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Home My WebLink AboutBuilding Permit #783-11 - 165 BOSTON STREET 5/20/2011 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: -2 Date Received - 4-11, //f Date Issued: SAoz/� ORTANT: Applicant must complete all items on this page LOCATION Prin PROPERTY OWNER �r� 11M A ck Print MAP NO: _PARCEL&2�4_ZONING DISTRICT: Historic District yes Machine Shop Village yes o TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ,Kkddition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other rel';, -�''_`t"w�"''�."�.K e--gsv�.rro..,•��8 �❑� U 1sSept OWell=:{ y < J Lk ,- ,p Wetlan s I aters eli� t ` s g0?WateT�SeWOT DESCRIPTION OF WP RK TO BE.PERFO D: 'ey-c" (Identification Pleaseype or Print Clearly) OWNER: Name: C LLAT Phone: (4 /7) '77k-3 71 f Address: A 6veexv, 4xAL13 CONTRACTOR Name: A lolvilb k4"Vo i/06 Phone: Z/ Address: Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT.$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ � FEE: $ 1/ 4Q Check No.: Receipt No.: �d/ G NOTE: Persons c'& gistered contr ctors do not have access to the guar ' fund Signature of Agent/Owner. .Signature=of contractor _(;; TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: 7�3 Date Received Date Issued: 0 ORTANT:Applicant must complete all items on this page LOCATION 165- 00�+C-V\ Prin PROPERTY OWNER �r« inH A r-k Print MAP NO:tt)/L.A PARCELW�ZONING DISTRICT: Historic District yes Machine Shop Village yes o TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family J<�4ddition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other r:'DiSepticy O,�Well M "D�Flooclplauij '�!® W�,etla Y { ❑I Wafersh�- D 'P F ,titer /Sewer x DESCRIPTION OF WARK TO BE PERFO D: t ct r (Identification Please ype or Print Clearly) OWNER: Name: d4�' ay C um Phone: (4�0) 77k-3 71 f . Address: A 6vee4.1 CONTRACTOR Name: Ati l N» G n S k4lzlo � / � Phone: Z117q Address: Supervisor's Construction License: '70 t' Exp. Date: Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ �1� o�c� FEE: $ Check No.: �g 09 Receipt No.: el/ NOTE: Persons c gistered contr ctors do not have access to the guar ty fund Signature of Agent/Owner Signature of contractor _ I,; Location No. r -� Date MORTq TOWN OF NORTH ANDOVER 9 � s Certificate of Occupancy $ s�CMus<�' Building/Frame Permit Fee $ "1"2- Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 24 � i � Building Inspector Location No. e NORTq T W F N ANDOVER O � F w A w rtificate of Occupancy $ f NUs tom• Building/Frame Permit Fee $ Foundation ermit Fee $ I Other PermFee $ TOTAL $ Check # �� 3 2416J01 E v Building Inspector i Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL El Public Sewer ❑ Tanning/Massage/Body Art E] Swimming Pools Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ _ Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ 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 Si natur COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit 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 Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL El Public Sewer ❑ Tanning/Massage/Body Art E] Swimming Pools Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ 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 Si-qnatwW4---.? -- Z,— COMMENTS A- A-%, 7 rL.>oys-V 3 _ 3,j Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit 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 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 ® Notified for pickup - Date Doc:.Building Permit Revised 2008mi 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 de artment use ❑ Notified for pickup - Date Doc:-Building Permit Revised 2008mi 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 ❑ Flo or/Crossection/Elevation Plan Of Proposed osed Work With Sprinkler Plan And p P Hydraulic Calculationspp If Applicable) ( ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits g g davits for Engineered products g NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) a Building Permit Application ❑ an o •Photo of H.I.C. And C.S.L. Licenses d Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydrau Ic ) ❑ Copy of Contract �-- Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products IOTL: All dumpster permits require sign off from Fire Department prior to issuance of Bldg .Permit i all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals int the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording Lust be submitted with the building application Doc: Doc.Building Permit Revised 2008m! 