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HomeMy WebLinkAboutMiscellaneous - 197 HICKORY HILL ROAD 4/30/2018 197 HICKORY HILL ROAD f/ 210/062.0-0133-0000.0 I I i 27 �r►ORT�y, O do TOWN OF NORTH ANDOVER i PERMIT FOR PLUMBING s`4ACMU5� This certifies that..... � '.nl J.EJId ✓ J .................................................................................. has permission to perform..G` :7....�.2 h-� _ ....................................................................... plumbing in the buildings of........ ?. ' ................................................................. at........../17.. .� ...................................... North Andover, Mass. Fee.,�.—...Lic. No. `,?..... ................................................................................. PLUMBING INSPECTOR Check# MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY _ MA DATE j! ( PERMIT# 11321 JOBSITE ADDRESS GSC -OW R'S NAMEp Q� POWNER ADDRESS i' ar / TEL — FAX TYPE OR OCCUPANCY TYPE COMMERCIAL M EDUCATIONAL © RESIDENTIAL IN PRINT CLEARLY NEW: 0 RENOVATION: REPLACEMENT: M PLANS SUBMITTED: YES® N0E� FIXTURES Z FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB ( ( ..,___,f _____f CROSS CONNECTION DEVICE v _._ 1 .— ( _.__� .._.r� DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIUSAND SYSTEM DEDICATED GREASE SYSTEM __._.__f T! f DEDICATED GRAY WATER SYSTEM i - _.�j ( . _.1 I l --j DEDICATED WATER RECYCLE SYSTEM ( _. DISHWASHER _ �t .__. f —_ f .___.._I ) .._..__ 1 _--.._.. I I _.-..._f ! _-.-_i DRINKING FOUNTAIN ----_._.f FOOD DISPOSER -I -..____f _._._.1 ! FLOOR/AREA DRAIN �__! ( ._. INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ! __._I -.__.__.._f ___I __ _-.___1 __._.._f ___ __.____( ...-__.._1 .___.__! _.____ _ I ► __-___i ROOF DRAIN SHOWER STALL SERVICE/MOP SINK I __.._l 1 f __— I l { --- ----_._i ._..__.c TOILET I l � __._{ _.._ ( _ URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER _ _ _ f _f I .___.-._-1 -_.__._J ^1 i _____.._1 ._...__._.► ...__._( _ _._-.__I i _I INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY6I OTHER TYPE OF INDEMNITY Q BOND 0 OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the (Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER [j AGENT SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance trp�ion of the (Massachusetts State Plumbin Code and Chapter 142 of the General Laws. PLUMBER'S NAME _ G✓Y1 ` (LICENSE# SIGNATURE MP El JP�] CORPORATION E.1#=PARTNERSHIP_-F PARTNERSHIP PI# _ s LLC COMPANY NAME ADDRESS ,f P1j _ CITY L��/r _ d JK I'—STATE ZIP Ol TEL j FAX L CELL EMAIL __ ! ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECT16N NOTES Yes No S' THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ q7, h,� I # FEE: $ PERMIT# PLAN REVIEW NOTES I Date...O, P /S� f �p10RT/y TOWN OF NORTH ANDOVER � � p PERMIT FOR GAS INSTALLATION CW his certifies that ✓.. .................................................................................. has permission for gas installation ...G in the buildings of.................f.. .�.Q at...../17....`?�b............o.✓.. .`- /......C........., North Andover, Mass. Fee..,.W—P....... Lic. No. .3.../......7.3..... ..................................................................... GASINSPECTOR Check# 16-37 •` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK - Z Cr- CITY /� �( MA DATE 7 ( PERMIT# JOBSITE ADDRESSOWNER'S NAME , G" OWNER ADDRESS LJ ? TE =FAX��� TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ® RESIDENTIAL PRINT CLEARLY NEW:F--jI . RENOVATION:D REPLACEMENT:p PLANS SUBMITTED: YESE] NO A APPLIANCES Z FLOORS-- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACET.J FRYOLATORT FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS (_— MAKEUP AIR UNIT (-� __. _ .L_- OVEN �- I- L_ POOL HEATER 1 ( «( _ I ROOM/SPACE HEATER ROOFTOP UNIT TEST _ UNIT HEATER T1 UNVENTED ROOM HEATER WATER HEATER � �- -dT H­ERF .............. .. ........ ..... - - INSURANCE COVERAGE hake a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 16]_1 NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Mi OTHER TYPE INDEMNITY ® BOND OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER 0AGENT �I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with 4 Pertinen provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAMEG�M VU i cwt LICENSE It SIGNA MP El MGF JP JGFJ LPGI CORPORATION©# PARTNERSHIP 0#=LLC[J#= COMPANY NAME: _ t _ ADDRESS _ CITY ✓ STATEZIPO&tl =TEL FAX CELL EMAIL ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL 1111SPECTIOLN NOTES Yes No S� THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES The Commonwealth of Massachusetts _ F Department of IndustrialAccidents ~� I Congress Street,Suite 100 F Boston,MA 02114-2017 www mass.gov/dia oRM SJ'�a Workers,Compensation Insurance Affidavit:Builder/Contractors/Electricians/Plurnbers. TO BE PILED WITH THE PERMITTING AUTHORITY. • -,Please Print Le 'bl A ' licant Information r Name(Business/Organization/lndividual): l�U( ✓I Address: City/State/Zip:/�� phone if: 7� zx Are you an employex?Check the appropriate box: Type of project(Terluired); I. I am a employer with employees(frill and/or part-time).' T ❑New'constr6ction 2K]I am a sole proprietor or partnership and have no employees Working for me in g. E]Remodel hg any capacity.[No workers'comp.insurance required.] 9, ❑Demolition 3.❑I am a homeowner doing all work myself[No workers'comp.insurance required.]t 10❑Building addition 4.F11 am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions „ � proprietors with no employees. 12.[�Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13•, I Roof repairs ,,. These sub-contractors have employees and have workers'comp.insurance.t 14,0 Other 6.Q We are a corporation and its,officers have exercised their right of exemption per MGL c. 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 mast also fill out the section below showing their workers'compensation policy information: i Homeowners who submit•tbis a 6r avit indicating they are doing all work and then hire outside contractors must subrsut anew affidavit indicating such Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether c r not those entities have employees. If the sub contractors have employees,they must provide their workers'comp.policy number. lam an employer tliat is providingworkeis'compensation insurance for my employees. ,below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' p . com ensation policy declaration page(showing the policy number and expiration date). 'on punishable b a fine u to$1,500.00 Failure to secure coverage as required under MGL a.152,§25A is a criminal violation p Y P 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA.for insurance coverage verification. I do hereby cerci and r tl pains andpenalties ofperjury that the information provided above is true an�dj,correct. Si ature: Date: U ^ )? -a` Phone#: t 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): i 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'defuied 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 receivef'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 b6 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 requiired." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter intQ any contract for theperformance 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=contractor(s)name(s),address(es)and phone numbers)along with their certificates)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 maybe 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 Industxial-Accidenis. 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 (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel.#617-727-4900 ext.7406 or 1-877-NUSSAFE Fax#617-727-7749 Revised 02-23-15 wwwmass.gov/dia . i y� Fold,Then Detach Along All Perforations ' COMMONWEALTH OF MASSACHUSETTS D I kU RJ • o • V 111 BOA IDOF PI.UP1BE# S; AND GASF ITTERS iSSJES THE F0L;J)WING -LIDENSE: : . w GF E[! %AS A .�OU�'�'.MAN RULIMBER SHA'rJN, P SFV0I AN r w t 5 ME!Dow S 1 SW J M- 01354 970$ k . 