURTLEBACK RU L�� '6stg4r�SR�,10M5 MILLS MR 02646 40MI,YISTHATOii 10'd 0191 -BZb-Bog 1H9I2gIV NHOr VVI :60 L6-LZ-q8J J ' � .•t �itP T9pOJUIn47Ll//EQAC�L 6�✓��LCCJE�,J DBPARTKENT Of PUBLIC SAYETY CONSTRUCTION SUPERVISOR LICENSE i Number: Expires: Restricted To: 00 JOHN T ALBRIGHT 336 TURTLEBACK RD NARSTONS KILLS. NA 02648 i ;V v. lRel N, PX S�f �� . i � � �U 10�- � Ill I �� r �, �� ., - r -- DEPARTMENT OF HOMELAND SECURITY-FEDERAL EMERGENCY MANAGEMENT AGENCY O.M.B.NO.1660.0015 PROPERTY INFORMATION FORM Expires Februory28,2014 PAPERWORK BURDEN DISCLOSURE NOTICE Public reporting burden for this data collection is estimated to average 1.63 hours per response. The burden estimate includes the time for reviewing instructions, searching existing data sources,gathering and maintaining the needed data,and completing and submitting the form. This collection is required to obtain or retain benefits. You are not required to respond to this collection of information unless a valid OMB control number is displayed on this form. Send comments regarding the accuracy of the burden estimate and any suggestions for reducing this burden to:Information Collections Management,Department of Homeland Security,Federal Emergency Management Agency,1800 South Bell Street,Arlington,VA 20598-3005,Paperwork Reduction Project(1660-0015). NOTE:Do not send your completed form to this address. This form may be completed by the property owner,property owner's agent,licensed land surveyor,or registered professional engineer to support a request for a Letter of Map Amendment(LOMA),Conditional Letter of Map Amendment(CLOMA),Letter of Map Revision Based on Fill(LOMR-F),or Conditional Letter of Map Revision Based on Fill(CLOMR-F)for existing or proposed,single or multiple lots/structures. In order to process your request,all information on this form must be completed in its entirety,unless stated as optional. Incomplete submissions will result in processing delays. Please check the item below that describes your request: ❑ LOMA A letter from DHS-FEMA stating that an existing structure or parcel of land that has not been elevated by fill(natural grade)would not be inundated by the base flood. ❑ CLOMA A letter from DHS-FEMA stating that a proposed structure that is not to be elevated by fill(natural grade)would not be inundated by the base flood if built as proposed. ❑ LOMR-F A letter from DHS-FEMA stating that an existing structure or parcel of land that has been elevated by fill would not be inundated by the base flood. A letter from DHS-FEMA stating that a parcel of land or proposed structure that will be elevated by fill ❑■ CLOMR F would not be inundated by the base flood if fill is placed on the parcel as proposed or the structure is built as proposed. Fill is defined as material from any source(including the subject property)placed that raises the ground to or above the Base Flood Elevation(BFE). The common construction practice of removing unsuitable existing material(topsoil)and backfilling with select structural material is not considered the placement of fill if the practice does not alter the existing(natural grade)elevation,which is at or above the BFE. Fill that is placed before the date of the first National Flood Insurance Program(NFIP)map showing the area in a Special Flood Hazard Area(SFHA)is considered natural grade. Has fill been placed on your property to raise j ground that was previously below the BFE? ❑ Yes ❑ No If yes,when was fill placed? mm/dd/yyyy Will fill be placed on your property to raise ground that is below the BFE? Q Yes* ❑ No If yes,when will fill be placed? 05/01/2021 mm/dd/yyyy 'If yes,Endangered Species Ad(ESA)compliance must be documented to FEMA prior to issuance of the CLOMR-F determination(please refer page 4 to the MT-1 instructions). 1. Street Address of the Property(if request is for multiple structures or units,please attach additional sheet referencing each address and enter street names below): 377 Sea View Avenue, Barnstable (Osterville) 2. Legal description of Property(Lot,Block,Subdivision or abbreviated description from the Deed): Assessors Map 138 Parcel 032 3. Are you requesting that a flood zone determination be completed for(check one): Q Structures on the property? What are the dates of construction? 0512021 (MM/YYYY) A portion of land within the bounds of the property?(A certified metes and bounds description and map of the area to be removed,certified by a licensed land surveyor or registered professional engineer,are required.For the preferred format of metes and bounds descriptions,please refer to the MT-1 Form 1 Instructions.) ❑ The entire legally recorded property? 