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Home My WebLink AboutBuilding Permit #693-11 - 110 FULLER ROAD 4/13/2011 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION 2 � Permit NO: 3 Date Received Date Issued. l�-- // IMPORTANT:Applicant must com Tete all items on this page LOCATION rint / PROPERTY OWNER Al" /�//t°,�,.,/ /•I �,�,/ Prmt MAP NO: PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential J�E] on- Residential ❑ New Building ne family El Addition El Two or more family Industrial ❑ Iteration No. of units: ❑ Commercial Repair, replacement ❑Assessory Bldg ❑ Others: 0 Demolition ❑ Other ❑ Septic p,Well 11 Floodplain. Q Weflands. Watershed District Water/,Sewer DESCRIPTION OF WORK TO BE PERFORMED: 71*1 (Identification Please Typerrr Print Clea OWNER: Name:J1 y'.v/-P a--,/ /��. Phone Address: `�� L�� CONTRACTOR Name: A f 3 ,><'i A rfPhone: Address: 3 0 A A A.-- - 4� Supervisor's Construction License: C7 00 1111 � Exp. Date: � � Zai 2-- Home Improvement License: �IJD�j Exp. Date: Z j' • ZpJ� ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT.$12.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $_ 8�D .� , FEE: $__ Check No.: �S �v� Receipt No.: NOTE: Persons contracting with unregistered contractors do not have jes to rano fund tSi nature.of'A ent/Owner $ianatUre of contra r Location zw /uz/A A-Yo"O,' No. �'� Date Y113 b "S.0 TOWN OF NORTH ANDOVER 9 41 Certificate of Occupancy $ .:.. - � Nis Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 244 - Buiiding Inspector Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ ' I THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments N Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit th [n m. DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS ,. 4 e i e Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— For department use 1 LJ i Notified for pickup - Date Doc:.Building Permit Revised 2008mi J Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg .Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc: Doc.Building Permit Revised 2008mi ORTH TO'" of And 0 No.._( q3 . a2oil 0LAKE o dover, Mass. I 1 COC HIC HE WICK V ADRATED PP�`�J SS ` BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THISCERTIFIES THATz4..V% 1... ...�C .r- ................. .............................. .. ........................ ..................... � .... Foundation has permission to erect........................................ buildings on .....U.0........ .......f . . ............................. Rough • tobe occupied as........... .. .......... ..... ..................... . .................................................................................... Chimney provided that the person accepting this permit shall in eve respi conform to the terms of thea application on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Final Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUC STARTS _ Rough .................................................:.......................... Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. Proposal AB CARNES, INC. 30 Arrowhead farm Rd Page 1 of 1 Boxford, Ma. 01921 978-887-1431 or 781-599-9197 Mass,Builders License No.000230 Contractors Registration.No 100733 Proposal Submitted To: RONN&KATHLEEN FAIGEN Date March 30, 2011 110 FULLER RD Project Name SAME NORTH ANDOVER, MA Address 978-689-7217 We propose to furnish material and labor-in accordance with the specifications below: P Eighty Four Hundred And Five Dollars($8,405.00)Payment to be made as follows: $300.00 Deposit, Balance Upon Compl tion Notice:All home improvement contractors and subcontractors engaged in homeAuthorizimprovement contracting,unless specifically exempt from registration by provisionsSignaturof Chapter 142A of the General Laws,must be registered with the Commonwealthof Massachusetts. Inquiries about registration and status should be made to the Note:Thwn by us it not acceptedw)'hin 30 Mass.gov/licenses website. days. / ROOF PROPOSAL ® STRIP ROOF OF ALL LAYERS OF ASPHALT SHINGLES,COVER ROOF DECK WITH 15 POUND FELT PAPER. COVER EXTERIOR WALLS AND FOLIAGE WITH TARPS TO HELP PREV AGE. ® INSTALL ICE&WATER SHIEL IX FEET IDE AT LEADING EDGE ONLY, AND THREE FEET IN ALL VALLEYS AND ALL ROOF PENETRATIONS.UNHEATED AREA X&L D. ® COVER ALL PERIMETERS WITH EIGHT INCH ALUMINUM DRIP EDGE. ® INSTALL RIDGE VENT AND/OR®AS NEEDED