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HomeMy WebLinkAboutMiscellaneous - 175 FOREST STREET 4/30/2018N O Date..... . 2—.. ... ...... Z .. �) .... .. . ..... TOWN OF NORTH ANDOVER PERMIT FOR WIRING ............ This certifies that 6< ................................................................................. ?3 14-C has permission to perform ................................................................... .......I.. wiring in the building of ............ ........... . ...................................... at .... .......... 57 . . .......... . Njarth Andover, Mas 4�- Or ......... Fee.. -::-)..9..777= Lic. NoJ ....... ..... ........... ............. INSPECTOR Check # `10681 Commonwealth of Massachusetts Of�ciaTl se Only Department Permit No. !) p t of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 1/071 (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 2-21- 12- City 2City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) kZ S kr- T'4z>h- � c�•rt-- Owner or Tenant .�� �Vu n Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No 0 (Check Appropriate Box) Purpose of Building/rte c__ Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters _ New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work:i5, rn-7otL— of iLo fh77n,o;-- #-1.1- ,,,. . L .. .....:.....7 L...7_., No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans .... vcu�caaa: ciao ccavry rrues. No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool AboveEJIn- El rnd. rnd. o. o mergency ig ing Batter Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices g No. of Waste Disposers Heat Pump Totals: Number _Tons KW ..........."". No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local El Municipal El Other Connection No. of Dryers No. of Water Heaters KW Heating Appliances KW No. of No. of Signs Ballasts Security Systems:* No. of Devices or Equivalent Data Wiring: No. of Devices or E uivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail y desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: L}t{%D p (When required by municipal policy.) Work to Start: 2,- 2-L4 - 17-- Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE f�] BOND ❑ OTHER ❑ (Specify:) I certify, under the sins and penalties �fperju y, that the informAtion on this application is true and complete. FIRM NA J. (e-,,,? LIC. NO.: A 1SY29 Licensee: t9, w -% e."" Signature LIC. NO.:—A i SS Z 5 (Ifapplicable ent exempt" in t e lice number ne. 233- g� r�s� �E J Bus. Tel. No.; 7�yS' Address: 1,4Lr'f �c� �'t - JA- . 6�i(4 03 a 7f Alt. Tel. No.: •05 • S2-- H r66 *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lie. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE:.$ • E),ECMCA.L PERMT ATO, ]lei PEC ONr EPS T. EEEC7 ICAL I SPEC'Z'®R kPasse� -- [ ] raped— [ i ?fie -inspection regui eff ($50.00) ~ [ j ectors' comtnenfs: Qlgectors' 5ignatue -no iWtials) Date 2..VMALTN8FYCil0W: Passed Failed—[ ) - Rt, -f spectionrequiured ($50.00) •- [ � Znspecto:rs' c fs: 3- W (Inspectors' $ign tore •- no initials) Date 3. UNDER GROUND INSPECTION: Passed -- r) Failed— j ] ?fie -inspection required ($50.00) - [ J Inspectors' comments: (Inspectors' Signature -• no initials) Date 4. INSPECTION— SERVICE: D T E CA:r �D I+A i ONM1 G: I : Passed— [ ] ]♦'ailed -- (� Ile -inspection required ($50.00) - [ ] Inspectors' coxn�nenfs: (xuspectors' Sigaat-ure - ito initials) Date DOOR TAGS .ARE TO BE FRIED OUT AND LEFT OX SITE IF THE .A.FXA TO BE INSPECTED IS NOT ACCESSIBLE AND .A BE USPECTZON OF $50.00 IS TO BE CHARGED. e The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations go 600 Washington Street Boston, MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): A \ Pk,e t Lc -_j Address: City/State/Zip: Phone #: - Are you an employer? Check the appropriate 3 box: 1. VI I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. t ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.R1 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13. ❑ Other *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 are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors 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. n _ Insurance Company Name: _ y s S oc-t -AAc �_ C� ✓'f a r rs LIAS Qv ,a,— Policy # or Self -ins. Lic. #: WL,(, CSbr- (a cto_Z, O) 2,x57"O -1 Expiration Date: 3 i^ Job Site Address: [ �� r���r- S-� J` 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 of MGL c. 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. I do hereby "YT under the pains and penalties of perjury that the information provided above is true and correct. Si ature: 0113 Date: Z- 23- 12 Phone #: L33 — -7 4 4!C Official use only. Do not write in this area, to be completed by city or town officiaL 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 Contact Person: Phone #: Information and Instructions 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 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, §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), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit 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. 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 (if necessary) 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. A new 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 0 (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. 10 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: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www raass,govfdia Date. /'. .In. nom...... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ...................... has permission for gas installation ........................ in the buildings of ............ at e4' ............. North Andover, Mass. Fee:.,?. Lic. No.. ��....... GAS INSF=W Check 4876 MASSACHUSETTS UNIFORM APH ICATON (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Locations 175 Forest St. Judith VonKummer New [A Renovation ❑ Replacem PERMIT TO DO GAS ffrMG Date 10/6/04 Permit # Amount 6-7 978 685 7955 Plans Submitted 121 6TH. FLOOR 7TH. FLOOR STH. FLOOR (Print or type) Chime k one: Certificate Installing Company Name_. Eastern Propane Gas in Corp. ,Address 131 Water St., Danvers MA 01923 1 1 800 322 6628 ❑ Partner.