HomeMy WebLinkAboutHealth Permit # 9/16/2010 xsw Commonwealth of Massachusetts Map-Block-Lot
098.A0013
Qr R e --- --- - —
Board of Health PennitNo
-0
P-2o1
B
North Andover
BHP-2010-0722------
722
P.I. FEE
` �'6, :_ •
..i
�ssAC„usk� F.I. $250-0
DISPOSAL CONSTRUCTION IT
Permission is hereby granted Daniel-R. Briscoe
to(Repair)an Individual Sewage Disposal System.
at No 545 JOHNSON STREET
as shown on the application for Disposal Works Construction Permit No. B1-IP-2010-072 Dated September 16,2010
Issued On: Sep-16-2010 Board of Health
. �
`
Construction Permit - TOWN OF TO 5D ATE
50.00717 I!,R
Important: ApplicationJ2±2rlq��de for a permit to:
When filling out 0 Coifstruct a now on-site sewage disposal system*
forms on the
�
~^' 2�epa/r exisUn0on-oKesewogedkapomo| system°
only the tab key �j�c I I
to move your FlRepmirwrmmp|aoeanaxktingeystemnuonmponent—VVhat?
oumm do not
use the return
key. A. Facility
Address or Lot#
2 *oTYPE OF SEPTIC SYSTEM
ump El .. avity (choose one)
- `~^~|f pump system, attach copy of electrical permit bmapp|icsdion*°°
��'� �
�� �onvmnbona| System (pipeandstone system)
El Infiltrator or Biodiffuser(Gravel-Less) (Attach a copy of your certification to install this type of system.
El Pressure Distribution S.4.S. (No 0-Box) (Attach Draft Maintenance Agreement)
El Pressure Dosed (D-Box Present) S./\.S'
2.
Name
Address if different from above)
City/Town State Zip—Code
3. Installer Information
Name Name of Company
Address
City[Town State Zip Code
Telephone Number(Cell Phone#if possible please)
4.
Namd Name of Company
Add
CityfTown State p Code
phone Number(Best#to Reach)
Application for Disposal System Construction Permit^Page 1o/o �
�
�
�
7
fication tor SejLtLc Qj§pos@LSystem
0
TODAY'S DATE
oConstruction Permit — TOWN OF
V
ORTH ANDOVER:,-MA.- 01845 $ 250.00—Full Repair
'7A IU
$125.00 -Component
PAGE 2 OF 2
A. Facility Information continued....
5. Type of Building:)(Residential 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
been issueWthis Board of Health.
Name Date'
/C
Application App.oved By: (Board f Health Representative)
Name V/ Date
�ng reasons:
Application,�isa' pproveq,f&the foll 'i"
For Office U§q Only.
1. Fee Attached? yes'',/, No
2. Project Manaacr Obligation Form Attached? yes No
3. Pump System? If so,A ttacli copy of Electrical Permit Ye s No
4. Foundation As-Built?(new construction ronly): Yes No
(Same scale as approved plan)
5. Floor Plans?(new construction onl✓): Yea- No
Application for Disposal System Construction Permit-Page 2 of 2
Ldlrrrrr)U1AFMt:11¢AAbA1 Uff A°AICA��SAIyAA(lA9t�d6� -- / - ---�
Permit No. J
Department (of Fire ServffCes
' Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank)
� O^w
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Codee(MEG,527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMA TION) Date: V /I 0/1 o
City or Town of. NORTH ANDOVER 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) ,)
Owner or Tenant ®� r°t V� ��L S ,. Telephone No. G S/- 001
Owner's Address
Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box)
Purpose of Buildings ' �� �� Utility Authorization No.
