HomeMy WebLinkAbout0036 HADRADA LANE �� �a���
t TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Ma Parcel
p "'1 CA10 Application #
Health Division Date Issued 3 Z
Conservation Division J" '.:Application Fee
Planning'Dept. „ 'Permit Fee' qb
Date Definitive Plan Approved by Planning Board
Historic = OKH Preservati n H nni o / ya s
Project Street Address
Village
G:•. �•
a
Owner_ I Address a
S '
Telephone
Permit Request kaik s-ti� t_t, V�+. ,
A$
Square feet: 1 st floor: existing 144f proposed s�►��2nd floor: existing proposed Total new
_4
Zoning District Flood Plain Groundwater Overlay
1
Project Valuation 191000 Construction Type
Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation.
Dwelling Type: Single Family Two Family ❑ Multi-Family (# units)
Age of Existing Structure d S Historic House: ❑Yes $-No On Old King's Highway: ❑Yes Olo
Basement Type: $,Full ❑ Crawl ❑Walkout ❑ Other
Basement Finished Area (sq.ft.) Basement Unfinished Area(sq.ft)
Number of Baths: Full: existing new Half: existing new
_n
Number of Bedrooms: existing —new vrnv
N `
Total Room Count not including baths): existing new First Floor R "i 00 o C nt( g ) g � ou �
Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other
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Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/cc al stove,❑l�[s ❑ No
c-n rn
Detached garage: ❑ existing 0 new size_Pool: ❑existing ❑ new size _ Barn: ❑ex'Aing ❑ new size_
Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other:
Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑
Commercial ❑Yes ❑ No If yes, site plan review#
Current Use Proposed Use
APPLICANT INFORMATION
(BUILDER OR HOMEOWNER)
Name Ins Z�`Felephone Number
Address 1 /V • f.H,. ,4 License# �C�
s^^ pi�AjsZ-1/w.•e-,�� w.aa► Cr2 ,JY fr Home Improvement Contractor# r l y`fl o
Worker's Compensation # ���e- 3 ) a d y/ a
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE DATE
,4
FOR OFFICIAL USE ONLY
APPLICATION#
a
DATE ISSUED
MAP/PARCEL NO.
ADDRESS VILLAGE
OWNER
DATE OF INSPECTION:
I
FOUNDATION ok �i Zwy
x
FRAME
t
` INSULATION
FIREPLACE
ELECTRICAL: ROUGH FINAL
t
PLUMBING: ROUGH FINAL
GAS: ROUGH FINAL
FINAL BUILDING _K 3/Z2`&7
}
DATE CLOSED OUT
ASSOCIATION PLAN NO.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
' d 600 Washington Street "
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/individual): 0D1t�-4 et_,✓
Address: .i s-r
City/State/Zip: - A,.►s oc 14t-', 4- 02.01V Phone.#: 3 3 g--5alf5—
Are you an employer?Check the appropriate box: Type of project(required):
1.9I am a employer with . Lf 4.10 I am a general contractor and I
employees(full and/or part-time). �°
* have hired the sub-contractors 6. 0 New construction
D1 2. I am a sole proprietor or partner-' listed on the attached sheet. 7.. Remodeling
ship and have no employees These sub-contractors have g• O Demolition
workingfor.me in an capacity. employees and have workers'
Y P tY• # 9.. ❑Building addition
[No workers' comp.insurance comp. insurance.
required.]. 5. 0 We are a corporation and its 10.❑ Electrical repairs or additions
re
q ]..
3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself[No workers'comp. right of exemption per MGL 12.0 Roof repairs
insurance required.] t c. 152, §1(4),and we have no
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 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.
iContractors.that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
Iam an employer that is providing workers'compensation insurance for my employees. Below is the policy andjob site
information.
