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I � ��,j,i: :.:",,, � . ,- 1, " ;�,t_ ",�, "I - - " �� � h-��.7, n, I. , 11 I '!, . . __ � _',. hannowou 0 �q, - , ,� , ,_ . _� � - , , , . ��,- ��,, , , , � .� .,,�''.;,� , - - I ,� I. , ,:,��",,,i; �, :i, "",;;,�,:".�,-,',�,"��-,�,,�!k�,�. ,�;',."�'i': � �,�� ", , , _ � ;,�, '. :� 1 '', ___:��'�' . , � , I � - - - I Vic I -to-r2 Q Town of Barnstable *Permit DI o Vd Qa Expires 6mo o is Regulatory Services Fee , reesa Thomas F.Geiler,Director t� Building Division Tom Perry,_CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax:508-790-6230 EXPRESS PERmrr APPLICATION RESIDENTIAL ONLY Not Valid without Red X-Press Lnp int Map/parcel Number Property Address �611MA 6 ,32 [,Residential Value of work Jam, 760 Minimum fee of.$25.00 for work under$6000.00 Owner's Name&Address rl 2f t Ylp i 31 �Brandv wimp RJ �-roYjKI 'rj �U 02-038 Contractor's Name- rnSe i gm Telephone Number Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) 9-+(D(o sus wee®e6apa ae-®p� ® V 0 rCMM 12f Workman's Compensation Insurance Check one: ❑ I am a sole proprietor U 0 5 2 2 I am the Homeowner - I have Worker's Compensation Insurance Insurance Company Name Uri i ors Fi'r e QF�ARNSTABLE nsur Workman's Comp.Policy#_ hl C_a OR 9 14?0 to O r Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) Re-roof(stripping old shingles) All construction debris will be taken to so� Z ❑Re-roof(not stripping: Going over existing layers of roof) Re-side � � G f�t.��W'' '�© Replacement #of doors Windows/doors/sliders.U-Value (maximum.44)#of windows 'Where required: hauance of this pmmit does not exempt compliance with other town dq-unent regulations,i.e.Historic;Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is required. . SIGNATURE: Q:\WPFUM\FORMS%WWin&p=h forms\EXPRESS.doc Revised 090809 _T40 ComsMnweaft offMassachusetts I D�p'�►bnent`ofhadratrial gcdde>zh : . Office oflnv4*afions 600 Washington Slti Bestow;A"02111 � mnss.gov/din 1 'Workers'ComPe MtIOn Insuranu licaat I orm o BurflderslCo>naCto dn, ; btrs Nallzc ease P f L ' Co nSAry C-�l L t Address: S Ci /StateJZi : J t�if l�C�( ��,3 Ph�ow#: sue— v28 ERd Aie yen ea emP�' ppropt� 13 1• I am a employer witb 4 ❑Iam a general pe of project(rvga�).employees 041l gym')Mme)* havehiO d{bft� [f INew uctioa ,.2• I am a sole proprietor orplat_ listedorRthe attached siship tnid have Mo emplo These&&coatrac tors hR OdeWgwotk�g for me is a�capacity', emplayees and have worDemolition[1Vo wo&M,comp.tmmance camp msmaac�e= j]Building addition3• I q a Id.] 5.❑ we are a corporation and &1eawtrer doing all work offices have exercises thectricWrepaim or additionsmyself(No Workm,comp: right Ofwcempciott per M �P[m ibiM repairs or additim �smaats d]t ' c I52,§I(4),od we hav (]Roofr 1°S' -(No worms' fret��'$PPHM dW woksboa iI roast also fm otrtt>tesxtlam > aanCei s cbaokaktbis box belowehocumdthan •cow �mnaoY boa � t5ey ere dofdg aiI wostt end il:en hbe offside Yea Iftbes�tb. bm CWWe l sbooteow�the name oft>4e Mbmitamw such. stdo 1 ttteir"ad=-4onap Pao9nc*=. enw=bxft 1 avt asr 8U9 kyff*at tspy ��,cor> sa1PaR t�ormc�ion, ceforatyP�Yces Belora tl4epob�y mrdJob site IMaaMceCosnpMyName: lug ee f olfcy#oz Self-ice.I ic. y