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HomeMy WebLinkAboutBuilding Permit #240-15 - 1721 OSGOOD STREET 9/5/2014 NORTH BUILDING PERMIT 0Ftt,Eo qti TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATIONto Permit No#: ( S Date Receivede,'°o gSSAC Hu`��� Date Issued: 'IMPORTANT: Applicant must complete all items on this page LOCATION / -7 c O..S S ! ri t PROPERTY OWNER R 0 V r ,/lam. Print 100 Year Structure yes 6no MAP _PARCELd" ZONING DISTRICT: Historic District yes Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: Demolition I -_ ❑ ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: 41z j Identification- Please Type or Print Clearly OWNER: Name: Phone: Address: Contractor Name: ' &X Phone: 9425 Address: Y"© To z �" �1-{ l Supervisor's Construction License- �' (l!5" 7 �I .3 Exp. Date-.-Vie, /6 Home Improvement License: Exp. Date: 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: $ �� FEE: $ ! �- Check No.: `[ rV — Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the r toy f 6ignature of Agent/Owner Signature of contractor i Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swiimning 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 PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature OMMENTS HEALTH Reviewed on Siqnature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS 1 I li Dimension �I 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 No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— For department use I II ❑ Notified for pickup Call Email Date Time Contact Name Doc.Building Permit 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 LiEngineering 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 Location00 � No. ® . . � � � , TOWN OF NORTH ANDOVER \ Cewif+m.e¥Occupancy Bu.Q.mg%%mme ePr. F w Foundation Pr2 Fee ~ \ \\w > Other P r 2 Fee \� \ \ j � �� : • ©.�a s TOIL < fy � ^ Ch U}NZ ( 27927 ` Qbm lmp 6' ' l Town of North Andover NORTH q Building Department X"°*A,tE t�, D 64 do 1600 Osgood Street Bldg 20, Suite 2035 �' y'' 6 North Andover MA 01845 0 :0 Tel: 978-688-9545 Fax: 978-688-9542 DEMOLITION OF BUILDING AFFIDAVIT °�A CoC1CiWjC1( 1 4` �d 0 ArED APp,t�S r DATE S`SgCHUs, , y OWNER'S NAME &ADDRESS Ray% M6[�C we i 1 y 1.� --L\ QSg, be�� SO - LOCATION OF PROPERTY TO DEMOLISH 172(4-_9S&O0{)Sig �OlLTHf7'irlDDt/'�6Z- / '/r7 DESCRIPTION RAA2LL* uS CONTRACTOR'S NAME &ADDRESS DL A.1 _ ic' POoK fS� TZE-0440,AlH0 304f4i DEP MENT SIGN-0 S 4 DEPT. OF PUBLIC WORKS -WATER:_N)t�( 4,,e4-f,//CSEWER: TREE WARDEN TOWN ENGINEER r r pv' DEPT. OF CONSER ION J4 t'`J) 'v LE HEALTH DEP V� SEPTIC I� WELL HISTORIC COMMISSIONy Z - P PLANNING GAS � J ELECTRIC TELEPHONE TAXES cr Gt6 POLICE o FIRE eL7� - -/L EXTERMINATOR G u DUMPSTER- O /OFF TREET DIG SAFE NU TR 9-01V53,01 3L L BLDG. INSPECTO Building Demolition Affidavit BOARD OF HEALTH 1600 Osgood Street, Suite 2035 North Andover,MA 01845 978-688-9540 APPLICATION FOR ABANDONMENT OF SUBSURFACE DISPOSAL SYSTEM (SEPTIC SYSTEM) Pursuant to Section 310 CMR 15.354 Of the State Environmental Code, Title V Name �� 0Y 'r QK1 NLCY Phone Q78.6 8G -3(oey3 Address 172-1 