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0075 CARLOTTA AVENUE
� � ��: , � r�� i s � ' � � a: I i i i �. Application number- ........ q9. Date Issued........81 .................................. \ Building Inspectors Initials..... . ............................. AUG 29 2018 Map/Parcel.......9..... .................1. ....................... TOWN OF BARNSTABLE EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDOWS/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMATION Address of Project: � � C ARu_ rTA, A%ta NUMBER STREET VILLAGE Owner's Name: —Fo"to yj w E-P`� Phone Number to 17 6 91.. 0 P 9 — Email Address: f7eaT.3tcx6 BFUS`A, Corn Cell Phone Number Project cost $ 6000.'�o Check one Residential I✓ Commercial OWNER'S AUTHORIZATION As owner of the above property I hereby authorize to make application for a building permit in-'accordance with 780 CNI Owner.Signature: Date: TYPE OF WORK Siding Windows (no header change) # Insulation/Weatherization Doors (no header change) # Commercial Doors require an inspector's review 0 Rooft(not:applying more than 1 layer of shingles) Construction Debris will be going to L ROC�c R �'-rV�r',+ et-cc,erViCe- I CONTRACTOR'S INFORMATION Contractor's name Home Improvement Contractors Registration(if applicable) # (attach copy) Construction Supervisor's License# (attach copy) Email of Contractor Phone number ALL PROPERTIES THAT HAVE STRUCTURES OVER 75 YEARS OLD OR IF THE SUBJECT PROPERTY/S IN A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. APPLICATION NUMBER *For Tents Only* Date Tent (s) will.be erected Removed on number of tents total Does the.tent have sides? Yes No (If yes please attach floor plan with exits marked) Dimensions of each Tent X X X Additional tent dimensions can be attached on a separate piece of paper. Check one: this event is a: for profit non-profit event Check one: Food served Yes No Flame Spread Sheet of each tent must be attached. Provide a site plan with the location(s) of each tent If food is being served at your event please obtain a Health Department approval between the hours . of 8:00am-9:30 am or 3:30 pm-4:30pm. Commercial events may require Fire Department approval. *WOOD/COAL/PELLET STOVES Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from combustibles: front back left side right side HOMEOWNER'S LICENSE EXEMPTION . Homeowner's Name: 6 HIU Wi of A L T Telephone Number Cell or Work number I.understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and t T wn of Barnstable. Signature Date d a2 APPLICANT'S SIGNATURE Signature Date All permit a lications are subject to a building official's approval prior to issuance. The Commonwealth of Massachusetts ty Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): `P�1t7 Address: °7 S- egI'aZZrr" ka N91-6:.-r'aJ' City/State/Zip: ft 4 AAav� j#,4 Phone#: Are you an employer?theck the appropriate'box: Type of project(required): 1.❑ I am a employer with <�4:'❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp.insurance comp.insurance.: 10. Electrical repairs or additions _/equired.] 5. ❑ We are a corporation and its ❑ P 3.[0 I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.�C] Other PwK fir,„ v F1��S comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of InvestigatioriAof the DIA for insurance coverage verification. I do hereb c tify under the pains afnddppenaldes ofperjury that the information provided above is true and correct. Si ature: �� �-l�.W� Date: f� Phone#: <f ' l I - O 74— Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: u Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,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, §25C(6)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,MGL chapter 152, §25C(7)states"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 out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to cant'workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit 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. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials 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. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, 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 Tel.#617-727-4900 xt e 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 4-24-07 www.mass.gov/dia Parcel Detail Page 1 of 4 IT (/ � t }:'iXAFLu.`aH:tttlf<. ,�: � w t �`R.�✓, V t Lagged In As: Parcel Detail NPdnesday,August 29 2018. Parcel Lookup Parcellnfo _-- _ rr .... _------,_.. Parcel ID�248-206 Developer Lot LOT 39 Location 58 CARL0TTA AVENUE Pri Frontage!100 ' Sec Road . . .. Sec Frontage Village Hyannis ) Fire District FHYANNIS Town sewer exists at this address ENO ' Road Index�IP0249 Interactive Map 3 q� Owner info Owner FSACKETT, DGHT P l Dwne WI 'r %NEAL,JOHN Streets rl WINNIESWAY - 'Streetz � City EAST S ANDWICH MA� state � � w�zip[02537 '- �Country Land Info .... Acres,0.23 use Single Fam MDL-01 I Zoning RB Nghbd 0106 Topography Level ( Road[ utilities iPub cI Water,Gas,Septicf Location Construction Info Building 1 of 1 _ . .. ... Year 968 RoofGable/Hip Ext Wood Shin le Bear Struct I wall 9 Living["m"".,�,.,�.,.'.«.`..,.w�...»,::, Roof »,»» ,», „»»»:. AC �. » »,„„,. 1476 As h/F GIs/Cm None Area Cover p p Type �� Style iRanch _ I wall Drywall _ l Rooms 3 Bedrooms Model!Residential Flo ardw Hood R oms 1 FuII-0 Half Type Hot Water Roome 5 Roy,• » .. � : Grade AVera „>ge Plus oms Stories°1 2 Heat �fI Found poured Conc. Fuel »».»�.,.,�,,,,,,,.....�.,», ,»�.,, ation Gross i4260 I Area,�� Permit History Issue Date Purpose Permit# Amount Ins p Date Comments 12/2/2009 New Windows 200905895 $1,000 REPL WINDOWS Visit History Date Who Purpose http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=17791 8/29/2018 Parcel Detail Page 2 of 4 4/25/2018 12:00:00 AM Michael Scalia In Office Review 5/10/2017 12:00:00 AM Pamela Taylor Change of Address 2/11/2015 12:00:00 AM Susan Ricci Cyclical Inspection 1/23/2015 12:00:00 AM Anne Leonelli Change of Address 12/22/2014 12:00:00 AM Anne Leonelli In Office Review . 11/27/2001 12:00:00 AM Paul Talbot Meas/Listed-Interior Access Sales History Line Sale Date Owner Book/Page Sale Price 1 2/3/2017 SACKETT, DWIGHT P 30280/94 $100 2 1/14/2005 SACKETT, DAVID C TR 19441/191 $100 3 9/7/1973 SACKETT, DWIGHT P & SUSAN M 1929/247 $0 4 8/24/2018 NEAL, JOHN• 31488/304 $245,000 Assessment History Save Year Building XF Value OB Value Land Value Total Parcel # Value Value 1 2018 $107,500 $34,000 $0 $130,000 $271,500 2 2017 $99,700 $34,900 $0 $130,000 $264,600 3 2016 $99,700 $34,900 $0 $132,200 $266,800 4 2015 $98,000 $34,500 $0 $126,100 $258,600 5 2014 $98,000 $34,500 $0 $126,100 $258,600 6 2013 $98,000 $34,500 $0 $164,400 $296,900 7 2012 $98,000 $33,900 $0 $156,400 $288,300 8 2011 $129,800 $3,100 $1,600 $156,400 $290,900 9 2010 $129,700 $3,100 $1,700 $151,300 $285,800 10 2009 $134,000 $2,500 $800 $151,200 $288,500 11 2008 $159,800 $2,500 $800 $161,800 $324,900 13 2007 $159,000 $2,500 $800 $161,800 $324,100 14 2006 $140,300 $2,500 $800 $162,000 $305,600 15 2005 $130,700 $2,500 $800 $147,300 $281,300 16 2004 $106,300 $2,500 $800 $128,100 $237,700 17 2003 $95,500 $2,500 $900 $41,900 $140,800 18 2002 $95,500 $2,500 $700 $41,900 $140,600 19 2001 $95,500 $2,500 $700 $41,900 $140,600 20 2000 $60,900 $2,100 $400 $31,100 $94,500 21 1999 $60,900 $2,100 $400 $31,100 $94,500 22 1998 $60,900 $2,100 $400 $31,100 $94,500 23 1997 $62,500 $0 $0 $24,800 $88,400 24 1996 ' $62,500 $0 $0 $24,800 $88,400 25 1995 $62,500 $0 $0 $24,800 $88,400 26 1994 $63,600 $0 $0 $27,900 $92,600 27 1993 $63,600 $0 $0 $27,900 $92,600 28 1992 .