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Location: 35 WASHINGTON STREET
309262
N46 Owner: DE SOUZA, MARCOS ANTONIO 7
f Location Infformation
.z Map & Parcel 309199
+ Location 35 WASHINGTON STREET
Acreage 0.18 acres
�i 327022 t
#32 !E i
Current Owner
Mailing Address DE SOUZA, MARCOS ANTONIO 7
a46 U b„ SOUZA, ELIZABETH FERREIRA
309199,x " '"
ALM EIDA
125 MAIN 5 T
DENNISPORT, MA 02639
Appraised Value (FY 2009)
Extra Features $12,000
Out Buildings $0
Land $107,600
Buildings $125,800
309198 Total Appraised $245,400
327010 Assessed Value (FY 2009)
38 Feet
NIB Extra Features $12,000
Out Buildings $0
C" :_ Land $107,600
Set Scale 1" = 38 Aerial Photos k;;F MAP DISCLAIMER Buildings $125,800
Copyright 2005-2008 Town of Barnstable,MA All rights reserved.Send questions or comments to GIS
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O O O O O O O O O O O: O O�O O O O O O O.O O O O O O�O O O O O O O O O O O O•'O 0 0 0 0 0 0 0 0 0 O'O.........0 0 0 0 0 0 0 0 0 0 O O O O O O RANSACTIONS
.....:. ..... ............................................................. . ..:.................................
...
Town Buyer Buyer 2 Seller;Seller 2 ...... ....... Address .... .........Pricg
Barnstable Stanley Dean F ' Jones,Stephen B Hill,Casper.W.................. 263 Cammett Rd ...........$165 000
Bamstable Barreiro Felis� berto� Desouza,MarcosAntomo Souza EhzabethFerreiraA `35Washmgton'St $150000 .
Barnstable Herlihy Mark Obribn Stephen B Jr Obnen Mary K 44 Headwaters Rd "'.�$325 000� '
Barnstable Lrthwin•Roy A Lithwm;Wendy M Ellsworth Camilla C „ 242 Winding Cove Rd $333 000
Barnstable `Lunenfeld,Matthew L;Cunenfeld Lrsa N ,:Masci Susan Pleasant Realty Nominee Trust: 14 Periwindle Dr $299 900
Barnstable Thompson Kimb@rly M KirnhdyMThompson'Tms(10%Code Realty'Lic 68 Center St $270 000
Barnstable Gadoury,Vincent J.Gadoury.Elizabeth A Nickulas,Georgette R;Ford Christine M..:..94 Waterfield Rd .:..:....:.$240,000'
Barnstable Wolsky;Gilbert;Wolsky,Betty Ann ......Craig;Paul-: `:. 38 Indian Pond Point.$1,3p0,000
Barnstable. Vecchione,Nancy Jane Field,Melvin D.:.......... ....::..: ..........Long Beach Rd..........$1,525 000�. £,
Barnstable Ochoa,Demian J;Hartman,Hilary .......Hufnagel,Adam;Hufnagel,Adam M 133 Phinneys Ln..:.....:..$230,000
Barnstable Burleson,Barbara ...e - Silverman,Moses David Silverman David .3040 Falmouth Rd' $1.1,5,000
Barnstable Ellis John P;Ellis;Laurie J Elks Joari E,Ellis,James 0 3200 Mam St $300;000_
Barnstable Grasso Donald J;Grassso Carolyn Pt math William J Smith, Frances;C 173 Seth Parker Rd $335,000. V
as pee Baker Melinda E;Baker,William J.Jr arter Pamela W LbbRealty Trust 73 South Sandwich Rd $239 000 -
Maslipee :Tfiapa Naresh;Gautam Punam '` Adams Laura A Dasufa Dean,A` 53 Dee�Ridge Rd .......$280 000`.