�
ii _
Insurance Company Name: Df
Policy#or Self-ins. Lic.#: 3 Expiration Date: --U y
Job Site Address: 3 (o 4c, -1 City/State/Zip: o-2` 3
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the'imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day.against.the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
Ido hereby certify under the pai s a dpenalties ofperjury that the information provided above is true and correct
Signature: I Date: — —d
Phone#: I
Official use only. Do not write in this area,to be completed by city or town offxclat
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department'3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
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 tiustee 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
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 permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in__(city or —.
town).".A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business.or commercial venture
(i.e.a dog license or permit to 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 ladustrigi Accidents
Office of Investigatlans
600 Washington Street
Boston,MA 02111
Tel. #617-727-4900 ext 406 or 1-877-MASSAFE
Fax# 617-727=7749
Revised 11-22-06
mas
s.gov/dia
pfIHKE Town of Barnstable
Regulatory Services
MASS. Thomas F.Geiler,Director
'iOrEnµ�&A Building Division
Tom Perry,Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
Property Owner Must
Complete and Sign This Section
If Using A Builder
I7AvL t-,► DiMl- , as Owner of the subject.property
hereby authorize d C a- Soon to act on my behalf,
in all matters relative to work authorized by this building permit application for:
(Address of Job)
Signature of Owner Date
Print Name
If Property Owner is applying for permit please complete.the- -
Homeowners License Exemption Form on the reverse side. ,
Q:F0RMS:0 WNERPERM ISSION
Town of Barnstable
of THE ram,
Regulatory Services
RAIM Thomas F. Geiler,Director
1 .19 Building Division
Tom Perry,Building Commissioner
200 Mairi:Sireet, Hyannis,MA 02601_
www.town.barnstable.ma.us
Office: 508-862-403 8 Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION
Please Print
DATE:
JOB LOCATION:
number street 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.
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 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.
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 assurning 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:for ms:homeexempt
DURABLE GENERAL POWER OF ATTORNEY 4
KNOW ALL MEN BY THESE: PRESENTS, that I, FRANCIS U. GALASSI, ,o
36 Hadrada Lane, Centerville, ` Barnstable County, Massachusetts
02632, do hereby make, constitute and appoint my' grandson, PAUL E.
DIETEL, of 2918 Francis Ave. , Mansfield, Massachusetts 02048, m
true and lawful attorney-in-fact. In the event that he is unable
or unwilling to 'serve, I appoint my ;granddaughter, 'KAREN TROCKMAN
of 18-1 Stoney Brook ,Drive, Millis,' Massachusetts 02054, my true
and _lawful attorney-in-fact. My attorney-in-fact may act' for .m
and in my name, ,place and stead', .and .on my behalf, and for'my use
and :benefit:
1. To exercise or ;perform . anynact, power, - duty, right o
obligation whatsoever that ' I. 'now have or may hereafter acquire,
relating to any person, matter, transaction or property, real o
personal, tangible or intangible, now owned or hereafter acquire
by me, including but without limitation the specifically enumerate
powers granted below. I further grant,to my said attorney-in-fact
full power and authority to, do everything necessary to exercise an
of the powers herein granted as- fully as I might or could do if
personally present;
i
2. To ask, demand, . sue for, recover and receive all manner of
goods, chattels, debts, rents, ,interest, sums of money and demands
whatsoever, due .or hereafter to become due and owing, or belonging
to - me, -and to make', giVe and execute acquittances, receipts,
releases-, satisfactions or other' discharges for-the same, whether '
under seal or otherwise;
3. To make, execute,` endorse, accept and deliver in my name
or in the name of my , said attorney-in-fact all " checks, `notes,
s
drafts, warrants, acknowledgments, agreements' and all other
instruments in writing of whatsoever nature as to myRsaid attorney-
in-fact may ' seem necessary- to conserve my interests;'-
4 . To have access to all my, safe deposit boxes, whether in my
ARDITO,SWEENEY name, , alone or -held jointly with 'others, and to place property
STUSSE, PUYSON
3 DUPUY, therein or to remove any `property from said 'box or boxes.
PC PC
ATTORNEYS AT LAW 5. To execute, acknowledge and deliver any and all contracts,
WEST YARMOUTH,MASS
02673 deeds, leases, assignments of mortgage, extensions of mortgage,
(508)775-3433
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satisfactions, of mortgage,. � releases of mortgage,, subordination
agreements, and =any, ,other instrument, or�-agreement of any kind or
nature whatsoever, - in connection therewith and affecting any and
all property presently m ne •,orY hereafter acquired, located
anywhere, which to my said attorney-in=fact shall seem necessary or
advantageous for my iriterests;'
6. To enter into and take pos ession of any lands, real
estate, tenements, houses, stores or buildings or •parts thereof,
belonging to„me,, that may become. vacant „or unoccupied, .orYto ,the .
