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HomeMy WebLinkAboutMiscellaneous - 83 CAMPBELL ROAD 4/30/2018BUTTERWORTH & 01TOOLE, INC. ADJUSTERS/APPRAISERS FOR INSURANCE COMPANIES ONLY P.O. BOX 8294 SALEM, MA 01971-8294 TEL. (978) 741-5731 FAX (978) 740-9109 claimsgbutterworthotoole.com 11/09/2015 FORM OF NOTICE OF CASUALTY LOSS TO BUILDING UNDER MASS. GEN. LAWS, CH. 139, SEC. 3B T0: Building Commissioner or Board of Health or Inspector of Buildings Board of Selectmen City/Town Hall ADDRESSES North Andover, MA 01845 RE: Insured: Thomas Fallon Address: 83 Campbell Road City/Town Hall North Andover, MA 01845 North Andover, MA 01845 Policy No.: 3083624 Loss of: 03/04/2015 CAT ICE DAM File or Claim No.: 051-2040 Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or cause Mass. Gen. Laws, Chapter 143, Section 6 to be applicable. If any notice under Mass. Gen. Laws, Ch. 139, Sec. 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. If no reply is received from your office within ten days, we will assume you have no liens of any type against this property and we will recommend to the insuring company that this claim is paid. Brad Doherty Adjuster Member of National Association of Independent Insurance Adjusters Location—C-j No. �C3 6), 1 Date TOWN OF NORTH ANDOVER 0. Certificate of Occupancy $ Building/Frame Permit Fee $ C Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # e 'S q, 6 -9, /v r1l"A, Building Inspector r TOWN OF NORTH ANDOVER BUILD' G DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: DATE ISSUED: _ _ 0 f _ SIGNATURE: Building Commissioner/Inspector ofBaildings Date SECTION 1- SITE INFORMATION I IA Property Address: 3 C.kef P 131-L n . 1.2 Assessors Map and Parcel 106 -it Map Number Number: `L- O >s Sq_ Omo a Parcel Number 1.3 Zoning Information: roning 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 .7 Water Supply M.GL.C.40. 34) ublic ❑ Private ❑ 1.3. Flood Zone Information: Zone Outside Flood Zone ❑ 1.8 Municipal Sewerage Disposal System: 0 On Site Disposal System 0 'ECTION 2 - PROPERTY OWNERSIEIP/AUTHORIZED AGENT .1 Owner of Record L( I Sccm- lame (Print) ignature 2 Owner of Record: [dame Print T ACTION 3 - CONSTRUCTION SERVICES I Licensed Construction Supervisor: tensed Construction Supervisor: dress. nature Telephone Registered Home Improvement Contractor Kj lLLi kt,1 �yl �66 npany Name Iress 31 8.3 L/Cm P SCu Address for Service : Address for Service: Not Applicable ❑ License Number 1(!) 3 - ©q - Zoo 2 - Expiration Date Not Applicable ❑ W-4-30 0 Registration Number dG-22ooZ Expiration Date r rte - The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass, 02111 Workers' Compensation Insurance Affidavit Name Please Print - phe A� rC,� i�l S Location- CATOPetat- City k.AZTJI/1 tq A Phone # 14 3-216� 1 am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity I am an employer providing workers' compensation for my employees working on this job. Company name: Address Company name' L iwAu/� 1n t X121 O.c(r Address 19 $ LQ? m n� AN-/ - City- Phone .#: q 6196 - 8ri3 KID Inswranoe:Co. , �i� z' fl__ ft-YUT AZ Policy FailuCe to secure coverage as required'underS'ction 25A or MGL 152 can lead to the imposition of cnminal.penalties of afine up t6$1, and/or one years' iinpnsonment_as �ell_as_ciW-penalties-inJhakrm�f-6aloP WDRK9RDER.and..mine_of ($1QO n--a-day-againstme. 1 understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify and r the pains an naltiesof pequry that the information provided above is true and correct. Signature /�( �. Date XIIAAe Phone# 93-8 3 / 726 3 Print name '� J 1-4-I Art -0 � LAI� Official use only do not write in this area to be completed by city or town official' City or Town Permit/Licensing I] Building Dept FlCheck if immediate response is required 0 Licensing Board i p Selectman's Office Contact person: Phone #: Health Department I Other '6/;—Xe -iDomzan4nr[Ia/11/1 o��faa;saria�r0el�a BOARD OF BUILDING REGULATIONS t License: CONSTRUCTION SUPERVISOR Number: CS 057754 ` Birthdate: 03/04/1965 i r I Expires: 03/04/2002 Tr. no: 17870 1 � Restricted To: 00 WILLIAM D HOPE / i 80 CAMPBELL RD N ANDOVER, MA 01845 Administrator ✓ler, V/ 697to7t09LttMQ[[!e O��Z(CdiIJ1,7/!!!6B%�6 Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR i Registration: 301730 Expiration: 06/29/2002 Type: INDIVIDUAL WILLIAM CAVY HOPE William Hope 80 Campbell Rd N. Andover, MA 0"1845 Administrator Town of North Andover Building Department 27 Charles Street. North Andover, Massachusetts 01845 (978) 688-9545 Fax. (978) 688-9542 DEBRIS DISPOSAL FORM NORTH AA-- 01-(S1"�� /G"Y O G y y Y O Area In accordance