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Miscellaneous - 121 OLD CART WAY 4/30/2018
121 OLD CART WAY 210/107.8-0101-0000.0 _ __ Date. . . . . . . . . . . . . NORT" t=�°`• •�"• 0� TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING f��� rye.• SSACNusEt This certifies that . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . has permission to perform . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . plumbing in the buildings of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . at. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . North Andover, Mass. Fee. . . . . . . . .Lic. No.. . . . . . . . . .. LUMBING INSPE TOR WHITE: Applicant CANARY: Building Dept. PINK:Treasurer GOLD: File ,. .+..�v...,..s4%0 j- o.a vivir%innn Ar't'1..1t,,Aitun r Ain too-r1Mii iw ij%j ri unnows- (Print of Type) NORTH ANDOVER, , Mast. Datsi�Y\PvXckn 7 .•_Ig`1 6 Building Perml Location.1-0 as (z+ o+�i C•�u w±, Owner's Name 4 UL. 14J,41,6 New Renovation p Replacement ❑ Plans Submitted: Yes p No p FIXTURES ~ w o s s W J w s- u s w e er X 44 K >s44 l 01 o u ~ s i M _ n ~ < s ~ s 16 X s V s O i~t o " " s M .4 r _ < a s a ` Id x �.Id old a s � � 3+ < _ � Y � < O s J Q • � _ { < o � r 1 n w o o s • i s < I! s : 0 sue—e9MT. BAeeMeNT I 1sT FLOOR 2ND FLOOR 3 a oZ Silo FLOOR ITHFLOOR 9TH FLOOR 9TH FLOOR. lTH FLOOR 9TH FLOOR - Check one: Certificate Installing Company NamepkmGG 4c,P-3 Q Corp. Address L+ `�rocl �tL�v-2, O Partnership (Z Firm/Co. Business Telephone 015r) •Name of Ucensed Plumber INSURANCE COVERAGE: Check one 1 have a current liability Insurance policy or As substantial equivaienl Yes.9 No p If you have checked jM. please Indicate the type coverage by checking the appropriate box. A liability Insurance policy] . Other type o1 Indemnity O Bond O OWNER'S INSURANCE WAIVER: i am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General laws, and that my signature on this permit application waives this requirement. Check one: Slonstute of Owner or Ovmer s Agent Owner ❑ Agent p I Mteby certify that aM of the details and Information i have submitted toe entered)in above appikatlon at*We and accurate to the best of my knowledge and that all plumbing"It and Installattons performed under the permit Issued fat this appilcatkm will be h compliance with all pertinent provi0ons of the Massachusetts State Plumbing Code and Chapter 112 of the General laws. Title signa uce 04 Ucensed Plumber Gty/Town Ucenss Number k 13 Type of Plumbing Lksnse: Master-8 APPnOUED(OFF)CE USE ONLY] Journeyman 0 Date..k"?///Z.. .. ... . MORTM TOWN OF NORTH ANDOVER t° • - -PERMIT FOR GAS INSTALLATION �9 tt ^. �,SSACMUSESty l {"y This certifies that . . . . . . . . . . . . AS �>lce Cry ��- has permission for gas instal ation in the buildings f . ! . .�. oL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . /Z/ a/ . f 4.�? at y�cv r.� a� . . . . . . . . North ��ver�s. iz Fee. . . . .,. . . . Lic. No.. .�. .:V' . 1. `/ GAS INSPECTO Check# Zo 7/7 k 8038 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK klwwl CITY I NORTH ANDOVER MA DATE FEB.6 2012 PERMIT# JOBSITE ADDRESS 121 OLD CART WAY OWNER'S NAME I MARK NICHOLS GOWNER ADDRESS w+e TE 9786831823 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL ® RESIDENTIAL E] PRINT CLEARLY NEW:E] RENOVATION:® REPLACEMENT:® PLANS SUBMITTED: YES® NO® APPLIANCES 7 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 FRYOLATOR FURNACE GENERATOR 1 GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST 1 UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER INSTALL 2 VENT FREE 2 FIREPLACE UNITS INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES E]NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 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 SIGNATURE 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 complia wi all Pertinent rovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. - PLUMBER-GASFITTER NAME I ROBERT WHITE LICENSE SIGNATURE MP® MGF® JP® JGF[j LPGI® CORPORATION E]# PARTNERSHIP E3#®LLC®# COMPANY NAME: EASTERN PROPANE GAS ADDRESS 1131 WATER ST. CITY I DANVERS STATE MA ZIP 01923 TEL 800-322-6628 FAX 978-750-6534 j CELL EMAIL z�� t Aum, 12. 010 9 36A No. 3096 ° r' TAe Commonwealth.ofMassachuseW .Departnxent of lndustrial Accidents Office Df-Investigations 600 Washington Street www.rnas5:bovfdia Workers' Compensationlinsurance.�davit: Bni?id---.-s/ContsaaersMe--tn-cians/Piumbers. .. A-Pulicant Information Please IFint�,eeibl� Name (Business/Dtganim;ion/Individual) �i ``��: li�Oo� r ,' / _ City/state/Zip: /� v��s � bom� Are you an employer?Check tbe.appropriate.box: Type of project(required): I- I-am.aP toY ecwitii j 4- EDI am z;general.con= orandI 6. NevE'coasrwtion � employees(ftffl and/or parttime}-' have hired the sub-contractors 2.EDT ama sole proprietor or partner= listed on tht.zttaclied sheet 7. ❑Remodeling . ship and have na employees Thi sub-contractors have 8. []:Demolition working for tae in any capacity: workers' comp.insurance. g, ❑Building addition w c ce: 5. ❑ We area corporation and its 0 o rs aim .'insttrttn zkc � P • �or additions �. e 'cal. arr Q. EI ctn reuuired:l officers have exercised their 1 ❑ r1.1:Q Eiumbing repairs m additions 33--[] I atm a homo- ewnec doing ail'woik right A w exemption per MGL thyself. [No worker'camp c. 152,§1(4)„and we have no 12.11Roar rut aizs. insurance re uired. t eutployees.,[No workers' r 4 ) 23. Uther G S'T� comp.insurance required-1 , - 'Aovv aapliman i sat cbeckc box#1 mtat a1w iV ow taasatioa:below sbowioZ suci:wvd=' or,policy tntoaatsaa Homeowners who submit flus amcavr.iadiating they ate dorms aU work and tom hue fid=eoniiacrots m¢z:tabm3t x tier aSidavit iadi��sn .. IContm=r.that check this box mtm astnhad an sddrm3na1 eortshummg the same oitbe sub-eonuzcz ;and mer:warier cauap POBLy,, Fo . F am an employer that Is providing workers'competts�Yr itrsurance for sty employees Below ds the poiicy:and jot siw- informatirax�` . Insuranr^CompanyName: P olicy t or Self-ins,Lic. 5-'66 05� Ezgiratiom7�atr //. �Zo/ _ Job SiteAddt-ss: aM yld C o..t �o City/stat-1 ip:n&yl& A,,,d -�'✓�LZ n�c��IS ti o erd:e irtttion;dstc . Attachz gopy.of'.the workers-:-:eotitvew tion poUq dmlzmtaon-pa�ee�-Sh wing the paras tinm . zp. a Failto s-eure cow�,ge as required under Section 25A.of MGL..c. IS2 cam lead to the iutpositian af.criminal penalties.or a ure fi=up to S 1,500.00 and/or.o=-year imprisonment,as well as c.*vil p-nattics in the form of a STOP WORK 4RD and fine of up to 5250.00 a day against the.violator.:Be advised-that a copy of this statement maybe fo;v�arded to the Of R=of. Investigations of the DIA for n=anoc coverage vmtf cstiofl F der herebp certify under:thepains and pend- ,,perjitr� ire ttzformatiort prof idad abovE fs/mac and correct. - 71” nly Do oar U in this area,Jo be.co, pleted by city or Pvwr oJfi>faL - Penn t/L.lcense.m ority(circle one): r 1.Boardnf e Itb 2.Building Department Cry/Town Clerk 4-Electrical Inspector S.Pru n bin gInspector 6. Other __ -- -- Contact Person-.,-- f. Date.../.... .. ... ... . ........ k NORTH TOWN OF NORTH ANDOVER y. 0 PERMIT FOR WIRING This certifies that ................. . .......... .................. ........................................ has permission to perform ......... . ..... .��4.5...........................a.. .. .... Le, wiring in the buildin of...... .......... 21 04.634 at..../ .......................AW....r.... ................... North Andover,Mass. "40r'n "GOV:4 Fee..�' Lic.No.��7TVR........... --4CTR ... ............... AE, ELECTRICAL IC'AL,IN*'S*Ai 15e Check # 10583 r . 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.c.143,§3L,the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed J 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 notification of completion of the work as required in M.G.L.c.1:3,§31- Permits shall-be limited as to the time ofongoing construction activity,and inay 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 entitystated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chanter 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 pulpose 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 effector existence"during the qualifying periodeginning on Auguskj 2�008 and extending through August 15,2012. [ le —Permit/Date Closed: f v% ***Note:Reapply for new permit ❑Permit Extension Act—Permit/Date Closed: Commonwealth of Massachusetts Official Use only v, ` Department of Fire Services Permit No. l6 �� Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Co (M)EC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: I.0 City or Town of. NORTH ANDOVER To the In pec or of Wires: By this application the undersigned gives notice of his or her inte ion to perform the electrical work described below. Location(Street&Number) OL Owner or Tenant ('� Telephone No. Owner's Address Is this permit in conjunction with a bu' ding p it? Yes ❑ No (Check Appropriate Box) Purpose of Building l 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 Location and Nature of Proposed Electrical Work: xk) - a h r Completion of the ollowing table may be waived by the Inspector o Wires. No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs GeneratorsKVA 7) No.of Luminaires Swimming Pool Above ❑ In- ❑ o. o Emergency Lighting (.6' rnd. rnd. Batter 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. Total No.of Alerting Devices Tons No.of Waste Disposers Heat Pump Number Tons KW 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 Kms, 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: -� Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Val4ofec is Work: (When required by municipal policy.) Work to Start: U Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE AGE: 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 equ.vale t. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the pe it is uing Tice. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) �fp I cern under the and na!�)440-1,21wc erthat the in ormation on t i�ic r.fY � P J , f PPfi�Pon rs t ue and om lete.FIRM NAME: iJLIC.NO.: M=;3.! Licensee: Signature LIC.NO.: _ (If applicable e ter `1 pt" 'n the license n b r line Bus.Tel.No.: Address: l Alt.Tel.No.: *Per M.G.L c. 147,s. 57-61,security wor r uires Department of Publk Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I 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 Owner/Agent Signature Telephone No. PERMIT FEE. $ Date......:P NORTH TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING A 9D CHU This certifies that ........ ....... ............................... . ....... ... .... ........ .. ............ has permission to perform ....2a ........................ ........... wiring in the building of.........../...U... ................................... ........... atJA................. ............................................. N rhAn,do ve Mas. Fe... .......... Lic.No. Z...... . ELECTRICAL INSPEF&R Check # 10660 2012 Massachusetts]Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.Cr.L.c.143 3L the 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 firm or corporation stated on the permit application. Such entity shall be responsible for the electrical permit shall be issued to the person, notification of completion of the work as required in M.G.L.C.143,§3L. r Permits shLas determined -to the time of ongoing construction.activity,and may be.deemed by the.Inspector_of_Wires abandoned-and-inxalid-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 thq permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of2010 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. ule —Permit/Date Closed: ***Note:Reapply for new permii ��— ❑Permit Extension Act—Permit/Date Closed: ConunoneueaUfi o j Il(as�acjiusel a Official Use Only cc� Permit No. 2.parfraenf o/-7ire Seruic.w Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.l/07] (leave blank: APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(M:E ,),52 CMR 12.00 (PLF.4SE PRINT W INK OR TYPX ALLINF IA ION) Date: lr,� !� City or Town of. �� � � oye—rC To the Insp for f Wires: By this application the undersigned gives notice of his or er intention to perform the electrical work described below. Location(Street&Number) -Am -T— vim" Owner or Tenant MAU7 Ac J[Jch6is Telephone No. Owner's Address 51i-lvi-e Is this permit in conjunction with a building permit? Yes ❑ No' (Check Appropriate Box) Purpose of Building 5111 �'(' Utility thorization No. Existing Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: -Z(; Y' " A Completion of the ollowin !able ma be waived b"the Inspector of Wires. TrNo.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans o Tota Tans[ormers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- ❑ o.o Emergency Lighting g rad. nd. Ba4e Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS I No.of Zones No.of Switches No.of Gas Burners o.o election andInitiating Devices Total No.of Ranges No.of Air Cond. Tons No.of Alerting Devices No,of Waste Disposers eat Pump umber ons K o.oSelf-Contained p Totals: Detection/Alerting Devices 4 No.of Dishwashers S ace/Area Heating KW Local El un ecti ❑ Other p gConnection No.of D ers Heating Appliances KW Security Systems: ry No.of Devices or Equivalent No.of Watero,of No.of Data Wiring: Heaters KW signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring No.of Devices or Equivalent OTHER: Atlach additional derail if desired,or as required by the Inspector of 11 Tres. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: e. 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 Iicensee provides proof of liability' surance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such cov a is in force,and has exhibited proof of s e to the pe it issuing o ice. gn g . CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) j j� - Icertify,under the ants olid pen of erjury,tJl�'t the nt natation or: tis appttcatl Ls true!rue and on el FIRM NAME: vEc� iC �C? LIC.NO.:� x:33 Licensee: <5pohe h <Joj A Signature ( LIC.NO.: (Ijapplicable,ent "exempt in the license number li p Bus.Tel.No.• Address: v� t 6 /� �v Alt.Tel.No.: k ,/ *Per M.G.L.c. 147,s.57-61,security w requires Departnkrit of Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I 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 a enL Owner/Agent PERMIT FEE: $ Signature Telephone No. Date. .! �q 9585 NpRTry TOWN OF NORTH ANDOVER p PERMIT FOR PLUMBING sC �S �� � � l ` This certifies that . :. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . has permission to perform A!2. . . . . . . plumbing in the build VS f . �� ' '"� r. . . . . . . . . . . . . . . . . // at- - . . ., ,/�. . . r,7 orth Andover, Mass. Fee.. .Lic. No��473. . �. . . . . v PLUMBING NSPECTOR Check µ l� _Cx MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY'W"I_ 6-7 MA DAT _.>.APERMIT# 7 JOBSITEADDRESS OWNER'S R NAME11-47 OWNER ADDRESS TEL= : _jFAX[_ TYPE OR OCCUPANCY TYPE COMMERCIAL Q EDUCATIONAL D RESIDENTIAL Or PRINT I CLEARLY NEW.F_711 RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO J.- FIXTURES-1 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 1 11 12 13 14 BSM BATHTUB 14 CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM j 'J DEDICATED GASfO11JSAND SYSTEM ........... .......... DEDICATED GREASE SYSTEM _-.-.._.I DEDICATED GRAY WATER SYSTEM J11_._._.—_.I DEDICATED WATER RECYCLE SYSTEM =F 1 . j L__ __)L-_.__1 L_11 DISHWASHER ( ----...._.I- DRINKING FOUNTAIN F IF I FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) ................i KITCHEN SINK J .......... LAVATORY ROOF DRAIN [E-721 ................. ........... SHOWER STALL = ======E SERVICE I MOP SINK i .4 j ........... TOILET L= URINAL ............. --------------- WASHING MACHINE CONNECTION J F_7 F_ WATER HEATER ALL TYPES WATER PIPING OTHER I Fif ........... ------------ r r INSURANCE COVERAGE: I have a current liability insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.142, YES N IF YOU CHECKED YES,PLEASE INDICATE THE TYP OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY EJ BOND OWNER NCE)%AIVER:I am aware that the licapsee does not have the Insurance coverage required by Chapter 142 of the Massa uGetts VGne aws, I that gnatu on is permit application waives this requirement, CHECK ONE ONLY; OWNER E-,]!f AGENT SI'diNAtUREOFOWNER ORAGIENT 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 1 ws , f' SIGNATURE, le, MP[] JP[Q-' CORPORATION I:j#=PARTNERSHIP LLC[g#-I' I lit COMPANY NAME ADDRESS CITY b444V5W' S ATEFAJ ZIP JTEL 1 ---------- - FAX CELL=_j EMAIL Pq 1 l d 41 �►�- ►� nes Date.. . lxZ-/z.. . ... .. r,OQTM 3�Oy ,..o ,e�tioc TOWN OF NORTH ANDOVER • PERMIT FOR GAS INSTALLATION O� �,SSACHUSESS .. This certifies that . . !. . . . . . . . . . . . . �. . . . . . . . has permission for gas installation in the buildings of 1/v/ �►0�v. . . . . . . . . . . ' . . . . . . . at . . . . . .Ck�./ ! . .�???�-. a�. , North d ver, Mass. y Feel.1�: Lic. No.JS (!. . . . -7 GASI P CTOR Check# ,1 , 8329 i MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY MA DATE 1 PERMIT# S"5 JOBSITE ADDRESS 1 Gid CRpa Cc) _ OWNER'S NAME GOWNER ADDRESS _jj TE 1666 FAX�� TYPE OR OCCUPANCYTYPE COMMERCIALQ_I EDUCATIONAL ® RESIDENTIALM PRINT CLEARLY NEW:Q RENOVATION:Q REPLACEMENT:Q PLANS SUBMITTED: YES QI NO QI APPLIANCES Z FLOORS— BSM 1 2 3 4 5 6 7 S 9 10 11, 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR I FURNACE JP GENERATOR GRILLE f • INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT I I I I OVEN J POOL HEATER I ROOM/SPACE HEATER ( __ ROOF TOP UNIT I J TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER ee-TV OTHER ..................................... ................... ........_.. ........ INSURANCE COVERAGE 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO QI IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ® OTHER TYPE INDEMNITY Q BOND Q 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 Q AGENT Q 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 com� with all Pertinent rovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAMESEI ' _ _ LICENSE# 6 _ J SIGNATURE MP Q MGF.N JP Q JGF- LPGI Q CORPORATION®# PARTNERSHIP E3# LLC Q#� COMPANY NAME:_ :__. l e_^ ec(,o ADDRESS GG,� �` _-_-.—_--__-_ —_-I CITYV�GlL STATE® ©ITEL7 — FAX 1 D CELL: ]EMAIL ' R _ 1 V ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No J THIS APPLICATION SERVES AS THE PERMIT ❑ e- �+Ss -t L LAA VV-4a A. tv�c FEE: $ PERMIT# PLAN REVIEW NOTES r. I The Commonwealth o Massachusetts 07 Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/OrganizatiorAndividual): l l KC k.0 c-Ar4•iy 1C.4 L_ 4- ;O L Address: 31 R C 601Z Ac.S � City/State/Zip: 0J• 9U 4/ Ll�5 Phone#: C!?8- Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ,E]New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet.# 7• ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]r employees.[No workers' comp.insurance required.] Mr!Other *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 aie 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 their workers'comp.policy information. 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: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one=year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido Izerebcera under the pains and pe Wes erjury that the information provided above is true and correct. Signatura. �. 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#: 1\ 1, 1 f 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 h 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 Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department oflndustrial Accidents Office of Investigations 604 Washington Street Boston,MA 02111 TeX,#617-727,4900 ext 406 or 1-877rMASSAFB Revised 5-26-05 Fax##617-727-7749 www-mass,gov/dia Y,.-_..-._ __.. .. .._,_-�.�. .._ -...=-.T--.-.,*---'�"'..K�+.as'=....-+r�i.�n'a.'..,w.s�....��av�-.-�,�y+....�---•i�'7�'--•, Date.....��.�!4 ....................... �r10R7F/, TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION ss�cHus� This certifies that .. ...�c.�.axw--a........................... . has permission for gas installation ...a,)..