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 Pp uildin 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 ❑ 10n o °Photo of H.I.C. And C.S.L. Licenses d Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydrau Ic ) ❑ Copy of Contract �- Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products BOTS: All dumpster permits require sign ofi from Fire Department prior to issuance of Bldg .Permit all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals iat the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording lust be submitted with the building application Doc: Doe.Building Permit Revised 2008mi W. Location / No. 5 pRTN W F N ANDOVER T pf M`•o rtificate of Occupancy Building/Frame Permit Fee $ 1 ,J3ACHU`�f'4 Foundation ermit Fee Other Perm' Fee l $ �— TOTAL I $ Check # 2 i 6.C ti' Building Inspector Location No. �if�� Datel N°"TM TOWN OF NORTH ANDOVER o - � Certificate of Occupancy $ CMUs Building/Frame Permit Fee $. Foundation Permit Fee $ Other Permit.Fee ' $ TOTAL. $ Check # 24 .1 r 8 Building Inspector TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION , Permit NO: 7 Date Received ;*2 Date Issued: ORTANT:Applicant must com Tete all items on this pLge LOCATION 16 �0 5+4^1 _PROPERTY OWNER �l'► ily PrinJ_, +4 C_ Print MAP NO: , -PARCEL,�Oc' ZONING DISTRICT: Historic District yes Machine Shop Village yes o TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential 11 New Building ❑ One family ,4ddition I]Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ®S p �Wel'1' :' ;�� ,❑F ood 1auit® Weflan�� ```� '" "'�.� "`�'" '� - ,��„ � = w-.�.� � < w -� 4� �' �. �� ❑ Waters ed District �� ,� � , DESCRIPTION OF WQRK TO BE PERFO �D: 7-r CV71 ` w'eGG: ✓ t`(�'`+1 �� fc5ck. g 1 ✓J (Identification Please Yype or Print Clearly) OWNER: Name: Esl d" Phone: �a0) 7k-3 71 f , Address: �� i��'v 4111A,�; _ CONTRACTOR Name: Ati I ti1 1�2 G r t S �t A/U� 6 /6A Phone: Address: Supervisor's Construction License: Exp. Date: .,�/q f Home Improvement License: Exp. Date: r' 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. I ' Total Project Cost: $ 96 o oe9 FEE: $ Check No.: Z* ��gistered � O Receipt No.: -2 �'/ 6, NOTE: Persons c i contr ctors do not have access to the guar ty fund - - - -- ignature of A ent/Owner ; : Sa nature of contractor ,- (;_ g - 9 - :- __ .�.t.>-_...�24'..ear.-'...�_.. - �`. �� I E( ;, . , ;-�:- . . , . ,[ Location . r- ;��-r No. 1IF2 Date o�U �� - t . . I .... . . . . . . .. I , I . V .. .,�.�.. -... .. NaRTM TOWN OF NORTH ANDOVER : o _,� O�L F % t. y y +i ; , Certificate of Occupancy $ ;,sA". A Building/Frame Permit Fee $ '�"J"�"� _ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ . . . k. Check # C/ _G� d ; 24i '/ - Building Inspector 1r-, .. .. _y. .. look SO SPOT! SAW AT:WAY T 7401 Location / � 1—Td-5-7Z0,11 S�- No. e 5 a � O� NOR7�y T W DF N ANDOVER - L ►. w � a rtificate of Occupancy $ , s„CMUst�' Building/Frame Permit Fee $ . .2 Foundationermit Fee $ 1 Other Perm' Fee $_ TOTAL $ ; Check # 24169 A/ t fi Building Inspector Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools D Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on Siqnature COMMENTS HEALTH Reviewed on Siqnature/-"-'." COMMENTS A--%, 7 I,>v,-, Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes .Planning Board Decision: Comments Conservation Decision: Comments Wager & Sewer Connection/Signature& Date Driveway Permit 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 F µoRrM TOWN OF NORTH ANDOVER OFFICE OF BUILDING DEPARTMENT 1600 Osgood Street Building 20, Suite 2-36 ��a q�*cD•� North Andover,Massachusetts 01845 Sgc►+use Gerald A.Brown Telephone(978)688-9545 Inspector of Buildings Fax (978) 688-9542 HOMEOWNER