HomeMy WebLinkAbout0800 BEARSE'S WAY (10) Foy
Parcel Detail Page 1 of 2
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Logged In As: Parcel Detail Monday, February 9 2015
Parcel Lookup
Parcel Info
Parcel ID 1294-061-OOZ , Condo Unit UNIT 1WF I
Condo!CAPE CROSSROADS Buildin FiKDG
Complex i g
Location 180 EABO RSE'S WAY I Pri Frontage F—M.
Sec Road FrontaSec
ge
Village!HYANNIS _ Fire District[HYANNIS _.— l
Town sewer exists at this address Yes —1 Road Index 0109
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Interactive
Map ( �
Owner Info
Owner I IAFRATE, PATRICIA A Co-Owner
Streets 103 MAIN ST I Street2 F I
City[ORLEANS �� State MA zip�02653 Country
Land Info
Acres 0 use Z d miniu MDL-05 ) zoning SPLIT HB;B _ rughbd 0001 _
Topography — _ .....I Road L
Utilities� � �1 Location
Construction Info
Permit History
Visit History
Date Who Purpose
3/22/2010 12:00:00 AM Tony Podlesney Abatement Review
8/7/2008 12:00:00 AM Karen Perry In Office Review
8/10/2005 12:00:00 AM Martin Flynn Drive by inspection only
- Sales History
Line Sale Date Owner Book/Page Sale Price
1 10/30/2007 IAFRATE, PATRICIA A C33-1 WF $154,600
http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=23386 2/9/2015
k
Fd Parcel Detail Page 2 of 2
2 6/15/1990 MARKT, KATHLEEN M C33-1WF $1
3 7/15/1978 MARKT,WILLIAM J&MARTHA A C33-1 WF $37,900
- Assessment History
Save# Year Building Value XF Value OB Value Land Value Total Parcel Value
1 2015 $70,200 $0 $0 $0 $70,200
2 2014 $70,200 $0 $0 $0 $70,200
3 2013 $82,000 $0 $0 $0 $82,000
4 2012 $85,600 $0 $0 $0 $85,600
5 2011 $114,100 $0 $0 $0 $114,100
6 2010 $116,800 $0 $0 $0 $116,800
7 2009 $150,100 $0 $0 $0 $150,100
8 2008 $165,000 $0 $0 $0 $165,000
10 2007 $175,000 $0 $0 $0 $175,000
11 2006 $163,600 $0 $0 $0 $163,600
12 2005 $158,200 $0 $0 $0 $158,200
13 2004 $128,300 $0 $0 $0 $128,300
14 2003 $48,800 $0 $0 $0 $48,800
15 2002 $48,800 $0 $0 $0 $48,800
16 2001 $48,800 $0 $0 $0 $48,800
17 2000 $38,000 $0 $0 $0 $38,000
18 1999 $38,000 $0 $0 $0 $38,000
19 1998 $38,000 $0 $0 $0 $38,000
20 1997 $42,100 $0 $0 $0 $42,100
21 1996 $42,100 $0 $0 $0 $42,100
22 1995 $42,100 $0 $0 $0 $42,100
23 1994 $54,500 $0 $0 $0 $54,500
24 1993 $54,500 $0 $0 $0 $54,500
25 1992 $62,200 $0 $0 $0 $62,200
26 1991 $73,000 $0 $0 $0 $73,000
27 1990 $73,000 $0 $0 $0 $73,000
28 1989 $73,500 $0 $0 $0 $73,500
29 1988 $60,800 $0 $0 $0 $60,800
30 1987 $60,800 $0 $0 $0 $60,800
31 1 1986 1 $60,800 $0 $0 $0 $60,800JI
Photos
http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=23386 2/9/2015
Page 1 of 2
NIc' - .`inie, Rol- tort
Fro v Shawn S -.mons [shawn.simmons@fieldassets.com]
Ser ,: Wednesc �, January 13, 2016 10:54 AM
To: Mckechn Robert
cu` Request ' Deregister/ Bond Release
Tov it may cc :ern,
Ass. .: i"-field Assc° Services (AFAS) is working on behalf of Solutionstar Mortgage LLC,to ensure compliance
wit„ dances re. ,firing vacant/foreclosure property registration in the Town of Barnstable.
