HomeMy WebLinkAboutBuilding Permit #283-14 - 894 GREAT POND ROAD 9/27/2013 TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
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Permit NO: Date Received
Date Issued: f II
IMPORTANT: Applicant must complete all items on this page
1` l y alp- _ -
P.Tint �.- 100 Year Old Structure es" no. st,
`PROPERTY OWNER0
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_ — -
x
ii X
,MAP, bPARCEL- �ZZ ZCQNIiNG RISTRICT. ` - €Historic District yes nog
.
Machine Shop Village yes ,.no. _
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential j
❑ New Building /one family
❑Addition ❑Two or more family ❑ Industrial h
❑Alteration No. of units: ❑ Commercial j
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other _
n:
r _
T ❑zFloos _ ❑-,Watersh❑ Septics ❑Well lanpam ❑;WetedD'istnctf
_ -
❑-Water(Sewer
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DESCRIPTION OF WORK TO BE PERFORMED:
spq +
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dentification Please Ty a or Print Clearly)
OWNER: Name: 0 I,,) Phone:
Address:
_ 6
CONTRACTOR;Name,. Awaq.r_ Phone
s _
- L
u �
Address:
_ - -
�'
Supervisor s Construction:License �T� Z ._ — Exp .;Dater t
Home Improvement License: e.J � - Exp jDate' -
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: $ o FEE: $
Check No.: 4,1 Receipt No.:
NOTE: Persons contracting with u egistered contractors do not have access to the u my fund
Signaturecof•entJO enature,ofi contRracfo
Plans Submitted ❑ Pla aive ❑ Certified Plot Plan F1amped lans ❑
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
-TYPE--OF SEWERAGE:DISP_OSAL
Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑
Well ❑ Tobacco.Sales ❑
Food Packaging/Sales ❑
Private(septic tank,etc._ ❑ - . „ Permanent Dumpster ori Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT'- ❑ ❑
COMMENTS
1
-CONSERVATION Reviewed on Signature
COMMENTS
I
HEALTH Reviewed on Signature
COMMENTS
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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 Tows Engineer: Signature:
Located 384 Osgood Street
FIREDEPARTMENt - Temp Dumpster on site eyes
no .. '
Located-at 124 Mair Street
Fire DepartM tsignatureldate`' "F x �•;i °Y �, x � , :.� `
COIVIMEfVTS
Dimension
I" Number of Stories: Total square feet of floor area, based on Exterior dimensions._
.Total land areasq. 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
ry -
® Notified for pickup - Date
Doc.Building Permit Revised 2010
i
Building Department
The fol(swing 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/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And k
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
a
New Construction (Single and Two Family)
a
❑ Building Permit Application i
❑ 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 apw al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be subm.tted with the building application
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Doc: Doc.Building Permit Revised 2012
i
Location 6-1 1
No. `� Date
o - TOWN OF NORTH ANDOVER
e Certificate of Occupancy $ ��
Building/Frame Permit Fee $ G
Foundation Permit Fee $
Other Permit Permit Fee $
�`~ TOTAL
Check# i
26916 Building Inspector
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No.
% �AKe h , ver,-Mass), . �1
COCHICKI-ICK y1.
S V
BOARD OF HEALTH
Food/Kitchen
PER IT T LD Septic System
THIS CERTIFIES THAT ......... ..��� BUILDING INSPECTOR
..... ............ ...... ............ ... ....... .......................
.. . . Foundation
has permission to erect .......................... buildings on ..... .... ...tp�i........w!j...�n......
Rough
Spipto be occupied as ....... ....4............t...Rood g
............................................................................... 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 i
PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONSTRUCTV STTS Rough
Service
............. ... ....... ............................................... Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required 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.
SEE REVERSE SIDE
: ,4w n r }z1E`�. .x ;3..t '� �d �,,, zzti s c ,. ,3, e x.�
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Y 5� sem' . r'
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Chfrnp- Residential & Commercial Roofing All Types Of
CHIMNEYS POINTED-REBUILT-CAPPED
dExpert Masonry Work
Mass Tr1iI Free =;° Licensed & Insurt;d
f.:tc�x:f} (1 t�rta�d e'-,C)jrw'ltr d =<'r !Q76
1-Boo-WAIT-4-US =�, '- License#034200
(924-8487) OL-
We Work Year Hound
2
Proposal To: Don Jabkle Date 7/22/2013
Street: 894 Great Pond Rd. 978-683-5302
Andover, MA
� Roof proposal don@pmdtechnology.com
1. Extra caution will be taken to protect barn 10.Removal of all work related debris. Planks will be
exterior and landscaping as best as possible. placed under dumpster to prevent any damage to
(tarps etc.) Magnets run at final clean up. driveway.