31573 05°iolllb 208320 1 \ Office Use Only s z O : u4P `amnwnwralt4 of Issar4nBEtt$ Permit No. c'a',�-,�l9/7 i94;)IF rtment Df public *afetq Occupancy,& Fee Checked�!0 BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 3/90 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK .. All work to be performed in accordance with the Massachusetts Electrical Code, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date T& or Town of NORTH ANDOVER To the Inspector of Wires: The udersigned applies for a permit to perform the el ctrical work described below. Location (Street & Number) L� f G —c- Owner or Tenant Owner's Address �4< LttC " Lle C �L r/ Is this permit in coniunction with a building permit: Yes � No ❑ (Check Appropriate Box) Purcose of Building Utility Authorization No. ZOO Existing Service Amos Volts Overhead 1 Undgrnd �I� No. of Meters New Service ZO 0 Amps _LpiVcits Overhead ❑ Undgrnd E� No. of Meters Number of Feeders and Ampacity Location and Nature of Prcoosed Electrical Work a 7 LAI e -4-"t)C--,— 5,,,e G ? � No. of Lign;;r,g Outlets Noof Hot No Total •' ^ . .-ucs . of Transformers !1 KVA No. of Lighting Fixtures Swimming Pool Accve— in- uj I grne. — crnc. �' I Generators KVA /►hJl' ,� No. of Emergency Lighting of Recectac!e Outlets U I No. of Oil turners I Battery Units No. of Switch Outlets No. of Gas Eurners l FIRE ALARMS No. of Zones �II No. of Ranges I No. of Air Ccnc. tons' No. Detection and IO , ;ons Initiating Devices ` No. of Disbosais No.of rear :otai Tatai Pumps :ons K',1 No. of Sounding Devices !I No. of Self Contained No. of Dishwashers i SbacerArea :;eating ?0IV DetacaonrSoundind Devices No. of Dryers y — Municioai I Hearn^ Devices KN Local Connection Other No. of No. of Low Voltage No. of Water Heaters KW Signs Sailasts Wiring I No. Hvoro Massage Tucs ; No. of mccrs Tatal HP OTHER: INSURANCE COVERAGE. Pursuant to the recuiremen:s :f Massacnusers general Laws I have a current Liaotiity Insurance Policy including Ccm^:ei uceratiers Coverage or its sucstantiai ecuivaient. YES _ <, O = I have submitted valid proof of same to the Office. YES _ :f you have cnecxee YES. please indicate the type of coverage by checking the appro tate box. INSURANCE BOND = OTHER = ;Please Spec:fyl O� (Expiration Datel Estimated Value of Electrical Work S y5bo CJ �+ Work to Start Y G� `S� Inseecrcn :ate Recues:ec_ Rough ^��/ /�S Fnal Signed under/31 a Penalties of perjury: FIRM 1JA1,1E r M•4-,r— L S IJLCLIC. NO. Licensee /t/l/C,t/1-� .. e LIC. NC. /L Z 7 Bus. Tei. No. _ g AddressL�(.� w�� J S i c� ^I� l c/ Alt. el. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee aces net have the insurance coverage or its substantial equivalent as re- cWred by Massachusetts General Laws, and that my signature on t:^.:5 Dermt application waives this reouvement. Owner Agent (Please cnecK one) Teieonone No. PERMIT FEE 3 ;Signature of Owner or Agent; x•5..o�5__ ti Date........../. .......... tko TOWN OF NORTH ANDOVER (z PERMIT FOR WIRING C; CHUS XT ... ...... This certifies that .......... ......... ... .... has permission to perform ..... ....:...:...........1...................................................(U wiring in the building of... ...................._.....'r...... ......Z.......... .................................................................. orth'Andover,Mass. Fee..... ....... Lic.No. ........1... ..................... aft -VIR!'CAL*NSPECOZatt-- WHITE: Applicant CANARY: Building Dept. PINK:Treasurer GOLD: File 4,cation N ��? Date f NOR701 TOWN OF NORTH ANDOVER Ot�t�a° °,tip Certificate of Occupancy $ 0 Building/Frame Permit Fee $ CX Foundation Permit Fee $ t. - SsuNusE u. Other Permit Fee $ 63 Sewer Connection Fee $ _ Water Connection Fee $ f 077.58 TOTAL $ n LJ -Buil i g Ins ect r.7, 1,(`, T3 Div'Rublic Works Q L6+ 7� Location No. C Date NORTH TOWN OF NORTH ANDOVER 3 Certificate of Occupancy $ Building/Frame Permit Fee $ AcMus`� Foundation Permit Fee , $ too Other Permit Fee $ _4, Sewer Connection Fee $ Water Connection Fee $ --t �r TOTAL $ Building Inspector �7 7804;.5/9. t5:�a rrv.a� ��ia Div. Public Works Location 4,1� No. �J.