r I A� Pa Dare o z ac t Job Site Address: / �O At4tch a�pyog8teworicers'.com Cfty/5tate/Zip:Cen rvil le M.i} Failure to some co n P° 'declaration page(showing the Poly number and eiplMO=date). j! verage as x04�ed order Section 25A ofMM c 152 can Iead to the Sidon of caiz»al fine uP to$1,500.00 and/or ar�yeat imp as I as civil penalties ofa of ap to$MDO as is the form of a SIOP WORK ORDER and a foe i �Y against rite imce violator. Be13 advised that s of this�mem may be forwarded to the Office of of the DIA.R�it>sunarrce vet cation. i 1 do heroby cut 01'PM*UY dbe:t theWWWIeoaPmvlddabove is and cam j -7 _.. OfflAWaseanl3c Do Aar w,ite fn m be c6jVk&d by*orjMM q,Wd City or rows: Lfcense# t T ani%Authority(drek one): f L Board of Raft 2.BuMbWDepatfinent 3.G lynows Cleric 9 Edectxical �f cow Inspector I Plambbig Inspector I Contact Petaon• pl<one m , +C o FRASCON-01 MOSU �,..� CERTIFICATE OF LIABILITY INSURANCE'--; OATE"" w" 9126/2011 PRODUCER (508)67MG9 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Vri375 lrosAirport Insurance Road Agency,Inc. HOLDER. THIS AND CERTIFICATEFERS NO wDOES GM NOT AMENTHE EXTEND OR 378 Airport Road Fall River,MA 02720 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC III INSURED Fraser Construction LLC INSURER A:National Union Fire Insurance Company P.O.BOX 1845 INSURER S: COtult,MA 02635• INSYAiEIi C: INSURER D: INSURER F. COVERAGES 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 SUCK POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INMADUL POLICY NUMBER MEOW LIMITS GENERAL LIABILITY EACH OCCURRENCE S COMMERCIAL GENERAL LIABILITY PREMI g CLAIMS MADE OCCUR MED EXP aria person S PERSONALS ACV INJURY S GENERAL AGGREGATE S GENL AGGREGATE LIMIT APPLIES PER PRODUCTS-00MPIOP AGOri S POLICY LOC AUTOMOBILE LIABILITY AUTO (Ee CONIBINFI) SINGLE LIMIT ALL OWNED AUTOS .BODILY NJURY . 6CHEDULEDALlTOS (pew ) S HIRED AUTOS BODILY INJURY NON-0WNED AUTOS (Pe ewideA S PROPERTY DAMAGE S (Per acaden) GARAGELIABUTY AUTO ONLY-EA ACCIDENT S ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGO S EXCESS I UMBRELLA LIABILITY EACH OCCURRENCE S OCCUR CLAIMS MADE AGGREGATE $ DEDUCTIBLE g RETENTION g S. MINUI IS COMPENSATION x OTH AND EMPLOVEW LIABILITY YIN A ANY PROPRIETO"AR'TNEIVEXECUTIVE 09930601 91261T2011y 9/2612012 E.LEACHACCIDENT g 500, qq CERIMEMBER EXCLUDED? � 500,? ,.NN) r E.LDISEASE-EAEMPLOYE S E.L.DISEASE-POLICY LIMIT S 500, OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL.PROVISIONS CERTIFICATE HOLDER CANCELLATION BNOIRDANYOF TREABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Fraser COnstructl0n,LLC DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN PO BOX 1945 _ NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALI. CotUit,MA 02635 IMPOSE NO OBLIGATION OR LIABILITY OF ANYIOND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPR EUNTATNE ACORD 28(20091M) @ IMB-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are Hagisbered marks of ACORD 91te -commVMmaa Office of Consumer Affairs and Ifusiness Regulation 10'Park Plaza - Suite 5170 Boston, Massachu�setts 02116 Home Improvement C-oln-- r ctor.Registaration y. Registration: 112536 Type: DBA Expiration: 3123/2013 Tr# 209024 FRASER CONSTRUCTION