LICENSE EXEMPTION BUIDING PERMIT APPLICATION Please print DATE: I 1 JOB LOCATION: �� dS S� , 1 � Via Ucf p44A Number Street Address Map/Lot HOMEOWNER ,Ef i t W �hU'� `7`�v��8t; -�'�-(c) Name Home Phone Work Phone PRESENT MAILING ADDRESS City Town stwt�. Zip Code The current exemption for"homeowners"was extended to include owner-occupied dwellings to two units or less and to allow such homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor). State Building (Code Section 108.3.5.1) DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two family structures. A person who constructs more that one home in a two-year period shall not be considered a homeowner. Qr` The undersigned"homeowner"assumes responsibility for compliances with the State Building Code and other , Applicable codes,by-laws,rules and regulations. � r The undersigned"homeowner"certifies-that he/she understands the Town of North Andover Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. � HOMEOWNERS SIGNATURE '000 APPROVAL OF BUILDING OFFICIAL Revised 7.2009 Form Homeowners Exemption BOARD O.F APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 Location f ' �-' d'/0 A/ No. / Date c/i &ORTM �W OF NORTH ANDOVER Oii . c :�,•yG > ; : ertificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL I Check # 05' 0 24 � ;� �' Building Inspector � I r ' ERIC W LYNCH 02/ 605 165 BOSTON ST 5-7017/2110 ANDOVER,MA 0184 ` rU\ 139 NORTH Date PY a to the � I Order of _ a liar s Feeluroa � Ue�eBe ea Beck. RR V V VV- Citizens Bank Massachusetts � FpT `:. For �� 130 to S 301 0 6 0 5 I '. 75 ��-�-••� � GUARDIAN SAFETY®GREEN Hadand Clarke C � i h f NORTH ovm O ., 6 Andover No. _ 7 odover, Mass., .,S, GOCrICMEICK 1 7 ADRATED W BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System 'A� ) / BUILDING INSPECTOR / L THIS CERTIFIES THAT...... ...........Gtr..../, . 'IV.G. ..... �,,f.. ...................................................................................... Foundation has permission to erect........................................ buildings .�a D��(.. ............... .................. Rough to be occupied as............p� q /OPi- �c'I /.`. 1.QC4l............. Chimney p' .................... ... lr^... . � ' ............................. provided that the person accepting this permit shall in every respect conf; rm to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of 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 UNLESS CONSTRUCTION STARTS ELECTRICAL INSPECTOR ........................................... 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. The Cd.mmonwealth of -Massachusetts a De.partmeht-of Fire Servi_Ges ' Office of the State Fire Marsha! P.0.Bax 102 SC-ite'Raad,.Stow,MA 01775 _ PERMIT Dart: S moi/ North Andover Permit No Di Safe Num er -(City of Town) (If Applicable•) g In accordancc.with the provisions of M:Gl,_l 4$ Chap.ter_J_(Z as provided in section-5-22—CMR 34 rt ��'AStaData .This Pcnnit is granted to:. E e ,�t/„�� Full name of persca,Firm or Corporation Pcrmissionto locate dumpster • for construction/renovation/demolition of building. Comments:' dumpster. must be . 25 t from structure if unable to place with required Restrictions:clearance dumps-ter must be covered with plywood or tarp end of 'work -da y .at G b 6.� .-_ -j _.. . . (Give location by street and no,,or desen6c' u annex as top d adequate identification.of location) FeePaids 50.00 Fire Chief This Permit will expire- (Signa c of o cdl ting perrrut) Offical granting permit (Title) 4 ,..r.,, l Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4 M 165 Boston Rd Property Address Eric Lynch Owner Owner's Name information is required for North Andover Ma. 01845 12-11-10 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms on the computer, use 1. Inspector: only the tab key to move your N. Timothy White cursor-do not Name of Inspector use the return key. Homepro Northshore Company Name K,LA75 Glen St. ( P.O. box 101) Company Address Rowley Ma. 01969 City/Town State Zip Code (978-948-8428 ) S12015 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340"of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority _, 12-11-10 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)Within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 165 Boston Rd Property Address Eric Lynch Owner Owner's Name information is required for North Andover Ma. 01845 12-11-10 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y. ❑ N ❑ ND (Explain below): na 15ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 165 Boston Rd Property Address Eric Lynch Owner Owner's Name information is required for North Andover Ma. 01845 12-11-10 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): na ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): na C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-09106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 165 Boston Rd Property Address Eric Lynch Owner Owner's Name information is required for North Andover Ma. 01845 12-11-10 every page. Citylfown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: na D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 165 Boston Rd 'M Property Address Eric Lynch Owner Owner's Name information is required for North Andover Ma. 01845 12-11-10 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] j ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 165 Boston Rd Property Address Eric Lynch Owner Owner's Name information is required for North Andover Ma. 01845 12-11-10 every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (if they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] Ii D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 110-330 gpd t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 165 Boston Rd Property Address Eric Lynch Owner Owner's Name information is required for North Andover Ma. 01845 12-11-10 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 5 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required) ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 08 & 09 105,750 9 ( Y 9 (gpd))-. gal = 144 gpd Detail: Sump pump? ❑ Yes ® No Last date of occupancy: still occupied Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•09/08 Title 5 Oficial Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,,0'� 165 Boston Rd Property Address Eric Lynch Owner Owner's Name information is required for North Andover Ma. 01845 12-11-10 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): na General Information Pumping Records: Source of information: last pumped Oct 10 2010 information from owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 165 Boston Rd Property Address Eric Lynch Owner Owner's Name information is required for North Andover Ma. 01845 12-11-10 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 14 years old Information from owner Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 32 in feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 28 ft from incoming water line tooutgoing sewer line Comments (on condition of joints, venting, evidence of leakage, etc.): joints&venting good condition - no evidence of leakage Septic Tank(locate on site plan): Depth below grade: 26in with riser&cover at grade feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 10 long-5ft wide wide- 5ft deep 1500 gal Sludge depth: 2in t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 165 Boston Rd Property Address Eric Lynch owner Owner's Name information is required for North Andover Ma. 01845 12-11-10 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 34in Scum thickness lin Distance from top of scum to top of outlet tee or baffle 7 In Distance from bottom of scum to bottom of outlet tee or baffle 14in How were dimensions determined? rulers&measuring rod Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): tank does not need to be pumped-inlet tee good condition-rear tee good condition- tank structural integrity good-liquid at bottom of outlet invert-no leakage in or out of tank Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-09/08 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 165 Boston Rd Property Address Eric Lynch Owner Owner's Name information is required for North Andover