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HomeMy WebLinkAboutBuilding Permit #644-2016 - 169 GRAY STREET 11/23/2015BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATIOjN ,r Permit No#: " I� Date Received Date Issued: 111 IMPORTANT: Applicant must complete all items on this page LOCATION fc-r-�.c�►" Print PROPERTY OWNER �et(v±- Print 0 100 Year Structure •yes no ' MAP_PARCEL:DWZ.... ZONING DISTRICT: Historic District yes Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building A One family 'Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial ❑ Repair; replacement I-Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic El Well ❑ Floodplain ❑ Wetlands ❑ Watershed District ❑ Water/Sewer DESCRIPTION OF WOKK i v tit 1-tM1-UM1v1tu: Identification - Please Type or Print Clearly OWNER: Name: Address: 16!1 bir221 N, Contractor Name:±.. ,-%-'' _ Address: 0 (J/ 2,y/ 1-7 42;71 Supervisor's Construction License: 0/0-i3p Exp. Date: n'7 -/q-17 Home Improvement License: 11`?` Exp. Date: 0-1-13-2 ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ ,2 FEE: $ CQ �O t No.: ��� Check No.: � Receipt NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund ture of Aaent/Owner P7)6 � Signature of contractor L Location No. 104q- za,(p Date Check �Ooo I 2- c." 7 2 5 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee $—�� TOTAL $ Building Inspector Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private (septic tank, etc. Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM i PLANNING & DEVELOPMENT Reviewed On �U (ISS Signature COMMENTS CONSERVATION COMMENTS Reviewed on `(a-lSD--? (11('0116 Si re `toning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Conservation Decision: Comments Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT =Temp Dumpster on site: yesna - - Locafed of 124°Main; Street Fire Department signature /date COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes MGL Chapter 166 Section 21A -F and G min.$100-$1000 fine NOTES and DATA — (Fnr dPnarfmanf meal No Doc.Building Pennit Revised 2014 rte- lC5 �Q C - C s ❑ Notified for pickup Call Email Date Time Contact Name Doc.Building Pennit Revised 2014 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Cross Section/Elevation Plan Of. Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to- issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc: Building Permit Revised 2014 Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 27X0.00 m $ - $ 335.40 Plumbing Fee $ 41.93 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 41.93 Total fees collected $ 519.25 169 Gray Street 644-2016 on 11/23/15 Inground Pool v C N 0 .0 O SD n Z N m 010 i�o �' c=CLn 0 vCD MQ o C ZS cr CD CD O CD a cn� CL O N � v U) O n O o CD (D A 3.- m cn Z Z O S m N O O� O W Q. X CD to 0 N 0. U) r.« U) 3 o = O 2) 2 <, (D a W C) m 0 rtrt=C) m C = S m CO) S2 TI O O .+ M 0. m W D' CD f0/� p CD <D 2 F = C O —DI n CQ O' O '� _N, O O O �'* 0 : 0 a CD CD CD 0 rr c 'r = 0 it S. Q.0 (Q O CL f N CD N CD N CD U) . a) N r0•r C.) Ocm O O C CD C CDCD U)C CD y • O CD 0 O � rt o CL (n O rD :-r (A I (D .�.+ z O W C (D •n m rn m T 7 O) x O C S D y N O A T :3O N V1 m x O C S r m V V M T p7 :O O C S r C 3 W p M T j Dl n O" CD `< ;a O C 3 T O C n. ft) c O O W C F o m m O Vl (D 'D [l N 3 T O O \ S fD W O > C D r 2 O '0 South Broadway V 45 Route 125 ,awrence, MA 01843 Kingston, NH 03848 :el: 978-688-8307;Tel: Tel: 603-642-9909 ax: 978-688-1.949 srnce rms Fax: 603-642-9906 6'PM e—Ary( 5@ ( kqe, C�roviding a full line of services and supplies 11 I t fi 1 fully licensed and insured www.familypoolsonline.com to JameDate 2z S 4 6' >}� _"�--- iddress "C City -A"J n -r State _ A. _ Zip �L(�s tome Phone ll Q_.Work Phone .[P_(_171 q'Z 11 We Cell50 � - � G L - 61 Addl # _— '•�"t IAZj 'rossStreet/Direction s ivul _stimated Start Date -_ Tv E=stimated Completion Date We propose to fumish and install one inyl unite --A Sr >; }© L' 2.G J &-cf, swimming pool for the ;Um of$ •Li 'Z-" 'HIS PRICE INCLUDES: Normal Excavation up to 8 hours on day of dig Manual vacuum cleaner kit Waterline Tile (6') Backfill and Sub -Grade up to 3 hours 3-Slep stainless ladder Liner Choice -•— e t" Z�/le Underwater White Light 120 Volt Rope and floats Test Kit Steel Reinforcing per Engineered Plans for gunite Steel Structure per Engineered Plans for vinyl Initial balancing chemicals Surface skimmer (s) Z Over -Flo Line for added protection 8 to 12 Wk supply of maintenance chemicals (supply depends on pool size) Dual Main Drains Coping Pressure testing of plumbing during construction Leaf