HomeMy WebLinkAboutMiscellaneous - 125 GRAY STREET 4/30/2018 (2) 125 GRAY STREET
2.10/107.D-0056-0000.0
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FILE COMMENTS
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Name: Paul Robbat
Comments:
Date: 12-17-04
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Called Paul on December 17, 2004, requesting more info regarding the exact
location of the septic system on the 125 Gray A property.
Michele E. Grant
fYI
Date.. S:..75
NORTH
0 TOWN OF NORTH ANDOVER
Snook
p PERMIT FOR WIRING
,SSACMUS�
This certifies that ............`� L�l`��! ...............
has permission to perform ......
wiring in the building of. .......!.. ..................................
/ Z� �2 S ,North Andover,Mass.
at.......f.^.app. .......... ..................
Fee 9Z.7 �e G.. --'..'�
ELECTRICAL INSPEC'E'OR
Aeck #(�
5741
Offi
ci
—
al Use Only
Permit No. S7
De�anux�xt°��r�lie Saady ,��'�
Occupancy&Fee Checked
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" `
To the Inspector of Wires:
Town.of North Andover
The undersigned applies for a permit to perform the electrical work described below.
Location(Street&Number
Owner or Tenant
Owner's Address) Sll m
Is this permit in conjunction with a building permit Yes Q,'— No 0 (Check Appropriate Box)
Purpose of Building Z_<,46 P Utility Authorization No.
Existing Service Amps Volts Overhead 0 Undgmd 0 No.of Meters
New Service Amps Voits Overhead 0 Undgmd 0 No.of Meters
Number of Feeders and Ampacity,
Location and Nature of Propo�ed Electr'c 31 Work Lt D l l O h 0r, p C E.
To �Q.1+ 0f- S1ide, n T 1-$-e re-ov`.Ji, porCAt a 1 so a t.vcv- in[ fbr I=irowlr 4F ky
Total
No.of Lighting Outlets No.of Hot fuse No.of Transformers INA
Above 0 In 0
No.of Lighting Fbdures Swimming Pool gmd 0 gmd 0 Generators KVA
No.of Emergency Lighting
No.of Receptacles Outlets No.of Oil Burners Battwry Units
No.of Switch Outlets No of Gas Burners FIRE ALARMS No.of Zone
Total No.of Detection and
No.of Ranges No of Air Cond Tons Initiating Devices
Heat Total Total
No.of Diposal No. Pumps Tons KW No.of Sounding Devices
NoJ of Self Contained
No.of Dishwashers Space/Area Heating KW Detection/Sounding Devices
0 Municipal 0 Other
No.of Dryers Heating Devices KW Local Connection
No.of No.of Low Voftage
' No.of Water Heaters KW Signs Bailases Wiring
No.Hydro Massage Tuds No.of Motors Total HP
OTHER:
INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws
I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES=NO
h miffed id proof of same to the Office YES= NO - If you have checked YES please indicate the type of coverage by checking the appropriate box.
INSURANC BOND - OTHER - (Please Specify)
- (Expiration Date)
Estimated Value of.Electrical W rk$
Work to Start D S Inspection Date Resquested Rough Final
Signed under t e haloes ofg�ury: f
FIRM NAME J (-1f /l<.IA toil/ lfc iii-t CA LIC.NO. Z;1 ;
117
Licensee lr(5 .r l/i ijtN� Signature LIC.NO.
�/ ,J / Bus.Tel No. 97 �� �� ?Jl8'.7
Address l� �'!l -ftfiGf !— Alt Tel.No. (�
OWNER'S INSURANtEE WAIVER: I am aware that the Licenses does not have the insurance coverage or its substantial equivalent as required by Massachusetts
General Laws.And that my signature on this permit application waives this requirement. Owner Agent (Please Check one)
Telephone No. PERMIT FEE $
(Signature of Owner or Agent)
The Commonwealth of Massachusetts t
Department of Industrial Accidents
Office of Investigations
Boston, Mass. 02111
Workers'Compensation Insurance Affidavit
Please Print
Name:
Location:
Ci1y Phone
L� am a homeowner performing all work myself.