��.......5..... ..................................... inthe buildi s ....................................................r.................................... at. /. ... . .. .................................., No And ver, Mass. Feo,�....•6j)..... Lic. No. I.. .P............. f ..................... G�S NSPECTOR Check# 10142 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK •6 _ n CITY �� < /�AJ 0UC,t2 MA DATE - �— G s PERMIT# JOBSITE ADDRESS 11r7 (� t 4A4 OWNER'S NAME ��e GOWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIALff PRINT CLEARLY NEW: RENOVATION: ❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ APPLIANCES 7 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 FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM I SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO ❑ 1 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY M? 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 ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true nd 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 com i c/ ith all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME 6'5 6L.)k_em��-e_> LICENSE# 06 I SIGNATURE MP jg MGF❑ JP❑ JGFF 0 LLPGGII ❑ CORPORATION ❑# PARTNERSHIP❑# LLC E]# COMPANY NAME 51nii / I C F�C,C,6E i t (tel// 6.- DRESS C) X Q© —6f CITYM_r�[)e'Aj STATED ZIP(n t c� LL� TEL 24PRE FAX CELL EMAIL Date....2-1.13....... r 13 U"' 3 NOR T TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that.........S......N.................. ................................................ perform..... ................................ has permission to . ............. ...... plumbing in the buildings of....... ........NJ...C.Y\'a k..S.................. at.....1 0�dQ (-MIT L--> ............. . ....... N ....................................................................... �oh Andover, Mass. Fee.q0 .....Lic. No. ..... ........... .PLUMBI Ns. ................... PECTOR Check# 9 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK l: ' CITY �,4 2 MA DATE j PERMIT# JOBSITE ADDRESS GR OWNER'S NAME y' t POWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL Q RESIDENTIAL* PRINT CLEARLY NEW: 0 RENOVATION: REPLACEMENT:JN PLANS SUBMITTED: YES® NO 01 FIXTURES 7 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 GAS/OILISAND SYSTEM ! ( ._.____-1 DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM 1 _ _! _____.I ___ _1 ! ___I DEDICATED WATER RECYCLE SYSTEM 1 __.-._f DISHWASHER DRINKING FOUNTAIN ! ..-_ _( ..__, ______( .____._{ ( __._..._1 __._..._i ._____ ..___.._.__1_.-_.._._! ......__. .._.....1 ( ....._( FOOD DISPOSER ! 1 .__.--E ___.__( __..__i I _ _.-! ._.__.1 .__..__.i FLOOR/AREA DRAIN 1 _.____._1 .____► ___ _.� ( __..__.! _____1 _�_.__{ _____1 __ ____._.( .___._I ( _..v_( INTERCEPTOR(INTERIOR) ! ___._^! _.�-_I __.._ ..__..,_..( f _.__._1 _.__� _�f .___.._.__I .,-____1 ____.._ ( ► __.__i KITCHEN SINK ! -1 LAVATORY - "ROOF DRAIN .'SHOWER STALL i -------- SERVICE MOP ---_.SERVICE/MOP SINK TOILET URINALI _...__._ ____1 ___ t �_J ._.._.`s ..___ __.( _._._. I ___.__! _..-__- ..__.._.._ __...._ _..._.-! —_f WASHING MACHINE CONNECTION i { _.. ._ ._....__f ___- 1 ._! __j WATER HEATER ALL TYPES 1 [ ___-- 11 I ._ I= _____-_1 __- I _1 WATER PIPING ( ! J==_...._! 1 .__...-_._t -- f __._- 1 _I I OTHER -_._._i ....._J I _ I INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142, YES NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY jo OTHER TYPE OF INDEMNITY 0 BOND P 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 Q AGENT ID SIGNATURE 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# b e! I SIGNATURE MPA JP Q CORPORATION�1# PARTNERSHIP 0# _ _ LLC COMPANY NAME�sc ��� � �. ; ADDRESS _ CITY '� .� /- -......_...._.......__I STATE ZIP _ . - �—i TEL FAX f CELL EMAIL UGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES G o / , Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES r The Commonwealth of Massachusetts Department ofIndustirial Accidents 1 Congress Sheet,Suite 100 Boston,MA 02714 2017 .` ,•�� �: �F www mass.gov/dia ODM S��V Workers'Compensation Insurance Affidavit:Builders/Contractors/Electxicians/Plumbers. TO BE PILED WITH THE PERMITTING AU M01U Y please Print Le 'bl A ' licantlnformation Name(Businesslftan7- .tion&dividual): Address: o p Cr`Cl� y Phone City/State/Zip: S Are you an employer?Check the appropriate box: F8. E] project(required): employees(firll and/or part-time). ew'donstruotion 1,❑I am a employer with__- 2.®I am a sole proprietor or partnership and have no employees Working for me in emodeling any capacity.[Noworkers'comp.insurance required.] emolition3. I am a homeowner doing all work myself.[No workers'comp.insurance required.]t uilding addition ill4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I w lectrical repairs or additions ensure that all contractors either have workers'compensation insurance or are sole bin re airs Or additions to 'ees. 12 W Pawn, g p em proprietors with no p, Y 5.❑I am a general contractor and T have hired the sub-contractors listed on the attached sheet. 110 Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 14.[]Other 6.❑We are a corporatiori and its,officers have exercised their right of exemption per MGL c. 152,§1(4),and•we.have r o employees.[No workers'comp.insurance required.] a plicant that check's box#1 must also fill out the section below showing their workers'compensation policy information. P . af1.fidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such i eowners who submit.this. e name of the sub contractors and state whether qr not those entities,have Isom $Contractors that checkihis box must attached an additional sheet showing the comp.policy number. s the mus t provide their If the sub-contractors have employee, y employees. the olio and)oh site .::.row is y to ees. Be p lam an employer that is providing workers'compensation insurance for my emr y information. Insurance Company Name: Expiration Date: Policy#or Self-ins.Lie.#: l �// � � G'/;g--�C City/State/Zip: 4/1) Job Site Address:_ showing the policy number and expiration date). Attach a copy of the workers' compensation policy declarati page olation Failure to secure coverage as required undeyrMGLenaltieszinthe form of as a criminal STOPrWORK ORDER and a fine of up to $250.00 a and/or one-year imprisonment,as well as p day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. X do hereby certify under thepains andpenalties of perjury that the information provided above is true and correct. Date: _ Signature: Phone#: � l Official use only. Do not write in this area,to he completed by city or town official. Permit/License# City or Towyn: i Issuing Authority(circle one): i 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Phone#: Contact Person: 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 receiv6for 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 b6 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(1)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 Pleasb fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub contractor(s)name(s),address(es)and phone number(s)along with their certificates)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-Accidenis. Should you have any questions regarding the law or if you are required to obtain a workers' compensationolic lease ca p y,p ll the Department at the number Iisted below. Self-insured companies p 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(ifnecessary)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 fulled 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-MA.SSAFE Fax#617•-727-7749 Revised 02-23-15 www.mass.gov/dia c � Date.......6 .1...L..:... .. 3 NOR7#y TOWN OF NORTH ANDOVER a PERMIT FOR WIRING d CHUS�t + —� E t This certifies that ............,,��^..�..!°`................. 'c ✓t G has permission to perform .... il Vii(r ........''f.d. ` ............................................. wiring in the building of........./�..O.`�.g......�1.����5........................... : ...,...t. ....................... at ....... Z ® �G� C� .. ....�... North Andover,Mass. Fee.. .�:.>�...�..........Lic.NoA.a.... k.V.... ELECTRICAL INSPECTOR Check# 93 - Commonwealth of Massachusetts Official Use Only i 1 Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] eaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code C),127 CDM 12.00 R (PLEASE PRINTWINK OR TYPE ALL INFORMATIOA9 Date: City or Town of: NORTH ANDOVER To the Insp ctor of Wires: By this application the undersigned gives notice of o�er enhon to perform the electrical work described below. Location(Street&Number) / Owner or Tenant M& 1- Telephone No. Owner's Address sowbf Is this permit in conjunction with a b,Mingmit? Yes No ❑ (Check Appropriate Box) Purpose of Building Utility Authorizatiop No. - Existing Service Amps / Volts Overhead ❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion o the following table maybe waived by the Inspector of Wires. No. of No.of Recessed Luminaires No.of Cell.-Susp.(Paddle)Fans Trans Total Z Trsformers KVA No.of Luminaire Outlets P of Hot Tubs Generators KVA AboveIn- o.o Emergency Lig ting No.of Luminaires , imming pool rnd. ❑ rnd. ❑ Battery Units No.of Receptacle Outlets ® P b/of Oil Burners FIRE ALARMS No. of Zones No.of Gas Burners No. of Detection and No.of Switches Initiating Devices No.of Ranges No.of Air Cond. Tons TotNo.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained P Totals: - - ........... Detection/Alerting Devices Municipal E] other No.of Dishwashers Space/Area Heating KW Local ElConnection No.of Dryers Heating Appliances KW Security Systems:Y No.of Devices or E uivalent i No.of Water KW 0.0 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: 1/ Attach additional detail if desired, or as required by the Inspector of Wires. Estimated'Value of F4ectrical Work: (When required by municipal policy.) Work to Start: fD Inspections to be requested in accordance with NEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of elecifical work may issue unless the licensee provides proof of liability' surance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such cover e is in force,and has exhibited proof of s e tit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) Xcertify,under thepains andpenalties ofperjury,t1 t tIz'nformation on hzs application is true and complete ,33 FIRM NAME: . U 6 i) LIC.NO.: Licensee: SjAokh Q7-&- /,o 1 Signature LIC.NO.: (If applicable,enter "exe t"i the 11c nse number Bus.Tel.No.: Address: v� Alt.Tel.No.: *Per M.G.L c. 147,s.57-61,security wor quires Department of Public Safety"S"License: Lic.No. • OWNER'S INSURANCE WAIVER: I 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/AgentPF,RMTT FEE. S f Z — m.1_._l._�_ AT_ `-L ID Ck Date...../�...... 'F f �OR7M 1 TOWN OF NORTH ANDOVER o p PERMIT FOR WIRING �,SSACm S This certifies that ......R.L.1...........J. .!-t.z uu-...................................... has permission to perform ......t`�.�..C..�.............!.`.o.1!vx.t........................ wiring in the building of.....R.:.... :......� •.................. .... ................ .............. .:!.:...�`! ....kP ......... .... ,North Andover,Mass. J �— Fie > 7:v v... Lic.No.f .....�./ ............................................................... ELECTRICAL INSPECCOR �03/49b 14:44 427.00 PAID WHITE:Applicant CANARY: Building Dept. PINK:Treasurer GOLD: File �i \ Office Use Only Opt (fummsnwtatt i If f II5sa0uBE1h Permit No. %partmPut of Public _*afttg Occupancy&Fee Checked 3/90 (leave blank) BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date �� '� (X)�, or Town of NORTH ANDOVER To the Inspector of Wires: The udersigned applies for a permit to perform the electrical workscri e below. Location (Street & Number) Owner or Tenant t Owner's Address (Azw 4k Is this permit in conju ction with a building permit: Yes No ❑ (Check Appropriate Box) Puroose of BuildingUtility Authorization No.(an L/ / r 1 �I � No. of Meters Existing Service Amps Volts Overhead Undgrnd 9 New Service OQ:f& — Amps -P.&J Z11.10 Volts Overhead ❑ Undgrnd No. of Meters Number of Feeders and Ampacity E kW CA, rJ2` !�tf t�fvI v Location and Nature of Proposed Electrical Work G.I an UI Total No. of Lighting Outlets I No. of Hot :ubs I No. of Transformers KVA Yr ```{{{ No. of Lighting Fixtures ((� I Swimming Pooi Above— In- n- r' Generators KVA / I / No. of Emergency Lighting No. of Receptacle Outlets No. of Oil Burner (f ( Battery Units No. of Switch Outlets Burner FIRE ALARMS No. of Zones Total No. of Detection and No. of Air Cor. No. of Ranges 2 / I tons Inniittiati(n�g.D..e�viice v tai 1 d V wK Gf No. of Disposals I No.of Heat –total Tons KW No. of Sounding Devices No. of Seif Contained No. of Dishwashers SbaceiArea Heating KW Detection/Sounding Devices Municipal Other No. of Dryers Heating Devices KW Local Connection I No. of No. of Low Voltage No. of Water Heaters KW Signs Bauasts Wiring No. Hyaro Massage Tubs W�. I No. cf Motors Total HP OTHER: INSURANCE COVERAGE: Pursuant to the redutrements of htassacnuserts general Laws _ I have a current Liability Insurance Policy inciucing Comb:etec Operations Coverage or its substantial equivalent. YES NO I have submitted valid proof of same to the Office. YES V NO = If you have checked YES, please indicate the type of coverage by checking the appropriate box. NX-CL N 4, INSURANCE 114 BOND = OTHER = (Please Scec:fy) (Expiration Date) Estimated Value of E'.ecttrical Work S 2Q, — Work to Start 2) {(Q Insbectton Cate Recuested: Rough Final Ut Signed under th Penalties of erj J�{D UC. NO. FIRM NAME Licensee Siorature LIC. NO. q QQ O Sus. a..)F'�` � j Address `' �1�t1 a I ��4 fW(C_U3U"trcl I�Z�p - Alt. Tel:�� OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its substantial equivalent as re- quired by Massachusetts General Laws. and that my signature on ;his permit aopiication waives :his requirement. Owner q Agent, (Please check onel 'eleoh7one No. PERMIT FEES vt / (Signature of Owner or Agent) x-5565 I n Location / / o t of No. r � `- C Date 'I. r TOWN OF NORTH ANDOVER A Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ ---- C - S t siuse I Other Permit Fee $ � Sewer Connection Fee $ Water Connection Fee $ TOTAL $ Xc� co —Y,/ /Z/q Building Inspector M I 9596 Div. Public Works i Location Dated- No. •' ro N r [J1 of "°;T; +tio TOWN OF NORTH ANDOVER p Certificate of Occupancy $ ` Building/Frame Permit Fee $ Foundation Permit Fee $ O , sAGMUS t v Other Permit Fee $ Ln ' Sewer Connection Fee $ Water Connection Fee $ /07�•'SU TOTAL $ to ' /► • <~ p � _ uild'ir+g Ins ctor ,,:> Iv u Jc Wor s i Location �zl OLC> I No. - 6,�4n Date t "ORTN 1 TOWN OF NORTH ANDOVER O? •i � o 'MOOR „ Certificate of Occupancy $ 5� ` Building/Frame Permit Fee $ .s , . Foundation Permit Fee $ J00 sACMust Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL $ = L Buildingf5tInspector 95 14:29 150,00 PAID Y 9475 Div. Public Works PEEt\tITvO. APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. PAGE 1 MAP d-40. I LOT NO. 2 RECORD OF OWNERSHIP jDATE BOOK 'PAGE — ZONE SUB DIV. LOT NO. n F_ I 77 ��7�L.^tCATION �/� C �J. �/' PURPOSE OF BUILDING A.c � Vf OWNER'S NAME •L /� /l-!7{ NO. OF STORIES /v �- SIZELL OWNER'S ADDRESS � /GrfAe'o C6�k iJ BASEMENT OR SLAB l r �T ARCHITECT'S NAME I /,/` �/G.` /`/� SIZE OF FLOOR TIMBERS 1ST�X/d 2NDn ,wlv 3RD ;\ ? BUILDER'S NAME /I /�tr� /l� SPAN /)_I� f [ o� —� 'T `r - DISTANCE TO NEAREST BUILDING /W 1 'T 1 DIMENSIONS OF SILLS --- I DISTANCE FROM STREET J POSTS _1,4 DISTANCE FROM LOT LINES-SIDES j1Q REAR ��'�. /� I, GIRDERS G• 1 AREA OF LOT £f T' FRONTAGE 16rV,,t_j, HEIGHT OF/FOOUNDATION O=o I 1 THICKNESS IS BUILDING NEW SIZE OF FOOTINGI X ry �Q If IS BUILDING ADDITION MATERIAL OF CHIMNEYeel T IS BUILDING ALTERATION f/ `A/Y)' IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE ��� IS BUILDING CONNECTED TO TOWN WATER) BOARD OF APPEALS ACTION, IF ANY IS BUILDING CONNECTED TO TOWN SEWER ��/ IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS 3 PROPERTY INFORMATION LAND COST SEE BOTH SIDES PERMIT FOR FOUNDATION ONLY .✓7(�J`t°A Q Q EST. BLDG. COST PAGE I FILL OUT SECTIONS I - 3 REGULATED BY PARA. 11-*"'�C"' B.C. EBT. BLDG. COST PER SQ. FT. EST. BLDG. COST PER ROOM PAGE 2 FILL OUT SECTIONS I - 12 DATE -REPAID -'5 ��,,�� SEPTIC PERMIT NO. + ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING DGJ 4 APPROVED BY ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR • DATE FILED �YILDINO INSPECTOR SIGNATURE OF OWNER OR AUTHORIZED AGENT / ' } F E E ©O " OWNERTEL.# PERMIT GRANTED sm CIO PERMIT FOR FRAMUBUILDING CONTR.TEL.// — 19 ATE: FEE PAIDCONTR.LIC.# O H.LC.JJ CLEC 14 Bim•� em t> WA� b2 - C c BUILDING RECORD 1 OCC UWlCY 12 SINGLE FAMILY 400, S.-OICES THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM } MULTI. FAMILY OFF _ LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA- APARTMENTSRAGES, ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. CONSTRUCTION n 2 FOUNDATION o,,Z INTERIOR FINISH CONCRETE _ B 1 2 13 CONCRETE BL K. PINE t BRICK OR STONE HARDW D __ PIERS PLASTER _ DRY WALL _ UNFIN. - 3 BASEMENT AREA FULL FIN. B M AREA _ 1/1 1/2 1/1 FIN. ATTIC AREA _ N_O B M T FIRE PLACES _ HEAD ROOM MODERN KITCHEN 4 WALLS I 9 FLOORS CLAPBOARDS B 1 2 3 DROP SIDING CONCRETE �_ WOOD SHINGLES EARTH _ ASPHALT SIDING HARD\'✓'D _ ASBESTOS SIDING _ COMMCN VERT. SIDING ASPH.TILE STUCCO ON MASONRY STUCCO ON FRAME BRICK ON MAS NRY ATTIC STIRS. & FLOOR _ BRICK ON FRAME _ CONC. OR CINDER K. STONE ON MASONRY WIRING STONE ON FRAME SUPERIOR POOR _ ADEQUATE NONE 5 R99F 1,,40 - PLUMBING ole GABLE HIP BATH (3 FIX.) GAMBREL MANSARD TOILET RM. 12 FIX.) FLAT SHED WATER CLOSET ASPHALT SHINGLES LAVATORY WOOD SHINGES KITCHEN SINK SLATE NO PLUMBING 0000l TAR & GRAVEL STALL SHOWER _ ROLL ROOFING MODERN FIXTURES TILE FLOOR TILE DADO 6 FRAMING 11 HEATING ; WOOD JOIST PIPELESS FURNACE t FORCED HOT AIR FURN. 1� TIMBER BMS. 6 COLS. STEAM STEEL BMS. & COLS. HOT W'T'R OR VAPOR WOOD RAFTERS AIR CONDITIONING RADIANT H'T'G UNIT HEATERS 7 NO. OF ROOMS GAS OIL B'M'T2nd ELECTRIC 1st 13rd I NO HEATING _ ' AORTH Town of over 0 0 No. 640 it " dover, Mass.; kc¢ ffi i T COC HICHtWICK 7 5 BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System BUILDING INSPECTOR THISCERTIFIES THAT.. .`.. .....co.c..p........................................................................................ Foundation has permission to erect X�.... .buildings on .AjZ.k.......&L)11...�RT....(AM ..... . . '".+�i�, [tough to be occupied asQ1W2tL..l$AiW_NAtld�. .... 3..C/d2...�d. ........................................... chimney provided that the person accepting this1 permit shall Inery spect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. M�T_FO_R_F_U_NpAA_ [0N-0NtY-� PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. OEWLATED-BY EARA. 114.8-S._ RX. Rough PERMIT EXP 6 MO 5in _ Final EE_PAID -� ELECTRICAL INSPECTOR UNLESS CO C T TRough Service INSPECTORFinalOccupancy Permit Required to Occupy Buil ' GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To BeDone FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. i Smoke Det. i 8lt3 -q J b . FORM U - IAT 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 local or state law, regulations or requirements. ****************APPlicant fills out this section***************** APPLICANT: a r-cir� Phone1�-7t°2 I LOCATION: Assessor' s Map Number Parcel Subdivision Lot(s) Street St. Number 12 ************************Official Use Only************************ RECO- NDATI OF TOWN AGENTS: Date Approved % C nservat_on Administrator Date Rejected Comments Date Approved Zl �q!i Town Planner Date Rejec-ed Comments Date Approved Food inspector-Health Date Rejected Date Approved ��� Sep z-c Inspec or-Health Date Rej ec--ed Comp^er.ts P�Ci'biic Wcr*;s - set'4er,'water. connections - driveway pe_. its Fire Decart:aent - r - r, Received by Building Inspector Date eeeV - ,S0.470 �O 7- 19 19 Z wE�✓p3 ES/�Y � 5p'�✓o ,Quito Es/"s? .t g� Exp S� � h � 1 NE•PEBY CE.�T/FY TO T,yE riTGE/.t/SUeo�gc/O �L Q T ��/SIN T17 T/+�6 BA.Vi('TsigT TyE O�►'EGG/tib /S GOCATEO OV Tf/E'GaT AS S.