$72,400 $0 $0 $31,100 $104,700 29 1991 $78,400 $0 $0 $49,700 $129,300 http://`issgl2/intranet/prbpdata/ParcelDetail.aspx?ID=17791 8/29/2018 Parcel Detail Page 3 of 4 30 1990 $78,400 $0 $0 $49,700 $129,300 31 1989 $78,400 $0 $0 $49,700 $129,300 32 1988 $50,700 $0 $0 $20,000 $71,800 33 1987 $50,700 $0 $0 $20,000 $71,800 34 1986 $50,700 $0 $0 $20,000 $71,800 � Photos _.. os. R'r i y an ,. y r 6 t- n http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=17791 8/29/2018 Parcel Detail Page 4 of 4 r .nrcL �.#3• �S, r t 3 a �� n rsnzz% s sx � any �W http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=17791 8/29/2018 Town of BarnstableBuilding t .�s Vim Ie Fro h n s - Post7This Card So Th at�t`im'te Street-Approved Plans Must;be.Retained on'Job.and this CardiMust be Kept. Posted Until Finalanspection Hasi een,, e n '• " Wherea>Certificate of Occupancy,is Required,suchBuildmgshalhNot'be'Occupied until'aFinalan5pection�has been made . ,,:_ Permtl � Permit NO. B-18-2291 Applicant Name: CAPE COD INSULATION, INC Approvals Date Issued: 07/18/2018 Current Use: Structure Permit Type:'.Building-Insulation-Residential Expiration Date: 01/18/2019 Foundation: _Location: 75 CARLOTTA AVENUE, HYANNIS Map/Lot: 248-162 Zoning District: RB Sheathing: Owner on Record: HUGHES,ANNE MARIE ESTATE OF Cont ctor Na e` CAPE COD INSULATION, INC Framing: 1 r 4` ' Address 1 WINNIES WAY y - Contractor License :153567 2 EAST SANDWICH, MA 02537 Est. Proje}ct Cost: $3,500.00 Chimney: Description` Weatherization Permit Fee: $85.00 4 ae. Insulation: Project Review Req: Fee Paid: $85.00 7/18/2018 Final: Plumbing/Gas Rough Plumbing: #. -r'.-.nos-..fit �Y -r`#. .{> .Building Official Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authonied by this permit is commenced within six months after issuance: fi r �<•.� Rough Gas: All work authorized by this permit shall conform to the approved application6a 66-`approved construction documents for which this permit has been granted. All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by la s and codes. Final Gas: This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public inspection for the entire duration of the work until the completion of the same. Electrical The Certificate of Occupancy will not be issued until all applicable signatures by the Building and:Fire re Officials are provided on thisp rmit. Service: Minimum of Five Call Inspections Required for All Construction Work: 1.Foundation or Footing Rough: 2.Sheathing Inspection 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Final: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection 5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough: 6.Insulation 7.Final Inspection before Occupancy Low Voltage Final: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. v' Health Work shall not proceed until the Inspector has approved the various stages of construction. Final: "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Fire Department Building plans are to be available on site Final: All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT F r, TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION BUiLUI�q Map Parcel � �EPT Application # ' Health Division JUL 17 2018 Date Issued " Conservation Division TOW►v OF BARNSTABLE Application Fee ]x� Planning Dept. Permit Fee 'w Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis Project Street Address 7T 91e7_-1W �. Village Owners�di,ca ,�f/�,L —Address11M� Telephone Permit Request J1iA.gl ,// Zell Z V Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation 3,5'�lU Construction Type_,ZVY411111-1�1' Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family 1211" Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes 4 No On Old King's Highway: ❑Yes Ao Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing new Number 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 Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review # Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name Mld2�p Ce Telephone Number R -77,5 /Z /9— Address License# Home Improvement Contractor# �L���✓'��Z Email i, z!At Worker's Compensation # 14_26�D4 5�=5!4' 2 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO , SIGNATURE DATE 1 1 FOR OFFICIAL USE ONLY ' APPLICATION # DATE ISSUED MAP/ PARCEL NO. L ADDRESS VILLAGE OWNER t DATE OF INSPECTION: r 1 FOUNDATION FRAME A` INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL .z FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. f pop The Com>fitortweauh ofll waoliusetls ' l0eparttnenl of Xnduslr'dalAooldertts � r Congress S'lreetr Suite 100 Boston, MA 021144017 wwwmass�ov/dla 71rotkersr Compmnsatlon Ynsurance TO Bs FILDD WITH THZ PAflldavit{;;BullderslContractors/�lectrlclans/Fl.umbers, RMI`Iki'C1�� ArITWnRITY, Name (9uslness/OrganlzeNonl(ndlvidual.); Cape Cod Insulation address; 18 Reardon Circle --�— Cky/Statollpl South Yarmouth,MA 02U4 phone ; 608�7T6-1214 an yov he+mpioyeri Cbeek the Ipproprlate bozo I m I em a rmployer with 48 employeeJ(�Il and/or part.time),r �'YPe of proJeet (required); t,Q I a role propr{ator or partnarohip and htye no employees working forme In 7. ❑ New oonstruodon anyospeoly,(No workers' oomp, Insursnoe rogvlred,) 8, [� RomOdel.ing J Q I em a homeowner doing e11 work my;elf'(Noworkera'oomp,Insurance roqulro')t ❑ Dem01111on 4,Q I om a homeowner w will be hNng oontraoton to oonduot a 1 work on m ro e enrure Chet�I oontreo{ors either have workers'oompenset{on Inew�anoe or vi sot ' I will 10 ❑ Suildlag addition proprielorawlth no employees, I 1 Q �(ootrloal repairs or addltl S,Q I a r+nerol oont utor and 1 Kaye hired the sub,00ntreoton Ilstod on the attached shoot, 12,❑plumbing ropalrs or addltl �(�10ae M 4onv oton heye omployeas L)1 hlye Workora'ooznp,insuran4c t 13, Q Roof repairs 6,Q We ue e oorporsdon and ita ofiloen Kaye exercised their right of exemption per MOL v, Ist,41(6);end we h%ye no employees, Mo worken'oomp, Insurance requlrcd,) 14, Offer Weatherizatlor +Any►ppl cant thel QSeoksIII x I .............m also tit out a scot on below show ng thelrworkers170 mpensstion polio Informs t Homeawn►n who submfi°�ie°t deylt Indlaating theayy are doing all work and than hire ouulde oonaao{ors must 11 tlon {Contrso0rs Vut oM this Eox mwt attached en addldonel sheet ahowing We neme�of she*Montraacors and state w employees, Itthe rub.cogtrsoton h><ye ern 10 ass they mun royide their workers Qom , llo number, bmlt a new Lmeoyl{Moettng suoh, lam am employer lhut is providing w'ork¢rs� oo hethar or not►hose cntltles have trttormallon, �¢n�rallon Inauranee for�,y ¢>ftpleyees, 8¢!ow !s the po!!e and ob sl I�suranoe Company Name; Atlantic Charter P0110y k or Self h s, Clog#I WCE�04 31902 •"` •„ �xplraHon t7ate 06/30/201� Attaoh a copyoft�e�rorkersr oompcnsatloa policy declaration pale (sbowlb 1ty/State/Z1 r � Failure to secure coverage as required under MOB, o, the policy number and ezplratioa day `'e' a>id/or.oneyear Imprisonment, as wall as olyll ponalties2nMA Is a criminal ylolatlon punishable b a ff day agalnsl Iho violator A Dopy of this stat.em�nt may be fohe fo doe a�M�c Cf �' ne uP t0 $1,300 C �` ORDER and a ff ne of up to S2�OC ooverago Yorl�oatlon, Investigations of t o DLA for Insuranc 1 do h¢reby Der. nor t!r s andpena.l!!e� o er u �'crm�atlon rovld fp J lhallhe lr p ed above is true and correct~ Q fi,yi, , 6r'S�",wwwrawuuw�„ww,,,w,M 50$ 75.12 `7 7 OfJlclal use only, Do not write in tf{ts rrr¢e, to be Completed by city or town o City or Townl NulneAuthorh`l FermltlLlcense # I, Board of Veal 2rBuiiditig bepa�.ment 6 Other 3 Cltymown Clerk 4 �leotrloal Inspeeto>✓''S, Plumblii�Cnspeetor Contact Persons �1 CAPECOD-27 MAKER ACORO' DATE(MMIDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 