�I am a sole proprietor and have no one working in any capacity
aI am an employer providing.workers' compensation for my employees working on this job.
Company name:
Address
City: Phone#:
Insurance Co Policy#
Company name:
Address
City: Phone#:
Insurance Co Policy#
R.
Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00
and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of($100.00)a day against me. I
understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
I do herby certify under the pains and penalties of perjury that the information provided above is true and correct
Signature Date
Print name Phone#
Official use only do not write in this area to be completed by city or town official' ❑ Building Dept
❑Check if immediate response is required Building Dept ❑ Licensing Board
❑ Selectman's Office
Contact person: Phone A ❑ Health Department
❑ Other
FORM WORKMAN'S COMPENSATION
t
Official Use Only
Permit No. J-7 4
Occupancy&Fee Checked 3
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'/r 1 A 5
To the Insp^ or of res:
Town of North Andover
The undersigned applies for a permit to perform the electrical work described below.
Location(Street&Number �1�,7 / 61A AQ-4 5T.
Owner or Tenant Fa 6(/ �' /—!f iclei ON he
Owner's Address
Is this permit in conjunction with a building permit Yes A-'- No 0 (Check Appropriate Box)
Purpose of Building �S;141)C a Utility Authorization No.
Existing Service Amps Volts Overhead 0 Undgmd 0 No.of Meters
New Service Amps Volts Overhead 0 Undgmd 0 No.of Meters
Number of Feeders and Ampacity.
Location and Nature of Proposed Electrical Work Add 4zo. oct '51 G Ll1 fe 9o i+ 0,1- o 4 ry Tib Q S,E,
7`o 'p-► 1-e r 5 1.c,4 t> # t l.r Fro 1-4r v AGN r Ci 1 so Ck e54 4 ,,v Lit- i^j, r )`'v,n ox 4q 9f
Total
1 No.of Lighting Outlets No.of Hot fuse No.of Transformers KVA
` Above 0 In 0
t� ;so.of Lighting Fixtures
Swimming
wimmi Pool and 0 gmd 0 Generators KVA
No.of Emergency Lighting
No.of Receptacles Outlets No.of Oil Burners Battery Units
No.of Switch Outlets No of Gas Burners FIRE ALARMS No.of Zone
Total No.of Detection and
No.of Ranges No of Air Cond Tons Initiating Devices
! Heat Total Total
No.of Di 1 No. Pum Tons KW No.of Sounding Devices
Not of Self Contained
No.of Dishwashers Space/A-Heatingi KW Detection/Sounding Devices
0 Municipal 0 Other
No.of Dryers Heating Devices. KW Local Connection
No.of No.of Low Voltage
No.of Water Heaters 'KW Signs Bailases Wiring
o.H ro Massa Tuds No.of Motors Total HP
1
OTHER:
LSURANCE COVERAGE. Pursuant to the requirements of Massachusetts General taws
a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES= NO
mitted id proof of some to the Office YES= NO - If you have checked YES please indicate the type of coverage by checking the appropriate box.
URANC BOND - OTHER - (Please Specify)
(Expiration Date)
imated Value of.Electrical W rk$
rk to Start D 7 Inspection Date Resquested Rough Final
M under t o F�nalties of g�rjnry`A C r c 4 LIC.NO. 4,; ;7
M NAME/ �'7 (f/ fr
nsee, ( Irl 5 /- �IV lN� SignatureLIC.NO.
