HomeMy WebLinkAboutHealth Permit # 11/10/2009 — Map-Block-Lot
Commonwealth of Massachusetts 106.B0128
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Board of Health Permit No
0 BHP-2009-0701
a North Andover
# m FEE
P.I.
---'� $250.00
F
s sE F.I. -----------------------
SAC Mg1. i
DISPOSAL T LJ `I"I PERMIT
Permission is hereby granted John-Soucy
to(Repair)an Individual Sewage Disposal System.
at No -194 OLYMPIC LANE
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as shown on the application for Disposal Works Construction Permit No. BHP-2009-070_ Dated -November 1-0--,-20-09
Issued On:Nov-10-2009 ------------- P,
Board of'Health
1
r'
�w r,
!on for S SIC o 0 v
tem
Y' E
$ 250.00®Full Repair
Important; Application is hereby made for permit to:
When filling out ❑ nstruct a new on-site sewage disposal system*
forms on the
computer,use Repair or replace an existing on-site sewage disposal system*
only the tab key
to move your ❑ Repair or replace an existing system component®what?
cursor-do not
use t he return A. Facility Information
key.
. �,.. �
r, Address or Lot �
109 �
en�n City. own
2.- YPE C7F SEPTIC -SYSTEM*:
Pump ❑ Gravity(choose one)
***If pump system,attach copy of electrical permit to application
❑Conventional System (pipe and stone system)
❑Infiltrator or Biodiff user(Gravel-Less) (Attach a copy of your certification to install this type of system.
❑ Pressure Distribution S.A.S. (No D-Box) (Attach Draft Maintenance Agreement)
❑ Pressure Dosed (D-Box Present)S.A.S.
2. Owner Inform Lion
Name ..0
M ,
Address(if diff erent from
abo�v"e) �
-/AA State Zip Code
City/Town
Telephone Number
3. Installer
..Information
'
�� w M
Name of Comp
Aell
Address
Name � °
A-/�
�` 2 " ` State Ai Zip Code
City/Town
Telephone Number(Cell Phone#if possible please)
4. Devi ner Information
Na - Name or dompany p
Address
State -® Zip Code I .
City/Town
Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit•Page 1 of 2
..........
of to on for Swtic Diwosal S stem
Construction Permit — TOWN OF TOD /SD
A�E
<� µ $ 250.00-Full RepaigL,,,�
,wa ANDOVER, 01845 $125.00 -Component
PAGE 2 OF z
A. acilit Information ®ntinue ..
5. Type of Bu ildlncl: esidential Dwelling or®Commercial
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 ntil a ,ertificate of Compliance has
been isxfe by this Boar of Health.
Na ate
Appligaiion Approved 'Board of Health Representative)
/,IV me Date
/ Application Disapproved for the following reasons:
For Office Use Only:
L Fee Attached? Yes i.l No
2. Project Manager Obligation Form Attached? Yes L,/�f No
3. Pump S sy teni? If so,Attach copy of Electrical Permit Yes No
C
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
SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS
As the North Andover licensed installer for the construction for the septic system for the property at:
1dc rlss'o] s prsc System)
For plans by �4� �" ���"���
(Engineer)
Relative to the applicatio 1 of
(Iy And dated 7 e
zi�rallez°'s rxair�c;)
Dated
cac av s(laic) With revisions dated
(I a st revis d da.s)
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 approved 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 Title 5 and the Board of Health Regulations may result in a $50.00 fine being levied against me and/or
any 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 OIL(or e-mail to: lac;td� L�Ia< �t(cx)t(.)Nvn(.)ft1orthan�d0 N',-e'rcont 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 sihIple 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
gn Septic Installer: I i oday's Cate)
it i A
Lk r / +
aware rant ame-.. gtied)
TOWN OF NORTH
ANDOVER Permit Number
NORTH ANDOVER,MASSACHUSETTS 01845, 'a
�RYh Bate Issued ��
U pK�me 4 11 y
P
- ... to Expiration Date
na^AT80 '. y
CHU „.m
f i
Jackie's Law ® Permit Application
Pursuant to G.L. c, 82.A §1 and 520 CMR 7.00 et seq.(as alnended)
THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION,
Applicant
Pho e C
Name of App "
_.
Street Address r
City/Town ZTP
"9
Cell
Name'of Excavator(if different from applicant) Phone
Street Address
City/Town MA ZIP
Name of Owner s)of Property
Owner(s)
Street Address rve
� 0
City own MAP� ZIP "
Other Contact _ Permit Fee Received No Yes
Description,location and purpose pf proposed trench:
Please describe the exact location of the proposed trench and its purpose(include a description of what is(or is intended)to
be laid in proposed trench(eg;pipes/cable lines etc..)Please use reverse side if additional space is needed.
