Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
0250 FAWCETT LANE
f �� �, r ��� yj 44L- 4 i I 0 � -- Co� �6 is to be disposed of. luired. - 1 no certification needed if on-site septic system) commercial projects t form must be submitted if more than one person will be er better of Permission ater require a permit from the Fire Department having �. /'� � . . .,�.�. � ; ;�,:;� � � �_. i .�� j , ��- fa '�,.� i- i �'r ,� t __ �' �� � � �� j� J y l_-�.. , � wilding permit application for: . • � C Date I . --- -- ---NAME OF FEN ��- ------ -]BAR 76341 TOWN OF ADDfl SSOFOF DE BARNSTABLE CITY E,ZIP CODE NeR d.I ► IMB REGISTTRATION NUMBER • OFFE S XAXMAl'API.E. ' �1A55. LLJ S I•/ g" fA ED P ! •' L_- '_" / / 17"r' �T'1••G- > TIME AND DAT VJO' LOCATION OF ION Z NOTICE OF M P.M.)o - -_ � ti ° C a VIOLATION J SITU ,_ ENFORL°ING• RSON / f EN R INGDE . BA ENO. � 0 OF TOWN {ERE ACKNOWLEDGE RECEIPT OF CITATION XLU ORDINANCE unable t0 obtain Sig 5ture f off ndeF/ I t �T THE NONCRIMINAL FINE FOR THIS OFFENSE IS Date mailed i !J W OR 1 YOU HAVE THE FOLLOWING ALTERNATI ES WITH REGARD TO DISPOSITION OF THIS MATTER.EITHER OPTION(1)OR OPTION(2)WILL OPERATE AS A FINAL 0- � DISPOSITION WITH NO RESULTING CRIMINAL RECORD. W REGULATION a (1)You may elect to pay the above fine,either by appearing in person between 8:30 A.M.and 4:00 P.M.,Monday through Friday,legal holidays excepted, ty before:The Bametab1.Clerk,200 Main Street,Hyannis,MA 02601,or by mailing a check,money order or postal note to Barnstable Clerk,P.O Box 2430, a Hyannis,MA 02601,WITHIN TWENTY-ONE(21)DAYS OF THE DATE OF THIS NOTICE. ((2)1 If you desire to contest this matter in a noncriminal proceeding,yyou mayy do so by making written request to DISTRICT COURT DEPARTMENT,FIRST dUNSTABLE DIVISION,COURT COMPOUND,MAIN STREET,BARNSTABLE,MA 02630,Attn:21D Noncriminal Hearings and enclose a copy of this citation for a hearing. (3)If you fail to pay the above offense or to request a hearing within 21 days,or if you fail to appear for the hearing or to pay any fine determined at the hearing to be due,criminal complaint may be issued against you. ❑ 1 HEREBY ELECT the first option above,confess to the offense charged,and enclose payment in the amount of$ Signature NAME OF0 END..... ? s BAR 76/'40 TOWN OF ADDLES of OF,FEN, r^ f , y �Ki BARNSTABLE CITY,STATE,ZIP CODE + �4 pIFTKE►O�Y MVIMB REGISIFIATION NUMBER OFFENSE • NAX\1A7AR IE�0 MASS ! .�� u . G639. >"C' TIME AND DATE OF VIOLATIONS- LOCATION OF.WO•Ai�ON d ! W NOTICE OF r''° (A. ! ,P.M.}ON j . /� d44— SIGNAT Ea 9UFARCI PERSON ,..-�'� ENFORCING PT BADG N W. »-°C HER�&�F-AfCKNOWLEDGE RECEIPT OF CITATION X a ORPINANCE Unable to obtain sig tur of ff r. I THE NONCRIMINAL FINE FOR THIS OFFENSE IS Date mailed ' W. OR YOU HAVE THE FOLLOWIN ALTER ATIVES WITH REGARD TO DISPOSITION OF THIS MATTER.EITHER OPTION(1)OR OPTION(2)WILL OPERATE AS A FINAL a DISPOSITION WITH NO RESULTING RIMINAL RECORD. Uj REGULATION may elect to pay the above fine,either by appearinggannis,MA in person between mailing8:30 A.M.and 4:00 P.M.,Monday through Friday,legal holidays excepted, LU Hyannis,MA 02601 bW TH W TWEN 200 ein TY--ONE(21{)DAYS OF THE DATE or OF THIS NOTICCE.money order or postal note to Barnstable Clerk,P.O.Box 2430, CL (2 Uyou desire to contest this matter in a noncriminal proceeding,you may do so by making written request to DISTRICT COURT DEPARTMENT,FIRST NSTABLE DIVISION,COURT COMPOUND,MAIN STREET, ARNS ABLE,MA 02630,Attn:21 D Noncriminal Hearings and enclose a copy of this citation for a hearing. (3)If you fail to pay the above offense or to request a hearing within 21 days,or if you fail to appear for the hearing or to pay any fine determined at the hearing to be due,criminal complaint may be issued against you. ❑ 1 HEREBY ELECT the first option above,confess to the offense charged,and enclose payment in the amount of$ Signature I��i� ����J � � P�7� �' e ��-"� �,�P- so���O���� /fs'.�Wi� J-�v OR ALTERATION onstruction or alteration not requiring notice. is required to notify the Administrator for any of the following construction n: 'ect that would be shielded by existing structures of a permanent and `. I character or by natural terrain or topographic features of equal or greater d would be located in the congested area of a city,town,or settlement evident beyond all reasonable doubt that the structure so shielded will ely affect safety in air navigation. tenna structure of 20 feet or less in height except one that would increase. of another antenna structure. navigation facility,airport visual approach or landing aid,aircraft evice,or meteorological device,of a type approved by the Administrator, ' ropriate military service on military airports,the location and height of xed by Its functional purpose. , nstruction of alteration for which notice is required by any other FAA; . orm and time of notice. person who is required to notify the Administrator under§77.13(a)shall executed form set of FAA Form 7460-1,Notice of Proposed Construction ion,to the Manager,Air Traffic Division, FAA Regional Office having 4n over the area within which the construction or alteration will be located. f FAA Form 7460-1 may be obtained from the headquarters of the Federal Administration and the regional offices. iotice required under§77.13(a)(1)through(4)must be submitted at least before the earlier of the following dates; ie date the proposed construction or alteration is to begin. ie date an application for a construction permit is to be filed. a notice relating to proposed construction or alteration that is subject to sing requirements of the Federal Communications Act may be sent to the ie same time the application for construction is filed with the Federal iications Commission,or at any time before that filing. oposed structure or an alteration toy an existing structure that exceeds et in height above the ground will'be presumed to,be,a hazard to air )n and to result in an inefficien6 utilization of airspace and the applicant has ien of overcoming that presumption.-Each notice submitted urider the t provisions of this part 77 proposing a structure in excess of 2,000 feet NAME O r OFFENDER Mi!'9R 76337 -� 1 ) w ✓. ✓ TOWN OF ADDRESSOf•0_FENDERjr BARNSTABLE CITY STATE ZIP CODE f,T } y tt + pf 1l�t�1 MV/MB REGISTRATION NUMBER _ OFFENSE UAx ASS.LY.. % � r !'nF + A r .... •� , -J} ,,- -f a,, .I� ,a s• �mS / t� #'x� tt� sue.' q{•__:, 4�1 C) la..-i 1, s',�a +� / Cf/ i .}r I [ si', �_d`r%%%• �)' '-� LU TIMEAND DATE OF VIOL�?ION -- f p 1�pCATION GEVIOLAAOf�F + ""Z' NOTICE OF i A.M.