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Miscellaneous - 78 CROSSBOW LANE 4/30/2018 (2)
O r O L711Massachusetts Department of Environmental Protection Bureau of Resource Protection - Wetlands WPA Form 8B — Certificate of Compliance Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 DEP File Number: 242-1137 Provided by DEP A. Project Information Important: 1. This Certificate of Compliance is issued to: When filling out p forms on the Timothy Bugbee computer, use Name only the tab key to move 78 Crossbow Lane your cursor - Mailing Address do not use the North Andover MA. 01845 return key. City/Town State Zip Code 2. This Certificate of Compliance is issued for work regulated by a final Order of Conditions issued to: Timothy Bugbee Name 4/25/02 242-1137 Dated DEP File Number 3. The project site is located at: 78 Crossbow Lane North Andover Street Address CitylTown Map 106B Parcel 200 Assessors Map/Plat Number Parcel/Lot Number the final Order of Condition was recorded at the Registry of Deeds for: Property Owner (if different) Essex North County N/A Certificate Document # 22242 recorded 5/22/02 Page 4. A site inspection was made in the presence of the applicant, or the applicant's agent, on: 2/21/04 Date B. Certification Check all that apply: ® Complete Certification: It is hereby certified that the work regulated by the above -referenced Order of Conditions has been satisfactorily completed. ❑ Partial Certification: It is hereby certified that only the following portions of work regulated by the above -referenced Order of Conditions have been satisfactorily completed. The project areas or work subject to this partial certification that have been completed and are released from this Order are: wpaform 8b.doc • rev. ,12/15/00 Pagel of 3 Massachusetts Department of Environmental Protection ILIBureau of Resource Protection - Wetlands WPA Form 8B — Certificate of Compliance Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 DEP File Number: 242-1137 Provided by DEP B. Certification (cont.) ❑ Invalid Order of Conditions: It is hereby certified that the work regulated by the above - referenced Order of Conditions never commenced. The Order of Conditions has lapsed and is therefore no longer valid. No future work subject to regulation under the Wetlands Protection Act may commence without filing a new Notice of Intent and receiving a new Order of Conditions. ® Ongoing Conditions: The following conditions of the Order shall continue: (Include any conditions contained in the Final Order, such as maintenance or monitoring, that should continue for a longer period). Condition Numbers: 62 C. Authorization Issued by: North Andover Conservation Commission Dai% of This Certificate must be signed by a majority of the Conservation Commission an y sent to the applicant and appropriate DEP Regional Office (See Appendix A). Signalure� On '�LY 4 Day before me personally a red l0 Ofruo4 y o`?004/ Month and Year to me known to be the person described in and who executed the foregoing instrument and acknowledged that he/she executed the same as his/her free act and deed. Notary Pubic My commissi ex s DQNNA M. WEDGE wpaform 8b.doc•rev. 12/15/00 f NOTARY PUBUC CMsVWA►.TH OF Wl $$4H�S M � Aw �2 Page 2 of 3 y i Massachusetts Department of Environmental Protection Bureau of Resource Protection - Wetlands DEP File Number: WPA Form 8B— Certificate of Compliance 242-1137 Massachusetts Wetlands Protection Act M.G.L. c. 131, §40ILI Provided by DEP D. Recording Confirmation The applicant is responsible for ensuring that this Certificate of Compliance is recorded in the Registry of Deeds or the Land Court for the district in which the land is located. Detach on dotted line and submit to the Conservation Commission. --------------------------------------------------------------------------------------------------------------------------- To: North Andover A Conservation Commission Please be advised that the Certificate of Compliance for the project at: 242-1137 Project Location DEP File Number I v Has been recorded at the Registry of Deeds of: County ,c for: Property Owner and has been noted in the chain of title of the affected property on: Date Book If recorded land, the instrument number which identifies this transaction is: If registered land, the document number which identifies this transaction is: Document Number Signature of Applicant Page wpaform Bb.doc • rev. 12/15/00 Page 