HomeMy WebLinkAboutMiscellaneous - 1270 TURNPIKE STREET 4/30/2018 (7)6033
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Town of North Andover
HEALTH DEPARTMENT
�SS4CMUSt�
CHECK #: 7� D Te E:
LOCATION:
H/ O NAME:
!; CONTRACTOR NAME:
Type
of Permit or Lic6nse: ('Check box)
'
❑
Animal
$
❑
Body Art Establishment
$
❑
Body Art Practitioner
$
❑
Dumpster
$
❑
Food Service - Type.
$
❑
Funeral Directors
$
❑
Massage Establishment
$
❑
Massage Practice
$
❑
Offal (Septic) Hauler
$
❑
Recreational Camp
$
❑
Sun tanning
$
❑
Swimming Pool
$
❑
Tobacco
$
❑
Trash/Solid Waste Hauler
$
❑
Well Construction
$
SEPTIC Systems:
❑
Septic - Soil Testing
$
❑
Septic - Design Approval
$
❑
Septic Disposal Works Construction (DWC) $
❑
Septic Disposal Works Installers (DWI)
$
❑
Title 5 Inspector
$
❑
Title 5 Report
$
$��
Q, -Other. (Indicate)
Health Agent Initials
White - Applicant Yellow - Health Pink - Treasurer
TOWN or� NORTH ANDOVER
.NORTH ANDOVER, MASSACHUSETTS 01845
rev
4
Permit Number
Datelssued &IIIIa"gla
Expiration Date.
glll�
jackie's Law — Permit Application
Pursuant. to O.L. e. 82A §1 and 510 CMR 7.00 et seq.(js amended) 0
THIS PERMIT MUST BE FULLY COMPLETED PRIOkTO CONSIDERATION
1Name .of Applied tPhone
Az s ear A&A4A('q
Celt
-Street Address M� :
f 0S
City/roWn
M.
f7 t"A
0� Z:47'�'
Name of Excavator (if different 1roinapplidant):
Mite coil
Street Address
City/FO;;
MA
ZXP
- t .
Name of owierw'. 9 rovok . y
Cell
!L
SOeet AddrIess(0-14-7
414 A4 �e iuoi�
� .T
A -t. a k �s 2XQ
CW"Town .
zir
Permit Fee Received No Yes
Other Contact
Description, location and purpose of proposed. tienicb.,
Please:describe, the exact location of-therproposed trench and its purpose (Include a description of what is (or is intended) to
be la(din pr6posed trench (eji; pipt6lcablo lines otci):Please use reverse.sido if additional space Is needed.
5,a- A ec.,w- -A-Srza rt I V1 q --6t c
4
A
:Insurance CeWricate *a
Name apd..Coutact Information of Insurers
lz
NameofCompkeid Pe*rson.(as defined by $10 CMR
1"atk
4-0!
#
ey,�-U,4,,
1. Woo Cade-,
Eip'..
gagoub4to,
BY SIGNING: THIS 'FORME THE. APPLICAN-T.j::OWNER, AND EXCAVATOR ALL ACKNOWLEDGE*
AND CERTIFY TH
AT THEY AR9 FAMILIAR Wr M, OR, 'BEF09E.C-ONMENCEMEN, 70F Tim
wo WILL 89COMENFMI. FAMILIAR
IAR WI - TH,,..ALL LAWS AND REGULATIONS APPLICABLE TO
WORT: PROPOSED,: IPIWO 911 -,M.CM*R7.#Qetseq.,ANDANY
. 4. %V OSTIA, R9G'VLATIOXS,. OX.. c.. V A
APPLICABLE MUNICIPAL: ORDINANCES, BY-LAWS' ANY) REGULATIONS AND THEY COVENANT
AND AQ EE THAT ALC.- WORK. DONE UN THE PLUMIT ISSUED FOR'SUCH. WORK WILL
T `T.HE COIqDff'* IONS SET FORTH BELOW.
