HomeMy WebLinkAboutHealth Permit # 3/30/2012 e�
Commonwealth of Massachusetts Map-Brook-Lot
BOARD OF HEALTH 038.00010
North Andover Permit No
P.I. BHP-2012-0545
F.I. FEE
I $250.00 WORKS T LJ TI I'I'
Permission is hereby granted Todd Bateson
-------
to(Repair)an Individual Sewage Disposal-System-------------------------------------------------------------------------------------------------
at No 491 SALEM STREET
-- --- ------------------------- - ---- _
- - -- --------
as shown on the application for Disposal Works Construction Permit No. 2
BHP- 012-054
_ Dated__March 30 2012
Issued On:Mar-30-2012
-- ---------
------- ---"----- -------------- BOARD OF HEALTH
stem
TODAY'S DATE.
o
250.00—Pull Repair
q s;,H $125.00 a Component
ACRU
Important:* A Iication is hereby made for a permit too
When filing out ® Construct a new on-site sewage disposal system*
forms on the
computer,use if pair 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 a do not
use the return A. Facility Information �
a
key. e,, f r %.
Address or Lot#
rCitylfown
2 .* PE OF SEPTIC SrYST'EM�
plump E]Gravity(choose one)
***If primp system,attach copy of electrical permit to application *
®Conventional 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. ,
®
2. Owner Information
1 �
l��. m� V" s t t �..
Name
'19'/
Address(S different from above) f
Cityltown State . Zip Code
Telephone Number
3. Installer Information
Name Name of Co ON ENT RPITS55,INC.
f.., � III ARC ILLA ROAD
Address i
City/Town State' Zip Code
1'
Telephone Number(Cell Phone#if possible please)
4. Designer Information
67(
Warne Name of Company
Address
Alt
CitylTown State p;d -
-13 Telephone Number(Best#toReach)
Application for Disposal System Construction Permit.Page 1 of 2
. Application for Septic Disposal System -
�,�.. �tio
•: 3= ��,, . ., . c� � TODAY'S DATE
AConstruction Permit - TOW N OF
* R M $.250.00-Full Repair
ORTH ANDOVE , A 01845
�. •,�4n.;,,. � $125.00.-Component
,SSACHUS�S _
PAGE 2OF2
A. Facility.Information continued....
5. Type-of Building: Residential Dwelling or EjCommercial
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 issue - y this Board of Health.
Name Date
Application App.6ve y: (Board of Health Representative)
- ;
Name Date r
Application Disappro ed for the following reasons:
For Office Use Only:
1. Fee Attached? Yes No
2. Project Manager Obligation Form Attaebed? Yes No
3.: Pump System? If so)Attach copy of Eleadcal Permit:. Yes No
4. FoundationAs-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 SYSTE.M.INSTALLER PROJECT MANAGEMENT OBLIGATIONS
As the North Andover licensed installer for the.construction fc&the septic system for the property at:
Jc
For plans by
(Address of septic system) (Engineer)
>
Relative to the.application of 1
.,e�ra,s.� And dated 11 A)
(in'staller's name) ngina ate .
Dated °{ -- - With revisions dated �~
o a s ate (Last revised date)
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 t,
perfor ning any work on a site. I must have the apprroov,ed_ lans and the permit on site when any work is
b'ein>�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.y As the installer,I•ata.required to.have.the necessary work completed prioY ao the applicable inspections as
indicated below. I urtiierstand that rec�iupstin�an inspection,without completion:of the_items in.accordance
with Title 5 and the Bosfd of Health Regulations may resultin a$50 OO fine bein;?levied aeatnst:me..And/or
rnycompany:
a.. Bo`tfom of Bed=Generally, this-is the first(t")inspection unless.there is a:retaining wall,which
shotild.be•done. irsf. Tlie:install�i tsiust roquest the iiispecti6a but does not have to be present. .
b. Final-Construct ori.Iiispectioti—Engineer must firsi:do their.inspection for elevations,ties, etc.
As-built ofwerbal OK(or e-mail•to:liealtldelitownofnorthandover.com) from the engineer must
be subniitEed to ahe Board-of afterwhichmstOdt 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
causeputnp to work arid;alarni:to function..
c. FinafGtaddGrade Installer must request�inspection when ll grading is complete. .Installer does not
have to be on=site.