JJ // Bus.Tel No. 9 7 5--
�. ress //I Alt Tei.No.T7ff%
ER'S INSURAN E WAIVER: 1 am aware that the Licenses does not have the insurance coverage or its substantial equivalent as required by Massachusetts
ral Laws.And that my signature on this permit application waives this requirement. Owner Agent (Please Check one)
Telephone No. PERMIT FEE $
i (Signature of Owner or Agent)
1 ,
I i
x Location fol I U/tA `� 'T
No. 9,3 / Date
NORT1y TOWN OF NORTH ANDOVER
3�O�,t`•O ,•,hO
Certificate of Occupancy $
Building/Frame/Frame Permit Fee $ i d
s�CHust 9
Foundation Permit Fee $
Other Permit Fee $
TOTAL
Check #
17 29
Builring Inspector
TOWN OF NORTH ANDOVER '
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REP RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
.. ~
BUILDING PERMIT NUMBER: _ J DATE ISSUED:4 A I a
LO
SIGNATURE:
Building CommissioEELhsRector of Buildings Date z
SECTION 1-SITE INFORMATION 1 O
1.1 Property A#ess: 1.2 Assessors Map and Parcel Number:7
i C r-\O�-L( Map Nurrfber Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Areas Fronts ft
1.6 BUILDING SETBACKS 00
Front Yard Side Yard Rear Yard
Regaired Provide Required Provided Re red Provided
v
1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System:
Public 0 Private 0 Zone Outside Flood Zone ❑ Municipal 0 On Site Disposal System ❑ J
SECTION 2-PROPERTYOWNERSHIP/AUTHORIZEDAGENT 1t: 'ictr!Ct: Yes No M
2.1 Owner of rd
Name(Prin Address for Service
-- 2--
Signature Telephone
2.2 Owner of Record:
0
r/ J]tName Print Address for Service: z
h M
111YYY_III ��re Telephone
SECTION 3-CONSTRUCTION SERVICES 90
3.1 Licensed Construction Supervisor: Not Applicable ❑
4 LD
Licensed Construction Su rvisor: / / 0
✓ / License Number
ddre s
: 7 a� ic
Expiration Date
gnature Telephone r
3.2 Registered7me Improvement Contractor Not Applicable ❑
Com any 1 ame �/ /0 �L�� 1 a 1
Registration Number r
o V�- r
Address
G)
v- Expiration Date
Signature / r Telephone
SECTION 4-WORKERS COMPENSATION(M.G.L. C 152 § 25c(6)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed affidavit Attached Yes.......❑ No.......❑
SECTION 5 Description of Proposed Work check a0 a Ilcable
New Construction ❑ Existing Building ❑ Repair(s) 0 Alterations(s) ❑ Addition ❑
Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify
Brief Description of Proposed W rk: �O
SECTION 6-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollar)to be OMCM USE ONLY
Com 1 ted by permit applicant
1. Building (a) Building Permit Fee
l/
Multiplier
2 Electrical (b) Estimated Total Cost of
Construction
3 Plumbing ✓ Building Permit fee(a)x (b)
4 Mechanical HVAC
5 Fire Protection
6 Total 1+2+3+4+5 Check Number
SECTION 7a OWNER AUTHORIZAVON TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT _T
as Owner/Authorized Agent of subject property
Hereby autho ' e to act on
My beha all m er at' to work authorized by this building permit applicatioig,
Si re of Owner Date
SECTION OWNER/AU RIZED AGENT DECLARATION
I> ,as Owner/Authorized Agent of subject
property
Hereby declare that the statements and information on the foregoing application are tnae and accurate,to the best of my knowledge "
and belief
Print Name
Si tune of Owner/Agent Date
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TIMBERS 7 ! i s 2 RD
3
SPAN I L4 —
DD,4ENSIONS OF SILLS --
DIMENSIONS OF POSTS r Z. i
DIMENSIONS OF GIItDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CHIMNEY
1S BUILDING ON SOLID OR FILLED LAND _
IS BUILDING CONNECTED TO NATURAL GAS LINE
ENC ibS`L /� I
New PJV+ S�acr w�
FORM U - LOT RELEASE FORM 2 no F r--
INSTRUCTIONS:
^INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from
Boards and Departments having jurisdiction have been obtained. This does not relieve
the applicant and/or landowner from compliance with any applicable or requirements.
