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Home My WebLink AboutHealth Permit # 4/23/2013 o' ® � rtsn'i�� , Commonwealth of Massachusetts Map-Block-Lot • 104.D0071 BOARD OF HEALTH Permit No North Andover BHP-2013-0625 FEE $125.00 DISPOSAL WORKS CONSTRUCTION IT Permission is hereby granted Soucy's Sewer Service ---------------------------------------------------------------------------------------- to(Repair)an Individual Sewage Disposal System. at No 20 BRIDGES LANE - as shown on the application for Disposal Works Construction Permit No. BHP-2013-062 Dated April 23,2013 --------------------------------------------------------------- Issued On:Apr-23-2013 BOARD OF HEALTH _A licatl®n for pti i al t ) - ti n truct' n Permit - TOWN TO Y' DAT -- r A 014 $ 250.00—Pun Repair CHU S�' $125.00 -Component Important: Application is hereby made for a permit to: When filling out forms on the El Construct a new on-site sewage disposal system* computer,use * only the tab key ❑ pair or replace an existing an-site sewage disposal system 1( d to move your Repair or replace an existing system component—What.7 cursor-do not , use the return Y n Facility Infor atlO r A dress or Lot# REc -- _ F_IiIEMT�-?City/Town 2.- *TYPE ®F SEPTIC SYSTEM*:❑ Pump ❑ Gravity (choose one) .f.)1***If pump system, attach copy of electrical permit to application*** j 4: Ll❑ Conventional System (pipe and stone system) . -�r'TMEN ❑ 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 Name Address(if different from above) City/Town State Zip Code Telephone Number 3. Installer Information ,1 _ ,,, Name _ Name of Company Addr ss � . City/Town —�--" Statp,� Zip Code 9.. Tele one Nu r(cell Phone#if possible please) 4. Desiciner Inf rmation Nan)d Name of Company Address City/Town State Zip Code Telephone Number(Best#to Reach) Application for Disposal System Construction Permit•Page 1 of 2 pOR7}, Application for Septic Disposal System Xonstruction Permit ® TOWN OF TODA 'S ATE ORTH ANDOVER, MA 01845 $ 250.00—Full Repair �'9sSACHUSE�� $125.00 -Componen PAGE 2OF2 A. Facility Information ontinued.... 5. Type of Building:p esidential Dwelling or❑Commercial B. Agreement The unders,i ed a rees to ensure the construction and maintenance of the afore-described on-site s ge di posal system in accordance with the provisions of Title 5 of the Enviro ental C de, as well as the Local Subsurface Disposal Regulati s for a Town of Nort Andover, nd not to place the system in operation until a Certiff a of Co pliance has be n issued b this Board of alth. me Date Application Approved By: (Board of Health Representative) Name Date Application Disapproved for the following reasons: For Office Use Only: 1. Fee Attached. Yes No Z. PtojectManager Obligation Form Attached? Yes No 3. Pump Sys tem? If so,Attach copy 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 Street&Trench Opening Permit.pdf littp://www.townofiortl)andovet•.coiiVPages/FV1-00024F EC/Street&,.. Town of North Andover "RECEIVED � Pursuant to Policy & Town Bylaw Chapter 161-3 Street Excavation permit (as amended) ritG �w With PERFORMANCE BOND AGREEMENT AND "rm! N 0 N A,0 H V��RN�G��slh'�� The Commonwealth of Massachusetts 1.1E L'11 -1 1EFIA r°r "EN Jackie's Law— Trench Permit Pursuant to G.L. c. 82A §1 and 520 OMR 14.00 et seq. (as amended) PERMIT APPLICATION= t- > _Wor Trench Permit Permit Number: Applicant: r SITE EMERGENCY �� 1 �� ' Di m Safe Nuber: Date Issued: CONTAC EMERGENCY NUMBER: SECTION 1 -SITE INFORMATION-PRINTOR TYPE IN BLUE OR BLACK INK 1.1 Property Description,� r 4 ._ 1.3 l ocatl on and purpose of proposed (5 street opening and trench: use back of page if needed a Cl (ky 1.2 Ma /Parcel Number: X116qj D ;1 Sur Builder's of No: Block: 1.4 Anticipated Date to Begin Operatio s C.; C a 0..7 Begin: Awe-, I End: GIS Property ID: 1.5 Anticipated Date to conclude Operations Provided by the Town SECTION 2 m PROPERTY OWNERSHIP AND PERMIT HOLDER INFORMATION-PRINTOR TYPE IN BLUE OR BLACK INK 2.1 Owner of Record: l0 fil � a' f) ' �� 1 r� IC C'" : �, 1 � � LC} C' 9 C> N6 Printed Name & Address .w Signature � � F fT )1 hone C mr g p 2.2 Excavator Pen-nit Holder Information: ri Printed je & Add Sig to Telephone / Emergency Contact Number 2.:E avator Permit Holder Infom7ation-continued 1 1 of5 3/14/2013 1:04 PM Street&Trench Opening Pere-tpdf http://www.townofnorthandover.com/Pages/FVI-00024FEC/Strr Competent Person as defined by 520CMR 7.02 Printed Name: Massachusetts Hoisting License#: 13 3 f, I License Grade: License Expiration Date: �t 2.3 Name and Contact Information of Insurer: a 1 -T-o t)r6k.n ce- i 10 L i `i? , M(A a c-' I 4) 14 Company Name Address Telephone Insurance Certificate#: 10 L Policy Expiration Date: Whereas pursuant to the provisions of Chapter 161 Section 161-3 of the North Andover Town Bylaws, the grantee agrees to provide a plan and a bond in the sutra of $10,000.00 bound unto the Town of North Andover and an additional refundable amount of $ to assure proper performance and completion as defined in the general specifications and conditions below and as attached. By signing this form, the applicant/excavator and owner, 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/excavator 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 governing such work. The undersigned applicantlexcavator and owner 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/excavator and owner 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 durin a work conducted under this permit. In rivitne s whereof tho signed below have here unto executed this agree t. APP ANT SIGN ATUR ate EXCAVATOR SIGNATJJRE Date OWNER'S SIGNATURE(IF DIFFERENT) D to For 'yITown use-- o of write in this section PERMITAPPROVED BY PERMITTING AUTHORf`Y division of i761blic as Date 2 of 5 3/14/2013 1:04 PM