❑ Business Telephone Fimi/Co. Name of Licensed Plumber or Gas Fitter Brian Kimball INSURANCE COVERAGE Check on I have a current liability Insurance policy or it's substantial equivalent. Yes f No ❑ Ifyou have checkedyes, please Indicate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity 0 Bond ❑ 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 El hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the est of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in 'compliance with all pertinent provisions of the Massachusetts to Gas Code%r.05�the General Laws. (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter ❑ Plumber #1210 uj Gas Fitter License Number ❑ Master ❑ Journeyman W .. nd rg oun X30.50 a z o 9 ga 1 ne to 19 11 d 14 IU H ° z z pl b r' s ub 00 w d � 0 z a c 4 0 F z a x �' W 0 0 W W o COD 3 A a A a H p UB-BA SEM ENT BASEMENT [3R ST. FLOOR ND. FLOOR D. FLOOR 4TH. FLOOR 6TH. FLOOR 7TH. FLOOR STH. FLOOR (Print or type) Chime k one: Certificate Installing Company Name_. Eastern Propane Gas in Corp. ,Address 131 Water St., Danvers MA 01923 1 1 800 322 6628 ❑ Partner.❑ Business Telephone Fimi/Co. Name of Licensed Plumber or Gas Fitter Brian Kimball INSURANCE COVERAGE Check on I have a current liability Insurance policy or it's substantial equivalent. Yes f No ❑ Ifyou have checkedyes, please Indicate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity 0 Bond ❑ 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 El hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the est of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in 'compliance with all pertinent provisions of the Massachusetts to Gas Code%r.05�the General Laws. 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(D (D (i (D O (D n0 X (D Q Sy uQ N rt -0 Ortuo (D d rt I . rt rt 3(D OQO =r :�3 QQp O �• C: (D N ua N (D = C CU N rr+ N 0 �' ,A Date ... !.. ,-/ ...... TOWN OF NORTH ANDOVER -.� PERMIT FOR GAS INSTALLATION C:!- 1- This certifies that . � .... .. .`7 . .................. has permission for gas installation .......... in the buildings of .......................... at'176 ... *0-1 -�.. .......... , .. . , North Andover, Mass. Fee.. 3 � .... Lic. No./ ,7.. �.�4 GAS INSPECTOR Check # 4863 MASSACHUSEIIS UNIFORM (Type or print) NORTH ANDOVER, MASSA Building Locations VI'l-e' sf FOR PIIMT TO DO GAS H'ITNG Date (— e OL( LQ�c� w�Clst�,sff� f� bio &c - k v c,.,,�,� Permit # X09 / &l ? Olt Olt — t4 /0619 L � % Amount $ �( � "Owner's Name New Renovation I Replacement ❑ Plans Submitted d (Print or type) Name Address .0 CA_e_� -f—& t^— Check one: Certificate Installing Company EyCorp. ElPartner. end � E]Firm/Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes 13 Noo If you have checked yes, please indicate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity Bond0 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: Sign re of Owner or Owner's ent 77TOwner 0 Agent r 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 installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. Title City/Town APPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter Plumber %S 2- C !�A-- Gas FitterLicense Number �j Master Journeyman r • • 13RD. FLOOR 4TH. -FLOOR 16TH. FLOOR ;18TH. FLOOR (Print or type) Name Address .0 CA_e_� -f—& t^— Check one: Certificate Installing Company EyCorp. ElPartner. end � E]Firm/Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes 13 Noo If you have checked yes, please indicate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity Bond0 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: Sign re of Owner or Owner's ent 77TOwner 0 Agent r 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 installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. Title City/Town APPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter Plumber %S 2- C !�A-- Gas FitterLicense Number �j Master Journeyman Date �. ° ?!! V. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING. This certifies that ........................................... has permission to perform plumbing n the buildings of .................... at ........... ...... . ................ North Andover, Mass. .... Fee''�'-,P�Lic. No..'��!:2 .. .... .......... PLUMBING INSPECTOR Check# -- 1t1-21 6'196 MASSACHUSETTS UNIFr APPLICATION FOR PERMIT TO DO PLUMBI? (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Location l ;�S FoY-e- s 3 Type of Kea.- Name te-o..Name (/DA, ?,<Lvlv,,—�� Date 1 — 1(" Permit # / (� Amount fv3 CZ New Renovation Replacement Plans Submitted Yes No ❑ FIXTURES (Print or type) /� , A Installing Company Name. 4e f P 1`-'( -'- Check one: Certificate Corp. Partner. 0 Firm/Co. Name of Licensed Plumber: /G' / /G (14-4,1190 Cle— Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy E Other type of indemnity 0 Bond 10 Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above threeinsurance re 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 installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. By i ice um e i type of Plumbing License Title J z (p City/Town License um er Master Journeyman APPROVED (OFFICE USE ONLY. El Date.....l../ /C7 TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that.......�G.h.`<...A...........!...j.�....�.�.................... has permission to perform-c- wiring�.in the building of U °�` V v — t LA IH fO i .....................r............................................................ at ....,i..�.7..s.... ... �... .................. ...... orth Andover a9s. Fee.... ...... LIc. T ........................ 1.....No..--......... ............... „�r... ,, LECTRICAI: INSPECTOR Check # 541.8� o: ^� The Commonwealth of Massa usetts :tce Use Onty � — — Permit b. Department of Public Safety ' — Occupancy S Tec Checked BOARD OF FIRE PREVENTION REGULATIO 527 CMR 1200 3/90 heave blank) APPLICATION FOR PERMIT O ERFORM ELECTRICAL WORK - All work to be performed In accordance wi h the Macsachusctu Electrical Code. 