Loading...
HomeMy WebLinkAboutMiscellaneous - 27 WEYLAND CIRCLE 4/30/2018N SEC & Associates, Inco Surveying & Engineering Consultants January 2, 2015 Jeanne Colachico 27 Weyland Circle N. Andover, Iola 01845 Ree Boundary Survey to Verify Encroachments. Tax Map 65 Lot .236. 27 Weyland Circle. N..Aindover, Zia Dear Jeanne; Please find attached our survey worksheet for your above referenced property. As discussed,,=we have completed the survey to verify encroachments identified on the plain entitled "Plan of band Jeanne M. Colachico 27 Weyland Circle.North Andover, Essex County, Ma.,`Dated 11-12-14, Scale I"=30', Prepared by Cornerstone Energy Services" as provided by you.. We have survey tied to. the available property monuments as shown on the Cornerstone:plan (and the record plan(s) referenced on their plan) in order to accurately identify the amount of encroachment onto your property from the; abutting chimney and AC unit. This survey data was collectedvia a. closed connecting:survey traverse of acceptable closure. All metes and bourids descriptions fror i the record plans were found to be accurate.and tied well. to the monuments found, All considered, the encroachment from the abutting property is depicted accuratly as shown on the Cornerstone plan, and the :amount of:tlie encroachment is accurate. I hope that this letter addresses your coiicerns and if l can be of any additional assistance please do not hesitate to contact me at the number provided. Regards, C Charlie Zilcl Proj ect Manager P.01. Box 1337 *: US NEWTON ROAD UNIT.33A X PLAISTOW, NH 03565 TELL: (603) 382-5065 Fk (603) 352-5216 Jeanne Colachico From: walter lohnes <waiter_lohnes@hotmail.com> Sent: Friday, November 14, 2014 9:32 PM To: Jeanne Colachico Subject: Re: Survey -Plot Plan I understood what you were asking for. You misinterpreted me. I am not on your property. Thank you. Please take a brick from the chimney if you would like. Also, Lets not forget about the tree you took down on my property with out my permission. Again I am open to suggestions on what would make you feel better. On Nov 14, 2014, at 5:26 PM, "Jeanne Colachico" <1mcolachico@comcast.net> wrote: Walter, You apparently misunderstood the purpose of my email and prior communications to you. I do not have a "gripe". I simply was trying to help with a solution. I have no plans or interest which will be impacted by a short-term resolution to this issue one way or the other. The encroachment identified in the survey, does, however, make it necessary that I place you on notice that I did not and do not grant you permission to place or maintain these structures on my property. This is a necessary notice to prevent adverse possession. Although I would expect that this encroachment will be resolved before it is necessary, I am also compelled to require that you make plans to remove the encroaching structures as soon as possible from my property. Regards, Jeanne No virus found in this message. Checked by AVG - www.avg_com Version: 10.0.1432 / Virus Database: 4189/8069 - Release Date: 11/14/14 A A 0 o u �ZZ bw1 � oz �r ir27.3.3- A=oX26`1s'' R=500.00' •L=30.o� DECK 3 EXISTING DVCLLIIqD NNNv-11\ \NN FOXWOOD DRIVE (51Y WDE -- PRIVATE) S2T45'305'E 90.7W DECK SEIDH(F) M AP 65 LOT 236 JEA NINE M. COLACHICD $i : 105[3 PG-. 2411 21,792 t 'F #27 EXIVNG DWELUNG ' H(S)+--SEE DETAIL v IRM F4'r ELAND CIRCLE (4Y WIDE. --- VA -TE) wX MAp f),q. LOT 235 d YAEL f(ADMI l & BK: 9516 £G: 278 van r � �. 0.9 ■ J. �s N .. � ,20,5• 2z' � u5E E�� j T X i r - Ie ' r .r,Y� �� *,,.,.,:R ' •��� .. _ .. ... .. /� yM.. 2, Y /�/J9GC1//�/Y / �F ell 9' S. tea" An/n1 OLS O rE .a/IG".trt✓.�GIGt' f:v�.�vL�E� .J►`'�.►'s.Pf.4 .4,voorE,e; W,,4S-C4ofvSe-rrs ®i!s® S.E. C & Associates, Inc. Surveying & Engineering Consultants January 2, 2015 Jeanne Co , lachico 27 Weyland Circle N. Andover, Ma 01845 Re: Boundary Survey to Verify Encroachments. Tax Map 65 Lo.t.236. 27 Weyland Circle. N. Andover, Ma Dear Jeanne; Please find attached our survey worksheet for your above referenced property. As discussed, w'e have completed the survey to verify encroachments identified, on the plan entitled "Plan of Ema Jeanne M. Colachicoy 27 Neyland Circle.North Andover Essex County, Ma.,*Dated 11-11-14, Scale 1"=30% Prepared by Cornerstone Energy Services" as provided by you. We have survey tied to, the available property monuments as shown, oil n the Cornerst6ne.plah. (and the record plan(s) referenced on their plan) in order. to accurately identify the amount of encroachment onto your property . from the, abutting chimney and. AC unit. This survey data .was collected via a, closed connecting:surve y traverse of acceptable closure. All metes and bounds I descriptions fiom the record plans were found to be accurate and tied well. to the monuments found. All . considered, the encroachment from the abutting property is depicted accuratly as shown on the Cornerstone plan, and the wnowt of the encroachment is accurate. I hope that this letter addresses your concerns and if I can be of any additional assistance Please do not hesitate to contact me at the numberPro vided. Regards, C, Charlie Zilcloq Project Manager P.Q. Box 1337 * 138: NEWTON ROAD UNIT 33A * PLAISTOW, NH 03865 TELE: (603) 382-5065 FAX (603.) 