HomeMy WebLinkAboutMiscellaneous - 40 LAVENDER CIRCLE 4/30/2018 Peachtree Farms
Lot # 21
401
Circle
RECEIVED
N 0 V 22 2004
BUILDING DEPT.
GROWTH MANAGEMENT BYLAW EXEMPTION STATEMENT
TOWN OF NORTH ANDOVERBUILDING DEPARTMENT
This form shall be used to assist the Building Department in their determination of exemption under section
8.7.6 of the Town of North Andover Growth Management Bylaw.The applicant shall provide all of the
necessary information as requested below.
!0 LcWCA/deA
Permit_Applicant Property address Iola
p/Parcel
3a�-iso
A li
cant
s Ph n
o e'
pp Number
Single Family Two Family
I the undersigned applicant fot.the above property attest tliat'the attached building permit for which this form is completed
does comply with the,E.`IDMPTION section 8.7.6 of the Growth Management Bylaw.I also understand providing this form does not,
absolve.rme or any partyto this peiimt from the requirements of-blaming other permits required prior to the issuance of the building
permit-Further I understand that my interpretation of the exemption status is subjecbto review by the Building Department and is only
officially accepted when'the building permit is issued..
Based on sed ion 8.7.6.ofthe Noi#h Andoyer Growth:Bylaw the above`lot and the work as applied for on the above lot in the building.
permit application and associated.attachments,complies with one or more of the following sections as indicated by:a'check mark. .
This is an apphcahon:for a buddingperniit for the enlargement;restoration or reconstruction ofa dwell' in
ofthe effectiveexistence as
date-£this bylaw;"provided that no additionafresidariial unit is created.
The lot(i)
was/were created prior May 6,1996:and are exempt from the provisions of sedibn 8.7 oftlre Zoning Bylaw..
This application is for dwellmgunrts for low and or moderate income families or individuals;where all of tfie conditions
of 8.7.6 are mei and or represents dwellmg,units for senror residents where occupancy of the unRs is reslric[ed to senior.citrzens`,
through a properly executed and recorded deed restriction running with the land.For purposes ofthis section"senrot"..shall mean
persons over the age of M.-
This application IS part of a development probed which voluntarily agreed to a minimum 40%permanent reduction in:
density(buildable lots)below the'ilensrty permitted under zoning and feasible gnien the environmental conditions ofth'e tract with.the...
surplus land equal to at least ten buildable acres and permanently designated as open space or farmland.The land to be preserve&shall
be protected from development by an Agnci Itural Preservation RestncUon;Conservation Restnaion,dedication to.the Town or other
similar mechanism approved by the planning board that will ensure its protection.
This application represents a qad of land existing and not held by Developer in common ownership with an adjacent,
parceton the effedive date Ofthis'Sedron 87,and shall receive a onetime exemption from the Planned Growth Rafe and
Development Scheduling provisions for the purpose of constructing one single famlydwelling unit on the parcel.
This,
application represeats a lbit which is ready fora building permit all other permits from all other boards and
commissions have been received and the project is.in corr>pliance with those permits);and the Development Schedule does not
accommodate issuing a budding peL.rmit i1.n thatyear.One building peimit.will be issued per year per Development until such time as
the development schedule accommodates issumg building permits!Applicant must submit an approved FORM U with this
EXEMPTION:
PLEASE PROVIDE ANY,AND ALL INFORMATION THAT WOULD ASSIST THE BUILDING DEPARTMENT IN MAKING A
DETERMINATION THAT THIS APPLICATION IS ALLO WED UNDER ONE OR MORE OF THE ABOVE EXEMPTIONS.
BY SIGNING BELOW I ATTEST TO THE.;ACCURACY OF THE INFORMATION PROVIDED AND THAT THEATTACHED
BUI
LDING PERMIT IS ALLOWED AN EXEMPTION AS CITED_ABOVE. ,;,
FURTHER I UNDERS I'AND THAT THE='SUBMITTAL OF MISLEADING OR INACCURATE INFORMATION OR THE
CHECKING OFF OF A ABOVE EXE .TI WHICH DOES NOT COMPLY,WHETHER DONE TO MY KNOWLEDGE OR
NOT IS �t REFUS Y BUILDING DEPARTMENT TO ISSUE A BUILDIN PERMIT.
