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HomeMy WebLinkAboutMiscellaneous - 67 VEST WAY 4/30/2018Adjusters' Collaborative, Inc. HP2659301 January 9, 2018 Building or Inspectional Services Department Town of North Andover c/o 120 Main Street North Andover, MA 01845 P.O. Box 297. Wakefield, MA 01880 781-245-5882 • FAX 781-245-6099 E-MAIL: rgonnam33@comcast.net NOTIFICATION UNDER M.G.L. c. 139, Sec 313 RE: Bay State Insurance Company Insured : Glenn & Patricia Schmidt Policy No.: HP2659301 Date of Loss: 1/9/18 Type of Loss : Freeze-up/ water damage Dear Sir or Madam: Adjusters' Collaborative, Inc. is the independent adjuster retained by Bay State Insurance Company to investigate and adjust the captioned claim for damage to a building or other structure at the property at 67 Vest Way, North Andover, MA. Pursuant to M.G.L. c. 139, Sec 313, Bay State Ins. Co. hereby notifies you that payment of $1,000.00 or more may be made in connection with the captioned claim. If the Town of North Andover intends to initiate proceedings under M.G.L. c. Sec 3A; c. 143, Sec 9, or c. 111, Sec 127B, please forward the notice required under M.G.L. c. 129, Sec 313, to my attention within the time provided under that statute. Thank you for your attention. Yours very truly, ADJUSTERS' COLLABORATIVE, INC. Robert C. Gonnam Adjuster Copy to : Bay State Ins. Co Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS, Ch. 139, Sec. 3B To: Building Commissioner or Inspector of Buildings 1600 Osgood Street North Andover, MA 01845 RE: Insured: Property Address Policy Number: Date/Cause of Loss File or Claim Number: Glenn & Patricia Schmidt 67 Vest Way HP2659301 8/4/2015, Hail Damage 32684-R 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 3B 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. Ryan Werner 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. /% A /? Signitife and Date ANDERSON ADJUSTMENT CO., INC. 50 Nashua Road, Suite 303 PO Box 1098 Londonderry, NH 03053 N2 4947 Date.'!, TOWN OF NORTH ANDOVER p PERMIT FOR PLUMBING This certifies that .., .. •� .................. • has permission to perform ...�......... plumbing in the buildings of ..p%J.l.��..-c ................. at ...b V 5 ! <� .l'././ ...... • • .... , North Andover, Mass. Fee Lic. No./ 6,� (-: Y. � . ........ ���... � �.� �.-:-� .. . PLUMBING INSPECTOR Check # U WHITE: Applicant CANARY: Building Dept. PINK: Treasurer -33 --- MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS ` Date l Building Location 47 -' C , 1 dot� �,� W Owners Name ,C� Permit # Amount y �c0 Type of Occupancy New F1 Renovation M Replacement 1:1 Plans Submitted Yes r-1 No (Print or type) / /J Check one: Installing Company Name �C l� r ��p �� (�i 52'�j Ix— acorp. RPartner Lj Firm/Co. Certificate L Name of Licensed Plumber I hwn dv S %Uy\-Lt _ Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity ❑ Bond ❑ J 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 Agent 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 Massachusetts State Plumbing Code andCh142 of the Genera By: Signature of Licensedd um er Type of Plumbing License Title City/Town icensse um er — Master M-- Journeyman APPROVED (OFFICE USE ONLY N2 311 85 Date... TOWN OF NORTH ANDOVER OL PERMITFOR WIRING This certifies that ............... ....... ............................. . ............ ....... .................. has permission to perform,-.:-..- ...................................................................... wiring in the building of .............. ........ ............................................ at . 2 .................... North Andover, Mass. .............................. Fee _;_� .... :-... Lic. ............ ... ..... ....... --<,ELECTRICAL INSPECTOR Check # WHITE: Applicant CANARY: Building Dept. PINK: Treasurer 1 1 Th F 0QMMONWEALTHOFMASSACffUSEM DEPARTAMWOFPUBLICS MY BOARD OFFIREPREVF.M17ONREGUTA7I0NSS270MR 12.110 Office Use only Permit No. —Zlri Occupancy & Fees Checked L JUL LICATTONFOR PATO PERFORMELECI'RICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION)Dat�/ U Town of North Andover The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number) 16 7 V Owner or Tenant Owner's Address (b / M) T -__W/f To the Inspector of Wires: Is this permit in conjunction with a building permit: Yes rM No M (Check Appropriate Box) Purpose of Building Npirry 0/y Imli6*/y Utility Authorization No. Existing Service WO 0 Amps V 1 � o Volts Overhead r7 Underground No. of Meters 1 New Service Amps / Volts Overhead [M Underground No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work ij4li iii/ t91= 0071etJ� GTS 15U,191kS 7$ f o& No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures® Swimming Pool Above and Below ground Generators KVA No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch tis BS No. of Gas Burners • FIRE ALARMS No. of Detection and Initiating Devices No. of Sounding Devices No. of Self Contained Detection/Sounding Devices Local a Municipal Connections No. of Zones a Other' No. of RangespPCO��r��L let No. of Air Cond. Total Tons No. of Disposals No. of Heat Total Total Pumps Tons KW No. of Dishwashers ! Space Area Heating KW No. of Dryers Heating Devices KW No. of Water Heaters KW No. of No. of Signs Bailasis No. Hydro Massage Tubs No. of Motors Total HP OTHER --- - Ic>St==CO � PtastMttDthem4martatsdNbm&BMCOX.rALaws �—�/ Iha%eaa=tLi�yh�stra=PUbcy d►dMCmVi& GaezaWarits lOWmatut YES (E/ NO ID Iha%esubm9WdvMptoofofsametoftOfmYES MNO r If}Doha%edxdWYES,pimeQ&etctAxcfwmagebydtedttgthe BOND OTFM _ WJ d� Fsbm&dVakledUech2l Wak $ WctkoSlatt lnspectionDtateRe7sted Rough k1i G (- c1? I L, _.� Find! signadunda'�iePtr>altres - FIRMNAME lr fC L- LiomseNa'EWY o? 1, OWNER'S ll,NURANCE WAIVFR, I.amawatetbattheLi=ised mddxtmysi m�<)n uspeti *wpfiab vmi%Md ism m> lnt (Please check one) Owner Q Agent 101 Telephone No. PERMIT FEE $ �3 -100 N° 2577 Date ..... q.. f�`.. /,-) (} TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ....... / �!. t �� .v�` (����i✓? has permission to perform / 1" f C�? l................f'....... wiring in the building of .......... ��..�CIh. `'Q ............................................... 7 .... , orth Andover; Mass. Fee......UC� Lic. No.l-.-.7!�`: ..:..........'..::............... ELECTRICAL INSPECTOR SO � Z,. .. Check # WHITE: Applicant CANARY: Building Dept. PINK: Treasurer Official Use Only Permit No. CJ`J �� ae:*ut Sam Occupancy &Fee Checked BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code 527 CMR 12:00 (Please Print in ink or type all information) Date Ins cr Town of North Andover To the tof Wires: The undersigned applies for a permit to performs the electrical work described below. Location (Street & Number Owner or Tenant ,, 1 dd- T71 X 4,/ Owner's Address ,Y &SS J ,!k4y / Is this permit in conjunction with a building permit Yes Com/ No ❑ (Check Appropriate Box) Purpose of Building�/Qf T` %� Utility Authorization No. Existing Service _ Amp s l l7 yd Voits Overhead ❑ Undgrnd No. of Meters New Service Amps Voits