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HomeMy WebLinkAboutMiscellaneous - 133 DALE STREET 4/30/2018 i i I I i i �I 4 f � 0'0000-L600 8-Lc&lmz __13381S 3lb'0££l , 1 - ------- J Date.. . ... ................ •HONTH TOWN OF NORTH ANDOVER p PERMIT FOR GAS INSTALLATION � m i • SACHUSES This certifies that l has permission for gas installation . .". . . ... . .. . . . . . . . . . .. .. . . . in the buildings of . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . at . . :. :. . . .. . . . . . . . . . . . . . . . . . . . . , No"dover, Mass. Fee. . . . . . . . . Lic. No.. . . . • 49/23!49 DBe . GAS INSPE" WHITE:Applicant CANARY:Building opt. PINK:Treasurer MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING _ (Print or Type) -- Mass. Date_ 19 ( Permit # ` Building Location /3 Owners Name A'1 1 I 1 t� v✓l�" r. Telephone a— -L -7-2 1ZType of occupancy New.V Renovation ❑ Replacement ❑ Plans Submitted: Yes❑ No❑ N N W N Y Y a rn N U N ¢ O ul a W O V in t .`C z O u Q rt O Q < m N y W O d C �( N tl W < S Z N .rn O W V W y W < 0. W W dl J Z < S X {C O Q W ~ W V J h a t, W W O > W !- .� �. W 2 < W C W O O W O ti h rr •2 O O S U. ? ; O O J V C > D a SUB—BSMT. BASEMENT • 1ST FLOOR 2ND FLOOR 1 9RD'FLOOR 4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR 6TH FLOOR Installing Company Name EnergyUSA, Inc. Check one: Certificate Address 2000 West Park Drive, Suite 300 9 Corporation 1150 Westborough, MA 01581 ❑ Partnership Business Telephone 11800-822-1300 ext. 8051 ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter William. Kent Corson INSURANCE COVERAGE: EnergyUSA has )4XWO a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes EW No ❑ If you havk checked yes. please Indicate the type coverage by checking the appropriate box. A liability insurance policy Er Other type of indemnity❑ Bond ❑ 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: Owner❑ Agent ❑ Signature of Owner or Owners Agent I hereby certify that all of the details and information 1 have submitted(or entered)in above 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 provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. By Tie of License: `���✓� � Plumber Signature of Licensed Plumber or Gas Fitter Title h�'Gasfitter S'Master License Number 3707 City/Town J Journeyman APPROVED(O FICE US .ONL BELOW FOR OFFICE USE ONLY FINAL INSPECTION SKETCHES PROGRESS INSPEC'I0`1 FEE NO. APPLICATION FOR PERMIT TO DO OASFITTING NAME A TYPE OF BUILDING LOCATION OF BUILDING PLUMBER OR GASFITTER LIC. NO. PERMIT GRANTED DATE 19 P 4rGASINSPECTOR /add ress I1 3. l��e�F' S� Title of File Page Of Date file Open: Date file Closed:— Floc Document/Action Title Date of action d0tu a other Purpose of©ocume tin /Act of nand notes Num. Docu°meat/ sloeunvent/ --- Action Department Board of Appeals — Board of Heal h Plann�%ng,Board ; CanSerUatiion commission — Building pepartnlen;t ------ SEPTIC SYSTEM INSPECTION FORM ADDRESS DATE INSPECTED PROPERLY FUNCTIONING? (ny N WEATHER CONDITIONS COMMENTS : 14 MATER aVALI i Y TES to `? JZESoLTS? DYE TEST PERFORMED? Y N DATE? SKETCH: 13,3 TJX �� ��� l � �� Please forward us as much of the following information that is possible; 1• Type of system ,;,-A-) &11,7q �-- 4 - 3. Loa at ion,1C/�' Al Q /�©// 4 . aintenance records and date of last pumping out �)0914 a� ��� ,����,�� U UP- �,�y, ,�7/0 5. T ocumentation of repairs and reconstruction 6. Site conditions 4:!�—x eC1140�1' 7. Builder of systemL�ti���� CUIOI 6,11F97ZAOIW - 8. Engineer who approved% '. — Site Com , o vE) — S-ystem r ' 9. Installation Procedure 10, Problems //G �'✓E WATERSHED RESIDENTS QUESTIONNAIRE 1. Name 2. Street Address 3 l� a le S l � f 3. How many members are in your household? L�7 4. What type of sewage disposal system do you have? ❑ cesspool Er'-septic tank and leaching area ❑ connection to municipal sewer( T� P n- (2- t S a S e we r / e'p- t ❑ other (describe) ❑ do not know 5. Are the plans (drawings) for your sewage disposal system on file with the Board of Health? ❑ yes ❑ no R-'-do not know . 6. How old is your sewage disposal system? ❑ 0-5 years ❑ 6-10 years ❑ 11-20 years L� over 20 years ❑ do not know 7. Has your sewage disposal system been rebuilt o red aired? Lyes ❑ no F1do not know If yes, approximately how long ago? -L Ot 3 years. What was done? 8. How frequently is your sewage disposal system pumped out? ❑ annually 0' everyJ2' 4 years ❑ every 5-10 years ❑ over 10 years ❑ never / ry� 9. Have you had any problems with your sewage disposal system? El yes R no If yes, what problems? ❑ repeated pump-outs needed ❑ system clogs, backs up, or drains slowly ❑ odors ❑ sewage surfaces through ground 10. How many of each appliance are connected to your sewage disposal system? washing machine _L dishwasher garbage disposal dehumidifier drain sump pump toilet - roof/pavement drains shower/bathtub —/- 11. Please state the brand and type (liqui or powder) of detergent you use for: dishwasher EL e c%Y-o 5 a'/ clotheswasher �s�u�d 12. Does your property have a lawn? T yes ❑ no If es, approximately what size? less than 1/4 acre ❑ 1/4 acre ❑ 1/2 acre ❑ 3/4 acre ❑ 1 acre ❑ more than 1 acre (Specify) acres - n 13. How often do you fertilize your lawn? -' 10 i No. of applications per year — Season(s) of the year "Y`U�' Z i� 14. Please state the brand and type (liquid or granular) of lawn fertilizer you use: 1 S • w•R I`C.C � �/.Vt�lJ1C ffWC.Q_JZf, a. Nnad, "4 4-L cr� ❑ Check here if your lawn is maintained by a profession;�lanscap�racctor-