382-5216 Jeanne Colachico From: walter lohnes <walter_lohnes@hotmail.com> Sent: Friday, November 14, 2014 9:32 PM To: Jeanne Colachico Subject: Re: Survey -Plot Plan I understood what you were asking for. You misinterpreted me. I am not on your property. Thank you. Please take a brick from the chimney if you would like. Also, Lets not forget about the tree you took down on my property with out my permission. Again I am open to suggestions on what would make you feel better. On Nov 14, 2014, at 5:26 PM, "Jeanne Colachico" <imcolachico@comcast.net> wrote: Walter, You apparently misunderstood the purpose of my email and prior communications to you. I do not have a "gripe". I simply was trying to help with a solution. I have no plans or interest which will be impacted by a short-term resolution to this issue one way or the other. The encroachment identified in the survey, does, however, make it necessary that I place you on notice that I did not and do not grant you permission to place or maintain these structures on my property. This is a necessary notice to prevent adverse possession. Although I would expect that this encroachment will be resolved before it is necessary, I am also compelled to require that you make plans to remove the encroaching structures as soon as possible from my property. Regards, Jeanne No virus found in this message. Checked by AVG - www.avg.com Version: 10.0.1432 / Virus Database: 4189/8069 - Release Date: 11/14/14 r a. ir27-.3,3- A=03*26'16" R=500.000 .L=3 0 %4"4V 110 'i8H.27'' FOXWOOD DRIVE (50' WDE -- PRI'M'ATE) S27M5r3 E 90.7W SBDH(F) GAAP 65 LOT 236 JEANNE M. C{LACHiC'D DK: 50!iti PIS: 2419 21.792 t SP DECK x , DECK oY!n rto EXISTING , COMM il' DKLLltqG 13WELLJNG S JR(S) SEE DL. ETAI .�' z 1=72.W I� ,� I4760.DD ��`264'r A a4 5313 WEYLAND CIRCLE (AKY WIDE -- PRIMATE) X M A' 65 LDT 235 YiAEL KADMI[ & YOSEF ROT BI,t: 951fi PC: 2713 1 ��m 0 133 ' , . .. ..._ .. Yrs - .�,. ... ..... •.. .. - .. - \ 0 20� `777 .Qf�O.�Gt.S�O f -/DUSK C �C.9�/ons .._/E,�• E -•Y-::5. Iya �' � An/n1 SLS O�rE ........ ,. .. A✓E.�1�!®.+rGIG!' f:�.rvL�E�� ..tf/•�.✓®.�E.f >t Date...' .' ........ TOWN OF NORTH ANDOVER PERMIT FOR WIRING f . This certifies that . .. '::�. '". �� :............................................... has permission to perform .. `.... ...................................... wiring in the building of .... �`........................................ at c7 .. ..... .� ��- >.......... , North Andover, Mass. fi - Fee ............. Lic. No �`?�.c��27 a�}'.....:--c ...�L"' .............. ELECTRICAL INSPEM- R Check # 7201 Commonwealth of Massachusetts Official Use Only Permit No. '% C Department of Fire Services �, Occupancy and Fee Checked 5 BOARD OF FIRE PREVENTION REGULATIONS [Rev. 9/05] (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— %—o i City 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) 2-7 Owner or Tenant 196—/44./ (fC-4D Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes Q® No ❑ (Check Appropriate Box) Purpose of Building 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: /�y�,4i�o� t Completion of the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Above Swimming Pool rnd. ❑ Inrid. nd. ❑ o. o Emergency Lighting Battery 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 g No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Dis osers p Heat Totals Number Tons K. .................... No. o Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW itSyonnection Sec1Vo. of Devi es or Equivalent No. of Water KW of Noof No. of Data Wiring: I Heaters Signs Ballasts No. of Dor Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: AQq*2 j Ple Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: /6-D D r (When required by municipal policy.) Work to Start. Z -7"C7'2 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 covera i in force, and has exhibited proof of same to the permit issuing office. A CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify, under the pains zd penalties of perjury, that the information on lis Ipplic -is true and complete.` t FIRM NAME: /��.Zc�f� LIC. NO.: Licensee: Signature LIC. NO.: (If applicable, enter "exempt" in the license number line.) Bus. Tel. No.: 46526Z6 2— Address: Address: �J� 'Irscl*_4 Jai Z*_451_4dF:: 4 Alt. Tel. No.: 3-) S 573 . *Security System Contractor License required for this work; if applicable, enter the license number here: OWNER'S INSURANCE WAIVER: 1 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 PERMIT FEE: Signature Telephone No. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 mss. www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): /// Address: City/State/Zip: i / Phone #: ��� ��� L �� -2- — Are you an employer? Check the appropriate box: L ❑ I am a employer with '7 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. + 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 ❑ 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 10.0 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. TContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy infonnation. I am an employer that is providing workers' compensation insurance for my employees.. Below is the policy and job site information. Insurance Company Name: i'J��l7d Policy # or Self -ins. Lic. #:yV� 3674- Expiration Date: J Job Site Address: 22 Gy&4, NC: > City/State/Zip: / C 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains andpenalties ofperjury that the information provided above is true and correct Signature: Date: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Issuing Authority (circle one): 1. Board of Health 2. Building Department 6. Other Contact Person: Permit/License # City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector Phone #: Date TOWN OF NORTH ANDOVER PERMIT FOR WIRING This oertifies that .?� PC ........ ..... . has permission to perform .... .... . wiring in the building of..0 Q 0 .ck i P . e� ............ ....... . at ... Q. ! ...... Nodh Andover, Mass. tf y Fee .:! Lic. No. 6 aoa . 0)�r...... .. ... . ELECTRICALINSPECTOR Check # �} 51 1135'9 r _ r <L111\ commonwealth of Massachusetts iO`feryci�al Use Only Permit No. 11 / Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [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 NK OR TYPE ALL INFORMATION) Date: City 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) p27 1A l 6/1 � �t �G Owner or Tenant P h U� C -C A O C k t C C� Telephone No. i. Owner's Address Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. - Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters N S Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters ew ex y ce Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: a No. of Recessed Luminaires No. of Ceii. Susp. (Paddle) Fans No. of Hot Tubs No. of Luminaire Outlets swimmin Pool Above ❑ In- ❑ g rnd. rnd. No. of Luminaires No. of Oil Burners No. of Gas Burners No. of Air Cond. Total . Tons No. of Receptacle Outlets No. of Switches No. of Ranges Heat Pump Totals: Number.. Tons KW ..