AFt'" viously re tered a property located at:
,ESS CITY STATE ZIP
f arses Way• =pt 1WF Hyannis MA 02601
This if is to ser, as notice that the property has either been sold to a new owner,the.property is now
cc,, and/or f,, closure has been rescinded.
AFA s not repr Tent the new owner and has not been provided any further information or documents.
Pie, nd bond r fund'' by mail to:
ASSU., Field Ass( Services
A!, Acosta
1C' uis Henna 'lvd #400
Au i X 78728
Th< -I, for your ;,e and attention to this matter.
Sh;;. nmons
A `. . -ervices S -cialist
8- - 743 x 73-
{ .737,'t
f A , ,
S _;z�r�.oF:s�: �aa:,_,�.:t,.com
P` `_R: Thic ;jail d any files transmitted with it are confidential and intended solely for the use of the
-'M = p y are addressed. If you have received this email in error please notify the sender
t a and then delete it from your system. Use, dissemination or copying of this message
!I,, , authorized and may be unlawful. Please note that any views or opinions presented
i J-^:. the author an] co not necessarily represent those of the company. Finally, the
r u ail and any attaci,ments for the presence of viruses. The company accepts no
l, ' ,6
Page 2 of 2
! �, . :su3d by any virus transmitted by this email.
"I : ;l rn�s, C ! attachmcnts transmitted with it may contain legally privileged and/or
CO' info, *„on i:.'cndcd solely for the use of the addressee(s). If the reader of this message is
ou are hereby notified that any reading, dissemination, distribution, copying,
or ot, X ,;1is PICSSIMle or its attachments is strictly prohibited. If you have received this
m�s in error. :rise notify the sender immediately and delete this message and all copies and
Ui thereol. n1'11K VOL].
M7 M
1234809 135958
REGISTRATION AND CERTIFICATION FORM
FOR FORECLOSING/FORECLOSED PROPERTY
Thank you for registering in accordance with Town of Barnstable Code chapter 224
sections 224-3 and 224-4. Please complete one form for each property in foreclosure
(section 224-3)or already foreclosed for which possession has been taken(section 224-
4). Please file the original with the Building Commissioner and a copy with the Chief of
the Fire District in which the property is located.
If you claim you are exempt from registering under Massachusetts law,please state the
reason(s) and complete section 1 (property information) and the first paragraph of
section 2 (foreclosing party, court, etc. and foreclosing party representative,but not other
representatives and attorney) so that the Town can review the exemption and update its
records: N/A
Section 1 —Propegy Information
Property Address: :800 Bearses Way Apt 1 WF HYANNIS, MA 02601
Assessors Map#: 294 Parcel#: 294 /061/ OOZ -.Use Code: 1020
Land area and description Condo, residential
Building(s)description and contents. Stories 1 Story IYear Built 1974
Total Rooms .4 Rooms
Occupied: Occupant(s)(if borrowers so state and include name(s))
t
Phone: email: other:
Vacant: Yes Date: 3/21/2014 Anticipated Length of Vacancy: Until sold
Last occupant(s))(if borrowers so state and include name(s)) Unknow 4� rn
Last owner: PATRICIA IAFRATE
N/A
Phone: N/A
email: other:
Has possession been taken . If so,please explain and complete and file the
maintenance and security plan form(unless exempt as stated above)
Section 2—Foreclosing Pagy Information
Foreclosing Party(full name/title) Nationstar Mortgage LLC
Foreclosure Case Court: N/A Docket# N/A
Date filed: N/A. Current Status: Pre-Foreclosure
Foreclosing Party's representative(s)for property(entry,management, repair,
etc.)(name,title,): Property Manager
Company(if different from foreclosing party): Assurant Field Asset Services
Address: 101. W Louis Henna Blvd Ste 400, Austin, TX 78728
Phone:800-468-1743: email: vpr@fieldassets.com other: N/A
If an exemption is claimed,please do not complete the remainder.