Existing Service Amps Volts Overhead ❑ Undgrd ❑ No.of Meters
New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters
Number of Feeders and Ampacity
Illowing table may be waived by the Inspector of Wires.
t �°
Date......, .......,7..:......��... No.of Total
Transformers KVA"
Generators KVA
O`°T'""o°�
� oto merg
ecy i TOWN OF NORTH ANDOVER Units El Bate ghnlg
° p PERMIT FOR WIRING
FIRE ALARMS I No. of Zones
• �° ° No.of Detection and
�r��•%'` Initiatin Devices
SSACWUS�
No.of Alerting Devices
This certifies that ` t `.� ' ` .........•••.• >W No. of Self-Contained
{" Detection/Alerting Devices
has permission to perform ........ Local Municipal Other
1. ��............... '. S..C..� . .:r ................ El ❑
_ f Security Systems:-
wiring in the building of......... t r� t .?....•••••••••••••••••••••••••••••• • No.of Devices or Equivalent
_ - Data Wiring:
at......... � .: ......,✓E.....t . .. ..• ,North Andover,Mass. No of Devices or uivale nt
I Telecommunications Wiring:
Fee../.::...... :..... Lic.No..: ..f.. :? y.:. ...... ....; :...... .:...... No.of Devices or Equivalent
'ELECTRICAL INSPECTOR ,f
Check # ail if desired,or as required by the Inspector of Wires.
Iunicipal policy.)
ith 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 co erage is in force,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:)
I certify,under thepains andpenalties ofpeJury,that the information on this application is trite and complete.
FIRM NAME: LIC.NO.:
Licensee: b Signature LIC.NO.: L'S'I 5 0
(If applicable„gnter "exempt"in the I cense number line.) 9 Bus.Tel.No.:�it2 3 61 b
Address: (7 yl� '.Gi.( �� r7 ( v Ala nq, c�%5� � Alt.Tel.No.:
*Per M.G.L c. 147,s.57-61,security work requires Department 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,I hereby waive this requirement. I am the(check one)❑owner ❑owner's
Owner/Agent PERMIT FEE. $
Signature Telephone No.
SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS
As the North Andover licensed installer for the construction for the septic system for the property at:
vs—
For plans by S C 6" lej, El
(iWdress of septic System) (Elngincer) I,/
Relative to the application of X", -71A11 C,
(Installer's narrie) And dated (Unginal date)
Dated With revisions dated
It (I octay777-77- (Last rcvised(late,)
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 p1ior to
performing any work on a site. I must have the approved plans and the permit on site when any work
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 an
my company.
a. Bottom of Bed-Generally,this is the first(V 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.
bde
As-built of verbal OK (or e-mail to:h_(��alt .
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. 14
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 Voss
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.
c.
Undersigned Licensed Septic Installer: (Today's 111te)
777 (Narne- Sign-ed
T
%.1U1YY11ffU1ffYVVaff1LB,7 U11 ffUatzPa(uffffU,
Permit No.
Department of Fire Services
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (1,,veblank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical C de(ME,C�,527 C-MR 12.00
(1/�0 // o
(PLEASE, 111OWTININIC OR TYPE ALL INFORMATION) Date: -
City or Town of- NORTH ANDOVER 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) 4
Owner or Tenant Fro-�k, Telephone
Owner's Address
Is this permit in conjunction with a building permit? Yes ❑ No (Cheek Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service Amps _Volts Overhead ❑ Undgrd ❑ No.of Meters
New Service Amps Volts Overhead❑ Undgrd ❑ No. of Meters
Number of Feeders and Ampacity
RECEIVED
11mving table may be waived by the inspector
Date...... No. of Total
Transformers I(VA'
thor T14 ()WN OF NOM Generators I(VA
:e
Ig
-Y
'genp
Units
in
n
F NORTH ANDOVER o. o mergency ig ing
-iEALTH DE
6 o
❑ Battery Units
10 0 PERMIT FOR WIRING ---r
FIRE ALARMS No.�of Zones
No.of Detection and
'SSAC US Initiating Devices
No.of Alerting Devices
f Self-Contained
VV No. of
This certifies that ............................................... .............................. Detection/Alerting De-vices
icipfil
..............
❑ other
has permission to perform ...... ......... Local❑F1 Mun
Connection
Security Systems:*
................................... ......... .
wiring in the building of........... No.of Devices or Equivalent
Data Wiring:
............. .North Andover,Mass.
at ............. ..................... ..................... --v No.of Devices or Equiva ent
F— relecornmunications Wiring:
.................... ........ .............
