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Building Permit #344-12 - 295 CAMPBELL ROAD 10/19/2011
NORTH BUILDING PERMIT c�tt��°.�bq�o TOWN OF NORTH ANDOVER o` APPLICATION FOR PLAN EXAMINATION e Permit NO: / - Date Received ��ssAc►+us���� Date Issued: IMP TANT: Applicant must complete all items on this page LOCATION Z 9.5 C be.jl � . Prin,� PROPERTY OWNER �L obc.t�� LeSlrc \ Print MAP NO: ZONING DISTRICT: `Historic District yes n PARCEL: o �-- � - . � Machine Shop Village yes:. . :_ no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential N 'Iding One family A ddition Two or more family Industrial( � lteratio No. of units: A Commercial Repair, replacement Assessory Bldg .'-.)/A Others: Demolition Other Septic 'Well Floodplain Wetlands Watershed:District Water/Sewer i n DESCRIPTION OF WORK TO BE PREFORMED: Cn,46��l ck. —ONSI� n� 64..,;k �cv.�d�iv �/►fA6C�^+/` Ww� Identification Please Type or Print Clearly) OWNER: Name: -c, {.cs/!� Phone: 916 Address: ZAS r b e-11 �d �n910JCVq– IVA — // 6a3 f�98 08.68 [`Address: NTRACTOR Name: c,ildc�5lr.�L Phone __. c dvwo .A,�- : Sate , 9 S/3 -Exp. Date;pervisor's Construction License:.__me lm rovement_Licensd: /0:6-$ _ -' Exp. "Date: Z8 /Z P i ARCHITECT/ENGINEER t /A Phone: i Address: '� a Reg. No. FEE SCHEDULE.BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. M 12 Total Project Cost: $ � S• FEE: $ I Check No.: Iy Receipt No.: 1 t NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund - i Signature of:Agent/Ownec-See 66 c Signature of-contract _ s A I i i I Location %� � a4— t No. Date l TOWN OF NORTH ANDOVER - 1 9 t ' Certificate of Occupancy $ s i a • o • -��� i - �",s••^°•'t�' Building/Frame Permit Fee $ SAC14Ust Foundation Permit Fee $ -- Other Permit Fee $ TOTAL $ I - Check # Building inspector 2474 l Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/1V4assageBody Art 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 Signature COMLENTS I " Zoning Boardof Appeals. Variance, Petition No. Zoning Dec ision/recei t submitted ed yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature&Date Driveway Permit DPW Town Engineer: Signature: Located 384'Os ood Street FIRE-DEPARTMENT .-Temp Dumpster on site yes no Located at 124:-Main Street �F'ire.Department.signature/date { NQRTH 0 0 t _ _ ° over o dover, Mass., 1 LAKE ;- COCMIC EWICK ��• S RATED �G BOARD OF HEALTH I. Food/Kitchen Septic System PERM .IT T D BUILDING INSPECTOR { THIS CERTIFIES THAT.............. .... ...� T� w�. .................................................................. .......................................... Foundation •• d ' has permission to erect........................................ buildings on ......a ......... .��I!K?... ... .. ...................... Rough to be occupied as........S�..�.6......... ^ ..0........okk.....�4. ..... 4o.6...�........... Chimney �'� provided that the person accepting this permit shall in every respect conform to the t 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 ONTHS ELECTRICAL INSPECTOR 3 _ . UNLESS CONSTRU S�' TS Rough _........................... ....................... Service BUILDING INSPECTOR_ Final Occupancy Permit Required to Ocaipy 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. �l IBM ILI i COPYRIGHT RE5IDENCE OF: CLIENT APPROVAL: 5CALE: PAGE BY BLACKDOG BUILDER5, INC. 1 /4��= 1 � B�MBURY THESE PLAN5 MAY NOT BE U5E0 IN ANY WAY WITHOUT 5UBJECT: DATE: DATE: D E S I Gj WRITTEN PERM155ION OF FRONT E L E VAT I O N (NEN) 1 O/13/2011 THE COPYRIGHT OWNER REMODEL O O IE' l 11 1 1 1�� I FBI 'uji COPYRIGHT RE5IDENCE OF: CLIENT APPROVAL: 5CALE: PAGE BY BLACKDOG BUILDERS, INC. 1 /4��= 1 THESE PLAN5 MAY NOT BE BAM B U RY U5ED IN ANY WAY WITHOUT 5UBJECT: DATE: DATE: Y4RTHE COPYRIGHT OWNER FRONT ELEVATION 10/13/2011 REMODEL i k t f I I r i i r F r I I I I I i i I I I I I I E I I I 4 E k 'F it • i OFYR16HT RE51DEN BY BL4CKDOG BUILDERS, INC. G� OF: THESE PLANS MAY NOT BE $ CLIENT APPROVAL: USED IN ANYYgAYWITHOUT NRITTEN PERMISSION OF SUBJECT: MB REMODELTHE COPYRIGHT ONNER AS DA11211 PAGE -BUILT TE: k I - -- -- DATE: ` 10/13/.2011 _ -- - -- - �- - - -�-y i 1 --- - ��-.__-- - - - '.J - � � �� i 1 �I �, _ _ -- I. i 4 I I i 41/4 131/211 13 1/21 4 1/4" PVC WRAPPED BEAM (FIR OUT TRIPLE NOTE5: 2x10 BEAM) (11 (V 1. INSTALL COLUMNS 3'-b" FROM "TURNCRAFT" DOOR CENTER TO COLUMN CENTER, 8" x 8" 5Q. COLUMN5 to 3'-1" FROM HOUSE WALL SHEATHING (10 3/4" GAP/BASE) ' TO COLUMN CENTER AT 85" HIGH. 2. FIR OUT DBL 2x10 ROOF BEAM, WRAP WITH PVC TRIM TO 3'-6go I 12" WIDE (FINISH WIDTH). 3. 4" SOFFIT OVERHANG ON SIDES. 4. b" EAVE OVERHANG ON FRONT. - - - - - - - - � - - - - - - —� I BLACKDOG I L I I I I COPYRIGHT RESIDENCE OF: CLIENT APPROVAL: SCALE: PAGE BY BLAGKDOG BUILDERS, INC. BAM B U RY 1 THE5E PLAN5 MAY NOT BE U5ED IN ANY WAY WITHOUT SUBJECT: DATE: DATE: WRITTEN PF-RM155ION OF NAL LAYOUT UT 1 O/13/2011 8 U I L D THE COPYRIGHT OWNER REM 0. 0 [F NOTES: 1. 2xb RAFTERS AT 1 b" 0.C. 2x8 RIDGE BEAM 8" OVER 12" ROOF PITCH T— (VERIFY IN FIELD TO AVOID ' SECOND FLOOR WINDOWS). 