Mashpee Lehahan,Jofin F;Burrell Phillip J Cloutier,Amanda;Hronek,Louis A .....392 Great Neck Road North $333,167
Mashpee 'Thibodeau,Matthew W ....Mero;Robert H 81 Sunset Strip............$183,000
Sandwich Fraser,Stephen D;Balducci Judith E Bautz,Craig M .... ..18 Settlers Path .... $310 000
Sandwich Camiolo,Donna M,263 Phillips Rd Nominee Realty Trust Lott,Gregory Miller..... .........................263 Phillips Rd...... $525,000
Sandwich Nurse,Ronald W Jr;Nurse Lisa A Hichar,Joseph K Hichar Barbara J 219 Cotuit Rd $200 000
Sandwich Miller,Luke P;Miller Anne F * Wiliam§ Bruce C,Dur can Estelle Vera ..:..31 Windswept Dr $255;000.
Yarmouth Hill Robert T'Hill Donna L Herrmann;Robert 0,Herrmann Constance 12 Dundee Dr $490;000 ...
Yarmouth Wirth James`F Wirth Teresa A .. Georges John P Georges Armantla C 76 Country.Club Drr "$410,000.'
Yarmouth Niedermerer,Jerome J Nietlermerer Helen G Mcgourty,Walter V Walter V Mcgourty Trust` 25 Campion Rd $410 000
Yarmouth . Cronin Tara D Habitat For Humanity Cif Cape C,'Od Inc..... 50:$wan'Lake Rd .` $105 000 f
Yarmouth Moore;William JJr ..... Manolis,Demetnos Manohs'Valene L 8 Marion Rd $245,000 t
Yarmouth Proc Jennifer L Proc;Cynthia L..:. Karpinski,Maciel ....... ... .......: BAmos'Rd ...•......$140,000 .
Yarmouth Kimball;Angela G;Kimball,Peter V Karyanis,Charles R,Kollias,Carol C 84 Homers Dock Rd .:$383,000,
Yarmouth Mcallister,Sean Mcalhster,Maureen Handel,Robert 638 Route 28 $70 000'
Yarmouth Ohare Wdham F Ohare Jo Ann M Federal National Mortgage Associahon;Fannie Mae; 25 Cottage Dr r $180 000=
Yarmouth Tarr KellyA ?. Mcfarland,Todd M Mcfadand LauraA 248 Camp St $187 500
Yarmouth Newton Robert L Weiss Marsha'E Johnson,,Raymond -!Johnson,Debra A 665 Willow St t $360 009
Yarmouth Aigurer Brenden Goulart All 9'. ...Marshall,William J,Ma.ichle Cynthia R 105 Webbers Pafh $224:;000
Yarmouth Pieties James 0 ....Bennett Lois A;2007 LoisA Bennett Revocable Trust 248 Camp St $173 500:
Yarmouth ' Deutsche Bank Trust Company Americas..1Nalls,Troy A' .....::.".................................97 Cranberry Ln..... $438 264
Yarmouth Difonzo,Joseph A;Difonzo,Pamela M.......Deutsche Bank National Trust C,0................638 Main St ...:................$44,625
-Yarmouth Murray,Christopher A;Murray,Janis .:........Rogers,Paula;Murray,Janis;Murray,Janis 12 Squirrel Run..............$115,000
Town of Barnstable
Regulatory Services
9MAS& �" Richard V. Scali, Director
�A 16g9.
>fn N,or A Building Division
.Thomas Perry, CBO
Building Commissioner
200 Main Street, Hyannis, MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
April 24,2014
I Debra Barrows, Administrative Assistant to the Town of Barnstable Building Department
certify this is a True Attested Copy for all copies from the Building Department file for 35
Washington Street, Hyannis MA-
C7OPY ATTEST
Debra Barrows ..
Administrative Assistant
Town Clerk
SARNSTABLE
Witness
Town of Barnstable *Permit
318b'1SN8y8.10 NMOl Expires 67mo �Vom issue date
50 _ Regulatory Services Fee
OZ ��Q Thomas F.Geiler,Director
11W113d Building Division
om Perry,CBO, Building Commissioner
200 Main Street,Hyannis,MA 02601
'. www.town.bamstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
p Not Valid without Red X Press imprint
Map/parcel Numbei�r 30�'l q'�
Property Address
❑Residential aloe of Work O •C3A Minimum fee of$25.00 f r ork under$6000.