CO. DEAN FRASER P.O: BOX 1845 ` COTUIT, MA 02635 Update Address and return card.Mark reason for change., C] Address Renewal Q Employment Lost Card 0PS-CA1 0 50M-04/04-G701216 '. Office-TRE'Lm'r` a111A ness egu a on License or registration.valid.for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: 112536 Type: . Office of Consumer Affairs and Business Regulation Expiration: 3123013 DBA 10 Park Plaza-Suite 5170 Boston,MA 02116 F R CONSTI1tUCTI0N�O. ' DEAN FRASER i - v 104TWINN VIEW LANE E FALMOUTH,MA of va ut si eUnderaere u Kassac6tiisetts- epat'tment of Public'Safety Board of Building Regulations and Standards ConatructiOn Supervisor.License.. License: CS 97MB • � r DEAN i= R 104 TM �ii� W �E .. 4 EAST PALlO 1tf ;AA 02536 Expiration. 6J712013 - Conunissioear: - Tr#: 96692 Frasier ConstrtictiolfLLC`,� P.O. Box 1845, Cotuit,'MA. 0263,5 1. Email: fraser_construction@verizon.net www:fraserroo fang.com Phone 1-508-428-2292 & FAX 1-508-428--0.123 DATE: May 9, 2012 PHONE:'774-279-0730 NAME: Chris Palermo EMAIL: c_d_palermo@yahoo.com: MAIL ADDRESS: N/A JOB ADDRESS: 1096 Craigville Beach Rd Centerville MA 02632 RE: Chimney & Skylight Proposal = Roofing Repair } Remove existing roofing around chimney. Custom made black flashing over rubber on top unit. Custom made black flashing over rubber roof.on, top of unit. Re-flashingroof shingles new chimney.box. Clean Remove all debris. PRICE- $4,950.00 Initial, VELUX SKYLIGHT Replace bubble skylight with Velux FSR D26 deck mount'10 year no leak skylight. Flash.roof to skylight with new flashing kit and trim inside as needed. PRICE $750.00 . Initial G� Required'Deposit- 2 000.00 initial C of f � PAYMENTS ARE DUE )IMMEDIATELY AFTER JOB COMPLETION. Payments accepted are; CASH- CHECK-]USTERCARdD- VISA --AMBRICAAI'EXP ESS Any payments not immediately paid.upon job completion will b.eL charged 0.005% , for every day after the given 5 day grace period upon day of job completion. Any deviation or alteration from above specification will be executed upon written orders and will becorne an extra charge over and above the estimate. All agreements contingent upon strikes;accidents or delays are beyond our control. Owner should carry,fire, tornado and other necessary,insurance upon G the above work. We, if not accepted within thirty days may withdraw this proposal. FRASER CONSTRUCTION, I.`LC; Carries Workman's Compensation and Public Liability Insurance on the above work, certificate available upon request. DATE OF ACCEPTANCE: z Homeowner Trzaer Co ion, LLC I �TME Town of Barnstable *Permit 03 Regulatory Fap�s 6 monde from issue date g ry Services Fee MAW 63q. h�b� Thomas F. Geiler,Director 1 Building Division Q 7f8/11 Tom Perry, CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 Office: 508-862-4038 www.town.bamstabid.ma.us Fax: 508-790-6230 EXPRESS PERMIT APPLICATI ID ON - RESENTIAL ONLY Not Valid without Red X-Press Imprint -.Map/parcel Number '3)0(-P a Property Address M + Residential Value of Work ; .SCSI Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address ��nE� C�,��.