� Date � pORTIy TOWN OF NORTH ANDOVER t • ° L t p Certifica o,&occupancy $ �e Building/Frame Permit Fee $ a ,SJACMUSEt Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL $ _ &DBuilding Inspector I !Ib/9•� 15::3 1,00&00 PAID ?805 Div. Public Works PERMIT NO. Z APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. PAGE 1 MAP d40. �^� LOT NO. 2 RECORD OF OWNERSHIP IDATE BOOK PAGE 'TONE SUB DIV. LOT NO. 7E lcl, 0- LOCATION i d , PURPOSE OF IdUILDING OWNER'S NAME },. c J 17�/V• - NO. OF STORIES "� SIZE OWNER'S ADDRESS Y7Yt11G`// /q BASEMENT OR SLAB ` ARCHITECT'S NAME � ! I-at `e> SIZE OF FLOOR TIMBERS 1ST � � 2ND � � 3RD BUILDER'S NAME - SPAN DISTANCE TO NEAREST BUILDING / / DIMENSIONS OF SILLS--( j `7 DISTANCE FROM STREET �j F�(�• POSTS •-� �f�!/C/ •p ___ ,>-, � DISTANCE FROM LOT LINES-SIDES ;� REAR 7��-f^ GIRDERS/C AREA OF LOT ) �y y C FRONTAGE //`,� HEIGHT OF FOUNDATION( 1•�1 'dC� THICKNESS IS BUILDING NEW Z515 SIZE OF FOOTING // % IS BUILDING ADDITION ` MATERIAL OF CHIMNEY IS BUILDING ALTERATION ��?, IS BUILDING ON SOLID OR FILLED LAND Z, WILL BUILDING CONFORM TO REQUIREMENTS OF CODE _^F. 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 JA nvc (>R. eoo '✓v EST. BLDG. COST .�7 l6 78t� PAGE I FILL OUT SECTIONS 1 - 3 �J�� EST. BLDG. COST PER SQ. FT. COST PER ROOM OM PAGE 2 FILL OUT SECTIONS 1 - 12 EST. SEPTIC PERMIT NO. ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING PERMIT FOR FOUNDATION ONLY 4 APPROVED B ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULN'WTED BY PARA 114.8-5. B.C.- PLANS MUST BE FILED AND APPROVED BY BUILDING INSO f •DATE FILED � DPECTFEE PAID BOARD OF HEALTH SIGNATURE OF OWNER OR AUT IZED AGENT ,10 FEE Llos NG .:Sz 4-00 cld PLANNING BOARD PERMIT GRANTED • 19 DATE: ._...FEE PAID.• OWNER TEL.#, BOARD OF SELECTMEN CONTR.TEL.#6E2:4 S' ' CONTR.LIC.#el-(- DEC —7 m BLDG..PERMIT FEE00. �1���,. LESS FDA FEg ...�.■ Ocl _ BUILDING INBPECTOR DUE FRAME PERMIT 8 10012 ' BUILDING RECORD 1 OCCUPANCY 12 SINGLE FAMILY SiOR1ES THIS SECTION MUSTSHOW EXACT DIMENSIONS OF.LOT AND.DISTANCE FROM APART_ FAMILY OFFICES LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES, GA- , APARTMENTS _RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. CONSTRUCTION 2 FOUNDATION 8 INTERIOR FINISH CONCRETE 3 1 2 13 CONCRETE BL K. PINE BRICK OR STONE HARDW D PIERS PLASTER _ DRYWALL UNFIN 3 BASEMENT AREA FULL FIN. BM'T AREA _ 1144 1/1 l/, FIN. ATTIC AREA _ NO BMT FIRE PLACES HEAD ROOM MODERN KITCHEN 4 WALLS 9 FLOORS CLAPBOARDS B 1 2 3 DROP SIDING CONCRETE ��_ WOOD SHINGLES EARTH _ ASBESTOS SIDING COMMON SIDING HARD"✓D COMMON VERT. SIDING ASPH. TILE _ STUCCO ON MASONRY _ 9 STUCCO ON FRAME BRIC6ON MASONRY _ ATTIC STRS. & FLOOR _ BRICK ON FRAME CONIC. OR CINDER$LK. STONE ON MASONRY WIRING STONE ON FRAME _ SUPERIOR IJ POOR ADEQUATE l NONE '• ,•S 5 ROOF 10 PLUMBING + 1 GABLE HIP BATH )3 FIX.) GAMBREL MANSARD TOILET RM. 12 FIX.) FLAT SHED WATER CLOSET _ ASPHALT SHINGLES LAVATORY WOOD SHINGES KITCHEN SINK - SLATE NO PLUMBING TAR & GRAVEL STALL SHOWER - -- ROLL ROOFING MODERN FIXTURES _ TILE FLOOR _ TILE DADO � t 6 FRAMING 11 HEATING WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. TIMBE BMS. &COLS. STEAM STEEL B . & COLS HOT W'T'R OR VAPOR WOOD RAFTERS AIR CONDITIONING RADIANT H'T'G _ UNIT HEATERS 7 NO. OF ROOMS GAS OIL , B'M'T 2nd I ELECTRIC 1st 13rd NO HEATING p 11? ♦ s e ....... I?AC? �? 1 .0 1 / over Town of � z .A� llft.4�-�� No 592 �--- � ate- t 3 19CK ort � dower, Mass., O LAKE ` C OC NICh1E WICK 1. 0mq re= BOARD OF HEALTH I Food/Kitchen PERMIT T D Septic System i BUILDING INSPECTOR THIS CERTIFIES THAT eA .�t oun ation ,+.ttq��- has permission to erect.V ..... ��buildings on .�kl......' � t..•• �•••• •......••..............••. Rough ll to be occupied .