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Building Permit #Exception - 40 CARTY CIRCLE 5/1/2018
BUILDING PERMITof `'O oT" qti TOWN OF NORTH ANDOVER o� APPLICATION FOR PLAN EXAMINATION . i ~ 0Q F Permit No#: Date Received Sys gw7.°��Pp�c5 ACV-`E Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION Print PROPERTY OWNER_ Print 100 Year Structure yes no MAP PARCEL: . . ZONING DISTRICT: , Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family Y ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands 0 Watershed' District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Identification- Please Type or Print Clearly 9 OWNER: Name: Phone: Address: Contractor Name: __ _ Phone: Address: Supervisor's Construction License: _ _ _ _. _ Exp. Date: Home Improvement License: ._. Exp. Dates ARCHITECT/ENGINEER Phone: : Address: Reg. No.— FEE SCHEDULE:BOLDING PERMIT: 12.00 PER 1000.00 OF THE TOTAL ESTIMATED CbST BASED N 12 . $ $ O $ 5 00 PER S.F. Total Project Cost: $ FEE: $ Ct,reck No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have.access to the guaranty fund Signature of Agent/Owner _ Signature of contractor=. f VtORTol '9 O tt,.o ,6 ao BUILDING PERMIT �.? s!::. ._ 0 TOWN OF NORTH ANDOVER 9 ' /- APPLICATION FOR PLAN EXAMINATION ; sRL ,* Permit NO: Date Received �•9 oN�ie o'Pp,�•ly Date Issued: -SACHU IMPORTANT: Applicant must complete all items on this page LOCATION P nt PROPERTY OWNER Print MAP NO: PARCEL:3 ZONING DISTRICT: Historic District yes Machine Shop Village yes o TYPE OF IMPROVEMENT PROPOSED USE Resid Gal Non- Residential U New Building ne family U Addition Li Two or more family U Industrial U eration No. of units: Li Commercial Repair, replacement U Assessory Bldg U Others: U Demolition U Other U Septic L Well L Floodplain U Wetlands L Watershed District U Water/Sewer I hAv, t Identification Please Type or Print Clearly) OWNER: Name: I bit,LV "VL Phone: Address: CONTRACTOR Name: Phone: Address: Supervisor's.Construction License. Exp. Date: Horne Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: s M Address: Reg. No. FEE SCHEDULE:BOLDING PERMIT:$1200 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access o t e ar ty and gnature of Agent/Owner 1A Signature of contr Location VO 1���---- �� 2 / No. Date o - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ ^ Other Permit Fee $. TOTAL Check# � Building nspector Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ IYPF_OF SEWERAGE DISPOSAL i 1 Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ ❑ Tobacco Sales Food Packaging/Sales ❑ � Privatese tic tank etc. ❑ � p � Permanent Dumpster on Site ❑ i THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS t,HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Oonservation Decision: Comments WLater & 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 Streef 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 No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— (For department use) ❑ 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 i o Building Permit Application a Workers Comp Affidavit o Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract a Floor Plan Or Proposed Interior Work o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks a Building Permit Application o Certified Surveyed Plot Plan o Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract o Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o Mass check Energy Compliance Report (If Applicable) a 