06/05/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsements. PRODUCER C N ACT Rogers&Gray Insurance Agency,Inc. PHONE FAX 434 Rte 134 A/C,No,Ext: A/C,No:(877)816-2166 South Dennis,MA 02660 E- ' .mall@rogersgray.com INSURERS AFFORDING COVERAGE NAIC# INSURER A:West American Insurance Com an 44393 INSURED INSURERS:Safety Indemnity Insurance Company 33618 Cape Cod Insulation,Inc. INSURER C:Endurance American Specialty Insurance Company 41718 18 Reardon Circle INSURER D:Atlantic Charter Insurance Company44326 South Yarmouth,MA 02664 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTRNSR TYPE OF INSURANCE ADDL SUER POLICY EFF POLICY EXP WVnlNqD POLICY NUMBER LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE IX OCCUR BKW(19)63328281 04/01/2018 04/01/2019 DAMAGE TO RENTED 100,000 MED EXP(Any oneperson) 5,000 PERSONAL&ADV INJURY 11000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE 2,000,000 X OTHER:POLICY a JEL�T L00 PRODUCTS-COMP/OPAGG 2,0N00,000 X see holder descrip of operations B $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 $ ANY AUTO 6232707 04/01/2018 04/01/2019 BODILY INJURY Perperson) $ AUTOS ONLY X AUTOS BODILY II EE N py�NEp BODILY INJURY Peraccitlent $ X AURTOS ONLY X AUTOS ONLY Pf�eOacatlent AMAGE C UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 2,000,000 X EXCESS LIAB CLAIMS-MADE EXCl0006635003 04/01/2018 04/01/2019 AGGREGATE 2,000,000 DED RETENTION$ D WORKERS COMPENSATION PER TUTE OTH- AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N WCE00431903 06/30/2018 06/30/2019 E.L.EACH ACCIDENT 1,000,000 �FFICER/MEMBER EXCLUDED? ❑ N/A Jlandatory in NH) E.L.DISEASE-EA EMPLOYEE 1,000,000 If yes,describe under 1,000,000 DES RIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if more space Is required) Workers Compensation includes Officers or Proprietors. Additional Insured status is provided under the General Liability and Auto Liability when required by written contract or agreement with the Certificate Holder. Excess Liability is follow form. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25(2016103) ©1988-2015 ACORD CORPORATION. All rights reserved. I , l r commonwealth of Massachusetts ® Division of Professional Licensure ;Board of Building Regulations and Standards Cons�ra<I,.&*ititp rvisor CS-100988 fir. °• y r Eg Tres; 11/11/2019 HENRY E CASSIDY ` 8 SHED WEST YARM0GT11 MA0 .1 Commissioner C'4 r� B ' Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Ma , "Giusetts 02116 Home Improveme..-Vad.tractor Registration fit ' / Type: Corporation Cape Cod Insulation Inc j i ti i, u Registration; 153587 ' i.� �•s.:f� �� Expiration: 12/14/2018 18 Reardon Circle *01 ` - p So. Yarmouth, MA 02664 ;aaa 0 20M•06n1 _ --' �—} Update Address and return card. Mark reason for change. ' � do c0anamaa�atuera�o�C%�r�adu.�redetlJ "rr—/mart.L�_t.ast^i?.r;i...., Office of Consumer Affalrs&Business Regulation (�l HOME IMPROVEMENT CONTRACTOR Type: Corporation Registration valid for Individual use only f before the expiration date, If foun urn to; :„........ la n L rstlon Office of Consumer Atfairs and sl ss Ragutatlan r 3 t 7 g67� 12/14/2018 10 Park Plaza• e 5170 Cape Cod Insulati'fi*j'c�'` +;! Boston,MA. tt lI Henry Cassidy P'�, s :� 18 Reardon So,Yarmouth,Mka,. g- Undersecretary It of hout sf atu I DocuSign,Envelope ID:887C18B2-B558-4740-8DCC-47D6144E7BA9 os�¢yoE T oq� Town of Barnstable n�RST„ , . Building Department Services MAss. o Florence, CBO '�pA 1639. �,p0 � Tto aA+ Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-8624038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I, John W Neal , as Owner of the subject property hereby authorize Cape Cod Insulation to act on my behalf, in all matters relative to work authorized by this building permit application for: 75 Carlotta Avenue West Hyannisport (Address of Job) Doc Signed by: IQ 3C 18926AEA9F4A 3 Signature o�Owner Signature of Applicant John Neal Print Name Print Name 7/11/2018 18:53 PM EDT Date I BK12131 P0177 21 �? ., 03- 17- 1933 & 12 : 02�: HOME rNVESTMENTS PARTNERSHIP PROGRAM MORTGAGE THIS MORTGAGE(this"Mortgage")is nude this // day off dA,e . 199.9 between the mortgagor. fl�/yiQ/,E Z-1a B yam" !� (herein"Borrower")whose address is 7 % !!!/ .dam/�Massachusetts Oo't6 0/ .and the mortgagee Barnstable County,which i organized and existing under the laws of The Commonwealth of Massachusetts whose address is Superior Court House,Main Street, Barnstable,Massachusetts 02630(the"L.eadee). Background and Granting Clause Borrower is indebted to Lead"in the pdWpal win of and 00/100 Dollars(S-2AeeQ O j(the"Loan")which indebOlness is evidenced by Borrower's Promissory Note of even date herewith(the"Note"),providing for repayment of the Loan under certain conditions and providing for other conditions of the Loan. To SECURE to Leader the repayment under the Note and the performance of the covenants and agrecments of Borrower contained in this Mortgage and in the Loaa Agreement of even date between Borrower and Lender(the"Loan Agreement"),Borrower does hereby mortgage,grant and convey to Leader,with!MORTGAGE COVENANTS,upon the STATUTORY CONDITION and with the STATUARY POWER OF SALE rho following described property looted in the County of BamsG k Commonwealth of MessaeLusetts,which has the address of ` u � oa6_o/ (she"Property Address"),as.more pafticularly described on Exhibit A sttachod hereto; ' TOGETHER with all the buildings and improvements now or hereafter erected on such real property,and all fixtures,easements,rights,licenses,appurtenances and rents,all of which shalt be deemed to be and remain a part of the property covered by this Mortgage;and all of the foregoing,together with said real property are hereinafter referred to as the"Property." Borrower covenants that Borrower is lawfully seized of the estate hereby conveyed and has the right to mortgage,grants,and convey the Property,and that the Property is unencumbered,except for those certain mortgages by and between the Borrower and (the "Senior Mortgages"). Borrower warrants and covenants to defend generally the title to the Property against all claims and demands,subject to encumbrances of record. For purposes of this Mortgage and the Note. -P � o , Lender designates the Cape Cod �S� BK 12131 PG 178 2137,2 Commission (tile"Commission")as its agent,with the power to administer the Note and the Mortgage,and to take any and all actions which Holder is entitled to take hereunder or thereunder. The Commission has a principal office at 3225 Main Street,P.O. Box.226, Barnstable, Massachusetts 02630. All notices and payments to fender under this Mortgage or the Loan Documents shall be made to the Commission at this address. Covenants Borrower and Lender covenant and agree as follows: 1. gpt: in the event the Borrower sells or transfers the property before the fifteenth anniversary of the Note, the Borrower shall repay to the Lender an amount as calculated under the Note. 2. Prior Moortgages.Charges„ Borrower shall perform all of the Borrower's obligations under the Senior Mortgage,including Borrower's covenants to make payments when due. Borrower shall pay or cause to be paid all taxes,assessments and other charges,fitos and impositions attributable to the Property which may attain a priority over this Mortgage and leasehold payments or ground rents,if any. 3. Huard Insurance. Borrower shall keep improvements now existing fir hereafter erected on the Property insured against loss by fire,hazards included within the term"extended coverage,"and such other hazards as Leader may require and in such amounts and for such periods as Lender may require,subject to the terms and conditions of the Senior Mortgage. AU insurance policies and renewals thereof shall include a standard mortgage clause in favor of Lender. Leader shall have the right to hold the policies and renewals thereof,subject to the terms of any mortgage or other security agreement with a lien which has priority over this Mortgage. , In the event of loss,Borrower shall give prompt notice to the insurance carrier and to Lender. Lender may make proof of Jos$*if not made promptly by Borrower. • If the Property is abandoned by Borrower,or if Borrower fails to respond to Lender within 30 days from the date notice is mailed by Lender to Borrower that the insurance carrier offers to settle a claim for insurance benefits,subject N the rights of the mortgagee under the Senior Mortgage,Lender is authorized to collect and apply the insurance proceeds at Lendees option either to restoration or repair of the Property or to the sums secured by this Mortgage. 