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HomeMy WebLinkAboutMiscellaneous - 1000 FOREST STREET 4/30/2018N 0 w Y JW N \ < Y z Z Y 0• Y Y W W t W W f W W z W W Z O z Y i � x � o u z S f X Z z o z 9 N " W u < z 0 r r 0- 0 V 0 W C Y JW N \ < Y z Z C W Z 0 0• 0 Y W W t Y W f W W W Z N0 W W Z O z • i � x � o i z S I z o z 9 " 0 o FjL ON,z IK o $ Y = r $ o 0 u zrW 0 t IL I 0 Z = 0 • W L60 0 W Y L E z p It0 • • M O 0 Z • I UU C L H W u < z 0 r r 0- 0 V 0 W C d JW \ < Y O W Z r Z C W Z 0 0• u Y W t i Y a f W z W Z N0 W W Z O p D i 10 1 W u < z 0 r r 0- 0 V 0 W C N z 0 u H z Z I 9 ON,z L C = v L60 0 W L E z p It0 0 u UU C L H L 1.-u g r c u u $4 w w Z* O ■ r ■ t (V u G U i, i t' �I N z 0 u H z /�r 1• r ur urr irrr'r r��/� r / wc/ri.,i•//, DEPARTMENT OF PUBLIC SAFETY CONSTRUCTION SUPERVISOR LICENSE hiber: Expires: Birthdate CS 012831 08/09/1999 08/09/1950 x (Restricted To: 00 YILLIAM J PERRY 29 SEAYIEN LN EHURY, MA 01950 \ q -- HOME IMPROVEMENT CONTRACTOR Registration 108292 _. Type - PRIVATE CORPORATION Expiration 08/14/98 PERRY BROTHERS CONSTRUCTION, William J. Perry 67 &Broadway ADMINISTRATOR gus MA 01906 1 c WRIJAM J. SCOTT Director Town of North Andover OFFICE OF COMMUNITY DEVELOPMENT AND SERVICES 146 Main Street North Andover, Massachusetts 01845 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 1V1GL c 111, S 150A. The debris will be disposed of in: Z, 0 /,,,J - Ae-,4"�, (Location of Facility) ��Vzx�, Signature of Permit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Once of the Building Inspector. BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 R w ' N O z W W w O z O pG W poa a aa \ O u. .a v cn Or - 'r O w 7 O w E C u ctsoor. C X. a W OG a: iv r�. W x p u: U cx C w x O n4 G w" w v 7 cA z Y v� 01 .hd E cn W am c o O c O C N O C r O w_ v d C R A := O o N � Ea +: c :CDQ r GL o n N E c o� CD E CL N lC CD O cm O N m O • a 10 N C O Em m Z O pm N O O =L+ m w N o L. t: cao o o cm a c Q O y O C O = O :0� 3 N � d O w h CD D CO) 4D W p 2Z zr.�.. c •- � U.•tNA CL=MOUO C Z cc o"rm•0-0 QN O V •m C3 .0 C - C013 a g _ a ` H o t $awm E � L O w Z a3 CL O h D � G3 CM i O CIO. - m CL = C3 m O a CL �a C3 CID v CL. O s��., c Z 0 CL C.i N� c C C cts M NoDate ................. `............... r10RTH °•t `'°-:•,"°0 TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING ,SSACHUSES Thiscertifies that............................................................................................. has permission to perform............................................................................... wiringin the building of.....................:............................................................. at.................................................p............................. , North Andover, Mass. Fee` ............... Lic.-N2 � ... Q' Z' .......................................................... ELECTRICAL INSPECTOR Check # WHITE: Applicant CANARY: Building Dept. PINK: Treasurer mum DEPARTMENTOFPUBLICS MY Permit No. BOARD OFF7REPREVEWONREGUTATIONN527(MR12.00 Occupancy & Fees Checked WPUCATIONFOR PERMIT TO PERFORM ELECTRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Dat Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location (Street 6 Owner or Tenant Uwner's Address Is this permit in conjunctl�with a building permit: Yes M No (Check Appropriate Box) Purpose of Building Existing Service C)Q� Amps a�0/�� 4Volts Overhead 0 Underground New Service OCA Ampso� C�Volts Overhead Im Underground Number of Feeders and Ampacity