3 of 3 r Massachusetts Department of Environmental Protection Bureau of Resource Protection - Wetlands WPA Appendix A - DEP Regional Addresses Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 Mail transmittal forms and DEP payments, payable to: Abington Dartmouth Freetown Mattapoisett Commonwealth of Massachusetts 20 Riverside Drive Acushnet Dennis Gay Head Middleborough Department of Environmental Protection Attleboro Dighton Gosnold Box 4062 Rehoboth Wareham Lakeville, MA 02347 Avon Duxbury Halifax Boston, MA 02211 Rochester Welffleet Phone: 508-946-2700 Barnstable Eastham DEP Western Region Adams Colrain Hampden Monroe Pittsfield Tyringham 436 Dwight Street Agawam Conway Hancock Montague Plainfield Wales Suite 402 Alford Cummington Hatfield Monterey Richmond Ware Kingston Amherst Dalton Hawley Montgomery Rowe Warwick Springfield, MA 01103 Ashfield Deerfield Heath Monson Russell Washington Phone: 413-784-1100 Becket Easthampton Hinsdale Mount Washington Sandisfield Wendell Fax: 413-784-1149 Belchertown East Longmeadow Holland New Ashford Savoy Westfield Marshfield Bemardston Egremont Holyoke New Marlborough Sheffield Westhampton Mashpee Blandford Erving Huntington New Salem Shelburne West Springfield i Brimfield Florida Lanesborough North Adams Shutesbury West Stockbridge Medford Buckland Gill Lee Northampton Southampton Whately Melrose Charlemont Goshen Lenox Northfield South Hadley Wilbraham Cheshire Granby Leverett Orange Southwick Williamsburg Chester Granville Leyden Otis Springfield Williamstown Chesterfield Great Barrington — Longmeadow Palmer Stockbridge Windsor Chicopee Greenfield Ludlow Pelham Sunderland Worthington Clarksburg Hadley Middlefield Peru Tolland DEP Central Region Acton Charlton Hopkinton Millbury Rutland Uxbridge 627 Main Street Ashburnham Clinton Hubbardston Millville Shirley Warren Worcester, MA 01605 Ashby Athol Douglas Hudson New Braintree Shrewsbury Webster Dudley Holliston Northborough Southborough Westborough Phone: 508-792-7650 Auburn Dunstable Lancater Northbridge Southbridge West Boylston Fax: 508-792-7621 Ayer East Brookfield Leicester North Brookfield Spencer West Brookfield Barre Fitchburg Leominster Oakham Sterling Westford TDD: 508-767-2788 Bellingham Gardner Littleton Oxford Stow Westminster Berlin Grafton Lunenburg Paxton Sturbridge Winchendon Blackstone Groton_ Marlborough Pepperell Sutton Worcester Bolton rarvafd Crdwick Maynard Petersham Templeton Boxborough Medway Phillipston Townsend Boylston Holden Mendon Princeton Tyngsborough Brookfield Hopedale Milford Royalston Upton DEP Southeast Region Abington Dartmouth Freetown Mattapoisett Provincetown Tisbury 20 Riverside Drive Acushnet Dennis Gay Head Middleborough Raynham Truro Attleboro Dighton Gosnold Nantucket Rehoboth Wareham Lakeville, MA 02347 Avon Duxbury Halifax NewBedford Rochester Welffleet Phone: 508-946-2700 Barnstable Eastham Hanover North Attleborough Rockland West Bridgewater Fax: 508-947-6557 Berkley East Bridgewater Hanson Norton Sandwich Westport TDD: 508-946-2795 Bourne Easton Harwich Norwell Scituate West Tisbury TDD: 978-661-7679 Brewster Edgartown Kingston Oak Bluffs Seekonk Whitman Bridgewater Fairhaven Lakeville Orleans Sharon Wrentham Brockton Fall River Mansfield Pembroke Somerset Yarmouth Carver Falmouth Marion Plainville Stoughton Weymouth Chatham Foxborough Marshfield Plymouth Swansea .Wilmington Chilmark Franklin Mashpee Plympton Taunton Winchester DEP Northeast Region Amesbury Chelmsford Hingham Merrimac Quincy Wakefield 205 Lowell Street Andover Chelsea Holbrook Methuen Randolph Walpole Arlington Cohasset Hull Middleton Reading Waltham Wilmington, MA 01887 Ashland Concord Ipswich Millis Revere Watertown Phone: 978-661-7600 Bedford Danvers Lawrence Milton Rockport Wayland Fax: 978-661-7615 Belmont Dedham Lexington Nahant Rowley Wellesley Beverly Dover Lincoln Natick Salem Wenham TDD: 978-661-7679 Billerica Dracut Lowell Needham Salisbury West Newbury Boston Essex Lynn Newbury Saugus Weston Boxford Everett Lynnfield Newburyport Sherbom Westwood Braintree Framingham Malden Newton Somerville Weymouth Brookline Georgetown Manchester -By -The -Sea Norfolk Stoneham .Wilmington Burlington Gloucester Marblehead North Andover Sudbury Winchester Cambridge Groveland Medfield North Reading Swampscott Winthrop Canton Hamilton Medford Norwood Tewksbury Woburn Carlisle Haverhill Melrose Peabody Topsfield wpaform8b.doc • Appendix A • rev. 2/25104 Page 1 of 1 Date. �- .0.Z TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that .6v"?.