HomeMy WebLinkAboutMiscellaneous - 96 SUGARCANE LANE 4/30/2018'o Box 55098
3oston, MA 02205-5098
517-951-0600
Form of Notice of Casualty Loss to Building
Under MASS. GEN. LAWS, Ch. 139, Sec. 3B
To: Building Commissioner or
Inspector of Buildings
City Hall
NORTH ANDOVER, MA 01845
Board of Health or
Board of Selectman
City Hall
NORTH ANDOVER, MA 01845
- RE: Insured: - CHRISTOPHER MADIGAN-and MELANIE GARGER
Property Address: 96 SUGARCANE LN, NORTH ANDOVER, MA
Policy Number: HMA 0311730
Claim Number: BOS00048622
Date of Loss: 1/29/2015
Company: Safety Indemnity Insurance Company
;Claim has been.made involving. loss, damageor 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, Chapter 139, Section 3B is appropriate, please
direct it to the attention of the writer and include a reference to the captioned insured, location,
policy number, date of loss and claim number.
Lindsey Hodgens Claim Examiner 2/17/2015
Safety Insurance Company
Homeowners Claims Unit
P. O. Box 55098
Boston, MA 02205-5098
Phone: (617)95170600: EXT 3418
Fax:.(617) 603-4914
Email;•LindseyHodgens@SafetyInsurance.com
Location�����-
No. �5 % � Date /
NORT"
TOWN OF NORTH ANDOVER
Ota"�� '•,4O
.
- Y
6 ; .
Certificate of Occupancy
$
y,SSACMUSEt�
Building/Frame Permit Fee
$ %�1-7)'
Foundation Permit Fee
$
Other Permit Fee
$
TOTAL
$
Check #/ 1"I- 2
14393
Building In sreqtor
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REP,4 RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
tom, � v A
.. yaw ,: i'M ,.r �' ,:.
BUILDING PERMIT NUMBER:
✓ -: t ' � ;- � � .{'�� - � nM;..,' �` �` `��`l.4
... .. -. ,,,., ,, r... .. - .••. ., .. .n. ,_a_" ter.
/ DATE ISSUED: ® ..� eo
4/0
SIGNATURE:
Building Commissione
t r of Buildings Date
SECTION 1- SITE INFORMATION
1.1 Property Address:
61(o Sug rcaw. Ln.
1.2 Assessors Map and Parcel Number:
to6A z�s
Map Number Parcel Number
[ / 1 7
1.3 Zoning Information:
Zoning District Proposed Use
CPn_,)j
1.4 Property Dimensions:
L4gi { 17 $, 5
Lot Areas Frontage ft
1.6 BUILDING SETBACKS ft
Front Yard
Side Yard
Rear Yard
Required Provide
Required Provided
Required Provided
30 l KO+
ZD i? +
30 +
1.7 Water Sugply M.G.L.C.40. 54)
Public @/ Private ❑ Zone
1.5. Flood Zone Information: /
Outside Flood Zone by
1.8 Sewerage Disposal System:
Municipal ❑ On Site Disposal System
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record
wren -t..10 clolrl
Name (Print
9& Sa� Lv►,
n Address for Service:
Signatur
Telephone
2.2 Owner of Record:
`i -
Name Print
r'
Address for Service:
Signature
Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Crow[ 0,qygon
Licensed onstruction Supervisor:
- ~J ,�oloyi ip Of./rt
Addr
vG"----�—
SigY6ture
koe r 111/ o ig `o
79 4176'— 00':� l
Telephone
Not Applicable ❑
0 L{ {�
License Number
•-y !310
Expiration Date {
3.2 Registered Home Improvement Contractor
Not Applicable ❑
Company Name
Registration Number
Address
Expiration Date
Signature
Telephone
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SECTION 4 - WORKERS COMPENSATION (M.G.L C 152 § 25c(6)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed affidavit Attached Yes ....... No ....... 0
SECTION 5 Description of Proposed Work check all a h'cable
New Construction ❑
Existing Building ❑
Repair(s) ❑
Alterations(s) ❑
Addition ❑
Accessory Bldg. ❑
Demolition ❑
Other ❑ Specify
Brief Description of Proposed Work:
SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost (Dollar) to be�
Completed by permit applicant
@FFiCIAi USE OIYIsY '
�(a)
1. Building
12 300
j
Building Permit Fee
Multiplier
2 Electrical
,/V
(b) Estimated Total Cost of
Construction
/7�J'�
� 3
3 Plumbing
Building Permit fee (a) X (b)
4 " Mechanical HVAC
5 Fire Protection
6 Total 1+2+3+4+5
1"
Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS OR CONTRACTOR APPLIES FOR BUILDING PERMIT
tAGENT
f
I, �t�f0► arlol . Ve,�Oen C 10 k as Owner/Authorized Agent of subject property
Hereby authoriz (,i'ol i A 14-06&-o to act on
M behalf it < 1 matter e t ork authorized by this building permit application. !