%P.M.)ON r mot~ 20 f+ L•;/� +r - y+f L7:>i,.s� f' r.f+r "d' i, ; p /✓f I, J j SIGNAtURFOF ENFORCINCPERSON s" - -A ENFORCING DEPT, BAD E NO. W. VIOLATION'. - r. ._-...... ... ...� ter, OF TOWN I (,HEREB.Y-A"CKNOWLEDGE,RECEIPT OF CITATION X wa ORDINANCE Unable to obtain signature of f)ffend THE NONCRIMINAL FINE FOR THIS OFFENSE IS S , f ~' OR Date mailed . i„i /. ,�. w L., . YOU HAVE THE FOLLOWING ALTERNATIVES WITH REGARD TO DISPOSITION OF THIS MATTER.EITHER OPTION(1)OR OPTION(2)WILL OPERATE AS A FINAL rL .1 REGULATION DISPOSITION WITH NO RESULTING CRIMINAL RECORD. w �, (1)You may elect to pay the above fine,either by appearing in person between 8:30 A.M.and 4:00 P.M.,Monday through Friday,legal holidays excepted, w before:The Barnstable Clerk,200 Main Street,Hyannis,MA 02601,or by mailing a check,money order or postal note to Barnstable Clerk,P.O.Box 2430, Hyannis,MA 02601,WITHIN TWENTY-ONE(21)DAYS OF THE DATE OF THIS NOTICE. a.. 1 �2)If you desire to contest this matter in a noncriminal proceeding,you may do so by making written request to DISTRICT COURT DEPARTMENT,FIRST RNSTABLE DIVISION,COURT COMPOUND,MAIN STREET,BARNSTABLE,MA 02630,Attn:21 D Noncriminal Hearings and enclose a copy of this citation for a hearing. i (3)If you fail to pay the above offense or to request a hearing within 21 days,or if you fail to appear for the hearing or to pay any fine determined at the hearing to be due,criminal complaint may be issued against you. ❑ I HEREBY ELECT the first option above,confess to the offense charged,and enclose payment in the amount of$ Signature A9 ,r ry i� 9L_ TOWN- OF BARNSTABLEBuildingWI Application Ref: 200701196 App PermitIssue Date: 03/13/07 9 MASS. �j 1639. �� Applicant: PILO,ARGOS TR Permit Number: B 20070444 Ar�p �a Proposed Use: SINGLE FAMILY HOME p Expiration Date: 09/10/07 Location 250 FAWCETT LANE Zoning District RB Petmit.Type: RESIDENTIAL ADDITION/ALTERATIO Map Parcel 270130 Permit Fee$ 25.00 Contractor PROPERTY OWNER Village HYANNIS App Fee$ 50.00 License Num Est Construction Cost$ 150 Remarks APPROVED PLANS MUST BE RETAINED ON JOB AND REMOVE DOORS IN BASEMENT,MAKE 5 FT OPENINGS THIS CARD MUST BE KEPT POSTED UNTIL FINAL REMOVE KITCHEN TO RESTORE TO A SINGLE FAMILY HOME INSPECTION HAS BEEN MADE. WHERE A CERTIFICATE OF OCCUPANCY IS REQUIRED,SUCH Owner on Record: PILO,ARGOS TR BUILDING SHALL NOT BE OCCUPIED UNTIL A FINAL Address: P O BOX 667 INSPECTION HAS BEEN MADE. HYANNIS,MA 02601 Application Entered by: PR Building Permit Issued By: "— THIS:PERMIT CONVEYS NO RIGHT TO OCCUPY ANY STREET,ALLY`OR;SIDEWAZK OR ANY PART THEREOF EITHER TEMPORARbLY OR PERMANENTLY.:. ENCROAC.HENIENTS"ON PUBLIC PROPERTY,NOT SPECIFICALLY PERMITTED UNDER THE BUILDING CODE ]vIUST,BE APPROVED BY THEJURISDICTION... STREET OR ALLY;GRADES-AS-WELL AS DEPTH AND LOCATION OF PUBLIC SEWERS MAY BE OBTAINED.,FROM THE DEPARTMENT OF PUBLIC WORKS.:` THE ISSUANCE OF-THIS PERMIT DOES NOT RELEASE THE APPLICANT FROM THE CONDITIONS OF A1•Iy APPLICABLE SUBDIVISION;RESTRICTIONS MINIMUM OF FOUR CALL INSPECTIONS REQUIRED FOR ALL CONTSTRUCTION WORK: I.FOUNDATION OR FOOTINGS. Z.ALL FIREPLACES MUST BE INSPECTED AT THE THROAT LEVEL BEFORE FIRST FLUE LINING IS INSTALLED. 3.WIRING&PLUMBING INSPECTIONS TO BE COMPLETED PRIOR TO FRAME INSPECTION. 4.PRIOR TO COVERING STRUCTURAL MEMBERS(READY TO LATH). 5.INSULATION. 6.FINAL INSPECTION BEFORE OCCUPANCY. WHERE APPLICABLE,SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL,PLUMBING AND MECHANICAL INSTALLATIONS. WORK SHALL NOT PROCEED UNTIL THE INSPECTOR HAS APPROVED THE VARIOUS STAGES OF CONSTRUCTION. PERMIT WILL BECOME NULL AND VOID IF CONSTRUCTION WORK IS NOT STARTED WITHIN SIX MONTHS OF DATE THE PERMIT IS ISSUED AS NOTED ABOVE. PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO GUARANTY FUND(as set forth in MGL c.142A). BUILDING INSPECTION APPROVALS PLUMBING INSPECTION APPROVALS ELECTRICAL INSPECTION APPROVALS 1 1 1 ,2 2 2 3 (/ ' © �C 1 Heating Inspection Approvals Engineering Dept Fire Dept 2 Board of Health m r�. W ark, r ft' F �F x 1 r a � I 4 f r ___ _ _ _ ......_...� w _ .____ y w �- S��.e. '�a y, ,' k 4 } ;�r �. 0. -�� �. i . ,',�.fir,>, r �� ��` ` � „�7 :. ,,_„s F r .*se' :+ � .,,R ka.., �t�w�. > � � � � .x �,n r � .i.. "�r f,t �> 's-: �� �, �, a '�" �+r,�;: D �5 �.per �..,.. �Syfj- ti ''r �r+�N�a.. y _ _ e i k t t 1 . j c4Nx' �ti I v zlet y ti { 6 { t r + } v w w Page 2 of 4 of its members legally qualified to vote at a r the purpose of amending its articles. M.G.L.A. 950 CMR § 106.09. ration shall organize for a non-profit purpose g articles of organization with the Corporations A. c 180 § 4 (1971); 950 CMR 106.03. irectors or officers r tions must specify any changes in officers or a certificate of change of directors or officers. D(1991). r rinci al office ions must specify any changes'to the principal cling a certificate of change of principal office. re not acceptable as a principal office address. OC (1989); M.G.L.A. c156B § 14 (1964); 950 ' ! r scal year tions must specify any changes to the date of the cling a certificate of change of fiscal year. OC (1989); 950 CMR 104.08. t . � .. NAME OFF DER DAD 76337 TOWN OF ADD OF tFFENDER BARNSTABLE CITY, T ZIP CODE ,�{ " MV MB REGISTRATION NUMBER �. q OFFS/NjSE G J eAlt\VI APLF..V ! I�.. S" ~• Y' �9n 1„/�. W MASS C✓ I O. 6jq w•0 lFD MJ�A � CLU _ f TI ME AND D TE .VIO -10 — - . ll TION OF LION 't M LU !7L•. .Srd NOTICE OF M49 M. pm.)oN,y 471_ 20 6— —�P'— bc� " �. SIGNAENFORCINC'PERSON '"' ENFOH IN"DEPT BAD N0. W VIOLATION :�... - �,.c�" .:" " ..� _. ._. r "' 0 j OF TOWN " �� REBY. KNOWLEDGE RECEIPT OF CITATION X a ORDINANCE Unable to obtain signa re o nder 5j✓THE NONCRIMINAL FINE FOR THIS OFFENSE IS Date mailedWOR YOU HAVE THE FOLLOWING AL��f TIVES WITH REGARD TO DISPOSITION OF THIS MATTER.EITHER OPTION(1)OR OPTION(2)WILL OPERATE AS A FINAL a DISPOSITION WITH NO RESULTING CRIMINAL RECORD. W REGULATION 1 You may elect to a the above fine,either b Q ( ) y pay y appearing In person between 8:30 A.M.and 4:00 P.M.,Monday through Friday,legal holidays excepted, W before:The Barnstable Clerk,200 Main Street,Hyannis,MA 02601,or by mailing a check,money order or postal note to Barnstable Clerk,P.O.Box 2430, Hyannis,MA 02601,WITHIN TWENTY-ONE(21)DAYS OF THE DATE OF THIS NOTICE. d �21 If you desire to contest this matter in a noncriminal proceeding,you may do so by making written request to DISTRICT COURT DEPARTMENT,FIRST "^ ARNSTABLE DIVISION,COURT COMPOUND,MAIN STREET BARNS'ABLE,MA 02630,Attn:21 D Noncriminal Hearings and enclose a copy of this citation for a hearing. (3)If you fail to pay the above offense or to request a hearing within 21 days,or N you fail to appear for the hearing or to pay any fine determined at the hearing to be due,criminal complaint may be issued against you. ❑ I HEREBY ELECT the first option above,confess to the offense charged,and enclose payment in the amount of$ Signature R e /+1y� NAME F OFFEND,.. i �."