Other representatives) (if foregoing representative is primarily responsible for
property and/or foreclosure and is most likely to be able to address town matters
concerning the property and/or foreclosure,please so state and do not complete
contact information(i. e. "none"'or"see above")).
I
Name,title, other: KriSti Christopher
Company(if different from foreclosing party): AFAS c/o Gryphon Group LLC - MA
Address: 879 Pine St Raynham, MA 02767
Phone(s): 508=202-7777 email(s) vpr@fieldassets.com other: 24HS 800-468-1.74.3
Name,title, other:: N/A
i
Company(if different from foreclosing party): N/A
Address:
Phone: email: other:
Attorney representing foreclosing party N/A
Firm name(if different from attorney's name): N/A
Address:
Phone(s): email(s): other:
I acknowledge that the information provided is accurate and correct. I also understand
that any inaccurate information will result in non-compliance with section 224-3 of
ch ter 224 of the Code of the Town of Barnstable.
Date: 02/04/2015
Name: R bin J: Brown
Title: AF Authorized Agent
**Please send confirmation to PM at vpr@fieldassets.com. Thank you!" **
I hereby certify that the above-named foreclosing.party is in compliance with the
provisions of section 224-3 of chapter 224 of the Code of the Town of Barnstable.
Date:
Building Commissioner,Town of Barnstable
I
LICENSE OR Liberty Mutual surety
450 Plymouth Road,Suite 400
PERMIT BOND Plymouth Meeting,PA 19462
Bond 016062107
LICENSE OR PERMIT BOND
KNOW ALL BY THESE PRESENTS,That we, Field Asset Services, LLC
as Principal,and the Liberty Mutual Insurance Company ,'a Massachusetts corporation,
as Surety,are held and firmly bound unto Town of Barnstable, MA
as Obligee,
in the sum of - Ten.Thousand and No/100
Dollars($-10,000.00 )
for which sum,well and truly to be paid,we bind ourselves,our heirs,executors,administrators,successors and assigns,jointly and
severally,firmly by these presents.
Signed and sealed this 29th - day of. January 2015
THE CONDITION OF THIS OBLIGATION IS SUCH, That WHEREAS,the Principal has been or is about to be granted a license or
permit to do business as 800 Bearses Way UNT, Hyannis, MA 02601
by the Obligee.
NOW,Therefore,if the Principal well and truly comply with applicable local ordinances,and conduct business in conformity therewith,
then this obligation to be void;otherwise to remain in full force and effect.
PROVIDED,HOWEVER; 1.This bond
shall continue in force:
Until ,or until the date of expiration of any Continuation Certificate
executed by the Surety
OR
® Until canceled as herein provided.
2 This bond may be canceled by the Surety by the sending of notice in writing to the Obligee,stating when,not less than thirty days
thereafter,liability hereunder shall terminate as to subsequent acts or omissions of the Principal.
Field Asset Services, LLC
Principal
aa_e rti B
cn
Qn
P
CC -. Liberty Mutual Insurance Company
I __'- Y.S.b[rJ�i
By.
> ylvi . Ogle Attorney-in-Fact
NY License PC-1182562
S-0909/1-M 10/06
XDP
THIS POWER OF ATTORNEY IS NOT VALID UNLESS IT IS PRINTED ON RED BACKGROUND.
This Power of Attorney limits the acts of those named herein,and they have no authority to bind the Company except in the manner and to the extent herein stated.