65&0,0 l�ol'LZ'H�iyo ✓F—R ,fit AgS7 Contractor hired for work: NameAI1,L�Ybj;MOj_j 7"l6NG, Phone 60 • 895'� 4901) Address P X —rL�f ,FREM AN 030 Date for scheduled abandonment The septic system at the above address has been abandoned according to Title V specifications. Signature of Contractor Method of septic tank abandonment(check one). O removal O sandfill rush O other Name of Offal Hauler This form must be returned to the North Andover Board of Health. PLEASE DO NOT WRITE IN THE SPACE BELOW FOR HEALTH REPRESENTATIVES ONLY Inspecting Agent Date 4/23/2014 Gmail-Work Request:Electrical Service and Meter Removal from 1721 Osgood Street Roy McKinney <rjmckinney@gmail.com> Work Request: Electrical Service and Meter Removal from 1721 Osgood Street 1 message Roy McKinney <dmckinney@gmail.com> Wed, Apr 23, 2014 at 8:54 PM To: workrequest@nationalgdd.com Please start the appropriate process for removing the electrical service and meter from my home. 1721 Osgood Street North Andover, MA 01845 (Account Number: 66088-43005). Also, please send me a statement of removal for the town and my demolition crew. This statement can be mailed to: P.O. Box 8373 Ward Hill, MA 01835 I can be reached at (978) 686-3663. Thank You. Roy McKinney • https://mail.google.corrVniail/u/0/?ui=2&ik=3adbl882ac&vievv=pt&search=sent&th=145913a6c483421f&siml=145913a6c48342if 1!1 ADT Security Services ATTN:Loyalty Team 4926 kernan Blvd South U0 Jacksonville,F132224 ADT Always There' 800.238.2455 www.MyADT.com May 25, 2014 Mailing Address Protected Premises Roy McKinney Roy McKinney 1721 Osgood St 1721 Osgood St North Andover,MA 01845 North Andover,MA 01845 Customer Account#: 19300798 Dear Mr.McKinney, Please accept this letter as proof that as of April 30'2014 at approximately 20:30 EST,ADT cancelled your account due to you relocating. The system installed is obsolete and we do not require the system to be removed, prior to the site demolition. i Should you have any questions,please contact us at loyaltyhelp@adt.com.You may also call us at(800)23 8-245 5 between the hours of 7 a.m. and 11 p.m.Eastern time,Monday through Friday. I Thank you for choosing ADT. It is our pleasure to serve you. { Sincerely, Adele J Fletcher ADT Loyalty department License information available at www.ADT.com or by callin 800.ADT.ASAP®. CA AC07155, 974443; PP017232; FL EF0001121; LA F1639, F1407,F1640;MA 172C;NY 12000305615;PA 090797;MSI 5019511 ©2012 ADT LLC dba ADT Security Services.All rights reserved.ADT,the ADT logo,800 ADT.ASAP and the product/service names listed in this document are marks and/or registered marks.Unauthorized use is strictly prohibited. RETOFR 0912 "Ur, 11 lv 1G: evp Ins Offices 6036353815 p, 3 CERTIFICATE OF LIABILITY INSURANCE /11/2014 /20 4 THIS CERTIFICATE 1S ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THISl/2014 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(fes)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 ACT M P ROBERTS INS AGENCY INC NAME: NAME: 25 Old Lawrence Rd PA,NOc No En: (603)635-2539 FAX, E-RUIL (603)635-383.5 ADDRES Pelham, NH 03076 S: insoffices@aol.com