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Home My WebLink AboutMiscellaneous - 100 COURT STREET 4/30/2018 (2)I Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS, Ch. 139, Sec. 3B To: Building Commissioner or Inspector of Buildings 1600 Osgood Street North Andover, MA 01845 RE: Insured: Property Address: Company: Policy/Claim Number: Date/Cause of Loss: Our File Number: Eric & Suzanne Fischer 100 Court Street Bay State Insurance Company HP3058369, HP3058369 12/1/2015, Water Damage 33024-M Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or cause MASSACHUSETTS GENERAL LAWS, CHAPTER 143, SECTION 6, to be applicable. If any notice under MASSACHUSETTS GENERAL LAWS, CHAPTER 139, SECTION 3B is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim or file number. Mike Peterson, Ext. 115 On this date, I caused copies of this Notice to be sent to the persons named above at the addresses indicated above by First Class Mail. 2 - Signature and Date ANDERSON ADJUSTMENT CO., INC. 50 Nashua Road, Suite 303 PO Box 1098 Londonderry, NH 03053 Cc: Health Department North Andover Fire Department 1600 Osgood Street 795 Chickering Road Building 20, Unit 2035 North Andover, MA 01845 North Andover, MA 01845 Location / J� No. Date pORTly TOWN OF NORTH ANDOVER f �ti � 9 Certificate of Occupancy $ i ; ,' moo, _ •. �'�a •,•'° E<�' s�GMus Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ r Check # 15623 r-�1� �" �.... `Building Inspec TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING B%� BUILDING PERMIT ERMIT NUMBER: DATE ISSUED: n, SIGNATURE: Building Commissioner/IEEpector of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: /00 cou-r- " Sf � _ 1 a0r�A1/1 I �� Map Number Parcel Number /ihdl�l/��— 1 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided ReqWred Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private 0 ZOne Outside Flood Zone 0 Municipal ❑ On Site Disposal System 0 SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record Q 5 L � C' %Z C-�- Nam7(Pt) Address for Service rture Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: License Number Address Expiration Date Signature Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Address Expiration Date Signature Telephone LQ SECTION 4 - WORKERS COMPENSATION (M.G.L C 152 & 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. -Signed affidavit Attached Yes .......0 No ....... 0 SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) 0 Addition 0 Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit applicant �. R UFFCIAL fiiSE.ONLY Y .. 1. Building (a) BuildingPermit Fee Multiplier 5 K r %t O A c� 2 Electrical (b) Estimated Total Cost of Construction D ' 3 Plumbing Building Permit fee (a) x (b) eJ 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 , p Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1 11 t / C^- " - / /& '- ' , as Owner/Authorized Agent of subject property Hereby authorize J , %� , '- to act on My e calf in all matte . relative tawork authorized by this building pen -nit applicati i._ G Si i tre of Owner DatT TION 7b OWNER/AUTHORIZED AGENT DECLARATION 1, as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief Print Name Signature of Owner/A Ient Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIIvMERS 1ST2 3RD SPAN DIMENSIONS OF SILLS DM ENSIONS OF POSTS DIN4ENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. l *****************************APPLICANT FILLS OUT THIS SECTION*********************** APPLICANT r.L k� PHONE i 7 -. 