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Miscellaneous - 148 CANDLESTICK ROAD 4/30/2018 (2)
148 CANDLESTICK ROAD 2101106-A-0100-0000.0 I I II S- B 1LT 7i " Gee. Y 9T.r1,H.(m) q0-9' Z8.7 ' t D-Box "I D-rwx "z 38.7' — �Z.o ' � 'IZ3 S.F. p-Box #3 GS:(` I,t l wzwver— �QJU FI W— lJ/U-A-NVA C:A; OST) S OWW4 PEDP&TZ SVUUW' AcE _ SEk1Ef1.�46E A��Pasi1C. sys'rEr-�„ �fL-Mrs S iE DATED; 11/2/78 Ey CY2 FuGi"Wili� SE(1ar,LES -%Z ALM'�PGAq ar Owwev AS-Bv►t,T of ' .S'u8Sv2I�r-E, SEWAGE p�4R�(, SYSTI:t�' 502 -Ml t RrrF- D41W, MAY Z9 , I q7q `'rR F)UM It2.o2 _ ' By Gll� E'�tC�ruW1Nv4 SF�2v►c�S - )14 PVC-►uu lki D-6ox'la- Ev 0(l ez +� CAPS s�E AtW�Q W Fo1L Rei R. of S FAs, Juy.007 (fix 1 a l0�.�7 (nP) �rrrc�TTo_I _soic. Z b)�PC ,, s\t r-R¢--> �s 9,71—= - 1{"��,Y�[', t�fV ISI A-R,,pX 3 z=1D9�f0 DA7�:t r�6t'fL , t49� Ry HEWtlAC 410P.y.e. WV. wrb-t;Ox*3 �I67,z& Cwt Eulr�rE7 wG s' vrc . I 1}''�Pee!' IUY•G,F� GuE� fvl�srl f N qoo aireoX�Z �x�It IN IN ,o0o come. s GAS �n� A!?. Fvi!o ell. PaZMYE A 1ZEA sEct ;t D:209 3 ,• �.,- _j�xIr►uG MEW qoo S.F — t,EA6H[j.rG F'i ELD - ' ; �' �p.p4 ' „Mtiu 5'1"oiiE PM65b Ci z&i PlPw4 �' 3, t,"� - (y"-* SAul� PiAC�. gaaJ 13o7°IbPI /� pl�c,E.� �u s-rAu.�l� F¢or•� p-t�x �1 . )""Q? D-box "Z kl tTF} GAPPM E,uCD.-ro AS BUILT. �-�PLAN rhd�� M- VSA of °b �&GN;4;� OF Al- A W9F04fr'- AW4 I>.I -P15 SUBSURFACE DISPOSAL SYSTEM LOCATED IN MORTR- Aki.0c)VER, HASS. -AS PREPARED FOR DATE: ::rA,uvAe\/ S, I R4Z SCALE: ►�=3Z� _._ . ... . -_ i MERRIMACK ENGINEERING SERVICES, INC. PROFESSIONAL ENGINEERS • LAND SURVEYORS • PLANNERS 66 PARK STREET • ANDOVER. MASSACHUSETTS 01810 Or TEL x;08)475-3553. 373-5721 4 NORTN F 9 • Town of North Andover `,�'• HEALTH DEPARTMENT ,SS�CHU�+tt CHECK#: DATE: LOCATION: H/O NAME: CONTRACTOR NAME: Tyne of Permit or License:(Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5Inspector $ ❑ Title 5 Report $ ❑ Other. (Indicate) 1 P $3 . �Z7 ea lth A Initials White-Applicant Yellow-Health Pink-Treasurer 4127 O`MORTM 4 o;••yo Town of North Andover HEALTH DEPARTMENT S�CHUSf CHECK#: � PATE: ill LOCATION: g 1-1/0 NAM • �f CONTRACTOR NAME: dam, Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title nspector $ Title 5 Report $ -12ce-1140 ❑ Other. (Indicate) $ 1 Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer 1 1 •� 4 i 2 7 OfµOFTp 1y i r Town of North Andover HEALTH DEPARTMENT ,SSACHUSt� r. q CHECK#: e a- ATE: i// LOCATION: H/O NAM CONTRACTOR NAME: ._ � . Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $ ❑Title 5 Report $ ❑ Other. (Indicate) $ Health Agent Initials White-Applicant Yellow-Health Pink- Treasurer Commonwealth of Massachusetts Title 5 Official Inspection Form RECEIVED Subsurface Sewage Disposal System Form-Not for Voluntary Assessrr ents JUN 3 0 2009 M , 148 Candlestick Road Property Address TOWN HEALTH DEPARTMENT Gregory Sarmanian Owner Owners Name information is required for North Andover MA 01845 6/13/2009 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: When filling out A. General Information forms on the computer,use 1. Inspector: only the tab key to move your Neil J. Bateson cursor-do not Name of Inspector use the return key. Bateson Enterprises Inc. Company Name 111 Argilla Road Company Address Andover Ma 01810 Cityrrown State Zip Code 9784754786 SI15 Telephone Number License Number B. Certification 1 certify that I have personally inspected the sewage disposal system at this address and that the Information reported below Is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority '.'di,&--&��- 6/13/2009 Inspector's Signa a Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Foran-Not for Voluntary Assessments 148 Candlestick Road Property Address Gregory Sarmanian Owner Owner's Name information is required for North Andover MA 01845 6/13/2009 every page. Cityfrown State Zip Code Date of Inspection i B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: j i B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old"or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): I t5ins•09108 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 2 of 17 w ' Commonwealth of Massachusetts k u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments i 148 Candlestick Road Property Address Gregory Sarmanian Owner Owner's Name information is required for North Andover MA 01845 6/13/2009 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): I ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 148 Candlestick Road Property Address Gregory Sarmanian Owner Owner's Name information is required for North Andover MA 01845 6/13/2009 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 'h day flow t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 148 Candlestick Road Property Address Gregory Sarmanian Owner Owner's Name information is required for North Andover MA 01845 6/13/2009 every page. CityrFown State Zip Code Date of Inspection B. Certification (cont.) Yes No El ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. El ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 148 Candlestick Road Property Address Gregory Sarmanian Owner Owner's Name information is required for North Andover MA 01845 6/13/2009 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health i ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? El ® Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined? if the were not p Y ( Y ® ❑ available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. I ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information y Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 450 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ��M ,•''� 148 Candlestick Road Property Address l Gregory Sarmanian Owner Owner's Name information is required for North Andover MA 01845 6/13/2009 every page. City/Town State Zip Code Date of Inspection D. System Information Description: I M I Number of current residents: 4 i Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? El Yes 0 No Water meter readings, if available last 2 ears usage Yes 9 ( Y 9 (gPd))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Current Date ' I Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 li Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments i M Sy`• 148 Candlestick Road f Property Address Gregory Sarmanian i Owner Owner's Name information is required for North Andover MA 01845 6/13/2009 I every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): i General Information Pumping Records: Source of information: Pumped last year, owner Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped. 1000gallons How was quantity pumped determined? Measured tank Reason for pumping: Inspect tank&tees Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): I t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 I I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 148 Candlestick Road Property Address E Gregory Sarmanian Owner Owner's Name information is required for North Andover MA 01845 6/13/2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Tank original,d-boxes&field 17 years old, 1/8/1992 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.6 feet Material of