HomeMy WebLinkAboutHealth Permit # 3/30/2011 Commonwealth of Massachusetts Map-Block-Lot
®, ,. •t;�"+® 106.60044
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4� Board of Health
Permit No
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« North Andover BHP-2011-0569
P.I. FEE
'�. `°•.,dr,•�'"ti`s $250.00
ACN�I �� F.I.
I CONSTRUCTION.,I IT
Permission is hereby granted James-Kellett
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to(Repair-FULL SYSTEM)an Individual Sewage Disposal System.
at No 531 FOREST STREET
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as shown on the application for Disposal Works Construction Permit No. BHP-2011-056 Dated March 30 2011
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Issued On:Mar-30-2011 Board of Health
tem
tructi n Permit — o AYSdATE
n 1 $ 250.00-Full Repair
,.
$125.00®Component
Important: Application is hereby made far a permit to:
When filling out — L] Construct a new on-site sewage disposal system*
forms on the
computer,use JE�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. tion
Facility C� 4� , M � � ..�� i�um�um� �i�� �mwiomfu �VMIPn"'�I�fWVI
1;
norm
I: i� �w� RECEIVED
Address or Lot#
p y �@ �{ y q )
A'f !;� °,p Nr.�E'A ,``^�, d/0�`'`�I�A d�A �M1.r -
,� � 6ity/Town
2.� *TYPE OF SEPTIC SYSTEM : ��¢ M T � ��I� ARTM�� T
���IAlw.�i°��� �
Pump ❑ Gravity(choose one)
�.�o
***If pump system, attach copy of electrical permit to application***
❑ Conventional System (pipe and stone system)
Infiltrator or Biodiffuser(Caravel-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)
e
City/Town State Zip Code
Telephone Number
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3. Installer Information
M
Name Name of Company /
Address
fifir ^p r,%/
City/Town State Zip Code ,.
Telephone Number(Cell Phone#if possible please)
4.
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
�1 tion for SgpIjg_Qjgp2ggL§M§LeM
Construction r it — T F TODAY'S DATE
* ORTH ANDOVER MA 01845 $250.00-Full Repair
HA $125.00 -Component
PAGE 2 OF 2
A. Facility Information continued....
5. Type of Building:,Q Residential Dwelling or❑Commercial
r`
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
b eh'
issued by this Board
of Health.
.
Name Date
Applicati n"' pproved Fly; ,�aard of Wealth Representative)
rName r Date
Application Disapproved for the following reasons:
For Office Use Only:
1. Fee Attached?__ _ Yes "
No,— ,K
2. Project Manager Qbligatrao Form Attached Yes o
3. Pump S sy tem. Ifso,Attach copy of Electrical Permit es 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 SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS
As the North Andover licensed installe for the.construction for the septic system for the property at:
, For plans U Y
° l LIV
d� 6
1lcttw,of'G7P1C �
S�C.i1CnT� o' � (l°,t1S�Itlef".P')
Relative to the application of /'`' � "�� 1 1 '
�lnwralle.z`'
s nanxcx} And dated
THgazx<t
Dated
o y s dal:e.
With revisions dated '2'_
(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 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 infection 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 OIL (or e-mail to: Ize lt;l cl )t iz)tc.rwt trfna rrth<l_ndowLi. ar-t) frotrt 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,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
ap roved 121ans No instructions by the homeowner, general contractor, or an other ther persons shall absolve
me of this obligation.
Undersigned Licensed Septic Installer: L//._ '� �� (Today's Date)
( a rne,- Print) Signed))
Official Use Only
,C\ commonwealth of Massachusetts /
Department of Fire Services Permit Na.
Occupancy and Fee Checked
BOARD OF FIDE PREVENTION REGULATIONS [Rev.9/05] leave blanks
APPLICATION ' PERFORM ELECTRI
o
All work to be performed in accordance with the Massachusetts Electrical Code(MEC),52 C
(PLEASE PRINT IN)XK OR TYPE ALL INFORMATION) hate: March 30,201
City or Town of: North Andover To the Inspector of
Y pp g t it j ni / I? w . .1 7t7m ofq�4Ct below.
ANDOVER
B this application the undersigned gives notice of his or her intention to erform the electrical war described
Location(Street&Number)
Owner or Tenant C11C Realty InvestmeaL LLC Telep
Owner's Address 76 State Street ort MA.01950
Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box)
Purpose of Building Residential Dwelling _Utility Authorization No.
Existing Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters
New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters
Number of Feeders and Ampacity
float switches and control panel•
in table may be waived by the Inspector of Wires.
No.o Total
�� Transformers KVA
Date.....A e .:.. '°,
Generators KVA
%40RY^p ® o.a mergency t7,g m
oe..... 1 4 TOWN NORTH ANDOVER Baste Units
" :~ FIRE ALARMS No.of Zones
'LOW PERMIT FOR WIRING
* z No.o Detection an
Wtiating Devices
S$ACwusE�
Na.of Alerting Devices
No.of Se d ontame
This certifies that ......
Detection/Alertin Devices
a
�,. ............. Other
. r Local❑ Muni Connection
has permission to perform ... .. f ? °J
.......... Security Systems:
wiring in the building of i� ✓ No.of Devices or E uivalent
............ ........ ........................... .
I Data Wiring.
7 at �. `� (°fit t' , No.of Devices or Equivalent
/. tdorth Andover, ass. Telecommunications wiring:
1' Fee.... ..... ; ," Lic.No. � f, ./' EECeeic Ir,s E uivalent
1 { ` No.of Devices or
Check tt 10 � 7 ril if desired, or as required by the Inspector of Wires.
milicipal policy.)
ith MEC Rule 10,and upon completion.
INSURANCE COVERACit1: unless wa,vcu„y ...« -_,__r erformance 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 cav rage is. force,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:)
I certify, tinder the pains and penalties ofpetjury, that the information on this application is true and complete.
FIRM NAME: David W Meehan LIC,NO.: 81296A
Licensee: David Meehan Signatu P if e� LIC.NO.: 8126A
(If applicable, enter "exempt"in the license nttrnber line) Bus.Tel.No.: 278-587-7518
Address: 4 MulberKy Drive Peahod .01960 Alt.Tel.No.: 975-535-4022
*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 re-
quired by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent-
Owner/Agent PERMIT FEE:$
Signature Telephone No.