2. Remove all shingles from entire barn. 11. Building permit included.
3. Inspect and re-nail any loose or lifted roof boards 12. Contractor workmanship warranty: 10 years under
4. Any compromised boards will be replaced at an normal wind and rain conditions.
additional cost of$2.75 per lineal foot of I x8
spruce. Total cost: $ 9,000.00
5. Install heavy gauge 8 white aluminum drip edge (Angie's List discount applied and included)
to all eaves and rakes.
6. Install heavy 30LB felt underlayment to entire
roof
7. Install IKO Leading Edge starter shingles to all Balance due upon completion
eaves and rakes. References available upon request
8. Install. IKO Cambridge Limited Lifetime
architectural shingles to entire barn roof.All Highly rated member of the accredited BBB and
shingles will be installed and fastened according Highl s List
to mfg.specs.
9. Install color matched IKO hip and ridge shingles
to entire ridge. Thank you!
Acceptance of Proposal—The above prices, specificE tions and conditions are satisfactory and are herby
accepted. You are authorized to do the work as specifid. Payment will be made as outlined above.
Date of Acceptance: Signature:
Signature:
n ' c ,4s � •.� -k�� ` F, tl� ]i g;ay "k'�+�.'°-'"ai- 'KA
tzaG�1"����
ery: � ;E.. x 1
s 5', - Ste.i x L r vt tss 3
v
tae
��^`�'
ammercial Roofing All Types Of
l it l tt o• � t ` - Expert Masonry Work ,
Mass Toll Free Licensed & Insured
1-800-WAIT-4-US License#034200
(924-848T) C7V vh-v _:Gaj We Work Year Round
Proposal To: Don Jabkle Date, 7/22/2013
Street: 894 Great Pond Rd. 978-683-5302
Andover, MA
Roof proposal don@pmdtechnology.com
I. Extra caution will be taken to protect barn 10. Removal of all work related debris.Planks will be
exterior and landscaping as best as possible. placed under dumpster to prevent any damage to
(tarps etc.)Magnets run at final clean up. driveway.
2. Remove all shingles from entire barn. 11. Building permit included.
3. Inspect and re-nail any loose or lifted roof boards 12. Contractor workmanship warranty: 10 years under
4. Any compromised boards will be replaced at an normal wind and rain conditions.
additional cost of$2.75 per lineal foot of I x8
spruce. Total cost: $ 9,000.00
5. Install heavy gauge $ white aluminum drip edge
to all eaves and rakes. (Angie's List discount applied and included)
6. Install heavy 30LB felt underlayment to entire
roof. Balance due upon completion
7. Install IKO Leading Edge starter shingles to all
eaves and rakes. `.� References available upon request
8. Install IKO Cambridge Limited Lifetime
architectural shingles to entire barn roof. All Highly rated member of the accredited BBB and
shingles will be installed and fastened according
to mfg.specs. Angie,s List
9. Install color matched IKO hip and ridge shingles Thank vou!
to entire ridge.
Acceptance of Proposal—The above prices,specific ions and conditions are satisfactory and are herby
accepted. You are authorized to do the work as specifi A. Payment will be a as outlined above.
Date of Acceptance: Signature:
: r
Signatur
Rig$tfax N1-1 8/29/2013 5: 59:22 AM PAUE ZI VU4 ram LJ UA .%,
CERTIFICATE OF LIABILITY INSURANCE DATE 812A 9niJ Y
jr,TwaxreRTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE OLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
NIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED
B=ESENTATNE 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
hQ terms and conditions of the policy,certain policies may require and endorsement. A statement on this certificate does not confer rights to
the certificate holder in lieu of such endorsements).
PRODUCER CONTACT
NAME:
DAVID E ZELLER INS AGCY PHONE FAX
370 LYNNWAY (A/C,No,Ext): (AIC,No):
E-MAIL
LYNN,MA 01901 ADDRESS: `
25D6D tNSURER(S)Affol;tom COVERAGE NAIC#
INSURER A: ACE AMERICAN INSURANCE COMPANY
INSURED
1
BERRY,FRANK&BERRY,JAMES DBA FRANK&SONS INSURER B.
INSURER C:
INSUPMR.D: s
45 WINDBROOK DR INSURER E:
EPPING,NH 03042 INSURER F:
I
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THISIS O CERTIFY THAT THE rO—UCIESOFImSuRANCELJSTED BELOW HAVE BEEN ISSUED TO THEINSURED 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 CLAIM, 1
RISR ADD SUB POLICY EFF DATE POLICY EXP DATE
LTR TYPE OF INSURANCE L R POLICY NUMBER (MMODWYYY) (MM1DDXYYYY) LIMITS
GENERAL LIABILITYACH OCCURRENCE $
COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $
CLAIMS MADE a OCCUR. :REMISES(Ea occurrence)
ED EXP(Ary one person) $
RSONAL&ADV INJURY $
GENL AGGREGATE LIMIT APPLIES PER: 3ENERAL AGGREGATE $
i
POLICY 0 PROJECT LOC ODUCTS-COMP/OP AGG $
AUTOMOBILE LIABILITY COMBINED SINGLE $ (
ANY AUTO LIMIT(Ea accident) I
ALL OWNED AUTOS BODILY INJURY $ I
SCHEDULE AUTOS (Per person)
BODILY INJURY $
HIRED AUTOS (Per accident)
NON-OWNED AUTOS 1PROPERTY DAMAGE $ 1
(Per accident)
I I
UMBRELLA LIABOCCUR EACH OCCURRENCE $ j
EXCESS LIAB CLAIMS-MADE AGGREGATE $
$
DEDUCTIBLE
RETENTION $
A WORKER'S COMPENSATION ANDWC STATUTORY OTHER
EMPLOYER'S LIABILITY YIN UB-4689P893-13 0722/2013 07/22/2014 XJ LIMITS v�
ANY PROPERrroRIPARTNERiExECUTIVE N/A E.L EACH ACCIDENT $ 100,0_00
OFFICERIMEMBER EXCLUDED?