construction: ❑ cast iron ❑ 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Finish cellar unable to see piping Septic Tank(locate on site plan): Depth below grade: 7 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Tx 5'x 4' Sludge depth: 2 t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y< f M , 148 Candlestick Road Property Address Gregory Sarmanian Owner Owner's Name information is required for North Andover MA 01845 6/13/2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 25" Scum thickness 2.1 Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 19" How were dimensions determined? Tape Measure i Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumped septic tank. Inlet tee ok. Outlet tee ok. Depth of liquid at outlet invert. No evidence of leakage. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date I t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 148 Candlestick Road Property Address Gregory Sarmanian Owner Owner's Name information is required for North Andover MA 01845 6/13/2009 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): r i I Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: i Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No i t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts I Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 148 Candlestick Road Property Address Gregory Sarmanian Owner Owner's Name information is required for North Andover MA 01845 6/13/2009 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box# 1 is a drop box. D-box#2 level&distribution equal. No evidence of leakage. Evidence of light carryover. D-box#3 not being used, goes to old system, Pipe out of D-box# 1 going to D-box# 3 is capped off. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 I t i i i i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Foran-Not for Voluntary Assessments 148 Candlestick Road Property Address Gregory Sarmanian - 9 Owner Owner's Name information is required for North Andover MA 01845 6/13/2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: j ❑ leaching trenches number, length: ® leaching fields number, dimensions: 1 field 15'x 60' ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soil ok. Vegetation ok. No sign of ponding to surface. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•(79/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,•�''� 0 148 Candlestick Road Property Address Gregory Sarmanian Owner Owner's Name information is required for North Andover MA 01845 6/13/2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): i Privy (locate on site plan): Materials of construction: Dimensions Depth f solids p o so ds Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 14 of 17 L fX Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 148 Candlestick Road Property Address Gregory Sarmanian Owner Owner's Name information is required for North Andover MA 01845 6/13/2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system,including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.Check one of the boxes below. 