�iry A.VO Tf/,4T/T OGEES Co.1/FOPA1 /N H'/T// T//ETnw✓ OF✓4✓oo�ER ZON/N6 PEI,v[AT,f�,vS , /c Q �/� �7 ipLr6vle0/.✓G SETSAC.t'S F�O�1 ST'PEETS f GOT uN6S.' ��Q, �NOO!� G/� // /f'7, LOG4TE0 /,�/ T E FEOE AG Fi0000 ApZ.PO A.PEAOT �.PA`✓/V FOiP i �SFjeWN O/t/FEM C �.c.� v /rY/'.4�tlGL 25Q098 Oo oBC, A • 760 mac,; ✓.4.v / 99Co • ,a /sIE.P.P/iYl.9Gf' �.vG/.t�EE,P�.I/G SE,PI���'ES r +� A.t/DDYE.P, /y/'QSS,4C/!//SETTS O/8/O 20 1 ;ldain Ste!.02345 KAREN H.P. NELSON 1. --: _-Town of - - 1 _ -:NORTH_ ANDOVER 086s24M , CO\SERt:A.TION HE.aLT.H pL: y�iING g CONDIUN= DEVELOP-NNT P1.aX�I�G -= CgZ NEY APPLICATION AND _.I PER` Iy DST C 7z- /,Z- OWNER s let e- L L S2L S u ^ S 'I ' S VDDR=Sc i � 9 .. 22 OT OT - e S L��. TC ,,, . =S^' =?7S.'RLC-TG`7 C.:a_ Q(�-- C' ._ G _3 /,� - -= RE MAR-RS THIS PER= :Sr.:S_ S- DDSPLAYED ON T::... PR '-=SES i ,-` -�� _ _ _-_ -, < < r CERTIFICATE OF USE & OCCUPANCY Town of North Andover Building Permit Number 640 (1995) Date AUGUST 9, 1996 THIS CERTIFIES THAT THE BUILDING LOCATED ON 191 nT n CART WAV (Tnt #2A) MAY BE OCCUPIED AS SINGLE FAMILY DWELLING W/3-CAR GARAGE IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. O' NOR77y • . CERTIFICATE ISSUED TO R. J. Richard Co m 01d Cart Wa ADDRESS N cMus� it nspector r ' �,#ORTH, aF � Tovm of dover 0 No 64 ' o ' dover, Mass., Cn<..nC rre wic K V 1 - 5 BOARD OF HEALTH PERMIT T D Food/Kitchen Septic SysteM. // BUILDING INSPECTOR THIS CERTIFIES THAT.....z.'.�..CoAeb.r..... -P....... . 53 "' F tion has permission to erecter ....FRAMILbuildings on J24....... ...5n ..?�) oU �s- to be occupied asQqF_. ltl� ��� . ....�� ... ..CA9.,....Q . .QAQ .......................................... chi provided that the person accepting this ermit shall in%eryspect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PERMIT FOR FOUNDATION ONLY PLUMBING I s CTOR VIOLATION of the Zoningor Building Regulations Voids this Permit. REGULATED BY PARA. 114.8-S. B.C. ou aL C "4 a- 9 9 �' PERMIT E XP1 6 MOI��I E FEE PAID 13— �1I� LESS COQ+� �T C AgT46� S� ' ELECTyC INSPE ............ ........... .......................... ervi D G INSPECTOR Occupancy PermitRequired to Occupy Buildin GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove RoughFinal /W No Lathing or Dry Wall To Be Done Until Inspected and Approved by the Building Inspector. FIRE DPARTMEN rr Burner Ve f V �✓ i' r Street No. � R �G Smoke Det. I . i I i INSTALLATION INSTRUCTIONS I I AND OWNER'S MANUAL The White Mountain UNVENTED GAS LOG HEATER OR ENTED DECORATIVE APPLIANCE VentedNent-Free Burner V MODELS VFSR-16-3 VFSV 16-3 j VFSR-18-3 VFSV 18-3 VFSM-18-3 VFSR-24-3 VFSV-24-3 VFSM-24-3 VFSR-30-3 VFSV 30-3 VF'SM -30-3 I SH This appliance may be installed in an �xnnsv aftermarket permanently Iocated, i manufactured (mobile) home, where not EFFECTIVE DATE prohibited by local codes. r This appliance is only for use with the type of MAY 2004 ' PP y yP I gas indicated on the rating plate. This appliance is not convertible for use with other Installer:Please leave these instructions with the gases. consumer. I WARNINGS Consumer: Please retain these instructions for j If the information in this manual is not followed future use. 1� exactly, a fire or explosion may result causing property damage,personal injury or loss of life. T an unvented gas-fired heater. It uses air (oxygen) from the room in which it is installed. r� Provisions for adequate combustion and ventila- - Do not store or use gasoline or other flam- enable vapors and liquids in the vicinity of tion air must be provided. Refer to page 7. this or any other appliance. WARNING:If not installed,operated and main- WHAT TO DO IF YOU SMELL GAS • Do not to appliance. tained in accordance with the manufacturer' � tany pp instructions, this product could expose you tc • Do not touch any electrical switch; do not use any phone in your building. substances in fuel or from fuel combustion which • Immediately call your gas supplier from can cause death or serious illness. neighbor's phone.Follow the gas_supplier's instructions. WATER VAPOR: A BY-PRODUCT OF • If you cannot reach your gas supplier, call UNVENTED ROOM HEATERS the fire department Water vapor is a by-product of gas combustion. An unvented room heater produces approxi- Installation and service must be performed mately one (1) ounce (30ml) of water for ever3 j by a qualified installer,service agency or the 1,000 BTU's (.3KW's) of gas input per hour gas supplier. Refer to page 6. 15994-2-0504 Page I TABLE OF CONTENTS Section Page Important Safety Information......................................................................................................................... . Safety Information for Users of LP Gas......................................................................................................... 4 ii Introduction .................................................................................................................................................... 5 GeneralInformation ....................................................................................................................................... 6 Water Vapor- By Product of Unvented Room Heaters................................................................................... 6 Provisions for Adequate Combustion and Ventilation Air ............................................................................. 7 Clearances ...................................................................................................................................................7-8 CombustibleMaterial...................................................................................................................................... 9 FireplacePreparation...................................................................................................................................... 9 ................ Installing as a Vented Appliance .................................................................................................. 10 Before Fully Installing the Appliance ............................................................................................................ 10 GasSupply ............................................................................................................................................... Placement of Glowing Embers and Lava Rock ........................................................................................... 12 Operation Instructions/Flame Appearance................................................................................................... 12 VFSR-(1 6, 18,24, 30) Lighting Instructions ............................................................................................... 13 � li VFSV-(16, 18,24, 30) Lighting Instructions ............................................................................................... 14 VFSM-(18,24, 30) Lighting Instructions .................................................................................................... 15 Pilot Flame Characteristics...................................................................................................................... 16-17 Cleaningand Servicing. ........................................ ....................................................................................... 17 Wiring............................................................................................................................................................ 18 Troubleshooting .......................... .............................................................................. 19 ............................... ..... PartsList......................................................................................................................•-•••-•-•--.._._......._......... 20 PartsView..................................................................................................................................................... 21 Howto Order Repair Parts --------------------------------------------------------------------------------------------------------------------------- 21 ServiceNotes...................................................................................................... ------------------------------------22-23 , i I Pale 2 159942-0504 i TION IMPORTANT SAFETY INFORMA • An unvented room heater having an input rating of more • The installation mast conform with local codes or, in fl than 6,000 Btu;per hour shall not be installed in a bath- absence of local codes, with the National Fuel Gas Cod room ANSI 2223.1/NFPA54. j • An unvented room heater having an input rating of more • NOTE: Installation and repair should be done by a qua than 10,000 Btu per hour shall not be installed in a bed- fied service person.The appliance should be inspected b room or bathroom fore use and at least annually by a qualified service perse •Never barn solid feels in a fireplace where a gas log set is More frequent cleaning may be required due to excessi i installed. lint from carpeting,bedding material, etc It is imperati •Due.to high temperatures,the appliance should be located that the control compartment,burners and circ ting out of traffic and away from furniture and draperies. passageways of the appliance be kept clean. •Do not place clothing or other flammable material on or • Any safety screen or guard removed for servicing an app near the appliance. ance must be replaced prior to operating the appliance.Pi • Children and adults should be alerted to the hazards of high vide adequate combustion and ventilation air. surface temperature and should stay away to avoid burns •The flow of combustion and ventilation air MUST NOT or clothing ignition. obstructed. i • Young children should be carefully supervised when they •Provide adequate clearances around air openings into t are in the same room as the appliance. combustion chamber and adequate accessibility clearat •This unit complies with ANSI Z21.11-2 Unvented Heaters for servicing and proper operation. NEVER obstruct and it also complies with ANSI Z21.60 Decorative Vented front opening of the appliance. Appliances foriSolid Feel Burning Fireplaces.State or local • An nnvented room heater intended for installation is I codes may only,allow operation of this appliance in a vented solid-feel burning fireplace shall comply with the follow: configuration.;Check your state or local codes. instructions. • Correct installation of logs, proper location of the heater • A fireplace screen must be in place when the applianc and annual cleaning are necessary to avoid potential prob- operating and, unless other provisions for combustion lems with sooting.Sooting,resulting from improper instal- are provided, the screen shall have an opening(s) lation or operation, can settle on surfaces outside the Etre- introduction of combustion air. • Solid-fuels shall not be burned in a masonry or UL place . • Avoid any drafts that could alter burner flame patterns.Do factory-built fireplace in which an unvented room heate not allow fans to blow directly into the fireplace. Do not installed- place a blower,inside burn box area of firebox.Ceiling fans •Any glass doors shall be fully opened when the applianc may create drafts that alter burner flame patterns.Sooting in operation. and improper(burning will occur as a result of drafts. • Any outside air ducts and/or ash dumps in the fireplaces. •WARNING: Do not allow fans to blow directly into the be permanently closed at time of appliance installation fireplace.Avoid any drafts thatalterbnrnerflamepatterns. • WARNING: Failure to keep the primary air openings •WARNING: Do not use a blower insert, heat exchanger the burner(s) clean may result in sooting and props insert or other accessory not approved for use with this damage- heater. • WARNING: Before installing in a solid-fuel burr, •Periodic examination and cleaning of the venting system of fireplace,the chimney flue and firebox must be cleane the solid-feel limning fireplace,including frequency of such soot,creosote,ashes and loose paint by a qualified chin examination and cleaning,by a qualified agency. cleaner. I � I WARMING CARBON MONOXIDE POISONING MAY LEAD i When used without adequate combustion and ventilation air, 11 mly g� of carbon monoxide poLsonmg resemble heater may give off CARBON MONOXIDE, an odorless, flu,with headache, dizziness and/or nausea. If you b ipoisonous gas. these signs,heater may not be working properly.f&th 4 Do not install heater until all necessary provisions are made air at once! Have heater sex viced_ j for combustion and ventilation air. Consult the written Some people— pregnant women, persons with hear instructions provided with the heater for information lung disease,anemia,those under the influence of alto i I concerning combustion and ventilation air In the absence those at high altitudes — are more affected by car j of instructions,refer to the National Fuel Gas Code,ANSI monoxide than others. 2223.1,Section 5.3 or applicable local codes. The pilot light safety system senses the depletion of ox3 This heater is equipped with a PILOT LIGHT SAFETY at its location. If this heater is installed in a strut SYSTEM designed to turn off the heater if not enough fresh having a high vertical dimension,the possibility exists air is available. the oxygen supply at the higher levels will be less t DO NOT TAMPER WITH PILOT LIGHT SAFETY that at the heater. In this type of application, a fa i SYSTEM! circulate the structure air will minimize this effect- If ffectIf heater shuts off,do not relight until you provide fresh air. use of this fan will also improve the comfort level in If heater keeps shutting off, have it serviced. Keep burner . structure.When a fan is used to circulate air,it shoal and control compartment clean. located so that the air flow is not directed at the burs � 15994-2-0504 I � V 1, ! USERS LP-GAS ' 1 Ir SAFETY INFORMATION i•6 u, 3 1'v .,,ya� �'' �� Propane(LP-Gas)is a flammable gas which can causefires by point with the members of your household. Someday and explosions.In its natural state,propane is odorless and when there may not be a minute to lose,everyone's safety will colorless.You may not know all the following safety precau- depend on knowing exactly what to do.If,after reading the tions which can protect both you and your family from an following information,you feel you still need more informa- !„ accident Read them carefully now,then review them point tion,please contact your gas supplier. LP-GAS WARDING ODOR If a gas leak happens,you should be able to smell the gas because of the odorant put in the LP-Gas. That's your signal to go into immediate action! I Do not operate electric switches, light matches, use your Use your neighbor's phone and call a trained LP-Gas service phone.Do not do anything that could ignite the gas. person and the fire department-Even though you may not '! Get everyone out of the building,vehicle,trailer,or area.Do continue to smell gas,do notturn on the gas again.Do not re- that IMMEDIATELY. enter the building,vehicle,trailer,or area_ Close all gas tank or cylinder supply valves. Finally, let the service man and firefighters check for LP-Gas is heavier than air and may settle in low areas such escaped gas.Have them air out the area before you return as basements.When you have reason to suspect a gas leak, Properly trained LP-Gas service people should repair the keep out of basements and other low areas. Stay out until leak,then check and relight the gas appliance for you. firefighters declare them to be safe. NO ODOR DETECTED - ODOR FADE Some people cannot smellwell.Some people cannotsmell the occur if there is rust inside the storage tank or in iron gas pipes. odor ofthe chemical put into the gas.You mustfindout ifyon The odorant in escaped gas can adsorb or absorb onto or into can smell the odorant in propane Smoking can decrease your wails,masonry and other materials and fabrics in a room That ability to smell.Being around an odor for a time can affect your will take some of the odorant out of the gas,reducing its odor sensitivity or ability to detect that odor.Sometimes other odors intensity. I'I I in the area mask the gas odor.People may not smell the gas,odor i or their minds are on something else.Thinking about smelling a LP-Gas may stratify in a closed area,and the odor intensity could Pas odor can make it easier to smell. a vary at different levels.Since it is heavier than air,there may be more odor at lower levels.Always be sensitive to the slightest I! The odorant in LP-gas is colorless, and it can fade under gas odor. If you detect any odor, treat it as a serious leak some circumstances.For example,if there is an underground Mediately go into action as instructed earlier.' ij leak,the movement of the gas through soil can filter the odorant Odorants in LP-Gas also are subjectto oxidation.This fading can SOME POINTS TO REMEMBER ILearn to recognize the odor of LP-gas.Your local LP-Gas to set too lona before refilling.Cylinders and tanks which • Dealer can give you a"Scratch and Sniff'pamphlet Use it to have been out of service for a time may develop internal rust find out what the propane odor smells like.If you suspect that which will cause odor fade.If such conditions are suspected your LP-Gas has a weak or abnormal odor,call your LP-Gas to exist, a periodic sniff test of the gas is advisable. If you Dealer. have any question about the gas odor, call your LP-gas dealer.A periodic sniff test of the LP-gas is a good safety - If you are not qualified, do not light pilot Iights, perform measure ander any condition. service, or make adjustments to appliances on the LP-Gas system.If you are qualified,consciously think about the odor - If,at any time,you do not smell the LP-Gas odorant and you of LP-Gas prior to and while lighting pilot lights or perform- think you should,assume you have a leak.Then take the same ing.service or making adjustments. immediate action recommended above for the occasion when you do detect the odorized LP-Gas. Sometimes a basement or a closed-up house has a musty experience a complete "gas out," (the container is ex en 'g t If you p P o . t to light Y smell that can cover up the LP-Gas odor.Do no try a pilot lights,perform service,or make adjustments in an area under no vapor pressure), tum the tank valve off tmmedt- where the conditions are such that you may not detect the ately.If the container valve is left on,the container may draw odor if there has been a leak of LP-Gas. in some air through openings such as pilot light orifices. If this occurs, some new internal rusting could occur. If the • Odorfade,due to oxidation by rust or adsorption on walls of valve is left open, then treat the container as a new tank_ new cylinders and tanks, is possible. Therefore, people Always be sure your container is under vapor pressure by �i should be particularly alert and careful when new tanks orturning it off at the container before it goes completely empty Cylinders are placed in service.Odor fade can occur in new or havinP it refilled before it is completely empty. tanks,or reinstalled old tanks,if they are filled and allowed ! 