Loading...
HomeMy WebLinkAboutMiscellaneous - 981 JOHNSON STREET 4/30/2018 (2)Date... ..��..G.` ..... p p TOWN OF NORTANDOVER r t . PERMIT FOR GAS NSTALLATION • o + ACMUSES This certifies that .Se -,?i.9 � .c �c� ............. has permission for gas installation ...G+L. ' 4�' ........ in the buildings of ..4+t S. /'40/ ........................ at .... l... ��c t. .............. North -Andover, Mass. Fee.d.-) ... Lic. No../?.Y.2/.. ..... GAS INSPECTOR Check # J 550 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) :; KI aln 6,v -e -t— . Mass. Date MIQ Permit # Jf" Building Location 1 nSa^ S+ Owner's Name A Type of Occupancy r New 2r/ Renovation ❑ Replacement ❑ Plans Submitted: Yes❑ No ❑ Installing Company Address AY5 l( CC k one: W Corporation ❑ . Partnership Certificate Business Telephone—)^i61 ` 6 LA u - -4 ) 1 1 ❑ Firm/Co. Name of Ucensed Plumber or Gas Fitter k'nl A 1OCa- C f o -- INSURANCE COVERAGE: I have a current ility insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes 0 No ❑ If you have.checked yes. please I tate the type coverage by checking the appropriate box. dY A liability insurance policy Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner❑ Agent ❑ Signature of Owner or Owner's Agent I hereby certify that all of the details and information I have submitted (or entered) in above applicati are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for thi . plication will be in compliance with all pertinent provisions of the Massachusetts State.Gas Code and Chapter 142 of the Ge I gy TvPofsLuicense:r a u d lumber or Gas fitter Title rZa License NumberCity/Town man APOP040--WrI USE ONLA V a ffAM4!j4.1E mom UM MONSOON mom i 3RD FLOOR ME MENNEN No Mi mom INNEEM somosomom GM=M MEN EM -NOME IMEMMIMEMMENIMEM Installing Company Address AY5 l( CC k one: W Corporation ❑ . Partnership Certificate Business Telephone—)^i61 ` 6 LA u - -4 ) 1 1 ❑ Firm/Co. Name of Ucensed Plumber or Gas Fitter k'nl A 1OCa- C f o -- INSURANCE COVERAGE: I have a current ility insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes 0 No ❑ If you have.checked yes. please I tate the type coverage by checking the appropriate box. dY A liability insurance policy Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner❑ Agent ❑ Signature of Owner or Owner's Agent I hereby certify that all of the details and information I have submitted (or entered) in above applicati are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for thi . plication will be in compliance with all pertinent provisions of the Massachusetts State.Gas Code and Chapter 142 of the Ge I gy TvPofsLuicense:r a u d lumber or Gas fitter Title rZa License NumberCity/Town man APOP040--WrI USE ONLA V Date. . �. TOWN F NORTH ANDOV P MIT FOR PLU ING f ♦ _ i i i : • �y ,SSACMUSE� This certifies that ..t:. T V�7� ............. . has permission to perform ....%. .. plumbing in the buildings of .. !.��J.`..................... at .. c`f11...� .. J. - ................ . North Andover, Mass. Fee .10` ..... Lic. No. P Y ? .'