0 hand-sketch in the area below [] drawing attached separately vhe Do o a ID +0a = ,L4ffa �i rJ o a =S1 , to" t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 148 Candlestick Road Property Address Gregory Sarmanian Owner Owner's Name information is required for North Andover MA 01845 6/13/2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 8 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 6/4/1977 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: As per design plan test pit data no water 8'deep i i Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 148 Candlestick Road Property Address Gregory Sarmanian Owner Owner's Name information is North Andover MA 01845 6/13/2009 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 Commonwealth of Massachusetts City/Town of System Pumping Record Form 4 f DEP has provided this form for use by local Boards of Health.Other forms may be used,but the information o mation must be substantially the same as that provided here. Before using this form,check with your local Board of Health to determine the form they use.The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility information Important: When filling out 1. System Location: eft fronQbft rear,left side house. fight front, right rear, right side of house. forms on the computer,use only the fab key Address + L( (e-�G� to move your (, \ cursor-do not use the return Citylrown State Tp Code key. 2. System Owner ia6 Name Address(if different from location) City/rown State I Code Telephone Number B. Pumping Record 1. Date of Pumping paw 2. Quantity Pumped: Gallons 3. Type of system: Lj Cesspool(s) �eptic Tank Tight Tank Other(describe): 4. Effluent Tee Filter present? [j Yes ErNo If yes,was it cleaned? L] Yes ® No 5. Condition of System: 6. System Pumped By- Neil yNeil Bateson F 5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location where contents were disposed: 01.S. Lowell Waste Water "' �v � � •3_Qcl igna re ofu Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 MASSACHUSETTS UNIFORM APPUCATON FOR PERMIT TO DO GAS FITTING (Type or print) Date NORTH ANDOVER,MASSACHUSETTS Building Locations � � � S� �^ Permit# `? Amount$ Owner's Name S � 01/4 IV 11 -40L/ New Renovation Replacement Plans Submitted z o a z F c o $ z H � aw m Q w a G z >o x 3 a .a F o SUB-BASEMENT v C4 > Q BASEMENT 1ST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH . FLOOR STH . FLOOR 6TH . FLOOR 7TH . FLOOR 8TH . FLOOR (Print or type) Name ,T ��/ /� — f L C k one: Certificate Installing Company /< v r /vr �'h -2 i"�, Corp. Address LQ ]4) 11 --vT U, � Partner. usmess a ep one G A �rm/Co. Name of Licensed Plumber or Gas FitterJ 40-0 1-1� �l� INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes o- No 13 If you have checked yes,please indicate the type coverage by checking the appropriate box. Liability insurance policy ©-- Other type of indemnity Bond 1 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: 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 apd installations performed under Permit Issue for this plication will be in compliance with all pertinent provisions of the Massachusetts e G de and C ter 142 f the eral Laws. By: S' nature of Licensed umber Or Gas Fitter Title Plumber City/Town Gas Fitter License Number ter APPROVED(OFFICE USE ONLY) Journeyman Date... Of ,40RTN 3� O ° TOWN OF NORTH AND ER h R � D 41 -1 PERMIT FOR GAS INST LATION � s a i SS�CMUSE This certifies that . . . . . -. . . . . . . . . . . has permission for gas installation . . .k:- . . . . . . . . . . . . . . . . . . . . in the buildings of A . . . . . . . . . . . . . . . . . . . at �!`. . . . . North Andover, Mass. Fee. . .).