Overhead ❑ Undgmd ❑ No. of Meters Number of Feeders and Ampaciry • Location and Nature of Proposed Electrical Work r�I/P J7/rCj/ZG v/�S` C;a W No. of Lighting Outlets No. of Hot fuse Total No. of Transformers KVA Above ❑ In ❑ No. of Lighting Fixtures Swimming Pool grnd ❑ grnd ❑ Generators KVA No. of Receptacles Outlets No. of Oil Burners No. of Emergency Lighting Batte Units No. of Switch Outlets No of Gas Burners FIRE ALARMS No. of Zone No. of Detection and Initiating Devices No. of Ranges Total No of Air Cord Tons Heat Total Total No. of Di osal No. Pumps . Tons KW No. of Sounding Devices of Self Contained Detection/Sounding Devices ❑ Municipal ❑ Other Local__, Connection No. of Dishwashers Space/Area HeatingNo./ KW No. of D17 rs Heating Devices KW No. of No. of Low%Voltage No. of Water Heaters KW Signs Bailases Wiring No. Hydro Massage TudsI No. of Motors Total HP OTHER: INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalentES = O= fitted valid proof of same to the Office YES= NO = If you have checked YES please indicate the type overage by checking the appropriate box. INSURANC BOND = OTHER = (Please Specify) (Expiration Date) Estimated Value of Electrical Work$ /,G! [ni Work to Start -inspection Date Resquested Rough Final Signed under the Penalties of perjury: FIRM NAME LIC. NO LenseeU/rf/GP ICK oPZ/" & Signature LIC. NO.� . yd) �7�r� �/C �/ U� e"7/TY/Cr Bus. Tel No. Address Alt Tel. No. OWNER'S INSURANC WAIVER: I am aware tha�censes does not have the insurance coverage or its substantial equivalent as required by Massachusetts General Laws. And that my signature on this permit application waives this requirement. Owner Agent (Please Check one) (Signature of Owner or Agent) /• S n . Telephone No. PERMITTEE $ 6 ✓ 2487 Date ....... 7.....` U TOWN OF NORTH ANDOVER PERMIT FOR WIRING T This certifies that ..........a pn.......5 �........J..f 4/1.r ...... I=.%' has permission to perform 2 O1� �����. 5 y �' wiring in the building of.........,1.0c3..�v....`e............................................. 7...........P ................... . . North Andover, Mass. Fee... ...00.. Lic. No.//* . . ...:.����................... ELECTRICALINSPECTOR Check # 5 - WHITE: Applicant CANARY: Building Dept. PINK: Treasurer ICS t� fJLY1LYLV1 �IIYC.t� lC2 iAl LYLf$J $rY fJ�r.1 1J vttu;c U�c unty DEPARTMU'TOFPUBLIC,&4FETY Permit No. C� BOARD OFFREPREVEN77ONREGUL4TIOAS527OfR 12.00 Occupancy & Fees Checked Al PJ...I.CAT ION FOR P TO PERFORM E,E CI 1L WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 �!, ` ,1/.t (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date tl L 7,(�V Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number) 6, 7 veJ J- wA- Owner or Tenant s (,t /�/ ,� 1) 9&&.A az L p/Ue Owner's Address 7yesr w,4y 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 Underground New Service Amps / Volts Overhead ® Underground No. 'of Meters No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work WJQrNir 0 F !/ ;2AI O-AIIA41 /3 C 7- /6777 S477,i 1124 No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures Swimming Pool Above Below Generators KVA ground ground No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting Battery Units Np, of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Ranges No. of Air Cond. Total Tons No. of Detection and No. of Disposals No. of Heat Total Total Pumps Tons KW Initiating Devices No. of Sounding Devices No. of Dishwashers Space Area Heating KW No. of Self Contained Detection/Sounding Devices Local