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HomeMy WebLinkAboutMiscellaneous - 451 Windkist Street (2) -F- J TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: l l-oZ y Gf SYSTEM OWNER & ADDRESS SYSTEM LOCATION r fn (example: left front of house) � Ish DATE OF PUMPING: QUANTITY PUMPED 1—=--GALLONS CESSPOOL: N t 0 YES SEPTIC TANK: NO (� __ YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE FULL TO COVER ROOTS ----- BAFFLES IN PLACE EXCESSIVE SOLIDS "-- LEACHFIELD RUNBACK SOLfn,S CARRy,, 0`'L ----- FLOODED OTHER (EXPLAIN) SYSTEM PUMPED BY: OMMENTS: o- [ rr � ONTENTS TRANSFERRED TO: Commonwealth of Massachusetts North Andover, Massachusetts System Pumpinz Record System Owner& Address: James Tringale 451 Winter St North Andover, Ma 01845 Location of system: Rear Date of Pumping: August 29, 2011 Type of system: Septic Tank Gallons Pumped: 1000 gallons System pumped by: Service Pumping& Drain Co.,Inc. S Hallberg Park North Reading,Ma License#: BHP-2011-0413,0412,0411,0410,0409,0408 Contents transferred tr Greater Lawrence Sanitary District Date: August 23 !i. l -Pumping-Technician: PD This is PROPRIE'___�RY and CONFIDENTIAL information that may be used only by the Board of Health for regulatory purposes COMMONWEALTH OF MASSACHUSETTS JD EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS v d DEPARTMENT OF ENVIRONMENTAL PROTECTION , TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: Lk►5N W,Ntr' Jk. Owner's Name: 1'%nne-. Owner's Address: 43Xy;,.\zr S4. Date of Inspection: 10-,L\-01, Name of Inspector:(please print --�OSzAl APIN Company Name: S;zrv,u �C� ( 6 Mailing Address: WA Telephone Number: Geld CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: 10 -1, �)-0'�\ The system inspector sha Zmit a copy of this' pection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspe 'on.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes.conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: �'\ � �(;n�tr-CV. Owner: Win„\:sem Date of Inspection: Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Sy em Passes: V71have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: ©nC c��1c,(� ti. �..ln �n 1`.y.nc a� cyr✓��', �..�.\�.. PIA„\ 1-111-All", %6-4001,) B. System Conditionally Passes: e or more system components as described in the"Conditional Pass"section need to be replaced or repaired. a system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no o not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. The septic tank i�metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits subst nI I infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existing tank is replaced wit a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less thin 20 years old is available. ND explain: Observation of sewage ba\setfler ut or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a brokneven distribution box. System will pass inspection if(with approval of Board of Health): are replaced s re oved box is veled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Lt&\ Owner: Date of Inspection: 1�-1�►-0�. C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is fai i g to protect public health,safety or the environment. 1. stem will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the sy em is not functioning in a manner which will protect public health,safety and the environment: sspool or privy is within 50 feet of a surface water Ce spool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail less the Board of Health(and Public Water Supplier,if any)determines that the system is functioning a manner that protects the public health,safety and environment: _ The system has a eptic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or ibutary to a surface water supply. The system has a sept tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic k and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank d SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Metho used to determine distance "This system passes if the well water lysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds i icates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrat nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the and sis must be attached to this form. 3. Other: Page 4 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: c-\S:\ �4 ,A e' &� (-, P�^A"td W\rA Owner: Date of Inspection: D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or / clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or _ Jcesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than 'h day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number 7Y/ of times pumped . Any portion of the SAS,cesspool or privy is below high ground water elevation. y portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. _ Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this forma Na (Yes&The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To b onsidered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must i icate either"yes"or"no"to