4• smrily. Borrower shalt keep the Property in good repair and shall not commit waste or permit impairment or deterioration of the Property. ' 2 r r BK 12131 PG 1 ?1-1-1 i f Borrower fails to perform the covenants and agreements contained in this Mortgage,or if any action or proceeding is commenced which materially affects Lenders interest in the Property, then Lender,at Lenders option, upon notice to Borrower,may disburse such sums, including reasonable attorneys'fees.and take such actions as are necessary to protect Lender's interest,and any expenses so incurred by Lender shall be secured by this Mortgage. S. Inspotion. Lender may make or cause to be made reasonable entries upon and inspections of the Property,provided that lender shall give Borrower notice prior to any such inspections specifying reasonable cause therefor relating to Lende es interest in the Property. b. Condemnation. The proceeds of any award or claim for damages,direct or consequential,in connection with any condemnation or other taking of the Property,or part thereof,or for conveyance in lieu of condemnation are hereby assigned and shall be paid to Lender,subject to the terms and conditions of the Senior Mortgage. 7. $onom Not Released:Forbearance By[.ender Not a liver. Extension of the time for payment or modification of the conditions of the terms for payment of the sums secured by this Mortgage granted by Leader to any successor in interest of Borrower shall not operate to release,in any manner,the liability of the original Borrower and Borrowe es successors in interest. Lender shall not be required to eomme not proceeding against such successor or refuse to extend time for payment or otherwise modify amortindon of the aunts secured by this Mortgage by reason of any demand made by the odghW Borrower and Borro%ees successors in interest. Any forbearance by Lender in exercising any right or remedy,hereunder,or otherwise afforded by applicable law,shall not be a waiver of or preclude the eitmreise of any such right or remedy. 8. successors,and Amigas Bound!Joint aW Seyoerd Liabilitw :Sig=. 7be Borrowers internal under the Note and this Mortgrge may not be transferred,ass Sn4 or assumed without the written consent of Leader. The covenants and agreements herein oontained steal l bind,and the rights hereunder shall inure to,the respective successors and assigns of Lender and Borrower. AU covextants and agreements of Borrower shall be joint and several. 9.Notice. Except for any notice required wider applicable law to be givers in another manner.(a)any notice to Borrower provided for in this Mortgage shall be'given by delivering it or by mailing such notice by certified mall addressed to Borrower at the Property Address,and (b)any notice to Lender"be given by,'hkA delivery or certified malt to LendWd edemas stated herein or to such other address Under may designate by notice to Borrowe r as provided herein.Any notice provided for in this Mortgage shall be deemed to have been given to Borrower or Lender when given in the manner designated herein. 10.Goveming L,gww;Cverability. This Mortgage shall be governed by the laws of The Commonwealth of Massachusetts.The foregoing sentence shall not limit the applicability of Federal law to this mortgage.In the event that any provision or clause of this Mortgage or the 3 GK 12131 PG 160 Note conflicts with applicable law,such conflict shall not affect other provisions of this Mortgage or the Note which can be;given effect without the conflicting provision,and to this end the provision of this Mortgage and the Note are declared to be severable, As used herein, "costs," "expenses"and "attorneys'fees"include all sums to the extent not prohibited by applicable law or limited herein. 11. Breach, Remedies.Subject to the terms and conditions of the Senior Mortgage, upon Borrowees breach of the STATUTORY CONDITION or any covenant or agreement of Borrower in the Note,the Loan Agreement or this Mortgage,including the covenant to pay when due any sutras secured by this Mortgage,Lender,prior to acceleration shall give notice to Borrower as provided in paragraph 10 hereof specifying;(1)the breach;(2)the action required to cure such breach;(3)a date,not less than 10 days from the date the notice is mailed to borrower, by which such breach must be cured;and(4)that failure to cure such breach on or before the date specified in the notice may result in acceleration sums secured by this Mortgage and sale of the Property. The notice shall further inform Borrower of the right to reinstate after acceleration and the right to bring a court action to assert the nonexistence of a deGutlt or any other defense of Borrower to acceleration and sale.. If the breach is not cured on or before the date specified In the notice,Larder,at L.ende es option,may declare all of the stuns secured by this Mortgage to be immediately due and payable without huther demand and may invoke the STATUTORY POWER OF SAL$and any other remedy permitted by applicable law. Lender shall be entitled to collect all reasonable costs and expenses incurred in pursing the remedies provided in this paragraph 12,including,brit not limited to,reasonable attorneys'foes,all of which shall be saatrod by this Mortgage. If Lender invokes the STATUTORY POWER OF SALE,Larder shall nail a copy of a notice of sale to Borrower,and to any other person required by applicable law,in the manner provided by applicable law. Lender ahaU publish the notice of sale and the Property shall be sold i in the manner prescribed by applicable law. Larder or Larder's deesignoe may purelmk•tM property at any sale. The proceeds of the.mde"be applied in the following order (a)to A, reasonable costs and expenses of the sale,including reasonable attwwyes fees and costs of title evidence;(b)to all sums secured by any.mottgage with a lien which has priority over this Mortgage;(c)to all sums secured by this Mottgagey and(d)the excess,if any,to the person or person legally entitled thereto. 12•Berrowees Right to Reinstate. Notwithstanding I acceleration of the arias = secured by this Mortgage due to Borr+owees breach,subject to thotar s and conditions of the Senior Mortgage,Borrower shall have the right to have any proceedings begun by Lender to enforce this mortgage discontinued at any time prior to the earlier to occur of(i)sale of the Property pursuant to the Statutory Power of Sale contained in this Mortgage or(ii)entry of judgment enforcing this Mortgage if:(a)Borrower cures all breaches of any covenants or agreements of Borrower contained in the Note,the Loan Agreement and this Mortgage (b) borrower pays all reasonable expenses incurred by Leader in enforcing the covenants and 4 B.K12101 PG161 21372 agreements of Borrower contained in this mortgage and in enforcing Lender's remedies as provided in paragraph 12 hereof; including, but not limited to reasonable attorneys'fees;and(c) Borrower takes such action as lender may reasonably require to assure that the lien of this Mortgage, lender's interest in the Property and Borrowees obligation to pay the sums secured by this Mortgage shall continue unimpaired. Upon such payment and cure by Borrower,the Note, the Loan Agreement,this Mortgage and the obligations secured hereby shall remain in full force and effect as if no acceleration had occurred. 