HomeMy WebLinkAbout0034 STRAIGHTWAY �� \\J\ �f I �N ��
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TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
%7
Map Parcel V Application#
Health Division
Conservation Division a Permit#
Tax Collector Date Issued //X zO,6
Treasurer Application Fee $S m
Planning Dept. Permit Fee
Date Definitive Plan Approved by Planning Board
Historic-OKH Preservation/Hyannis I —
Pr oject Street Address V4nn
Village
Owner 1c,v► M11SWee 1e,i Address I M ci4✓101r'c, L_N YIIAS ee
Telephone Soft -53 5— /O&a
Permit Request Re p Igc 01J <ti�e�1 ✓o�� p to c l--Ij J�, s /G �c, oi� -P i1/rw Shoe�/oc�
o_,&G_,4,.1; eVedyi[a) eyAf } , F-� ^ i-5 GSe via era
Square feet: 1st floor:existing proposed 2nd floor:existing proposed Total new
Zoning District Flood Plain Groundwater Overlay
*Project Valuation 3;moo, Construction Type
Lot Size Grandfathered: ❑Yes ❑No If yes, attach supporting documentation.
Dwelling Type: Single Family &r' Two Family ❑ Multi-Family(#units)
Age of Existing Structure Historic House: ❑Yes O'No On Old King's Highway: ❑Yes O No
Basement Type: CJ'Full ❑Crawl ❑Walkout ❑Other
Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft)
Number of Baths: Full:existing _2 new Half:existing new
Number of Bedrooms: existing new 0
Total Room Count(not including baths):existing y new 0 First Floor Room Count
A16i Dad -
Heat Type and Fuel: was ❑Oil ❑Electric ❑Other
Central Air: ❑Yes U 1INo Fireplaces: Existing New Existing wood/coal stove: ees ❑No
Detached garage:❑existing ❑new size Pool:❑existing ❑new size Barn:❑existing ❑new size
Attached garage:❑existing ❑new size Shed:❑existing ❑new size Other: j
Zoning Board of AppealZo
rization ❑ Appeal# Recorded❑ ! K '
co :V
Commercial ❑Yes . If yes, site plan review#
-=— —.
Current Use Proposed Use f
BUILDER INFORMATION
Name �a� �5����•tPs� Telephone
Address I &--q oo/es Lam/ License#
J100 0 Home Improvement Contractor#
Worker's Compensation# /
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO ���►lD57YI"
SIGNATURE DATE
FOR OFFICIAL USE ONLY
PERMIT NO.
DATE ISSUED
MAP/PARCEL NO. "
ADDRESS VILLAGE
OWNER
r.
DATE OF INSPECTION:
FOUNDATION pip
FRAME
INSULATION
FIREPLACE
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
GAS: ROUGH FINAL
FINAL BUILDING
f
DATE CLOSED OUT
ASSOCIATION PLAN NO.
The Commonwealth ofMassachusetts
` Department of Industrial Accidents
Y Office'of Investigations
600 Washington Street
i Boston,MA 02111
www.mass.gov/din
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Wormattion Please Print Legibly
Name(Busiuess/Ora nization/Individual): Dq!3
Address: I' /yi�00 �f g Z4,1
City/State/Zip:_1A�nl� � s7i?a� hone#: S'3 �7
Are you an employer? Check the-appropriate box; Type of project(repaired):
1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑.New construction
employees(fall and/or part-time).* have hired the sub-contractoTs
2.❑ I am a sole proprietor or partner- listed on the attached sheet t [/Remodeling
ship and have no employees These sub-contractors have 8: ❑ Demolition
working for me in any capacity. workers' comp.insurance. 9. ❑ Building addition
[No workers'eoarp.insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
required,] officers have exercised their
34�-I am a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repairs or additions
myself.[No workers' comp. c. 152, §1(4),and we have no 12.[] Roof repairs
insurance required.] t . employees. [No workers' 13.0 Other
comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policyinformatioa: `
t Homeowners wbo submit this affidavit indicating they are doing all work and then hire outside contmctcrs must submit anew affidavit indicating such
tContractms that check this box must attached an additional sheet showing the name ofthe sub-contractors and their workers'comp.policy information.
ram an employer that Is providing workers'compensation insurance for my employees. Below is the policy andjob 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 a finical penalties of a
fine up to$1,304,.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
Investigations of the DIA far insurance coverage verification.
I do hereby certify under the pain dpenalties ofperjury that the information provided above is true and correct:
Si afore: r Date:
Phone#;
Off cid 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 3.Building Department 3.City/Town Clerk 4.Electrical inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone#�:
ini®rmaia®n ana mszructiuns
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*li4.oia1 or written."