THE UNDERSIGNED OWNER AUTHORIZES THE APPLICANT TO APPLY FOR THEPERMIT AND
THE EXCAVATOR. TO UNDERTAKE SUCH WORK ON THE PROPERTY" OF THE OWNER, AND
ALSO, FOR THE DURATION OF CONSTRUCTION, AUTHORIZES PERSONS DULY APPOINTED BY
THE MUNICIPALITY TO ENTER UPON THE PROPERTY TO MONITOR AND INSPECT THE WORK
FOR CONFORMITY WITH THE CONDITIONS ATTACHED ]CIE ItETO AND THE LAWS AND
REGULATIONS GOVERING SUCH WOM
THF,,YJNDEOI.0,NF,PAPPLICANT, OWNS I N YEXCAVAT0RA0WJOIN L-YANDSEVXRALtY
TO REIMBURSE TH-t. MlUNICIPALIT'YFOR AN.Y..Al4D.-.AL)L COSTS. AND XP
E EN$ESINCUR-REDRY.
.
Tot ?4UNICIPALIVIN CONNE-Cn - ON WIT -117105 AND TIM D.
WORK CONDUCTED
THEREUNMR, INCLUDINGUUTNOT LIMITED'TO ENVORCINGITHE REQUIREMENTS OF STATE
LAW A" CONDITIONS Of THIS PERMIT, INSP mmw TO A U'
.-W -H AND IOASU 9:TAKEN DYTHE M NICWALITY TO PAOTECTTHE PUBLIC
WHERE THE APPLICANT OWNER OR EXCAVATOR UASFAILED TO COMPLY THEREWITH
INCLUDING POLICE *DETAILS AND OTHER REMEDIAL MEASVRE S DEEMED NECESSARY -'BY
THE MUNICIPALITY:
THE VNI)ERSIGN)MAM"" X'ANT, OWNER, AND EXCAVATOR. AGREEJOINTLY AND SEVERALLY
TO bkftft, N"1119Y, AND HOLD HARMLESS THE 'MUNICIPALITY AND ALL OF ITS AGENTS
AND tmrwyus FROM AN . Y AN . D . AL I L LIABILITY, CAUSES OR. -ACTION, COSTS, AND `.EXPENSES
RESULTING FROM OR -ARISING OUT 'OF ANY INJURY, DEA TH LOSS, OP. DAMAGE TO ANY
PER
RSON OR PROPERTY DURING THE WORK CONDUCTED UNWRTHIS PERMIT.
QNATUR
DATE
EXCAVATOR SIGNATURE (IF DIFFERENT)
DATE.
Ow (IF DIFFY&,RENT)
DATE: Afteh 2-,
1 A�QU�E�TS P�URSUA�14TTO G1 C/.*-82tACATK/D 1520 - CMR 7.;Oo et seq.
'BY signing the application; Otidthe APPItt-uhdOsOt9tt.es to Ohp yW
the following?
No trench may .-Oe;excava1edq Wess4he requirements: orf sections 40 through 401 of-chaptor OZ, and any
accomFoying.regulations, havo been met and. this permit is Invalid unless and until said-r.eq4iramont'&
have been complied with by the excavator applyinglor the,.perniJt including, but not.limited to, :the
establishment of a vaNexcayation number with the underground. Plant dam*age prevention. s.y4OM as
said system is defined in section 76D of chapter 1-64 (DIG SAFE)11.
Trenches may pose a significant health and safety. hazard. Pursuant to Section I of Chapter 82 of the
General Laws, an. excavator shall not loave.any open:trench unattended without first, making every
reasonable effort to elinfinate.:any recognized safety hazard that.may exist as a result.of leaving said
open hunch unattend .. Excp%p(t:shoixid Ongoltogulationg promulgated by the Department of
PON Safety in -order to. famfliarizo t.hmg selves V1(htIp-,reOOgnij .1 zed safety. . hazards associated.with
jregqhes OAdihe procedures req ited pr recommended by soiddepartment in
order -to make every reasonable effort.to eliminate said s4fety hazards which imay InOude covering,
barri*oadihg or otherwise protecting open .-trenches froth accidental, entry,
Persons engaging lri 'in- an 11-fadijif " iethernselves with. the:fOderal safety
yttoicliffigo.peratibil.sha. I arl
standardspro gated q the ocqupatibn4l Safety: Oalth Administration on excavations: 29 CM
mW y and If
1526,050 v.soq.,,-entItlod Subpart P'Sxcavadons".
Excavators engaging In any trenching. operation who. utilize hoisting or othermechanical equipment
subject to chapter 146 shall only employ lndlvidiials licensed toopdrate. said equipment by. the
Mpartment of Public. Safety pursuant to said chapter and this pegnit must be presented to said licensed
operator b6breanY exavation is commenced,.
