HomeMy WebLinkAboutMiscellaneous - 35 MEADOWOOD ROAD 4/30/2018v
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GENERAL BUILDING NOTES/CHECKLIST- NOT LIMITED TO ITEMS BELOW
POST ALL LOT NUMBERS, ADDRESS, AND PERMIT (COPY 0K)..or no inspections
INSPECTIONS: (Minimum) Excavation, Footing, Foundation, Frame, Insulation, Final.
FOOTINGS: Continuous Full 2x4 Keyway
Continuous strip footings for interior columns
FOUNDATION: Rebar as required
Anchor bolts or straps
Damproofing
Foundation drain - pipe/stone/fabric filter/cover and outlet connection.
FRAME: Fireblock - over girts/plates between floor joist
Penetrations for plumbing, heat, elec, etc.
Walls at stair stringers.
Windbrace corners and center bearing partitions.
Size ridge to provide full bearing at rafter cuts.
Hip and Valley rafters - watch bearing at walls.
Ridge & Hip - Provide proper connections.
Cathedral roof rafters provide proper connections and use "Hurricane Clips" tie to plate.
Stair stringers - watch cuts and heal support.
Joist hangers - fully nailed w/ hanger nails.
Sill plates 2-2X6 (1 PT) w/sill seal.
Girls - solid brick or steel plate bearing at foundations
'% " air space at sides in foundation pockets.
Lateral bracing at ends.
Certified calculations. required for Beams/LVL's Trusses.
Solid bearing support for Headers/Beams etc.
Check headroom clearances - stairways, under beams
Attic Access. (min. 22x30 w/3' headroom above).
Crawl space access. (min. 18x24).
Bath exhaust fans to have metal duct to exterior (not in soffit).
Firecode S/R wood frame of "0" clearance fireplaces & stoves
Window Schedule or Every Habitable Room Must Have:
Natural light equal to 8% of floor area.
1/2of required glazing shall be openable.
Bedrooms required min. 20x24 egress window or door.
Vent attic spaces - "proper vent", soffit and required ridge vents.
Firecode under stairs if used for storage
FIREPLACES: Separate permit required.
Inspections at Footing - Smoke Chamber - Finish
Smooth parging, clean joints, 8" solid @ combust. Surf.
DECKS: Separate permit required:
Lag to house, provide flashing.
Rails min. 36 " high, Baluster max space 5" on center.
Over 8' above grade, use 6x6 posts w/lateral bracing.
Lag all posts and rails.
Pier footings down 48", Conc. pad at stair base.
FINISH: Handrails returned to wall/newall post.
Guardrails required alongside open cellar stairs.
Exterior grading complete.
Certificate or occupancy required prior to occupying structure.
Temporary Stairs required for inspection.
Re -inspection fee - $30.00 (Be Ready).
Certificate of occupancy required prior to occupying structure.
RE FIVE
JUL 0 1 2005
.TOWN OF NORTH ANDOVER BUILDING DEPT
BUILDING DEPARTMENT
BUIMING PERMTF NUMBER: a DATE ISSM:
SIGNATURE: v�
Building Colntnissioner/Instlea:tor of Buildinas Date
I SECTION I- SITE INFORMATION I
1.1 Property Address+
af5
12 Asmors D4sp and'hrcd
MapNumber
Numba:
bloc pate
Parcel Number
'
M
1.3 Zoning tefor malion:
uo
Zonis District hqmsod Use
1.4 Pfopaty Dimensions:
0
l.ot
(0(' q
fronta ft
1.6 BUMMING SETBACKS ft
2 rv1
MIC�ol�S6]j 35 1 l�'LC1Wn
Narry„ Print) Address for Service :
p j
Front Yard Side Yard
Rear Yard
Required Provide
Provided Rmuired
Provided
CRO O
a
1.7'%'aterSWplyMQLCA0. 54) 1.5. FloodZoaoldonaeao: - 1.6
SawaWD1sp-1Sy*=
40
M
Z
0
pbbLlc ❑ Privrio ❑ 7a outsidelFloodZoee ❑ Mooklpsl D OaSite thspaasl SpHao ❑
J
SECTION 2 - PROPEM OWNERSHMAUTHORMED AGENT
M
2.1 Owner of Record
2 rv1
MIC�ol�S6]j 35 1 l�'LC1Wn
Narry„ Print) Address for Service :
p j
r
\.
