HomeMy WebLinkAboutHealth Permit # 7/7/2006 Map-Block-Lot
Commonwealth of Massachusetts
�a� q 061.0--0090-
Board of Health Permit No j
BHP-2006-0213
• North Andover -
FEE
a P.I.
$250.00
CHO F.I.
I
Disposal Works Construction Permit
Permission is hereby granted JOSEPH R. WATSON ________________- --
- -
I
to(Repair)an Individual Sewage Disposal System.
i
atNo 53 WHITE BIRCH LANE------------------ ------ -------- --- - - -
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as shown on the application for Disposal Works Construction Permit No. BHP-2006-021 Dated July 0-- ...
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o
-Boa t 04,11
Issued On:Jul-07-2006
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62RRIC—ation for Septic Disposal System rrAk's o f -
� ors tru tl Permit T
$250.0Full Repair
�� 4 t1--$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 Mlrepair or replace an existing on-site sewage disposal system*
only the tab key
to move your ❑ Repair or replace an existing system component
cursor-do not
use the return
key, A. Facility Infor t'o
_— ��,,✓
spa A dress or Lot#
Ci y/Town
2.-* PE 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 Riodiffuser(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) �/ q
City own - State Zip Code
Telephone Number
3. Installer Information
Name , Name of Company
V3 t-4�Iacle?
Address
G tyfrown State Zip Code
Telephone Number(Cell Phone#if possible please)
a. Desi ner Information -
,,,
N Name of Company
a y
Address --- – ---.....__--
City own State _ Zip Code
Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit^Page 1 of 2
lip lion for tip i I y t
a Construction Permit — F TODAY'S DATE
NORTH 0184 $250.00_Full repair
$125.00-Component
PAGE 2OF2
A. Facility Information continued....
5. Type of Building: esidential Dwelling or❑Commercial
B. Agreement
The undersigned agrees to ensure the construction and maintenance of the afore-described
on-site sewage disposal system in accordance with the provisions of Title 5 of the
Environmental Code,as well as the Local Subsurface Disposal Regulations for the Town of
North Andover,and not to place the system in operation until a Certificate of Compliance has
bee issued by this Board of Wealth.
Name `s Date
Ap 1i tion A proved By: i ar of Wean Representative)
am Date
Application Disapproved for the following reasons:
For Office Use Only:
1. Fee Attached? Yeses" No
2. Project Manager Obligation Form Attached? Yes �' i� No
711 3. Pump S sv tem? Ifso,Attach cape afElectrical Permit Yes No
4. Foundation As-Built?(new construction ronly): Yes- '"" No
(Same scale as approved plan)
9. Floor Plains?(new construction only): Yes" No
Application for Disposal System Construction Permit^Page 2 of 2
JUL 10,2006 13:13 J W WATSON, JR. INC. 978-975-0413 page 1
A!12 1,1: i'Jt.lutiQl,?G HFN I L
INSTALLER'pRC'iXXT Mls.NAGIE1VAJl;NT 01131,16rATKYN$
N,.r th4 North Andover lir.rneed installor for the c:nnAtuction of the soptic iyqtelti for the
propcity at � //� Viz, rclafi've to the application
of for plans ley..��- `?�,G'L 1 � and
dated with ravisiotlS!1a1ed
i underst.and Llic following,obligation^for managcownt of thia project:
I. A. the installer i am obligated to obtain all permitts and Board of Boalttt approved plans prior
to rtorrning airy work on a site. I must have the approved plans and the porntit on site
when any work is beuq dome,
2. M the installer T moat call for any and ;�iI inspcc(:iona. If homeowner, contractor, prnjecr
tnarrtrer,or any oft_:r pOrson not associated with my company schedules an inspection and the
sy,Acnr is not rertdy theta.item three shall be applicable,
1- As tho installer I am requited to have the ne=saiy work.completed prior to the applicable
inspections as indicated below. I understand that requesting an inslaectiob, withow
oompletion of the items in accordance with Tile 5 and the Board of,Health Ragnlmions may
result in a$50,00 tine.bt;ing levied against my company,
a) Tiotton, of Red�,generally first inspetron unless there is a retaining wall which should t)u done
fl.rst. Installer nru„t.reyueht the,inspection but canes not have;to lee present.
h) Final inahemon -- Engineer must first du their in.pection for elevations. tio,,, rrc. As-built or
verbal OK from engitwur „u,,.st h+� submitted to 8(mrd of lNultll, after which inntaller calls tut
1.taspe4al)o1) time Imtallcr mast be present for this inspection. With pump system all olemric3l
work must be really Ind able,to r,.ausee pump to work and alanti to function.
