HomeMy WebLinkAboutHealth Permit # 8/26/2010 1
. 41 Commonwealth of Massachusetts
Map-Block-Lot
Board of Health 107.00057
North Andover BHP-201
P.I. _ _ --_--_ -BHP-2010 0708
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�s�acwu�kj F.I. FEE
$250.00
DISPOSAL WORKS CONSTRUCTION IT
Permission is hereby granted Todd-Bateson
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to(Repair)an Individual Sewage Disposal System.
at No 44 MARIAN DRIVE
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as shown on the application for Disposal Works Construction Permit No. BHP-201-- --- - --------- ----------------
-070 Dated Au
-gust 26,2010_
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Issued-On:-Aug-26--2010 --
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- ---- - -- ---- -
— — Board of Health
a - on tru tion rmit — 76"WV1W
®� $250.0 Full Repair
� a "j 25'4 0 Component
CHUS Important: Application is hereby made for a permit to:
When filling out
forms on the forms a new on-site sewage disposal syst T
computer,use EDRepair 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
Address or Lot#
raruu City/Town
2.g* P OF SEPTIC SYSTEM*:
Pump El Gravity(choose one)
***If pump system,attach copy of electrical permit to application***
❑ Conventional 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.S.
2. Owner Information
Name
Address(if different from above)
City/Town State
Zip Cod
Telephone Number
3. Installer Information
Name Name of Co
)t" (' rpany 11 AV(F4 A I OAD
MA 01510
Address
.., yy
Q� / / /
City/Town State Zip Code
I " .
Telephone Number(Cell Phone#if possible please)
4. Designer Information
Name
sj�o i d 17 Name of Company
i
Address
City/Town State
Zip Code
�I? a.
Telephone Number(Best#fo l2'each)
Application for Disposal system Construction Permit•Page t of 2
�a�rW li ti r tip i l t „M�� 3 /
4.
G TODAY'S DATE
° -Construction Permit — TOWN OF
�*
NORTH ANDOVER., MA 01 4 $ 250.00- Full Repair
ACNUSE� $125.00 -Component
�SS
PAGE 2 OF 2
A. Facility Information continued....
5. Type of uildinct: 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
North Andover, and not to place the system in operation until a Certificate of Compliance has
been issued by this Board of Health.
.....���•� .q, ,.w Wh•mwi ,.,._... 1,...,..-. Aug{ g^p,.
Name Date
Applicati R Approved By-,, oard of Health Representative)
Nam
Date
pliation D 'pproved r the following reasons:
For Office Use ®niy: �..
Z Fee Attached Yes No
2. ProiectManager Obligation Form Attacheda Yes y W No
3, Przmp S sy tern? Ifsa;Attach coy ofElectrical Pennit Yes_ No
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 2
SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS
As the North Andover licensed installer for the construction for the septic system for the property at:
(Address of septic system) Fos p lans by
(Engineer)
Relative to the application of
(Installer's name) And dated ®/
rigma date).
Dated
o ay s ate With revisions dated
(Last revised date)
I understand the following obligations for management of this project:
I. 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 hree 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(15�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 OK(or e-mail to: healthdept@townofnorthandover coin) 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 tnay 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. .1 fiuther
understand:that work done b others unlicensed to install se .tics stems in North Andover can constitute
reasons for denial of the system andlorrevocation 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.
h. Inspection of the sand and stone to be used
c. Final inspection by Board ofHealth 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 Septic Installer:
leev SA (Today's Date)
(Name.— ring
e .
TOWN OF NORTH ANDOVER Permit Number
NORTH ANDOVER,MASSACHUSETTS 01845
%;0R?h Date Issued
of"'do i.
OOb
Expiration Date
Ss�CHUg�
Jackie's Law — Permit Application
Pursuant to G.L. c. 82A §1 and 520 CMR 7.00 et seq.(as amended)
THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION
Name of Applicant• Phone Cell
Street Address /!1 }r !t,¢ .
City/Town MA ZIP
[Name of Excavator(if different from applicant) Phone Cell
treet Address
City/Town MA ZIP
Name of Owner(s)of Property Phone Cell
Street Address
City/Town MA ZIP
/V j L/ `�
Other Contact 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/cablefflines eta.)Please use reverse side if additional space is needed.
t,l j 14
Insurance Certificate#:
Name and Contact Information of Insurer:
/v-;_ A-I Mme .
