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Home My WebLink AboutMiscellaneous - 11 MARGATE STREET 4/30/2018 11 MARGATE STREET --- -- ------- ------_ _� 2101022.0-0113-0000.0 U � \\ Date....... .......... 11169 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that....... .. ............... . ... ........... .. ..................................................... has permission to perform.... Vv�,Oj!q" .... . ...... ... . ............................................. ..... -,f 'e�A rj plumbing in the buildings of.................................. ......... .......--....).. ........................... at................ ........................................... North Andover, Mass. Fee'15—....Lic. P4o. ................................................................................. PLUMBING INSPECTOR Check# MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY _ � -- -----.__�..'.'�" -'"._ ---I MA DATE . "' PERMIT 1 t 161 JOBSITE ADDRESS1OWNER'S NAME _ .� _ ____..._ Z.u !r'vy�i _I OWNER ADDRESS ----_--____-- ...... ......._. P -- — -— -- _ —_. TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL ® RESIDENTIAL PRINT CLEARLY NEW:F-1 RENOVATION:[ REPLACEMENT: PLANS SUBMITTED: YES; ] NO[!] FIXTURES Z FLOOR-► BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN ....... ------ FOOD ----FOOD DISPOSER .-............ I FLOORIAREADRAIN _ .—I .._._ _ _ � -__-- ._._-.._.1 _.-.,._1 _ __..._i _.._.__ _...1 INTERCEPTOR INTERIOR KITCHEN SINK LAVATORY f ROOF DRAIN I SHOWER STALL SERVICE I MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING ! OTHER -— Wgigi, ---- - 1 INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES[ NO.0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY :.I OTHER TYPE OF INDEMNITY Ej BOND [� OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of tate Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER [�,,_].'�. AGENT SIG' NATURE OF OWNER OR AGENT I hereby certify that all of the details and Information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and Installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME _.__... _.i LICENSE# 3(,.SO_ SIGNAT E MP F-1 JP Q CORPORATION[:]# PARTNERSHIP[D# LLC D COMPANY NAME -—--- --= ADDRESS SP ..S.. .... ODI.✓ L ...__ CIN C.NS _� .. ._ STATE _It - ZIP .(�_"a>_I.Q�I.. TEL r FAX ---__.,_---.--_._-.-- - CELL EMAIL w 41 4' �no Date.. ... ................... oar 0 9TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION .� �Z, This certifies that ....................................... . ................................................................. has permission for g s inst 11 t*io n .. .... .................I..... ........ .... a in the buildings of.... ...... ......Z ...................................................... ..... ................................ . at....... .............................................. North Andover, Mass. Fee...A....... Lic. No. . ..................................................................... GASINSPECTOR Check# 09969 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY T 1 WD 0 L/E�"— MA 1p DATE PERMIT JOBSITE ADDRESS J—/ f A9kftrf > OWNER'SNAME �C�Ro ��,� TyvlA72cc,�p��t'� GOWNER ADDRESS TEL FAX TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL DQ CLEARLY NEW:[1 RENOVATION: REPLACEMENT:[3 PLANS SUBMITTED: YES D NO Q APPLIANCES 1 FLOORS- BSM' 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE _1 FRYOLATOR FURNACE _.h_ ! ...._ I — L�� -- — --_ 1. —. . _ t - GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNITI OVEN POOL HEATER ROOM/SPACE HEATER T�J ROOF TOP UNIT TEST UNIT HEATER _ UNVENTED ROOM HEATER ( r WATER HEATER OTHERWr INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY F--11 OTHER TYPE INDEMNITY ® BOND OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT Ral SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code.and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME _N:p�t _ �� N LICENSE# 7 SIGNATUR MP ED MGF 0 JP JGF LPGI CORPORATION[ # PARTNERSHIP®#=LLC D#� COMPANY NAME: ADDRESS I L CITY STATE N_i ZIP TEL lOo O FAX CELLEMAIL ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES i t. Y' l COMMONWEALTH OF MAWCHUSETTS,:..:. � BOAF3D QF PLUMBEf2S ::AND GASF1TTERS ISSUES THE FOLLOWf ISG . L I1rENSE I LICEN. b'AS A JOURNEYMAN PLUMBER #� RlINDY M GRUDZ I EN ,f 1555 BOUWELL' RD MANCHESTER Nei 03109-58+9 30530 . ' 05./0 l/16 365199 j . ROgti l � � �; ? - . � A �- I i a i r{ f Vit` t Ct,.. ` i h �� i ;t'•. � i 4 - �� /� ,i P The Commonwealth of Massa chusetts Department of Industrial Accidents ,e r T art d 1 Congress Street, Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Ledbly Name(Business/Organization/Individual): Rh/vo y ilg u b zi g N Address: 1.55'5 f?n 0 Li E/—I- City/State/Zip: LCity/State/Zip: AAA1C4V-55'rt f2, NN 3io5 Phone#: �'® 3 J 9q Are you an employer?Check the appropriate box: Type of project(required): 1.