HomeMy WebLinkAboutMiscellaneous - 1000 DALE STREET 4/30/2018 (2)Now
Important:
When filling out
forms on the
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Commonwealth of Massachusetts
City/Town of �v RECEIVED
System Pumpingecord 1
JUL 1 2005
Form 4
TOWN OF NORTH ANDOVER
DEP has provided this form for use by local Boards of Health. Other for s rri4 ^b6--utedA uV1fhd
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location:
/1,46 10
Address
City own State Zip Code
2. System Owner:
1ea4a4r/
Name
Address (if different from location)
City/Town
B. Pumping Record
1. Date of Pumping
3. Type of system: ❑
❑ Other (describe):
State
Telephone Number
Da 2. Quantity Pumped
Cesspool(s) ❑ Septic Tank
4. Effluent Tee Filter present? ❑ Yes No
5. Condition of System:
Zip Code
M�ffl " UF 9 - �
❑ Tight Tank
If yes, was it cleaned? ❑ Yes ❑ No
6. Syste Pumped By:
Name Vehicle License Number
VoecL
Company
7. Location where contents were disposed:
Date
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1
Commonwealth of Massachusetts
City/Town of Ay
System Pumping Record RECEIVED
Form 4
" JUL 1 1 2005
DEP has provided this form for use by local Boards of Health. Otheq forms may be used, but th
information must be substantially the same as that provided here. B foT,eluging.itthislfiorm;ccbmk with your
local Board of Health to determine the form they use. The System PLM{'� ad!YnlgfjbiZ su�mitted to
the local Board of Health or other approving authority.
A. Facility Information
Important:
When filling out 1. System Location:
forms on the �-�7
computer, use l &j�
__
only the tab key Address "
to move your
cursor - donot
use the return City/Town State Zip Code
key. 2. System Owner:
Name
FrMn x
Address (if different from location)
Cityrrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 1.41 Da 2. Quantity Pumped: Gallo
_/ _1106
3. Type of system: ElCesspool(s) ElSeptic Tank ElTight Tankkfis
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes_ _/ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. Syste Pumped By:
aii
&�r
ompany
7. LocatLon where contents were disposed:
Vehicle License Number
Date
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1
TOWN OF NORTH ANDOVER , p���:H `
SYSTEM PUMPING RECO OF -HF."
DATE:
SYSTEM OWNER & ADDRESS
bear- hPc-a
-
Al I=;
SYSTEM LOCATION
(example: left front of house)
DATE OF PUMPING: b3 QUANTITY PUMPED GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES `✓
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
FULL TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
OTHER (EXPLAIN)
SYSTEM PUMPED BY: �p�- r , �Aa A
COMMENTS:
CONTENTS TRANSFERRED TO: 'S'�
FORM U - LOT RELEASE FORM
6 �cS Da ele
20 /0
INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from
Boards and Departments having jurisdiction have been obtained. This does not relieve
the applicant and/or landowner from compliance with any applicable or requirements.
****************************APPLICANT FILLS OUT THIS SEC40
TION
APPLICANT 5G.�c,� i-.�vr\1'�G. re�g � l!
PHONES -
LOCATION: Assessor's Map Number
PARCEL_
SUBDIVISION LOT (S) _
STREET_ �- f � ST. NUMBER OQ0
OFFICIAL USE ONLY***
AGENTS:
11
CONSERVATION ADMIND OR DATE APPROVED
DATE REJECTED
COMMENTS s5
TOWN PLANNER
DATE APPROVED
DATE REJECTED
FOOD INSPECTOR -HEALTH DATE APPROVED
DATE REJECTED
SEPTIC INSPE OR -HEALTH DATE APPROVED
111
DATE -REJECTED
COMMENTS 6AM—A
�CLf
PUBLIC WORKS, - SEWERIWATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTMENT
RECEIVED BY BUILDING INSPECTOR
DATE
Revised 9W jm
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TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE:
SYSTEM OWNER & ADDRESS
WOO 9
N�At•
SYSTEM LOCATION
(example: left front of house)
DATE OF PUMPING: "1 QUANTITY PUMPED GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES V
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION
FULL TO COVER
HEAVY GREASE
BAFFLES IN PLACE
ROOTS
LEACHFIELD RUNBACK
EXCESSIVE SOLIDS
FLOODED
SOLIDS CARRYOVER
OTHER (EXPLAIN)
SYSTEM PUMPED BY:��l
COMMENTS:
AUG {
P �
CONTENTS TRANSFERRED TO:
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Town'of North Andover, MA
Watctbrshed Septic System
Servicing Report
Date : a- q(p
Homeowner:.