Ma. 01845 12-11-10 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): na Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): na "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 165 Boston Rd Property Address Eric Lynch Owner Owner's Name information is required for North Andover Ma. 01845 12-11-10 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): d-box was level-distribution was equal -no evidence of any solids carryover-no sign of leakage in or out of d-box-d- box 16in below grade size 22x32 inside depth 16 in Pump Chamber(locate on site plan): Pumps in working order: ® Yes ❑ No Alarms in working order: ® Yes ❑ No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): pump&alarm good working order-pump chamber 29 in below grade with riser&cover 2 in below grade Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 165 Boston Rd Property Address Eric Lynch Owner Owner's Name information is required for North Andover Ma. 01845 12-11-10 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 4 trenches 50 ft long each ❑ leaching fields number, dimensions: 1000 sq ft ofleaching ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): dry sand soil-no hydraulic failure- no ponding-system was under upper side lawn Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ;M 165 Boston Rd Property Address Eric Lynch Owner Owner's Name information is required for North Andover Ma. 01845 12-11-10 every page. City(rown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): na Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•09/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 165 Boston Rd Property Address Eric Lynch Owner Owner's Name information is required for North Andover Ma. 01845 12-11-10 every page. cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand sketch in the area below ❑ drawing attached separately O a ", C 331 C� r7 3d 3 � �� Title 5 official Inspection Fomc Subsurface Sewage Disposal System•Page 15 of 17 t5ins•09108 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M 165 Boston Rd Property Address Eric Lynch Owner Owner's Name information is required for North Andover Ma. 01845 12-11-10 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: eshgw 40 in feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: from plans test pit#t1 eshgw at 40 in in from ori nal grade- system is raised Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 4'M 165 Boston Rd Property Address Eric Lynch Owner Owner's Name information is required for North Andover Ma. 01845 12-11-10 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, b, or E checked ® Inspection Summ"airy D (Sy�efrn Fbildtbtb Criteria Applicable to All Systems) completed ® System Inform •-,Estirt d depth to high groundwater ® Sketch of Sewage bispbtal System either drawn on page 15 or attached in separate file t5ins•09/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Windows Live Hotmail Print Message Page 1 of 2 RE: : ERICK ANDOVER - quote From: Sergio Goncalves (littleredtruck@hotmail.com) Sent: Wed 5/11/114:38 PM To: liomargms@hotmail.com (liomargms@hotmail.com) LITTLE RED TRUCK PAINTING & MORE 88 QUEEN ANNES CRT.#27.WEYMOUTH,MA 02189 (617)778-3718 Littleredtruck@hotmaii.com #BILL# CONTRACT DATE: 05/11/11 BILL TO:ERICK-----(978)807-6348 165 BOSTON.ST-NORTH ANDOVER,MA 308 DESCRIPTION:$14,000.00 ALL NEW FRAMING AND PLYWOOD,TYVEK AND DEMO REMOVAL. 19,200 = ORIGINAL 200= EXTRA MARERIAL 300= OTHER MATERIALS MATERIAL BY OWNER = -5,700 JOBDURATION:7 DAYS................................................................................................................... START DATE:_ MAY 2011..........................................FINISH DATE:.... JUNE 2011 ................ INSURANCE:AAW.INSURANCE($1,000,000.00/2,000,000.00-COVERAGE) PENN-AMERICA INSURANCE COMPANY IMPORTANT INFO: .NO INSULATION,ROOFING,OR FINISHING WORK INCLUDED!=not included BUILDING= LITTLE RED TRUCK=LRT CONTRCTOR=LRT.=ANTONIO FILHO(96701) DUMPSTER= NEW INGLAND SOLID WASTE JO PRICE: $14,000.00 PAYMENT: JOB START:$50%=DEPOSIT PAYMENT=7,000.00 JOB DONE:$50%= FINAL PAYMENT=7,000.00+EXTRA LABOR AND MATERIALS http:Hsnl 07w.snt107.mail.live.com/mail/PrintMessages.aspx?cpids=bacO5002-8aae-4a90-... 