15994-2-0504 Pale 4 INTRODUCTION IMPORTANT: Read all instructions carefully before starting Attention:During initial use of log you will detect an odor as the log installation. Failure to follow these installation instructions may is cured. f result in a possible fire hazard and will void the warranty. Notice:During initial firing of this unit,its paint will bake out and smoke will occur.To prevent triggering of smoke alarms,ventilate the room in Save this manual for future reference. i Please read this manual before installing and using the appliance. Which the unit is installed. Instructions to Installer WARNING:This appliance is for installation only in a solid- 1. Installer must leave instruction manual with owner after installation. fuel burning masonry or UL 127 factory-built fireplace or in a Installer must have owner fill out and mail warranty card supplied listed ventless firebox enclosure.It has been design certified for l these installations.Exception:DO NOT install this appliance in with unvented room heater/vented decorative appliance. a factory-built fireplace that includes instructions stating it has 3. Installer should show owner how to start and operate unvented room not been tested or should not be used with unvented gas logs. heater/vented decorative appliance. Always consult your local Building Department regarding regulations, WARNING:Any modification to this unvented gas heater or its r codes or ordinances which apply to the installation of an unvented room controls can be dangerous.Improper installation or use of the heater/vented decorative appliance. heater can cause serious injury or death from fire, burns, f This appliance may be installed in an aftermarket* manufactured explosion or carbon monoxide poisoning. (mobile)home,where not prohibited by state or local codes. Well Read Gas Installations j ( *Aftermarket Completion of sale,not for purpose of resale,from the Some natural gas utilities use"well head"gas_This may affect the Btu manufacturer. output of the unit. Contact the gas company for the heating value. This appliance is only for use with the type of gas indicated on the rating Contact the manufacturer or your gas company before changing spud/ plate.This appliance is not convertible for use with other gases. orifice size. New Installation ACCESSORIES VFSV Model-variable does not operate-ON is OFF/OFF is ON-wires Description Color into the back of receiver are reversed. fSolid-fuels shall not be burned in&fireplace where a vented decorative For use with VFSV,VFSM and VFSR models I appliance is installed EK-1 Embers Kit A vented decorative appliance must be installed only in a solid-fuel aH-1 Fireplace Hood for Vent-Free Logs Black bumingfireplacewith aworkingflueand consttuctedofnon-combustible ELH-2 Fireplace Hood for Vent-Free Logs Brass material. i For use with VFSR models only Any alteration of the original design,installed other than as shown ! in these instructions or use with a type of gas not shown on the rating FRB BatteryOperated Remote Control plate is the responsibility of the person and company making the FRBTC Battery Operated Remote Control with Thermostat FREC Electric Remote Control change. it Important FWS Wall Switch All correspondence should refer to complete Model Number, Serial GWSG-T Wall Thermostat,Millivolt Number and type of gas. TMV Wall Thermostat,Millivolt-Reed Switch PRODUCT SPECIFICATION Natural Gas Propane Gas Variable Millivolt Manual Variable Millivolt Manual Regulator pressure setting 3.5"W.C. 3.5"W.C. 6-0"W.C. 10.0"W.C. 10.0"W.0 10.0"W-C Gas inlet pressure Max. 10.5"W.C. 10-51,W. 1 5"W. - 1 "W. . 13.0"W.C. 13. "W.C. Min. 5.0"W.C. 5.0"W.C. 7.0"W.C. 11.0"W.C. 11.0"W.0 11.0"W.C. BTUH BTUg BTUH Model Gas Valve Type Max-Rate Med.Rate Min-Rate VFSV-16 Natural Variable 25,000 - 17,500 VFSV-16 Propane Variable 22,500 - 15,750 VFSR-16 Natural Millivolt 25,000 _ 17,500 V FSR-16 Propane Millivolt 22,500 15,750 VFSV-18 Natural Variable 32.000 - 19,000 VFSV-18 Propane Variable 32,000 - 19,000 VFSR-18 Natural Millivolt 32,000 - 22,000 VFSR-18 Propane Millivolt 32,000 - 22,000 VFSM-18 Natural Manual 32,000 27,000 22,000 VFSM-18 Propane Manual 32,000 27,000 22,000 VFSV-24 Natural Variable 36,000 - 20,000 VFSV-24 Propane Variable 36,000 - 20,000 VFSR-24 NaturalMillivolt 36,000 - 25,000 VFSR-24 Propane Millivolt 36,000 - 25,000 VFSM-24 Natural Manual 36.000 27,000 22.000 u VFSM-34 Propane Manual 36,000 27,000 22,000 VFSV-30 Natural Variable 38,000 - 20,000 ii VFSV-30 Propane Variable 38,000 - 26,000,000 VFSR-30 Natural Millivolt 38,000 26 j VFSR-30 Pro ane Millivolt 38,000 26,000 VFSM-30 Nani al Manual 38,000 27,000 22,000 VFSM 30 Propane Manual 38,000 27.000 22,000 Gj Page 5 t i5994-2-0501 �LTJEJNERi`. INFORMATION j . ` This is an unvented gas-fired heater.It uses air(oxygen)from the Make sere you have received all parts: room in which it is installed.Provisions for adequate combustion Check your packing list to verify that all listed parts have been and ventilation air must be provided. received You should have the following: Keep room area clear and free from combustible materials, Gas log grate/bumer assembly. gasoline and other flammable vapors and liquids. Two(2)masonry anchoring screws and two(2)10 x 1/2"black I sheet metal anchorin-screws. Unvented gas heaters are a supplemental zone heater. They are not intended to be a primary heating appliance. Water vapor Plastic bag containing glowing embers(rock wool)for burner produced by an unvented heater can create moisture problems in coverage. a home when operated for extended periods of time. Plastic bag containing lava rock. During manufacturing, fabricating and shipping, various Switch log assembly-VFSR models components of this appliance are treated with certain oils,films • Remote kit-VFSV models or bondin- agents. These chemicals are not harmful but may Millivolt controlled heater designed to be operated with optional produce annoying smoke and smells as they are burned off during devices for ON/OFF functions. the initial operation of the appliance;possibly causing headaches Wall switch or thermostat with wire. or eye or lung irritation. This is a normal and temporary Hand held remote control with ON/OFF switch or thermostat- occurrence. hermostatoccurrence. Handle the gas log burner assembly by the grate and legs only. The initial break-in operation should last 2-3 hours with the burner Do not pick the unit up by the burner at the highest setting.Provide maximum ventilation by opening fI windows or doors to allow odors to dissipate.Any odors remaining Gloves are recommended when handling logs to prevent skin l after this initial break-in period will be slight and will disappear irritation.Logs are fragile-Handle with care. with continued use. Qualified Installing Agency This appliance must not be used with glass doors in the closed Installation and replacement of gas piping,gas utilization equip- ' ( position.This can lead to pilot outages and severe sooting outside ment or accessories and repairand servicing of equipment shall be the fireplace. performedonly byaqualified agency.The term"qualified agency" Fmeans any individual,firm,corporation,or company that either in Do not use this room heater if any part has been under water. Immediately call a qualified service technician to inspect the room person orthrough a representative is engaged in and is responsible heater and replace any part of the control system and any gas for(a)the installation testing,or replacement of gas piping or(b) control which has been under water the connection,installation,testing,repair,or servicing of equip- ment; that is experienced in such work; that is familiar with all WARMING: This appliance is equipped for (natural or precautions required,and that has complied with all the require- propane)gas.Field conversion is not permitted. menu of the authority having jurisdiction. i Before you get started State of Massachusetts:The installation must be made by a ! Carefully inspect the contents for shipping damage. If any parts licensed plumber or gas fitter in the Commonwealth of ! are missing or damaged, immediately inform the dealer from Massachusetts. whom you purchased the appliance.Do not attempt to install any part of the appliance unless you have all parts in good condition The installation must conform with local codes or,in the absence of local codes,with the National Fuel Gas Code,ANSI7223.1.* *Available from the American National Standards Institute,Inc.11 West 42nd St.,New York,N.Y.10018. ':. High Altitudes:For altitudes/elevation above 2,000 feet ratings should be reduced at the rate of 4 percent for each 1,000 feet above sea level.Contact the manufacturer. I WATER VAPOR: A BY-PIRODUCT OF UNVENTED ROOM ]HEATERS Water vapor is a by-product of gas combustion. An unvented The following steps will help insure that water vapor does not room heater produces approximately one (1) ounce (30ml) of become a problem. water for every 1,000 BTU's(.3KW's)of gas input per hour. 1. Be sure the heater is sized properly for the application,includ- Unvented room heaters must be used as supplemental heat (a ing ample combustion air and circulation air. room)rather than a primary heat source(an entire house).In most 2. If high humidity is experienced,a dehumidifier may be used to supplemental heat applications,the water vapor does not create a help lower the water vapor content of the air. problem.In most applications,the water vapor enhances the low 3. Do not use an unvented room heater as the primary heat source f humidity atmosphere experienced during cold weather. (an entire house). !! Paoe 6 i coo Henn I PROVISIONS FOR ADEQUATE COMBUSTION & VENTILATION AIR I ' This heater shall not be installed in a confined space unless provisions DIVIDER are provided for adequate combustion and ventilation air. The National Fuel Gas Code defines a confined space as a space whose FIREPLACE volume is less than 50 cubic feet per 1,000 Btu per hour(4.8m3 per kw) of the aggregate input rating of all appliances installed in that space and an unconfined space as a space whose volume is not less than 50 cubic i i feet per 1,000 Btu per hour(4.8 m3 per kw)of the aggregate input rating of all appliances installed in that space.Rooms communicating directly / with the space in which the appliances are installed,through openings not furnished with doors,are considered a part of the unconfined space. Unusually Tight Construction hi L 2 The air that leaks around doors and windows may provide enough fresh air for combustion and ventilation.However,in buildings of unusually tight construction,you must provide additional fresh air. W- Unusually tight construction is defined as construction where: a. Walls and ceilings exposed to the outside atmosphere have a continuous water vapor retarder with a rating of one perm or less Example of Large Room with 112 Wall divider. with openings gasketed or sealed,and Figure 1 b. Weatherstripping has been added on openable windows and doors,and The following formula can be used to determine the maximum heate i c. Caulking or sealants are applied to areas such as joints around rating per the definition of unconfined space: window and door frames, between sole plates and floors, be- B�Hr_(L,+L,FT x(MFT x(1)FT z 1000 I [ween wall-ceiling joints,between wall panels,at penetrations i for plumbing,electrical,and gas Iines,and at other openings. 50 fi If your home meets all of the three criteria above,you must provide If the area in which the heater may be operated is smaller than that define additional fresh air. as an unconfined space,provide adequate combustion and ventilatio. i air by one of the methods described in the National Fuel Gas Code Warning:If the area in which the heater may be operated is smaller than ANSI 2223.1,Section 53. that defined as an unconfined space or if the building is of unusually tight Adhere to all codes, or in their absence, the latest edition of TE construction,provide adequate combustion and ventilation air by one of - �c I I NATIONAL FUEL GAS CODEANSI ZZZ.i.l or NFPA�4w which canb the methods described in the National Fuel Gas Code, ANSI 2223.1, obtained from: I Section 5.3.ora applicable local codes. pp American National Standards Insritutc National Fire ProtecdonAssociaaon,Inc 11 West 42nd St Banaymarch Park New YorK NY 10018 Quincy,MA 02269 CLEARAMCES i4 1 Minimum Dimensions For Solid Fuel Burning Fireplaces Glass Doors IUL127 Factory Built Fireplaces(Figure 2) Make sure that glass doors are open during all operations of the loaset.The opening of the glass door frame should be the M Model A B C D dimension used forthe minimum front openina of the firebox_ j VFSV-16 18" 11 1/2" 24" 18" Follow these instructions to ensure safe i VFSR-16 18" 11 1/2" 24" 18" installation. VFSV-18 17" 14" 28" 17" SA VFSR-18 17" 14" 28" 17" Failure to follow \ VFSM-18 21" 14" 32" 17" tl instructions exacy VFSV-24 23" 14" 30" 18" can create a fire D / VFSR-24 23" 14" 30" 18" hazard. " I ! VFSM-24 27" 14" 34" 18 VFSV-30 26" 14" 34" 20" VFSR-30 26" 14" 34" 20" ( i VFSM-30 30" 14" 38" 20" The dimensions shown and defined in the fireplace manufacturer's instructions are minimum clearances to maintain in installing this heater.Len and richt clearances are determined when facing the front of the heater. Figure 2 �( 159942-0504 Pa aP, CLEARANCES (continued) Sidewall & Ceiling Clearances (Figure 3) Non-Combustible Requirements for Material Distance Safe Installation 12"or more Non-combustible material- Less than 12" Non-combustible material must be extended 18",24",30"Log 41 to at least 8" with the installation of the 16"Log 36" optional fireplace hood.If you cannot extend non-combustible material at least 8", you must operate heater with flue damper open. Mantel Clearances with Hood(Figure s) You must have non-combustible materials above the fireplace opening. Non-combustible material must extend at least 8"above fireplace opening. With sheet metal,you must have non-combusdble material behind it. Heat resistant materials such as slate and marble must be at least 1/2" thick.Sheet metal should not be installed onto combustible material. Figure 3 Example:A mantel may project from the wall a maximum of 2" at a The sides of the fireplace opening must be 6" from any combustible minimum of 13-1/2"above the opening,and a maximum of 6"at a mini- wall.The ceiling must be at least 36"(for the 16"log)and 41" (for 18" mum of 15'above the opening., 24"and 30"logs)from the fireplace opening. 8" Mantel 6" Mantel H Mantel Clearances Without Hood (Figure 4) 4" Mantel You must have non-combustible materials above the fireplace opening. HEAT RESISTANT 2" Mantel Non-combustible material must extend at least 12" above fireplace opening. With sheet metal, you must have non-combustible material MATERIAL---,,, behind it. 8"WITH HOOD 14.25" 16.0" Heat resistant materials such as slate and marble must be at least 1/2 13.5" 1 15.0" thick Sheet Sheet metal should not be installed onto combustible material. iI 10" and less Mantel HOOD HEATER IN FIREPLACE HEAT RESISTANT OR FIREBOX MATERIAL 12"WITHOUT 28" HOOD Figure 5 12" If your installation does not meet the above minimum clearances,you must proceed to one of the following steps: - Operate the heater with the flue damper open. See page l0for Installing as a Vented Appliance. - Raise the mantel to the proper height. HEATER IN FIREPLACE - Remove the mantel. OR FIREBOX Floor Clearance (Figure 6) If installing heater at floor level,the minimum distance to combustibles is"0"inches. Ali ill Figure 4 HEATER IN FIREPLACE If your installation does not meet the above clearances,you must pro- OR FIREBOX ceed to one of the following steps: Use a hood COMBUSTIBLE Operate the heater with flue damper open.See page 10 for Installing MATERIAL as a Vented Appliance. Raise the mantel to the proper height. 5i . ......... Remove the mantel. Figure 6 I�)QQ4__?_n ()A Page 8 f COMBUSTIBLE MATERIAL i i. Do not attach combustible material to the mantel of your fireplace.This No greeting card, stockings or ornamentation of any type should be is a fire hazard, placed on or attached to the fireplace.This is a heating appliance.The flow of heat can ignite combustibles. :i 1, HEAT ! FLOW 1 is HEAT FLOW i' CD �h i 1�I� i Il Figure S ti Figure 7 REPLACE • Turn off gas supply to fireplace or firebox- FOR MASONRY BUILT FIREPLACES • Have the fireplace floor and chimney professionally cleaned to remove FREE OPENING AREA OF CHIMNEY DAMPER FOR VENT !t ashes,soot,creosote or other obstructions. ING COMBUSTION PRODUCTS FROM DECORATIVI Have this cleaning performed annually after installation. APPPLIANCES FOR INSTALLATION-IN SOLID FUEL BURN • Seal any fresh air vents or ash clean-out doors located on floor or ING FIREPLACES wall of fireplace.If not,drafting may cause pilot Appliance Input Rate(BTU/hr) outage or sooting-Use a heat-resistant sealant-Do not seal chimney j flue damper. 20 30 40 f Install and operate thea appliance as directed in this manual. Chimney j p pp Height* Minimum Opening**(sq.in.) FOR FACTORY BUILT FIREPLACES (ft) FREE OPENING AREA OF CHIMNEY DAMPER FOR VENT- 6 17.6 25.7 33-8 ING COMBUSTION PRODUCTS FROM DECORATIVE AP- 16.5 23.7 31.2 f j PLIANCES FOR INSTALLATION IN SOLID FUEL BURNING 10 15.1 21.7 28.7 FIREPLACES 15 14.1 19.9 26.1 Appliance Input Rate(BTU/hr) 20 12.9 18.5 21.7 it 3 122 16.9 21.6 I20 1 30 40 - * Height is from hearth to top of chimney and the minimum height i Chimney 6 feet. F Height* Minimum Opening**(sq.in.) ** Chan shows minimum opening(sq.in.)for given height and inpu f (ft) rate. 10 11.3 16.6 22.1 !I 15 8.6 12.6 17.3 20 7.5 10.8 14.5 25 6.6 9.6 12.6 30 6.2 9.1 11.3 35 5.7 8.0 10.8 40 5.3 1 7.5 1 10.2 j * Height is from hearth to top of chimney and the minimum height is 10 feet. j ** Chart shows minimum opening(sq.in.)for given height and input rate. Page 159942-0504 INSTALLING AS A VENTED APPLIANCE it Notice (Damper Clamp Installation) When installing your log set as a vent-free installation the damper When installing your log set as a vented installation thedamper clamp can be used to eliminate the potential for odors when bum- clamp must be used. in-the logs for the first time. Installing Damper Climp(Figure 9) Remove all ashes or other debris from the fireplace.If the fireplace is equipped with an ash dump be sure to seal the door with furnace cement or high temperature silicone.Be sure to check the damper for proper operation and verify that the flue passageway is open. Place the clamp over the lip of the damper and tighten the hold DAMPER CLAMP down bolt until the clamp is securely attached to the damper.This will prevent the damper from accidentally closing D AMMP Manual and millivolt controlled gas logs may be installed as a P vented decorative log set in compliance with ANSI 21.60 and National Fuel Gas Code.When the gas logs,are operated with the damper open,non-combustible material and minimum mantel re- quirements do not apply. State of Massachusetts requirement for installation of vented decorative appliance in a vented fireplace is the following: 0 TYPICAL. FIREPLACE In the Commonwealth of Massachusetts vent free products are not approved. A vented decorative gas appliance must be installed in a vented fireplace only in the state of Massachusetts.The vent damper Figure 9 must be removed or welded permanently open. BEFORE FULLY INST,ALLING THE APPLIANCE Turn off the-as supply to the fireplace or firebox. Assembly Procedure: (Figure 10) Seal any fresh air vents and/or ash clean-out doors located on 1.Center the gas log unit in the fireplace or firebox.Make certain the floor or wall of the fireplace.If left unsealed,drafting may the front feet of the grate sit inside the front edge of'the cause pilot outage or sooting.Use a heat resistant sealant.Do fireplace or firebox. not seal the chimney flue damper. 2.An anchor hole is provided in the two bottom side members of the rate frame.After centering the grate correctly, mark the Before instaIlinc in a solid fuel burning fireplace, the chimneye ga hole positions on the fireplace/firebox floor. Drill two (2) 51 flue and firebox must be cleaned of soot,creosote,ashes and loose paint by a qualified chimney cleaner. 