with the provisions of MGL c 40 s 54, anda condition of Building permit• # 321 the debris resulting from the work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL cl 1, s150a. The debrisAvill be disposed of in /at: Facility location Signature of Applicant Alk 2 20M NOTE: A demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector. This form satisfies all basic requirements of the state's Home Improvement Contractor Law (MGL chapter 142A), but does not include standard language to protect homeowners. Seek legal advice if necessary. Any person planning home improvements should first obtain a copy of "A Consumer Guide to the Home Improvement Contractor Law" before agreeing to any work on your residence. You may obtain a free copy by calling the Office of Consumer Affairs and Business Regulation's Consumer Information Hotline at 617-727-7780. Homeowner Tnfnrmntion r.....___.__ \.LVI 1111V1 111"LIMA Name Company Name 1, A IQ H v4� 1A ZAwAl S Street Address (do not use a Post Office Box address) Contractor/ Salesperson/ Owner Name CA P92LL %� _' )AVC City/Town State Code Business Address (must include a street address) /Zip Am VIZ K NIA S b!)CCl'-1 P G 8_LL Daytime Phone Evening Phone City/Town State Zip Code -- (� 8 � 52 I_TCJ-`j 52 KL-44ty—le M'/A Mailing Address (It different from above) Business Phone Federal Employer ID or S.S. Number Law requires that most home im- I Home Improvement Contractor Reg. Numberl provernBtcontraemnhave a It�l-�� valid reen Expiration date G -z`) -20o2 The Contractor agrees to do the following work for the Homeoi .w ,,ber mer* tLescribe to uetan the worK to completed, specifying the type, brand, and grade of materials to be used, use additional sheets if necessary.) �A-N 7 ,7 Lf lc t z(�nt.4 hZL.>e , &I Sze Required Permits - The following building permits are required Proposed Start and Completion Schedule - The following schedule will and will be secured by the contractor as the homeowner's agent, be adhered to unless circumstances beyond the contractor's control arise (Owners who secure their own permits will be excluded from the Guaranty Fund provisions of 12obi Date when contractor will begin contracted work. MGL chapter 142A.) '`&/cu��c LCL Viz✓ ice''. t C/(ft— ���E�Tq42c, 2o6l Date when contracted work will be substantially completed. Total Contract Price and Payment Schedule The Contractor agrees to perform the work, furnish the material and labor specified above for the total sum o� 3 Payments will be made according to the following schedule: $11,500 upon signing contract (not to exceed 1/3 of the total contract price or the cost of special order items, whichever is greater) $4495e act by ,ym& cL /`�i or upon completion of FgAM,_ kW i!S7,77Z6Z izyz q on 1 / OXI to M " $ q Sd W b/ j /moi or upon completion of �[7Lt --;GE '03 L 11511..(6 4- t'j tax net c�t(L -E &&zg � _-1 ff ftf A atYAr, $ > 1 upon completion of the contract. (Law forbids demanding full payment until contract is completed to both party's satisfaction) The following material/equipment must be special $M 18 to be paid for V ► t ", A a > S f �j - ordered before the contracted work begins in order $ to be paid for to meet the completion schedule.(**) NOTES: (*) Including all finance charges (**) Law requires that any deposit or down -payment required by the contractor before work begins may not exceed the greater of (a) one-third of the total contract price or (b) the actual cost of any special equipment or custom made material which must be special ordered in advance to meet the completion schedule. Express Warranty - Is an express warranty being provided by the contractor? No Yes (all terms of the warranty must be attached to the contract) Subcontractors.- The contractor agrees to be solely responsible for completion of the work described regardless of the actions of any third party/subcontractor utilized by the contractor. The contractor further agrees to be solely responsible for all payments to all subcontractors for materials and labor under this agreement Contract Acceptance - Upon signing, this document becomes a binding contract under law. Unless otherwise noted within this document, the contract shall not imply that any lien or other security interest has been placed on the residence. Review the following cautions and notices carefully before signing this contract. • Don't be pressured into signing the contract. Take time to read and fully understand it. Ask questions if something is unclear. • Make sure the contractor has a valid Home Improvement Contractor Registration. The law requires most home improvement contractors and subcontractors to be registered with the Director of Home Improvement Contractor Registration. You may inquire about contractor registration by writing to the Director at One Ashburton Place, Room 1301, Boston, MA 02108 or by calling 617-727-3200, ext. 25205. .