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TOWN OF BARNSTABLE
REGISTRATION AND CERTIFICATION FO�RK , 9, 45
FOR FORECLOSING/FORECLOSED MVURT
Thank you for registering in accordance with Town of Barnstable Code chapter 224
sections 224-3 and 224-4. Please complete one form for ea a Y5s"ure
(section 224-3) or already foreclosed for which possession H%s 1 t en (section 224-
4). Please file the original with the Building Commissioner and a copy with the Chief of
the Fire District in which the property is located.
If you claim you are exempt from registering under Massachusetts law, please state the
reason(s) and complete section 1 (property information) and the first paragraph of
section 2 (foreclosing party, court, etc. and foreclosing party representative, but not other
representatives and attorney) so that the Town can review the exemption and update its
records:
Section 1 —Property Information
Property Address: 620 Main StXEST BARNSTABLE,MA 02668
Assessors Map #: 157-004 Parcel #: 157-004
j Land area and description
Building(s) description and contents BARNM:157L:004
620 Main St,West Barnstable,MA is a single family home that contains 2,003 sq ft and was built in 1790.It
contains 4 bedrooms and 2 bathrooms.This home last sold for$325,000 in August 1991.
Occupied: Yes Occupant(s)(if borrowers so state and include name(s))
Robert C Dunlop Jr c/o Ocwen Loan Servicing,LLC-Judy Credit
Phone: email: other:
Vacant: No Date: Anticipated Length of Vacancy:
Last occupant(s))(if borrowers so state and include name(s))
U.S.Bank National Association,as Trustee for Residential Funding Mortgage Securities I, Inc.,Mortgage Pass-Through Certificates,Series
2006-S2 c/o Ocwen Loan Servicing,LLC-Judy Credit
Phone: 8007462936 email: PropegRegistration@ocwen.com other:
Has possession been taken If so, please explain and complete and file the
maintenance and security plan form (unless exempt as stated above)
Section 2 —Foreclosing Party Information
U.S. Bank National Association, as Trustee for Residential Funding Mortgage
Foreclosin Pa (full name/title Securities I, Inc., Mortgage Pass-Through Certificates, Series 2006-S2 c/o Ocwen
g Party (f ) Loan Servicing,L LC-Judy Credit
Foreclosure Case Court: Docket#
� 1
Date filed: 11/15/2018 Current Status:
Foreclosing Party's representative(s) for property (entry, management, repair,
etc.)(name, title,): Ocwen Loan Servicing, LLC-Judy Credit
Company (if different from foreclosing party):
Address: 1661 Worthington Road, Suite 100,West Palm Beach, FL 33409
Phone: (800)746-2936 email:PropertyRegistration@ocwen.comother:
If an exemption is claimed, please do not complete the remainder.
Other representative(s) (if foregoing representative is primarily responsible for
property and/or foreclosure and is most likely to be able to address town matters
concerning the property and/or foreclosure, please so state and do not complete
contact information (i. e. "none" or"see above")).
"Note: Please mail correspondence to Atlanta office. Darren is local to address property conditions and emergency matters."
Name, title, other: Darren D Wisniewski-Regional Field Service Manager
Company (if different from foreclosing party): Altisource Solutions,Inc.
Address: 1000 Abernathy Road Northpark Town Center,Building 400 Suite 200 Atlanta,GA 30328
8669526514 VPR@altisource.com/ Darren.Wisniewski@Altisource.com
Phone(S): /(407)739-3930 emall(S): REOCodeviolations@altisource.coulther:
Name, title, other:
Company (if different from foreclosing party):
Address:
Phone: email: other:
Attorney representing foreclosing party
Firm name (if different from attorney's name): orlans PC
Address: TROY,MI
Phone(s): (248)502-8600 email(s): other:
I acknowledge that the information provided is accurate and correct. I also understand
that any inaccurate information will result in non-compliance with section 224-3 of
chapter 224 of the Code of the Town of Barnstable.
Date: tj
Name: Alma Emery
Title: Manager
. C
I hereby certify that the above-named foreclosing party is in compliance with the
provisions of section 224-3 of chapter 224 of the Code of the Town of Barnstable.
Date:
Building Commissioner, Town of Barnstable
I
REGISTRATION AND CERTIFICATION FORM
FOR FORECLOSING/FORECLOSED PROPERTY
CD
Thank you for registering in accordance with Town of Barnstable Code chapt� 24 Z;
sections 224-3 and 224-4. Please complete one form for each property in fort-clbsure G, c,]
(section 224-3) or already foreclosed for which possession has been taken(s65tipn 224-�
4). Please file the original with the Building Commissioner and a copy with to Chief of
the Fire District in which the property is located.