****** ****APPLICANT FILLS OUT THIS SECTION��
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APPLICANT—&, PHONEP�54>5=
LOCATION: Assessor's Map Number d PARCEL
SUBDIVISION LOT (S)
i
STREET5 ST. NUMBER
OFFICIAL USE ONLY
RECOMMENDATIONS OF TOWN AGENTS:
CONSERVATION ADMINISTRATOR DATE APPROVED
DATE REJECTED
COMMENTS
TOWN PLANNER DATE APPROVED
DATE REJECTED
COMMENTS
FOOD INSPECTOR-REALTH DATE APPROVED
DATE REJECTED
4SEPTILCI�NSPECTOR-HEXLtH DATE APPROVED U
DATE REJECTED
COMMENTS /? 4-m
PUBLIC WORKS-SEWER/WATER CONNECTIONS
DRIVEWAY PERMIT
FIREiDEPARTMENT
RECEIVED BY BUILDING INSPECTOR DATE
Revised 9197 Jm
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BUYER: R,A L
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DEcK.
ep
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_Lo fi
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TO TME MORTGAGE INSPECTION PLANMND ITS TITLE INSURERS
1 LOCATED IN
i �FanFv T14AT THF Run cors, smvai Do f 1 CONFORM TO SETBACK REQUIREMENTS
pORTM
Of,
TOWN OF NORTH ANDOVER
�SS�cNuSet
BUILDING DEPARTMENT
400 OSGOOD STREET
NORTH ANDOVER MA 01845
T). Robert Nicetta,
Building Commissioner
978-688-9545
978-688-9542 Fax
HOMEOWNER LICENSE EXEMPTION
Please print
DATE
JOB LOCATIONp� e.rl 0 Z-111A��
N Street Address Map/Lot
HOMEOWNER
Name Home Phone Work Phone
PRESENT MAILING ADDRESS
City/Town State Zip Code
The current exemption for"homeowners"was extended to include owner-occupied dwellings of
two units or less and to allow such homeowners to engage an individual for hire who does not possess a
license,provided that the owner acts as supervisor. (State Building Code Section 108.3.5.1.)
DEFINITION OF HOMEOWNER:
Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is or is
intended to be,one or two family dwelling,attached or detached structures attached or detached structures
accessory to such use and/or farm structures. A person who constructs more than one home in a two-year
period shall not be considered a homeowner.
The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and
other Applicable codes,by-laws,rules and regulations.
The undersigned"homeowner"certifies that he/she understands the Town of North Andover Building
Department minimum inspection procedures and requirements and that he/she will comply with said
procedures and requirements.
HOMEWOWNER'S SIGNATURE
APROVAL OF BUILDING OFFICIAL
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North Andover Building Department
Tel: 978-688-9545
DEBRIS DISPOSAL FORM `
c 40 S 54 a condition of Building Permit
In accordance with the provision of MGL ,
Number is that the debris resulting from this work shall be
disposed of in a properly licensed solid waste disposal facility as defined by MGL
c11, S150A.
The debris will be disposed of in:
(L cation of acility)
OZ2Signature of Permit Applicant
Date
NOTE: Demolition permit from the Town of North Andover must be obtained for
this project through the Office of the Building Inspector
Bo "ii o�) �ogeguTatic7ns an tan �d"s� License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Registr8.tion: 107278 Board of Building Regulations and Standards
Expiration.,::7,/30/2006 One Ashburton Place Rm 1301
j Boston,Ma.02108
TYPe: DBA
BUONOMOCONSTRUCTICIN ';� 1 - — -:q__� -_-s_ - •
John Buonomo
41 Floral Avenue "` ' " BOARD OF BUILDING REGULATIONS
Maldenl-MA 02148 Administrator License: CONSTRUCTION SUPERVISOR
Numbers CS 004416.