32" diameter holes approximately 1-1/2" deep for masonry You must secure the gas log heater to the fireplace floor. screws or 1/8" hole for sheet metal screws. If not, the entire unit may move when you adjust the 3.Anchor the-rate to the fireplace/firebox floor using the screws controls.Movement of unit may cause shifting of the gas provided.Refer to FigurelO. logs which leads to sooting and improper burning.Grate Proper installation of the grate is essential to prevent any movement could cause a-as leak. movement of the gas logs and controls during operation. Special care is required if you are installing the unit into a sunken fireplace.You must raise the fireplace floor to ANCHOR SCREWS allow access to gas log controls.This will insure adequate air flow and guard against sooting. Raise the fireplace floor using noncombustible materials. Figure 10 itPage 10 15994-2-0504 i GAS SUPPLY jj Check all local codes for requirements,especially for the size and FLEXIBLE GAS LINE CONNECTION type of gas supply line required. Gas SUPPLY 3/8 NPT rTEE HANDLE NIPPLE t, Recommended Gas Pipe Diameter FLEX TUBING Pipe Length Schedule 40 Pipe Tubing,Type L �i (Feet) Inside;Diameter Outside Diameter G Nat I L.P. Nat L.P. 0-101/2° 3/8° 1/2" 3/8" FLARE SHUT OFF VALVE FLARE FITTING 1.3 cm 1.0 cm 1.3 cm 1.0 cm 10-40 1/2" 1/2" 5/8" 1/2" 41 1.3 cm 1.3 cm 1.6 cm. 13 cm RIGID GAS LINE CONNEC11ON "" 40-100 1/2 1/2 3/4" 1/2" CLOSE NIPPLE 3/8 NPT NIPPLE j' 1.3 cm 1.3 cm 1.9 cm 1.3 cm TEE IDLE 100-150 3/4" 1/2" 7/8" 3/4" I' 1.9 cm 1.3 cm 2.2 cm 1.9 cm - �( Note:Never use plastic pipe.Checktoconfirm whetheryourlocal SHUT OFF VALVE i; codes allow copper tubing or galvanized. Note:Since some municipalities have additional local codes,it is NPT GAS SUPPLY NPT UNION JG always best to consult your local authority and installation code. It Installing a New Main Gas Cock Figure 11 ns Each appliance should have its own manual gas cock The use of the following gas connectors is recommended — ANS 221.24 Appliance Connectors of Corrugated Metal In the state of Massachusetts the gas cock must be a T handle Tubing and Fittings type. — ANS 221.45 Assembled Flexible Appliance Connectors of A manual main gas cock should be located in the vicinity of the Other Than All-Metal Construction unit Where none exists, or where its size or location is not The above connectors may be used if acceptable by the authority adequate, contact your local authorized installer for installa- having jurisdiction The state of Massachusetts requires that a tion or relocation. flexible appliance connector cannot exceed three feet in length. Compounds used on threaded joints of gas piping shall be Pressure Testing of the Gas Supply System resistant to the action of Iiquefied petroleum gases. The gas 1. To check the inlet pressure to the gas valve,a 1/8"(3.175mm) lines must be checked for leaks by the installer.This should be N.P.T.plugged tapping,accessible for test gauge connection, done with a soap solution watching for bubbles on all exposed must be placed immediately upstream of the gas supply connections,and if unexposed,a pressure test should be made. connection to the appliance. Never use an exposed flame to check for leaks. Appliance 2. The appliance and its individual shutoff valve must be must be disconnected from piping at inlet of control valve disconnected from the gas supply piping system during any and pipe capped or plugged for pressure test.Never pres- pressure testing of that system at test pressures in excess of l/ sure test with appliance connected; control valve will sus- 2 psig(3.5 kPa). tain damage! 3. The appliance must be isolated from the gas supply piping iA gas valve and;round joint union should be installed in the system by closing its individual manual shutoff valve during gas line upstream of the gas control to aid in servicing. It is any pressure testing of the gas supply piping system at test I� required by the National Fuel Gas Code that a drip line be pressures equal to or less than 1/2 psig(3.5 kPa). I` installed near the gas inlet_ This should consist of a vertical Attention!If one of the procedures results in pressures in excess length of pipe tee connected into the gas line that is capped on of 1/2 psig(14"w.c.)(3.5 kPa)on the appliance gas valve,it will the bottom in which condensation and foreign particles may result in a hazardous condition. collect. rt i i I II is 159942-0504 CK PLACEMENT GLOWENG EMBERS LAVA O l� Placement of the glowing embers (rock wool)is very individual Placing Lava Rock in Front of Burner on Fireplace Floor and light coverage will provide your best effects.We recommend Spread lava rocks on fireplace floor in front of the burner pan. separation of the rock wool by hand and make your coverage as The lava rocks are for decorative effect and are not required for light and fluffy as possible. fireplace operation. I' Place just enough embers on the burner to obtain the glow and a ATTENTION: DO NOT PLACE LAVA ROCKS ON gold,yellow flame. BURNER,LOGS OR ROCK WOOL.THE LAVA ROCKS Do not place embers(rock wool)over large ports in rear portion SHOULD ONLY BE PLACED ON THE FIREPLACE ii of burner. FLOOR. Rock wool should not be placed in the area of the pilot assembly. Replacement of loose material (glowing embers) must be purchased from Empire Comfort Systems, Inc. Application of excess loose material (glowing embers) may adversely affect r performance of the heater. WARNING: All previously applied i loose material must be removed prior to reapplication. Refer to Parts List,Page 20 to order loose material(rock wool). S/FLAME APPEARANCE I fI I a. Flames from the pilot(rear right back side of the pan burner)as well as the main flame should be visually checked as the log set is installed. In normal operation at full rate after 10 to 15 minutes,the flame jappearance should be sets of yellow flames. f NOTE: all flames will be random by design,flame height will ' III go up and down. m ! i C Glowing embers(rock wool)can cover the pan burner in between Variable-Figure 13 the front and middle logs,but very little is necessary to cover this area Excess ember material causes the yellow flame to become ( I orange and stringy.Apply just enough to obtain slow glow and a i gold yellow flame. f Avoid any drafts that alter burner flame patterns. Do not allow fans to blow directly into fireplace.Do not place a blower inside f ' the burner area of the firebox.Ceiling fans may create drafts thatA;A alter flame patterns. Sooting and improper burning will result m During manufacturing, fabricating and shipping, various Millivolt-Figure 14 I components of this appliance are treated with certain oils,films I � or bonding agents. These chemicals are not harmful, but may 0 I : . produce annoying smoke and smells as they are burned off during i I the initial operation of the appliance,possibly causing headaches I temporary or eye or lung irritation. This is a normal and p y occurrence. The initial break-in operation should last 2-3 hours with the burner at the hi hest setting. Provide maximum ventilation by opening windows or doors to allow odors to dissipate.Any odors remaining m after this initial break-in will be slight and will disappear with Manual-Figure 15 continued use. { I G t Page 12 15994-2-0504 I VFSR4169 189 24� 30) LIGHTING INSTRUCTIONS FOR YOUR SAFETY READ BEFORE LIGHTE-;G, WARNING:If you do not follow these instructions exactly, a fire or explosion may result causing property damage, personal injury or loss of life. A. This appliance has a pilot which must be lighted by If you cannot reach your-as supplier,call the fire hand.When lighting the pilot,follow these instructions department. exactly. C. Use only your hand to push in or turn the gas control B. BEFORE LIGHTING smell all around the appliance knob.Never use tools.If the knob will not push in oz area for-as.Be sure to smell next to the floor because tam by hand, don't try to repair it; call a qualified some gas is heavier than air and will settle on the floor. service technician.Force or attempted repair ma} WHAT TO DO IF YOU SMELL GAS result in a fire or explosion. * Do not try to light any appliance. D. Do not use this appliance if any part has been undel - Do not touch any electrical switch; water.Immediately call a qualified service techni• do not use any phone in your building. clan to inspect the appliance and to replace any pari , Immediately call your gas supplier from a neigh- of the control system and any gas control which has bor's phone-Follow the gas supplier's instructions. been under water. LIGHTING INSTRUCTIONS Note: For easy access to valve for lighting pilot�remove branch C 8. Continue pushing the control knob in for a further 60 s loa and middle loc,from burner assembly before lighting. onds to prevent the flame detector from shutting off the! I. STOP! Read the safety information label. while the probe-is warming up.Release the control kno 9. Turn gas control knob counterclockwise,,�� to 2. Make sure the manual shutoff valve is fully open. 3. This gas log set is equipped with an ignition device(piezo) "ON"position. if which lights the pilot. If piezo ignitor does not light the 10. After the pilot has been lit for one minute,the burner can pilot,refer to Step 7. turned on. Turn the ON/OFF switch to "ON" position II 4. Turn gas control knob clockwise to the "OFF' adjust thermostat to desired setting position, set the thermostat to the lowest setting and turn 11. If the gas logs will not operate,follow the instructions ON/OFF switch to OFF position. Turn Off Gas To Appliance" and call your service tech 5. Wait ten(10) minutes to clear out any gas.Then smell for cian or gas supplier. gas,including near the floor. If you smell gas STOP! Fol- Wait 30 seconds before readjusting the heater when the coni low"B"in the safety information label.If you do not smell knob has been turned down to a lower settincr gas,go C, to the next step. 6. From OFF position,turn the-as control knob counterclock- 0 PIEZO wise to"Pilot"position.Push in and hold control IGNITOR knob for 5 seconds. THERMOPILE PILOT THERMOCOUPLE THERMOCOUPLE (NATURAL) CLPG) Q o 0 H I/LO ip REGULATOR 7. With the control knob pushed in,repeatedly push the piezo ignitor button until pilot is lit (or use a match to light CONTROL KNOB pilot). TO TURN OFF GAS TO APPLIANCE 1. Turn control knob clock-wise to OFF position to 2. If applicable:Turn ON/OFF switch to OFF position and completely shut off the heater. set thermostat (if present) to lowest setting. If applicat Turn off all electric power to the heater. 159942-0504 Pa-e 'I -VFSV-(169 185, 249 30) LIGHTING INSTRUCTIONS FOR YOUR SAFETY READ BEFORE LIGHTING fE WARNING: If you do not follow these instructions exactly, a fire or explosion may result p causing property damage, personal injury or loss of life. A. This appliance has a pilot which must be lighted by •If yon cannotreach your gas supplier,callthe fire hand.When lighting the pilot,follow these instructions department f exactly' C. Use only your hand to push in or turn the gas control B. BEFORE LIGHTING smell all around the appliance knob.Never use tools.If the knob will not push in or next to the floor because turn b hand,don't to repair it; call a qualified area for as.Be sure to smell d, n'3' P b y some gase is heavier than air and will settle on the floor. service technician.Force or attempted repair may � result in a fire or explosion. LL GAS res � WHAT TO DO IF YOU SME •Do not try to light any appliance. D. Do not use this appliance if any part has been under �I • Do not touch any electrical switch; water.Immediately call a qualified service techni- i do not use any phone in your building. cian to inspect the appliance and to replace any part I�I • Immediately call your gas supplier from a neigh- of the control system and any gas control which has bor's phone.Follow the gas supplier's instructions. been under water. i LIGHTING INSTRUCTIONS Note:For easyaccess to valve for lighting pilot,remove branch 7. Depress and tum gas control knob counterclockwise jf log and middle log from burner assembly before lighting. �— to "PILOT". A spark is produced when gas r control knob is turned between `IGN" and PILOT". 1. STOP! Read the safety information. Repeatedly depress and turn gas control knob between ', "IGN'and PILOT"until pilot is ignited-Continue to hold { 2. Push in Das control knob O the control knob in for about one(1)minute after pilot is sli-a1Ctly and turn ciocicwise lit. Release knob and it will pop back up. Pilot should "" to the OFF GAs flow ADJUSTMENT remain lit If it Does out,repeat steps 2 through 7. position Do not force. POSMON.B SHOWN IN.°� • If the knob does not pop out when released, stop and 3. Turn gas flow adjustment ! immediately call your service technician or gas supplier knob clockwise GAS CONTROL KNOB . If the pilot will not stay lit after several tries, turn the either manually or with POSMONroFF gas control knob to OFF and call your service remote control to"OFF'. technician. 4. Wait ten (10) minutes to { 8. Attention! Gas control has an INTERLOCK latching ! clear out any gas. Then smell for gas, including TH�+ocoupLE device.When the pilot is initially lit and the safety magnet ��GI p1LOT is energized (pilot stays on ) the INTERLOCK latching near the floor.If you smell TrtEwnocoUPLe gas control is turned to � gas STOP! Follow"B" in (NATTIRAL) device becomes operative.If the a a the "OFF" position or gas flow to the appliance is shut ii the safety information. If you do not smell Das,go to off,the pilot cannot be relighted until the safety magnet is I the next step. de-energized(approximately 60 seconds).There will be an audible"click"when he safety magnet in the gas control 5. Find pilot-the pilot is attached to rear of burner. is de-energized. Pilot can now be relighted. Repeat steps 6. Turn gas knob counterclockwise to"IGN". 2 through 7. 9. Turn Das control knob counterclockwise ,,� to i "ON". 10. Turn gas flow adjustment knob counterclockwise,,,� either manually or with remote control between "OFF" and"ON"to adjust flame height. TO TURN OFF GAS TO APPLIANCE a 1. Turn gas flow adjustment knob clockwise either 2. Push in gas control control knob slightly and tum clockwise jmanually or with remote control to"OFF". to"OFF'.Do not force. i Page 14 159942-0504 VFSM-(189 2,4119 30) 'LIGHTING INSTRUCTIONS FOR YOUR SAFETY READ BEFORE LIGHTING WARNING: If you do not follow these instructions exactly, a fire or explosion may result causing property damage,personal injury or loss of life. A. This appliance has a pilot which must be lighted by •Ifyou cannot reach your gas supplier,call the fire hand.When lighting the pilot,follow these instructions department exactly- C. Use only your hand to push in or tam the gas control B. BEFORE LIGHTING smell all around the appliance knob.Never use tools.If the knob will not push in or area for gas.Be sure to smell next to the floor because turn by hand,don't try to repair it; call a qualified Er Il r some gas is heavier than air and will settle on the floor. service technician.Force or attempted repair may WHAT TO DO IF YOU SMELL GAS result in a fire or explosion. , Do not try.to light any appliance. D. Do not use this appliance if any part has been under - Do not touch any electrical switch; water. Immediately call a qualified service techni- do not useany phone in your building. ciao to inspect the appliance and to replace any part - Immediately call your gas supplier from a neigh- of the control system and any-as control which has bor's phone-Follow the gas supplier's instructions. been under water. Mt LIGHTING INSTRUCTIONS 1. STOP! Read the safety information. 7. With the control knob pushed in,push and release the piez, t. 9. Make sure the manual shutoff valve is fully open. ignitor button to light the ODS pilot-The pilot is located a 3. This heater is equipped with an ignition device(piezo)which the right rear side of the heater,behind the middle log and i: automatically lights the pilot. front of the rear log..If piezo ignitor does not light L,Pilo, 4. Refer to Figure 15 for the location of the piezo ignitor and refer to"Match Lighting Instructions". control knob.Push in gas control knob slightly and turn PILOT jk control knob clockwise to the OFF position. THERMOCOUPLE THERMOCOUPLE NOTE:Knob cannot be turned to OFF unless knob is pushed (LPG) (NATURAL) in slightly.Do not force. 0 0 CONTROL KNOB INDICATOR OFF0 0 GAS CONTROL KNOB SHOWN IN "OFF' POSITON 5. Wait ten(10) minutes to clear out any gas.Then smell for 8. Hold the control knob in for an additional 10 seconds t ,as-including near the floor.If you smell gas STOP!Follow prevent the ODS pilot from shutting off the gas while th the instructions under 'What To Do If You Smell Gas". If thermocouple is warming up. you do not smelt gas, -0 to the next step. 9. Release the control knob. 6. From OFF position, push in gas control knob slightly and If the knob does not pop out when released, stop an t=counterclockwise,,-----to the PILOT position. Push immediately call your service technician or gas supplie in and hold control knob for 5 seconds. If the ODS pilot will not stay lit after several tries, pus NOTE. If you are riming the beater for the first time, it and turn the gas control knob clockwise to OF will be necessary to press in the control knob for 30 seconds and wait 15 seconds.Repeat steps 6 through 9. to allow air to bleed out of the gas piping 10. Push in control knob and turn to desired setting (1, 2, 3 The control knob must be set at either the low or hi- position,and the control knob will pop out when position correctly. Do not set the control knob at a position betwee pilot(1,2,3). TO TURN OFF GAS TO APPLIANCE 1. Turn control knob clock-wise to OFF position to completely shut off the heater. 15994-2-0504 TICS PILOT FLAMIE CHARACTERIS j. g Figures 16 and 19 show a correct pilot flame pattern.The correct 2. Blow air pressure through the holes indicated by the arrows. flame will be blue and will extend.beyond the thermocouple.The This will blow out foreign materials such as dust, lint and ii flame will surround the thermocouple just below the tip.A sli--ht spider webs.Tighten nut B also by grasping nut A. yellow flame may occur where the pilot flame and main burner flame meet. Figures 17 and 20 show an incorrect pilot flame pattern.The incorrectpilotflame isnot touching the thermocouple. This will cause the thermocoupte to cool.When the thermocouple IN cools,the heater will shut down. VFSR PILOT 8 A THERMOPILE PILOT Figure 18 iii li0 VFSV AND VFSM PILOT PILOT rid j �l THERMOCOUPLETHE E=Z- (LPG) (NATURAL) If Correct appearance of pilot fiame- Figure 16 0 II L THERMOPILE—\ PILOT THERMOCOUPLE THERMOCOUPLE (LPG) (NATURAL) Correct Pilot Flame Pattern 0 Figure 19 11 PILOT ill O jf THERMOCOUPLE THERMOCOUPLE (LPG) (NATURAL) Incorrect appearance of pilot flame. jfl Figure 17 If pilot flame pattern is incorrect,as shown in Figure 17 THERMOCOUPLE THERMOCOUPLE See Troubleshooting,page 19. (LPG) (NATURAL) Cleaning and Maintenance/Pilot Incorrect Pilot Flame Pattern Oxygen Depletion Sensor Pilot(Figure IS) M When the pilot has a large yellow tip flame, clean the Oxygen Figure 20 i Depletion Sensor as follows: If pilot flame pattern is incorrect,as shown in Figure 20 1. Clean the ODS pilot by loosening nut B from the pilot See Troubleshooting,page 19. tubing. When this procedure is required, -rasp nut A with an Open end wrench. 15994-2-0504 Page 16 J TDT I MCDT FLAME CHARACTERISTICS (continued) yi Cleaning and Maintenance/Pilot Warning: Oxygen Depletion Sensor Pilot(Figure 21) Never use needles,wires,or similar cylindrical objects When the pilot has a large yellow tip flame, clean the Oxygen to clean the pilot to avoid damaging the calibrated ruby Depletion Sensor as follows: that controls the gas flow. 1. Clean the ODS pilot by loosening nut B from the pilot tubing.When this procedure is required, -rasp nut A with an open end wrench. 22 Blow air pressure through the holes indicated by the arrows. This will blow out foreign materials such as dust, lint and spider webs.Tighten nut B also by grasping nut A. B A Ii Figure 21 III it CLEANING AND SER"CING Annual inspection and cleaning by your dealer or qualified ANNUAL CLEANING/INSPECTION — Refer to parts service technician is recommended to prevent malfunction diagram for location of items discussed below. and/or sooting. inspect and clean burner air intake hole. Remove lint or TURN OFF BEATER AND ALLOW TO COOL BEFORE particles with vacuum or brush.Failure to keep air intake hole clean will result in sooting and poor combustion- CLEANING. Remove logs, handling carefully by holding g gently at each end. inspect and clean all burner ports. 