�. c .alts...... .... ....Mrd►R!...9 ............................................. Chimney provided that the person accepting this permit shall in eery reflect conform to the terms of the application on file in Final P P P 9 , 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. PERMIT FOR FOUNDATION ONLY PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. REGULATED BY PARA. 114.8-S. B.C. Rough �Z --', Final PERMI F E..V,, f E S IN 6 MSA 1 "A � ._ FEE PAID ELECTRIC SPECTOR UNLESS CON` " =7N. Rough � �s .. ..... ....... ..... BUILDING IN ECTOR inal . < CBuildingQ�'�D• GAS INSPECTOR Occupancy Permit Required to OcLlpy_ _ Display in a Conspicuous Place on the Premises — Do Not Remove pQ' ' h Finag 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. SEWER/WATER FINAL DRIVEWAY ENTRY PERMIT • Y FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicant fills out this section***************** APPLICANT: / '1D 2�S �q Iia �L{/�® Phone z677-76 3S LOCATION: Assessor' s Map Number �� Parcel Subdivision 1C / W, Lot(s) 3' Street R�. St. Number 197 ************************Official Use Only************************ RECOMMENDAT ONS OF TOWN AGENTS: Date Approved Conservation Administrator Date Rejected Comments 94 Date Approved 8 4 Town Planner Date Rejected Comments Date Approved Health Agent Date Rejected Comments Public Works - sewer/water connections �- ♦ � - driveway permit T� Fire Department �p Received by Building Inspector Date ' ; }: .` iii .:'s ' J-G; '''., w r,# .t is 7.: / a YY f p �,:i T} p ..:.•4. x'i"2", °'': Y s;5i. `. ,i ^.r_ �► r `w.r•• G ,Vf t `E ,b' .t � ry. •�i R �•`' � .0 "i r �� xn: :� �" ;„r,"':,�r, 3ita�.•r� �iX�:,;. �•'_ P ',y, " 'i�' r �� y �,� � { •� Y `,r Reil-.. ') d ai« ,;,^�j I�..'.,,L.3•�R`�i°,d""+'u' 'cta',. t^Ts•L`.'. r" g:r T83 S:,IC r. � jv A 6 I S r�r w ,.s• aitia -H . e r t i F7'` •f �c:. rri[� � �' w:�� ' is ... 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I CERTIFY THAT THE OFFSETS OFFSETS SHOWN ARE FOR THE USE or �► OF THE BUILDING INSPECTOR ONLY SHOWN COMPLY AND SUCH USE IS FOR THE WITH THE ZONING 13972 DETERMINATION OF ZONING BY LAWS OF gF�j�lAE� NORTH ANDOVER CONFORMITY OR NON-CONFORMITY!lANOg WHEN BUILT WHEN CONSTRUCTED. Location J Aw- No. Date 7 �� A NORTH TOWN OF NORTH ANDOVER2 p Certificate of Occupancy $ 4L 1 Building/Frame Permit Fee $ Foundation Permit Fee $ sACHu [.t1 ! ermit Fee $ zs � Sewer Connection Fee $ Water Connection Fee $ TOTAL $ Building Inspector + 8007 Div. Public Works KAREN H.P. NELSON + Town of 120 Main Street, 01845 °:r"`°' f NORTH ANDOVER 45081682-64$3 BUILDING •'�;�•.��' CONSERVATION '""°° DIVISION OF HEALTH PLA\\[\C, PLANNING & COMMUNITY DEVELOPMENT CHIMNEY APPLICATION AND PERMIT DATE /�'!JJ" `t S� PERMIT # LOCATION co T h ( OWNER'S NAME Jo ]- BUILDER'S NAME -75i"✓1 - �(�`1 11, GSI/0 MASON' S NAME , 7 L / �IGtNclitl�yi MASON' S ADDRESS �)- MASON'S TELEPHONE MATERIAL OF CHIMNEY L �L r I l c. Az a e. INTERIOR CHIMNEY EXTERIOR CHIMNEY NUMBER AND SIZE OF FLUES X X,�� �7 THICKNESS OF HEARTH Will chimney or fireplace conform to requirements of the code and have rules and regulations been received: DATE 3 ' SIGNATURE OF MASON / zi' C NTR. LIC. EST. CONSTRUCTION COST/CONTRACT PRICE CJD Od PERMIT GRANTED y/G�l4 FEE— ROBERT ROBERT NICETTA, BUILDING INSPECTOR I INSPECTED REMARKS SOLID BRICK REQUIRED THIS PERMIT MUST BE DISPLAYED ON THE PREMISES ORT TO" of dover No. 592 R.rrt, dower, Mass. I MBSL 3 199.'4 C OC HIC HE WICK �1 A°Rgrev PPa\ �y BOARD OF HEALTH E Food/KitchenPERMIT T D Septic System BUILDING 1 SPECTOR : � ..... �t4�''� ����ln�ST ...............................................................` ....................................................... THIS CERTIFIES THAT 31uIc( -C oun alio has permission to erect.V- .....F )%-,buildings on..4q-1....... .....•....•............•• 1'Ro-u-6 Jfl jj+A Cz,� to be occupied as 41 . �y�m►.��I c .alb ....0 ...�+a(L... !d Ar,,�....... ......................................... CRRUe provided that the arson acce tin this pbrmit shall In eJ�ry re4oct conform to the terms of the application on file in ,ane P P P g 3 14l qt` this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings In the Town of North Andover. PERMIT FOR FOUNDATION ONLY 6PLUMBIN I SPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. REGULATED BY PARA. 114.$-S, $,O, � 1 Ss " I .3 �4 , X901/ /-- - PERMIT EXPIRES IN 6 M@I FEE PAID� ELECTRIJPA INSP UNLESS CON C T � ��' � Rough pERMIT R FRAME/BUILDING ervice 3/ l BUILDING IN ECTOR 3� �/ C- DAT:...,.