Owner's Nam
3�, ult4sl�r��� s� •
Contractor's Name Telephone Number
Home Improvement Contractor License#(if applicable)
Construction Supervisor's License#(if applicable)
❑Workman's Compensation Insurance
Check one:
❑ I am a sole proprietor
I am 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)
❑ Re-side
❑ Replacement Windows. U-Value (maximum.44)
*Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
***Note: Property Owner must sign Property Owner Letter of Permission.
H e Improvement Contractors License is required.
SIGNATURE:
Q:Forms:expmtrg
Revise071405
. Department of Industrial Accidents
i .
Office.of Investigations' ' .
' 600 Washington Street
o, yea
Boston,AM 02111'
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plnnabers
Applicant Information Please Print Legibly
Name (Business/orga=ationdndividual). //lil ARG'D
Address: 35 ; w11SA1U6-;i • S T
City/State/Zip:�wy�t�i 1/ 14 ,za.Wo'l Phone#: �S d — 36 1�-
Are you an employer? Check the-appropriate box:. Type of project(required):.
1.❑ I am a employer with 4. ❑ I am a general contractor and I
6. ❑ New construction
employees (full'and/or part-time).* have hired the siib-contractors 7. Remodelin
2.❑ I am a sole proprietor or partner- listed on the attached sheet I g
ship and have no employees These sub-contractors have 8. Demolition
working for me in any•capacity. workers' comp.insurance. _ g. Building addition
[No workers' comp. insurance 5. ❑ We are a-corporation and its 10.❑ Electrical repairs or.additions
required,] officers have exercised their
3. I am a homeowner doing all work right of exemption per MGL ME] Plumbing repairs or additions
myself.(No workers' comp, c. 152, §1(4),and we have no 12.0 Roof repairs
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: �
t Homeowners.who submit this affidavit indicating they sae 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 sub-contractors 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 statement maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify nder the pains and penalties of perjury that the information provided above is true and correct
Sf atur - —- �. '
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):
1.Board of Health 2.•Puilding Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#•
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employes: s'
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."
association,gorporation'or other legal entity,or any two or more
An employer is defined aS._�ind�Slpah.:P���P�. . . •
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. Howfvier:tle
owner of a dwelling house having not more than three apartments and who resides therein,or.the occupant of the
do maintenance,construction or repair work-on such dwelling house
dwelling house of another who employs persons to
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 perfoanance 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 rt your situation and,if
necessary,supply sub-contractors)name(s), address(es)and phone number(s)along with their certificates)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 far confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned 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'
use call the Department at the number listed below.. Self-insured companies should enter
compensation Policy,please 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
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 thata valid affidavit is on file for,future permits-or liceaases..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
would hike to thank you in advance for your cooperation and should you have any questions,
'ons Y -
The Office of Investigate
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 qtf nvestigations
600 Washington Street .
Boston,MA 02111..
Tel.#617-727-4900 ext 406 or•1-877-MASSAFE
Fax#617-7274749
Revised 5-26-05 www.mass.gov/dia
COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, ss. SUPERIOR COURT
C.A. No. BACV2014-00033
BARNSTABLE COUNTY MUNICIPAL )
MUTUAL INSURANCE COMPANY as )
Subrogee of FELISBERTO BARREIRO )
Plaintiff, )
V. )
HOP ENERGY, LLC d/b/a THE OIL )
EXPRESS )
Defendant. )
AFFIDAVIT FOR RECORDS
As custodian of the attached records,I hereby certify that the enclosed s
(number of pages) are a true, complete and accurate cop of records relating to.35 Washington
Street, Hyannis,MA 02601 for the period covering O Z to �-/U j d These
records are produced in response to the duly-issued Subpoena of the defendant,HOP Energy,LLC
d/b/a The Oil Express. I further certify that it is the regular practice of the Town of Barnstable,
Building Division, to make such records;that these records are maintained by the Town of
Barnstable,Building Division,in the regular course of business; that these records were made
contemporaneous to the event(s) which they describe; and made by a person(s) with knowledge of
the event(s) described therein.