possession of which I maybe or may,become entitled, .and to receive
and take for me, in my name and to:,my use, any or all rents,
profits or issues of any real",estate to me belonging, and to ~let
the same in such manner as to my said attorney-in-fact shall .see
necessary and proper, and from time to time to" renew leases; -
7. To ` commence` and prosecute in my behalf .,any suits � or
actions or other:legal 'or equitable, proceedings for the recovery of
any of my lands. or for any goods,- chattels, debts, duties, demands,
cause or, thing whatsoever -due or tobecome due or belonging, to'me, .
and to prosecute, maintain" and discontinue the same, if said
attorney-in-fact shall deem proper;
8•. To take all steps and remediesnecessary' and proper for t
the -.conduct and 'management of my; business affairs, and for the
recovery, -receiving, -obtaining and---holding ion of. `aY
n lands
- g possession..tenements,, rents or ` real estate, goods and chattels, debts,
interest,. demands, duties, sum 'or sums of money or any -other thing
whatsoever, located anywhere,' that is, are or shall be, by my said
attorney-in-fact, thought to be due, owing, belonging to or payable
to me in my own right- or--otherwise;
9.. To.., administer', invest and .reinvest in, any, property,
including. real -and personal'property,
, stocks, bonds and other
securities, . investment companies, and common trust funds, in. any
state `or jurisdiction and whether or not of a kind or in 'a
ARDITO,SWEENEY proportion ordinarily considered suitable for ' fiduciary
STUSSE,ROBERTSON
3 DUPUY,PC investments; !'
ATTORNEYS AT LAW
WEST YARMOUTH,MASS
02673
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(508)775-3433
10. To sell, , �,redeem^' or transfer any U.' S., Treasury
Securities, including Seriei E},'Savings Bonds,.'in 'which I may have
an interest; .. ;
11. In the event.- of -my illness, incapacity or other
emergency, to incur, and pay , and satisfy such expenses an
obligations for my comforti .benefit *and care, and obligations of
nature customarily incurred by, me, ,asyin; the attorney-in-fact'
judgment may be necessary or desirable `or consistent 'with m
wishes; _
12. -To prepare, execute and file -Federal or state income,
gift or other tax returns or, to pay or. compromise any or all .suc
taxes or apply for and collect any refunds, due;
13. To- transfer any or.-all property, tangible, `intangible o
real, in which .I may".have , any interest into atrust or trusts,
whether created by me or by my said attorney-in-fact on my behalf,
or to any other form of entity or ownership, including any. form of
co-tenancy, `under such terms and with such provisions as m
attorney deems. in the best interests of myself and' my family. , In ,
this regard',` .the . fact that my said attorney-in-fact may be
remainderman or a beneficiary in connection with" any such transfer
hereunder shall not affect the .validity thereof, nor, by itself,
constitute a breach of fiduciary duty hereunder;
14 . To-amend' for my benefit any trust I may have established
as a grantor- but only those � provisions which, affect .-payments of
principal 'or income during my lifetime;
15. To appear, answer and. defend 'in all actions and suits
whatsoever which shall be commenced against me and also for me and
in my name to compromise,, .settle and adjust with each .arid every
person' or 'persons, all actions, accounts,, dues and demands,
subsisting or to subsist between,,me and them.`or 'any of them' and in
such manner as my said attorney-in-fact shall think proper; hereby
giving to my said attorney-in-fact power and authority to do,
ARDITO, SWEENEY execute and perform and finish ,for me • and .in my naive` all those
STUSSE,ROBERTSON things which shall be' ex edent and necessary,
&DUPUY,Pc P y, or which my said
ATTORNEYS AT LAW attorney-in-fact shall judge expedient and necessary in'.and about
WEST YARMOUTH,MASS
02673 3
(508)775-3433
.a.
or concerning the pr`emses,* or '.any of, them,,=as n fully .as. I could do
if personally present hereby ratifying and confirming, whatever my
said attorney-iri-fact shall..doJ or `cause to 'be done yin, about or
or
concerning the premises' , " and ariy,part '-thereof;
16. To ::open and/or; close . bank accounts or accounts Inn the
nature ,of bank accounts.