--- FEE PAID:_._._._,— d Final ,f" l �s Occupancy Permit Required to Occupy Building GASW2!o ou 4s2 � Display in a Conspicuous Place on the Premises — Do Not Remove orls-64/5 No Lathing or Dry Wall To Be Done Until Inspected and Approved by the Building Inspector. FIRED PARTMEN /�/ � Burner �`� •"�>I' U �L 5I (8 CONSERVATION till AFN �� Street No. PLANNING 'FI AL Smoke Det. SEWER/WATER � FINAL DRIVEWAY ENTRY PER 1 5 -2-195, 1 � CERTIFICATE OF USE & OCCUPANCY Town of North Andover Building Permit Number •sz Date Mg%% tg lgcic- THIS CERTIFIES THAT THE BUILDING LOCATED ON IC 3Z MAY BE OCCUPIED AS �� �� w�ZG�(64Q.IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. CERTIFICATE ISSUED TO-TPaA . , ADDRE $S 1'k,.ANO Ap �• .�h'{' '134C Hu Building Inspector t 1 Location I Zo Az,- ' v • No. Date 141- 17 1123 NORTH TOWN OF NORTH ANDOVER i Certificate of Occupancy $ a �'�s'•" E<�' Building/Frame Permit Fee $ ncMus Foundation Permit Fee $ Other Permit Fee $ TOTAL i Check # 162u7 � e� Building Inspeailgf TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING mi BUILDING PERMIT NUMBER. 4DATE ISSUED: 0 3 SIGNATURE: ic Building Commissionef/Inspector of Buildings Date Z SECTION 1-SITE INFORMATION O 1.1 Property Address: 1.2 Assessors Map and Parcel Number: `G ' 6Z l33 1 A4 .0,f 4.0 O l � Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Lectred Provided Reqwred Provided 1.7 Water Supply M.(G-I.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public X Private ❑ Zone Outside Flood Zone Or Municipal jK On Site Disposal System 0 SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT M 2.1 Owner of Record /77 /I t CKO&Y A/ 71 A/-P, Name( ri ) Address for Service � c Si nature Telephone ' 1 I 2.2 Owner of Record: �N Name Print a Pn Address for Service: O M Signature Telephone 9" SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ �tLicensed Construction Supervisor: 6,5.� �� O License Number Address �/ ,, D Expiration Date 3 Si are Telephone r 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Namey 6 9 M /FS Registration Number r Address J rl 7 `6 Z Expiration Date ^ Si�,e Tele hone 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 thebuilding permit. Signed affidavit Attached Yes...... No...... 01 SECTION 5 Descri tion of Proposed Work check all licable New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: owx-- - pd&-& cyJ 68 S F K I SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OFFICIAL USE ONLY Completed b permit applicant 1. Building u _ (a) Building Permit Fee dU 2 Electrical Multiplier (b) Estimated Total Cost of Construction 3 Plumbin Building Permit fee(a) X (e) 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' 2�)Crl;;',� ,as ON-mer/Authorized Agent of subject property Hereby,authorize 1 O to act on My be if i all uta s r , iveItork-authorized7bythis building permit application. Vin 2 Signature of Ownier Date SECTION 7b OWNER/AUT.HORIZ D AGENT DECLARATION I' property as Owner/Authorized Agent of subject Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief Print Name Si ure of Owner/Agent .e D e NO. OF STORIES / SIZE BASEMENT OR SLAB NIA SIZE OF FLOOR TIMBERS 1 2 3 SPAN DEME-NSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS D 11EIGHT OF FOUNDATION N THICKNESS SIZE OF FOOTING �Z•� X MATERIAL,OF CHIMNEY 0 11F IS BUILDING ON SOLID OR FILLED LAND S dL1 D IS BUILDING CONNECTED TO NATURAL GAS LINE I FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. *****************************APPLICANT FILLS OUT THIS SECTION*********************** APPLICANT PHONEj�'Z-63 LOCATION: Assessor's Map Number 6G PARCEL_/33 SUBDIVISION 1 Orl� LOT(S) 3 7 STREET /G ST. NUMBER �9 ************************************OFFICIAL USE ONLY********************** *********** RECOMMENDA NS F TO AGENTS: A CONSERV ADM IS AOR DATE APPROVED_ DATE REJECTED COMMENTS_ WN PLA DATE APPROVED . 