••.• No. of Waste Disposers No. of Dishwashers Space/Area Heating KW No. of Dryers Heating Appliances 1 KW No. of No.No. Ballasts Bal Signs No. of Motors Total HP of Water Heaters KW No. Hydromassage Bathtubs table may be waived by the Generators KVA ALARMS I No. of Zones 0. o. of Alerting Devices o. of Self -Contained 1Vluntcipat Local El('nnnertinTi ElOther No. of Devices or :a Wiring: No. of Devices or. ecommunications Nn_ of Devices or Wires. OTHER: Attach additional detail if desired, oras required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MBC 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 ® BOND ❑ OTHER ❑ (Specify:) ' I certify, under the pins ndpenalties ofp rjury, that the information on this application is true and complete. LIC. NO.: FIRM NAME:. e Licensee: Signature LIC. NO.: (If applicable, enter "exempt" in the li nse number ' e.) I n Bus. Tel. No.-k-L� `71 l Alt. Tel. No.: Address:4F5'� *Per M.G.L c.147, s.57-61, security work requires Department of Public Safety "S" License. Lic. 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 I PERlMIIT FEE: $ Telenhone No. .0 _71 ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the ;t permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an electrical permit shall be issued to the person, fine or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shall.be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended'by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012. ❑ Rule 8 — Permit/Date Closed: *** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass (] Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass M Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass Failed ❑' Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH SPECTION: Pas Failed l] Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTION: Pass IN Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signat e: Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 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): Address City/State/Zip: J p 0 4Z I � 9 c i WFC. Phone #: q 7r Co ia G o Are you an employer? Check the appropriate box: 1. I am a employer with 4. 111 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. # ship and have no employees These sub -contractors have working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t workers' comp. insurance. 5. ❑ 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.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.0 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. Insurance Company Name: Policy # or Self -ins. Lic. #: -- a Expiration Date: 2 CS^ 2� l Job Site Address: �2 % Lje q City/State/Zip: dQ, .19t�t�a c i2Y 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 certifyy,er 11!rams andpenalties ofperjury that the information provided above is true and correct. Si nature: / r Date: " 1 -- 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 Phone #: Information and Instructions .f Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. M 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-contractor(s) 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 (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. 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 evised 5-26-05 Fax # 617-727-7749 www.mass.izov/dia 9626 Date..... .... 2,— .......I.....d .......... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .. Ci t.. L ...... - /1' 104.7 ............ .............................. has permission to perform .... xew4r4vop.. wiring in the building of ... gea ..... .................................... at ... ... ... ... North Andover, Mass. IZ.......... Fee ..-��.'� . ...... Lic. No ZCP!4� ................. . .. ....... 9LECTRICAL INSPECTOR Check # Department of Fire Services Permit No. V 2 6 ' ' Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leaveblank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Co e (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: � ® 2cyl C, City or Town of: NORTH ANDOVER To the nspector of Wires: By this application the undersigned gives notice of his or her ' tention to perform the electrical work described below. Location (Street & Number) ;27 f Owner or Tenant t ` Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ® No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps, / Volts) Overhead ❑ Undgrd 0 No. of Meters Number of Feeders and Ampacity - Location and `Nature of Proposed Electrical W k: 6e Completion ofthe following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil:P• (Paddle) Fans Sus. ofTotal TransTrsformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires SwimmingPool Above ❑ In- 1:10. rnd. rnd. o Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Detection andInitiating No. of Switches No. of Gas Burners Devices No. of Ran es g No. of Air Cond. Total Tons No. of Alerting Devices Heat Pump Number Tons KW No. of Self -Contained No. of Waste Disposers P Totals: ..... - , .. -7- Detection/Alerting Devices No. of Dishwashers S ace/Area Heating KW P g Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Securi of Devilc : or Equivalent No. of Water KW No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or E uivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: —,Z 6 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 & BOND ❑ OTHER ❑ (Specify:) I certify, under the ams and penalties of perjury, that the information on this application is true and complete. FIRM NAME: LIC. NO.:� Licensee: a Signature LIC. NO.: j,;z (If applicable, enter "exem t" in a license nu line) Bus. Tel. No.: o -l Address T CP P Alt. Tel. No.: oc; *Perm. c. 47, 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 Owner/Agent/ Signature Telephone No. FPE"ITFEE.