� . ,�e hv..... '+. %aSSoc has permission to perform ... R -� M o i ................. plumbing in the buildings of .......... at C.rd�-S 6o `v ... N............ North Andover, Mass. Fee... Lic. No.POI-1��co?Z� fl+t.'%(��y�---... PLUMBING INSPECTOR Check # 5430 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Date Building Location 7 8 (fro SS go w tGn e --Owners Name Permit # _ Amount 3 e 5 Type of Occupancy "' S /t ���-/ New ® Renovation ©� Replacement ri FIXTURES Plans Submitted Y (Print or type) / Installing Company Name -4 a M 9 s (I— Fr- o A 2�0 4- e � Address /un Son No Check one: Certificate ❑ Corp. rlPartner. 0--firm/Co. Name of Licensed Plumber: 74, 41 g f OC G- n Z 0 Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity ❑ Bond ❑ 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 V Signature Owner Agent El 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 pe ed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massach b an Chapter 142 of the General Laws. BY: 7ignaLure of Mcenseaum er Type of Plumbing License Title Cit/Town � 6 /( a Y Wense IN um er Master Journeyman v APPROVED (OFFICE USE ONLY 1� Location la Okiossioo 1,41()e-- No. 17a Date TOWN OF NORTH ANDOVER + • ; Certificate of Occupancy $ I CM�s <�' Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 15775�---- Building Inspector TnWN n1V Nn'R Tu ANnnVVID BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING ,. M+l- BUILDING PERMIT NUMBER: r.-Ja DATE ISSUED: g i SIGNATURE:�� GCS Building Commissioner/Inspector of Buildings Date SECTION I SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: z) 6 . V I3 - az 06_ 0000.10 Map Nuitiber Parcel Number 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Area Frontage ft 1.6 BUILDING SETBACKS ft Front Yard . Side Yard Rear Yard Required Provide Required Provided Required Provided l i7 •y S M.G L C.40. 54) >'ub • �` 0 Zone 1.5. Flood Zone Information: Outside Flood Zone ❑ 1.8 Sewerage Disposal System: Municipal 0 On Site Disposal System 0 SEC ON %` PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record Name (Print) G�n Address for Service: Signature Telephone 2.2 Owner of Record: Name Print Address for Service:. 4C4 t SECTION 4 - WORKERS COMPENSATION (KG.L C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this in the denial of the issuance of the building permit. Signed affidavit Attached Yes .......0 No ....... 0 SECTION 5 Description of Proposed Work check all applicable) Failure to provide this New Construction 0 Existing Building ❑ Repair(s) ❑ Alterations(s) 16 Addition � Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: I SF.CTTON 6 - RSTTMATF.D CONSTRTTrTTON rnv%TC l Item I . Building Estimated Cost Dollar �, ( �k#�k1ICIA ) to be%4%�{31.J Completed b permit a ldc -��`r��pa —�� v (a) Building Permit Fee Multiplier 1FX p 3' 2 Electrical(b) Estimated Total Cost of 1216 Construction J I-lumoing 1h 0 0 Building Permit tee (a) x (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 SD Check Number SECTION 7a OWNER RIZAA TION TO BE COMPLETED WHEN OWNERS AGE . R CON3 RACTOR APPLIES FOR BUILDING PERMIT as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf, in all matters relative to work authorized by this building permit application. Signature of r Date SECTION TV'9*NER/AU1J#AIZED AGENT DECLARATION I> ,as Owner/Authorized Agent of subject prope y Hereby eclare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief Print Name Signature of Owner/Agent Date y NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR T VIBERS 1ST2 ND 3 RD+ SPAN DUvIENSIONS OF SILLS DRv1ENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE i • FORM U - LOT RELEASE FORM ��t w `.f . V t_W P (A �J04 1 p INSTRUCTIONS: This form is used to verify that all necessary approvals/permits 7s�, from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from )compliance with any applicable or requirements. i*****************************APPLICANT FILLS OUT THIS SECTION C-0 W4 tN4 APPLICANT /!'!