Loading...
HomeMy WebLinkAboutMiscellaneous - 709 OSGOOD STREET 4/30/20180 O En La O O En rt Fi (D rt 09791 Date..-..-.�.3 � �.CyLF.i3J•. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ..... ! ` l• • p....� L�f i • has permission to perform . � �?w5�.. ,, o�L��. , , , , , , , plumbing in the buildings of. �`j . �s�„ . :lr ............ at , .. SE'.avSJ?';N ?rt An over, Mass. Fee. PLUMBING INSPEC OR Check # /t1 Date .,� 1. /— J3. . �W TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that .... M `iv. T. C.7.... !) L,.v err r�ur ..........� has permission for gas installation ' V in the buildings of. •�{1 ,% ��`-�,,�,�,r, . �5%���:. . at . -7 % 1 ....... `�, North Andover, p9 �� .5 17 . ... .. ... ,Mass. Fee .&4..... Lie. No. GASINSPEC L" Check # _ 8583 V Kl K) at; MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY e MA DATE � /„ I PERMIT # / JOBSITE ADDRESS O Q OWNER'S NAME POWNER ADDRESS _ _ ��'a > /V. Ov TEL FAX l TYPE OR OCCUPANCYTYPE COMMERCIAL( EDUCATIONAL Q RESIDENTIAL PRINT CLEARLY NEW: Zr RENOVATION: REPLACEMENT: Q PLANS SUBMITTED: YES ®I NOEg FIXTURES 7 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OILISAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM .j DEDICATED WATER RECYCLE SYSTEM I ._.._..-._1 ! 1 ......_.._� 1 (i ._-._.._.._.1 DISHWASHER DRINKING FOUNTAIN -_---1 .._...-...I-__----___f FOOD DISPOSER FLOOR/ AREA DRAIN INTERCEPTOR INTERIOR ! .____._._.._.._.� KITCHEN SINK i __-.i __.._1 -f _-_ ______J .1 _---....._1 _-. __I __.____I ___.___I _._____1 _-_.._I _j _------- -.._ LAVATORY I ROOF DRAIN6 __ .______1 SHOWER STALL SERVICE I MOP SINK I ._._—J ( .-____i TOILET 1 1 ..........J ._ _ _i _. _ 1 _...___I _._.__J __ ( ___._._! ____ 1 ..____ URINAL ! _-_._....__! I ( ! __._..._1 WASHING MACHINE CONNECTION WATER HEATER ALL TYPES i _ 1 1 _.__...___.i I ---I= _..._1 _ ___ WATER PIPING f OTHER ._._.-----1 INSURANCE COVERAGE: 142. I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. YES...dNO�_1 IF YOU CHECKED YES, PLEASE INDICATE TH TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICYIL9 OTHER TYPE OF INDEMNITY © BOND OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER D AGENT IF SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinen rovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME•To) L.. 'Td _ I LICENSE # dYSSS I SIGNATURE MP ID JP R CORPORATION EI# - _ _; PARTNERSHIP 0#=LLC Ej#j COMPANY NAME ��„i� ; ADDRESS CITY — — — - ........_...__.._ ISTATE _i ZIP 4� -s TEL FAX CELL EMAIL V Kl K) at; w O z 0 H w w o� z NEl �D W O p w a z D H = ~ H co Q W Cl) d LUW in O o aa, a 0 w a � U J 0- 0- aC/) C/) w EE W H LL O z IVH z 0 F U a The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leeibly Name (Business/Organization/Individual): Address: City/State/Zip: Phone #: Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. I ship and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, §1(4), and we have no insurance required.] t employees. [Ido workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12.❑ Roof repairs 13. ❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they aie doing all work and then hire outside contractors must submit anew affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that isproviding workers' compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one=year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: Phone #: 11 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced -acceptable evidence of compliance with the insurance coverage required" Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or p* to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 604 Washington Street Boston, MA. 021 It Tel, # 617-727-4900 ext 406 or 1-877,7MASS.AFE Revised 5-26-05 Fax # 617"727-7749 wwwmass.gov/dia _P vt X M c X MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY _ _ MA DATE ,/ PERMIT # � JOBSITE ADDRESS �,y OWNER'S NAME V4W, GOWNERADDRESS C__j� TEL�� FAX _ _ �_ _ TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL DJ PRINT CLEARLY NEW: Rr RENOVATION: El REPLACEMENT: F-11 PLANS SUBMITTED: YES Q NO Q APPLIANCES 7 FLOORS- BSMJ 1 2 3 1 4 5 6 7 8 1 9 10 11 12 13 14 I BOILER l J L„-, 1 !