HomeMy WebLinkAboutHealth Permit # 9/29/2010 Commonwealth of Massachusetts Map-Block-Lot
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� 104.80041
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�L Board of Health Permit No
p A BHP-2010-0733
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North Andover -----------------------
• 'aw P.I. FEE
$250.00
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DISPOSAL WORKS CONSTRUCTION T°C
Permission is hereby granted John_Soucy
to(Repair) an Individual Sewage Disposal System.
at No 855 WINTER STREET - -
as shown on the application for Disposal Works Constructi n Permit No. BHP 2010-073 ,;Dated September 29,2010
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Issued On: Sep-29-2010 �7 �l . c'- _ Bo d of Health
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N� rH Application for Septic Disposal lwlt 6
m-Construction Permit - TOWN TOD 'S DAtE
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ORTH 1�1 , ® $ 250.00—Full Repair
'� ^• $125.00 -Component
�SSACHUS��
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 ZRepair 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
key.y the return A. Facility Information
� Address or Lot#
AJ AW41 t !
clty/Town
Vi TYPE OF SEPTIC SYSTEM*:
ump ❑ 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 Dosed (D-Box Present)S.A.S.
2. Owner Information
e l �l k�&'VL
Name
Address(if different from above)
City/Town St e Zip Code
7 e( -?0, G
Telephone umber
3. Installer Information y
aCA04
Name ® Name of Compan
/t
Add ress
City/Town State Zip Code
60 j ( - -71 _7
Telephone Number(Cell Phone#if possible please)
4. Designer Information
t a` f .h ref
Name Name of Company
L 4
Address
CL
City/Town State Zip Code
7 r k�
Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit-Page 1 of 2
�W ,°0,-rJJ
Application ° r v _
N
G°� TODA DAT --
n trU ti n Permit OF
250.00—Full Repair
$125.00 °Component
PAGE 2 F
A. Facifit ion continued....
5. Type of uildinel: 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 u til a C ificate of Compliance has
been issued by this Board of(Wealth.
Name Date
Application/Approved y (Board of Health Representative)
Name . r Date —
Aoplication Disapprovdd for the following reasons:
For Off ice Ilse Only. /
1. Fee Attacbcd? Yes�/ ��' No
s�
2. Project Manager ObEgation Form Attached'. Yes � � No
.3. 1'11,0112 Sys tern? If so,Attach copy ofFlectrical Peillsit Yes Na
41. Foundation As-Built?(new construction ronly): e� No
(same scale as approved plan) ,...., 'm
5. Floor-Flans?(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;
(Address of septic s sic cn' For plans by (� cca- d/ G '►
(.: } y' )
/ � )
Relative to the app'cation o toy
(Installer's name) And dated '22,711c)
Dated l
oc.,ry s c atx, With revisions dated
(Last re(sed ate)
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 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 (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: healthde )t i.)tc r\vnof'nc:>rt:lrandrave,r.cuo9 z) 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 than 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, p pes, 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 y plans No instructions by the homeowner, general contractor, or any other persons shall absolve
me of this obligation.
Undersigned Licensed Septic Installer: r c:day's Date)
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TOWN OF NORTH ANDOVER Permit Number
NORTH ANDOVER,MASSACHUSETTS 41845
µDRfH Date Issued
Expiration Date
x � �
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MR"SACHU°`�
Jackie's Law — Permit Application
Pursuant t0 G.L. c. 82A §1 and 520 CMR 7.00 et seq.(as amended)
THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION
Name of Applicant -- Ph Cell a
717
Street Address
/Town MA I ZIP
Name of Excavator(if different from applicant) Phone Cell 5416
Street Address
City/Town I MA I ZIP
Name of Owner(s)of Prope Phone , Cell
Street Address (
City/Town MA ZIP
Other Contact 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 lines etc..)Please use reverse side if additional space is needed.
Insurance Certificate#:
Name and Contact Information of Insurer:
K e 1
Policy Expiration Date:
Dig Safe
Name of Compe ent Person(as defined bjr 520 CMR 7102):
Massas Hoisting License#
1 chu -� -� ,
License Grade: Expiration Date:Wj 7
l
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. 82A,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 R PROPERTY DURING THE WORK CONDUCTED UNDER THIS PERMIT.
PLI,ANT SIGNAT +
C I DATE
F&VATOR SIGNATURE DIFFERENT)
DATE /
01{11 R'S SIGN TURE(IF DIFFER NT)
': G
DATE: f
r' 2 I P a g e
The Commonwealth of c�chusetts �� Only
P.rmrt No.r �"
Department of Public Safety
ooeuPaICY&Fee Chacked
V (leav�a blank)
ELECTRICAL
Cooler 527 CMA 12;00
Date d � ....................
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TOWN�"q,y �p ry��,,�p H , p�0V R �ate ��"`��'. �,,.,.�..,,.,w...tf.. /"� r'"'C.7,fG�
5 'd.YrhP�gW(wM%"F0'"AP"%t�Nwi W,y tlA i�o-U"C
e jAoRT" HEA C"I°°i DEPARTMEN'T' To the Inspector of Wires:
PERMIT FOR WIRING
Tip
s�cwus�
,A
Appropriate 'ox)
This certifies that .......'
�ndgrd thoriz7tion No.
has permission to perform , �:': .... � r::': . IJ No.of meters
wiring in the building of .... :::: °. :......... g No.of Bete .
�:.... ..... ,. Jrtd rd
. .
{ at ... � ... N o rth Andoyer,Mas�s�
Tee ..:... Lic.
0 ELEcrRICA0I SPECCOR
Total
Check # r: ;o,of Transformers" r KVA
- iN
eneratorsA
roit4of mgency Lighii�
U
No.6f.Switch Outlets � No.of teas burners _ - EIRE ALARMS o,of Zones
No.of Ran es C l+lo.of Deteotio nd
9 No.of Air Cond, tons Initiating Devi
Heat Tot Total
No.of Disposals No.of Purn s T s KW No.of Sou ing Crevices
No.of f Contained
No.of Dishwashers / Space/Area Heatin' I(W Det on/Sounding Devices
M nicipal
No,of Dryers �� Heating Devises KW Connection[:]Other
No.of Water ters pW No.of No,of !Low Voltage
SI ns Ballasts Wprin�
No.Hydro Massage Tubs No.of Motors + Total HP
OTHER:
INSURANCE COVERAGE: Pursuant to the requirements of Massachuestte General Laws e
I have a current Liability Insurance Polley Including Completed ons Coverage or its substantial equivalent. YES Ii No
I have submitted valid proof of same to this office. YES '— NC p
It you have C ed YES,please indicate the typo of coverage by cheching the appropriate box.
INSURANCE 0; "I OND 0 OTHER El (Please specify)
�, � (Expiration Date)
Estimated Value of Electrical Work
Worts to Start
Signed under the penalties of perjury:
FIRM WhAE 4` ! LID.fdC. 7H
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✓x
LIC0115 Signature
pC 7
Address ~ `A Bus Tel,4�0 (�
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage or its substantial equivalent as
required by Massachusetts General taws,and that my signature on this permit application waives this requirement.
Owner 0 Agent EJ (please check one)
Telepho
(Signature of r )
A nm No.. PERMIT FEE S ---� _