HomeMy WebLinkAboutHealth Permit # 7/30/2008 Commonwealth of Massachusetts map-Block-Lot
0 104.B-0084-
Board of Health -----------------------
Permit No
P.I. North Andover BHP-2008-0167
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F.I. FEE
$250.00
Disposal Works Construction Permit -----------------------
Permission is hereby granted Mike Reilly
to(Repair)an Individual Sewage Disposal System.
at No 275 RAY MEADOW ROAD
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as shown on the application for Disposal Works Construction Permit No `B, D July. 0 0
P �V Da 30,2008
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Issued On:Jul-30-2008 0
- ----------------------------------------------------------------- �B o AdV"#f 46-6jjh�
� a III tl n r tl I r Y t a� N �"'
� TODAY'S DATE
Construction Permit — TOWN OF
�Y ���4 $250.00®Fun Repair
� k �
$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 [:]'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 c y Information
key. A. Facility F Po
/1 t Zp .. �
VU141 A ddress or Lo #
City/Town
2.° YPE OF SEPTIC SYSTEM*:
E Pump ❑ Gravity(choose one)
***If pump system, attach copy of electrical permit to application***
® C nventional 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 (D-Sox Present) S.A.S.
2. Owner Information
Name
Address(if dill ent from above)
CtVuo i Y?I State D.-. U 6 t
Zip Code
Telephone Number
3. Installer Information
Name
Name of Company
a01" Or
Address
1 ;H Ao
City/Town state Z
PF ,, ".. d 3 p Code
/
( ' ( 5
Telephone Number(Cell Phone#if possible please)
4. Designer Information p
Name Name of Com an
Address
Add �a " ? `, a i Y °t
City/Town State Zip Code
.22
Telephone Number(Best#to Reach)
Application for Disposal system Construction Permit Page 1 of 2
ion for tl ' ' stem 16,
TODAY'S DATE
tl onstruction r
It - TOWN OF
01845 $ 2510.00®Fail Repair
$125.00 Component
PAGE 2 OF 2
A. Facility Information continued....
5. Type of ac inCt: El&sidential 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
Y
oard of Health.
been rssu
Name Date
Applic l„oh Approved By: ( oard of Health Representative /
p '” r
Ml Date
p lication Gisa p roved f "r the f allowing reasons;
For Office Use Only:
1. Fee Attaclied? Yes No
2. Project Manager Obligation Form Attaclied? Yes No
3. Pump Svstein, If so,Attach co_ay ofElectrical Permit Yes I No
4 Foundation As-Built?(now construction ronl y); Yes No
(Saine scale as approvedplan)
5: Floor Plans?(new construction only): Yev_ No
Application for Disposal System Construction Permit•Page 2 of 2
SEPTY-' SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS
As the Mort i Ando-ver licensed installer for the constmction for the sq)tic sysre.m for the property at:
a ' �
Gi'��, r J r'r'-/ �'
� �
--
0
Relative to the application of
ti, lallrr r-n:�o,c) And iarc;l tl(iJ �> ���
Dated J �Ll
I understar.d the following obligations for management of this project:
I. As t e installer, I am obligated to obtain all permits and Board of HeJth approved pLuhs prj(Ar to
pert rmi lg a p,work on a site. I must have the W oowred pl;tnti and 'he hPrillit<ln si e hen ,Lai,yvor}� is
be done_
G. As t xe installer,I must call for. mii acrd ill) 'llspet fJ.()dls. If ilor c )\\'nf'r, i,C}rlCr]CCOY, I�r())eCl iniln:l«7, (a l':lI)r
Othe person trot associated tiwith nlv company schedules an lris>?ection ;end t1w system is riot ready, then
item three shall be applicable.
1 As die installer:, I mn redL>;red to have the necessary work conlpteied prior to the applicable inspections as
indicated beicyo,. T understand J ion o!'tl itr_�ns iritccoedance
with Title 5 awd the Board of f le;ltth Re rularinns n�lay resulr_�i� .1 t(i.{)U 6rle being levied a insr me stud/4r
m? m 111
Bottom of Bed—Geaeraily, this is the first (1")inspection unless there is a retaining wall, wl-ich
should be done first. Jlie installer must request the 111Spe.cTi(:nl hrrt 60CS not lhav-e to be present.
1 . Final C-onstructioi! WVec. n— Enl;ineer must first do then inspection for elevarioos,tits,etc-
As-builr of verbal OIL (or e-mail ro: h��;t[tl�rlc-�tlt�'.rtwvsx�tnrtrtli:)f)�(�r cr..c�lni) from the engineer must
be submitted to the Board of I-leJda,after which uhstallter calls €ur an u1<pecticln tine. Insialler must
be present for this inspection. With a purhth ',111 del trJull work m st be read)- ;acrd able to
cause pump to work and alarm to fitnctiou.
