HomeMy WebLinkAboutHealth Permit # 4/7/2008 Map-Block-Lot
Commonwealth of Massachusetts 104.B-0152--------
04 Board of Health Permit No
o BHP-2008-0036
-----------
m North Andover FEE
Y P.I. —__ $250.00
- --- ----------------
Disp®sal Works Construction Permit
Jon Wh man ---------- -
Permission is hereby granted Jon- -- y----- - - -- - - ----- - --- - - - -- - -- -- - - - - - - - --- -
to(Repair-Full)an Individual Sewage Disposal System.
at No 755 WINTER STREET --- ---------------------------------------------------------------------------
-------- --------
--------- --------- - ------
as shown on the application for Disposal Works Construction Permit No. BHP-20087003 Dated April 07--- ------------
--- -----------
---- -
------
Board of Health
Issued On:Apr-07-2008 ------------------------------------------
r -
r
*� r Dis losal SyQfam
&/_5
� F TODAY'S DATE
OVE113-MA 01845
m 126.00 m Component
Important; ,Arlication is hereby Made fvt a_prmit RECEIVED
forms When filling out ❑ Construct a now on site sewage disposal stem*
forms on the p Y
computer,use Repair or replace an existing on-site sewage disposal system
only the tab key
�,r ,t � ,f
to move your El Repair or replace an existing system component—What?
I i ii VE
,
ar-da not A. Facility Information TOWN OF I t DO
ii �M ..
use the return
key. ..
r d Address or Lot# 4 - - ---
n� )f City own -------
2.-*TYPE OF SEPTIC SYSTEM*':
❑ Pump KGravity (choose one)
***If pump system,attach copy of electrical permit to application***
Conventional System (pipe and stone system)
- _
nfiltrator r 13iodiffuser(Gravel-Loss) (Attach a copy of your certificatior7 to install this type ofystelrr. }r) '
Pressure Distribution S.A.S. (No D-Box) (Attach Draft Maintenance Agreement)
(l Pressure Dosed (D-Box present)S.A.S.
2. Owner Information
Name
Address(if different from above) -
--/T
Cityawn - - State Zip Cade
Telep ions umber
. Installer Information
Name Name of Company
M
Address
-- �. - �
Cit /TTowr State Zip Code --
Telephone N umber�(Cell � ssi
�.
ble please)
4. Des icl
nor Information
--�- �`~�?-�- -`.. .� � d� 4.r,✓t~.,�. _.Wit,..
am
Narrre of Company ---_
Ad tress -
�y ,
/Town _._
Y Zip Code
Cit Stat
Telephone Number
�. � '
p (Vest tl to Reach)
Application for Disposal System Construction Permit-Page 1 of 2
SEPTIC SYSTEM INSTALLER IDRCirJ'E iC A E MEN'r OBLIGATIONS
As the North Andover licensed installer for the construction for the septic system for the property at:
e
ltlrlu�.,.aoi?ta >t4a ya„�ssri Forplan, by
Relative to tazc application of `1
4 c ,”
(Ian 1allla d,rnamc)
And dated
Dated
With revisions dated ° cx. i
(I rest ren c dot^)
I understand the following obligations for aura ernent of this project:
1, As the installer,I a.rn obligated to obtain all permits and Board of Health approved plans priior to
performing any warp on a site. I na st kre 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 ta.rad .q,ncl that xec srira an inspection,withc7ut completion of the items in accordance
with Title 5 and the Board of 1- AL ate ut t ons may result in a$50.00 fine being levied against me and/or
mY,coMM"ny
a. Bottom of Tied . Generally, this is the first(15) 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. lFingl CogQtructiopL nspec ion—Engineer must first do their inspection for elevations,ties,etc.
As-built of verbal OK(or e-mail to: lta u114a<;le: ( ?t�;�ny�j,,C:�r.��r 11�trial„ov x cot.i) from the engineer must 11
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 purxrp to work and alarm to function.
c. Fina1_C rr dg—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 (otherthan simple excavation)and I am required
to complete the installation of the system identified in the attached application for installation. I further
understand thatvark dance bV al'lsrs unlicensec_ta install septic systems in North Andover can constitute
reasons fcr dpni of tlrc systcn ar cl ar,reyocat on or su ensian of my license to operate in the Town of
tlorth Andover W si nific arxt n_es t _l.l ersons 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.
e. 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 instate inderstand that I awn scely respansilale far the installation of the system as per the
approved pl_ ._. o insstr uctions by the lomeowner. general contractor,or any other persons shall absolve
nre of this ob—(7n.
Undersigned Licensed Septic Installer: rcl
,.:.
Ym' (l'�l,arty a, �.kz�,i M c )�,lw.
( rats ac. t[raP ,... r.
"ORYN Commonwealth of Massachusetts Map-Block-Lot
104.B 0 15 2
ti
Board of Health Permit No
149.