eDo/q- Location and Nature of Proposed Electrical Work' t C P— ` Utility Authorization N0.03�CQ QNo. of Meters No. of Meters No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures Swimming Pool Above Below Generators KVA ground ED ground No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Ranges No. of Air Cond. Total Tons No. of Detection and No of Disposals No. of Heat Total Total Pumps Tons KW britiating Devices No.. of Sounding Devices No. of Dishwashers Space Area Heating KW No. of Self Contained Detection/Sounding Devices LocalMunicipal Oth.;r"' No. of Dryers Heating Devices KW Connections No. of Water Heaters KW No. of No. of Signs Bailasis No. Hydro Massage Tubs No. of Motors Total HP OTHER fin==Caaa PlasttantbthetegltitartaisdMmmduscusCtnffWLaws Iha%ea=,atLiabtkyhzst a=PdWni&gCan Caaag cr#sWjskx letg,iubtt YES Er NO Iha%embinkedvatidpoofofmclotheOliim YES M NO Er ff} uhawduiWYES,plemmdc*lbeWofeaaagebydodmgthe apprLpbox RNSURANCE BOND OUER (Plea9eSpecify) EVirAm D* aktoSfatt a % Estal�*dVahtedUec1 iW Wak $ W �.� hVecficnD, eRa xsW Rough Final SNA m� � � .: ��°�- C- Liomselh Z5g Lioen9ae r- I Ct mtr�, ,l �a f`r�c°_ Sigt�ue Lioaw?, o 2 f BusirmsTd % AddltsS ).�ti1r � Ja VN`rl� t l l4 O f a3� AIL TeLNa OWNERSPgRJRANCEWANE,I.ammv&ethidrIdognot #VmW=WMmW"&kSWrtiatewAdatasttcpedbyMamadwsCknrl[ andgatmysigv a m hispem*Wphc imv"'As hism*RunaL (Please check one) Owner a Agent G� Telephone No. PERMIT FEE 5 THE NORTHERN ASSURANCE COMPANY OF AMERICA E •V -N'E-01-% A Stock Company, Boston, Massachusetts 0210&3100 COMMON POLICY DECLARATIONS NAMED INSURED and MAILING ADDRESS: JAMES BARRETT DBA BARRETT ELECTRIC 11 MUNROE ST HAVERHILL, MA 01830-0000 BUSINESS: ELECTRICAN FORM OF BUSINESS: INDIVIDUAL POLICY PERIOD: From 04/14/01 to 04/14/02 at 12:01 A.M. Standard Time at your mailing address. COVERAGE PARTS and SUPPLEMENTS PREMIUM PROPERTY FORM COVERAGES - SECTION I $159 LIABILITY FORM COVERAGES - SECTION II $473 UMBRELLA LIABILITY COVERAGES - SECTION III BOILER AND MACHINERY FORM COVERAGES - SECTION IV TOTAL PREMIUM THIS POLICY IS SUBJECT TO INSTALLMATIC MONTHLY BILLING $632 The COMPLETE POLICY consists of: (1) this declarations and (2) all other declarations, forms and endorsements for which symbol numbers G28100 (12.93) Page 01 of 02 INSURED COPY roinnznG TWSNOW /�!'. //� L Date ...... \0 A TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ... ,�� L .. ................................ has permission for gas installation Z' 2 . in the buildings of ................ ......... 41-t at .. ................. ,North Andover, Mass. Fee.(��'�%-��Lic. No... . ..... .......................... GAS INSPECTOR (check # 0 -z' U MASSACHUSETTS UNIFORM APPUC TON FOR PERMIT TO DO GAS FTrnNG (Type or print) Date 10/18/04 NORTH ANDOVER, MASSACHUSETTS Building Locations 1000 Forest t. Permit# 4�0 Frank Min Amount $ - _2 =1 �..,l g Owner's Name 978 258 2366 New Renovation ❑ placement ❑ Plans Submitted ❑ •••..� s 141nej o ao s ov he to $30.50 a ;20 1 x v, 0 u � x � F � a a > H O a a o o° o \J v a SUB -BA SEM ENT ]BASEMENT 1ST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR 7TH. FLOOR STH. FLOOR (Print or type) Ch one: Certificate Installing Company Name Eastern Propane Gas ECorp. Address 131 Water St., Danvers MA 01923 ❑ Partner. 1 800 322 6628 Business Telephone ❑ Finn/Co. Name of Licensed Plumber or Gas Fitter 91 FINSURANCE COVERAGE Check on current liability Insurance policy or it's substantial equivalent. Yes No❑ ave checked yes, please ndicate the type coverage by checking the appropriate box. insurance policy � Other type of indemnity ❑ Bond ❑ Owner's Insurance Waiver. I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Miss. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installationsperformed under permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter ofthe General Laws. itle itylI'own VED (OFFICE USE ONLY) -e Signature of Licensed Plumber Or Gas Fitter ❑ Plumber -4( /,2 13 © Gas Fitter lcense ?lumber ❑ Master ❑ Journeyman V 411 i ' : W l7 d 0 u 1 N z 8Y r 0 l� I I 00 9 I w z J u �M .� ISN 1 1 i y W Z it W Z z 0 w > c xW o 0 7 o O J_ N Y a Z i ja J 0 1 d Z < 0 0 0 u ! 0 h W Z • M t 0 > i 0 z O W J r c 0 0 J 0 • z 0' u z O J ■ M W r 3 Z 0 I.- 0 O I.- 0 0 W h u W z z 0 u u z i0 J I 0 Y z 0 0 L6 z W L 0 r12 s zoo 0 u 1 N z r 0 1 00 9 z J u � ' W W II W a > Lq z ' J 1 Z < 0 0 0 u ! 0 h W Z • M O c I f W O r < I < z z u x< 0 r G z F 0 U j < N 0 0 0 0 it < < z 4 L 0 O 0 ' ` 0 z O W J r c 0 0 J 0 • z 0' u z O J ■ M W r 3 Z 0 I.- 0 O I.- 0 0 W h u W z z 0 u u z i0 J I 0 Y z 0 0 L6 z W L 0 r12 s I� 66 0 u N z r 0 0 9 z u � W W a > Lq z ' J 1 0 0 0 h W Z z O c I ' J W O r < Z < u W u W h • 0 J ; r G z F 0 U j < N h • h � 0 0 z < < z 4 L 0 O 0 ' ` 0 u 2 u Z u 2 a< z i J p o 0 0 J 0 16 0 0 x h 0 b < M W • ■ r J < W V I O O < M M 3 O M < ♦ < l z I� R 1 Location No. t Date _ 0 H , ORTM TOWN OF NORTH ANDOVER , •_•o ,h•C p Certificate of Occupancy $ Building/Frame Permit Fee $ �SswcHustt Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL $ Building Inspector Div. Public Works D O b A r. 0 z W Cd i� w O c w- 0 O w z � o 0 O � OU C F w a � O p. V V a : •ate CL C _ l0 /0 Ccm D O O Q 'C ,2 rho •a ..a q E U w Q' °° ? rz° - w ►.a W � o a°G •u m w :cam moo a°' a � �' G ago o z �' cn .� o cn z 0 U Hca' .� 04 2 m O c w- 0 a c � o 0 OU C O p. V V O D : •ate CL C l0 /0 Ccm D O O Q 'C CO) M E m m CL �o n N �O :cam O O cmN O Q O L cc Icca O a �a A o m 3N Q! � v C a � L C N l0 O CD ' � N •E� C O aC� Ott C CL H cc c oa N _ O _c yZ �. c ao H O N C = O p H d ." r 0 WC N O O=..� D Cd r .E Q W C3 v o, OO C* :11 O- O� = A ca 0 N = �=-aim z 0 U Hca' .� 04 2 m O O E � L Z p. O D H C I Ccm H Q 'C M E m m CL O Q O L cc Icca O a �a 0 � v d O CD C w 0 V CL H cc C _c �. CO3 Cl Cd one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of 5100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby ce der the DaMs and penal 'es of perjury that the information provided above is true and correct. Signature Date &->-J� C7 r Print name G Phone # official use only do not write in this area to be completed by city or town official city or town: permit/license # OBuilding Department C]Licensing Board r-1 check if immediate response is required oSelectmen's Office OHealth Department contact person: phone #; MOther (revised 3/95 PJA) Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the "law", 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 section 25 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, 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 in the workers' compensation affidavit completely, by checking the box that applies to your situation and supplying company names, address and phone numbers as all affidavits may be submitted to the Department of Industrial Accidents for 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. City or Towns 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 evert 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. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions, please do not hesitate to give us a call. Department's address, Wl nhcn c and Ea -.L !"I.-. r: i : .v �..' . 'file c r, i P� Delvart,,-neti df ice of hivestidatiolis 600 Washington Street Boston, Ma. 02111 fax #: (617) 727-7749 phone 4: (617) 727-4900 ext. 406, 409 or 375 r Any appeal shall be filed within (''0! days after the date of fiiijg of ttlis Notice in the Office, of. the Town Clerk. Thew is to cwttA► ow �2k�zd ha."� elapsed � date / Cdsw • eli..ho A fiUng D� joym A. Town CA* TOWN OF NORTH ANDOVER MASSACHUSETTS BOARD OF APPEALS NOTICE OF DECISION Property: 75 Forest St. REI�IVI;"I JOYCYO�Ii SkAW N NORTH A%l.I�DOVRKCR SEP 16 1 59 4.17 NAME: Donald & Jennifer Melson Date: 9117197 ADDRESS: 75 Forest St.. Petition: 016-97 Hearing:9/9/97 � North Andover, MA 01845 The Board -of Appeals held a regular meeting on Tuesday evening, September 9, 1997 upon the application of Donald & Jennifer Melson, requesting a Variance from requirements of Section 7, paragraph 7.3 of a side setback for the construction of an addition, of the Zoning Bylaws. Said premises is land and building located at 75 Forest St., which is in the R-1 Zoning District. The following members were present: William Sullivan, Walter Soule, Raymond Vivenzio, Robert Ford, John Pallone, Scott Karpinski, Ellen McIntyre. The hearing was advertised in the Lawrence Tribune on 8/26/97 and 9/2197, and all abutters were notified by regular mail. Upon a motion made by Raymond Vivenzio and seconded by Ellen McIntyre, the Board of Appeals unanimously voted to GRANT the Variance requested of 6 1/2 feet on the Southerly side as shown on the plan revised 8/21/97. Voting in favor: William Sullivan, Walter Soule, Raymond Vivenzio, Robert Ford, Ellen McIntyre. The petitioner has satisfied the provisions of Section 10, paragraph 10.4 of the Zoning Bylaw and that the granting of these variances will not adversely affect the neighborhood or derogate from the intent and purpose of the Zoning Bylaw. Note: The granting of the Variances and/or Special Permit as requested by the applicant does not necessarily ensure the granting of a Building Permit as the applicant must abide by all applicable local, state and federal building codes and regulations, prior to the issuance of a building permit as requested by the Building Commission. BOARD OF APPEALS. �✓�CLL 'e-1-� - r�ec William J. Sullivan, Chairman Aestdec/3 AG0RD RTIIAT OF LIABILITY INSURIC iQ DATE (MMII >�ODUtR IYYI HIS CERTIFICATE IS ISSUE AS A MATTER OF INFORMA 08/26/97 T lAnill 1 r1sura n0c Agency, Inc ONLY AND CONFERS NO RIGHTS UPON THE CERT FIICATETION 198 dchIsrtt.s Avenue HOLDER. AFFAMEND,OES NOT EXTEND OR Andover MA 01$45-4190 —ALTER THE COVERAGE ORDED BY T POICESBE OW. COMPANIES AFFORDING COVERAGE C'hdrlos S. F(dlidone — — — — — neNo. 50A-GBH�$B29 Pax No.508-975_39$7 COMPANY — INSURED — — A — Travelers Insurance Co. COMPANY B s . J. Lar101 of s Building 6 Remod. COMPANY— — Steven a. I.af,gl cis C — 2$ Winter Street _ ATILesbur•Y MA 01913 C;0MrANY -- — — —" —' — �C'G.YERAOES :.:.:.. . THIS 70 N t[ 1 If Y I HAT THE I'pLi01ES OF I77, NSURANCE LISTED BELOW NAVE BEEN ISSUED TO THE'INSURED NAMED ABO FOR THE POLICY PERIOD . . INDICATED. RTIFIAE: M WI I F►ISSU DING ANY REQUIREMENT, TERMOR CONDITION OF ANY CONTRACTOR OTHr DOCUMENT WITH RESPECT TO WHICH THIS EXCLUSIO(TC MAYBE ISSUED Ok MAY PERTAIN, THE INSURANCE AFFORdED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS nNC) CON0171UN OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY CRIAID CLAIMS. t(01,ENERRAL rE or m�uaANnE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION - -- DATE (MMIMNYY) DATE (MMIDDky, LIMITS 1AHIl ITY FI{t;IAt(;IIJLIfAIIIALIILITY I6B0781F4235COF97 GENERALA4C:RCGAIE S200b00004/i1j97 09/11/98 PkUDUCT{;.COM(•roPA[IC i2000000 AIMc;MA1Q OCCUR — k':: g GON))IAGTUk'ti I'RO7 PERSONAL d ADV INJURY f 100000— . AUTOMOBILE. I IAEtII Il Y — LLI All CU AU10;; I I I AU I0Y; T 0`;r a AUT Us GARAGE LIABIL)1 Y —4 _ ANYAUIU EXCESS LIARILII Y.. UMItHCII A I ofm 01 HCR 1HAN UMr)ll I IA Fnr2M WORKERS Cnl N SADON AND EMPLOYERS'll IA[fIL I I Y A THEFIROPNILTO.r PARTRSlFxt (INCL 1UB252Y735897 PARTNEC:U7 ivf OFFCFR$ ARF CXCI DESCRIPTION Or oPERA1 n CfTrpantry Hol. (II.R CANCEL( A Aim$$- l SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE• CANCELLED BEFORE THE CXPIRATION DATE THEREOF, THC ISSUING COMPANY WILL ENDEAVOR TO MAIC Town HAS 1 owof ATneSbury 10 ,_ OAyg yyRRTEN NOTICE TO THE CERTIFIOATE HOLDER NAMEp TO THE LEFT, T6UT FAKIII TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY ATnesL�ury MR 01913 OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVE& AUTHORIZE G REPRESEN1A71VE Charles S. Randone ' — — -- FA(yHGCOJI'l N()E _ _O _ $1000000 FIRE[)AMAGF(Any wehte) $300000 MF0EXP (MyunePer>,un) $ 5000 COMBINED SINGLE LIMI1 S h0DILY INJURY (I'ai pttson) S OOCrILy INJURY— (Prr e�:cidKRJ f PROPERIYDAMACC S AtiTU ONLY • EA A()CIDEM 5 O)NCR THAN AU)OONLY: — CAGHACCIDENT i AGGREGATE f EAC;H OCCURRENGE $ AGGREfaATC s — W Al U• EIHi lo�iIIMITs f — .:..:..... . . EL EACH ACCIDENT 05/07/97 05/07/98 ELDISEASE.POLICYMMIT $ 100000 f 500000 EL UItitASE. to EIdF'LOYFF _ 6100000 CANCEL( A Aim$$- l SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE• CANCELLED BEFORE THE CXPIRATION DATE THEREOF, THC ISSUING COMPANY WILL ENDEAVOR TO MAIC Town HAS 1 owof ATneSbury 10 ,_ OAyg yyRRTEN NOTICE TO THE CERTIFIOATE HOLDER NAMEp TO THE LEFT, T6UT FAKIII TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY ATnesL�ury MR 01913 OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVE& AUTHORIZE G REPRESEN1A71VE Charles S. Randone ' HEAV/L Y N/F PAUL 8 ROBIN TRICKET T 156.1 W000 APPROX. EDGE I SHED F TREELI\ $ LOT 19 4 41286 SFI 2.� 20 PR --� z AD �.----� h � I ' EX/STING\ I �DZNE awiT\ I �NO. \ 35.8' d4 %5 t APPROX. U - POLE E SEPTIC 1 ' 1 S YS TFhf I LOCATION I \� -150.00, ; 52.33 73-37 (PUBLIC �o L_ POLE WA Y) LOT 18 43,723 SF f WOOD SCN. DECK POR. EXISTING\\ \ DWELL %NG\ 73\\ I � I� I I b I I k I I' I I I o N/F MATTHEW WOL$TROMER & VIRGINIA ONE/L. I I I � I I I I I �� I50.00 STREET PRO) /0 FORM U - LOT RELEASE FORD INSTRUCTIONS: This form is used to verify approvals/permits from Boards and Departments that all necessary have been obtained. This does not relihaving jurisdiction landowner from compliance with any applicableelocallo�stand/or regulations or requirements. law, ****************Applicant fills out this section***************** APPLICANT: "1. . ( mc-, (�c ) Phone �'�6� LOCATION: Assessor's Map Number (� /� Parcel Subdivision Lot(s) Street Free • St. Number Official Use Onl ***** RECOMMENDATION$ OF TOWN AGENTS: Conservation Administrator Comments Town Planner Comments /1 Food Inpecto r -Health '!§ep is Inspector -Health Date Approved Date Rejected a ck�//,L SAA' Comments c Public Works - sewer/water connections Date Approved Date Rejected Date Approved Date Rejected Date Approved %li -�-� 1 Date Rejected Com` driveway permit Fire Department ©lam V? a' 1''L 1 ?;7 Received by Building Inspector Date �_