9 03 g ILOCATION: Assessor's Map Number PARCEL SUBDIVISION _ LOT (S) L STREET S4, ST. NUMBER *****************************************OFFICIAL USE ONLY*********************************** RECO.MMENDATION%OF TOWN AGENTS: ATION ADMINISTRATOR DATE APPROVED ` DATE REJECTED TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD INSPECTOR -HEALTH SEPTIC INSPECTOR -HEALTH DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9\97 jm D. -Robert Nicetta Building Commissioner (978) 688-9545 •'(978) 688-9542 Fax Please print / DATE JOB LOCATION V Number "HOMEOWNER JC, rv&- Building Department 27 Charles Street North Andover, MA. 01845 HOMEOWNER UCENSE EXEMPTION CcCK� S�- Street Address rvame Home Phone PRESENT MAILING ADDRESS 0 C C7 t,_ y, t -S f do, city town gate x � x S�+c►�use� Map / lot Work Phone a4�s- Zip Code The current exemption for "homeowners" was extended to include owner -occupied dwellings of two units or less and to allow such homeowners to engage an individual for hire who does. not possess a license, provided that the owner acts as supervisor. (State Building Code Section 108.3.5.1)' DEFINITION OF HOMEWOWNER: Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one or two family dwelling, attached or detached structures c- cessa ory. to such use and/or farm structures. A person who constructs more than one hom two-year period shall not be'considered a homr. e c aeowne The undersigned "homeowner' assumes responsibility for compliance with the State Building Code and other Applicable codes, bylaws, rules and regulations, The undersigned "homeowner' certifies that Wshe understands the Town of No. Andover Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. HOMEOWNER'S SIGNATURE APPROVAL OF BUILDING OFFIC f EASTERN SHED COMPANY 39 Barthelmess Lane ` Hamps 7.) 688-4 IN ORDER TO SERVE YOU BETTER, PLEASE THIS IS A BINDING CONTRACT WHEN ACCEPTED CONTRACT. CONTRACT BETWEEN EASTERN SHED COMPANY and (customers nG_3 y; I Date '/t / / SheREAD THE FOLLOWING CAREFULLY BEFOR THE FOLLOWING CONDITIONS APPLY TO THIS 1) Due to the weight of each section, the Delivery Vehicle must be able to unload within .100 feet of where the shed is to be installed, otherwise an additional minimum charge of $30.00 will be required. 2) Installation requires that installers have a fairly level, firm site with approx. 21/z clearance at the rear, 11/2' on both ends, and clear of obstructions up to 12, high. If these requirements are not met, extra fees may apply. If unclear please call office prior to delivery for arrangements. 