❑I am a employer with employees(full and/or part-time).* 7. []New construction 2.A I am a sole proprietor or partnership and have no employees working for me in 8. ®.Remodelirig any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 0 4.FJI am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions propiietors with no employees. 12.®Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0 Roof repairs These sub-contractors have employees and have workers'comp.insurance.$ 6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. . 14.Q Other 152,§1(4),and we have no.employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-co have employees,they must provide their workers'comp.policy number. fain 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,Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.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 the pains and penalties of perjury that the information provided above is true and correct. _ JS Signature: � .� it2'ilin Date: 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 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall. enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and-phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should•enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permitilicense applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-NUSSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia Date......:.................................... r►ORTN OF��.■o TOWN OF NORTH ANDOVER o PERMIT FOR WIRING CF1U5� LA This certifie that ................. .......................................................................................... .... h.j permission to perform .........`. h..✓` j..� -l...��........................................ ............................. — Z� oLA2�G �`7 wiring in the building of............................................................. .......................................... at ,......�...1........ .. - .. .. P . ......D North Andover Mass. .............. ............................... �� LK Fee..............................Lic.No. ................. ...................... ............................................. ELECTRICAL INSPECTOR Check# 12 4" 2 3 n Commonwealth of Massachusetts Official Use Only Y Department of Fire Services Permit No. Z-$�- a Occupancy and Fee Checked ,M s BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/071 (leaveblank 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 ININK OR TYPE ALL INFORMATION) Date: /,' City or Town of: NORTH ANDOVER To the Inspect4 of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) Owner or Tenant Telephone No. Owner's Address /Z AArwu 9DAkt Is this permit in conjunction with a building permit? YesN No ❑ (Check Appropriate Box) Purpose of Building , s 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 4,3b� 1 Location and Nature of Proposed Electrical Work: Completion of thefollowing table maybe waived by the Inspector of Wires. .S 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 Above In- o.o Emergency Lighting No.of Luminaires Swimming Pool rnd. ❑ rnd. 1771 No' Units No.of Receptacle Outlets za No.of Oil Burners FIRE ALARMS No. of Zones No.of Switches No.of Gas Burners No. of Detection and InitiatinR Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons No.of Waste Disposers Heat Pump I Number I Tons 1KW No.of Self-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.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: Adach additional detail if desired,or as required by the Inspector of Wtres. Estimated Value of Electrical Work: �t�, '(When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE C VE GE: 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 suchoverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: . !llJb. LIC.NO.: Licensee: ..ra�ietl.�� J� � _Signature LTC.NO.: o-2 i h!S'_jf (If applicable,enter "exempt"in the license number line) Bus.Tel.No.