0 Huai Qi-ad>m Installer rmim rcgngst inspection when all grading,is aomplete, D=;not}rave to bm,,
on site.
4, As the installer I nnde,rstand that only 1, fatly perforttl the Work(other than :simple excavotion)
rerinired to 6omplete the in"a tlladon of the system identiflod in the attae,he d ;application for
installation. I Awfier tmdersto-and that tivork by nthr-rs unlicerim..d to i)ast»all scptin s;y.s;tcarl; in
North Andover can wnstitiite reacnns for denial of the system, and/or, rcvoratinn or
su.T.mrision of my license to operate in the Town of North Andover; significant fines to all
persans involved are,also possible.,
S. As the lnttallcr l utroerstand that T must be on site during the performance of the I'ollowin�
constrrrntion steps:
;i) Ntormination thnt the proper elevation Vrlie ckcavatian lt3e be.2n reach d.
1>) Tragpectiorl ofthc;:and and stolie to be used.
:) h'inal inspection by$oared of Health staff'or consultant.
d) Instndlation of tank, F.r.Urrr piper,., stone, vent, pump chamber, retaining wall and other
"'OnrlrG?tents
6. As the installer I understand that l atrt solely responsible for the installation of rha syvtcm ac,
pet'th,s approved plans. No ins-tructioos by the Homeowner, general contractor, or any r)lhcr
persons shall rrhsolvn rric of this obligation,
r
l;t dc; sipmt^ri L,icerls d Septic insi tal
Date,
REC r
J01- 1, cl ti
I'�<' !/ir`a 91 r¢��f A d t 3 �X&`: C.�l.. ' `s 01'ricial Use Only
i = Services
Permit No, Z,
� 1,
���partdt ent of re ,,_`�ervCt~"e
Occupancy and Fee Checked
(3C AE 1) t:)!= FIRE €=' \ll:NfC!(,1N CGtJLAFCC)ilS c -
fir ' ��z v 9/05� (leave blaflk)
APPLICATION FO RMIT TO PERFORM L I W)R
All work to be pertorined in accordance with the,rtassachusetts Electrical Code(NfEC)..527 GAR 12.00
("PLEA SE PRINTIN INK OR TYPE, .,fLL INFOIZA'IYYOM Date: 2 --// O
City or T own of: V, I "', �) "i e i To the Inspector of Wires:
By this.application the undersigned gi res notice of his or her intention to perform the electrical work described below.
Location (Street&1 duixiber) . ' a ."31 i l :
-- -�
Owner or Tenant VA I"/ (�1`. o s `telephone ado.
Owner's Address
Is this perinit in conjunction with a building permit? Yes El No ❑ (Check Appropriate'Box) _
Purpose of Building � Utility Authorization No.
E,Asting Service -�� Amps / Volts Overhead ❑'L Undgrd ❑ No.of Meters
New Service Amps / dolts Overhead ❑ Cndgrd ❑ No. of Nletei's
Number of feeders and.'rapacity
Location and Nature of Proposed Electrical Work: _:
Completion of thefolloiving table may be waived_b Z the Ins ect_o_r o I'r'ires.
No. of Recessed Luminaires No.of Ceil.�?usp.(Paddle)Fans x o. o Ntai!