2. TRIPLE 2x10 BEAM CENTERED F 1 ON 8" COLUMN AT 85" HIGH 3. FIR OUT BEAM TO 13-1/2" FINISH WIDTH (SEE SECTION ON PAGE b) 4. ALL SOFFIT, FASCIA, AND BEAM TRIM TO BE PVC. 5. GUT AND INSTALL PLYWOOD OU55ET5 TO ACHIEVE CURVED CEILING (SEE SECTION ON PAGE b) i i I i COPYRIGHT RE5IDENCE OF: CLIENT APPROVAL: 5CALE: PAGE BY BLAGKDOG BUILDERS, INC. SAM 8 U RY 1 /211= 1 ' THESE PLANS MAY NOT BE USED IN ANY WAY WITHOUT 5UBJECT: DATE: DATE: WRITTEN PERMISSION OF THE COPYRIGHT OWNER ROOF FRAMING 10/13/2011 REM 0. O 2xb RAFTERS S" OVER 12" PITCH VERIFY IN FIELD PLYWOOD GU55ET (ADD FRAMING TO SPAN BETWEEN GU55ET5) BEADBOARD CEILING O TRIPLE 2x10 BEAMS 91 TO STOOP 10 L� �►� 2x6 WITH 3/4" PLYWOOD BETWEEN �ec,,r O�,v55 �)C LolL t-- T��m COPYRIGHT RE5IDENCE OF: CLIENT APPROVAL: 56ALE: PAGE (� BY BLACKDOG BUILDERS, INC. BAM B U RY LJ THESE PLANS MAY NOT BE USED IN ANY WAY WITHOUT 5UBJECT: DATE: DATE; VqRDESIGNi (o THE COPYRIG T OWN RF ROOF SECTION 10/13/2011 REMODEL �J COPYRIGHT RE5IDENCE OF: CLIENT APPROVAL: 50ALE: PAGE BY BLACKDOG BUILDERS, INC. BAM 8 U RY NT5 THESE PLAN5 MAY NOT BE 07 U5ED IN ANY WAY WITHOUT SUBJECT: DATE: DATE: kNRGN ESI I COPYRIGHT OWN R� P E R5 P E GT IYE 10/13/2011 HE REMODEL, ® II COPYRIGHT RE5IDENGE 01=: CLIENT APPROVAL: SCALE: PAGE BY BLACKDOG BUILDER5, INC. U �1/1 $U RY NTS THESE PLAN5 MAY NOT BE U5ED IN ANY WAY WITHOUT 5UBJEGT: DATE: DATE:WRITTEN PERM15510N OF PER5PEGTIVE 10/13/2011 THE COPYRIGHT OWNER REM 0. �w gat tew`, WgOr &s 10* d* a� v r , 00 w ._...,. . . .w._ _,--_-_, ,. k, _;. .cam w stag aestvA SS fes. i i t i Nlassullusetts- Dcpai-tmcnt of Puhlic Safcl� Board of Buildin- Regulations and Standards Construction Supervisor License License: CS 94513 --- r TIMOTHY S WILLIAMS 272 CHESTNUT HILL ROAD ROCHESTER, NH 03867 —�-= Expiration: 8/28/2013 f ununiti�i+,n,'r Tr#: 6377 �fce fasnmeoaeurea�! e�`-tlaala<�ivae� _ Office of Co usumer Affairs&Business Regulation ro;` G� ._NOME IMPROVEMENT CONTRACTOR 4- 141���� , 3 s ' Y Registration: 106877 V� Type: Expiration: 7/28/2012 Supplement C t1 BLACKDOG BUILDERS, INC TIMOTHY WILLIAMS �� 7 RED ROOF LN.#1 m . Salem,NH 03079 Undersecretary10 UniversitY Of Cincinnati Occupational Health & Safety Continuing Education Program Co-Sponsored by Environmental Training Institute, LLC TIMOTHY "LLIAMS 4 7 Redmof Ln. Salcm.NH 03079 Has Successfully Completed the Lead Safety for Renovation, Repair and Painting Initial Course P*.!!Di!5;i00 Course Principal Instructor R-I-18459-10-01387 •8 Certificate Number Continuing Education Units April 28,2010 April 14,2010 Issue Date Language—English 1 9 j Course Date 1 Occupational Health&Safety Continuing Education,UC Reading Campus,2180 E.Galbraith Rd.,ML 0510,Cincinnati,OR 45237-1625,(513)558-1730, www.eh.uc.eduthsce i A RDM CERTIFICATE OF LIABILITY INSURANCE 07/13/2011 PRODUCER 603.424.9901 FAX 603.424.3203 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Brown & Brown of N H, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 309 Daniel Webster Highway ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P 0 Box 1510 Merrimack, NH 03054-1510 INSURERS AFFORDING COVERAGE NAIC# INSURED Black Dog Builders, Inc. INSURERA: Merchants Insurance Group 7 Red Roof Lane Unit #1 INSURER 8: Salem, NH 03079-2984 INSURER C: INSURER D: INSURER E: I 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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. DD' POLICY EFFECTIVE POLICY EXPIRATION LIMITS INSR TYPE OF INSURANCE POLICY NUMBER I TR NSR GENERAL LIABILITY CMP9152639 07/01/2011 07/01/2012 EACHOCCURRENCE $ 1,000,000 DAMAGE TO RENTED $ 100,000 )( COMMERCIAL GENERAL LIABILITY a OCCUR MED EXP(Any one person) $ 5,000 CLAIMS MADE A PERSONAL 8 ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,00 PRO POLICY T EC JLOC AUTOMOBILE LIABILITY CAP9267558 07/01/2011 07/01/2012 COMBINED SINGLE LIMIT $ (Ea accident) 1,000,000 ANY AUTO ALL OWNED AUTOS BODILY INJURY $ (Per person) A X SCHEDULED AUTOS X HIRED AUTOS BODILY INJURY $ (Per accident) X NON-OWNED AUTOS i PROPERTY DAMAGE $ (Per accident) AUTO ONLY-EA ACCIDENT $ GARAGE LIABILITY ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY CUP9143959 07/01/2011 07/01/2012 EACH OCCURRENCE $ 1,000,000 X OCCUR D CLAIMS MADE AGGREGATE $ 1,000,000 A $ DEDUCTIBLE X RETENTION $ 10,000 $ WORKERS COMPENSATION AND WCA9097912 07/01/2011 07/01/2012 X WC STATuT TEg EMPLOYERS'LIABILITY E.L.EACH ACCIDENT $ 500,000 A ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYE $ 500,000 If yes,describe under E.L.DISEASE-POLICY LIMIT $ 500,0 SPECIAL PROVISIONS below OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE Jennifer Kokol i s/CM4 ACORD 25(2001108) OACORD CORPORATION 1988 The Commonwealth ofWassaci:usetts ,department of fiidustrial Accidents Office oflnvestigations 600 Washington Street Boston,MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legible Name (Butsiness/Organintion/Individual): tatka/bcj 2ui���. Address: fl?eJ� � City/State/Zip:SaIt- k)k 0301F Phone#: 603- 896- 08(6 Are you an employer? Check the appropriate box: Type of project(required): I.4 I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet 7. Remodeling ship and have no employees These sub-contractors have g. C1 Demolition for me in any capacity. employees and have workers' (No workers' comp.insurance comp. insurance.t g- ❑Building addition required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 1 I.E]Plumbing repairs or additions myself. (No workers' coup, right of exemption per MGL 12.Q Roof repairs insurance required.] t C. 152, §1(4), and we have no 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. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that isproviding tuorlrem'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: mt4"�iS _-1:;,KLNT4VC � Policy#or Self-ins. Lic.#: �XA 909171Z., Expiration Date: V_6///? Job Site Address: X95 Caw+pbC// e:d City/State/Zip: N.A4u-g— MA 0/81-T Attach a copy of theworicers' 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 certify under thepain an penalties ofperjrtry that the information provided above is true and correct Sienatu Date: Phone#: Official use only. Do not tivrite in this area, to be completed by city or toren offi-ciaL City or Town: Permit/License# Issuing Authority (circle one): 1.Board of Health 2.Building Department 3. City/Town Cleric 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person- Phone#- Home Services Agreement Order Number: HSA5740S Customer Name: Leslie and Robert Bambury 7 RED ROOF LANE,UNIT 1 a SALEM,NH 0307 Address: 295 Campbell Road PH: 603.898.086£ Cit /State/Zi North Andover, MA 01845 --Fx-6u3.8g8.oszr ' 1M�NVREMODEL City/State/Zip:p' .BLACKDOGBUILDERS.CC Phone Number: (978)687-1825 Job No: BAMBU-9915 Descri tion Price Total PORCH ROOF 01.009. -Building Permit Fee Based on $per 1,000- 1 $M This item is the component driven by the cost of the project and adjust the price based on a fee per$1,000 of construction.Base permit fee should also be included in the proposal. 01.009.011 - Prepare Plans for permiting- 1 EA Prepare basic plan for permit purposes. SITE PREPARATION 02.108. -Masonite siding removal-40 SF Remove siding from existing exterior wall ROOF FRAMING 08.007. -'2"x 6"gable framing &ceiling joists-56 SF ! Ridge board Rafters 16" OC Ceiling joists 16" OC Collar ties, 1"x 6", 48"OC Nails Framing for overhang and eaves 08.017. -Curve ceiling of porch to recieve pine bead board- 1 EA Frame ceiling of porch roof with an arc and finish with pine bead board. 08.101. -1/2"plywood roof sheathing-56 SF CDX plywood I 08.113. -12"soffit nailer-8 LF 2"x 4"framing to support soffit Soffit Width ROOFING AND FLASHING 09.016. -375 Ib. roof shingles, <6 in 12 pitch -56 SF 375 LB. (40 Yr) On plain shed or gable wood roof deck Load onto roof Build staging if required 3 tab square butt self seal 215-225 Ib. 15 Ib.felt paper Galvanized shingle nails or staples Metal drip edge 5" 09.704. -Aluminum flashing on wood sheathing- 14 LF Flash gable roof to wall with stepflashing. EXTERIOR TRIM AND DECKS 10.000.01 - 1 x3 shadow board-Azek-22 LF Install 1x3 Azek board as exterior trim detail 10.000.New- 1 x5 Azek trim boards for exterior application-22 LF Provide and install Azek exterior trim board as per.plan 9/13/2011 5:47 PM Page 1 of 4 10.001.New-1 x 8 Azek trim boards for exterior-24 LF Provide and install Azek exterior trim board as per plan 10.002.New- 1 x 10 Azek trim boards for exterior-8 LF Provide and install Azek exterior trim board as per plan 10.200. - Post anchor-2 EA Secure post to concrete or masonry galvanized post anchor Drill hole in pier and secure post anchor with 1/2" -expansion t7vnP SIAA��A anrhnr holt 10.214- Provide and install Turncraft 8"fiberglass post -2 EA Provide and install 8x8 square fiberglass column with standard cap and base. Column to be be non-tapered. F 10.230. -2-2"x 8"wood beam or header-8 LF Solid or built-up wood beam or header on existing supports with pressure-treated fir or pine. These will be the support beams that carry the roof and rest on the posts. 10.421. - 1"x 6"pine V-joint porch ceiling-32 SF Includes ceiling cove at wall intersections i I SIDING 11.200. -8"width lap siding-60 SF Install siding on Gable end as well as weave new masonite siding into existing courses of siding after porch roof is built. Note: product comes rimed but should be painted shortly after install. p DOORS AND TRIM 12.000. -Trim exterior of existing door unit with 6"Fypon cross head and fypon flat lineals - 1 EA Provide and install Fypon 6" cross head over door and sideliights and install Fypon flat exterior casing left and right. Mull cover to be PVC. ELECTRICAL 16.000.00-Electrical permit-Small project-.1 EA This item covers the cost of an electrical permit and inspections for a small project with a minimal amount of electrical work. Some typical examples include but are not limited to; basic bathroom remodels and miscellaneous piecework. 16.120.03-Exterior light fixture-old work- 1 EA Under old work conditions, Install outside fixture over door or at the side of door.Fixture and lamp to be provided by others. 