Street : go��,/�
Phone (�,�C" 1 )5'b
Nature of Service: Routine
Observations:
Emergency __
Pumper Iy
Address: Ya-
Phone b (IK)
Good Condition NO
Full to Cover 441-
Baffles
r=
Baffles in Place w
Leachfield Runback
Excessive Solids to
Heavy Grease IVG
Roots
Other (Explain)
Description of Work: n
YZJA AA A7)
Comments::
TOWN OF�ANDOVER
SEPTIC SYSTEM SERVICING
REPORT
Date:
Homeowner: �Ir� Pumper %I(��, "� / a
Street /T Address:
Phone Phone : ,�ff /
Nature of &a_rvice:
Observations:
Description of Work:
Comments,:
Routine v
Emergency
Good Condition
Full to Cover
Baffles in Place
Leachfield Runback
Excessive Solids
Heavy Grease
Roots
Other' (Explain)
Date:
TOWN OF !X�
^ANDOVER
SEPTIC SYSTEM SERVICING
REPORT
Homeowner:_
Street ;_, �0
Phone
Natur. e (Df S.2rvice :
Routine
Emergency
P
V
Pumper
Address,:
Phone
C�
Observations:
Good Condition
Full to Cover
Baffles in Place _
Leachfield Runback
Excessive Solid.,
Heavy Grease
Roots
Other (Explain)
Description ()f Work:
Comments:
DATE
SYSTEM OWNER & ADDRESS
RECEIVED
JUL 13 2004
LEAOLTH DEPARTMENT RJ
SYSTEM LOCATION .
(example- left front of house)
elf r
DATE OF PUMPING: =-:�' �>>' QUANTITY PUMPED GALLONS
CESSPOOL: NO
YES SEPTIC TANK: NO YES '
NATURE OF SERVICE: ROUTINE_ EMERGENCY
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS —
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
FULL TO COVER
BAFFLES IN PLACE `=
LEACHFIELD RUNBACK
FLOODED
OTHER (EXPLAIN)
SYSTEM PUMPED BY: 1(a i�• �� J
COMMENTS:(/---/
J
CONTENTS TRANSFERRED TO:
Location
No. Date
Nom,. TOWN OF NORTH ANDOVER
a
i a
Certificate of Occupancy $
his'.^°uwuBuilding/Frame Permit Fee $
sst
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
"16461
Building Inspector
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
BUILDING PERMIT NUMBER: a ( DATE ISSUED:
SIGNATURE:
Building Commissioner/Inspector of Buildings Date
SECTION i- SITE INFORMATION
1.1 Property Address:
on ire •
1.2 Assessors Map and Parcel Number:
/� C/ o
Map Number Parcel Number
1.3 Zoning Information:
Zoning District Proposed Use
1.4 Property Dimensions:
1 Lot Area Frontage ft
1.6 BUILDING SETBACKS ft
Front Yard Side Yard
Rear Yard
Required Provide Required Provided
Required Provided
1
1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information:
Public ❑ Private 0 .Zone Outside Flood Zone 0
1.8 Sewerage Disposal System:
Municipal 0 On Site Disposal System 0
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record
VNVK ,s W�deo ✓ r.Q
Sc-rs-L. 6L r.