Final Grade—Installer thanst request inspcclion when all gradinl;is complete. .htsfialler dr�?es nor
have lii be on--site.
4. As flie installer, I understand that only I may perforrri the vvrota; :and I am required
to complete the installation of the spsrem identified in the attached applicarion for inst'Alarion. I Ea-r her
In , and th a hr r�ctne In others unlic<t1sc�1 to lust rll ,��U!'s terC)5 in North Ancio\ c;�n_cnattitutr:
reasons for denial of the s�-stern—and/or revocation or of m">lice"Se ro s��arf(sh the Town of
r hAndoy rsivnificani fires to a lldhersnn.�; involy'_4�stet to oIx�S il>le.
5. As t e installer,I understand that I must be on-situ during the perfo:thh-tance of Ole. follow la',',construction
step.:
Determination that the prop6r elevation of the excavation has been reraehed.
1. Inspection of the .rand and stone to be used
Final imoection by Board of Health xtraff or consultant.
Installation of tank, II-Box,pipes, stone, vent, paaraa]) chamber, retaining wall and other
components.
6. As the installer.I understand that I ;lm soldy for the installation_of lh( sy"swtn wS Oer the
a d tans. No irtstr 14c'ti�r ; E, the h<rrrn<i��-rtenral r�ti#r,�.t,c?r_ t. � e;�ti��rcr,c�ns �h rll�hl �l1
this ol7li�tti�.
Undersigned Licensed Septic Installer:
r .,11u
atlhe 1'r1 at) I\,uhtc.
Z-d d£O7-0 80 6L Inr
Commonwealth of Massachusetts Official Use Only
Permit No.
Department of Fire Services
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 leaveblank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
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) Date: V A l
City or Town of: NORTH ANDOVER To the Insr f Wires:
By this application the undersigned gives notice of his or her intention to perform.the electrical work described below.
Location(Street&Number)
" Telephone No.
Owner or Tenant �M.47'Z31�
,�ba°
Owner's Address lYI
Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box)
Purpose of Building =Z{Z� _ �lL�— Utility Authorization No.
Existing Service Amps /, / ,Volts Overhead ❑ Undgrdc❑1 No.of Meters
New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters
Number of Feeders and Ampacity _
Location and Nature of Proposed Electrical Work: i�iiG 9`yJXJ ,etc)o /}/ /�il� G/n ✓��S
completion of the followin table mav be waived by the Inspector of Wires.
No.of Total
No.of Recessed Luminaires No.of Ceil.-Susp. (Paddle)Fans Transformers KVA
No.of Luminaire Outlets No.of Hot Tubs
Generators KVA
Above In- o.o mergency ig ing
No.of Luminaires Swimming Pool rnd. ❑ rnd. ❑ Battery Units
No.of Receptacle Outlets No. of Oil Burners FIRE ALARMS No.of Zones -
No.of Detection and f
No.of Switches No.of Gas Burners Initiatin Devices
Total of Alerting No.of Ranges No. of Air Cond. Tons No. g Devices
® Heat Pump Number Tons KW No.of Self-Contained
No. of Waste Disposers Totals: Detection/Alertin Devices
Municip al Other
No.of Dishwashers Space/Area Heating KW Local❑ Connection ❑
Heating A Security Systems:*
No.of Dryers g pp liances KW No.of Devices or Equivalent
No.of Water KW Ball
No.of Ballasts of Data Wiring:
asts No.of Devices or Equivalent
Heaters Signs
Telecommunications Wiring:
No.Hydromassage Bathtubs No.of Motors Total HP y No.of Devices or Equivalent
OTHER:
Attach additional detail if desired, or ks required'by the Inspector of Wires.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: 4 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 coverages n force,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE UivD ❑ OTHER ❑ (Specify:)
I certify, under the pains and penalties of perjury, that the information on this application is true and complete.
LIC.NO.:
FIRM NAME: _
Licensee:
%zrGj� C i¢ Signature
LIC.NO.: GG
e
(If applicable, enter"exempt"in the license number line.) 6 Bus.Tel.No.: �7 ; ��
Address: U __.SC x�t {. /�//N� Alt.Tel.No.:
*Per M.G.L c. 147,s. 57-61,security work requires Department of Public Safety"S" License. Lic.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 agent.
Owner/Agent PERMIT FEE: $
Signature Telephone No.