_ _ 'Transformers ICVA
No. of Lunlinaire Outlets ~�No. of Hot Tubs Generators K-V
No.of Luminaires � Swirnining Fool g d. ❑ n- ❑ i, o. o inex gency ig i iig
i�rnd. end. Matte Units
No. of Receptacle Outlets No. of Oil Burners FIRE A L ARMS No. of Zones
o etechon and
No.of isvitelies No. of Gas Burners No. Initiatilag Devices
Total No. of Ranges No. of Air Cond.� Tons No.of Alerting Devices
No. of Waste Disposers - _ heat Pump �runx ex° ons KW T-457.of,'e! -Contained
_ Totals: Detection/,Mertin-De vices
No. of Disli�wsashers Space/Area e acing ICI l;oeal❑ Municipal Connection F1 Opier
_
Deatin liances Security Systems:* � r.N
No. of Dryers g` pP I � No.of evices or E uivalent
i�a, oC Wal—ter - - —KW y iNo oof - Ledo. o LData'tfiring:
Heaters sh! ns Ballasts No.of Devices or E uivalent
Na. .tlydi omassage Bathtubs No. of i Iotors. Tate!IMP l'e ecommunications iring:
_.H No.of Devices or.Equivalent
OTIIER:
Attach additional detail if desired, or as required by the Inspector of N'ires.
Estimated Value of Electrical\York: r P( t (When required by municipal policy.)
Work to Start: t ` Inspections to be requested in accordance with viEC Rule 10, and upon complciion.
INSUR NCE COVER_,kGE: Unless waived by the mvner, no permit.for the performance of electrical work may issue unless
he licensee provides proof of liability insurance including "completed operation"coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force, uid has exhibited proof of same to the permit issuing office.
CHECK ONE: fNSURAi'�tCE 1 " BOND ❑ OTHER ❑ (Specify:)
rceriify, under the pares and puurltie's ofperjuly, that the information on this application is true and cornpk:te.
FFRM isdNNI ' r s 7 �' i I E t"f r r t o _ LIC.NO
d y�
Licen see .y l § t t.J i Signatu2 f Q E LI.C.�' O
(Ifapplicahle, ,rater ti,:mpl"in the ttcense number line.) �y � Bus. Tel. Cho ( t S
.�.l t
�
scldress: jjt �i .,t? ,.9_ t .;�'C 9th J a i
. �"1.L
'�ecuirity System Contractor License required for this work;if applicable,enter the License number here:
OWNER'S INSURANCE WAIVER: l am aware that the Licensee does not have the liability insurance coverage norena11%'
required by law. By nay signature below, T hr reby valve this ngriirernent. T gun the (c:heck-one)[] ow-ner ❑ owrier's ;pent.
Signal/�gent
�igrizatiirc
10/19/2005 14:53 9786838476 HEATH (=AGE 02/02
INSTALLER PROJECT MANAGEMENT MENT OBLIGATION
As the North Andovor licensed installer for the construction of the septic system for the
property at /r� _ relative to the application
of _dated _ for plans by-��_Iey"&_C_ and
dated with revisions elated
T understand the following obligations for management of this project:
I. As the installer I am obligated to obtain all permits and Board of 1.4calth approved plans prior
to performing any work on a site. T must have the approved plans and the permit on site
when any work is being done.
I As the installers T roust call for any and all inspections. If homeowner, contractor, prgject
manger, or any other person not associated with my company schedules an inspection and the
system is not ready theft 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 "file 5 and the Board of Health regulations may
result in a$50.00 fine being levied against my company.
a) Bottom of Bed - generally first inspection unless there is a retaining wall which should be done
first. Installer rrrust requefit the inspection but does n.ot have to be present,
b) Final. inspection — ]engineer roust firq do their inspection for elevations, ties, etc. As-built or
verbal CSI{ from engineer must be submitted to Board of Health, after which installer calls for
inspection time, installer must be present for this inspection. With pump system all electrical
work must be ready and.able to cause pump to work and alarm to fiutction.
c) Final Grade—installer tttust request inspection when all grading is complete. Does not have to be
on site.
4. As the installer T understand that only I may perfonn the work(other than simple excavation)
required to complete the installation of the system identified in the attached application for
installation. I further understand that work 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 licetise 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 perf'orrnance of the following
construction steps:
a) Determination that the proper elevation of the excavation has been reached,
b) inVecti.on 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
COMpouents.
G. As the installer I understand that I aim solely responsible for the installation of the systems as
per the approved plans. No instructions by the homeowner, general contractor, or any other
persons shall absolve me of this obligation,
U de signed Licens Septic Install r