APP /C S SIGNATUIX
DA
THIS FORM TO BE ATTACHED TO.THE BUILDING PERMIT APPLICATION
FORM J
LOT RELEASE
The undersigned, being a majority of the Planning Board of the Town of North Andover,
Essex County, Massachusetts, hereby certify that:
a. the requirements for the construction of ways and municipal services called for by
the Performance Bond or Surety and dated and/or by the Covenant
dated May 20, 2003 and recorded in the Districts Deeds, Book 7827, Page 143; or
registered in Land Registry District as Document No.
and noted on Certificate of Title No. in
Registration Book Page has been completed/partially
completed, to the satisfaction of the Planning Board to adequately serve the
enumerated lots shown on Plan entitled "Definitive Subdivision and Special
Permit Plan Peachtree Farm in North Andover, Massachusetts" Plan dated
_October 24,2002, last revised May 16, 2003 recorded by the Essex North District
Registry of Deeds, Plan No. 14502 or registered in said Land Registry District,
Plan Book , and said lots are hereby released from the_.restrictions as to
sale and building specified thereon. U�
Lots designated on said Plan as follows: (Lot Number(s) and street(s))
Lots 1 —9 and 20.—28 inclusive, Peachtree Lane and Lavender Circle
b. (To be attested by a Registered Land Surveyor)
I hereby certify that lot number (s) Lots I — 9 and 20— 28 inclusive, on Peachtree
Lane and Lavender Circle do conform to layout as shown on Definitive Plan
entitled "Definitive Subdivision and Special Permit Plan Peachtree Fan-n in North
Andover. Massachusetts".
f - `�h
Registered Land Surveyor
Vr1 .......
1 of 2
(K0259892-1)
0 0
c. The Town of North Andover, a municipal corporation situated >n die County of
Essex. Commonwealth of Massachusetts, acting by its duly orQamzed Planning
Board, holder of a Performance Bond or Surety dated
70 , and/or Covenant dated May 20, 2003 from Big Kahuna Properties, LLC
of the City/Town of North Andover Essex County, Massachusetts recorded with
the Essex North District Registry of Deeds, Book 7827, Page 143, or registered in
Land Registry District as Document No. and noted Certificate of Title
No. in Registration Book Page acknowledges
satisfaction of the terms thereof and hereby releases its right, title lnd interest ill
the lots designated on said plan as follows:
Lots 1 —9 and 20—28 inclusive
EXECUTED as a sealed instrument this day of Noverxrb r, 2003.
Majority of the
Planning Board
of the Town of
North Andover " 1
COMMONWEALTH OF MASSACHUSETTS ((''
ESSEX, ss. November "A, 2003
Then personally appeared s��i 64 rY;' , one rtrthe above-named
members of the Planning Board of the Town of North Andover, Massachusetts, and
acknowledged the foregoing instrument to be the free act and deed of said Planning
board,before me,
Notary'Public
'lid( b 7(x)
My do>imission Expires
2of2
;K0259882.1
O d
BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR
Number: CS 055419
?'•.; Birthdate: 10/18/1965
r Y't Expires: 10/18/2004 Tr.no: 3206
Restricted: 00
MARK J VENTI
90 MIDDLE ST
WOBURN, MA 01801 Administrator
z tts
O The Commonwealth of Massach
y b
Department of Industrial Accidents
Office of Investigations
w~ Boston, Mass. 02111
M S�eyO Workers'Compensation Insurance Affidavit
Name eQC h[� Ny✓ (oot-Y er7.+-, Please Print
Name:
Location:
City Phone #
I am a homeowner performing all work myself.
I am a sole proprietor and have no one working in any capacity
I am an employer providing workers' compensation for my employees working on this job.