Birthdate: 05/04/1955 i
EXpires: 05/04/2006 Tr.no: 24452
Restricted: 00
JOHN J BUONOMO
41-FLORAL AVE
MALDEN, MA 02148
*0 _ Commissioner
J
N
sl;125
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TO THE
AND ITS TITLE INSURERS. MORTGAGE INSPECTION PLAN
I CERTIFY THAT THE BUILDINGS SHOWN DO ( ) CONFORM TO SETBACK REQUIREMENTSLOCATED (N
ppI
I.E. (FROM?, SIDE. It REAR SETBACK ONLY) OF No. Ia.N>�.l�i{, 0Qf��-t� �.��Q���.
WHEN CONSTRUCTED, OR ARE EXEMPT FROM VIOLATION ENFORCEMENT ACTION UNDER MASS. G.L
TITLE VII, CHAPTER 40A. SECTION 7. UNLESS OTHERWASE NOTED. MASSACHUSETTS
I FURTHER CERTIFY THAT THIS PROPERTY IS ABrr LOCATED IN THE ESTABLISHED FLOOD
HAZARD AREA. DEED
COMMUNITY PANEL NO.:?tjCX):)B•0010 1!;'DATE: 6-1Gj
1300K ` 3. _
THIS COMPANY IS NOT RESPONSIBLE FOR ANY INDENTURES MADE SUBSEQUENT TO THE RECORDED
DATE OF THE LATEST DEED OF RECORD.
PAGEI��. 4- _
WHENEVER BUILDINGS ARE SHOWN LESS THAN ONE FOOT FROM THEPROPER DVISED CERT. N0.
THAT A MORE PRECISE SURVEY BE MADE TO VERIFY THESE MEASUREMEN �H OF Afw_'
THIS CERTIFICATION IS BASED ON THE LOCATION OF SURVEY MARKERS R T PLAN BK. PAGE
RBE
T A PROPERTY SURVEY. VOUFICAIM OF SURVEY MARK S
MAY ACCOMPLISHED ONLY BY AN ACCURATE, INSTRUMENT SURVEY. WAYS CTET) PIAN t�
� 112 _._ DATED!g7d
ON THIS PLAN. BOUTnNg ��P T.
THIS CERTIFICATION TO BE USED FOR MORTGAGE P ES-ONLY. ;p
OFFSETS AS; ARE NOT TO BE AL 0 >611
USED FOR THE ESTABVIMENT OF PROPERTY , ��V ;� Som` l'a V
°slak BRADFORD
EGINEERING CO.
P.O. BOX 1244
HAVERHILL MA. 01831
I
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/ r Building Sketch (Page - 1)
BWowmTAvt PAUL ROBBAT
MmmAdgres'125 GRAY STREET
jCky NORTH ANDOVER cma ESSEX MA JbCode 01845
Lender NEW ENGLAND HOME MORTGAGE
I
2ND FLOOR
BATH BATH
BEDROOM
28
BEDROOM
BEDROOM
BEDROOM
4r
IST FLOOR ;
DECK �1T
I
r
BATH
WNINOROOM
KITCHEN Z
ZB
LMNO ROOM
i FOYER FAMILY
14•
_agkfiMlor NYArs," - - _
AREA CALCULATIONS SUMMARY AREA BREAKDOWN
Code Daaoriptbn sw NotToeah Breakdown subtotals
p/p porch 121.00 121.00
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Form SKf.BId5M—TOTAL for Vh dons'W"Wives by a 6 made,kr——14MBALAMODE
3 �
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Q-- 140-00 _ 4
40 0„w
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LOT 10�
1. 0 ACr-tES + c
49N
L o T C,, 'w
.a
42.38 r
LOT
31.7 t' 1.0 ACRS + M
7G-34-30 � O
1.0 A CRS
L o-r D o
R " 1.0 ACRS
s j
�✓ N
! - V
M o-
?3 N
�o• Roc. . -"-►
-- 1 xi. Qa
13 o0
S Go��F�•4o% cy SO X-GvZ
t NORTH '9
own of
:.� Andover
Y13
_
LAKE y dower, Mass.,
COCHIC HE wICH
ADRATED PPS` '�C
S BOARD OF HEALTH
Food/Kitchen
PERMIT T D Septic System
THIS CERTIFIES THAT.......?.41...