- Address: i1 Alt.Tel.No.: *Per M.G.L c. 147,s.57-61,security work requires Department of P lic Safety"S"License: Lic.No. L J OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normal y required si nature below,I hereby waive this requirement. I am the check one owner owner's a en by law. By my g y q ( )❑ ❑ g Owner/Agent PERMIT FEE. $ Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.c.143,§3L,the r permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§32,an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the t . notification of completion of the work as required in M.G.L.c.143,§3L. Permits shall.be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012. ❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit ❑ ❑ Permit Extension Act—Permit/Date Closed: Trench Inspection Pass 0 Failed Ed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed ❑' Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass M Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: r ROUGH INS TION: Pass Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTION: Pass 0 Failed M Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com The Commonwealth of Massachusetts Department of IndustrialAccidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organization/Individual): tt6 (>&•�1A.P-jbg= Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.�I am.a employer with _employees(full and/or part-time).* 7..�El New construction 2.F1 I am a sole proprietor or,partnership and have no employees working for me in 8. 1�1 Remodeling any capacity.[No workers'comp.insurance required.] J`� 9. ❑Demolition 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t �4.FJI am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole ME]Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0 Roof repairs These sub-contractors have employees and have workers'comp.insurance.$ 6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 14.E]Other 152,§1(4),and we have no,employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors 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 is providing workers'compensation insurance for my employees.'Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: I/ /J,t(„p dk& m & . ,c1 Sl 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 MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DTA for insurance coverage verification. I do hereby certify under the pains andpe5#1tres of verlury that the information provided above is true and correct. Signature: Date: o 57 Phone#: l1 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 5.Plumbing Inspector 6.Other Contact Person: Phone#: r r Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall. enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the'boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and-phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should'enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. Anew affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel.# 617-727-4900 ext. 7406 or 1-877-NUSSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia WORKERS COMPENSATION AND EMPLOYERS'LIABILITY ,t INSURANCE POLICY—INFORMATION PAGE >TTRANCE COMPANTY POLICY NO: WCT1544P ►�_r�CHTON ROAD EAST '1,00 NEW BUSINESS MLLE, FL 32245-6000 NCCI Company No: 16322 Account No: CACT1544P MED INSURED AND MAILING ADDRESS: AGENCY NAME AND ADDRESS: RIVIERE SEGREVE & HALL INS ASSOC INC ANDER RD ERRY NH 03053-2627 305 NORTH MAIN ST ANDOVER, MA 01810 AGENCY PHONE NO.: (978) 975-1300 AGENCY NO,: 201226 ENTITY: LIMITED LIABILITY COMPANY WORKPLACES NOT SHOWN ABOVE: (See Workers Compensation Location Schedule) DL ICY PIERIOD: From: 07-01-2014 To: 07-01-2015 ?ective 12:01 A.M. Standard Time at the Insured's mailing address- OVERAGE: o kers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states :ed here: nployers' Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of hiiiiy under Part Two are: Bodily Injury by Accident: $ 100, 000 each accident Bodily Injury by Disease: $ 500, 000 policy limit Bodily Injury by Disease: $ 100, 000 each employee her States Insurance: Part Three of the policy applies to the states, if any, listed here: states except: ND, OH, WA, WY i states designated in ITEM 3A of the information page. is Policy includes these Endorsements and Schedules: Schedule of Forms and Endorsements. EMIUM: The premium for this Policy will be determined by our Manuals of Rules, Classifications, Rates and `ing Plans. All information required on the Workers Compensation Classification Schedule is subject to ificafion and change by audit. Please see Classification Schedule. Total Estimated lirnum Premium: $ 1, 000 Annual Premium: $ 1, 000 Jit Period: ANNUAL - 07-02-2014 Countersigned by Copyrigtd 1987 National Council on Compensation Insurance INSURED COPY K 1•^ I COMMONWEALTH OF W.....Hl1SETTS o o � 4, gQAab fl I CTF�1 C I ANS...:;::.:, � ELf ISSUES .TNE FOLLOWING LICENSE W AS p, REG JOURNEYMAN: ELECTRI A,N`�� Z f OA ,J.pHUA J LARIVI ERE 6 � C 18 ALE X`RNDER R D 03053-2 6T>.:::: . _ NDONUERRY_;:: :<:''sNH .:::.. �.ONOo8 6, 4JR 0 1 1: 2 � �, 354 Dates. pf4HprrTM TOWN OF NORTH ANDOVER «.