ROOF LOUVERS FOR ADDED ATTIC VENTILATION. ® COVER SOIL PIPES WITH NEW RUBBER FLASHING BOOTS. ® REPLACE WALL FLASHING(S)AS NEEDED WITH ALUMINUM OR LEAD AT THE ADDITIONAL COST OF$25.00PLFT.WE MAY NEED TO REMOVE THE SIDING TO PERFORM THIS WORK.YOU MAY NEED TO HAVE A CARPENTER REINSTALL THE REMOVED SIDING. ® CHIMNEY FLASHING; CUT ALL EXISTING TAR AND LEAD FROM ONE CHIMNEY(S).CUT NEW REGLET WITH CARBIDE SAW AND SECURE NEW LEAD FLASHING IN PLACE W/LEAD ANCHORS. PROPERLY SEAL REGLET JOINT. PLEASE ADD$500.00 TO ABOVE PRICE. ❑ REBUILD CHIMNEY FROM ROOF DECK UP WI OR USED BRICK. ADD TO ABOVE PRICE. ® COVER ROOF SURFACE WITH CERTAiNTE ALGAE SISTANT WOODSCAPE THIRTIES. ® REPLACE DEFECTIVE ROOF DECKING WITH QOD AT AN ADDITIONAL COST OF$4.50PSQFT. ❑ COVER ROOF DECK WITH CDX PLYWOOD AS NEEDED TO REPLACE OR REPAIR DEFECTIVE DECKING,AT AN ADDITIONAL COST OF ® SHINGLES ARE TO BE STORM NAILED,(USE SIX NAILS PER SHINGLE) ❑ INSTALL SKYLIGHTS PROVIDED BY CUSTOMER,FRAME ROOF DECK AS NEEDED,PROPERLY FLASH UNITS WITH FLASHING KIT(S)PROVIDED, CUSTOMER TO PERFORM ALL INTERIOR WORK. ADD TO ABOVE PRICE. ❑ REMOVE EXISTING GUTTERS ❑INSTALL NEW SEAMLESS.032 ALUMINUM GUTTERS USING THE POSITIVE LOCKING BAR HANGER SYSTEM. ® REPLACE DEFECTIVE OR ROTTED TRIM BOARDS AS NEEDED WITH#2 PINE PRIMED,ADD$15.00 PER FOOT TO ABOVE PRICE. ❑ INSTALL NEW ALUMINUM DOWNSPOUTS. MECHANICALLY FASTEN ALL CONNECTIONS. CLEAN ALL PROJECT RELATED DEBRIS FROM OUTSIDE WORK AREA. OBTAIN ALL PERMITS AND CARRY ALL NECESSARY INSURANCE AS REQUIRED BY LAW. WE CANNOT ACCEPT RESPONSIBILITY FOR DEBRIS FALLING INTO ATTIC AREAS. CUSTOMER SHOULD COVER VALUABLES. GREAT CARE WILL BE USED TO PROTECT THE STRUCTURE AND FOLIAGE,HOWEVER,SOME MARRING AND OR MINOR DAMAGE COULD OCCUR. HAND NAIL ONLY,NO NAIL GUNS TO BE USED. SPECIAL INSTRUCTIONS: THE ABOVE PROPOSAL INCLUDES ALL ROOF SECTIONS OF THE HOUSE COMPLETE. CHIMNEY FLASHING:THIS SHOULD BE REPLACED AS PROPOSED ABOVE OR LEAKS COULD OCCUR.IF A CRICKET IS NEEDED BEHIND THE CHIMNEY WE WILL FABRICATE ONE WHEN DOING THE NEW FLASHING. WARRANTY-All work warranted to be free of installation defects for 5 years;This is limited to the installed item(s)and their repair only.Material warranted by mfg.to be free of defects for 30 years,see the manufacturers warranty for exact warranty performance. Customer has legal right under federal law to cancel this contract without penalty or obligation within four business days from the date of signing this agreement via Priority Mail Delivery Confirmation. Please see reverse side for cancellation procedures. Once all items in this contract are completed as agreed,customer has 3 days to fulfill payment schedule.All parties agree that all disputes shall be settled by the dispute resolution process on the back of this agreement. Please see reverse side,Dispute Resolution. F Signing this Propos means, u have accepted all the terms as stated on the front and back of this agreement. Please see reverse side. Date of Acceptancey - ' 1 e,I/ Signature Si9n ur a PLEASE SEE REVERSE SIDE d sial](hirds License: CS 230 Restricted to: 00 BARRY S CARNES 30 ARROWHEAD FARM RD BOXFOR D, MAO 1921 Expirat;on: 3/7/2012 17617 2 Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5 170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 100733 Type: Private Corporation Expiration: 6/23/2012 Tr# 298405 A. B. CARNES, INC. Barry Carnes 30 Arrowhead Farm Rd. Boxford, MA 01921 Update Address and return card.Mark reason for change. -CA1 0 50M-04104-GI01216 F� Address E] Renewal Employment Lost Card f�v,.ru CERTIFICATE OF LIABILITY INSURANCE OP ID SADATE(MUMDNYYY) PRONCER ABCAR-1 03 18/11 THIS CERTIFICATE IS!§SUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE ARMED Insurance Agency, Inc. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR PO BOX 449 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Salem MA 01970 Phone.