/j C.) I PHONE�%% �d� LOCATION: Assessor's Map Number PARCEL SUBDIVISION LOT (S) STREET bra 5S �c� �1� ST. NUMBER _q *****************************************OFFICIAL USE ONLY RECOMMENDATIONS OF TOWN AGENTS: CONSERVATIOITADMINISTR DF_?;&C�8a-1( 39 COMMENTS TOWN PLANNER COMMENTS FOOD INSPECT R- ALTH Z V— �.. SE IC INSPECTOR -HEALTH COMMENTS V' G J `�' I UK DATE APPROVED I2 -I0-01 DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED PUBLIC WORKS - SEWER/WATER CONNECTION DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTO Revised 9\97 I'm tar h�_4A TE North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11,S150A. The debris will be disposed of in: 6W z/U/ (Location of Fa Signature of Permit Applicant --LV7/—Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM i, PART C SYSTEM INFORMATION (continued) -,// Property Address: G , � R aSS Owner: Date of Inspection:, SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' DEPTH TO GROUNDWATER Depth to groundwater:_feet S �L method of determination or approximation:— (revised 8/15/95) 9 Please Print Location: City Phone am a homeowner performing all work myself. F -1I 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. Dany name: `) t) -- / "P Company name: Address City: Phone #• Insurance Co. Policv # 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 s exit ay be forwarded to the Office of Investigations of the DIA for coverage verification. I do herby certify Print name Mat the information provided above is true and correct Official use only do not write in this area to be completed by city or town official' ❑Check if immediate response is required Building Dept Contact person: Phone FORM WORKMAN'S COMPENSATION fl hone # bl b05-- /.! ) 2 Building Dept ❑ Licensing Board ❑ Selectman's Office ❑ Health Department ❑ Other i a ✓tie ��N�izureat(ti. o��, t'%cra,ac`u,.ae� t ; BOARD OF BUILDING REGULATIONS? License: CONSTRUCTION SUPERVISOR } Number: CS 075839 Birthdate: 02/07/1968 I ` Expires: 02/07/2003 � Tr. no: 75839 � 1 Restricted To: 00 - J HATEM M GOMAA 8 BENNER AVE MALDEN, MA 02148 Administrator _ HONE IMPROVEMENT CONTACTOR .. Registration: 130135 Expiration: 01/18/2002 TYpe: Individual NgiEN`GONAA � HATER GONAA "ENNER AVE ADMINISTRATOR NAlOEN '' 02148 x: ACORD CERTIFICATE OF LIABILITY INSURANCE o�ii8i2oo TYPE OF INSURANCEPOLICY NUMBER PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Phil Richard & Associates Insu ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 94 High St. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR Danvers, MA 01923 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE P:978-774-4338 F:978-777-8930 INSURED INSURER A: ARBELLA PROTECTION GOMAA DBA GOMAA CONSTRUCTION INSURER B: AMERICAN INTERNATIONAL GROUP 37 PR 37 PRINCE STREET INSURER C: DANVERS MA 01923- INSURER D: INSURER E: THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INLTR SR TYPE OF INSURANCEPOLICY NUMBER POLICY EFFECTIVE DATE (mminnNyi POLICY EXPIRATION DATE imminnim LIMITS A GENERAL LIABILITY ® COMMERCIAL GENERAL LIABILITY ❑ CLAIMS MADE T OCCUR ❑ 8500020627 01/24/2002 01/43/2003 EACH OCCURRENCE $ 11000,000 FIRE DAMAGE (Any one fire) $ 300,000 MED EXP (Any one person) $ 10,000 PERSONAL &ADV INJURY $ 1,000,000 ❑ GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: ❑ POLICY ❑ PRO ❑ LOC PRODUCTS - COMP/OPAGG $ 2,000,000 AUTOMOBILE LIABILITY ❑ ANY AUTO COMBINED SINGLE LIMIT (Ea accident) $ ■ ALL OWNED AUTOS El SCHEDULED AUTOS BODILY INJURY (Per (Per person) HIRED AUTOS NON -OWNED AUTOS BODILY INJURY (Per (Per accident) ❑ PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY ❑ ANY AUTO ❑ AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS LIABILITY ❑ OCCUR RMI CLAIMS MADE EACH OCCURRENCE $ AGGREGATE $ ❑ DEDUCTIBLE ❑ RETENTION $ $ WORKERS COMPENSATION ANDWC EMPLOYERS' LIABILITY STATU- OTH- E.L. EACH ACCIDENT $ 100,000 B WC 674-13-70 08/17/2001 08/17/2002 E.L. DISEASE - EA EMPLOYEE $ 100,000 E.L. DISEASE -POLICY LIMIT ,$ 500, 000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONSA/EHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CARPENTRY CONTRACTOR TOWN OF NORTH ANDOVER ATTN: BUILDING INSPECTOR NORTH ANDOVER, MA 01845 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 030 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILI12fpF ANY KIND UPON THE INSURER, ITS AGENTS OR COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: __-18 C Qoss q�o .. Owner's Name: `Ti rnoy y ¢5u Gi3 cc Owner's Address: 7,2) C 20 s s j2 -L,— i_,,jF --Vo (LTI-/ Aj Dooc-/L Date of Inspection: S I s l J t Name of Inspector: (please print) Company Name: -_t6C-w l IvG l A•�D ���G{N� 2cu(,� Mailing Address: ca o Telephone Number: 9 7 R- (, s 6 -1-76 8 CERTIFICATION STATEMENT --�— _ — WBOARD OF HEALTANDH `R/ AUG W 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: �-2 : C �2Date: ehlo .7 The system inspector shall submit a copy of this inspectYon report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. 