4. Is this request for a(check one): 0 Single structure ❑ Single lot ❑ Multiple structures(How many structures are involved in your request?List the number: ) ❑ Multiple lots(How many lots are involved in your request?List the number: ) DHS-FEMA Form 086-0-26,FEB 11 Property Information Form MT-1 Form 1 Page 1 of 2 i I In addition to this form(MT-1 Form 1),please complete the checklist below. ALL requests must include one copy of the following: W Copy of the effective FIRM panel on which the structure and/or property location has been accurately plotted(property inadvertently located in the NFIP regulatory floodway will require Section B of MT-1 Form 3) 0■ Copy of the Subdivision Plat Map for the property(with recordation data and stamp of the Recorder's Office) OR ❑■ Copy of the Property Deed(with recordation data and stamp of the Recorder's Office),accompanied by a tax assessor's map or other certified map showing the surveyed location of the property relative to local streets and watercourses. The map should include at least one street intersection that is shown on the FIRM panel. ❑■ Form 2—Elevation Form. If the request is to remove the structure,and an Elevation Certificate has already been completed for this property,it may be submitted in lieu of Form 2. If the request is to remove the entire legally recorded property,or a portion thereof,the lowest lot elevation must be provided on Form 2. ❑■ Please include a map scale and North arrow on all maps submitted. For LOMR-Fs and CLOMR-Fs,the following must be submitted in addition to the items listed above: ❑■ Form 3—Community Acknowledgment Form For CLOMR-Fs,the following must be submitted in addition to the items listed above: ❑Documented ESA compliance,which may include a copy of an Incidental Take Permit,an Incidental Take Statement,a"not likely to adversely affect" determination from the National Marine Fisheries Service(NMFS)or the U.S.Fish and Wildlife Service(USFWS),or an official letter from NMFS or USFWS concurring that the project has"No Effect"on proposed or listed species or designated critical habitat.Please refer to the MT-1 instructions for additional information. Please do not submit original documents. Please retain a copy of all submitted documents for your records. DHS-FEMA encourages the submission of all required data in a digital format(e.g.scanned documents and images on Compact Disc[CD]). Digital submissions help to further DHS-FEMA's Digital Vision and also may facilitate the processing of your request. Incomplete submissions will result in processing delays.For additional information regarding this form,including where to obtain the supporting documents listed above,please refer to the MT-1 Form Instructions located at http://www.fema.gov/plan/prevent/fhm/dl_mt-l.shtm. Processing Fee(see instructions for appropriate mailing address;or visit http://www.fema.gov/fhm/frm_fees.shtm for the most current fee schedule) Revised fee schedules are published periodically,but no more than once annually,as noted in the Federal Register. Please note: single/multiple lot(s)/structure(s)LOMAs are fee exempt. The current review and processing fees are listed below: Check the fee that applies to your request: i ❑$325(single lot/structure LOMR-F following a CLOMR-F) ❑$425(single lot/structure LOMR-F) M$500(single lot/structure CLOMA or CLOMR-F) ❑$700(multiple lot/structure LOMR-F following a CLOMR-F,or multiple lot/structure CLOMA) ❑$800(multiple lot/structure LOMR-F or CLOMR-F) Please submit the Payment Information Form for remittance of applicable fees. Please make your check or money order payable to: National Flood Insurance Program. All documents submitted in support of this request are correct to the best of my knowledge. I understand that any false statement may be punishable by fine or imprisonment under Title 1g of the United States Code,Section 1001. Applicant's Name(required): ,John O'Dea, P.E. Company(if applicable): Sullivan Engineering&Consulting, Inc. Mailing Address(required): Daytime Telephone No.(required): 508-428-3344 P.O. Box 659 Osterville, MA 02655 E-Mail Address(optional):❑■ By checking here you may receive Fax No.(optional): correspondence electronically at the email address provided): john@sullivanengin.com Date(required) 17_1?,0Zc>Zv Signatur Applicant(required) DHS-FEMA Form 086-0-26,FEB 11 Property Information Form MT-1 Form 1 Page 2 of 2 DEPARTMENT OF HOMELAND SECURITY-FEDERAL EMERGENCY MANAGEMENT AGENCY O.M.B.NO.1660-0015 COMMUNITY ACKNOWLEDGMENT FORM Expires February28,2024 PAPERWORK BURDEN DISCLOSURE NOTICE Public reporting burden for this data collection is estimated to average 1.38 hours per response. The burden estimate includes the time for reviewing instructions, searching existing data sources,gathering and maintaining the needed data,and completing and submitting the form. This collection is required to obtain or retain benefits. You are not required to respond to this collection of information unless a valid OMB control number is displayed on this form. Send comments regarding the accuracy of the burden estimate and any suggestions for reducing this burden to:Information Collections Management,Department of Homeland Security, Federal Emergency Management Agency,1800 South Bell Street,Arlington,VA 20598-3005,Paperwork Reduction Project(1660-0015). NOTE:Do not send your completed form to this address. This form must be completed for requests involving the existing or proposed placement of fill(complete Section A)OR to provide acknowledgment of this request to remove a property from the SFHA which was previously located within the regulatory