Signature
(�
2.2 Owner of Record:
e- t�� MPALi
bl ted d ICd .
0
Name Print Addre a for Scrvice:
,
sigans re Tat boat
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Not Appliatble
Licensed Construction Supervisor:
0
License Number
on
Address
Expiration Date
I
Signature Telephone
r
3.2 Registered Home improvement Contractor
Not Applicable
m
Company Name
Registration Number
r
r
z
Address
Expiration Date
0
- WORKERS COMPENSATION (KG.L C 152
must
SECTION 5 Desai tion of PCU Work(&he&ck 6le
NewConsbuction' ❑ ExistingBuitding ❑ Repair(s) ❑ Alteraaotts(s) 11Addition "[7
Accessory Bldg. ❑ Demolition 01
Other ❑ Specify
Brief Description of Proposed Work:
A - ACTYMATRn
Item
Estimated Cost (Dollar) to be' , �f1F11C1su:UDI.Y�� '.
comp) b ' applicaitt
1.
Building
(a) Building Permit Fee
0" multiplier
2
Electrical
(b) Estimated Total Cost of
Construction
3
Plumb"
Building Permit fee (a) x.(b)
4
Mechanical AC
T
Fire Protec6an
-
6
Total 1+2+3+4+5
0 Check Number
F]5
(ifp
(13 44
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State Form 290 MUNICIPAL LIEN CERTIFICATE NUMBER: 2003-3160
General Laws, THE COMMONWEALTH OF MASSACHUSETTS
Chapter 60, section 23 OFFICE OF THE COLLECTOR OF TAXES
TOWN OF NORTH ANDOVER - Quarterly Billing -
120 MAIN STREET
NORTH ANDOVER MA 01845 Issued: May 21, 2003
978-688-9550
I certify from available information that all taxes, assessments and charges now payable that constitute liens as of the date
of this certificate on the parcel of real estate specified in your application received on May 21, 2003 are listed below.
TO:
Parcel Id: Map 025.0 Block: 0024 Lot 0000.0
JOHN H. PERRONE & ASSOCIATES Location: 35 MEADOWOOD ROAD
ATTORNEYS AT LAW Acreage: 0.500
86 SUMMER STREET Legal Reference: 4707 239
HAVERHILL MA 01830-5891 Assessed Owner(s): ROFFER, DOUGLAS
C/O WRIGHT, D & RILLAHAN
Supposed Owner: WRIGHT, D & RILLAHAN
APPORTIONED BETTERMENT ASSESSMENTS NOT YET DUE $ 0.00 WITH INTEREST TO BE
I have no knowledge of any other lien outstanding.
ROBERTA N. MCGOWAN, Collector of Taxes
TOWN OF NORTH ANDOVER
Residential
301,400
®
13.12
Open Space
0
®
13.12
Commercial
0
®
15.92
Industrial
0
®
15.92
Exempt
0
®
0.00
Agr. Credits
0
BETTERMENT / LIEN
DETAIL
2 0 0 3 Amount
Com Int 2 0 0 2
Amount
Com int 2 0 0 1
Amount
Com Int
CPA 79.27
N/A
0.00 CPA
70.15
0.00 N/A
0.00
0.00
0.00
N/A
0.00 N/A
0.00
0.00 N/A
0.00
0.00
0.00
N/A
0.00 N/A
0.00
0.00 N/A
0.00
0.00
0.00
0.00 N/A
0.00
0.00 N/A
0.00
0.00
ASSESSMENT DETAIL Quarterl
Bill.ri
-
ASSESSMENTS
2003
.. ....
..
.: . .
