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MASSACHUSETTS UNIFORM APPUCATION FOR PSSMIT TO DO GA!
(Print or Type)
<5Z\ NORTH ANDOVER Mass. Date
tuilding Location 9ZY �-qmney- s-�, Permit #
Owners Name Pei
77 Renovation Reolacement Plans Submitted
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(P -int or Type) Check one: . Certificate
Instailing Company Name
44 li6,. c,4 Corp.
Address d. v. Partner.
Firm/Co.
Business Telephone:
Name of Licensed Plumber or Cas Fitter .&�Xn '4rd""'
Insurancr- Coverace: lnd;c2-.a z�-e zype of insurance coverage by checking the
appropriate box:
Liability insurance policy = Czi-.er type of indemnity = ..Sond-
Insurance Waiver: 1, the undersigne,-J, have been made aware that the licensee of
this appiLelition does not have ary one of the above three insurance coverages._
I CIL1�
Signature or owneri-age of properzy Owner = -Agent
I h=hy ceniry that i1i of the details and informadon I -have Luhruitted (or entercd) in above zoplication are true and accurate to the best of mY
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APPROV'ED (OFFICE USE 0MLYJ
G, a s f i e r
Signature of License,_4
Ma S t e r
Plumber �r sfitter
journeyman
L.L�:ense Number
92
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(P -int or Type) Check one: . Certificate
Instailing Company Name
44 li6,. c,4 Corp.
Address d. v. Partner.
Firm/Co.
Business Telephone:
Name of Licensed Plumber or Cas Fitter .&�Xn '4rd""'
Insurancr- Coverace: lnd;c2-.a z�-e zype of insurance coverage by checking the
appropriate box:
Liability insurance policy = Czi-.er type of indemnity = ..Sond-
Insurance Waiver: 1, the undersigne,-J, have been made aware that the licensee of
this appiLelition does not have ary one of the above three insurance coverages._
I CIL1�
Signature or owneri-age of properzy Owner = -Agent
I h=hy ceniry that i1i of the details and informadon I -have Luhruitted (or entercd) in above zoplication are true and accurate to the best of mY
kno-tcdge and tiLat aLL ;1(umbinr work and Instadatiatts -.cr-far=c1_ undzr* Pur.nuc i=uzd cc.- thil sprkication WiU b�c in cognpLiancs Wittz Ld pertln=t
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By
T i &-' I e
APPROV'ED (OFFICE USE 0MLYJ
G, a s f i e r
Signature of License,_4
Ma S t e r
Plumber �r sfitter
journeyman
L.L�:ense Number
.............
Date.
TOWN OF NORTH ANDOVER M
- t PERMIT FOR GAS INSTALLATION
,0
'I'SACH
This certifies that .......................................
has permission for gas installation,.". .................
in the buildings of ........... .............................
at ................................... North Andover, Mass.
Fee.......... Lic. ..........................
GASINSPECTOR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
Spy
Massachusetts Department of Environmental Protection DEP File Number:
Bureau of Resource Protection - Wetlands
WPA Form Q — Order of Resource Area Delineation 242-1256
Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 Provided by DEP
A. General Information
Important:
When filling out From:
forms on the North Andover
computer, use Conservation Commission
only the tab
key to move This Issuance is for (check one):
your cursor -
do not use the Z Order of Resource Area Delineation
return key.