'ty-applyinB,for., accepting and signing,this permit, the applicant hereby attests to the following. (1) that
thorhave read and understands theregulationspromuf-gat.ed.bythe .l)epartmentof Pulili,c . Safety with
regard to construction related .excavations and trepqh sgflity; (2), that he has.,PuW. and understands the
federal safely standards. promulgated. by the Occupational Safety and floalth Adniinistration on
excavations:. 19 CUR 1,926.650 et.-seq., entitled Subpa4 P "Excavations" as well as.any other
t)t;av4fjon. requirements established by this municipality; and (3) that he Is aware of and ha§*with
regard to the proposed trench excavation on private property or proposed excavation of a city or town
public way that form the basis of the permit application, oonipliod with the requirements of sections 40-
40D of Oba -ter 82A,
VI.;
This,perm,:it shall b6.posted; in plain view on.thesite of the trench.
For additional inforinotion, Department of Public :Safety's website at m�avx-mmuovks
31P.A.g.0
SumMgU0 EM-yati on §W _T_r1n_0. SA @(y Regulation (522 CMR 14.00ouog1
This summery waspro*oo bythe Massachusetts 5epartmento.fRijbilo-Safety pursuariv to G.Lc42Awd. does not
include: all requirements of the: $20 CMR 1:4.00. To. view ihe'Aill regulation and:G1.c.82A, go to: www1mass,gov/dps
Pursuant to MAIL c. 82, § 1, the Department of Public Safety, jointly With the Division of Occupational Safety,
drafted :regulations relative- to trench safety. The rogulation is.codified in svotion 14.00 of title 520 of the Code of
Massachusetts. Regulations, The -regulation requires all excavators to. obtain a permit prior to the excavation. of -a
trench made for a odpsttbPtion-related purpose on, public or private [and or rights-oftwq. All municipallift.s.must
establish a local permitting authority for the purpose of issuing permits for trenches within their municipality.
Trenches on land owned or controlled by.a public (state) agency requires a permit to be :issued. by that public agency
unless otherwise:designated.
In, addition to the permitting req �uir0rinonIt mandated by statute, the trench safety regulations require- that. all
exc4vators.; whether public or private; take speciff.oprocautlions to protect the general public and. prevent unauthorized
access to unattenM.tronoW, Ab6ordliqlyj unattended trenches: must be covered; barricaded .or backfilled Covers
must be road plates atleash l%il thivX.m.e.quivalonq Nriioados mum. be fences at least 6' high: with no openings.greater
604M Wt�v
: . -ettl.e-a I supp... ...
oft Backfilling mu
st be suffidlent to elindnawthd trench. Alternatively, excavators
May;Aq040 to attend fititchts at!9111imeg, f6r ihkaftooby hiring polled Mail, security -guard oroth.0 awn4antwho
MR be: present; during. timetwhon the trench will be unattended by the, excavator.
The replatio is. ffirtliteppovide that.local rmit049106104tiog, th6
Dopwtmot;of Public, gafw.. orth6Dhrisldn:of
Occupational' Safety may order an*immedlate:shutdown of atrench intho:evencof adeath :orserious iijuty.y the Uwe
to Main a .permit; or the failureto implement or eftetively use adequateprotections -for the general publlc. The
trench .shall remain shutdown until re -inspected and authorized to re -open provided, however, 'the: excavators shall
have. the right to appeal an immediate shutdown. Permitting authorities Are further authorized. to, suspend or revoke a
permit f6howing:.a hearing. "Excavators, may also be subject to-:ad1mIniW9lV.e floes Issued: by. the Department of
PObRoSaf khoj4ns?
Summary ummary of 1926 CM Subpart P -OSHA Excavation Standard
This is avorker protection standard, and is designed to protect employees who are working: inside. a trench.. This
swnniary was prepared by the :Mas kfiusOts Div*.Jsibn:of. Occupational Safety and. riot OSHA for informational
purposes only and .does not constitute om official interpretation by OSHA of their regulations, and may not,inclu4t all
aspects o.f-the standard.
For Author information or a f4lL.copy of the
lie. standard ard go:to www 4sha.gov,
Trench Nfirittionver the OSHA .9taWard.
o MaoxcavattOn maxio below the surface ofthe ground, narrow in: relation to. its. length.
6 ln.;o otal-,'the,depth is greater than the width, but the width of the trench is not greater than fifteen
.feet.