Preliminary 1st
Due: 08/01/2002
901.08
aooz
zoos
Preliminary 2nd
Due: 11/01/2002
901.08
860.32
757.43
AcLual 16L/3rd
Due; 02/03/2003
1,076.11
860.32
757.43
Actual 2nd/4th
Due: 05/01/2003
1,076.10
941. k$3
963.22
District
941.83
963.22
Betterment and Liens
79.27
70.15
0.00
Committed Interest
0.00
0.00
0.00
Interest
To: 05/21/2003
0.00
32.42
0.00
0.00
Charges and Fees
0.00
0.00
DEFERRALS
0.00
0.00
0.00
DEFERRAL
PAYMENTS
0.00
0.00
0.00
Preliminary
Actual
0.00
0.00
0.00
District
3,954.37
3,604.30
3,441.30
Betterments/Liens
79.27
70.15
0.00
Committed Interest
0.00
0.00
0.00
Interest Paid
0.00
0.00
0.00
Charges and Fees
32.42
0.00
0.00
Abatement/Exemption
0.00
0.00
0.00
Deferral,Ta:: Title Transfer
0.00
0.00
0.00
CURRENT UNPAID TAXES (PER
DIEM)
0.00
0.00 (0.00)
0.00
0.00
0.00
(0.00)
0.00 (0.00)
TOTAL AMOUNT DUE $
0.00 (0.00)
'NOTATIONS:'•'�:COMMENT$;'
PLEASE CONTACT TAX OFFICE FOR INTEREST & FEES 688-9550
PLEASE CONTACT WATER DEPT. AT 688-9570 10 DAYS PRIOR TO CLOSING
FOR FINAL BILLING NOT
INCLUDED
ON LIEN.
APPORTIONED BETTERMENT ASSESSMENTS NOT YET DUE $ 0.00 WITH INTEREST TO BE
I have no knowledge of any other lien outstanding.
ROBERTA N. MCGOWAN, Collector of Taxes
TOWN OF NORTH ANDOVER
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 M i Ck&eJ COYa sal
LOCATION: Assessor's Map Number (`�•
SUBDIVISION
��i 11't•s • '�
PHONE —��� �2 I
PARCEL 101 OUaq
LOT (S) 0000-0
ST. NUMBER -3S
DATE REJECTED
COMMENTS
TOWN PLANNER DATE APPROVED
DATE REJECTED
COMMENTS
FOOD INSPECTOR -HEALTH DATE APPROVED
DATE REJECTED
SEPTIC INSPECTOR -HEALTH DATE APPROVED
DATE REJECTED
COMMENTS
PUBLIC WORKS - SEWERIWATER CONNECTIONS
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:
of Facility)
Signature of Pert6it Applicant
Date
NOTE: Demolition permit from the Town of North Andover must be obtained for
this project through the Office of the Building Inspector
S5, R44k9wob� 0,
W
co
D
O
4)
.
M
if)
LOT A2
A= 20, 913± S. F.
— Northpoint —
Survey SeMiCeS
180 rater Street
JYaver&14 &4 01830
(978) 372-0835
2g 91-• `'�
77.78' -
17.79'.,
35,\\
�
I I
I
15'
I
WIDE
1 I
UTILITY
I I
EASEMENT I I
0
0 10' WIDE
I I
UTILITY
cNo
LoLd Ln
EASEMENT
4
i
)
I
I ci J
Du 0 W00D
R0 D
"-t�j
R=30.00'
L=22.83'
vi OF AlgS;, I
GREGORY yG
L m
0 BO::'DEN ti
a, 034610
cu
4
PLEASE CALL 978-372-0835 PRIOR TO USING THIS PLAN FOR ANY OTHER REASONS THAN MORTGAGE PURPOSES
THE ABOVE MORTGAGE INSPECTION WAS
PREPARED FOR
BANKNORTH. NA
AND IS NOT INTENDED OR REPRESENTED TO
BE A LAND OR PROPERTY LINE SURVEY.