Amended Order of Resource Area Delineation
To: Applicant:
William Gillen
Name
54 Spring Hill Road
Mailing Address
North Andover MA. 01845
Property Owner (if different from applicant):
Same
Name
Mailing Address
City/Town State Zip Code City/Town
1 . Project Location:
Summer Street & Mollytowne Road North Andover
Street Address City/Town
Map 38, Map 65 Lot 32 & 91
Assessors Map/Plat Number Parcel /Lot Number
2. Title and Date (or Revised Date if applicable) of Final Plans and Other Documents:
Abbreviated Notice of Resource Area Delineation Plan
Title
Title
Title
3. Dates:
5/8/04
Date Notice of Intent Filed
8/4/04
Date Public Hearing Closed
8/6/04
Date of Issuance
State Zip Code
4/28/04 last
revised 7/23/04
Date
Date
wpaform4b,doc - rev. 12/15/00 Page 1 of 3
A
Massachusetts Department of Environmental Protection DEP File Number:
Bureau of Resource Protection - Wetlands
WPA Form Q — Order of Resource Area Delineation 242-1256
Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 Provided by DEP
B. Order of Delineation
The Conservation Commission has determined the following (check whichever is applicable):
Z Accurate: The boundaries described on the referenced plan(s) above and in the Abbreviated Notice
of Resource Area Delineation are accurately drawn for the following resource area(s):
Z Bordering Vegetated Wetlands
Z Other Resource Area(s), specifically:
Limits of the Vernal Pool all local/buffer zones associated with the Bordering Vegetated Wetland & the
Vernal Pool.
F-1 Modified: The boundaries described on the plan(s) referenced above, as modified by the -
Conservation Commission from the plans contained in the Abbreviated Notice of Resource Area
Delineation, are accurately drawn from the following resource area(s):
Bordering Vegetated Wetlands
[] Other Resource Area(s), specifically:
inaccurate: The boundaries described on the referenced plan(s) and in the Abbreviated Notice of
Resource Area Delineation were found to be inaccurate and cannot be confirmed for the following
resource area(s):
F� Bordering Vegetated Wetlands
E] Other Resource Area(s), specifically:
The boundaries were determined to be inaccurate because:
wpaform4b.dod -rev. 12/15/00 Page 2 of 3
Massachusetts Department of Environmental Protection
Bureau of Resource Protection - Wetlands
DEP File Number:
WPA Form 4B — Order of Resource Area Delineation 141-1256 -
Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 Provided by DEP
B. Order of Delineation (cont.)
This Order of Resource Area Delineation determines the boundaries of those resource areas noted above
and is binding as to all decisions rendered pursuant to the Massachusetts Wetlands Protection Act
(M.G.L. c. 131, § 40) and its regulations (310 CIVIR 10.00) regarding such boundaries. This Order does
not, however, determine the boundaries of any resource area or Buffer Zone to any resource area not
specifically noted above, regardless of whether such boundaries are contained on the plans attached to
this Order or to the Abbreviated Notice of Resource Area Delineation.
This Order must be signed by a majority of the Conservation Commission. The Order must be sent by
certified mail (return receipt requested) or hand delivered to the applicant. A c a so �nust be mailed or
5pf0s?
hand delivered at the same time to the appropriate DEP Regional Office (;zee' Appendix A)
Sigi
This Order is valid for three years from the date of issuance.
This Order is issued to the applicant and the property owner (if different) as follows:
R by hand delivery on E� by certified mail, return receipt requested on
Date
C. Appeals
g
'& /0'/
Date ' ,
The applicant, the owner, any person aggrieved by this Order, any owner of land abutting the land subject
to this Order, or any ten residents of the city or town in which such land is located, are hereby notified of
their right to request the appropriate DEP Regional Office (see Appendix A) to issue a Superseding Order
of Resource Area Delineation. The request must be made by certified mail or hand delivery to the
Department, with the appropriate filing fee and a completed Appendix E: Request for Departmental Action
Fee Transmittal Form, as provided in 310 CMR 10.03(7) within ten business days from the date of
issuance of this Order. A copy of the request shall at the same time be sent by certified mail or hand
delivery to the Conservation Commission and to the applicant, if he/she is not the appellant.
The request shall state clearly and concisely the objections to the Order which is being appealed and how
the Order does not contribute to the protection of the interests identified in the Massachusetts Wetlands
Protection Act, (M.G. L. c. 131, § 40) and is inconsistent with the wetlands regulations (310 CIVIR 10.00).