Certificate No.8880188 _
American Fire and Casualty Company Liberty Mutual Insurance Company
The Ohio Casualty Insurance Company WestAmerican Insurance Company
POWER OF ATTORNEY
KNOWN ALL PERSONS BY THESE PRESENTS: That American Fire&Casualty Company and The Ohio Casualty Insurance Company are corporations duly organized under the laws of
the State of New Hampshire,that Liberty Mutual Insurance Company is a corporation duly organized under the laws of the State of Massachusetts,and WestAmerican Insurance Company
is aborporation duly organized under the laws of the State of Indiana(herein collectively called the"Companies"),pursuant to and by authority herein set forth,does hereby name,constitute
and appoint, Brooke A.Knowles:Chaun M.Wilson;D-Ann Kleidosty:Gary D.Eklund:Sharon J.Potts:Svlvia M.Ogle:William G.Moody
all of the city of Atlanta state of GA each individually if there be more than one named,its true and lawful attomey-in-fact to make,execute,seal,acknowledge
and deliver,for and on its behalf as surety and as its act and deed,any and all undertakings,bonds,recognizances and,other surety obligations,'in pursuance of these presents and shall
be as binding upon the Companies as if they have been duly signed by the president and attested by the secretary of the Companies in their own proper.persons.
IN WITNESS WHEREOF,this Power of Attomey has been subscribed by an authorized officer or official of the Companies and.the.corporate seals of the Companies have been affixed
theretothis 12th day of August 2014
y,
su „htiM Je American Fire and Casualty Company
`�e k r� 5 �, ��;- �;a v�� �3 r,�. `4 a. •F< The Ohio Casualty Insurance Company N
t r Liberty Mutual Insurance Company m
914 1! 2
West merican Insurance Company
�w � �l�F:.;. r yap • i •(n.
w By
STATE OF PENNSYLVANIA ss David M.Care , ssistant Secretary C
All
+_ COUNTY OF MONTGOMERY _ O
mOn this 12th day of August -ELL before me personally appeared David M. Carey,who acknowledged himself to be the Assistant Secretary of American Fire and v�
w4) Casualty Company,Liberty Mutual Insurance Company,The Ohio Casualty Insurance Company,and WestAmerican Insurance Company,and that he,as such,being authorized so to do, >,W
p execute the foregoing instrument for the purposes therein contained by signing on behalf of the corporations by himself as a duly authorized officer. c
a;.? IN WITNESS WHEREOF,I have hereunto subscr' and affixed my notarial seal at Plymouth Meeting,Pennsylvania-on.the day and year first above written. O a
d. C2Q. S COMMONWEALTH OF PENNSYLVANIA
^ota a 'SealM
C•N O � . ToseSa a e:lat NwatyPubl€c B �/�'.c^ �" ' O�
OL �" V r- n t.rxp o,;gomery County y" Teresa Pastella,Notary Public L
w L OF . Y1y Commission Ex?.-es lviarch 28.2017 € � �_
w-�C '� _ !rlen• e Pe,lrridania:;csari nofUotiec� .. - 'O E.
d a
CThis Power of Attorney is made and execute ority of the following By-laws and Authorizations of American Fire and Casualty Company,The Ohio Casualty Insurance_ W Q.
w, Company,Liberty Mutual Insurance Company, n Insurance Company which resolutions are now in full force and effect reading as follows: . E
to ` ARTICLE IV—OFFICERS—Section 12.Power of Attorney.Any officer or other official of the Corporation authorized.for that purpose in writing by the Chairman or the President,and.subject O. r—
+; to such limitation as the Chairman or President may prescribe,shall appoint such attorneys-in-fact;as may be necessary.to act in behalf of the Corporation to make,execute,seal,
4.