V 1 2 0 4..1; BUILDING INSPECTOR
has permission to erect......at..�. 1
.... uildings on ...!a ..... rA.`.........S.�'............................... Rough
tobeo •u ! Fr�� FNS' 414* 1t1 y P
occupied as 3 c�SO o tl% *,V J%Wbect4himney
provided that the person accepting this permit shall in every respect 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. , 9) $7 D/ " PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
Final
PERMIT EXPIRES IN 6 MONTHS
ELECTRICAL INSPECTOR
UNLESS CONSTRU N ST TS .
CRough
.. .... .. . . . ....... ..................
Service
BUILDING INSPECTOR
Final
Occupancy Permit Required to Ow cpy Building GAS INSPECTOR
Display in a Conspicuous Place on the Premises — Do Not Remove Rough
No Lathing or Dry Wall To BeDOne FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner
Street No.
SEE REVERSE SIDE 'smoke Det.
Dec 20 04 01 : 07p Paul Robbat 978-689-8110 p. 1
.519
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPEC710M FORM
PART C , -' l Ul74 ,
SYSTEM INFORMATION !continued!
Property Address: f 7
Owner: Tr�ci� - /V, 04z,"e,2., "AA _� � J/14
Date of Inspection:
.r-- ;,%'lel C'Cfi' i!«-'✓✓<< �
SKETCH OF SEWAGE DISPOSAL SYSTEM--
include
YSTEM:include ties to at least r--ro permanent references landmarks or benchmarics
locale all'wells within 100 (Locale where public crater supply comes into hovse)
�e5
'
FiouyG
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'
NEW ENGLAND ENGINEERING SERVICES
INC
PIC
April 4, 1998
North Andover Board of Health
Town Hall Annex
30 School Street
North Andgver,MA 01845
RE: 'TITLE V REP T 125 Gray Street.
Enclosed is,.a-copy o Title V-report for-125-Gray Street,North Andover, MA. The--system
asses our inspection.
If there are any questions please call me at my office, 686-1768.
Your 1
Yours truly,
c Q
Benjamin C. Osgood Jr.,E.I.T.
President
33 WALKER RD. - SUITE 22 - NORTH ANDOVER, MA 01845 - (508) 686-1768
COMMON\NTALTH OF MASSACHUSETTS
(�y EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET. BOSTON. SIA 02108 617-292-5.560
r
V,
WILLIA-f F.WELb TRUDY COXE
Govemo: Secretary
ARGEO PAUL CELLUCCi DAVID B.STRUHS
Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner
PART A
CERTIFICATION
Property Address: / GF-ctc� s�. Address of Owner:
Date of Inspection: '
),'719 g _ (If different)
Name of Inspector, ,(?je.i�a rn,✓� C 0-160co ,tz
I am a.DEP appr ved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: /Ue,,l Fnalaj ces y.c,
Mailing Address: 3 3 L.J.-;'t(A tt 2S Sv ie Z3 AJ- �4• ��e2 >�
Telephone Number: Ai 4?A- 6 jab- 17 b e
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 inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
Passes
Conditionally Passes
Needs further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: C Date:
The System !nspecdor shall submit a copy of this inspection report to the Approving Authority within thirty(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 Department of Environmental Protection. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
INSPECTION SUMMARY: Check A, B, C, or D:
AI SYSTEM PASSES: '
—ZI have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
COMMENTS:
BI 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.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not.
_ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty(20) years prior to the date of the inspection; or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
(revised 04/25/97) Page 1 of 10
DEP on the World Wide Web: http:/Mww.magnet.state.rna.us/dep
^ o,:,t-i—PwvMeA Paner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: IAS- (:S-(-ate S+fee ' r N. A'1J 0')elL AtA
Owner: Ra� T.��►-�, kv—
Date of Inspection: 31t7�q 9
BJ SYSTEM CONDITIONALLY PASSES (continued)
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if'(with approval of the
Board of Health). Describe observations:
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four 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 replaces
obstruction is.removed
CJ FURTHER EVAILUATION 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 protea the
public health, safety and the environment:
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
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 APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
_ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or
tributary to a surface water supply.
The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well. unless a well water analysis 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. Method used to determine distance (approximation not valid).
3) OTHER
I
(revised 04/25/97) Paga 2 of 10
.777
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: fey �s S t rec�'� N 4'so v im/ MA
Owner: nn
Date of Inspection:
3ltZI98
D) SYSTEM FAILS:
You must indicate either "Yes" or "No" as to each of the following:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
Yes No
,Backup of sewage into facility or system component due to an 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.
Static liquid level in the distribution boa 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 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any porton of a 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 I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Ahv porton 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. If the well has been analyzed to be acceptable, attach copv of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E) LARGE SYSTEM FAILS:
You must indicate either "Yes"or "No" as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
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)
The owner or operator,of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 04/25/97) Page D of 10
I
I -
... ..
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: /,2IS �J"Y�a.y N A'e"J&Zc OYl
Owner: ieaJ rno.+�Q V70� a 4r.0
Date of Inspection. r
Check if the following have been done: You must indicate either"Yes"or"No" as to each-of the following:
Yes No
✓' — Pumping information was provided by the owner, occupant, or Board of Health.
✓ None of the system components have been pumped for at least two weeks and the system has been receiving normal
— — I
flow rates during that period. Large volumes of water have not been introduced into the system recently or
as part of this inspection.
I -
✓ As built plans have been obtained and examined. Note if they are not available with N/A.
I
►� — The facility or dwelling was inspected for signs of sewage back-up.
✓ — The system does not receive non-sanitary or industrial waste flow.
The site was inspected for signs of breakout.
All system components, excluding the Soil Absorption System, have been located on the site.
The septic tank manholes were uncovered, opened. and the interior of the septic tank was inspected for condition of
baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
The size;and location of the Soil Absorption System on the site has been determined based on:
✓ — The facility owner tand occupants, if different from owner) were provided with information on the proper maintenance of
Sub-Surface Disposal System.
Existing information. Ex. Plan at B.O.H.
— Determined in the field (n anv of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) (15.302(3)(b)]
(reviaed 04/25/97) page 4 of 10
• ' r
L
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 12,5- 6rrc,..3 S4-� N_ A J.5,ivt , /14A
Owner: l�tr-
Date of Inspection:
3`f-1�0t3
FLOW CONDITIONS
RESIDENTIAL:
Design flow: g.p.d./bedroom for S.A.S.
Number of bedrooms:
Number of current;residents: 3
Garbage gnr der (yes or no):_*_
Laundry connected to system (yes or no):L
Seasonal use lyes oar no): //
Water meter readings, if available (last two (2) year usage (gpd): �- 60 q.�.9. L�F}�j ectl-�
Sump Pump (yes or'no):
Last date of occupant•: 'Cor,-e..T
COMMERCIAUINDUSTRIAL•
Type of establishment:
Design flow: gallons/dav
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 o:cupancy:
OTHER: (Describe,
Last date of occupancy.
I
GENERAL INFORMATION
PUMPING RECORDS and source of information:
yw,etl 3 N s_t ecx-s 43 r` ld,^aU- D4j- !).-,/ri
System pumped as part of inspection: (yes or no)NO
If yes, volume pumped: gallons
Reason for pumping-
TYPE
umpingTYPE 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)
VA Technology etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information: «,rs. y- Q�ny
Sewage odors detected when arriving at the site: (yes or no)AZ
(revised 01/25/97) Page 5 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: f � Gr�a� Si, /V, A.Joue/i.