3) Upon delivery customer must aknowledge exact position of shed. After the shed floor has been leveled andy movement of shed will constitue an extra fee. 4) Customer will be called and notified of proposed delivery date. If, after agreeing to this date, shed cannot be accepted, a 24hr notice prior to delivery is required. If the shed cannot be installed due to customer responsibility without the required notice, an additional $60 will be added for a 2nd delivery. 5) Customer is responsible for all building permits if required. 6) FINAL PAYMENT must be made on delivery by CERTIFIED CHECK, OR BANK CHECK. All checks payable to: EASTERN SHED COMPANY. 7) Any cancellation of this contract must be in writing and received by company at this office, 39 Barthelmess Lane, Hampstead, NH 03481 within (4) FOUR BUSINESS DAYS of the date you signed this contract. 8) Until final payment is received and cleared, shed and all component parts remain the property of EASTERN SHED COMPANY. In the event of default of payment, customer specifically authorizes Company and its Agents to enter upon his/her premises to remove said shed and all component parts, without being guilty of trespass. 9) All deliveries will take place Mon. -Fri. only. Customer will be called 4-5 days prior to delivery to schedule time. With proper maintenance, EASTERN SHED COMPANY offers a warranty of three years, from purchase date, that your building will maintain its structural integrity. All sheds must be painted/stained within 30 days of instalation, and all door edges (top, bottoms, etc.), to prevent swelling. We take great pride in knowing that our buildings are built better, and will last longer. Our principle goal is for a sat- isfied customer. A satisfied customer has always been our best advertising. This warranty does not cover any building that has been altered in anyway or conditions resulting from neglect, abuse, accident, or natural disasters. The roof shingles are warranteed for 20 years against leakage (natural disasters, gale force winds, damage by accident, or neglect are excluded). EASTERN SHED COMPANY gives no other guarantee expressed or implied, either,o ad or in writing. DATEDf > t � ,� ,/ CUSTOMERS SIGNATURE----�' ;;-j .,,• ;� ,.'�_ , '% �:� ;-�'._.,, ACCEPTED EASTERN SHED COMPANY DATED AUTHORIZED SIGNATURE +EASTERN SHED L -,COMPANY (978) 688-4222 FAX: (978) 688-4244 CUSTOMER INFORMATION NAME L. STREET fttU( CITY >? s 3 r Ic STATE �A A ZIP HOME PHONE (j ) WORK PHONE ( ) REMARKS DATE,~ SHED# _ '' (- SIZE .::r x Width x Length MODEL: ❑ GLENWOOD f4CHATEAU ❑ GAMBREL ❑ SIERRA ❑ DELMAR ❑ GAZEBO WOOD:, CEDAR 11 PINE Shed Price $--_- i Total cost of options from below $ S-/ Sub Total $ Sales Tax $ Sub Total $ t Moving Charge $ Carrying Charge $_ Delivery Charge $= Sub Total Deposit $ �,2 C;�; -- . Total Amount Due Upon Delivery $ SALES PERSON -� For office use only; Date Deliverd / / AMOUNT RECEIVED $ ROOFCOLOR Check# LACK ❑ GREY ❑ BROWN PLACEMENT OF DOORS AND WINDOWS SIDE FRONT (Length) r SPECIAL INSTRUCTIONS OPTIONS QUANTITY ITEM COST l Wide Door Exchange ($25) $ ' Extra Reg. Door ($65) $ --- Extra Wide Door ($90) $ Extra Window ($35) $ Louvres ($35) $ - Ramp ($60) $ Floor Cutout ($50) $ / Pressure Treated Floor Joists $ Pressure Treated Plywood $ J` t $ W TOTAL COST OF OPTIONS $ ROOFCOLOR Check# LACK ❑ GREY ❑ BROWN PLACEMENT OF DOORS AND WINDOWS SIDE FRONT (Length) r SPECIAL INSTRUCTIONS C/) m m 0 m CO) CD St Z CD O ar O O a� a� -0 OCD p CL Q CD O CA 10 CD 0 SIM col .O _d O c O CO) d Cl) CD O r� CD CD a. y CD CO) O CD 0 CD O - .yoQ H �0SO .02 y �'0 m n C y C2 d 0m CD El Z �� vi �n-*c = m C C N G N� �CD m 2 o i m m a _ y m �•o=o V- n 0 CS I •m o I � � � � ♦ :� C� CA CL 0-54 ttCC Cn W Cnc Q C° � 0 m CD n cr z C C C/) 5: c 2 I.Z H ,� : Z C/)CD �..y CD N O O � g c� n p gcn :e z � CD: N CD tx o CC°D Cn a 3 VJ W H :� ZCRQ� Zca b: o CD 9 �' a o r y �" o fD M C� w o On ,� r p '� x � � i o ac o w 0 cp cin o 7C trj I I 9.1 O 0 f 46- w LU 0 a5 Z t~ C. 210.00' 0 co Sc. 0 i2 010 00 c- 0 u 10 W 0 0. LO kn In 10 a (N E wm to v U - co as's u C) cc Co CS C)CD OAA,m 0 p II uj 13"Al i IL ul L3 Z 4-J C. (j, . tn Lnn-3 4 v-4 <1 9C 4) C C .00 0 zz < x X won a 0 X 0 0 La 0 21. =;" m 0 0 04 wa r* C7 to tD wa &� 0 2 z CA. dt3 tn d& .2 so a 0 4&0 ul w .0 &",a Is %10 10 z 0 I m 9z V ZW4 O Cts Cu ZUJ QHS >-L Jn cn CD CL co, cuto d > C 03 a a -07c ro 9- 404A." Ogg C < s=r-4 C-440 M 0 z Ca X "04 < u rq CZQi it" Inc, lo. O� 10 -cm Lu cg 0*3 LI)c LU IQ < C 93rq 013 t- 0 OJ2.0 Amos > Udm CA 0 so t3.J go u 9C 43C w a owar-9ZO, 42= 0 LU c C6C.-D C X V) Q= cAldo 0.40.00 N -t 49O'S. Ilk' Ima cop cc 'c" 4D a go. a t -JC < its b U C C. 0.0 *$w* czro ex a u Ofte..'613 0 41 G Z z a cg.or, wo as t< wo vcl,.%2 Z rmb 39C. 0 A LL CT3 3cm CW.0 .2 < X C 404&4& ca 40 QQMCWo�gm 21% S 0 C. ev C6-4.0 =lox wqr- CC313 �W*-* we � 4�.bAA 93 a 21-41 a w 4A 0 X CA& LU Aimc-Omm W=rL m4JAA a a 0 0 Mo. r-= 0-0 210.00' 0 co Sc. 0 i2 010 00 c- 0 u 10 W 0 0. LO kn In 10 a (N E wm to v U - co as's u C) cc Co CS C)CD OAA,m 0 p II uj 13"Al i IL ul L3 Z 4-J C. (j, . tn Lnn-3 4 v-4 <1 9C 4) C C .00 0 zz < x X won a 0 X 0 0 La 0 21. =;" m 0 0 04 wa r* C7 to tD wa &� 0 2 z CA. dt3 tn d& .2 so a 0 4&0 ul w .0 &",a Is %10 10 z 0 I m 9z V ZW4 O Cts Cu ZUJ QHS >-L Jn cn CD CL co, cuto d E1. li; ��... 'n _ h.i "i R '-"£Std�s.w•'Maisy ;..._..'.e..r_.. _ v,,.� UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type)) NORTH ANDOVER , Maas. Dal Building #�J LocationtzL Permit----r�� OwnerLU�bq Name ) E New ❑ Renovation ❑ Replacement p Plans Submitted:. Yes ❑ No p Installing Company Business Telephone�`-- Name of Licensed Plumber or Gas Fitter Check one: Corp. d Partnership ❑ Firm/Co. INSURANCE COVERAGE:; Check one I have a current IlabAfty Insurance policy or its substantial equivalent. ' Yes ❑ No ❑ If you have checked yes, please Indicate the type coverage by checking the approprtale box. A liability Insurance policy L Other type of Indemnity ❑ Bond ❑ Certificate �C�1-I2 OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signatuts of Owner or Owner's ent Owner ❑ Agent ❑ I hereby certify that all of the details and Information 1 have submitted (or entered) M above application are (We and accurate to jhwbest of my It go and that all plumbing work and Installations performed under the permit Issued for2�bapplkawill be in oompli nce with At pertinent provisions of the Massachusetts State Gas a a and Chapter lA2 of the Genera) i :17 Title