Company name: Rao- l-fTY-e ;AJ'cC VQ I(d eaVof( LI-L
Address ( �1 Hon _
City: v )O )J M[IP.4� i_!`l� I u 7 J Phone#. 1 1 d 'c l'-to 5>q6
+
Insurance Co. ! V�Ue I'e� Policy# 6L 6' `Ao6&4 W-5-6 3
Company name: t0 (- I/ f �T
0
Address - ) Su I'bn
City: Phone#:
Insurance Co. h�r>�j /"1 a Policy# w G J
Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of.a fine up to$1,500:00
and/or one years'imprisonment as wellas civ.il,penattiesjn-ffie9nrm d a STOP WORK ORD1=R_arzd a fine-of.(.$1.0.0_ 0.)_atlay-against.me. I
understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
I do hereby certify under the pains and penalties of perj that the information provided above is true and correct.
Signature C Date ( 6
Print name Fco-n Sb n Phone# 320-6?6'
Official use only do not write in this area to be completed by city or town official'
City or Town Permit/Licensing
Building Dept
❑Check if immediate response is required Licensing Board
❑ Selectman's Office
Contact person: Phone#: F-1 Health Deparment
Other
F41M (FRI ) FEB 13 2004 140ST. 14 :11/No. 6802897182 P 2
Permit Number
REScheck Compliance Certificate Checked By/Date
Massachusetts Energy Code
RE Scheck Software Version 3.5 Release Id
Data filename:K:1Laudani\PeachtrcclHouscC14996C.rck
PROJECT TITLE: Peachtree Development
CITY:North Andover
STATE:Massachusetts
HDD: 6322
CONSTRUCTION TYPE: 1 or 2 Family,Detached
HEATING SYSTEM TYPE:Other(Non-Electric Resistance)
DATE:02/13/04
DATE OF PLANS: 12-19-03
PROJECT DESCRIPTION:
House C
COMPLIANCE:Passes
Maximum UA—557
Your Humc UA=551
1.1%Better Than Code(UA)
Gross Glazing
Arca or Cavity Cont. or Door
Perimeter R-Value R-Value U-Factor UA
Ceiling 1:Plat Ceiling or Scissor Truss 1452 30.0 0.0 51
Ceiling 2:Cathedral Ceiling(no attic) 572 19.0 0.0 30
Wall 1:Wood Frame, 16"o.c. 3252 13.0 0.0 235
Window 1:Wood Frame:Double Pane with Low-E 312 0.340 100
Door 1:Solid 13 0.180 2
Door 2:Glass 61 0.340 21
Floor 1:All-Wood Joist/Truss:Over Unconditioned Space 2250 19.0 0.0 106
Boiler 1:Other(Except Gas-Fired Steam),80 AFUE
COMPLIANCE STATEMENT: The proposed building design described here is consistent with the building plans,specifications,
and other calculations submitted with the permit application. The proposed building has been designed to meet the Massachusetts
Energy Code requirements in REScheckVersion 3.5 Release Id (formerly MECchec4 and to comply with the mandatory
requirements listed in the RES cheeklnspection Checklist.
The heating load for this building,and the cooling load if appropriate,has been determined using the applicable Standard Design
Conditions found in the Code. The HVAC equipment selected to heat or cool the building shall be no greater than 125%of the
design load as specified in Sections 780CMR 1310 and J4.4.
Builder/Desigrr _ r Date /
06/16/2003 14:59 197832 "9,17 WILLOWSO PAGE 02
NOTICE OF ASSIGNMENT
EMPLOYER: PEACHTRFE DEVELOPMENT LLC COMBO I.D. STATUS OF EMPLOYER
231 SUTTON ST SUITE 2E-F 000139954 Limited Liability Com
NORTH ANDOVER, MA 01845
COVERAGE GRGVP
0139954
The Waiver of Our Right to Coverage under this assignment
Recover from Others Endorsement applies to Massachusetts
is available on Pool policies. operations only, For Coverage
Contact your agent for details. outside of Massachusetts, contact
the appropriate Pool or Plan for
that state.