(.r i Contractor's Name / Telephone Number Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) ]Workman's Compensation Insurance Check one: JUL ❑ I am a sole proprietor TOWN I am the Homeowner OF BARNSTABLE I have Worker's Compensation Insurance isurance Company Name Jorkman's Comp. Policy# opy of Insurance Compliance Certificate must accompany each permit. ;rmit 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/doors/sliders. U-Value #of doors (maximum .44)#of windows- *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. A copy of the Home Improvement Contractors License&Construction Supervisors License is required NATURE; i PFILESTORMSIbuilding permit formslEXPRESS.doc sed 070I10 The Commonwealth ofMassachuseits , Department of Industrial Accidents O z ations .ff ce of Investi g it zt]; i 600 Washington Street { \4,� Boston,MA 02111 �- www.massgovldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: r City/State/Zip: c�s. \+��1 � �?`� Phone #: © 4�C? '� (� ; [3.XI as employer?Check the appropriate box: Type of project(required): a employer with 4. ❑ I am'a general contractor and I 6. El New construction loyees(full and/or part-time).* have hired the sub-contractors a sole proprietor or partner- "listed on the attached sheet.t .• .❑Remodeling and have no employees These sub-contractors have 8. ❑'Demolition ing for me in any capacity. workers' comp. insurance. 9. ❑Building addition orkers' comp. insurance 5. ❑ We are a corporation and its 10: Electrical re red.] officers have exercised their pairs or additions a homeowner doing allwork- right of exemption per MGL 11.❑ Plumbing repairs or additions lf. [No workers' comp. c. 152, §1(4), and we have no 12.❑ Roof repairsnce required] t. employees.[No workers' 13.0 Other comp. insurance required.] *Any applicant that checks box 11 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 their workers'comp.policy information. I am an employer that is providing workers compensation insurance for tray employees. Below is the policy and jab 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$1,300.00 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 uncle th pains andpenabies ofperjury that the information provided above is true and correct Si nature. Date; Phone#: 'o is Aht 5V70 Official use only. Do not lvrite in this area;to.be completed by city or,town'vfftciar 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 da • J 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-contractors)name(s),address(es)and phone numbers)along with their certificate(s)of f 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' oompensation 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 permit1cense number which will be used as a reference number. In addition, an applicant that must submit multiple permitAicense 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 andlix number. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations' ' 600 Washington St=t Boston,MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax# 617-727-7749 Town of Barnstable P` YH�E roryy ��. Regulatory Services Thomas F. Geller,Director g6 '.b� Building Division CEO lei} Tom Perry,Building Commissioner 200 Ma:hi_ t cct, Ayannis,MA 02601 A•wsr.toWn_b arnsfable_ma.us Office: 508-862403 8 Fax: 508-790-6230 -7 \ HOMEOWNER T: MNISE EXEMPTION 1 1 Plisse Print DATE �\ JOB LOCATION: number street rt age !'a' 44 C) `j 6 f name home phone# work phone# CURRENT MATTING ADDRESS: 9 ��=�4' I "QNI" J!e cit)'Aown s•tato ap code Tbc current exemption for`homeowners"was extended to include owner-occupied dwelliatrs of six units or less and to allow homeowners to engage an individual for lure who does not possess a license,provided that the owner acts as supervisor. DEFRgMON OF BOMMOWN'ER Person(s)who'owns a parcel of land on which he/she resides or intends to reside,an which.there is, or is intended to- be, a one or two-faurly dwelling, attached or detaghed structures accessory to such use and/or farm structures. A person who constru;ets more than one home in a two-year period shaIl not be considered a homeowner, ,Such "homeowner"shall submit to the Building Official on a form acceptable to t6c:Building Official, that he/she shall be respoIle for all such workPt:dbx c:d.underthe buildine pcumiL (Section 109.1.1) The undersigned`homeowner"a ssumcs responsibility for compliance with the State Building Coda and other applicable codes, bylaws,roles and regulati°ns. The undersigned"homcowne'certifies that.. e/ c,understands the Town of Barnstable Building Departix=t minimum inspection procedures and requirements and that he/she will comply with said procedures and rcquirt:mcnts. Signaticre of Hamcawner Approval ofEurld ng•Official Note: Three-family dweRings co hining,35,000 cubic feet or larger will be requimd to comply with the State Building Code Section 127.Q C°nstraction Control. HOAdOwNER,S EXEMPTION The Code states that day homecwnaperfmaring work for which a building pernit is required sbaD be exempt from the provisions of this secd=(Sccdcn l D9.I.1-Ucensiag of mnstruetion Supervisors);provided that if the homeowner eagagcs a persons)for hire to do such word that such Homeawna shall act As supervisor,• )Jzny homeowners who use d:ds.rzcooption arc unaware that they are issurrang the responsfbihties of a svpovisor(sce Appendix Q Rulcs&RFgula tiros far L.ic=Tint Consturtimr Supervis=,Scction 2.1.5) This lack of awarrness bflar rmsurlts in serious problems,particularly vhcn the homeowner hires unlicensed pe== In this case,our Board cannot proceed against the unlicensed person as it would with:licensed *pervisor. The homeowner acting ss Supervisor is ultimately responsible To erxsum that the bameowna is fully aware ofbiAcrirsponsubrlitics,many communities require,ss part of the permit xpplicadon, rat the b=cowner certify that helshe undcrstands the rrsponri'brlities of a Supervisor. On the last page of this issue is a farm cw=ly used by necral towns. You may care t an=d and adopt such i formleatifiaxtion for use in your community. • r • r, 1 1 oFTy Town of Barnstable o Regulatory Services Yl ST1JICri Rf�^Y i . KAM $ Thomas F.Geiler,Director Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02501 WWW town.barnstable_ma.us Office: 508-8624.03 8 Fax: 508-790-623 0 Property Ovrner'Must Complete and Sign This Section IfIf�A Builder as Owner of the subject property hereby authorize to act on rap behalf, M all matters relative to work authorized by this building permit application for. . (.Address of Jab) ' $ice„m of Owner Date Print Name , If Prove Owneris applying for permit please complete. the Homeowners License Exemption pomz on :the reverse side. 11/24/2009 09:26 678--556-9611 FEDEX OFFICE 0912' PAGE 01 Office, Fax cover Sheet FedEx Kinko's is now FedE`sx Office Date Ozq Number of pages. (including cover page) To: From Name Je fit"F Le L)2o r� Name Company lc46nb} 'ble Cowh, � � ln��mSP Company 66e c.y - 10 Telephone Telephone yOy y �iSZ Fax SO'S 'l4l,f.7 - �? 