+11. _. Y!'',Q Mff *„J R TOWN OF ADO BE SS F d ER t BARNSTABLE CITY S AT 'E r e aIF1 ►p� MVI B REGISTRATION NUMBER ¢ �►�� OFFENSE Lj yf' a J/ �x ��//� /y' /g NAN AIARLE.O $✓ A4 i it) Y .v, J',. ���,,.+� ;J' . • C� 'LASS 67q: �O LU T AND ATE OF VIOLAT �,, f LO ATION Of�IVI AT 0�„ LU NOTICE OF �!hMl/ P.M.) w , i 20L� J "" �[} ,4 SIG AdJ�ftE*OF ENFORCI PERSON �� - ENF Ru "I BADGE . W VIOLATION � —'. RpGfCn OF TOWN `"�I A/ ACKNOWLEDGE RECEIPT OF CITATION X a ORDINANCE , bUnable to obtain sign lure of ffer r. I ••� < THE NONCRIMINAL. FOR THIS OFFENSE IS 18146 W Date mailed w OR YOU HAVE THE FOLLOWING'ALTERNATIVES WITH REGARD TO DISPOSITION OF THIS MATTER.EITHER OPTION(1)OR OPTION(2)WILL OPERATE AS A FINAL a DISPOSITION WITH NO RESULTING CRIMINAL RECORD. w R EGU CAT IO N , You ma elect to a the above fine,either b appearing in person between 8:30 A.M.and 4:00 P.M.,Monday through Friday,legal holidays excepted, , before:The Barnstable Clerk,'200 Main Street,by nnis,MA 0201,or by mailing a check,money order or postal note to Barnsable Clerk,P.O.Box 2430, Hyannis;MA 02601,WITHIN TWENTY-ONE(21)DAYS OF THE DATE OF THIS NOTICE_ n- 's:x (2)If you'desire to contest this matter in a noncriminal proceeding,you mayy do so by making written request to DISTRICT COURT DEPARTMENT,FIRST t RNSTABLE DIVISION,COURT COMPOUND,MAIN STREET, ARNSTABLE,MA 02630,Attn:21 D Noncriminal Hearings and enclose a copy of this citation for a hearing. "0' (3)If you fail to pay the above offense or to request a hearing within 21 days,or if you fail to appear for the hearing or to pay any fine determined at the hearing to be due,criminal complaint may be issued against you. ❑ 1 HEREBY ELECT the first option above,confess to the offense charged;and enclose payment in the amount of$ Signature -- � \` r .-- �_ �� File' id)t TdQI$` ! jj e._ ;I 25 s_ ° r�a,� a m® �l A✓v x 4 m^" ,� z d'W:tidn.....� -- - �— -- ,,-,.. '% S" .�:` .*:a�2»�_°°_ lx�. �A i .'' -�,.� 3k � = �*Y�::�•�,'� ��"' � 7,7 77777 Detdrl; pRlicahan', 2007,0119 :Mw v, a +1 ,L DPP SD � �� ,m lEcant Cut -;PROP '4'�TYflLL v ctdtas C COMPLETE" ,JF Cd11ecE' AT Z$5d�91 4 t - µ Departrner fi3�}i} BU9L ItVG DEP'tRTfi9Efd,T _ .� r xr A! � k� �oselDeny L a GS Tom, ftiectJl4ctivity 434-RESID TIA-L'ADD]T1C�;1JNIT T4C������ �¢ �� � 0.. i _ _ .� Carac#dr Ior3cfldvti Descriptranl> �-[REMOVEhDC�CRSIt�BASftET tf�IICE5 FlEhl'ICS,��� tBu Hess,., . Cescriptaan2 FiEtu9CE "( ESTRETOSIGLEF141d }�dJl£ a .� ° � s Par{cmg (llsC # g � **Y . act' --77-77T «" � PrdpeO/Use 1�dn-Car2drmir�.Propepe g I qa es utisc 1� ds ' �;.. Property } a S +:; Y ,„� + P petty CJse } edGtlV3te s —� Fs c aa 'i' � a _ IAcation i t <Unr � �tx "baslinguse � 1�1D.`'Stfil6L�I 0 .414t 4 `+s �.•+ :a ! d��si,FeEs SIrEt FtVvETTfiIE �- + 14, s " , 1 r ;. a i + aanrrag f'rB RSIID R$ F r 1 ; Patin 2013s ;° zi 'xa y .=r { 7 " '~ �a� 5 „ I; lESCfd4�t j ' � s �, .' # ,.munci P} em ° p n ."r i.a-�..,...a.,� .. T" �"g x � 'x r� s P"' r'2.r �5 '*• y r s�.(�msldln/13t a � R"rr aka s 1 1f �. FrDptased use .�I 10 t'SINGLE; ngs RB F.ES1DR B' t f� i and k r a k3. #+ s.a 'ss.•`� 5 „Y fk 7 y -.� a>..... a "` i e e .w=,v:.... tw�:✓x,,.., ,� "F .:' `a°f- e.y�'u, j�Miia` a'�''a ^.: s � dd Hlstar�. _ r C r . , raernd� it§ - `" .: l.. Upton desc TVl6`7 s Yi„ ' ,r r ay`F'"s«i�rrefr ,, t*3„ np rw.2 �..r - r,. .. S�amr�T E3TITYIt A t 7r `# t J kY .z r $ X #i� Aq- 5 ""�dp}• a.6 `�.` '. .xy a, x .,.- •xt° .. - atitr.€r 'ate ;7-77 1-0 #~ _" '°Prer�q�rsitas ? HazrdlRe��tf j( h7es [ Bands S%nl� ddrs (� Tead � n:P�an Review s _ - H r, `= ,.- �ry r ~.•L k# §� ry� �P"' y��� ry - + Y.�., 3 P,radr hrstary. <' g�tnspectrans, #( aiaYdtrons ��, e�reays ( CrpenGms �s ?laran�ngs• ° (aFnd Ralated , � _ -g� —� "sue d•.taw A � e � "ti .mac c R�a fi w Rik r � .';- _,r,. s- .� # •�.. --'.• is s u,�_ r r f7a a , 1VOT �sss. '��.. izt; --'" 1`°f{ �-,;.�be.,:= •.ti.•','`'. 'I'�,y E T ': p= w _ # . ? -d^ "z ,,F ;• ",5* '._! 1r , � � ;-�. `.#' .rr.. . r ,.`ss� e _3*r� �.•� � c�'�",tN� .�.°¢z��'�e'�,'�P`� �"t'� SCE- 'x'�=rr.�`'s t > '�a �.� '� %�,� s'�^i�' � �, c i Maint,mn'3rCijECt!6ct,vib/dE�far tfhL icurfent,d plicatran « : r, < - r v i 'Parcel Detail Page 1 of 3 IN s. AiriR�F\PLLf , ra r•"++ c� n4lAllwY "nwi �o�,��arm _;• �:.�.,.,.:�.- :� �G`ti ���G' .`�c� ..;���t�r9 ��'o���i� Logged In As: Parcel Detail Tuesday, Februa Parcel Lookup Parcellnfo Parcel ID 270-130 Developeer'LOT 67 Lo Location '250 FAWCETT LANE Pri Frontage 170 Sec Road ,PITCHER'S WAY Sec 1127 -- - Frontage Village HYANNIS Fire District;HYANNIS Sewer Acct , Road Index :0526 Interactive .-LOW ' Map I4 .sue Owner Info owner PILO, ARGOS TR Co-owner PILO REVOCABLE TRUST Streets P O BOX 667 Street2 City IHYANNIS State IMA zip i02601 Country Land Info Acres 10.29 Use ilSinde Fam MDL 01 Zoning RB `—~ Nghbd 10107 Topography Level Road !Paved utilities ISeptic,Gas,Public Water Location Construction Info Building 1 of 1 Year! _ Roof;G- /Hip _ Ext .. -- Built,1968 Struct; able I Wall !Wood Shingle Effect r __ ___ Roof - - - ' - AC Area 1099 Cover;Asph/F GIs/Cmp Type iNone _ . ._. Int; -- ____ .. Bed r___ Style Ranch Drywall 12 Bedrooms Wall I rYwa Rooms Int� - '' Bath ;^ Model Residential 2 Full Floor _ Rooms Heat Total _. ._ Grade Average !Hot Water 14 Rooms - TYpe - - Rooms -- — http://issql/intranet/propdata/PareelDetail.aspx?ID=20135 2/20/2007 ; - I Parcel Detail Page 2 of 3 • WD.K1�4 Heat - Stories 11 Story _ Fuel 'Gas �� F ation Typical a:24 - } 05 Permit History Visit History Sales History Line Sale Date Owner Book/Page Sale P 1 11/23/2005 PILO, ARGOS TR C178622 2 7/31/2003 PILO,ARGOS C170039 3 3/31/2000 GAUMONT, GARY R C157110 4 4/15/1988 HEMMER, LYNNE D & GUALTIERI, J M C114097 5 7/15/1983 SHEEHY, EMILY A C92693 6 5/15/1983 MYCOCK, RONALD J C91941 Assessment History Save# Year Building Value XF Value OB Value Land Value Total Parc( 1 2007 $109,400 $13,000 $800 $183,800 2 2006 $100,400 $13,000 $800 $185,500 3 2005 $95,800 $12,900 $800 $131,900 4 2004 $74,600 $2,500 $0 $112,100 5 2003 $67,300 $2,500 $0 $30,000 6 2002 $67,300 $2,500 $0 $30,000 7 2001 $66,700 $2,500 $0 $30,000 8 2000 $50,200 $2,300 $0 $19,500 9 1999 $50,200 $2,300 $0 $19,500 10 1998 $50,200 $2,300 $0 $19,500 11 1997 $43,300 $0 $0 $19,500 12 1996 $43,300 $0 $0 $19,500 13 1995 $43,300 $0 $0 $19,500 14 1994 $45,100 $0 $0 $23,400 15 1993 $45,100 $0 $0 $23,400 16 1992 $51,100 $0 $0 $26,000 http://issgl/intranet/propdata/PareelDetail.aspx?ID=20135 2/20/2007 Parcel Detail Page 3 of 3 17 1991 $57,800 $0 $0 $42,200 ; 18 1990 $57,800 $0 $0 $42,200 19 1989 $57,800 $0 $0 $42,200 ; 20 1988 $41,600 $0 $0 $19,300 21 1987 $41,600 $0 $0 $19,300 22 1986 $41,600 $0 $0 $19,300 Photos http://issql/intranet/propdata/ParcelDetail.aspx?ID=20135 2/20/2007 yycFI ETpk, Town of Barnstable Regulatory Services BAR9 MASS. Thomas F.Geiler,Director �p t6gq. ♦0 rE1639.