INSURANCE COMPANY:
AGENT WILLOWS INS AGCY INC
OR 522 CHICKERZNG RD TRAVELERS INDEMNITY CO
PRODUCER: N p,MOVER, MA 01845 MS JACKIE DENNIS
P O BOX 3556
ORLANDO, FL 32802
(800) 443-4404
AGENCY FEIN:223856664
CLASSIFICATION OF OPERATION ..r CLASS ESTIMATED RATE FSTZMA-ED
CODE TOTAL ANNUAL PREMIUM
REMUNERATION
-------------------------------------- ----- -------------- ---------- ----------
RPENTRY-DETACHED PRIVATE RESIDENCES 5645 $0 10.62 $0
_2PENTRY-DWELLINGS-3 STORIES OR LESS 5651 $0 10.62 $0
EMPLOYERS LIABILITY 100/100/500 9845
LOSS CONSTANT 0032 $50
STANDARD PREMIUM $50
EXPENSE CONSTANT 0900 $122
TERRORISM CHARGE 9740 $0
RISK MINIMUM PREMIUM 0990 $500
ESTIMATED ANNUAL PREMIUM $500
DTA ASSESS. 4.5% OF STANDARD PREM. $17
----------
EST. ANNUAL PREM. PLUS ASSESSMENT $517
INSTALLMENT BASIS: Annual REQUIRED DEPOSIT PREMIUM $517
COMMENTS
Coverage effective 12:01 AM on 05/23/03
PATE OF NOTICE: 05/24/03 PREPARED BY: Joanne Shea
EXT 530
* * SERVICING CARRIER ASSIGNMENT * *
LETTER ID: 419982 COPY: AGENCY
The Workers' Compensation Rating and Inspection Bureau of Massachusetts
101 Arch Street• Boston, MA 02110
(617)439-9030 - FAX(617)439-6055 •www.wcribma.org
0 0
AFFIDAVIT
I, SCOTT L. MASSE,attorney for KENNETH W. REA do hereby depose and state:
1. 1 represent Kenneth W. Rea, owner of a certain parcel of land located on Rea Street, North
Andover, MA and more specifically described in a plan of land recorded with the Essex North
Registry of Deeds as instrument/plan number 14502.
2. 1 am duly authorized by Kenneth W. Rea to act on his behalf regarding furtherance of the
above stated instrument/plan.
3. Authorization is hereby given that Gerry-Lynn Darcy,and/or Peach Tree Development LLC
be allowed to act as the agent for Kenneth W. Rea regarding any and all matters relative to a
certain Building permit(s)issued by the Town of North Andover for any lots affiliated with the
above stated plan.
Signed under the pains and penalties of perjury this day of J e2003.
S T"f L. MA SE
drn :an Pn 9i unr
. O
r
I
TON" OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR RENOV U7T oR DEbfious.H A ONE OR TWO FANULY DWELLING 7
} ' ,.i..;-� s?_Y `}�;�iiz4.�!c7�� .'t��'�. �1�.3p����nL�� .91.'.... . n�. x�s1S�r..�L.'.�7.�•��"�£•+T^4,1."�w�}a nr„ 11i
BUILDING PERMIT NUMBER: DATE ISSUED:
kS I
�� X
SIGNATURR.—
Buil&g ConarrussionerAnsmtorofBuildin Date Z
SECTION 1-SITE INFORMATIONO
1.1 Property Address: 1.2 A4:aaois M.tp and P.M Number
1�+
�nsdry 1 I ser �1 al I_i0 �ufnd� S PermsavI nl ,bd
rterlcord/e�}r
MapNumb& Parcel'Number
1:3 Lonmglnformation: 055 1.4 Property 12immstms
Zmiii Distrid Use Lot Area F ft
1.6$1JITiDiING SETBACKS A
Front Yard Side Yard Rear Yard .
ReqWred Provide: .red... Provided. red Provided
17WtlaIyhfGJ:CA0. 34j 1 :' b7oodZoaelnfmmaloa: t,$' DisposASyv—, >PnUISo. Pm+aie 0,. Z6m .OaeadeF7oodZotra Mmicw V On SibDis3"System U
SECTION 2=PROPERTY UWNEILSIIIP7AU3TdORIZED.AGENT m
til Oiarner d Record
�Q nQ exp / y
Name(�Prmt) Address for service
C9 ,
Signature Tckpbone n
22 Owaer of Record:
Name Print Address for Service: z
m
Simmm T hone
SRCTION 3-CONSMUCTION:SERVICES go
3_1 Uemsed Construction Supervl . Not Applicable 0
Liosed Con ti uperviso� �
eni C.5 Q
x 9 i � {0�S License Number O
reYZIL �� I
O '7Q Expiration Date e
Si &frc Telephone r
3.2 Registered im eot Conhaclor Not Applicable 0 0
Company Name
Registration Number r
Address r
Expiration Date
Si afore Tek hono
0 0
v
SECTION 4-WORKERS COMPENSATION(M.G.L C I52 § 25c{6)
Workers Compensation Insurance affidavit must be completed aad submitted nith this application. Failure to provide this affidavit will result
in the denial of rho issuance of the building it.