If you claim you are exempt from registering under Massachusetts law, please Itate the(M
reason(s) and complete section 1 (property information) and the first,paragraph of
section 2 (foreclosing party, court, etc. and foreclosing party representative, but not other
representatives and attorney) so that the Town can review the exemption and update its
records:
Section I —Property Information
Property Address: 620 Main St, BARNSTABLE, MA 02668
Assessors Map#: 157 Parcel #: 004
Land area and description
Building(s) description and contents
Occupied: NO Occupant(s)(if borrowers so state and include name(s))
Christopher P Kuhn c/o Ocwen Loan Servicing,.LLC .
Phone: email: other:
Vacant: YES Date: 04/22/2014 Anticipated Length of Vacancy:
Last occupant(s) )(if borrowers so state and include name(s))
Christopher P Kuhn c/o Ocwen Loan Servicing, LLC
Phone: 770-612-7007 email: VPR@altisource.com other:
Has possession been taken If so, please explain and complete and file the
maintenance and security plan form (unless exempt as stated above)
Section 2—Foreclosing PaM Information
Foreclosing Party (full name/title)
Foreclosure Case Court: Docket#
Date filed: Current Status:
Foreclosing Party's representative(s) for property (entry, management, repair,
etc.)(name, title,):
Company (if different from foreclosing party):
Address:
Phone: email: other:
If an exemption is claimed, please do not complete the remainder.
Other representative(s) (if foregoing representative is primarily responsible for
property and/or foreclosure and is most likely to be able to address town matters
concerning the property and/or foreclosure, please so state and do not complete
contact information (i. e. "none" or"see above")).
Name, title, other: Zaverl Mark Anthony
Company (if different from foreclosing party): US Best Repairs Inc
Address: 2004 McGaw Avenue IRVINE CA 92614
Phone(s): (714)-599-7722 email(s): vms@usbestrepairs.com other:
Name, title, other: Abigail McCutcheon - Supervisor Property Registration
Company (if different from foreclosing party): Altisource® Portfolio Solutions
Address: 2002 Summit Boulevard, Suite 600 Atlanta, Georgia 30319
Phone: 770-612-7007 email: VPR@altisource.com other:
Attorney representing foreclosing party
Firm name (if different from attorney's name): Orlans Moran PLLC
Address: Waltham, MA
Phone(s): (781)790-7815 email(s): other:
I acknowledge that the information provided is accurate and correct. I also understand
that any inaccurate information will result in non-compliance with section 224-3 of
chapter 224 A"z
f Barnstable.
AUG 19 2014
Date:
Name: .{ �C"',
Title: S-1-Ap
i
I hereby certify that the above-named foreclosing party is in compliance with the
provisions of section 224-3 of chapter 224 of the Code of the Town of Barnstable.
Date:
Building Commissioner, Town of Barnstable
Town of Barnstable *Permit
Expires 6 months from issue date
V� �L Regulatory Services Fee
Thomas F.Geiler,Director
Q Building Division X-PRESS PERMIT
Tom Perry,CBO, Building Commissioner
200 Main Street,Hyannis,MA 02601 JUN 0..1 2006
www.town.barnstable.ma.us TOWN OF BARNSTT��
Office: 508-862-4038 Fax: 5 "W-6230
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY !
Not Valid without Red X-Press Imprint
. C�
P (�
� dap/parcel Number 16 7
' !roperty Address D Z 0 M1411V w• Fgftox 4k, 11?4, o2w-68
?Residential Value of Work Z UDO_ Minimum fee of$25.00 for work under$6000.00
owner's Name&Address
PO/box 1/17 4y&✓AILI . Ad- 107E -3` I- C 3 L
2ontractor's Name C Telephone Number
t (,j-C%
Home Improvement Contractor License#(if applicable) 1 t 1�55
Construction Supervisor's License#(if applicable) b
❑Workman's Compensation Insurance
Check one:
- I am a sole proprietor
I am the Homeowner
❑ I have Worker's Compensation Insurance
Insurance Company Name
Woikman's Comp.Policy#
Copy of Insurance Compliance Certificate must be on file.
Permit Request(check box)
E3"R'e-roof(stripping old shingles) All construction debris will be taken to T o W-d Pry
❑Re-roof(not stripping. Going over existing layers of roof)
❑ Re-side
❑ Replacement Windows. U-Value (maximum.44)
*Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
***Note: Property Owner must sign Property Owner Letter of Permission.
Home Improvement Contractors License is required.