To the extent that the Order is based on a municipal bylaw or ordinance, and not on the Massachusetts
Wetlands Protection Act or regulations, the Department of Environmental Protection has no appellate
jurisdiction.
wpaform4b.doc - rev. 12/15/00 Page 3 of 3
Massachusetts Department of Environmental Protection
Bureau of Resource Protection - Wetlands
WPA Ap�pendix A - DEP Regional Addresses
Massachusetts Wetlands Protection Act M.G.L. c. 131, §40
Mail transmittal forms and DEP payments, payable to:
Commonwealth of Massachusetts
Department of Environmental Protection
Box 4062
Boston, MA 02211
DEP Western Region
Adams
Colrain
Hampden
Monroe
Pittsfield
Plainfield
Tyringham
Wales
436 Dwight Street
Agawam
Conway
Cummington
Hancock
Hatfield
Montague
Monterey
Richmond
Ware
Suite 402
Afford
Amherst
Dalton
Hawley
Montgomery
Rowe
Warwick
Springfield, MA 01103
Ashfield
Deerfield
Heath
Monson
Mount Washington
Russell
Sandisfield
Washington
Wendell
Phone: 413-784-1100
Be ket
Becicherlown
Easthampton
East Longmeadow
Hinsdale
Holland
New Ashford
Savoy
Westfield
Fax: 413-784-1149
Bernardston
Egremont
Holyoke
New Marlborough
Sheffield
Westhampton
West Springfield
Fax: 508-947-6557
Blandford
Erving
Florida
Huntington
Lanesborough
New Salem
North Adams
Shelburne
Shutesbury
West Stockbridge
TDD: 508-946-2795
Brimfield
Buck and
Gill
Lee
Northampton
Southampton
Whately
Charlemont
Goshen
Lenox
Northfield
South Hadley
Wilbraham
Cheshire
Granby
Levereft
Orange
Southwick
Williamsburg
Chester
Granville
Leyden
Otis
Springfield
Williamstown
Chesterfield
Great Barrington
Longmeadow
Palmer
Stockbridge
Windsor
Chicopee
Greenfield
Ludlow
Pelham
Sunderland
Worthington
DEP . Northeast Region
Clarksburg
Hadley
Middlefield
Peru
Tolland
Wakefield
Walpole
DEP Central Region
Acton
Charlton
Hopkinton
Millbury
Millville
Rutland
Shirley
Uxbridge
Warren
627 Main Street
Ashburnham
Ashby
Clinton
Douglas
Hubbardston
Hudson
New Braintree
Shrewsbury
Webster
Worcester, MA 0 1605
Athol
Dudley
Holliston
Northborough
Southborough
Westborough
Phone: 508-792-7650
Auburn
Dunstable
Lancater
Northbridge
North Brookfield
Southbridge
Spencer
West Boylston
West Brookfield
Fax: 508-792-7621
Ayer
Barre
East Brookfield
Fitchburg
Leicester
Leominster
Oakharn
Sterling
Westford
TDD: 508-767-2788
Bellingham
Gardner
Littleton
Oxford
Stow
Westminster
Fax: 508-947-6557
Berlin
Grafton
Lunenburg
Paxton
Sturbridge
Winchendon
TDD: 508-946-2795
Blackstone
Groton
Marlborough
Pepperell
Sutton
Worcester
Bolton
Harvard
Maynard
Petersham
Templeton
Wrentham
Boxborough
Hardwick
Medway
Phillipston
Townsend
Yarmouth
Boylston
Holden
Mendon
Princeton
Tyngsborough
Brookfield
Hopedale
Milford
Royalston
Upton
DEP Southeast Region
Abington
Dartmouth
Freetown
Mattapoisett
Provincetown
Tisbury
Truro
Acushnet
Dennis
Gay Head
Middleborough
Raynham
20 Riverside Drive
Attleboro
Dighton
Gosnold
Nantucket
Rehoboth
Wareham
Lakeville, MA 02347
Avon
Duxbury
Halifax
NewBedford
Rochester
Wellfleet
Phone: 508-946-2700
Barnstable
Eastham
Hanover
North Aftleborough
Rockland
West Bridgewater
Westport
Berkley
East Bridgewater
Hanson
Norton
Sandwich
Fax: 508-947-6557
Bourne
Easton
Harwich
Norwell
Scituate
West Tisbury
TDD: 508-946-2795
Brewster
Edgartown
Kingston
Oak Bluffs
Seekonk
Whitman
Bridgewater
Fairhaven
Lakeville
Orleans
Sharon
Wrentham
Brockton
Fall River
Mansfield
Pembroke
Somerset
Yarmouth
Carver
Falmouth
Marion
Plainville
Stoughton
Chatham
Foxborough