Signed affidavit Attached Yes......A No......J
SECTIONS Ileicri lionofP ti ed Work* cbeckall cable
New Construction Existing Building ❑ Repair(s) 0 Altcrations{�DAddifiort 0
Accessory Bldg. 0 Demolition 0 Other 0 Specify
Brief Description of Proposed Work:
i
i-W Od rCGt
SECTION 6-ESTIMATED CONSTRUCTION COSTS ll
!',tern EstimntedCost.(1)oklar)10 be U, 01x CS $� xf`- if '� i Y`'1"4•
Com lard permit applicant
'3Yt:"'�'11Y�r.�5r k'{%°'j ° ,a�",�. yl=;r
1. wilding r5' CU,Oa20 (a) Building Permit Fee
P1
U01 QC,0 Mail'tier
2 Electrical a44 (b) Estimated Total Cost of Cnnstritction.
3 Plumbing. 13uilding'Pennit fee!s)s:(t,)
4 MecbimiW.(HVAC
5 Fite Protectia,
6 Total 1+2+3+4+5 . Check Number
SECTION 7a OWNRR AUTHORIZATION TOM COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR AFPLTES FOR IIUILDING PM11T
d.
I, U I Wweer uthcrizetlAgent of subjectproperty
authorize. \� to act on
My behalf,in all matters relative to kork authorized by this boarding permit application
SS
ignature of Owner Date
SECTION 7b OWNEWAUTHORIZED AGENT DECLARATION
I, .as Owner/Aulhorized Agent of subject
FrWAY
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
Signatitte of Owner/Agent Date
N.O.OF STORIES. SIZE i f1777
BASEMENT OR SLAB.
SIZE OF FLOOR TROERS 1 2' X 3 X/ 14 C
SPAN rq 5 Wn
DIMENSIONSOFSILLS �
DIMENSIONS OOF POSTS ` �a
.DIMENSIONS OF GIRDERS y X %4 L
HEIGHT OF FOUNDATION fl' 10" lA b0 v-e THICKNESS
SIZE OF FOOTING g �y
MATF,RIAI OF CHIMNEY
1S BULDING ON SOLID OR FILLED LAND ( L-cA
1S BUILDING CONNECTED TO NATURAL GAS LINTE
Town of Andover
No. �( S" ` "y
o '� dover, Mass.,
T O = L A K
COCMICMEWICK
ADRATED
S U BOARD OF HEALTH
Food/Kitchen
PERMIT T D Septic System
BUILDING INSPECTO..
THIS CERTIFIES THAT.................................� -` ' =�`-..." ": :.: .......:eti. r..................................... Foundation `b 13
has permission to erect........:. .............. buildings on Rough
. Z'
to be occupied asc :: . .... ss� ....... ...... �:.... ................. Chimney _-
provided that the person accepting this permit shall in eery respect conform to the terms of the apprication on file in Finalc��(' .�'
this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of 1_'— �
Buildings in the Town of North Andover. PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit. u Gr1��Z�—C�
m ,
PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONSTRUCTION, STARTS
. .. :.... Rough
t v .�. .t...�'. �A .. Servic '1 v
BUILDING INSPECTOR
mal ok
Occupancy Permit Required to Occupy Building GAS INSPECT(
Display in a Conspicuous Place on the Premises — Do Not Remove �-�jj
P Y P
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner
Street No. _)_`,.k
SEE REVERSE SIDE Smoke Det.
Location
No. ` Date
NORTH TOWN OF NORTH ANDOVER
Of�t•ao ;�'�'y
3: � 0
O ?