MSUNER(S) AFFORDING COVERAGE -Y. NAIL• INSUREDINSURERA: Burlington Insurance Danley Demolition, Inc P O Box 154 INSURER 0: Progressive 92 Scribner Road "'L"'c C. Scottsdale Insurance Fremont, NH 03044 IBRD: AIM 603-895-4900 INSURER E: Great American Rockhill Ins '-' '- COVERAGES INSURER F. I CERTIFICATE NUMBER: REVISION NUMBER; 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 CONTRACT OR 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. LTR 'TYPE OF INSURANCE �o i fr� POLICY NUMBER POCKY EFF POLICY ERP X COMMERCIAL GENERAL LIABILnY (MNIM"� I(MM�YYY) LIMITS EACH OCCURRENCE s 1,000,0_00 CtNMSMAOE CI OCCUR _ I 1 PREMISES(Ea cmmr ) S 50,000 A x Blanket Al I AAEDETIP(AnyanePer ) s 5,000 Y 807BW26331 9/29/2013 9/29/2014 PE��LannVINJURY s 1,000,000 GENL AGGREGATE LINT APPLIES PER: _ I X POLICY C(JEGT LOG I GENERAL AGGREGATE , 2,000,000 i OTHER PRODUCTS-COMPIOPAGG S 2,000,000 AUTOMOBILE LIABILITY S GOMBINEO SINGLE LIMIT ANYAUTO (Ea aradmn s 1,000,000 A ALL B i — ATOS ED X SCHEDULED 034498876 9/30/2013 9/30/2014 BODILY tWURY(Per aermM s AUTOS _ HIRLD AUTOS AAIDS ED PROPERLY oAMAGE��) S --'-- cracridea S UMBRELLA LIAR X OCCUR S C X EXCESS LIAB CLAIMS-MADE Y EACH OCCURRENCE I S 3,000,000 OED RETTrrnoN s XLS0090339 9/29/2013 9/29/2014 AGGREGATE s 3,000,000 WORIIERRS COMPENSAnON ' s AND EMPLOYERV LIASUrY ; PER OTh- YIN STATUTE ER D nro AI IMOWFARINZREIMCWry VWC10060187082014A :5/23/2014 5/23/2015 aRtUkr.ewtk EACWMM ❑NIA EL EACH ACCIDENT I s 100,000 ,Mandatary in NHJ U yeS,d Lwibc weer ' E.L.DISEASE-EA EMPLOYEE s 100,000 DESCRIPTION OF OPERATIONS DeMr E Inland Marine EL OSCE-POL1-- i s 506,000 IMP306751702 9/29/2013 9/29/2014 $385,000 F Pollution Liabili $1,000,000 ea poll cond tY ENVP00525001 9/4/2013 9/4/2014 $2,000,000 aggregate DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORO TDI,Ad4Udd31 Remarks 60WWe,nuy W agsChed if more SOace is required) Job: 1721 Osgood St, No Andover, t9A i Blanket additional insured form applies and provides automatic status when there is a written agreement with you and Will extend to Roy McKinney ' f CERTIFICATE HOLDER CANCELLATION I Roy McKinney P O Box 8373 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFOR Ward MA 01835 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORQED REPRESFMA7yLE ID '•, ./ 1. r /�1 ACORD25(2013104) The ACORD name and logo are registered marks1of ACORD CORD CORPORATION. All rights reserved. r 1 NORTH . . . w t 1c ve" . 0 No. .T ... - .:�. y i th ver, Mass s T O LAKE COC NIC Nl WICN � A°RAreo ok? S U BOARD OF HEALTH Food/Kitchen PER I-T T LD Septic System THIS CERTIFIES THAT ......... � .......................... BUILDING INSPECTOR .'. Foundation has permission to erect ................:......... buildings on .....� ,�it. ......... Alp ........ Rough to be occupied as ........ .. .w..�!�......�2cn�.'.�.'.+4.L........cr. .. . ..... Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final ��• PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION S T Rough Service ........................... .... ...... ............................. Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Reguired to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. U of B Massachusetts _ . Board department of Public Building RegulationsSafety Construction Su and Standards License: Pervisor CS-057893 LEE MDANLEY 92 Scribner Road: Fremont 1VH 03044 .J1'i9 Commissioner Expiration 03/04/2016 I Town of North Andover ®� �o oT aA Building Department �r 0t *-eQ 27 Charles Street North Andover,Massachusetts 01845 (978)688-9545 Fax(978)688-9542 <ecwrcwwrtw y. Building Demolition Affidavit SS�cKuse� DATE jq P 12.E L —30. Z 0 I!:j OWNERS NAME 8t ADDRESS Ido Y_e�.' /Iri lit cy n1 Y T l 7ZlaS&Q� �r,�PArtf A N DO E,& A4 - tg S 00, PROPERTY LOCATION I 7LI[ CrO_ oj)ST. �O�Te��}NA'�V�LC/Z DESCRIPTION i apjcij k&u S,g T CONTRACTORS NAME&ADDRESS Il ge4L E y D cm a t rr1 Q NV,Z-Ai4.. AIP DEPARTMENT SIGN-OFFS D.P.W./WATER SEWER a GAS I ELECTRIC TELEPHONE CABLE TAXES POLICE FIRE EXTERMINATOR DUMPSTER-ON/OFF STREET DIG SAFE NUMBER BLDG.INSPECTOR DATE RECD I nationalgrid 40 Sylvan Rd Waltham MA 02451 April 30, 2014 RE: Service Removal for Building Demolition. 1721 Osgood St. North Andover, MA 01845 To whom it may concern: This letter is to confirm that per your request, National Grid has confirmed electrical meter# 13818761 and service line have been removed from 1721 Osgood St. North Andover, MA. The work was processed on work request 16890797. If you have any questions or need further assistance,please feel free to contact me at 508 357 4554. Sincerely, 4 Z;r Amanda Rodriguez Customer Order Fulfillment nationalgrid U/Stewart's Septic Service ❑ Andover Septic ❑ Stratham Hill Septic ❑ Roto-Ram (978)372-7471 (978) 475-2593 (603) 772-5548 (978) 452-9022 58 South Kimball Street, Bradford, MA 01835 -°f s rvi�e�,• ,r PAY FROM THIS BILL Customer Name: J/ C7 Reg. Na pre of Service V1 �❑ N/C Reg.Maint. Se ice=Location: ✓ /// �� J ✓ ❑ Emergency x Phone: C" Septic Tank Pumping and Cleaning ❑ Day ❑ Night "Done the Right Way" Contact: Billing Address: N t Responsible for Covers �o;rrigation Systems Ci, f V1 a✓,• zip: i Special Instructions Completed ❑ Incompleted Reason: Per: AM/PM Services Rendered V�cuum Pumping Observations Drain Cleaning ❑ Septic Tank rr] Good Condition ❑ Main Line /6 Drywell t❑ Leechfield Runback ❑ Toilet Bowl ❑ Leech Pit/Overflow ❑ Riding High ❑ Kitchen Sink ❑ D-Box (liquid level) ❑ Bathtub/Shower ❑ Pump Chamber ❑ Full to Cover ❑ Vanity ❑ Grease Trap ❑ Excessive Solids ❑ Floor Drain ❑ Catch Basin Top/Bottom ❑ Vent ❑ Portable Toilet ❑ Use No Powdered Soap ❑ Sewer Jet ❑ Other ❑ Heavy Grease ❑ Other Qty: ❑ Roots Footage: Size: ❑ Suggest Electric ❑ Under 1000 gallons1000 gallons ❑ 1500 gallons Rootering ❑ 2000 gallons ❑ 3000 gallons ❑ 4000 gallons ❑ Van Called ❑ 5,000 gallons LlOther LlOther o 'Misc. ❑ Digging Charge ❑ Backhoe ❑ Inspection ft./in. hrs. Ll Location /iLl Consultion ❑ Certification: P/F ❑ Service.C&IIA! ❑ Estimate Reason: ❑ Labor ❑ Portable Toilet Rental ❑Pump Repair ❑ Waiting Time ❑ Baffle ❑ Repair * Digging Charge is Per Driver ❑ Chemical Treatment Discretion ❑ Other Description of work ✓7 r E Recommendations Terms of Payment Parts Vacuum Pumping Drain Cleaning NET 15 DAYS Yr. Month - Yr. Month Tax Terms&Conditions ��+ is❑ Cash is Check Credit Total 1. Not responsible for damage beyond curb line. 3. 