13, Release. Upon the expiration of the term of the Note or upon proper payment of all sums secured by this Mortgage,Lender shall discharge this Mortgage without cost to Borrower. Borrower shall pay all costs or recordation,if any. �2� M• &&4- Borrower Borrower COMMONWEALTH OF MASSACHUSETTS IMSTABLE County:ss On this day 193 9 before tee personally appeared &Lx&le �'. L�Ql, 3 and ackrwwledged the foregoing to be_ Ile-4- free act and deed. Notary Public My commission expires: - • t V�a p p s o+ ci� t .. �.. .J Title Reference: `��, r�i'c�tU6���� .�y, ''a t(� Book 0 !�S ,r V Page p LARNSTABLE REGISTRY OF DEEDS s . 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AIR, 7 e - �+- r NXa Fl� � F x Ase'_ ��� r a Iff !%� � �.};� `3 •-, � ""*al y �' 1� .�•t. Ali v , e r - c� Wn 4k i a.. x • y r v y - f.7 V' � �, ��y�: ,� � .� ! y�' .v.'�"VY,•jr'._ Sle m+i)i 'I r , a .a� � � �•�.� �' � .e�:�''+�'f��',y^ � '. gyp`• � �y �- , j y � 75 Carlotta Ave., Hyannis 6/4/2014 f 75' 1 i t Boor29447 973 i CO!@ioD ann OF M►SSAGMSETTS Barnstable, on. 29th 1979 ORDER OF THEM OF LAND IN BARNBTABLE (BYANW) FOR BIGRWAY PMOBBB - �� CARLOTTA AVENUE - TOWN OF We, EDWIN F. TAYLOR, MARY 8. MONPAONA and ALFRED B. BIIM=' the duly elected Board of Selectman for the Town of Barnstable, by virtue of and in 1 r W, pursuance of the vote of the Inhabitants of the Town of Barnstable acting under ARTICLE 139 of the 1979 Annual Town Meeting warrant, said meeting having J; y> 000mw*d an May 5, 1979, for the purposes of acquiring land for highway purposes in the Village of Hyannis and having complied with all preliminary yrequirements prescribed by and directed by law, do hereby order the taking and. do hereby take by eminent domain for hi*aW purposes wider the provisions of ~ Chapter 79 of the General Laws, in the name of and for The Inhabitants Of the `.1 Town of Barnstable, a municipal corporation within the County of Barnstable and the Oommonwealth of Massachusetts, an easement in certain parcels of land within said Town of Barnstable being shown an a plan hereinafter mentioned, which plan is incorporated by reference as a part of this Order and is to be �.�► recorded herewith and marginally indexed hereon in the Barnstable County Registry of Deeds and made a part of this Order. The parcels hereby taken are described in accordance with said plan as followst Beginning at a point in the ,southerly sideline of Carlotta Avenue at the end of the 1965 Tows Layout of said Carlotta Awn"{ ' . m2947 fear 274 thence N 780 57' 39" W by said southerly sideline a distance of 221.691 to a pointy k thence by a curve to the northwest with a t radius of 336.471 and an arc length of f 218.921 to a pointy thence N 410 40' 54" W a distance of 127.621 to a pointy thence by a curve to the northeast with a radius of 355.51 and an arc length of 226.741 to a pointy thence N Olo 18' 31" E a distance of 211.531 to a pointy thence by a curve to the northwest with a radius of 20.55' and an arc length of 31.720 to a point on the southerly sideline of Linda Lane, a private ways thence 8 870 07' 39" E by the southerly sideline of said Linda Lane a distance of 80.00' to a pointy thence by a curve to the southwest with a radius of 19.46' and an arc distance of 31.10' to a point on the northerly sideline of said Carlotta Avenue; thence 5 OP 18' 31" W by said northerly sideline a distance of 210.451; 1 thence b a curve to the southeast with a radius of 315.51 and an arc length of 236.731 to a point; thence 8 410 40' 54" E a distance of 127.621 to a pointy thence by a curve to the southeast with a radius of 296.471 to a pointy thence 8 780 57' 39" E a distance of 221.69' to a point at the and of the 1965 Town Layout; thence 8 110 02' 21" W by said 1965 Town Layout a distance of 40.00' to the point of beginning. —2- 1 • eoor2947 w,- 271E i Said land is shown and delineated on a plan entitled "TOWN OF BARNSTABLE PLAN OF LAYOUT CARLOTTA AVENUE BARNSTABLE (HYANNIS) MASS. AS MADE BY THE SELECTMEN February 6, 1976" which plan is to be recorded with the Barnstable County Registry of Deeds together with the original or a certified copy of this Order ^ of Taking. All trees within the perimeter of the taking are included in the taking. Structures within the perimeter of the taking are not included in the taking and may be removed by the owner within sixty (60) days. Weting easements to public utility companies and districts and the right, title and interest of such companies and districts in their property lying in such easements are excluded from this taking. The easement taken includes the right to install and maintain all utilities, including but not limited to drainage and sewers, which the Town of Barnstable may now W here- after provide. Owners aooaxa interest ralmn area Taken Amard (Book) (Page) goadvar L. Robert Holds and Ysank L. 1128 75 Easement 419692. sq. ft. ± -0- Min, ft-astees of Rclldn Healty'rust, 144 metal leloe Rd., Oater►ille, !lass. 1 Richard J. A;Masi E. Gviffin, 1516 282 Easement Abutter -0- husband and rife, 48 Carlotta Avenue, ItFRIMMIs, llama. 02601 City Bwdq a Bank of Pittsfield 1516 293 Easement Abutter -0- Pittsfield, Naas. Parcel, _ _ QP Dright P. do Susan N. Sacket, 1929 247 Basement Abw.ter -0- husband and wife, Carlotta Ave. +� $yamia, Naas. 02601 -4 Attleboro Savlap Bank 1929 249 Aasament Abutter -O- Attleboro, Mesa. N v Nsrohanta Bank&Trust Company 2147 40 Easement Abutter -0- CD of Cape Cod IVSmis, Muss. Parcel 3 llioholas S. do Mary Pubis, 2754 30 Easement Abutter -0- husband and We, 83 Bwerstt St., Arlington, Mess. 02174 Hyamia Cooperative Bank 2754 32 Eseemeat Abutter -0- Byamis, Maas. 02601 -4- Ft; .. 1 � pest TatM Area'Paloen Mud (Boot) (Page) George 8 Ant:A. Bagdamas 2488 146 Basement Abutter -0- • hasbmad mad rife, 65 Old sboxwom Bill geed Yoodbarl, aetmeaticut halter J. b Angela S. Serho 1419 236 easement Abutter -a- busband mad rite Carlotta Ave., loannise Nano-6 t Dena R. A Virginia L. Meece 1745 72. easement Abutter -0- basband and rife Carlotta Ave., Bysmis, Maas. Parcel 7 Ale>endras rk 019LSIOPav1011M 2649 222 easement Abutter -0- basbaad and rife, 20 Marie Ave. Al Contesvil.le, Mass. parcels 8 and 9 Robert M. do Eileen T. BradY 1495 52 easement Abutter -0- lme6and and rife 21 Linda Leese, Flannis, !lass. P17mouth Federal Saviagm d Lam 2651 304 Easement Abutter -0- A�socisti Pl Vocuthe Mass. , sCy �- f U L c LI(. parosll�0 3; /urr1L i«No Roger h Ire= moat 1489 1088 easement Abutter -0- husband and rife - 139 Bommit Avenue Btrootliaa, Mass. 02146 -5- 1 - - °. Record Interest 2sba n Area •"l (Back) (PaV) P&ycel Walter V. &Genoe3ate Janson 1974 84 Brien=t Abutter -O— husband and rife Drive �on, maw cre9 07083 12 Ratban&Lillian Auerbach 2312 289 Muscat Abutter -0- husband and rife 54 Leaman Street amoklins, lase. Sannis Coopessti" Beak 2312 291 Basement Abutter -0' • $yamis, !lass. IT lariatopher J. &Reis M. Jayce 1433 762 Easement Abutter husband and rife 4 Oenter 8131 Road Siaestao, Maas. 02360 N1 sandvioh Cooperative Bank 2433 763 Rum �t Abutter -0- Sandwich, Mesa. -Jobn J. &Barbara D. Driscoll 1439 390 Sas®ent Abutter �- husband and rite 63 Blelaoulh Rd., W. Springfield Mass. 01809 Springfield Mast. for Saviags 1439 391 Easement Abutter -0- Spriagfield, Mass. - Madeline G. Muss 2596 71 Easement Abutter -0- Wasson, Rhode Island x' -6- f Interest Taken lraa 4slma d 1 0 (Book) Page) Parcel 16 Robert C. &Rath E. Bsa1e7 2551 338 East fitter -0- busband and rite 85 Carlotta Avenue $UXULsr Mass. Itramsis Cooperative Bank 2022 301 Easement abutter -0- $tannis, Mass. paioel 17 Robert E. &Marie G. Baghes 34" 412 Sasemeat Abutter -0- husband and vice . ! 