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Miscellaneous - 175 OLD CART WAY 4/30/2018 (2)
Commonwealth of Massachusetts City/Town of System Pumping Record r` Form 4 JUN U b 2012 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left / Right front of house, Left / Right rear of house, Leftght side of hou , Left / Right side of building, Left / Right front of building, Left / Right rear of building, nder deck Address V 7 Cityfrown c State Zip Code 2. System Owner. a Name Address (if different from location) City/Town States O Telephone Number B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): Date Cesspool(s) — 2. Quantity Pumped Septic Tank Gallons ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Conditio of`t(em`ry� Y\- 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Lo here contents were disposed: G. S. Lowell Waste Water of F5821 Vehicle License Number �5- / 7— /,A - Date t5fonn4.doc• 06/03 System Pumping Record • Page 1 of 1 I ,=Location a eAA ("i5 440.!i ' C Date w 3?0.;;° "T ;�tioL TOWN OF NORTH ANDOVER f p Certificate of Occupancy $ Building/Frame Permit Fee $ $ 'ss�c►+ur sEth Foundation Per Fee $ Other Permit F e M $ S� Sewer Connection Fee $ Water Connection Fee $ TOTAL $(0 k34-,0Building Inspector � T7 708 Div. Public Works 120 blain Strr_s. 0134.5 - x.?. a�_=oN Town of = _ -- .. (508) saz-sem °"`e°' =• = NORTH ANDOVER .. LoXSER TION PLAN—N tiG CONDAUNI TY DEVELOP3fMN' T -f —�- DAT vrs+'t: l/L �� ��C�iJ losfi lJ..riY ✓ NAME VX x tf -eauc =:.e coca Cr _ u_es and la= = s - LIC. _ ole �PS— THISP��`��T = T-- — � = Di5?T..�a'jED ON Tr.= Location V7 O L-0 CA CZT W No. Q 2-51 Date 8212 Div. Public Works 0 TOWN OF NORTH ANDOVER s Certificate of Occupancy Building/Frame Permit Fee $ asz $ Foundation Permit Fee $ Other Permit Fee $ i° g Sewer Connection Fee $ .o Water Connection Fee $ o• Z` TOTAL $ 6 k Building Inspector Div. Public Works Location' ,, No.' ©� Dat UA 8485 7 A g TOWN OF NORTH ANDOVER Certificate of Occupancy $ 0 Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ _ Sewer Connection Fee $ Water Connection Fee $ 0 TOTAL $ ByUdi g Insp ctor wDiv. , Works Location ��� �L�� G4 W AQ No. Date ,1 r vld-�- -� a M.- TOWN OF NORTH ANDOVER Certificate of Occupancy $ S� Building/Frame Permit Fee $ Foundation Permit Fee $ 100 Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL $(2'&I5� 0 N Building Inspector ` Div. Public Works PERMIT NO. • l APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. PAGE 1 MAP 4d0. /Q ZONE O I LOT NO. SUB DIV. LOT No. — 2 RECORD OF OWNERSHIP—IDATI BOOK :PAGE — L'bCATION �A[D �/1 1�ij l PURPOSE OF BUILDING 14 o e-- cd A cAp- 6� OWNER'S NAME NO. OF STORIES SIZE f� 3SZ64r- �.! 11s� C�vVNER'S ADDRESS IxJ 41 01*1 Tl #A-r/Gf'/u 1 /m / �T'6 /�/A`� BASEMENT OR SLAB ARCHITECT'S NAME SIZE OF FLOOR TIMBERS1lS'Tx,v/1 2ND �v'rt 3RD �//� BUILDER'S NAME NAME �y, 11�IC [/LADt'T/I'/`'q SPANK of - DISTANCE TO NEAREST BUILDING �l��Tt/T�' T DIMENSIONS OF SILLS / --- POSTS ZA44 r DISTANCE FROM STREET 347 ,r. DISTANCE FROM LOT LINES - SIDES�d L REAR oda -'4-GIRDERS T �-x /"7- FRONTAGE tSp AREA OF LOT / t� I/)CC L -c HEIGHT OF FOUNDATION p� << THICKNESS O� �ot� IS BUILDING NEW I/lf• ! J SIZE OF FOOTING !• x IS BUILDING ADDITION)eV MATERIAL OF CHIMNEY IfQrcK IS BUILDING ALTERATION/" IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE ,ru IS BUILDING CONNECTED TO TOWN WATER [YS BOARD OF APPEALS ACTION, IF ANY IS BUILDING CONNECTED TO TOWN SEWER �c IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS SbrnE As c0- Ac,4 SEE BOTH SIDES PERMIT FOR FOUNDATIONONLY PAGE 1 FILL OUT SECTIONS 1 - 3 REGULATED BY PARA. 114.8-S. B.C.U PAGE 2 FILL OUT SECTIONS 1 - 12 ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING DATE <<° Ict4 FEE PAID ~ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR DATE FILED • SIGNATURE OF OWNER OR AUTHORIZED AGENT V (� F E E ►`�^�= �� PERMIT FOR FRAME/BUtt.DING 00 G .f� . PERMIT GRANTED 19 — DATE: 'S�Act�� FEE PAID•. 