�p Building Division Thomas Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4024 Fax: 508-790-6230 February 19, 2007 Mr. Argos Pilo 250 Fawcett Lane Hyannis, MA 02601 Re: Illegal Apartment: 250 Fawcett Lane Hyannis, MA 02601 Map: 270 Parcel: 130 Our records indicate that your house at the above-referenced location is currently being used as a multi-family home, which is contrary to Barnstable Zoning Ordinances. Violation of zoning ordinances is a misdemeanor, conviction for which results in a criminal record. You must contact this office within 14 days to either: • Apply for a building permit to restore the property to a one-family home • Apply to the Amnesty Program • Prove that this is a legal multi-family home. Please contact this office immediately to tell us what direction you wish to take. Sincerely,? Linda Edson Amnesty Zoning Enforcement Officer Building Department gforms:zoning3 Citizen Web Request Page 1 of 3 E s ` ` k c4� i 44, i i z eRequest Tuesday, Februa Logged In As: Tt�l^1N\edsonl Route to Users Search Requests Create Requests Request Information Request ID: 20723 Created: 2/16/2007 4:04:44 PM Status: Assigned To Staff Assigned To: Edson, Linda Building Dept Anonymous: Yes Request Category: Zoning - Illegal apts edit Estimated 2/20/2007 Change Estimated ]an February 2007 Mar Completion Completion Date: Date: Sun Mon Tue Wed Thu Fri Sat 28 29 30 31 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 122 23 24 25 26 27 28 1 1 2 3 4 5 6 7 8 9 10 Created By: Shea, Sally Priority: .Medium edit Building Dept Citation Numbers: edit Requestor Information Requestor Request DETAILS: LOCATION: 250 FAWCETT LANE Hyannis, Ma 02601 Request Parcel Number 270 Block 130 Lot: 000 CALLER STATES -THE ADDRESS Map: IS RENTING A HOME WITH AN APARTMENT IN THE BASEMENT Parcel Lookup THERE A STOVE IN THE BASEMENT. THERE IS A FULL RANGE AND KITCHEN. THE CALLER KNOWS THE HOMEOWNER AND STATES THE OWNER HAS RENTED THE HOME IS http://issgl/IntemalWRS/WRequest.aspx?ID=20723 2/20/2007 Citizen Web Request Page 2 of 3 RENTED WITH TWO FAMILIES. UPSTAIRS AND DOWN (SHE THINKS) Email: Edit Re uestor Information Track Request Progress Request Work History: Internal Note History: System entry on 2/16/2007 4:04:07 PM: Assigned to Edson, Linda System entry on 2/16/2007 4:04:30 PM: Related Request 20724 Enter work progress: Enter internal note: (Viewed by everybody) (Viewed internally only) SpeII,Che k I C eckE -Add document or image link: Browse M * You can also type in a folder name to see everything in the folder Current Links: Time worked on request: F7 Response time: P77. * Time entries are in hours. Examples of time entries: 1.25, 0.5, 0.75, 1, 3.5, 0.25, 0.10 * Response time: Measured from the creation date to your first actions on the request. * Do not include nights, weekends, and holidays in response time for most departments. 6. Save changes Check to notify town employee below http://issgl/IntemalWRS/WRequest.aspx?ID=20723 2/20/2007 :eR -- TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map �` w Parcel O Application# 00 p Health Division Conservation Division I/r/ Permit# �I Tax Collector Date Issued 13 1 Treasurer Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board P Historic-OKH Preservation/Hyannis Project Street Address �� .� Village s' e / �//g ,Oclev/ S Owner 17)-A-3 i / Address Telephone _510-f— 7Z190 J �- 714 9j Permit Request e ztv A�l 4 fix/ r Square feet: 1 st floor:existing roposed 2nd floor:existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation -Z50 Construction Type Lot Size Grandfathered: ❑Yes ❑No If yes, attachlsupporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House: Cl Yes �o On �Id King's Highway: ❑Yes ZLW Basement Type: ❑Full ❑Crawl alkout ❑Other7 -r7 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 ❑Electric ❑Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑No 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 &k1 tho If yes, site plan review# Current Use Proposed Use t BUILDER INFORMATION Name_ � �®�/ i ® Telephone Number�so �' � �� ?6 Address -Q License# Yl�4 z CIO.4' 409 Home Improvement Contractor# Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE -- C - 7 1 ' FOR OFFICIAL USE ONLY, � Y x PERMIT NO. DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER x ' 'r DATE OF INSPECTION: s FOUNDATION FRAME INSULATION ' FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL ' 1 GAS: ROUGHrr FINAL pp i FINAL BUILDING o g= � � � "6 -7 i DATE'CLOSED OUT ASSOCIATION PLAN NO. f I , The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations n 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LeLyffil Name(Business/OrganizationUdividual) X6& I Address: �A u-000-(!::!� &,7� � Z"- City/State/Zip: � ��o J ?og hone.#: Are you an employer?Check the appropriate box: Type of project(required):. 1.❑ I am a employer with 4. E. I am a general contractor and I employees (full and/or pait-time). * have hired the sub-contractors 6. New construction.. 2.0 I am a'sole proprietor or partner- listed on the'attached sheet. 7. Remodeling ship and have no employees 'These sub-contractors have, g• 0 Demolition working for me in any capacity. employees and have workers' 9 0 Building addition comp.insurance.$' [No workers' comp.insurance 5• We are a corporation and its 10.0 Electrical repairs or additions aired.] • 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•❑ Other comp•insurance required.j *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. tContractors 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. I am an employer that is providing workers'compensation insurance for my employees. Below is.the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure.to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the vio or. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for: ce covers a verification. I do hereby cent' __ nder ns and nalties of p th tt++the information provided above is true and correct. i afore: (�fJ 7 . Date: _ Phone#: Official use only: Do not write in this area, to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.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 hiie, 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_oLttust_ee-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-contiactor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies'(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents.. Should you have any questions regarding the law or if you are required to obtain a workers,' compensation policy,please call the Department at the number 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 thatmust 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 Morn)."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 fo any business or commercial venture (ix.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.CommouwWth of Massachuwtts Departmmt of Li ustrial Aeei€ients Office of Investigat oats 600 Washington Street B.ostm,MA 0.2111 "l O #617-727-4400 ext 406 ar 1-977-MASSA E Revised 11-22-06 Fax#617-727-7749 wVw.mass.gov/dia Town of Barnstable Regulatory Services BAMSrABM Thomas F.Geiler,Director Mass. 163 o.,A`0� Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the"reconstruction,alterations,renovation,repair,modernization,conversion, improvement,removal,demolition,or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors,with certain exceptions,along with other requirements. Type of Work:��/�®�� dyoae J 7 M )C//�� sfmated Cost f r Address of Work: A"/ �� � d j /j'1 Owner's Nalne: Date of Application: I hereby certify that: Registration is not required for the following reason(s): ❑Work excluded by law ❑Job Under$1,000 ❑Building not owner-occupied Owner pulling own permit Notice is hereby given that:- OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c.142A. SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner: Date Contractor Name Registration No. OR Date Owner's Name t Q:formslomeaffidav ZHE Town of Barnstable yP�pF 3'p��o.� Regulatory Services Thomas F.Geller, sAxNsrAsrs, » ,Director MAW. 1639• Building Division lEn MAt° Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstible.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number + �� street village "HM OEOWNER': IW 6®i % O lb name home phone# work phone# CURRENT MAILING ADDRESS: - ® ' eet 6,6,2� yod'VAI1 �� 0414 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. minimum inspectio roced s and re ements and that he/she will comply with said procedures and requirements. IJ V - �`Signa one Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. . HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application, that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. Q:forms:homeexempt -� . . .� _ � �� o �v " �� � , � t, J s _!� � N � �� 1 �� s' �'� ��� wi IvJa"� � r ___�_- �F TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map 61 D`4 P rcel e'O 4!�; Permit,#, 03 . TOY fW Ui CFi1Ct6ti,:sitA0 Health Division r � �1 1� Date Issued a- Conservation Division Approval of tent only, A pf catio eeV Tax Collector Permit Fee V 02�, �D Treasurer Planning Dept. iNST,5,'�,LED IN CONIPLIANG WiTH TITLE 5 Date Definitive Plan Approved by Planning Board ENVIRONIMENTAL CODE AND Historic-OKH Preservation/Hyannis TOWN REGU L.ATf£DNS Project Street Address o�s� �i}K/Ce TT Gam,-ram Villagey ✓t/1�1//S Owner G 191tV Address S4 Gi��v�TT G rrl� Telephone SD 8 790 Permit Request ��ml-�/ �.¢�fta �✓� P,-!}TeS TL-,t.% 5e7- 7TeAll= x o Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation 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 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 Cl Electric ❑Other Central Air: ❑Yes ❑No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑No 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 94o If yes,site plan review# Current Use Proposed Use BUILDER INFORMATION Name e ARC/ Gf1(/-n 0 41%_ Telephone Number 9 Address QS D Ce%T 4�r- 1,0 License# Home Improvement Contractor# Worker's Compensation# ��-- ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE o� -4 FOR OFFICIAL USE ONLY PERM"IT NO. rf DATE ISSUED MAP/PARCEL NO. i `± ADDRESS VILLAGE OWNER DATE OF INSPECTION: 1 FOUNDATION,-ter c� FRAME (� a INSULATION , 44 FIREPLACE ELECTRICAL: "ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING r DATE CLOSED OUT ASSOCIATION PLAN NO. i The Commonwealth of Massachusetts -� Department of Industrial Accidents -� office of/n�es0atfans . - 600 Washington Street Boston,Mass. 02111 Workers' Com ensation Insurance Affidavit i i'' !?�✓'�� hone# y0 j'oj, city ' ❑ •I am a homeowner performing all work myself. ❑ I am a sole I rietor and have no one workin in ca achy am a s �%/////%/ G/%//%% ' m ensationfor m9 a lopees working anthis job. ..�., n c� •:.a}:G>:;c{:.•:• :{:{;:}, ::�,•,:7},:'•Si•:}}.:::?�•• ?+i.<:Y?^g}:Yi�.i ::,:•„} 5:..:v${ ?..v., :ir•}:{ :?•i i} ::a 5;<:: e 1 OYl P I :.vr:•}•{{:ro.. ..<}}:.r:? :�G}x:}}{....,,.T:3ir.}i••r}7 •i,: ::::4�... $.•:?'�±• .. :.. .... ....... .. ... ,........ .... ...{. :..•:••:::.:•::•::::::•v{.;h..;.,v..• v,...v v+:v'+�>i='±•,a":':S?Y�4}}i.`,.:r:{•}}::nG::::::v:;'{'J:}::;is ...... ....n• ...... ........ ........,:Vh:.n...:v:,.......v:-{n:• : :..nv:}y•:::.v:.v::'{•:Y:::•`:::x::..}:v:•.h v.:r}:SC3:.v: v:..r.....:•.:.......v:........•n:..,.,.......,:..:.:...:.....:•.n.r........n........,$::•?..v::x::±:.... ......rvv:::,,..^.•:vl.::.vv.,;..,..}; v..;!.}: ........... ................:...r......... .........v......,.........r.:•.......v.....};GY.v...•.....::..v...... ......::........vS•n..•:•;... :.: ..... :•.}{:Y?;::::n]};. y� ..., ....:..... ........ ... ...........:....::-::::.�.�::::::::••.•::.v::•:.v:+i::i....,:•:• r..,•?C•::`•:ii::•�:}{{?!>:tit:.;ai:.,}•h>•:rY•.i}i::{:Y.<}:•}}'.:.y. ... .....:..:.,:;.;• ...............v::x:::•::•::::n:v::::x.:{v::::;:::.•::::n:%;:v::•..:v:••: r.•rv::•:,:v::^v++••:v:Y:::h•:::::.:v,•.:::v.G:.....+ ,:^=....v.r.,�. .cam ........ .. ...... . ........ .......... ........ .... ....... ..... ::.:L!.:;........::i::{.};::::.;•:.::.,•:.h>�;iisi;;y:{::-:•. ....... ..r.r... ...J....:.:. ..... ,.... .. ....,n.,..,:.r>..,......n.... ...r.,,•.,n...•.h{f,..,i}�::•}•a:{.}}n.::.,•n:. .a:••J.,.:,..,• >.•%,.,].rv.