An employer is defined as-"an individual,partnership,association, corporation dr 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 bean 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 ofpublic 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'canVensation affidavit completely,by checking the boxes that apply to your situation and, if
necessary,supply sub-contractors)name(s),address(es)and phone numbers)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 carry 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 confnmation of insurance coverage. Also be sure to sign and date the aff davit. 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.eater 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 mast submit multiple permitllicense 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 off cially 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. Anew affidavit must be filled out each
year.Where a&me 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 hike to thank you in advance fox 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 ent 406 or 1-877-MASSAFE
Revised 5-26-05 Fax#' 617-727-7749
www.mass.ao-v/M"a
I�
it RE Town of Barnstable
Regulatory Services
&'ST'"HM ' Thomas F.Geiler,Director
taws
Building Division
Tom Perry,Building Commissioner
200 Main Street, Hyannis,MA 02601
Office: 509-862-4038 Fax: 508-790-6230
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: Estimated Cost
Address of Work: ^3 y S�,af. kla� ,kyarri%S
Owner's Name: �a r /vl S Gtl t�✓�l c�
Date of Application: S— 2,-0(o
I hereby certify that:
Registration is not required for the following reason(s):
OWork excluded by law
El Job Under$1,000
MBuilding not owner-occupied
26;vner 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 PENALTMS OF PERDU-RY
I hereby apply for a permit as the agent of the owner:
Date Contractor Name Registration No.
5 O(o —)OR
Date Owner's Name
Q*mislomeaffidav
IKE ip Town of Barnstable
Regulatory Services
BAMSiABLE, Thomas F.Geiler,Director
9 MASS. g
t439• Building Division
�A/FD MAC a
Tom Perry,Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION
Please Print
DATE:
JOB LOCATION: 3V
numb r street village
"HOMEOWNER": ! 4 Y11*d /��Sv�c Pn c°.� S°8 -539-i06� Sodr-�'LZ`(vo7'd
name home phone#/ work phone#
CURRENT MAILING ADDRESS:
city/towli state zip code
The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and
to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as
supervisor.
DEFINITION OF HOMEOWNER
Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to
be,a one of two-family dwelling,attached or detached structures accessory to such use and/or farm structures. A
person who constructs more than one home in a two-year period shall not be considered a homeowner. Such
"homeowner"shall submit.to the Building Official on a form acceptable to the Building Official,that he/she shall be
responsible for all such work performed under the building permit. (Section 109.1.1) -
The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other
applicable codes,bylaws,rules and regulations.
The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department
minimum inspection procedures and requirements and that he/she will comply with said procedures and
requirements.
l
Signature of Homeowner
Approval of Building Official
Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the
State Building Code Section 127.0 Construction Control..
HOMEOWNER'S EXEMPTION
The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions
of this section(Section 109.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such
work,that such Homeowner shall act as supervisor."
Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q,
Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly
when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed
Supervisor. The homeowner acting as Supervisor is ultimately responsible.
To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,
that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by
several towns. You may care t amend and adopt such a form/certification for use in your community.
Q:forms:homeexempt
r �
6�
✓ S
d
Q
IMPORTANT
ANY CONSTRUCTION THAT INCREASES.LIVING SPACE
BEYOND 1200 SQ. FT. PER LEVEL MAY,REQUIRE THE
INSTALLATION OF ADDITIONAL SMOKE 'DETECTORS
NOTE: A SEPARATE PERMIT IS REQUIRED FOR THE,
INSTALLATION OF SMOKE DETECTORS-THE ELECTRICALS
PERMIT DOES NOT SATISFY THIS REQUIREMENT. �y
YOU WISH TO OPEN A BUSINESS?
For Your Information: Business certificates (cost$30.00 for 4 years). A business certificate ONLY R�EGIERS YOUR NAMEin town (which
you must do by M.G.L.-it does not give you permission to operate.) Business Certificates are availableTown Clerk's Office, 1"FL., 367
Main Street, Hyannis, MA 02601 (Town Half)
DATE: '
Fill in please:
APPLICANT'S' YOUR NAME: A N a+-p -t r V 1 V i+-�,k
x Y BUSINESS YOUR HOME ADDRESS:
+
TELEPHONE # Home Telephone Number o (
NAME OF NEW BUSINESS O
CAV\5 u pv1 TYPE OF BUSINESS a rZ o,/
IS THIS A HOME OCCUPATION?'.. YES NO .
Have you been given approval from the building divig0P. 'YES NO
ADDRESS OF BUSINESS 3 Lt _16v^ca C K-t w V\ MAP/PARCEL NUMBER z�,(, 7 94
�wiS p2 " �
When starting anew business there are several things you mus o in order to be in compliance with the rules and regulations of the Town of
Barnstable. This form is intended to assist you in obtaining th formation you may need. You MUST GO TO 200 Main St. - (corner of Yarmou
Rd. & Main Street) to make sure you have the appropriat permits and licenses required to legally operate your business in this town.
1. BUILDING_COMMISSIONER'S OFFICE
This individual has been informed of any per requirements that pertain to this type of business.
Authorized Signature-** ��
COMMENTS:
2. BOARD OF HEALTH J '
This individual has been infor d of the permit requirements that pertain to this type of business, �\
Authorize Signature** V
COMMENTS- .