Subscribed and sworn'under the pains.and penalties of perjury this p? day of
A �- ,2014:
Signature
Printed Name
lcdm�ir:
Title
O
COMMONWEALTH OF MASSACHUSETTS
BARNSTABL$,ss. SUPERIOR COURT `
C.A.No.BACV2014-00033
BARNSTABLE COUNTY MUNICIPAL `
MUTUAL INSURANCE COMPANY as )
Subrogee of FELISBERTO BARREIRO ) M.R.C.P.
Plaintiff, ) RULE 30(a)AND RULE 45 j
V. )
HOP ENERGY,LLC d/b/a THE OIL )
EXPRESS ) A TRUE COPY ATTEST
Defendant. )
APR609�
Pak
TO: Keeper of Records DEPUTY SFIE�IFF
Town of Barnstable
Regulatory Services Department .
Building Division
200 Main Street i
Hyannis,MA 02601 Ii
Greetings:
YOU ARE HEREBY COMMANDED in the name of the Commonwealth of Massachusetts in accordance-,with the
provisions of Rules 30(a)and 45 of the Massachusetts Rules of Civil Procedure to appear and testify on behalf of the
defendant,HOP Energy,LLC d/b/a The Oil Express,before a Notary Public of the Commonwealth of
Massachusetts,at the office of BARTON GILMAN,LLP,Attorney Greg Vanden-Eykel,160 Federal Street,in the
City of Boston,on May 8,2014 at 1:00 p.m.,and to testify as to your knowledge,at the taking of the deposition in the
above-entitled action.
And you are further required to bring with you all documents requested on the attached Schedule A..
IN LIEU OF A PERSONAL APPEARANCE,COPIES OF THESE RECORDS MAY BE MAILED WITH
THE ATTACHED AFFIDAVIT CERTIFYING THAT SAME ARE TRUE AND CORRECT COPIES OF
ALL REPORTS AND RECORDS ON FILE.
HEREOF FAIL NOT AS YOU WILL ANSWER YOUR DEFAULT UNDER THE PAINS AND '
PENALTIES IN THE LAW IN THAT BEHALF MADE AND PROVIDED
Dated:April 17,2014
EdwarA Shoulkin B.B.O.No. 555483 N T' �UBLIC
eshoulkin@bartongilman.com .
Greg Vanden-Eykel I B.B.O.No.682397 C.WDONALD
gvandeneykel@bartongilman.com Nfty pwft
BARTON GILMAN,LLP
160 Federal Street m
Boston,MA 02110 AW.M29,201g
(617) 654-8200 1 (617)482-5350-Fax
i 4
f
SCHEDULE A
1. All documents and communications concerning Felisberto Barreiro and/or the
property located at 35 Washington Street, Hyannis, Massachusetts 02601 ("Property")
between January 1, 2007 and the date upon which the Building Division responds to
this subpoena.
2. All documents, including but not limited to,permits generally, permits for
demolition, permit applications, reports, memoranda, journals, notes, building code
citations concerning the Property between January 1, 2007 and the date upon which
the Building Division responds to this subpoena.
3. All documents concerning the Aboveground Storage Tank ("AST") and/or the
heating equipment located on the Property between January 1, 2007 and the date
upon which the Building Division responds to this subpoena.
4. All photographs,videos, and/or other recordings concerning the AST, the heating
equipment, and/or the Property.
5. All communications (written and/or electronic) between the Building Division, and
Felisberto Barreiro, his tenants, and/or any contractors working on Mr. Barreiro's
behalf concerning the AST, the heating equipment, and/or the Property between
January 1, 2007 and the date upon which the Building Division responds to this
subpoena.
6. All communications (written and/or electronic) between the Building Division and
any person not identified in the preceding paragraph concerning the AST, the heating
equipment, and/or the Property between January 1, 2007 and the date upon which
the Building Division responds to this subpoena.
7. All other documents and/or things concerning and/or relating in any way to the
Property between January 1, 2007 and.the date upon which the Building Division
responds to this subpoena.
As used herein, the terms "documents, "communications," "concerning," and "persons"
shall be'defined as set forth in Superior Court Standing Order 1-09,where appropriate.