17 . This instrument is tobe construed and. interpreted as a
durable general power 'of ,attorney pursuant_;to 'M.G.L`. 'Chapter 201B,' „
as amended. The 'enumeration of,.specific -items, rights, ;:`acts or
powers herein', is-,notJ intended o,- nor' dolls it limit' or restrict,
and s. -not •. to be c}oristiued or : interpreted as,;'`limiting' p or
restricting, the general powers..her granted to said attorney-in
fact. - a,
18. The rights,,-,.powers and-authorit= of said attorne in-fact .
g P y. _ , y-
granted `in this instrument shall commence 'and be in full force and
:..
effect' on£ ;the,' date shown below and " such rights; 'powers . and ' A
authority;:shal,l remain in full force and,"'effect thereafter until I
give notice in` writing, -that` such- power is terminated':;: "
w ...
s
19. A, Y party'deahing`with my said attorney s-fact hereunder
may' rely absolutely on the`�authority. granted.hereinsand need not
look to the application of any proceeds ,or. the authority ofx'my said
attorney-in-fact,as to any action taken hereunder. In,this regard,
_;
no person who may in good faith "Tact.° in reliance , upon`, the
representation
F
sP,of my,,,,agent o'r the , authority` granted .hereundeer _
shall,"incur any.' to mek or to. my estate4-as a .result, of ®such
act. - R
20. . This durable' general power ofattorney„ shall not,, be
affected-by my subsequent -disability or:' ncapacity:. ' Further, if a?
petition sbrou ht:before an court for the 4
P g y purpose of-naming a
tem oi`ar uardian, guar dian, �temporary conservator or conservator
L.for. me; I hereby '-respectfully request that „said .court =appoint 'my
`,attorney-in fact, he `named _ .
ARDITO, SWEENEY 21 I hereby_ revoke-%any` and ,A1 powers of, attorney; that are `STUSSE ROSERTSON .r ,
3 DUPUY Pc in existence.' at this ',time, except) >this :Durable 'General.r Power. of
ATTORNEYS AT LAWAttorney. ' .ram
WEST YARMOUTH,MASS
02673
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(508)775-3433 _
f'
WITNESS my hand and seal• this %-, day of
1997 .
t
CIS J. GWSSI
I hereby accept appointment in' accordance with the above . Durabl
General Power of Attorney this RR- day of , 1997 .
tiPAUL E. DIETEL.
I 'hereby accept appointment in accordance with . he 4bove Durable
General Power of Attorney this ;;�7,;� 'day of , 1997 .
i6r)JU
KAREN TROCKMAN
COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, SS.' /_� 1997
Then personally appeared the above named' FRANCIS J. GALASSI
and acknowledged the foregoing instrument .to be his free an
voluntary act and deed,, before me,
Notary Public
My"Commission Expires: ,
ARDITO SWEENEY 4
STUSSE,ROBERTSON
h DUPUY,PC
ATTORNEYS AT LAW
WEST YARMOUTH,MASS
02673
5
(508)775-3433
COMMONWEALTH OF MASSACHUSETTS
SS
1997
Then personally -appeared the above ame PAUL E. DIETEL and
acknowledged the foregoing instrument' to`be his free and voluntary
act and deed, before me
A , Notary Public
My Commission Expires:,
COMMONWEALTH.OF` MASSACHUSETTS-_;-,:
'SS. 1997
Then personally appeared the 'abov. nam d KAREN TROCKMAN and
acknowledged the foregoing instrument, to be her free and voluntary
act and deed, 'before me,` _
y Notary, Public
' My Commission •Expires
,
ARDITO,SWEENEY
STUSSE,ROBERTSON
S DUPUY,PC
ATTORNEYS AT LAW
WEST YARMOUTH,MASS
02673
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(508)775-3433
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Ty .
"HEALTH 'CARE PROXY , . '
I. A ointment-' 4 p° • ,4.0
PP
I, FRANC IS_,•',J.," °GALASSI; residing' at 36 ;Hadrada Land
Centerville, Massachusetts 02632; do hereby appoint my grandson
PAUL E. DIETEL 'of: 2918 Francis'- Ave` , , Mansfield, Massachusett
02048, as my Healtha'Care.:Agent`° u-nder this document. In "so doing
I intend to create a- Health, Care ,Proxy, according to.Chapter 2O1D o
the Massachusetts ..'General "Laws: This; - Proxy- is,',to° _be construe
according to the laws of Massachusetts '.I, revoke:. any, ,previou 5,
Health Care. Proxy-,or -Durable Power of ,Attorney for. Health Care.
