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FORM II -IAT 1 LEME FORM
INSTRUCTIONS: This form is used to verify that all necessary
approvals/permits from Boards and Departments having jurisdiction
have been obtained. This does not relieve the applicant and/or
landowner from compliance with any applicable local or state law,
regulations or requirements.-
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/APPLICANT: � V�11�G� _ Phone
LOCATION: Assessor's Map Number 2 / Parcel
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Rec=__':ed
by 3ui1ding, Inspe=r
0a=c
No 670
APPLICATION FOR SEWER SERVICE CONNECTION
19
North Andover, Mass.
CApplication by the undersigned is hereby made to connect with the town sewer main in Street,
subject to the rules and regulations of the BWd of P lic V:Oorks. j
The premises are known as No.
or subdivision lot no.
7
C. C
�--6�ZL
Owner 6 jA '_ -Address
, ���
Contractor
PERMIT TO CONNECT WITH SEWER MAIN
The Board of Public Works hereby grants permission to �/ , L1 �r
to make a connection with the sewer main at `--
subject to the rules and regulations of the Board of Public Wor
Inspected by
Date
By
See back for rules and regulations