CIty/Town K"10NED (OFFICE USE ONLY) Tof License: Plumber na urs W Gasfitler of Master C� Journeyman License Number mom Now NNO MEN ONO soon Installing Company Business Telephone�`-- Name of Licensed Plumber or Gas Fitter Check one: Corp. d Partnership ❑ Firm/Co. INSURANCE COVERAGE:; Check one I have a current IlabAfty Insurance policy or its substantial equivalent. ' Yes ❑ No ❑ If you have checked yes, please Indicate the type coverage by checking the approprtale box. A liability Insurance policy L Other type of Indemnity ❑ Bond ❑ Certificate �C�1-I2 OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signatuts of Owner or Owner's ent Owner ❑ Agent ❑ I hereby certify that all of the details and Information 1 have submitted (or entered) M above application are (We and accurate to jhwbest of my It go and that all plumbing work and Installations performed under the permit Issued for2�bapplkawill be in oompli nce with At pertinent provisions of the Massachusetts State Gas a a and Chapter lA2 of the Genera) i :17 Title CIty/Town K"10NED (OFFICE USE ONLY) Tof License: Plumber na urs W Gasfitler of Master C� Journeyman License Number Of N m m r r s = rn �f 7. a M r • z N b rn A -1 O Z N m m r r O = rn M •� I � p j '� r z •1 � Z � Z O M =) C •z t + 0 3t , O O 31 rn N N N b m n -1 0 z Aw Date .. �V/ y� 1... . Q ' _ 789 TOWN OF NORTH ANDOVER IVEDRkffltTNffOR GAS INSTALLATION CT 2 3 1.991 No, And Collector This certifies that .......... has permission for gas installation. ..---�... C4in the buildings of ... C4 g d ........................... at ,� o..L. X4! . .. '....... ,North Andover, Mass. Fee. .145 . v... Lic. No. 1-76 E3.5 . ......................... . C/e� 7 Ci� GAS INSPECTOR WHITE: Applicant f CAAN.AIRY�: Building Dept. PINK: Treasurer GOLD: File Location No. Date i TOWN OF NORTH ANDOVER A Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL $ 3 Building Inspector Div. Public Works 0 $A mW 00 �y b O tu O Z Z O U. 9 �9 _Z Q b K W _ mc ~O 0 J j m b W m J N 0 F H 0 0 Z I J th 60 C 4 0 W i LLWO N z < m 00 O 9 �9 d V H H J cd W 3 o cd o O U U lll/1J Z P Z ) 0 7 h a 0 Z ,� > O 8 0 0 m N ^ 0 z: �0 !,a W F W C 0 W < Z O r W Z 0 < < Z b O < b b H W f x IL Q Z N U 0 W z 0 W z 0< u Lo is a 21 b 0 b d R &N Z f O W I Z Zl7 = 3 z v 0 F 0 0 1 0 W <LL 1 I 0 W W N < 1 x in f ! Fool G z a i 0 u U, J W L L U. 0 D K 0 m z 0 Q m LL Z W IL 0 IK IL M G � tFtpp u u O J J G m m z F F j W W N z f a L u E m 1 1 I F j Z I W < 0 I N Qj 0 x i < i c 0 1 rc i W ; I 0 W 1 Z W W E J O 0 1 W < W F WC O b IL d t 00 9 �9 J J LU V H H J cd W 3 o cd o O U U 2 1 1 I F j Z I W < 0 I N Qj 0 x i < i c 0 1 rc i W ; I 0 W 1 Z W W E J O 0 1 W < W F WC O b IL d t 0 N D N D Nrm � �Zn m� DO N Z °c mmN �x� D Q 0�0 U)0* v;m- mx IZD ton a6o �Z_ mox "U0z �N mm0 CZ .UFO rN 020 -10r NO lu r -+ ?�i -40 =v ni xn mm mm 00 D0 3 1 t V f n D D nT n lZOD;N n ��O IxZ� D ?o T O2 m> 0000Z ZZAOOOx2A OOn yNND O 0 ; 01m00 A A y< Z ZN (T O s CO 0 00 On T N D 0 T O 1 Z Z0m Na III ILL 1 _1 11 1_ ILllll W OZxDni ^nAn' r T oA yy yA Z_x DT ;DZ D�I WOm?? T COyo T{ /� C OTONCZAASODyA O m C A xn y Z D i f xO DNi yyO Z O DO ZNA Z w A DO T Z OTA ZD DA -{ OZ OOT OO% 0 XOOZ_ Zmxy OA DZ y 0 A ~ DD A � �n 111 10' Dn p TZ O ZZ O A Z p I I II I I I I IW I I I I� I I I 0 N D N D Nrm � �Zn m� DO N Z °c mmN �x� D Q 0�0 U)0* v;m- mx IZD ton a6o �Z_ mox "U0z �N mm0 CZ .UFO rN 020 -10r NO lu r -+ ?