floodway(complete Section B). This form must be completed and signed by the official responsible for floodplain management in the community. The six digit NFIP community number and the subject property address must appear in the spaces provided below. Incomplete submissions will result in processing delays.Please refer to the MT-1 instructions for additional information about this form. Community Number: 250001 Property Name or Address: 377 Sea View Avenue, OSterville MA 02655 A. REQUESTS INVOLVING THE PLACEMENT OF FILL As the community official responsible for floodplain management,I hereby acknowledge that we have received and reviewed this Letter of Map Revision Based on Fill(LOMR-F)or Conditional LOMR-F request. Based upon the community's review,we find the completed or proposed project meets or is designed to meet all of the community floodplain management requirements,including the requirement that no fill be placed in the regulatory floodway,and that all necessary Federal,State,and local permits have been,or in the case of a Conditional LOMR-F,will be obtained. For Conditional LOMR-F requests,the applicant has or will document Endangered Species Act(ESA)compliance to FEMA prior to issuance of the Conditional LOMR-F determination.For LOMR-F requests,I acknowledge that compliance with Sections 9 and 10 of the ESA has been achieved independently of FEMA's process.Section 9 of the ESA prohibits anyone from"taking"or harming an endangered species. If an action might harm an endangered species,a permit is required from U.S.Fish and Wildlife Service or National Marine Fisheries Service under Section 10 of the ESA. For actions authorized,funded,or being carried out by Federal or State agencies,documentation from the agency showing its compliance with Section 7(a)(2)of the ESA will be submitted.In addition,we have determined that the land and any existing or proposed structures to be removed from the SFHA are or will be reasonably safe from flooding as defined in 44CFR 65.2(c),and that we have available upon request by DHS-FEMA,all analyses and documentation used to make this determination. For LOMR-F requests,we understand that this request is being forwarded to DHS- FEMA for a possible map revision. Community Comments: J I l�kA-'SV,/1,..� �js1/� l� j>'S-�.�.:Q� S(i Lt;T�.v► Cr..� v�+�IJ�1'il��Z-�'�V )J�3i'W�.TV?i9-(�� Cr— Community Official's Name and Title: (Please Print or Type) Telephone No.: 5 a1V,. K• 2 ' U 5 Community Name: C m unityial.'s Signature: (required) Date: Barnstable B. PROPERTY LOCATED WITHIN THE REGULATORY FLOODWAY As the community official responsible for floodplain management,I hereby acknowledge that we have received and reviewed this request for a LOMA. We understand that this request is being forwarded to DHS-FEMA to determine if this property has been inadvertently included in the regulatory floodway. We acknowledge that no fill on this property has been or will be placed within the designated regulatory floodway. We find that the completed or proposed project meets or is designed to meet all of the community floodplain management requirements. Community Comments: Community Official's Name and Title: (Please Print or Type) Telephone No.: Community Name: Community Official's Signature(required): Date: DHS-FEMA Form 086-0-26B,FES 11 Community Acknowledgment Form MT-1 Form 3 Page 1 of 1 DEPARTMENT OF HOMELAND SECURITY-FEDERAL EMERGENCY MANAGEMENT AGENCY O.M.B.NO.1660-0015 ELEVATION FORM Expires February 28,2014 PAPERWORK BURDEN DISCLOSURE NOTICE Public reporting burden for this data collection is estimated to average 1.25 hours per response. The burden estimate includes the time for reviewing instructions, searching existing data sources,gathering and maintaining the needed data,and completing and submitting the form. This collection is required to obtain or retain benefits. You are not required to respond to this collection of information unless a valid OMB control number is displayed on this form. Send comments regarding the accuracy of the burden estimate and any suggestions for reducing this burden to:Information Collections Management,Department of Homeland Security,Federal Emergency Management Agency,1800 South Bell Street,Arlington,VA 20598-3005,Paperwork Reduction Project(1660-0015). NOTE:Do not send your completed form to this address. This form must be completed for requests and must be completed and signed by a registered professional engineer or licensed land surveyor. A DHS-FEMA National Flood Insurance Program(NFIP)Elevation Certificate may be submitted in lieu of this form for single structure requests. For requests to remove a structure on natural grade OR on engineered fill from the Special Flood Hazard Area(SFHA),submit the lowest adjacent grade(the lowest ground touching the structure),including an attached deck or garage.For requests to remove an entire parcel of land from the SFHA,provide the lowest lot elevation; or,if the request involves an area described by metes and bounds,provide the lowest elevation within the metes and bounds description.All measurements are to be rounded to nearest tenth of a foot. In order to process your request,all information on this form must be completed in Its entirety. Incomplete submissions will result in processing delays. 