II-: Alternate
f:
If: my. Agent named°'' abovefor' any reason, unwilling
`incompetent; or "'i unavailable to ., act for me,":`then . I' :name ` m
granddaughter;' 'KAREN TROCKMAN, -of' 18-1 `'Stoney'Brook Drive,--Millis =
Massachusetts "02054, as `Alternate to,-my Agent.
III.. Effective Periods- �
. y
T This Health ,Care 'Proxy shall become of fect ."ve only if !whe
and for so long as. I am' unable,"to make or :communicate an 3-nforme
decision ` about ,r myr health care. ,. My ,,capacity ato .'make?;informe
` decisions:: -,about,' my own Health" -car"e shall, be `determined , by m
attending physician ,after``consulting with-my Agent; Rin accordance -
with, the directv ,dd statute:w .s :
IV. Authority,`
:I have discussed �th ' document w th' limy Agent, and, Alternat `
Agent,,and 1I, have assured' said `Agents ,i that this document cl'earl
state_ s the authority, given.=, . `Said -Agents`r have,:assured me° that 'the,
will- act according to my wishes or: in "my'abest interests
I -have also discussed with. my Agent and Alt'e`rnate Agent .;m
personal values, µbeliefs,' and convictions {which`° have' led-me ,to hav
certain preferences in "'health; care, after having discussed' th
various gene"ral,. medical -scenarios -and treatment`" or nontreatmen ,
options`. as outlined in the AMA's Medical Directive Fbrm: ,I believe-
that my ;Agents (understand my views:,completely;',,:realize that- such
views are-fundamental to me, and will act accordingly ~ I',know,tha
MY Agents . care for me .,'and I have absolute 'confidence', that:,the
will- act with sound judgment in my' behalf. A
a
I . give ,my, Agents full and final author t o make ^ al
y
ARDITO, SWEENEY- decisions relating to my ;,hearth `and. medical care... ;,They shal
-3 STUSSE, RoeERTSON consult with my' . health r` `*caress providers, consider ,fully `, th
3 DUPUY,ac `acceptable r medical' alternatives.-Lregarding a diagnosis, ;prognosis
ATTORNEYS AT LAW treatments and their side effects. before .exercising this authority +'
WEST YARMOUTH,MASS My Agents shall first try to discuss the' proposed decision with m
02673 to determine my wishes if I am able to communicate in any way. ` I
(508)775-3433
my Agents cannot determine the choice 'I would 'want made, then the
shall make a choice for me based upon what 'they.believe to be in m
best interests, being mindful of my personal, 'philosophical an
religious principles
To extend and not to, limit this grant of,authority, and to the
extent allowed by law,` I authorize my Agent'and Alternate Agent:
A. To have access to' my, medical-"records and other information
verbal or written, regarding my mental or physical health t
the same, extent that' I,. myself, am entitled to, including the
right to disclose information-to others as appropriate;
B. To select, employ, and discharge medical and other health car
and social• service providers responsible for my care;-
C.. To give or withhold consent to any medical test, procedure, o'
treatment, including .-.,the providing or' withholding o
artificial_ hydration and nutrition or: both, in,., my , Agent'
absolute discretion.
D. To authorize my admission. to or discharge (even against
medical'-,advice) from any hospital,', hospice, ;nursing home
residential care, assisted living or similar facility, service .
or institution; . , . 7, -
E.' To take any other health care action-'necessary to comply wit
my wishes, including . (but not limited .to) giving or making an
applications, - consents, refusals, releases, waivers, an
indemnities to. any appropriate,.person or provider; pursue an F
legal action in my name and at my expense to force compliance
with my wishes as`my' Agent shall determine, or to seek money
damages- for the failure. to comply.
V. Nomination of Guardian
In the event a guardian of my person shall be necessary,
nominate my Agent or my Alternate Agent.