5/11/2011 Windows Live Hotmail Print Message Page 2 of 2 / o DATE Q LITTLE RED TRUCK HOMEOWNER:-. DAT ( / l E I PLEASE MAKE PAYMENT TO : SERGIO GONCALVES http:Hsn l 07w.sntI O7.mail.live.com/mail/PrintMessages.aspx?cpids=bacO5002-8aac-4a90-... 5/11/2011 • r it IS lC/<l7 71v- Y� ♦ Q n• r CE.cT/FY TO Tye T/TGE/,V-fe1eOX ANO Rl- o r TD THE B�4 N.(�T//.4T.THE OA-4Z41,VO /S LOCATE'O 10,41 /N TyE GoT AS AHO T//AT/r OaClf G'oA/FG�P/YI REGAA'OMWO .f6-rX4COrV FeO,if SzPEETS E LOT s FU,Crs�E.r Ceer/FY r//Ar T.y/.S OA✓ELL/�Y6 /s mar p,PAI�iV FO.P I LQC.4rElO /N ris'E FEOEA 4e- FL O ff'4Z.4.PO 4.PE.4. %Syawn!Oit/ FE,w,4• 40"A Z 6'00 9g �.� �e000B� / .� o4 6STA 771/S PLAAI,moo, i POSES-NOT FD.P / Bovvo,Py a�-rE.e �i �, ouva,4, Y�.tiFo,P.H- �E•P,P/rff.4lX E'.VGidEE�P/,ti6 SE.PI�/CEs AriO-t/ T.4�E.S/ ,�,raij��rk •t/c ,Pe-Lo.P.oX. (oto �•4�P.(� .S'T.rEET 797? . 004XS,4C/Yl/SZ-77S o/8/D µoRTH TOWN OF NORTH ANDOVER 2ot,t�oo , �tid 09 OFFICE OF BUILDING DEPARTMENT 1600 Osgood Street Building 20, Suite 2-36 yea A,•,o "�� North Andover,Massachusetts 01845 SACHUSE Gerald A.Brown Telephone(978)688-9545 Inspector of Buildings Fax (978)688-9542 HOMEOWNER LICENSE EXEMPTION BUIDING PEPMT APPLICATION Please Print DATE: —/✓1c y — o� l JOB LOCATION: 16 R644ten Number Street Address Map/Lot HOMEOWNER 15f ytc� Name Home Phone Work Phone r— PRESENT MAILING ADDRESS I(SY City Town S*w+e Zip Code The current exemption for"homeowners"was extended to include owner-occupied dwellings to two units or less and to allow such homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor). State Building (Code Section 108.3.5.1) . DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two family structures. A person who constructs more that one home in a two-year period shall not be considered a homeowner. i The undersigned"homeowner"assumes responsibility for compliances with the State Building Code and other Applicable codes,by-laws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of North Andover Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. , HOMEOWNERS SIGNATURE APPROVAL OF BUILDING OFFICIAL Revised 7.2009 Form Homeowners Exemption . BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 The Commonwealth of Massachusetts ! Department of Industrial Accidents ;1 4i' l Office of Investigations e t ' 600 Washington Street Boston, MA 02111 www massgov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers A licant Information -/ Please Print Legibly _____ Name(Business/Organization/Individual): 4/'y �� c Address:_ of 4&,oeti AtiNmz Gvz ZmAll 41,4 - OZ 1 City/State/Zip: /wt - f�t � Phone Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction loyces(full and/or part-time).* have hired the sub-contractors 2. I am a sole proprietor or partner- listed on the attached sheet.$ ?• ❑ Remodeling ship and have no employees These suit-contractors have 8. []Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers'comp.insurance 5• ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself.[No-workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees. [No workers' comp. insurance required_] 13.[]Other *Any applicant that checks bo)(#l 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. tContmetors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. 1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: .cob 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 fine up to$1.,500.00 and/or one-year imprisonment,as well as civil penalties in the form 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 cerci un#r thepa6insa6dpenaltks of perjury that the information provided above is true and correct �t Date: p5-O Signature: - Phone#: Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing inspector 6.Other Contact Person; Phone#: ENERGY CONSERVATION APPLICATION FORM FOR. LOW-RISE RESIDENTIAL NEW CONSTRUCTION and ADDITIONS 780 CMR Appendix J Applicant Name: W, Z,-1 ix,h Site Address: t awn: f' M v Use Group: 6 l3YDate of Application: 4(41 Applicant Phone: Applicant Signature: Compliance Path (check one): ❑ Prescriptive Package (Limited to 1-or 2-family wood frame buildings heated with fossil fuels only) Package(A through KK from Table J5.2.1 b): Heating Degree Days (HDD65) from Table J5.2.la: (For items d. through i., fill in all values that apply from Table J5.2.Ib:) a. Gross Wall Area sq.ft f. Wall R-value R- '11- b. Glazing Area sq.ft. g. Floor R-value R- 30 c.. Glazing%(100 x b_a) % h. Basement wall R- /L 1, d. Glazing U-value U- 233 i. Slab Perimeter R- e. Ceiling R-value R- $ j, Heating AFUE I ❑ Component Performanpe: "Manual Trade-Off' (Limited to wood or metal framed buildings only) CIimate Zone(from Figure�6.2.2) ❑ Zone 12 ❑ Zone 13 ❑ Zone 14 Attach Trade-Off Worksheet from Appendix J, [and HVAC Trade-Off Worksheet, if applicable] ❑ K4Scheck Software Attach Compliance Report and Inspection Checklist printouts ❑ Home Energy Rating System Evaluation Attach Home Energy Rating Certificate(HERS rating score must be 83 or higher) ❑ S stems Analysis} y is OR ❑ Renewable Energy Sources Attach Mass Registered Architect or Engineer Analysis A-LTERNATIVE FOR ADDITIONS ONLY: a. Gross 'wail-r Ceiling A=rea �/ sq.ft. b. Glazing Area , sq.ft. c. Glazing% (100 x b=a) cl % ADDITION with Glazing % (c.) up to 40% may use.780 CMR Table J1.1.2.3.1 below: MAXIMi1M Li-value I t MTNTWTM R-Values Fenestration2 I Ceilino3 II Floor Basement %a11 I lab Perimeter De ih 0.392 R-37 R- R-19 R-10 R-10.4 ft I Glazing Area may be either Rough Opening o: Unit dimensions. 2 Based on NFRC Iisting. Applies either to every unit, or to area-weighted average of all units. 3 R-30 ceiling insulation may be used in place of R-37 if the insulation achieves the full P,-value over the entire ceiiin,area (i.e.-not compressed over exterior walls, and including any access opermgs.) . ❑ "SITNROC}M addition (greater than 40% glazinb-to-wall and ceiling gross area) Attach "Consumer Information Form"from 700 CMR Appendix B. Official's Name: Official's Signature: Massachusetts- Depai-tin:eit of PiAbtic Safety Board of Building Rcaulations and Standards Construction Supervisor License License: CS 96701 Restricted to: 00 ANTONIO FiLHO 51 HANNAH WAY#A ROCKLAND, MA 02370 Expiration: 3/19/2012 t'„mnaixir,ner Trn: 22915 NQ FD 7837 Date .............. OF p10RTf/,a� TOWN OF NORTH ANDOVER RECEIPT sSaoHueE This certifies that4.ez ...z.............................................. haspaid...& .......06...................................................................... ....................... Received by . ..L...)............. Department...... .fi..&�............................................................. WHITE: Applicant CANARY:Department PINK:Treasurer 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 ® Notified for pickup - Date Doc:.Building Permit Revised 2008mi 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 DOTE: 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 ° an o .Photo of H.I.C. And C.S.L. Licenses d Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydrau is ) ❑ Copy of Contract -.a- Mass check Energy Compliance Report ❑ .Engineering Affidavits for Engineered products TOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg .Permit i all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals tat the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording lust be submitted with the building application Doc: Doc.Building Permit Revised 2008mi �a G1 � c� �b EM 1 1 8 - ® I p � M8® ® ®® $ E i � " " a Port City De velopmen t o Proposed Front Elevation Design Build b� 59 Ashland Street 0 Newburyport MA 01950 Q� Q) 05o Cl 0 b tip a � o o � � a 44 W Lef t El e gra tion Righ t El e va tl on =,,'S,�_ DI-280 Mtn A Foss Date Lynch Residence �°°�.