1. NFIP Community Number: Property Name or Address: 2. Are the elevations listed below based on ❑existing or proposed conditions? (Check one) 3. For the existing or proposed structures listed below,what are the types of construction? (check all that apply) ❑crawl space❑slab on grade ❑■ basement/enclosure ❑other(explain) 4. Has DHS-FEMA identified this area as subject to land subsidence or uplift?(see instructions) ❑Yes ❑■ No If yes,what is the date of the current re-leveling? / (month/year) 5. What is the elevation datum?❑NGVD 29 Q NAVD 88 ❑Other(explain) If any of the elevations listed below were computed using a datum different than the datum used for the effective Flood Insurance Rate Map (FIRM)(e.g.,NGVD 29 or NAVD 88),what was the conversion factor? Local Elevation+/-ft.=FIRM Datum 6. Please provide the Latitude and Longitude of the most upstream edge of the structure(in decimal degrees to the nearest fifth decimal place): Indicate Datum: ❑WGS84 ❑NAD83 ❑NAD27 Lat. 41.61212 Long. 70.37901 Please provide the Latitude and Longitude of the most upstream edge of the property(in decimal degrees to the nearest fifth decimal place): Indicate Datum: ❑WGS84 ❑NAD83 ❑■ NAD27 Lat. 41.61182 Long' 70.37891 Lowest Address Lot Number Block Lowest Lot Adjacent Base Flood BFE Source Number Elevation* Grade To Elevation Structure 377 Sea View Avenue 1 032 138 0 13.5 13 FIRM Barnstable(Osterville)MA This certification is to be signed and sealed by a licensed land surveyor,registered professional engineer,or architect authorized by law to certify elevation information. All documents submitted in support of this request are correct to the best of my knowledge. I understand that any false statement may be punishable by fine or imprisonment under Title 18 of the United States Code,Section 1001. Certifier's Name: License No.: Expiration Date: John O'Dea,P.E. 48168 Company Name: Telephone No.: Sullivan Engineering&consuning,Inc. 508428-33M Email: Fax No. iohr4sul1ivaneng1n v��LSH OF! Signature: Date: 1 IZ'ZZ-Z02d G� C, L i No.4ti1�3 �'p 9FGIS;EfF�ell For requests involving a portion of property,include the lowest ground elevation within the metes and bounds description. Ss/ �1`(OptlO aI) Id;L �' Please note:If the Lowest Adjacent Grade to Structure is the only elevation provided,a determination will be issued for the structure only. DHS-FEMA Form 086-0-26A,FEB 11 Elevation Form MT-1 Form 2 Page 1 of 2 Continued from Page 1. Lowest Adjacent Lowest Lot Base Flood Address Lot Number Block Number Elevation* Grade To Elevation BFE Source Structure I I I This certification is to be signed and sealed by a licensed land surveyor,registered professional engineer,or architect authorized by law to certify elevation information. All documents submitted in support of this request are correct to the best of my knowledge. I understand that any false statement may be punishable by fine or imprisonment under Title 18 of the United States Code,Section 1001. Certifier's Name: License No.: Expiration Date: John O'Dea,P.E. 48168 Company Name: Telephone No.: Sullivan Engineering&Consulting,Inc. 508-428-3344 Email: Fax No. john@sullivanengin.com Signature: Date: '2—ZZ—ZaIt� •For requests involving a portion of property,include the lowest ground elevation within Seal(optional) the metes and bounds description. Please note:If the Lowest Adjacent Grade to Structure is the only elevation provided,a determination will be issued for the structure only. DHS-FEMA Form 086-0-26A,FEB 11 Elevation Form MT-1 Form 2 Page 2 of 2 I FEDERAL EMERGENCY MANAGEMENT AGENCY PAYMENT INFORMATION FORM Community Name:Barnstable Project Identifier: THIS FORM MUST BE MAILED,ALONG WITH THE APPROPRIATE FEE,TO THE ADDRESS BELOW OR FAXED TO THE FAX NUMBER BELOW. I Please make check or money order payable to the National Flood Insurance Program. Type of Request: LOMC Clearinghouse ❑ MT-1 application 847 South Pickett Street ❑ MT-2 application} Alexandria,VA 22304-4605 Attn.: LOMC Manager FEMA Project Library ❑ EDR application 847 South Pickett Street Alexandria,VA 22304-4605 FAX(703)212-4090 Request No.(if known): Check No.: Amount: ❑ INITIAL FEE* ❑ FINAL FEE ❑ FEE BALANCE*" ❑ MASTER CARD ❑ VISA ❑ CHECK ❑ MONEY ORDER *Note: Check only for EDR and/or Alluvial Fan requests(as appropriate). "*Note:Check only if submitting a corrected fee for an ongoing request. COMPLETE THIS SECTION ONLY IF PAYING BY CREDIT CARD CARD NUMBER EXP. DATE m m 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Month Year Date Signature NAME(AS IT APPEARS ON CARD): (please print or type) ADDRESS: (for your credit card receipt-please print or type) DAYTIME PHONE: FEMA Form 81-107 Payment Information Form YOFEMA ! Legend National 00 Hazard Layer ette 70e23'4"W 41"36'S7"N SEE FIS REPORT FOR DETAILED LEGEND AND INDEX MAP FOR FIRM PANEL LAYOUT I Without Base Flood Elevation(BFE) _ Zone A,V,A99 t SPECIAL FLOOD With BFE or Depth zone AE AO.AH.VE.AR ' }}� HAZARD AREAS G' �J Regulatory Floodway I� 0.2%Annual Chance Flood