-. . . Lic. No.. :r. . . . . . ... L1✓'---� . . . . GASINSPECTOR Check# 13 C/ , 5992 i NORTH O A * a NORTH ANDOVER BUILDING DEPARTMENT 27 CHARLES STREET 9ss�c►fustt Tel: 978-688-9545 Fax: 978-688-9542 DATE: NAME ,sL18 ADDRESS C ZONING DISTRICT: TYPE OF BUSINESS: t C BUILDING LAYOUT PROVIDED: YES NO AVAILABLE PARKING SPACES: :'r ZONING BY LAW USAGE: YES NO i tri BUILDING INSPECTOR SIGNATURE 1 1 1 I Location_ t�'i+ t,tb� tr IL LL No. Date IZ � A TOWN OF NORTH ANDOVER Certificate of Occupancy $ �. } ; . Building/Frame Permit Fee $ Foundation Permit Fee $ s,+cMust Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL $ Building Inspector F 3Div. Public Works PERMIT NO. I S f APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. PAGE 1 MAP 4-40. I LOT NO. 2 RECORD OF OWNERSHIP IDATE BOOK ;PAGE ZONE SUB DIV. LOT NO. i LOCATION I q Fd Q �c0 P1/ l PURPOSE OF BUILDING ! `` •7 OWNER'S NAME F NO. OF STORIES SIZE ]` L OWNER'S ADDRESS BASEMENT OR SLAB -- ARCHITECT'S NAME l VIG�jI� 1't SIZE OF FLOOR TIMBERS IST 2ND 3RD BUILDER'S NAME ,IJ'L SPAN DISTANCE TO NEAREST BUILDING DIMENSIONS OF SILLS DISTANCE FROM STREET y�D POSTS DISTANCE FROM LOT LINES-SIDES y�f,REAR 4O� GIRDERS AREA OF LOT ft4e ( V FRONTAGEI HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW A10 SIZE OF FOOTING X IS BUILDING ADDITION X)D MATERIAL OF CHIMNEY IS BUILDING ALTERATION OV6/ at !ow IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE e. IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS 3 PROPERTY INFORMATION LAND COST SEE BOTH SIDES EST. BLDG. COST 7,oL,'/��KJ PAGE I FILL OUT SECTIONS I - 3 EST. BLDG. COST PER SQ. FT. PAGE 2 FILL OUT SECTIONS 1 12 EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR � I r'DATE F LED00 BUILDING INBrlCTOR BI NATURE OF OWNER O AUTHORIZED AGENT F E E OWNER TEL.# PERMIT GRANTED CONTR.TEL.# ���✓ 19 CONTR.LIC.# H.I.C.# KW 1995 � Z � i BUILDING RECORD , 1 OCCUPANCY 12 SINGLE FAMILY _ StORIE$ THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM MULTI. FAMILY OFFICES LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA- ` APARTMENTS RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. CONSTRUCTION ` 2 FOUNDATION —I 8 INTERIOR FINISH CONCRETE B 1 2 13 CONCRETE BL'K. PINE BRICK OR STONE HARDW D PIERS PLASTER _ DRY WALL UNFIN. 3 BASEMENT 11 AREA FULL FIN. B M'T' AREA _ '/, 1/2 FIN. ATTIC AREA _ N_O B M T FIRE PLACES _ HEAD ROOM _ MODERN KITCHEN _ i« 4 WALLS I 9 FLOORS CLAPBOARDS B 1 2 3 DROP SIDING CONCRETE WOOD SHINGLES EARTH _ ASPHALT SIDING HARDVJ'D _ ASBESTOS SIDING _ COM/dCN VERT. SIDING ASPH.TILE _ STUCCO ON MASONRY _ STUCCO ON FRAME BRICK ON MASONRY ATTIC STIRS. 8 FLOOR I_ BRICK ON FRAME CONC. OR CINDER BLK. STONE ON MASONRY WIRING STONE ON FRAME _ SUPERIORI� POOR _ ADEQUATE NONE 5 ROOF 10 PLUMBING GABLE I I HIP BATH 13 FIX.) _ GAMBREL MANSARD TOILET RM. 12 FIX.) FLAT SHED WATER CLOSET _ s ASPHALT SHINGLES LAVATORY WOOD SHINGES KITCHEN SINK SLATE NO PLUMBING _ TAR & GRAVEL STALL SHOWER _ ROLL ROOFING MODERN FIXTURES _ TILE FLOOR TILE DADO 6 FRAMING I 11 HEATING WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. TIMBER BMS. &COLS. STEAM STEEL BMS. &COLS. _ HOT W'T'R OR VAPOR WOOD RAFTERS _ AIR CONDITIONING RADIANT H'T'G UNIT HEATERS GAS 7 NO. OF ROOMS OIL B'M'T 2nd I_ ELECTRIC 1st 13rd NO HEATING y f.i tt R 1"6�{ , 3 . ovm Of NO over � IV 4 18 6 Torth . dover, Mass., CflPrq L2— 19`(a y�i.� � COC Hic ilE wiCn �' TO D UIL 1 A ��!H BOARD OF HEALTH r Food/Kitchen yin1 Septic System r�. ' PERMIT BUILDING INSPECTOR S AQ..aI�drlll�� THIS CERTIFIES THAT...Q. ��[............................................................... ............................... Foundation has permission to owcL.A.1. 1 .......... g ..I �4 .c ,...... . buildings to be occupied a ;PJP Chimney ,�, c. .....�a�.��... + .b...... ..... ? ................................................................ provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final 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 PERIvII'T E 1'l F 11-4 6 MONTHS Final UNLESS CC 1 S,1_Rt.. ,. . 