Further the terms "documents" and "communications" shall be deemed to include both
hard copy and Electronically Stored Information, including but not limited to e-mails, text
messages, and/or social media postings.
B A R T ❑ N o G I L M A N PLEASE RESPOND TO BOSTON
GREG VANDEN-EYKEL
gvandeneykel@bartongilman.coin
www.bartongilman.com
April 17, 2014
Keeper of Records
Town of Barnstable
Regulatory Services Department
Building Division
200 Main Street
Hyannis, MA 02601
Re: Barnstable County Municipal Mutual Insurance Company as Subrogee of
Felisberto Barreiro v. HOP Energy, LLC, d/b/a The Oil Express
Barnstable Superior Court, C.A. No. 14-00033
Dear Sir or Madam:
We represent the defendant, HOP Energy, LLC d/b/a The Oil Express,in the above-referenced
action. Attached to this letter is a subpoena requiring you to produce all records relating to Felisberto
Barreiro and/or the property located at 35 Washington Street, Hyannis,Massachusetts, as identified in
the Schedule A attached to the subpoena. The date of this deposition is May 8, 2014, at 1:00 p.m. at
our Boston office. However,we will not require your actual appearance at the deposition if
you provide us with a copy of the records. If you choose to produce the records in lieu of
appearing for the deposition, please notify us of your intent to do so.
We are also enclosing an Affidavit for Records. Please sign the affidavit and return it along with
a complete copy of the requested records. This affidavit will serve to authenticate the records in
lieu of your appearing to do so. Please contact my paralegal,Jeff McDonald, upon receipt of the
subpoena if you have any questions or comments.
Thank you for your attention to this matter.
Very truly yours,
C
Greg Vanden-Eykel
GVE/jcm
Enclosures
Barton a Gilman LLP
160 Federal Street Boston,MA 02110 P 617.654.8200 o F 617.482.5350 0 10 Dorrance Street o Providence,RI 02903 o P 401.273.7171 F 401.273.2904
t TOWN OF BARNSTABLE,BUILDING PERMIT APPLICATION
Map 6 Parcel` 'l �,p icatio 2# [
Health Division Date Issued
Conservation Division C �� Application Fee
Planning Dept. Permit Fee �n
Date Definitive Plan Approved by Planning Board P I V
Historic - OKH _ Preservation / Hyannis
Project Street Address Ptr1s11 5
Village A'Y AI-%f)15. _
Owner�l�— i$ 19C. s yep Address
Telephone 6biB &q - %+ 7-7 0
Permit Request L
Square feet: 1 st floor: existing CIO proposed 2nd floor: existing. _proposed Total new _i1fo
Zoning District _Flood Plain Groundwater Overlay
Project Valuation *A ft Construction Type
Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation.
Dwelling Type: Single Family ❑ Two Family dlt` Multi-Family(# units
Age of Existing Structure 6
g g ' 0'�' Historic House: --Yes ❑ No On Old King's Highway: ❑Yes WAlo
0 Basement Type: ❑ Full tWrawl ❑Walkout ❑ Other
o Basement Finished Area (sq.ft.) Basement Unfinished Area(sq.ft)
�\ Number of Baths: Full: existing 2. new `Z Half: existing 1 new _
Number of Bedrooms: _ existing+new ; 1 '
zE
Total Room Count (not including baths): existing i_new First Floor Rooml COUntt . „
Heat Type and Fuel: ❑ Gas _ -Oil ❑ Electric ❑ Other
Central Air: Lf Yes ❑ No Fireplaces: Existing ( New Existing wood/coal stove❑Y6s @475
Detached garage: ❑ existing ❑ new size—Pool: ❑existing ❑ new size _ Barn: ❑ existing Ghnew ize_
r—
Attached garage: ❑ existing 0 new size.—Shed: ❑ existing ❑ new size _ Other: w M
PtZoning pp Board of Appeals Authorization ❑ Appeal # Recorded ❑
pp
Commercial ❑Yes ❑ No If yes, site plan review#
`Current Use - T Proposed Use
APPLICANT INFORMATION
(BUILDER OR HOMEOWNER)
L)LL4in 5 1 e, a3Nes c''tl oo e 0.1-AreA
Name _�dnr 4t� iau'. Telephone Number 1
Address ?,46 ML tZO M "A111044 License
Home Improvement Contractor#
Worker's Compensation #
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO.
