HomeMy WebLinkAboutHealth Permit # 8/13/2009 pORg6y
Commonwealth of Massachusetts Map-Block-Lot
107.D0079
Board of Health
r w Permit No
North Andover BHP-2009-0650
P.I. -----------------------
0.
F.I. FEE
$250.00
-----------------------
DISPOSAL WORKS CONSTRUCTION TT
Permission is hereby granted peter Breen
to(Repair-FULL REPAIR)an Individual Sewage Disposal System.
at No 506 BOSTON STREET
-- ------- - --------
--------- - - - -- - -
- --- --- ------- ------------------
as shown on the application for Disposal Works Construction Permit No. BHP-2009-065 Dated August 13,2009_
----
R,
Issued On:Aug-13-2009 ----
------------------------------------ ------------------------ oard of Health
OR jj
1p lip tI ri for tip 1
� D tructi n Permit — TOWN TODAY'S DATE.
4V NORTH ANDOVER MA 0184 $ 250.00-,Full R 'pair
�1sspcwus .I2-6.00 Ccrn0onent
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 kethe return
y. A. Facility Information
y w,
C.
. tl.,,...�, ,.......�....
r 4 woo
rad Address or Lot#
--
City/Town
2.- *TYPE OF SEPTIC Sl(�TEfWI : r� t r l w��� i l i ANDOVER
I I T n�n t FIAR rMBI t
®4"ump ❑ Gravity (choose one)
***If pump system, attach copy of electrical permit to application***
EZ 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
---
Name �lr'_ �— -- -
Address(if different from above)
------- ----
City/Town State Zip Code
- - -------- ----------
Telephone Number
3. Installer Information
C�C u
Name Name of Company
Address
- - --
City/Town State Zip Code
_ . 6 cal
Telephone Number(Cell Phone#if possible please)
4. Designer Information
Name Name of Company
Address
---- - -
City[Town State Zip Code
Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit-Page 1 of 2
Ilt tl o for t9C I V t
Construction C It TODAY'S DATE —
*
i
01845 z5o.o0®Fuu Repair
1
"SSgc�ius K $125.00 -Component
PAGE 2 OF 2
A. Facility Information continued....
5. Type of By iding: DResidential 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
been issued by this Board of Health.
Name — -
") Date
A pp i ed eye ��oard of Health Representative)
I catl n pp rov
? .. x.. .
Na4-- �- -
L ----
-^- Date
Application Disapproved for the following reasons:
For Office Use On!�:
L Fee Attached. Yes °' No
2, Project Manager Obligation Form Attached. Yes Z" f^f No
3. Pump-Sys tem? Ifso.Attach colry ofElectrical Permit Yes No
4. Foundation As-Built. (new construction ronly): Yeses No
(Same scale as approved plan)
5. Floor Plans?(new construction only): Yes No
Application for Disposal System Construction Permit•Page 2 of 2
SILPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS
As the North Andover licensed installer for the construction for the septic system for the property at:
\c.6clrCss c7w,e,septic system)y) ,�..�k ,..n,
9 For plans by ? �� V (a✓ l
(1�a�girtexex�)
Relative to the application of
("Installer's nallic) And dated
Dated .._. �,� ��
rigtna date')
air ate} With revisions 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 .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 requited 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 compa%.
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 OIL (or e-mail to: hca thd�g2t,(t tLj i2(a fiiortliatl.(Iove COIl-) 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 sihiple 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, Z7-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
the of this obligation.
Undersigned Licensed Septic Installer: �s�."� Z, (E ockly's Elate)
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HP Officejet Pro L7700 All-in-One series Fax Log for
TOWN OF NORTH ANDOVER
9786888476
Aug 13 2009 8:41 AM
Last Transaction
Date Time Type Station ID Duration Pages Result
Aug 13 8:41AM Fax Sent 89786898740 0:28 1 OK
("onif"Tfon wealth of " 5;achusetj @� Official T Ise Only
_ > Department of Fire Services- Pen-nit No.
Occupancy and Fee Checked ex
<°
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leaveblanlc �
APPLICATION ELECTRICAL
All wort,to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORAM TION) Date: .-,+ W� p6
City ot• Town of: NORTH H �0�� To the Inspector of Wires:
By this application the undersigned gives notice of his or her inte�� ntion to perform the electrical work described below.