��� 0
�iNgifaWe Owner Date
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
1, as Owner/Authorized Agent of subject
property
Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief
Print Name
Signature of Own er/A ent Date
NO. OF STORIES SIZE !D !
BASEMENT OR SLAB
SIZE OF FLOOR TINIBERS Z 10 1 2ND 3
SPAN `
DIN ENSIONS OF SILLS
DIN ENSIONS OF POSTS 4 X6
DIMENSIONS OF GIRDERS 2 to
HEIGHT OF FOUNDATION IVA THICKNESS
SIZE OF FOOTING q q! X
MATERIAL OF CIVVINEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE Y&S
FORD - U - LOT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all -necessary approval / permits from
Boards and Departments having jurisdiction have been obtained. This does not relieve the
applicant and or landowner from compliance with any applicable requirements.
APPLICANT Cv,71 icy �67 5®Y1 PHONE 01-7e 476-009/
ASSESSORS MAP NUMBER -LP 6 LOT NUMBER
SUBDIVISION LOT NUMBER
STREET S 12 off% z✓ STREET NUMBER `
�.........................................................................
OFFICIAL USE ONLY
RECON vIENDATIONS OF TOWN AGENTS
DATE APPROVED I�-
C SERVATION ADMINISTRATOR
DATE REJECTED
COIviMENIS
TOWN PLANNER
CONffviENTS
FOOD INSPECTOR -HEALTH
C
SPtIfffOR - HEALTH
CONB&'NTS
PUBLIC WORKS — SEWER / WATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTMENT
COMrdENTS
DATE APPROVED
DATE REJECTED
DATE APPROVED
DATE REJECTED
DATE APPROVED !
DATE REJECTED
DATE APPROVED
DATE REJECTED
RECEIVED BY BUILDING INSPECTOR DATE
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DEPARTNENT OF PUBLIC SAFETY
CONSTRUCTION SUPERVISOR LICENSE
5..
-Expires: birthdate
Ov !70415."-07'11812001 1sf1st2
Restricted to. % 90
41 ELl ST APT 1 T.
NORWREADING, KA 01864
!!1C VU!!/ll/V/lVVGdlI/! UI IV/dJJdWIUJCIIJ
Department of Industrial Accidents
Office of Investigations
Boston, Mass. 02191
Workers' Compensation Insurance Affidavit
Please Print
Location- JDA r—olo ►i(::t I t)`•
G78 Ll
am a homeowner performing all work
�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
City Phone #
Insurance Co. Policy.#
Company name:
Address
City Phone #
Insurance Co Policy #
Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00
and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of ($100.00) a day against me. I
understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
I do herby certify under the pains and penalties of perjury that the information provided above is true and correct
Signature Date
Print name Phone #
Official use only do not write in this area to be completed by city or town official- F Building Dept
❑Check if immediate response is required Building Dept p Licensing Board
Q Selectman's Office
Contact person:_ Phone #: n Health Department
11 Other
FORM WORKMAN'S COMPENSATION
Town of North Andover
Building Department
27 Charles Street
North Andover, Massachusetts 01845
(978) 688-9545 Fax(978)688 -9542
DEBRIS DISPOSAL FORM
f NORTH '9
O L
�ywK A
�.g p�'P4TED PPa��„�5
`Ss,gcElus�
In accordance with the provisions of MGL c 40 s 54, and a condition of
Building permit # the debris resulting from the work shall be disposed
of in a properly licensed solid waste disposal facility as defined by MGL c11, sl 50a.
The debris will be disposed of in /at:
Facility location
Signatur of Applicant
Date
NOTE: A demolition permit from the Town of North Andover must be obtained for this
project through the Office of the Building Inspector.
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3
Growth Management Bylaw Exemption Statement
Town of North Andover Building Department
This form shall be used to assist the Building Department in their determination of exemptions under section 8.7.6 of the
Town of North Andover Growth Management Bylaw. The building applicant shall provide all of the necessary information
as requested below.