Hazard,Areas of 1%annual chance flood with average _ 1 depth less than one foot or with drainage ti 4.y areas of less than one square mile zone x Future Conditions 1%Annual 4 t} Chance Flood Hazard zone x /^- Area with Reduced Flood Risk due to l OTHER AREAS OF Levee.See Notes.zone x FLOOD HAZARD �OQ Area with Flood Risk due to Leveezone o No SCREEN Area of Minimal Flood Hazard zone x ♦ `, '•AJ Q Effective LOMRs ♦ �. , OTHER AREAS ;Area of Undetermined Flood Hazard zone o • GENERAL Channel,Culvert,or Storm Sewer 1 t,: \ ` �'••S STRUCTURES r r r I t r r Levee,Dike,or Floodwall t. TON F BAMU."ME1 Zone AO ` 25��01 - �_, WEPTH-2 a zo.z Cross Sections with i%Annual Chance 4 Water Surface Elevation - z VE � `. � -- `•,f ems- — — Coastal Transect ♦ •_ (E 16 Feet) —sa—Base Flood Elevation Line(BFE) El �, Limit of Study ♦ 1 / i AO Jurisdiction Boundary ♦ 2one AE rH 2 Fe2t) Coastal Transect Baseline ♦ (El 14tFeeq"Zone VE (El 14 Feed °�• OTHER _ — Profile Baseline FEATURES Hydrographlc Feature one, y•'�� EL 13 Feet) [j Digital Data Available N t' / •� , Q No Digital Data Available ♦ •�� 4� MAP PANELS ® Unmapped Zone AO �♦ _ j V 4 The pin displayed on the map Is an approximate DEPTH-2;Feet point selected by the user and does not represent �•,r ♦ Zone YE an authoritative property location. (EL 15 Feet) �• ♦ This map complies with FEMA's standards for the use of ♦ digital flood maps if It Is not void as described below. ♦ The basemap shown complies with FEMA's basemap ♦ accuracy standards ♦ The flood hazard Information is derived directly from the • authoritative NFHL web services provided by FEMA.This map ♦ was exported on 11/30/2020 at 2:02 PM and does not reflect changes or amendments subsequent to this date and t time.The NFHL and effective Information may change or I become superseded by new data over time. This map Image Is void If the one or more of the following map elements do not appear"basemap Imagery,flood zone labels, legend,scale bar,map creation date,community Identifiers, t FIRM panel number,and FIRM effective date.Map Images for Feet 1.61000 70e22'26"W 43e36'30"N unmapped and unmodemlzed areas cannot be used for 0 250 500 1,000 1,500 2,000 regulatory purposes. N SUBDIVISION PWTOF LAND IN NSTABL.E NOT N TBaxt�F AN AN 1 'Ac `fAL OFFICIA107 FFTC L ArwpY 28, 1998COPY COPY COPY wr NOT NOT NOT NOT E AN AN AN AN OFFICIAL OFFICIAL OFFICIAL OFFICIAL COPY COPY COPY COPY NOT NOT NOT NOT AN AN AN AN apse ICIAL OFFICIAL OFFICIAL OFFICIAL COPY COPY COPY x a'ce NOT OT NOT NOT AN �// AN AN CIA�FFICIA FFICIAL OFFICIAL 60$Y Y COPY c ?Soo '1,j —NOT m o°; N �9p a��/� AN u; xOFF IAL OFFICIAL CIAL OFFICIAL a Y COPY 0 COPY h� 4Y h T NOT OT NOT e AN AN N AN 2 FICIAL OFFICIAL OF CIAL OFFICIAL i � COPY COPY C PY COPY 1 28 30 12 D° Plan No. 1748 e` 11 N Cent N. 48539 F{ No 3jJ N Plon No. 1748-4 n Cert. No. 0 h w i 2 29 I NANTUCKET SOUND Subdivision of Lot 13 Shown on Plan 1748—V Fled with Cert. of Title No. 48539 Registry District of Barnstable County Separate certificates of title may be issued for land shown hereon as Lots 27 and 28 By the Court. Red in ✓� LAND REGJSIR47ION OfRCE SEPr. 29, 1998 er 01 Inch JA/F-0360 A Yoa q En �CorAI i Do.== ] r3eS1 . 951 01-03-2019 9: 16 Return to: C t f :218 316 NOT NOT Ni9AR tSTAEkW LAND COURT REGISTRY Robert E.Langway,Eagi AN AN AN Law Office ofRobnWiLK[gWOFFICIAL OFFICIAL OFFICIAL 187 Washington Strfjftite 2A COPY COPY COPY North Easton, Massachusetts 02356 NOT NOT NOT NOT AN AN AN AN OFFICIAL OFFICIAL OFFICIAL OFFICIAL COPY COPY COPY COPY NOT NOT NOT NOT AN AN ��,, pp AN AN OFFICIAL OFFUUf*LMIffkb OFFICIAL COPY COY COPY COPY 1, MARK M. CHRISTOPHER, as Trustee of 377 Sea View Avenue Realty Trust under a Declaration of TrusiMd DecemIMPT, 2012 andlWd with thelpaTnstable Registry District of the Land Court on Dekiiber 18,201$l'hs Documenfflo. 12092041 grantor")with an address of c/o Goulston & WAPW AtPAffJ ue,Cff6%16Y.Pnffd2'1:b W Massachusetts 02110- 2 3333, COPY COPY COPY COPY for consideration paNQT SIX MILI OR and 00/109MLLARS(1S6A00,000.00) AN AN AN AN y hereby grant to c1MPULE. d&WGTJQ 4,Y, WM IMMee af'NAMGLNominee Trust under Declaration of Trustobaed March 25QR916 ("Gra m, as evid=gi)y a Certificate of Trustee recorded herewith, with an address of 187 Washington Street, Suite 2A, North Easton, Bristol County,Massachusegj!@2356 NOT NOT NOT AN AN AN AN with quitclaim cR& lLJf-AL OFFICIAL OFFICIAL OFFICIAL ti A COPY COPY COPY COPY the land together with the buildings and improvements thereon situated at 377 Sea View Avenue, Barnstable(Osterville),Barnstable County, Massachusetts bounded and described as follows: 3 a� ;> LOT 28 R As shown on Land Court Plan#1748-3,dated August 28, 1998 M LOT 29 N As shown on Land Court Plan#1748-4,dated August 28, 1998 So much of said premises as lies below mean high water mark are subject to any and all public c rights legally existing in and over the same. � a Said premises are conveyed subject to and with the benefit of all rights, agreements,restrictions, reservations, and easements of record, insofar as the same are now in force and applicable. 