SIGNATURE:
Q:Fonns:expmtrg
Revise071405
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1
Town of)Barnstable *Permit# Rt 0
�' �,� ..::._.. . ._ ..• —--.. .:.. ..... Expires ��'�°"`
6 mo issue'
to
g sic MM. :.�.... .. �_ - ::Regulatory Services FeeBAPN ..
- _,Tfiomasf.-Geiler,Director
.. r'�m-- ..._. . . .._..Building Division
Perry, Building Commissioner -
-200 Main•Street,• Hyannis,MA 02601--... . 0: �
Office: 508-862-4038
Fax:'5081790-6230 :: :.:.::.:.•::•.:... :....; _.... y Zoos _ :..._...... _..
-''-t3a Ei S J?191 GYTT. TPUCA'TTON = RESID�rfTIA �O�tLY.
Not Valid without RedX-Press Imprint C., j3ARNSTABLE
�- ►-� �1
Rap/pazcel Number � • A n
'roperty Address (Rat) 00
ZResidential Value of Work ��Minimum fee of$25.00 for work under$6000.00
Dwner's Name&Address
Contractor's Name Telephone Number—UDML0
Home Improvement Contractor License#(if applicable) d
Construction Supervisor's License#(if applicable) V
❑Workman's Compensation Insurance
Check one:
❑ I am a sole proprietor
❑ am the Homeowner
have Worker's Compensation'Insurance Cz -
AL Y1&
Insurance Company Nam k J
Workman's Comp.Policy#
Copy of Insurance Compliance Certificate'must be on file.
Permit Reque (checkbox) _
Re-roof(stripping old shingles) All construction debris will be taken to
❑Re-roof(not stripping. Going over existing layers of roof)
❑ Re-side /0i I W
❑ Replacement Windows. U-Value (maximum.44)
*Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
***Note: Property Owner must sign Property Owner Letter of Permission.
Home Improvement Contractors License is required.
Signature
Q:Forms:expmeg
Revise063004
1
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---_=:3 The Commonwealth of Massachusetts
=- Department of Industrial Accidents
Office of investigations
600 Washington Street, e Floor
Boston.-Mass. 02111
Workers' Compensation Insurance Affidavit: Buildin /Plumbin /Electrical Contractors
lic t�informati.o,' ?kPlease ;ale°b1 t ;..
name:
address:
city state: zip: phone#
work site location(full address):
' ❑ I am a homeowner performing all work myself. Project Type: ❑New Construction❑Remodel
❑ Ijam a sole proprietor and have no one working in any ca aci ❑Building Addition
I am an em] loye 3roviding workers' compensation for my employees working on this job
i
cOm' an(.iname v_..w.i.r... .., s:a k ?�.' _�rc_ � .x,,.-:�%%t.� ..•.:: �. .:.�
�+k h _� � t i.. �X(1 � _ �d•fs,-t�fi� 7'� � .'J -tS'Kt y 4,Y� y�'.Y_. ` i t ) ` + ; F
•L' d W7�>. '.k '0 e .��� i "''G yy??•F x. .�c.o."r 'L'� (i�"�i� �X r
Cl ,�.% .J.t'y� .�, '* ��$ "" e �...s.�z;;>;.,r�s^.e2o•sue a,� ehAi �:a.�, ..33..Y3:a ne.#...f, .._-
r t�� Q il r.5•w roa k i rr, S -,,k. 4"rya f— y, t ,�'.k'+ f ,tea. .:fr'�x)r^Z f (,2 f �,.�y z�ys,,`•^v�2 c5 � � F
�x5 � e
in'surance.ca: _° _ a t t.t r + .
❑ I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have
the win f0 Ilo workers'rs compensationpolices:
ComDanVfiBme. ..-:::.
7 .I aw. •� i 7 0) r =ik.y c'ylc�a,'t} ;b 4l •a k r
address., n.,b31. .ir�'...L:..S..:S .1 v_...I.a, rY.l-rw.s.(..:b,�".C•.NFriY �. ..:._i '-.r.K
-
r )
�risura`nce:•co ...::,:....�.... ._.r:5,..�. .a ._,,..,_;. ;...:..... ,_.._A ..,� ..,�r:,.:a:rr.:,.:, obc.�lR.,. :F -
r1 4.
t •�� 1 �1 pJ .
company•nane k ...:« .. ..... G
,..:..
........:.... ..