Policy Expiration Date:
Dig Safe#:
P of Competent Person(as defined by 520 CMR 7,02):
husetts Hoisting License#
License Grade: =Exiration j
BY SIGNING THIS FORM, THE APPLICANT, OWNER, AND EXCAVATOR ALL ACKNOWLEDGE
AND CERTIFY THAT THEY ARE FAMILIAR WITH, OR, BEFORE COMMENCEMENT OF THE
'FORK, 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 WORD
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 DETAILS 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 -SIGNATURE
DATE —j
EXCAVATOR SIGNATURE(IF DIFFERENT)
DATE
:OWNIERWIS 4IGNATURE(IF DIFFERENT)
L. DATE:
--_.-..-----------,-------------------•-------------._------..
NK
A g,
pe,
............
M
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 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 to,the
establishment of a valid excavation number with the underground plant damage prevention system as
ii, said system is defined in section 76D of chapter 164(DIG SAFE);
Trenches may pose a significant health and safety hazard. Pursuant to Section 1 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,
iii. 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 Saf6ty and Health Administration
Adm nistratio on excavations:29 C
FR 1926.650 et.seq.,entitled Subpart P'Excavations",
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
mu t 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 CNIR 1926.650 et-seq.,entitled Subpar 'Excavations"as well y other
excavation requirements established by this municipality;P as an
y;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 www,mass.gov/do
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3 1 P a g e
Sumnary of Excavation and Trench Safety Re ug�l tion(520 CMR 14.00 et seq.)
This summary was prepared by the Massachusetts Department of Public Safety pursuant to G.L,c.82A and does not
include all requirements of the 520 CMR 14.00. To view the full regulation and G.L.o.82A,go to www/mass,gov/dps
Pursuant to M.G.L. c. 82, § 1, the Department of Public Safety,jointly with the Division of Occupational Safety,
drafted regulations relative to trench safety. The regulation is codified in section 14.00 of title 520 of the Code of
Massachusetts Regulations, The regulation requires all excavators to obtain a permit prior to the excavation of a
trench made for a construction-related purpose on public or private land or rights-of-way, All municipalities must
establish a local permitting authority for the purpose of issuing permits for trenches within their municipality.
Trenches on land owned or controlled by a public(state)agency requires a permit to be issued by that public agency
unless otherwise designated.
In addition to the permitting requirements mandated by statute, the trench safety regulations require that all
excavators,whether public or private,take specific precautions to protect the general public and prevent unauthorized
access to unattended trenches. Accordingly,unattended trenches must be covered, barricaded or backfilled, Covers
must be road plates at least'/,"thick or equivalent;barricades must be fences at least 6'high with no openings greater
than 4" between vertical supports; backfilling must be sufficient to eliminate the trench. Alternatively, excavators
may choose to attend trenches at all times,for instance by hiring a police detail,security guard or other attendant who
will be present during times when the trench will be unattended by the excavator.
The regulations further provide that local permitting authorities,the Department of Public Safety, or the Division of
Occupational Safety may order an immediate shutdown of a trench in the event of a death or serious injury;the failure
to obtain a permit; or the failure to implement or effectively use adequate protections for the general public. The
trench shall remain shutdown until re-inspected and authorized to re-open provided, however, the excavators shall
have the right to appeal an immediate shutdown. Permitting authorities are further authorized to suspend or revoke a
permit following a hearing. Excavators may also be subject to administrative fines issued by the Department of
Public Safety for identified violations.
Summary of 1926 CFR Subpart P-OSHA Excavation Standard
This is a worker protection standard,and is designed to protect employees who are working inside a trench. This
summary was prepared by the Massachusetts Division of Occupational Safety and not OSHA for informational
purposes only and does not constitute an official interpretation by OSHA of their regulations,and may not include all
aspects of the standard,
For further information or a full copy of the standard go to www.osha.aov.
Trench Definition per the OSHA standard:
• An excavation made below the surface of the ground,narrow in relation to its length.
feet.
• In general,the depth is greater than the width,but the width of the trench is not greater than fifteen
• Protective Systems to.prevent soil wall collapse are always required in trenches deeper than 5',and are also
required in trenches less than 5'deep when the competent person determines that a hazard exists. Protection
options include:
o Shoring. Shoring must be used in accordance with the OSHA Excavation standard appendices,the
equipment manufacturer's tabulated data,or designed by a registered professional engineer.
o Shielding(Trench Boxes). Trench boxes must be used in accordance with the equipment
manufacturer's tabulated data,or a registered professional engineer.
o Sloping or Benching. In Type C soils(what is most typically encountered)the excavati
extend horizontally 1 %feet for every foot of tren on must
and ch depth on both sides, l foot for Type B soils,
'h foot for Type A soils.
o A registered professional engineer must design protective systems for all excavations greater than
20'in depth,
continued
4 P a g e ----- --- ——- _----- ------ _ _
• Ladders must be used in trenches deeper than 4'.