17016900.31 i NOT NOT NOT NOT, AN AN AN AN OFFICIAL OFFICIAL OFFICIAL OFFICIAL Said premises are coed subjectL4 j1%jaking bt*jT'own of fable for the layout of Sea View Avenue as a public way dated April 2, 1931 recorded as Document No. 5562 as affected by a DiscontinuancTof a portion Sea ViewAvlenue dated ,arch 21, 1933 recorded as Document No.6801. AN AN AN AN F OF ICI L OF FFI IAL The undersigned, laCr cTI - bristo�FhOe�'�rustee og��tA�ea V CO nue Realty Trust, hereby certifies as follows: i 1. 1 am the cur W Trustee oMT Sea View Alue Realty TWunder a Declaration of Trust dated Decemb&l 1, 2012 and ANI with the BMtable Regisotistrict of the Land Court on DecembePAFN 4i,DoLWEA 4209Q§f I C I AL OFFICIAL COPY COPY COPY COPY 2. The above-referenced Declaration of Trust has not been terminated and remains in full force and of M NOT NOT NOT AN AN AN AN 3. Pursuant OE1*0m2§ ofQWll MntheCU92Whzs thoWlldoapower and authority to convey said grty descrimin this quiMbft deed whtoifirected by the beneficiaries of the trust. NOT NOT NOT NOT 4. All beneficiariMof the Trust pW of full age qqA are competggt4 OFFICIAL OFFICIAL OFFICIAL OFFICIAL 5. I have beendff4iffically did by all g4it bcnefici ff 377 Sea View Avenue Realty Trust to convey the property located at 377 Sea View Avenue, Barnstable (Osterville),k6if sachusetts bert E. ay, Ir.,T of NAMC Nominee Trust under declaraRwi of trust dat March 23�for cons 5,on of$6,000,000.00. OFF I�I d datSM'05 ICIL Em te_ - s g hYAL For Grantor's title, ser ] a wr ble Re rs District of the Land Court as ocument and no Certifica of Title No. 199036. [SIGNATURE AND ACKNOWLEDGEMENT APPEAR ON FOLLOWING PAGE] i (W)016109.3) MASSACHUSETTS STATE EXCISE TAX BARNSTABLE LAND COURT REGISTRY NOT NOT NOT 01-03-2019 a Ci9:16ca. V 51 DocT: 1361951 AN AN AN redhN$20P520.00 Cons: $67000000.H OFFICIAL OFFICIAL OFFICIAL OFFICIAL COPY COPY COPY Bpfi'TTYABLE COUNTY EXCISE TAX BARNSTABLE LAND COURT REGISTRY NOT NOT NOT D 01-03-2019 0 09:16am Ctl�' `..1 Doc*: 1J51951 AN AN AN FedMi8t360.00 Cons: 16,00a 000.iiO OFFICIAL OFFICIAL OFFICIAL OFFICIAL COPY .COPY COPY COPY Witness my hand and seal this day of December 201 S. NOT NOT NOT NOT AN AN AN AN OFFICIAL OFFICIAL OF CAL FFICIAL COPY COPY Qy) OPY NOT NOT Mark M hristophe gustee of AN AN 377 SEkAtYH AVEINE REALTY TRUST OFFICIAL OFFICIAL OFFICIAL OFFICIAL COPY COPY COPY COPY NOT NOT NOT NOT AN AN AN AN OFFICIAL OFFICIAL OFFICIAL OFFICIAL COP60MMON XLTH OF$RK9SACHU§M% NOT ,ss NOT NOT Number q 2018 AN AN AN AN OFFICIAL OFFICIAL OFFICIAL OFFICIAL On this 1 686PIlay of DtWfSer, 2018,c%%re me, tWUdersigned notary public, personally appeard M eark M. Christopher, Trustee of 377 Sea View Avenue Realty Trust, proved to me through satisfactory evidence of identification, which was p��fcv%xL t Ian mot- — , to be the person whose name is signed on the preceding or attached document, and acknowledged to me that he signed it voluntarily for its stated purpose as Trustee of 377 Sea View Avenue Realty Trust. Notary Public My commission expires: :. JEAN M. FAANCE NoteryN bllc . CommornveaMoiMassacRusetts' Idly ComM�slon Exphas December tg.201� - BARNSTABLE REGISTRY OF DEEDS John F. Meade, Register .... (W7016YOD.2) t_ N,u�xI�UY� United States Department of the Interior FISH AND WILDLIFE SERVICE i o New England Ecological Services Field Office "s 70 Commercial Street,Suite 300 Concord, NH 03301-5094 Phone:(603)223-2541 Fax:(603)223-0104 http://www.fws.gov/neweneland IPaC Record Locator: 765-24360170 November 19, 2020 Subject: Consistency letter for the '377 Sea View' project indicating that any take of the northern long-eared bat that may occur as a result of the Action is not prohibited under the ESA Section 4(d) rule adopted for this species at 50 CFR §17.40(o). Dear John O'Dea: The U.S. Fish and Wildlife Service (Service)received on November 19, 2020 your effects determination for the '377 Sea View' (the Action)using the northern long-eared bat(Myotis septentrionalis) key within the Information for Planning and Consultation (IPaC) system.You indicated that no Federal agencies are involved in funding or authorizing this Action.This IPaC key assists users in determining whether a non-Federal action may cause "take"U of the northern long-eared bat that is prohibited under the Endangered Species Act of 1973 (ESA) (87 Stat.884, as amended; 16 U.S.C. 1531 et seq.). Based upon your IPaC submission, any take of the northern long-eared bat that may occur as a result of the Action is not prohibited under the ESA Section 4(d) rule adopted for this species at 50 CFR §17.40(o). Unless the Service advises you within 30 days of the date of this letter that your IPaC-assisted determination was incorrect, this letter verifies that the Action is not likely to result in unauthorized take of the northern long-eared bat. Please report to our office any changes to the information about the Action that you entered into IPaC, the results of any bat surveys conducted in the Action area, and any dead, injured, or sick northern long-eared bats that are found during Action implementation. If your Action proceeds as described and no additional information about the Action's effects on species protected under the ESA becomes available, no further coordination with the Service is required with respect to the northern long-eared bat. The IPaC-assisted determination for the northern long-eared bat does not apply to the following ESA-protected species that also may occur in your Action area: ■ American Chaffseed, Schwalbea americana (Endangered) 11/19/2020 IPaC Record Locator: 765-24360170 3 Action Description You provided to IPaC the following name and description for the subject Action. 