- 978-744-6715 Fax:978-741-0127 INSURERS AFFORDING COVERAGE NAIC 4 INSURED INSURER Essex Insurance Co INSURER B: A B Carnes Inc INSURER C: 30 Arrowhead Farms Road Boxford MA 01921 INSURER D: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. EFFECTIVE Po EXPI ON LTR S TYPE OF INSURANCE POLICY NUMBER DATE M DATE MMID LIMITS GENERAL LUU31UTY EACH OCCURRENCE $1000000 A COMMERCIAL GENERAL LIABILITY T$A03/18/11 03/18 12 PREMISES IUKEN I ncel $50000 CLAIMS MADE ®OCCUR MED EXP(Airy one Per3m) $1000 t PERSONAL&ADV INJURY $1000000 GENERALAGGREGATE s200000 GEML AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMProPAGG s2000000 X POLICYF—j EC LOC PD Deduct 500 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANYAUTO (Ea accident) $ ALL OWNED AUTOS SCHEDULED AUTOS (Per ILperson)INJURY It HIRED AUTOS BODILY INJURY NON-OWNEDAUTOS (Por all $ PROPERTY DAMAGE $ I H (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT E ANY AUTO OTHER THAN EA ACC i AUTO ONLY: AC,C, s EXCESS I UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE s S DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY OTK- Y l N TORY LIMITS Flt ANY PROPRIETOIUPARTNER/EXECUTI s OFFICERALEMBER EXCLUDED? E.L.EACH ACCIDENT (Mandatory Inunder IPa,describe under E.L.DISEASE-EA EMPLOYEE $ ye SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT 1 s OTHER DESCRIPTION OF OPERATIONS I LOCATIONS!VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Roofing contractor- see original policy for all conditions, limitations and exclusions. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION NONE001 DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL None IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED ENTATNE ACORD 25(2009101) RATION. All rights reserved. The ACORD name and logo are registered marks of ACORD GRANITE STATE INSURANCE COMPANY 13102 007o806-oo WC 002-50-2480 --------------------------------------------- 013-66-0311-10 A B CARNES INC C H K R TI C { • BOXFORD, MAD019211-0000 •i A Chartis company SEE EXTENSION OF ITEM 1. OF THE INFORMATION PAGE - WC990610 EXECUTIVE OFFICES: 175 Water Street I.D# New York, NY 10038 WORKERS COMPENSATION AND EMPLOYERS AHMED INSURANCE AGENCY INC PO BOX LIABILITY POLICY INFORMATION PAGE SALEM, MA01970-0449 INSUREDIS T PREVIOUS POLICY NUMBER CORPORATION RENEWAL 00250248o OTHER WORKPLACES NOT SHOWN ABOVE: SEE EXTENSION OF ITEM 1. OF THE INFORMATION PAGE - WC990610 REM 2 POLICY PERIOD 12:01 A.M,standard time at the insured's mailing address FROM 03/31/11 TO 03/31/12 ITEM 3 A. Workers Compensation Insurance: Part One of the Policy applies to the Workers Compensation Law of the states listed p P cV pP here: MA B. Employers Liability Insurance: Part Two of the policy applies to the work in each state listed in item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident$ 1 -000,000 each accident Bodily Injury by Disease $ 1 .000,000 policy limit Bodily Injury by Disease $ 1 ,000,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: SEE ENDORSEMENT WC200306A D. This policy includes these endorsements and schedules: SEE EXTENSION OF ITEM 3.D. OF THE INFORMATION PAGE - WC990612 ITEM4 The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Premium Basis Rate Per Estimated Classifications Code Number Total Remuneration $100 OF Re- Premium ❑X Annual ❑3 Year muneration Annual ❑3 Year SEE EXTENSION OF ITEM 4. OF THE INFORMATION PAGE - WC7754 TAXES/ASSESSMENTS/SURCHARGES $232 EXPENSE CONSTANT(EXCEPT WHERE APPLICABLE BY STATE) - MA MINIMUM PREMIUM 00 MA TOTAL ESTIMATED ANNUAL PREMIUM If indicated below, interim adjustments of premium shall be made: $3,851 Semi-Annually ❑ Quarterly Monthly DEPOSIT PREMIUM 03117111 ASSIGNED RISK 66 Issue Date Issuing Office Authorized Representative 38967(Rev'd 04/08) WC 00 00 OlA The Commonwealth of Massachusetts I f Department of IndustrialAccidents Office of Investigations 600 Washington Street iV ie'«; Boston,MA 0.211- r""moi www.massg ov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print'Legibly Name (Business/Organization/Individual): / ce-4 / Address: City/State/Zip: Phone#: Are ou aln employer?Check the appropriate box: Type of project(required): 1 I am a employer with 4- 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. T �• ❑Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp.insurance. 9_ ❑Building addition [No workers' comp.insurance S. ❑ We are a corporation and its required.] officers have exercised their ME] Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.0�Wmbing repairs or additions myself.[No workers'comp. c. 152, §1(4),and we have no 12. Roof repairs insurance required.] employees.[No workers' 13.❑Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors acid their workers'comp.policy information. I am an employer that is providing workers compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: ✓L S Policy#or Self-ins.Lie.