16.225-Rework as needed-3 EA This item address miscellaneous electrical labor required on all jobs. Specifically, these labor hours will be used in omitting or reworking existing electrical to allow for wall or ceiling removal as well as reframing walls to add or increase openings. Electrical labor may also be used in unusual conditions where standard unit pricing does not address the actual labor required for the work PAINTING 24.006. -This project does not include painting work- 1 EA This specification has no cost. It exists to clarify that no interior or exterior paint has been included in the project. The project will be delivered in a"ready for paint' manner. The client will be responsible for paint preparation and painting. Blackdog will set all nails but there will be no filling, sanding or caulking. These tasks all fall under the catagory of paint preparation. i G 9/13/2011 5:47 PM Page 2 of 4 CLEAN-UP 25.000.02-Clean up exterior job - 1 EA Clean up exterior of project to include the removal of all debris generated by the construction process. Grounds shall be swept and/or raked as appropriate. Debris will be loaded into roll-off container if included in proposal. If roll-off container is not in the general conditions section of the proposal, the client is responsible for debris removal from site. This item reflects a base fee for exterior clean up. Payment will be made as follows: Deposit $2,513.91 Start of project $2,513.92 r Start of roofing $2,513.92 Completion of Punch List $233.25 Subtotal $7,775.00 MA Sales Tax (if applicable) *Total Due $7,775.00 Terms and Conditions of Blackdog Home Services 1. The Homeowner/Client shown on the attached document desires to retain Blackdog Builders,Home Services Department(BHS)to provide Home J. Services according to the information provided on the attached document and the terms set forth herein.When signed by the Client,this Work Order (WO)and its terms and conditions will cover all the work to be performed. ;y, 2. AII'work to be performed under this WO will be in accordance with local,state and county building codes.Permits,if included will be specified on the attached document and included in the estimate.If permits are not specified and are needed,BHS can obtain permits for an additional fee. include any unspecified items including but not limited to unforeseen conditions,unbid items required by any local 3. The contracted price does not building official,items discussed but not written into the specifications. 4. Any extra work either required or requested shall be agreed to in writing and such extras shall become part of this contract as if fully set forth herein.If 'a written agreement is not practical,BHS will notify Client verbally to expedite agreement as to any charge necessary to proceed with the work and will provide a written Change Order as soon as practicable.Payment terms to be the same as the original contract unless specifically stated in writing. 5. Blackdog at its sole discretion will determine the proper number of workers required for any job based on the type of project,efficiency of work,safety and other factors.On sone projects the number of workers may vary from time to time during the project.Execution of this WO means acceptance of BHS's right to determine the appropriate number of workers. 6. Client freely agrees to waive any rights of rescission that may or may not be applicable to this WO and the services provided. 7. We encourage our clients to bring to our attention any defect they find in our work or service.Client also agrees to inspect the work provided prior to the workman leaving or when that is not possible within 24 hours and report any problems within that time frame.We will inspect the work and if in our sole opinion the work did not meet industry standards or our higher standards,we will correct the defect at no charge 8. There is a one hour rescheduling charge in the event a scheduled appointment has to be rescheduled with less than 24 hours notice. The hourly rate is S85/hr. 9. There is a two hour cancellation charge if the appointment is cancelled with less than 24 hours notice,and there is a 3 hour cancellation charge if the appointment is cancelled with less than 4 business hours notice. 10. It is agreed by the Client and BHS that BHS is not responsible for direct,indirect or consequential damage due,in part or in whole,on the failure(s)of the existing structure or its systems or Client provided materials,supplies or products before,during or after BHS services have been provided. 11. In the event a BHS worker determines that it is dangerous to work in the home due to any cause,work will be terminated immediately and the homeowner notified.Such dangers might include,but are not limited to,structural instability,asbestos,the smell of gas,the presence of an animal deemed menacing by the worker,etc. 12. In the event BHS determines,in its sole discretion,the need to hire collection or legal services to obtain payment,recover property,prevent or seek remedy from false,inaccurate or malicious complaints,slander or liable,the Client agrees to pay for any and all attorneys fees and related costs incurred by BHS. 9/13/2011 5:47 PM Page 3 of 4 G 13. BHS reserves all rights and remedies it may have in connection with the services provided or the Client's obligations under this W0.BHS also reserves the right to waive any one or more of its rights,as it deems appropriate at any time without giving up its right to use or enforce all of its rights in the future. 