.. ........, . ...... . I PLUMBING INSPECTOR Check * l /'()'- 6973 `() 6973 `MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Print or Type) . oP4, cJOy c Mass. Date c� WjPermit # %3 — Building L.ocatlon � U � ' �(�h�San Owners Name G— Type of Occupanry, New ❑ Renovation O Replacement Plans Submitted: Yes O No O 1i FIXTURES installing Company I's Business Telephone )'K ( - Names of Licensed Plumber _ YYl (&G, , C Ctm�xk one:. /Corporation .O Partnership O hrm/Co. Certificate INSURANCE CO GE: I have a current I pity insurance polity or its substantial equivalent which meets the requirements of MGL Ch. 142: Yes No O If you have checked yg, please h1leite the type coverage by checking the appropriate box A liability Insurance policy tJ"' Other type of Indemnity ❑ Bond O OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General taws, and that my signature on this permit application waives this requirement. Check one: onature of Owner or Owner's Anent Owner O Agent ❑ I hereby certify that all of the details and information 1 have submdtW (or knowledge and that all plumbing work and installations pert a pertinent provisions of the Massachusetts State Plumbing By. Title g e et iin above application are true and accurate to the best of my nit issued for this application will be in compliance with all of the General taws. Type of License: Master �` Journeyman ❑ City/Town �c,2 y L License Number %/ V z ZY � _z y h VI y J} W O U! Z > W y W ¢ z N d ¢ O V= W h A W S y F+ U < ¢ Y! 2 y U. C z 6 z t - S O O z ¢! M W > ¢ a< h y W O i y z ¢ e. ¢ O o v. W11 S < S 3 31: C Y Z Y 0. 0 !- h < fC < ¢ W LL 46 79 Ac W < �V„ > C. h O a 7 N I- Z O p y o = Z, W 3 O 0a 0 S x m r vJ, u o C m o SUB—BSMT. BASEMENT IST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR STH FLOOR installing Company I's Business Telephone )'K ( - Names of Licensed Plumber _ YYl (&G, , C Ctm�xk one:. /Corporation .O Partnership O hrm/Co. Certificate INSURANCE CO GE: I have a current I pity insurance polity or its substantial equivalent which meets the requirements of MGL Ch. 142: Yes No O If you have checked yg, please h1leite the type coverage by checking the appropriate box A liability Insurance policy tJ"' Other type of Indemnity ❑ Bond O OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General taws, and that my signature on this permit application waives this requirement. Check one: onature of Owner or Owner's Anent Owner O Agent ❑ I hereby certify that all of the details and information 1 have submdtW (or knowledge and that all plumbing work and installations pert a pertinent provisions of the Massachusetts State Plumbing By. Title g e et iin above application are true and accurate to the best of my nit issued for this application will be in compliance with all of the General taws. Type of License: Master �` Journeyman ❑ City/Town �c,2 y L License Number %/ V M Date.................... ................ TOWN OF NORTH ANDOVER PERMIT, FOR WIRING This certifies that..................:c.a............................................... has permission to perform.....................�r,rr..�............. wiring in the building of ..-�.............................................. v �' .. North Andover Mass. Fee ............... Lic. NONA- ........... ................................ ELECTRICAL INSPE iv Check # 67"1 1 • l Commonwealth of Massachusetts Department of Fire Services Permit '`.'u 1 )rrci;ll I :.0 ( )nlN 0!� 7// OCcupanc% and Fee Checked_ BOARD OF FIRE PREVENTION REGULATIONS [Rev. 9 05] le lie g,I APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK \II %%ork to he hertornlcd in,ICu)rdanCe with the %1:11,MlC•I1LISC(tS FIC01-ic.11 Curie (\IF.C). i?" AIR I'.til) li'LE.ISE PRL%T1.