m ,
Insurance Certificate#:
Name and Contact Information of Insurer:
Poiic x iration Date:
Dig 60c(
Name of Compete t Person(as defined by 520 CMR 7,02):
Massachusetts Hoisting License#
r 3 E iration Date: 3 L
License Grade:
BY SIGNING THIS FORM, THE APPLICANT, OWNER, AND EXCAVATOR ALL ACKNOWLEDGE
AND CERTIFY THAT THEY ARE FAMILIAR WITH, OR, BEFORE COMMENCEMENT OF THE
WORK, WILL BECOME FAMILIAR WITH, ALL LAWS AND REGULATIONS 00 et APPLICABLE
AND ANOY
WORK PROPOSED,INCLUDING OSHA REGULATIONS,G.L. c. 82A,520 CMR 7
APPLICABLE MUNICIPAL ORDINANCES,BY-LAWS AND REGULATIONS AND THEY COVENANT
AND L THETRIEWI H IN AL WORK
L RESPECTS UNDER D WITH THE CONDITIONS SET FORTH BELOW.
COMPLY
THE UNDERSIGNED OWNER AUTHORIZES THE APPLICANT TO APPLY FOR THE PERMIT AND
THE EXCAVATOR TO UNDERTAKE SUCH WORK ON THE PROPERTY OF THE OWNER, AND
ALSO,FOR THE DURATION OF CONSTRUCTION,AUTHORIZES PERSONS DULY APPOINTED BY
THE MUNICIPALITY PROPERTY TO MONITOR AND INS
FOR CONFORMITY THE CONDITIONS ATTACH DHERETOANDTHE LAWS AND
REGULATIONS GOVERING SUCH WORK.
THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY
TO REIMBURSE THE MUNICIPALITY FOR ANY AND ALL COSTS AND EXPENSES INCURRED BY
THE MUNICIPALITY IN CONNECTION WITH THIS PERMIT AND THE WORK CONDUCTED
THEREUNDER,INCLUDING BUT NOT LIMITED TO ENFORCING THE REQUIREMENTS OF STATE
LAW AND CONDITIONS OF THIS PERMIT,INSPECTIONS MADE TO ASSURE COMPLIANCE
THEREWITH,AND MEASURES TAKEN BY THE MUNICIPALITY TO PROTECT THE PUBLIC
WHERE THE APPLICANT OWNER OR EXCAVATOR HAS FAILED TO COMPLY THEREWITH
INCLUDING POLICE DETAILS AND OTHER REMEDIAL MEASURE' DEEMED NECESSARY BY
THE MUNICIPALITY.
THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY
TO DEFEND,INDEMNIFY,AND HOLD HARMLESS THE MUNICIPALITY AND ALL OF ITS AGENTS
AND EMPLOYEES FROM ANY AND ALL LIABILITY,CAUSES OR ACTION,COSTS,AND EXPENSES
RESULTING FROM OERTY DURING THE WORK CONDUCTED UNDER THIS PERMIT AGE TO ANY
PERSON OR
APP CANT IGNATUR
DATE
EXC TOR SIGNATURE( IFFERENT}
DATE
OWNER'S SIGNATU (IF DIFFERENT)
1 DATE: 4®
i
2{Page
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CONDITIONS AND REQUIREMENTS pa d)RSUAN O G.L.C.82A AND 520 CMR 7.00 et seq.
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 through 40D of chapter 82,and any
accompanying regulations,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 o,the
establishment of a valid excavation number with the underground plant damage prevention system as
said system is defined in section 76D of chapter 164(DIG SAFE);
ii.
Trenches may pose a significant health and safety hazard. Pursuant to Section 10€Chapter 82 of e
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 by the result of leaving of
open trench unattended. Excavators should consult regulationp safety hazards associated with
Public Safety in order to familiarize themselves with the recognized
excavations and open trenches and the procedures required or recommended by said include covering,
order to make every reasonable effort to eliminate said safety hazards which may
barricading or otherwise protecting open trenches from accidental entry.
iii• in any trenching operation shall familiarize themselves with the federal safety
Persons engaging in any
standards promulgated by the Occupational Safety and Health Administration on excavations:29 CF
1926.650 et.seq.,entitled Subpart P"Excavations".
iv. Excavators engaging in any trenching op eration who utilize hoisting or other mechanical equipment
subject o chapter 146Sa€el only o s d chapter and this permit must be presented o said licensed
Department of Public Safety Pursuant
operator before any excavation is commenced;
V. applicant hereby attests to the fallowing:(1)that
By applying for,accepting and signing this permit,the app
with
they have read and understands the regulations promulgated by the Department as f Public Safety the
regard to construction related excavations and trench safety; ( )that
federal safety standards promulgated by the Occupational Safety and Health Administration on
excavations:29 CMR 1926.650 et.seq.,entitled Subpart P"Excavations"as well as any 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 of sections 40-
40D of chapter 82A.
A.
This permit shall be posted in plain view on the site of the trench.
For additional information please visit the Department of Public Safety's website at www mass gov/dns
3Ipage
HP Officejet Pro L7500 All-in-One series Fax Log for
Town Of North Andover Cle
9786889557
Nov 10 2009 2:37PM
Last Transaction
Date Time Type Station ID Duration Pages Result
16038981876 0:55 3 OK
Nov 10 2:36PM Fax Sent