° ,e,'t'O 0 pp PERMIT FOR MECHANICAL INSTALLATION �9SSACHUSEt This certifies that . ! .� v. . . .�'h -<. . . �ti � has permission for mechanical installation . . . . V. . . . . . H.' ' in the buildings of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . at . . . . . . it/. . . . Norf h Andover, Mass. Fee. c. Lic. No.. ./,30.4y . . . . . . . . . . . . . . . . . . . GAS INSPECTOR WHITE:Applicant CANARY: Building Dept. PINK:Treasurer ,.- Commonwealth of Massachusetts Sheet Metal Permit Date : 1 ) Permit# '� (� v $ Estimated Job Cost: � Permit Fee: Plans Submitted: YES NO Plans Reviewed: YES NO Business License# 13o �M Applicant License# I,�0 Business Information: Property Owner/Job Location Information: Name: �e Name: Street: Street: C City/Town: N V��1SvC� City/Town: N\3QqcX_ Telephone: ( �\�31�`(PO-7 Telephone: V Photo I.D. required/Copy of Photo I.D. attached: YES NO Building Type: / Residential: 1-2 family ✓ Multi-family Condo/Townhouses Commercial: Office Retail Industrial Educational Institutional Building Cubic Footage: under 35,000 cu. ft. over 35,000 cu. ft. Sheet metal work to be completed: New Work- ✓ Renovation: HVAC V_ Metal Roofing Kitchen-Exhaust System Chimney/Vents Provide brief description of work to be done: \ II 11 INSURANCE COVERAGE: I have a current liability insurance policy or its equivalent which meets the requirements of M.G.L.Ch.112 Yes /No❑ If you have checked Yes, indicate the type of coverage by checking the appropriate box below: A liability insurance policy nz Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 112 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. Check One Only Owner Agent ❑ Signature of Owner or Owner's Agent By checking this boxEl,I hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the best of my knowledge and that all sheet metal work and installations performed under the permit issued for this application will be in compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws. Progress Inspections Date Comments Final Inspection Date Comments Type of License: By Master Title ❑ Master-Restricted City/Town ❑Journeyperson Signature of Licensee Permit# 2 ❑Journeyperson-Restricted License Number: Fee$ ❑ Check at www.mass.gov/dpl Inspector Signature of Permit Approval 1 _ i M1 Sheet Metal Commercial Guidelines/Life Safety/Critical Systems Inspection Checklist Yes No N/A, Set of stamped engineering documents and detailed description of mechanical system to be installed has been provided All workers performing sheet metal work onsite has valid Massachusetts sheet metal license All sheet metal work being performed with proper journeyperson-to-apprentice ratios Fire dampers with access door properly installed and checked for operation Smoke and combination fire/smoke dampers with access doors properly installed- actuator checked for proper operation(May also be verified by fire department during fire alarm testing) Duct smoke detectors with access doors properly located (May also be verified by fire department during fire alarm testing) Smoke/atrium exhaust systems installed and operation verified (May also be verified by fire department during fire alarm testing) Stair pressurization systems installed(where required)and operation verified(May also be verified by fire department during fire alarm testing) Grease/kitchen hood exhaust system installed with all seams and connections welded - airtight with properly located cleanouts. Proper c1di"ances,fire rated enclosures and pressure testing required: S .is iii;resliaints installed Wh&,c'required'bft equipment and du..h, y Duct penetrations in fire'rdtc ivall=3 and floors sealed Metal roofing systems installed watertight using proper materials and fasteners Flexible duct rams installed 6'-0"maximum length Ductwork installed using proper hanger spacing,hanger stock,threaded rod