• Does the contractor have insurance? Check to see that your contractor is properly insured. 0 Know your rights and resoonsibilities. Read the Imnortant Infrirmatinn nn .the rrvrrer cir♦P of this farm ar, rt -t � 1 .......... f /�Irt ki.6 __. I I , t I 1 i : 1 ,.. 11 I i I I i i i.... I t i i I 1 a I i I f I I 1 I I I , : f i I- I �I t _ I I r t j ._J _• + I i r I i t I I -- - ------ --- PC -------- ----- - ---- ----- -- --- ------- Z -- ------- --- ---- - --- ----- -- . . . ....... -------- - - --------- .. ...... . ..... -- ----- ------ it T_ -7- --- ---------- .. ... ..... i 0-9- --- - ----- - --1- 4 f -1-K, kl_ � i) Y -SM __ S�l it 1374 364 11l//-- 291 591 804 33 24 804 21 36 – W3336 WC24361- --------------- B21 L 6 291 291 MERILLAT ARBOR FALLS II DELUXE 24 -EB" 6L EILING HEIGHT 90" HANG 741W3 ` S NG AT APPR.89 1/2" B 30 30 36 0 SMALL CSM (1 1/8"H) TO CEILING - 1:TILT DOWN TRAY i B CONTRACTOR TO INSTALL �8 W 2:WASTE BASKET 156 3:TRIM VALANCE UNDER DI 15 15 W1 ! D4: REFRIGERATOR TO FIT ; H. 2-1 491 36L 5 24" 6R Ef W36241 --------------------- i 3 gL 36 6 BD4 24 36 6 36" -3D 364 132 1144113 63 � 24 36 X501 214 704 15 36- -4540 1511 30 -24- 21 61 51 36 36 6 4:BUILD UP UNDER 24 { 36 ' 94 W3018 & COVER 60 WITH 3" FILLER TO DROP MICROWAVE (RECOMMENDED HANGING HEIGHT FOR MICROWAVE/HOOD IS APPRX.69" 60 5:KITCHEN HEIGHT COUNTERTOPS (NEED KITCHEN HEIGHT STOOLS) 6:OUTSIDE CORNER MOULDING 7:PLAIN PANEL BACK OF PEN.& SIDES OF P>GtON HOLE TO WALL CAB. BD4 5)/ BD4 411 15 PIGION HO FS; B36 �15 J, _----------- VV 11) 36R W3630 ! W3630 36L 15 36 —T 3P 36� 15 15 36 3b = 36 15 511 3I 511 694 It 694 1384 111 All dimensions & s¢e designations This is an original design and must hope3 Scale: maximum Design: 05/25/01 Dale :06/20/01 c no. + Ij given are subject to verification on not be released or copied unless job site and adjustment to fit job applicable fee has been paid or job KI KIM & SCOTT ARN Designer condition order placed. CAMPBELL RD .s. NO.ANDOVER, MA Karen DiNoto O a co � o M m OEM rc.07 2 M Lf ) J DD CDS co _ co_ cD M —� LO �� L co T N O co O co co co1, CD M co O O C Z Q Q (3_ .� W- w F- W W U CL 0O U Q M b YcoZ N I cD M N - (D 114 M co M J M. CD I 0=-Dj 0Lo LC) 0 co Cl) M m f M LO M co Cl) 0 1. M M r Cl) I /7�z - T CC)T / /Y LO co cfl CO a LO \t - 7 O � In X Z C � m V cfl CO a LO \t - N N / Cl) Q e-� � k J W W W O C SMO Y00Z a m V) o ti M M M I i /� LO M N CO M W Dj m m m 0 m C �f .. . . a o c= CD COO) CD 0 H .0 0 CO) 'O Cl) C O C CO) -v E C) CD 0 CD a H. CD CO) C c =r �. y O Q N a 0 C Cl) y 0 m n 0 H C) d C.) C4 Z CD CA CD �a o. = m O O N 0 �_ O m m ;nes CD O 0 y n CD Er a � _ R r n r. CMmON K p cn o 't7 c CCD = r ^ CD :v J O C� 0 co') " d y Z H CL w C c CD C to ► m CO) CD �M C) \ 17v 0 l� N CD 3 c 0 CD cn �N m SCD V Q, =s: d cn cn m _ a ni °w PO oa CA m 7 cn z C ou Cil cn m 7 zm O w w n T Pj"I O C ov O C U) ^ r -1 8 n It x I MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO Uro GASATTING (Print or Type) �aJ j ✓ Mass. Date 19 U City, Town Permit # OCL % Building Owner's AT: Location q 3 �y� ��' Poe Name 77- �✓� Type of Occupancy :Llw New ❑ RenovationZ---� Replacement ❑ Plans Submitted Yes ❑ No ❑ (Print or Type) Check One: Installing Company Name CA &- ❑ Corp. Certificate Address / � ❑ Partnership irm/ Company Business Telephone ��/� _ � �' Name of Li ensed Plumber ,�or Gasfi t r de 1 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 Gas Code and Chapter 142 of the General Laws. I have informed the owner or his agent that I do not have liability insurance including completed operations coverage. Signature of Owner/ Agent I have a current liability insurance policy to include completed operations coverage. ❑ B TYPE LICENSE: By tgnature of Licen Title P-151umber Plumber or Gasfitter City/Town ❑ Gasfitter �� APPROVED OFFICE USE ONLY El Master ( ) ❑ License Numr Journeyman be FORM 1243 AM. SULKIN CO. 1989 ......................... (Print or Type) Check One: Installing Company Name CA &- ❑ Corp. Certificate Address / � ❑ Partnership irm/ Company Business Telephone ��/� _ � �' Name of Li ensed Plumber ,�or Gasfi t r de 1 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 Gas Code and Chapter 142 of the General Laws. I have informed the owner or his agent that I do not have liability insurance including completed operations coverage. Signature of Owner/ Agent I have a current liability insurance policy to include completed operations coverage. ❑ B TYPE LICENSE: By tgnature of Licen Title P-151umber Plumber or Gasfitter City/Town ❑ Gasfitter �� APPROVED OFFICE USE ONLY El Master ( ) ❑ License Numr Journeyman be FORM 1243 AM. SULKIN CO. 1989 7 66 Date.. 5� ........ vo� ,40RTPI TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATIOW ca This certifies that ................ cc has permission for gas installation Y. in the buildings of ......... ....................... CU at ass. ........ North Andover, M "" Fee.. Lic. No..".�-.� .. .......................... GASINSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer Location No. Date TOWN OF NORTH ANDOVER U Sewer Connection Fee $ Water Connection Fee 9 Ife, Building Inspector'. Div. Public Works Certificate of Occupancy $ Building/Frame Permit Fee $ .r SACIMU Foundation Permit Fee $ Other Permit Fee $ U Sewer Connection Fee $ Water Connection Fee 9 Ife, Building Inspector'. Div. Public Works li RMIT NO, 366 APPLICATION FOR PERMIT TO BUILD,- NORTH ANDOVER, MASS. PAGE 1 MAP KJO. LOT NO. 2 RECORD OF OWNERSHIP IDATE BOOK ;PAGE ZONE SUB DIV. LOT NO. LOCATIO PURPOSE OF BUILDING OWNER'S NAME Ll Ar NO. OF STORIES SIZE OWNER'S ADDRESS (1531 l/IQ�"I41ge V 4 BASEMENT OR SLAB ARCHITECT'S NAME SIZE OF FLOOR TIMBERS IST 2ND 3RD BUILDER'S NAME 1 IC _ ._d � e� SPAN DISTANCE TO NEAREST BUILDING/,,� / [1 DIMENSIONS OF SILLS - DISTANCE FROM STREET 2.51 S --- .. POSTS DISTANCE FROM LOT LINES — SIDES REAR GIRDERS AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW SIZE OF FOOTING X IS BUILDING ADDITION - MATERIAL OF CHIMNEY IS BUILDING ALTERATION � �� 1_ IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE l,, �o 1 IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS SEE BOTH SIDES PAGE 1 FILL OUT SECTIONS 1 - 3 PAGE 2 FILL OUT SECTIONS 1 - 12 ELECTRIC METERS MUST BE ON OUTSIDE OF BUILDING ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND AcPP�ROVED BY BUILDING INSPECTOR DATE FILED �/?/1/�l SIdNATURE OlrOWNER OR AUTHORIZED AGENT CONTR. TEL. #_ -'GNTR. LIG. u F E E PERMIT GRAN`FED / 19 F/ 3 PROPERTY INFORMATION LAND COST EST. BLDG. COST 2-3&0 � EST. BLDG. COST PER SQ. FT. EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. 4 APPROVED BY BOARD OF HEALTH PLANNING BOARD BOARD OF SELECTMEN 1 _Y OCCUPANCY SINGLE FAMILYS'DRIES MULTI. FAMILY OFFICES APARTMENTS CONSTRUCTION 2 FOUNDATION �I 8 INTERIOR FINISH CONCRETES d l 2 13 _ CONCRETE BL K. BRICK OR STONE _ PINE HARDW D PIERS PLASTER DRY) WALL UNFIN. 3 BASEMENT AREA FULL '/ r/} l/. FIN..B M AREA .FIN. ATTIC AREA _ _ NO BMT FIRE PLACES _ HEAD ROOM MODERN. KITCHEN 4 WALLS II 9 FLOORS CLAPBOARDS B _ 1 2 �_ 3 _ _ DROP SIDING CONCRETE EARTH HARDW D COMMON ASPH. TILE WOOD SHINGLES ASPHALT SIDING ASBESTOS SIDING VERT. SIDING STUCCO ON MASONRY _ STUCCO ON FRAME BRICK ON MASONRY ATTIC STRS. & FLOOR BRICK ON FRAME I_ CONC. OR CINDER ELK. WIRING STONE ON MASONRY STONE ON FRAME SUPERIOR I� POOR ADEQUATE NONE 5 ROOF 10 PLUMBING GABLE I IP BATH (3 FIX.) GAMBREL MANSARD TOILET RM. )2 FIX.) _ FLAT SHED WATER CLOSET _ ASPHALT SHINGLES LAVATORY WOOD SHINGES KITCHEN SINK SLATE NO PLUMBING _ TAR & GRAVEL STALL SHOWER _ ROLL ROOFING MODERN FIXTURES _ TILE FLOOR TILE DADO 6 FRAMING I 11 HEATING WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. TIMBER BMS. & COLS. STEAM k STEEL BMS. & COLS. HOT W'T'R OR VAPOR WOOD RAFTERS AIR CONDITIONING RADIANT H'T'G UNIT'HEATERS 7 NO. Of ROOMS GASOI L B'M' 2nd _ lse 1 13rd I ELECTRIC NO HEATING BUILDING RECORD 12 THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA- RAGES, ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. „OnTH Of, ... ,ti OFFICES OF: o�' Town Of APPEALS BUILDINGNORTH ANDOVER ♦ ,'^ 1440 DIVISION OF HEALTH PLANNING PLANNING & COMMUNITY DEVELOPMENT KAREN H.P. NELSON, DIREC'MR 1109 1 2O Main Street North Andover, Massilchnselts O 1845 (G 1 7) G85-4775 In accordance with the provisions of MGL c 40, S 54, a condition of Building Permit Number , -qA g:.”- is that the. debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 111, S 150A. The debris will be disposed of in: F � CC 6 (Location of acllt ty) �s Signa re of Permit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the.Office of the Building Inspector. HAUL LIC # 777 $100 1996 INST LIC # 659 $200 1996 NO ANDOVER. BOH TOWN HALL ANNEX 120 MAIN STREET NO ANDOVER, MA 01845 PH# 508-682-6483 508-688-9540 ** FAX 508-688-9556 Dear SIRS: STEWART'S SEPTIC TANK SERVICE 47 RAILROAD STREET BRADFORD, MA 01835 508-372-7471 May 3, 1996 The following is a list of properties that we pumped in your town. In accordance with TITLE V regulations, we are complying by sending you the following on a monthly basis, if need be. If we didn't pump, you will not be notified. PUMP DATE ADDRESS GALIANS 04-01-96 197 ABBOTT STREET 1,500 105 WINTERGREEN DRIVE 11000 04-02-96 A 42 OLYMPIC LANE 11000 04-04-96 A 71 PENNI LANE 11000 04-06-.96 492 SHARPNER'S POND ROAD 11000 A 39 HAYMEADOW ROAD 1,500 04-08-96 498 WINTER STREET 11000 187 SOUTH BRADFORD 11000 04-09-96 A 495 REA STREET 11000 04-10-96 A 706 FOSTER STREEET 11000 04-11-96 A. _$3 CAMRBELL_ROAD 11000 04-11-96 A 43 CHRISTIAN LANE(?) 