P
Certificate of Occupancy $
s"ACM Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL
Check #17125
Building I n s p e er�
v
0 0
Location��5 /�� �2 L;aDC
No. � Date l�
,,ORT„ TOWN OF NORTH ANDOVER
O� ,..
.• ti43
F i -41e
Certificate of Occupancy $
Building/Frame Permit Fee $
s�cMus _
Foundation Permit Fee $
Other Permit Fee $ _
TOTAL $
Check # /0/7-
�t►�vC�Zs sYc" 6
17017
Bui ing Inspector
/ p 0)_
DRAINAGE & UTILITY
EASEMENT
> 100
< SOT 21 q
a0 rn - 2 .6� 13544 S.F. '
`
CDT ,�- > 0.31 Ac.
�0 zm 000 m
C)
rn0) 0
W � r
Q
cIl
m C) c
Q A � 38.7' O
o o -� TOP OF C)
0 0p FOUNDATION
O ELEV.=278.19
J 23.3'
; m 0 ;
°= -10(
20.8'
`�o° _ 79.64' I 100
o N29`53'44"E 220.57'
.y r' cTE�Hf`, Ae. `� ��pJ = �"'r 4�► 11 1 G l� AN
•4 Cdr•. J
f PROPOSED 40' WIDE
'" WE HEREBY CERTIFY THAT WE HAVE EXAMINED
THE PREMISES AND THAT THE BUILDING IS LOCATED
THIS PLAN IS INTENDED FOR ZONING ASS �Hn t Ir R r1�Ncnd.�c
rtJnrv"�" vrvl,r_ It vy^zj I"I(LI"MI(LU I(7 INF )NIIV C, I W� R���TISE TU ktVUIFl E=1J S�TB/1CKS OF
FROM EXISTING PLANS AND RECORDS THE MUNICIPALITY WHEN CONSTRUCTED_ ALSO, ACCORDING
WITH THE STRUCTURES SHOWN LOCATED TO THE F.E_M.A./H.U.D. FLOOD INSURANCE RATE MAP,
OY AN INSTRUMENT SURVEY. THIS PLAN COMMUNITY PANEL N0, 250098 0006 C
SHOULD NOT BE USED FOR PROPERTY DATED 8/2/1993 , THE STRUCTURE IS NOT LOCATED
LINE DETERMINATION. IN AN ESTABLISHED 100 YR.FLOOD HAZARD ZONE.
CERTIFIED FOUNDATION PLAN
l_OT 21 PEACHTREE FARMS NIARCHIONDA & ASSOC.,L.P.
NORTH ANDOVER, MA ENGINEERING AND PLANNING CONSULTANTS
PREPARED FOR
PEACHTREE DEVELOPMENT, L.L.C. E2 MONTVALE AVE. SUITE I
STONEHAM, MA. 02180
P.O. BOX 3039 (781) 438-6121
ANDOVER, MA 01810 SCALE- 1"=30' DATE: 2/3/04
FORM U*- LOT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all necessary approvals/permits fro
Boards and Departments having jurisdiction have been obtained. This doe m
the applicant and/or la snot relieve
landowner from,
compliance with
p any applicable or requirements.
`APPLICANT FILLS OUT THIS SECTION
APPLICANT_ I'h&Il ru' PHONE �ll�
�'` ' ion lgsc)� cis' r,tc deC! s )G�SyC1
LOCATION: Assessor's Map NumberGf
PARCEL
_—
SUBDIVISION_ SGCL,+T-u �t LOT(S) _
STREET
ST.NUMBER,
'`OFFICIAL USE ONLY*** **
RECOM A 10 'S F TOWN AGENTS:
Co SER_.: 'TI AD WISTRATOR DATE APPROVED /
DATE REJECTED
� Il
COMMENTS.
a
TOWN`PLA R DATE APPROVED
DATE REJECTED
COMMENTS
FOOD INSPECTOR-HEALTH DATE�tPPROVED
DATE REJECTED
SEPTIC INSPECTOR-HEALTH DATE APPROVED.
DATE-REJECTED
COMMENTS
V/
PUBLIC WORKS-SEWERIWATER CONNECTION
L/DRIVE Y PERMIT
It j
FIRE DEPARTMENT
RECEIVED BY BUILDING)SPECT: R
DATE_
Revised 9W im