SIIGNAT m - DATE I 1
" FOR OFFICIAL USE ONLY
APPLICATION#
DATE ISSUED
MAP./PARCEL NO.
S '
t: ADDRESS VILLAGE
OWNER
DATE OF INSPECTION:
FOUNDATION
FRAME
INSULATION '
FIREPLACE
ELECTRICAL: ROUGH FINAL -
PLUMBING: ROUGH FINAL -
GAS: ROUGH FINAL
r -
-,-;FINAL�BUILDING.,
t
III . � •
DATE CLOSED OUT
ASSOCIATION PLAN NO. ,
3
r The Commonwealth of Massachusetts
Department of Industrial Accidents
�6 Office of Investigations
600 Washington Street
t 4i;ru
.Y
Boston, MA 02111
ev~" www.mass.g ov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumberg
Applicant Information Please Print Le0bly
Name (Business/organizationflndividual):
Address: ?d6 !
City/State/Zip: 6WI MAC,. Phone #:_7_11- 2-38
Are you an employer? Check the appropriate box: Type of project(required):
am a employer with 4. ❑ I am a general contractor and I 6 ❑ New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet $ ❑ Remodeling
ship and have no employees These sub-contractors have S. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their
10.❑ Electrical repairs or additions
3.❑ I am 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.❑ Roof repairs
insurance required.) t. employees. [No workers' 13.0 Other
comp. insurance required.]
*Any applicant that checks box#I 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.
ZContractors that check this box must attached an additional sheet showing the name of the sub-contractors 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. #:VJ C°J Wf-t Z Zb`3— Expiration Date: d
Job Site Address: W05(s1 Y'L1� Sef 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 maybe forwarded to the Office of
Investigations of the DIA insurance coverage verification.
I do here certify der r ains and per es of perjury that the infonnation provided above is true and correct.
Si ature: Date:
Phon #: -
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 S. Plumbing Inspector
6. Other
Contact Person: Phone#:
Information and Instructions T
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 chapter152, §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 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 Iisted below. Self-insured companies should enter their
self-insurance license number on the appropriate he.
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"ail 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 proofthat 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 4
Department of Industrial Accidents
Office of Investigations
600 WasEngton Street
Boston,MA 02111
Tel. # 617-727-49.00 ext 406 or 1-877-MASSAFE
Revised 5-26-05 Fax 4 617-727-7749
www.mass..gov/dia
,15 .Ju'1 2011 12: 22PM HP LASERJET FAX P• 1
07/15/2011 10:32 FAX 6174886501 UNDER'kRITIND
f001/001
MMW=7111 1
THIS CERTIFICATE tS WUED A8 A MATTER OF INFORMATION ONLY AND CONFERS NO R113HYS UPON THE CERTIFICATE HOLDER,THIS CERTIFICATE DOES NOT
AFFIRMATIVELY OR NEGATIVELYAMEND,EXTEND DR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES
NOT DONSTRUTE ACONTR'ACT BETWL'l11,I THE ISSUING WSURER(SN AUTHORtte0 RjpRQSENRATiVe OR PRODUCER,AND THE CERTIFICATE HOLDER,
IMPORTANT,. Ire*coTD6eate holder re on ADDITIONAL INSURED,#w PC4GyQos} uat be endorsel If SUBROGATION 13 WAIVED,aubleot 10 ttu teams and carKnons
Of th0 Polley,dell,,pollelr R18 roRuiro sTI nndpM•mont. A stedT:uneM On this co Cato does not confer rights to the cortlilce/e gOlQer In hau of such endorsomOrAx(a).