0 Gloves are recommended to prevent skin irritation from ceramic inspect ODS pilot for operation and accumulation of lint at fibers.If skin becomes irritated,wash gently with soap and water. air intake holes. g Refer to manual for correct log placement. Verify flame pattern and lo0 placement for proper operation. • Verify smooth and responsive ignition of main burner. PERIODIC CLEANING—Refer to parts diagram for location Check level of ceramic media in burner. Burner should be of items discussed below. full,up to the level of openings in burner top. 0 Do not use cleaning fluid to clean logs or any part of heater. . Logs - brush with soft bristle brush or vacuum with brush attachment . Remove loose particles and dust from the burner areas, controls, piezo covers and grate. Don't remove media from inside burner box. • Inspect and clean burner air intake hole. Remove lint or particles with brush. Failure to keep air intake hole clean will result in sooting and poor combustion. Pale Y 15994-2-0504 'i f k( It VFSR Wiring Diagram(Figure 22) Thermostats are not approved on vented decorative appliances. REMOTE CONTROL RECEIVER/ t THERMOSTAT/ CONTROLS E I Label all wires prior to disconnection when servicing controls. DISTANCE OU RECEPTEUR Wiring errors can cause improper and dangerous operation.Verify proper operation after servicing. Gas VALVE 16", 18", 24" and 30" Gas Logs (Millivolt) thermopile is self VALVE DE GAZ powered gas valve and does ndtTequire 110 volts.See Figure 22 to provide optional wall switch,thermostat, or remote control. Maximum length of 20 feet of 16 AWG to conductor wires is to (OPTIONAL) WALL SWITCH i be used with all optional switches. INTERRUPTEUR MURAL D P REMOTE/OFF/ON SWITCH (FACULTATIVE) I Use the two leads(black wires)from ON/OFF switch to attach A DISTANCE/OUYERT/FERMf INTERRUPTEUR (OPTIONAL) THERMOSTAT k. optional components- (FACULTATIVE) THERMOSTAT Check System Operation 4l� (OPTIONAL) REMOTE CONTROL RECEIVER Millivolt system and all individual components may be checked ((OPTIONAL) RE CONTROLS E D15TANCE `P; with a millivolt meter 0-1000 MV range. DU RECEPTEUR Remote Receiver-VFSR-(16, 18,24,30) Use the following steps to place the remote receiver adjacent to 1; OFF/ON SWITCH the gas valve, OUVERT/FERME INTERRUPTEUR Attention: k 1. The remote receiver can not be placed behind the gas valve OFF ' BLACK NOIR and burner assembly. THERMOCOUPLE ON BLACK NOIR 2- When facing the appliance,the remote receiver must be placed (LPG) THERMOPILE to the right of the gas valve and burner assembly. THERMOCOUPLE 6 (NATURAL) Note: Do not let remote control receiver come in contact with • e • f bum r assembly. .( µ On circulating vent-free firebox,install remote control receiver I� • behind bottom louver. IF ANY OF THE ORIGIONAL WIRE AS SUPPLIED WITH THIS UNIT MUST BE Refer to remote control installation and operating instructions for REPLACED. IT MUST BE REPLACED WITH NO. IB. 150'C WIRE OR ITS EOUIVALENT. more details on remote control. Figure 22 IB I 750 Millivolt System �. When you ignite the pilot,the thermocouple produces millivolts electrical current which energizes the maanet in the gas valve. VFSV Whin D' e 23 j ( ) a .. o g 18aR'am(F1gIII' ) I After 30 seconds to i minute time period you can release the-as i� P y a control knob and the pilot will stay ON.Allow your pilot flame to operate an additional one(1)to two(2)minutes before you tutu the gas control knob from the PILOT position to the ON position. I �N1OIX D°- ' This time period allows the millivolts (electrical current) to f GPAM buildup to a sufficient level allowing the gas control to operate f properly. C e. Millivolt Control BLACKlRED-3/16'iHtMIN4L f The valve regulator control's the burner pressure which should BLACK-1XIERMNAL be checked at the pressure test point-Turn captured screw counter clockwise 2 or 3 turns and then place tubing to pressure gauge �a LL I over test point(Use test point"A"closest to control knob).After / o fE taking pressure reading, be sure and turn captured screw s ss Clockwise firmly to re-seal. Do not over torque. Check for gas ( : leaks. Figure 23 I( VFSR VFSV Note: (Wiring harness located in envelope) Note- (Wiring harness located in envelope) Connect the 2- 1/4"terminals onto the TH and TH/TP terminals Connect black/red 3/16" terminal wire from receiver to 3/16' on valve.Place decorative log or switch bracket(switch bracket terminal on valve. Connect black 1/4" terminal wire from g right is used with Flame Art log sets) to riof the as valve and Ij o b C receiver to 1/4" terminal on valve. Install remote receiver cover i burner assembly.When connecting to remote receiver,cut off 1/ over receiver when receiver is installed into fireplace area- 4" rea4" terminals from wires attached to ON/OFF switch.Strip wires Locate receiver and cover to the richt and forward of valve. (Do back about 1/4". Connect stripped ends into remote receiver. not put receiver behind logs) it Page 18 15994-2-0504 TROUBLESHOOTING SYMPTOMS- POSSIBLE CAUSES AND CORRECTION Turn appliance OFF and allow to cool before servicing.Only a qualified service person should service and repair the heater. 1. When ignitor button is pressed, there is no spark at b. Control knob not pressed in Ion-enough-After ODS/ ODS/piloL pilot lights,keep control knob pressed in 30 seconds. a. Ignitor electrode positioned wrong- Replace pilot. c. Manual Shutoff valve not fully open - Fully open b. Ignitor electrode is broken- Replace pilot. manual shutoff valve. c. Ianitor electrode not connected to ignitor cable d. Thermocouple connection loose at control valve - Reconnect ignitor cable. Hand tighten until snug, then tighten 1/4 turn more. d. Ignitor cable pinched or wet.Keep ignitor cable dry- e. Pilot flame not touching thermocouple, which allows Free ignitor cable if pinched by any metal or tubing. thermocouple to cool, causing pilot flame to go out- e. Broken ignitor cable -Replace ignitor cable. This problem could be caused by either low-as pressure O f. Bad piezo ignitor-Replace piezo ignitor. or dirty or partially clogged ODS/pilot-Contact local -jC, 1. Appliance produces unwanted odors. gas company. a. Appliance burning vapors from paint,hair spray,glues, f. Thermocouple damaged Replace thermocouple. etc.-Ventilate room.Stop using odor causing products h. Control valve damaged-Replace control valve. while heater is running. 8. Burner does not light after ODS/pilot is lit. b. Gas leak-Locate and correct all leaks. a. Burner orifice clogged-Clean burner or replace main ai 3. Appliance shuts off during use.(Pilot and main burner burner orifice. are off.) b. Burner orifice diameter is too small - Replace burner a. Not enough fresh air is available for ODS/pilot to orifice. 1 i` operate'- Open window and/or door for ventilation. c. Inlet gas pressure is too low-Contact qualified service b. Low linepressure- Contact local gas company. person. c. ODS/pilot is partially clogged- Clean ODS/pilot. 9. If burning at main burner orifice occurs(a load,roaring d. Defective thermocouple-Replace pilot blow torch noise). 4. Appliance shuts off during use. (Pilot stays on.) a- You must num off bumer assembly and contact 2 I a. Low line pressure- Check line pressure to the valve. qualified service person. b. Defective thermopile- Check pilot flame,check wire b. Manifold pressure is too low - Contact local -w connections, output should be a minimum of 325 company. millivolts across. THITP and TP terminals with ON/ c. Burner orifice clogged-Clean burner or replace burner OFF switch off. orifice. S. Gas odor even when control knob is in OFT position. 10. Logs appear to smoke after initial operation. a- Gas leak- Locate and correct all leaks. a. Vapors from paint or curing process of logs-Problen b. Control valve defective- Replace control valve. will stop after a few hours of operation.Run the heate: 6. When ignitor button is pressed,there is spark at ODS/ with the damper open if you have one, or open pilot, but no ignition. window for the first few hours. a. Gas supply turned off or manual shutoff valve closed Loo heater is intended to be smokeless. Turn OF1 Turn on -as supply or open manual shutoff valve. heater and call qualified service person. b. Control knob not in PILOT position - Turn control 11. Heater produces a whistling noise when main burner i knob to PILOT position. lit. pressed in while in PILOT position- a. Turnin- c. Control knob not pr M control knob to HIGH position when mail Press in control knob while in PILOT position. burner is cold-Turn control knob to LOW position an( d. Air in -as lines when installed - Continue holdino, let warm up for a minute. 0 C - control knob.Repeat igniting operation until air b. Air in as line - Operate burner until air is removesdown 0 is removed. from line.Have gas line checked by local gas company Cr c. Dirty or partially clogged burner orifice-Clean burne e. ODS/pilot is clogged-Replace ODS/pilot assembly or M� get it serviced. or replace burner orifice. ace gas 12. No gas to pilot.Gas regulator setting is not correct - Replace a. LP-regulator shut down due to inlet pressure too hig regulator. 7. ODS/pilot lights but flame goes out when control knob -.Verify LP tank regulator is installed and set at 11 is released. 13" w.c. Replace regulator on heater. a. Control knob not fully pressed in - Press in control 13. New Installation. knob fully. a. On VFSV Model variable does not operate-On is OFF OFFis ON-wires into the back of receiver are reversec If the gas quality is bad,your pilot may not stay lit,the burners may produce soot and the heater may back-fire when lit.If the gas quality o pressure is low,contact your local gas supplier immediately. 159942-0504 Page 1 xt 5 Attention:When ordering parts,it is very important that part number and description of part coincide. Index Part Index Part No. Number Description No. Number Description COMMON PARTS NS 14041 TUBING-PILOT REGULATOR TO 1 15425 REAR LOG SUPPORT(16) PILOT-NAT NS 11291 TUBING-VALVE TO BURNER 1 15426 REAR LOG SUPPORT(18) NS R-5668 IGNITOR WIRE 1 15427 REAR LOG SUPPORT(24) NS R-5910 SWITCH LOG ASSEMBLY 1 15428 REAR LOG SUPPORT(30) (INCLUDES SWITCH AND WIRE) 2 11285 BURNER SUPPORT-LEFT(16) NS R-5757 OFF/ON SWITCH i 2 11376 BURNER SUPPORT-LEFT NS R-5699 WIRE HARNESS I !f (18,24,30) ( 3 P-200 ORIFICE FITTING VARIABLE SYSTEM �i 4 P-204 ORIFICE-LP (VFSR-16 VFSV-16) 6 R-5170 PILOT LP 4 P-256 ORIFICE-NAT(VFSR-16 VFSV- 6 R-5171 PILOT NAT it 16) 8 R-7063 PILOT REGULATOR(NAT ONLY) { i 4 P-250 ORIFICE-LP(VFSR-18 VFSV-18 VFSM-18) 10 11333 BURNER SUPPORT-RIGHT(16) 4 P-203 ORIFICE-NAT(VFSM-18) 10 11308 BURNER SUPPORT-RIGHT E 4 P-243 ORIFICE-NAT(VFSR-18 VFSV (18,24,30) 18) 12 R-5672 GAS VALVE NATURAL 4 P-245 ORIFICE-LP(VFSR-24 VFSV 24 12 R5673 GAS VALVE LPG VFSM-24) NS 11335 TUBING-VALVE TO PILOT-LPG ! 4 P-244 ORIFICE-NAT(VFSR-24 VFSV-24 NS 14040 TUBING-VALVE TO PILOT VFSM-24) REGULATOR-NAT 4 P-265 ORIFICE-LP(VFSR-30 VFSV 30 NS 14041 TUBING-PILOT REGULATOR TO VFSM-30) PILOT-NAT 4 P-209 ORIFICE-NAT(VFSM-30) NS 11291 TUBING-VALVE TO BURNER 4 P-211 ORIFICE-NAT(VFSR-30 VFSV- NS R-5797 REMOTE KIT ; ( 30) 5 R-5676 AIR SHUTTER-NAT MANUAL SYSTEM 5 R-5675 AIR SHUTTER-LP6 R i -5'170 PILOT LP 7 11833 PILOT SHIELD (NAT ONLY) 6 R-5171 PILOT NAT 9 12347 BURNER ASSEMBLY(16) NAT 10 11481 BURNER SUPPORT-RIGHT 9 12348 BURNER ASSEMBLY(16)LPG 13 15414 REGULATOR MOUNTING 9 14033 BURNER ASSEMBLY(18) BRACKET 9 14035 BURNER ASSEMBLY(24) 14 R-2480 INLET REGULATOR-LP 9 14037 BURNER ASSEMBLY(30) 14 R-2479 INLET REGULATOR-NAT NS 12389 CERAMIC MEDIA 15 R-2313 PIEZO IGNITOR NS 15998 ROCK WOOL(16) 16 R-2783 CONTROL KNOB i NS 15999 ROCK WOOL(18) 17 15416 VALVE BRACKET �f NS 15970 ROCK WOOL(24,30) 18 R-4499 GAS VALVE-LP I NS 11788 DECORATIVE ROCK(2 REQ'D) 18 R-4495 GAS VALVE-NAT NS R-2809 DAMPER CLAMP (INCLUDED IN 19 15494 COVER PLATE I HARDWARE PACKAGE) NS R-5668 IGNITOR WIRE NS 15528 TUBING ASSEMBLY-INLET REGULATOR TO VALVE MILLIVOLT SYSTEM NS 15529 TUBING-VALVE TO BURNER �) 6 R-3624 PILOT NAT NS 15530 TUBING-VALVE TO PILOT-LPG I 6 R-3623 PILOT LP NS 15531 TUBING-VALVE TO PILOT ` 8 R-7063 PILOT REGULATOR(NAT ONLY) REGULATOR-NAT 10 11286 BURNER SUPPORT-RIGHT(16) NS 15532 TUBING-PILOT REGULATOR TO 10 11375 BURNER SUPPORT-RIGHT PILOT-NAT i (1:8,24,30) 11 R-4323 GAS VALVE NATURAL 11 R-4324 GAS VALVE LPG 1 NS 11292 TUBING-VALVE TO PILOT-LPG I NS 14039 TUBING-VALVE TO PILOT 1 f REGULATOR-NAT a� t USE ONLY MA_NUFACTURER'S REPLACEMENT PARTS.USE OF ANY OTHER PARTS COULD CAUSE INJURY OR DEATH. Page 20 15994-2-0504 I� _i Y 19 "VFSM"MODELS I 18 k / 17 i I� j 1 ; 14 � ' \13 15 16 I "VFSV"MODELS 12 6 8 Z / 1 D "VFSR"MODELS 7 K r 9 ;aI HOW TO ORDER REPAIR PARTS I Parts can be ordered only through;your service person or dealer.For best results,the service person or dealer should order parts through the distributor. Parrs can be shipped directly to the service person/dealer. All parts listed in the Parts List have a Parc Number.When ordering parts,first obtain the Model Number from the name plate on your equipment Then determine the Parc Number(not the Index Number)and the Description of each part from the following appropriate it lustration and list Be sure to give (l all this information... Applaince Model Number Pan Description 4! Appliance Serial Number Part Number jType of Gas(Propane or Natural) 1 Do not order bolts,screws,washers or nuts.They are standard hardware items and can be purchased at any local hardware store. Shipments contingent upon strikes,fires and all causes beyond our control. Empire Comfort Systems,Inc.Nine Eighteen Freeburg Ave.Belleville,IIlinois 62222-0529 I 159942-0504 Page 21 { 121 OLD CART WAY 210/107.6-0101-0000.0 WAY I I APPLICANT: GAUTHIER i l� v � �W n z z�ICE o zw E �2 on 1 50 ',A.-)\ U 4VQ. Blue Medicare PFFS t (Blue Cross Blue Shield of MA) Fallon Senior Plan (Fallon Community Health Plan) First Seniority Freedom (Harvard Pilgrim Health Care) Senior Whole Health Tufts Health Plan Medicare Prefe (Tufts Health Plan) Medicare Card Number # I give per my insut (Signature Berson to re ive vaccin X S,a r- : For Clinic z e ase: Vaccine na Injection sit z _ Date JVaccine m fturer. �C Name and t leaf vaccine ad inistrator: _ Clinic/office address: Influenza Forms-MAHP/Masspro Plan Relmburser i • 1 2- a1 ,,��/ MAR #_ -- --- LOT #__..._._...........6m0................_. - -- -_----_— BARGEE # 'G-7 STREET......... .......... CONSTRUCTION APPROVAL S PLAN REVIEW FEE BEEN PAID? YES NO PLAN APPROVAL: DATE-12�' APP. BY..,.., _,__.. ..LG DESIGNER: PLAN DATE. CONDITIONS 1) toc9rra�/ OF iw_ ---2 _c r...._ �Ev_o ....... a.2A�V WATER SUPPLY: OWN WELL WELL PERMIT,---- --- -- DRILLER.._..........._......... ............ WELL TESTS: CHEMICAL ;DA I E APPROVED ....... ..____._...... BACTERIA I DALE APPROVED BACTERIA II DAZE APPROVED ....._..............---_._...._ COMMENTS: FOAM U ARPROVAL: APPROVAL TO ISSUE-:. YES ' U DATE ISSUED- CONDITIONS: DQ/) o. .C.._ �............ FINAL APPROVAL: ALL PERMITS PAID YES NO WELL CONSTRUCTION APPROVAL YES NO SEPTIC SYSTEM CONSTRUCTION APPROVAL YES NO OTHER YES NO ANY VARIANCE NEEDED YES NO FINAL BOARD OF HEALTH APPROVAL: DATE: BY: SEPTIC_ S_Y_STEM_—INSTRL.LA.T.�_QN IS THE INSTALLER LICENSED? YES NO r; TYPE OF CONSTRUCTION: NL`W REPAIR, ;�'; ;;'�•;': ? +. NEW CONSTRUCTION: CERTIFIED PLOT PLAN REVIEW Yk.S NO CONDITIONS OF APPROVAL YES NO ��,� ) '! '•�, ,'• (FROM FORM U) ISSUANCE OF DWC PERMIT YES NO DWC PERMIT NO. INSTALLER: BEGIN INSPECTION 0: ' EXCAVATION . INSPECTION: NEEDED: � �` Citi, ' �!;:y,,N� •_ ---�._.._.__ _-- PASSED BY- CON STRUCTION Y-CONSTRUCTION INSPECT ION s NEEDED: _...____._.__.__._.._....__—__..._....___. ''a'r't''•'.r•''•'.rs,'-,t�ua, ---.._"---------------._—.—_— AS BUILT PLAN SATISFACTORY: APPROVAL TO BACKFILL: DATE: _— B Y FINAL . GRADING APPROVAL: DATE z, 7 DATE: FINAL CONSTRUCTION APPROVAL. (ARD of H 'Ii-� nor Z dLD C,of�Z' rvrOY . (� TEr{ SOPR-Y wrJ D t uEu- SS WTic sY STEXA PEsI6,Aj APRT OUw6 AurlyoK)ry DA-76� 7 -i7_ D1 SAPPRUVEp 14 TE R�ASoNS Dw� 5fprf C SY5TErv1 I j SQA(.1.4T,otil i�--X4V4TON )tiSPt�--6T 1OAj 94Q IA5S E] FQiL- t T100 FIFE FRot-\ Nom 1-0 TA Ll Pry SS �O R)L 4 PFRO\)EP U/3TC AP121z0vJti6 A j roto j�j-ry ADPITIpMAL (A15bc.j IONS ( hso DiSAPP);�ovF,p D,arC Ru4L APP )VAL DA�� DelleChiaie, Pamela From: DelleChiaie, Pamela Sent: Monday, May 02, 2011 1:12 PM To: 'mnichols@sfgus.com' Subject: I.R. -Septic File- 121 Old Cart Way Attachments: I.R. -Septic- 121 Old Cart Way-Septic As Built Plan; I.R. -Septic- 121 Old Cart Way- Scanned File Information Importance: High To: Mark W.Nichols 121 Old Cart Way North Andover,MA 01845 978.683.1823—Home 978.621-1401—Cell Dear Mr. Nichols, As we spoke about,here is a scanned copy of your Health Department septic file for your records. Vent Ri"ida, Pamela DelleChiaie Departmental Assistant I Community Development I Health Department Town of North Andover 1600 Osgood Street I Bldg 20 1 Suite 2-36 North Andover,MA 01845 2 Office-978-688-9540 2 Fax-978-688-8476 D Email-pdellechiaieotownofnorthandover.com ''!� Website http://www.townofnorthandover.com/Pages/index "We can never see the path of our We if we are too busy focusing on the pebbles under our feet"--Anonymous ' 1 Town of North Andover, Massachusetts Form No.2 f MORTq BOARD OF HEALTH , F w p DESIGN APPROVAL FOR �s.1 CHUSEt� SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant CJV1 Sk-u-���n S� Test No. Site Location 101-14-7, -Wagon `whee- l Reference Plans and Specs. ► in 16 • ENGINEER DESIGN DATE Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. CHAIRMAN,BOARD OF HEALTH • OU Fee'i(oo• Site System Permit No. !� g NOW- Form No.4 Town of North Andover, Massachusetts BOARD OF HEALTH August 12 , 114}96 CERTIFICATE OF COMPLIANCE This is to certify that the Individual Soil Absorption Sewage Disposal System constructed (X ) or repaired ( ) by Roger Richard INSTALLER at Lot 2A Old Cart Way, North Andover, MA 01845 SITE LOCATION has been installed in accordance with Board of Health'Regulations as described in the Design Approval Site System Permit No. 481 datedSeptember 6 , 19 91 The issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. ARD OF HEAL Town of North Andover Massachusetts Form No.a BOARD OF HEALTH %ORTH t 1 O t .ao;aa tiO p � 3rsM. •. a OL iC1 19q46 o � DISPOSAL WORKS CONSTRUCTION PERMIT ,SSACMUSEt f-" ApplicantOGE,e /C%�j �� NAME ADDRESS TELEPHONE Site Location Lf1% 1---�19 t Permission is hereby granted to Construct (• or Repair ( ) an Individual Soil Absorption r:• Sewage Disposal System as shown on the Design Approval S.S. No. AV I RNIAN,BOARD OF HEALTH Fee D.W.C. No. a PLAN REVIEW CHECKLIST ADDRESS-,,/- 066 Ci91?T GIJA)l ENGINEER s GENERAL 3 COPIES `� STAMP �1 LOCUS NORTH ARROW L- SCALEI'- CONTOURS �� PROFILE ✓ SECTION BENCHMARK11'�� SOIL & PERC INFO ELEVATIONS WETS. DISCLAIMER L WELLS & WETLANDS WATERSHED? Ah DRIVEWAY Ll�(Elev) WATER LINE c% FDN DRAIN1, SCH40 �' TESTS CURRENT? / Z SEPTIC TANK MIN 1500G. . 17 INVERT DROP `� GARB. GRINDER AC +200% EDF _/ ( ) 25' TO CELLAR L/' MANHOLE TO GRADE ELEV GW D-BOX SIZE B -3 # LINES FIRST 2' LEVEL STATEMENT INLET /� - OUTLETS _ (2" OR . 17 FT) TEE REQ'D? Aln LEACHING RESERVE AREA L-"" 4' FROM PRIMARY? ✓' 100' TO WETLANDS L-""'2% SLOPE 100' TO WELLS ;/ 35' TO FND & INTRCPTR DRAINS L---- 4' TO S.H.GW 325' TO SURFACE H2O SUPP l� 4' PERM. SOIL BELOW FACILITY MIN 12" COVER ✓� FILL? c/(25' if above natural elev; 10'if below) BREAKOUT MET? TRENCHES MIN 660 gpd (/ SLOPE (min . 005 or 6"/100' ) t/ >3' COVER? - VENT SIDEWALL DIST. 2X EFF. W OR D (MIN 61 ) ,-- / IS RESERVE BETWEEN TRENCHES? —, /' IN FILL? l-/ MUST BE 10' MIN. L---- 4" PEA STONE?�� BOT ' X LDNG A/( + SIDE 404- X LDNG TOT �19oZ 7ln�p� (L x W x #) (G/ft2) (DxLx2x#) DATE_ /����9� Sheet of BOARD OF HEALTH TOWN OF NORTH ANDOVER SUBSURFACE DISPOSAL DESIGN REVIEW FEE 0/6 PERMIT # l DATE RECEIVED zr477, APPLICANT ASSESSOR'S MAP /�76 ADDRESS PARCEL # a`� LOT # STREET �266 Cl?,e7- 60gL ENGINEERIE/�/�//yI/3G� CNG. ADDRESS 739,e< 5/-- 191vDO! Ea /xo PLAN DATE / REVISION DATE CONDITIONS OF APPROVAL: 1) C«V t LOc. OF .Fb/y b2Al/V oU7-/=/3G4 ISI APPROVED L/ DISAPPROVED I DA'T'E 124 q ( Sheet . � of BOARD OF HEALTH TOWN OF NORTH ANDOVER SUBSURFACE DISPOSAL DESIGN REVIEW FEE �D PERMIT # DATE / � RECEIVED !J f APPLICANT A2i7k/2 6.4,j ASSESSOR'S MAP Z6- ADDRESS _� l�C�/l�/.l�S 7 PARCEL # - Z_? LOT # ;: �..