75 Carlotta Aver& sr Mass. Jobn G. Dobsrt7s at is 1499 413 Easement Abutter -O- Pleasant St., S. MMM th �O plarcel is Tam of Harastable 2855 28 No Taking Parcel 19 Patriak J. & Jinja Anna 'Tobin 2148 304 Easement abutter '-0- Imsband and wife Carlotta Ave., Byamaisr Mass. Parcel 20 R. B. Benderaon, Jr. & 2655 317 Easesemt Abutter -0- Tbaress H. Beniexsan busband and wife 291 Pleasant Street voymouth, Mass. Hass Federal Say. &Lase Assrn. 2655 128 Easement abutter -0- YoTcester, Nose. -7- ADOPT AND IIA at Bamatable this 29th day of Jums 1979 Bbin P. ftwi m • Mazy Ko �a a11ffr6"B. Bwk3 Subaoribod and avaaa to bofa= W thia 29th day of June, 1979 v - . Biot8m9 POb1io:.-`.. Official Website of The Town of Barnstable - Property Lookup Page 1 of 5 Assessing Division Property Lookup Results - 2014 L 367 Main Street,Hyannis,MA.02601 � «BACK TO SEARCH« Print F04 Owner Information - Map/Block/Lot: 248 / 162/-Use Code: 1010 Owner Owner Name as of 1/1/13 HUGHES,ROBERT E&MARIE G Map/Block/Lot G/S MAPS PO BOX 796 248/162/ WEST HYANNISPORT, MA. 02672 f Property Address Co-Owner Name C/O HUGHES,ANNE 75 CARLOTTA AVENUE Village: Hyannis Town Sewer At Address: No GIS Zoning Value: RB k Oat-(z�r n Assessed Values 2014 - Map/Block/Lot: / 162/- Use Code: 1010 2014 Appraised Value 2014 Assessed Value Past Comparisons Building $90,800 $90,800 Year Total Assessed Value `A Value: Extra $34,500 $34,500 2013-$300,300 d Features: 2012-$291,100 Outbuildings: $0 $0 2011 -$292,400 - Land Value: $134,200 $134,200 2010-$286,900 2009-$280,100 C 2008-$314,400 (� 3 2014 Totals $259,500 $269,500 2007-$313,600 Q Tax Information 2014 - Map/Block/Lot: 248 / 1621- Use Code: 1010 Taxes Hyannis FD Tax(Residential) $578.69 Community Preservation Act Tax $71 Fiscal Year 2014 TAX RATES HERE b � Town Tax(Residential) $2,366.64 $3,016.33 Sales History - Map/Block/Lot: 248 / 162/-Use Code: 1010 History:- Owner: Sale Date Book/Page: Sale Price: HUGHES, ROBERT E&MARIE G 1971-02-08 1499/412 $0 Photos 248 / 162/ - Use Code: 1010 le1L'l� CUSS S1 r'n � �. (S d� s��� ►�'�ts �e �� I _ � Nt Cep� a n r d`— htt ://www.town. am y _b stable.ma.us/Assessor / roe i p g p p rtyd splayscreenl4.asp.ap 0&searchpar... 6/4/2014 Ce n + c,v �s �-- ►•� -.. C U n `1 S j S DATE: June, 4, 29014 TO: Building File— FROM: R. Anderson LOCUS: 75 Carlotta Ave, Centerville M&P R248-162 RB District OWNER: Anne Hughes RE: Assessment Inspection ALSO PRESENT: James Parziale, Patrick Franey, FPO Norman Sylvester, HFD We reported to the site as a result of a HFD response on the previous day. The owner had locked herself out of the house and the conditions of the property were noted to be of concern to the responders. . The front of the house is not visible to the street but is completely hidden from view by over growth; only the drive way and garage door is visible. The house has obviously been neglected as well. The property owner, Anne Hughes inherited the home with her brother from their deceased father. It is not clear to her if she owns it alone or with her brother as their father apparently died intestate. At this time, it appears that Anne's name is the only name on the deed but she indicated that she is still not clear about the ownership. Ms Hughes answered the door and spoke to FPO Sylvester. She asked him who "all of the idiots are" with him. He replied that we are from the town and she agreed to let us in. Anne said she knows.her house is cluttered but she didn't need or want any help and she didn't want anyone going through her stuff. When asked about getting assistance for her to fill out a form for a reduced dump sticker(or whatever else), she retorted quickly that she can read and write; she is, she declared from a middle class family in Connecticut— not from the Cape—not raised here- she is educated! The conditions found inside the dwelling did not appear to pose an immediate danger but the house was clearly cluttered and smelled musty and moldy. Anne explained that she had taken 6 bags to the dump this morning and would continue to work on getting rid of more. She informed us that it is hard without a dump sticker and that is why she is applying for a low-income sticker. We moved into the kitchen area. Scanning the kitchen I saw that the stove was rusted and moldy. The fridge was chock full of bad food. The kitchen sink was not accessible (later I was informed that it has no running water). A washer and dryer were in the kitchen along the outside wall—Anne said they didn't work but one appliance looked brand new and they appeared to be installed. (Anne was not very clear about this matter and it may be that the original appliance had stopped working and that unit was recently replaced. I am not quite sure about what she actually meant). a Patrick was very concerned about the dryer vent being full as it was obvious no maintenance had been performed on the property or anything in it for quite a while.. The bathroom tile was falling off the walls and was covered with a plastic trash bag in the shower area. The bulb in the bathroom light was burnt out and I asked FPO Sylvester to change the bulb for Anne who produced a replacement very quickly. We proceeded to the basement from the kitchen—through a connecting door to the garage (noting an absence of a door knob or locking mechanism). The garage was cleanest space on the property. The cellar was full of many very impressive cob webs. The oil tank was in decent condition but the Anne admitted that the furnace was 6 years over due for a cleaning. A water heater on the rear outside wall was noted to be disconnected. Patrick and I walked around the house to the rear yard. The growth was very thick and we were unable to easily find the dryer vent. One vent was exposed but estimated to not be located in the vicinity the actual dryer. Patrick later found another vent in the correct area but was unable to actually reach it through the underbrush and growth. Returning to the front of the house, we met FPO Sylvester and James (Health) who were speaking with a neighbor and Anne. The neighbor agreed to obtain a house key from Anne for emergency use. She also agreed to any bags Anne installed in the garage to the dump for her. The plan is to sort through and clean out areas in the house starting with trash from the kitchen(as determined by Anne) and then to commence cleaning the kitchen counters appliances, sink and refrigerator with the neighbor's help. The neighbor also stated that others would assist with the lawn care and trimming back the over growth. Ultimately, the cleaning effort is to extend to other rooms and areas FPO Sylvester and I advised Anne that we would check back on her periodically to see how things are progressing. We spoke with the neighbor alone to review the plan again. At the conclusion of the inspection, every one was satisfied with the plan and Anne appeared to be comfortable with it as well. MM DD yyyy Delete NFIRS —1 101922 U 1 061 1 031 1 2014 1 114-0002519 1 1 000 ❑ FDID State Incident Date Change Basic * * * .Station Incident Number * .Exposure �* ❑No Activity Check this box to Indicate that the address for this incident is provided on the Wildland Fire ' I BLocation* Module In Section B"Alternative Location Specification". Use only for Wildland fires. Census Tract 50 ,street address 75 I CARLOTTA AV ❑Intersection Number/Milepost Prefix Street or Highway Street Type suffix [-]In front of ❑Rear of I J HYANNIS IMA 1102601 Apt./Suite/Room City - State Zip Code ❑Adjacent to ❑Directions Cross street or directions, as applicable C Incident Type * El Date & Times. Midnight is 0000 E2 Shift & Alarm 511 (Lock-out I check boxes if Month Day Year Br Min Sec Local option dates are the Incident Type same as Alarm ALARM always required IA Date. Alarm * Q 03 2014 15.59.09 hi I u D Aid Given or Received* �� L� ���_� Shift or Alarms District Platoon .ARRIVAL required, unless canceled or did not arrive 1 ❑Mutual aid received ® Arrival *. L_0�6 03 ( 20141116 14:41 �,3 . 