1 �� SrT,A I?,.—'SAELECTRICAL INSPECTOR - Rough ... ... . ............ .................. ... ................. ............................ Service BUI G INSPECTOR Final Ocat an Pe7rllit IZcc icired to Occ�c y I3uilc�ill �7 GAS INSPECTOR Rou Display in a Conspicuous Place on the Premises — Do Not Remove Finagh No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner PLANNING FINAL CONSERVATION FINAL Street No. Smoke Det. a SEWER/WATER FINAL DRIVEWAY ENTRY PERMIT i $ N I b'I'�o1 2-►:Z?n rj b5l�vf` T*3n7 QrN -An/ ,vim 'I'Z'Epl&"a S -fir hS �VSsdSrQ o C���J Z« X9=4 (21-_L3ZLnI�I (AL) L9101-V,, To Q_Lr)o Ant ',-)',A 4 9,� '3`.��ja-►sem :�o �1 '� � � � s�� �s S-�1nM� �Jn2f_-bfy1 tjrf,3 � l�$ ZSb+o1� ?�► d-C7 Pf/ AM- ?'AV 01 tT a ��.ta 3Ls a 1 a� Zo'Z�!-' t uor� �;? �3� � S hV7J =¢7a , s-�l.�3 ; �'*' ,� WAS & 8C j z/l l :a3wq WVWA ?kVd3lg ��PVagrq33 -- -42103►^s Q3Y%O! d `fin f MQ4s rY�` ' S ft�b�H`V"ylrl 37tZI rrp '35F2fx. - Vk�,y�� vs * k v 0*1B7 77 _ � .SOIL' P, V ID "vx+$+ rte 100 ou IF Gv- ' g-(Iaat�' G1+P ►u� s-�• ,vim `G� ���-� �u �Z ��T f � t,�+G+' �� SAW:,) jJG f>�D o� P S� L� 8 � . AS 0� of �,FA mss. v �A S .�Ep 1N ONO, aS0. . SCp`'E• 1��. ' ��� GES, iNG• RS n, IP MERR�MAG bb YAaK StREE� i r' �i i+ � .. .,. I -- ------- --- - -- . .. . . . . . . . . . . . . , `' �-:�',. ''' W p�yr/�''fix' \ � '•� " s >. `t g . sN ,Tr-j`'t Y - N m N b�'�r-�2,�►�rr r7 �d �, ,, ,r �s s��.amt ar cdu oh boh ��xo�-ct ryl AM ',2'n�o„k hS '�f J -73 '7VSsd� � d ✓ Z« 9-Q cZL LcnI (A) L%'bvl� 4.1np int J� 6N3Z( '70� f�Y7�� S70r 33S s rn�35 n rZ13�n' rjrr3 -3A-2 A$ t 1l A -J A'd it,h' IIfa a69 Zo'Z1/ 3' ru deL Nv- �a31.s�•s 7E�S�b 3�t�-�r�s '3�vnS$�S ���`l�b � �!2rtg WAO i(g 8L f 2 j r c : 31. s s��Ziac ,,(-�3u�.s 71�,Q 39►�ryr3,S ' CLd20 fiL7b�H Y�fY/1''[ rj ry '3,V ' 7 •-S 6� — ,S'Ul7 �w ko8-Q M 47 � )Lie �X 3� vtv¢�. BYE AQP Y,sE .. XIST�l1G � Wy q40 S.F C.r�lAJ4 v EL.D �x p0 lVf SAUZ P(ACM 9Vad l3olWI U 0--T . �uT"t,E� iu srpt F-Ewt AS BUILT PLAN Jia D-� *Z ) �1TN GAPED ESD �'o >=Adiblky>r E-- vsc OF IMb G acra��iC,� OFs- A W-C,5041—c ASA E± aV- SUQSURFACE DISPOSAL SYSTEM LOCATEDIN �J 4RT1+ A h0c)VE ?, HASS, AS PREPARED FOR WKT�Q IA4r-. DATE : :1-MOaey SCALE:, t '--20 ' MERRIMACK ENGINEERING SERVICES, INC. PROFESSIONAL ENGINEERS • LAND SURVEYORS 0 PLANNERS 60 PARK STREET 0 ANDOVER. MASSACHUS& 01810 * TEL x, )475-3533. 3MS721 ' --- - 47.E..; ! YfJ^/,JIyr1 Yui:1 / f r• -- . r LJ..,.# c� �i�ti�GI � � � j `�. •, -70 �fll�r f gid,• � �.—�— "�--�' r .- r,.,- � f ��Y/ r!� � ice'✓, .-, M _„- �� �, r)S• . r f-• ,.� - .�! -. F. ..•.r �'�i" _ l•�r f I rrr 1 F/ �_ _ y ±` ..*YPXT.v.cecw:�-yYs.... ,ate. .. --, .. ... :.,+&.7..st+r^i,».s.,..d..:a- ,�.,Z s.=t+C^2'S'.:Y-w�.... i-1 kw +:.—v::'.c"a�..�;rny.0 ,.:•ic.ux�s«m..w--....x. _ FORK U - IAT RELEASE FORK s 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: Phone _ F --!53'l f .i LOCATION: Assessor's Map Number Parcel Subdivision —` Lot(s) /D S treet Q(QLD 1 �) ,{ (CLC &::, St. Number y ************************Official Use Only************************ RECOMMEND4V TO AGENTS: pp Date Approved Tl'Z lJ Conservation Administrator Date Rejected Comments Date Approved Town Planner Date Rejected Comments J x Date Approved � Food Inspector-Health to Rejected Date Approved Septic Inspector-Health Date Rejected Comments Public Works - sewer/water connections 't - driveway permit Fire Department Received by Building Inspector Date -4== 21995 _ V . . OFFICES OF: :Town of _ 4, 120 Main Street APPEAL :• North Andover, BUILDING ;�� �� NORTH ANDOV ER � Massachusetts o I84 