Municipal Other No. of Dryers Heating Devices KW ® Connections ® No. of 'Pater Heaters KW No. of No. of Signs Bailasis No. Hydro Massage Tubs 4 No. of Motors Total HP OTHER hx==Caerage. Rttsuar4iothetaWmxWofMasmd setisCmaalLaws IhateaamartIanittyhsu=PoliyaxidirgCznCDvaaWcritsabividegivalut YES NO IhawaftnittedvalidproofofsametDthe0ffm YES NO ® IfjcuhsechaicedYES, pkmeink&theNxofcmaaWbyd,=kgthe wstRANc.E BOND oTI-Ili (Pleasespe*> Le, 9 / V0 Q 117 Stet 7 °� 7 r7 0 Esft a Val dEleWxal Wotk $ Wodc � � Roti► Fatal7/7 ��� a n Sigtx derPa FIRM NAME /��COi?� LIZ, Z/Z/-V �' t:%�/li�%�L IkaseNa �WZ-� f Lia sae Qdhl/ TO T j7°/%%l/ 1 A o� /{��1/✓� f / �/P . �T���� �� � /�°'�y Bus�a>ess Td. Na (97,�) AtTel. N , OWNER'S II�6URANCEWAVER;Iamaw=dXtdVLXa�se $ieama oe ta�ss a rite dby da GaalLaws andfixtmysigrn�aernthis pamA Wpficahm wmivsthis rx"ix ert (Please check one) OwnerEl Agent a Telephone No. PERMIT FEE S 7 K.A. a Cq f AlK,—(DO N1VA ANreO Ivel— 61 Y3 3vl3,�z Location No. 3 77 Date �ORTM TOWN OF NORTH ANDOVER f �,y O A Q Certificate of Occupancy $ 37.5 Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ &rT.) TOTAL $ 375 f" Check # 4 h L Q EMI Iding Inspector a d{. TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: 3 7g DATE ISSUED: SIGNATURE: Building Commissioner/I for of Buildings ate SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: 7 A5 -7- TD Z,U ��i�� Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: �- l 5. Vis; yy, is0 Zoning District Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard RegWred .Provide ReqWred Provided 1 Re red Provided O 3Y4-. Y� ® /00 '-H 1.7 Water S ly 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 OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record it/ e—_ Name (Print) Address for Service Signature Telephone 2'.62 Owner of Record: �p dcJ,�I/s9 �ig C�G O ivy S"f! /il � Tjame Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ -:9-0 11A -j "-,J fI;.7sti��, �✓ � �S o Yo � 7D Licensed Construction Supervisor: / 2 X A License Number Address Expiration Date t nature Telephone 3.2 RegisteredHom Improvement Con�tractor Not Applicable ❑ Company Name Registration Number Address � �/ 7 0 17r� Expiration Date Si natu Telephone no M �i z �M,, �1 0 O z M go 0 wn r M 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 bgil&g permit. Signed affidavit Attached Yes ...... A 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: U n/ ��dY✓1-a? � SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit applicant. OFFICIAL iUSE ONLY_ 1. Building (a) Building Permit Fee Multiplier 2 Electrical 5 ODD � (b) Estimated Total Cost of Construction o �. 3 Plumbing OU, Building Permit fee (a) X (b) 0= u S o a^ S 4 Mechanical (HVAC) p ev 0' 5 Fire Protection 6 Total 1+2+3+4+5) 000,1e Check Number c52144 -e, SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BURDING PERMIT 1, Je /�GGo e-- as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf mer tive to work authorized by this building permit application. /�3 Si nature of Ow er Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, ✓D'�'�> l�/TfSii�wl ,/2� 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 "/.✓J. A&: ,q -;,-n;;, ✓z Print Name Si atl f Owner/Anttt Date NO. OF STORIES SIZE X Z_ BASEMENT OR SLAB 7` SIZE OF FLOOR TIMBERS IST Z yC / Zj 2ND 3RD -- SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION -7 YZ ' THICKNESS SIZE OF FOGTING—, /o jC ZO X MATERIAL OF CHIMNEY 'Cle ��— IS BUILDING ON SOLID OR FILLED LAND o u e IS BUILDING CONNECTED TO NATURAL GAS LINE / d 6. 