HomeMy WebLinkAboutPERMIT „a T� Commonwealth of Massachusetts Map-Block-Lot
105.A0035
BOARD OF HEALTH Permit No
0
° North Andover BHP-2011-0728
F P.I. FEE
�S��4CH'J§Fi F.I. $250.00
DISPOSAL WORKS CONSTRUCTION IT
Permission is hereby granted Robert T. Amor
to(Construct)an Individual Sewage Disposal System.
at No 470 LACK STREET
as shown on the application for Disposal Works Construction Permit No. 1311M011-072 Dated June_13,-2011
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Issued On:Jun-14-2011 BpA'RD OF'IEALTH
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C.MB¢7'yq °"w" e•_. SS" '`, x,,,m „_.,,,,,,,.'� �' ,/` N ,w,.x'"/
lication for epti� I p® 0 y t R
TODAY'S DATE
,pe„a
Construction r it TOWN OF
$ 250.00—Full Repair, ,
rv.
, 01$45 �.�.�� ��� �$`��25�1���°Companent_,"a
N 1411
twtp nr ant: out Application is hereby made for a permit to: ( C
forms on the ❑ Construct a new on-site sewage disposal system* �
p(� '
computer,use 21fiepair 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 A. Facilit Information
key. Y
aB Address or L
~
of#
gun City/Town � ^ /
le
�.
2.-*TYPE 0 FzSEPTIC SYSTEM*: °
❑ Pump EjGravity(choose one) o
***If pump system, attach copy of electrical permit to applicat on � «
El Conventional System (pipe and stone system) x
❑ Infiltrator or Biodiffuser(Gravel-Less)(Attach a copy of our certification to ihVstall this t
y ype"cf system.
❑ Pressure Distribution S.A.S. (No D-Box)(Attach Draft Maintenance Agreement)
❑
Pressured�Dosed (D-Box Present)S.A.S.
d �s� ,„
2. Ownernformation
Name
Address(if different from above)
City/Town State y p Zip Code
Telephone Number 6
3. Installer Information
Name Name of Company
Address
.X A BM
City/Town State Zip Code
Telephone Number(Cell Phone#if possible please)
4. Designer Information
Name ) Name o Company
J
Address
City/Town State Zip Code
Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit>Page 1 of 2
0,,4,00 rh lic tin for S tip i I y
stem
.+ «.
Construction Permit
TODAY'S DATE
,s t
ORTH ANDOVER, MA 0145 $250.00-Full Repair
$125.00 a Component
PAGE 2 OF 2
A. Facility Information,continued....
5. Type of Building: [i3/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.
M
Name Date i
Application Approved Y%'(Board of Health Representative)
Name „r
„. ..._ ..,..,.. . .. Date
Application .,.
titian Disa pp rov/dfor the following reasons:
For Office Use Only:
1. Fee Attached? Yes No
Z. Project Manager Obligation Form Attached? Yes t No
3. Pump tem? If so,Attach co ofElectricalPennit Yes No
p yv —
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:
(Add�cicltcss c>f�
(� septic�syst a) For plans by s`mod: "e""""'
ress (1;rte
Relative to the application of
(mist rller's n to e) And dated
rtgtna (.:ate;
Dated '�Lzzl
oc:ay s c:ate With revisions dated `_
(Last revised 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 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 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 (1s) 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: l'ic alt:lide,at i)towtic>ftio th,,in(ioN,er.cg;)n) 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 lather than ripple 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 .rand 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.
t
Undersigned Licensed.Septic Installer: � (Today's I.7<zte)
TN—ame— Print) fic',L t.ignec ,"
HAYES ENGINEERING, INC.
603 SALEM STREET
WAKEFIELD, MA. 01880
Tel: (781) 246-2800
Fax: (781) 246-7596
June 13, 2011
Ms. Susan Y. Sawyer, REHS/R.S.
Health Department
1600 Osgood Street
No. Andover, Ma. 01845
Re: Septic system design plan
470 Lucy Street
North Andover, Ma. 01845
Dear Ms. Sawyer;
It was a pleasure speaking with you at your office. As you requested, I am addressing the changes
to the approved septic system design-repair plan by ASB design group that I feel that will not affect
the workings of the septic system.
1) That a sweep be installed out of the septic tank to eliminate the use of the cleanout
#1.