1,500 -04-12-96 7 HAYMEADOW ROAD 11000 1577 SALEM STREET 11000 04-13-96 278 BARKER STREET 11000 04-16-96 A 30 BREL CIRCLE 11000 04-17-96 A 27 COACHMAN'S LANE 11000 04-18-96 369 HIGH PLAIN ROAD 11000 28 CEDAR LANE 11000 A 121 CAMPBELL ROAD 11000 04-19-96 A 160 BRIDALPATH LANE 2,200 04-20-96 A 200 RALEIGH TAVERN LAME 1,500 A 1 GARFIELD LANE 1,800 Zv i A *4 Beiriy o revision of Lof 3 S,/ow// /i,- o er>//fled, ',-Z AN OF 1-4 A10 //V IVORT// 4AVDo v,5-17, /L/ASS. Surveyed for .70H�v 00/1/Oh'oE Dorso f. Perrins � Sons 1r/c. Cii-iYEnyinecrr f Svrreyorr Readi�y, /Y/oss, W E S PLAN OF LAND Iw NORTH AWpC)VER MASS, nREPAREd AOR 30 (4P4 DONOHO E SCALE. ; I° = too FEB. 3. 1966 DANA F, PERKINS 4 SONS INC. Clvfl Engineers � Surveyors Reading, Mass, `06 43 43 E' i N B2` ZS Ab 126.26 142 N YIo 3Ap9"E /;/�/�rovo/ ar�der ffie Su6dirision COa/ro/ LoW 1701 repaired Norfi/ //r/dovtr /Pl71/r//12y Berard Loi 3B I is Ac RES WEST -2-o MWIN lr�abrrf h! � /yodc%/nc B Com/v6e1/ ;7a-00,l96b•at P6:3oa..7iu, ga� ooh Rn -C. e. North Andover MIMAP October 9, 2014 _._. A;. .:::: -.... vlu {::_. ; 106. 06S .. •,alu..::.::-aUcr. •: ,�,..: »J,r� :" 60 CAMPBELL RD 106.B-0168. ._.... lcr ::::-.: :�alir :::_::. 106.B-0066 -'-' • Valu.:::_:-: ::-._. i .__ •,�<.'.•1Q6B=0067 AV/7. • Via, •_���,�•:•_::-�::�,�.-:•: 306.B-006.8 Zo .._:. � gip, ,_ �]Jli. �'..:_:==-;:::'�altt. ._::.:?� ,-:....c:..,;-- vlu .: _.._..• ::::_: 90 CAMPBELL RD :_. _ •:. _.-.._.......... _ :. ,'•-;-� A& .:_ _.:.B-0245 ,atrc .:_ _.._.. ... ..�:.._..., `�•:::__.-:--flu:::_:=-'alu:::_=•:�_:::_'ulli. _. --'sJ.u• .:. \ 'lu • ':::: �at!r .,�,.: ..�.: 299 WEBSTER: WOODS 06 100; CAMPBELL RD At r. :"' ::_:'u _...•.: �' 106.B-0069 83. CAMPBELL RD. . ::: _ _ Vz - >„ lU6.B-0216 ` 95 CAMPBELL RD 106X-0, 039 z"' 106.B-0038 106.B-0169 111 CAMPBELL RD G" 300 WEBSTER WOODS 106.B-0037 J. 106.B-0167 =-' '- 290 WEBSTER WOODS 106.B-0036 40, WEBSTER WOODS, • } _-1: "-. _ `: 106.B-0170 7. uJ.cr. -;.-... •- 106.B-0034 .I, 106.B-0171 �:-::...-_... .:::: .. .:::? . — Reil Line a Wetlands Zoning Busin Interstates C7 Exempt Lands O Bus! a. I s 1 District s 2 District Horizontal Datum: MA Staleplane Coordinate System, Datum NAD83, — ■ Busina E Busine Roads 0 Gene Ci Easements m Pl.r. 5 3 District s 4 District Business Distric Commercial Dev NORTN O� ",to q� ��� �• O j �e �� O Meters Data Sources: The data for this map was produced by Merrimack Valley Planning Commission (MVPC) using data provided by the Town of North Andover. Additional date provided by the Executive Office of Environmental AHa(rslMassGIS. The Information depicted on This map is O Conrido 0 MVPC Boundary O Corrldo ❑ Municipal Boundary M Comdo Indust' Development Dist Development Dist Development Dist 1 District ,�. L p _, — avikbiL to F S for planning purposes only. It may not be adequate for legal boundary definition or regulatory Interpretation. THE TOWN OF NORTH ANDOVER MAKES NO WARRANTIES, EXPRESSED OR IMPLIED, CONCERNING Zoning Overlay O Industri 12 District • ♦ 's THE ACCURACY, COMPLETENESS, RELIABILITY, OR SUITABILITY 8 Adult Entertainment Industri Downtown Overlay District 13 District • « • } e i OF THESE DATA. THE TOWN OF NORTH ANDOVER DOES NOT ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF IndusM 0 Historic District Residence Water Protection r.. Reside I S District 1 Dislric ce 2 District •�! ~� q°3 .� '��'.a � S`SA�NUSeS THIS INFORMATION 0 Parcels Im R—ide ce 3 D'alrid C: Hydrographic Featuresde --Streams 1" = 103 ft de •de ce4 District ce 5 District ce 6 District .o a esidential District Town of North Andover Base Map Zoning 2012 Aerials Watershed Zone Utilities http://mimap.mvpc.org/NorthAndovermimap/Viewer.aspx Page 1 of 1 Select Parcels, (show all) Owner I Prop _ID jAddress Lot ARN, SCOTT 31106.B-0039-0000.0183 CAMPBELL ROAD < > 1 selected To Mailing Labels To Spreadsheet I Property II Building Permits II Planning II Septic Pu Print Owners ARN, SCOTT J ^ Owner2 KIM V ARN Address 83 CAMPBELL ROAD PropertyID 106.B-0039-0000.0 Lot Size 1.19 A Fiscal Year 2013 Land Use Code 101 Last Sale Date 33407 