� STREET C�G� /a72i (,Jr;4 -e / ENGINEER l'V -,g4-clG '�iiC'j ADDRESS G 9 PLAN DATE REVISION DATE CONDITIONS OF APPROVAL: APPROVED DISAPPROVED X ` c-"�'P T1 C� S'i�-*-t 51 1 vJ� 4 ��cc _�c S,C��t D 12 A ►J o F 7-) Le-A-Wel �2�-,p 2. �} FT (Nv► � Z3� r "RAE �C�wc Sl �� "13E No LEss 'R�� to iFF ; A. RiZI I t F-C c i s T4AQ vl I r�TM-7-1-3 it i�T �Ft� Wl�i L-�2 Sc2�l C� ��J�a�o►.� �� ;�i�.sC �.� FNS ��►J oJ; ��. I 1 . cf) 7- 19 9,51 i / 5 i �-_ ,✓03 ESOT O L Z:�) c-- ,-9 7T S .HEREBY CECT/fY TO 7'11E T/TGE/NSU.POPANO /.,�z or TO THE B.4.V r T//qT TsiE On'EGG/.u6 /S GOCATEO O.v Tf/E LOT AS S.5(�/I'N ANO Tf/AT/T OGiES CONFO.Ph/ /N /Y/Tf/ T//ETnw✓ OF✓4✓oO�ER Z,owlwa PEI,vLATivA1s ,PL�GvI.PO/N6 SET�AC.t'S FEOM STPEETS f LOT U✓ES."' �/Q ���Q O vLC� ��� �r F/ir1//E.P CE.PT/FY T//.OT TiY/S OIYELL/N6 /S NOT � LOG4TE0 /N TYE FEOEPAG F,4WO f/.9ZAP0 APES+. OP. ,*5A1 FO,P SyOIvN OiS/Ffia/ C i,c,� C/ /�'Y P•4.VGL 2Soo98 Oo oBG Lp&���a , +� A.t/OOYE.P, /Y1.4SS,4C,f///S6'TTS O/8/O Town of dover P )3 ~.^ , 1�I&W8W I S 19RS o ` crt " dover, Mass., 'Q COC��C MF WICK "A T E D M 5 BOARD OF HEALTH Food/Kitchen Septic SystePERMIT T D m`/�w� �C�U --'p BUILDING INSPECTOR THIS CERTIFIES THAT..............n..C[-A.......r ' .................................................................................. "".' F tion has permission to erect CCA')....f4tjUuildings on ..k.Zl....... T....(A. 4�......6�% .?-41 ) o„ to be occupied asQ1wP_. J1t�.(^� ll. I,ll . ....�� ..a--CAQ.. -44.Q.e Q ............`.............................. ZfChi provided that the person accepting thislpermit shall in%ery rbspect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. ''PERMIT FOR FOUNDATION ONLY PLUMBING I SPECTTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. REGULATED BY PARA. 114.8-S. B.C. ou aLPERM IT EXPI ��_ 4y 6 MO C � FEE PAID 1ba ��1 < UNLESS SS C.0� '3 .. C� d � T • ELEC C INSPE ervi BUILD G INSPECTOR Occupancy Permit Required to Occupy Buildin GAS INSPECTOR Display in a Conspicuous Place on the Premises -- Do Not Remove Rough P Y P Final /W No Lathing or Dry Wall To Be Done FIRED PARTMEN Until Inspected and Approved by the Building Inspector. vq� Burner f y r Street No. ^\�� Smoke Det. ,ste FORM U - LOT RASE 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 local or state law, regulations or requirements. ****************APPlicant fills out this section***************** APPLICANT: a Phone LOCATION: Assessor' s Map Number Parcel Subdivision 111T Lot(s) Street St. Number 12 ************************Official Use Only************************ RECOMMENDATIONS OF TOWN AGENTS: Date Approved Conservation Administrator Date Rejected Comments Date Approved Town Planner Date Rejeczad Comments Date Approved Food Inspe�ct_o`r- e=lth Date Rejected 4, A__> Date Approved Septic Inspector-Health Data Rejected Coi,=eats Public Wcrks - seSaer,'water connections _/,i 3 -2 7- - driveway permit -25- Fire Denartment Received by Building Inspector Date f NEW ENGLAND ENG'Ic EERING SERVICES SSP W93 September 5, 2003 North Andover Board of Health Town Hall Annex 27 Charles Street North Andover MA 01845 RE: TITLE V REPORT: 121 Old Cart Way,North Andover, MA Dear Sirs: Enclosed is a copy of the Title V report for the above referenced property. The system PASSED our inspection. If there are any questions please call me at my office, 686-1768. Sincerely zy- ��� Benjamin C. Osgo r. 60 BEECHWOOD DRIVE-NORTH ANDOVER, MA 01845-(978)686-1768-(888)359-7645-FAX(978)685-1099 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION SyB TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: fa?1 . O L-D c/ -r r.j ,4y :►,4 A Owner's Name: -:�-O;EE 5—10,A f CL Owner's Address: 191 0L-9 GA2, wHy r0o(MH A-)poot-7a sit Date of Inspection: 6 zo f u 3 I€.k. `QR t` T CIF N EEv'L �- .. _t Name of Inspector: (please print) Benjamin C. Osgood, Jr. Company Name:New England Engineering Services Inc. " 233 o , li Mailing Address:60 Beechwood Drive, North Andover, NLA 01845 Telephone Number: 978-686-1768 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 Inspector's Signature: Date: 9/ Zo o 3 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. Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1 A 1 OLD c/F 2 i w r4H Owner: )2C� 5-r-111 FE-- Date of Inspection: a f t 0 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: 1/I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,,,will pass. Answer yes,no or not det fined(Y,N,ND)in the for the following.statements.If"not etermmed"please explain. / The septic tank is metal and o 20 years old*or the septic tank(whethe"etal or not)is structurally unsound,exhibits substantial infiltration exfiltration or tank failure�VH?ard mm' tnt.System will pass inspection if the existing tank is replaced with a complying tic tank as approved by of Health. *A metal septic tank will pass inspection if it is cturally sound, ing and if a Certificate of Compliance indicating that the tank is less than 20 years old is ailable. ND explain: Observation of sewage backup or breakor high sta' water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled uneven distributi box. System will pass inspection if(with approval of Board of Health): oken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: system required pumping more than 4 times a year due to broken or obstructe ipe(s).The system will pass ins nc oynif(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: a I oz-p-- A(LT Owner: v TJ M PC-L— Date of Inspection:- 0 ) 20 103 C. Further Evaluation is Required b the Board of Health: q y Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing t protect public health,safety or the environment. 1. Syste 'll pass unless Board of Health determines in accordance with 310 CMR 15.303(l)(b)that the system is t functioning in a manner which will protect public health,safety and the environment: _ Cesspool or ivy is within 50 feet of a surface water _ Cesspool or pri is within 50 feet of a bordering vegetated wetland or a salt marsh , 2. System will fail unless the Board of He (and Public Water Supp ' r,if any)determines that the system is functioning in a manner that protec he public health,safe and environment: _ The system has a septic tank and soil absorpti system S)and the SAS is within 100 feet of a surface water supply or tributary to a surface water sup _ The system has a septic tank and SAS and the S is w ' a Zone 1 of a public water supply. _ The system has a septic tank and SAS an e SAS is withinfeet of a private water supply well. The system has a septic tank and SQ and the SAS is less than 100 t but 50 feet or more from a private water supply well".Method ed to determine distance "This tem asses if the 1 system p wel ter analysts,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 ni�`ogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are trigg7,6d.A copy of the analysis must be attached to this form. �f 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: i Z l D c p c R RT w,rt y iJv fLT11 1-1-"JD v 0 e (z /1 Owner: Date of Inspection: q) Zo1 a?;- D. 3D. System Failure Criteria applicable to all systems: You must indicate`yes"or`oro"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool v Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than%z day flow L,- Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. = Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for 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.] /VU (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 be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 g;Pd• You must iftate either"yes"or`fro"to each of the following: (The following is apply to large systems in addition to the criteria above) yes no _ the system is within 400 f surface drinking water supif the system is within 200 feet of a tributes urface drinking water supply the system is located in a.nitrogen sensitive area(Int Wellhead Protection Area-IWPA)or a mapped Zone 11 of a publiE-W4v r supply well If you have answered"yes"to any question in Section E the system is consider ignificant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any lar �ace tconsidered a significant threat under Section E or failed under Section D shall upgrade the system in with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. �,, Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: I Z I D i 7 c &2T w � ivy a-M /-kN po0C-2 . Owner: ,,o Z EF 57u tt i964-- Date of Inspection: e,12 o 103 Check if the following have been done.You must indicate`yes"or"no"as to each of the following: Yes No _yz-Pumping information was provided by the owner,occupant,or Board of Health Were any of the system components pumped out in the previous two weeks? _/Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built'plans of the system obtained and examined?(If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? Were all system components,excluding the SAS,located on site? Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no Existing information.For example,a plan at the Board of Health. tel'-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)] Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 12 l D t-D c 0'�Vz w R y Owner: ;3a ZE F s70 6-L- Date of Inspection: Q Z3 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): 1Y DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): &60 G-PP Number of current residents: 3 Does residence have a garbage grinder(yes or no):bg�s Is laundry on a separate sewage system(yes or no):,t/'.D[if yes separate inspection required] Laundry system inspected(yes or no): — Seasonal use:(yes or no): No Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no): A10 Last date of occupancy: COMMERCIAL/MUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): Qnd 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 Source of information: V .v e nr .✓ Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tank,distribution box, soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Altemative 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: t"I�tG Were sewage odors detected when arriving at the site(yes or no):�� Page 7 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 4 eL l D L;> L&a i tvo 2n•1• �F•�17 o�tti - J Owner: Zr1= STJT ?GL- Date of Inspection: 3 BUILDING SEWER(locate on site plan) Depth below grade: Z I Materials of construction:_cast iron -✓'40 PVC other(explain): Distance from private water supply well or suction line: —'4 Comments(on condition of joints,venting,evidence of leakage,etc.): PI ?C t--)o V.-f. &-00 0 1-'✓ i�'A-S&-1r'yT SEPTIC TANK:_(locate on site plan) Depth below grade: 7 Material of construction:_,,cconcrete 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) Dimensions: 15 0�3 Sludge depth: z Distance from top of sludge to bottom of outlet tee or baffle: 3 a Scum thickness: z" Distance from top of scum to top of outlet tee or baffle: C s Distance from bottom of scum to bottom of outlet tee or baffle:�/a How were dimensions determined: 41 12 r S;1 C Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): ,rat-; k t 6-00O C a ti 7)Oel soc1d Yu R v c [c9r �7 �TZay' GREASE TRAP:6L^ocate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 121 y Lo c A 2•w f�y Owner: ao2Er- S/uMFF-L- Date of Inspection: e V)1 zz>)O 3 TIGHT or HOLDING TANK:rV✓t'(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/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: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 0 Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): �3ox �A JA,e- neo.. PUMP CHAMBER: /V4-(locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: )z¢ tai-P c A--(Lf L, ,R rv-3 a-h( A-A--'7 n. tit- ,u�} Owner: JJvzCF STv---FCL Date of Inspection: 8�,Z' I v 3 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: f leaching trenches,number,length: Z 76•s r�-e�c��r s leaching fields,number,dimensions: overflow cesspool,number: innovativetalternative system Typetname of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): A 2E�F F Z'rc ac K f?—'F s 4 L- CESSPOOLS:IV& (cesspool must be pumped as part ins ection locate on siteplan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY:A[&(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.): Page 10 of 11 l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1 Z 1 01-C) c tra; L.,,+y 000-TV &— 1-)O,-JC4- Owner• 062-EF ST"-,PCS Date of Inspection: PJ1 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. G I D f3 T, Vr 3Z•w �- �3 ls•� t ♦ t Page 11 of 11 a OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 121 0 I-17 c A&i ,,.f+y Owner: CTO Z CI- S i o m p- Date of Inspection: G 1 z- 105 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water C, 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: You must describe how you established the high ground water elevation: c 43✓+a e%v Jy dL 4f t IQ (Sv d e- u,yc�ry—k 4- ' `2, COMMONWEALTH OF MASSACHUSETTS V�;� [v EXECUTIVE EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS d DEPARTMENT OF ENVIRONMENTAL PR * A Oq� Seo JUL' - • 2006 �rh TOWN OF NORTH ANDOVER HEALTH DEPARTMENT TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:_121 Old Cart Way_ _North Andover_ a Owner's Name:_Greg Kolligian Owner's Address:_121 Old Cart Way _North Andover,MA 01845_ Date of Inspection:6/21/2006_ Name of Inspector:_Neil J.Bateson_ Company Name: Bateson Enterprises Inc._ Mailing Address:_111 Argilla Road_ _Andover,Ma.01810_ Telephone Number: (978)475-4786_ , 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 app ioved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fail Inspector's Signature: Date: _6/21/2006_ 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. } Page 2 of 11 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:_121 Old Cart Way_ _North Andover_ Owner:_Kolligian— Date of Inspection: 6/21/2006_ Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: 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: Page 3 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:_121 Old Cart Way_ _North Andover_ Owner: Kolligian_ Date of Inspection: 6/21/2006_ C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the h environment: r which will protect public health,safety and the system is not functioning in a manner p _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a ce water supply. surface water supply or tributary to a surfs PP Y �' The system has a septic tank and SAS and the SAS is within a Zone I 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 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. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:_121 Old Cart Way_ _North Andover— Owner: Kolligian_ Date of Inspection: 6/21/2006_ D. System Failure Criteria applicable to all systems: You must indicate"yes"or`no"to each of the following for all inspections: No_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool T _No_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _ _No Liquid depth in cesspool is less than 6"below invert or available volume is'/2 day flow. _ _No_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _ _No_ Any portion of the SAS,cesspool or privy is below high ground water elevation. _ _No_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _ _No_ Any portion of a cesspool or privy is within a Zone 1 of a public well. _No_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _No_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for 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.] No (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 be considered a large system the system must serve a facility with a design now of 10,000 gpd to 15,000 gpd. 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 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. Page g I OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:_121 Old Cart Way_ _North Andover_ Owner: Kolligian_ Date of Inspection:_6/21/2006_ Check if the following have been done You must indicate"yes"or"no"as to each of the following: Yes No yes Pumping information was provided by the owner,occupant,or Board of Health No Were any of the system components pumped out in the previous two weeks? Yes Has the system received normal flows in the previous two week period? No Have large volumes of water been introduced to the system recently or as part of this inspection? Yes Were as built plans of the system obtained and examined? Yes Was the facility or dwelling inspected for signs of sewage back up? Yes Was the site inspected for signs of break out? Yes Were all system components,excluding the SAS,located on site? _Yes_ _ 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? _Yes_ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No _Yes_ _ Existing information. _Yes_ _ 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)] Page 6 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:_121 Old Cart Way_ _North Andover– Owner: Kolligian_ Date of Inspection: 6/21/2006_ FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 4 Number of bedrooms(actual):_5_ DESIGN flow based on 310 CMR 15.203_660_ Number of current residents:_4 Does residence have a garbage grinder(yes or no): Yes_ Is laundry on a separate sewage system(yes or no):_No_ Laundry system inspected(yes or no): Seasonal use: (yes or no): No_ Water meter reading: Yes_ Sump pump(yes or no): No– Last date of occupancy:_Current_ COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203):____gpd 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 Source of information:_Pumped last year,owner_ Was system pumped as part of the inspection(yes or no): Yes_ If yes,volume pumped:_1500 gallons--How was quantity pumped determined?