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HomeMy WebLinkAboutBuilding Permit # 11/30/2015 `AORTPi BUILDING PERMIT O �iLeo ""6 '5 o 4 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION - - Permit Geo#o � � 7 �� � Date Received � RaC Date Issued: i" IMPORTANT: Applicant must complete all Items on this page , ,:.....,, ,r r / err r .r r ✓ )/,I f �.. / ;, r. ,/r. r��//,1,l�/ � , ! / ,H._,... w " / r > ,Ir r l rr�lGl.,,/rl,,;/ >)n( ,�. rr//..: / r r/�i ✓/r��I ,�1 !.� I„fir r/_... % '� JB1 )� r l'i�'`IY'� X100 YearYSruc'<ure D es na f/r i al . eA�ur<✓,�,[ , l, /, r;� r, ,, „, a/,,+ri,,H!�!r/i/I a 1�i///I / . .�/hl,”,, 11 �l 1 J// /, P,�+RC EL,N, , r! ✓/rd 4!' (0r r'I/„J//r/%/f% <r r0 r/ r //tl,�r(c/I,jl%?fufr,'� ��//>��, � ri // /I/,�/ � r I», rrir ,n /9 ,,,%1,///„////„,✓ / r%, r / .. � .� J „rr n�l�,,,�, m,)�l�li ,tis/��r1��mr l�ui r/D/aylr/r �/..✓��,i,�,,/_r, ur 1 /,H,r,r, � u/�//l a,d TYPE OF IMPROVENIENT PROPOSED USE Residential Non Residential ❑ New Building ❑ One family [I Addition El Two or more family El Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg Others: ❑ Other �v�S El Demolition / /,r �� lNatershed D`istr ctr r��/r ;,. ✓ ❑ //i / ,� /r 1Netland r„/r e r/ l r/, � ❑ , f//r / /�, r r r rrr r ,,,r r� ,r r / r� ✓ r / r r r// r/r„ i`// ,r,/�/I, fr tl/li/r�/J�,;/r '��r< iWate,r/Sewers//�r/��, �l...n.._, DESCRlP1 ION OF WORK TO DE PERFORMED: Identification- Please Type or Print Clearly OWNER: Name: v®' � � Phone: 7�G Address: / /� Al/.. %rq 'clZ"d,1 ., Phone. � f.. ✓ c, ,. tactor N � r<'<!✓, /i,F /r� r r /,.r.// I I/ SDH r,,. .. /� ,,..... r r ..,+„ /, /. r/ �.. /.������������.� 1. «,,,, ,r/r(!„//v��///l,.r//i/////1/ /���Jl/rr/i//1,/.:rr„ .:., to ,..✓no ,,,, r ., .r.,: ,r„ r ,:.;� Ir '; r / �r r / / ,r ✓ / %/ /r/ L/ l' (, /// `(,J�.!�(!,�: fl���, r,o, ,l r/ (/r / / r,,,Ur r/% 0 _Ir DIY/ f� r r,V1�G/G%do,,✓, , Sup,ery or C S YlGlrl-r�/. ,v!-✓ JN V i� /.,/ver/:u �,�/I,HI !%.;�/G//r%�i„ r��,Ir�EX .ID ,��� �,x %« r a,rf// ,�/�, r/ ///,9 / r / � ,r / r,r, rf / _r, ,!, ri /fir r. ✓ /� f r � , r, , 4Homerlm o r,„rr15 ARCHITECT/ENGINEER Phone: Address: Reg” No. FEE SCHEDULE;BULDINO PERMIT:$12.00 PER$9000.00 OF THE TOTAL.ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: $ ��� FEE: $_ . Check No.: ( Receipt No: = NOTE: Persons contracting with unregistered contractors do not have�ccess to the guaranty,f and signature of Agenf/�wner Signature of_ca,ntracfio _�_. 'Town oft%®RT H 1 Ir' ndover® ''Y�'. M No. F17 �O SAKE h Ver, Mass, COCMICMEWICK tea. SRATED PPe PE R fJBOARD OF HEALTH IL Aff Food/Kitchen M1 ii� T L mumoh' Septic System S4 THIS CERTIFIES THAT ......410AIL664 ............................... BUILDING INSPECTOR has permission to erect .......................... buildings on .. ..&. Foundation ....A.MPP&,&4j. ®®,, ® ��� Rough to be occupied as .. .4 &... .. ............................Ain... Ko'... ................ Chimney provided that the person accepting this permit shall in every respect conform to the ter f the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspec ion,Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough MONTHS Final PERMIT EXPIRES IN 6 ELECTRICAL INSPECTOR ® UNLESS T Rough Service ................. . ..... .... ......................................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required t® ccupy BuRough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approvedthe Building Inspector. Burner Street No. Smoke Det. Federal ID#05-NOW29 RISE Engineering Ri Contractor Registration No 5168 MA Contractor Reglstration No 120979 R I A division of TbieWb Engineering f ENGINEERINGb I 60 awmut Unit t#2,Canton,irzAn 02021 CONTRACT 339-502-6335 FAX 339-502-6345 •: Page 1 ,� PROGRAM ^:',•i:.''�:.:''• f)Q\ y, MIS CONTRACT186rTUMWTO Sh1WEE ME p 1, CiVMA-I S ENOWE RM AND UIE CUSTOM FOR WOW AS DEMMUSAW CUSTOM OC i' pliorm DATE cumao WORKORm David Saba (978)689-0194 10/06/2015 421160 00003 SERVICE STWEET slutNo STREET 183 Appleton Street 'k' ,� 183 Appleton Street SERVICE CITY.STATE,ZIP mWNO MY.STATE,ZIP North Andover,MA 01845 North Andover,MA 01845 JOB DESCRIPTION HASE OW Proposal for this calendar year. $0.00 AIR SEALING:Provide labor and materials to seal areas of your home against wastefid,excess air leakage. This work will be performed in concert with the use of special tools and diagnostic tests to assure that your home will be left with a healthful level of air exchange and indoor air quality.Materials to be used to seal your home can include caulks,foams and other products. Primary areas for sealing include air leakage to attics,basements,attached garages and other unheated areas(windows are not generally addressed.) This will require(8)working hours.A reduction in cubic feet per minute(cfin)of air infiltration will occur,but the actual number of cfin is not guaranteed. At the completion of the weatherization work,and at no additional cost to the homeowner,a final blower door and/or combustion safety analysis will be conducted by the sub-contractor to ensure the safety of the indoor air quality. $680.00 AIR SEALING ADDER: (2)working hours. $170.00 DAMMING:Provide labor and materials to install a 12"layer of R-38 unfac ed fiberglass batts to(124)square feet for damming purposes. $254.20 ATTIC FLAT:Provide labor and materials to install an 8"layer of R-28 Class 1 Cellulose added to(1096)square feet of open attic space. $1,501.52 KNEEWALLS:Provide labor and materials to install 2" FSK faced semi-rigid fiberglass board insulation to(194)square feet of kneewail area.TMS IS THE KWALL OF VAULTS IS MASTER BEDROOMMITCHEN AND FRONT ENTRY. $679.00 ATTIC ACCESS:Provide labor and materials to insulate the back of(1)attic batch with 2"rigid Themmax board Weatherstrip the perimeter. $60.00 VENTILATION:Provide labor and materials to install(4)insulated exhaust hose to existing bathroom fen(s). $200.00 RISE Engineering will apply all applicable,eligible incentives to this contract. You will only be billed the Net amount. Curreatly, for eligible measures,Columbia Gas offers 759/o incentive,not to exceed$2,000 per calendar year,and an incentive of 1000/6 for the Air Sealing measures up to the first$680 and an additional$340 if savings are justified by the auditor. For the safety and health of your home's indoor air quality,we will be conducting a blower door diagnostic of the available air flow in your home both before the work is begun,and after the weatherization work is complete.We will also conduct a fidl assessment of the combustion safety of your heating system and water heater.This has a value of$90 and is at no cost to you. Total allowable weatherization incentive is$3,110. $90.00 OWNER AUTHORIZATION FORM (Owner's Name) owner of the property located at I Y' :3 iQe-)-,o 6/ 4 (Property Address) l Q (Property Address) hereby authorize (Subcontractor) an authorized subcontractor for RISE Engineering,to act on my behalf to obtain a building permit and to perform work on my property. Owner's Signature / Date e Federal ID#>~054405828 RISE Engineering RI Contractor Registration No 8186 j RiSrp*,,-- MA Contractor RegFehation No 120978 i t &Z� A division of Thielseh Engineering ENGINEERING 60ShawmutUnit##2,Canton,MA02021 CONTRACT 339-502-6335 FAX 339-502-6345 Page 2 PROGRAM CONIMCTISOBNETOBETWEeN RISE CMA-HES BWBWOMEWO AM THE C IST MR FOR WORK As Div BELOW CUSTOMER PHONE DAIS CIIENTO WORKORDER David Saba (978)689-0194 10/06/2015 421160 00003 ! SERVICE STREET BILLING sn2EET 183 Appleton Street 183 Appleton Street SERVICE CRY,STATE,IIP BAUJNG CnY,STATE,LP North Andover,MA 01845 North Andover,MA 01845 JOB DESCRIPTION Total: $3,634.72 Program incentive: $2,861.04 Customer Total: $673.68 WE AGREE HEREBY TO FURNISH SERVICES-COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS.FOR THE SUM OF ***Six Hundred Seventy-Three&681100 Dollars $673.68 UPON FINAL INSPECTION AND APPROVAL BY RISE ENGINEERING.CUSTOMER AGREES TO REMIT AMOUNT DUE IN FULL.DITEREST OF i%WILL BE CHARGED MONTHLY ON ANY UNPAID SMANCB AFTER JO DAYS.SEE REVERSE FOR IMPORTANT INFORMATION ON GUARANTEES,RIGHTS OF RECISION,SCHEDULING,AND CONTRACTOR RECIBTRATHIN. D NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES ov�_ �_bdg:,Ca x .. "d& ) ,�,. AUTHO aIGNATURB-RihEng ftq CUSTOM ANCE NOTE:THISCONTRACT MAY BEWITHDRAWN DYLIS IFNor EXECUTED WITHIN DATE OF ACCEPTANCE 16ZV�sC ACCEPTANCE OF CONTRACT-THE ABM PRICES,SPECIFICATIONS AND CONDITIONS ARS 30 DAYS. AASSSSPPFECIPUMPRY AYMENTWUlBEMADEASUS AND AN HIMM A O�EDAABOVEE ARE AIRHaR®raooTHE WORK 'a The Common wealth of Hassachttsetts Deptu'tment of Intlustrial Accitlents - -9 - Office of Investigations W 't- = 71 600 TI'asltuiatoii Street Boston, NIA 02111 ivlviv.nuiss.a ov1dia Workers' Compensation Insurance affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legible \ame (Business/Organization/Indi�•idual): PO 14tr Aea `%— Address: P. ® ®)e City/State/Zip: &&doticr m Phone #: Q Are you an employer?Check the appropriate box: Type of project(required): i.Z I am a employer with 4• ❑ I am a general contractor and I employees(fitll andfor part-time).' have hired the sub-contractors 6. ❑New construction 2.ElI am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have S. F] Demolition irorking for me in any capacity. employees and have Nvorkers- 9 ❑ Building addition [\o workers' comp.insurance comp. insurance. required.] 5. ❑ We are a corporation and its 10.F] Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.F] Plumbing repairs or additions myself.[\o workers-comp, right of exemption per MGL 12-0 Roof repairs insurance required.] c. 152. §1(4),and we have no employees. [No workers' 11MOther A�7dA i p� comp.insurance required.] *Am-applicant that checks box=I mast also till out the section below showing their corkers'compensation police infomiatiou. r I lomeowoers who submit this affidavit iudicatins they are doing all r.ork and then hire outside contractors must submit a new affidavit indicatins such. =Coutractors that check this box must attached no additional sheet showiu the name of the sub-contractors and state whether or not those entities have cntpimees. If the sub-contractors have employees-they must protide their corkers'comp-policy number- I tint an emp/ober that is providing;Porkers'compensation insurance for ntl•efnpkpees Below is the polith anti job site i»formation. Insurance Company Name: Q ri Policy t or Self-ins.Lic.F: ® Vie— $-57—&ep& j Expiration Date: f Job Site Address: P/Yi0V1. G7f City/State/Zip: P. 14rodQ.°rr Attach a cope of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to-secure coverage as required under Section 25A of MGL c- 152 can lead to the imposition of criminal penalties of a fine up to S1.500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 a day against the violator" Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. 1 do herehr certify and�e�r the pains card pe[raltie-s tfperjttrl'/lint the information provided above is true and correel. Sisnature: �a��/�/�� Date 1 / r ��r✓ Phone !q?,? V D>- - Official use only. Do 1101 it,rite in this area,to be completed bir cifr or town of-ciaL City or Town: Permit/License# Issuing Authority(circle one): I. Board of Health 2. Building Department 3. Cit lTown Clerbi -l. Electrical Inspector• 5. Plumbing Inspector 6. Other Contact Person: Phone#: 1 CER-11FICA iE OF LAG ILrFY INSURANCE a\lE(�UtADNYYY) 12/18/2014 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOTAFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOTCONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED I REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:i the certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed.IfSUBROGATION 15 WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER IAL I I,M)E: Automatic Data Processing Insurance Agency.Inc. Ar-No.Exl): (nt Nu: 1 Adp Boulevard ADDRESS: Roseland,NJ 07068 WSURER(S)AFFORDING COVERAGE MAIC ,,SURER A. NorGUARD insurance Company 31470 INSURED POLAR BEAR INSULATION CO INC IPISURER 6: DBA:Polar Bear Insulation CO Inc ,,SURER C: PO BOX 958 INSURER D: Andover,MA 01810 WSURER E: ENSURER F: COVERAGES CERTIFICATE NUMBER: 291629 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUEDTO 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 SUBJ ECTTO ALL THE TERMS, EXCLUSIONS AND CONOM0,14S OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF WSURANCE Y 04 L WSD IYVD POLICY NUl18ER @@LtILYYYY) B.U)DD:YYYY1 01I15 CQ11M1tERC1ALGENEItALUABILITY EACH OCCURRENCE 5 1 CLNGIS-fdADE OCCUR PREMISES IEa cuwrcrcel 5 LIED EXP fAnyune pesuN 5 PERSONA EADe W)UItV S CERT.AGGREGATE Li6111'APPLIES PER, GENERAL ACCRECATE S POLICY❑jECT �LOC PRODUCTS-COIIP.OP ACG 5 OTHER. S AUIOdIDBILE LIABILITY LUMBI EU 5 ANY TO BODILY INJURY(Per wiscn! 5 ALL OWNED SCHEDULED AUTOS AUTOS 6001LY IN:URY(Per aceiderEl 5 NON4l'iNEU HIItEU AUTOS AUTOS tPer 2cudenll 5 UISRELLALUIB Occult EACH OCCURRENCE 5 i EXCESS LIAB CLAIMS-MADE ACCREGATE 5 DED RETFUTIOraS S ANDEMRf YERS'L6AILR x STA\.UTE ER MY Pit PLOYERS•,IRTf,nY 1,000,OOD AFFICER'IRNSER XC U DED, DTII£ Y!N E1.EACHACCIOEtai 5 A OFFICERh£L16Eft EXCLUDED, Y N In N POIYC660990 01191/2015 0701/2016 (tlmldaturyin NH) El DISEASE-EAENI'LOYEE 5 1+000.000 If Yes.desmba render 1,000,000 DESCRIPRONOF OPERATIONS LYlus E1.DISEATE-POUCY UbUT 5 DESCRIPTION OF OPERATIONS ILOCATIONS I VEHICLES(ACORD IDL Ad&tiuwJ Remulo Schedule,may be aluchw irmomsttace is retluk,-d) Columbia Gas massachusetts CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN "eitsch Engineering,Inc. ACCORDANCE,WMTHE POLICY PROWS IONS. 19S Frances Ave Cranston,RI(12910 AUiHORREDREPRESENTATNE lit. TIL.._ t j AG 1988-2014 ACORD CORPORATION.All rights reserved. ACORD 2S(2014,01) The ACORD name and logo are registered marks ofACORD I i I I OP iD:SS DATE(MMIDWYYYY) CERTIFICATE LIABILITY INSURANCE 03/19/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RiGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: if the certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WANED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsoment(s). PRODUCER CONTACT Durso&Jankowski ins Agcy LLC PHONE 198 Massachusetts Avenue euc R%NON North Andover,MA 01845 aonaEss: Durso&Jankowski Ins.Agcy. cRODUER IDs:i'OLAR-1 INSURER S3 AFFORDING COVERAGE NAIC& INSURED Polar Sear Insulation Co.Inc. INSURER A:Penn America 32059 P 0 Box 958 INSURERB:Safety insurance Co. 33618 Andover,MA 01810 INSURER C- INSURER 0: INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. PO INSRTA TYPE OF INSURANCE POLICYNUMBER MOMDCY �DPAIM- MULM YE y !IRITIS L GENERALLIABILITY EACH OCCURRENCE S 1,000,000 A COMMERCIAL GENERAL LIABILITY PAC7052023 03/24P2015 03/24/P016 DAMAGE TO REM I—tE) PREMISES JE8 occurrence S 50,00 CLAIMS-MADE ®OCCUR MED EXP(Any one person) S 5100 PERSONALBADVINJURY $ 1,000,00 GENERALAGGREGATE S 21000,00 GEN'L AGGREGATE LIMIT APPLIES PER; PRODUCTS-COMPIOPAGG S 1,000,000 riPOLICY JECT ED PRO LOC S AUTOMOBILE LIABILITY COMBINED SINGLE LIMiT S 1,000,000 S ANY AUTO 2100926 01/0412015 01/04/2016 (Ea accident) BODILY INJURY(Per person) S ALL OWNED AUTOS BODILY INJURY(Per acddent) S X SCHEDULED AUTOS PROPERTY DAMAGE }i HIRED AUTOS (PER ACCIDENT) S X NON-0WNEDAUTOS S 5 UMBRELLAUA13 OCCUR EACH OCCURRENCE S 1,000,00 EXCESS LIAB CLAIMS-MADE AGGREGATE S � PACssassss a�/24/zo15 a�/24/zms DEDUCTIBLE $ RETENTION SS WORKEFISCOMPENSA71ON STAfU- IER TH- AND EMPLOYERS'LIABILITY ANY PROPRIETORIPARTNERIEXECUTiVE YIN N/A E L EACH ACCIDENT S OFFiCERiMEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE S If yes,describe under DESCRIPTION OF OPERATIONS belvtr E.L DISEASE-POLICY LIMIT S DESCRIPTION OFOPERATIONS/LOCATIONS/VEHICLES(Attach ACORD1011,Additional Remarks Schedule,ifmor)apacorarequlmd) insulation Work-Mineral;Additional Insured forgeneral liability,with gnspecet's n work performed on their behalf by th€above insured is'Thielsch CERTIFICATE HOLDER CANCELLATION TTr11ELS2 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE IME DATE THEREOF, NOTICE ThielschEngineering AACCORDANCCE(OWITHTHE PO POLICY PROVISIONS. iNtLL BE DELIVERED IN Columbia Gas 195 Francis Ave AUTHORIZED REPRESENTATIVE Cranston,8102910 AA990- @) ACORD CORPORATION. All rights reserved. ACORD 25(2009109) The ACORD name and logo are registered marks of ACOiRD r � d usiness Regulation Office of Consumer -plaza 10 Par Plaza® quite 5170 st®n,Massachusetts 0211b Bo ctor Registration 1.®me Improvement CUl1t 1291 ®n: 102726 Type: DBA Tr# 252249 Expiration: 7/2/2016 pQLAR BEAR INSULATION CQ- Vincent LeBlanc _----- P,(a. BQX 958 1$1® _ card.Nark reason far change. ANDOVER, MA® update Address and return-- Employment 0 Lost Card yy Address Renewal DPS CAl €s 50M404-G101216 ety y ss a E ats s is = e � eu a aTIndar ds smc �sickit ec9sti�sr�s �d3t, T., re.s�,:r�.�c¢�s,az��a7s�t•siana4��i�a:a'i:a�t;� ' icanse: CrISL 106017 ' PETER A LEBLAW 2 EAST ppM STREET Plaistow NK 03865 0412812018 �'aE•�a�uiss��ron�r