Book/Page 3270 Total Valuation $414100 Building Type CP Year Built 1967 Finished Area 0 sq. ft. Assessor Map NorthAndoverAssessorMapl06B_26�I More Info: Click here for Assessor website Water Tie: CAMPBELL_ROAD_0083.pdf I. t i E V 10/9/2014 Help Mobile Scale 1" = 103 ft r Property Search Page v Go 4.0.6 (production) Appceo Save Map FaTInnage v http://mimap.mvpc.org/NorthAndovermimap/Viewer.aspx Page 1 of 1 Select Parcels, (show all) Owner I Prop _ID jAddress Lot ARN, SCOTT 31106.B-0039-0000.0183 CAMPBELL ROAD < > 1 selected To Mailing Labels To Spreadsheet I Property II Building Permits II Planning II Septic Pu Print Owners ARN, SCOTT J ^ Owner2 KIM V ARN Address 83 CAMPBELL ROAD PropertyID 106.B-0039-0000.0 Lot Size 1.19 A Fiscal Year 2013 Land Use Code 101 Last Sale Date 33407 Book/Page 3270 Total Valuation $414100 Building Type CP Year Built 1967 Finished Area 0 sq. ft. Assessor Map NorthAndoverAssessorMapl06B_26�I More Info: Click here for Assessor website Water Tie: CAMPBELL_ROAD_0083.pdf I. t i E V 10/9/2014 North Andover MIMAP October 9, 2014 y>: 60 CAMPBELL R© SAX" sw '. �8-661 - ' �1.7►6':kB'-OiD a row t 9`0 GA{9PBggRD ' 99 WEB 'TER"ViIOb:DS I 106+> B 60'69 80 C P7PBELki R© 9:0 'C, �c1BBEL-LRDi - . ✓ / f v_`�1�.�B�Il038 . • 111 �G C1P LZ'RD. _ X06 B 0169 X340 wCB09R ilki 106.B4 7 - gki JEBBB� ER+jll"lAODS �t ;40008STER�.S 5fp61__�_B 0w17b 166B 'moi f ;i;OB-0�„L1 Interstates —1 — SR Horizontal Datum: MA Stateplane Coordinate System, Datum NAD83, - Roads Cs Easements 0 MVPC Boundary t NORTH , O i��tta r•' ti0 r �t O Meters Data Sources: The data for this map was produced by Merrimack Valley Planning Commission (MVPC) using data provided by the Town of North Andover. Additional data provided by the Executive Office of Environmental Affairs/MassGIS. The information depicted on this map is for It be for legal boundary Parcels3' L O F'- planning purposes only. may not adequate definition or regulatory interpretation. THE TOWN OF NORTH ANDOVER ♦�(`,_r_`�� ir` i s Y MAKES NO WARRANTIES, EXPRESSED OR IMPLIED, CONCERNING THE ACCURACY, COMPLETENESS, RELIABILITY, OR SUITABILITY OF THESE DATA. THE TOWN OF NORTH ANDOVER DOES NOT ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF �� �, S�1tMU5 t THIS INFORMATION 1" = 103 ft ^�° Location CA*01)w11 14 No. 6- 6 C? — Date 10 -)F -a TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ Check # TOTAL $ 14 22 7 9 Rh 'BubldinOr-6ector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPA15 RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: DATE ISSUED:` j SIGNATURE: 14 A cc�z�� BuilYn—g COMAission6r/Inspector of Buildings Date SECTION 1 -SITE INFORMATION 1.1 Property Address: n AAR 1.2 Assessors Map and Parcel Number: M umber —7ParcelNurAer 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided R •red T— Provided 1 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: Public ❑ Private ❑ Zone Outside Flood Zone ❑ 1.8 Sewerage Disposal System: Municipal ❑ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record /t W --,Sc® �N Name (Print) Address for Service Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Liicceen�sm] Constrrru/c/yttiioo'n Supey}r/_/�)�1///]$apo^r/: //{aL/�� Licensed Cgnstruction Supervis : y d if `► W Vl " ` Address Signature Telephone Not Applicable ❑ --) S License Number Expiration Date 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Address Expiration Date Signature Telephone gm, �J i 0 mn ic r M r r z 0 . `WOOD STOVE INSTALLAHON CHECKLIST F'='.IIi'� [10: Permit A building permit is required for the installation of any solid fuel burning appliance. The building permit and installation inspection are limited to the stove installation and not to the stove construction. ;.� Stove `-..i A. New `/ Used B. Typeiradiant Circulating C. Manufacturer Fink oeTli 14&-Q6 Ike Lab. No. Name/Model No. EROE- `E 2-0 Collar size 3 �� Dimensions! Height 2 rt Length 3 ° Width 23 r imney A. New A. e�nr -T-k'PL k1rair Existing B. Size (flue area) 311 C. Other appliances attached to flue (Number arid flue size) 0. Prefab (Manufacturer—name and type) SIMIPSOA r- fLL_ftr E. Masonry/tined N f ik F?ue liner tl )A Unlined tYoe 6 manu,actur6r) F. Height (refer to diagrams) cap % CHIMNEY HEIGHT HEARTH Hearth (non-combustible) A. Materials S LATE B. Sub -floor construction ix I cicl C. Minimum dimensions (refer to aiacram) Clearances and Wall Protecaan (see stcve installar.cn c!e=_rances chart) A. Type ofwall protection provided i\lonIR'"'&I Dt r txG -r+C P,Ary, - st�mrj& B. Clearances (refer to diagrams) FIREPLACE == ..� Rt-IER I r WALL'CENTER. 