BY SIGNING_HERE, - I CERTIFY THAT I' HAVE READ AND UNDERSTAND ALL THE
PROVISIONS OF THIS 'DOCUMENT,, AND THAT THEY "TRULY . SET FORTH THE
AUTHORITY :THAT I WISH TO CONVEY. TO MY AGENT AND ALTERNATE AGENT.
I . sign my name .to this Health Care Proxy on this o��h day 'o
1997.
ARDITO,SWEENEY z.
STUSSE, ROBERTSON
&DUPUY,PC ^'
-:F CIS J. G SSI
ATTORNEYS AT LAW
WEST YARMOUTH,MASS
02673 '
(508)775-3433
r
b VI. Witness, Statement
c>
We,. the ,undersigned witnesses; , ea' h .declare that ;.we know th
person who signed this ,Health`= Care :Proxy.and that he ,signed thi -
document in our presence. :,<To .the -best -of' our °knowledge, he is, a
least eighteen years of, age,,::of. sound -mind-and under no constrain
or• undue influence. $'Neither .of,. s has °been appointed an Agent b
this document ,and-. neitIhei of us =° s ..the pr ncipal'.s health car
' provider nor an employee �of"h•is -health- carer'provider: Neither o
i us` is related' .to the""principal-°by. birth,"marriage, :or adoption. T
the best 'of.,our knowledge, neither.pof us, is 'entitled to part: .'of'.th
principal's 'aestate . under a"`will` or, by operation of law.
y, w
WiM.,ss
A `� a_5 , 1997 at West FYarmouth MA
e ;i
Signat #1 K
MATTHEW J.' DUPUY 25"Mid Tech Drive` West Yarmouth MA 02673
Printed Name and Address of Witness #1'-`
v' � F
Sig ature ,of Wi ss
F
MELISSA E: 'LEWANDOWSKI , ,312 Com a`ss Circle, -H� annis=, -MA 02601
Printed H Name and =Address of Witness- 241
x ;
VII." Statements 'of Anent- and 'Alternate"Agent
4 .
I, PAULYE ' DIETEL, have beenVnamed' by ,FRANCIS J. xGALASSI a
his Health, Care Agent by thris Health Care, Proxy:-"'�I` have read},thi t
document carefully, #and have ,'.personally discussed `` with' ;the'
P �P me of possible incapacity
rind al his, health health° care' wishes ,ate a time
I know the principal well and accept this appointment freel ;I `
called upon -,and to the best t o.f my-`ab li'ty,. ^I,'.= will', .try."to give:
effect to the° principal's ,wishes
PAUL-E.,, DIETEL.
I
„ g y #
his Alternate He' lth.,CareW"A ent. b . .this by FRANCIS ^J. GALASSI a
KAREN .TROCKMAN, have,wbeen named
Y Health C e ' roxy hav
ar P I
read, this document carefully`; and ,.`have ,;personally '-discussed.°wit
the -,principal . his health'- care wishes at a . 'time of possibl
ARDITO; sWEENEY -rincapacity. I know` the°pr ncipalp well• and accept. this 'appo-ntmen
s?ussE,ROBERTsoN ='freely. If called upon*and- to_.the-,'best- of.my ab �l'ity,,`'I,.,will .`tr
&DUPUY,Pc to' give effect to'the principai's 'wishes.
ATTORNEYS AT LAW s
WEST YA 02673 ,MASS
02873
aKAREN TROCKMAN =
(508)775-3433
02/26/2009 15:13 50B3399524 BARROWS INSURANCE PAGE 02/02
' o11TE(ILfaIDDI'�!
Ac_c M. CERTIFICATE OF LIABILITY INSUR C:E 2, 09
aaaouc�R THS CEFMRCAT9 IS ISSUED AS A MATTER OF grl?ORMATION
Barrows Insurance Agency, Inc. ONLY AND C NO RL[aIITS _� THECEFMRCATE
ANIEND, EXTEND OR
215 North Main Street A TM CCOV IA A BY THE POLICIES BELOW.
Mansfield, MA 02048
lNSIJRm COVERAGE NAIL s
Immmm INSURERA Harle ille Worcester Insura
iodi,ce 6 sons Inc iNSURERB.Colmmer Insurance an
PO Box 1036 INSUREnc:OHU
Mansfield, MA 0204E INSURERD!