and angle iron Ductwork/plenum connections sealed substantially airtight Ductwork insulated by means of external covering or internal lining Volume dampers installed for each supply air.branch duct New/clean-properly sized filters installed(final inspection) Testing and Balancing report complete(final sign-off) f r1 Sheet Metal Residential Guidelines/Inspection Checklist Yes No N/A Detailed description and sketch of sheet metal system to be installed has been provided All workers performing sheet metal work onsite has valid Massachusetts sheet metal license All sheet metal work being performed with proper joumeyperson-to- apprentice ratios Equipment sized per heating/cooling load calculations Duct work sized per manual "D"calculations Bath/shower rooms contain mechanical exhaust fan vented outdoors Electric dryer exhaust properly installed maximum total run 35'-0", maximum flexible run 8'-0" Flexible duct runs installed 14'-0"maximum length Volume dampers installed for each supply air branch duct Ductwork installed using proper gauges and hangers Ductwork/plenum connections sealed substantially airtight Ductwork insulated by means of external covering or internal lining New/clean-properly sized filter installed(final inspection) Testing and Balancing report complete(final sign-off) I The Commonwealth of Massachusetts Department of IndustrialACcidents -- ~ I Congress Street,Suite 100 Boston,MA 02114-2017 .�` www mass-gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. A licant Information Please Print Le •bl Name(Business/Organization/Individual): p e ! �� Address: City/State/Zip: 1 CQ fts"-b m f�-y ti5(K>3 Phone.#- Are you an employer?Check the appropriate box: project(required):1. am a employer with_employees(full and/or part-time).* 2.Q I am a sole proprietor or partnership and have no employees working for me in 8. emodeling any capacity.[No workers'comp.insurance required.] 9• ❑Demolition 3.❑I am a homeowner doing all work myself[No workers'comp.insurance required.]t 10❑Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 11.0 Electrical repairs or additions ensure that all contractors either have workers'compensation insurance or are sole proprietors with no employees. 12.[]Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 11E]Roof repairs These sub-contractors have employees and have workers'comp.insurance.$ 14.❑Other 6.0 We are a corporation and its,officers have exercised their right of exemption per MGL c. 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Contractors that check this box must attached an additional sheet showing the name of the sub-contractors 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 is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: I "� (� �`'g 3 l I� Policy#or Self-ins.Lie.#: I Expiration Date: _ Job Site Address: City/State/Zip: �J- Attach a copy of4thheworkers compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify an z ns an penalties of perjury that the information provided above is true and correct. Date: Si ature: 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 5.Plumbing Inspector 6.Other Contact Person: Phone#: n Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub=contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-NUSSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia Y v � Load Short Form Job: Date: May 14,2015 Entire House By: Custom Climates HVAC • eict information For: Bob Ouellette 14 North Margate, North Andover, MA Htg Clg Infiltration Outside db(°F) 9 88 Method Simplified Inside db(°F) 68 75 Construction quality Average Design TD ('F) 59 13 Fireplaces 0 Daily range - M Inside humidity(%) 50 50 Moisture difference(gr/Ib) 44 31 HEATING EQUIPMENT COOLING EQUIPMENT Make Make Trade Trade Model Cond AHRI ref Coil AHRI ref Efficiency 80 AFLIE Efficiency 0 SEER Heating input 0 Btuh Sensible cooling 0 Btuh Heating output 0 Btuh Latent cooling 0 Btuh Temperature rise 0 OF Total cooling 0 Btuh Actual air flow 919 cfm Actual air flow 919 cfm Air flow factor 0.026 cfm/Btuh Air flow factor 0.042 cfm/Btuh Static pressure 0 in H2O Static pressure 0 in H2O Space thermostat Load sensible heat ratio 0.88 ROOM NAME Area Htg load Clg load Htg AVF Cig AVF (ftp (Btuh) (Btuh) (cfm) (cfm) basement 1080 12707 3729 335 157 pantry 120 3284 2145 87 90 closet 1 48 781 384 21 16 kitchen 196 4608 4469 121 188 kids room 140 1907 1396 50 59 master 196 4070 3374 107 142 Room9 380 7537 6395 199 269 Entire