{;H.;}:<:.:•L�<>�: ......... ....... ........ .....:r:.. ............. ......,. :.R....:. .r..,.... .••.:.. :::::-::::::.. .,....,......... .. ... ...{>::;.,,:v::...?*i}ii:;i''y'i't?:;•!s•:}:.;i•:Y{:=:Y•;:::.a. S{ ...................................3..........:...x..........n•......^....n::......,., ...n..... .....r......:. ,.rR4}:'{r.;??{:i:k?i•:?r.•.:•S:+F.;•}•:S.`:.•;. ...:...... .......:. ............:^...... ........r....v..n....•.....x...•....v........::::::^vn••:.. .......,. ,,;.,Y;..}.:.{.......L............?.:G;T7't+• ' •:w;;:.�•:•!;;x::•.;•}:::rv:•vC+.v:::::::r{v w::•.......y..::.v.h:;;,:F.::,+w:.....••:•::.:.•:...:•x::::a} ...v r.n:Y•!:3:?h:::::::::•...... ..... ,...... .......:.. :...Jh....• .......... n.....r. .....:... ..... a•: ,:.Gi'.v, •,S:'4.{:"{'?:}ir':ti•±]{i}%:•. S$ .... ...... .v..... ....v:. ..........n.• .........} .........:, ;.. ..r. ... ... ... .........:::.. :.:T�;.7:•aTi>:.}�::.�:.;��::-.zsr,:r>:...:{.,:....•:,n:•v:.,+,r:a....... ,:•:, �;.::}�';Yy.�'...... .... ..... .... ..... ..:.:::.....,r...};.........v....:•:. :•.......r...:{•:?r:.,•............:rT::.}:;:•:.;�i'•:.::}?'+3:a::::{•?:•:•}•::•.,.;:.%.;{.}%>.t;;Y?Y:rYr,•:i{.,»} ;`.'•.,:: : ...............:..::.::.�:.::......�:::T::..:.:::.,: :,.}:::.:.....?-:::::.r...::n.::•:..�:. ..::.:::.,{.:::.:...:..,.::..::..a. ...,.:.:.::i.::::r.,:...}:::.:;�:.}.,....r::.:Y}::..:::.�:.Y f..;...,:.r.,•.:::.....�;::�G:G;•:::.::.-.:•:: ............:::::....n..,v..•:v.,:.,. n::{w:,•.:•:::v..,...•h•::i•:}:..v.••,:Y:$::•.......{...••.....•:•i:•:Vii;:. ....::•.v:•.n•...n.. -Ni........ .....r.... ^:...}...nx• ...., ........ :....... ..v..........:•n...... •.;.axv•::].v:�.w:n•.,::::::}::::{:.;:..:v:•:w::.•:v{}. .... n ...v...... r...a......:.....nn..n,.r.......,... ..v..v.................r........n.w:..]}:: ..v.,r.:::.v:n ..r.,.. .,...... .......:.. ..r..Y:... .....r....... ..:...... ...,.. ..,.•r.,....:,,r. ... ,....:.. ....... ..5•. .. -.:. } .,.:.....;.,.. :�•::.,: .:]:+•:Y•:.••:•i:+::•.:}.: :}:i:5 i::5•ii<:::i:�$a�b.. ::Y>i:<: r.,........... ...:.,.n.,...................:..•.....r....,.:c:f......r..::.:...,.....,..,..3:.}... .ti. .. :........,.}:..::.:.,?:+�ii}:.{.,}.:.......}.r::.a]:„•:•........ ,>.,+ }........�....................... .........,......:.....................:..... ......,....n.........•, r...v. .... ::::v.....v. •. C:ai}:{Ga}:;;v..: ...... .,.....:...:::nv::::. ....:.... ...n v ........ .;. ....:v.:•::::: ....,:.,......Ghw::., ....v'•:x:.:+': Pi.• .::..::.^.,...•;....:.nv:...n..i..,vr:•:}}•.•::::.vv?v....:.... ... ........ .......... ::..........f. ....:.r.r.......:.:w:•:-•: r..:Aw:::vvv:•;:x3:3:•Yri{C+J•:a}::::::..{::•.}. :: :.i:!Y•;:;+.;:•^.- }}+•.G.r:{>i ......... ......n.;.. . ...... .. ..... ....,.. .........:t,..r...... .......-..n.., .s.,....a. ...... ?.:::•:,.,.y}:+•,•:.•^•'+::::,r•;,.i,i:]:=;.,...,M1h{Y>:E�:Jnai'Y'•:vv;�,}, v .............:::::•.-::::.:,:^:::w:n:...};:}•;^•.+•:^?{?h}:}:v::•+••:^C!•:.Cw:.�•...: ..:.•..:::... ...:^.vnv::•:•.},:}}i7};:•?:•}:;:.. •:v v:.v w.•;}::.:v::):?{?•}:?::,::,:n}};••:; .... ...... ......... ., ..,... .x.. .... ....:: .... ......,:•.}...........:••:i.n....:....::::.iv, ,. .n.n,............vw::::.•..n.x Y>.v'i:^}}}:.;...:.::rr: <S:�YY'<G.: :;S:i,:$>;:'.: ....... ...... ...... ....,,.: , .:{..... ...r.^.• ......^. Y..... n.,..:•:n...},.x::::.:,.. ...n•:Y.:va:.v:x.....?..v:::i•}::n. ,.....::.k ....nv•......::••an......r`r.::r,^:n....'i....r::•..........^:•:........;:r,.}.......:....:.}..,......::.......x....:::...n..,......: .i:v7}+{•:..... v.i•:v::•:!}{�Si7,';v:}::.:. -..Y..:•.f..::.^ •:..........:J.........::..............:....:......ri•::::........,.:::.......:..:::........?•:::..r....v.:.:::Y}:•}:•}:{•}:-.,:•;;}:.:....... ::•:r::::.h::?.: :•:..ai:•!:t+-.}:ri:•i:3}}:.}:?•i:fn:•S:{.::......:. }.... :.,., Q:::CD:'.r••.z:;,••;s::;?<E.>:;;^E:>:%:'::i::: <::::�:i:.Y:•7:t:..;G:::.}:r:.7> .}7:••:3:.%:.}:::::.:..::.:.....:.�.�::... . lnstll aJic . circle one and have hired the contractors listed below who _ I am a sole plopzietor, general contractor, o omeofrne ( ' ) have ,.;:•,:. - _ _____.... — - - olices: ?i?y: h• ::r$•: i^: ;:va}c •Y 4<K"r,': v : :.+£+ comp ensation ..:!:ir:!i:!r . .::.,.•,�{ .. �N`>' ark polices: •nri}:{+? `<�:: >f},..} win .::. Chef g :,..a...... . ;}r..........::?.: :;,:x.N>Y•,{h=.., Gr:{:s„q•.. • •�:{v'•.< .. Y......IN,? ....w::x.,.....•}:a::•x.v:v,{•Si:.v:::?•a}S':v:•: }:{•?Y:h::.v.v::.,v .. .,::•:•::+.•:v.;....}:x:y:..vr.{•:, ��pp ..........:•.. .:: ...?.}}.4.:u:w, .....r,. ......r.r:.x••v•.:: ..., .}=:Y$:}S.:,tw.•. •v y..{. ...>.•.v:•'Y•%•5:::'?.v\f4,:• i\• . .........:^vv::.n•..{r{.;::,:}:+ ..{v::::r.v..:...........,. rnv::•.. r.v,...: ...,}}:{h'.::.. .... .. .^ .. •n.;.,.. •.,........n.................n.::.....a ... ..t,....5.....:... :........... .v .. ..... .: .. •:?:•G:.;v•. +io v}, :r• S> 'Y: :;.;: r{: rtr, ...�+.a..},' ........ ...... .:....... ... ;...... .: ...... ... ... :: ........ ... ... :•. :.......... .. •..:::l+�>i:Y`v :`•:::i::CYY^kyS::J}:::....};} Yea'+:::5.':u........:n±5'>�:}:• ..r....:..:......... ..,..:.... . ... ...,::::.viv:•:r}i:;;>.: •::T:.,•.::?•'.=.Y•$:i}ti•i$::}.•.4y:::::,. ....:..... a .n... r , .. ........ :..... ......w:,:• }T},a:{'G.::+-:�:..:?? ... :t+•Y•}h-:}:isSiS:+O'•}:•iYYa%!•}.'•`Y'n,',;*,i:}v}:;�!fE:;ShO:n.n �riv:.:,....i; • �i r..::.::.: :. ... ....... :•........v... ... .?::.......nnY.v va,:{:{^':Yin.,::•;•?•.YY{>•S}'.;v:..:..;.r.:,..;•v:. ............:.....r::::::•%x.....,:. .,..f..n:3::;:i•}:;?.•:n•.Y':f+.v.. r .A•Y+:'•.C•:3..';,::.:v}::"d;}?:•f,.:: }:v}::%t'?:S:}S:'Ci+•i44i:?.JttY::}:•�:;::•:':;:: • � �n..lJ ........ .......:v: .v:..n•:•.v:}......n:•:::n•.v-:.±v:.+v:...r•.t: n •:,.ay..,r.n v..:•x•.^^..n}Y:{•.}T::r:.+.•:+.+.:^::`r;^}}:.^..++.v:::�,-r•.3 ..... ,..;..,,.....•:..,...r,..:••..:..... :.::........a:.,....,..v::^....... x......: ...:^.,...,.:,,?:•}}: ...::,Y•x.. X:},:' it t:+$'• .l.: w'`v'�`:�,�.Y si«.. ;:'•iii• •..........:.::......,v,+,{G v;::::?{•}:v..^n...:.v} ...... :::....... :::...r...... .n..:.......:.... .....: ...v......,. ;.::•}.•.••.:.......rh•..•{..:......{„ .:x:.::::•4•h±i .. y�( ...::::.•:•:....:w::.v v{•:n,•:•.....nv:•:•,?::•.. .;{.,.......::1::: .r.:•;.. ...v.w:::Y•.,..,r.}:x:• •::....:......^.....r........ .... .. : ... .. .n ....... ...^ ^ .. ::Y'G}:G' Y}%w•; .tj...::},},.n;uva. A{;,.5.;1.:'•:i i• ........ .......... .... ...... .... ........ .. .,, •.:.. .v:}::• ..:......Y :;. :..n •} r..A•...?:v .i::%y,: Y :�,L:y;::i? }:1.. ..SS... . :L•::.. :.a•:: „•{:•. fa$.o: ... ...............;n n.v.