Fee... .................. Lic. ............��ECTRICAL INSPECtOR No.of Devices or Equivalent
Check It
�iil if desired, or as required by the inspector of Mres.
I nicipal policy.)
'ILI
nth 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'ice including"completed.operation"coverage or its substantial equivalent. The
undersigned certifies that such coyerage is in force, and has exhibited proof of same to the permit issuing office.
CBECKONE: INSURANCE M BOND ❑ OTIIER ❑ (Specify:)
I cerfify,under the pains and penalties of perjury,that the information on this application is true and complete.
FIRM NAME: I - LTC.NO.:
Licensee: 2 Sigru:1(11�1111'4! -9
6, PIIAO-006 1 00, 6,S'�J5
(If applicableenter "exelnpt"in the lucense 17111TIber line.) Bus.Tel.No.: 0&3-j 61
Address: /111, ON't-A, Alt.Tel.No.-
*Per M.G.Ec. 147,s.57-61,security work requires Department of Public Safety"S"License: Lie.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,I hereby waive this requirement. I am the(check one)❑owner ❑ owner's
Owner/Agent FPEI�1127�'FEE: $
Signature Telephone No.
TOWN OF NORTH ANDOVER Permit Number
NORTH ANDOVER,MASSACHUSETTS 01845
RT Date Issued
Expiration Date
ACH"
Jackde's Law — Pennit Application
Pursuant to G.L. c. 82A §1 and 520 CIS. 7.00 et seq.(as amended)
THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION
Name of Applicant Phone Cell
V
Street Address
City/Town MA I ZIP
Name of Excavator(if different from applicant) Phone Cell
Street Address
City/Town MA ZIP
Name of Ownfr(s)of Property Phone Cell
0
Street A reA
d!�
t
City/Town MA ZIP
Other Contact L -']--Permit Fee Received No Yes
Description,location and purpose of 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.
R \1&
Insurance Certificate#:
Name and Contact Information of Insurer:
ti z �
.-Policy Expiration Date:
Dig Safe#: ,
' O �
Na a of Com etent Person(as defined by 520 CMR 7.02):
(
04A-t2 A
< p�
Massachusetts Hoisting License# ?
License Grade: �_ _-�_ ` Ex iration Date: e
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 APPLICABLE TO
WORK PROPOSED,INCLUDING OSHA REGULATIONS, G.L.c.82A,520 CMR 7.00 et seq.,AND ANY
APPLICABLE MUNICIPAL ORDINANCES,BY-LAWS AND REGULATIONS AND THEY COVENANT
AND AGREE THAT ALL WORK DONE UNDER THE PERMIT ISSUED FOR SUCH WORK WILL
COMPLY THEREWITH IN ALL RESPECTS AND WITH THE CONDITIONS SET FORTH BELOW,
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 TO ENTER UPON THE PROPERTY TO MONITOR AND INSPECT THE WORK
FOR CONFORMITY WITH THE CONDITIONS ATTACHED HERETO AND THE 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 DETAHS AND OTHER REMEDIAL MEASURES 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 OR ARISING OUT OF ANY INJURY, DEATH, LOSS, OR DAMAGE TO ANY
PERSON OR PROPERTY DURING THE WORK CONDUCTED UNDER THIS PERMIT.
APPLIC NT SIG TUBE
[ ' DATE -7 f /1
EXCAVATOR SIGNATURE(IF DIFFERENT)
DATE
OWNER'S SIGNATURE(IF DIFFERENT)
DATE:
2 1 P a g e
...........
CONDITIONS AND REQUIREMENTS PURSUANT 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 may be 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 to,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);
Trenches may pose a significant health and safety hazard. Pursuant to Section I 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 recognized safety hazards associated with
excavations and open trenches and the procedures required or recommended by said department in
order to make every reasonable effort to eliminate said safety hazards which may include 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 must 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 CMR 1926,650 et.seq.,entitled Subpart P'Txcavations"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.
vi.
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 w_ww,Laass.g-ov/dDa
NORTH ANDOVER HEALTH DEPT,
1600 Osgood Street
Building 20, Suite 2-36
North Andover, MA 01845
3 1 P a g e