NO CORNERS WERE SET. IT CANNOT BE USED
FOR ESTABLISHING FENCE, HEDGE, OR
BUILDING LINES. THE LAND SHOWN IS BASED
ON CLIENT FURNISHED INFORMATION AND MAY
BE SUBJECT TO FURTHER OUT -SALES,
TAKINGS, EASEMENTS AND RIGHT OF WAYS.
NO RESPONSIBILITY IS EXTENDED TO
THE LAND OWNERS OR OCCUPANT. IT IS
NOT INTENDED FOR THIS DOCUMENT TO BE
RECORDED.
JOHN H. PERRONE
CLIENT: & 9s.S.0)IAifr--,_
DATE: 5-9-03
SCALE: 1 "= 40'
JOB NO.: 3849.00
TO THE BEST OF MY PROFESSIONAL
KNOWLEDGE AND BELIEF
THE LOCATION OF THE PRIMARY
STRUCTURE SHOWN WAS EITHER IN
COMPLIANCE WITH LOCAL APPLICABLE
ZONING BY-LAWS IN EFFECT WHEN
CONSTRUCTED (WITH RESPECT TO
HORIZONTAL DIMENSIONAL
REQUIREMENTS ONLY) OR IS
EXEMPT FROM VIOLATION ENFORCEMENT
ACTION UNDER M.G.L. TITLE VII,
CHAPTER 40A, SEC, 7, UNLESS
OTHERWISE NOTED OR SHOWN.
BORROWER: MICHAEL P & BETH ANN
CONSOLLI
ADDRESS: 35 MEADOWOOD ROAD
NORTH ANDOV R MA
RECORDED AT ESSEX NORTH REGISTRY OF DEEDS
BOOK: 6842 PAGE: 156 L.C. CERT.#
PLAN REFERENCE:
DRAWN PER OF ASSESSORS
MAP# BLOCK PARCEL
SUBJECT DWELLING LIES IN FLOOD ZONE X
AS SHOWN ON NATIONAL FLOOD INSURANCE
RATE MAP DATED: JUNE 2, 1993
COMMUNITY 250098 PANEL# 0006C
I
17.79'.,
35,\\
, .
oi
Du 0 W00D
R0 D
"-t�j
R=30.00'
L=22.83'
vi OF AlgS;, I
GREGORY yG
L m
0 BO::'DEN ti
a, 034610
cu
4
PLEASE CALL 978-372-0835 PRIOR TO USING THIS PLAN FOR ANY OTHER REASONS THAN MORTGAGE PURPOSES
THE ABOVE MORTGAGE INSPECTION WAS
PREPARED FOR
BANKNORTH. NA
AND IS NOT INTENDED OR REPRESENTED TO
BE A LAND OR PROPERTY LINE SURVEY.
NO CORNERS WERE SET. IT CANNOT BE USED
FOR ESTABLISHING FENCE, HEDGE, OR
BUILDING LINES. THE LAND SHOWN IS BASED
ON CLIENT FURNISHED INFORMATION AND MAY
BE SUBJECT TO FURTHER OUT -SALES,
TAKINGS, EASEMENTS AND RIGHT OF WAYS.
NO RESPONSIBILITY IS EXTENDED TO
THE LAND OWNERS OR OCCUPANT. IT IS
NOT INTENDED FOR THIS DOCUMENT TO BE
RECORDED.
JOHN H. PERRONE
CLIENT: & 9s.S.0)IAifr--,_
DATE: 5-9-03
SCALE: 1 "= 40'
JOB NO.: 3849.00
TO THE BEST OF MY PROFESSIONAL
KNOWLEDGE AND BELIEF
THE LOCATION OF THE PRIMARY
STRUCTURE SHOWN WAS EITHER IN
COMPLIANCE WITH LOCAL APPLICABLE
ZONING BY-LAWS IN EFFECT WHEN
CONSTRUCTED (WITH RESPECT TO
HORIZONTAL DIMENSIONAL
REQUIREMENTS ONLY) OR IS
EXEMPT FROM VIOLATION ENFORCEMENT
ACTION UNDER M.G.L. TITLE VII,
CHAPTER 40A, SEC, 7, UNLESS
OTHERWISE NOTED OR SHOWN.