0 a 1*3 " O � ca x � � r � U x aCl) � w uz w w w H a ° o w G w w x w co o z cn Fir' 2 4 L 1 94 4-J a 2 co 1 O co L co _O V m O y COC CD yO •9 m m i O CO CL _~ CD 0 0 C Oar ccC CO •CO)% Z a5 CL C9 CO) � c CL CO) 0 N Q O z W4 p u w cn tz v z a co w w v C U x o w 44 a bo cL tv ir. w w r.a to w u cn w a p v z d .G a:. w F-4 w d w w w w co z cn Q cn o m c C*CS Q ` �cc 4 C.3 31 Cc D o ' Q L m QQ � EQ V ym. C r v 20 N o O Ri r m m� a� € �mm a N �4 � • S' ca •p N N y m ' C: N 0 m p m }•% O C3 y CO S. O C 1� m /�- N m C •C t � •N dt m c. 2 oc •E N o L3 m o m c g CO3 a. m� O 2 coi m y•� O F- •O.. d_... m ? 0 ►, -t O ' O' 0 Z Z Q• � O y ® C rm I 0 ca • m m CL O O ® O !8 O O' CL a' os Q O � � C O O o co c Z s 0 CL C..9 CO) C C _cc CL CO2 D 8l 10 yJ 0� b t N t U 0- ATVGE?� t 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. APPLICANT Jv,y 1�6AJIu,-1 Fv9.//,D o t 'PHONE l V - �0 ASSESSORS MAP NUMBER 10q— LOT NUMBER © IL 2 -- SUBDIVISION NUMBER STREET STREET NUMBER OFFICIAL USE ONLY INESURNOMME RECOMMENDATIONS OF TOWN AGENTS moo 868000008888mus DATE APPROVED CO SERVATION ADMINISTRATOR COMMENTS FOOD INSPECTOR - HEALTH SEPTIC INSPECTOR - HEALTH PUBLIC WORKS - SEWER / WATER CONNECTIONS DRIVEWAY PERMIT ' ,, . A /// � Ni FIRE DEPARTWW COMMENTS RECEIVED BY BUILDING INSPECTOR g06 D_,TE REJECTED DATE APPROVED L04 ) DATE REJECTED DATE APPROVED DATE REJECTED. DATE APPROVED d DATE REJECTED . M DATE APPROVED DATE REJECTED rz • TE I -27-o0 1 m O z ol M W4 Q a G Q) u w LE v V) 04 ° uw wco z 5CO G o w o a X U G x o w aw o pG c w a �" uz rr u a W o n4 cn G w a H a � o C4 G u. z A w x v w 0 z U) o .� o cn z 0 w w it co OL c� o O d c 0 • ` L ,•'1 � O C Z Z .R c O CO) co ® C = o pp ' o � N �' cl ' : E,< 1l C r V Z o c (V N E C ��: Do •mom E y �mm L go 2 v H m [-; C Z N Em A Q ' o L my 0 mm a oig c coma &N M 'o 0caj N O m L 0 r.+ c d O C Q v � y m C •p x m :oho N H CO 0 ea Z o •N -00 A f.. �E = G.t10 c=3 Z uj C3 m p O C C#* x O. m� 0 �oy•� o z . n. *. m � z 0 w w it co OL ' O 0 O Z Z CL O CO) ® C Ico cm C C V2 0 'D c MA c CO Co Q G3 CL ..+ co Oimp% � O co M o a CL OM Q C C= ccC vCc J10 co CO2 Z co CL C..) VD c . C _R d E 0 U) U) crw w Erw E o Town of North Andover o� NORTH Building Department o 27 Charles Street North Andover Massachusetts 01845 (978) 688-9545 Fax (978) 688-9542 9SSgcHus�t DEBRIS DISPOSAL FORM In accordance with the provisions of MGL c 40 s 54, and a condition of Building permit # G11 the debris resulting from the 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 /at: D,04- e- Te 10/.4. Facility location Signat e of Applicant Date NOTE: A demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02119 Workers' Compensation Insurance Affidavit S//� .I- t I Please Print 7� Location: 1315 City I V © /4�Phone %S" — z;j� V— V/ aam a homeowner performing all work myself. a sole proprietor and have no one working in any capacity aI am an employer providing workers' compensation for my employees working on this job. Company name: Address City. Phone #: Insurance Co Policv # Company name: Address City Phone #: Insurance Co Policy # 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 well as civil penalties in the form of a STOP WORK ORDER and a fine of ($100.00) a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do herby certify under the pains and penaXes of Si the information provided above is true and correct. Print name f%' J Phone # G— Z3 o U 92j-6IoY-Y/9 / Official use only do not write in this area to be completed by city or town official' ❑ Building Dept ❑Check if immediate response is required Building Dept ❑ Licensing Board ❑ Selectman's Office Contact person: Phone #. ❑ Health Department ❑ Other FORM WORKMAN'S COMPENSATION to /'LAN SHALL BE INCLClpEp AS HART OF °THf" C`QNSTRLICTION0=tL'TtiACT i. ! FOR. TWE REP -11R '(OR UPGRA'DE; O^F SYSTEh�fS; . TIDE EXSTaf�1G =r , S A3S A�d,D`6SfFUl1D3 ASD Ur�,17ERLYfNG6 SPOT -ED SOf� SHALL BE E CA A rAND REh G`dED I NERE1?