3 PROPERTY INFORMATION LAND COST `n 5zw EST. BLDG. COST 77 ����`_ n' .rrt,•r/ "7t EST. BLDG. COST PER SQ. FT. EST. BLDG. COST PER ROOM 9 SEPTIC PERMIT NO. 4 APPROVED BY OWNERTEL # CONTR. TEL. # 3d fp;;� ' � CONTR. LIC. N. /4 O 4 8 H.I.C. # put em PERMIT IFEE I©� S LESS IN W.� �. DUE FRAME PERMIT; 1 3, B ILDING RECORD 1 OCCUPANCY 12 SINGLE FAMILY STORIES THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTA�E FROM r MULTI. FAMILY oFFiceS _- LOT LINES AND EXACT DIMENSIONS OF BUILDINGS, WITH POR ES. GA- APARTMENTS RAGES, ETC. SUPERIMPOSED. THIS REPLACES, PLOT: PLAN._. CONSTRUCTION S' 2 FOUNDATION 8 INTERIOR FINISH CONCRETE PINE 3 1 _ ✓ 2 13 ✓' ✓ CONCRETE BL BRICK OR STONE TON - HLAST PIERS PLASTER R DRY WALL —_ — _ _ UNFIN. 3 BASEMENT AREA FULL FIN. B M AREA 7, 1/1 '/, FIN. ATTIC AREA _ NO B M T FIRE PLACES HEAD ROOM MODERN KITCHEN 4 WALLS IL 9 FLOORS CLAPBOARDS B (� _ 1 _ 2 �_ 3 DROP SIDING CONCRETE WOOD SHINGLES - - EARTH ASPHALT SIDING ASBESTOS SIDING HARDVJ D COM/ACN VERT. SIDING ASPH. TILE STUCCO ON MASONRY _ STUCCO ON FRAME BRICK ON MASONRY ATTIC STRS. & FLOOR _ III BRICK ON FRAME I CONC. OR CINDER BLK. WIRING STONE ON MASONRY STONE ON FRAMESUPERIOR ADEQUATE I� POOR NONE 5 OF 10 PLUMBING GABLE GAMBQEL HIP BATH 13 MANSARD TOILET RM. I2 FIX.) M. ( — FLAT SHED WATER CLOSET ASPHALT SHINGLES LAVATORY WOOD SHINGES KITCHEN SINK _ J SLATE NO PLUMBING TAR & GRAVEL STALL SHOWER ROLL ROOFING MODERN FIXTURES _ TILE FLOOR _ _ - TILE DADO 6 FRAMING 11 HEATING WOOD JOIST It PIPELESS FURNACE FORCED HOT AIR FURN. 1� TIMBER BMS. & COLS. STEAM _ STEEL BMS. & COLS. HOT W T'R OR VAPOR _ WOOD RAFTERS AIR CONDITIONING _ RADIANT H'T'G UNIT HEATERS _ VM -T 2nd t ELECTRIC 1st 13rd I NO HEATING . �:_.;,..,..., Tv ,I ,goyy v CO) C � CO) I�I�^ CD Y/ Cl)co z CO2 CD O 'O tz r C'i Di1 .O -a O d= y O O v CD CD O Q � c CD CD o CD C CD rn Q O in O O CD v CO) O -v z CD O CD CD 0 C CD t"f ca C m Go N Amo ® � H m � w = • m N T F as O ?m H CD q .+ C =m �^ m = t t CD -% tm9 a Som o tz :! V m 55- C :r CD C-3-0 = r _ m :!n y d P. m . cr C O � _d N 9 m O �. m i m . N CA O m d N :^ :-j o�` 0 0 mo C40 -0 0 CD .- CD o n D r*� o m S sCDd C=1 CD f Pb o ao�=: m 3 o c C) °=' G ^1 �^,• •°= _7i a'— rD tom,,, z c �z x GO) vz �J y 0 0 c 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. ****************App icant fills out this section***************** APPLICANT• Phoneb8"3%�% LOCATION: Assessor's Map Number �G%-� Parcel S u b d i v i s ions Lot (s) Street St. Number ************************Official Use RECOMMENDAT ONS OF TOWN ENTS: / Date Approved `0 / 5� Conservation Administrator Date Rejected Comnents Town Planner Comments Food Inss��pector-Health ,.�6 LSC / Q Septic Insnecpor-Health Conumerts Date Approved q Date Rejected Date Approved Date Rejected 1/6 Date Approved 3 Date Rejected Pub -is Wcr::s - set.;er; water connections - dr'_veway permit Fire Department Received by Building Inspector Date W, -'MOW . 30 �iviP AGG j/" i� -- — _ i49.71_2 ,F 43, 9/8 S, F. T. _ /AZ. 22 /, oag2 Ac. D� r 3Z qs �L e4,e 7— _— S //EREBY CE.eT/FY TO T.yE T/T[E 1A1S6-,e0•C- 44,0 TU Tf✓E BAN,r TygT TyE OwEL[ iu6 /S LOCATED O,c/ T/iE 40r off—loW.'rW AMV T,v,4T?OAFS CO.dFGiP�r1 .,W7W T.S/E >uw.v ' OF,vd. An/Govr.= 20N/NG ,eE6vL,4Tit�,t�S AW4 4R0/yv SETBAC,C.S' FG0A1 STeEG`'TS ; r GOT U•uES. 1 F!/,PT,Yfe CE.eT/FY ;;VWT 7WI-r Oi4-ELL/N6 /S -VDT L40l.4TE0 /AI T,YE FEOE,PAG FiCAoO fi4 Z.4e0 4,e—E.W. �OwN O/y FEMA' CO�MUN/Ty ,o,,rNGL '� ,/� �G� noa� llg 000e e r OF Aigs,S v MCCPIZ�r HOF%'J;P�iVy /7L O T Re- OiC ,4�/V FDiP �� 'Y�►�a'rivVw A.t/ODYE.