- $ The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 ,Ye www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: Phone #: Are you an employer? Check the appropriate box: 1. ❑ 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. # 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.] employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ 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. Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: 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 certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: 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 Date., -3. -./—.'!?.7 ..... ,e�tioL M TOWN OF NORTH ANDOVER of o ' A f PERMIT FOR GAS INSTALLATION �9SSACHUSEI This certifies that.'"�:...............Z�-/-e"..t.`... ....... has permission for gas installation in the buildings of .... -r-- �� f .................. . at C= , North ,Andover, Mass. Fee.:.... Lic. o. �. .�E6,&W .......... GAS IN Check # 13 YO 5920 MASSACHUSETTS UNIFORM APPUCATON FOR PERNIlT TO DO GAS FITTING (Type or pint) NORTH A DOVER, MASSACHUSETTS Building Locations �% iso% Qy 119,Nc/ Date 3 -j - 0 `� Permit # L Amount $' Owner's Name New D Renovation Replacement 13-1� Plans Submitted 1-3 (Print or Name_ 0 Name of Licensed Plumber or Gas Fitter pq� ��t,/yt Che k one: Certificate Installing Company tj Corp. 0 Partner. 0 Firm/Co. INSURANCE COVERAGE Check on I have a current liability Insurance policy or it's substantial equivalent. Yes No� If you have checked Les, please jadicate the type coverage by checking the appropriate box. Liability insurance policy El Other type of indemnity 1:1 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 n Agent n harahv rarli A, th.t oil -ftl,e ,lot :1.. --.j -- -- _ --- --- -- ------•-••- .-.• ...........,,.. . .I V kUl clncrcu) In aoove appucation 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 Massachu Sate Gds Code an�Chapter 142 of the General Laws. Title City/Town VED (OFFICE USE ONLY) � 5ignature of Licensed Plumber Or Gas Fitter LJ Plumber J 1 ) Q Gas 'ffFitter icense um e aster 0 Journeyman a w vt O a z w rx V W C7 z H d x w a > w E✓ x e [w- w> w a= m° z' o z W o x m x o x S 3 a ° a > a a o SU B -BASE ENT .ea N BASEM ENT 1ST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR 7TH. FLOOR STH. FLOOR (Print or Name_ 0 Name of Licensed Plumber or Gas Fitter pq� ��t,/yt Che k one: Certificate Installing Company tj Corp. 0 Partner. 0 Firm/Co. INSURANCE COVERAGE Check on I have a current liability Insurance policy or it's substantial equivalent. Yes No� If you have checked Les, please jadicate the type coverage by checking the appropriate box. Liability insurance policy El Other type of indemnity 1:1 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 n Agent n harahv rarli A, th.t oil -ftl,e ,lot :1.. --.j -- -- _ --- --- -- ------•-••- .-.• ...........,,.. . .I V kUl clncrcu) In aoove appucation 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 Massachu Sate Gds Code an�Chapter 142 of the General Laws. Title City/Town VED (OFFICE USE ONLY) � 5ignature of Licensed Plumber Or Gas Fitter LJ Plumber J 1 ) Q Gas 'ffFitter icense um e aster 0 Journeyman NORTH o Date.'77/—.- �. 7. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ................. ......................... has permission to perform ................................ plumbing in the buildings of ................ at ....... .... North Andover, Mass. � Fee Lic. No .%% '­`� ....... ....... PLU &;NC INSPECTOR Check # MASSACHUSETTS (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Location eV 114IV/1 G12, [t APPLICATION FOR PERMIT TO DO PLUMBING Date Name @A n} P Z Cts Permit # 72 y y - Amount 15/9 New Renovation Replacement' FIXTURES Plans Submitted Yes E] No (Print or type) , ` Check one: Certificate Installing Company Name % �,win 6d 7/ [ i- l7 . / ❑ Corp. Partner. , ® Firm/CO. Name of Licensed Plumber. � ,a / �1] � ,�/ Q t i r d Insurance Coverage: Indicate the of insurance coverage by checking the appropriate box: Liability insurance policy 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 1 Agent 11 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 Mas efts te Plum ng Code and Chapter 142 of the General Laws. By: Signature of 17censeaum •er Title Type of Plumbing License / l .. APR City/Town L►'cense um e'1i' r Master IT �j' Journeyman PPROVED (OFFICE USE ONLY ���---+++ � J ry Location w � ��� No. �o�� r Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $s -46 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ r Check # r1 `� �J { 14074 ' �, Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAI RENOVAT OR DEMOLISH A ONE OR TWO FAMILY DWELLING tNG PERMIT NUMBER: j DATE ISSUED: SIGNATURE: Building Commissioner or of Buildings Date 1.1 Property Address: 1.2 Assessors Map and Parcel Number: Map Number Parcel Number �V 1.3Zoning Information: 1 v V-{- 1.4 Property Dimensions: Zoning Dishict Proposed Use Lot Area Fronts e ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard R 'redProvide R 'red Provided Required Provided 1.7 Rater Supply M.G.L.C.40. R 54) 1.5. Flood Zone Information: Public ❑ Private ❑ Zone Outside Flood Zone 0 SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record N e (Print) Address for Sig ature Telephone 2.2 Owner of Record: Name Print SECTION 3 - CONSTRUCTION 3.1 Licensed Construction Supervisor: Licensed Construction Supervisor: Addres4 Signature 3.2 Registered F Company Name Address Contractor Telephone 1.8 Sewerage Disposal System: Municipal ❑ On Site Disposal System C Address for Service: 6. Not Applicable ❑ License Number Expiration Date Not Applicable ❑ Registration Number Expiration Date NML`1 k 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 .......0 No ....... 