net Steps , _ Ten Year Plumbing Guarantee (see specifications) Transferable Lifetime Structural Warranty Wall brush Extension pole Handrails Filler _ �,y�----?4 —"i (plumbed no more than 25ft frpool)' Pump & motor i r1 m t_ HIS PRICE DOES NOT INCLUDE: 1 11F -r t Any plumbing over 25ft from pool. Additional runs are not recommended but would beat a cost of per toot per line. Machine time in excess of that specified above. Additional machine time to be billed at $►► Gam, including machine, operator, and laborer, due with second pool payment All hours of trucking will be charged at $ k per hour per truck due with second pod payment. Any dumping costs incurred for disposal of ledge, large rocks, garbage, stumps buried or otherwise, building materials, unsuitable or nonstructural soils, or any unforeseen material that must be removed. Removal of ledge or large rocks by way of a Starr bit, chipper, or blasting. Additional fill, if necessary, for proper backfill or reshaping of hole, supply or spreading of loam, reseeding of grass. Patio, fence, retaining wall, or'any accessory items other than noted on contract. Electrical wiring, fuel connections, heater venting, fuel storage tanks or permits. Repair or replacement of sprinkler systems or any buried Items such as well lines, drywells, leach fields, electrical lines, cables, etc. that are damaged during construction. Cos due to water or soil conditions (ex. clay, peat, live sand, excessive rock, etc.) requiring a stone pack of the hole. The stone pack will be at an extra charge of $ — Y—" a minimum to S W maximum and at the discretion of the job supervisor. Additional machine time and/or materials necessary to rectify such a condition will be at a cost over and above the stone pack and will be quoted by thejob supervisor. Water to fill pool. :USTOMERS MUST SUPPLY: Access for all trucks and equipment Water and electric necessary for construction of pool Water to fill pool immediately upon interior finish TOTES: Initials Building and Electrical Permits or assume the costs necessary to obtain such permits. Customer mustwater cure Gunite shell for 7 to 10 days if applicable. )PTIONS: TOTALS: living Board ;olar Cover ( ) _ — Basic Pod Price $ additional Pool Lighting S r N.iG (a ) dcc r _ leater ) _ Options $ Gr 7 �_J ;nvironpool Plus, 8 hd 2 surface ,. (_ ) r% 0 V SUBTOTAL $ 2 2) ,dditional Floor Heads !3 olarisVac-Sweep ( ) �� •.(,�� _,Q�i IC",5%Sales Tax $ p Vans retrofit only ( ) _ "' TOTAL $ Z 23 -wi o Bench Ji C itedor Finish ( pa ( ) ) — Less 10% DepositJ 1 $ fl.�. N, ` ,utomated Control System ' ( ) --' — Balance of Contract $ _ b L 3 :all Chlorine Generator ( A'- )that ( ) PAYMENTS: 113 EXCAVATION 113 BACKFILL + EXTRAS 113 SYSTEM START-UP 'he buyer hereby agrees to pay, in full, the total amount of this transaction upon start-up of the installed pool. Your salesman or job supervisor will meet with ou prior to excavation at which time all decisions including pool size, shape, elevation, liner print, and all options must be final. Changes after this date will be ubject to extra charges, where applicable, and will result in unavoidable delays. You, the Buyer, may cancel this transaction at any time prior to midnight of the iird business day after the date of this transaction. Credit card payrnents not accepted on contract amount. 2, L 0CG{- BUYER �� e ` date 10-d1-1 �J cwt �� �` date TELL - �_ CO -BUYER � _date W, po Em y Im N O'er 90 39dd — sene S'Iow ILvyS,IYH f . The Commonwealth of Massachusetts Department of IndustrialAccidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dna Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Name (Business/Organization/Individual): Address: 770 ,.So, &D N D O)i City/State/Zip: Phone #: d $3 a7 Are you an employer? Check the appropriate box: Type of project (required): 1i I am a employer with employees (full and/or part-time).* J, New construction 2.Q I am a sole proprietor or partnership and have no employees working for me in 8. E] Remodeling any capacity. [No workers' comp. insurance required.] 9. ❑ Demolition 3. 1-11 am a homeowner doing all work myself. [No workers' comp. insurance required.] t ! 10 ❑ Building addition <1 I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole 11. Q Electrical repairs or additions proprietors with no employees. 12. [:] Plumbing repairs or additions 5.❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. 13. FJ Roof repairs These sub -contractors have employees and have workers' comp. insurance.