1.5%per month will be charged to accounts past due:? 2. All complaints shall be reported within 48 hours. 4. The purchaser agrees to pay all cost of collection. 1r7 _ ok 7 Customer SignatureV '1 m u e./ Serviceman r ANTE X Pest Control Co. LLC 4 SUNRISE TERRACE • PLAISTOW, NH 03865 (603) 382-1776 • (978) 372-9929 PEST CONTROL SERVICE AGREEMENT DATE OF li NAME NAM ADDRESS ADDRESS ITY ` • CITY STATE ZIP TE ZIP t PHONE 2ND PHON PHONE 2ND PHONE X i I 7 D SCRIPTION STRUCTURE(S)COVERED 1. THE COMPANY AGREES TO PROVIDE PEST CONTROL SERVICES AT THE SERVICE ADDRESS INDICATED ABOVE. 2. THE COMPANY WILL PROVIDE PEST CONTROL SERVICE TO CONTROL THE PEST(S) CHECKED BELOW. 3. CUSTOMER AGREES TO MAKE THE PLACE OF SERVICE AVAILABLE FOR TREATMENT AND/OR INSPECTION AS OFTEN AS NECESSARY TO CONTROL PEST(S) CHECKED BELOW. 4. THIS AGREEMENT WILL BE FOR AN INITIAL PERIOD OF--�-��MONTHS. 5. AFTER THE INITIAL MONTHS,THIS AGREEMENT MAY BE CANCELLED BY EITHER PARTY BY GIVING THIIRTY(30) DAYS WRITTEN NOTICE TO THE OTHER PARTY. 6. THIS AGREEMENT DOES NOT PROVIDE FOR THE REPAIR OF PRESENT OR FUTURE DAMAGES TO THE SERVICE ADDRESS, NOR DOES IT PROVIDE REIMBURSEMENT FOR REPAIR EXPENSES ALLEGEDLY ARISING FROM PEST INFESTATIONS. 7. IN ENTERING INTO THIS AGREEMENT CUSTOMER WAIVES ALLCLAIMS FOR DAMAGES TO PROPERTY OR PERSONS WHICH MAY RESULT INDIRECTLY FROM WORK PERFORMED BY THE COMPANY, WITH THE EXCEPTION OF GROSS NEGLIGENCE ON THE PART OF THE COMPANY. 8. THIS AGREEMENT DOES NOT INCLUDE SERVICE FOR TERMITES OR OTHER WOOD INSECTS, NOR DOES IT PROVIDE FOR DAMAGES ARISING FROM INFESTATION OF SAME. TO 7BE CONTROLLED ❑ CARPENTER ANTS ❑ SILVERFISH ❑ WASPS ❑ HOUSE ANTS ,a RATS ❑ HOUSE CRICKETS ❑ FLEAS MICE ❑ CLOTHES MOTHS ❑ INDOOR SPIDER CONTROL ❑ GERMAN COCKROACHES ❑ PANTRY PESTS (SPECIFY) ❑ CARPET BEETLES ❑ BEES ❑ MATERIALS USED METHOD OF APPLICATION MAX FORCE FC MAGNUM 432-1460 CONTRACT BLOX 12455-79 dp�j L J TERMIDOR SC 7969-210 �� jA, DELTA DUST 432-772 DEMON MAX 100-1218 SUSPEND SC 432-763 DITRAC TRACKING POWDER 12455-56 APPLICATOR'S NO. T CHNIC SIGNAT E J CUSTOMER SIGNATURE TOTAL FEE FEE IS FOR AMOUNT OF PAYMENT I PAYMENTS TO BE MADE AMOUNT PAID TODAY ❑ONE TIME ❑QUARTERLY _ MONTHS LI MONTHLY ❑ANNUALLY --> YOU,THE CUSTOMER, MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION. A HOR COM NY, IGNATU DAT / CUSTO GN URE DATE Y � I Asbestos identification Laboratory 165U New Boston St., Stye 271 Wobum,MA- 01801 Lab Code:200919-0 Bulk asbestos Analysis by Polarized Light Microscopy EPA Method. 600/R-93/116 Results Table An alytical eoionSample SamplLcaL Results 1D Kitchen No Asbestos 2/7-1 33917 Lino Detected No Asbestos 2/7-2 33918 Sheetrock Living Room Detected No Asbestos 217-3 33919 Carpet Stairs to Cellar Detected No Asbestos 2174 33920 Plaster Ceiling Basement Detected No Asbestos 2/7-5 33921 Homosote Siding (Exterior) Detected Roof No Asbestos 217-6 33922 Roofing Detected Porch No Asbestos 217-7T33923 Carpet Detected i