each of the following: (The followin riteria apply to large systems in addition to the criteria above) yes no the system is 'hin 400 feet of a surface drinking water supply the system is within feet of a tributary to a surface drinking water supply the system is located in a nitr \sensitiverea(Interim Wellhead Protection Area—IWPA)or a mapped Zone Il of a public water suppIf you have answered"yes"to any questE the system is considered a significant threat,or answered yes" in Section D above the large systehe owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: �-1 S 1 n. n�1c G!1 Owner: Date of Inspection: 10 -iy Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yep No Pumping information was provided by the owner,occupant,or Board of Health Were any of the system components pumped out in the previous two weeks? Has the system received normal flows in the previous two week period? 7 Have large volumes of water been introduced to the system recently or as part of this inspection? Y11.r-) Were as built plans of the system obtained and examined?(If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? 7 _ Was the site inspected for signs of break out? y-�6/ Were all system components,excluding the SAS,located on site? _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition 7of t baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum ? _ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no Existing information.For example,a plan at the Board of Health. _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[3 10 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: `'1S `'4"' Lr Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CPq C, 15.203(for example: 110 gpd x#of bedrooms):'130 C—t'0 Number of current residents: Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system es r no):4ft& [if yes separate inspection required] Laundry system inspected(yes or no):Lqc,& '4'0's Seasonal use:(yes or no): Water meter readings,if available(last 2 years usage(gpd)): P4--'Cy4'A Sump pump(yes or no):n1•o \ Last date of occupancy: CCvi`n-�1' COMMERCIAL/INDUSTRIAL Typ f establishment: Design w(based on 310 CMR 15.203): gpd Basis of deign flow(seats/persons/sgft,etc.): Grease trap p ent(yes or no): Industrial waste olding tank present(yes or no): Non-sanitary wast discharged to the Title 5 system (yes or no): Water meter readings,if available: Last date of occupancy/use: OTH (describe): GENERAL INFORMATION Pumping Records \� Source of information: ,r r. Was system pumped as part of the inspection(yes r no): If yes,volume pumped: gallons--How was quantity pumped determined? P00 Reason for pumping: TYPE OF SYSTEM Septic tank,distribution box,soil absorption system _Single cesspool Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or o): Page 7 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1'1�- \.J,., ,(r f\, Owner: nc�:s Date of Inspection \0 ��►-off BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: cast iron _40 PVC_other(explain): Distance from private water supply well or suction line: MA –T. ,, %rt© Comments(on condition of joints,venting,evidence of leakage,etc.): SSC^S alv. nA Ca. VeR.���\ SEPTIC TANK:_(locate on site plan) Depth below grade: \�-to,,-/ Materialof construction:1concrete_metal_fiberglass_polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: �'4 lF,r� S s":�P:. S ��%:��• y' c�tP��.�•� Jle� Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: \1 Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: —\ ,� enuAiwPAZ Comments(on pumping recommendations',inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): GREASE TRAP:_(locate on site plan) Depth below gr e:_ Material of constru ion:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum top of outlet tee or baffle: Distance from bottom of scum bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: `-1Sl -�./�,��Lr- Owner: Date of Inspection: \0--\N VI, TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grad Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: lions Design Flow: ga ns/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: -A_ Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): PUMPCH R: (locate on site plan) Pumps in working or (yes or no): Alarms in working order es or no): Comments(note condition pump chamber,condition of pumps and appurtenances,etc.): Page 9 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: -\S\ \-J:^� r S� Owner: Date of Inspections \v \y-02, SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number:_ leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: CSS. XS x 4o overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): Ji'�+n'.', r.r4�j �•\�... �- cJ\1�1 '�© ic�d��.nr 's��;..n� CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number andconfiguration: Depth—top of liquid to inlet invert: Depth of solids layer.: Depth of scum layer: • Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY:'\ (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil, sig s of hydraulic failure,level of ponding,condition of vegetation,etc.): Page 10 of 11 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: LA!S\ Q-"Ac r Owner: C-n,�a�^ Date of Inspection: w t4-01- SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. C"')tr ID LoJe'�,oi^ '3a r 9 . rA i i 1�J Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: I1S7 \w,Ar_/ fl` A�JIuaG� Owner: Grc\;6n Date of Inspection: »-iy-,5;L, SITE EXAM Slope S.