HomeMy WebLinkAboutHealth Permit # 5/28/2013 i
• ���`�p' ,,, , Commonwealth of Massachusetts Map-Block-Lot
'`' ~ • 107.A0105
BOARD OF HEALTH
Permit No
I
North Andover BHP-2013-0729
x P.I. -------------
FEE
F.I.
$250.00
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DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted James Kellett
to(Construct) an Individual Sewage Disposal System.
at No 34 RALEIGH TAVERN LANE
as shown on the application for Disposal Works Construction Permit No. BHP-2013-072 gated`i
Printed On:May-28-2013
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BOARD OF HEALTH
"oRrH IICI 11 IsI� I tem MAY 23,2013
TODAY'S DATE
nl tn°ucti D Permit - TOWN
« ®145 $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*
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 the return
key. A. Facility Information
34 RALEIGH TAVERN LANE
rab Address or Lot#
NORTH ANDOVER
City/Town
2.-*TYPE OF SEPTIC SYSTEM*:
❑ Pump ❑ Gravity (choose one)
***If pump 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.S.
2. Owner Information
FRANCES STIGLIN CEI E
Name
SAMEr � ?03
Address(if different from above)
Q` L_)F 10111'u I/"1 fC) VEf�'.
TC
City/Town State tkAR.°'i'°itwu
Telephone Number
3. Installer Information
JAMES KELLETT KELLETT EXCAVATING
Name Name of Company
400 SALEM STREET
Address
LYNNFIELD MA 01940
City/Town State Zip Code
781-953-7146
Telephone Number(Cell Phone#if possible please)
4. Designer Information
BILL DUFRANE MERRIMACK ENGINEERING SERVICES
Name Name of Company
66 PARK STREET
Address
ANDOVER MA 01810
City/Town State Zip Code
978-475-3555
Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit•Page 1 of 2
��� SIC tN�l1 cr tlrµ MAY �3 2013
Construction Permit -- C ..
yGCFaFYF4
9
ORTH ANDOVER ,. 0184 50.C1Cr M trll Repair
ww
$126.00 -Component
34 RALEIGH TAVERN LANE
PAGE 2 OF
A. Facilit y Information continued....
5. Type of Building: LlResidential Dwelling or[_-,)Cornmercial
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
bee'sued by this hoard of I leWr.
.ht re Datc
Application Approved By: (Board of Health Representative)
Name C.)ate
Application Disapproved for Vie following reasons:
For Office Use Only,
1. FecAttaclred?
2, Project Manager Obli atiort Fornt Attached? No_--
3. PuiriP System? Mso, Attach co-pi,o11'/ectrrc-a/Permit pi's.._____ No1,,/'
4. Foundation As-Built?(new construction ronly): Yes-1-1— Ncr.__-
(Sarne scale as aillrroved plan)
5. TYoor l laps?(new construction curly): s.__.:, No-
Application for Disposal System Constriction Permit-Page 2 of 2
Commonwealth of Massachusetts F[Rev. 1/07] Official Use OuhV
Department of Fire Services �(('
BOARD OF FIRE PREVENTION REGULATIONS and Fee Checked
(leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be perlbrmed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00
(PLEASE PRINT IN INK OR n PE ALL INFORMATION) Date: l _°�/ 7
City or Town of; NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned gives notice of s or her intention to perform the electrical work described below.
Location(Street&Number) 3.1 RI�11 Q 1 VEK.N
Owner or Tenant ; rC�1f� �r�5 S t (i�J Telephone No.
Owner's Address
Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box)
Purpose of Building Utility Authorization No. Q
Existing Service Amps / Volts Overhead ❑ Undgrd❑ No.of Meters
No.of Meters
r .
Date i 1 A,01>
OF p4ORTh
My be waived h,the In
or°1„ '••doom TOWN OF NORTH AN®OVER of Total
nsformers KVA (�
PERMIT FOR WIRING erators KVA
_•
o mergency tg mg
..
CHUS��� to Units
(�E,ALARMS No.of Zones
of Detection and
This certifies that., ' i{ l
[
(' initiating Devices
°• •• of Alerting Devices
has permission to perform ( + ' (
�. f�F l•i { �. ....... .. 1 ( �i I i - ofSelf-Contained
{"... t 1 ... tection/Alertin Devices
wiring m the building of..... t s , ❑ Municipal
t 1 [ )! ............................. cal Connection ❑ Other
at ..... ... i a ,s - . t `ti c i r r i . urity stems.
t° ' C - ,North Andover,Mass. No.of Devices or E uivalent
to Wiring:
Tree.•, Lic No. .. r; r No.of Devices or E uivalent
) ) EuECucau Ivsr """"' Iecommunications Wiring:Check#
No,of Devices or Equivalent
led,or as required by the Inspeefor aj•Wire s.
- =----- .
Woik�o policy.)
start: — __ 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 certiff,,under the pains a1nd penalties oQr perjury,that the information on this application is true and complete.
FIRM NAME: Llt:.NO.: !Wld A (r1
Licensee: Sp M� Signatu e I'h� l:c LIC.NO.: 1�}
tlfapplicable,enter "esempt"in the hc•ense rmmbe lin .J Bus.Tel.No.:
Address: 2!'iv//err w etlh Alt.Tel.No.:
`Per M.G.L c. 147,s.5761,gecurity work requires 15epartment of Public Safety"S"License: Lic.No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below,t hereby waive this requirement. I am the(check one ❑owner ❑owner's a gent,
Owner/Agent
Signature Telephone No. PERMIT FEE: $ ''