�E VYI-T-H1;1! F' OF: rHE l'Rf P(3"�ED - Y a�<S.YSrEM,tT,1, ,u i 3, rOtc THE REPAfR ;(OR 11PGRAI7E� OF SYSTEMS 'Tref E1STliC� SE'�%`l SfA�: •t �s UPPED AND efTffER f?'UNCTURED Y�':t TTI'RCIT�TOfi� z�ND FICLD 1�dTE�A SN�'�t ys4 kms*4, OR 'COLLA'I'SED ,q: /n .RF_MO1�E FR.6M T -HE' S,TE 1 tif3$: t�xr s x�t p 01 . i,�r�Np-5�:5 t . ►.� �� fns �r, Alf" tie, F q r T0111N OF f�OKTA: ou c AOproved t Vele �l ! L :m. .+�� . .. - w�lzd� � .y4S�;.�{znature '. �,. " tet. y . �, � 1 x.� x>�-..fY, y �„€t' `y}� +,, ti .. � .` st '�''u > '. d � " w.'�,r 4k'�'�%d°W�F' wA� •r h+ti8^"S �a- �- . DESIGN . FLO'vV .: BEDROOMS. x Ie GSL DESIGN PERC .,RA -TI-:- of P,1. ' SOIL CLASS:. DESIGN FOR LEACH FIELD SEE t?ETAPL) i LEACHING s,REA REQUIRED: = _� GA.L. x f '+ LEA=CHING AREA PROVIDED .LANG " . WIDE x — - F.' s f CERTIFY THAT ON WAY 9, 1996, 'i PASSED TH.E EXAA!fiIJATIDN APPROV-D 'BY 7?fE DEPARTMENT I','' EST OF` ENVIIZUNM:FfITAL PROTEC,IOIV ANG ':HAT lfifE A?f1E r.rx� '° jv ANALYSIS WAS PERFORMED -By ME GONSISTENT WITH THE PEOUfREDa TRAINING R` EXP ERTISE AND, EXPERIENCE DESCRIBED -IN I'v CMR t'S Qt SIGNATURE (,.rR.;�"*�- _ IJATE 0,1 /' ? ISF­ 01 Wo 571 j. dy1 , PA AS -PRE RED: SCA LE' AS SHOW iJll I . �tia ri' i- ASSESSORS M>4`��i°�•s4�gipz *y,i S A T�` V%5 , !1 dye ¢ ERR Pte- f�� Lj p�' .{ `..� 6'.�Al ��'Y 1. .e, r Q .6"I (� i " pn. Il "�•M r°t ,q, �T' Igµ �?` �..r.a ' S d 7',C.,. ' 1_�d%„ 5 r � � � w...° fi9v .ala •,: ,: _.,T u f �ft iwAc'F.•&.a.Hi�xn}�v°ed'�:'�'bl`'GB..�:- ._._...�.,_.� I . j' �;. I 1 { _ ..1 -, -'"'set" u11— IN �t.' r j- :i IVV +' , 11 V , '' 1: ''s 1� :O;:GALLOiv OQNCRfTE ., x� 1 t S�f'T,t"jC .TANIf _-IT tr �. - ''. 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SCOTT Director (978) 688-9531 October 20, 1999 Bill Dufresne Merrimack Engineering 66 Park Street Andover, MA 01810 Re: 67 Vest Way NORTN Ottt�eo ,e,ti0 O A x* ^p9 ^ #J Fax(978)688-9542 Dear Bill: This -is to inform you that the proposed septic system plans for the site referenced above have been approved. However, please be aware that a note required on the deed stating that there can be no additioiial flow to the septic system, ie., no additional rooms, because of the depth to ground water variance.. If you have any questions, please do not hesitate to call the Board of Health Office at 978-688-9540. Sincerely, �--7 Sandra Starr, R.S. Health Administrator SS/smc cc: John Pallone File BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 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. APPLICANT IJ i�Ff C PHONE ASSESSORS MAP NUMBER 104- LOT NUMBER SUBDIVISION LOT NUMBER STREET Wtj!-t STREET NUMBER 67 OFFICIAL USE ONLY RECONMIENDATIONS OF TOWN AGENTS / DATE APPROVED CONSERVATION ADMINISTRATOR DATE REJECTED CONMIENTS DATE APPROVED TOWN PLANNER DATE REJECTED CON94ENTS DATE APPROVED FOOD INSPECTOR - HEALTH DATE REJECTED DATE APPROVED SEPTIC INSPECTOR - HEALTH DATE REJECTED CON94ENTS PUBLIC WORKS - SEWER / WATER CONNECTIONS N/0 DRIVEWA k T I ASO �� SFR D P TMENT DATE APPROVED 5 6,6 DATE REJECTED CONM4ENTS RECEIVED BY BUILDING INSPECTOR DATE