$ 6. Q We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other 152, §1(4), and we have no, employees. [No workers' comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. V 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-contraciors 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: ► v Policy # or Self -ins. Lie. #: 1n1 O 2 412 2 Z!') Expiration Date: % � 3f ^ ( Job Site Address: rASE City/State/Zip: (V� ,i>7']ol1p1M-n 41k. 6) k'.N® Attach a copy of the woriers' com ensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA. for insurance coverage verification. I do hereby certify under the pains and penalties ofperjury that the information provided above is true and correct. Signature: *A4 Date: 14 &/t zo 1ST 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 hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall. enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(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 Depattment of Industrial Accidents foi• confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should'enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia Client#: 53642 FAMILYPOOLI ACORD. CERTIFICATE OF LIABILITY INSURANCE C DATE (MMIDDIY M CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, 9130/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER HUB International New England CONTACT NAME: AACCPHONE Ext:800.370.0642 AIC, 866.475.7959 St ADORESS: nee.certificates@hubinternational.com Wil ingtodvM Wilmington, MA 01887 09/1912016 OCCURRENCE $1,000,000 978 667-5100' INSURERS) AFFORDING COVERAGE NAIC # INSURER A: Valley Forge 20508 INSURED Family Pools Patios Inc. INSURER B: Technology Insurance Co 42376 INSURER C: Safety Insurance Co 39454 Family Pools North LLC INSURER 0: 70 S. Broadway INSURER E: Lawrence, MA 01843 INSURER F : OVERAGES CERTIFICATE NUMBER' DMI101Au k.. iaan�s. THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. fN—SLTR TYPE OF INSURANCE X0- —DL INS SUER WVD POLICY NUMBER POLICY EFF M/DD POLICY EXP MM/DDLIMITS A GENERAL LIABILITY 6015920803 09/19/2015 09/1912016 OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY pEAACCHH PREMISES Ea occutr0ence $100 00� CLAIMS -MADE OCCUR MED EXP (Any one person) $ 5,000 Blanket Addl ins X as contractually required PERSONAL & ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,000 POLICY PRO - ECT LOC $ C AUTOMOBILE LIABILITY 3947232 12131/2014 12/31/201 a Ea ccid.n SINGLE LIMIT 1,000,000 ANY AUTO BODILY INJURY (Par person) $ ALL OWNED X SCHEDULED AUTOS AUTOS BODILY INJURY Per accident $ ( ) X HIRED AUTOS X AUTOSWNED PROPERTY DAMAGE $ Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE AGGREGATE $ DED I RETENTION $ $ B ION WORKERS EMPLOY RS' LI A ILII AND EMPLOYERS' LIABILITY WWC3112837 12/31/2014 12/31/201 X WC STATU- OTH- ANY CERIMEMBEPROPRIETORIPXCLUDE/EXECUTNE Y I N OFFICERIMEMBEREXCLUDED7 � N/A E.L. EACH ACCIDENT $500,000 (Mandatory in N If ityes, describe under E.L. DISEASE - EA EMPLOYEE $500,000 DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $500,000 A Property 6015920803 09/19/2015 09/19/2016 vrs limits Spec Form Repi Cost $1000 ded DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more apace Is required) Workers Compensation has Blanket Waiver of Subrogation, as required by executed contract. Work In NY is excluded; new construction of 10+ units is excluded. Re: Ellen & Fran Murphy, 169 Gray Street Town of North Andover 1600 Osgood Street North Andover, MA 01845 ACORD 25 (2010/05) 1 of 1 #S1466778/ M1453341 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE V 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD CW001 1 22 r t0�4c�11'r(wola. Office Of Consumer Affair."' s and Business Regulation 10 Park Plaza - Suite 5170 -Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 118204 Type: supple,ment card FAMILY POOLS & PATIOS INC Expiration: 2/13/2017 GLEN WIGGIN 70 S. BROADWAY LAWRENCE, MA 01843 . ....... SCAI e.2Pr,4-05rjj Update Address and return-- . ..... Address ; ca rd-�Mark reason for change. Renewal E� Lost Card n1ployment of Consumer Affairs &Business Regul,,jion E IMPROVEMENT CONTRACTOR License or registration valid for individul use V`heg'stratiOn: 118204 before the expiration date. If found return to: Offic Expiration: Type. e "Consumer Affairs and Business Regulation{". 2/13/2017 10 Park Plata - S,ii,65170 FAMILY POOL Supplement Card S & PATIOS INC Boston, MA 02116 GLEN WIGGIN 70 S. BROADWAY LAWRENCE, MA 01843 Gndersecrctar, Net valid without signature }S: S a r- I - me, io � V 0? , uk d -Tj/ {a.1Z-j n,4 CS -010,330 WELLIAM,C PO S 1 70 8 BROAI)WAy- jLAWnNiCE 0.1 jA E x p jj, _rn 07/1912017