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) Li Building Permit Application ❑ Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract o Mass check Energy Compliance Report D 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 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 o Building Permit Application o Workers Comp Affidavit o Photo Copy Of H.I.C. And/Or C.S.L. Licenses o Copy of Contract o Floor Plan Or Proposed Interior Work o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks L3 Building Permit Application o Certified Surveyed Plot Plan L3 Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o Mass check Energy Compliance Report (If Applicable) o Engineering Affidavits for Engineered products NOTP: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit ANew Construction (Single and Two Family) o Building Permit Application o Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract o Mass check Energy Compliance Report o 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 Appealtthat 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:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2007 'i' FEB-11-2015 08:24 AM WATERHOUSE 978 346 9365 P.01 HOME IMPROVEMENT CONTRACT G�p PLEASE READ THIS Branch N botonSouth DaZj I o f � Sold,Fumished and Installed by; ice+-��^ THD At-Home Services,Inc, Branch Numl e31 nd 33 d/b/a The Home Depot At-Hamm Services 908 Boston Turnpike,Unit I.Shrewsbury,MA 01545 Toll Pm 977-903-376 Federal ID#75.2698460;ME Lic 0 C 02439;RI Cont.Uo#16427 Cr Lic 0 HIC.0565522,MA Home improvement Contractor Reg,ti 126893 Ingtrllatlon A Mess: �(y' City State Zip Purchaser(s): ii work Phone.• Nome Phone: Cell Phone: [ ] [ [ Home Addre : (If different fro R (tstallation Address) City State 7ip IIIAdd b receive proieel communications and Home Depot update EI1 D(Nl7f i i to receive any marketing en>nils from The Home Depot au"Pro e t of r a Undersigned("I.uStOmer"),the owners of the property located at.the alcove in address,agrees to buy, THI)Al•H Servitc ,Ills.("The Home Depot")agrees to furnish,deliver and arrange for the installation("Installatl(n")of all materials deRcirtibed on dee below and on the rcferenccd Spec:Sheet(s). all of which are incorporated into this Contract by this reference,alOtil 4th any applicable State Supplement.and Payment Summary attached hereto and any Change Orders(collectively, "Contract"): Job 4: anoe_i ) Products: S Shoes 4: a, Rcrofing Siding Windawn lnsulatioet C�� ��Z Prolert Amount ;►�N'pAJ/C7 :' ❑Gotten;/Covers. ❑L�nlry Doors., aor. ❑ _.,. _ , J J� ..J 3 $ �5� � �� Roofing Siding Windows Insulation LIGuttem/Covers ❑Entry Doors (] $ Roo eng Siding Windows Insulation ❑Gutters/Coven ❑Entry Doors❑_ $ Roofing Siding WindowsEl Insulation ❑Clutters/Covers ❑Entry rkK,rs ❑ Nrudtnum 2S?b atC.eatract AMomttdpe ups,a Lmfi n ot'thls marmot. Mahe Purchase y riot depndt mw•e than une thlyd of the C lit act AeMtattt. Total Contract Amount $ Ste► Customer agrees t immediately upon completion of the work for each Product,Customer will execute a Completion Certificate (one for each pict as defined by vl individual Spec Shcct)and pay any balance due. As applicable,each Customer under this Contract.agrees t> jointly and severally obligated and liable hereunder. The Home D r Ilerves the right to issue a Change Order or terminate this Contract or any individual Product(s)included herein,at its discrctitrn.if"11 4VOIne Depot or its authorized service provider