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000
if yes.describe under E.L.DISEASE-POLICY LIMIT $ 500,000
DESCRIPTION OF OPERATIONS below
DESCRIPTION OF OPERATIONS/LOCATIONSNBilCLES/RESTRICTIONS/SPECIAL ITEMS S
THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE.
NO PARTNERS ARE COVERED BY THE WORKERS'COMPENSATION POLICY. f
i
t
CERTIFICATE HOLDER CANCELLATION t .
ALL UNDER ONE ROOF SHOULD ANY OF THE ABOVE DESCRIBE)POLICIES BE CANCELLED
ATTN:NORMAN JOHN BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL B DE-
IN ACCORDANCE WITH THE POLICY PROVI
30 TEMPLE DRIVE AUTHORIZED REPRESENTATIVE
METHUEN,MA 01844
ACORD 2a(2010!05) The ACORD name and logo are registered marks of ACORD 1988-2010 ACORD CORPO . . nghts eserved.
The Commonwealth ofMassachusetts
Department oflndustriglAccidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www.massgov/dia '
Workers' Compensation Insurance.Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Lessibly
Name(Business/Organization/fndividual): i f U a
Address: 3 -�.,�i/I -c pn r�✓i' c,�. -
City/State/Zip: v►-1 vL Atli Phone
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ employer I am a with 4. am a general contractor and I
6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet.z �• E]Remodeling
ship and'have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers'comp.insurance. 9• ❑Building addition
[No workers' comp.insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
required.] officers have exercised their
3.❑ 1 am a homeowner,.doing all work. right of exemption per MGL ILEI Plumbing repairs or additions
myself. [No workers'comp. c. 152,§1(4),and we have no 12,E]Roof repairs
insurance required.)t employees.[No workers' 13.�Other �Y
comp.insurance required.]
*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 ere 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 their workers'comp.policy information.
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 ofMGL o.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 violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
Ido hereby certiounderMexalas and penalties of perjury that the information provided above is true and correct. -
Sign "A Date:
Phone#: V IYL
-9V'S--,7�3
Official use only. Do not write in this area,to be completed by city or town offrcial.
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 - -
t'nn4a rt PPrcnn Phone#:
i
Information -.nd Instruction's
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 ofhire,.
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-contractors)name(s), es address hone num
( )and p ber(s)along with t
heir certificate(s)
ofinsurance. Limited Liability Companies( LC or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'compensation insurance T
P . If an LSC or LLP does shave
employees,a policy is required. B e advised that this affidavit maybe submitted to the Department o
. f Industrial
Accidentsp
for confirmation nfirmation of insurance coverage. Also be sure to sign date the affidavit.
be returned to the g The affidavit should
city or town wn that the application for the permit or license is beingrequested,not the Department
of
Industrial Accidents. Should you have any questions regarding the la q
q $ g w 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(ifnecessary)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. Anew 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 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:
P -
The Coxnx�.onwealth of Ma ssa chvse#s
Department of IndwWal Accidents
Office ofI"Ostigat iolls.
600 Washington.Stxeet
Boston?MA 02111
Teel,#617-72.74900 ext 406 oz 1-877,MASSAFE
Revised 5-26-05 Fax#617-727-7749
}business Regulaijol)
Regutown tOCABR)
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Consumer Affa and
,provement C011118CIn8
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on list tyy any of the c6
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F37057
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by R"istrat"
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EXPIRATION
STATUS
RErpOt4Sj8LE REGISTRATto" ADDRESS DATE
REGISTRANT
NjjbwER
INDIVtDUAL C;urren!
NAME 10102,12014
166 A FINACHARO
poc), LANZAFAME. 137057
A,U k)r4[)F-R ONE BUILDING
jOHN mETHELIK MA 0184
2
011 UUMMQflYW3j4tj LA MEISSac"SetlS
m,e.of the Coffdft"801th
Mass Gov0 is 2 service
47epa;Tmcn4 0
Bo.ar:l of
-icevse CS
-069129
JOHN W LANZA
310 TEMPLE OR
MIETRUEN MA 01