O S acknowledge and deliver as surety any and all undertakings,bonds,recognizances and other-surety obligations. Such attomeys-in-fact,subject to the limitations set forth in their respective.�p
E 46 powers of attorney,shall have full power to bind the Corporation by their signature and execution of any such instruments and to attach thereto the seal of the Corporation. When so a)
p executed,such instruments shall be as binding as if signed by the President and attested to by the Secretary.Any power or authority granted to any representative or attorney-in-fact under > a
the provisions of this article may be revoked at any time by the Board,the Chairman,the President or by the officer or officers granting such power or authority. D
♦.N
CC r ARTICLE XIII 7 Execution of Contracts-SECTION 5.Surety Bonds and Undertakings.Any officer of the Company authorized for that purpose in writing by the chairman or the president, E
and subject to such limitations as the chairman or the president may prescribe,shall appoint such attomeys-in-fact,as may be necessary to act in behalf of the Company to make,execute, L.M
O 3 seal,acknowledge and deliver as surety any and all undertakings,bonds,,recognizances and other surety obligations. Such attomeys-in-fact subject to the limitations set forth in their C o0
Z v respective powers of attorney,shall have full power to bind the Company by their signature and execution of any such instruments and to attach thereto the seal of the Company. When so 0 o
executed such instruments shall be as binding as if signed by the president and attested by the secretary. OCID
Certificate of Designation—The President of the Company,acting pursuant to the Bylaws of the Company,authorizes David M.Carey,Assistant Secretary to appoint such attorneys-in- ~
fact as may be necessary to act on behalf of the Company to make,execute,seal,acknowledge and deliver as surety any and all undertakings,bonds,recognizances and other surety
obligations. .
Authorization—By unanimous consent of the Company's Board of Directors,the Company consents that facsimile or mechanically reproduced signature of any assistant secretary of the
Company,wherever appearing upon a certified copy of any power of attorney issued by the Company in connection with surety bonds,shall be valid and binding upon the Company with
the same force and effect as though manually affixed.. -
I,Gregory W.Davenport,the undersigned,Assistant Secretary,of American Fire and Casualty Company,The Ohio Casualty Insurance Company,Liberty Mutual Insurance Company,and
West American Insurance Company do hereby certifythat the original power of attorney of which the foregoing is a full,true and correct copy of the Power of Attorney executed by said
Companies,is in full force and effect and has not been revoked.
IN TESTIMONY WHEREOF,I have hereunto set my hand and affixed the seals of said Companies this /26 day of 20L3 .
tQ``\ v`''nv�9l.; y P�ar3'.�> 9..^ �J•.n•�"J�k`C���\;. �F�.��,,wc�:r�i^ . �� - .
99 n >f ?gig r L 1997 By:.
av Gregory W.Davenport,Assistant Secretary
`��y is',AugSC�a" 'vJ',y�'.:n?..�=�`�,•nb Y6'�j'�ssa;_'��2 ��?'M,nans
LMS 12873 122013
pFTME roy, Town of Barnstable
Regulatory Services
BAMSTABM
v MASS. $ Thomas F. Geiler,Director
qj i6g9. �0
'0rE0►Jle'�A Building Division
Thomas Perry,Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
October 12, 2004
G. Douglas Bridge
Friedline& Carter Adjustment, Inc.
436 Main Street
PO Box 338
Hyannis, MA 02601
RE: 800 Bearses Way,Unit 1WF
Dear Mr. Bridge,
My inspection at the above referenced property showed the damaged areas have been
completely gutted with the exception of some aluminum wiring. Due to the effects of the
moisture on the aluminum wiring (oxidation), I instructed the electrician to replace the
aluminum wiring in the effected areas only. I did not instructthe wiring be replaced anywhere
else.
Should you have any further questions or concerns please feel free to contact me,at 508-862-
4089.
Sincerely
William Amara
Electrical Inspector
09/30/2004 08:00 5087902344 FCC HYANNIS PAGE 01
r
J�
FRIF.DLINE&CARTER APtUSTIk[I N7,INC.
436 Main Srtmct,.I'.U.Box 338
HY;WM,Mw.gadxWfI (I`l6Uf o - •
Tel. (508)77,"P2 :Adjustment, lhc.