2 DATE REJECTED COMMENTS FOO I PECTO,R-HEALTH DATE APPROVED ' DATE REJECTED SEP4C INSPECTOR-HEALTH DATE APPROVED DATE REJECTED COMMENTS_ OA Sp PUBLIC - " WORKS SEWER/WATER CONNECTIONS � ,. DRIVEWAY PERMIT /V /�- FIRE DEPARTMENT I/* � RECEIVED BY BUILDING INSPECTOR DATE Revised 9197 jm CERTIFIED PLOT PLAN LOCATED IN NORTH ANDOVER SCALE:1"= 40' DATE:4/5/95 Scott L. Giles R.P.L.S. 50 Deer Meadow Road / Q, y,�,� North Andover, Mass. � 10 O�y !Q� O% 2500 \ 6 .x� .06 - LOT 16 P C a 29'+/- #19�F FNo 3g', ti `fir 8 - �Ckkop ,beP 2 / k 10 `o' D LOT 36 / m LOT 37 ; z o 21,801•S.F. j r Z ' • m � O 15.17 pp 70 1 CERTIFY THAT tN A THE OFFSETS OFFSETS SHOWN ARE FOR THE USE OF SHOWN COMPLY OF THE BUILDING INSPECTOR ONLY �� WITH THE ZONING AND SUCH USE IS FOR THE BY LAWS OF DETERMINATION OF ZONING �' 1 � NORTH ANDOVER CONFORMITY OR NON-CONFORMITY -,WHEN BUILT WHEN CONSTRUCTED. ¢/ s x , Q T ��, �✓t Eli BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number t& 055417 Birthdate 04/05/1,960 Expires' 04/05/2004 Tr.no: 21586 Restricted`T00 THOMAS D ZAHORUIKO 185 HICKORY HILL,RD.' N ANDOVER, MA 01845 Administrator F t. Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration: 107679 Expiration: 8/5/2004 Type: Individual THOMAS DAVID ZAHORUIKO Thomas Zahoruiko 185 Hickory Hill Road � 4,` North Andover MA -` 01845 Administrator u F- The Commonwealth of Massachusetts W Department of Industrial Accidents Office of Investigations Boston, Mass. 02919 ,alb Workers'Compensation Insurance Aff1davit Name Please Print Name: Location: / .City ki , ✓`-1 ✓, Phone # I am a homeowner rforming all work myself. ® 1 am a sole proprietor and have no one working in any capacity I am an employer providing workers' compensation for my employees working on this job. Company name: Address CI Phone#: tY Insurance.Co. Policy# Company name: Address City: Phone#: Insurance Co. Poligy# Failure to secure coverage as required.under Section 25A or MG can lead to the imposition of criminal penalties of,a fine up to si.5oo.00 and/or one years'imprisorunent_as_welLas_cxvll jxnattiesin.ihe a STOP WORK ORDERand afine_d_(3I.00.DD)ajday.against� understand that a copy of this statement may be forwarded t the ice of Investigations of the DIA for coverage verification. l do hereby ceddy under the pains d penalties of pe] th the infonnatron provided above is true and correct. Signature Date r Print name Pbone Official use only do not write in this area to be completed by city or town official' City or Town PermrAicensing ❑Check d immediate response is required Building Dept 0 LJcensinq Board o Selectman's Dfce Contact person: phone#: o Health Department ❑ Other 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) 59 Siatu e of Permit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for thisro'ect through.p ) the Office of the Building Inspector i rJl LAO R1D6& x io 4 �cd k RST -4[14T 171 scatty (ryp) M n � d P - n` L -1-11 Fx15�11J6 �cK 2xt0 PT. � 1 Fw6 I TkISTwe. STRUCTURE �kPoSfD I i SUN 1200k1� O _ o � E��S t�►�6 D 6G 4� 'PR\V ACX q X H y j f� — � r i 1 l baA3ONRot, (2x10 PT ®140OG� 1Z'SPW 1G. «LD ' I I Styx(o PT• .Dttkl�(�� _ I � LAG IO 1�1_tj ixl ING silt X6Iq 1 Dec K Sic-tloN � �. C7YP.� t-anc,� MRtrKR�SIy�>UL� - SuNtZoou�Ib�cKhrMl-rlUM iz"so'-o, 48"�t 11 197 N\CX<c iA1LL A i NvK rM o E _ o .::�:�: •. Andover 0% No. q V7 0 4( �74-7A " ,?00 3- o�A COCH,C W dover, Mass., ORATED P?��,�5 S BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT......... MAC x .. ........... ................................................................................ Foundation has permission to erect... . .... . .. .............. . . . ......N � . ......My....�. .1.1...R............. Rough to be occupied as..SIAy."Im. ►..+ 1 �$;V P.off.>&CIL M f r o R eit Chimney 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 a Inspection, Alteration and Construction of Buildings in the Town of North Andover. 1 so PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations olds this Permit. Rough PERMEXPIRES IN 6 MONTHS Final IT UNLESS CONSTRUCTIONLSTARTS ELECTRICAL INSPECTOR Rough ....... ..... ..&0 ...... ' coamkoftwAmwService .............................. BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Fina, No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner • Street No. SEE REVERSE SIDE smoke Det. Date........yj�/�! 