+.v...,.n.:... ....v .....!..x... v4}...?.vb....^..- .x........ .v xw.v.......,n n.h..,f..{. ,. ., '•..�$ �C�� Si'i�t,'•vt}:Fx, n,•., .: •: .. .. ... +•r' :Y::a`::Y^n...f.Y.:x:,::..v.: r.r,+,.;<•:tv.A•:;•.,i:4. :....r.• .: ..r.MO!'! ... .v•: ..:: ..,.::{:b•:::.::..:.....�.. ,?•:?• �d ,:^%{4}'}'•:;.:Gi:S;Y;�i S:`.Y�Fiji ... .. , .. .... v'•T:3a ha...,...,. '.nv 'v}.....v.:i'Y;.ha;vi,S•}:•s', h'v'.',v%{•:;:?:'+:•:i �.j .:....... .. .... ... .. ........ .. .....w:::nv: b......{v:}:::::....n:4++v:.v,v•v::n•.,.v.;}.h,•%•,v,•i'•i::},}^...:.+v}y::n.::}.`:.:;L•k:{{;r.•::,: : ]a, ;vS .r.:.,.r$ . ...... ... ,..r:v^v••.:?}:T}:::...:.. ....?..,.. ..........n..{.]•t• ::.::!.;,....:r....v ....;...:r.r•. v .:nv:•'f.•}:v}:.;n .{Ij............. . +w:x•:w,.,..n•• ............v,;n•:.v;:...•.. ..r,....}...... S..` }:.,:•.?:Y ..e ,..}•aa r,y:}f.''JY<L:' G,+"'+Yx ... .............................,...•;•r.........:..... \...... ..... .3:::]{.•..,-..;;...,..v.:•.:,a•: .3:.::•;Y{XC}v:•'•:%:;;${.??:Jf>Y.Y?yiY':::•i. .,-£.•:. ;.}i••a•!Y+t}ii::!•! {. Y�S(.�..{7•�.',.T ..;T.........=:;{•r.:v' .ttf .:3'.+.Fri �'S r. 'v»•i:}r:.h;t..:}::::f.•i7:?•%:{?•.. •x::.}}}vYhp:•nv:?•::!•..a...r.•.,.+ ., .......r. .. ....... +ftv::n,r:... +:,,•.v v{;G'i,v'x...-: ,A.:..:: :•>::Sv.-. :y.;;:v,:v - ...:..........r.,...:.......... ........ ..;:r,•-!.} ....r. .• .1..... .. .. ... ::{•:• - t'.. •, {.. .i:;•:i,::.<::.:iA' -Y#`,a-::.:• .,F;{;i-::.d. «.a,.a,.a:.'�}:.}:..>:y::?:•} •r.•.}:}::.r.•:.v:.}:•}:::.:::.;:{••::r •.y.}::+:1... :•.} ::•;ry}.:•, .::.,}}•a.r. ,:?+.•},. .yam k• ,. ] / iS1YtJEBIL •.v;....w:••. nyv::n;.n•;::.:::::::::.w+•a::;:•}:+SSi:Y�Si�':Y:'+.'; \'Y{C ........... v::::xa}w::::: rv:.•v:+..::v::.v:...y: '`• ::v}}v:3•••;'!:,:+:;:.:.:; .... .J:::;::::•...:::••...::••::::r.n.•:nv,:Lfvi}}:+vi}r}}:!:Y:.•::�i:.:'v:.:..........+, v.:r.::•:w•y;;r,••;,Y;;•?},:.•:•.v..;f'...3:v:+::n; .:. v.., ............•:::.......•••:::........•:Y.....:,. •::.,......;:,;. :.::•::..:..r...•:::••:.f......•:•::{;.•}%:.}::>:::•:•:....'{•:vY},,:.:xi ..xiYYti:{:y:G+•$:'+.•:•{{?h}:k,,'Yv. .,1..:i:'.{•.:: ....:.::..:...... .... :.. ....v.....n n..n .....:••::.,.:::.n:v::•:::......... ......:..,,{.,Y•G:a:•!'::.....:.:::: .vm,..:::}-. -:•h•}•:{:?.v ..f'i:?.Y.•Y'}v}SK?......., {S'�S?.•. ^:rr:..r.....r,.:m.::.,..r.v ..frn:•......, ..f., :.iv..::i':!}tvn•., ..... ....::::.:•::•n}'b}:•}•:vn• ........r ....:::.•.......:•::•.4:n..... ..}.f r::.....:`a.h::::...3::::•:::r::.:.r.:.r::.v v::r..::•i.::.::::. :.X}:::r:Y ... v.•.!i•}r ....rvn.• .....,.r. r....^• .J+..... .............:... ....:......:..:......t...•.xu.:..••.../.... ...r............ ............:r... :..r.r... .n......n•n..........n,..v,•r:::•x...J..../vv:.:.. i•iJt{'f.:.n:v}:.,�.+T:.}:-T:•}:?Y.{;r�.. .....::•r:f•:....-::.•::...v•:?8....•::rn;}....{.....:v:.C•.n•...;v:::.......•,v,v.v:....•v,v::.,.,+• •,{{v„ ...... r....:. .. + .?.:: . ` .:... .:1.•?:}'}:. .........;.,..... .....,...•........:.::• ... ..r.........................:............,...:..... :v::::n•.•:::::;•}•,:..^•:.}'-•::•>^.`;{?'e!.::•::....:,.••:+;•:;•?aril:ic... ...:w•. w::. ...:::•. v:n..::.it•r:+:±......:v:.•,.?:•....:::::::.:...:.r......,..^;;•;v:....,••:::::.v....:a:}:}}:•}a}::•}r.}%$,.>{:N.n•.n.v:::n:{v:.............n.v............ .v.. ..v:n.v..r•.,•:,.y,.^::: •.fi......::v:h x}..n:•::•::.,,n•w::::.....•„v:•......}:+•::h n-i::v^...;..••.:v}::::::::::.......r.....,.... Ali . r. :r.f..... .:.... ........ .:.v:.-x.•vx;}:}niS{S•v{•r'•a}Y.^,:h.:x,?:r..,.v'+:•}}h;h,l...:n ',?r'i'::..:.��C.a ti.;.•'R{k.;ri. ........ ......;.vj:.......^v.,.••?....r...... •nvn3..h..h:::}::.t:... ^'v:}:.:. ;.F;}}% ?•.:'++if+. f .. ,y..... .,r......r........... :...:..::• :.,•:}.•:' .... ..t...,...:•.:... ...:+.,••:..icYc:,•,.•::r}i?,?:.?F.Sii7.�?ifi}$f:.'itir;i}+i:?•}';•l.(:. �mF..i....v. ........n::::nYx v:::•,....:�v..:!fC.}..' {�:i.. ...:.•:.•:::::.v... v:m.:.v .....:v:.,,+.. .� .::...... ....... ,.... ..Y ,?..,:::':v:.;:SY a;,:;:Tii:. .r::•:w.w:•: .:}x::•r:•va•;•:Y•:{y, }:•y{{,6SV,•.=,}ti,,vf, %>,:. •.0 311 ..}.:....v:, ,:'{S... :q,{..,:e{ '$:aS:::.:i:•'n.A.•:ii::,. :;iY{.;{.::�,i.;r .. ........:..:.::•v; ...,:r::+w...+•:v+•:•;:......... •r\v•::::r.•:::•:•:.v.S�.iv:•:.v.}}:•a:h:?•]:': ,•x:::•:`:+:•::::}a:•:{•}:•M1:i??I{{{jS$:•}:i!•}.. ' .. . ..........r.;. ,......,::•.:.....v...,$::....n.....:::..,r...,..............3.:.:...... ..:..:.........:.:r. r:L•K ..t..:.,...:::••::.,••::....:. r.;•}i}:•:... ;.t:.}:+J::.,•::.,.y•{;•:....•:}•:: �.........::..r...n:}.n.vM..f.... .. .................7..:,..........:v.........•,v.......:..v .:..t x::::v:•:......... r.. .n.n...n• ....... ...... ..;. ..... ....... ....:•.v:v ..... .. },:::.:::.w;• r....,,.....:.:"}:O}:{?;+{'Y.C.'•}:: ...?r., a.•a�::�$;`v,;.{ .. ..... x. ................... . :•-}:'r':!:?•}ir%•}}:h:::.i}i:i�i...... ...•..... ... ........ ....,............r.......:•...........•.:...........•.... •:.h•::x.v::::.:•::::•:,;,•,.;..:::nv::•?.}}iT:::::{;EG}:.f., S{.}}::3:•�r=.:}i:.f. .Si±i:S,}r:;:}:y .. ................... r...r........n..• n..:...n:• ...........J...r...n.....•:....... x•.}};:::. .:^v......w:•v};{......::w::.v.}...:..... :..::.x?!.}^rv'w;:hy:: •,:,...{..�::::.....:.�::::....}..;.::.:....r+t•::n•,.......i-::,:.v:... .,.:rn•:•.:...::::.,•.•:. n:.-:.,.r: :}.:r,::::.:.::^•n,.?:..:. ,.....,...:::.r::......k•::::•::.}::•}..... :...... ...... ...<.... ...... ,...n ........ ....? ...^... .................... .. x•v•+i}:i•'fi...i..!{r:•r T!::'f.+S$S::Si�i:^f!;i.'�$i}LR?:•'%!YY.Y.•-Y!:!}}'p}} is ..... .... ...... ....... ......... ................ ..... ...nr.vv.•::,:::•::.;.•:::.}}7i:::{v•::K+, ,::.;/.4? ....-]. ... ... .. .... ... ....:.,.......r:v:v:v;,;.-' ; .r.::::.....x,}:::•:..r.}ii:•$:•:n}.}}v•Y:i}:a'•:GG:vx:,•:J:r:?{:Y:v::nvny,{n.:,R:i:�}<,{.}}v:?h•i.•}:iG:}Y' ... ..... .....r,.....•:•....... .....$..:....+v.iv•:.^..n•:r.•................:•::•a'•?:C:•}•::::.;.;:::G:•i:.•: n:..•....... ..in;:::.}•yv:'T.,:;.:.{vY ':.!{ YH:YYi,_', ........ ....... ......�.. ........... ......:... ....... .G::.w;::::.. •::::.J.,.. .........r .i?;,::!h:r:,v:•}}iii::}},}}:•:r::;�h}}':)}:•i:::]vii:`•+} :+.+4i:;;YY+f�i�•:3:tiY�4 ;.:}:•}} :}. . x.. w. ...r... .,..... .::.. .........:. ^...:.. .r. ...:. ..... ..:.. ., ...n.vv v.v..,....,. ...•:::.:,... �yn.• r.....vr:•: ..^r. .:.,.. ...r ...!..,. .:...f... ,•-::•::•::...:..+:,:,:::r..:{{{r :::.:.}:tt•r:•::::}+:....::•.h:•}Y:h+ : ..:...... .. .. ,...v... l?•%+:r•:f.... ...... .... ..:.... :.:•:•:$::•::•.....:!�..r.v...