�.INK O)R TYPE, ILL 1AFO)RJ/.ITlo,%') Date: ! , 0(11 Civ or Town of: A�I w /�,iDoyer To lilt 1-1.speclu • u U`ires. BY this application Che lllldtl'SI-IICd oIveS IlUfll't' llt 1115 or I1Cr IIIICIIhllll tt) Pfffo l-ln the electrical work descrihed bCluw. Location (Street & Number) 98 ❑ Gj,uj o,,/ si�,Ye Owner or Tenant (-i^41-x !qa r -A 4 t f e S- f ep -q Telephone No. Owner's Address S4 M P Is this permit in conjunction with a buildi g permit? Yes A No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service 0c) Anips Ido ! c9ga Volts Overhead Undgrd ❑ No. of deters / New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: lUccJ (fe.,7ac1ce A X', 4f,v No. of Recessed Luminaires/O No. of Ceil.-Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires 3 In- Swimming! Pool ,above E] In- JrnJ. Vrrid. , o. o Emergency Lighting BattCry U lits -- q FIRE ALARMS F0. of Zones No. of Receptacle Outlets No. of Oil Burners No. of Switches % No. of Gas Burners iNo. of Detection and ll initiating Devices No. of Ranges Tota11 No. of Air Cond. No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: Number Tons KW No. of Self -Contained Detection/Alerting Devices No. of Dishwashers / Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW _ Security Systems:* No. of Devices or Equivalent No. of Water KW Heaters No. of No. of __ Si ns Ballasts Data Wiring: No. of Devices or Equivalent______ No. Hydromassage Bathtubs No. of Motors Total HP _ telecommunications Wiring: No. ul' Devices or E uiv alent O FHER: �• tyV .tllu-'ilrnl.lNfUl7[l.,tri.lu!(.h^;;;(�.•,l',Id)'�',)!!N'Cil �'',F l)c lli?�.t ` F.,Aimated f E Value olec rival Work: �,2 SOV . 1 \� hen required by municipal policy.) \bark to Start: 6 S 0 (, In:,pcctiuns to be requested in accordance h EIEC Rule 10, and upon completion. INSLRANCE COVERAGE: RACE: C.nless waived by the owner. no permit for the performance ofclectrical work mat i• -AIC unlc, the licensee Provides tlroofof liahility insurance includin-, "'_,onlpleted ))peration" covera'te or its ,l.lbr,tantial'quk"llcnt. ' h. uder:,i.nC),I satirise that such cukCra"•e i:. in hl-cc,:nld ha, c".hihitcd proof of ;axle to rile t'crnlit i�­tlin', office. r'III:a_KO�,L:: Ii�SI R,\�l'i� � I)l;�.l) �� I)fF!I R ❑ I'ipCcily:) '.'1)// 'hE' lt) !li'')la1J�411 )1 . %1/J' ) )l' + /.•/ • .�" 1 ,� / it 1 I • ,f :/./ /cuJiun ,.� ;!•uc' 'lr r/ r'N a). c. :'9RtiI N:1,blF: lJ.f x,- tT�iG c ?_iL'rllSee: i" ._1c. yc3.:.41y33 3 i%as. TO. ,'o.: l / 626X Address: -U,j1C s� E Security : y,tcm Contractor 1Jcen,:e ra.luircd tin' thiS if uppliUNC. CntCr 111C liCcnse lltlillber 1XIV tDbti.NER'S INSUR, VNCE A,kIVER: I am aw: re that i le I.i;cn:-eC / ,. ma huvc file iiabilit, insw,IIICC 1: r : I C 11 rill;,IIL ._. required by law. By my .i nature below. I hcrChy '.vaivC this, requirulunt. I .un the (,_heck )lie) ❑ .;caner ❑ u�� Iger':, .e_,: nt. Commonwealth of Massachusetts IrrLi..I t ()111\ Department of Fire Services Occuranc% and Fre C hcckrd S — BOARD OF FIRE PREVENTION REGULATIONS _ :Irav� L•Iankr APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK �II'�,nk t+l i,r 1 �rtornlrJ ill.truuJ:ulc� t�ilh the \I;I»arLu rm I Icctrie.11 Cu lr!�II:C1. 5'_- 'vIR 1'_.x;0 !'L E. ISE PR L% ['/,N l.