4. As-the installer;I understand that only I•may perform the.woik (other than simple excavation)and I at-n required
to complete the installation of the system identified in.the attached applicatio 1:for.installation: .I fiaxther
understand'that work done e others unlicensed.to-install septic systems in North Andover can consi tute
reasons for denial of the systern and%ot'"revocatioti'or suspension of.my lieense:to operate in.the Town.of
North Andover significant fines to all persons involved ale also possible.
5.. As tlie:installer,T understand that:I mu§t be onrsite during the.perforrriance.of the following constraction,
steps:
a. Deternunation that.the proper elevation of the e-keovation has been reached
A Inspection of the sand and stone to be used.
c, Final inspection-by Board of.Health staff or consultant.
d. Installa don,oftank D-Box;pipes,stone, vent,primp chamFjet,retarving waff and other
components.
6. As the installer.I understand that I:am solely responsible for the installation.of the system as per the
roved lilans No instructions by the:homeowrier,general contractor.-or aM. other persons shall-absolve
me of-flits obligation.
( ody's d €3�% Date)UndersignL Is 1
a me,- .tint
1
1. mmonwea&o f Majjacbmeffi Official Use Only
I g y Permit No. /0 7 2
uI ePaPlmenL O��LPdJ�eFULCe.� .
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] leaveblank
APPLICATION IT TO PERFORM ELECTRICAL.
All work to be performed in accordance with-the Massachusetts Electrical Code(MEC),527 CUR 12,00
(PLEASE PRINT W xNt(OR ITPEALL I1vF0 TZ01V) Date: -3 — �,f°�- t c_.-
Oity air Town of: y���c .0 J ,(2 To the Inspector of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location'(Street&Number) t + aA
C Telephone No. j; 14'. 27-rt.D
R �
(Check Appropriate Box)
,m Authorization No.
'rO� O NO0:R ` MOB EtR Date.....:::..::.... .... (:°. Undgrd❑ No.of Meters
i°Ifni Ci i OE6' 1` p Undgrd❑ No.of Meters
uuMMw.nuvpwignN.MrvnW1MRI1WpppM WW
t;oRTW (
N TOWN OF NORTH ANDOVER
fo
PERMIT FOR WIRING
?" in table maybe waived b the Ins ector o Wires.
jy� ._._. .. }�_ .. . . .. _.. .
RR4TI0��`•1- Na.of _ Total --.
"ssecwus� Transformers KVVA
Generators I�VE1
Thiscertifies that ................................. ....... . .........,,....
tter
G
has permission to perform .;,)t l ,. .....:....................... ones _..
.. .. , .mergency g r<g
�,) ,-•�r :;% ® Bst Units
L { ALARMS:
wiring in the building of �`.r=:'> , .I.. ............................................... No.of etection
Initiating Device
at...... t .a A011 ;4P/ . North �s Np
.. .d....................... Andover, .of Alerting Devices
>J^a ) r f r
No.of e o
ee„
............ LIc.Ado.l)".. y�? .. . W AL IN ECTOR
t�lI1
Detection/Alerting])eviCeB
ELE RIC u®1Clp�
4,70 �, Local❑ Connection
- ❑ Other
Check # _ uecNo orD,vicesorE•uivalent
.,
Data N.of Devices or Equivalent
ivri:of xGtotois_::.__ .._ `ol - Telecommunications W gg.
No.of Devices or E uWalent
Attach additional detail f desired,or as required by the Inspector of Wires.
Estimated Value of Electrical Work; I ` oe) (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion.
INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent The
undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office.
CHECK ONE' INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:)
I certify,under the pales andpenaMes ofperjury,that the information on Mis application is true and complete_
FIRM N _ LIC.NO..
(!f pP
Licensee:
e S Ipt'pt'o t(he lt`cens(e nurraG (line. lgnature r, I,IC.NO.:' �e °j ,
stn ( T.' _c do�lUd 4 C J'.a ,y1 �7,,._
a lirabd eater eXeJJJ 4
Bus.Tel.No<. /` .t T �)
Address. Alt.TeL No..
*Per M.G.L.c.147,s.51-61,see urity work requires Department of Public Safety"S"License: Lie.No.
OWNER'S INSURANCE WAI VER: I am aware that.the Licensee does not have the liability insurance coverage normally
required by law.. By my signatur,below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent.