BORROWER: MICHAEL P & BETH ANN
CONSOLLI
ADDRESS: 35 MEADOWOOD ROAD
NORTH ANDOV R MA
RECORDED AT ESSEX NORTH REGISTRY OF DEEDS
BOOK: 6842 PAGE: 156 L.C. CERT.#
PLAN REFERENCE:
DRAWN PER OF ASSESSORS
MAP# BLOCK PARCEL
SUBJECT DWELLING LIES IN FLOOD ZONE X
AS SHOWN ON NATIONAL FLOOD INSURANCE
RATE MAP DATED: JUNE 2, 1993
COMMUNITY 250098 PANEL# 0006C
Location t) Ae,:466000� A
No. 631 / Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $ c3t, 5—
Check #
i
5573 Building Inspector
4
TOWN OF NORTH ANDOVER
BUILDIN
G DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
-:. 1 y' A' "'� S s•, 4 :.ti•.r ria�.r'r4 .3- ^`aY' 2
+�,#.•- rk,i " cL-.m-X
BUILDING PERMIT NUMBER: / DATE ISSUED: —
1 V� `
SIGNATURE: l
Building Commissioner/I for of Buildings Date
SECTION 1- SITE INFORMATION
1.1 Property Address:
1.2 Assessors Map and Parcel Number: r A
Map Number Parcel Number
1.3 Zoning Information:
Zonina Distrid Proposed Use
1.4 Property Dimensions:
a6 3
Lot Areas Frontage ft
1.6 BUILDING SETBACKS ft
Front Yard Side Yard
Rear Yard
Required Provide R red Provided
R 'red Provided
11
1.7 Water Supply M.GLC.Q.. 54) 1.5. Flood Zone Infomution:
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
me (Print ot Address for Service
�-
Signature Telephone
2.2 Owner of Record:
Name Print Address for Service:
Signature Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Licensed Construc ion Supervisor:
Address i
Signature Telephone
Not Applicable ❑
License Number
Expiration Date
3.2 Registered Home Improvement Contractor
Not Applicable ❑
Company Name
Registration Number
Address
Expiration Date
Signature Telephone
i
0
SECTION 4 - WORKERS COMPENSATION (M.G.L C 152 6 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 scription of Proposed Work.
� a lam" (� c,�. ( Q �^ � tet• c(!
SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost (Dollar) to be
Completed bermit applicant
,x OFFICIAI:,USE30NI:Y
1. Building(a)
d Q
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 CONTRACTOR APPLIES FOR BUILDING PERMIT
1, as-Owner/Au rized 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/AUTHORIZED AGENT DECLARATION
1, 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 ti
Signature of Owner/A ent Date
t
NO. OF STORIES SIZE
BASEMENT OR SLAB -
S17 -E OF FLOOR TIMBERS 1 2 ND 3 RD
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
FORM U - LOT RELEASE FORM
s *41-tto V-14�bllc�
'W ,- 9..'b—n2
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.
AFIJLIC;ANT FILLS OUT THIS SECTION*************** *******
APPLICANT �a �� l� 4 PHONE!27.-9-
LOCATION: Assessor's Map Number 1 PARCEL
SUBDIVISION Qc,�,Lf d U j LOT (S)
STREET ��c P �G /)G✓!1U }, NUMBER -35
*****************************************OFFICIAL USE
RECOM ENDATION -OF TOWN AGENTS:
CONSERVATION ADMIN RATOR DATE APPROVED _
�pp DATE REJECTED
N
COMMENTS o Oe ��✓�j� �d 0
TOWN PLANNER
COMMENTS
FOOD INSPECTOR -HEALTH
SEPTIC INSPECTOR -HEALTH
CO
DATE APPROVED
DATE REJECTED
DATE APPROVED
DATE REJECTED
DATE APPROVED
DATE REJECTED
PUBLIC WORKS - SEWER/WATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTMENT
RECEIVED BY BUILDING INSPECTO
Revised 9\97 jm
DATE
Town of North Andover
Building Department
27 Charles -Street
North Andover, MA. 01845
D. Robert Nicetta
Building Commissioner
(978) 688-9545
... • °f 978) 688-=9542 Fax
HOMEOWNER LICENSE EXEMPTION
Please print
DATE
JOB LOCATION/. _, ? �)_ /I--? &,_e) � 6-cf '.