_ BOOSTER -_ _ (-__,._ _ _. •- _- _._ _ . _ � __ CONVERSION BURNER _--- --a --1 ____J ,tel _-^_ �___ I m _ �J. .--___i COOK STOVE DIRECT VENT HEATER DRYER Ln_ =- .=�.. I =_. _ FIREPLACE -.J L._._ J _ . _(!�. - I__. <_r� J I�-1 _ _.I r - FRYOLATOR-_I (,- . I .-d� - : ���. - l _mlI - ---. I ( J J FURNACE --- -r-I ---- (�„>e--1 t., -_z= -�- h- =1 =--J - --- f GENERATOR _.- i_ _ _( . f (_- �:_ L _.--1 j __:-_f GRILLE INFRARED HEATER_ _ [_— ( _ _. (,.. _-_ I r._-_ .. -'-- __- LABORATORY COCKS MAKEUP AIR UNITr _,t _. _�( _.._ ... I T _-� _ . �^ _ -_�.( OVEN POOL HEATER ��� L I - �....J _ 41 I _ _.._.. -� i _- f - J== ROOM I SPACE HEATER ti__= i_- _ _ _. ROOF TOP UNIT TEST --- UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER I� -- l I ,. I INSURANCE COVERAGE 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES I..._ NO Q IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 01”, OTHER TYPE INDEMNITY 0 BONDEjj OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER �,_f AGENT ]I SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all P rtinent provi on of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME .10 5�_-_Gti1 p _ Yj LICENSE # SIGNATURE -� MP MGF ���f JP (�( JGF LPGI ��l CORPORATION [J]# PARTNERSHIPO#�_-' LLC [f�#��,..-_�II COMPANY NAME: Tp /�:� - l-ADDRESSJ CITY_..yt�T STATE ZIP TEL _ _ . _ ''_�..._ _ FAXK': EMAIL vt X M c X ..3��bA.4.} O F�1 F U PW.f w Y�Si� .r •yti . ,„-��a. �j5�% �i-`o R:a.:�1 l �d'C • •�� � !�� 4'etl, 4n l �.ti. t-`.. Q �„•.A RY Thb �o � Z O y ~ W U LU nt a LU a 5 ti P4 LU ° W w CO) a o a, a U J F n - a Q te co ui x w H LL � F z 0 LO 1 r(� °:' 'Arm � a ::f. �. ` !� ♦.`µj �, 1 .' The Commonwealth ofMassachusetts " Department of Industdgl Accidents Office of Investigations 600 -Washington Street Boston, MA 02111 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): City/State/Zip:, Phone #: Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2• ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, §1(4), and we have no insurance required.] employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. FJ Electrical repairs or additions 11. E] Plumbing repairs or additions 12. ❑ Roof repairs 13.❑ Other *Any applicant that checks box #1 must also fill cut the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Policy # or Self -ins. Lic. #: Job Site Address:. Expiration Date: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one=year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Sip -nature: Date: Phone #• Official use only. Do not write in this area, to be completed by city or town official. City or Town.:• Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing inspector 6. Other - Contact Person: Phone #: Information and Instruction's Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced -acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (ifnecessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or' -permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of industrial .Accidents Office ofIuvestigations 600 Washington Street Boston, M.A, 02111 Tet. # 617-727-4900 ext 406 or 1-877, MASSAFE Revised 5-26-05 Fax # 617-727-7749 wwvv.rnass,govfdja MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING ik (Print or Type) _ Mass. Date 19 / Permit — _ 't Building Location U �� Owner's Name �. 