•:::>::...,:.^•:....:::•::,} alic.:$l►:i ::•n{:•:::::• :�T�T1T.812CE�'.::GO::••,:;�::y:i:�i:+;}:i+:�.{::{.?:>:±{.Y.... Fafllue to secure coveTa�e as nquirednnder Seetion25A of MGL 15Z ci atlead to the imposition of of lie es of a$neap to si soo.0o and/or WORKOone yenta'imprisonment as weA as drIl penalties in of Invests atipna of the DTAfor coverage���tion.00 a dap again�tma I mtders{and that a' .. copy of this statementmay be forwarded to the Ofa g I do hereby�erti nderthepains- d penalties-of-perjury thid-the-information-pr-o3ddedabvve isstu�a:i�correct Date Signature ;'• oZ r .. Phone# Ll Prir<t name 2 oMcial we only do not write in this area to b e completed by city or town official perntit/license# • [3Butlding Department city or town: ❑Licensing Board ❑selectmen's Office ❑ checkif immediate response is required _❑Health.Department ; ' a phone#; ❑Other. contactperson: 1—ivd 9/95 PJA1 Information and Instructions Massachusetts General Laws chapter�152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the `law , an employee is.defined as every inthe service of another under any contract of hire,'express or implied, oral or written. y�°tit partnership, association corporation or other legal.entity ©r any two or more of An employer is defined as;an individual, P P> > the foregoing engaged in a joint enterprise, and including the legal representatives of a dece ased employer, or the receiver or trustee of an individual,partnership, association or other legal entity, employing employees. However the ovmeivof 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 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 commonwealth'nor any of its political subdivisions shall enter into any contract for the performance of public work until ac�ceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority. .y, . r . .. • rr.. _ t Applicants Please fill in the workers' compensation affidavit completely,by, checking the box that applies to your`situation and supplying companp.names,, address and phone numbers along,with a ceitificate`of insurance as all affidavits maybe submitted to the Departmeat:of Ind Ls*Accidents for confirmatimn of insurance coverage. Also be sure to sign and date the affidavit. The affidayit"should'be returned to the city or t6m that the application for the perinzt'or license is being requested, not the Deparment of Industrial Acaid`eats. Should you have any questions regarding the,,law",or-if.yQu ed,to obtaia`a workers' cAmpensatiohpolioy please cill`the Depaiti iiit atthe'number'liitEdbelow: arc requir City or.Towns : •- Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom oM affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Plea e be sure.to fill the.pem tTlicense number which will tie used as a refeieace number. Tfie affidavits maylie'r �" _;t •,. the Department by�ai1_"FAX iinle'ss othei arrangements have been made: .,111.•' f r7. .. .. .. . .'.F ank you in advance for you any�n cooperation and should you have estions, The Office of Investigations would like to th . please do not hesitate to gave us acall - , . . ;5% IVA The Department's address,telephone and fax number: M ThCCommonwealth Of Massachusetts Department of Industrial Accidents Me of 111vestigauans 600 Washington Street ,=- Boston,Ma. 02111 fax#: (617) 727-7749 : phone #: (617) 727-4900 eat. 406, 409 or 375 MMMMMMMMMMMMMMMMMMMOM �j Certatcate of farce tot5tance REGISTERED ISSUED BY APPLICATION '(11Ae Date treated or i CONCERN NO. monviliodured 1060 This is to certify that the materials described on.the reverse side hereof have been flame- retardant treated (or are inherently nonflammable). FOR 7APITY CAPE 000 ARTHUR BGt;; .,ADDRESS--..—.--. CITY_ Certification is hereby made that., (Check "a" or "b") ❑ (a) The articles described at, the reverse side op this Certificate have been treated with a flame-retardant chemical approved and registered by the State Fire Marshal and that the application of said chemical was done in conformance with the laws of the State of California and the Rules and Regulations of the State Fire Mcirshci. Name of chemical ..._..... ....._.. .....Chem. Reg, No..._.................... . .. Method of application............. ........ (b) The articles described or, the reverse side J.e-'ecf are made from a'flom'e-res'!'ston*t-fabric..o.r.'m.a-teriaI registered and approved by the State F;re Murshol for such use. Trade name of flame-resistant fabric a, material used.,.............XCR..V...i.r.l.y.l......Reg. No....F-3.3.7 .. The Flame Retardant Process Used 'Vv;'j N".)I Be Removed by Washing ctii or will�of� David Bradley F, i C"! shapito - Pres:dent Name of Applicator or Prodj,':!i1*)n Title J �111 11111111,11111 ktl IAN JAUXANNNJAI PJLL.1A1PLjA!Sj1a—Ed NAOTV AL J" The Massachusetts State Code requires a permit for tent installation. Please contad your local building department with this certificate for your event. I '02-07-23 08:20 PARTY CAPE COD INCo5087595478 P.1 Massachusetts Retail Merchants Workers' Compensation Group, Inc. 190 Forbes Road * Suite 237 Braintree MA 02184-2613 Certificate Number: 1004-08 - Coverage period: January 1, 2002 to January 1,2003 Item, 1 Participant: Administrator: Party Cape Cod,Inc. First Cardinal Corporation 660 Mac Arthur Blvd. 10 British American Blvd. Pocasset, MA 02559 Latham NY 12110-1415 1 (800)438-0160 Business form: Corporation Agent: Other workplaces not shown above: See Schedule First Cardinal Corp. Item: 2 Certificate period is from January 1, 2002 to January 1,2003 # 12:01 AM standard time at the Participant's mailing address. Item: 3A Workers'Compensation Coverage' Part One of the certificate applies to the Workers' Compensation Law of the states listed here- Applicable States: MA I3 Employers'Liability Coverage: Part Two of the certificate applies to work in each state listed in Item. 3A. The limits of our liability under Part 2 are: V Bodily Injury by accident: $100,000 Each accident. Bodily Injury by disease $500,000 Certificate limit. Bodily Injury by disease. $100,000 Each employee. C This certificate includes the endorserrrents lisled on the attached endorsement schedule. Item: 4 The fee for this certificate will he determined by our manual of rules, classifications, rates and rating plans. All information required below is subject to verification and change by audit. See attached schedule, r a tr 00406 Issued: November 24,2001 • a lu r b � f � ` V JUL-23-02 TUE 09:26 AM FROM:508 759 5478 TMENNIS WATER DISTRICT PAGE 1