30 Comments &A1Vlor,z,..tr7VVI III 0 L�I�� :112 7 90363 00711 1 7 . 90363 0 II III II IIII 071k 7 90363 00720 3 Fax•Local Send Fax-Domestic Send Fax-International Send fedeX.COM 1.800.GoFedE)[ 1.800.463.3339 m 2009 WEX,All tiphts raserved,Products,eeraces ono hour%vnry by locotion.010.0P00.009 sEP.06 7MS U :g h Z gtq L glevls j'Y8 JO Nhio, 11/24/2009 09:26 678--556-9611 FEDEX OFFICE 0912 PAGE 02 Mr.Jeff Lauzon, Bamstable County Building Inspector FAX; 508 790-6230 November 24,2009 Dear Mr. Lauzon, Frances Beumgartnar Estate I am contacting you to inform you that I am the executor to the Frances Baumgartner Estate Michael F.srIth Ex=dor and that I am authoH7Jng the repairs to be done on two properties; 296 Lincoln Road, Hyannis, Massachusetts and 16 C�aigville Beach R ao d pCenterville, Massachusetts, with the consent of Frances Porcaro and Mary Connolly,daughters and sole beneficiaries of these properties. I have enclosed for your considAration a copy of the death certificate and a copy of the Allowance of Foreign Will filed in Massachusetts,where Frances Porcaro and Mary Connolly are listed as surviving daughters. Should you have any questions or concerns,you can contact me at 404 664-8150. Thank you for your assistance and attention to this matter. Sincerely yours, Michael F. Smith 11/24/2009 09:26 678--556-9611 FEDEX OFFICE 0912 PAGE 03 rr f-OIL=PMIJt Ibt±'' REBIyTEFI HOARDER CERTIFICATE�.OF DEATH 162 47 - - 1.NAME.r]R.,T MIDDLE LAW 2,SEX: F 3A DATE OF b,wH: 10.HOUR: MALE 1_U DAY YEAR -4 NCI Frances Baumgartner ❑, EAR 03 13 2007 8 25P m aA,PLACE OF DEATH: HOSPITAL HDD4Y'lhL HOSPITAL " NIIRSINS PRIVATE HOSVr(% OTHER AB.W FACILITY.OATE ADMIITEO: ICneakona) DOA ER OUTPr-0-t.11T IMPAnTIFM HOOMME RESIDENCE FACILITY FSancfM: r MONTH DAY dC C.NAME OF FACILITY:Ittnol001ty,,pmr.ANaInFpl 141J LOCALITY:(Chock 4naandsppelfy) I 14E.COUNTY OF DEATH; Sound Shore 14edj,cal Center ; GIIY VILLAGE TOWN CX q ❑ New Rochelle Westchester 4 dG, ,MEDICAL RECORD NO. 10.WAS IIECEDENI yRANBFEHHEU FROM ANOTHER INSTITL111UN7(11 yas,pneGMMslimNan namo,ally ort4wn,rantely And'TWO) 617951 I ND YEs 94 I — ` I NYC 9,SERVED INU.S.ARMED 9.DECEDE.NT III:HIRIY'NICORIDIN7ClNrdllleAmetlnaraeiraarerfinNAatnprinagpceaenlaaAnnxnMfen+A+r�laNno. 1G,DECF.DENT'ARACE.Ch.AmmMmororarpxlernOlxNawnarhrnneaiammnaMarnnnNlrA,OaAnrW+for FORCE"ai(.AppclryyAMr1 A(Rkmat 5nIINAAMmilardUTAMa 0E Yoe,MHnexn,MN1011 AmeflcM,Chtcam 7A NO YES 441 .rdMINCMcnwAn BE]Pock orAlrlehnAmnnrnr, r,❑Mom InUfan-D n CAmosh Z 0 ❑I C❑Yne,PUBIIA Plran D 0 Yon,rnhan E[]Flllpinn F Q Jannn�n G❑brown ❑UNmnn asa ~ E❑Ye:,Other$fpNaARllapnnlsMUna(5=111y) 1 C1 NAII o Hawellep K 11 NIIAmMIRO or GDarnhrm -M❑Samoan T 11.DECEDENTS EDUCATION;CAMe mn nnx rnnl Dtnraonrrws mr hlpnrsidcpraanrtnwl nrsegnolmmmeled4t Dorlmrwaarh. 