FAX f., g)790-2,M4,
Fax
To; Bill Amara From G.Douglas Bridge
foam 1-508-790.6230 Pages: 1 (including rover)
Phan 508-771-3232 Date: 9130/2004
Rm Cape Crossroads CC:
❑Urgent x For Review 0 Please Comment ® Please Reply O Please Recycle
A Cornments:
'B11,
Thanks for returning my call yesterday. Per our discussion could you please generate the details
involving Unit 1WF located at the Cape Crossroads at 800 Bearses Way in Hyannis. You had
inspected the unit after a flood occurs from a washing machine hose located on the second floor. The
water damage was to Ms Katy Markt unit(IWF). Please refer to the fact that the aluminum wires
needed to to rolaced throughout the entire unit and refer to other code issues that needed to be
replaced. I understand your busy sdeduW however a quick response would be greatly appreciated.
Kindest Regards,
G.
d u�sterlas Bridge
Adjuster
508-T71-3232
" TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
dap E '� -� Parcel 60 Permit# 7 Jf 6
Health Division � � � y
Date Issued 00
Conservation Division (9 GL 04')(-- Application Fee SD
O
Tax Collector Zo V Permit Fee f i �e
Treasurer �-Planning Dept. `'}
Date Definitive Plan Approved by Planning Board
Historic-OKH Preservation/Hyannis ` ' c;
ry r-
Project Street Address 860 E-9jL-S(a5
Village
Owner 1'ti T-�f`� /►'� { Address V d✓Z�,
Telephone -7
Permit Request f_E-#0 _A c-C—
��o C. 90� S a /Z L t�✓; 4—r-yt
Square feet: 1 st floor: existing proposed _2nd floor: existing proposed _ Total new
Zoning District Flood Plain -- Groundwater Overlay —
Project Valuation jf; a Construction Type
Lot Size Grandfathered: ❑Yes Cl No If yes, attach supporting documentation.
Dwelling Type: Single Family Cl Two Family ❑ Multi-Family(#units)
Age of Existing Structure `/A` Historic House: ❑Yes ❑No On Old King's Highway: ❑Yes ❑No
Basement Type: ❑Full ❑Crawl ❑Walkout ❑Other
Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft)
Number of Baths: Full: existing new Half: existing new
Number of Bedrooms: existing new
Total Room Count(not including baths): existing new First Floor Room Count
Heat Type and Fuel: ❑Gas ❑Oil 2tZlectric ❑Other
Central Air: ❑Yes Flo Fireplaces: Existing New Existing wood/coal stove: ❑YesO
Detached garage:❑existing ❑new size ---- Pool:❑existing ❑new size Barn:❑existing ❑new size
Attached garage:❑existing ❑new _size '—Shed: ❑existing ❑new size Other:
Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑
Commercial ❑Yes ❑No If yes,site plan review#
Current Use Proposed Use
BUILDER INFORMATION
Name �,I �g E� Telephone Number ��0 7 7 q 0
Address License#
���` Home Improvement Contractor# /€� :�� 9 SO
Worker's Compensation#
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO Tc)ter✓ Q A7t,✓fM,3C;
L d Lk-
SIGNATURE DATE Z q . U
i
s FOR OFFICIAL USE ONLY
s 17.
` I PERMIT NO. ," r
DATE ISSUED
MAi/PARCEL NO. :
ADDRESS r VILLAGE
OWNER
DATE'OF INSPECTION:
FOUNDATION -! <
FRAME
INSULATION
t
FIREPLACE
1 -
ELECTRICAL: ROUGH FINAL,- +
PLUMBING: ROUGH FINAL
a ..
GAS: ROUGH 7 FINAL A- ' y
FINAL BUILDING
DATECLOSEDOUT'?
j ASSOCIATION'PLAN NOP I -
f .
The Commonwealth of Massachusetts
ti -- Department of Industrial Accidents
' - OAI6B6f�rStl�sd�s' .
600 Washington Street -
- , 1 Boston,Mass. 02111
Workers' Com ensation.•Insurance Affidavit-General Businesses
J..JiaYr'.
address. Z •� ^ �yw � i � ' ,-;.
city ^'' `' state: Ak '5 zip: 6� G i' phone# d 1 l� k�
work site location(full address):
t3I-am a sole proprietor and have no one Business Types E]Retail❑Restaurant/Bar/Eating Establishment
working in any capacity. ❑ Office[1 Sales(mcluding Real Estate,Autos etc.)
