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DOCKET NUMBER Trial; Court of Massachusetts <br /> CIVIL ACTION COVER SHEET F 7-7,5'---,'-' - � The Superior Court <br /> COUNTY <br /> PLAINTIFF(S): Katherine McBrien Barnstable <br /> ADDRESS: 31 Center Street,Mashpee,MA.02649 <br /> DEFENDANT(S); Furbush et al.as the Mashpee zoning Board of Appeal <br /> ATTORNEY: Paul Revere,III <br /> ADDRESS: 226 River View Lane,Centerville,MA.02632 ADDRESS: <br /> 16 Great Neck Road,South,Mashpee,MA 02649 <br /> BBO: 636200 <br /> TYPE OF ACTION AND TRACK DESIGNATION(see reverse side) <br /> CODE NO, TYPE OF ACTION(specify) TRACK HAS A JURY CLAIM BEEN MADE? <br /> CO2 Zoning Appeal-G.L.ch.40A F YES QX NO <br /> `If"Other"please describe: <br /> STATEMENT OF DAMAGES PURSUANT TO G.L.c.212,§3A <br /> The following is a full,itemized and detailed statement of the facts on which the undersigned plaintiff or plaintiff counsel relies to determine money damages. For <br /> this form,disregard double or treble damage claims;indicate single damages only. <br /> TORT CLAIM5 <br /> (attach additional sheets as necessary) <br /> A.Documented medical expenses to date: $ <br /> 1.Total hospital expenses.............. ................................................................................................................ $ <br /> 2.Total doctor expenses......................... ........................................................................... <br /> ........ ...... .......................................... $ <br /> 3.Total chiropractic expenses.................... I--................................. ................................................._..................................................................... $ <br /> 4.Total physical therapy expenses...........................................................................................- ... <br /> .......... ...... . $ <br /> 5.Total other expenses(describe below) ..... ....................................... .................... <br /> Subtotal(A): $ <br /> $ NIA <br /> B.Documented lost wages and compensation to date.................................... <br /> ................................................................................................. $ NrA <br /> C.Documented property damages to dated................................................................................................................................. ................. .....� <br /> D.Reasonably anticipated future medical and hospital expenses.................................................................................................................... N1A <br /> E.Reasonably anticipated lost wages...........................................................................................................................................................""..... $ �.. <br /> F.Other documented items of damages(describe below) ............................................................. <br /> G.Briefly describe plaintiff's injury,including the nature and extent of Injury: <br /> TOTAL(A-F):$ NIA <br /> CONTRACT CSL tN S <br /> (attach additional sheets as necessary) <br /> Provide a detailed description of claims(s): TOTAL:$ NIA <br /> Signature of Attorney/Pro Se Plaintiff:X 0- <br /> - Date: 81912017 <br /> RELATED ACTIONS:Please provide the case number, case name,and county of any related actions pending in the Superior Court. <br /> CERTIFICATION PURSUANT To SJC RULE 1:18 <br /> 1 hereby certify that l have complied with requirements of Rule 5 of the Supreme Judicial Court Uniform Rules on Dispute Resolution(SJC <br /> Rule 1:18)requiring that I provide my clients with information about court-connected dispute resolution services and discuss with them the <br /> advantages and disadvantages of the various method�?�Pulte-""l <br /> Signature of Attorney of Record: X Date: 81912017 <br />