Name of Applicant on Building Permit (bei w Address of Property for Permit (below)
Map and Parcel : Purpose of Application (check belo
Phone�� ber ofA pp vacant: 1---Stgle Family — Two Family
Y
I the undersigned applicant for the above property attest that the attached building permit for which this
form is completed does comply with the EXEMPTION section 8.7.6 of the North Andover Growth
Management Bylaw. I also understand providing this form does not absolve me or any party to this permit
from the requirements of obtaining other permits required prior to the issuance of the Building Permit.
Further I understand that my interpretation of the EXEMPTION status is subject to review by the Building
Department and is only officially accepted when the Building Permit is issued.
Based on section 8.7.6 of the North Andover Growth Bylaw the above lot and the work as applied for on the
above lot, in the building permit application and associated attachments, complies with one or more of the
following sections as indicated by a check mark.
This is an application for a building permit for the enlargement, restoration, or reconstruction of a dwelling in
existence as of the effective date of this by-law, provided that no additional residential unit is created.
�11_1The lot(s) were/was created prior to May 6, 1996 are exempt from the provisions of this Section 8.7 of the Zoning
B aw.
This application is for dwelling units for low and/or moderate income families or individuals, where all of the
conditions of 8.7.6.c are met and/or represents Dwelling units for senior residents, where occupancy of the units is
restricted to senior persons through a properly executed and recorded deed restriction running with the land. For
purposes of this Section "senior" shall mean persons over the age of 55.
This application is a part of a development project which voluntarily agreed to a minimum 40% permanent
reduction in density, (buildable lots), below the density, (buildable lots), permitted under zoning and feasible given the
environmental conditions of the tract, with the surplus land equal to at least ten buildable acres and permanently
designated as open space and/or farmland. The land to be preserved shall be protected from development by an
Agricultural Preservation Restriction, Conservation Restriction, dedication to the Town, or other similar mechanism
approved by the Planning Board that will ensure its protection.
This application represents a tract of land existing and not held by a Developer in common ownership with an
adjacent parcel on the effective date of this Section 8.7 shall receive a one-time exemption from the Planned Growth
Rate and Development Scheduling provisions for the purpose of constructing one single family dwelling unit on the
parcel.
This application represents a lot which is ready for building permits,(i.e. all other permits from all other boards and
commissions have been received and the project is in compliance with those permits), and the Development Schedule
does not accommodate issuing a building permit in that Year, one building permit will be issued per Year per
Development until such time as the Development Schedule accommodates issuing building permits. Applicant must
supply approved form U with this EXEMPTION.
Please provide any and all information that would assist the Building Department in making a determination
that your application is allowed one or more of the above EXEMPTIONS.
By signing below I attest to the accuracy of the information provided and that the attached building permit is
allowed an EXEMPTION as cited above. Further I understand that the submittal of misleading and or
inaccurate information, or the checking off of an above item which does not comply, whether done to my
know dge or not is grounds for refusal by the Building Department to issue a Building Permit.
ature of Owner'or Authorized Agent who signe a Attached Building Permit 4iate
form must be attached to the Building Permit upon application for such permit.
w
INSTRUCTIONS: This form is used to verify that all necessary
approvals/permits from Boards and Departments having jurisdiction
have been obtained. This does not relieve the applicant and/or
landowner from compliance with any applicable local or state law,
regulations or requirements.
****************Applicant fills out this section*****************
APPLICANT: If6 toov (;r� 11111 f e - (/nnC.yLl. l/o Rrd Phone Gf-Z
LOCATION: Assessor's Map Number / O 6+9 Parcel
Subdivision % 09'leS Lots) %
Street-QksA4_ gzdW& _ L ew St. Number
************************Official Use Only************************
RECO DATIO OF S: Aa/
Date Approved 71
Conservation Admrator Date Rejected
Comments
Date Approved l
Town Planner Date Rejected
Comments
Food Inspector -Health
/.LX ki,t
Septic Inspector -Health
Comments
Date Approved
Date Rejected
Date Approved %1
Date Rejected
Public Works - sewer/water connections tt) /z -
- driveway permit
Fire Department
Received by Building Inspector
OCT - 1 1996
Date
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OWNER'S INSURANCE WAIVER: 1 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 G Agent ='
Signature of Owner or Ov:ner's Agent
I here! certify that all of the de:aiis and information I ha. a submitted for entered ir. the abovc application are true and accurate to the nest of.. my knoalede= and that alt plcmbing work
and inga'!ations pe o,mead undo: the perrnr, issued for this application wit; b, in comp,:ante with al: pertinent provisions ofthe Nl;assachusetts State Gas Code and Chatrer 142 0 tf . General La. s,
o is
TVPensa
z Feinber
r'00000a
fl
fin- f s Ga ;Finer
.
