HomeMy WebLinkAboutHealth Permit # 7/25/2012 Commonwealth of Massachusetts Map-Block-Lot
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• �cLEn� 106.A0018
------ ---------------
BOARD OF HEALTH Permit No
BHP-2012-0695
North Andover -----------------------
P FEE
F.I. $250.00
DISPOSAL K 'T"RUC"TI Ili PERMIT
Permission is hereby granted William Rodenhlser
to(Repair)an Individual Sewage Disposal System.
at No 1476 SALEM STREET------------ -------------------------------------- ------------------------------------------------------------
as shown on the application for Disposal Works Construction Permit No. BHP-2012-069 Dated -_July 25,2012__---__
Issued On: Jul-25-2012 BOARD OF HEALTH
fication u C"
TODAY'S DATE
Construction Permit —
y,
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NORTH ANDOVER MA 1k845
0. 0 Pun Repair
°fs �z .oc� -Component
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Important: Application ' hereb made fora 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
— LAC ", - . -------- _ _.__
-----
Address or Lot##
— --— — --
V -
{{ -
City/To-w-
ity/Town — T WN F NOR H A9'IfJ 0`d ER
HEALTH EPART TENT
2.- *TYPE OF SEPTIC Slr'STEW:
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 Closed (G-Box Present) S.A.S.
2. Owner Information
f> f M
Name --------- ----------
Address(if different from above)
City/Town State Zip Code
Telephone Number
3. Installer Information
Name Name of Company
Address - ---- -- ---
City/Town State Zip Code
Telephone Number(Cell phone#if possible please) 3�5 r
4. Designer Information
Name Name aftCompany
— --- - -
City/Town State
Zip Code
Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit-Page 1 of 2
� �wau¢arras"
nn tin for Se tic Dis sal S evn ll° t
a r TODAY'S DATL-
�p Construction Permit - F
M O T V. 0184
$ 250.00--Full Repair
� $125.00 -Component
PAGE 2 a
F
A. Facility Information continued....
5. 'Type of uildig : 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 focal 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.
Name Date
Application pproved ray: (R aid of Health Representative)
m -
——d- —1 -----------------------. .----- —...
Naii Date (((
Application Diaappfrrved for the following reasons:
For Office Use pnly:
1. Fee Attached? Yes No
2. Pfoject Managef Obligation Form Attached? yesv No
3. .P°umn S sue? If so,Attach cogy ofFlectdeal Permit Yes No
4 Fouizdation As-Built?(crew construction ronly): 1,es c)
Game scale as appfoyedplan)
9. Floof flans?(new construction only): Yes No
Application for Disposal System Construction Permit•Page 2 of 2
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SEPTIC. SYSTEM INSTALLER PRQJEC.`I IVI ACEI IsNI' C.IBI ICIA'f'[ON
As the Ncuth Andovcr licensed installer for the construction for the septic system for t c,property at:
«r plans b
l,GllFr. : ereiri,°
Relative to the,application of �. [ ( J C 'DIE�11`j1a�''C��'._
(� ) And dated
Dated ��zo1/
o a ;, , a.,i v�.� With revisions dated
o
EEyy,t
I understand the following obligations Ior management of this project: °°�^
ICS 0q 01 fit'"ttl �t� a,
I. As the installer,I am obligated to obtain all permits and Board of Health app tf �t�k 41"i""r
crformin an work on a site. I must have the approved Mans and the errnit: on site whc�t1 aiiy wci l s
performing� y plans �
being done.
2. As the installer., I must call for any and all inspections. I:f 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 cotnl7a��7v.
a. Bottom of lied, —Clenerally, this is the first(1") inspection sinless 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—l:"sngineer must first do their inspection for elevations, ties, etc.
As-built of verbal OK, (or e-mail to: �µa°<o9tU����.�i�rf�(�i.���� �b,��,kirt,rr�u4ns��;ta��� d�;;��s�.,t�.) 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 f-unction.
c. Final Gracie—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 thalr sbilple ex-eavatim)and I aim required
to complete the installation of the system identified in the attached application for.installation. I further
understand that worl 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, siLynificant 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. Deterr�aination 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, purPlp chamber, retaining ivall and other
components.
G. As the installer. understand that I am solel.y responsible for the installation of the system as leer the
a 7 proved glans. No instructions by the;homeowner, general contractor or another persons shall absolve
me:of this obligation.
Jnlcrsi � ;� �j nL � /1
W (C._t lA^ ( 1 P► 16 ti .
0 ttt� i 'dfh1F 6
Commonwealth Massachusetts Official Use Only
Department it Services Permit No. J� L�1—
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] peaveblank)
PERMIT APPLICATION FOR TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(/MEC),527 CMR 12.00
(PLEASE PRINTTNINK OR TYPE ALL INFORMATION) .Date: -� /w/i
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) / tz(o bftt AA STtuT 1
Owner or Tenant At -vEr,-f KOE016 Telephone No.g7g, -6,�-3,
Owner's Address SA/A G
(Checlk Appropriate Box)
thorization No.
Date . . ndgrd ❑ No.of Meters
o y�rttrus�c a udgrd ❑ No.of Meters
TOWN OF® NORTH ANDOVER c--.
PERMV
r FOR WIRING
f° �, f;,J `� 9 t able in y be waived by the I Vec or a Wires.
t1
f (.... / . . . . . . . • C.. . . . , . . . Transformers ICZ'A
6
This certifies that . . . . , . • • • ' ' ' ' ' ' Generators ICVA
has permission to perform . . . . o.o Emergency rg ing
°' a. ✓ P i�'
Battery Units
wiring in the building of . . . . .
FIRE ALARMS No.of Zones
, ,North Andover, Mass., o
at . , . . .r. • �� ,1 �r J ��` '„ Initiating bDevi es
r
(;
Lie. o. �" No.of Alerting Devices
Fee . �. 1�1 1
ELECTRICAL INSPEC TOR No.of'Self-Contained
Detection/Alertinf4 Devices
Municipal
Check Check# Local❑ El Other
Connection
Security Systems:*
No of Devices or Equivalent
Data Wiring:
....��n � auuuns No.of No.of Devices or E uivalent
Motors Total HP Telecommunications Wiring:
No.of Devices or E uivalent
OTHER:
Attach additional detail if desired,or as required by the Inspector of Wires.
Estimated Value of El;/7-51?-trical.Work: �,�� (When required by municipal policy.)
Work to Start: 6 it 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 FA BOND ❑ OTHER ❑ (Specify:)
I certify, under the sins andpenalties of'peijmy,that the inforfruttion on this application is true and complete.
FIRM NAME: ll/cr c /» CT e I- ' LIC.NO.: Zc(,, O
Licensee: 'i9x.,s �';G �rb��y1��-.__ ' ) Signatur Bus.Tel..NO.:// l -1
(If'applicable,enter "exern t"to the l�e& ra anC ber•litre, el-(U.3�
Address: ;/� f �, / /�r IrTMvi 6i/, c9 l o/(, - Alt.Tel. 5c�t�-c)ZZ t 5 3 tl
*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 sloes 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 agent.
Owner/Agent FERIVIIT FEE: $
Signature Telephone No.