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL IN -FO To Date 7 � X�QO City or Town of /�%ok /J To the In.;pector of Wires: The undersigned applies for a permit to perform weelectrical work described beloj. c Loation (Street & Number) /" /erV— RMEis {— 5/ Owner or Tenantud V�— J(�(�` ,#?E& Owner's Address Is this permit in conjunction with a building permit: Yes 1:0 ❑ (Check Appr�ooprriatte' BoJxj) :�:/ Purpose of Building_ USS Utility Authorization NO. 7 / / �(J Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New SeryiceZoo _Mps%,WpVolts Overhead Undgrd ❑ No. of Meters 4"Z_ Number of Feeders and Ampacity Location and nature of Proposed Electrical Work s/l /yew s e,e y'ce . 1J1Jifd� ll "h y 2T17�.z� No. of Hot Tubs 01411- No. No. :2� �� No. of Transformers Total KVA Bove In - of Switch Outlets No. of Gas Burners No. of Lighting Outlets No. of Hot Tubs 01411- No. No. of Lighting Fixtures) of Receptacle Outlets �� Swimming Pool A grnd. ❑ grnd. ❑ No. of Oil Burners Generators KVA No. of Emergency Lighting Batter Units No. of Switch Outlets No. of Gas Burners FIRE ALAUMS No. of Zones No. of Detection and Initiating Devices No. of Sounding Devices No. of Self Contained Detection/Sounding Devices No. of Ranges No. of Air Cond. Total tons pto�. of Disposals No. of Heat Total Total Pumps Tons KW ti Nq. of Dishwashers Space/Area Heating KW No. of Dryers Heating Devices KW Local, 1:1 Municipal Other Connection[] No. of Water Heaters KW No, of Ballasts Low Voltage Wiring No. Hydro Massage Tubs No. of Motors Total HP OTHER: INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent. YES ❑ NO ❑ I have submitted valid proof of same to this office. YES ❑ NO ❑ If you have checked YES, please indicate the type of coverage by checking the appropriate oox. / < INSURANCE [J BOND [JOTHER ❑ (Please Specify) L / /� 71_ 9 / 3 Q Expiration Date Estimated Value of Electrical Work S 0De / / / pork to Start Inspection Date Requested: Rough l e4! FinaI ! ( �j Signed under the penalties of perjury: FIF`: NA"l= / J LIC. NO. Q Licensee %.0(Jp��i�lGL /. ,fL'% /�/' A Signature �� N0.4—, Address / % / V A �/�/(//may �i 6/e—, G o LJ0_/ %Yf-4' Bus. Tel. No. ' 3 �S r 5 S Alt. Tel. No. m OWNER'S INSURANCE WAIVER: I aaware that the Licensee does not have the insurance coverage or its sub- stantial equivalent as required by Massachusetts General Laws, and that my signature on this permit application waives this requirement. 0w;.er Agent (Please check one) U --- Telephone Ko._ PFh'1_= FEL (Si.enaCure of 0,., or The Commonwealth of Massa usetts or °s` °n`y � Permit b. 7` r" u- Department of Public Safety ` , Occupancy S Fee Checked BOARD OF FIRE PREVENTION REGULATIO S27 CMR 1200 3/90 r.. (have blank) � n APPLICATION FOR bc FOR�PERMIT�accordance W �MnuElectricalscru 0ERF0R I ELE2CT RICAL WORK AJI (PLEASE PRINT IN INK OR TYPE ALL INFMR 12:00 O I0N) Date_ �/a City or Town of D To the Inspector of Wires: The undersigned applies for a permit to perform a electrical work described below. Location (Street & Number) r T_ Owner or Tenant Owner's Address Is this permit in conjunction with a building permit: Yes ANO ❑ (Check AppropriateBox) ;_--t?se of Building_ OUSE Utility Authorization N0, 9'1 / / / '�/(f ng Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters ce _Amps zw / pvolts Overhead 01 Undgrd ❑ No. of Meters e/%Z r of Feeders and Ampacity h Outlets ion and Nature of Proposed Electrical Mork s74A /Iew �5eeo'cc_ ' � f Lighting Outlets No. of Hat Tubs sals No. of Transformers T�A1 of Lighting Fixtures 3 Swimving Pool Above grnd. In- E] INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent. YES 0 NO ❑ I have submitted valid proof of same to this office. YES[] NO ❑ If you have checked YES, please indicate the type of coverage by checking the appropriate Dox. [:][:]/ INSURANCE BOND OTHER ❑ (Please Specify) L /A 6/1/ Expiration Date Estimated Value of Electr'cal Work $ t�Os / l:orF: to S -art Inspection Date Requested: Rough /6l c / ` 4 iir.al� c4 Signed under the penalties of perjury: F l r, ! N t* C. N0 . Q _S' n /� , / �f` ign ture t10. Address/79 i�A pelllf {i Come_, /01,,0 /fire Bus, Tel. No. -; 3 7� ✓mss S. Alt. Tel. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its sub- stantial equivalent as required b)• Massachusetts General laws, and that my signature on this permit application waives this requirement. 0%,•ner Agent (Please check one) %U k v _-- --- Telephone \o__ PEr'_ac FEE: (Si r.hture of 0•..mer nr A,,,An-,T�- grnd. ❑ Generators KVA of Receptacle Outlets 4.1.1.1 No. of Oil Burners Batter Emergency Lighting h Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Detection and Initiating Devices No. of Sounding Devices No. of Self Contained Detection/Sounding Devices s % Total No. of Air Cond. tons sals Heat Total Total No. of Pumps Tons KW ashers / kHydro Space/Area Heating KW s Heating Devices KW Local ❑ Municipal Other Connection❑ Heaters KW Si�nsf No. OT Ballasts - Low Voltage Wiring ssage Tubs No. of Motors Total HP INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent. YES 0 NO ❑ I have submitted valid proof of same to this office. YES[] NO ❑ If you have checked YES, please indicate the type of coverage by checking the appropriate Dox. [:][:]/ INSURANCE BOND OTHER ❑ (Please Specify) L /A 6/1/ Expiration Date Estimated Value of Electr'cal Work $ t�Os / l:orF: to S -art Inspection Date Requested: Rough /6l c / ` 4 iir.al� c4 Signed under the penalties of perjury: F l r, ! N t* C. N0 . Q _S' n /� , / �f` ign ture t10. Address/79 i�A pelllf {i Come_, /01,,0 /fire Bus, Tel. No. -; 3 7� ✓mss S. Alt. Tel. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its sub- stantial equivalent as required b)• Massachusetts General laws, and that my signature on this permit application waives this requirement. 0%,•ner Agent (Please check one) %U k v _-- --- Telephone \o__ PEr'_ac FEE: (Si r.hture of 0•..mer nr A,,,An-,T�- Rb o I)-/ &K 16— ly _oy *�5 C--ev ek / a - Iq _ oz/ DK rj- OG -as PJ'� Date.... ��'0 ........ TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ..... -! £. ...... ....................... ................................ has permission to perform .......................... •firing in the building of.............................................................. at ...........-'!.. .............................. .North Andover, Mass. Fee,4& ............... Lic. No `�jAX .,..f, /,a, ......'e"..:.......................... ELECTRICAL INSPECTOR Check # Ali _ 5194 TBE COWOI TRE4LTHOFARSS4CHUSE7TS Office Use only DEPARTNIENTOFPUBLICSAF= Permit No. BOARDOFFIREPREVEIVTIONREG ONS527CAR12. Occupancy & Fees Checked APPLICA77ONFOR PERART TO PERFORM ELECTRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, S2% CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) I Date Town of North Andover The undersigned applies for a permit to perform the electrical work described below. Location (Street ( Owner or Tenant Owner's Address To the Inspector of Wires: Is this permit in conjunction with a/building permit: Yes ® No r --j (Check Appropriate Box) Purpose of Building Q// 7�j�J Utility Authorization No. Existing Service Amps/" Volts Overhead Underground No. of Meters New Service Amps f 2t)12 -yo Volts (f% Overhead Underground No. of Meters Number of Feeders and Ampacity / Location and Nature of Proposed Electrical Work 'TE37Kf old/G No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures Swimming Pool Above M Below Generators KVA round ground No. of Receptacle Outlets No. of Oil Bumers No. of Emergency Lighting Battery Units No. of Switch Outlets No. of Gas Burners No. of Ranges No. of Air Cond. Total FIRE ALARMS No. of Zones Tons No. of Disposals No. of Heat Total Total No. of Detection and Pumps Tons KW Initiating Devices No. of Dishwashers Space Area Heating KW N9.,of Sounding Devices Y No of Self Contained Detection/Sounding Devices No. of Dryers Heating Devices KW Local Municipal Other Connections u No. of Water Heaters KW No. of No. of Signs Bailasis No. Hydro Massage Tubs No. of Motors Total HP )THER- M&=CoAngCgC Rmialttotbet TmmiettsofMa%ad seBCerteralLaws IawaalnmLml)Etyhoxm=Pblicyinr-kKEngCompletcCoveiageoritsstil tEffMeg� YES F7 NO tavesub vandpfoofofsmietodroffim YES FWuhawche&dYES, pkaqFai►xhca drgpeofcowrageby ing ti >y box u 1SURAt,, BOND F-1 OII IFR r --j (Please Spey) Eyniratu-D& NOW 1 �"" .Ilw • •: I • I F-grrnated VahieofElechicalWodc $ Rough Final e".WE-me ens 6. MI Lt�"YL Signature a Iic�No V�IASc, 3`�'Sgs6 BusinessTelNo. S�{ Z P�-t�li►�1 /7t�LC 1 / I T ® AIL Tel. No. //,6-S 9 4 q-1 '4 VINER'S INSURANCE WAIVER; I am aware that the Lim does nothave the ma ante coverage ork; substantial equivalent as required by Nlassachusen Gmcral Iam that my signahne on this p`unit application waives this recTmen-ol ease check one) Owner Agent q q Telephone No. ! l r� 23 PERMIT FEE $ J� Igna ure of uwf... or -61— The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass, 02111 Workers' Compensation insurance Affidavit Name Please Print Name: Location: City _ __ _ Phone # I am a homeowner performing all work myself. . I am a sole proprietor and have no one working in any capacity aI am an employer providing workers' compensation for my employees working on this job. Company name: Address City: Phone #: Insurance Co. Policy # r Company name: Address City: Phone #: Insurance Co. _ Policv # Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of.a fine up to $1,500.00 and/or one years' imprisonment -as _well_as_civil.penattiesiniheform iof-a_STOP W_0RK_ORQER.and_a fine.of_($10.0.00)_aidayagainst.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 certify under the pains and penalties of perjury that the information provided above is true and correct Signature Date Print name P:hon.e.# 5 Official use only do not write in this area to be completed by city or town official' City or Town Permit/Licensing Building Dept ❑Check if immediate response is required p licensing Board E] Selectman's Office Contact person: Phone #. n Health Department ❑ Other Date .K :J .`� . TOWN OF NORTH ANDOVER ° PERMIT FOR PLUMBING This certifies that .. P.— V :. U' --I � ....... .............. . has permission to perform ... LA. �'. .. 1. -. : ; plumbing in the buildings of ..0 . ! /. !: 1. � ...................... at .. ................. North Andover, Mass. Fee. Lic. No.. �.'..' .'.: `. ....... ......... /PLUMBING INSPECTOR Check # ') I r 5638 Zr c( f MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS c� Date �% 7 Building Location S� , Owners Name ` ped' Permit # )^`34r Amount 7 d ,. Type of Occupancy New ❑ Renovation ® Replacement ❑ Plans Submitted Yes ❑ No ❑ FIXTURES Wrint,or type)C `i Check one: Certificate Installing Company Name Q, (Nam, \� J �� ��► .l _C_ [a Corp. Address �_� C `�`�- �^►� co1` i ❑ Partner. Business Telephone IT 0 7 ❑ Fkm/Co. Name of Licensed Plumber. Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy 1 Other type of indemnity ❑ Bond ❑ Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature 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 installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachus-costate mbing=andp �the ral Laws. By: 5Igna ot Licenseaum r Type of Plumbing License Title 1" �7 L City/Town License Num Der Master ® Journeyman APPROVED (OFFICE USE ONLY El Location L Date I- °"T" TOWN OF NORTH ANDOVER Fp Certificate of Occupancy $ Building/Frame Permit Fee $ S', C" E` Foundation Permit Fee _ $ -� f OtheF Permit Fee $ ocr I Sewer Connection Fee $ W'F5' D a connection Fee $ TOTAL $ . Building Inspector Div. Public Works t Location No. • Date %- r /- -z - 1p- NCRT" .-' TOWN OF NORTH ANDOVER O?O• tt`•e ,•,hOOA Certificate of Occupancy $ 41 Building/Frame Permit Fee $ 0 -4411- 4- 'I. I. -tet`' Foundation Permit Fee $ s�CHuse Other Permit Fee �' -t I $ wer Connection Fee $ Water Connection Fee $ TOTAL $ Prao�e� Building Inspector Div. Public Works Location 21� Date WN OF NORTH ANDOVER icate of Occupancy $ ng/Frame Permit Fee $ Jation Permit Fee Permit Fee ��Wvr Connection Fee QN I *Water Connection Fee ��G Q OL 5� e�G Building Inspector Div. Public Works A Location_ No. - Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ ' Building/Frame Permit Fee $ Foundation Permit Fee $ I r' h►T 1EIDFRItO r"Permit Fee $ 19wer Connection Fee $ 7WLater Connection Fee $ j Building Inspector Div. Public Works Location-- ,'40. ocation_.'Jo. A I 9 Date y V40PTIV TOWN OF NORTH ANDOVER p Certificate of Occupancy $ °r ; ,' Building/Frame Permit Fee $ 0. Foundation Foundation Permit Fee $ s�CHust Other Permit Fee $ RECs/V�//��Se,,,,wer Connection Fee $ J, `W`a+t�l��ection Fee $ JUt 2 d 199 L T $ 2 N0. Anof Over collector Building Inspector Div. Public Works rl ti �7 - J� p in .