House d 2160 34896 21890 919 919 Other equip loads 0 0 Equip. @ 0.93 RSM 20314 Latent cooling 2908 TOTALS i 2160 I 34896 i 23222 I 919 I 919 Calculations approved by ACCA to meet all requirements of Manual J 8th Ed. ` 2015-May-14 19:11:03 {f1F1"1 9 Rght-Suite®Universal 2013 13.0,13 RSU1e206 Page 1 Projectl.rup Calc=MA Front Dow faces: E Project Summary Dat J Date: May 14,2015 Entire House By: Custom Climates HVAC For: Bob Ouellette 14 North Margate, North Andover, MA Notes: Desigormation Weather: Lawrence Muni, MA, US Winter Design Conditions Summer Design Conditions Outside db 9 OF Outside db 88 OF Inside db 68 OF Inside db 75 OF Design TD 59 OF Design TD 13 OF Daily range M Relative humidity 50 % Moisture difference 31 gr/Ib Heating Summary Sensible Cooling Equipment Load Sizing Structure 27028 Btuh Structure 15548 Btuh Ducts 7867 Btuh Ducts 6343 Btuh Central vent(0 cfm) 0 Btuh Central vent(0 cfm) 0 Btuh Humidification 0 Btuh Blower 0 Btuh Piping 0 Btuh Equipment load 34896 Btuh Use manufacturer's data n Rate/swing multiplier 0.93 Infiltration Equipment sensible load 20314 Btuh Method Simplified Latent Cooling Equipment Load Sizing Construction quality Average Fireplaces 0 Structure 1882 Btuh Ducts 1027 Btuh Heating Cooling Central vent(0 cfm) 0 Btuh Area(ftp 2160 2160 Equipment latent load 2908 Btuh Volume(ftp 15660 15660 Air changes/hour 0.32 0.16 Equipment total load 23222 Btuh Equiv.AVF(cfm) 84 42 Req.total capacity at 0.70 SHR 2.4 ton Heating Equipment Summary Cooling Equipment Summary Make Make Trade Trade Model Cond AHRI ref Coil AHRI ref Efficiency 80 AFUE Efficiency 0 SEER Heating Input 0 Btuh Sensible cooling 0 Btuh Heating output 0 Btuh Latent cooling 0 Btuh Temperature rise 0 OF Total cooling 0 Btuh Actual air flow 919 cfm Actual air flow 919 cfm Air flow factor 0.026 cfm/Btuh Air flow factor 0.042 cfm/Btuh Static pressure 0 in H2O Static pressure 0 in H2O Space thermostat Load sensible heat ratio 0.88 Calculations approved by ACCA to meet all requirements of Manual J 8th Ed. N� wri htl:sot , 2015-May-1419:11:03 Right-Suite&Univeisal 201313.0.13 RSU16206 Pagel Projectl.rup Calc=MJ8 Front Door faces: E j Level 1 basement Job#: Custom Climates HVAC Scale: 1 :60 Performed for: Page 1 Bob Ouellette Rig M-Suite®Universal 2013 14 North Margate 13.0.13 RSU16206 North Andover,MA 2015-May-14 19:11:39 Projectl.rup Level 2 pantry master kids room closet 1 Room9 kitchen Job#: Custom Climates HVAC Scale: 1 :so Performed for: Page 2 Bob Ouellette Rig ht-Suited Umve mat 2013 14 North Margate 13.0.13 RSU16206 North Andover,MA 2015-May-14 19:11:39 Project1 sup g 2 _ r 1.`• � i j ' i r ¢ i �p i S 44K . { OR i .. ..,.. -,. .. t � � + � meq..••« i S E i a F i y r j u y @ w '1 i ,g taxi a 's ` t. • ' i TOWN OF NORTH .ANDOVER SYSTEM PUMPING RECORD DATE: 7 SYSTEM OWNER & ADDRESS SYSTEM LOCATION (example: left front of house) /gl. SZ rl�46t lildo . � r I G - DATE OF PUMPING: 2 QUANTITY PUMPED ' �dGALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES 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: �Az 7 , jg-f2,,z,,4, COMMENTS: CONTENTS TRANSFERRED TO: l i i COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS r a DEPARTMENT OF ENVIRONMENTAL PROTECTION r` F TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A C IFICATION Property Add ess: /" � i _ , Owner's Na e: Owner's Add Date of Inspection: Name of Inspector: (please print) 3—nL. �nzo Company Name: 5f 11 �✓� Mailing Address: 7- Telephone Number:ME— 3 77--rf '7 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 Conditiona ly Passe's KFieels F er Evaluation by the Local Approving Authority s Inspector's Signature: ! mac,.. late: The system inspector shall�s bmit a copy of this inspection report to a Approving Authority(Board of Health or DEP)within 30 days of co pleting 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 r r F Page 2ofII 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS 'SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM .r. PART A CERTIFICATION (continued) Property Address: F Wo, 4A1AAZ1&--Y Owner• Date of Inspectiond Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D + A. System Pa3ses: --_ Y I have not fo�ua ny information which indicates tha y of the failure criteria described in 310 CMR 15.303 or in 310 C R 15.304 exist. Any failure criteria note v luated are indicated below. __. Comments: : r 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. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please , explain. ,, • i 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 exf ltration 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. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipes)or due to a broken,settled or_uneven distribution box. System will pass inspection if(with, , � :_:. .. rt Y.: _ approval of Board of Health): _. 4 broken pipes)are replaced r 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: 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) ' Property Address: { Owner: Date of Inspection: C. Further Evaluation is Required by the Board of Health: Condit ons*existt<W1ich require further evaluation by the Board of Health in order to determine if the system is failing to prot]f1pass clic health, safety or the environment: 1. System unless B 'yBoard of Health determines m accordance with 310 CMR 15.303(1)(b)that the system iS not functioning,in.a manner which wi"rotect public.health,safety�.and the.enyironment: .1 _ Cessspool,or_privy- .is within-50`fe'et_of as surface water — Cesspool or p ivy is-wi'thm 50 feet of a bordering vegetated wetland or a salt marsh A' 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: 'f 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. i- _ 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 indicates that the well is free from pollution from that facility and `f ` the'prtsence ofammonia nitio"gen and'nitrate nitrogeiit s�equal to or le"ss than=5 ppm,provided that no othei failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: 1 3 1 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 11.10� Q Owner: Date of In pection: a 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 mer 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 t. - :.,.. . . clogged,SAS on-cesspool _w_. ., v ' Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or /cesspool. .---�------ V,Liquid depth in`cesspool'is less than 6"below invert or available volume is less than V2day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number `of times pumped V Any portion of the SAS,cesspool or privy is below high ground water elevation. _L,,'"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. _jz-Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ _VAny 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, i_ 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 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (Yes/No)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 tie consider!&w1arge systeiAthe system`must-serve a facility with a design flow of 10,000 god to 15,000~,' god. +� You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply s _ _ 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 napped 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 i 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. 4 �k�,.:_11....:+.+•J uN'wa..*M'.:•,.--^ «.�::k.i,A* ..... Lir_. Y - " • h•t'i,. ,N-•. .7yv,:. �. ii 1. :?—,�..rJ ::n..,,�"°,r ir•v'ti', -�i-kr, �'�i..1'$.,"h:.,,.Ny�tr'l'' �•z`" -v ,,;'S. Y• _yt•K...,..�r,r.�+ :ri. ,r. ..,d.r -..,G'•.n. Page 5 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: ✓//Y1ar 7e A, ;. Owner: . 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 _(!'-WtfeiLny of the systeih comp6nents pumpedl"otitLi the previb s two-weeks?. � Has the system received normal flows in the previous two week period? —ZHave large volumes of water been introduced to the system recently or as part of this inspection? t/ Were as built plans of the system obtained and examined?(If they were not available note as N/A) V 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? 5 The size and location of the Soil Absorption System(SAS)on the site has been determined based on: _r - �tr � w yt �t - Yes` n � . ,3 - a�• � _� o _. .. v r'C 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)[3 10 CMR 15.302(3)(b)] r M S:. 5 ,V.. -. .,:..... .;, ,_ .. .. . . ......... . ... ......:. .. _. .. ,... ,...,..a+. vm _ ?n:x,.ct.. ,a.a....rr'R+i.•, .vyaa.* .... - .. .a...,..._ ._.