Name (Pont) Address for Service
-- f(
Signature/ Telephone
2.2 Owner of Record:
Name Print Address for Service:
Signature Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
censed Construction Supervisor:
Wfdress
Signature Telephone
Not Applicable ❑
License Number
Expiration Date
3.2 Registered Home Improvement Contractor
Not Applicable ❑
Company Name
Registration Number
Address
Expiration Date
Signature Telephone
Mo
M
s
Lim
SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 § 25c(6)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed affidavit Attached Yes .......0 No ....... 0
SECTION 5 Description of Proposed Work check all applicable)
New Construction ❑
Existing Building [IRepair(s)
❑
Alterations(s) ❑
Addition ❑
Accessory Bldg. ❑
Demolition ❑
Other ❑ Specify
Brief Description of Proposed Work:
P(� ►�,-t hie V" 2 Wq 4t W
Ge1�. 14r l «'1 6 t O� C1 •L W 1 � t�.�lc�
SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost (Dollar) to be
Completed by permit applicant
OFIINTAL"USE ONLY
1. Building
O O
(a) Building Pernut Fee
Multiplier
2 Electrical
(b) Estimated Total Cost of
Construction
3 Plumbing
Building Permit fee (a) X (b)
(30
4 Mechanical HVAC
5 Fire Protection
6 Total 1+2+3+4+5
Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
Z. L--eQvkA&G-I` as Owner/Authorized Agent of subject property
Hereby authorize C('t ` n ec-45\ to act on
My behalf in all ma rs relative ICO
w k authonizeh by this building permit application.
�'SignadlYof Owner Date
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
I, as Owner/Authorized Agent of subject
property
Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief
Print Name
Signature of Owner/A ent Date
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TIMBERS 1ST 2NO 3 KD
SPAN
DIMENSIONS OF SILLS
DIMENSIONS OF POSTS
Diw1ENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CH[IVINEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
FORM U - LOT RELEASE FORM
$ [7� Ile-
"s- /0 ---�
INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from
Boards and Departments having jurisdiction have been obtained. This does not re ie ve
the applicant and/or landowner from compliance with any applicable or requirements.
******************APPLICANT FILLS OUT THIS SECTION
APPLICANT S�-cc,, C3 . ��vr\�G. r oC _ ��
PHONE_ -
LOCATION: Assessor's Map Number ./tv
PARCEL---8({�
SUBDIVISION LOT (S) 2 1
STREET__,- j ST. NUMBER��
**********************►*****'`OFFICIAL USE ONLY******************
REC ENDATIONS OF TOWN AGENTS:
CONSERVATION AI
COM
TOWN PLANNER
COM
FOOD INSPECTOR -HEALTH
COMMENTS ktt- l
DATE APPROVED
DATE REJECTED
DATE APPROVED
DATE REJECTED
DATE APPROVED
DATE REJECTED
e e
DATE APPROVED to
DATE REJECTED
PUBLIC WORKS - SEWER/WATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTMENT
9
RECEIVED BY BUILDING INSPECTOR DATE_
Revised 9197 jm
North Andover Building Department
Tel: 978-688-9545
DEBRIS DISPOSAL FORM
In accordance with the provision of MGL c 40 S 54, a condition of Building Permit
Number is -that the debris resulting from this work shall be
disposed of in a properly licensed solid waste disposal facility as defined by MGL
c11,S150A..
The debris will be disposed of in:
t \ C, V -' k- t V1 toga 111 � '~kt, 0 ice- I�
(Location of Facility)
Signature of erm 4&p-pd-t�nt
Date
(VOTE: Demolition permit from the Town of North Andover must be obtained for
this project through. the Office of the Building Inspector
Tel: 978-688-9545
3� r`. �' ,...
O .