0 SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: _ j SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed b permit a licant MRCIAL s .. USE ONLY �. " ,:�'Z 1. Building '` 7UDC� , (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) 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�C/,ONTRR%ACTOR`APPLIES FOR BUILDING PERMIT I, �IeanoP ��1 , (�� (!%vii s Owner/A orized Agent of subject property Hereby authorize to act on My behalf, in allt er lative to work authorized by this building permit applicati Si iature of Own - - Date SECTION 7b OWN AUTHORIZED AGENT DECLARA ION I, as Owner/Authorized Agent of subject property 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 Signature of Owner/A ent NO. OF STORIES Date SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 2ND 3PD SPAN DIMENSIONS OF SILLS DIN ENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHFVINEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE C) P£ A) ' s FORM - U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all -necessary approval / permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and or landowner from compliance with any applicable requirements. APPLICANTJ�fl—[ ,-& %' 1. 0 61CSLiC,, c:) PHONE 97 F -,557- ASSESSORS ,557" ASSESSORS MAP NUMBER ('016— SUBDIVISION LOTNUMBER a3(,�, LOT NUMBER STREET6�f 7 4 [ �c STREET NUMBERC-5-2 121 ■ ........■ .............ERNE. ■ ■ ............................. ■ ....... OFFICIAL USE ONLY INMENDENNOMMEN RECOMMENDATIONS OF TOWN AGENTS DATE APPROVED CO SERVATION ADMINISTRATOR .� l�'DATE REJECTED COMMENT'S �� � 1 V%��S t/'�I 1�1 t Cid` � TOWN PLANNER COMMENTS FOOD INSPECTOR - HEALTH SEPTIC INSPECTOR - HEALTH COMMENTS PUBLIC WORKS — SEWER / WATER CONNECTIONS DRIVEWAY PERMIT DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED FIRE DEPARTMENT DATE REJECTED COMMENTS RECEIVED BY BUILDING INSPECTOR i eZ<27- 782 s,,c 'O.SOO AG. i WED C /'GLC YL�, 1 ,s�E.PE�f cE.cr�� To T, .- ;1-17Z-- /-r 1-1TZE/S Coc.ATEO O,V TyE cor.�s s.�n�r-,v A,vo r.�vTrToa�s co,✓Fae� lY/T/1 T,s/E ra�,�/ OF�o_ A.vOO✓E'.Q ZON/NC .c�E6vGAT,l9,t�,S' ,QL�6YI.e0/,t4�s SETB.�C.CS FEO.f1 ST,PEETS � COT C/,uES. '' S F(/,�Tif�E,C CECT/FY TNiIT Tif�/.S GiY'ELL/.Y6 /S it/OT LOG4TE0 /iS/ T,f'E FEGfE,PAG FLOIOO H.92,4f0 A.PE,4. ,SMOiVAt O/S/ FfMA' CO•aAMUN/Ty P.l�eIGL '� z,Sdo98 cbo7C 1G or �,2TN i`1.c/lXSYE,t/ ///qSs' O.P,9f✓i(/ FO.P -rt��oD •E'E,o � ry �a.eG /NE.P.Pyirl.9Gr E.f/G/.t/EE,P/,!/6 SE,E'!�/lES 66 f'.4,P� .S7.rEET A.t/OOI�E.P, /17.4SS.v�//vSETTS O/8/O �o��pGC pa A. aims 'V N i Aat-,V.0.0 riaN. I i i WED C /'GLC YL�, 1 ,s�E.PE�f cE.cr�� To T, .- ;1-17Z-- /-r 1-1TZE/S Coc.ATEO O,V TyE cor.�s s.�n�r-,v A,vo r.�vTrToa�s co,✓Fae� lY/T/1 T,s/E ra�,�/ OF�o_ A.vOO✓E'.Q ZON/NC .c�E6vGAT,l9,t�,S' ,QL�6YI.e0/,t4�s SETB.�C.CS FEO.f1 ST,PEETS � COT C/,uES. '' S F(/,�Tif�E,C CECT/FY TNiIT Tif�/.S GiY'ELL/.Y6 /S it/OT LOG4TE0 /iS/ T,f'E FEGfE,PAG FLOIOO H.92,4f0 A.PE,4. ,SMOiVAt O/S/ FfMA' CO•aAMUN/Ty P.l�eIGL '� z,Sdo98 cbo7C 1G or �,2TN i`1.c/lXSYE,t/ ///qSs' O.P,9f✓i(/ FO.P -rt��oD •E'E,o � ry �a.eG /NE.P.Pyirl.9Gr E.f/G/.t/EE,P/,!/6 SE,E'!�/lES 66 f'.4,P� .S7.rEET A.t/OOI�E.P, /17.4SS.v�//vSETTS O/8/O es lox M W 44 \O w° CO p" ro- G w2 �M A°G G U ww°' ® E-4 ADD w O H W W Ga Dp GAG U w ® U X00 w F" W C r a 2 y cnn Q oC V)) U 0 z 0 u Cn M�1 O O v v P4 COD co co co C co Q _m CL CA v sCL COD C o� _cc ca r� CD CM ®co� cc cc 0 U) crW W W U) Cs .. Q •; � C CO O Cg : C o ca CJ � C W a: Q L co CA= Q �. Q CaO a.m CD E ` C=2 y H co ®� to c ®® a cm CD y CD CS cm � � C �e ® p f ti Q/i O r3 N ® c C NL O?Lm� 3 ®co :® ® o ID t uj 40D ta (M L2•® CL O m ®- COO ®- ® � C 4- CLECoC U 0 z 0 u Cn M�1 O O v v P4 COD co co co C co Q _m CL CA v sCL COD C o� _cc ca r� CD CM ®co� cc cc 0 U) crW W W U) TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER .� DATE ISSUED: -< SIGNATURE: /11 P Building Commissioner for of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: A 623 Map Number Parcel Number 1.3 Zoning Information: Zoning Distrid Proposed Use 1.4 Property Dimensions: Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide ReAWred Provided R red Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: Public ❑ Private ❑ Zone Outside Flood Zone ❑ 1.8 Sewerage Disposal System: Municipal ❑ On Site Disposal System 0 SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record Na a (Punt) Address for S rvice Si ature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Licensed Construction Supervisor: Address Signature Telephone Not Applicable ❑ License Number Expiration Date 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Address Expiration Date Signature Tele hone /X SECTION 4 - WORKERS COMPENSATION (NLG.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. Si ned affidavit Attached Yes .......0 No ....... ❑ SECTION 5 IDescri tion of Pro osed Work Lheck all a licahle New Construction 0 1 Existing Building ❑ 1 Repair(s) ❑ 1 Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: cls. I SECTION 6 - ESTIMATED C'ONSTRUC'TION COSTS I Item Estimated Cost (Dollar) to be� Completed by permit applicant OFFICLI�USE Building Permit Fee Multiplier Multi lier 1. Building(a) 7V 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) 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, �.1E���/"J� `�" . �..L:U' t' (sO wner/A orized Agent of subject property Hereby authorize to act on My behalf, in all er lative to work authorized by this building permit applicati Signature of Own ' Date SECTION 7b OWN AUTHORIZED AGENT DECLARA ION01 I, as Owner/Authorized Agent of subject property 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 of Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TRVIBERS 1 2ND 3 SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE TOWN OF NORTH ANDOVER BUILDING DEPART'MEN'T APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING roro BUILDING PERMIT NUMBER: DATE ISSUED: C SIGNATURE: Building Commissioner/Intector of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: Map Nuxr6er Parnef 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 Required Provided Required Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal ❑ . On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSI[IP/AUTHORIZED AGENT 2.1 Owner of Record L l C-r�- id ��Z ��►� ��- � �'�..