HomeMy WebLinkAboutHealth Permit # 10/22/2014 Commonwealth of Massachusetts Map-Block-Lot
BOARD OF HEALTH
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Permit No
North Andover BHP-2014-1274
P.I. ------------------
F.I.
FEE
$250.00
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DISPOSAL WORKS CONSTRUCTION PERMIT
Pei-mission is hereby granted Peter Breen
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to(Construct)an Individual Sewage Disposal System.
at No 100 OGUNQUIT ROAD
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as shown on the application for Disposal Works Construction Permit No. BHP_-_2014' 127 paled P October 22,2014
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Issued On: Oct-22-2014 --- --
— — - ---------------------------------------------------------- BOARD OF HEALTH
k, ~7 70
Application for Septic Disposal System 6 b,d 4
TODAY' DATE
so Construction Permit — TOWN OF
A$,25" Full Repair
ORTH ANDOVER, MA 01845 4Component
Important: Apl2licatioais hereby made for a permit to:
,^
When filling out PI'Conetnuctm new on-site sewage disposal system*
forms onthe
computer,use �� Repair orreplace an existing on-site sewage disposal system*vn|y\ho� key
--
m move your El Repair or replace on existing system component—What?
cursor do not
use the return �
A.key. A. Facility InformaPon �
0 Address or Lot#
2^~ .
^~ . _., ~~ _—. y(choose_ -.—'
°°If pump system, attach copy of electrical permit tonpp|bnUon***
ETConvmndmne| System (pipe and stone system)
R Infiltrator or Biodiffuser(Gravel-Less) (Attach a copy of your certification to install this type of system.
R Pressure Distribution S.A.S. (No O-Box)(Attach Draft Maintenance Agreement)
Fl Pressure Dosed (D'Box Present) S.A.S.
2. Owner Information �
Address(if di I from above)
CIL
cfft��Town' State Zip Code :>
Telephone Number
3. Installer Information
Name Name of Company
Address
City/Town state' r ' Zip Code
Telephone Number(Cell Phone#if possible please)
4. Designer Information
�
Name Name orCompany
tYy
Address
City/Town State Zip Code
Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit~Page 1ofo
Application for Septic Disposal System
TODAY'S DATE
construction Permit - TOWN OF
01845 $250.00—Fun Repair
ORTH ANDOVER• MA
$125.00-Component
PAGE 2 OF 2
A. Facility Information continued....
5. Type of Building: Residential Dwelling or❑Comrnercial
B. Agreement
The undersigned agrees to ensure the construction and maintenance of the afore-described
on-site sewage disposal system in accordance with the provisions of Title 5 of the
Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of
North Andover, and not to place the system in operation until a Certificate of Compliance has
been issued by this Board of Health.
0- 6
&
Name Date
Application (Bo
,pM of Health Representative)
Name Date
V
44'pplication Disapproved forothe following reasons:
For Office Use Only:
1. FeeAttacbed? yes No
2. Project Manager Obligation Form Attached. Yes tl-' No
3. System?Pump
- ffso,Attach copy ofElectrical Permit Yes No
4. Foundation As-Built?(new construction ronly): Yes No
(Same scale as approved plan)
5. Floor Plans?(new construction only): Yes No
Application for Disposal System Construction Permit-Page 2 of 2
SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS
As the North Andover licensed installer for the construction for the septic system for the property at:
— 166 o 6(wy,' Q%s a-eA 4
(:\ddress of scpticswstern) For plans by 4A,6 Ile -C
(Engineer)
Relative to the application of OCN-e-f dated And dat 2, /0
(Installer's name)
(()ngm c ate)
Dated 16 .
(110 day s(iate) With revisions dated — le;�X
(Last re%,Ised chxt4
I understand the following obligations for management of this project:
1. As the installer,I am obligated to obtain all permits and Board of Health approved plans Prior to
performing any work on a site. I must have the a1212roved plans and the permit on site when any work is
being done.
2. As the installer,I must call for any and all inspections. If homeowner,contractor,project manager, or any
other person not associated with my company schedules an inspection and the system is not ready,then
item three shall be applicable.
3. As the installer,I am required to have the necessary work completed prior to the applicable inspections as
indicated below. I understand that requesting an inspection,without completion of the items in accordance
with Tide 5 and the Board of Health Regulations may result in a$50.00 fine being levied against me and/or
my company.
a. Bottom of Bed—Generally, this is the first(1') inspection unless there is a retaining wall,which
should be done first. The installer must request the inspection but does not have to be present.
b. Final Construction Inspection—Engineer must first do their inspection for elevations, ties, etc.