1
covg=m
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE F THE POUOY PERIOD INDICATED. NOTWITHSTANDING
ANY REQUIREMENT, TERM OR CONDITION OF ANY GUN IHAGT OR OTHER OOGUMENT WITH RESP TO W uon TNIB 0£R7IFICAm MAY eE ISSUED OR
MAY PERTAIN,THE INSURANCI:AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJEOT To THE TERMS.E7CLLISIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS BROWN MAY HAVE BEEN REDUCED BY PAID CL AIW
Imm nna FOLIC'/NUNII PouCY EFFBCTIYE PD I IM A
flpr�LMseuTY I EnCH 000URRENGE $ 1,000,000
A g OOMMERGALOEhwmLUABIuTY CB 4J7408 6/21/08 6 21/09 p1M"¢TORENTEDNL— E 100.000
CIANSMME ®OCCUR ally DCP&yTR 4.000
FERSONALBADVINJLRY S 1 000 000
_QftR4LAGt1i1pAPE 5 2,000,000
GEV'LAGMEOAT6UMUTAPPUBSPER: R307UMS-00APpPAM 3 2,000,000
7g POLICY PRO- L:OC
AVT0PO2L.ELMBILRY 1haft DlDVCLPUMR
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ALL OWNED AUTOS (�PYENJ RY
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HIRED AUTOS 53CILYNJURY $
NON.OWNED AUTOS (ftr°cd cImt)
PROPERTY DAMIAGE S
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ANY AUTO OTHER714AN EAA►CC $
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SHOULD AN
YOFESORB�POUCIMBE CMCELLED BEFORETHE E7lPMTIOIt
Galassi Residence/ Paul Dietel DAM THIMINUH IL WI L eN UVOR To NAI 10 DAYS wmi in.
36 Hadrada Lane NOTICE TO HOLDER NAM®TO THE LEFT.BUT FAAURE TO DOCenterville, MA 02632 mom NoMIBILWf Of MY HIND UPON TA WMMM.rM AQUITG OR
AVTHOMM
�
ACOFID25 0001/00) A ACfiffl CORPORATION 1988
I�
`I. ��, o�,/�aaaac�ivarlta I
r Board ofBuilding Regulations and Standards s
HOME IMPROVEMENT CONTRACTOR
' Registry n\114410
Expiration 9715/2009 Tr# 133386
.,�
} Type Private Corporation a
t(
JODICE&SONS`• -C-5 K +
PAUL JODICE yerf
t_ 281 NORTH MAIN
MANSFIELD,MA 02048 Administrator
4i?- -__._-_.. .
,�I � I ✓�ie�an�no�n,��sea� a�✓l�aaaactiueel�a, I. :k
I
oard of Building Regulations and Standards
onstiuction Supervisor License f i
Licep@e*NCS 66077
+ ' _ BAmhdate 6/5/1968
E -xpiration� ^6/15/2069- 1- Tr# 15301
;E
R'estflct�on�0�{ "
ANTHONY L JODICEt�,< 1 jj
d 518GILBERTST
MANSFIELD,MA 02048 Commissioner
- _
� rt.
'G License or registration valid for individul use only
• � before the expiration date. If found return to:
.i
j Board`of Building Regulations and Standards .j
One Ashburton Place Rm 1301
Boston,Ma.02108
Not valid w ho t signature a t
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Asse�s'or's `map and lot number ... '/'• � .<.............. � .,:..........
r -
Sewage,Permit number /........................................
TOWN OF BARNSTTABLE "
j B6BB,!TAELE, i
"6 q :_ R;URDING INSPECTOR
'F0 MPY a
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t
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APPLICATION FOR;PERMIT TO ................................./.1......................
.. ............................................................
c .
... . p4L�P'/1l
TYPE OF CONSTRUCTION ....®............. ........ ...........:................................................................................
C. .............. ../.,1... ..............19.
TO THE INSPECTOR OF BUILDINGS:
The undersigned here y applies for a permit according to the following information:
-
Location ......... ..........X(1..... .......... 4� Qt;..........
.......�I�/ ;.......,............................................................
Proposed Use /�..P.�°,.(.��G
n
Zoning District .......... .............................Fire District ��.•.•..
R..c.................. ............................. ...................... ............. . .......
Name of Owner ..........Address ... .
