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Home My WebLink AboutHealth Permit # 11/1/2010 Map-Block-Lot Commonwealth of Massachusetts 107.A0128 ----------------------- 0q Permit No s'` � Board of Health 4r "4 BHP-2010-0754 ------ North Andover FEE a �.. P.I. $250.00 ac+W�`��{a~ F.I. __— DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted James_Kellett------------------------------------------------------------------------------------------- to(Repair)an Individual Sewage Disposal System- atNo 300 RALEIGI�TAVERN LANE __________ _ _____ _ ________ - - - - - - - - --- --- - ------- - on Permit as shown on the application for Disposal Works Constructi No. BHP 2010-075 Dated November 01,2010 ------ Board of Health Issued On:Nov-01-2010 ification for Se atic i i S stem .w. . onstruction emit — TOWN TODAY'S DATE ORTH ANDOVER MA 0 $ 250.00®Full Repair $125.00 -Component Important: Application is hereby made for a permit to: When filling out _ ❑ Construct a new on-site sewage disposal system* farms on the � p y 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 key.y the return A. Facility Information 4:3 Address or Lot# mzrn City/Town " :• .., ✓ �.,' t l° 2. TYPE OF SEPTIC SYSTEM*: Pump ❑ Gravity (choose one) "t t ***If pump system, attach copy of electrical permit to application** HE, Li�i��f OVER ' ❑Conventional stem � � " System(pipe and stone system) Infiltrator or Biodiffuser(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 Information Name Address(if different from above) Ciiy/Town Stake Zip Code Telephone Number 3. Installer Information Name Company Address t t,j r J ... t L.... . � " City/Town State Zip Code Telephone Number(Cell Phone#if possible please) 4. Designer Information - '..a Name of Company Name k «(J ( �s ( �7,� �(. (.. ✓ / Oaf" /Yt.� Address City/Town State Zip Code Telephone Number(Best#to Reach) Application for Disposal System Construction Permit•Page 1 of 2 onstruction Permit - TOWN OF TODAY'S DATE ORTH ANDOVER,_MA 01845 $ 250.00- Full Repair $125.00 -Component PAGE 2 OF 2 A. Facility Information continued.... 5. Type of Building: Residential 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 N Andover, and otfa place the system in operation until a Certificate of Compliance has e issued by thi Bo6rd of Health. /N Date Appllc� "64n Approved B (Board of Health Representative) Date Application Disapproved for the following reasons: For Office Use Paly, 1. Fee Attached. Yes No 2. Project Manager Obligation Form Attached? Yes No 3. PymP System? If so, Attach copy ofElectrical Permit Yes No 4. Foundation As-Built?(new construction ronly): YX's'--)I Na (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: ('Wdress oi-Xa septa System)q� For plans by " ,e application of F,,n anee Relative to the a ply i Phu , MW, (hi st,aile s name) And dated o rt;,tcawt a:at,. Dated u:ji,s date) With revisions dated �✓ t� �" (Lat.:t mt sed dace) 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 Pdor 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 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 OIL (or e-mail to:h ql¢hd(lr:,(l�t�a��vtteartaab�li,t: c c>r twr; � r::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 simple 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 tang, 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. Unde signed Licensed Septic Installer; (`1"oda)"s I)atc;( (Name Signcd) ��wmi�m ^auammmmww,wwm000momwawrzauwuu�. /� Officielll .° ME N1' V Services oepartment of Fire I'errtllY No. -�-^ Occupancy and Fee Chwkcd _ BOARD OF FIRE PREVENTION REGULATION ! . 1/07) havablank APPLICATION FOR PERMIT TO PERFORM ELECTRCAL WORK All work to be performed in accordance idth the M a EI cal (MEC},527 CWR 12.00 (PLEA SE PMT W INK Oft TYPE ALLINFO TION) Date: City or Town of: NORTHANDOV= To the Impector of Wires: By this appliomion die underoigned gives notecm ofhis or War intention to perform- a electrical work described below, Location(Street � �) p G' ' Owner or"r ant/ Telephone No. Owner's Address is this permit in conjonedon with a building pc it? Yes No (Check Appropriate s) -- _arm lion No. 9 G �u"'d® No.of Meters ffrd No.or cten `;�., t Q ykoRTH"0 •a"o `T1�/I"� OF Iti1T"I°� �aP�l® !/ eobls� tr�w�tmhv o� PERMIT F®R WIRIN i'rwnefo ° Genera A o map �s$pcwusE� lanrta Units FIRE ALARMS No.of Zones This certifies that .,,./.. � ��} ' ....� A"-. ......................................... 0.0 cc an an arv°� Ian has permission to perform P p * :......,, .. . ' ...................•..,.. No.of Alerting ��dr t tte°o W/® rtiasin Di wiring in the building of......... ............................................ nn �. . N 1® C nee at F . � .�... �� ,North Andover,Mas,q. P rn _ . . Fee.,; . .. I ic.bla. .,:° „ � . ........ . .... .�4 - .:.. Nor.of ices or!£MOiuoti t Data Wiring: ELECTRICAL INSPE OR Na.of II is or Nova t �° p ✓ f ,- C vP� �n to 0 Check # C �� No.of Devices or E niwn e sired,or as ragmired by thr Impreemr of Wires. policy,) Work to 5 Inspections to be requa5tod in aocordenrx with MEC Rule 10,and upon completion. INSU N COVE G E: Unless waivcd by the ow ,no permit few the performance ofelectrical work may issue unless the license*provides proof of liability insurance Including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and hu exhibited proof of same to the permit issuing office, CHECK ONE: INSURANCE ® BOND ® OTHER EJ (Specify;) I ce ' , the hu fdpfflnalfies of rjuj y,that the Wormdan on this applicadon is t e ajid conrlde nRM NAME; e� dtro LIC.Nth.: A I 0 uce :. Sl attire 1LIC.ND., l a c. cab le.r ' V �°tA I q ua Bn.Tel.No.° 132t. Alt, fee.No. "Per M.01 o" 147,s,5761,security vworic uirea ent of Prrblia 3a License: Lie.No. OWNER'S INSURANCE WAIVER: I urn aware that the Liccnsac does nal have tho liability insurance coverage normally required by taw. By My signature below,I hereby waive this requirement, I am the(checrP;NtRAMY1T owner aw 's a R, owner/Agent FEEEo S St ature Telephone No,