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 Property Address: _ Owner: Date of Inspection: _ PART A CERTIFICATION (continued) 78 CROSSBOW LANE NORTH ANDOVER, MA TIMOTHY BUGBEE 8/06/02 Inspection Summary: I--- __,.., — — . _� .. __ _ _ _ __r __ _ _ all of Section D A. System Passes: ,X/ I have 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: i B. System Conditionally Passes: e or more system components as described in the "Conditional Pass" section need to be replaced or repaired. system, upon completion of the replacement or repair, as approved by the Board. of Health, will pass. Answer yes, no or not ermined (Y,N,ND' in the for the following stat ts. If "not determined" please explain. I The septic tank is metal an over 20 years old* or the septic (whether metal or not) is structurally unsound, exhibits substantial infiltra%yeusol tion or tank fa' a is imminent. System will pass inspection if the existing tank is replaced with a comnk as appr ed by the Board of Health. *A metal septic tank will pass inspeucturall sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 2avail le. ND explain: Observation of sewage backup or fi" out or high sta ' water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, sealed or uneven distribufi box. System will pass inspection if (with approval of Board of Health): % broken pipe(s) are replaced obstruction is removed f; distribution box is leveled or replaced ND explain: t` 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: y Page! of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: _ Owner: Date of Inspection: _ 78 CROSSBOW LANE NORTH ANDOVER, MA TIMOTHY BUGBEE 8/06/02 C. Further Evaluation is nequireu uy tnu Dual u. uG...,.. Conditions exist which require further evaluation by the Board of Health in order to determine if the system is'fai�ng to protect public health, safety or the environment. i 1. Stem will pass unless Board of Health determines in accordance with 310 C 15.303(lxb) that the sys m is not functioning in a manner which will protect public health, safe nd the environment: C ool or privy is within 50 feet of a surface water Ces of or privy is within 50 feet of a bordering vegetated wetlan or a salt marsh 2. System will fail unless th oard of Health (and 'c Water Supplier, if any) determines that the system is functioning in a mann that protects the blic health, safety and environment: _ The system has a septic tank d soil surface water supply or tributary to a fa _ The system has a septic tank an A; The system has a septic _ The system has a private water supply ; rrption system (SAS) and the SAS is within 100 feet of a water supply. id the SAS is within a Zone 1 of a public water supply. and SAS and SAS is within 50 feet of a private water supply well. Yfic tank and SAS and the SA is less than 100 feet but 50 feet or more from a **. Method used to determine tance **This system ses if the well water analysis, performed at EP bacteria and tile organic compounds indicates that the well i the ;res of ammonia nitrogen and nitrate nitrogen is equal to 0 failur criteria are triggered. A copy of the analysis must be attached I 3. Other: certified laboratory, for coliform ee from pollution from that facility and ess than 5 ppm, provided that no other t this form. ,Page 4 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A Property Address; _ Owner: Date of Inspection: _ CERTIFICATION (continued) 78 CROSSBOW LANE NORTH ANDOVER, MA TIMOTHY BUGBEE 8/06/02 D. System Failure Criteria appucame to an 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 cesspool Liquid depth in cesspool is less than 6" below invert or available volume is less than %z day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped r Any portion of the SAS, cesspool or privy is below high ground water elevation. Any 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 1 of a public well. V 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 form.] 0 (Yes/No) 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�nndi a either "yes" or `bio" to each of the followin�ia (The follog crit apply to large systems in addition to th yes no _ _the system is within 400 fee a surf drinking water supply the system is within 200 of a tribut to a surface drinking water supply the system is ated