2) That the distribution box be rotated 90 degrees to except the 4" pvc pipe directly
into the distribution box.
3) That the high vent be eliminated from the plan because it is not required. The
system is a gravity flow and not a pumped system.
Thank you for your attention to these changes.
W. Gordon Rogerson SE2074
Sanitary Design Engineer
Certified Soil Evaluator
Certified Wetland Scientist
wg r
TOWN OF NORTH ANDOVER Permit Number
NORTH ANDOVER,MASSACHUSETTS 01845
'ApRth Date Issued
to
Expiration Date
Jackie's Law — Permit Application
Pursuant to G.L. e. 82A §1 and 520 CMR 7.00 et seq.(as amended)
THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION
Name of Applicant G*/rW-,--,6,,, ,rV Phone Cell
Street Address
City/Town MA ZIP
Name of Excavator(if different from applicant) Phone Cell
Street Address
City/Town MA ZIP
Name of Owner(a)of Property Phone �d Cell
Street Address
City/Town MA ZIP
i� , C1
Other Contact I 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 tines etc..)Please use reverse side if additional space is needed.
Insurance Certificate#: r>
Name and Contact Information of Insurer:
Policy Expiration Date: 4-"x47 /
Dig Safe#:
Name of Competent Person(as defined 6y 520 CMR 7.02):
Massachusetts Hoisting License#
V_/
License Grade: Expiration Date: ��
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. $2A,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 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.
APPLICANT SIGNATURE
DATE
EXCAVATOR SIGNATURE(IF DIFFERENT)
All / DATE 4, '
OWNER'S SIGNATURE(IF DIFFERENT)
DATE:
21Page
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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);
FI,
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,
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"Excavations"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 www,mgss.gov/-dM
3 1 P a g e
I
DEPARTMENT OF PUBLIC SAFETY
Hoisting Engineer License
Number: HE 009587
Expires: 08/11/2012 Ti.no: 1789.0
Restricted: 2A
ROBERT T AMOR
290 MIDDLETON l
BQXFO FQRD, MA 01921 1921 q—T;
Commissioner
Fro.Hub Irdernatioml Now algiand To:C;erfFffcaf8-Town of RowLay{1B7 11 R 22H1GIff-06 Pg 03-03
CltenW.56123 ITTANORSOME
ACaRL-L CERTIFICATE OF LIABILITY INSURANCE
4129!2011
THIS CERTIFICATE IS MUM AS A11Mn R OF FORMATION DIt y"W COBS NO RIGHTS UPON THE C6Wf9 LATE HOLDER.THIS
CERTIFICATE DOES MM AR MATIVELY OR W-MMB.Y AMBM,MnT: )OR ALTER IW COVERAGE AFFORDED BY THE POLICIES
BELOW-THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETVVEEi THE ISSUING easuRER(St AUTHORIZED
REPRESE11TATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER
IMPORTANT:Nthe cerilflcm holder is an ADDITIONAL UMIRM,the poNW(fes)must be endorsed_IPSUBROGATiON IS WANED,subjealo
the terms and conditions-ef the pQW.cerWn poems nay requilrean end semenL A slatenwItt en this eer6Bcat a does not confer rights to the
cerlifkatehoklwInIleaof such
endo eteatjs�
PRODUCER CONTACT
HUB MIanationat New EnghW W
976 07-5100 � 978g8NM
298 Ba[tardvatc St �M
Wilmington,MA 01807
978657-5100 INSURERiS)AFFORDINGCOVERAGE NAWN
V=RER A-MBSS Bay bmira ice Co
MSURm B<,SUBER 13:Travelers Indemnity Co of Atneri
R T Amon i Son Excavating Inc
Bab Amur i NWFtE c:deacon Insurance
11275 Turnpike Rd WSURERD:
Rowley,!IAA 01969 tH E
NUMBER F:
COVERAGES CERTH ICATE NUMBER REVISION NUOIBER:
THIS IS TO CERTIFY THAT THE POUCIES OF*LAnmNCE UWm Bmow HAVE BERd mmm-ro nm v4m;m)NAmm ABOVE FOR THE POLICY PERIOD
IMICAT®. N07HVM4 rMDING ANY FlIMUMMENT,78tla OR CONDITION OF ANY CONTRACT OR GTHER DOCUMENT WUH RESPECT TD WNCH THIS