4 a ' Type of Occupancy m 5 New Renovation Replacement ❑ Plans Submitted: Yes ❑ No ❑ FIXTURES Installing Company Name Crane's Plumbing & Heating Address 70 Douglas Street Business Telephone Haverhill, MA 01830 373-4001 Name of Licensed Plumber Peter Crane Check one ❑ Corporation ❑ Partnership INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes ® No ❑ If you have checked yes, please indicate the type coverage by checking the appropriate box. A liability insurance policy U Other type of indemnity ❑ Bond ❑ Certificate OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner ❑ Agent ❑ Signature of Owner or Owner's Agent I hereby certify that all of the details and information I have submitted for entered) in the above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application willJ� in complia ce with all pertinent provisions of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. By Signature of Licensed Plumber Title Type of License: Masters ❑ Journeyman O Citv/Town License Number 21805 APPROVED (OFFICE USE ONLY) ■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■ •• none■■■■■■■■■■■■■■■■■■■■■ 2nd FLOOR ■■■■■■■■■■■■■■■■■■■■■■■■■ Installing Company Name Crane's Plumbing & Heating Address 70 Douglas Street Business Telephone Haverhill, MA 01830 373-4001 Name of Licensed Plumber Peter Crane Check one ❑ Corporation ❑ Partnership INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes ® No ❑ If you have checked yes, please indicate the type coverage by checking the appropriate box. A liability insurance policy U Other type of indemnity ❑ Bond ❑ Certificate OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner ❑ Agent ❑ Signature of Owner or Owner's Agent I hereby certify that all of the details and information I have submitted for entered) in the above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application willJ� in complia ce with all pertinent provisions of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. By Signature of Licensed Plumber Title Type of License: Masters ❑ Journeyman O Citv/Town License Number 21805 APPROVED (OFFICE USE ONLY) r V H R T n m T y T T a C � n m a r' O O z o O X Z ; r" O 3 T i n � m O C v cn O m r O C z 1" _W -t z C) m o C) rn m z rm T n 0 z z w C1 S` r V H R T n m T y T T a C � n m a r' O O z o O X Z ; r" O 3 T i n � m O C v cn O m r O C z 1" _W -t z C) m o C) rn m z rm T n 0 z ,..,.,y.:--°-'Zt'"--.*e._.rs...:�:.,,a.:..xn:-,fir_: a+"�t:-'. :•a ---*-9+. ;�w�.'"�^Y�RT•r-�� `+'fie." --" .. Date.I.Q.� .�... 2657 NORTH � F 9 ,SSACMUS� TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that F- ................ . has permission to perform . :. Rm.............. . plumbing in the buildings of{l4si�-(...� ..1./Q]-ru%�.... . at ..�d.0. ..05� -u-M.- .� - ......... 'North Andover, Mass. Fee 4D..... Lic. No.(.8C2�.............................. . PLUMBING INSPECTOR 09;4.8 40.00 RAID WHITE: Applicant CANARY: Building Dept. PI�er GOLD: File d -µ DEAD BIRD REPORTING FORM FOR WEST NILE VIRUS CALLER (person reporting dead bird[s]) / Caller's name: Date of report: Caller's address: �SJJ l E/J S &57W767 j 67 - 7QC7 a 5GOD b 3�7- city/town: zip: OZ 6 Phone: BIRDS) lzlee Number of dead birds observed: Date dead bird(s) found or seen: 46 Species of dead birds observed, if known:_ /006 Condition of dead birds observed (eyes visible?, maggots, 14)J TES -i- q F /GS ® 65G -':e U5P IVO V/5> 6Z " ! iL 6- fio)Z r&t9 'dq"gii�G�-' Any evidence of trauma (e.g. wounds on the bird or damage to its body)?: ❑ YES rrgo- Odd behavior of sick birds, if observed: . LOCATION OF DEAD BIRDS) r - Address or location of observed birrd(s): 3 City/Town of observed bird(s): /ir• 19/YQ040C zip: 6 HANDLING OF BIRD(S)? Has the caller or someone known by the caller handled the dead bird(s) with bare hands? ❑ YES 9H<6 If yes, how many persons handled the dead bird(s)?: SUBMISSION OF BIRD(S)? For a SINGLE dead bird: Submission of the dead bird IS NOT recommended, except in unusual circumstances. • Advise the caller to safely dispose of the bird: DO NOT HANDLE THE BIRD WITH BARE HANDS. Use gloves or a shovel (or other appropriate tool) to either bury the bird or to double bag it in plastic and then dispose of it in the trash. For MULTIPLE dead birds (2 or more dead birds observed at the same time and place): •. Submission.of the dead birds IS recommended. • Advise the caller NOT TO HANDLE THE BIRDS WITH BARE HANDS. • Arrange for submission with the local WNV Dead Bird Contact Person. Will the bird(s) be submitted for testing? 