in a nitrogen sensitive area ( Wellhead Protection Area — IWPA) or a mapped Zone a public water supply well If you have answered "yes" to any question in Section E the system is cons"ed a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator o 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. " y Page 5 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST i Property Address: _ Owner: Date of Inspection: _ 78 CROSSBOW LANE NORTH ANDOVER, MA TIMOTHY BUGBEE 8/06/02 Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No — Pumping information was provided by the owner, occupant, or Board of Health Y 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 ? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection ? 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 ? J _ Was the site inspected for signs of break out ? i _ Were all system components, excluding the SAS, located on site 9 Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the 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) [310 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Property Address: _ Owner: — Date of Inspection: _ PART C SYSTEM INFORMATION 78 CROSSBOW LANE NORTH ANDOVER, MA TIMOTHY BUGBEE 8/06/02 RESIDENTIAL , Number of bedrooms (design): Number of bedrooms (actual): Lf DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): Number of current residents: '-I Does residence have a garbage grinder (yes or no): No Is laundry on a separate sewage system (yes or no): N4 [if yes separate inspection required) Laundry system inspected (yes or no): — Seasonal use: (yes or no): " Water meter readings, if available (last 2 years usage (gpd)): Sump pump (yes or no): AID Last date of occupancy: r N i COMMERCIALM DUSTRIAL Type of establishment: Design flow (based on 310 CMR 15.203): gpd Basis of design flow (seats/persons/sgft,etc.): Grease trap present (yes or no): Industrial waste holding tank present (yes or no): Non -sanitary waste discharged to the Title 5 system (yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER (describe): GENERAL INFORMATION Pumping Records Source of information: ! CWa_ 5. 9Jr O-1 n 6 (L Was system pumped as part of the inspection (yes or no): mo If yes, volume pumped: gallons -- How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM �C 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 currant 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: Gonf, cTED )RS3 Were sewage odors detected when arriving at the site (yes or no): No Page 7 of 11 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _ 78 CROSSBOW LANE NORTH ANDOVER, MA Owner: TIMOTHY BUGBEE Date of Inspection: _ 8/06/02 BUILDING SEWER (locate on site plan) Depth below grade: 110 Materials of construction: _cast iron _40 PVC _other (explain): Distance from private water supply well or suction line: Comments (on condition of joints, venting, evidence of leakage, etc.): SEPTIC TANK: _ (locate on site plan) Depth below grade: j� Material of construction: /concrete 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: 1 j5 -o o &-A L t C A S Sludge depth: Z " Distance from top of sludge to bottom of outlet tee or baffle: 2 9 Scum thickness: _ 0 Distance from top of scum to top of outlet tee or baffle: /0 Distance from bottom of scum to bottom of outlet tee or baffle: /'V , How were dimensions determined: 4dEf►so re. s i is iL Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 'TAN fl r tir G-c� :0 c 0.,L D /1 /1 c 1-1 y 0 ry c- [ C L S i els 6-0vD C-0nDWTic> ,n GREASE TRAPvtL011(locate on site plan) Depth below grade: _ Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to 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: Owner: Date of Inspection: _ 78 CROSSBOW LANE NORTH ANDOVER, MA TIMOTHY BUGBEE 8/06/02 TIGHT or HOLDING TANK: & (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass _polyethylene Dimensions: Capacity: gallons Design Flow:. gallons/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) other(explain): Depth of liquid level above outlet invert: 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of PUMP CHAMBER: 1y(I'(locate on site plan) Pumps in working order (yes or no): Alarms in working order (yes or no): Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): L Page 9 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 78 CROSSBOW LANE Property Address: _ NORTH ANDOVER, MA TIMOTHY BUGBEE Owner: 8/06/02 Date of Inspection• SOIL ABSORPTION SYSTEM (SAS): (locate on site pina, 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: H (o ` k o n G- X p i e,- V overflow cesspool, number: innovativelaltemative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): A -&CA-- o f L D L o o KS N c7 iZiyl sF L. CESSPOOLS: Al A (cesspool must be pumped as part of inspectionxlocate on site plan) Number and configuration: 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: ,4/A (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments (note condition of soil, signs 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 Property Address: Owner: Date of Inspection: PART C SYSTEM INFORMATION (continued) 78 CROSSBOW LANE NORTH ANDOVER, MA TIMOTHY BUGBEE 8/06/02 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. t Page 11 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 78 CROSSBOW LANE NORTH ANDOVER, MA Owner• TIMOTHY BUGBEE Date of Inspection: 8/06/02 SITE EXAM Slope Surface water Check cellar Shallow wells 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: 4 Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health -explain: Checked with local excavators, installers- (attach documentation) -4_ Accessed USGS database -explain: You must describe how you established the high ground water elevation: CE( -L -Aa )s 2AS1 6t GEt-o & ?_ oi> E ■ NEW ENGLAND ENGINEERING SERVICES a S INC 7GV4 0 ANDO� .:ii/ OA BRD OF HEALTH AUG 'u- 0 2002 j August 6, 2002 North Andover Board of Health Town Hall Annex 27 Charles Street North Andover, MA 01845 RE: TITLE V REPORT: 78 Crossbow Lane, North Andover, MA Dear Sirs:. Enclosed is a copy of the Title V report for the above referenced property. The system PASSED our inspection. If there are any questions please call me at my office, 686-1768. Sincerely Benjamin C. Osgo , h. 60 BEECHWOOD DRIVE - NORTH ANDOVER, MA 01845 - (978) 686-1768 - (888) 359-7645 - FAX (978) 685-1099 . IRP [gyp (9 oCA v. tz � y TJ ��O --1 C � �o 0 pOp tTj f7 �ft.. P� ODQ gm n y � :31 �• � CACD n O 2 n Z y d CLO �. '^ CL S. O ' Cl) O n v vw I m m o o v d CD mCD O O CL m mc CD >_ m O _ < d •• .� p m CD O CD y. C CCD CZ y 0 O CC CD CA O -0 i CD Z o CD o CD IRP lw Ed VJ n 0 w a] 10A, 0 O 4 0 [gyp (9 oCA —• to c w tz w. 0 A ��O --1 F c m n �o 0 pOp tTj f7 �ft.. P� ODQ gm n y � :31 �• � Pci 0 aCc r � O 2 o ,� c �� vi S= O CA �o _I -4 d �Or. P.O. . .=•r ^to m 0 an d= dO m T y O -IV H O • -� O O O �10 ? m m > m m ♦ >_ m O _ < d •• .� lw Ed VJ n 0 w a] 10A, 0 O 4 0 [gyp (9 oCA d tz w. 0 A �. �o 0 pOp tTj f7 :11 :30 � P� ODQ .d r :31 �• � Pci 0 aCc r � b ^ d omi 0 0 c ARTICLE 1 THE WORK OF THIS CONTRACT The Contractor shall fully execute the Work described in the Contract Documents, except to the extent specifically indicated in the Contract Documents to be the responsibility of others. ARTICLE. 2 DATE OF COMMENCEMENT AND SUBSTANTIAL COMPLETION 2.1 ' The date of commencement of the Work shall be the date of this Agreement unless a different date is stated below or provision is made for the date to be fixed in a notice to proceed issued by the Owner. (Insert the date of commencement, if it differs from the date of this Agreement or, if applicable, state that the date will be fixed in a notice to proceed.) 406— I A,�VQjAJ(y 2.2 1 The Contract Time shall be measured from the date of commencement. 2.3 The Contractor shall achieve Substantial Completion of the entire Work not later than MO✓6,1#1W / 2& ',Z—days from the date of commencement, or as follows: (Insert -number of calendar da Alternatively, a calendar date may be used when coordinated with the date of commencement. Unless stated elsewhere in the Contract Documents, insert any requirements for earlier Substantial Completion of certain portions of the Work.) subject to adjustments of this Contract Time as provided in the Contract Documents. (Insert provisions, if any, for liquidated damages relating to failure to complete on tiAe or for bonus payments for early completion of the Work.) ARTICLE3 CONTRACT SUM 3.1 The Owner shall pay the Contractor the Contract Sum in current funds for the Contractor's performance of the Contract. The Contract Sum shall be Dollars ($ 16 3 OU ), subject to additions and deletions as provided in the Contract Documents. XW67*6ff , 7b 614, -- WARNING: Unlicensed photocopying violates U.S. copyright laws and will subject the violator to legal prosecution. 