�i -40 =v ni xn mm mm 00 D0 3 1 t WILLIAM J. SCOTT Director f Town of North Andover t HORTil , OFFICE OF 3?0`�,,eo 1r� COMMUNITY DEVELOPMENT AND SERVICES ° 146 Main Street * North Andover, Massachusetts 01845 q�ifD �I In accordance with the provisions of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 111, S 150A. The debris will be disposed of in: cation of Facility) Signature of Permit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector. BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 '-- DAVID HOWES CONSTRUCTION, INC. Quality Built Custom Homes & Remodeling ® 62 North Lowell Road Windham, NH 03087 (603) 434-7086 TT Restricted To: 1G DEPARTMENT OF PUBLIC SAFETY CONSTRUCTION SUPERVISOR LICENSE Nattier �' --Expires: Birthdate: 06/09/1998 06/09/1952 Restr�ct�d Tq 1G �` w pAVID I HONES LONELL RD NINDHAM, NH 03081 00 - None 1A - Masonry only 1G - 1 S 2 Fatily Notes �T� ,�,,�1� g�✓l�aaoah4a HOME IMPROVEMENT CONTRACTOR ' Registration 123402 Type - INDIVIDUAL Expiration 02/12/99 ..'' pp IIDp }{ EESS 6PRRWWili RE RD ,�IPDHAM NH 03081 ADMINISTRATOR IF ka �0D L0 Tit Na. 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D mom: m y 77N :_ Pm .�rkl�,1,y �0 I ex '�xo'r7 � 2 o D �}" • to m D z n m .". w I(b J FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicant fills out this section***************** APPLICANT: 6, :6C e u ) HO -C, U,p �cnn � _ Phone 1 l00 zY- L? S LOCATION: Assessor's Map Number Parcel Subdivision Lot s) :,919 Street Im �'�s�,r oa St. Number ************************Official Use Only************************ RECOMMENDATIONS OF TOWN AGENTS: ¢ Date Approved Co servation Administrator ` Date -Rejected Comments EL(,( y�► ` f C1 Town Planner Comments Food Inspector-Healthti'8'uJ� m ' V"Septic Inspector -Health Comments Public Works - sewer/water connections - driveway permit Fire Department Date Approved Date Rejected Date Approved Date Rejected Date Approved Date Rejected Received by Building Inspector Date m i W a �Ia Y 0 m W � W N N 1/1 IL VI _ Q = X p� W W Z 3 p 0 z Z o i 0 J N m C 0 0 0 1 Z W N IQ W IL 0 p N d Z m m 0 F Ot W N: z Q Z v r �o 0 % Z 0 D J U! ti \ N N W IZ i 0 Z < D 2 < 0 0 !A to W Q w w p a z U z z ? o N o 0 0 WIa 0 rc 0 z N r N N K W m i F C 0 J LL LL 0 N z < L N K Q W rc N z z 0 F- W H :)Z = s � O 0 p G } W < C Z Z N W 0 m LL_ Z f 4 N 1 J J V I 0 U O 0 m m O m d U O z UA ~ ~ ce Z " J W W W 01 'Q f ZZ U�) C U V = I f Z W 7 M m f 0 m r z Z p rc r _O r W J_ z F 0 a 0 N O I W 0 m f 0 < r < C n i N E Q U1 -I ; p U J W < a Z< z 0 0 z<< Z N z O 0 0 0 p< r {A LL LL 0 J Z V W W W Q O 0 F W z z Z O J J J m O u � N N N w m m m j< m m m < m o 0 0<- 3 N z z 0 F- Z H = s � 0: 1D �` p G } � Z C C Z D W 0 rIp u uu N Z f 4 N 1 J J V L 0 U O 0 m m O m d U z UA ~ ~ ce Z " j W W W 01 'Q f ZZ U�) C U V = I N z 0 F- I I � N Z N N I N m 1 z z 1 O O f r ! 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