Name of Builder 7 .:........Address ./ `.!/Q!�//l�/5..................
Name of Architect .... ..L° .��.C.. .. � .:Address ...............
l ,
Number of Rooms ....... ............Foundation / ® ....
`K...................................
/ f
Exterior ..........�..................................,.............................Roofing ......���. .f�'/. .. ........................................
S . ......,...
Floors W......... �J... .. ................................Interior ............ .... :. ...
Heating ..........................:.......................................................Plumbing ............ ................:.........:....................................
Fireplace .......Q ..�� te Cost ................................ ..:..................................
Definitive Plan Approved by Planning Board __________ ______19________ . Area ........
Diagram of Lot and Building with Dimensions a�
g 9 Fee .....��?..............................
SUBJECT TO APPROVAL OF BOARD OF HEALTH
/y
S7?
i
i
• - 1
I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above
construction. a
Name ............................................:. ...............................
Capawi8e Development Corp.
/
/ . .
�6 —.l8�7.5.. parmh-for —.00e story............
x --' ' ------ ^
' ` ^ .
� famlly dwelling
�*� ....------------ ............................
=��8 �
�� ��..�dr� Lane _ '
�
' Centerville '
.—,------------------------ .
Owner ---- e�1 .Davel t..Cmrp.
- /
Type of Construction .............fr�m�--.---.
-----~—.--.----------------. '
� ;'Plot �� #18
---------' ----------''
'
. - -
March 30 76 ^
'P�ermit Granted lA
-------.. ---.
Dote�of Inspection . .� A ^ '
' 6--e� ^�
_ Date Completed —+�e6 ---.^. ]9
.
. .
'
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� PERMIT REFUSED
. ^
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Assessor's map and" lot number ............:.............;.:.............
Sewage Permit number ...............:..........................................
F
'IN E.r°��,� - TOWN QF , BARNSTABLE
Z BARNSTABLE, i
"b 9 BUILDING ] NSPECTOR
�/ c-C ! C!j e.` �G
APPLICATION FOR PERMIT TO .................................�.....................
TYPEOF CONSTRUCTION n✓ .a o < `...�...... . .... .... ........ ..........................................................................................
l,1...9.............l 9. !�
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies
for a permit according to the following information:
Location ....... .d.. ./Q............... .V... �.........�9./�......-....................................................................
Proposed Use ......./1.. .°.!.. ��...........................................................................
.. ... .....
r
... '
Zoning District .......... FC................................................Fire Distract ........... P/�l!/....�, ............ t...../....
C-c�P6f//�P //1`G,..�:�?��pi..........Address ... /!/ /Y
Name of Owner ...d' ................... �.�.! .sc�%y................................................................
Name of Builder E �. ./..QF'..!1.r°Ut...4�..Q..!� .:........Address ., eel/y/! S
Name of Architect "Q� ..t° ./..SP.C�.1./... .. d!� ........Address .. ..v� !...........................
Number of Rooms Foundation .. ...
�o
�
Exlerior •.......... .�//........................................................................:.............Roofing ......�� . . / .........................................
Floors ......��/ ......Interior ........ F' ..0��C...� ......................................
.. �� ...
Heating ..................................................................................Plumbing ............�...............................................................
Fireplace .......Q..A#.(1.. -...................................................Approximate Cost ............................
Definitive Plan Approved by Planning Board ___________�____7 ___19________. Area �. Gx.y
........... ................... ..........
Diagram of Lot and Building with Dimensions Fee .....: t...................................
SUBJECT TO APPROVAL OF BOARD OF HEALTH
"71 G
S 1
I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above
construction.
Name ........................................... ...................................
. . . '
Cupew1de Development -Corp. - A=148-98 '
�^
�
18275 ' , one
.....................................
story,
No P�n � for ''' '-------''
single �a�1 ' dwelling
.
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' in
�°- W� 8��rada �ane
^"`".�, ..............................................
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------�-------.~--.----- . ^
' - Centerville
----.----------------------
Capew1de Development Corp.
Owner ....................................................
frame
-
Type of Construction --------------.
' . .
.
..........................................
.
'
Plot "'.
'
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Permit. Granted
----.
In-'__n -- '
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--'~ Completed
_
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-PERMIT REFUSED
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