❑I am an employer with em to ees(full& art time. ❑Other
I am an employer providing workers' compensation for my employees working on this job.
eoiiipanV DeIIie• -- --
1>
address: ..
I am a sole proprietor and have hired the independent contractors listed below who'have the following workers'
compensation polices:
comAanV name
address:.
A one
city.:.
insurance co....:
company name:.,; :. . • :.' ',: -
address:.
I iv
one
insurance so:
Fallure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or
one years'imprisonment as well as civil penalties in the foim of s STOP WORK O�tDER and a fine of$100.00 a day against me. I understand that ti
copy of this statement maybe forwarded to the Office of Investigations of the DIA for coverage verification. ;
I do hereby certify der the pains an pen ties f perjury that the information provided above is trudge ar,d cor ect
Signature Date rf ��
Print name
f��'/t A,( �/�:G/ Phone# �e 7 1 I` t9 ct'.�,
official use only do not write in this area to be completed by city or town official
ems' city or town: permittlicense# []Building Department '
❑Licensing Board
L ❑check if immediate response is required ❑Selectmen's Office
❑Health Department
contact person: phone#; []Other
(revised Sept 2003)
n
r
Information and Instructions
Massachusetts General ILaws chapter 152 section 25.requires all employers to provide workers' compensation for their.
employees.. As quoted from the illaw", 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 mare of
the foregoing engaged in ajoint 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 eiriploys_persons to do.maintenance, construction or repair work on such dwelling house or on the grounds or
building appurtenant thereto shall not because of such employment.be deemed to bean employer. .
MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or renewal
of a license or permit to operate a business or to construct buildings in the.commonwealth for any applicant who has
not produced acceptable evidence of compliance with the insurance coverage required. Additionally,neither the
coirnnonwealth 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 in the workers' compensation affidavit completely,by checking the box that applies to your situation..Please
supply company name, address and phone numbers along with a certificate of insurance.as all affidavits may be submitted
to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the
affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being
requested, not the Department of Industrial Accidents. Should you have any questions regarding the"law"or if you are
required to obtain a workers' compensation policy,please call the Department at the number listedbelow.
City or Towns .
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the
affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please
be sure to fill in the pernit/license number which will be used as a reference number. The.affidavits may be.returned to
the Department by.mail or FAX unless other'arrangements have been made._
The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions,
please do not hesitate to give us a call
The Deparhnent's address,telephone and fax number:
The Commonwealth Of Massachusetts
Department of Industrial Accidents
am"of Nes gaNns
600 Washington Street
Boston,Ma. 02111
fax#: (617)727-7749
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phone#: (617) 727-4900 ext.406
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j Board of Baildi tg Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
�a Re91 4 105488
17/2006
tidual
ARTHUR M.PA J
Arthur Pacheco --"
26 Nancy's Ln, _.y`0„' GG..«- ii� ✓
{ Hyannis,MA 02601
Administrator t�
BORp,O�B iUiILDi RBGULA�TI®ANS i
License"'; C®�ISTRUCTION SUPEEt;UCSOR
Nurn�b��S 03�1802
Bpi; _1953
6 Tr.no: 25966
R
�? ARTH1, NI PA
26aN►AN{`fS L�AIS`�\y
HY>AV Ij,IS, MA IkYidv
I + Commissiou�er
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i.!v
HE Town of Barnstable
�FS Tpkti
Regulatory Services
#, x3TABI.E,$ Thomas F.Geller,Director
9 '6 9 Building Division
Tom Perry, Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
Fax: 508-790-6230
office: 508-962-4038
Property Owner Must
Complete and Sign This Section
If Using ABuilder
as Owner of the subject property
�,-r— �� G� 4-o to act on my behalf,
hereby authorize f,.
in all matters relative to work authorized by this building permit application for
9"4G oGgr CeS Gt/
(Address of Jo
isin re of Owner
Date
Pnnt Name
gFORMS:OW m"'ERMISS10N