determines that it cannot Worm its obligations due to a structural problem with th 1 40nc,environmental hazards such as mold,asbestos or lead paint,other safety concerns,pricing enbrs or because work required to complete the job was not included'n th Con a K Payment Su : The Payment Summary# Z J included as part of this Contract, sets forth the total Cone,ct atnounf payments requiral for Qre deposits and final payments by Product(a..applicable). NOTICE TO CU`TOMER You are entitled III completely filled-in copy of the Contract at the time you sign. Do not sign a Completion Certificate(note: there is line Con kpletion Certificate for each listed Product as defined by individual Spec Sheets)before work at that Product I%complete. In the event oft ' nation of this Contract,Customer agrees to pay The Horne Depot the costs of materials,labor,expenses and services pry by The Home Depot or Authorized Service Provider through the date of termfuatlan,pltu any outer amounts set fort N this Agreement,or allowed under applicable law. THE HOME DEPOT MAY WITHHOLD AMOUNTS OWED TO TH HOMF DEPOT FROM THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE WITHOUT LIM(TING TIi E OMDEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS. M Acceptance and Mori ation: Customer agrees and understands that this Agreement is the entire agreement between Customer and The Home with regard to the products and installation serviLes and supLTsedes all prior discusL,6uns and agreemeis,either oral or written,r ng to said Products and installation.This Agreement cannot,be assigned or amended except by a writing signed temils e CustomBand t Hem,e Depot.Customer acknowledges and agrees that Customer has read,understands,voluntarily accepts the ofand jived a copy of this Agreement. Accep d y: � � i, 1 X Xate' :to 'sSSeries Conultans Signature pate - _ Telephone No. Customer's Signa A Date Sales Consultant License No. CANCEL ATI CUSTOMER MAY CANCEL THIS (us applicable) AGREEMENT OUT PENALTY OR OBLIGATION BY DELIVF W=N NOTICE TO THF. HOME DEPOT BV GHT ON THE THiRD BUSINESS DAY AFIER G THIS AGREEMENT. THE STATE S MENT ATTACHED HERETO CONTAINS A FORM TO USE IF ONE IS SPECIFICALL i;PRESCRIBED BY LAW 1N ' CUSTOMER'S TE. NOTICE.:A110110TONAL TERMS AND CONDITIONS ARE STATE ON TILL+REVERSE SIDF AND ARF PART OF 11-1141,S CONTRACT 0"f+14 White—Branch File Yellow—customer ! t%O R TIi Town of nciover o No. 151.016 y � T �O LANE h n ver, Mass, COCNIC Nt WICM 1' 7 RATED s V BOARD OF HEALTH Food/Kitchen IT T Septic System PERMI THIS CERTIFIES THAT ,,,, BUILDING INSPECTOR w .................... .. ... ....................................... .. . .�..... ..,,,� �. wwAv ...,. Foundation has permission to erect .....A ............... buildings on ....q.0 ...,... Rough tobe occupied as ............. . . ........ I�, .�.1r4.:R ........................................ ...... 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 VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN OMON4HS ELECTRICAL INSPECTOR UNLESS CONSTRUCTI CRough Service ............................................. Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Buildinz 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. 09,L flu I C©rr6-7e_qISSOU;ea,SOO 00 Bosgoaj ME 4 02124-2017' ° %-I'm✓J un2us. „r.%dva Rage Flat H.,es�nbfl NaM@ (Busincss/()-,gs ..