� 0 do tAj a J m z 0 a � g uJ w ta. n � k D i p IL O v iv Q LA-pC y 0 0 } F M w a w d O> 0 0 a U a 0 0 o:tE a d a 0 u m m m u M l� Qz W d N ,, � Z W O a C Z_ Q Ck 0 V .�.i m N Z N Q F- 00 c N �. 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Ma CL He n c C H tv =A to ao 3 c m o aco CO) M cn o <. m T o of m s o w 0 m v "M' n = T n s r c � ae m c o0 p m v Z M Z z Q o �1 n O y ,0 N m H m T = OA 0 = 70 4 sm v M N 0 c c� C2) 7E I— )►TIC HS Ol � U w l t) f AI'i'Ia\►a 's;;'".• hlUl�"1 Al 11.h11�U1'L1� 11011.1)IN(; .: �;' nl;Iti�.II //lira Iltii,lti•I � e:()N I :ItvATION ��" I IIVV;II Irv, 11: tt; 171 4;W14 ;7r; I I I iiV : l'l l • I�i.��NNwc; PLANN1N(; & (;t)tlif�ll!Nl"1'1' Ui'sVt:l.Ol'A1LN"1' ' I:,�I;I:fJ I LI'. Nlil.tit )N, 1 )Iltla:l t )IZ • CHIMNEY APPLICATION ANO I'L13111' PERMIT # )CATION LOT ZJ P �E7J2 T �l` INER' S NAME: IILDER'S NAME: ,SON'S NAME: j1�_���IL� — - ,SON'S ADDRESS: IS� gr,y�il�-7—r Q c1'g? SON'S TELEPHONE: G .TERIAL OF CHIMNEY: 'T ERIOR CHIMNEY: — EX I ER I OR C11104E Y: f c /C- MIBER AND SIZE OF FLUES: Z PLu /2n1 Z IICKNESS OF HEARTH: ' S?' 0 .0 chbilney ore. OiAepeaee eon(oarto .t11e lte.qu.0(emelr.t:s u( .the curie curt/ Il(tve AUCC—s (tilt( gue.tati.orvs been neeesved: C=am ___-- TE:— 7 e GNATURE OF MASON: :KNIT GRANTED: sE 3r 41 FEE BERT NICETTA ' 'ILDING INSPECTOR—' SPECTEU: :MARKS: SOLID FLOCK REQUIRED V-6sr;> 3--%) c� THIS PERMIT" MUSV BE VISPLAYLU 014 WE I'UMSLS S s� W 00 v wl A a I �i0 < cm ? o m -� y O .Q h C f° A v� s A y� H A S 'c Q % m R ° o =r ° cr o z c A .: C� � � a ' R( z m �. rn CL m Tc zcr n X m a = =. ^ ° y � •, mf9 H m N < a o aCl C r � o Z n 7 �4 mQO Mm = >t-C�, W nr, _ C T o m 0 C r_ W m Hn ZfA � w, 0 c 0 or r- rrrc- 0 4 40 co O z `t M cr- LM In O O `` r r Q V W W O W W C d H CL. 4A y V W Z 6. Z H O u v Z Lu { oc cco o r 1.1 T mi V CA LAJL GI o L c cc o o m o E Q U tL Q m m ii \ Lc U. m CO) In a V) O OFA 9 LU chm oe � Q u W 0 of O W W 06 • � W O Z Z Z O W W o Q% ti. z ? ac o Z c m un W o= -o c m m L C J L J W L V L �N C Y O L O oz V L O m C O O O oC U U- oC ii oC to u. ¢cE aW LU chm C a m • � ' V :z H O O Q% ti. un o= -o c oz V L O O one V aW a W c Z O C a' o Z �wv V �— w o 0 'O m 0- ZD o c m Z v N e o y � a o0 O z -C one e � CC > Z C a m FORM U ► TOWN OF NORTH ANDOVER LOT RELEASE FORM SUBDIVISION ASSESSORS MAP 1061 1-7(0 SUBDIVISION LOT(S) CZS/j PERMANENT ADDRESS (ASSIGNED BY D.P.W. STREET �j—a72�5- - APPLICANT %,�l///f»a /� %�/�22e PHONE �'7-1fr23 DATE OF APPLICATION ,%�%A2GAl 30 /ff Z TOWN USE BELOW THIS LINE PLAN IN BOARD TOW LANNER CONSERVAT ON COMMIS ION � JZWZ� CONSERVATION AAiSMfN. BOARD OF HEALTH HEALTH SANITARI DEPARTMENT OF PUBLIC WORKS DRIVEWAY ,PERMIT (Z SEWER/WATER CONNECTIONS Aj FIRE DEPT. 1)ATE APPROVED Z> • • ��, DATE REJECTED DA'L'E APPROVED DATE REJECTED DATE APPROVED DATE REJECTED RECEIVED BY BUILDING INSPECTION�;a - 71992 DATE 4 This form shall be signed by the agents of the Planning and Ilealtl► 11wirds, the Conservation Commission prior to the issuance of any building; perml.ts for the subject lot. This form shall not releive the applicant from the compliance of any applicable Town requirement or Bylaw. Location No. loth �% Date MQRTM TOWN OF NORTH ANDOVER f 1 s Certificate of Occupancy $ s�CHus Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ 3 Check # C� a-, Z) 17212 AAM(c_ `� Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVAT OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER:O DATE ISSUED: (0V -2, ao 0 SIGNATURE: X`%� 2 2--o Building Commissioner/Inspector of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: s F=2: a <stf 1.2 Assessors Map and Parcel Number: 00010(n A 73 Map Number Parcel Number 1.3 Zoning Information: t� %5 _Di 1 f�1&.VaM Zoning District Proposed Use 1.4 Property Dimensions: ---� 'sQ —1, Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Reqwred Provided I r 1 , 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: Public X Private ❑ Zone Outside Flood Zone 1.8 Sewerage Disposal System: Municipal ❑ On Site Disposal System X SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record Name (Print) �p a [Address for Service Signature Telephone 2.2 Owner of Record: Vain K' Uyy\y,r" - Name Print Address for Service: q7- - q�5 - Si 'ita— e — Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Licensed Construction Supervisor: Address Signature Telephone Not Applicable License Number Expiration Date 3.2�Zegistered Home Improvement Contractor Not Applicable Company Name Registration Number Address Expiration Date Signature Telephone O v M 'V S 0 z M 90 0 r Y♦ 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 .......❑ No...... SECTION 5 Description of Proposed Work check a0 applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: I SECTION 6 - ESTIMATED CONSTRUCTION COSTS I Item Estimated Cost (Dollar) to be Com leted bypermit applicant OFFICIAL USI•; ONLY" 1. Building (a) Building Permit Fee Multiplier 2 Electrical cup (b) Estimated Total Cost of Construction OO 3 Plumbing Building Permit fee (8) X (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I> `� as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZE D AGENT DECLARATION mi Y 'vv ► v M,& ` C�n9 %%� i� ,as Owner/Authorized Agent of subject pr6per<Y Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief Zx2di 4)-\ Yi!w LAM "o C Print Name Si ature of Owner/Agent Date �— NO. OF STORIES I Ya SIZE 2TY 23/2 BASEMENT OR SLAB RD SIZE OF FLOOR T MBERS 1 2 3 SPAN DIMENSIONS OF SILLS – )C DIMENSIONS OF POSTS DIN ENSIONS OF GIRDERS X IQ HEIGHT OF FOUNDATION THICKNESS rt SIZE OF FOOTING X e� MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE FORM U — LOT RELEASE FORM Ielf 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. *****************************APPLICANT FILLS OUT THIS SECTION APPLICANT P f1,�)�� tY�S y,�; Y���JYY11)vf- LOCATION: Assessor's Map Number Q SUBDIVISION STREET V/ CONSERVA' COMMENTS - 'Oe- - TOWN PLANNER COMMENTS PHONE g%� ,`719.5 -, � 23� PARCEL LOT (S) ST. NUMBER, ------..