• Ladders must be inside the trench with workers at all times,and located within 25'of unobstructed
lateral travel for every worker in the trench.
• Ladders must extend 3'above the top of the trench so workers can safely get onto and off of the
ladder.
• Inspections of every trench worksite are required:
• Prior to the start of each shift,and again when there is a change in conditions such as a rainstorm.
• Inspections must be conducted by the competent person(see below).
• Competent Person(s)is:
o CApable(i.e.,trained and knowledgeable)in identifying existing and predictable hazards in the
trench,and other working conditions which may pose a hazard to workers,and
o Authorized by management to take necessary corrective action to eliminate the hazards. Employees
must be removed from hazardous areas until the hazard has been corrected.
• Underground Utilities must be:
o Identified prior to opening the excavation(e.g.,contact Dig Safe).
o Located by safe and acceptable means while excavating.
o Protected,supported,or removed once exposed
• Spoils must be kept back a minimum of 2'from the edge of the trench.
• Surface Encumbrances creating a hazard must be removed or supported to safeguard employees. Keep
heavy equipment and heavy material as far back from the edge of the trench as possible.
• Stability of Adjacent Structures:
• Where the stability of adjacent structures is endangered by creation of the trench,they must be
underpinned,braced,or otherwise supported.
• Sidewalks,pavements,etc,shall not be undermined unless a support system or other method of
protection is provided.
• Protection from water accumulation hazards:
• It is not allowable for employees to work in trenches with accumulated water. If water control such
as pumping is used to prevent water accumulation,this must be monitored by the competent person.
• If the trench interrupts natural drainage of surface water,ditches,dikes or other means must be used
to prevent this water from entering the excavation.
• Additional Requirements:
• For mobile equipment operated near the edge of the trench,a warning system such as barricades or
stop logs must be used.
• Employees are not permitted to work underneath Ioads. Operators may not remain in vehicles
being loaded unless vehicles are equipped with adequate protection as per 1926.601(b)(6).
• Employees must wear high-visibility clothing in traffic work zones.
• Air monitoring must be conducted in trenches deeper than 4'if the potential for a hazardous
atmosphere exists. If a hazardous atmosphere is found to exist(e.g.,O2<19.5%or>23.5%,20%
LEL,specific chemical hazard),adequate protections shall be taken such as ventilation of the space.
• Walkways are required where employees must cross over the trench. Walkways with guardrails
must be provided for crossing over trenches>6'deep.
• Employees must be protected from loose rock or soil through protections such as scaling or
protective barricades,
5 Page ._....__-_._.._..._._._..-----••
— Permit No. ":z
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leaveblanlc)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL
All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Dated
City or Town of. NORTH ANDOVER To the.Inspector of ZVzres:
By this application the undersigned gives notice of his or her intention to perform the el ctrical work described below.
Location(Street&Number)
Ownner ar Tenant ✓ C.f��", r �,>6,,.12 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.
Existing Service Amps Volts Overhead ❑ Und rd
g ❑ Na, of Meters
New Service Amps / Volts Overhead❑ Und rd
g ❑ No. of Meters
M
Q°1 Date.., .,� . ? :.. .
living table may be waived by the Inspector of Wires.
No.of Total
,&ORTM Transformers I�VA
OWN Of l F NORTH ANDOVER Generators KVA
" i PERMIT FAR V�/IRIY`1 ❑
No. of Emergency Lighting -
" ' Batter Unnits
FIRE ALARMS No.of Zones
SS US No.of Detection and
Initiating Devices
This certifies that ....... 1 ...... ........................... No.of Alerting Devices
No.of Self-Contained
has permission to perform • •••• / ' "' ' "" Detection/Alertin Devices
................ pp
�7 Local❑ Coznnectioln F1 Other
wiring in the building of...................
1s?..��'���Z..................•.......................
Security Systems:
North Andover,Mass. No.of Devices or Equivalent
at ...,..
a _ Wz g.
Data Wiring:
Fee A......:`:°�"��m Lie.No. ... No,of Devices or Equivalent
g ECra►ca.z.INS oR / Telecommunications Wiring
No.of Devices or Equivalent
t
Check tt --------
f desired or as required by the Inspector of Tf7ires.
icipal policy.)
vv uArc ro btart: 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 cert fy,aara.der the pains and penalties ofperjiny,that the information on this application is true and complete.
FIRM NAME: LIC.NO.:
Licensee: Sn nat LIC.NO '
t"
(Ifcapplicable, enter `exempt"in the license namaber line) Bus. Tel.N0.:
Address: ( Alt.Tel.No.: t
*Per M.G.L c. 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
Signature Telephonne No. PE121VlIT FEE.