��T ' ,5"�l lei- ��'���" �c�. ,v'. � �,�i.e,/ Name (Print) Address for Service: 61800 —6916,30 Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 'censed Construction,Suu rvisor: Not Applicable ❑ Licensed Construc kon Supervisor: / License Number c7c1✓ Ad ss -70 6 UES [ Expiration ate ignature Telephone 3.2 Registered Home Improvemen Contractor Not Applicable ❑ •7 % l Company Name Number , /� A oRegistration :, �-) Y/1 A dre s /I I - y,, r ., t, ify 7 �'� L)Li Expira on date Si nature Telephone J 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. Si ned affidavit Attached Yes .......❑ No ....... ❑ SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ 1 Existing Building ❑ 1 Repair(s) ❑ Alterations(s) ❑ Addition 0 Accessory Bldg. ❑ I Demolition ❑ I Other ❑ Specify Brief Description of Proposed Work: ILITiliI CIX610 *4101u I:'l}3 OX0111 1;1V:UWIN I Ell %', Item Estimated Cost (Dollar) to be Completed by permit applicant V 1. Building (a) Building Permit Fee Ota Multiplier 2 Electrical (b) Estimated Total Cost of U O [ Construction 3 Plumbing (j , Building Permit fee (a) X (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 0 Ed- 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/AUTHOR17,ED AGENT DECLARATION as Own uthorized Agent of 'sub' t property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief /vri Print e Si tore of e ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIIvMERS 15F 2 3 RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIN ENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHRANEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE t :6 - � TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: DATE ISSUED: SIGNATURE: Building Commissionerfl for of Buildings Date SECTION 1- SITE INFORMATION �1.1 Property Address: 1.2 Assessors Map and Parcel Number: G� c t� Map Number Parcel Number 1.3 Zoning Information: Zoning DQ-ric—t Proposed Use 1.4 Property Dimensions: Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: Public ❑ Private ❑ Zone Outside Flood Zone ❑ 1.8 Sewerage Disposal System: Municipal ❑ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record �f Q o Name 6i/nt)� �iAddress for Service: Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTIO 3 - CONSTRUCTION SERVICES 3.1 LiceConst Otion Supervis . 9 7 L' d Cons ruction Supervisor: le c�. Z A ess s 's ignature Telephone Not Applicable ❑ / License Number Expiration Date 3.2 Registered ome Improvement Contractor Not Applicable ❑ q tri e Company Ne y V • Vtl ... �� (/ 0 v 6 G.Y � V Y Registration Number jAddress 7"�(�y u Telephone Expiration Date la/ 0 V Y� R z M 0 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 in the denial of the issuance of the building permit. Signed affidavit Attached Yes .......❑ No ....... 0 SECTION 5 Description of Proposed Work(check all a Ucable New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) 0 Addition 0 Accessory Bldg. 0 Demolition 0 Other 0 Specify Brief Description of Proposed Work: I SECTION 6 - ESTIMATED CONSTRUCTION COSTS 1 ate- a .'. _-. i M11 result Item Estimated Cost (Dollar) to be Completed t%�GIAIUSEiDNLY r by 2ermit a licant 1. Building© (a) Building Permit Fee Multi lier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) x (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWINEK AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Ow0f( Hereby authorize My behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION zed Agent of to act on property I, as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING T�il9CCti08";fOC,QIA(9C~i BUILDING PERMIT NUMBER: DATE ISSUED: C SIGNATURE: Building Commissioner/Ins ctor of Buildings Date MMM p�q Iii z O M 00 f 0 O M 90 O r M r r 0 z 0 SECTION I- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: Number Parcel Number ter ill � 013Map `i Sl _ 1.3 Zoning Information: ' 3 �' e� J,�- a ---------- - ----------------------- Zonin 1 i.. ct Proposed Use 1.4 Property Dimensions: ,a s J � � e v "I t°t �9°I 1 p P11,00: - y — -gyp `7/"------ j � �-------- Lot Area SO J Fronta e ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided 30 • 1.7 Nater Supph' M.C.L.C.40. 54) public ❑ private i� 1.5. Flood Zone Information: Zone Outside Flood Zone ❑ 1.8 Sewerage Disposal System: Municipal ❑ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record Name (11n Address for Service Z 15�14nature Telephone 2.2 Owner of Record: M rm�ft I cr,c' .--------L-1-�1�_1 [l__.� 1��. nN�c���:r 11t/ --------- Name Print Address for Service: g Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Licensed Construction Supervisor: Address Signature Telephone Not Applicable 0 License Number Expiration Date 3.2 Registered Home Improvement Contractor Not Applicable 0 Company Name---- — Registration Number —---- ----------- ------------ — — Address Expiration Date Sienature Telephone MMM p�q Iii z O M 00 f 0 O M 90 O r M r r 0 z 0 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 all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition Accessory Bldg:. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: 2S x its r 6+'OcAe�� alail. —a� SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit applicant '104WIAL,USYONLY 1. Building (a) Building Permit Fee Multiplier 6 0 2 Electrical �1 (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) X (b) IV SD 4 Mechanical (HVAC) Fire Protection ( 6 Total—( 1 +2+3+4+5) 1 /00 , oe Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1. Clas Owne horized Agent of subject property Hereby a orize to act on Mv t, in1 i ers rely ve to work authorized by this building permit application. nat e of O�yner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belie( Print Name Signature of 0\ er/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TD,1BERS 1 2 3 SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DMINSIONS OF GIRDERS I IF IG I Ff OF FOUNDATION THICKNESS SIZE Oi= FOOTING X MATERIAL. OF CI-IININEY IS BUILDING ON SOLID OR FILLED LAND IS 13(JIL,DING CONNECTED TO NATURAL GAS LINE �i�r uuutututtwettttt( ut �Utttul�tt�l�ttuett.� Office Use Only Depnrtruenf of Public Safety BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 Permit No. _. 0� 6j, Occupancy & Fee Checked 3/911 (leave blank► APPLICATION FOR PERMIT -1-0 PERFORM ELECTRICA All work to be performed in arcurd.mse with the h1dssa(husetts fleclri<al Code, 527 CMR 12:00 WORK (PLEASE PRINT IN INK OR YPE A L INFO ATION) O Date City or Lown of the undersigned applies for a•permit to perform the electrical work described relow --"-- —To the Inspector of Wires Location (Street & Number) —— / Owner or Tenant��Q(' Owner's Address — Is this permit in conjunction with a build'ng permit: �----'— Y(.s ❑ No `�' (Check Appropriate Box) Purpose of BuildingGalivsp Existing Service -- -- --------------__-UUhly Authorization NO. .—.— Amps--------/ _—_ Volts Overhead 11llndgrd ❑ New Service No. of Meters Volts Overhead ❑ ❑ Number of Feeders and Ampacily llndgrd No. of Meters _ _-- -- location and Nature of Proposed Electrical Work -� ear- No. of Lighting Outlets No. of I lot 1 ubs TOTAL No, of li hlin Fixtures A 1>Ve Swimmin Pool No. of Transformers KVA In - ❑ ❑ md. rnd. Generafnrs No. of Receptacle Outlets No, of Oil Burners KVA No, o Emergency Lighting No. of Switch Outlets BatteryUnits No. of Gas Burners No. of Ranges Tota FIRE ALARMS No. of Zones._________, No. of Air Conditioners No. of Defection and Tuns No. of Disposals Feat total TotalInitiating Devices No. of Pum rs Tons KW No. of Sounding Devices No. of Dishwashers No. of Self Contained -Space/Area f it alir� KW Dele(lion/Sounding Devices No. of Dr ersMunicipal I featiniz Devices local[],Connection ❑Other KW No. of Water Heaters KW o. o No. of Signs Ballasts Low Vo to e n No. hydro Massage Tubs I No of Motors Total HP _ OTHER: :. FIAT r =U INSURANCE COVERAGE: Pursuant to the reclmrements of Massa('rmsltes General Laws I have a current Liability Insurance Policy including Completed Operralions Coverage or its substantial equivalent. YES L7 NO O !have submitted valid prop( of same to Ibis office. YES (J NO 11 If you have checked YES, please indicate the type of coverage by chocking the appropriate box. INSURANCE ❑ BOND ❑ OTHER❑ (Please Spe(-ify) --_ Estimated Value of Electrical Work $ _ Work to Start _ Signed under the penalties of neriurv. . FIRM NAME —40— 11EM51 Licensee t2 Address X9.2 Inspection Dale Requested: Rough Final (Expiration Date) OL — LIC. NO. .Signature — �� Tel.Tel. o. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its substantial equilvalent as required b assachus its General Laws, and that my signature on Ihis permit application waives this requirement. Owner Agent (Please check one) `� (Signature of Owner or Agent)- Telephone No._____ —�ZYJ PERMIT FEES vvv--- C4 & V�lCf : 2 6 0 5 Date. i.. - h r of No o' "9tia TOWN OF NORTH ANDOVER 3 0 PERMIT FOR INSTALLATIONS' S« �97SACMUSESAy - M This certifies that... =`. ?.. ... ° has permission for SW installation ... y in the buildings of .... at .. 1.. W F �:l t` <<�� ! % ............ North Andover,., Masg Ll 3 Fee..JS ::.0 Lic. No......... ... ........... GAS INSPECTOR d -WHITE: Applican�." • •CANARY Building Dept. -PINK Treasurer GOLD File Two Center Plaza Boston, Massachusetts 02108-1904 (617) 723-3800, Ma Only (800) 392-6108, Fax (617) 557-5675 Form of Notice of Casualty Loss to Building Under Mass. Gen. Laws, Ch. 139, Sec.3B NORTH ANDOVER HEALTH DEPT. NORTH ANDOVER TOWN HALL NORTH ANDOVER MA 01845 Re: Insured: Property Address: Policy Number: Type Loss: Date of Loss: Claim Number: 09/11/03 p Rei Aa 6-F SEP 1 , JEANNE M COLACHICO 27 WEYLAND CIR, NORTH ANDOVER, MA 01845-4933 0659322 Vandalism 09/11/03 201264 Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or cause Massachusetts General Laws, Chapter 143, Section 6 to be applicable. If any notice under Massachusetts General Laws, chapter 139, Section 3 B is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim or file number. MPIUA Claims Division CMA00021 Location Z1������ �- No. 009V Date 7915 Div. Public Works .:TOWN OF NORTH ANDOVEW Certificate of Occupancy $ -Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL $_ Building Inspector Div. Public Works } LocationC1fLcu, wr�o4 No. Date Z b 1 j NORTM TOWN OF NORTH ANDOVER Certificate of Occupancy Y . Building/Frame Permit Fee $ y• 4 a.4Y` sAcHus Foundation Permit Fee $ I`/■4.: ! /\ Other Permit Fee . $ Sewer Connection Fee $ .t. Water Connection Fee $ TOTAL $� Building Inspector 02/01/95 10:21 150.00 PAID N2 --7901 M � _ Div. Public Works Location Z? Q41 Date- TOWN ate , TOWN OF NORTH ANDOVER ro�t,�.o Certificate of -occupancy $ Y � R Building/Frame Permit Fee $ Foundation Permit Fee $ ` E,.• - Other Permit Fee $ Sewer Connection Fee $ 4�7 Water Connection Fee $ /077. TOTAL $ Inspector 4 g A'Tf 9 Dive lic Works 8 `# I d PERMIT NO. APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. PAGE 1 , I MAP KVO. LOT NO. 2 RECORD OF OWNERSHIP IDATE BOOK 'PAGE ZONE SUB DIV. LOT NO. 244 sq LOCATION y �. _ ] C PURPOSE OF BUILDING a k" % (/ OWNER'S NAME �� NO. OF STORIES SIIE �Q j OWNER'S ADDRESS 77, , I S _— BASEMENT OR SLAB / ARCHITECT'S NAME f SIZE OF FLOOR TIMBERS IST ;2 )(/02ND �/� 3RD V BUILDER'S NAMESPAN _ 15 DISTANCE TO NEAREST BUILDING G1 i1 a DIMENSIONS OF SILLS - -' POSTS 3 DISTANCE FROM STREET ,.