Town of North Andover
Building Department '��� q-�•-P°'�'
27 Charles Street �SSaCousEt
North Andover MA 01845
HOMEOWNER LICENSE EXEMPTION
Please print. N�
DATE -,?qt0 7
JOB LOCATION l o ® Q 'tae Yy O • ► Aovex- vA h
Number r Street AddressSection of Town
"HOMEOWNER eco ;Aj4. Y�' n_d oue r
Number Home Phone Work Phone
PRESENT MAILING ADDRESS
City Town
State
The current exemption for "homeowners" was extended to include owner -occupied dwellings
of six 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 109.1.1)
Zip Code
DEFINITION OF HOMEWOWNER:
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 to six family dwelling, attached or detached structures ac-
cessory to such use and and/or farm structures. A person who constructs more than one home in a
two-year period shall not be considered a homeowner. Such "homeowner" shall submit to the Building Official,
a form acceptable to the Building Official, that he/she shall be responsible for all such work performed under the
building permit. (Section 109.1.1)
The undersigned "homeowner" assumes responsibility for compliance 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 No. Andover
Building Department minimum inspection procedures and requirements and that he/she will
comply with said procedures and requir ments.
HOMEOWNER'S SIGNATURE
APPROVAL OF BUILDING OFFICIAL
Note: Three family dwelling 35,000 cubic feet, or larger, will be required to comply with
State Building Code Section 127.0 Construction Control.
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SEE PLAT
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2001 MAPS DRAWT
MEASUREMENTS ARE SCALED 0
SCALE - 400 FEET = 1 INCH
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TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR RENOVA++TI�,, OR DEMj!yOLISH A ONE OR TWO FAMILY DWELLING
�'�.
BUILDING PERMIT NUMBER: DATE ISSUED:
SIGNATURE.
Building Commissioner/Inspector of Buildin s Date
SECTION 1- SITE INFORMATION
1.1 Property Address:
1.2 Assessors Map and Parcel Number:
Map Number Parcel Number
(Nc2��.Loi0 � r- Nn � p t Y�F �
1.3 Zoning Information:
Zoning District Proposed Use
1.4 Property Dimensions:
Lot Areas Frontage ft
1.6 BUILDING SETBACKS ft
Front Yard Side Yard
Rear Yard
Required Provide Required Provided
Required
Provided
1.7 Water Supply M.G.L.C.40. 5 54) 1.5. Flood Zone Information:
Public 0 Private ❑ Zone Outside Flood Zone ❑
1.8 Sewerage Disposal System:
Municipal 0 On Site Disposal System 0
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record
X7V,0" ,CS W\ L—eo
SCL(c�11 G.
Name (P nt) Address for Service
Ct
Signature Telephone
2.2 Owner of Record:
Name Print Address for Service:
Signature Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Licensed Construction Supervisor:
Address
Signature Telephone
Not Applicable ❑
License Number
Expiration Date
3.2 Registered Home Improvement Contractor
Not Applicable ❑
Company Name
Registration Number
Address
Expiration Date
Signature Telephone
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SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 § 25c(6)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed affidavit Attached Yes .......❑ No ....... ❑
SECTION 5 Description of Proposed Work check all applicable)
New Construction 0
Existing Building ❑
Repair(s) ❑
Alterations(s) ❑
Addition ❑
Accessory Bldg. ❑
Demolition ❑
Other ❑ Specify
Brief Description of Proposed Work:
s-tdoars (C:"((mss
SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Item
Estunated Cost (Dollar) to be
Completed by permit applicant
OMCLkL USE ONLY
1. Building
D O
(a) Building Permit Fee
Multiplier
2 Electrical
(b) Estimated Total Cost of
Construction
3 Plumbing
Building Permit fee (a) X (e)
��
4 Mechanical HVAC
5 Fire Protection
6 Total (1+2+3+4+5)
Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, v\ ��G� �►`G-r^ as Owner/Authorized Agent of subject property
Hereby authorize �P`e \J2c_r5` e to act on
M� behalf n all inatWrs relative t w k authorize by this building permit application.
SIgnartlivot Owner Date
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
1, as Owner/Authorized Agent of subject
property
1-iereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief
Print Name
Signature of Owner/Agent Date
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TIMBERS lST 2 ND3Ku
SPAN
DIMENSIONS OF SILLS
DIM}_NSIONS 01= POSTS
DiM]:NSIONS OF GIRDERS
111:IMIT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL, OF CIEMNEY
IS BUILDING ON SOLID OR FILLED LAND
1S BUILDING CONNECTED TO NATURAL. GAS LINE
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