1❑A am pmtla 2 L]0m-1291 preao;no d1plama 3 IJ Hlph cnool OmaUAIC Or GED N❑Amoncan MalnD At qln tat Na1Na(enAeldy) 4[]Some edPopn rndU,hiN nonaptio 5 n Asennlaln's dopme A 0 Beahelor'r.degmr." P I,]Other ABlan 1mecIN) ti❑Olh4r PatQk ImagrW(PAGryJ 7�Mrclrr'a onprao a❑Dnnlmmntprnloerannm dnpreo G❑Color(saeruyl - ❑1 ❑2 II3 [�� ❑(, 6.ontormp+aonname. None 15A USUAL OCCUPATION;TOO nOl antat milrerN 150.DING OF BUSINESS OR INDUSTRY: 1 14(„NAME N!D Lr1f.AI,TY OF COMPANY DR FIRM: School Teachr..?r Public School ! White Plains N.Y. SI 16A Fl@51DENCF:; 1AB,Co(mry or RoplonlProvinea teC.LDCAIJTY;IClrora Drava acil (Slate orco+ml!v IT nm 11Sq; sA 'y) 116P.IF CITY OR VILLAGE:,IS RESIDENCE 11 nm USA) New .Y o r.11: CITY VILLAGE TOWN I WITHIN CITY OR VILLAGE LIMITS9 Westchester D XX © pelham Manor!QYS ONO IF NO,SPECIFY TOWN; 1R0,STREF�AND NUMBER OF RESIDENCE;W I IDE,ZIP CODE! zs 441 Wyrtnewood Rd' Pelham" Manor N.Y. :10803 _ I 17.NAME OF FIRST MI LAST 1a, FATHER! MAIDEN NAME FIRST MI Ln51 A1be�:t J. Smith nFMOTHER: 3D Frances Flannagan 19A NAME OF INFORMANT; 1DO.MAILING ADDRESS:fndaca zlo to7el Trances Porca.ro ; 441 Wyn.hewood Rd Pelham Manor N.Y; 10803 Jt 20A.I OIUIRIA;. 35*9A-AY109 1(IRF,M1PZ',1❑11OLD 5 0 DONATION 2119;PLACE OF BURIAL,CREMATION. 6❑ENTDMRNENI MONTH DAe' YEAR REMOVAL ON OTHER DISPOSITION, 20C.LOCATION:ICav urrmm pM Alptc) ,u K73 __l 15 12007 n Ferncliff Cremator. Hartsdale N. Y. 310 21A.NAME AND ADDRESS Of FUNERAL HOHORAI 210.REGISTRATION NUMBER; Pelham Funeral. Home Inc. 64 Lincoln Ave Pelham N.Y. i 01415 OR 22A.NAME;OFFUNEIinL Dllircrnq; -- 228.SIGWITi RINEAAL DIRECTOR: 122C.AEGISTRnnoN NUMAL-A: - Anthony M. Barone iloaZt,�rtpo 00209 2OA.S IATunE OF DISTR � �~ zsD.DATE F BED: 1� g11E � )a MDMH Unv En 1 1,d ,ellgIAL OR n[MavAh PERMI 135UE OY; adB.GATE ISSUED; � MONTry DAY YEAR I1'843 2E THRU 33 CGA4PLETED BY CERTIFYING PHYSICIAN,-OR•-COODNER/CORONER'S PHYSICIAN On- EDICAL EXAMINER 25A.CERTIFICATION: Tn the DESI 00 My knowledge,death occurred Rt VIC time,date and place sand duo to the Ruses stated. f1G)U CArt111er's Now License Mn.: Slptra u ate MomD Di CANCER COnlllorn Thlr. p _ Ahondlnp Phyroclap D D Phyalcaln nctm on Doha11, AneROlnq PhyEltlnn AdN4xa: J / manor 2 CI MnA1ml Exnminar I Deouty Mctlmal Examiner y6 b 25D.II Immntlr to not a Nry n,nan,Ontar Caronar!PIIyslulnn's namo a Iwo: Larnnxn Na.: Srpnaln.: F ""T�1• (R" A Yew 2GC.II CBNlllol In nh1 malmmo Fnynirw.amer AlloadIrm Phy;irNn'S Emma&131o: Vonso NO., 'aIAAA: P.DA Al1anDU1n pplryslclnA MonIA Rn Ar moon Ua A aDDn00tl r1aCAann{I;, 2b0.OaeaffinA neI noon Alive month uy VmI - 2F',�I'ronnnnmrte o IA M o, FAnuD f� hyenonem h slunn: Dpea Time I d2e+ �Iro 3 � .boo PP� y� v At 6 H 27.MANNER BF DL•ATH. � �'— UNDETfRMINED PENDING �20,WAS CASE REFERRED To 29A.AUTOPSY? 20D.IFVES,WERE FINDI GS USED TO DETERMI E NATO I}!I,CAUSE - nrnIDEIJT NOMICIIIF- SUICIDE_ CIRCUMSTANCES INIVESTIOATION CO NER OR MEDICAL EXAMINF;F? NO YES RERISED I CAUSE DF DEATIIe ❑2 .