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Home My WebLink AboutHealth Permit # 10/21/2011 Commonwealth of Massachusetts Map-Block-Lot • •• • BOARD OF HEALTH 107.00043 --- --------------- North Andover Permit No P.I. BHP-2010-0753 F.I. ----------------------- i FEE DISPOSAL WORKS -------- $250.00 CONSTRUCTION P - --------- Permission is hereby granted James_Kellett ERIVII7°" --- to(Repair-FULL,SYSTEM)an Individual Sewage Di-Sp-os-al System. at No 35 MARIAN DRIVE - - - - - - - - - - - - - --------- as shown on the application for Disposal --- Works Construction Permit No. B -- ----------- HP-2010 07S —Dated Dated October 21,2011 - - -- ---- Issued On: Oct-21-2011 Application for S2pjj i ... (r; Construction er it ® TOWN F TODAY'S DATE ORTH ANDOVER A 0 $250.00—Full Repair tl� ❑ " $125.00 -Component ❑. Important: Application is hereby made for a hermit to: ^ l�,J/ I❑ When filling out ❑ Construct a new on-site sewage disposal system* ❑7 �, 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. Facilit y Information dray' H ✓1 0(-r 1 �h Address or Lot# 9 City/Town � 2.- TYPE OF SEPTIC SYSTEW: TOWN O AV:..t, ❑Pump El Gravity (choose one) HEALTH It�PAR'rMEl'Ij.t: ***If pump system, attach copy of electrical permit to application*** ❑ Conventional system (pipe and stone system) /Efl 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 gaff Maintenance Agreement) ❑ Pressure Dosed (D-Box Present) S.A.S. 2. ♦Owner Information 'wmmW it i4 y� �:,1 Name f\A M Address(if different from above) City/Town State Zip Code Telephone Number 3. Installer Information .. (le Name Name of Company Address ,(,M '�✓n..,< - �:_,r.. p1 s'�."1,�_i: d�,�� r tom° City own State Zip Code Telephone Number(Cell Phone#if possible please) 4. Designer Information Name Name of Company Address City/Town State Zip Code Telephone Number(Rest#to Reach) Application for Disposal System Construction Permit•Page 1 of 2 Da log to for Set)tic Di G y term •• �' TODAY'S DATE n trcacti Permit — TOWN ORTH ANDOVER. MA $ 250.00—Full Repair 1 $125.00-Component PAGE 2 OF 2 A. Facility Information continued.... 5. Tylae of Building }�esidential 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 Cade, 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 oard of Health. N�/rhe Date 1,.. A pp lic�t n A p roved �Y� (Board of Health re p resentat�v e) m NaGg4 Z �, Date Dis A llcatlon c, app "approved for the following reasons , For Office Use Only: Z Fee Attached. Yes No 2. Project Manager Obligation Form Attached? Yes,'/ No 3. Pump Sys tem? If so,Attach copy of Electrical Permit Yes No 4. Foundation As-built?(new construction ronly): Ye No (Same scale as approvedplan) m_ 9. 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: I(, drt ,s of'scptic sysCem) Far plans by , 1 (I.0.Y}ry%Eka'4;I Relative to the application of ; �...t11 ��". 7 (Ins^ alter s n arne�') And dated Dated c,rtkq°s date). With revisions dated (Lskso acw)ase°d 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 pdor to performing any work on a site. I must have the appiT�oved 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 OK (or e-mail to: hc alo p lc 1 tC t t,r vvp4 ry«¢t wr ...... a,) 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 that 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 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. 0 Undersigned Licensed Septic Installer. , ,.... _. .. ,.� r� °� ; (Today's N,tni __. 1'nnt (N S�t.s:.. y"wuwiwn+;�muoawngpwwnuuoma.morv+r, V �Mi Official Use i commonwealth of c u � � LI � 1 I P/I��.°u�'n ��I Permit AIa. Department of Fire Servicss Occupancy and Fee Checked _ -- BOARD OF FIRE PREVENTION REGULATIONS Eev. 1107) leave blank APPLICATION All work to be performed in accordance with the Massachusetts Electrical Code(MEQ,427 UAR 12.00 (PLEASE PWNT IN INK OR TYPE AU INFORMATION) Date: City or Fawn of: °s To the Inspector of Wires: By this liontion the undersign gives natrce of his 0r or Into�®n to perform erf� t electrical work described below. C, 1 le 1115 anon Street miser) � l Telephone No. Owner or Tenant Owner's Address ves No (Chock Appropriate x) tion No. g ® No.of M6011% m — ,� No.of Meters a „air„ �► � �° �0„ Diem be waived the lnr czar a N'lrss. } (ransformers KVA A anerators �SS'acwus 4 0.0 mergency g a alto Units This certifies that V- 64."L f �� ..�° � I A�,A�)Vf5 pJo»of nos ....... .............. ra.o e to on all Inttla o.of Alerting Illevice9s has permission to perform 0 wiring in the building bf..,,: � "..... .� <e `:�e �°,�� (M�,.a 2,100219�nto _ .. .... _ . at tian North,Andover,NY � i � at.,.,� I.°...i� ��/"�_a�' /c �.,,. p: Other I ... , , ass. ction d h ecur. at Nee•.. .. Lic. hlo. ` ° ........ 1V®.® a o f!� to rofan ELECTR L IN CTOR Data WiNo.o or E u1v®Iont Check tl a M taona No oor E uiiva�nt hurl,or as roqutred by the Inspector of wires. Estimated Value ofEleotrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested In accordance with MEC Rule 10,and upon completion. INSU CE tv0VE GEc 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. C14ECK ONE: INSURANCE ® BOND ® OTHER ® (S ify;) l carlefyr,anderthe vainNandpenuldes0f hrjuoy,that the information on his application is trace and �O.el� I �f store >t.,C< Licensee: Bus.Tel.No.� (if applicable, rt ter "exam t"in the licer;se number Jlne, 1 o Alt,Tel.No.. `� t Add s: tt $per M.01 c. 147,s.37-61,Be urity work requires partrnene of Public Safety" "License: :coverage normally INSURANCE WAIVER: I am aware that the licensee aces trot have the liability insurance®owner owner"s a ant. required by law. By my signature below,I hereby waive this requirement, I am the(check ono Owner/Agent Telephone iuo. PERMIT FEE' S Signature