2 ❑Automatic aid reaV. Thei�The State CONTROLLED Optional, Except_for wildland fires. Special Studies 3 ❑Mutual aid given __ P 4 ❑Automatic aid given ❑Controlled ' Local option 5 ❑other aid given Their LAST UNIT CLEARED, required except for wildland fires Incident Number Last Unit ` t LJ ® Special Special 0None ClearedL06 2014 16:55:04 udyD# Study Value F Actions Taken* G1 Resources * G2 Estimated Dollar Losses & Values ❑ Check this box and skip this LOSSES: Required for allfires if known. Optional section if an Apparatus or for non fires. 70 (Assistance, Other I Personnel form is used. None Apparatus Personnel Property Primary Action Taken (1) - .$�I Id --t d�000 d�000 ❑ 186 IlInvestigate $U L - Suppression 0001 0004 Contents 000 000 � I I �u' � ❑ Additional Action Taken (2) EMS �J �J PRE—INCIDENT VALUE: Optional Other 0001 0001, Property 000 000 Additional Action Taken (3) � � ❑ ❑ Check box if resource counts include aid received resources. Contents $LI 000 000 ❑ Completed Modules Hl*Casual ties®None H3 Hazardous Materials Release I Mixed Use Property ❑Fire-2 Deaths Injuries N ❑None NN Not Mixed ❑ Fire. 10 Assembly use Service Structure-3 I I 1 Natural Gas: slow leak, no e°anation or H—blat acticoa 20 Education use u ❑ ❑Civil Fire Cas.-4 2 [-]Propane gas; <21 lb. tam Lan in nome_BBp grill) 33 Medical use ❑Fire Serv. Cas.-5 Civilian J 1 3 40 Residential use ❑Gasoline: .,enicle foal tank°=portable conta;nn_ 'I ❑EMS-6 4 ❑Kerosene: fuel 51 Row of stores H2 Detector horsing equipment°=portable storage 53 Enclosed mall ❑HazMat-7 Required for Confined Fires. 5 ❑Di.esel fuel/fuel oil:v hici.fuel tank otportable 58 Bus. & Residential ❑wildland Fire-8 1 6 [-]Household solvents: home/office spill, eleannp only 59 Office use❑Detector alerted occupants ®Apparatus-9 7 []Motor oil: from engine or portable cantalner 60 Industrial use 0 Personnel-10 2❑Detector did not alert them 8 ❑Paint: from paint cane totaling.<55 gallons 63 Military use ❑Arson-il U unknown 65 Farm use ❑ 0 ❑Other: �al BauMat action.required or.pill>.s5gal., 00 Other mixed use Please a ate the 9asMat form J Property Use* Structures 341❑Clinic,clinic type infirmary 539 ❑Household goods,sales,repairs 342❑Doctor/dentist office 579 []motor vehicle/boat sales/repair 131 ❑Church, place of worship 361❑Prison or jail, not juvenile 571 ❑Gas or service station 161 ❑Restaurant or cafeteria 419®1-or 2-family dwelling 599 ❑Business office 162 ❑Bar/Tavern or nightclub 429❑Multi-family dwelling 615 ❑Electric generating plant 213 ❑Elementary school or kindergarten 439❑Rooming/boarding house 629 ❑Laboratory/science lab 215 ❑High school or junior high' 449❑Commercial hotel or motel 700 ❑Manufacturing plant 241 ❑College, adult education 459 Residential, board and care 819 Livestock oul❑ ❑ /p try storage(barn) 311 ❑Care facility for the aged, 464❑Dormitory/barracks 882❑Non-residential parking garage 331 ❑Hospital 519[:]Food and beverage sales 89.1 ❑warehouse Outside 936[]Vacant lot 981 ❑Construction site 124 ❑Playground or park 938 ❑Graded/care for plot of land 984 ❑ Industrial plant yard 655 ❑Crops or orchard 946 ❑Lake, river, stream 669,. Forest (timberland) 951 Railroad right of way Lookup and enter a Property Use code only if ❑ ❑ g y you have NOT checked a Property Use box: 807 ❑outdoor storage area 960 []Other street Property Use 1419 919 ❑Dump or sanitary landfill 961 ❑Highway/divided highway 931 ❑Open land or field 962 ❑Residential street/driveway. 11 or 2 family dwelling NFIRS-1 Revision 03 11 99 1 Person/Entity Involved Local Option I Business.name (if applicable) I I I Area Code Phone Number uI ❑.Check This Box if Mr.,Ms., Mrs. First Name, mi Last Name , same address as Suffix inciaznt location. L� u Ther•:'cate the three ' duplicate address Number lines. Prefix- Street or Highway II Street Type Suffix (Post Office Box Apt:/Suite/Room City State Zip Code More people involved? Check this box and attach Supplemental Forms (NFIRS-lS) as necessary �2 Owner Same as person involved? Then check this box and skip _- The rest of this section. Local Option I I I Business name (if Applicable) ' - Area Code Phone Number ❑ Check this box if Mr.,Ms., Mrs. First Name MI Last Name Suffix same address as incident location. Then skip the three - �J duplicate address Number Prefix Street or Highway - - Street_Type""r Suffix lines. (Post Office Box Apt./Suite/Room City State Zip Code - L Remarks Local Option _ Caller Phone 774-3683249 cad ; 2014/06/03 16:14:41 - 823 AT EVENT MANNING. IS 0 cad 2014/06/03 16:30:58 - 806 AT EVENT MANNING IS 1 MS. ANNE M. HUGHES CALL 911 REPORT SHE LOCKED HERSELF OUT OF. THE HOUSE. FOR SOME REASON BARNSTABLE POLICE KICKED IT TO COMM.. COMM. DISPATCHER CALLED REPORTING THIS INCIDENT TO US REPORTING SHE BEEN LOCKED OUT OF HER HOUSE FOR ABOUT A HALF HOUR [1/2]. ARRIVING ON SCENE, WE FOUND A•COMPLETELY COVER HOUSE AND YARD WITH TREES AND OVER .GROWN BRUSH, A ONE STORY [RANCH] CAR IN THE DRIVEWAY AND MS. HUGHES STANDING AT THE FRONT DOOR. INVESTIGATING WE SPOKE WITH MS. HUGHES WHO STATED SHE ACCIDENTALLY LOCKED THE DEAD BOLT WHICH SHE NORMALLY DOESN'T. WE TOOK THE KEYS AND WITH LIMITED DIFFICULTY WE GAIN ACCESS. ONCE THE DOOR WAS OPEN AN ODOR OF TRASH HIT US IN THE FACE. WE ENTERED THE HOUSE AND FOUND IT TO BE A HORDER'S PARADISE. THERE WERE NUMEROUS PLASTIC BAGS OF HOUSEHOLD TRASH IN THE KITCHEN ALONG WITH THE GARAGE AND THREE [3] BAGS IN HER CAR. I DON'T BELIEVE THE KITCHEN SINK IS WORKING. THERE WERE BAGS OF CLOTHES EVERY WHERE. ENTERING INTO THE BASEMENT TO CHECK ON THE BOILER AND ELECTRICAL PANEL I HAD TO CUT MY WAY THROUGH THE COBB WEBB'S AND ,SPIDERS. THERE WERE FRUIT.FLY IN EVERY SPACE, KITCHEN, GARAGE, BATHROOM, LIVING ROOM, BED ROOM, ETC. -COBB WEBB'S WE HANGING FROM EVERY CORNER. STOVE TOP WAS COVERED WITH JUNK. AT THIS POINT- WE REQUESTED A FIRE INSPECTOR ALONG WITH HEALTH. HEALTH INSPECTOR COULD NOT CHECK THE PROPERTY UNTIL.TOMORROW 06/04/14 . INVESTIGATING FURTHER LIEUTENANT SYLVESTER ARRIVED ON SCENE AND WAS SHOWN THE SITUATION. HE L Authorization 1197201 IFarrenkopf, Craig E. IICAPT/EMT 061 0311 2014 Officer in charge ID Signature Position or rank Assignment Month Day Year Check Box if® 1197201 I Farrenkopf, Craig E. I CAPT/EMT I I 1 061 U 2014 same Position or rank Assignment - Month Da Year as Officer Member making report ID Signature - g Y . in charge. 