Owner: yrho T-o a a►keg
Date of Inspectiol5: 311-7 I�
BUILDING SEWER:
(Locate on site plan)
Y
Depth below grade:
Material of construction: cast iron _40 PVC—other (explain)
Distance from private water supply well or suction Ire /V 19
Diameter
Comments: (condition of joints, venting, evidence of leakage, etc.)
PC 1 ti
SEPTIC TANK:_
(locate on site plan)
Depth below grader_ �
Material of construction: Vconcrete _metal _Fiberglass _Polyethylene _other(explain)
If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No)
Dimensions:_JSOOI C-f}LIdNS
Sludge depth: 3"
Dislance from top of sludge to bottom of outlet tee or baffle:34/
Scum thickness: 1
Distance from top of scum to top of outlet tee or baffle: S „
Distance from bottom sof scum to bottom of outlet tee or baffle: /2
How dimensions were'determined: measu re. snc K
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles depth of liquid level in relation to outlet invert, structural n
integrity, evidence of leakage, etc.) is ,.moi 4 0 Co.cf? fion L'ross '%^ ,ct!e
/1 Qe,r)1v.._,A +Le. n/ �v���I(F�1�.n a -ccA Y0 Yee
*lof IneL�LQ +o flu G elo -
GREASE TRAP: IV
(locate 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:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.)
(revised 01/25/97) Page 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 12S' Gc,. s1-,,ec-}� Ala,41, 4j.*.'Vt—
Owner: 2aZ)--!,-J, Tog
Date of Inspection:
3 l t`1 1q 8
TIGHT OR HOLDING TANK: .Crank must be pumped prior to, or 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 _ gallonJda%
Alarm level: Alarm in working order_ Yes; _ No
Date of previous pumping:
Comments:
(condition of inlet tee. condition ci alarm and float switches, etc.)
DISTRIBUTION BOX:_
(locate on site plan)
Depth of liquid level'above outlet invert:
Comments:
(note if level and distribution is equal,nevidence of solids carryover, evidence of leakage into or out of box, etc.)
i, O K e-cvi •*'C' � By x wC.s` A ,,S bt/ o d xll ewe/
9 i 7tS r ef1P C& gi tV 1.n �L
!f cd 7�p 7G�Ow. / �O�.tJ �E�Jf(P/`S wyy ins 1 Ile.Q
CJ//C c� f'l. fJ�t�•llt�
i
PUMP CHAMBER:0
(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.)
(raviaed 0{/2S/97) Page 7 of 10
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address': )�s GVwk� Sf-Ve}; A). � ntq
Owner: a-b m o,&Q %,,14." (SER
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS):
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type.
leaching pits, number:_
leaching chambers, number:_
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:1 -6,
overflow cesspool, number:
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
CESSPOOLS:
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth.of solids layer:
Depth of scum laver:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow (cesspool must be pumped as part of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:AA
(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.)
(revised 04/25/97) 1 Page a of 10
a
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: aS G � �- /V� ����e�� i+ntA
Owner:
Date of Inspection: R�� "i°"� � "��
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (locate where public water supply comes into house)
i�lu05C
O�
0
(revised 04/25/97) Page 9 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 1 �m,-) sfinef /J_
Owner:
Date of Inspection: R `Q al(ej?
98
Depth to Groundwater , Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observation of Site (Abuttingproperty,p perry, observation:hole, basement sump etc.)
>f Determine it from local conditions
Check with !oca! Board of health
Check FEMA maps
Check pumping records
Check local excavators, installers
✓ Use USGS Data
Describe in your ow•n,words how you established the High Groundwater Elevation. (Must be completed)
Sod-S i n f4w
Z, 7Gsf was'
ne V1�e*1 we;�fj - & .,SCA
v u n l d it c f'�s
c`}' •.A' 114-
� �e�.,2l� o�sehvs���s. /✓a
(revised 04/25/97) Page 10 of 10
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