14. In the event a check or charge is rejected by the bank or credit card company,BHS reserves the right to charge and collect$50 for the first incident and $85 per incident thereafter. 15. Any payment not paid upon the date of service shall be subject to a$25 service fee and 15.5%interest or Wall Street Journal prime plus 13.5% whichever is greater until full payment is received. 16. Client agrees to make no agreements with trades person,subcontractor or BHS employees outside the scope of this contract without the written consent of BHS Management. 17. No employee of Blackdog Builders or any of its subcontractors can modify or change these terms or conditions.Any changes must be agreed to in writing by the President of Blackdog Builders and the Client.This WO cannot be orally modified.This contract is non-assignable. 18. In the event that one or more of the provisions of this WO are invalidated,illegal,unenforceable in any respect or waived,the validity,legality and enforceability of the remaining provisions will in no way be affected or impaired. i 19. In the unlikely event of a dispute,BHS and Client agree to first attempt to,in good faith,resolve the dispute.If the dispute cannot be,settled through j direct discussions,the parties agree the dispute shall be settled by mediation.If mediation should fail,the parties are lefto theiY>e edies at law. I agree to;e above ��trnd condi ions ,1Q4 7 Le 1i a Robert Bam ury Date David Bryan, CG Date President i I i 4 i I i t i 9/13/2011 5:47 PM Page 4 of 4 i 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 i , I I c i ❑ Notified for pickup - Date i i Doc.Building Permit Revised 2008 I t 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 a Photo Copy Of H.I.C. And/Or C.S.L. Licenses o Copy of Contract o 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 o Certified Surveyed Plot Plan ❑ Workers Comp Affidavit E3 Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) Li 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) o Building Permit Application ❑ Certified Proposed Plot Plan Li Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit u Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract o 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:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2008 h I Septic System Information 295 CAMPBELL ROAD Printed On:Monday,August 07, 2006 System ID: BHS-2002-0584 L General System Information Latest Permit Information Calcaluted Design Flow: Test Pits Septic Tank Disposal Trench Design Flow: One Two Capacity: Number: Design Flow Provided. Minutes per inch: Width: Width: Total Flow: Depth: Length: Length: Seasonal: No No Depth to Water: Diameter: Leaching: Grinder. No No Soil Type: Depth: I Laundry: No No I a Inspections: Inspected: Expires: Inspector: Status: 06/06/2006 James Boraczek Passes Comments: Title 5 I I I \ GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Page 1 of 1 i Commonwealth of Massachusetts Title 5 Official Inspection Form l Not for Voluntary Assessments Subsurface Sewage Disposal System Form Inspection results must be submitted on this form or on the official Title 6 Inspection Form dated 6/1612000. Inspection forms may not be altered In any way. A.'Certificatlon Important: when filling out 1. Property Information: forms on the 2-C?,-�° computer,use ^�..."--F.--- only the tab key Property,,Address to move your cursor-do n use the retur, key. (j YS state Zip Code w. (P-6--06 Me v Date AH 61 WR State Zip Code , vage disposal system at this address and that the D i complete as of the time of the inspection. The inspection ience In the proper function and maintenance of on site Ird system Inspector pursuant to Section 16.340 of iditionally Passes ❑ Falls ❑ tl • ds Further valuatio:: ley t Local Approving Authority :.r's Nature Date Thu system inspector shall sr:bmit a copy of this Inspection report to the Approving Authority(Board of I i6alth or DEP)within 30 c!�ays of completing this inspection. If the system Is a shared system or has 1-1 design flow of 10,000 pd or greater,the Inspector and the system owner shall submit the repoi I to tl:.-, appropriate regi_:nal office of the DEP. The original should be sent to the system owner of copies: sent to the buyer, (,'applicable, and the approving authority. '**"Tt,i a report only describes ::onditions at the time of Inspection and under the conditions of use at; ,a t tim'. This inspectic r does not address how the system will perforin In the future under the sL-me or different gond+cions of use. t5imp.doc•11/2004 Title 5 Official Inspection Form:Subsurfooe Sewage Disposal System- Page 1 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 29.T 4^-4g// M Property Address Al tits state Zip Code _ l�IG'a t�r►►r. 6-6-06 Owner'6 Name Date of Inspection 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: I �C/h (`s i sir �� �k�'�5 �uti.ai'� �r'yv /����i S �►�r''1�. B) Sys ern Conditionally Passes: i ❑ 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.. Inc Board of Health,will pass. Answer yes, no or not determined (Y, N, ND)in the❑for the following statements. If"not deten!