- DISTANCE FROM LOT LINES - SIDES 1��, REAR ®{�/ GIRDERS I% f AREA OF LOT I . FRONTAGE / HEIGHT OF FOUNDATION �THICKNESS IS BUILDING NEW V _�i s r T/Il SIZE OF FOOTING - ®�� X .91-.;r1 IS BUILDING ADDITION ,v 0 MATERIAL OF CHIMNEY v� r I IS BUILDING ALTERATION A %I a IS BUILDING ON SOLID OR FILLED LAND S© WILL BUILDING CONFORM TO REQUIREMENTS OF CODE .e IS BUILDING CONNECTED TO TOWN WATER 7'/ BOARD OF APPEALS ACTION. IF ANY / '/ AM � IS BUILDING CONNECTED TO TOWN SEWER 1° s IS BUILDING CONNECTED TO NATURAL GAS LINE ,..P INSTRUCTIONS SEE BOTH SIDES PAGE 1 FILL OUT SECTIONS 1 - 3 PAGE 2 FILL OUT SECTIONS 1 - 12 3 PROPERTY INFORMATION PERMIT FOR FOUNDATION ONLY -4 e LAND COST - REGULATED BY PARA. 114.8-S. B.C. EST. BLDG. COST _ ,Z 0 00, EST. BLDG. COST PER SQ. FT. d DATE , 9'C- FEE PAID l w EST. BLDG. COST PER ROOM t{ii i�ri�l PTIC PERMIT NO. ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING 4 - APPROVED BY ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILLED AND/APPROVED BY BUILDING INSPECTOR • DATE FILED . SIGNATURE OF OWNER OR AUTHOWIZED AGENT w FEE Lq=14 o0 PERMIT GRANTED PERMIT FOR FRAME/BUILDING DATE: FEEPAID- l8i4r e i WIN F-OMIV41 ■UILDING IN:PHCTC OWNER TEL. J! CONTR. TEL. N CONTR. LIC. #. C) 4 F 1 OCCUPANCY SINGLE FAMILY —4 STORIES MULTI. FAMILY APARTMENTS CONSTRUCTION 2 FOUNDATION CONCRETE_ CONCRETE SL K. BRICK OR STONE PIERS _ 8 INTERIOR 3 PINE HARDW'D PLASTER DRY WAIL UNFIN. FINISH 1 2 13 _ 3 BASEMENT AREA FULL FIN': BM T' AREA V. 1/2 1/1 FIN. ATTIC AREA NO B M T FIRE PEACES HEAD ROOM MODERN KITCHEN — 4 WALLS I 9 FLOORS CLAPBOARDS B 1 2 3 �_ _ —{I_ DROP SIDING WOOD SHINGLES CONCRETE EARTH ASPHALT SIDING HARDW D ASBESTOS SIDING VERT. SIDING _ COMMON ASPH. TILE STUCCO ON MASONRY. _ STUCCO ON FRAME, BRICK ON MASONRY ATTIC STRS. & FLOOR BRICK, ON' FRAME , I_ CONC. OR..CINDE R- BLK. WIRING STONE bN..MASONRY, STONE ON FRAME" SUPERIOR POOR ADEQUATE NONE ADEQUATE 5 ROOF 10 PLUMBING GABLE GAMBREL I HIP MANSARD BATH 13 FIX.) 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 6 FRAMING I i l HEATING WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. TIMBER BMS. & COLS. STEAM STEEL BMS. & COLS. HOT W'T'R OR VAPOR WOOD RAFTERS AIR CONDITIONING _ RADIANT H'T'G UNIT HEATERS 7 NO. OF ROOMS GOAL B'M'T 12nd _ j ELECTRIC 1st -3rd NO HEATING ff BUILDING RECORD 12"Il.. r THIS SECTION MUSTSHOWtE- ACT\DIMENSIONS'OF LOT AND DISTANCE FROM LOT LINES AND EXACT DIMENSIONS OF 6UILDINGS'*. WITH PORCHES. GA- RAGES. ETC. SUPERIMPOSED. THIS REPLAGES:PL•OT PLAN." \ Tl 4 PAC �„ _ ,+ a ,r �' ar.. �vsa.. -sar. "�•• 1rup"31 Zia " Amp c r ��-- 77.08' o0 d ' o o �orE P�'oPE•.erY L�.✓E �'' �NO/CATS ,a,�oPosEp �,ee.�E•ery L�,�.E,s, � � � �•e,.sr • ti� N hr �Yc9vo 2 i IT Z /1EREBY CE.cTlFY 727 TyE ;-/TLE /.</SU.�O.CA.VO �` O T TD 7.yE 7W,,QT /-f LVe,4TEO OW T//E GoT .IS S.fGi!✓•t/ ANO T,iG4T?.0462• O/r.IO. gvoa� ZO�✓�i�6 c�E6vLAT.lot/S ,�6r/.e0/.4ts SET�If�t'S FEOA1 ST.PEGTS 1 LOT U•vES. " /VQ,2Tj�/ �iVOd �E,�1 �q.SJ: 1 f!/.rJ'iYl..0 tE,CTjFY THAT T•Y/.t O.V2rGt/N6 /S.t/OT LOG4TE0 /� T.f�E FEGIE.P.4G �O!OO fi�i4Z.4C0 APER. �.Pq�� FO.P �fydlvil! OJV FEM�f' COMMt/N/Ty PifNGL '� C y �.2� 2SCY%98 Off% C / �JCLuG7Q.D �EAC.T �NOFAfiL4� OATFD 6Iz/93 JE ./ .4 �n#36u i �v SSK�,;�` iVOT FD.P Boavv.PY � ` /.?3+.e6tA�!O _ BD!/.VOA.PY /�(/FOiP/1•f- /NE.P.P/rfl.4G(� E'.VGivEE.P/.v6 SE.P�i�'ES AT/O•�/ TA.t�E.S/ F � rsT�.vc .eEcoeos. GG i'q•P,f� ,.ST,PEET A.t/OOYE.� �1.4.5_S.4G'//!/SETTS O/8/O I MOO I pl U O r Q 0 l�— co 0 CD O O C3 Z O O.. O y � C ICD >a C CD c y 0 � An O •O •E m m CL O O G i Off. aO �a ca C •O O Cc vCc J10 CD c Z CD V CD ca O y On w F— z LU Q w 0 i -O CC W Q W ®R W O rz 0 UU w a IA w � "•' ...� z z r• � E A u i V C L z b O a LE V) ° U x C" w I MOO I pl U O r Q 0 l�— co 0 CD O O C3 Z O O.. O y � C ICD >a C CD c y 0 � An O •O •E m m CL O O G i Off. aO �a ca C •O O Cc vCc J10 CD c Z CD V CD ca O y On w F— z LU Q w 0 i -O CC W Q W ®R C� "•' ...� Z 00 CO O .,moi cmQ C L z O OU cz �ecvuO..W . N Zm•' a W : m c X Q C2o. N ?' V E 5 Ibl: .o 3'C. jj a 3 IS '*' cm m C U N :mm C 16-� VJ g CO o N � : N ea C 0 N W CDo :•m O O m C: s = o os 3 � � •� X a�z mom Q: - v N O U F. O c CL •O Q m : i m C O. •NO.t CD O H ac E C Z. �� v•N O¢ cp Q CO2 O. m� O 0 I MOO I pl U O r Q 0 l�— co 0 CD O O C3 Z O O.. O y � C ICD >a C CD c y 0 � An O •O •E m m CL O O G i Off. aO �a ca C •O O Cc vCc J10 CD c Z CD V CD ca O y On w F— z LU Q w 0 i -O CC W Q W ®R a;. Y FORM U - IAT REMME FMM 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 outthis section***************** APPLICANT: APPLICANT 7 ---�k r (n 1- 10 Phone [� �� M c� LOCATION: Assess or's Map Number Parcel Subdivision Lots) Street 42- C La m cyl L1 r /P St. Nu::tcer9.% Use Only*******************w**** F RECOMMENDATIONS IOFF TOWN AGENTS: ('66 ��D K- l M t -y% Date Approved l Cons er•: a -_on ?,dam _nis teat ,r Date Rejected Cc= en-_ �Q Date Approved 1 Town Planner Date Re j ec -ed Cc=en":s Fco:: Sect:.c Date Approved Date Rejec-ed Date Apprcved Date Rej ec -ed Pu_'-_ wcr�:s - seT•rer,'water connections i- 3c) -`?S - driveway pe�--iit Fire Dec r"=,er.- �f Received by Bui ing Ins:ec..orDate d ON CD C� uj 6 z z c c Cl oq c Z� 000a„ 'v m := o -33 :c`mwcm Ea a.W L m C CL N a 3 cm N - L2 U •mm .2 o �z N y > 3 r � m� CIO 1fi : N y N P �E cD D: O a O a O J•Nmm 3� U W O W x O zw a H O CD c7 CD o a A z�y y m U A •N O -M c 'dt A ~ � E w oa W �+ W °°° > CdE c o w° Cin ° � U w w w°' cn x � w W ci) cn CD C� uj 6 z z c c Cl oq c Z� 000a„ 'v m := o -33 :c`mwcm Ea a.W L m C CL N a 3 cm N - L2 U •mm .2 o �z N y > 3 r � m� CIO 1fi : N y N P �E cD D: mo - J•Nmm 3� QQ os o c CD CL CD o C42 CA�mo = H yam+ y m WC '�O_•+ 'O •N O -M c 'dt A ~ � E c V �"' m •y c, -o v C.3 c o 0:c COD y '� = =ONa0m 4 i c O Uui J �LU �-- d • Ll � � � bLo co PQ CO) o F- z Z t tz w cmo CO) y � .�LU W 'Eppm z > Q CD o) o o CL ~ E o C CD i aC21 z �a a. fl. �a WCIO o CO2 -v ��C CJ -Jcm z 'Q o ,CD m Z CD z CD U V CO) cm j per... O c C c W C 14 p� w C ' Li. y Rt z LULU a. C/) 0