Title (taster Signature of Loc sed.f'iumbcr o' Ga= +firer
. - - - - , Lt('enG< 1„J^•rS'_' � t`.J�,LD . _
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Date.
2377
A.
HORTM {'
C�
TOWN OF NORTH ,.ANDOVER
PERMIT FOR GAS INSTALLAtlo
h O p
40
�9SSACHUSEt 9
This certifies that... .?' 4:! �_N ; i, r (1 0 a� 'J =�
has permission for gas installation ...:�q?CU
�'-
in the buildings of .. .V V. .
at ^ 4 . S ;i 4i?.�c� •' '.e ....... ... , North Andover, Mass
do
Fee %U :. Lic. No..
GAS INSPECTOR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD:• Pile
?J 1 8 9 Date.. `J • r1/............. {
40RTH TOWN OF NORTH ANDOVER 4
pf +.ao ,s,ti0
PERMIT FOR GAS INSTALLATION
i • i
This certifies that ...: r• • • • • • • ` {
i 7
has permission for gas installation . -, ....................... .
in the buildings of ..l!. =`c' ...••...................•
at . YA2 .' '• ` North Andover, Mass.
Fee=:? � .. Lic. No ..7
.!` f �..: ........
GAS INSPECTOR ,
05/27gyq4:7Jpiicant 25a66NAfWi fuilding Dept. PINK: Treasurer
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Type) `
NORTH ANDOVER Mass. Date
4uildin Location '` / Dy 9 9� �69� ,r�rr// /�//��- Permit ��
Owners Name 1JfX,6V e1jAe,6L-'
New Renovation Replacement Plans Submitted 13
'9 FIXTURES
(Print or Type) Check one: Certificate
Installing Company.`Name ANDOVER PLBG. & HTG. CO., INCM Corp. 2122
Address 5731 S0. UNION STREET = Partner.
LAWRENCE, MA. 01843 = Firm/Co.
Business Telephone: 978 685-8383
Name{� of.,Llcensye}W per ler. or Gas Fitter GEOgGE GEORGEn AROSF
Insurance Cbwerage Indicate the type of insurance coverage by`Chetking the
appropriate box:
Liability insurance policy C211110ther type of indemnity 0 Bond
Insurance Waiver: I, the undersigned, have been made aware that the licensee of
this application sloes not have any one of the above three insurance coverages.
Signature of owner/agent of property Owner 17 Agent El
I hcceby certify ttut all of the dcuils and infocmation t hare submitted (of entered) in above application ace true and atxurate to the best of my
knowledge and that ati plumbing work and instatlatiom petformed under' Permit issued for this application will be 4t oo pllance with all patlncnt
pcorisions of the Massachusetts State Cas Gide and Gapter 142 of tho Gcnttal Laws.
By PE LICENSE: ---
Title Plumber Si n Lure of Licensed
Gasf fitter- 4
Master Plumber or Gasfitter
City/Town: Journeyman....
APPROVED (OFFICE USE ONLY) License,Number
MEOW
MEMENEEN
"M M.-MEME
no
ONEENSENNEEE=EE
(Print or Type) Check one: Certificate
Installing Company.`Name ANDOVER PLBG. & HTG. CO., INCM Corp. 2122
Address 5731 S0. UNION STREET = Partner.
LAWRENCE, MA. 01843 = Firm/Co.
Business Telephone: 978 685-8383
Name{� of.,Llcensye}W per ler. or Gas Fitter GEOgGE GEORGEn AROSF
Insurance Cbwerage Indicate the type of insurance coverage by`Chetking the
appropriate box:
Liability insurance policy C211110ther type of indemnity 0 Bond
Insurance Waiver: I, the undersigned, have been made aware that the licensee of
this application sloes not have any one of the above three insurance coverages.
Signature of owner/agent of property Owner 17 Agent El
I hcceby certify ttut all of the dcuils and infocmation t hare submitted (of entered) in above application ace true and atxurate to the best of my
knowledge and that ati plumbing work and instatlatiom petformed under' Permit issued for this application will be 4t oo pllance with all patlncnt
pcorisions of the Massachusetts State Cas Gide and Gapter 142 of tho Gcnttal Laws.
By PE LICENSE: ---
Title Plumber Si n Lure of Licensed
Gasf fitter- 4
Master Plumber or Gasfitter
City/Town: Journeyman....
APPROVED (OFFICE USE ONLY) License,Number
014t (flommonwralth of onr*rtt9
lepmtment of Publir —qafettl
BOARD OF FIRE PREVENTION REGULATIONS 527 CL1R 12:00
Office Use Only
Permit No.