:Protective Systems to prevent soil wait collapse. are always- required. in.trenohes deeper than 5% and af.e also
Tqq.tt.4W..' trenches: less'than 5' deep when the oompelontperson determines: that a hazard. exists, Protection:
op_ flarisinclude
o Shoring, Shoring must be .used in ac-opydano With. W OSHAExoava.tion, standard appendices, tk
equipment
'hiahufaot
oter's tabulatedulatod data, orAesigaed bya registered
professional engineer. r.
p $Jt1eldfiig (Trtn6h 3ox.Trench boxes rnust.bo,used in accordance with the oquipmetit
mintifacture,el iabulato4 datai% a registered professional engineer,
o Slopiing.or*Bonchih$in, Type C: soils (what, ismost typically encountered) thelexcavationmust
extend horizontally I Y2 feet for every foot of treftch depth oti both sides,, I foot for Type B sells,
and % foot for Type A soils.
-0 A registered professional engineer must design protective -systems for all excavations greater than
20' in depth.
continued
4 J.P al.g 0
• Ladders must be. used Intromhos. d0por than 4'.
o Ladders;tust be inside the-tronch.Wtith workers at. all timesk and, located within 25' of unobstructed
literal ttaM fdf *v!:ry-Wofkef In the -ttenoh.
o Ladderstust ewnd.V above -ft-top of tbetrO%h so. Workers qan.srdely got onto and off of the
ladder.,
InspottI.6n,9,6foverytrtitchworksite areireqtjired,
0 Pri6rto the start of each shift, and againwhentherv, is tchange :inconditions such as a 'storm.
A ram
o Inspections must be conducted by the competent person (Soo below),
• Competent Persons) Is:
o CApkLd('tq,,trained tnd..kftowledg"le) inidenti.6iii.9existing and predietablthazards inthe
trench, and other, workih& conditions which maypoic a hazard to:workers,ind
b AZWw
�kby management to take necessary corrective action to eliminate the hazards.Employees
mustbe Temovediombazardous areasuntilthe hazard has been corrected.
• Underground: . Utilities: must bc-
0. ldejitifledptiorto.opeting;thoexcavatio.ni(a.g..,00.'ntutDig.Sgf6),
0 Locatedby_safeand acceptable means while excavating.
o Protdotedi supported, or removed once exposed.
• Spoils must be kept Woltz minim= of 2" :from tlie:-edge of the trench.
Surfitoo-Encuinbrawcos creating.ahazard must-be. removed or supported w-safeguard-6raployess. Keep
-heavy eqUipmenVand heavy material as far baok,kom the. edgeoftheonchas p ossib1c.,
tr.
•
Stability of Adjacent Sthictures.,
.Q stability ostructures is:endangered by creation of the trench; they must`be
u .
tinaorpi*w4, brfted,.-or otherwise supported,
.o
Sidewalks, pavetnerits; etc. shall not be:tuidermined unless.a.support system. o.r other method of
protoctioo is provided.
• It isnot allowable for employees to work in trenches with accumulated water.. If watercontrol such
as pianping is used: to prevent water accumulation, this must be monitored by the competent:person.
• If the. trench interrupts natural drainagv, of surface water, ditches, dikes;. or other meansmustbe used
to prevent thls,water from, entering the wAva
. 11on.
Additional Requirements.,
0 Formobile .equipment operated near the -edge oftbe trench,, a warning system such as barricades or
stop IV must be used.
.0 Employses,are not permitted to work underneath loads. Operators may not remain in vehicles
being loaded unless- vehicles are equipped with adequate-protection as per 1.9-26.661 (:b
o Emplpy.ees-inugt.weehigh-visibility olothinglo, Vattio woA zonex.
o Air monitoring mustbo,00.nduoted in trenches deeVer than: 41 ifthe potential for.4-hazardous
atmosphere, exists..hazardouss, b4tardoaUtios0.1i*reJs:1bn0 to;exist .(e,g.,02.-<19.5%..or��23.59/6,20*/���
LFIL,speeiffq p .heolleM haz ventilation ard):44equ4to protections.shall be taken suo.b.-as ve lation Of the space.
`Walkways are required where employees must cro-".overthe trench. Walkwayswith,gOardmits.
crossing over im.nehos.>.6'deep.
o .9mployees must be protected from loose rook or soil. through
protoctions such as scaling or
prot%, tivebarricades,
5 J -P a &0