� /l7,4SS.oC/Y�/SE7TS O/8/O q E' --ca i s Date ............. TOWN OF NORTH ANDOVER o p PERMIT FOR PLUMBING This certifies that ........................................... has permission to perform .......:........................... . plumbing in the buildings of .................................. at ...................................... North Andover, Mass. Fee......... Lic. No.......... .............................. PLUMBING INSPECTOR Check # MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS .i Date Building Location G.t Owners Name Permit # Amount New 0 Renovation ❑ Replacements Plans Submitted Yes ❑ No FIXTURES (Print or type) �"'t �Pl2 Check one: Certificate Installing Company Name �% �� C_ _ Corp. '7 Address " 7 ❑ Pariner. Buffness Telephone D �S3 ❑ Firm/co. Name of Licensed Plumber. Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policya Other type of indemnity ElBond❑ Insurance Waiver. I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner ❑ Agent ❑ I hereby certify that all of the details and information I best of my knowledge and that all plumbing work an compliance with all pertinent provisions of the Mas By: NrgnaM Title City/Town cense APPROVED (OFFICE USE ONLY submitted (or entered) in above application are true and accurate to the it5hs p ed under Permit Issued forthis application will be in s'te,P u Sde and Chapter 142 of the General ws. Master ® Journeyman ❑ a. 47Ub Of MOPTM 7y ti p Town of North Andover HEALTH DEPARTMENT ass^cMus�� CHECK #: ✓ / ATE: LOCATION: H/O NAME: CONTRACTOR NAME: Type of Permit or License: (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 $ 0,� T etie- Report $ ❑ Other. (Indicate) $ Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer Commonwealth of Massachusetts 1 Ins ec ion Fo Title 5 Official p Subsurface Sewage Disposal System Form - Not for Voluntary) 175 Old Cart Property Address Graham .Innes ;sessments 7 2910 fiCi4N t OF I?flMTH AkliMm„— Owner Owner's Name information isNorth Andover MA 01845 2/5/2010 required for State Zip Code Date of Inspection every page. CitylTown 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. Important: A. General Information When filling out forms on the computer, use 1. Inspector: only the tab key to move your Neil J. Bateson cursor - do not Name of Inspector use the return key. Bateson Enterprises Inc. Company Name VQ 111 Ar ilia Road Company Address Andover Ma 01810 reaan Cityrrown state Zip Code 978-475-4786 SI15 Telephone Number License Number B. Certification 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 ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority -�zA(, - Inspectoft Signat e 2/5/2010 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 • 09/08 Title 5 Official Inspection Forth: 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 Forth - Not for Voluntary Assessments 175 Old Cart Way Property Address Graham Jones Owner's Name North Andover MA 01845 2/5/2010 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 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: 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 . 09/08 Title 5 Official inspection Form: Subsurface Sewage Disposal System • Pane 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 175 Old Cart Way Property Address Graham Jones Owner Owner's Name information is required for North Andover MA 01845 2/5/2010 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 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 • 09108 Idle 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 175 Old Cart V1 Property Address Graham Jones Owner's Name North Andover Cityrrown B. Certification (cont.) MA 01845 State Zip Code 2/5/2010 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 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 fallowing 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 El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins • 09/08 Title 5 Oficial Inspection Forth: Subsurface Sewage Disposal System - Page 4 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 175 Old Cart V Property Address Graham Jones Owner's Name North Andover Cityrrown B. Certification (cont.) Yes No MA 01845 State Zip Code 2/5/2010 Date of Inspection ❑ ® 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. El ® Any portion of cesspool or privy is within 100 feet of a surface water supply or the system is within 200 feet of a tributary to a surface drinking water supply tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. E] ® Any portion of a cesspool or privy is within 50 feet of a private water supply Area — IWPA) or a mapped Zone 11 of a public water supply well 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 N 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 11 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. t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 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 175 Old Cart Way Property Address Graham Jones Owner's Name North Andover MA 01845 2/5/2010 Citylrown 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 ® ❑ El 0 ® ❑ El z ® ❑ ® ❑ ® ❑ ® ❑ ® ❑ 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): 600 t5ins • 09/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 17 Sump pump? Commonwealth of Massachusetts —_ Title 5 Official Inspection Form Date " Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Type of Establishment: 175 Old Cart Way - Basis of design flow (seats/persons/sq.ft., etc.): Property Address Grease trap present? ❑ Yes ❑ No Graham Jones ❑ Yes ❑ No Owner Owner's Name Water meter readings, if available: information is required for North Andover MA 01845 2/5/2010 every page. City/Town state Zip Code Date of Inspection D. System Information Description: 2 Number of current residents: Does residence have a garbage grinder? Yes ❑ No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No Yes Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Current Last date of occupancy: Date CommerciaUlndustrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day (gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non -sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins • 09/08 Tille 5 official Inspection Form: Subsurface Sewage Disposal System • Page 7 or 17 Commonwealth of Massachusetts -- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w '< 175 Old Cart Way 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: Date Pumped 2006 owner 2/5/2010 Date of Inspection ® Yes ❑ No 1500 gallons Measured tank Inspect tank & baffles ® 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 . 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 Property Address Graham Jones Owner Owner's Name information is North Andover MA 01845 required for Cityrrown State Zip Code every page. 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: Date Pumped 2006 owner 2/5/2010 Date of Inspection ® Yes ❑ No 1500 gallons Measured tank Inspect tank & baffles ® 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 . 