Occupancy ,& Fee Checked G`� 04)
3190 (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code, 527 CMR 12:00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date
(XV or Town of NORTH ANDOVER To the In pecto of Wires:
The udersigned applies for a permit to
perform the electrical work describ d below.
Location (Street & Number) 4 r ) y 6 d e 04`Np B�N� 10
Owner or Tenant C a L ON /,ht V141- +6 T
Owner's Address 1() `i'9-Jesyp1/(,j UT-
Is this permit in conjunction with a building permit: Yes No C (Check Appropriate Box) 9
Purecse of Building_ rSi /V17 a- r0? M /, (- Y1/1xi �iAI& Utility Authorization No.
Existing Service Amos —J Voits Overhead '_ Undgrnd No. of Meters
New Service d op Amps 120 11G=Veits Overhead Unogrnd No. of Meters
Numoer of Feeders and Amoacity
Lccaticn and Nature of Pr000sed Eiectrxai 'Mork , IVT 1 % -LL O i QV✓6 F61 l/UGGv S) /t46
rA-M I t,/ D I.0 L G U J✓V
totai
Hot No. of Transformers KV
No. of Lighting Outlets � No. a of '.:bs K`JA
No. of Lighting Fixtures
Swimming ?poi AC a e=
gr n
crne. _ I
Generators KVA
No. of Emergency Lighting
No. of Recectacie Cutlets
No. of Cil Burners
I
Battery Units
No. Switch Outlets
; No. of Gas Burners
FIRE ALARMS No. of Zones
of
No. of Detection and
Total
No. of Ranges
I No. -of Air Ccne. tens
Initialing Devices
No. of Bouncing Devices
No. of Self Contained
Heat Total •Dial
No. of Disposals No"f lent :ons -oto
No. of Dishwashers
SoaceiArea Heating
K7W
OetecuoniSouncing Devices
— Mun:cioai
Local I_ Connec::on _Other
No. of Orvers Heating Devices KW
No. at No. w
Low Voltage
No. of Water Heaters KW
! Signs Ballasts
Wiring
No. Hvaro Massage Tubs
No. of Motors •otat !-IP
O.HER:
INSURANCE COVERAGE. Pursuant to the requirements of `.tassacrusens general Laws
I have a current Liao0ity insurance Policy inctucmg Comc:etec Cceranons Coverage or its suostanual eeuivaient. YES 154 NO = I
have suomttted valid proof of same to the Office. YES X NO = It you nave cnecxecl YES. please incticate the type of coverage ey
checxtng the appropriate cox.
INSURANCE � BONO = OTHER = (Pease Scec:fy►
���0 (Exgtrauon Datei
Esurnated Value of E' ctncat Worx 5 fn/i L L C/f L Final
Wcrx :d Start Insoecuon Date Recuestec: Rough
Signed unser the Penalties of perjurye
FIRM NAME ,-� L�G �/` f LIC. NO.
Licensee � � � Signature dff
LIC. NO. R
Bus. .el. No.
Address 5! 80Jy Nr bN faJphu2r✓ Alt. Tel. No. - 7040
OWNER'S INSURANCE WAIVER: I am aware that the Licensee goes not have the insurance coverage or its suostanttal edurvalentt estte-
ouireo oy Massachusetts General Laws. ano :hat my signature on ;his permit aoplication waives this regwrement. OvYey Ir g
(Mease cnecx one) Clp(
one
p7o. T--- PERMIT FEE S
'ete
o8eo -
iSignature of Owner or Agenti
//v f
Date...
520
NORTH
° TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
�,SSACHUS� -
This certifies that ...... rzwl ' s...... A
�,
has permission to perform .......... 5--,f' f,%........-P/r...........P........�...
1-1
wiring in the building of 'i�tj 1.0 t� .. 4 ..U&../.L.. ... ��...... ...:
at .... ...... >. .'qz, 6Cr cue .....! t. ....... 7.......... , North Andover, Mass.
.... Lic. No..Y................:..:..........................................
ELECTRICAL INSPECTOR '
WHITE: Applicant CANARY: Building Dept: PINK: Treasurer
H, 594
Date....
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
cc
CL
This certifies that ....... Df J
.............................
has permission to perform ....... ....... ....... ......
wiring in the building of ..... .......... R.J
at. . ........
.............North Andover, Mass.
...
CU
Fee..... Lic. No. RV ...............................................................
' -ELECTRICAL INSPECTOR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer