HomeMy WebLinkAboutHealth Permit # 10/16/2006 Map-Block-Lot
Commonwealth of Massachusetts
107.d-0006-
0 Board of Health -----------------------
Permit No
BHP-2006-0694
North Andover -------------------
FEE
$250.00
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Disposal Works Construction Permit
Permission is hereby granted ----------------------------------------------------------------------------------------------------------------
to(Construct)an Individual Sewage Disposal System.
at No 365 BOSTON STREET
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as shown on the application for Disposal Works Construction Permit No. BHP-2006,-06-9? Dated October 16,2006
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Issued On: Oct-16-2006
Board of alth
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,°R7H Application for tic Disposal stern i
oF� ao „.14, Application
0pConstruction Permit — TOWN OF TODAY'S DA YE
ORTH ANDOVER, MA 01845 $ 250.00— Full Repair
�sSACHUS $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
key. A. Facility Information
Address or Lot#
F n City/Town 4i"4/
2.-J`"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 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
s. Ins% Iler Information
Name Name of Company
-S TCv9 124
Address
City/Town Sta e
Z)09
Telephone Number(Cell Phone#if possible please)
4. Designer Information i
��eme Name of Company
l
Address
City/Town State Zip Code
Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit^Page 1 of 2
, T,., effi ---
b �o TODAY'S DATE
Construction Permit — TOWN
4 $ 250.00—Full repair ORTH $125.00 _Component
SA U'��
PAGE 2 OF 2
A. Facility Information continued....
5. Type of uildin : PResidential Dwelling or F�Commereial
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 E'oard o He lth. ✓ J
Name Date
I
A pp lication pp roved Ely: (Boa f Health Rep
resentat�ve)
.
� - � ---- ---
Name, � f Date
Application Disapproved for the following reasons:
For Office Use Only:
Z Fee Attached. Yes f No
2. Project Manager Obligation Form Attached? Yes_"" No
3. Pump system? If so,Attach copy of Electrical Permit Yes No
4. Foundation As-Bllilt?(new construction ronly): Yes „' No
(Same scale as approvedplan)
5. Floor Plans?(new construction only): Yes No
Application for Disposal System Construction Permit^Page 2 of 2
SEPTIC SYSTEM INSTALLED PROJECT MANAGEMENT OBLIGATIONS
As c North Andover licensed install er for
the construction for the septic system for the property at:
0
(Addrcss of septic systcm) For plans
y
(Engineer)
er
Relative to the application of �"' � 'd�a�t�° �.�� ��r '(��°��
(Installer's lialne) And dated 1-12 I-1
r
(Original at
Dated aa ay sTc� Wi h r e i n n s 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 ts i•nor to
performing any work on a site. I must have the approved plans and the hermit 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: healtb,,c: t u u n;<rlrn >t°t➢? ,z:c#4� rer c ct mx) 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 silvple eveawlim)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. Finalinspection 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.
Undersigned Licensed.Septic Installer: (:I"odaV's l)ate)
acme rant (Name ._..., tlnnec.
�.
Date ... °:...... ....
pORYI{
oar, .o
.,p ,,�tio TOWN OF NORTH ANDOVER
� ,ya
° p PERMIT FOR WIRING RECEIVED
tl OCT
TOWN OF WWII ANE)OVER
H ..T H D o.P f.�R M
This certifies that ,... . .. . _. .
try f
has permission to perform .. ; ....... ......................................
wiring in the building of
....... r ............ ...........,..
............ No rthAndover,Mass.at a
.....,,. .... ....
Fee �° r� Lic.No.,�.�.a�< � �, �,.. � .. .........
ELECTRICAL INSPP,&rOR r
n
Check b
r1 t '
Commonwealth of t Official Use Only
- Department of Fire Services Permit No.
x BOARD OF FIRE PREVENTION REGULATIONS [R v 9//05]Y and Fee Checked
leave blank)
APPLICATION I ELECTRICAL
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:City or'Town of. NORTH ANDOVER o � "�M�i By this application the undersigned gives notice of his ar her intention to perform t e d scribed below.
Location(Street& Number) (� O 0VI Ll(,Xt,l' 1
Owner or Tenant �� �� C caL c, o o'R „n 'e epho e No.71-.7U-1uy
Owner's Address (�, c. OWN OF NO&���i�l�t :��:DOVER
Is this
Buildingjunctio�n�h a building mit? Yes Utility Authorization g p ""_ .-""."°" ropriate Box)
��_ Y on No. 1 q�flvCJ�
Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters
New Service , J Amps (ZU/ LLO Volts Overhead �
rd Und g No. of Meters �—
•.
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
Completion of fire fol able ma be waived by the Inspector of Wires.
No. of Recessed Luminaires 4o No.of Ceil.-Susp.(Paddle) Fans 0.0 ota
Transformers KVA
No. of Luminaire Outlets No. of Hot Tubs Generators KVA
No. of Luminaires Swimming Pool Above ❑ n- ❑ o. o +mergency Li g mg
rnd. rnd.
2!qay Units
No. of Receptacle Outlets eF�C) No.of Oil Burners FIRE ALARMS No.of Zones
No, of Switches Initiati No.of Gas Burners Z- o. o Deteni!D and
Devices
No, of Ranges No. of Air Cond. Tota /
�- Tans b Na.of Alerting Devices
No. of Waste Disposers ea Tot Ip _umber Tons o.o el - ontame
Detection/Alertin Devices
No, of Dishwashers i Space/Area Heating KW Local unicipa
Connection Other
No. of Dryers Heating Appliances KW Security Systems:
o, o titer No,of Devices or Equivalent J
a
Heaters \ KW o Si ns Ballasts Data Wiring:
No.of Devices or E uivalent C
No. Hydromassage Bathtubs r, No.of Motors Total HP I a ecommunications Wiring:
OTHER:
No.of Devices or Equivalent 4 ,
41tach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start:�_2 2L-0 0 Inspe tions to be requested in accordance with MeEC 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 coverage is in force,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE Er- BOND ❑ OTHER ❑ (Specify:)
certify,under the pains and enaffies of perjury,that the information on this application is true and complete.
FIRM NAME: r `� T P�C ( j LIC. NO.:0-16 6Z 4
Licensee: �� w°s Signatur LIC. NO.:�7.
W'applicable)l enter "exempt"in ie license nu nber lin
4�7 ("r'` 1 1 y 1C Bus. Tel. No.:7f/-2-?.2-(f6
Address:
x -- Alt. Tel. No.: ??6-ti0?:fn2
*Security System Contractor License required for this work; if applicable,enter the license number here:
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
Signature Telephone No. PE1�MI7'FEE. $
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