---linEAndividLsl): '1 r Address: i I M �• r A O v11 LLA Aire an empleyw?Checlk gbh appsolplrlaee boll: TTPL a of 1pIIajee1(Peg®ls eco): � y� J 4, 1 RM a genu @flat x and I 6: ®RIM cons�6tion 1�] T era a u to vtith , employees(full and/or part-timc).c have hired the mb-con�toxs 2.❑ I am a sole proprietor orpartner- listed on the atsched Shed, 9. C]Rk empdeling -ship and have no etsployees These sub-cotitractors have g• ®DemoTtlDn working for me in any capacity. es3tploy>;es and have v�ork 9. ®Boildmi g addition [No workers'comp.insurance comp.i-bumce.* re aired.] 5.®ale are a corporation and its 10.®Plecical repay 03 additions 3.® 4 ofc€zs have t xsi�ised their 11. Plumbing-repels or additions I am a homeowner doing all work myself.[No workers' comp. right of ezxemptson•pe? 12.®s a insurance r t c.152;§1(4),and we eve 120 cm*dwe mince regLi P-IL] *Any applicant that checks 1n#1 mud also fill ca the=don below nhgcbg their wwiml caa awe i,sem�aticg►iAfcst�rion. f l iomeosmeru vino submit this aftrdavit indicating they ae doing ail wmkznd then hire ozizidz ccntrtastont toast submit a r_av affidavit indiuming such. (Contractor that chock thio bw mutat attached ao additiou^1 whet ahoarbrg the name of the mb-coabn�."w s=whaher a,rot these endt'san haw employees. 7f the aub-caausctvrs have employees,they must provide chair sorkml eoW.policy munber. •d am ex employer that as providing jpnsm ase yvp relay emPloy¢m Below&9he pond Bad Job ae8e ., e�a•�® mea. - �\N ' � 16-` �--p-----� /� Inswmce Company Natne: 101,� lWI� A 1 f�r� p, . 1�� ( n _- 4 I Policy or Self-ins.1: rr: �pi„ti is Date: Or Job Sim Addrss• CitylStstea p• Attach m s®py-o6 tbewarken'e04en8aitam POR eleel M rataon pM Y(sh®wavag A pat:y MMMber arsel Mirata8z(dat@). Fail-am to secure.coverage as required ander Section 25A of MIGI c. 152 can lead to the t osition-of cs9_76--a1 penalties of a fine tap to$1,500.00&n&or one-year as ear imprisonnimt,as well cavil pertedtys in the foaut of a ST®P WORK OlZl3ER arca a3.fine of-up to$250.00 a day Qainst the violator. Bo advised*at a copy of this stat€an,;.jt may be fomwded to the ice of Investigations of tbr.A, TR for insurancc covgMge v6r,•fication. 1T d®hereby septa} egad 8bg d flies®$pea3aDa�v 81ae8.8iae drat®r e8dosap><9vaded above is er-a and sit L Si�tatare: - Dalff, Phone rte: 1 �' �•fikial use only. Do nog wa8e in-glais iwe,%•8o be;9RPR29_-d by X17 ms it-Y of dpi', ECatly osr'1l®wra: Pertce;>a€e lissaaastag Auttla®alty.(drele one): lie Board of-Hes lth 2.Blanding 3.Myrrown Caerh c ltilleCttAcaa umpectorr Se-PItatbk"M IMsPOet®ff 6.Other (Contact Person: Mane#i: , Tl-!!S CERTIFICATE 1S ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CE 11/18014 CERTIFICATE DOES NOT AFFIRMATIVELY OR ONLY AMEND, EXTEND OR ALTc'R-THE COVE BELOW. THIS CFRT►FIC'kTE*OF INSURANCE DOES NOT CONSTITUTE A CONT CERTIFICATE By HOLDER. THIS REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. CONTRACT gE—1 RAGE AFFORDED 3Y THE POLICIES 1 A/EEN THE ISSUING INSURER(S), AUTHORIZED I he terms an If the certificate holder is an ADDITIONAL INSURED, the policy(iesJ must ba endorsed. 