..........
addi•ess....r.: •�.. ,.<. .:s:___ .,k_.,:,_ .�� _n,. sue:,;:,�.a:z.�:.�..: ,.�. .. ,
L
phone#::
msurance�eo�.__.::<�_.. ,... .. _...._�... . . .:..:.. ..: .... ._ ..:_....:... . .... . . oh>: :# ..:... ._.,. `. ':
@.."�;4Q'. -ror,-'-•�'�'P ai5�.s9r. .eta-. s ;u: lYt"" �•�'C ;Y t
Ai�t'ac ad'd�io al-sbeeKif�ne"cc'sSaYr r��� €a � �`
Failure to secure coverage as required under Section 25A of MGL 152 can lead to the-imposition of criminal penalties of a fine up to$1,500.00 and/or
one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a
copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
I do hereby certi y under the pains an enalties of perjury that the information provided above is true and eorr eb
Signature Date 0
Print name Phone#
official use only, do.not write in this area to be completed by city or town official
city or town: permit/license 0 ❑Building Department'
t ❑Licensing Board
❑check if immediate response is required ❑Selectmen's Office
[]Health Department
contact person: phone N, ❑Other
(revised Sept.2003) - _
r
Information and Instructions
i
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their
employees. As quoted from the"law",an employee is defined as every person in the service of another under any
contract of hire, express or implied, oral or written.
An employer is defined as an individual,partnership,association,corporation or other legal entity,or any two or more of
the foregoing 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 house of
another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds
or building appurtenant thereto shall not because of such employment be deemed to be an employer.
MGL chapter 152 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 have
been presented to the contracting authority.
Applicants
Please fill in the workers' compensation affidavit completely,by checking the box that applies to your situation. Please
supply company name, address and phone numbers along with a certificate of insurance 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.
a
City or Towns
i
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. Please
be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned to
the Department by mail or FAX unless other arrangements have been miade.The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions,
please do not hesitate to give us a call.
; N
The Department's address,telephone and fax number:
The Commonwealth Of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street,71"Floor -
Boston,Ma. 02111
fax#: (617)727-7749
phone#: (617) 727-4900 ext. 406
Application:to:
�0
GPM'yO NEE E PaPPN .' •' ••
� ���N►�• Old Kings Highway Regional"' soric District Committee
in the Town of Barnstable for a
CERTIFICATION.OF EXEMPTION.
Application is hereby'made, in triplicate,for the issuance of a certificate of exemption under Section 6 and 7 of Chapter 470,
Acts and Resolves of Massachusetts, 1973, as amended for proposed work as described below and on plans, drawings,or photo-
graphs accompanying this application. -.
TYPE OR PRINT.LEGIBLY DATE 4
ADDRESS OF PROPOSED WORK ASSESSORS MAP NO.
OWNER ASSESSORS LOT NO.
HOME ADDRESS [LEL.N0. �� 1
AGENT OR CONTRACTOR .
ADDRESS TEL, NO,
,This application is for exemption of proposed exterior construction on the grown at:
❑ (1) It will not be visible from any way or public place.
(2) It is within a category declared entitled to exemption by Old King's Highway Regional Historic District Commission.
(Check applicable box)
PROPOSED WORK: Describe and furnish plan of proposed work, showing location on lot, and, if an addition Is involved, show•
ing location of existing building.
. E
SIGNED
Space below line for Committee use. Owner-Contra ct0 Agent
Received by:.H.D.C. The Ce a her by
Date ZXALA
Time
By Date
Approved ❑ The categories.of work entitled'to exemption are listed on
Disapproved 13 the back of this form.
411
CAPIZZI HOME IMPROVEMENT INC .
SPECIFICATIONS AND ESTIMATES PAGE 6 OF 6
STATE OF MASSACHUSETTS
LETTER OF AUTHORIZATION TO APPLY FOR A BUILDING PERMIT
I
OWN THE PROPERTY LOCATED AT U elV IL 11
IN MASSACHUSETTS.
I HAVE AUTHORIZED CAPIZZI HOME IMPROVEMENT
TO ACT AS MY AGENT TO APPLY FOR A BUILDING PERMIT IN ACCORDANCE WITH 780 CMR,
THE MASSACHUSETTS STATE BUILDING CODE.
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:
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 02639
APPLICANT'S TELEPHONE: 508/428-9518
RESPONSIBLE OFFICER:
RESPONSIBLE OFFICER ADDRESS:
RESPONSIBLE OFFICER TELEPHONE:
c
ACCEPTED BY C°l DATE
THIS PAGE IS PART OF AND IN CONFORMANCE W H PROPOSAL #
coInanions and Standar�
Board Trutiliong Regul
One Ashbu fbn Place - Room 1301
"Boston. Massachusetts 02108
Home Improvement: ogtractor Registration
- Registration: 100740
Type: Private Corporation
Expiration: 6/23/2006
CAPI=I HOME IMPROVEMENT, INC. .`
Thomas Capizzi, jr.