CONTACT
PRODUCM
Paul PC=Agency,Inc. tAICIC,N.E,Rr (508)477-0021 FAX ft l
AIL
680 Faimoutb Road ADDRESS:
Maghipee,MA 02649 PAT1nt{T FR
INSURERS AFFORDING COVERAGE NAIC R
INSURED INBURERA Atlantic Charter Insurance Company VL?AC
INSURERS:
Oceanside Construction,itw.
ASSURER C:
419 River Road INSURER D:
Marston Mills,MA 02648 INSURER E'
JNSVRER F:
COVERAGES: CERTiFICATL NUMBER: REVISION NUMBER.
TfuBfE TO CoRT"THATTRE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISBUEDTOTtE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF AMY CONTRACT OR OTHER DOCUNENT'WITH RESPECT TO WHICH THIS
CERTIFICATE:MAY RE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY TILE POLICIES DESCRIBED IEREIN 19 SUBJECT TO ALL T'HE TERMS,
rXCL.V&* !ANO CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,
NnR Twt Or INIWRJWCE AOOL Z.. PIQUrYNUMBlR POucyEFFECTN! Soucy ExPw►nDH uMrTS
LTR low V'M DUTE(MM MO"j DATE(MMAOFirn M Thou"AI16}
CENFAALLYLBIUTY N0WARREMM I
E TD RENTED PREMISE6 E
CDMMERCIAI OELEML 1y9t1TY LE,nea.M'rnw
�FMaMADE OCCUR ❑D MMEw%07—P-4)
eA6DIw 6A17v11uURY 16
EAEI ALAGMEGAT% a
OEN'LAOGREGAIR LAAI AAPLIEE PER RODDGTl-COOJW AGO I
POLICY❑PROJECT LOC
ANrOMOEILE W6gJTT COMBINED SINGLE UMR i
IE"Amaenl) �_
ANYAUTO - BODILY INJURY
f
ALL OVdEO AVR pwAe•+erl Os I
B9GLY INALIR'r 6
eCNEDULED AUTOS Ma Awwe,q
WIRE)AUTOS PROPERTy0AMA0E 6
NONOVWCE0 AUT06 Cb ACVCV„0
6U1S MEW o � PACH OCCURRENCE I
LIAMUTY
EXCEEBLNa CLAINSALADE ♦ AGGREGATE 6
i
RETCNTION ,. , j
weRasLOMP¢69ATONAIID WCV00617206 02103/2011 Q/03/2012 X V""I��` onleR
A WYER6'Uskujrf r
ANYP9OPR15T'DR0AR,NlRJFxwUTNE YIN
O�Cr-APJELweI�V N Nu O EAc+EaocIDENT s 1,000,000
muom y ANN
s,..aery 0s v ea 6PECML PRON6+OWB DMOw OLSEASE-POLICY LIMIT 6 1,000,000
DMEASE-EACH EMPLOYEE It 1,000,000
OTTER FI
aFaaetPTtoR OF wERA7I0R6R,0CAnQWfflE"CLlA IArA%h ACORG Lei,Additiard Romeo 6d1MIA,it MM"Pico Y IMlindl
SHOULO ANY QF THE A60VE DESCR®SD POLICIES BE CANCELLED EEFon THE
EXPIRATION DATE THEREOF,THE 13$14ING COMPANY WILL ENDEAVOR TO MAIL
12 DAYS YVWnN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
BUT FAILURE TO D 0 SHALL IMPOSE NO OBLIGATION OR LIABILITY
OF ANY KIND UylktHE INSURER.ITS tCgy§OR REPRESENTATIVES.
AvnlDluzm
6 cOKPDRATION.All rights Pesarred.
Paps 1 of CERTIFICATE HULDER COPY
J,UI. 1.9. 2011 3: 18PM No. 3884 P. 1
ONSTAROne
NSTAR Way,SW330
EL EC TRI e Wastwood.MA 02090-9230
OAS Phone/FAX 781.441.3334
juslin.telhl@nster.com
July 19, 2011
Felisberto Barreiro
35 Washington St
Hyannis MA 02601
RE: 35 Washington Street WO#01838850
To Whom It May Concern:
At NSTAR, we're committed to delivering great service.
This letter serves as confirmation that, as of July 19, 2011, the electric service to 35
Washington Street, has been removed.