CONSERVATION DIVISION OF HEALTH - PLANNINGPLANNING & COMMUNITY DEVELOPMENT KAREN H.P.NELSON,DIRECTOR r. In accordance withe provisions of ;LiGL c 10. S 54. a condition of Building Permit Number I t L is that the debris resulting from this work shall be disposed of in a properly Iiccased solid waste disposal facility as defined by MGL c 111, S 150A- The 50AThe debris will be disposed of in: T Met— (11.,ocationion of Facility Sicnature of Permit Applicant 12- Date 2Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector. , Town of North Andover BUILDING DEPARTMENT Homeowner License Exemption (Please print) DATE �• i l - p JOB LOCATION ` Ct(�1��{�� Iclk et> Number Street Address Section of town "HOMEOWNER" (7�a,<acmarlian 8 J j ame Home Phone Work Phone PRESENT MAILING ADDRESS 5a ry-c— 'y City Town State Zip code The current exemption for "homeowners" was extended to include owner -occupied dwellings of six 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 109 . 1 . 1) DEFINITION OF HOMEOWNER: 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 to six family dwell- ing , attached or detached structures accessory to such use and/or farm structures . A person who constructs more than one home in a two-year period shall not be considered a homeowner . Such "homeowner" shall submit to the Building Official, on a form acceptable to the Bulding Official , that he/she shall be responsible for all such work performed under the building permit . (Section 109 . 1 . 1 ) The undersigned "homeowner" assumes responsibility for compliance with the State Building Code and other apo_ licabie codes , by-laws , rules and regulations . The undersigned "homeowner" certifies that he/she understands the Town of North Andover Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements . HOS lE0[;NER' S SIGNATURE i APPROVAL OF BUILDING OFFICIAL Note : Three family dwellings 35 ,000 cubic feet , or larger, will be required to comply with State Building Code Section 127 .0, Construction Control . { i I S � fr; , All fommonveaft6 of 71)46sac6u tts - '' DRIVERS LICENSE 'F Ot3567452 07-21-99 07-21-61 M i 6-01 BROWN CHRISTOPHER J 1264 SALEM ST N ANDOVER MA r i " 1645-4910 1t , ^�1f/ COMMOMWEALTH nFPARTt•4FNT OF PURIAr,SA.FFTv I� OF ONE ASHBORTON PLACE Fa�lan to Fassa as a aarnat { BOSTON, MA 02108 A7na+aaAas :zc :r.rta 0611009 MASSACHUSETTS �' Colla/a pnawa st+r r4valaaltOD - -• ;; 1. ... L 4 LilCE r.. CAIJ 'EXPIRATION DATE i C 0 14 S / k. U P 1E Q U , . H ` 07/21 /19FOR PROTECTION AGAINST i RESTRICTIONS EFFECTIVE DATE LIC-NO. THEFT, PUT RIGHT THUMB t:.:.;(` .• _ , N O N F '1 S 0, 1 J'7 4 L 5 1 1 4 L" PRINT IN APPROPRIATE ° BOX ON LICENSE. r,' rc.'.�. �� C H R I S T"3 P:I F ;1 J ,:s R 0 ri 1 264 i' +L t ' :�T FP R S f.�13�?6-745 it at D+)Ur ^ 1a 1 kL MU NCLUD HOT I r? PHOTO(BLASTING OPR ONLY) FE —'�'" ta[;. Gr) I NOT VALID UNTIL SIGNED BY LICENSEE AND OFFICIALLY HEIGHT: i SIAMPED OR-SIGNAIURE OF THE COMMISSIONEH i I. ./„ DOB: 0 THIS DOCUMENT MUST BE I ---� « SIGN NAME IPJ' rt-L RG�NQ LINE CARRIED ON THE PERSON OF SIGNA 11111E OF LICENSEE • "�f' s�.,f•1'r^...r THE HOLDEN WHEN EN (1111 (': f(II,1,i 11 I I'• Iilll I ('•l(;f 11111 loll^-!('f'I tnnilnnl ' � ,e �� •M �4�fe1M•'�RI(ll�� .- . c7e�ailIq ��QmN� R£StD�Nc. ,ysC�ales��k K.�- SUS zoo-� 1�fiai 1 � CJS Z io � 1((o PT (d£� Soepicra By 3k„'galf edJom ns �1�: � jh'G �� C.(�rrrn s s c+. to"D. ye"oPica � ' on eene� y Z)( 10 xiyPr !(o do lrv� I `42 2Yo -r 2- 21�roPT f M Z.Xto R J�ei Sia fie. ,Av�lldl�� t �tr�e►�s� u�IU�!�S : 2.)olv2r &A> > 0 1 )1 8.1.4 Zit Z � � � sod �•d �x�, -1146 p del .1•d '1x Z