HomeMy WebLinkAboutHealth Permit # 4/16/2010 "ORTH Commonwealth of (Massachusetts Map-Block-Lot
Qa 14, 107.A0037
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®
Board of Health PennitNo
• North Andover BHP-2010-0552
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P.I. FEE
$250.00
F.I.
DISPOSAL CONSTRUCTION IT
Permission is hereby granted John-T. Shaw,III
to(Repair)an Individual Sewage Disposal System.
at No 163 FARNUM STREET
as shown on the application for Disposal Works Construction Permit No. BHP-2010 055 Dated April 16,2010-------
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Issued On:Apr-16-2010 Board of Health
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�� �I � � SIC
* TODAY'S DATE
oWConstruction Permit — TOWN
a $ 250.00—Full Repair
$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
key the return A. Facility Information
Y
/ �, .� ,Cot✓r/ 11 -j�/-
r�h Address or Lot t#
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)
alnfiltrator 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-Sox Present)S.A.S.
2. Owner Information
Name /
Add^re/ss(if different from above)
City/Town State Zip Code
Telephone Number"? 4 /Z)
C7,
3. Installer Information J
C.�Lw. �� °'y!✓�E" ���"* %1�1 d'�r,�a,✓'�� ' +'� ,,?" ,rr�r�F��n /(r ^� Fv,�6,i f�'.
Name Name of Company
Address
City/Town State Zip Code
; 1 V,-///
Telephone Number(Cell Phone#if possible please)
4. Designer Information
Name Name of Company
Address ,� r
City/Town' State Zip Code
Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit•Page 1 of 2
0.4 r , t stem
*1 TODAY'S DATE
Construction Permit - TOWN OF
ORTH $250.00®Full Repair
° $125.00 -Component
C `
PAGE 2 OF 2
A. Facility Information continued....
5. Type of Building: Residential 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 Cade,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
p rid,of Health Representative)
pp on roved �y. (Boa
A licatl
w
Name` ,my ._. M. Date
Application Disapproved for the following reasons:
For Office Use Only:
1. Fee Attached? Yes No
2. Pro'ectMana er Obligation Form Attached? Yes . No
3. Pump System? II'sa,Attach copy ofElectricalPelmtt Yes No
4. Foundation As-Built?(new construction ronly): Yeses No
Game scale as approved plan)
9. Floor Plans?(new construction only): Yes ��F No
a
Application for Disposal System Construction Permit o Page 2 of 2
SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS
As the North Andover licensed installer for the construction for the septic system for the property at:
.° 3 114,
(Address of wptic SYStem) For plans by
(l?�bp,prfceri
Relative to the application of (��� (, �m ✓ .
(Installer's name) And dated ri �
l gal date)
Dated � �
odaye s(late)
With revisions dated
(Last revised(bte)
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 n 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 OIL (or e-mail to: lie a]t�hLie nttJ town()fn,o tlnan(loyer.cc>rsa) 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 119an sinyple evcatel ion)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 . 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 staffor cons uhant.
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 an other ther persons shall absolve
me of this obligation.
Undersigned Licensed Septic Installer: (1 oday's Dale)
/ 7
atn]c Print)
Department f it Services Permit No.
Y
BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked
[Rev. 1/07] (leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(MEC), 27 CMR 12.00
(PLEASE PRINTININK OR TYPE ALL INFORALMOA9 Date: r
City or Town of: NORTH ANDOVER To the I ect r of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street&Number) 191 A
Owner or Tenant p _ Telephone No.
Owner's Address
Is this permit in conlu�action with a building permit? yes ❑ No 2---" (Check Appropriate Box)
Purpose of Building S 6_t _ � Utility Authorization No.
Existing Service 160 Amps C / ? Volts Overhead [Undgrd❑ No.of Meters
New Service Amps / Volts Overhead❑ Und rd
g ❑ No.of Meters
Number of Feeders and Ampacity
�Location n N_a.#u_r e,n.f-p *�• :,..u_.: n -, > ..
�®ice
Ilowin table may be waived b the Inspector of Wires.