-901" Surface water r,o Check cellar S�aS Shallow wells ho,,.Z, Estimated depth to ground water �;+-feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Ahecked with local excavators,installers-(attach documentation) ccessed USGS database-explain: You must describe how you established the high ground water elevation: �oy�d\` �ne.\� �`y ( r�S,�n�r...:nL �e.�.�/3� v��ot£e �C,�Y �.T i.1 e��.c• ���JE.^ U WATER BILLING HISTORY 3180038-ENGLISH, RAYMOND METER #1: 3180038 --------------------- 451 WILATER ST sn .� .`' # CYCLE SERVICE PRIOR CURRENT USE WATER SEWER FEES TOTAL j 1 2000-13 09/13/1999 757 817 60 163.80 0.08 0.00 163.8 roo 2 2000-23 01/26/2000 817 862 45 122.85 0.00 0.00 122.85 3 2©00-33 04/03/2000 862 907 45 422.85 0.00 0.00 122.85 4 2000-43 06/14/2000 907 907 0 8.00 0.00 0.00 0.0 5 2801-13 09/26/2000 907 930 23 62.79 0.00 11 .00 73.79. 6 2001-23 11/15/2000. 0 0 18 49.14 0.00 11.00 60.1 7 2001-33 03/30/2001 0 47 47 128.31 0.00 11.00 139.31 8 2001-43 06/19/2001 47 72 25 68.25 0.00 11.00 79.25 -_ 9 2002-13 08/28/2001 72 92 20 49.40 0.00 5.55 54.95 10 2002-23 02/07/2002 92 136 44 113.16 0.00 5.55 118.71 ,x. 11 2002-33 04/11/2082 136 153 17 41.99 0.00 5.55 47.5 ' 12 2802-43 06/17/2002 153 172 19 46.93 0.80 5.55 52.48 > - �gFREVIEW CHOICE # or <ENTER> MORE HISTORY: x.-10,va J ia r x yi r Cunningham Lindsey U.S.,Inc. P.O.Box 703689 uranin Cam Dallas,TX 75370-3689 j" �����!' Telephone(888)738-8714 Facsimile(214)488-6766 j� f�f CLCAT@CL-NA.COM March 20, 2015 TOWN OF NORTH ANDOVER BUILDING COMMISSIONER NORTH ANDOVER TOWN HALL 120 Main Street North Andover, MA 01845 Claim Number: A033558878 Policy Number: 88319400004 Company Name: Arbella Mutual Insurance Company Date of Loss: 03/03/2015 Insured: JAMES TRINGALE Property Location: 451 WINTER STREET, NORTH ANDOVER, MA 01845 To Whom It May Concern: Claim has been made involving loss, damage, or destruction of the above captioned property, which may either exceed $1,000 or cause Massachusetts General Laws, Chapter 143, Section 6, to be applicable. If any notice under Massachusetts General Law, Chapter 139, Section 3B is appropriate, please direct it to the attention of the writer. Kindly include a reference to the captioned insured, location, date of loss and claim number. Date...��.. //......... f NORTH� ° ``° • "� TOWN OF NORTH ANDOVER PERMIT FOR WIRING s � r ,Sv US� This certifies that e� has permission to perform ....... S wiring in the building of.. � t. .F.'... ,� S-� , Int/, � � .. ................................................. at .. .. ......................f..�......... ......... North Andover, ads OU Fee...l.45........... Lic.No/. 3.J�.. ............. ..... .,t ...... c� LECTRICAL INSPECTOR Check # 458 Commonwealth of Massachusetts Official Use Only is 0 Department of Fire Services Permit No. BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 11/991 leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),5 7 CMR 2.00 (PLEASE PRINT IN INK OR TYP_ ALL FO ATION) Date: 3 City or Town of: To the Inspect r of fres: By this application the undersigned 'ves notwe o 1his or h r intention Aperforin the electrical work described below. Location(Street&N ber) Owner or Tenant Qt 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❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Installation of Security system Completion of the followin table may be waived by the Inspector qf Wires. No.of Recessed Fixtures No.of Ceil:Susp.(Paddle)Fans No.of TotalTransformers KVA No.of Lighting Outlets No.of Hot Tubs Generators KVA M No.of Lighting Fixtures Swimming Pool rnd.Above ❑ In-rnd. ❑ o.o Emergency Lighting Baffm Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.o Detection and No.of Switches No.of Gas Burners Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other v Connection No.of D Heating Appliances Kit Security Systems: Dryers No.of Devices or Equivalent No.of Water Kit No.of No.o Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. 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:) (Expiration Date) Estimated Value of El ctri al Work: �l � (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. I certify, under the ai s andpenalties ofperjury,that the information on this application is true and complete. FIRM NAME: ty cas LIC.NO.: l-531(' Licensee: John S. Bassett Signature LIC.NO.: 1533C (If applicable, enter"exempt"in the license number line.) Bus.Tel.No., 603 594 5928 Address: Alt.Tel.No.: OWNER'S INSURANCE WAIVER: I am aware that the Lic, see 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 Signature Telephone No. PERMIT FEE: $