Owner/Agent °
Signature ____ Telephone No.
OR N II I f r tl 1 j 3-.w..
TODAYS DATE
���::d ®nrtil� erlrti
$250000-Full Repair
OQ Componen
Important: Application is hereby made for a permit to:
When filing out ®Construct a new on.,site sewage disposal system
forms on the p y
computer,use existing stem component What?
only the tab key �7epalr air or replace an existing on-site sewage disposal system*
� .
p
to move your or replace an exis i g sy p
cursor-do not
use the return A. Facility Information _ �� ��
key. �, a
Address or Lot#
Cityrrown l�w �, � . .
i"r;:� N"'F�N l r i�� �E�C2� \�Fp��:m,
2.-*TYPE �F 'SEPTIC SYSTEM*: , li A i &i`�E I�r�l,a r�' i„r„”
®Pump ravity(choose one)
***If pump system, attach copy of electrical permit to application***
53*16onventional System(pipe and stone system)
®Infiltrator or Blodiffuser(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,6.
2. Owner Information
.. k ., .
Name
Address(if different from above)
Cityrrown State Zip Code
2W
Telephone Number
3. Installer Information
Name Name of Comps 111 ARGILLA ROAD
ANDOVEH,MA ni Pin
Address d NO °119p-
City/Town State' Zip Code
Telephone Number(Cell Phone#ifpossible please)
4. Designer Inform tion
Narne Name of Company
Address
City/Town State Zip Code
Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit.Page 1 of 2
N RrN App li i tic Di I y 43 -0
3t 0. a 0 e TODAY'S DATE
` ' Construction Permit — TOWN OF
* $.250.00-®Full Repair
-ORTH AND(
$125.00 -Component
N„9S RT90 P� 1'
SACNUS��
PAGE 2 OF
A. Facility.Information continued....
5. t, esidential Dwelling or FICommercial
. 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 issu by this Board of Health.
m
Nam Date
Applioaf Approved ny Board of Health Representative)
N e Date
pplication Dina proved for the following reasons:
For Office Use Only:
,f
L Fee Attached. Yes No
2. Project Manager Obligation Form Attached. yes No
3.: Pump System? Ifso�Attach copy ofElectrical Permit'.. Yes No
r ..
4. Found'ati'on As-Built?(new construction ronly): Yes r Nc
(Same scale as approved plan) F
5 Floor Plans?(new construction only): yes No
APP!t cation'for Disposai System Construction Permit<Rage 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:
lv ,9/ L . b
(Address of septic system) For plans y
(En ' eer)
Relative to the application of And dated
(Installer
rigina a e).
Dated A " 13 -11 With revisions date ' —
1 o a s ate (bast r wised date)
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 apl2roved: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,thn
item three-shall.be, applicable.
3.4 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 iii a$50:00 fine being.levied against mearid/or
v company.
a. Bottom of Bed—Generally, this is the first(V).`ins pec a tionunless.:there is retaining wall,which
should be doneIrst: The installer must request'the inspection but does not have to be present. .%
b. Final Construet on.Ins pection—Engineer must first:do their inspection for elevations,'ties, etc.
As-built of verbal OK (or e-mail to:healtldept nu,townofnorthandover.com) from the engineer must
be submitted to the Board of Health,.after which instal'�er,calls for an inspection time. Installer must
be present for this inspection. With a pump system,all electrical w6ii-mustbe ready and able to
cause.pump to work arid,alarm.to function..
c. Final Grade Installer must request inspection when 411 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:rimple excavation)and I am required
to complete the installation of the system identified in.tli.e attached application for installation:'_I further
understand.that work done by others uiilicens4.to iiistall septic systems in North Andover can constitute
reasons for denial of the system and/oi revocation or suspension of my license.to operate in.the Town:of
North Andover,siPnificant fines to.all persons involved are also possible.
5. As the.installer, T understand that I must be on-site during the.perfozrnance of the following construction.
steps:
a. Determination that.the proper elevation of the excavation has heed reached.
A Inspection of the sand and stogie to be used.
c. Final inspection by Board offlealth staff or consultant.
d. Installation..of tank,D-Box;pipes, stone, vent,primp chamber, retar,'tzing walland other
components.
6. As the installer, h understand that Lam 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)
�d (l to 5 .,.
ame.- Tint <- igi e