Location (Street&Number) j 6
Owner or Tenant ;��4144 K ---- -
Telephone No.
Owner's Address Is this permit in conjunction with a building permit? Ye
No ❑ (Check Appropriate Box)
Purpose of Building Utility Authorization.No.
Existing Service__ Amps / Volts Overhead ❑ Undgrd
❑ No. of Meters
L,jw Service Amps / l
Vots Overhead
— --- ❑ Undgrd ❑ No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Elects°ical Wox°l : —v f - °---
Completion of the fallowin table may be waived by the Inspector of>t"ires.
No.of Recessed Luminaires No.of Ceil,-Susp. (Paddle)Farts ° °f Total -
Transformers 101A
No.of Luminaire Outlets No,of Hot Tubs Generators KVA
No.of Luminaires Swimming Pool Above 1nW 0. a mergency Er ung
grnd. crud, ❑ Batten v Units
- No.of Receptacle Outlets No.of Oil Bur°mess —
ALAP1lf1S No.of?o;xes
No.of Switches No.of Gas Burners Ido. of IDetectii a_tn_d_
Initiating Devices
No.of Ranges No.of Air Cont. Ttt -
OAS No.of Alerting Devices
No.of Waste Disposers Heat Pump INazzrnl,�p ons 1£VF TVo. of Seif-Captained
Totals: ... ,.._ _...,
_ �TDetection/Alerting Devices
No. of Dishwashers Space/Area Heating I{W Local❑ Municipal I
Connection Other
No.of Dryers Heating Appliances KW Security Systems.*
No.of Mlater No.of Devices or E uivalent
No, of
Heaters `+T � No.of Data Wiring:
Signs Ballasts No.of Devices or E Quivalent
No.Hydromassage Bathtubs No. of Motors Total HP � Telecrixnrnunicatians iring:
----� _ No.of Devices or Equivalent
OTHER: -
tlrtach additional detail if desired, or as required by,the Inspector of FFires,
Estimated Value of Electrical Work: (When required by municipal policy.)
,Vork to Start: Inspections tOe requested in accordance with MEC Rule 10, and upon completion.
INSU .ANCE COVERAGE: Unless waived by the owner,no perxnit 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 cov rage is in force, and has exhibited proof of same to the permit issuing office,
CHECK ONE: INSURANCE ] BOND ❑ OTHER ❑ (Specify:)
P Y:)
I cer°tify, urt der th pa its and penal tes afperptry that the irtforrrtattorz on this application is true ttrztl complete,
FIRM NAI�✓IE. Cad! �/ t t/2
LIC. NO.: 41
Licensee: a l ��� 4 2�a�e,�,, C
tr \G gnatur e-- LIC.NO.:
(If applicable, enter "exempt"in the license numb r line.)
Address: — _ -17' l/(? jf� r/'i`Z, t / 0, 'C Bus.Tel.
*Per M.G.L c. 147,s. 5'7-61,security work requires Department of Public Safety"S"License: A11 L cl No.
OWNER'S JNISURANCE 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 agerrt.
Owner/Agent
Signature "Telephone No._ PEAMI-T FEE: $
Commonwealth of Massachusetts
City/Town of North Andover
r' p
s
Certificate
NO Form 3
I
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here, Before using this form, check with
the local Board of Health to determine the form they use.
This is to Certify that the following work on an On-Site Sewage Disposal System
Important:
When filling out ❑ Construction of a new system
forms on the ® Repair or replacement of an existing system
computer, use F-1 Repair or replacement of an existing system component
only the tab key
to move your
cursor-do not Has been done in accordance with Title 5 and the Disposal System Construction Permit (DSCP):
use the return
key. -- ----- --- —--- — —
DSCP Number DSCP Date
r� James E. -- —
Facility Owner
506 Boston Street
erum Street Address or Lot#
North Andover MA 01845
City/Town State Zip Code
Designer Information:
GrerHochmuth, RS The Neve-Morin Group, Inc.
Name of Company
Name 11/6/09
Signature Date
Installer Information:
Peter Breen
Name Name of Company
Signature Date
Use of this system is conditioned on compliance with the provisions set forth below:
The issuance of this certificate shall not be construed as a guarantee that the system will function as
designed.
Approving Authority
Signature Date
t5form3.doc•06/03 Certificate of Compliance•Page 1 of 1