Date......:.:.... ;.:
No.of Total
Transformers KVA
NORTH Generators KVA
3?0��,��•�„•��oo TOWN OF NORTH ANDOVER o.of mergency Eigliting
O p
PERMIT FOR WIRING Battery Units
F
., y F” E AL_asRPvIS No.of Zones
°, • ''��' No.of Detection and
SS/ICMUSEt� - Initiating Devices
r��
No.of Alerting Devices
This certifies that ...i....' .......... .. 1 :j`' �. . No.of Self-Contained
Deteetion/Aler•tin Devices
has permission to perform i'' Local❑ Municipal
Connection ❑ Outer
wiring in the building of.. ...•...•• ..... Security Systems:*
No.of Devices or Equivalent
............ ' .'?...'. ?.................................... }North Andover,Mass. Data Wiring:
No.of Devices or E uivalent
' Telecommunications Wiring:
j° Fee....................... Lic.No.....:r::r :y .. ............ f bC' RiceL INSPEC QR No.of e
Devices or Equivalent
Check #
if desired, or as required by the Inspector of Wires.
nicipal policy.)
�' 1 - ........ wadi MEC Rule 10,and upon completion.
--•--- .t..�.�.r»r:
'Unless waived by the owner,no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance '!Drluding "completed operation"coverage or its substantial equivalent The
undersigned certifies that such c�O�� e, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE OTHER ❑ (Spec ify:)
I certify, under the pains and penalties of perjury, that the information on this application is true and complete.
FIRM N
LIC.NO.:
Licensee: C Signature LIC.NO. `'
(If applicab e, enter "exempt"in the license number line.)
Address: ,SD s� ���c, /�t�l /�fl�' 4) � Bus.Tel.No.:97zf 973
Alt.Tel.No.:
*Per M.G.L c. 147,s. 57-61,security work requires Department of Public Safety"S"License: Lic.No.
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. PERMIT FEE: S
TOWN OFNOR.TH ANDOVER Permit Number
NORTH ANDOVER,Iv ASSACI IUSIETTS 0 18 45
date Issued
Expiration Date
"9'b`3eaWCous
�y
Jacks ' Law — Permit Application
:pursuant to G.L. c. 82.A. §1 and 520 CMR 7.00 et sega(as amended)
TIUS PE RMIT MUST BE, FULLY COMPLETED PRIOR'1[O CONSIllE RATION
Name of Applicant n Phone Coll
Street Address ` .. s r I I
City/Town ^= M11- ZIP
Name of Excavator(if different from.applicant) Phonno Cell
Street Address
Cityrrown _ I�U SIP
Piamo of dAwner(s)of Propert T
Phone Cell
Stroot Address
City/Town MA ZIP
C, V
Other Contact Permit F'e�Received No(} Yes( )
Description,location and purpose of proposed trench:
Please describe the exact location of the proposed trench and its purpose(include a description of what is(or is intended)to
he laid in proposed trench(eg;pipes/cable lines etc..)Please use reverse side If additional space is needed.
Iunsurance Certificate ; ,(7 & i �'j � Cj G ' 6 1' der''
Name and Contact Information of Insurer:
0(1/ n-
Pol!Ey Expiration Date: _ I 1 .1 L%. `�' i
Did Safe#: .2 C 2 � 0 /
Name of Competent Person(as defin4by 520 CMR 7,02):
p�zi°e,k t,)w o erg U ► h s o ru
Massachusetts Hoisting License# If ff p 03
License Grade: / Expiration Date: '
BY SIGNING THIS FORM, THE APPLICANT, OWNER, AND EXCAVATOR ALL 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 TIIEY 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 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 WORT{
FOR CONFORMITY WITH THE CONDITIONS ATTACHED HERETO AND THE LAWS AND
REGULATIONS GOVERING SUCH WORK.
THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR 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,OWNER AND EXCAVATOR 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 DURING THE WORK CONDUCTED UNDER THIS PERMIT.
APPLICANT SIGNATURE
G U� DATE Ff ' � Cf
EXCAVATOR SIGNATUI (1F DIFFERENT)
DATE
OWNER'S SIGNATURE(IF DIFFERENT)
DATE:
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