­­­ WWW***********OFFICIAL USE ONLY********************** x************ TIONS OF TOWN AGENTS: TOR DATE APPROVSD DATE REJECTED I " - / FOOD INSPECTOR -HEALTH U h, J U 1>-r1^S tg SEPTIC INSPECTOR -HEALTH COMMENTS4 0�- �UbN- DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED DATE REJF:CTED PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTO DATE Revised 9\97 jm c�q� _/236 North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision 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 c11,S150A. The debris will be disposed of in: (Location 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 Town of North Andover Building Department 27 Charles Street North Andover, MA. 01845 D. Robert Nicetta- Building Commissioner (978) 688-9545 (978) 688-9542 Fax HOMEOWNER LICENSE EXEMPTION Please print. DATE a JOB LOCATION Number "HOMEOWNER L l Name PRESENT MAILING ADDRESS 52yya- City Town Street Address -- V0 Y) Home Ph State Map / lot ,45-2 F,55 Work Phone 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 ac- cessory 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. The undersigned "homeowner" assumes responsibility for compliance with the State Building Code and other Applicable codes, by-laws, rules and regulations, The undersigned "homeowner" certifies that he/she 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 SIGNA APPROVAL OF BUILDING OFFI �T Zip Code i The Commonwealth of Massachusetts Department of Industrial Accidents Office of investigations Boston, Mass. 02911 Workers' Compensation Insurance Affidavit Name Please Print MEMO I • / I • c• - •- • • • - 1 am a sole proprietor and have no one working in any capacity ED 1 am an employer providing workers' compensation for Cry employees working on this job. Company name. 6ddress City: Phone-* Insurance. Co. Policy # Company name. Address. P .* Faikwe to secure coverage as required under Section 2SA or MG1.152 can 1ead toathe irirqo idM cf cirnuraw,penaltip. of af W'to and/or one Years' imPrisonment-asjataJS7DP AW-00MM-2 understand that a copy of this statement may be'forwarded to the Office of Investigations cf the DIA for coverage verifrkation. s 1 do hereby rey w,der fire pains and penaffies of pe*wy that Me aftr7natJarrprOVA*d above is true arrd c onect Signature Date Print name phone # Official use only do not write in this area to He completed by city or town ofric.iar City or Town D Ba tiling Dopt ❑Check ,Vimmediate response is reguked [.j L kenSfng Boat ❑ Selectbnanos O Contact person: Phone # ❑ Health Departs 0 Other ml MAP 106A LOT 73 959832± AC. 40'± 3/1 EXISTING DWELLING #175 1, t ' EXISTING PAVED DRIVEWAY 2$i 6'f > 35,6± FORE S TPUBLIC--VARIABLE WIDTH) -/ ARGEO PAUL CELLUCCI Governor COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION TRL'DY COXE Secretary DAVID B. STRUHS Conuniss:oner Property Address: /7,5- r� SfVt Sf- A-)' '4 Name of Owner L.Co.n W.) Address of Owner: / 7S ivy✓2 ST /iJ - %i'�ci:� J Date of Inspection: / 45 Name of Inspector: (Please Print)Pjlni R vn.✓+ e � 2 1 am a DEP approved system inspector Pursuant ttfSection 15.340 of title 5 (310 CMR 15.000) Company Name: �jJ�f if b—DVA-4.4.L) 5 tz # A.16 - ,5z > O c 1-F3 Mang Address: Lill 41_V, f2a ,t/f ff�t//fC?cJG��� Telephone Number: q�7 - 6 - 17 h F CERTIFICATION STATEMENT ---- -- -� --- ----- I 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: asses Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails Inspectors Signature: Date: The System Inspector shall submit a copy of thi inspection report to the Approving Authority (Board of Health or DEP)within thirty (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 Department otrEnv)ronmental Protection. The original should,be sent to-" system owner and copies sent to the buyer, if applicable, and the approving authority. NOTES AND COMMENTS 5 e- e-, k_11& �CSk-�^y revised 9/2/98 Page 1 of 11 w {�� Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIOMRM PART A CERTIFICATION (continued) Property Address: ) 7 5- fJ�-C S'j' S % < 1V` - %� /�%' j/) G> v b f2 Owner: 1. ..,i Date of Inspection: l 'it l^ I� IN -C- INSPECTION SUMMARY: Check A, B, C, o/ D: A. SYSTEM PASSES: have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated ! elow. COMMENTS: k-51 t;c; -� I -e_ LI V -(-T>(11 C Gx y ii 5 tJir'� T f? �— \ A..� ���� ' Q ✓' It =e.j-jam LAJI % T -C- 2 C) 14" 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. Indicate yes, no, or not determined (Y, N, or NO). Describe basis of determination in all instances. If "not determined", explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance_(attached)_indicating_that_the-tank_ was -.installed- within.twenty .(20) years. prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Board of Health). broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumpirtg-inore than four-tfines a yeardue to broken or obstructed pipe(s). The system'"I pass inspection if (with approval of the Board cf Health): -- _ .._ broken pipe(s) are replaced _._-obstruction is remote -----._-.....- - _ ----- revised 9/2/98 Page 2of11 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 17 !��©� C S ( S" i' �' _ �} ry :� 0 J Ciz -_i Owner: t ✓i lam.) - k A Date of Inspection: I Ik. ` iz�afQ 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 the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETER1011NES IN ACCORDANCE WITH 310 CMR 15.303 (1)(b) THAT THE SYST6IYI IS NOT FUNCTIONING IN A MANNER WHICH -WILL PROTECT THE PUBLIC HEALTH.AND SAFETY. AN12 THE ENMIRONMENI_ Cesspool or privy is within 50 feet -of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER C t L -J C l S `Z� �.ro ✓Yl (eG.c �. e. l ®� � .1-� c (� IrS � c� C$X ©K, C o 1- �rvvv )D V 1 ,C, �es 2) re. vn ? tc— revised 9/2/98 Page3of11 SUBSUYA CE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 'Z �� f -o .