Marshfield
Plymouth
Swansea
Chilmark
Franklin
Mashpee
Plympton
Taunton
DEP . Northeast Region
Amesbury
Chelmsford
Hingham
Merrimac
Quincy
Randolph
Wakefield
Walpole
Andover
Chelsea
Holbrook
Methuen
205 Lowell Street
Arlington
Cohasset
Hull
Middleton
Reading
Waltham
Wilmington, MA 0 1887
Ashland
Concord
Ipswich
Millis
Revere
Watertown
Phone: 978-661-7600
Bedford
Danvers
Lawrence
Milton
Rockport
Rowley
Wayland
Wellesley
Fax: 978-661-7615
Belmont
Dedham
Dover
Lexington
Lincoln
Nahant
Natick
Salem
Wenharn
TDD: 978-661-7679
Beverly
Billerica
Dracut
Lowell
Needham
Salisbury
West Newbury
Bo ton
S
Essex
Lynn
Newbury
Saugus
Weston
Boxford
Everett
Lynnfield
Newburyport
Sherborn
Westwood
Braintree
Framingham
Malden
Newton
Somerville
Weymouth
Brookline
Georgetown
Manchester -By -The -Sea
Norfolk
Stoneham
Wilmington
purlington
Gloucester
Marblehead
North Andover
Sudbury
Winchester
Cambridge
Groveland
Medfield
North Reading
Swampscott
Winthrop
Canton
Hamilton
Medford
Norwood
Tewksbury
Woburn
Carlisle
Haverhill
Melrose
Peabody
Topsfield
Wpafornri - Appendix A - rev. 11122/00 Page I of 1
Massachusetts Department of Environmental Protection
Bureau of Resource Protection - Wetlands
WPA. Appendix E — Request for Departmental Action ' Fee Transmittal Form
Massachusetts Wetlands Protection Act M.G.L. c. 131, §40
A. Request Information
Important: 1. Person or party making request (if appropriate, name the citizen group's representative):
When filling out
forms on the
computer, use Name
only the tab
key to move Mailing Address
your cursor -
do not use the
return key. Cityrr)wn State Zip Code
Phone Number Fax Number (if applicable)
Project Location
Mailin 3 Address
City/Town State Zip Code
2. Applicant (as shown on Notice of Intent (Form 3), Abbreviated Notice of Resource Area Delineation
(Form 4A); or Request for Determination of Applicability (Form 1)):
Name
Mailing Address
Cityrrown State Zip Code
Phone Number
3. DEP File Number:
B. Instructions
Fax Number (if applicable)
1. When the Departmental action request is for (check one): I
F] Superseding Order of Conditions
E] Superseding Determination of Applicability
Superseding Order of Resource Area Delineation
Send this form and check or money order for $50.00, payable to the Commonwealth of Massachusetts to:
Department of Environmental Protection
Box 4062
Boston, MA 02211
Wpaform4b.doc - Appendix E - rev. 2/00 Page 1 of 2
Massachusetts Department of Environmental Protection
Bureau of Resource Protection - Wetlands
WPA Appendix E — Request for Departmental Action Fee Transmittal Form
Massachusetts Wetlands Protection Act M.G.L. c. 131, §40
B. Instructions (cont.)
2. On a separate sheet attached to this form, state clearly and concisely the objections to the
Determination or Order which is being appealed. To the extent that the Determination or Order is
based on a municipal bylaw, and not on the Massachusetts Wetlands Protection Act or regulations,
the Department has no appellate jurisdiction.
3. Send a copy of this form and a copy of the check or money order with the Request for a Superseding
Determination or Order by certified mail or hand delivery to the appropriate DEP Regional Office (see
Appendix A).
4. A copy of the request shall at the same time be sent by certified mail or hand delivery to the
Conservation Commission and to the applicant, if he/she is not the appellant.
Wpaform4b.doc - Appendix E - rev. 2/00 Page 2 of 2 .