\k OR TYPE. ILL L1FO)RJI.ITION Date: � S o6 C'ihr or Town of: S/-tg 4' over To /he hispeo.-/u • o [Vires: 13y this ,Ipplic:Uiun the unJersi,ned -i�cs Itunce of his ur hrr intcntiun to Pcrti Location 75? ` ac Cjx,) 47Y No. "Date 9I / 4S NaRTh Q TOWN OF NORTH ANDOVEN 1 n Certificate of Occupancy $ 8 Building/Frame Permit Fee $ .}0 �sswcMusE< Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL $ g Building Inspector Div. Public Works 6-9 _ _ __ _� _ 7 D _ _o v _c -n n n n a r. L4 z p yrn �e 7 = D n Ll n - r: 7 -+ n z p a z N -� p - T r O O O N .z-t Z Z Y —' j D Z Z Z vi ^_ n Z :� 'o N •-' = p rn 0 0 0 ^ , •� 1n fn W c Z z N. � y i" n � � z Ml v� w a o ^D y 7 I n C/) m M C/) 0 m CO2 10 CD n. Z CD O ar m Co CZ. o p a� CD O a: C2 to CD CO) 10 CD Cl) 0 L-1 0) C) CD 0 CD CD a y. CD CO) c?oc m __ C. iA O Q w 4o�m = N o CD On m n v,Ccll,ac H -4 CD G m H C �; O m m: m a 0 n O,� 0 O ^� O ZS.g O y, !9 aCA Wim. 0• ,,. ,. • : �f CD CL a CD W H am: Q � � d o 60m CD ca n O O X 1%40 CD O CD c m ; I CD H . 1 o o W 0 d m AF) CCR: nr 0: c o moo: � co 0, S': O rD d p ti O � G w O G G� � O 0) O G M y O O yr O Gy oQ IV p O G O G O G ^ 0* r. d y0 cn rc 'O ,< . 171 O O i, a C o O y E" 0 y 0 0 c _ocation i No. Date J '. a r- - - =' NORTq TOWN OF NORTH ANDOVER O'�t�ao .• 100 i? •... � n Certificate of Occupancy $ ' �• + ; Building/Frame Permit Fee $ +ss try Foundation Permit Fee �cMuS $ P!�� ther Permit Fee $ - - Sewer Connection Fee $ Water Connection Fee $ TATAL Building Inspector Div. Public Works PE&JtIT NO._�d bT - AMICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. /PAGE 1 MAP KJO. LOT NO. I 2 RECORD OF OWNERSHIP IDATE BOOK PAGE : ZONE SUB DIV. LOT NO. 7I LOCATION %gI JokW,(r. e,+. fJ,-A.y c�*ve /M A PURPOSE OF BUILDING y OWNER'S NAME pawl Mei F -VW? NO. OF STORIES Z SIZE OWNER'S ADDRESS981 1&1 _ NSv� ✓1W �� ��� � _i� Q ASEMENT OR SLAB ARCHITECT'S NAME �Qi�1G SIZE OF FLOOR TIMBERS IST 2 v. (D 2ND 3RD BUILDER'S NAME PCl,,,, E>,i !j �l�'lyNra, SPAN DISTANCE TO NEAREST BUILDING 3 j!�aJaw;,4 � � DIMENSIONS OF SILLS DISTANCE FROM STREET 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 LTERATIONplaGG (I:IINOAliA� G',eA 4INC"13 IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE I fl V11Sin IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION. IF ANY r om ;,,4 IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE U S & INSTRUCTIONS SEE BOTH SIDES PAGE 1 FILL OUT SECTIONS 1 - 3 d PAGE 2 FILL OUT SECTIONS 1 - 12 ' ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING I ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED ANDpAPPPROVED BY BUILDING INSPECTOR DATE/FILED t.7 SIGNATURE OF WNER OR AUTHORIZED T FEE a" PERMIT GRANTED - I7 a OVVNER TEL. # CONTR. TEL. 19 CONIR. LIG it p3l> `a74• I"40� lvN�o1�0�/ a591 3 PROPERTY INFORMATION LAND COST EST. BLDG. COST �►' iJ00 ��' EST. BLDG. COST PER SQ. FT. EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. 4 APPROVED BY BOARD OF HEALTH PLANNING BOARD O BOARD OF SELECTMEN 1 421�� BUILDING INSPECTOR BUILDING RECORD 1 OCCUPANCY 12 SINGLE FAMILY STORIES MULTI. FAMILY OFFICES APARTMENTS _ CONSTRUCTION 2 FOUNDATION—I 8 INTERIOR FINISH CONCRETE PINE 3 t 2 I3 CONCRETE BL K. BRICK OR STONE HARDw D PIERS PIASTER DRY WALL _ _ UNFIN. 