1645 Newton Rd.
Cotuit, MA 02635
Update Address and return card.Mark reason for change.
Address Renewal Employment Lost Card
/,e 'L�omrmconuea�! 0�,/12t7a
Board of Building Regulations and Standards License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
•Board of Building Regulations and Standards
ei
Registration: 100740 One Ashburton Place Rm 1301
Expiration: 6/23/2006 Boston,Ma.02108
Type: Private Corporation
CAPIZZI HOME IMPROVEMENT,I
%omas Capizzi,jr.
1645 Newton Rd.
Cotuit,MA 02635 Administrator Not valid without
✓fir, �omr��wau�ea� of✓1/faod�civella
Yam` BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR
Number: CS 057032
Birthdate: 09/26/1963
Expires: 09/26/2005 Tr. no: 7171.0
Restricted: 00
THOMAS X CAPIZZI JR �
1645 NEWTOWN RD «�
COTUIT, MA 02635 Administrator
Jan-06-05 03:570m From-AIG IaTB-816-6903 T-724 .. P uuuuu[ ,,t ItLq
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PRODUCER THIS CERTIFICATI=IS ISSUED AS A MATTER OF INFORVIATION'},�, t-.,
ONLY AND CONFERS.NO RIGHTS UPON THE CERTIFICATE'
Employers Ins Group Inc HOLDER THIS CERTIFICATE DOES NOT AMEND,EXTEND OR'' #
281 Main Streit,Suite#f1 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW"'."U;,,,
sit
Fitchburg,MA 01420
COMPANIES AFFORDING INSURANCE
COMPANY A GRANITE STATE INSURANCE COMPANY: t '+',_, '1
INSUREDt
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Rmurca Nlanag®manta Inc
281 Main Street,Smits 96
Fitchburg,MA 01420
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THIS IA TO CERTIFY THAT THE POLICIES OF INSURANCE USTFD BELOW HAVE BEEN ISSUED TO THE INSURED NAM S0 ABOVE FOR
THE POLICY PERIOD INDICATED,NOT WITHSTANDING ANY REQUIIlEMENT.TERM OR CONDITION OF ANY CONTRACT OR O THER � a Y, ��� �'�y ;
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DOCUMENT WITH RESPECTTO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED THE J
POLICIES DESCRIBED HEREIN IS SUOLMCT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN 4t tY l fat rY'
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MAY HAVE BEEN REDUCED BY PAID CLAIMS.'
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CERTIFICATE HOLDER CANCELLATION `
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CAPIZZI HOME IMPROVEMENTS INC oc>MTMDATErn�.nMMWmccOMVAWWLL94MAVoRTV I�n,ap ;,
1645 NEWTON ROAD ��c;tY> ,fit .
DAYS wr M NOTICE TO THE C UF=TE moUm t MAN®TO Tm LEFT BIIT Fr yaI'y1 t jF n '
CO-WIT,MA02836 FAILURE TO MAIL SUCH NOMSK411YMeVMNOOEUOA ays ^iv jr• `',rr`
TbNORL1AeIlRYOR
ANY RIND UPON T}16 00EtPANY,ITS ALCM OR REPROONTAT[VES.
AUTHORIZED REPRESENTATIVE
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-- _ - The Commonwealth of Massachusetts
Department of Industrial Accidents
oxceOURNS992#ons
600 Washington Street
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
4;
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location:
city Dhone u
❑ 1 am a homeowner performing all work myself.
❑ a sole proprietor and have no one working in any capacity
1 am an employer providing workers' coin ensation for my employees working on this job.
( j..
nho
❑ I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who ha,::
the following workers'-compensation polices:
tompany.•name•• • . .. . .
address:.•.
phorie#f
RONFY�`
77
companv:name•' .. .
city phone b
irisara'n'txb policy h
Failure to secure coverage as required under Section 25A of h1GL 152 can lead to the imposition of criminal penalties of a fine up to S1.500.00 and/or
one years'imprisonment as well as civil penalties in-the form of a STOP WORK ORDER and a fine of S100.00 a day against me. 1 understand that a
COPY of this statement may be forwarded to the.Olfice of Investigations of the DIA for coverage verification.
I do herby certify under the pains and penalties of perjury that the information provided above is true and correct
Signature �' Date
Print same J hone#�111_^ . � � v
[check
nly do not write in this area to be completed by city or town official
permit license N -Building Department ;
Licensing Board
mediate response is required oSelcumen's OfficeClHealth Department
n: phone k;_ -Other
(M-4iscd 1/95 P1A) '