-J- ad," please explain. ❑ The septic tank is metal and over 20 yearn old"or the septic tank(whether metal or not) is structurally unsound, exhibits substantial Infiltratlon or exflltration or tank failure Is imminent. stem will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. • .>; 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 y46 old is available. ND Explain: i Minap.doc•1112004 Me 5 official Inspection Form:Subsurface Sewage Disposal System Page'2 of 16 Commonwealth of Massachusetts Title 5 official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) Z'ri S A/-Q#"l� ltd Property Address ,!f N ,IAolWWe`i Qtyrrownstate Zip code ` Owners Name Date of Inspection 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 ❑ obstruction is removed ❑ distribution box is leveled or replaced ND Explain: ❑ 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 ❑ obstruction is removed ND Explain: C) Further Evaluation Is Required by the Board of Health: ❑ Conditions exist w!;ich 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: ❑ Cesspoo; 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 tShsp.doc•1112004 T tle 5 Oftel Inspection Form:Subsurface Sewage Disposal System Page 3 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) zcls' r-a4c/1 Property Address AV-A Jo ov cf Al Citylfow,n/� state Zip Code a//`1"Cea (e-6-06 Owner's Name Date of Inspection C) Further Evaluation is Required by the Board of Health (cont.): 2. System will fall 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 and volatile organic compounds Indlcalea that the well is free from pollution from that facility 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: i Minsp.doc•11/2004 TWe b Offldal Inspection Form:Subsurface Sewage Disposal System Page 4 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 90 Q PrAddress .-.. -- city v - state zCode ---- Ownees Name Date of Inspection D)System Failure Criteria Applicable to All Systems: You mu:>t indicate"Yes" or"No"to each of the following for all Inspections: Yes No ❑ Backup of sewage Into fac 11ty or system component due to overloaded or clogged SAS or cesspool ❑ 7- 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 S' below invert or available volume is less than 1/2 day flow ❑ 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. ❑ /f Any portion of a cesspool or privy is within a Zone 1 of a public well. El / Any portion of a cesspool or privy is within 50 feet of a private water supply f well. ❑ ;?f 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 sn*sis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds Indicates that the well Is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen Is equal to or less than 6 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] I Yes No ❑ �,( The system falls. I have determined that one or more of the above failure Y' 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 MI be necessary to correct the failure. t5tnw.d9c•11/2004 Title 6 Off[ 1 Irapecdon Form:Subsurface Sewage Disposai System Page 5 of 16 r I Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification cont. Property Address �✓Qovc( AA Ci govn / Stale Zip Code 1 Owners Name Date of Inspection i 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. t5lnsp.doc"11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 6 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Checklist Property Address �,�'Porrcr CitylTown . State Zip Code P-rh`1G/o I►*141� &-f•Yo Owher's Name Date of Inspection 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? two week period? ❑ Has the system received normal flows in the previous pe ❑ .o.- Have large volumes of water been Introduced to the system recently or as part bf this inspection? Were as builty of the lans system obtained and examined? ( Y If the were not available.,� ❑ p I le note as N/A) ❑ Was the facility or dwelling inspected for signs of sewage back up? f� ❑ 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 8011 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(3)(b)) t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 7 of 16 Commonwealth of Massachusetts Title $ Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information ! -zgs- 9Ck411 P4 Property Address �NjapVtl City own State Zip Code 91 rilef•v �h�w►fP¢�s —6—©6 Owners Name Date of Inspection Residential Flow Conditions: Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): S Number of current residents: Does residence have a garbage grinder? ❑ Yes-0 No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ;j rNo