13 Detailed Safety Precautions (cont'd) Auger - Pellet fuel is fed to the burn grate by a screw auger. This auger is driven by a high torque motor. The auger is capable of doing serious harm to fingers. Keep pellets in the hopper at all times and keep fingers away from auger. The auger can start and stop automatically at any time while the stove is running. Smoke Detector - Depending on your local codes, a smoke detector may be required in the room where the stove is installed. We recommend that smoke detectors be installed in all homes and maintained in an operational condition at all times, no matter whether you are using a heating appliance or not. Safety Testing Inp'accordance with the specifications and procedures listed in UL 1482 & ASTM E1509 for solid fuel room heater, the Hearth Trends Pellet Stove has been independently tested and listed by I.T.S, ('an accredited testing laboratory) to UL, ULC and CSA standards. UL 1482 states requirements for installations as a free- standing room heater, or hearth insert for masonry or metal (zero clearance) fireplaces. The safety listing label is located on an inside hopper surface of the pellet stove" Please read this safety label carefully. It contains important information about installation and operation of your Hearth Trends Pellet Stove. This Owner's Manual is provided to you to supplement, rather than replace or update, the information contained on the safety, label. Note that your STOVE'S serial number is located on the safety label. Your stoves serial number is preceded by a "WH -"(Example WH -0000000) . The serial number for insert stoves is also located on a label under the hopper lid. This appliance is designed specifically for use only with pel- letized fuels. It is tested and listed for residential installation according to current national and local build- ing codes as: • A Freestanding Room Heater • A hearth insert when installed into a masonry or factory built fireplace. • A Mobile Home Heater Note: This stove is not intended for use in commercial installations other than where the stove is being sold without prior approval from Hearth Trends Inc. The stove will not operate using natural draft nor without a power source for the blower and fuel feeding systems. The appliance is provided with an exhaust connector for a 3 inch listed type "1" double wall pellet vent pipe with stainless steel inner liner. Hearth Trends "Traditions" Pellet Stove Safety Label CERTIFIED FOR U.S. AND CANADA. LISTED Wamook Hersey ROOM HEATER FOR USE WITH APFI/FFI `I_I, APPROVED PELLETIZED WOOD FUEL ONLY. C US MAY BE MODEL: P111 TRADITIONS TESSTALLED IN OTED TO ASBILE TM E- 1509 /UL 1482 / ULC -S627 / WHPN-025 REPORT NO. 476-1129 (APRIL 1995). INSTALL AND USE ONLY IN ACCORDANCE WITH THE MANUFAC- TURER'S INSTALLATION INSTRUCTIONS. CONTACT LOCAL BUILDING OR FIRE OFFICIALS ABOUT RESTRICTIONS AND INSTALLATION IN- SPECTION IN YOUR AREA. DO NOT CONNECT THIS UNIT TO A CHIM- NEY FLUE SERVING ANOTHER APPLIANCE. SEE LOCAL BUILDING CODE AND MANUFACTURER'S INSTRUCTIONS FOR PRECAUTIONS REQUIRED F05 PASSING A CHIMNEY THROUGH A COMBUSTIBLE WALL OR CEILING. THIS PELLET FIRED APPLIANCE HAS BEEN TESTED AND LISTED FOR USE IN MANUFACTURED HOMES IN AC- CORDANCE WITH OREGON ADMINISTRATIVE RULES 814-23-900 THROUGH 814-23-909. OPERATE ONLY WITH FIREBRICK IN PLACE. WARNING: OPERATE ONLY WITH VIEWING DOOR CLOSED. INSPECT FLUE FREQUENTLY TO PREVENT ACCUMULATION OF SOOT. THE HEATER AND FLUE MUST BE IN GOOD CONDITION. KEEP FURNISHINGS AND OTHER COM- BUSTIBLE MATERIALS WELL AWAY FROM HEATER. ROUTINE MAINTENANCE REMINDER FREQUENCY OF CLEANING AND MAINTENANCE OF YOUR STOVE DEPENDS ON THE ASH CONTENT OF THE PELLETS YOU BURN. CHECK THE FOLLOWING PARTS OF YOUR STOVE WEEKLY FOR THE FIRST MONTH TO DETERMINE THE FREQUENCY OF CLEANING. A BURNGRATE e. HEAT EXCHANGER TUBES C. ASH PAN AND EXHAUST PIPE SEE YOUR MANUALAND/OR DEALER FOR MORE INFORMATION, INPUT RATING RANGE: 1.5T03.8 LBSJHOUR (NOMINAL) ELECTRICAL RATING: 60 HZ, 115V, LESSTHAN 10 AMP DO NOT REMOVE THIS LABEL WH - MINIMUM CLEARANCES TO COMBUSTIBLE MATERIALS eacK wuL CwEBACK wuLy a E L AwAtENr wnLl PROTECTION *60020142 IR* R—A CAUTION: HOT SURFACES WHILE IN OPERATION" DO NOT TOUCH. CONTACT MAY CAUSE SKIN BURNS. KEEP CHILDREN, COMBUSTIBLE MA- TERIALAND FURNISHINGS A CONSID- ERABLE DISTANCE AWAY. SEE NAMEPLACE AND INSTRUCTIONS. TYPE OF FUEL: PELLETIZED WOOD FUELONLY COMBUSTIBLE FLOOR MUST BE PROTECTED BY NON-COMBUS- TIBLE MATERIAL EXTENDING BENEATH THE HEATER AND 6"TO THE FRONT AND SIDES AS INDICATED OR TO THE NEAREST PERMITTEDCOMBUSTIBLE MATERIAL USE 3-/ 76mm or 4"/ 100mm Type'L" LISTED PELLET VENT AND COMPLETE COMPONENTS. P11 