3 BASEMENT AREA FULL FIN. B M TAREA 1/4 '/t '/, FIN. ATTIC AREA _ NO B M FIRE PLACES _ HEAD ROOM MODERN KITCHEN _ 4 WALLS I 9 FLOORS CLAPBOARDS B _ 1 2 3 _ _ _ DROP SIDING CONCRETE WOOD SHINGLES EARTH ASPHALT SIDING ASBESTOS SIDING HARD"�'D COMtdCN VERT. SIDING _ ASPH. TILE STUCCO ON MASONRY STUCCO ON FRAME _ BRICK ON MASONRY BRICK ON FRAME ATTIC STRS. b FLOOR I_ CONC. OR CINDER BLK. WIRING STONE ON MASONRY STONE ON FRAME SUPERIOR I� POOR _ ADEQUATE NONE 10 PLUMBING 5 ROOF GABLE GAMBREL HIP BATH 13 FIX.) MANSARD TOILET RM. 12 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 11 HEATING WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. TIMBER BMS. & COLS. STEAM STEEL BMS. & COLS. HOT W'T'R OR VAPOR WOOD RAFTERS _ AIR CONDITIONING _ RADIANT H'T'G UNIT HEATERS 7 NO. OF ROOMS GAS OIL ELECTRIC B'M'T 2nd _ 3rd NO HEATING 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. J \ a 1st � i / �Design Build Design Build Solutions, Inc. Three Baldwin Green Woburn, MA 01801 (617)932-1180 FAX (617)932-1174 MA License 101865 Purchase Agreement Name: Paul and Meg Rokos Address: 9 S 1 Johnson Street, North Andover, MA 01845 Phone: (508) 689-4550 Mailing Address: Same Work Description: 1. We will furnish and install in a workmanlike manner the remodeling project according to the conceptual plans, project specifications and terms and conditions attached and dated. December 30, 1992. 2. Subject to Addendum "A" made part of this agreement. 3. Includes reduction in the price listed below in the amount of $595.00 for the original design fee. 4. The final price listed below will change based'on the final scope of work determined at the pre -construction meeting and will be adjusted by change order outlining additions and deletions. 5. We will begin work on or about February 1, 1993. Barring delays beyond our control we will be completed by March 15, 1993. You agree that these scheduling dates are approximate and that such delays that are not avoidable by us shall not be considered violations of this agreement. 6. Includes reduction in the price listed below in the amount of $1,163.09 for winter build program. Cash Price: $8,000.00 This agreement supersedes all conversations, statements, and agreements expressed or implied b een' a parties, their agents and representatives. ayLd are to a made as work progresses according to the Payment Schedule attached and t of thi agreement. Hor. Do of sign this agreement if there are any blank spaces. �C ��2_ T� Owner Owner �o William C. Penny, President, Design Build/S ons, Inc. Date Zf d/9L Date /L, 30-9 Date 10 f roject Description Rokos December 30, 1992 Page 2 of 2 f --------------------------------- 8. Relocate dishwasher to other side of sink using existing cabinetry. 9. Remove all construction debris. ` 10. Includes permit application, permit fees, (2) hours of additional design time and all required construction drawings. 11. Does not include interior or exterior paint or carpet. ject Description & ,_ _ - December 30, 199 Page 1 of 2------------------ 1. Renovate existing family room as per conceptual drawings dated December 30, 1992, including removal of all aluminum doors and octagon window, removal of wall between itcheg��and family room and support with load carrying removal of existing electric heat, and removal of plaster as ation of new win required for new doors and windows, instoglhardboard clapboard ws and doors as specified below, patching doors and windows, installation of siding as required for new n in anR-19 R-13 fiberglass insulatio blueboardwalls with skim-coatfplasterson all new insulation in , wall areas, installation of FHW baseboard heat off existing floor zone, and all g and finish colonialg system and first 2 1/2" colonial door and window casing baseboard. 