Ily
3. CONSUMER AFFAIR (LICENSING AUTHORITY)
This individual has been informed of the licensing requirements that pertain to this type of business.
Authorized Signature*
COMMENTS:
F
Town of Barnstable *Permit#
Expires 6 months from issue date
Regulatory Services Feeo 15— a '
Thomas F.Geiler,Director X ®RES
pEr
Building Division
Tom Perry,CBO, Building Commissioner NOV 1 e 2OQ
200 Main Street,Hyannis,MA 02601
www.town.bamstable.ma.us TOWN OF BA�j[�(�'[��
Office: 508-862-4038 Fax: 508=/yU=b'1 3LEZ..
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
Not Valid without Red X-Press Imprint
�LMap/parcel Number
Property Address
Residential jWalue of Work t32Q. Minimum fee of$25.00 for work under$6000.00
Owner's Name&Address
Contractor's Name a,®-►i �t,J�-t_•�-c'� Telephone Number-5 V $,1e�� "(o O 70
Home Improvement Contractor License#(if applicable)
Construction Supervisor's License#(if applicable)
❑Workman's Compensation Insurance
Check one:
❑
Yam a sole proprietor
m the Homeowner
❑ I have Worker's Compensation Insurance
Insurance Company Name
Workman's Comp.Policy#
Copy of Insurance Compliance Certificate must be on file.
Permit Request(check box)
Re-roof(stripping old shingles) All construction debris will be taken to
❑Re-roof(not stripping. Going over existing layers of roof) /1L" (� , (�
❑ Re-side cc V ; .
,eReplacement Windows. U-Value /,0'W4 (maximum.44)
U�
*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 Improvem nt ontractors License is required.
SIGNATURE:
Q:Forms:expmtrg
Revise071405
k�l N iicc,L.vncinvnrveutcii UJ 1rLu5J(1Cn[iJei[J
. Department oflndustrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www-mas&gov/dia .
Workers' Compensation Insurance Affidavit: Builders/Contractors/El ectridans/Plumbers
Applicant Information Please Print Legibly
Name (Business/organization/h&vidual): r-to( rS'�rr,^-e
Address: r k06 r,10 /r*i7
City/State/Zip: 54,0 PQ .0A-Y7Phone#:
Are you an employer? Check the-appropriate box:. Type of project(required):
1 f❑ 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 El NewNew construction _
;; ❑ I am a sole proprietor or partner- listed on the attached sheet $ 7- E 1i odelmg
ship and have no employees These sub-contractors have `` 8. ❑ Demolition
working for mein any capacity. workers' comp. insurance. 9 ❑ Building addition
[No workers'comp. insurance 5• ❑ We area corporation and its 10.❑ Electrical repairs or.additions
r ed.] officers have exercised their ep
3.Pfarri a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself. [No workers' comp. c. 152,§1(4), and we have no 12,D-Rro-of rep
airs
insurance required.]t employees: [No workers'.
comp.insurance required.] 13.❑ Other
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information: �R
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such
tcontractors that check this box must attached an additional sheet showing the name of the contractor sub- and their workers'comp,policy information.
I am an employer that is providing workers'compensation insurance for my employees.'Below is the policy 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 statementmay be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the wins and pe ties of pedury that the information provided above is true and correct
i afore: Date: ,
Phone#:
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):
I.Board of Health 2.Building Department 3.City/Town Clerk 4..Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions
Fes,
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 I. individual,pagnership,« 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. How�ver: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. p.
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractors)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 carry 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 permitllicense 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 o (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 bum 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-Washingfon Street4 .
Boston, MA 02111.
Tel.#617-727-4900 ext 406 or-1-877-MASSAFE
Fax#617-727-7749
Revised 5-26-05 www.ma'ss.gov/dia
FRIEDLINE& CARTER ADJUSTMENT, INC.
436 Main Street, P. O. Box 338
Hyannis, Massachusetts 02601
Tel. (508) 771-3232
FAX (508) 790-2344
r
TO: Building Commissioner or Inspector of Buildings
( ) Board of Health or Board of Selectmen
( ) Fire Department
TOWN OF Hyannis
TOWN HALL
MA
RE: Insured: CHAFE, Patrick&Deidre
Property Address: 34 Straightway
Hyannis, MA
Policy Number: H09809279
Type of Loss: Fire
Date of Loss: 4/23/2003
File#: 96450
Claim has been made involving loss, damage or destruction of the above captioned '
property,which may either exceed $1,000.00 or cause Mass. General Laws, Chapter 143,
Section 6 to be applicable. If any notice under MGL, Ch. 139, Sec. 3B is appropriate,
please direct it to the attention of this writer and include a reference to the captioned
insured, location, policy number, date of loss and file number.
On this date, I caused copies of this notice to be sent to the persons named above at the
addresses indicated above by First Class Mail.
a �
N. LAGUE
Adjuster
4/25/2003