4 * MM DD YYYY L 01922 U L 61 L_J3 2014 L 14-0002519 1 000 Complete FDID ,* State* Incident Date Station Incident Number Exposure Narrative . * Narrative: Caller Phone 774-3683249 cad ; 2014/06/03 16:14:41 - 823 AT EVENT MANNING IS 0 cad ; 2014/06/03 16:30:58 - 806 AT EVENT MANNING IS 1 MS. ANNE M. HUGHES CALL 911 REPORT SHE LOCKED HERSELF OUT OF THE HOUSE. FOR SOME REASON BARNSTABLE POLICE KICKED IT TO COMM. COMM. DISPATCHER CALLED REPORTING THIS INCIDENT TO US REPORTING SHE BEEN LOCKED OUT OF HER HOUSE FOR ABOUT A HALF HOUR [1/2] . ARRIVING ON SCENE, WE FOUND A COMPLETELY. COVER HOUSE AND YARD WITH TREES AND OVER GROWN BRUSH, A ONE STORY [RANCH] CAR IN THE DRIVEWAY AND MS. HUGHES STANDING AT THE FRONT DOOR. INVESTIGATING WE SPOKE WITH MS. HUGHES WHO.STATED SHE ACCIDENTALLY LOCKED THE DEAD BOLT WHICH SHE NORMALLY DOESN'T. WE TOOK THE KEYS AND WITH LIMITED DIFFICULTY WE GAIN ACCESS. ONCE THE DOOR WAS OPEN AN ODOR OF TRASH HIT US IN THE FACE. WE ENTERED THE HOUSE AND FOUND IT TO BE A HORDER'S PARADISE. THERE WERE NUMEROUS PLASTIC BAGS OF HOUSEHOLD TRASH IN THE KITCHEN ALONG WITH THE GARAGE AND THREE [3] BAGS IN HER CAR. I DON'T BELIEVE THE KITCHEN SINK IS WORKING. THERE WERE BAGS OF CLOTHES EVERY WHERE. ENTERING INTO THE BASEMENT TO CHECK ON THE BOILER AND ELECTRICAL PANEL I HAD TO CUT MY WAY THROUGH THE. COBB WEBB'S AND SPIDERS. THERE WERE FRUIT FLY IN EVERY SPACE, KITCHEN, GARAGE, BATHROOM, ' LIVING ROOM, BED ROOM, ETC. COBB WEBB'S WE HANGING FROM EVERY CORNER. STOVE TOP WAS COVERED WITH JUNK. AT THIS POINT WE REQUESTED A FIRE INSPECTOR ALONG WITH HEALTH. HEALTH INSPECTOR COULD NOT CHECK THE PROPERTY UNTIL TOMORROW 06/04/14. INVESTIGATING FURTHER LIEUTENANT SYLVESTER ARRIVED ON, SCENE AND WAS SHOWN THE SITUATION. HE IS GOING TO DO A FOLLOW-UP WITH THE HEALTH INSPECTOR IN THE A. M. AROUND 10:30; SEE REPORT LIEUTENANT SYLVESTER. WHILE THERE WE FOUND TWO [2] COMBINATION C. 0. AND SMOKE -DETECTORS ON THE COUNTER. ONE COMBINATION WE WERE ABLE TO GET -WORKING.AND INSTALLED IN THE COMMON HALLWAY. THE OTHER WOULD NO STOP BEEPING SO WE-PLACED IT OUT. OF SERVICE. WE FOUND A SMOKE DETECTOR IN THE ENGINE AND PUT THAT IN SERVICE IN THE BASEMENT. OWNER: MS. ANNE M. HUGHES 508-775.-0341 CELL 774-368-3249. CAUSE: LOCK-OUT AND DEPLORABLE CONDITIONS. WEATHER CONDI-TION: CLEAR, COOL, WIND OUT OF THE SOUTHEAST ABOUT 9 MPH, 'T. 63* F. FARRENKOPF, C. CAPT. 06/03/14." .^• TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map —Parcel—, 'Permit# Health Division Date I sued Conservation Qivi "qn Fee o lO Tax Collect Treasurer —R2 ! ' { , Planning Dept ' Date Definitive'Plan Approved by Planning Board - Historic-OKH Preservation/Hyannis Project Street Address 7 r OW I A-1'TW ,Qv e, r '.Village Owner 117.4)2/z? tl'4`��s Address ,5 ' Telephone Permit Request 1'2 /6-- c���.v� i��or, Square feet: 1 st floor: existing proposed 2nd floor:existing proposed Total new Estimated Project Cost Zoning District Flood Plain Groundwater Overlay Construction Type Lot Size Grandfathered: ❑Yes ❑No If yes, attach supporting documentation. Dwelling Type: Single Family ,Two Family ❑ Multi-Family(#units) r Age of Existing Structure Historic House: ❑Yes L9 oo . On Old King's Highway: ❑Yes "o Basement Type: O Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: existing new Half:existing new Number 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 Detached garage:❑existing ❑new size Pool:❑existing' ❑new size Barn:❑existing ❑new size Attached garage:❑existing ❑new size Shed:❑existing ❑new size Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes, site plan review# , Current Use Proposed Use BUILDER INFORMATION Names��y is �,�U>�Gs^� Telephone Number Address 9,?`74-4 It W, License# 0 ?f- -&�/Sd 0 Home Improvement Contractor# Worker's Compensation# WC PS87 3 . ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO VS 7& SIGNATURE DATE _ �/,;)-1/2 9 ' FOR OFFICIAL USE ONLY PERMIT NO. q' 9 1 , DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE. OWNER' 1 x . -'yam = v �, • ; �. F w S , - , r f . P _ - .• - k .+ .. a .. DATE OF INSPECTIOi i z L FOUNDATION _. - i FRAME INSULATION FIREPLACE t' t ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL' GAS: ROUGH FINAL ' • V I "'� ' �. FINAL BUILDING z t" I vv DATE CLOSED OUT s ASSOCIATION PLAN NO. ' The Town of Barnstable EL 711 �o� Department of Health Safety and Environmental Services r- � ' Building Division 367 Main Street,Hyannis MA 02601 Office: 508-862-4038 Ralph,Crossen Fax: 508-790-6230 Building'Commissioner Permit no. Date 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: Sfie ;1'1t r / �UCr Estimated Cost&I A od UC--j 7t lot a-P&-o Address of Work: 7 S &,6 8/v<1(4 -W"—, ¢��,r„� S, ✓Gl�, Owner's Name: Date of Application:_ I hereby certify that: Registration is not required for the following reason(s): Work excluded by law [3Job Under$1,000 Building not owner-occupied E]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. Date i1tontractor Name Registration No. OR Date Owner's Name q:focros:Affidav The Commonwealth of Massachusetts Department of Industrial Accidents r vNeefilm S908ueos 600 Washington Street - - Boston,Mass. 02111 Workers' Co'm' ensation Insurance Affidavit name: ! city Ll 4,u u t S', P1W. @ a-6 0/ Dhone# 7 g 0-0 eV l ❑ I am a hbmeowner performing all work myself. ❑ am a sole etor and have no one wow in act I am an employer providing workers'compensation for sty employees working on this job. •::.::::._•:.:::.:.::.::i:::.......... :<:::;.::.: ........,.. ..... . . ;::::iii':. •fir ww:4}:?;??•i:->:.:.i: a �•trt,�`:,:... � :.:,.:. >: �.�' { Yk tv D ..::::::::::.:::.::::i;:: .:.. ..:. :!M:.: :. :: .:::: :::::.:::::::::::::nv:::::::h:•:::::::::::n.: ntaca:;: ✓t ':>.:::> i:;.i:;i;:.i::::............... ..insura ,...,,:. olicu.#::' �. ❑ I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have the following workers' ..........m policesr >' tbinD y •i}:i•;}iii} vi:4i'r:i}i;i:^i:v:•: ........... .......rh h .. ......................................n............, :.�: ..,..... <•:in:•:??•iii}}}i}i}i}i'.i:::?.;::nv::::::::::::::::::.v:i:::•::::::::::w::::::;:•}i:::4::::}i}:•::::::::4}i}}}}}}i}}:4i:.};:::::::::::::.v:::;::::.v:.v;:.::::::::............::••:•:.:::v: ::;.::�::.;�;:::::.:•::::::::: :::::::::.::::::.:::::::::::::::::::::::::::::::i::•i:•i:�:�ii:�i:�>}};� '-}•>::}: }>:-}:�»»:�>:.>:.>::?•}:•}:•}:;>:;•}••:}}:.;:•:::.;.::..>. :iii:> ::;:i:r':;;;:;::::;:::>r:• ;;::;;i i::i::i}::;.> ;.......;�4::.'4 .................... .........::.:. ............n....... .................:::......... .v:: ::.,}}}}}i':?•}}}:•}}}i}}}}}}:.:isw;::x:env:.v :::::::: .................... w:::n:v:::•::^ •}:::::':•}'v:"?::4:•:vn, ......... 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I understand ad a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage vetimtion. I do hereby euti/� the pains annd enaltiiees/ofperJury dsw die infonnalion provided above is&w.mid eoffat �a ✓�, J Hate Print name A/I `��/ B(j-r¢f b-.cl Ybme# 7 T�0- G,�Y f1laddly do not write ba this area to be completed by city or town ofhial peru license# Micensing Board mediate�is nguir ❑ electmen!x Oflee OHealthDepartment n: phone#; -_ ❑Other ------------ Ommd 9/95 PLU Information and Instructions 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 coatr-..6, 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 c: 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. , 4 Applicants . 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 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. 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. Please be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned io 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 questions. please do not hesitate to give us a call. i The Department's address,telephone and fax number. The Commonwealth Of Massachusetts Department of Industrial Accidents Me of Invesduatlons 600 Washington Street Boston;Ma. 02111 fax#: (617) 727-7749 phone#: (617) 7274900 eat 406, 409 or 375 I 0 x, �� - ��a..*`� � Wes"i"i .• ��q�,,tih`� 4tl's''S . IN Yll OR ill DEPARTMENT071 OF PUBLIC SAFETY 1 1 1' LICENSE � Ku t ------------ t + 119990811311942 hx is 86 BE HYANNIS, NA t 02601 f