2. Install (2) Andersen Frenchwood FWG6068 sliding glass doors with low E tempered glass and wood grilles. 3. Install (3) Andersen C25 high performance casement windows with low E glass and Tycote grilles. 4. Install (1) Andersen CTC2 high performance circle top window with low E glass and Tycote grille. 5. Install (2) Andersen CR15 high performance casement windows with Tycote grilles, low E glass and screens. 6. Install peninsula/breakfast bar cabinets as per cabinet w od lan to match existing with step down laminate countertop withedge. Remove existing countertop and sink, and install new laminate countertop with wood edge and reset existing sink and faucet. Install Dal -Tile 4x4 ceramic tile backsplash behind new countertops. sement 6. Construct office below family room in Decemberexisting 30, 1992, including space including2x4 as per conceptual drawings blueboard wall construction, R-13 fiberglass wall insulation, with skim -coat plaster, FHW baseboard heat off existing basement zone, trim (1) window and (2) doors with 2 1/2" colonial casing and install 3 1/2" colonial baseboard. 7. Install electrical in office to include (4) outlets, (1) telephone outlet, (4) Halo 75 watt recessed downlight with dimmer mmer in in office, (4) Halo 75 watt recessed downlights with d(1)eclient kitchen, installation of (4) client supplied sconces, supplied ceiling fan, (2) client supplied hanging fixtures and relocation of all wiring in disturbed walls and ceilings. r r s potiVERs a LICENSE �spa R BlF79SS88'3 11-i�4-94 � i;t-e� I� Na6pp1.EYCDR I ,i R m i E ENr OF PUB(_Cpo�M BOSTON, A�41/iAVEM�5_' Fes' i EONSTRLi EMSE "UpERVISOR EFFECTIVE PATE 0ai301,1 991 LIC-Np. 030-574 m�OXL312 E PEjqNY ERkyVjj 031041 NOT ST,MpEp UNOTRIL 6 SIGNED 9Y ' SIGNATU OF NEICE ECO O OFFICIALLY MMISSIONER ¢E C IF N r •;'�' SIGNATURE SIO a COMM, ��a P E FORM U - IAT RELEASE FORM r 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: R"F O os Phone &,??- LOCATION: Assessor's Map Number Parcel Subdivision Street Lot (s) St. Number ************************Official use only************************ RECOMMENDATIONS OF TOWN AGENTS: Conservation Administrator Comments Town Planner Comments Date Approved Date Rejected Date Approved Date Rejected Date Approved Health Agent Date Rejected Comments Public Works - sewer/water connections - driveway permit Fire Department' Received by Building Inspector Date Y) -0 cc 5= o m C O �• vi p Q vi C p ` p .p y „ z »mom m c) 7D z v Z H —01a c m _, ® mopy ^' y c —a1 � p 0 �• n T CO) n Co mA CD 0 m.. 5 ' z �r c' ;y C O Cf0 '" CLfib CL —' CO)p•�• CC AD AC-\_ Orn o to c O E c -r z ti. C d — c oo = 0 CD St C/) p \ �r CD MIS C') coo CD0 0CD Cf)CD ao co �. � Z 0 � o ♦ � O cD H a v y CD cm CD z — c yCD Z ail m CD O ..... A CD 90 CCD C• M T O p ^: C D CD O `F z m Cn CD d (n r� o q7 71 'jJ C Z M o '^t7 w (A JC1 G 7 O 7d m C ai C M O � C R? T re O C C Y (�" b Cn CD O 7C QJ o x E W W v y 0 9 0 c