HomeMy WebLinkAboutMiscellaneous - 1046 GREAT POND ROAD 4/30/2018 (5)it
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FORM U - LOT RELEASE FORM
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 SECTION***********************
APPLICANT [i 9 1, � J 9, W4501U PHONE G69
LOCATION: Assessor's Map Number 0 PARCEL
SUBDIVISION LOT (S)
STREET P6'ccilAoN M ST. NUMBER Q
*****************************************OFFICIAL USE ONLY************************ #* *****
WA -fid lZ S �A� c� ► I o
RECO DATIONS OF TOWN AGENTS: ���bi'� S12 `e! 0 " 5i'ru cAu 1, T__
_30`091 07 g*-z'"r.S �-
QA,/�� I/ K y q ® DE c/4
CONSERVATION ADMINISTRATOR DATE APPROVED
DATE REJECTED
COMMENTS _/yU0 CA /)/I UD(StSAaC
COMMENTS
FOOD INSPECTOR -HEALTH
SEPTIC INSPECTOR -HEALTH
COMMENTS
UH 1 C KCJCt, 1 CU
DATE APPROVED
DATE REJECTED
DATE APPROVED
DATE REJECTED
PUBLIC WORKS - SEWER/WATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTMENT
RECEIVED BY BUILDING INSPECTOR DATE
Revised 9197 jm
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\� c 1: PLAT NO. 63
m+ .1 l� � Y S" w3� v!'4+ .1• WvrVba." l ..�..�' �j �./.a' r
DEPRFTMENT OF PU8lI, ut
SRFETY`"fi'; rI
,s CONSTRUL,TION sup vi LICENSE,�?�
Number Expires: 61rthdat?, ,i
Cf$ 963165;.02�1220602(11JIS56' �I
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DERRY. NN UP8
ilOME ;IMPROVEMENT CONTRACTOR
' �Registr.ation x118848
; TYpe „,",DBA
Expiraton`S^ 04t27'/01
.s
.A F:` WATSON GEN CONTaACjING
VHUR F WATS.ON"� "
3 EDGEMONT ST`
ADMINISTRATOR
DERRY NH 03038
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The Commonwealth of Massachusetts
Department of Industrial Accidents
Cffice of Investieations
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
Please Print
Phone m
F7I am a homeowner performing all work myse!f.
L1 I am a sole proprietor and have no one working in any capacity
I am an employer providing workers' compensation for my employee working on this job.
Comoanv name: � � A F UJA Or-�Uc-fcA 001 rct6trul
Address
City: Ae c 0,,i -j
/)// ®3G3O Phcne'-
Insurance Co / -p-`, C, -a Ail Policv M
Comoanv name:
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Phone m:
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Insurance Co. Policv m
Failure to secure coverage as required under Section 25A or MCL 152 can lead to the imposition of cr urinal penalties of a rine up to 31,500.00jo
andicr one years' imerisonment as we!] as civil penaities in the form of a STOP WORK ORDER and a rine of (3 i 00.00) a day against me. I
understand that a copy of ;his statement may be fonroarded to the Office of Investigations of the DIA for coverage verification.
I do hereby cer;T✓ n r nalties oequry t rmatien provided above is true and correct
Signature ` date
Print name F�Y l Ci 1 A �G/ (S6 KJ Phone 7 603 711
Officcal use only do ,n/�ot write in this area to be completed by city or town cr"icai'
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City or Town No Ily d o i\
u e P=rmit/ icensine
❑ Building Dept
❑Check d immediate response is required ❑ Licensing Board
❑ Seiectman's Office
Contac: person: Phone T: Heaith Department
Other
Environmental Consultants
A.F. Watson
General Contracting
3 Edgemont Street
Derry, NH 03038
RE: 1046 Great Pond Road
North Andover, MA
Dear Mr. Watson:
O 235 Newbury Street
Route 1 North
4775-8 Danvers, MA 01923
(508)777-3050
(508)352-7590
(508)283-2200
(617)662-9659
FAX (508) 774-7816
1112 Farnsworth Street
Boston, MA 02210
(617)350-7906
This letter is in reference to our site inspection conducted on July 27, 1999 at 1046 Great Pond
Road, North Andover, MA to determine the presence of wetland resource areas on the site. A
bordering vegetated wetland resource area associated with Lake Cochichewick was measured in
the field, with a tape, at approximately 450 feet westerly of the existing subject house to be
renovated. An additional bordering vegetated wetland resource area was identified approximately
400+ feet southerly from the subject house. No resource areas were identified northerly of the
project area. The identified resource areas were not flagged in the field, and measurements were
conducted from the approximate visual delineation of the resource areas.
The North AndoverWatershed Protection Bylaw enforces various zones. from. Lake
Cochichewick and wetland resource areas within the Watershed -District. For lots created prior to
October 24, 1994, a Non -Disturbance Zone of 250 feet and a Non Discharge Zone of 325' is
enforced from the Annual High Water Mark of Lake Cochichewick. A Non -Disturbance Zone of
100 feet and a Non -Discharge Zone of 325 feet is enforced from the edge of wetland resource
areas within the Watershed District.
According to field measurements, it appears that renovations to the existing house will not occur
within the Non -Disturbance Zone and the Non -Discharge Zone to Lake -Cochichewick and
wetland resource areas. Work will. be conducted. approximately 580 feet from the Annual High
Water Mark of the lake -and approximately 400+ feet from the edge of identified bordering
vegetated wetlands. The proposed project ,will occur within the General Zone identified under the
Watershed Protection District and should not require permitting from the Planning Board or the
Zoning Board of Appeals.
Attached is an exhibit plan which displays the applicable Watershed Protection Zones on the
subject property.
If you have any questions, please feel -free-to contact me. Thank you.
Sincerely,
Hancock Environmental Consultants
J e Parrino, etland Scientist
Division of Hancock Survey Associates, Inc.
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North Andover Building Department
Tel: 978-688-9545
DEBRIS DISPOSAL FORM
In accordance with t e provision of MGL c 40 S 54, a condition of Building Permit
Number .3 5' 9' q 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:
G. M eA1 0
"(Location of Facility)
Signature of Permit Applicant
Date /
P�2�14 iss-0£.D 81,'rhI
NOTE: Demolition permit from the Town of North Andover must be obtained for
this project through the Office of the Building Inspector
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