9 -YES ❑ NO Person Completing Form: Name:S'r-k1,1)P I AZ Phone: 97f _G $— l`3 Z Agency: Please fax completed forms to Michael W. McGuill, DVM at (617) 983-6840, or mail to Michael W. McGuill, DVM, State Laboratory Institute, 305 South St, Boston, MA 02130. April 2000 DEAD BIRD COLLECTION CONTACT PERSON(S) CITY/TOWN: JlQk7-11 DATE (date this form is filled out): MAIN CONTACT PERSON Name: Agency: /Y Ci ' 5 ©Ae b O / Phone Number. Work hours: q7? Lkl�- 915"�6 Off -hours: Address: City/Town:,er,� /f�v�0 v�� ZIP Code: FaxNumber97(���g� Email address: boUtJa F bEq/>th �, �"bGt�hU�nor�flGrr��P�` C;Ur►? BACKUP CONTACT PERSON Name: Agency: `3a I'� � /9-5 A66 Phone Number: Work hours: Address: City/Town: Fax Number: Email. address: Off -hours: ZIP Code: Note: The Contact Person will be responsible for either going to the site identified by a caller to physically pick up the bird(s) and transport the bird(s) to a designated bird packaging site (which will then package the bird(s) for transport to the State Lab for testing) or, alternatively, arranging for transport of the bird(S) to a designated bird packaging site. Remember to WEAR GLOVES whenever handling dead birds (do not handle dead birds with your bare hands); place each bird into a plastic bag and then place the bagged bird into a second plastic bag. Keep the bird(s) cool (on ice, but not frozen) during transport, if possible. Please fax completed forms to Michael W. McGuill, DVM at (617) 983-6840, or mail to Michael W. McGuill, DVM, State Laboratory Institute, 305 South St, Boston, MA 02130. April 2000 WATERSHED RESIDENTS QUESTIONNAIRE 1. Name 2. Street Address 7e, (Z/o- 0 3. How many members are in your household? 4. What type of sewage disposal system do you have? ❑ cesspool ❑ septic tank and leaching area M connection to municipal sewer ❑ other (describe) ❑ do not know 5. Are the plans (drawings) for your sewage disposal system on file with the Board of Health? ❑ yes ❑ no ® do not know`-- _= 6. How old is your sewage disposal system? ❑ ),975 years ❑ 6-10 years ❑ 11-20 years--" ❑ over 20 years ❑ do not know 7. Has your sewage disposal system been rebuilt or repaired? ❑ yes ef no ❑ do not know If yes, approximately how long ago? years. What was done? 8. How frequently is your sewage disposal system pumped out? ❑ annually ❑ every 2-4 years ❑ every 5-10 years ❑ over 10 years [ never r 9. Have you had any problems with your sew -age disposal system? yes no - If yes, what problems? ❑ repeated pump -outs needed ❑ system clogs, backs up, or drains slowly ❑ odors ❑ sewage surfaces through ground c� 10. How many of each appliance are connected to your sewage disposal system? washing machine— dishwasher garbage disposal dehumidifier drain sump pump toilet X roof/pavement drains shower/bathtub 11. Please state the brand and type (liquid or powder) of detergent you use for: dishwasher clotheswasher 12. Does your property have a lawn? C, yes ❑ no If yes, approximately what size? ❑ less than 1/4 acre [2 1/4 acre ❑ 1/2 acre ❑ 3/4 acre ❑ 1 acre ❑ more than 1 acre (Specify) acres 13. How often do you fertilize your lawn? i No. of applications per year C16A,114" Season(s) of the year 14. Please state the brand and type (liquid or granular) of lawn fertilizer you use: Nv N C ❑ Check here if your lawn is maintained by a professional landscape contractor.