-e:5;-, Owner: Date of Inspection: �Z�ojQ D. SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of swage into facility-er-j"tem component•daetto an overloaded oi-c4ogged SA3or 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 112 day flow. 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a 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 isithin 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for -coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. - E. LARGE SYSTEM FAILS: - ------- You-must-indicate-either"Yes"-oc-".No-.to._each-of the _.. following-------__- The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system-ie-witWn 200 feet of a tfil9uta►y�eaaucfaoo drirrfciag �wter wpp1Y -- • - — •- the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area = IWPA) or a mapped Zone 11 of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4of11 revised 9/2/98 Page 5of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM --� PART B CHECKLIST Property Address: l 75- ✓� wc�Jt?1Z� Owner: Date of Inspection: V1.5 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No _ Pumping information was provided by the owner, occupant, or Board! of Health. None of the system xompowents.haw- ~--n pua4ped4or-sUeast two,wesks an&$Jae-system hasJswuanceisiwgmumal clow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. 1/ The facility or dwelling was inspected for signs of sewage back-up. Z_ The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. _ All system components, excluding the Soil Absorption System, have been located on the site. LZ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on-the site has been determined based on: Existing information. For example, Plan at B.O.H. _ Determined in the field (if any of the failure criteria related-to Part C is at issue, approximation of distance is unacceptable) _ _ ntion *h^ proper xnao ants�if differed from nner).SGLBI2 piAtlldeli.lWJth IIIfnrmaD ainsoaaoat The facility owner (and.occupw� _✓ SubSurface Disposal Systems. revised 9/2/98 Page 5of 11 Property Address: 5 Owner: Date of Inspection: SUBSURFACE SEWAGEIMOPMAL SYSTEM INSPECTION FORM - PART C SYSTEM INFORMATION o j erz- FLOW CONDITIONS RESIDENTIAL: Design flow: g.p.d./bedroom. Number of bedrooms (design):= Number of bedrooms (actuaq: Total DESIGN flow Number of current residents: Garbage grinder (yes or nol: /�% Laundry (separate system) (yes or no):.IV ; If yes, separate inspection. required _ Laundry system inspected (yes or no) Seasonal use (yes or no):.n�C, Water meter readings, if available (last two year's usage (gpd): l k C Sump Pump (yes or no):_.,VU Last date of occupancy:—LQLrnE✓1l COMMERCIAL/INDUSTR IA L: Type of establishment: Design flow: gpd ( Based on 15.203) Basis of design flow Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non -sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: - Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: e 5 System pumped as part of inspection: yes or no)s If yes, volume pumped: / a 60 gallons, Reason for pumping: rU iZe t7G, r— :h=_ -----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) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed•4if known) -end source o44Wormation: ---+- `�-- - - Sewage odors detected when arriving at the site: (yes or no) /V c 1° revised 9/2/98 Page 6of11 SUBSURFACE SEWAGE D POSAL SYSTEM INSPECTION FORM —� PART C SYSTEM INFORMATION (continued) Property Address: re 5;1- w. Date Inspection: 1 BUILDING SEWER: (Locate on site plan) Depth below 'grade: 16 Material of construction: V cast iron _ 40 PVC _ other (explain) Distance from private water supply well or suction line 30 Diameter Comments: (condition of joints, venting, evidence ofteakage,-etc.) / - 7 [_ (c -'Z -A-2,5 .5:4 /1 Vin e + SEPTIC TANK:— (locate on site plan) Depth below grade: CJ'-'J� Material of construction:�crete _metal _Fiberglass _Polyethylene _other(explain) If tank_is metal, list age ^ Is.age:confirmed by Certificate of Compliance _ (Yes/No) Dimensions: 100 0 CZ11 9 Sludge depth: / D" Distance from top of sludge to bottom of outlet tee yr (raffle: Z& - - Scum thickness: ! ' Distance from top of scum to top of outlet tee or baffle: noy— ejoen Distance from bottom of scum to bottom of outlet tee or baffle: 113 How dimensions were determined: Y✓► e-ct-cy;.e_ 11 G K Comments: (recommendation for pumping, condition of inlet and outlet tees or -baffles; depth of liquid level in relation to outlet.inveq, structure.► integrity, evidence of leakage, etc.) C -c 11 G ft° e_ c -s S GREASE TRAP:_4VA — (locate --on site plan)- - -------- - - - Depth below grade:_ 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: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid.level in relation to outlet invert, structural integrity, evidence of leakage, etc.) revised 9/2/98 Page 7of11 •J SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: 71GHT OR HOLDING TANK:Nlrt (Tank must be pumped prior to, or at time of, :inspection) (locate on site plan) Depth below grade:_ Material of construction: _concrete _metal _Fiberglass TPolyethylene _other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm present Alarm level: Alarm in working order: Yes _ No_ Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, ewd ee of solids c ryq er, ewd/��f1ce o_ f leakage int (q or out box, etc.)— Jh' ;, "4T:I r_A!_ A1'7c c�, i Com' GSt, , /�7i`:.. -'e r"' [..G r c COL -S !