� �a Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION J Property Address: Owner: Date of Inspection:] ; LOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CNR 15.203 (for example: 110 gpd x#of bedrooms): Number of current residents: Does residence have a garbage grinder(yes or no):Avo Is laundry on a separate sewage system(yes or no): [if yes separate inspection required] Laundry system inspected(eyes oj.no). J Seasonal use: (yeas or no) P t _ Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no): Last date of occupancy: GU Ped d COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): Qpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records f Source of information: b Was system pumped as part of the inspection(yes or no):Yff , If yes,volume pumped: gallons--How was quantitypumped determined? l4 - Reason for pumping: G CcIJ r ... .TY'P OF SYSTEM je'geptic' tank,distribution box,soil absorpti®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) Tight tank _Attach a copy of the DEP approval Other(describe): Appro T a e of all pomponents date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no))O 6 Je�.Jr"V'.!M1 Yp-Y t .. • V/Y+ Ywa.1..; :. � .�.-i,.m'M.'a+�i'FA'If%wldivMi'd%.h n`i"^' - .. _ -.... .fin— • ....�n ,N,r.VF�,yty« Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: ,.. Owner: /1T!.Z5&/ Date of In pection: BUILDING SEWER(locate on site plan) Depth below grade: d^6 Materials of construction:A.-fast iron _40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): A ' �y4 ` SEPTIC TANK:_(locate on site plan) y Depth below grade: Material of construction:_ oncrete_metal_fiberglass_polyethylene other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) aDimensions: 6o x Sludge depth: Distance from top of sludp to bottom of-outlet tee or baffler—J Scum thickness: F� Distance from top of scum to top of outlet tee or baffle: e2, Distance from bottom of scum to bottom of outlet tee or baffle: 3�' How were dimensions determined: — z?Vl Comments(on pumping recommendation , inlet and outlet tee or baffle condition,structural integrity,liquid levels as re to outlet invert,evi ence o leakage,etc.): ` , &b `. GREASE TRAP:_(locate on site plan) µ Depth below grade:_ f Material of construction:_concrete_metal_fiberglass_polyethylene_other xd (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: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): i �y r 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property'Address• l/ C11vG? , Owner: , Date of I spectiov 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: allons , Design Flow:' gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX:Zif present must be opened)(locate on site plan) y. Depth of liquid level above outlet invert:, Comments:(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of le age ' o or out o ox,etc :+ 4MCI N Ot 1 N �a t Gt S Gt,! t r PUMP CHAMBER: (locate on site plan) ++ t Pumps in working order(yes or no): fi; Alarms in.working order(yes P�: . . t, P PP ) - Co _ ents noxe'condition of chamber,,eondition of um , and'a urtenainces' etc. ! r, , #, { , a . c K. { a ' 8 ,,l-.e(i'y`_.._..-rt<..«:m .,-:rvr-•w•.:ve.e:yNvy...,y";,",�Ii'i,fc sK'u:v:µw„r=�r�;"v,.. ,6.r:.,i.:...6....•r:;�':�^'w�,. -- - ��.d. �r*yY�' '1. xYwn..,ry,,,.d�.?NI,�...a�•vwJ�.y .y,}a�,. `� .....wl...�M7 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: AiV 4W, Owner: Date of MSDeectioner SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not-required) If SAS not located explain why: ti.• Type. �(� .. «o�#11 p # , � leacfiinj pits,�Am�er: {'7.0� leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: 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.) +� it 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: r Depth of scum layer: Dimensions of cesspool: s rt Materials of construction: Indication of groundwater inflow(yes or no): ,nL Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): T 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.): ar i � 1 Y. 9 .ej. ,,(x-..r,+'rr• .. .. k�:ry .. .. ., ... ♦�,•.'kN'.�,�: T+b:� '�r..��.^k.�+,..� •'°"v'"yi Page 10 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM'INFORMATION(continued) Property Address: 1�� tG�G, 7, Owner: Date of IR(Pection. 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. Locate where public water supply enters the building. t' `i. � �` ;.�;�,„_ �,�r s � • pt r A V:'', , . 17 '; p i F.:•Y J• -7 .. ajj''7 L' i 7 'o i 10 " Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) ;wf P,roperty Addtess:' Owner• Date of I spectiod. SITE EXAM Slope Surface water Checl4cellar Shallow wells Estimated depth to,,V and water �'*feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: 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: t� You must describe.how you established the high ground water elevation: 4. V, r " s � si l 11