CEIMFICATE MAY BE ISSUED OR WAY PERTAIN, THE INSURANCE AFFORDED BY THE P011CfES OM MUM M HERM IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONIVIONS OF SUCH POLICIES. LWIM SHOWN WAY HAVE amN REmHcEP BY PAID CLAmm
LTR TYPE:OFINSURANCE ff MW POUCYNUIIBER soppyrffm ETF EXP Loxrs
A cQFERALUAeDr1Y ZDN89898W 1111126=111 01/261201 EACHOCCURRmm 0.000.000
X COMMERCIAL GENERALUABRHY —7 1 31000000
MS-M 0 OCCUR MED EXP kAw am ersm) 00.000
X PDDed-500 P61SONAL&ADVINJURY $1,000,000
GENERAL AGGREGATE s2,000A00
GERIAGGREGATE LIMIT APPLIES PEk PRODUCTS-colproPAGG s2,000,000
C AUTOMOBILE LIABILITY 3900007820000 D91261WIQ 09,12612011 SW01000
ANYAUTO BoiNLYMJURY(Perpason) f
ALLOWNED SCHEDULED
AUTOS AUTOS BODILY INJURY Owes dan) E
X NIREDAUT05 X P6t :oA S
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MGM
U618REW1tue EAC7iOCCURRENCE S
EXCESS LIAe gMADE AGGREGATE E
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B A ORS cO�°'� 4MM72 4MI12011 M11261 S MA's 0TH-
AND EMPLOYERS'LlABDJTY r.
ANYPROPR�TNEARTNERIMCMVEYIN ELEACHACC�9rr 0100000 ER
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Ifyw.6oryhrNH► ELDISEASE-EAEWO $100000
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DESCRIP910NOFOPERATIONSheow ELDLSFASE-POUCYIUW $500000
DESCRIPROIiOFOPERATIONSILO TIONsIVERICLESV UI&c hACORO101,AdManalRa4mts Schedule,Hramespacefsrequlreidj
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OFTHEABOVEDESCRIBEDPOUCiES 9H CANCELLED
THE E9WMA7ION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Town of No.Andover ACCORDANCE WITH THE POLICY PROVISIONS.
Board of Health
120 Main Street AUTHORIMREPRESENTATIVE
Andover, MA 01845 %V _/ _L.x C40— —
��G�! ®1988 2014 ACORD CORPORATIOM All rights reserved
ACORD 25(MUMS) 1 of 1l The AC ORD name and logo an6reeistered marks ofACORD
dS522977MA522976 MT001
—-—---------
NUMBER
ORT4 COMMONWEALTH OF MASSACHUSETTS BHP-2011-0729
North Andover FEE
$100.00
—-----------
BOARD OF HEALTH
IS A WINDRUSH FARM THERAPEUTIC EQUITATION, INC.
-------------------------
------------------------------- ------------------—---
NAME
470 LACY STREET
-------------------------------------1111------------ ------------------------------------------------
ADDRESS
IS HEREBY GRANTED A PERMIT
Trench Permit
This permit is granted in conformity with the Statutes and ordinances relating thereto, and
expires ...........September 13, 2011 unless sooner suspended or revoked.
-------------------------
June 14, 2011 -------------—------------------------------ ------------ BOARD OF
------------------------- --------------- ---- HEALTH-----
--------------------
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Public Health Director "t
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COMMONWEALTH OF MASSACHUSETTS NUMBER
BHP-2011-0729
0 North Andover
FEE
BOARD OF HEALTH $100.00
—go A
ACKU, WINDRUSH FARM THERAPEUTIC EQUITATION, INC.
--------------------------------------------------------------------------------- --------------------
NAME
470 LACY STREET
------------------I----------------------------------------------------------------------------------------------
ADDRESS
IS HEREBY GRANTED A PERMIT
Trench Permit
This permit is granted in conformity with the Statutes and ordinances relating thereto, and
expires ...........September 13, 2011 unless sooner suspended or revoked.
------------------------------
--------------------------------- -------------
BOARD OF
June 14, 2011
------- HEALTH
---------------- ---- ------------
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----------------------- ----------------------------- - -------
Public Health Director
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