[�,^ ❑4 q5 ❑G 0 0 1 DYES 01 - CONFIDENTIAL SFF INSTnUrTION SHEET FOq OMPLEFING CAUSE OF BEAT ❑2 I D❑Nn," 1 ❑Yls 10,DEATH WAS CAUSED BY:(ENTER ONLY DI11 CAUSE PER LII4E PON(A),(0),AND(01.) CONFIDENTAAI. nPARoauMnT41NtEAVAL . PAR r L IMMF(IIATE CAUSE; (IETWEEN ONSel AND DEATH (Al 1�t r �G ✓� DUE Tn DR A5 A CONSEOLIENCE OF: I Y I DUE TO DR/�A A CONSEOUEIdCF OF: I - IC1 I t r PART II.OTHEA SIfiNIF1NT CONDITIONS G]Id1RIALRING TO DF,giM BUT NOT RELATED TO C.AIJSE Oa/EN IN PART I(A): p (C r. J f / DID TAPgCL'0 USE CONTgISUTE 70 0F.AIWI 314.T INAURY.OAT: " ( ` I"—` 1 ❑NO 1[j YES 2❑PAOBhGLY UNKNOWN MONTH Onr ypM I HOUR; 131B.w�ugY Lnnntm:lcay nr town and cmmry nnO Sta(p) 131f,,,DESCRIBE HOW 1ra1)IRY OCCURRED: I.3ID.PLACE OF INJURY: 31E.IN,IUAYAT WORK? u I ND YES _w 31F.IF TRANSPORTATIDN INJURY,SPECIFY: r32. lu"OF.CEPENid — C11 IF FEMALEI�11�earan4eOSF-ITAL195IN I YES0Irornnammleu,ygrpnl II 9 E.DA'I'EOFOEIIVERY ClnrHrh++a.N AST2MON71{S? I JPrnnamallimnnlMnn No I MDRTH h nr OO enema.Gm nMaepnlwlmmlfnnus ni,nwn .. Um YFAN 11/24/2009 09:26 678--556-9611 FEDEX OFFICE 0912 PAGE 04 Commonwealth of Massachusetts Barns tabs,e The Trial Court _Division Probate and Family Court Department pocket No. 08P0759FE-1 Allowance-of Fbreign Will Name of Decedent Frances Baumgartner Domicile at Death ',l / h V N w (Srreel en No.) I CC l� M 1 -N /p` N , / 03/1 0 (Olt),or Town) Date of Death - ,, , (count') (gyp) Will Allowed �; 2��-a—o-a l s:: 3 star 'ount V�'e) (Court) SUrrogato Court New fork C of will and of p obate duly authenticated filed herewith, Locus of Property In Massachusetts re) �.�� Cr, aigc-a.1�e BEa.cn Road; Barns table P�oad , Barns table , 13aznstablE Coutt��nti) , Barnstable County and � l,i�o1n Name and addre ,;s of Petitioner($) Michael F, Smith 1831 Lakehurst GA 30080 Court Sm rna _Status Executor Heirs at law or Next of kin of d Name eceased including surviving spouse: - Residence (minor and incompetents must be so designated) Relationshipart' onnol- y eaves oa en ervi e Frances Porc.aro aug ter Ni�u a? a io rr t O The petitioner,(,sl hereby certif 1 e s Certificate has bee;:�r'i sent by c f�that a copy_of this document, along with a copy of the decedent's death a j to the Division of Medical Assistance, P.p, Box 15205,Worcester, Massachusetts a' ��15-9906, Petitioner( pray(,fl that the copy of said wily be filed and recorded in the Barnstable Registry of probate for the County of exe cut o_ __z and that he% surety on his/her�S;tfur bond _ es �"wMf___""t�sd - thereof,bvigm appointed true to the best of hi3 ( and certif��Under the penalties of perjury that the fore oing statements are f/ ftheir knowledge and belief. R Date �. Signatures) f',Gi. The undersigned.hereby assent to--the-Petition... n� !yil wp�;Y Pub'c notice h,aa�� in . D�CI�Et: ` ar n s t a e�e been given according to the law and It appearing that there is estate in i original will has been proved in the State of ew or said County of and ought to be allowed in this Commonwealth as the lesate t will and t on which said will may operate; and that the dared that the copy of.,aid will be filed and recorded in said Registry and that f sa id d I1g to deceased; it i of said re or- estament of said deceased; it is therefore or of Smyrna, Georgia Michael in the County ofCA(. �' Smi tl1 the will annexed therefore, first giving bond o u t with be appointed execut o r /administrat Au u� ,�`suretie�for the due p cr,,, ----�- with Date g '�Z 25.,<.U08 ance of said trust,