Laundry system inspected? ❑ Yes Z No Seasonal use? ❑ Yes JRr No Water meter readings, If available(last 2 years usage(gpd)): — Sump pump? ❑ Yes,[20No Last date of occupancy: Date--- — CommerclaUindustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/personsisq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Tltle 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date _ Other(describe): tSinsp:doc•11/2004 TO 6 Qltldal Inspection Form:Subsurface Sewage Disposal System- ... - Page 8 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form ` System Information cont. C. Sy (cont.) vis- Property Aodresp Npovcr AM City/Town � ' stateZip Code Pit^—" D►1i Mt l_f►s 6-6-06 Owner's Name Date of Inspection General Information Pumping Records: lit d Source of information: Was system pumped as part of the inspection? .. ''Yes ❑ No /SOO If yes,volume pumped: gallons GasC d� ��K luk e /3o// How was quantity pumped determined? Reason for pumping: Ahl JNAVCc._ 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) 13 maintenance technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date Installed(if known)and source of Information: /1%-'�' Were sewage odors detected when arriving at the site? ❑ Yes;�rNo Okua doc 11/2004 T1W S OlRdal IntsQedion Form: Sewag.rrace .. .... Drspotal5 ystem ...... Pale 9 of 16 i Commonwealth of Massachusetts Title 5 official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) Property Address /V'~-}tipoVtr 141/ City/Town - State Zip Code PC) � 1,r- bAI'AI¢►'j owners Name Date of Inspection Building Sewer(locate on site plan): Depth below grade: feet Material of construction: f cast iron [-140 PVC ❑other(explain): Distance from private water supply well or suction line: Z� ' feet Comments(on condition of joints, venting,evidence of leakage, etc.): I Septic Tank(locate on site plan): Z � Depth below 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 ❑ Yes ❑ No certificate) Al Dimensions: f Sludge depth: — � Distance from top of sludge to bottom of outlet tee or baffle / tG 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 `e v'/ 916A How were dimensions determined? /14C'Qsur C.4. t5insp,d •11/2W4 TqN 6 094#1 InwecWn Form:Subsurface Sewsp Dispo"System Page 10 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 2-95' Ktm&l/ l Property Address Cityrrown1,, 1 state r ! Zip Code per% f ud atii N►I TIS (0�(0'0�D Owners Name Date of Inspection Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as r lat d to outlet invert, evidence of leakage, etc.): z Grease Trap (locate on site plan): Depth below grade: ------------- ---_._ ._.__... feet Material of construction: ❑ concrete EJ 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 Comments(on pumping recommendations, Inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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): *nsp.doc•11/2004 Tale 5 Omdal Inspection Form:Subsurface Sewage Disposal System Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection' Form Not for.Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) Property Address Q --- Cityfrown ,( /_ • , state ,rte— Zip Code Pa71rfCrb DAl"P lois, �'�P-o 6 Owner's Name Date of inspection Tight or Holding Tank(cont.) 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 i Comments(condition of alarm and float switches, etc.): Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert /lino Comments(note If box Is level and distribution to outlets equal, any evidence of solids carryover, any ev'den�ISleakagEl into rout of box,etc.): —` '�' ��{ /L Cit nrA/ocK,'' /00 or Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ['] No Alarms in working order: ❑ Yes ❑ No t5i .d9c•11/2004 Tltle 0 9 InspaGton Form:Subsurface Sewa►pe Disposal System Page 12 of 16 Commonwealth of Massachusetts tipTitle 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) `Z9S le"11-11 I" Property Address ,/U' Dt ed 101A City own ^-T -- �- state Zip Code rlCIO D�r'041�iS 6-6-06 Owners Name Date of Inspection Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: --- ----- leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number. ❑ innovativelaltemative system ` Type/name of technology: -- --------- Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of vegetation, etc.): JJ 11 & Siti,r o t 9106 '�fi c F#41me t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 13 of 16 i Commonwealth of Massachusetts Title 5 official Inspection Form Not for Voluntary.Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) z Fs Xg Aill 0 Property Address N"f1N00vel —_ City/town State Zip Code py4 11 cr'O '��1i N•i�p►i� �-G�y6 Owners Name Date of Inspection 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 Dimensionsf o cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions I Depth of solids ------ — ----- Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•11/2004 Title 5 Official Inspection Fond:Subsurface Sewage Disposal System Page 14 of 16 Commonwealth of Massachusetts tipTitle 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) ZC(S Frc Mklf Rd, Properly Address City/Town State Zip Code p ,�,o ��i ►s -------- r--6-06 Owner's Name Date of Inspection Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. j Locate where public water supply enters the building. V to sic-sZ���" Q` a D-D, yuJSt- SUN Y-00 � 0 S f t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 15 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) Lgs- AM6411 � Prop" /j/-y%/D0(/Cr ........