1f SU$RCGATION IS VtJ:alllED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement On this certlricate does not confer rights to tha certificate holder in lieu of such endorsements}. PRODUCER MARSH USA,INC. CONTACT TWO ALLIANCE CENTER NAME: 3560 LENOX ROAD,SUITE 2400 PHONc . If No Ertl: �AX ATLANTA,GA 30326 EMAIL I'Alc No ADDRESS: '100492-HOmeD W-14-15 - INSURER(S)AFFORDING COVERAGE INSURED INSURER A:Sleadfast insurance Corriji NAiC; THD AT-HOME SERVICES,INC. 263,87 DBA THE HOME DEPOT AT-Holl SERVICES INSURER 3:Zurich Amann insurance Co io""535 2690 CUMBERLAND PARKWAY,SUlit:300 INSURER c:New Hampshire ins Co AT1ArLWA.GA 30339 Iii! 23641 INSURER D; ncis National Insurance Cam ` 231317 INSURER e, COVERAGES CERTIFICATE NUMBER: INSURER F: THIS IS TO CERTIFY THAT THE POLICIES OF-INSUPANCE LISTED BELOW NAVE KEENS SUED07 REVISION NUMSER:7 INDICATED NOiVVIT}JSTANDING ANY REQUIREMENT,TERM OR CONDI170N OF ANY CONTRACT O CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURA TO THE INSURED NAlv1ED ABOVE FOR THE POLICY PERIOD EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEE R OTHER DOCUMENT 1MTH RESPECT TO VVHICH THIS NCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, SRR BEENREDUCED 13Y PAID CLAIMS: LTR TYPE OF INSURANCE ADDL S A GENERAL LIABILITY SR WVDI POLICY NUMBER POLICY EFF M Dy EXP GLO4887714-04 MMIDD Lill X COMMERCIALGENERALLIABILiTY 03/01/2014 03101/2015 EACH OCCURRENCE S 9,000,000 CLAIMS-MADEX DAMAGE OR NT D occuR LIMITS OFPOLICYXS PREMISES Ea occurrence S 1,000.00D OF SIR$11A PER OCC LIED EXP Any one parson) S EXCLUDED PERSONAL&ADV INJURY S 9,000,000 GEN'LAGGREGATELIMITAPPLIESPER. GENERAL AGGREGATE g 91000,000 X POLICY Ji 14 PRODUCTS-COMP/OPAGG S 9,OIK),ODO B AUTOMOBILE LIABILITY BAP 2938863.11 S X ANY AUTO 03/01/2014 03/01/2015 Cot SINE D SINGLE LIMIJ Ea accident LL g 4,OW,ODO AOWNED SCHEDULED BODILY INJURY(Parpercn) S AUTOS AUTOS SELF INSURED AUTOP4YDtvIGO _ HIREOAUTOS AOU�NED BODILY INJURY(Per accident) S PROPERTY DAMAGE 10,2—daM S UMBRELLA LtAS S OCCUR EXCESS LEAS CLAIMS-MADE EACH OCCURRENCE 5 DED RETENTIONS AGGREGATE S C WORKERS coMPENSATION. WC049101882 C AND EMPLOYERS'LIABILITY (AOS S 03/0i/2014 03/01/2015 X WC STATU- ANY PROPRIETOR7PAR7NER/E(ECtlTIVE Y!N WC049101884(AK) TORY LIMITS O R D OFFICERIMEMBEREXCLUDED? NIA 03101/2014 03/01/2015 (Mandatory In NH) WC049101883(FLder. ) EL EACH ACCIDENT $ 1,000,OD0 EEI DESCRIPTION ibe OF OPERATIONS below 03/01/2014 03/01)2015 EL DISEASE-EA EMPLOYE S i,00D,000 C WORKERS COMPENSATION WC049101885(KY,NC,NH,VT} 03/012014 03/01/2015 E.L. 0,000 DISEASE-POLICY LIMIT S 1,00 C WC04910iIi(NJ) (EL)LIMIT 1,000,000 03/0112014 03/01/2015 DESCRIPTION OF OPERATIONS 1 LOCATIONS!VEHICLES(Attach ACORD 101,Addltlonal Remarks Schedule,if e ) space is required) EVIDENCE OF INSURANCE I CERTIFICATE HOLDER ' CANCELLATION [ATLANTA, HD AT-HOME SERVICES,INC. i BATHEHOMEDEPOTATHOMESERVICES SHOULD ANY-OF THE ABOVE DESCRIBED POLICIES BE CANCELLEDBEFORE 55 PACES FERRY ROAD THE EXPIRATION DATE THEREOF; NOTICE WILL BE DELIVERED IN I GA 30339 ACCORDANCE VdITH THE POLICY PROVISIONS. ! AUTHORIZED REPRESENTATIVE of Marsh USA Inc. _ _ Manash!Mukherjee T3 a 3/'1e tet:. n:f � �f: - / —!n �� �. f �-�•"jn -_! -�• .� 1Fb{_ ' Si-�:�i Y rs'`✓!�;�s�•�'Y'�,�"7.i��' !..�¢ � �✓�•ii�� �. 3,�•!i �'�L L:!. "���<z���� 1"x«'1.:..1:?��E..L 1.✓ ��a�o_�i" 'r'��� '� • r r ad(•y v swite mSi�>m P ' .Type: Sdpp'kvLnit Card THD AT HOME SERVICES INC. Update Addy=mid miarn ewd.Mzor3 rump for aay. Addrw 71 Pl4n ,a; ;rip➢�;snrat j Los!CA, � :? f•�rLlr.J�7/!P:II{ r-i^d./,»��rr�l.,z+P1 � �e of a ansrncs airz:Rs�n fs x is3.a�i� Ll€ice m,or r #.kion void for individal psi orly ei ]��, �ir�a xt t� f ..F n ��r�t�iW ,ffift •:riYti ^' I .w I<�S r(aL4B0� 'ii�r�,.5 —pg.p D, 5 , Supple-mint-C 'd gs`cis ; S F3f4-HtJRi9€m AT $RRVICES a�.c;i4 Fib FAIU NE � €?CfJMbikLAN9 PARKWAYS �— � � , `A.GAS t. i E li ?� CSSL-102535 DONALD L BURNfT f x 31 MARION ROAD MARBLF,HEAD MA 0144$1;' ., r rr;'a.; „:,:•; 12/06/2016 �I