�`� 2 Nov ��:� Yeef9eQ B�Ctmireobn Thane Dn wlujl liiw Hsea AvE 0 Awb�api!hu ytwldad ballQBy D`an ApPvd Bf Me N-W Orme: 165 Boston Street ftft ib A%e>� �� Avr.fw"eitaat � PnemUafan ' u r �1 O V� M 131 CIO CIS M " m Port y Cit De vel o men tob raProposed Design BuildNr Rear Elevation 0 0 59 Ashland Street Newburyport MA 01950 o 0 3� V 14=2" 7L 9' 7=a" ti 0 FWalk (Walk In i ICloset 1 `1•J .N 1 1 rh .1 � _ W I I ^ N Bedroom #2 to � }�j + A N .I Master Bedroom m m aw a ro scu^a s/a s' — 0. coxa n•�o• she Fodw Dab 2 Nov 9020 Lynch Residence � �`°° YMlsrQ�Wateeelon M.p➢ifstap 73w H.en Poet L, ap" Bb sae sdome Oeaees A 165 Boston Street ae�.r x.a..e u.bxc,s e e�a. ac.e,. Itet sb tle tapl.8� to�AN.tlon d Oar Cmh�.G Datt xivoeae.e wx3oaa 1lxem riemL.Boo Q � O ------------- Cz oo Kitchen Dining Room Family Room a _- Bedroom o Bedrom ^I i Llvfng Room �i � w w4 01 N 9CALi! ioiva � ss� A Foss Date 2 Nov 8020 Lynch Residence � Yer7lfd�,Caoireefon �.�„��. 165 Boston Street "'°� "°a"' °�°' '° IPot 2b 8�Cephd ar ID deTemon o/Orp CaeW°GA 5 Data! )bpaadooed vftLeuS NtlWm ri� sun MdjwRoadNthd C�Elnmu.uw m R1dgr Yie ! W f/a'cmr rz&y„ooa ^MI A ol 3h7, IK 1RDem�s 9 7hb Ro �- O Q 10 0 � "l:� "61u, 01� 4) o t><e•Jam,, D"M YMIr DrAP With r s uc �Sam nP11f�eff fe•o a MLb s'rs'saa�Ir ac f:•tB• . (> JA'Dj7-9 rrra, ;{.) S -3 U 3tnmf 4 101f A 1�vV I1er�i��y(�f0) Nrw n, ID�°l�ttoq J/8•C9Y Plysooe D d s abracing sbearar�er JAtQ caner cJeebaeMe� !WL b p►r-y 04 I I J-1717-7. (2} 2"x10"s2LAB'moor&m. Wac, (2) 2 2) 2 x 10 s I I I_ s/s-rasr Btbra, "x70 s i I IQ I I 11 It 11 11 511-2-11fi'-7.. 4.-9' II II SP Span Sp n I II II X 1x� erose bracing N mid span. 1--I --- —'--L SCALA 0. 2nd Floor Framing Cross Section A P*" Date AN nmsmraw Mwt>b. 2 Nov 2020 Lyne Residence v.�1y M�Drowkw Ito B� �coner'°P'"is.a S 2 Avw"vaa&wa r&mw O, .. 165 Boston Street �pwor r � ^� ��...Mm �"' �ry XWMdwwd x�at>�« > � e , �a C� v� \ J FMMQ p � IP Ir fL V � g w o b > Existing Port City De velopm en t D Front EIe va do @SIb71 Build o 59 Ashland Street Newburyport MA 01950 w t � I rrv�, v, o f 1C� FJ CS d CM ®n , tin Yj tHELM =M:11 gIFi t � g ' t8 Proposed fort City Development r Front ElevationDesign Build o � � 59 Ashland Street Newburmort MA 01950 43 O a ,P a o m-=Z-1 L a � o � w Left El e va tion Righ t El e va tion sCAu_ A Fors Data �n .Uwe a. 2 Nov 2010 Lynch Residence Y�� rh�n..,fts.m�Been 165 Boston Street b �°�"'ti` ��M.M. � A ?bt 4b B+CeDlM or m vlbhgop o/Ota ContneL Rspreltwa!-1&0 ri MUM Fifwin7nn � 4 O O —<a `Y C* i yg A � s u Q3� pv¢ B w M=!3:E3] x s fps Port City De velopmen t °a i o g � Proposed f� rot If '� Rear Elevation Design Build o 59 Ashland Street 4 Newburyport MA 011750 Q O O Kitchen Dining Room LO Family Room Existing � Bedroom i 0 Living Room _ qJ � w wQ M SCALM IO1V1S V&SAM Air A Floss Data 2 Nov 2010 Lynch ResidenceAN DhasuPlo ,�`�° •p,r.-d By ans gnu 0— 165 Boston Street �m rroe� x. �.aaR,>.,y,„�. ri Mw"due" awe�� Pgmtdm . �y Y aP 14L Z' 7-9" r-a' O z,-VN Walk fn I II Walk rf,n r-a^ I jgosetCloset Bedroom #2 m �q� ., A N Master Bedroom �eyy ro ILA I � a I �L 81_0' L 91_10" 8�4• "II 9CALM IOIViS Deafen ftT A Ams Dab .f8 Dfinemles 3hst De 1 Nov 8020 Lynch Residence YewwA � "movDr„fqFHBeen nvt Ctq n...brrow[rr. .,,w.a,&'Me Home Owner rrwem We X65 Boston Street We� IM"He u.nug re A. I%~planes`w"er A Not%a.�pn.e or .mn.aen er om -�-,„e.+ nee.e R.ywwawa.e+Runs nlmen Paen.NtBee 2r1a mdse Bard Nth CaaLlnaoas Ridge YsxA �(.. 21 18•a4 MM Ile 1Ywood sbsaffih{d ==19 rab 26 Year Q4hj � 10 ko rn O r 1`29•saws!!bard MU It a•a��p s 1a•G ffn ^I q !Red tr$a lit Yen! azaGRIaE 7064 1B'O.G Mt& Yz9'aaaFina 19•ac (R et so)m.w. m With 1/a"nrs"n((25,p) . p) r� N ti E�cB"9tvde 1B'0.Q 4 a011 33 reb Y.por a„�,rR�-,c) VV q A lmfd cross,bracing I Cl=board°, LO bP – tom! ►�.j I I I 11 j(2) Z"x10"s is (2) 2'x10"g �� 'i E z70•flour jb&t iB•O.C, 2) 2 x 10 s I I I_ 9/4.2q Bhb wr. 5—2" 1 s'-7" 0 Span Span SP n II II ------------11---------- � rT x 1x3 cross bracing N mid span. I I 111 I I a I I II I I I I I II _ •_•—J I J SCAL$ 2nd Floor Framing Cross Sectio. �o a� A Sbn Date AN MUGENlonv htwt Dy 2 Nov 2020 Lynch Residence v�BY ME"Zirueeqp M—s"M ls.e LYh n...bp�o.ac bu pew° h6d nntlalot PM— APp,o„d By z72WHume Oeaea : > to be aW a0hr snw Ccutnt 165 Boston Street ' " �° !°° W�70 H�Ceplr!ar 6 tlabtlao N Ow Cmtreet Aepevfa°ed sftbo"WMC= A7 Psmi}Wm , C31 � O � N I=nczj V s,c� F � 6 M Port City De velopmen t a,. i Existing M Front Elevation Design Build � off` � � � •� � o 59 Ashland Street Newburyport MA 01950