�_ Gty�a ,zip code '7fi^PC�'0-- Q n j wl I T I S ...__..._----... State � Owners Name Date of Inspection Site Exam: Slope Surface water Check cell Shallow wells Estimated depth to ground water: /26 If/ iVU C�,}c 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 1 ❑ Observed site(abutting property/observation hole within 150 feet of SAS) I ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, Installers-(attach documentation) ❑ Accessed USGS database-explain: ,. l. You must describe how you established the high ground water elevation: Vo SUbpy+'k0 (p Celtar Wnsp,doe 11/2W TW 5 Ofridar InwocWn Form:Subsurface Sews Dispospi System 16 of� Septic System Information 160 CARLTON LANE Printed On: Thursday,August 31, 200 System ID: BHS-2002-0458 General System Information Latest Permit Information Calcaluted Design Flow: Test Pits Septic Tank Disposal Trench Design Flow: One Two Capacity: Number: Design Flow Provided: Minutes per inch: Width: Width: Total Flow. Depth: Length: Length: Seasonal: No No Depth to Water: Diameter: Leaching: Grinder: No No Soil Type: Depth: Laundry: No No Haulinp/Pumping Listing Quantity Tvpe System Type Pumped Pumped By Transferred To Disposed At Date Pumped (gallons) Routine Septic Tank Andover Septic 05/05/2004 1500 Inspections: Inspected: Expires: Inspector: Status: 08/01/2006 Harold T. Lincoln,Jr. Passes Comments: Title 5 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Page 1 of 1 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION r TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 160 CARLTON LANE NORTH ANDOVER,MA 01845 Owner's Name: DARREN AND LAURA WINNIE Owner's Address: 1:60 CARLTON LANE ��� W NORTH ANDOVER,MA 01845 Date of Inspection: AUGUST 1,2006 Name of Inspector: (please print)HAROLD T. LINCOLN,JR. 2006 AUG 3 1 Company Name: RAGGS,INC. �r. - C',- TOJUN OF Nu LR Mailing Address: P.O. BOX 1027 HEALTH DE, CONCORD,MA 01742 Telephone Number: 978-369-1100 CERTIFICATION STATEMENT 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 Needs Further Evaluation by the Local Approving Authority Fails ``LL Inspector's Signature: 6�77� 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. Notes and Comments: ****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. Title 5 Inspection Form 6/15/2000 page 1 i ,: '375_ tE _Tti fAa 82/a.; f orMasuchumb �f E - ` N T �rY PUM*9 or NY fan MP Code 1 - .� � iioa4f �o4~Hsat�r�eihw t I A Nam QIP Code T w4AeNiimbir T ^9- 011/0 a;. I. F�uir► = ----------- LO. nLv Pumpa All '1` �.,i �ci'(3� 13i Tar* �4. �#TOO F Qtg'mw!7 .� Y� � � K y;, it k 7 �.S YaR u No If �r Why d- G DWI*FU;WT- 7. • Date........ .. .... .. .. ... .... ... NOR71� °��"`° '•�"� TOWN OF NORTH ANDOVER p PERMIT FOR WIRING SAC14USE� This certifies that -"' ?-. � ............................. has permission to perform 6--:A Ta,:V- A!' ...... ................ .... ... ,........................................ wiring in the building of /� RM gv R at.....:�..... 1 .......t?....... ,North Andover,Mass. Lic.No F. ................... 7 . ........ kAINE16tCTOR.j ..... 9 SP Check # Z 2.7`f 7 f 7327 Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. -73 Z 7 Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 9/05] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to erform the electrical work described below. Location(Street& Number) G�/f✓f 8�0�1 �zGr Owner or Tenant Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No 21- (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity t Location and Nature of Proposed Electrical Work: 7770-3-5& ee it b l i Completion of the following table maybe waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- ❑ o.o Emergency Lighting rnd. rnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. / TotalTons 3 No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons K o.of elf-Contained Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems: No.of Devices or Equivalent No.of Water KW No.of No.o Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No. Hydromassage Bathtubs No.of Motors Total HP elecommunications Wiring: No.of Devices or E uivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify,under th am and p nalt'es of perju ,that the information on this application is true and complete. FIRM NAME: /j�rc.5 11e1r �+1tr`+(T LIC. NO.: Licensee: rt ?- Signature C LIC. NO.: (If applicable, enter "exemp "in the license num er line.) Bus.Tel. No.: 71 "6�Q ✓?3 Address: A-Ylt9 /.�j(,�r-- ^-y4 Alt.Tel. No. *Security System Contractor License required for this work; if applicable,enter the license number here: OWNER'S INSURANCE WAIVER: 1 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. $