✓ C.i ✓L PUMP CHAMBER: (locate on site plan) Pumps in working order: (Yes or No) Alarms in working order (Yes or No) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) revised 9/2/98 Page 8of11 SUBSURFACE -SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: j 5 re . tOwner- Date of Inspection: oti w • l lac ,� s i2 q - SbIL ABSORPTION SYSTEM (SAS) (locate on site plan, if possible;: excavation not required, location may be approximated by non-)ntrusive methods) if .not located, explain: Type: leaching pits, number:_ leaching chambers, number:_ leaching galleries, number:_ leaching trenches, number, length: nn leaching fields, number, dimensions: / � c ka- i 0l ` overflow cesspool, number:_ Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, damp s _il, condition of vegetation, etc.) — n G_ 'k- f,IIC( i(Z5 Siv rc 1.S C ec. -1 CESSPOOLS: _N (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 (cesspool must be pumped as part of inspection) - 4 Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of -vegetation, etc.) -�- PRIVY:14 f4 (locate on site plan) Materjals of construction; Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation; etc.) revised 9/2/98 Page 9ofll SUBSURFACE SEWAGE DISPOSAL SYSTEM; INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: w Date of Inspection: , 2 l q SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at -least two permanent reference landmarks or benchmarks . locate all wells within 100' (Locate where public water supply comes into house) i G w revised 9/2/98 C, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: 1-� ,e, i .S i o,3 Date of Inspection: )"G 4:'!^ U✓ 1, it, L n.9 S NRCS Report name �50 J Su ^oG�j Soil Type_"a sl Typical depth to groundwater USGS Date website visited I Observation Wells checked Groundwater depth: Shallow Moderate jC Deep SITE EXAM Slope Surface water Check Cellar �/ 0 5✓ "lam �," Shallow wells No Estimated Depth to Groundwater 3 Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record - - - - Observed.Site (Abutting property, observation hole; basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) ' �. U' S. G-�S S Z.., � S✓Jli'Cj � : 4�[... CGv�� � �_ U t pT S 45 to ►'r'i - revised 9/2/98 Page 11 of 11 ��.r� I •L' (��I.?r/� E.J•G'1 G• � [iG�[t �Lti�TL`�(i�� . J rJ J� 66•1-ITYLETON ROAD, wES TFORD, MA of rs6 import Number: W-36048 - Client: Leon Wilkins 175 Forest Street North Andover, MA ol? 'Sample taken bv: Clicni. • - _ . Ccrtific • of Anal sia Test Parameter: EPA Lieut Total Coliform (P) 0 (N)= Primary EPA Std. (978) 692-8395 FAX (978) 692-0023 1 -800 -849 -TEST Report Date. January 14, 1999 Sample taken at: Same _s On: 1/13/99 Result Units 0 perl001111 This water saltnple as tested, meets EPA health standards for Coliform Bacteria, M2=chusetts State Certified -- Testing Laboratory #MA048 Ac&el P. Carlson, for Thorstensen Laboratory Inc. ------------- 01/17/99 SUN 11:30 FAX -77 — — _„R — 66 LITTLETON ROAD, WESTFORD, MA 01886 Report Number: W-35874 Client: Loon Wilk= 175 Forest Street North Andovcr, MA 01845 Sample taken by: Client TEST PARAMETER Total Coliform (P) Ammonia Nitrates (as IST) (P). Nitrites (as N)(P) (978) 692-8395 FAX (978) 692-0023 1 -800 -649 -TEST Report Date: January 12, 1999 Sample take Same< On:. 12/30/98 Certificate ofnalyslS EPA MAX RESULTS UNITS 0 # 15 per 100inl Not Spec. <0.03 mg/L 10 <0.01 mg/L 1 <0.01 mg/L NT=Not tested, #--Value Exceeds EPA STD, TNTC=Too Numerous To Count *=Background Bacteria Noted, ”=EPA Advisory 'Limit, '=Exceeds Advisory Limit (P)=Primary EPA Standard, (S) --Secondary EPA Standard (may affect aesthetics of Drinking Water, i.e. taste,color.,etc.) This water samplc as submitted, does not meet EPA requirements for Coliform Bacteria and is considered UNSAFE for human consumption_ Massachusetts State Certified Michael P. Carlson, for Testing Laboratory #MA048 Thorstensen Laboratory Inc. 'QST WART'S , ..,..�... s SEPTIC TANK SERVICE 47 RAILROAD STREET, BRADFORD, MASS. 0.1835 Telephone: 372-7479 -_�, / ` Date Street--/ City / SERVICE CHARGE DIGGING PUMP TANK � SNAKE LINE r SERVICE CHARGE Not responsible for grass & driveways. INVOICE DUE AND PAYABLE UPON RECEIPT r„moi r_.. TOTAL 7-z f Driver j� r Signature Work done in satisfactor manner. ,k. p Reg •ANDOVER SEPTIC O N/c (978) 475-2593 47 Railroad Street ROTO -RAM Nature of Service Bradford, MA 01835 (978) 452-9022 S -Reg. Maint. ❑ Emergency ❑ Day ❑ Night Dat© of Service PAY FROM THIS BILL Customer Name: cam_ Septic Tank Pumping and Cleaning "Done the Right Way" Emergency 24 Hour Service - 7 Days a Week Service Location: _ � yy j` S Phone: !t'!.Y't� Contact: j Billing Address: City: % Zip: Special Instructions ❑ Completed Per: EDIncomplete Reason: AM/PM Services Rendered Vacuum Pumping cu C�" Septic Tank Obserryations 91-1600d Condition Drain Cleaning ❑ Main Line ❑ Drywall ❑ Leechfield Runback ❑ Toilet Bowl ❑ Leech Pit / Overflow ❑ Riding High ❑ Kitchen Sink ❑ D -Box ❑ Pump Chamber ❑ Grease Trap ❑ Catch Basin ❑ Portable Toilet ❑ Other Size:�� C1 Under 1000 gallons t 1000 gallons ❑ 1500 gallons ❑ 2000 gallons ❑ 3000 gallons ❑ 4000 gallons (liquid level) ❑ Full to Cover ❑ Excessive Solids Top / Bottom ❑ Use No Powdered Soap ❑ Heavy Grease ❑ Roots ❑ Suggest Electric Rooteting ❑ Van Called ❑ Bathtub / Shower ❑ Vanity ❑ Floor Drain ❑ Yard Drain ❑ Vent ❑ Sewer Jet ❑ Other FOOfage. ❑ 5000 gallons ❑ other ❑ Other Misc. ❑ Digging Charge ❑ Backhoe 1:3 Location ❑ Consultation ❑ Service Call ❑ Estimate ❑ Inspection ❑ Certification: P/F Reason: ❑ Labor ❑ Portable Toilet Rental ❑ Pump Repair ❑ Waiting Time ❑ Baffle ❑ Repair Digging Charge Is Per Driver ❑ Chemical Treatment Discretion ❑ Other Description of Work / Recommendations Terms of Payment Vacuum Pumping Drain Cleaning Yr. Month Yr. Month NET 15 DAYS Parts Tax Discount Terms &Conditions EJ Cash [� Check C] Credit 1. Not responsible for damage beyond curb line. 2. All complaints shall be reported within 48 hours. 3. 1.5% per month will be charged to accounts past due. 4. The purchaser agrees to pay all coat of collection. Total Customer Signature Serviceman El m m x x m N m _v y C d Cl CD az y CLO C2. = CO) aCO -0 O o v co CDCL O c� =r %< CD CDo CD OD S. c� CD y CD CL O CO) �C C C Im s?�0 0 = Q N� a n0<m CO) -� OO a C m O h .-► C Z ='- H —4 ? m ��m y Cl N p m N '� m O'D 0co n 0 .-► ' 0 H n R C-' a a o = •X �] CL g .- . m o m y Ca l l _ CD C7] H O O Q d Vl N :t cn eV • [�/ C'n^ O �w� y E O� = m O ooN :� .z =[� N a J cnif co O H =a =- °c W I H 09 0 "b4 A. 2 L f O C � �� 0� o � t" w �. .� CGOD p ro �Z ro ro x °c W I H 09 0 "b4 A. 2 L f O C pliv.-Ia 4VA L to M o N rn 0 u u , v� cu U -r U U .m U O U � Z � L l � � T— U O X U € O O CD c 4` m _ L < LL c� M L Q) v Im CU .0-1 M CJ) S. 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