Number / Street Address
".HOMEOWNER
Name Home Phone
PRESENT MAILING
Map / lot
Work Phone
Zip code
The current. exemption for "homeowners" was extended to includeowner-occupied. dwellirigs
of two units or less and to allow such homeowners to engage an individualfiofhire .who.does .
not possess a license,, provided that the owner acts as supervisor. (State Budding Code Section 1 08.3. 5.1)
.DEFINITION OF HOMEWOWNER:
Person(s) who owns a parcel of land on which helshe resides orintends.to.reside, on which
there is, or is intended to be, a one or two family dwelling. attached or detached structures ac-
cessory to such use and/or farm structures. A person who constructs -in then one home -in a
two
period shall not be 'considered a homeowner
The undersigned "homeowner' assumes responsibility for compliance with the State Building Code and other
Applicable codes, bylaws, rules and regulations, ;
The undersigned "homeowner" certifies that hOshe understands the Town of No. Andover
Building Department minimum inspection procedures and requirements and that helshe will
comply with said procedures and requirements_
HOMEOWNER'S SIGNATURE
APPROVAL OF BUILDING OFFIC
i`
a
•
North Andover Building Department
Tel: 978-688_954 1
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 b
disposed of irl a properly licensed solid. waste disposal facility as defined b e
c11,S150A. yMGL
The debris will be disposed of in:
(Location of F
i
re of Permit Applicant `'i2
Date
NOTE: Demolition permit from tl)e Town of North Andover must be obtained for
this project through the Office of the Building Inspector
I
7 7.78
ODov�� • �: �Z.Bd � ��0
` I HEREBY CERTIFY TO THS TITLE LNSUROR AND
TO THS BANK THAT rHR DARLUM0 IS LOCAM ON
THE LOT AS SHOW AND TUT IT DOSS CONFORM!
WITH THRTow- OF,v;d,.00vE,Z SOHNc RNCULAr10NS
RNCmmc smACXS PRom srpjRrs & LOT LINRS.'
I FURTHRR CERTIFY ing THIS DI►numo IS Nor
LOCATED IN THE R LOOD HUM ARRA AS
SHOWN ON FRMA PANRL 2 S o0 9B caoa c
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MERRINACK ENOINEERINO SERVICES
66 PARK STREET
ANDOVER, MASSACHUSETTS 01810
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TC WN OF NOR' ' i M,:JO ,
BOARD OF HEALTH
FEB -22
Building Commissioner/Inspector of Buildings
GAB Business Services, Inc.
a ad "/Ieg kJOOlJ 66Z' l< SO irk
Date 4�)/-D �voi
L,/Board of Health/Board of Selectmen
lVd 4 7-11s�.�rJd I_e7 / 'd .
NOTICE OF CASUALTY LOSS TO BUILDING
UNDER MASSACHUSETTS GENERAL LAWS, CHAPTER 139, SECTION 3B
Claim has been made involving loss, damage or destruction of the property captioned below,
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 3B
is appropriate, please direct it to the attention of the writer and include a reference to the cap-
tioned insured, location, policy number, date of loss, and GAB file number.
Insured:O �/ 6411-s a
Property Address: 36- /"I�/+��"!oo� GZOg�
Policy No. '/f �O/I '�_ ad ° O
Loss of / a2 tea- 'IOdO
GAB File No. /�e-, 3 -/6 �'F`y
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(Signature)
Title/io 7 '
On this date, I caused copies of this notice to be sent to the persons named above at the addresses
indicated above by first class mail. .
_ ignature and date
Form 645 (2/78)