TRADITIONS Made in U.S.A. by HEARTH TRENDS, INC. Burlington, WA STraditions Stove Safety Label MOBILE HOME OR RESIDE -L INSTALLAT FREESTANDING STOVE HORITONTALFLUE- INTEWOR INSTALLATION DIRECTLYTHROUGHWALL VERTICA IM INSTALLATION INSTALLATION MI ALLTOUNR A 6"/1501-1 6"/150MM 9"/230 MM BACKWALLTOUMT B I-TOLINITCORNER G -M 2150MM 2"/SOMM AUC IIETOCASTTOP D 61150MM 6'/150 MM MAILOEPM OF ALCOVE E 1B ­M 161A60MM FLUE- F N/A 3-/TSMM FAO WMEAR/SI OE TO FLOOR PROTECTICN10=IDEEDGE I 61150MM E/150MM MINNUMALCOVEHEMHT d8"(J2TOMM MINIMUMALCOVEWIOTH 050MM eacK wuL CwEBACK wuLy a E L AwAtENr wnLl PROTECTION *60020142 IR* R—A CAUTION: HOT SURFACES WHILE IN OPERATION" DO NOT TOUCH. CONTACT MAY CAUSE SKIN BURNS. KEEP CHILDREN, COMBUSTIBLE MA- TERIALAND FURNISHINGS A CONSID- ERABLE DISTANCE AWAY. SEE NAMEPLACE AND INSTRUCTIONS. TYPE OF FUEL: PELLETIZED WOOD FUELONLY COMBUSTIBLE FLOOR MUST BE PROTECTED BY NON-COMBUS- TIBLE MATERIAL EXTENDING BENEATH THE HEATER AND 6"TO THE FRONT AND SIDES AS INDICATED OR TO THE NEAREST PERMITTEDCOMBUSTIBLE MATERIAL USE 3-/ 76mm or 4"/ 100mm Type'L" LISTED PELLET VENT AND COMPLETE COMPONENTS. P11 TRADITIONS Made in U.S.A. by HEARTH TRENDS, INC. Burlington, WA STraditions Stove Safety Label Fi Board of Building Regulations and Standards ka HOME IMPROVEMENT CONTRACTOR > Registration: 101730 Expiration: 06/29/2002 Type: INDI\./IOUAL WILLIAM DAVY HOPE William Hope 80 Campbell Rd '—� N. Andover, MA 01845 ✓/e �a�sz�na�rruca/�/:. a2�aarar�«�elfa BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR ! Number: CS f _ 057754 Birthdate: 03/04/1965 r t , Expires: 03/04/2002 Tr_ nn. 17SI-7n Restricted To: 00 WILLIAM D HOPE 80 CAMPBELL RD N ANDOVER, MA 01845 Administrator ERS iY>�a y`y E Q CL Y. I i si .1 Qu W JZ F ! f a0 o w° v 'v U) w° ao' v U m4 a w a o a O w U w IV � a o z � —ca W � a w x co ° cn Q E cn iY>�a y`y E Q CL Y. I i si .1 Qu W JZ F ! f • C H IV vV O Q off` Q. d C C S m O i iY>�a y`y E Q CL Y. I i si .1 Qu W JZ F ! f �I !' ll —1 co O co • L O Z a3 CL O CO) 0 C IaD cm co p� •� Co W C ~M. = O� 3� CL-) co cc O d CL cmac c C) c O O J .= CL. CD CD C � O d L.7 C. c C cc CLCOD cm LU 0 U) U) w w crw Lli U) IV _ O.L O Q off` Q. �I !' ll —1 co O co • L O Z a3 CL O CO) 0 C IaD cm co p� •� Co W C ~M. = O� 3� CL-) co cc O d CL cmac c C) c O O J .= CL. CD CD C � O d L.7 C. c C cc CLCOD cm LU 0 U) U) w w crw Lli U) N2, 3 �;- 6 0/ " "ORTPI 7% 07"T Date ....... 7//�/ - TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .. . ...... ............... has permission to perform ........ &L.Yr ...... e. -I .......... 0,-f ........... wiring in the building of ........ .................... ..................................... at ... ........... North And �,d�ox-e , Mass'. oo ...... /Z ........ !��/ Fee .......... Lic. No. jC7 ..... .......... ......... X,;I� ELECTRICAL INSPEC-MR Check # WHITE: Applicant CANARY: Building Dept. PINK: Treasurer t .\ TIEogMHUINWEALIHOFM4N"CHUSE-JIS Utfice Use only DLEPARTMENPOFPUBLICSAFETY Permit No. �? BOARD 0FFMPREVEN770NRB9JLAT10AN52701R 12:00 VAPPUCATIONFORPERAff Occupancy & Fees Checked TO PERFORMELECMCAL 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) QatS_ 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) SC -0 Owner or Tenant - J GO , Owner's Address Is this permit in conjunction with a building permit: Yes [ No (Check Appropriate Box) Purpose of Building Utility Authorization Nor Existing Service Amps Volts Overhead Underground No. of Meters New Service Amps Volts Overhead Underground No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work U ki T7 C 1!1 –1-" h No. ofLi hting Outlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures Swimming Pool Above 0 Below Generators KVA find ground No. of Relteptacle Outlets / o l No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch Outlets No. ofGas.Bumers 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 Water Heaters KW No. of No. of Si Bailasis No. HydriMassage Tubs No. of Motors Total HP OTHER -- - - Ir�str�rtceCv� R>rsuat�tbthetegtritana��Gata�alLaws Iha%eatua1LdALyIhsstraroePldigymdt&ECarqi&C.otw'aWcritss<aflivdlart YES E3 NO ED lha%esubn9ladvalidptodbfsarretottt Ofim YES M NO r IfjculmedWWYES,pimeatiC*thetypeofWVWdWbydtadmgthe applopnWCUX INSURANCE BOND OTHER W.W. ftffiesm* Eviraliat D * Fstim&dvahtedElec linl Wak $ � � J FM — LicaseNo 2– t !? > 0 Btsir=Td.Na_� �� J .�` i J`.2.7 — AiTdNid OWNER'S RsBURANCEWAIVFR;Iamaw wftAtheLk sedmnut ttteirstrratroeoaeragetr8ss>stat>f lecFrivata>rastecltmedbyMa se a4ct�atmysigrtattsarnihispam�nB>�otrwai�stttis t�taatta�. (Please check one) Owner 1:3 Agent Q Telephone No. PERMIT FEE da