01997 A I A 0 AIA DOCUMENT A107-1997 ABBREVIATED OWNER - CONTRACTOR AGREEMENT The American Institute of Architects 1735 New York Avenue, N.W. Washington, D.C. 20006-5292 Town of North Andover Office of the Health Department Community Development and Services Division 27 Charles Street North Andover, Massachusetts 01845 Sandra Starr Health Director December 18, 2001 Mr. and Mrs. Tim Bugbee 78 Crossbow Lane — North Andover, MA 01845 Re: 'Application for an addition and deck proposed at 48 Hawkins Lane, North Andover, MA Dear Mr. and Mrs. Bugbee: Telephone (978) 688-9540 Fax (978) 688-9542 The Health Department has reviewed your application for a proposed addition and deck. The application was denied on October 1, 2001 for the following reason: 1. X Missing information 2. X Passing Title 5 inspection of septic system may be required 3. Q Location of structure not acceptable To address the problem(s): If #1 is checked, please supply: a. Floor plan of the existing structure and the proposed addition b. Certified plot plan showing the house, septic system and the proposed addition to scale, including any associated grading and the limit of work. If #2 is checked: a. Have the septic system inspected by a certified Title 5 inspector to determine the size of the system and whether it is operating properly: OR b. Tie-in to municipal sewer If #3 is checked: a. Relocate the project Please feel free to call the Health Office at 978-688-9540 with any questions you may have. Since , B ' J.Grasse, Health Inspector Cc: Gomaa Construction Co., 37 Prince St., Danvers, MA 01923 Building Department File BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 NURSE 688-9543 PLANNING 688-9535 Date.. // . / U.4.... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that / ..........1 .../" ."..... " ..................( . ..... ..... has permission to perform ....... ; ...... ............................. wiring in the building of .f.e . ............................................. ................ �--74 ..... ate......... ................... orth Fee........ Lic. No...41 .... .......... /4 LEcrRICAL PECfOR Check # TIM COMMONWE4UH OFMASSACHUSEM OfficeU onlyy-- DEPAR rMEAT0FPUXJCS4FE7Y 3 BOARD OFFRMPREVEWONRE'GULVTONS527CM 12:00 Permit No. Occupancy & Fees Checked APPLICAHONFOR PERMIT TO PERFORMELECMCAL WO ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 / /R� (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date (/ y I a� 2— Town 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) 0120SS /-?8 0 /:-C -1'l 1P Owner or Tenant Owner's Address Is this permit in conjunction with a Purpose of Building Existing Service�i Amps/ (� /�A:�,jVolts New Service Amps / Volts Number of Feeders and Ampacity r Location and Nature of Proposed Electrical Work lk No. of Lighting`Outlets No. of LightiftS Fixtures No. of Receptacle Outlets No. of Switch Outlets No. of Ranges i No. of Disposals No. of Dishwashers No. of Dryers No. of Water Heaters No. Hydro M• saga g.Tubs Yes © No (Check Appropriate Box) Utility Authorization No. Overhead ED Underground M No. of Meters Overhead Im Underground M No. of Meters 1 -1 -ie /moo No. of Hot Tubs Swimming Pool Above round No. of Oil Burners No. of Gas Burners No. of Air Cond No. of Transformers Total Belowdnm KVA Generators :: KVA xZ, —--virn„cy iagntmg nattery Units Total FIRE ALARMS No. of Heat Total Pumps Tons Space Area Heating No. of Sounding Devices No. of Self Contained Heating Devices Detection/Sounding Devices LocalMunicipal ED KW No. of No. of Si ns Bailasis / No. of Motors Total HP Total No. of Detection and KW Initiating Devices KW No. of Sounding Devices No. of Self Contained KW Detection/Sounding Devices LocalMunicipal ED Connections No. of Zones Other I nsuanceCovwr- Pt>istwladrw4mmleM f ,ttsGan alba, hawaatnaltLial*hi POkyit b&gCuW CowrageoritsmbgmtalegmvalaY YES NO fuddnhawsixrm&dvalidploofofsazrtetolheOlhoe YES r—rp ffyouhavecbedod he tgdle box L—J 1 I'�,pkei 1fic*& ypeofmvetageby VSURANCE� BOND O�iPiQt (P1ea9eSpec�fy) ,� 7 Cii yr h 9- . 3 d O j B`'c'D& /. 0 So ca �otktoStatt Ralgtl E aineofEbcxdralWotk $ igpeduncixTyieP of ' ' D& FRl w ! // RRMNAA M /17,t4om C` / Lioeli9eNo. tJ e_LimwNo 'a�/i•~L• Signahue j[htcc_l,O G" VC;61 Btt�v�ssTelNo. NMR S INSURANCE W Alt Tei No. Sd Sr S a t�'705' AIVER,IamawarethattheLicrosedoesnothavetileinAua=oovaageOrilsSlll arttialequivalaYastagttueclbYMassac t> GenaalLaws 3thatmysignahueonttrisparrritapp)i ft�t lease check one) Owner Agent Telephone No. PERMIT FEE or gen lgna ure ocaner