Based on this information, there is no electric power at this address and you may proceed with
the demolition. If you have any questions, please contact me at (781)441-3334.
Sincerely,
Justin Reihl
New Customer Connects
}
FROM :HYANNIS WATER SYSTEM FAX NO. :508 790 1313 Jul. 05 2011 02:45PM P1/2
f141 Department of Public Works 47 Old Yarmouth Rd,
Water Supply Division P.O.Box 326
Hyannis,MA.
• BARNSTABLE, 02601.0326
MASS TEL:508.776-0063
, 039. ,�°� Hyannis Water System Operations FAX,509.790.1313
July 5, 201 1
Town.of Barnstable
Building Inspector
Town .1:Ia.11
Hyannis, MA 02601
Acct# 605294—35 Washington Avenue-Hyannis
Dear Sir.
please be.advised that the above water service was shut off and the meter removed on July 5, 2011. The
service was cut and capped today by the contractor with Ocean Side Construction. The owner is
demolishing the existing building.
If you have any questions, please call the office at (508)775-0063.
Sincerely,
e J,,V,
Jayne Starelc
Hyannis Water System
nationalg rid
July25,2011
Oceanside Construction and Development
Attention: John Hutchins
Re: 35 Washington Street,Hyannis,.Ma.
This Getter is to.notify you that after our investigation it has been determined that there is
no gas being supplied to 35 Washington Street,Hyannis,Ma.
If you have any questions,please feel.free,to.contact me at 781=907-2930.
Sincerely,
Diane.L. Stevenin
Customer Driven Construction
diane.stevenin@us.ngrid.com
781,-907-2930
78 L;-52271056 fax
40 Sylvan Road&2
Waltham,Ma 02451
".iL Al[assachusetts- Department or Public Safety
illLml Board of Building Re,r'ulations and Standards
Construction Supervisor License
License: CS 48102
•
JOHN J HUTCHINS "
419 RIVER RD
MARSTONS MILLS, MA 02648
Expiration: 9/16/2012
' ('ununisiuner
Tr#: 3834
P ,
Town of.Barnstable
Regulatory Services
stiarrsrest.�
MAB& Thomas F. Geiler,Director
QED µFl `
Building Division
Tom Perry,Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.b arnstable.ma,us
Off ce: 508-862-4038 Fax: 508-790-6230
Property Owner Must
Complete and Sign This Section
If Using ABuilder
r co as Owner of the svbject.property
hereby authorize -�170 U dCN)11,4s to act on my behalf,
is all matters relative to work authorized by this building permit application for.
(Address of Job)
20//
5' of Owner ate
t
Print Name C-0
If Property Owner is applying for permit please complete the
Homeowners License Exemption Form on the reverse side.
Q:F0RMS:0 WNERP ERMISSION
1►.
Town of Barnstable
yam. o Regulatory Services
Thomas F. Geiler,Director
uses.
�o i639. .�� Building Division
rfo � Tom Perry,Building Commissioner
200 Mairi.Stre: (,_Hyannis,MA.02601
www.town.barastable.ma.us
Office: 509-962-403 8 Fax: 509-790-6230
ETOTN EOV NERLICENSE EXEMPTION
Please Print
DATE:
JOB LOCATION:
number strcat village
"HOMEOWNER':
name home phone# work phone#
CURRENT MAILING ADDRESS:
city/town state zip code
The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and
to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as
supervisor.
DEFIhI ION OF HONMOwNER
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 or 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.
S•I'gnaturo 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.
HOMMDWNER'S EXEMPTION
.The Code states that "Any homeowner perfonrring work for which a building permit is required shall be exempt from the provisions
of this section.(Section 109.1.1 -Licensing of construction Supcvsors);provided that if the homeowner engages a parson(s)for biro to do such
work,that s�uCch Hom ct eowner shall a as supavisor."
Many homeowners who use this exemption are unaware that they are assuming the responnbilities of a supervisor(set Appendix Q,
Ru)cs&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 hamwwm=is fully aware of his/her rsporinbilitics,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 fcr use in your community,
Q:forma:homccxcmpt