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Home My WebLink AboutMiscellaneous - 1537 TURNPIKE STREET 4/30/2018v m Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. v I—I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Asses sm nt oop� 1537 Turnpike St Property Address Nancy Gauthier Owner's Name North Andover City/Town MA 01845 State Zip Code 6/29/2016 Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information KECEIVED Inspector: JUL 2 8 2016 William Pearce TOWN OF NORTH ANDOVER Name of Inspector Pearce Construction Company Name 196 Park Street Company Address North Reading Citylrown - 978-664-5264 Telephone Number B. Certification MA State SI13837 01864 Zip Code License Number ` I certify that I have personally inspected the sewage disposal system at this address and°tha(the information reported below is true, accurate and complete as of the time of the inspection. The inspe 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 ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority - I 4Ye Inspector's Sigrfature— Date 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. """"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. t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 =�- Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1537 Turnpike St Property Address Nancy Gauthier Owner's Name North Andover Cityfrown B. Certification (cont.) MA 01845 6/29/2016 State Zip Code Date of Inspection Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ® 1 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: Site appears dry and with slope down and away from the system. } 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. Check the box for "yes", "no" or "not determined" (Y, N, ND) 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. ❑ Y ❑ N ❑ ND (Explain below): t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1537 Turnpike St Property Address Nancy Gauthier Owner's Name North Andover MA 01845 6/29/2016 Cityfrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 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 system is not functioning in a manner which will protect public health, 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 t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 == = Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1537 Turnpike St Property Address Nancy Gauthier Owner's Name North Andover City/Town B. Certification (cont.) MA 01845 State Zip Code 6/29/2016 Date of Inspection 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 surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ 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 fecal coliform bacteria indicates absent 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: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into 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 ❑ ® 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 '/2 day flow t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 4 of 17 "Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1537 Turnpike St Property Address Nancy Gauthier Owner Owner's Name information is required for North Andover MA 01845 6/29/2016 every page. City1rown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® 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 fecal coliform bacteria indicates absent 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 and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® 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 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. 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 If 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. 15ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1537 Turnpike St Property Address Nancy Gauthier Owner Owner's Name information is required for North Andover MA 01845 6/29/2016 every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® 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: ❑ ® Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 440 t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 6 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1537 Turnpike St Property Address Nancy Gauthier Owner's Name North Andover Cityrrown D. System Information Description: Number of current residents: MA 01845 6/29/2016 State Zip Code Date of Inspection Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) El Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? Last date of occupancy: Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: Gallons per day (gpd) Attached ❑ Yes ® No Current Date ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System •Page 7 of 17 if Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1537 Turnpike St Property Address Nancy Gauthier Owner Owner's Name information is required for North Andover MA 01845 6/29/2016 every page. Cityrrown State Zip Code D. System Information (cont.) Last date of occupancy/use:- Other (describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Type of System: gallons Date Date of Inspection ❑ Yes ❑ No ® 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) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1537 Turnpike St Property Address Nancy Gauthier Owners Name North Andover City/Town D. System Information (cont.) MA 01845 State Zip Code 6/29/2016 Date of Inspection Approximate age of all components, date installed (if known) and source of information: 1990s Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): Depth below grade: Material of construction: ® cast iron ❑ 40 PVC ❑ other (explain): Distance from private water supply well or suction line: 43 inches feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: 1 foot feet ❑ Yes ® No Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene E3 other (explain) Baffles in place, tank looks OK roots have infiltrated the tank If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 5 x 8 x 5 feet deep Sludge depth: 2 feet t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 9 of 17 Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1537 Turnpike St Property Address Nancy Gauthier Owner Owner's Name information is required for North Andover MA 01845 6/29/2016 every page. City/Town t5ins - 3113 D. System Information (cont.) State Zip Code Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 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 Inspection 1 foot 10 inches 8 inches 1 foot How were dimensions determined? Tape Measurer Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): recommend pumping, baffles in place, no evidence of leakage Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal feet ❑ 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: Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 10 of 17 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 1537 Turnpike St Property Address Nancy Gauthier Owner Owner's Name information is _ required for every page- City/Town MA 01845 6/29/2016 State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene [I other (explain): Dimensions: Capacity: Design Flow: gallons gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: Date of last pumping: Date Comments (condition of alarm and float switches, etc.): ❑ Yes ❑ No * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 17 Commonwealth of Massachusetts .Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments b 1537 Turnpike St Property Address Nancy Gauthier Owner Owner's Name information is required for North Andover MA 01845 6/29/2016 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: l5ins - 3113 Title 5 official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 1537 Turnpike St Property Address Nancy Gauthier Owner Owner's Name information is required for North Andover MA 01845 6/29/2016 every page. Citylrown t5ins - 3/13 D. System Information (cont.) Type: ® leaching pits ❑ leaching chambers ❑ leaching galleries ❑ leaching trenches ❑ leaching fields State Zip Code number: Date of Inspection number: number: number, length: number, dimensions: (1) 5 foot diameter ❑ 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.): Concrete block leachpit, 2 feet of sludge Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth — top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Title 5 official Inspection Forth: Subsurface Sewage Disposal System - Page 13 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1537 Turnpike St Property Address Nancy Gauthier Owner's Name North Andover MA 01845 6/29/2016 Citylrown State Zip Code Date of Inspection D. System Information (cont.) 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.): t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 Owner information is required for every page. Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1537 Turnpike St Property Address Nancy Gauthier Owner's Name North Andover MA 01845 6/29/2016 Cityfrown State Zip Code Date of Inspection 40 D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view 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. Check one of the boxes below: ® hand -sketch in the area below t5ins - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1537 Turnpike St Property Address Nancy Gauthier Owner Owner's Name information is required for North Andover MA 01845 6/29/2016 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 6 - 8 feetfeet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® 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: Local wells indicate depth at over 8 feet. You must describe how you established the high ground water elevation: Site slopes down from house and system to about 2 feet below leach pit, then 8 feet near road. Site is at a hiqh elevation relative to surrounding area. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins • 3113 Title 5 Oficial Inspection Form: Subsurface Sewage Disposal System - Page 16 of 17 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 1537 Turnpike St t. Report Completeness Checklist 6/29/2016 Date of Inspection ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file (Sins • 3113 Title 5 Oficial Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 Property Address Owner Nancy Gauthier Owner's Name information is required for North Andover MA 01845 every page. Citylrown State Zip Code t. Report Completeness Checklist 6/29/2016 Date of Inspection ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file (Sins • 3113 Title 5 Oficial Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 Jun. 23. 2016 10:42AM ammmy Romd Cad acnem(rd on 6(231201614:20-MAM by ii W Hen(on Town of North Andover Tax Map # 210-107.B-0009-0000.0 Parcel id 18123 1537 TURNPIKE STREET GAUTHIER, ERNEST 1537 TURNPIKE STREET N. ANDOVER, MA 01845 No. 0837 P. 4 P�aa CIa95 101 Single Family Property Type 1 Residential Zoning2 1 Residential Zonin93 1 Residential Size Total 1.43 Acres FY 2016 UB Mai[insa Index Name/Address Type Loan Number Activellnact, From GAUTHIER, ERNEST payor 1537 TURNPIKE STREET N. ANDOVER, MA 01845 US Account Maint. Account No Cycle Occupant Name Activel(nactive Bldg Id. 13227.0 - 1537 TURNPIKE STREET Last Billing Date 6/14/2016 2100012 02 Cycle 02 Active UB Services Maint. Account No. 2100012 Service Cade Rate Charge MultiplierNaers MISCFEEADMIN FEE 0.635/8 7.82 1l WTR WATER 01 ALL METER SIZE 120.40 !i UB Meter Maintenance Account No. 2100012 serial No Status Location Brand Type 16944393 a Active ERT HH b Badger w Water Date Reading Code Consumption Posted Date 612/2016 1093 a Actual 28 6121/2016 2/1/2016 1065 a Actual 33 3128/2016 10/30/2015 1032 a Actual 37 12/30/2015 8/3/2015 995 a Actual 44 9/14/2015 511/2015 951 aActual 29 6/22/2015 214/2015 922 a Actual 33 3/20/2015 1114/2014 889 a Actual 33 12/15/2014 8/6/2014 856 a Actual 24 9/11/2014 5/912014 832 a Actual 24 6/12/2014 2/3/2014 808 aActual 23 3/17/2014 11/1/2013 785 aActual 28 12120/2013 8/7/2013 757 a Actual 37 9/18/2013 5/112013 720 a Actual 27 6116/2013 2/1/2013 693 aActual 32 3/13/2013 10/30/2012 661 aActual 24 12/13/2012 8/1/2012 637 a Actual 32 9125/2012 511/2012 605 a Actual 20 6/20/2012 2/1/2012 585 aActual 19 314/2012 1111/2011 566 a Actual 20 12/15/2011 81312011 546 a Actual 47 9/14/2011 5/3/2011 499 a Actual 18 6/13/2011 217/2011 481 a Actual 22 3/15/2011 11/212010 459 aActual 39 12113/2010 8/2/2010 420 a Actual 56 9/1312010 5/5/2010 364 a Actual 26 6/9/2010 2/212010 338 aActual 31 3/11/2010 11/3/2009 307 aActual 29 12/11/2009 8/5/2009 278 a Actual 35 9/112009 5/1/2009 243 a Actual 27 6/16/2009 Size 0.63 0.63 Until YTD Cons 991 Variance -12% -17% -10% 39% -6% -2% 36% 7% 3% -25% -14% 24% -11% 28°x6 -23% 57% 8% -7% -57% 141% -7% -46% -33% 123% -17% 6% -12% 23% 6% Date....!. Z":.—/**i�=/-040 TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ...... C A�. ................... has permission to perform .............. ... r.. ...... wiring in the building of ...... 5a�ert�— ..... ................................................................ at ..../,-77......1..;; �x........57.....North. Andover, M S. ........... /4 ............ 4 .A16 ......... :No. * 6-r Fee. Lic. Check# 3 71� ;C 10465 A Commonwealth of Massachusetts Official Use O,nly P De artment of Fire Services Permit No. f o 41 j` Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: /j�j t City or Town of. NORTH ANDOVER To the Ins ec or of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) /✓s37 j ojzoiol KL s7 Owner or Tenant 111,41,1c7 s y/j Telephone No. Owner's Address �f}rvr Gr Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service New Service Amps / ' Volts Amps Number of Feeders and Ampacity Volts Overhead ❑ Undgrd ❑ Overhead ❑ Undgrd ❑ No. of Meters No. of Meters Location and Nature of Proposed Electrical Work: !2C-2C &IA S7 te2.t Completion of the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- El rnd. rnd. o mergency ig ing Batte Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS I No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices g 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 Value of lectrical Work: "`�,jCZ� (When required by municipal policy.) Work to Start: o LIMP Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE C V RAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE °d BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and enalties of perjury, that the information on this applicatio 's true and complete. // FIRM NAME: P -t-41 (%L�Ki ft I (�Z aI✓%j7AC A' LIC. NO.: /�/ /q Licensee: _hyq/L(sy C4&-&44- Signature LIC. NO.:S-7/4)qF— (If applicable, enter "exempt" in the license number line.) Bus. Tel. No. �/-L`/.r nt t Address: Inter .(/C�i2iTl f1f/Gr d�/�46cC-'r/G�n �'1.t.A CJ/old Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires 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/Agent PERMIT FEE. $ Signature Telephone No. ) /- f f -1s www.mass.gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: IS % i&x j