3 t NOR71� °f<�-`°;•�"a TOWN OF NORTH ANDOVER p PERMIT FOR WIRING SACNUS� P This certifies that ....... ......} .�..1!v!.4.�-..... ..�.............................................. .. has per{nission to perform ..., ��.`'. ' S��"S C//17 �U�C .................................................. wiring in the building of......... ........ a. ../(.................................. r. �. ,/7` ,� . /.. .;/ .��r. orth Andover . s. at.............. . ..7.. �. ....... Fee.. � d� Lic.No ,�.��4.. -�► �!©J ... ........... e!/ �LE RICAL INSPECTOR Check # 1006 Z- 4444 TRECOAMONWEALTH17FMA4CHUSETIS Office Use only DEPA)U31E TOFPUBIICS4FM Permit No. q I BOARDOFFREPREVEMONREGUL4HONS527CMR12M Occupancy&Fees Checked APPUCATTONFOR PERMIT TO PERFORM ELECTRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE,527 CMR 12:00 J (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date y f (o f o 3 Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location(Street&Number) �j ") (�( GrLO Owner or Tenant Owner's Address Is this permit in conjunction with a building permit: YesNo a (Check Appropriate Box) Purpose of Building , �7( �� i�rQ�__ Utility Authorization No. Existing Service AmpsVolts Overhead M Underground M No.of Meters New Service Amps / Volts Overhead r--J Underground r--J No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work LoK (-DU4- '5 0 ti Gi j No.of Lighting Outlets 2— No.of Hot Tubs No.of Transformers Total KVA No.of Lighting Fixtures Swimming Pool Above El Below Generators KVA round ground No.of Receptacle Outlets r No.of Oil Burners No.of Emergency Lighting Battery Units No.of Switch Outlets 0 3 No.of Gas Burners No.of Rang8s No.of Air Cond. Total FIRE ALARMS No.of Zones Tons No.of Disposals No.of Heat Total Total No.of Detection and Pum s Tons KW Initiating Devices No.of Dishwashers Space Area Heating KW No.of Sounding Devices No.of Self Contained Detection/Sounding Devices No.of Dryers Heating Devices KW Local Municipal Other Connections No.of Water Heaters KW No.of No.of Signs Bailasis No.Hydro Ma sage Tubs No.of Motors Total HP OTHER' ` hmuanoeCoWrdg-- ROUarlttotbetegmrffZofMmxhjscUsGalaalLaws IbaNcaaraatliabl7l'tyhmuanoeRkyiwk&gComplell; ve orilsstil>srmvialetgrivaler>t YES NO Ibawstibrri edvalidproofofsametotheOffim YES CD�� IfyoubavedmkodYES plea h dicatethetypeofmvw4pby INSURANCE LZ BOND m ER (Pase Specify) Evirdlion Date / Esumratad VakieofF tl Work$ sigrw Slam `/ /b 1 0 h>SpecfiMD,*Regtlested Rough 1 /0 3 F Sigrredunda�ie ofperjury: FIRMNAME C I L"t LXUWNo. \ l Licerme All (Ct,44 ci/� ,tiSigrlaw A L=WNo rO S— BusamTel No. o S Z- Zo 9`1 ddmL vwo 0� I P�4 t S�Dw� ti� D 3 S AIL TeLNo. D Sr 7 OWNER'SN CEWAIVE,,IamawarethattheL=wdoesnothavetheit am=oovwageoritswborit lequivalalasm4medbyMassadu U G=alLaws and that my sipth nE on this permit apphcaaon waives this wquirmrtIt (Please check one) Owner F-1 Agent Telephone No. PERMIT FEE$ Signature of Owner or Agent M The Commonwealth of Massachusetts d Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 °�M 5�•' 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 I am an employer providing workers'compensation for my employees working on this job. Company name: Address City: Phone#- Insurance.Co. Policv# Company name: 1 Address City: Phone#- Insurance Co. Policv# Failure to secure coverage as nequired under section 25A or MGL 152 can lead to ttie irripasitian o/criminal penalties of.a fine up to si,5w.00 and/or one years'imprisorvnent_as_ncetLas_cavil.penaltieslnlheloan-cfa.STOPWORK ORDBIA d_a.fine-f_(,S11t0.DD)aAW.agabwme 1 understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. l do hereby certify under the pains and penalties of perjury that the infonnadw provided above is true and correct. Signature pie Print name Phone.# Official use only do not write in this area to be completed by city or town cfficiar City or Town Permit/Licensi . � [:]Check if immediate response is required Building Dept ❑ lJCenS%r q Board ❑ Selectman's Office Contact person: Phone#. ❑ Health Department ❑ Other