1. Name 377 Sea View 2. Description The following description was provided for the project'377 Sea View': Submit a C-LOMR- Fill with FEMA. Approximate location of the project can be viewed in Google Maps: https://www.google.com/ maps/place/41.612137551094804N70.37892872730276W Wiampho ..,�'� -• *dam r Determination Key Result This non-Federal Action may affect the northern long-eared bat; however, any take of this species that may occur incidental to this Action is not prohibited under the final 4(d) rule at 50 CFR §17.40(o). Determination Key Description: Northern Long-eared Bat 4(d) Rule This key was last updated in IPaC on May 15, 2017. Keys are subject to periodic revision. This key is intended for actions that may affect the threatened northern long-eared bat. The purpose of the key for non-Federal actions is to assist determinations as to whether proposed actions are excepted from take prohibitions under the northern long-eared bat 4(d) rule. i 11/19/2020 IPaC Record Locator: 765-24360170 5 Determination Key Result Based upon your IPaC submission, any take of the northern long-eared bat that may occur as a result of the Action is not prohibited under the ESA Section 4(d) rule adopted for this species at 50 CFR §17.40(o). Qualification Interview 1. Is the action authorized, funded, or being carried out by a Federal agency? No 2. Will your activity purposefully Take northern long-eared bats? No j 3. [Semantic] Is the project action area located wholly outside the White-nose Syndrome ' Zone? I Automatically answered No I 4. Have you contacted the appropriate agency to determine if your project is near a known hibernaculum or maternity roost tree? Location information for northern long-eared bat hibernacula is generally kept in state Natural Heritage Inventory databases—the availability of this data varies state-by-state. Many states provide online access to their data, either directly by providing maps or by providing the opportunity to make a data request. In some cases, to protect those resources, access to the information may be limited.A web page with links to state Natural Heritage Inventory databases and other sources of information on the locations of northern long- eared bat roost trees and hibernacula is available at www.fws.gov/midwest/endangered/ mammals/nleb/nhisites.html. Yes 5. Will the action affect a cave or mine where northern long-eared bats are known to hibernate (i.e., hibernaculum) or could it alter the entrance or the environment(physical or other alteration) of a hibernaculum? No 6. Will the action involve Tree Removal? No •11/19/2020 IPaC Record Locator: 765-24360170 7 10. What is the estimated wind capacity (in megawatts) of the new turbine(s)? 0 I NOTE: ASSESSORS MAP 138 PARCEL 32' FLOOD LINES DIGITIZED USING FIELD/TOWN GIS SHEET LOCATION OF EXISTING BUILDING ON LOCUS AS ORIENTATION; TOWN GIS SHEETS ZONES: ALLIGNED WITH FIRM COMMUNITY PANEL USING ROADS AND WATER LINES AQUIFER PROTECTION OVERLAY DISTRICT T7:?�-nn a H-IDQA"T s£ io-7 ZONING DISTRICT: RF _ 1 _ ELa 'sCi"bfE = I l.aL' ("&N4b� �ow15- _ FLOOD ZONES. AS NOTED S I COMMUNIT.-PANEL NO. 250001 0016DVISED JULY 2, 1992 CB/DH V � E tiV Rc1225.00• L�178.08, A V E N U E L. C. PI. 1748 V PROPOSED FLOOD ZONE BOUNDARY LOT 13 iv SEE AUBREY CONSULTING, INC. LOMR REQUEST FOR JACQUES SOLVAY N EXISTING SINGLE FAMILY DWEWNG 0 �� BARNSTABLE, MASSACHUSETTS a rn t car o DECEMBER 1995 O s 'P N �i 1 oa 4 X r to t� •• FOUNDATION WON -roP = ... rr v-1 Aso' t� ZONE B J` ZONE VE Ln Q 7.01 � E (� ZON VE (EL 16) t> '0 MEAN HIGH WATER 10-27-95 CB/DH gU -- K S 0 U • CERIMED PLOT PLAN 4 Of Na AT $ 377 SEA VIEW AVENUE o OSiERVI" MASS. Z Ci$SE p FOR Co/13�q DR. MICHIIEL A0lAND FOUNDATION LOCATION DATE: JUNE 12, 1996 SCALE: V • 4W JUNE 13, 1998 BAXTER k NYE, INC. I CERTIFY THE EXISTING BUILDING SHOWN HEREON COMPLIES WITH THE SIDELINE SETBACK 812 MAIN STREET REQUIREMENTS OF THE TOWN OF 8 STAB (508) D IS LOCATED WITHIN A SPECIAL FLOOD OSTE , MASS., 02655 HAZARD ZONE. 508)-428-9131 jr u6 l3, 19RCe 95172 (CPP02.DWG) ASSESSORS REF.: . Map 138. Parcel 032 - r` ' •.':' '•,•~'. �,I OVERLAY DISTRICT: AP- Aquifer Protection District t FLOOD ZONE: Zones VE Elev. 15. AE Elev. - 13, AO(Depth 2), X(0.2R Annual Chance) Community Panel Na. LOCATION MAP: 1250001 0776 J July 16, 2014 Scale: 1'- 2000•f 'IZONE. I I \` RF-1 I I \\\ \ ry Area(min.)87.120 SF(RPOO) q°°' DIRECTIONS: Frontage(min)20• width(min) 125• From Hyannis-Follow Main Street to the West f \ \ Abe Setbacks., ( \--_--- L'• `\ -�- �ae End Rotary, Take third exit onto Scudder Ave. Front 30• fff \ i Turn right onto smith street at the stop sign. Side 15• _ Continue on to CroigvAle Beach Road and left Rear 15• onto Soufh Main Street. Continue over the I f --- 1 I '`®�- bridge to Osterville. and left onto East Boy Road. Turn left onto Wonno Avenue and stay ��JJ right on Sea View Avenue. 8377 is on the left. -k'i',,_-- REFERENCES: r � `\-_ IV, ,"('` Deed: C213147 to.n I ff /1 / g \\` T/ -v�� - -- Plan: LCP 16265-A (f �i� \ \ LEGEND: " i(\\♦ `'``r://jam_ -�-''i---.��\ / 1 Q CDT cwor n« j II//♦`„�;-rj,(,H dg.��•%` -- t \ \ (,,Nr Nosy rr« DT 0s i&-s Tr« III,/♦,!'- _ \ � ,>�cr colltw-.r ' jllll /?p/r AE cofaan In,WHY P.I. III q`r3 -E- Oectrk t IIIIIII am °T \y\ \ 0. wttl-d nog U�hl Post /II oYlw ^I- J�� ! Fxbting SNfk\ ` la" i ElfS/DN . = fill?" / r"e cL- IY•�?� _ _ �Nw— 0-heed wk« I II 1 r 9b ��♦ 112'x40' : 4 n/f —25— D—tkn C-t— ro « fill Ct �k............''•. Lr c e \\ � 1•y \ IJJ370•El�fy ^if Iq t81 1 \ 2j st -F-VEL N er ape Vand won 7-1. la I {�itt M 9 "\\ Dwellin R 1 .T.O an �• / T 111 ( i 0 OF y-'e�j I'isl II j \\ �F? - \'1°-'-� ........,...�s" .� \� •\♦ \ FTLL I II II \ I\' ,mare \\ Lawn Qd� ♦► I:>} \ \ .................. 54' ... ` ..... Lot 28 & 29 . I l I I I Lot Area 56.0853r to Tknbw Mdkh«dto 1 mI/ / I !.' .i--- tnv.h ` v� env ._ FEMA Zrn T _- VE V-15 / I i_ -�- __--- T___ F / 1 / .-_ �--------------�YEF1Aa��- A.QY,r9 ! I I--- \ wood --- -'a- \ \ \ Deck ---- �\\ •JI'.49 TYnbar - T/ ----------------------------- \ \ -21 I / Beech ----_ ---rr---------------- --- -------------------1-- I -- 1 -— — — —— — ——— — — — — — � il ' i ram\ l _ ------- ------- '1 I _ - --------------------- Nantucket Sound 1 I • I t I 1 i \ r Stan.c-h TIRE: PREPARED BY., PREPARED FOR; NOTES Proposed Site Plan 1) The property Rne information shown was compiled from To Accompany CLOMR-F ava0abfe record information. p y Engineering& Mark M Christopher Trustee 2) The topographic information was obtained from on on m At p ,'t CIO Robert E. Lon wo Jr. Trust the ground survey performed on or between March 29, SU11i 11 Consulting,Ina 187 Washington Street Suite 2A 2019 and April 76, 2019. ~ 377 Sea View Avenue 9 3) The datum used is NAw U (508)428•3344-P.O.Box 959.711 Main Street,Ostervllle,MA 02555 North Easton MA 02356 4)Building dimensions are approximate and should be Barnstable psterwiie) Mass. secl@sullivanengln.com.w .sulllvanengln.com confirmed prior to construction. Draft: CTR Field. WNK/CTR/JOD 20 0 10 20 4p 5)Plan is for permitting purposes only and is not to be '1 used far construction, legal lot description or recording DATE' December 22, 2020 SCALE.- 1" _ 20' Review., CTR Comp./Review: CTR/JOD purposes. Pro' t: RAodes Pro'ct: 28003 rke Neck -- - P¢ r p Pond a "p a C 0°O .? (L TOE OF SLOPE 50• TREE LINE 5 ..---•• �n ° �,p a v,'. .-a+—�� yy •. � �y Y 3 18 18 16 _ _ - - ___�� - — . - -- -- —_._ _._ __. _ 16 .. - PROPOSED GRADE 14 _.. 14 12 _ _._ _.. _ _ _._ _ _ _.__ _ - 12 J = . 10 -- 1 (- ►� 10 -- 8 8 6 -- -EXISTING GRADE - 6 LOCATION MAP 0 0 0+5 0+11 0+17 0+50 0+56.4 COTUIT QUADRANGLE _ AllSCALE: 1:25,000 !; ASSESSORS MAP 138 PARCEL 32 o� ZONES: e4 8ECTI0N LINE AQUIFER PROTECTION OVERLAY DISTRICT VERTICAL & HORIZONTAL SCALE: 1" _ 10' ZONING DISTRICT: RF - 1 MINIMUMS AREA = 43,560 S. F. FRONTAGE = 20' WIDTH 125' s FRONT SETBACK = 30' SIDE SETBACK = 15' ,q �-J� -' REAR SETBACK _ 15' Spo, BUILDING HEIGHT - 30 (OR 2.5 STORIES IF LESS) `��264• FLOOD ZONES AS NOTED FIRM COMMUNITY PANEL No. TBM Q HYDRANT #107 REVISEDO01 JJULY 2 D1992 EL 0 SPINDLE a 11.06' �..n59'49" AUBREY CONSULTING, INC. N 7'.) LOMR REQUEST ��10 POLE 34 175.30' DECEMBER 1995 R�1 R:1185 p v .�° 130. 3.zs.00. ,3 ,,� _ A 0,00' -e- 210.71 S 49" w 2' 00' •"" EDGE OF PAVEMENT 1 L�178.08' [10 POLE 35SR-1225,00' L=321.03' LOW POINT PROPOSED \�`\ STONE DRIVE 8 � 1O � _ y p I rn rrl r �, r, �► i Q 12, 1 I" � 1 00 �� C. 1 48 T PROPOSED NEW CONSTRUCTION LOT 11 s.5' 8 FOUNDATION EL �.1 FEEL — 17.8 � ,LAB EL = a.o' I \ 14. 12 a � ZON r 1� 14, ( 1�) Z �E�- PROPOSED FLOOD ZONE BOUNDARY 1 2. SEE AUBREY CON SULTING;-I'NC�"-•- b '; ,,. ,2 r- — 8 -- LOMR REQUEST Q _46.9-Q Sw SOLVAY �' A� _ _m .-- PROPOSED SITE ALTERATIONS EXISTING SINGLE FAM(CY DINELUNG BARNSTABLE, MASSACHUSETTS PROPOSED FLOOD ZONE BOUNDARY A E ,_- -^ fi '�� 1 E - AT N - ,-' --'- ._,,,,_.•/�-- DECEMBER 1995 SEE AUBREY CONSULTING, INC. (p- LOMR REQUEST FOR JACQUES SOLVAY _,,r :- r. ._ EXISTING SINGLE FAMILY DWELLING V E . __ ' 377 SEA MEW AVENUE BARNSTABLE, MASSACHUSETTS ZONE 1 ! _ -- _ - MEAN HIGH WATER 10-27-95 (a" DECEMBER 1995 fi OSTERVILLE, MASS. FOR __ —---- ---- / DR. MICHAEL ACKLAND 4 �, CB WITH DRILLHOLE a �, p►1. �� SCALE: 1" 40' MAY 10, 1996 _ SULLNAN M��ti.�. J t 13 FLOOD LINES DIGITIZED USING FIELD TOWN GIS SHEET LOCATION ,OF EXISTING BUILDING ON LOCUS U, LQ $ NO'29733 BAXTER & NYE, INC. y CIVIL AS ORIENTATION; TOWN GIS SHEETS ALLIGNED WITH FIRM COMMUNITY PANELS USING ROAD AND WATER LINES. o {eet 812 MAIN STREET udre ► c OSTERMLLE, MASS. 02655 EXISTING CONTOUR 6 rn 55'995 SQ i1 -� /oN (508)—428-9131 z K CONTOUR ' PROPOSED FINISH R H GRADE 14.5 N I PIN FLAG AT TOE OF SLOPE (BY BAXTER..& NYE. INC.) ® S Q v N GRAPHIC SCALE LOCATION DATE: 05-07-96 BASE OF EXISTING JAPANESE PINE ® 40 0 20 40 eo 160 I ( IN FEET ) I 1 inch 40 tL , I 95172 STUDY06.DWG 17