#: �,(JCi UZ-�S 0 " � � Expiration Date: l� Job Site Address: ! / `'' /� City/State/Zip:�- Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a q p fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the fonn of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certif er the pal and penalties of perjury that the information provided above is true and correct.' Si nature: Date: f Phone#: f9 87 y Official use only. Do not write in this area,to be completed by city or town offrcial. City or Town: Permit/License# Issuing Authority(circle one): I. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or.on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s) of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the pen-nit or license is being requested,not the Department of Industrial Accidents. Should you have any,questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the pennit/license number which will be used as a reference number. In addition,an applicant that must submit multiple,.pennit/license applications in.any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or pen-nit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. #617-727-4900 ext 406 or 1-877 MASSAFE Revised 5-26-05 Fax#617-727-7749 www.mass.gov/dia Commonwealth of Massachusetts RECEIV City/Town of APR 2 3 2009 System Pumping Record Form 4 TOWN.OF NORTH ANDOVER HEALTH DEPARTMENT 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 your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information Important: When filling out 1. System Location: Left front, left rear, left side of house. Right fro right rear)right s' a of house. forms on the computer,use only the tab key Address IlSL/ V D Cid to move your cursor-do not use the return City/Town 1 State Zip Code key. 2. System Owner: Name Address(if different from location) Cityfrown State Code I� '7 Telephone Number B. Pumping Record v 1. Date of Pumping ( � 2. Quantity Pumped: Date Gallons 3. Type of system: 8 Cesspool(s) Septic Tank Ll Tight Tank Other(describe): 4. Effluent Tee Filter present? L1 Yes No If yes,was it cleaned? p Yes No 5. Condition ofOSystem: 6. System Pumped By: Neil Bateson F 5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Locationhere contents were disposed: L.S.D Lowell Waste Water igna ure of H"r Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts City/Town of :;ubmitted System Pumping RecordForm 4 MPDEP has provided this form for use by local Boards of Health. Oth r forms me information must be substantially the same as that provided here. 91k with your local Board of Health to determine the form they use. The System to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Lqeft3sjde of house, Right side of house, Left front of house, Right front of house, Left rear of h e, Right rear of hour . Left rear of building. Right rear of building. Address City/Town c l State/ Zip Code 2. System Owner: Name Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes t No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: y/A 0(V^-� 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Lo i where contents were disposed: D Lowell Waste Water g to a of Haul r Date / t5form4.doc•06/03 System Pumping Record•Page 1 of 1 1 1 Professional Land Surveyors & Civil Engineers ESSEX SURVEY SERVICE. 1958 - 1986 OSBORN PALMER 1911 - 1970 BRADFORD 8 WEED 1885 - 1972 April 17, 1992 o � Town of North Andover Board of Health Town Hall 120 Main Street North Andover, MA 01845 RE: F 9233 Request For Percolation Test Fuller Road (Lot 71) Assessors Map 65, Parcel 16 Gentlemen: On behalf of First City Development Corp., this firm requests a date and time to perform a soils inspection and percolation test at the referenced site. A check in the amount of $150.00 and a copy of the Assessors Map showing the site accompanies this letter. Very truly yours, James H. MacDo ell JHM/pa Enclosure 40 LOWELL STREET PEABODY, MASS. 01960 (508)531-8121 FAX:(508)531-5920 - - - - - - - - - - - - - - - - - - - - - --- - - - - - - - - - - - - - - - - . - - - - - - - - - - - - - - - - - - - - Ch#' Ili pp EF, pA 04• �� 4 � ou fp ��0►$T�R , 4► i�4 Q` .'+p` ��r moi•' ? �� ,tiR � W ` d W r w e 1f� las A !ZZ v MV ti ti � t.ee� 4 ti �4 h t� Ba�QOQD �aDd �OQC7O J 03aOO�YJ4O� �DQo 40 LOWELL STREET • PEABODY, MASS. 01960 Town of North Andover Board of Health Town Hall 120 Main Street N. Andover, MA 01845