BHP-2008-0065
North Andover -----------------------
P.I. FEE
,S,qc US F.I. -----------------------
Disposal Works Construction Permit
Permission is hereby granted Jon-Whyman--------
------------------------------------------ ---------------------------------------
to(Repair)an Individual Sewage Disposal System.
at No 755 WINTER STREET
as shown-o-n-the-application for Disposal Work s-Construction-Permit-No.----BHP--2008-006 Dated M-ay-01,200-8--------
--------------- -------------------
I-ssued-On:--May-01-2008------------------------------------------------ Board of Health
Q� WOB VT X16�N 19M I for Septic I �I, /w »..✓'
°a, eo TODAY'S DATE
Construction Permit - TOWN OF
° $ 250.00,-'#ull Repair
ORTH ANDOVER. MA 01845 $ ,256 Component
�$ACH
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 o
to move your ❑ epair or replace an existing system component—What?
cursor-do not
use the return
ey. �A. Facility Information
1 2 F 5,"
rab Address or Lot#
City%Town
2.- *TYPE 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 Biodiff user(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
i:-
Name - - - -
Address(if different from above)
---- ------ --
City/Town State Zip Code
Telephone Number
3. Installer Information
yuv�iA 0 asp i 'f !r w..r. t J
Name Name of Company
l
Address .`7 �
--- - --- ---
City/Town State Zip Code
Telephone Number(Cell Phone#ifpossible please)
4. Designer Information
... .
Name,_ Name of Company
(<m t of
- - — --- ----- --------
Address - -
City/Town State Zip Code
q
Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit•Page 1 of 2
o� 00 pr a Applica ion for I I 1
�� °`A `'r°o� TODAY'S DATE
Construction Permit — TOWN OF
ORTH ANDOVER, MA 01 45 $ 250.00® Full Repair
°hAY.°�rPv i°i $125.00 -Component
CHUSEK^l
PAGE 2 OF 2
A. Facility Information continued....
5. Type of Building: 12Residential 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
beep" ed by t �s Board of Health.
Ana
Name Date
Applicatip'n.Approved By: ( oard of Health Representative)
r rZ
Application Disapproved for the following reasons:
For Office Use Only:
1. Fee Attached? Yes �s No
2. Project Manager Obligation Form Attached.? Yes No
3. Pump System? If so,Attach cop.v ofElectrical Permit Yes No
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 SYS"T"EM INS"T"ALLER PROJECT" MANAGEMENT OBLIGATIONS
As the North Andover licensed installer for the construction for the septic system for the property at:
'i"_5( .
For plans by
(,Wdra.ss of ta< ,5y saran) (1:ragisaa.�a°)
Relative to the application of s nllcr ivVlo s col 3-C F _
(zJ r1 02J
a e)
And dated
n;arM�
t 191Y1&a G'<ate
Dated 2.. ...t':� >
way s date) With revisions dated
(Last ae:°Ntsed 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
m-y company.
a. Bottom of Bed—Generally, this is the first (1'r 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: from the engineer must
be submitted to the Board of Health, after which installer calls for an inspection tithe. 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 systern 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,pipes, stone, vent,pump chamber, retaining wall and other
components.
6. As the installer, I understand that I am solelL responsible for the installation of the system as per the
approved plans. No instructions by the homeowner, general contractor, or any other ersons shall absolve
me of this obligation.
Undersigned Licensed Septic Installer: ?_ 0 �; ("Today's D te)
;ttnc°° - Print) atni:
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O O
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o�Ea +•• � p }'� 4
ohM01 rrk U
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER,MASSACHUSETTS
I Date rat l 20 b
tt ', ''' �w l �
Building Location � �� W ���`�/1- Owners Name ( M0 re-- Permit#
Amount
Type of Occupancy 1 S 1
New 0 Renovation 0 Replacement Plans Submitted Yes No
FIXTURES
Lo
a. v
a
IDl14.AffA7.1u11r .
M1111O
MR M _
3-R
4M HDM
5M 1111M F -
6M RfM
7M RDM
gmRDM
(Print or type) 1 ' `� Check one: Certific TF;..
Installing Company Name W_.� CL A C O VV 5 F-1 Corp
Address S rd Cry a Partner.
Li A,4ze.U M A ,
Business Telephone '7 g 1 33 L( Z3 Z3 �irm/Co.
Name of Licensed Plumber: C-%-+/V
Insurance Coverage: Indicate the e-ofinsurance coverage by checking the appropriate box:
Liability insurance policy Other type cof indemnity Q Bond
i
Insurance Waiver: I,the undersigned,have been made aware that the licensee of this application does not have any one of the above
three insurance
Signature Owner El Agent
I her)'by certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the
best dF my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts State PI bmg Code and Chapter 142 of the General Laws.
Y: Signature 5717censea PRIME=
Type of Plumbing License
Title 5 -L 00 5-
City/Town �cense um er Master Journeyman
[APPROVED(OFFICE USE ONLY
DelleChiaie, Pamela
BREMEN=
From: DelleChiaie, Pamela
Sent: Wednesday, April 02, 2008 4:10 PIVI
To: Serwatka Joe (E-mail)
Subject: FW: 755 Winter Street- Septic Plan Approval
Joe,
Please renlind ,lon Whynian that fie needs to now apply, for a DWC permit and send check with tile $250.00 fee
(applications on our Nvebsite)to move oil to the next step. Thank you.
Pamela
-----Original Message-----
From: DelleChiaie, Pamela
Sent: Wednesday,April 02, 2008 4:05 PM
To: Serwatka Joe(E-mail)
Subject: 755 Winter Street-Septic Plan Approval
-----Original Message-----
From: noreply@yourcopier.com [mailto:noreply@yourcopier.com]
Sent: Wednesday,April 02,2008 5:02 PM
To: DelleChiaie, Pamela
Subject: Message from KMBT-600
SKMBT600080402
16020.pdf