–Measured tank Reason for pumping: Inspect tank&tees_ TYPE OF SYSTEM _X_Septic tank,distribution box,soil absorption system _Single cesspool_Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank _Attach a copy of the DEP approval Other describe Approximate age of all components,date installed(if known)and source of information:_10 Years old,5/20/1996, as built plan_ Were sewage odors detected when arriving at the site(yes or no): No Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_121 Old Cart Way_ _North Andover_ Owner: Kolligian_ Date of Inspection:_6/21/2006_ BUILDING SEWER_X_ (locate on site plan) Depth below grade:_24" Materials of construction: _cast iron X_40 PVC_other Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.) _3"PVC in house with no leaks visible_ SEPTIC TANKS:—X — Depth below grade:_12"_ Material of construction:_X concrete—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) Dimensions: 10'x 5'a 4'_ Sludge depth —4"_ Distance from top of sludge to bottom of outlet tee or baffle:_23"_ Scum thickness:_611 _ Distance from top of scum to top of outlet tee or baffle: 8"_ Distance from bottom of scum to bottom of outlet tee or baffle:_15"_ How were dimensions determined:_Tape Measure_ Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc:Pumped septic tank.Inlet tee ok. Outlet tee ok.Depth of liquid at outlet invert.No evidence of septic tank leaking in or out. GREASE TRAP:_(locate on site plan) I Depth below grade: Material of construction: concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_121 Old Cart Way_ North Andover_ Owner: Kolligian— Date of Inspection:_6/21/2006_ tank must be pumped at time of ins ection locate on site plan) TIGHT or HOLDING TANK: ( p p P )( Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons 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: X_ Depth below grade 24"_ Depth of liquid level above outlet invert:_0"_ Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.):_D-Box level&distribution equal.Evidence of carryover,pumped d-box to clean. No evidence of leakage._ PUMP CHAMBER:_(locate on site plan) Pump in working order(yes or no):_ Alarm in working order(yes or no):_ Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_121 Old Cart Way_ _North Andover— Owner: Kolligian_ Date of Inspection:_6/21/2006_ SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: _ leaching chambers,number:— leaching galleries,number: _X leaching trenches,number,length: 2 trenches 76'long_ leaching field,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.):_Soil ok.Vegetation ok.No sign of ponding to surface._ CESSPOOLS: Number and configuration:— Depth—top of liquid to inlet invert:_ Depth of sludge layer: Depth of scum layer:_ Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or 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: Depth of solids: Comments(note condition of soil,signs of Hydraulic failure,level of ponding,condition of vegetation,etc.): Page 10 of 11 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_121 Old Cart Way _North Andover— Owner: Kolligian_ Date of Inspection:_6/21/2006_ 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. C Driveway House Water Meter AB D- Box A to Tank=3219" B to tank=2019" B to D-Box=15' C to D-Box=45' Page 11 of 11 OFFICIAL INSPECTION FORINT—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_121 Old Cart Way_ _North Andover— Owner: Kolligian Date of Inspection: 6/21/2006_ SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water _4'_ Please indicate(check)all methods used to determine the high ground water elevation: X Obtained from system design plans on record-If checked,date of design plan reviewed:_6/10/1991_ Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local.Board of Health-explain:_ Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: As per design plan_ I i i Summary Record Card generated on 6/19/2006 11:48:15 AM by Elaine Barclay Page 1 a Town of North Andover Tax Map # 210-107.8-0101-0000.0 121 OLD CART WAY KOLLIGIAN JR GREGORY A 121 OLD CART WAY NORTH ANDOVER, MA 01845 Class 101 Single Family Property Type 1 Residential Size Total 1.99 Acres FY 2006 UB Mailing Index Name/Address Type Loan Number Active/Inact. From Until KOLLIGIAN JR GREGORY A Payor 121 OLD CART WAY NORTH ANDOVER, MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 13746.0- 121 OLD CART WAY Last Billing Date 5/10/2006 1090424 01 Cycle 01 Active UB Services Maint. Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE -94.30 /1 UB Meter Maintenance Serial No Status Location Brand Type Size YTD Cons 32707555 a Active ERT HH b Badger w Water 0.63 0.63 Date Reading Code Consumption Posted Date Variance 5/2/2006 21 a Actual 21 5/16/2006 0% 2/7/2006 0 n New Meter 0 5/16/2006 0% 2/7/2006 3618 r Replacement -46 5/16/2006 -828% 1/30/2006 3664 m Manual estimate 75 2/13/2006 -52% MSG 10/27/2005 3589 a Actual 155 11/9/2005 -15% Trouble Code:03 7/25/2005 3434 a Actual 185 8/10/2005 -36% Trouble Code:09 4/21/2005 3249 a Actual 242 5/13/2005 643% MSG 2/1/2005 3007 m Manual estimate 40 2/15/2005 -12% MSG 10/27/2004 2967 m Manual estimate 40 11/15/2004 0% 8/3/2004 2927 m Manual estimate 40 8/25/2004 -29% 5/10/2004 2887 a Actual 64 6/8/2004 148% 2/4/2004 2823 a Actual 25 2/24/2004 0% 11/3/2003 2798 n New Meter 0 11/3/2003 0% Tel: (978) 475-4786 Fax: (978) 475-5451 BATESON ENTERPRISES, INC. Excavating-Water.& Sewer Lines-Septic Systems&Pumping Service 111 Argilla Road Andover, Mass. 01810 Title 5 Inspection Report Property Address: 121 Old Cart Way, North Andover Owner: Kolligian Date of Inspection: 6/21/2006 My report contained herein does not constitute a guarantee of future usage and the functionality of the existing septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further operation of your current septic system. Neil J. Bateson Bateson Enterprises, Inc. COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARvmzNT of ENMONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A _CERTMCATION__------- - Property Address: 121 Old Cart Way _ Owner's Name:. Owner's Address: N. Andover,MA 01845 Wei ss Dab of Inspecdon: 09-14-01 OCT l 9 2001 Name of Inspector.(please print) ERIC LENARDSON Company Name: cr.►a Fit Mailhrg Address:._ P.O.Boat 5062 Greene,to TtlephoneNumber. - 2,- fga CERTIFICATION STATEMENT I arft that 1 have personally irked the sewage disposal system at tris address and that the mon reporeed below is true,acme and complete as of the time of the inspection.The mon was performed based on my and lraiaing is the function and maiat�ae an p� of site sewage disposal systems•I am a DEP approved srshm idpeetor pursuant to Smiles I&M of TWe 5(`.IIA CMR moo). 'the system:_ Passes Candbionally Passes Needs Further EvahmtioaLocal by the Approvrrg Amhotity F aill actor's Signature: Im,,L� Date: The system inspector shat!submit a copy of ft hopeaioa report to ffio Appm ftt (Board of Haft or DEP)within 30 days ofcompladog this*moon.If the system is a shww system or hes a design lbw of 10,0W Wd or V=W,the iospector sad the system owner shat!submit the report to the appropafate regional office of the DEP.The ai&d dmuN be me to the system awcer and copies sem In the bayce,if Whcebk,and the app wft aallarit3'• Notes and Comments report only deserlbes conditions at toe dm of inspection and oader the eondit as of use at tlatf ftm This htspfctioa daft not address how the system will perforce in the future ander the same or dffe-mat conditions of ase. Page 2 of 1 l OFFICIAL INSPECTION FORM,NOT FOR VOLIMARY 1lSSBSSME#�i1'i� SUSURFACE SEWAGEPWO"L PART A CEGL13UN ftaperty Addrem:= 121 Old Cart Way N. Andover,MA 01845 Owner. .. Weiss DabOf On: 09-14-01 InspectionSn�: C E all of Section II A. Sysbem Passes: 1/ I havenot found any hdmmatioa which indicates that any of the failure erlkeria described in 310 CMtt 3-03 or in 310 CMR 13.304 exist.Any fat'lnre criteria not evaluated ace indicated below. Comments: IL S Candice Passes: yam � One more systm components as described m die"Conditional Pass"section need to be replaced or or ',as the Sow d of health,will pass. The �t re�au >:cm Answer yes,no or determined(",ND)in the for the following�emems.If"not dettammed"please The septic tank is nd oyer 2& ms old'or the septic tads(whether metal or not)is strucInmHY tank.faithae is bninh=L S will if the unsound,exhtbits infiltration ar entfi�On at Y� task a4 the Board OfHaalth. wdsft tank�replaced a��� > �by *A metal septic tank wr'11 pass" if it is stcacturally sound,not leaking and if a CeMfic ate of Compliance indicadag do the a*is lees 20 years old is anah�le. j ND expW: observation of sewage badoap b MM*cant oxhigb stetic water level in the distn'butim box due to broken or obstruaod pipes)or due to a broken, or uneven distn'bartion box.System will pass if(with of Board ofHea fth broken s) smaphwed roved distrEndoo\=rewoved laced ND explain: The system ro9�pumping more than o broken n or obstraated pipes).'tire system will pm if(with approval oft>se Bowd ofbroke.a pipeobstruction i ND explenn: Page 3 of 1 l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SWAGE DISPOSAL SYSTEM INSPECTION FORM ART A CERTIFICATION(cordintted) Property Address: 121 Old Cart Way N. Andover,MA 01845 Owner: Weiss Date of Inspection: 09-14.01 C. Further Evaluation is Required by the Bird of Health: Co loons exist which require anther evaluation by the Board of Heap m order to determine if the system is failing to public health,safety or the environment. unless Board of Health determines in accordance with 310 lxn 1. System l m a manner which will protect public health,,safety the emrom system is n functioning — ent Cesspool privy is within 50 feet of a surface water _ Cesspool or 'vy is within 50 feet of a borduring vegetated wetland or a salt marsh 2. System Will fail unless the rd of Health(and poblw Water Supplier,if any)determines that tits System is functioning in a mann r that protects the public health,safety and environment: 7he syr has a septic soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributM sMUM wow supply The system has a septic tank and and the SAS is within a Zone 1 of a public water Supply- The upplyThe system has a septic tank and SA the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS-- SAS is less than 100 feet but 50 feet or more from a private water supply well**.Method used to distance at a DEP certified laboratory,for coliform **This system passes if the well water analysis, .. well is fine from polhrtion from that fecilih►and bacteria and volatile organic compounds n that pro videthat no other the presence of ammonia nitrogen and nitrate nitrogen is nal to or ess dm 5 this form.m, failure criteria are uiggeted.A copy of dw analysis must be 3. Other. Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FM VOLUNTARY ASSESSMEMS SUBSURFACE SEWAGE$d8M)SAL RSI INSPECTION FORM ]PART A CER21=ATiON{caue� PropwqAMn= 121 Old Cart Way N, Andover,MA 01845 Owner. Weiss Date of Inspection: - 09-14-01 A System Failure Criteria applicaMe to all systems: you I"indicate"yes"or-W to each of the following far a&JnIPD as: Yes No _ badmp of sewage lulu facility or system component due to overloaded or clogged SAS or cesspool VDisdiarge or podding ofefflucat to the shh ofthe ground or smthOe waters due to as Overloaded ar clogged SAS or cesspool ✓ Static liquid levet in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _✓LiqWd depth in cesspool is less than 6"below im►ert or available volume is less than%day flow Required pumping more than 4 times in the last year Rsduo to clogged or obstructed pipe(s).Number of times pumped Any portion of the SAS,cesspool or privy is below bkb ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface —" water ✓ Any portion of a cesspool or privy is within a Zone 1 of a public welt -/ Any pordw of a cesspool or privy is with 50 feet of a private water supply well. J Any portion of a cesspool or privy is less than 100 fees but Wvater tiara 50 feet from a private water supply well with no acceptable water quality analysis.M95 systan6asses d the wen water analysis, performed at a DFP certiBad laboratory.for callft M volatile organic oompon"s indicates that the well is free ftem polhdion from that fadlity and presence of ammonia aitrogers and nitrate nitrogen is equal to or less than 5 ppm,p that no other Mare crilwin are triggered.A eM of tbe•auaalysis must be ausehed to this forma yo) system .I have determined that one or mare of the above should condo the Board of in 310 CMR 15.303,therefore ter system faits.The system owner Heath to determine who will be necessary to cort+oct the bAn. lwSystems: ' To ba a Ls system the system must serve a theft with a design flow of 10,000 gpd to 15,000 gpd• YOU must' either`Yes"or"Dor to each ofthe fbtbwiev (nit following " apply to large systems in addition to the criteria above) yes no_ ! the system is 400 feet of a surface drinking water supply T the system is wit»a feet of a tributary to a surface drinking wanes•supply _ the system is located in a sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water welt if you have answered"yes"to any qct E the system is considered a sig Rent threat,or answered "yes"in Section D above the large system has rhe owner or operator of any lame system considered a significant threat tmdear Section E or failed under D shalt vpgmde the system in accordance with 310 CMR 15.304.The system owner should contact the regional office of the Department. Page 5 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSFFU MNTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION PART B CgECKLIST Property Address: 121 Old Cart Way N. Andover,MA 01845 Owner. Weiss Date of Inspection: 09-14-01 Check if the following have been done You mast indicate`eyes"or`tiro"as to each of the following: I Yes/No ✓ Pumping information was provided by the owner,occupant,or Board of Health .,/Wm any of the system components pumped out in the previous two weeks? J Has the system received normal flows in the pm"M two week period? Have large volumes_ es of water been introduced to the system recently or as part of this 'on . je,_ Were as built plans of the system obtained and examined?(if they were not available note as N/A) f _ was the facility or dwelling inspected for sips of wwageback"p? a/ Was the site inspected for signs of break out? Were all system components,excluding the SAS,located on site? _e baf_ c tank manholes uncovered, , for the condition � Were�� loveredopenedand the interior of the tank inspected of thfles or teM material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? r/ 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 locattn of the Soil Absorption System(SAS)an the site.has been determined based on: Y� Fmsgng information.For example,a Plan at the Board of Health. Deternnin�in the field(if any of the failure criteria related to Pact C is at issue appmximation of distance is unacceptable)[3 10 CMR 15.302(3)(b) Page b of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ABSE�+�l�S SUBSURFACE SEWAGES MPOSAL SYSTEM D �F'OHK PART C SYSEM M II iiAMON Property Address:. 121 Old Cart Way N. Andover,MA 01845 Owner: Weiss Date of Inspection. 09-14-01 Number of bedrooms(design): Of Number of bedrooms(actual): DESIGN flow based on 310 15.203(for example: 110 gpd x#of bedrooms): Number of current residents Does residence have a garbage Is laundry on a separate sewage systemor Eif yes inspection ) 3.aundrysystem inspeu�ed or no): Seasonal use:(yes or no): Water meter readmif available(last 2 years usage(gpd)): Swap pump(yes or Last date of occupancy: COj ULIINDUSTRiAL Type olisbment: Design on 310 CMR 15.203).- Basis 5203): s�wpd Basis on (Sim etMX Grease resent or no)- industrial o).,industrial waste bolding present(yes or no):_ Non-sanitary waste disd to the Title 5 system(yes or no).— Water meter readings,if avar�b i Last date of occupancybse: OTHER(desc nbe)P IN G FORMATION Pumping Records r Source of information: -01A Aft o — 2I Was system pumped as part of the inspection&es or no):_ If yes,volume pumped:__gallons—How was quality pumped determined? Reason for pumping: TYPI&OFSYSIMM _ tank,distribution box.soil absorption system —Single cesspool _Overflow cesspool Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) IffiEwativdAhmnative technology.Attach a copy of the current operation and mandeaance contract(to be obtained from system owner) -Tight tank _Attach a copy ofthe DEP approval —Other(describe): Approximate age of all ,date installed(if�aad source of information: C QA Were soup odmdeteeted when arriving atthe site(yes c jn Page 7 of 1 l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 121 Old Cart Way Owner. N. Andover,MA 01845 Date of Inspection: Weiss 09-14-01 BUILDING SEWER(locate on site plan) d Depth below grade: -- Materials of construction: cast iron v 40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,vent evidence of leakatetc.): SEPTIC TANK:�ocate on site plan) u ' Depth below grade: Material of construction: ✓concrete metal fiberglass_polyethylene otlter(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):`(attach a c9py of certificate) Dimensions: l5��- Sludge depth: ie tr Distance from top of sludge to bottom of outlet tee or baffle: _ Scum thickness: c $r Distance from top of scum to top of outlet tee or baffle: 5u Distance from bottom of scum tobottom of et or e: , 111"'TTT��� How were dimensions determined: Comments(on pumping recommendations,. et and outlet tee or baffle condition,structural integrity,liquid levels as rely to o at' vert,evidence of leakage,etc.): _ < 1 a GREASE TRAP• (locate on site plan) Depth below grade: Mderial of Via: concrete metal fiberglass�po ylOw other (exp�): Dimensions: Scum thickness: Distance from top of scum to topo tee or baffle: Distance from bottom of scum to bo of outlet tee or baffle: Date of last pumpings Comments(on pumping recommen�ti inlet and outlet tee or beffie condition,structural integrity,liquid levels as related to outlet invert,evidence of 16* ,etc.): Page 8 of l 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY"ASSESMM • SUBSURFACE SFWAGEMBPOSAL SYSTEM ICON FORM PART C sYSTEI�.�oi��t�rxi - Property Address: 121 Old Cart Way Owner. N. Andover,MA 01845 Date of Inspection:. Weiss 09-14-01 TiG rHOLDING TANK: (tank must be pumped at time of inspecaonMe xkon site plan) Depth Belo e: Material of concrete metal fiberglass polyethylene other(explain): Dimensions: arty _Aallons Design Flow: ons/day Alarm present(yes or no): Alarm level: Alarm' rking order(yes or no): Date of last pumping: ' Comments(condition of alarm and fl switches,etc.): - t if must be locate on site plan) DISTRIBUTION BOX. ( present opened)( u Depth of liquid level above outlet invert: Q Continents(note if box is level and dism'butian to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): I , site plan) PUMP CHAMBER (lode on s p ) in w order no): Pumps working Alarms in working order(yes no): . . Comments(note condition of p chamber,condition of pumps and appurtenances,etc.): Page 9 of 13 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 121 Old Ca Properly Andress rt WA)' N. Andover MA 01845 Owner: Weiss Date of InsPcetioi 09-14-01 SOEL ABSORPTION SYSTEM(SAS): (baste on site plan,excavation not required) If SAS not located explain why: Type- leaching pits,number:_ leaching chambers,number: imhing galleries,number: .aching trenches,number,length: 7G ' ieaching fields,number,dimensions: overflow cesspool,number. inaovativWalmnative system TM*mme of technology. Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): , AA !xu, Ck S.InAn kAQ CESSPOOLS: (cesspool must be pumped as part of inspectionXlocate on site plan) Number and confi on: Depth—top of liqui inlet invert: Depth of solids layer. Depth of scum layer. I Dimensions of cesspool: Materials of construction: Indication of groundwater (yes or no): Comments(note condition of il,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of clic failure,level of ponding,condition of vegetation,etc.): Page le of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUWARY ASSESSMEM SUMU"ACE SEWAGE t MPOSAL SYS XMI FOM FART C SYSTEr* Property Address; 121 Old Cart Way N. Andover,MA 01845 Owner. Weiss Date Of Inspection: 09-14-01 SKETCH OF SEWAGE DISPOSAL SYSTEM reference landmarks or Provide a sketch of the sewage disposal system including ties to at least two permanent benchmarks.Locate an wells within loo feet.Locate where public water supply enters the building. F-I I R O 3nK 3� 4 Page l l of l l OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 121 Old Cart Way Owner. N. Andover,MA 01845 Date of InsimWon, Weiss 09-1401 SITE EXAM -- slope �� Shallow wells Estimated depth to ground water_�feet Please indicate(check)all methods used to determine the high ground water elevation: -4btained from system desiga plans on record-N checked,date of design plan reviewed: 'Obwved site(abutting propertylobservatioon hole within ISO feet of SAS) Checked with local Board of Heath-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: Yo must describe how you fished the high ground water elevation: � t � I I I I I A B u I LT" T7E-Zs ' As - Bv i =�Ey- T 1oms Goin. 4'0 s'eN•�o P.vc . r,�v� Br�t.Y. =211�� 1 lam.! e; S.T =210 ,('l .b-Bo — 1S.O y '�S:C> pVi- - e S,-t=; =oto,tip{ x Tei l — qo.y ' 97 3' IQ eb-Box ogre- D-Bzx =zo9,19 L{o PEl,F', Uv, (5 1).dX-r-ra#/ =24q,9 f ,� bd Il I I '` if TOWN ANDOVER/ NDOV- .--� =110:02DO:8F LoXz48 i r—)()977. 7 . M Imo,F. r (`n ' G• � GAL SSC TAWK AS BUILT PLAN OF SUBSURFACE DISPOSAL SYSTEM LOCATED IN M02TO A�zo V�)R , M A . AS PREPARED FOR DATE : MA/ZD, 1496 -- SCALE: 1"1/0' A T- MERRIMACK ENGINEERING SERVICES, INC. PROFESSIONAL ENGINEERS • LAND SURVEYORS • PLANNERS: bb PARK STREET • ANDOVER, MASSACHUSETTS 01810 • TEL. (5*) 475-3555, 373-5721 A TESTS ODNDUCTED �z 28-88 AND WITNESSED BY "m5 G.,AF TOWN HEALTH XEN` DEEP OBSERV TION HOLE l SOIL DATA u/EfIGTH of MAS• , IV eA fill too F CpM�tilO� ,. 2� B.00 o -28 0 � t , _ o ,4 N f � � c J 0 � 4Z0 2 � V► � pU /20 � K ao ZoQ V► _ ,J'% pP O-Box i c foe. X f4 s ! --, � �iPw �IBO. •� 4 �•- F T i , , oiM I t of` TrG o8 P RoP.� c 1E � +21 r0 2 f � Z 2!Orso T � + ` Z\r h "id APSE MEQ e Wei 1 r� 7� ia — � \2.QiliEK/.Oy/ 2 0 � vi W PRO 4 1� : r1.7 Pi4pop/ 2.i Rep. Al