As-built of verbal OK(or e-mail to: lic,,tltliclet)tr(,i),towlic)fnortli,,ii-ldc)Ler.cori-i) from the engineer must
be submitted to the Board of Health,after which installer calls for an inspection time. Installer must
be present for this inspection. With a pump system,all electrical work must be ready and able to
cause pump to work and alarm to function.
c. Final Grade—Installer must request inspection when all grading is complete. Installer does not
have to be on-site.
4. As the installer,I understand that only I may perform the work (other than silziple excavation)and I am required
to complete the installation of the system identified in the attached application for installation. I further
understand that work done by others unlicensed to install septic systems in North Andover can constitute
reasons for denial of the system and/or revocation or suspension of my license to operate in the Town of
North Andover, significant fines to all persons involved are also possible.
5. As the installer,I understand that I must be on-site during the performance of the following construction
steps:
a. Determination that the proper elevation of the excavation has been reached.
b. Inspection of the sand and stone to be used.
c. Final inspection by Board of Health staff or consultant.
d. Installation of tank, D-Box,pipes, stone, vent,pump chamber, retaining wall and other
components.
6. As the installer, I understand that I am solely responsible for the installation of the system as per the
approved plans. No instructions by the homeowner, general contractor, or any other persons shall absolve
me of this obligation.
Undersigned Licensed Septic Installer: (Today's Date)
(Name---116 7t) (Name I Sighed)
TOWN OF r�®R Permit Number .... ...
NORTR ANDOVER,MASSACHUSETTS 01845
Or s Date Issued � ^�
Expiration Jute
«� rk
Jackie's Law _ Permit Application
Pursuant to G.L. c. 82A §1 and 520 CMR 7.00 et seq.(as amended)
THIS PERMIT MUST DIE FULLY COMPU9TP,D PRIOR TO 0ONS100WION
Name of Applicant g � Phone Cell
Street Address '7 i d ,6®�. G'AA01 � 99-6Y2 2 r
C44own MA ZILP
er dl`i5 ,5"
Name of Excavator(if different from applicant) Phone Cell
Street Address
City/Town ZIP
Name of Owner(s)of Property Phone Call
Street Address
D
City/Town M ZIP
Other Contact L'ermlt]Foe�teceived l�to Xes
Description,location and purpose of proposed trench.-
Please describe the exact location of the proposed trench and its purpose(include a description of whet is(or is intended)to
be laid in proposed trench(egi pipes//cable Linea etc..)please use reverse side if addltional space is needed.
Jismrance Cerd&--ate#:
Received Time Oct. 22, 2014 3: 01PM No- 0904
Name and Contact Information of Insurer:
Folky Ex iradon Pate.
Dig Safe#:
Name of Competent Person(as defined fuy 320 CMR 7.02);
Massachusetts Holsftg License#
License Grade: I Expiration Date;
BY SIGNING T)RXS VORM, 'x`ELE APPLICANT, OWNER, AND EXCAVATOR ALL ACKNOWLEDGE
AND CERTIFY THAT THEY ARE FAMILIAR WITH, OR, BEFORE COMMENCEMENT OF THE
WORK, WILL BECOME FAMILIAR WITI3f, ALL LAWS AND REGULATIONS APPLICABLE TO
WORT{PROPOSED,INCLUDING OSHA REGULATIONS,G.L.,c-82A,520 CMR 7.00 et seq.,AND ANY
,APPLICABLE MUNICIPAL ORDINANCES, BY-LAWS ANO REGULATIONS AND THEY COVENANT
AND AGREE THAT ALL WORK DONE UNDER THE PERMIT ISSUED FOR SUCH WORK WILL
COMPLY THERE'WUH IN ALL RESPECTS AND WITH THE CONDITIONS SET FORTH BELOW,
THE UNDERSIGNtO OWNER AUTJKORX=S THE APPLICANT TO APPLY FOR THE PERMIT AND
TIM EXCAVATOR TO UNDERTAKE SUCH WORK ON TOE PROPERTY OF T10tE OWNER, AND
ALSO,FOR THE DUIIA,TION OF CONSTRUCTION,AUTHORUTS PRRSONS DULY APPOINTED BY
THE MUNICIPALITY TO ENTER UPON THE PROPERTY TO MONITOR AND INSPECT THE WORK
FOR CONFORMITY WITH THE CONDITIONS ATTACHED HERETO AND THE LAWS AND
REGUTIA,TTONS GOVERXNG SUCH WORK
THE U"EMGNLD APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY
TO REIlIEDURSE THt MUNICIPALITY FOR ANY AND ALL COSTS AND EXPENSES INCURRED BY
THE MUNICIPALITY IN CONNZCnON WITH THIS PERMIT AND THE WORK CONDUCTED
THEREUNDER,INCLUDING BUT NOT LIMITED TO ENFORCING THE REQUIREMENTS OF STATE
LAW AND CONDITIONS OF TIUS PERMIT,INSPECTIONS MADE TO ASSURE COMPLIANCE
THEREWITH,AND MEASURES TAKEN BY THE MUNICIJPAILMY TO PROTECT T)U PUBLIC
' VHERE TITS APPLICANT OWNER OR EXCAVATOR HAS FAILED TO COMPLY THEREWITH
INCLUDING POLXCF DETAILS AND OTHER REMEDML MEASURES DEEMED NECESSARY BY
TIM MUNICIPALITY.
THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGUE JOINTLY AND SEVERALLY
TO DEFEND,INDEMNIFX,AND HOLD HARMLESS THE MUNICIPALITY AND ALL'OF ITS AGENTS
AND EMPLOYEES PRAM ANY AND ALL LIABILITY,CAUSES OR ACTION,COSTS,AND,EXPENSES
RESULTING FROM OR ARISING OUT OF ANY INJURY, DEATH, TOSS, OR DAMAGE TO ANY
PERSON OR PROPERTY DURING THE WORK CONDUCTED UNDER THIS PERMIT.
APPLICANT SIGNATURE
e, G`r' — d re DATE 1e)
EXCAVATOR SIGNATURE(IF DIFFERENT)
&Z:LI DATE
OWNER'S SIGNATURE(IF DIFFERENT)
HATE:
Wage
Received Time Oct, 22. 2014 3: 01PM No, 0904
e
f
CONIDA'><tONS AND R EQVIRE 1ENTS PTMSUANT TO G.L.C.82A AND 520 CMR 7.00 et seq.
(as amended)
By signing the application,the applicant understands and agrees to comply with the following:
i.
No trench,maybe excavated unless the requirements of-sections 40 tbzouo 40D of chapter 82,and any
accompanying replations,have been met and this permit is invalid unless and until said requirements
have been complied with by the excavator applying for the permit including,but not limited to,the
establishment of valid excavation number with the underground plant damage prevention system as
said system is defined in section 761)of chapter 164(MG SAFE);
Trenches may pose a significant health and safety ha�Ard_ pursuant to Section 1 of Chapter 82 of the
General Laws,an excavator shall not leave any open trench unattended without first making every
reasonable effort to eliminate any recognized safety hazard that may exist as a result of leaving said
open trench unattended, Excavators should consult regulations promulgated by the Department of
Public Safety in order to familiarize themselves with the recognised safety hazards associated with
excavations and open trenches and the procedures required or rezomme0ed by said department in
order to make every reasonable effort to eliminate said safety hazards which may laolude covering,
barricading or otherwise protecting open trenches from accidental entry.
Persons engaging in any in any trenching operation shall familiarize themselves with the federal safety
standards promulgated by the Occupational Safety and Health Administration on excavations,29 CFR.
1926.650 et.seq.,entitled Subpart P"Excavations
iv.
Excavators engaging in any trenching operation who utilize hoisting or other mechanical equipment
subject to chapter 146 shall only employ individuals licensed to operate said equipment by the
Department of Public Safety pursuant to said chapter and this permit most be presented to said licensed
operator before any excavation is commenced;
V.
By applying for,accepting and signing this permit,the applicant hereby attests to the following:(1)that
they have read and understands the regulations promulgated by the Department of public Safety with
regard to construction related excavations and trench safety; (2)that he has read and understands the
federal safety standards promulgated by the Occupational Safety and Health.Administration on
excavations:29 C1vRt.1926.650 et-seq.,entitled Subpart P`Txcavations"as well as arty other
excavation requirements established by this municipality;and(3)that he is aware of and has,with
regard to the proposed trench excavation on private property or proposed excavation of a city or town
public way that forms the basis of the permit application,complied with the requirements ofsections 40-
40D of chapter 82.A.
vi,
This permit shall be posted in plain view on the site of the trcneh.
For additional information please visit the Department of Public Safety's website at YM.mass.g-Qvldns.
ia
Received Time Oct, 22, 2014 3:01PM No. 0904
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Received Time Oct, 22. 2014 3: 01PM No. 0904