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ' 175 Old Cart Way Property Address Graham Jones Owner Owner's Name information is North Andover MA 01845 2/5/2010 required for State Zip Code Date of Inspection every page. Cityfrown D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 15 years old, 6/12/1995, as built plan Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer (locate on site plan): 3 Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other (explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): 4" PVC thru wall to tank, N1 PVC in house, no leaks visible Septic Tank (locate on site plan): 2 Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No 10' x 5' x 4' Dimensions: Z. Sludge depth: 15ins • 09108 Title 5 official Inspection Form: Subsurface Sewage Disposal System' Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 175 Old Cart Way Property Address Graham Jones Owner Owner's Name information is North Andover MA 01845 2/5/2010 required for every page. Cityrrown State Zip Code Date of Inspedion D. System Information (cont.) 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 How were dimensions determined? 24" LIS 19" 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 leakage. Grease Trap (locate on site plan): Depth below grade: feet 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: Date t5ins • 09/08 Intle 5 Oficial t spedion 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 175 Old Cart Way Property Address Graham Jones Owner Owner's Name information is North Andover MA 01845 2/5/2010 required for every page. Citylrown 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 Dimensions: Capacity: Design Flow: Alarm present: Alarm level: ❑ fiberglass ❑ polyethylene ❑ other (explain): gallons gallons per day ❑ Yes ❑ No Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins - 09108 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 w r 175 Old Cart Way Property Address Graham Jones Owner Owner's Name information is North Andover MA 01845 2/5/2010 required for every page. Cityrrown 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 C 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 & distibution equal. No evidence of leakage. No evidence of carryover. D -box cover broken, replaced it. 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: 15ins • 09/08 Title 5 official lnspeclion Fpm: Subsurface Sewage Disposal System • Page 12 of 17 Owner information is required for every page. t5ins - 09108 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 175 Old Cart Way Property Address Graham Jones Owner's Name North Andover MA 01845 2/5/2010 Cityrrown state Zip Code Date of Inspection D. System Information (cont.) Type: leaching pits El leaching chambers ❑ leaching galleries 21 leaching trenches ❑ leaching fields ❑ overflow cesspool ❑ innovative/altemative system number number: number number, length: number, dimensions: number. 3 trenches 50' long 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 snow covered. No sign of ponding to surface. 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 Tttle 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 175 Old Cart Way Property Address (,rnharn Jones Owner Owner's Name information is required for North Andover MA 01845 every page. City/Town state Zip Code D. System Information (cont.) 2/5/2010 Date of Inspection 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 - 09108 Tide 5 official Inspection Form: Subsurface sewage Disposai System - Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments '< 175 Old Cart Way Property Address Graham Jones Owner Owner's Name information is required for North Andover MA 01845 every page. City/Town state Zip Code D. System Information (cont.) 2/5/2010 Date of Inspection 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 ❑ drawing attached separately B A- 3 t 9_Vj �-a-A,!lt-, \4a 1 Is II t5ins - 09108 Tdle 5 Official Inspection Farm: Subsurface Sewage Disposal System •Page 15 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 175 Old Cart Way Property Address Graham Jones Owner's Name North Andover MA 01845 2/5/2010 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells 4' Estimated depth to high ground water: feet 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: 5/13/1986 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: You must describe how you established the high ground water elevation: No water 4' below trenches as per test pit data on design plan. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins - 09108 Title 5 Official Inspection Forth: 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 y 175 Old Cart Wad+ Property Address Graham Jones Owner Owner's Name information is required for North Andover MA 01845 2/5/2010 every page. City/Town state Zip Code Date of Inspection E. Report Completeness Checklist ® 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 t5ins - 09!08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 17 of 17 �-L\ Commonwealth of Massachusetts u City/Town of System Pumping Record Form 4 DEP has, provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left side of house, ik��uildir Left front of house, Right front of house, Left rear of house, Right rear of house.g. Right rear of building. Address 1 0 1C , C-CN`A- AvdL��r Cityfrown Zip Code 2. System Owner. Name Address (if different from location) CityfTown B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): OV\ a -E-1 0 Date State —106 tom. Code Telephone Number l� 2. Quantity Pumped: Gallons Cesspool(s) eptic Tank ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes 0; -Mo If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System": p� � e'�Ja-j ) v" _ �� 4 `- 6. System Pumped By: Neil Bateson F5821 Name vehicle License Number Bateson Enterprises Inc Company 7. Location where contents were disposed: D 'J n ,-% Lowell Waste Water �)- -S--1-0 MMM t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Summary Record Card generated on 2/11/2010 12:57:43 PM by Karen Hanlon Page 1 Town of North Andover Tax Map # 210-107.B-0106-0000.0 Parcel Id 18191 175 OLD CART WAY JONES, GRAHAM 175 OLD CART WAY NORTH ANDOVER, MA 01845 Class 101 Single Family Property Type 1 Residential Size Total 1.01 Acres FY 2010 UB Mailina Index Name/Address Type Loan Number Active/Inact. From Until JONES, GRAHAM Payor 175 OLD CART WAY NORTH ANDOVER, MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 13792.0 - 175 OLD CART WAY Last Billing Date 2/3/2010 1090469 01 Cycle 01 Active UB Services Maint. Account No. 1090469 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 19.00 /1 UB Meter Maintenance Account No. 1090469 Serial No Status Location Brand Type Size YTD Cons 32772691 a Active 00 b Badger w Water 0.63 0.63 117 Date Reading Code Consumption Posted Date Variance 1/21/2010 361 a Actual 5 2/12/2010 -76% 10/22/2009 356 a Actual 21 11/11/2009 63% 7/24/2009 335 a Actual 13 8/12/2009 63% 4/24/2009 322 a Actual 8 5/13/2009 2% 1/23/2009 314 aActual 8 2/10/2009 -81% 10/22/2008 306 a Actual 42 11/12/2008 105% 7/22/2008 264 a Actual 20 8/15/2008 91% 4/23/2008 244 a Actual 10 5/19/2008 -26% 1/28/2008 234 a Actual 15 2/19/2008 -80% 10/24/2007 219 a Actual 75 11/16/2007 82% 7/20/2007 144 a Actual 39 8/15/2007 247% 4/20/2007 105 a Actual 10 5/21/2007 -15% 1/29/2007 95 a Actual 14 2/20/2007 -69% 10/25/2006 81 a Actual 42 11/16/2006 105% 7/28/2006 39 a Actual 20 8/18/2006 19% 5/2/2006 19 a Actual 19 5/16/2006 -100% 1/24/2006 0 n New Meter 0 2/13/2006 -100% 1/24/2006 2516 rReplacement 20 2/13/2006 -81% 10/27/2005 2496 a Actual 112 11/9/2005 243% Trouble Code:03 7/25/2005 2384 a Actual 33 8/10/2005 83% 4/21/2005 2351 a Actual 15 5/13/2005 -20% 2/1/2005 2336 a Actual 23 2/15/2005 -22% Trouble Code:03 10/27/2004 2313 a Actual 26 11/15/2004 -63% Trouble Code:03 Date.................................. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ........... & ....... 7, 0- 4. .............................. has permission to perform ................... wiring in the building of ......... � < ......................... at ...... 1-7 ................. .......... North Andover, Mass. Fee ...3 :�� Lic............... LECTRICAL INSPECTOR Check # 7833 Commonwealth of Massachusetts Official Use only f Department of Fire Services Permit No. -753 BOARD OF FIRE PREVENTION REGULATIONSOccupancy and Fee Checked [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 WINK OR TYPE ALL INFORMATION) Date: NOV. 07 Zoo 7 City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) 175 Dro e',e. ti!/y Owner or Tenant .iolver, / 6"C -4 -1V64 -t-- Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ® No ❑ (Check Appropriate Boz) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ New Service Amps / Volts Overhead ❑ Undgrd ❑ Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: $.47-YV' oom jeG/V1 oDtf /A/ 6 No. of Meters No. of Meters No. of Recessed Luminaires 2• �.� V I'm uciuwin No. of CeL-Susp. (Paddle) Fans rab[e may be watvea bY the /nS ector of Wires. o. of Total Transformers KVA No, of Luminaire Outlets Z No. of Hot Tubs / Generators KVA No. of Luminaires Swimmin Pool Above In- Swimming ❑ o. o mergency tg g nd. rnd. Babe Units No. of Receptacle Outlets No. of On Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners o. of Detection an Initiatin Devices No. of Alerting Devices No. of Ranges No. of Air Cond. Total Tons No. of Waste Disposers eat Pump Number Tons o. of Se Contained Totals: _..... """""""' Detection/Aler[in Devices No. of Dishwashers Space/Area Heating KW g Local ❑ unicipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Water No. of Devices or Equivalent No. o No. of Heaters K' Data Wiring: Si s Ballasts . No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total Hp Telecommunications Wiring: No. of Devices or Equivalent OTHER: Estimated Value of Electrical Work: - ion — Attach additional detail if desired, or as required by the Inspector of Wires. (When required by municipal policy.) Work to Start: //. L7• pi 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 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 ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under the pains andpenalties ofperjury, that the information on this application is true and complete. FIRM NAME: 11&4 e -44-47,41C LIC. NO.: //21"/ A Licensee: fwz4/v 'e • /V/(,I- Signature LIC. NO.: I,ZY/ 4 (If applicable, enter "exempt " in the license number line) Address: Bus. Tel. No.:t'do3)�� *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Alt L cl. 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/Agent owner El owner's agent Signature Telephone No. PERMIT FEE: $ �� o� l /� � � e �� x The Commonwealth of Massachusetts ' l Department of Industrial Accidents ., Ogee of Investigations 600 Washington Street Boston, MA 02111 C-1 www nzassgov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual):E--cG!/-(C Address: S C/-. City/State/Zip: Znvon,,/L"G;[,CY Al /V70 #:. a!U3� Z�S-:3375 Are you an employer? Check the appropriate box: Type of project (required): i. 1Z f atn a employer with Z 4. ❑ I am a general contractor and I 6. ❑ 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. t 7. Remodeling ship and have no employees These su&contractors have S. ❑ Demolition working for mem" any capacity, workers' comp. insurance. q, ❑ Building addition [No workers' comp, insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3. ❑ 1 am a homeowner doing all work right of exemption per MOL 11.❑ Plumbing repairs or additions myself. [No•worke'rs' comp. c. 152, § 1(4),'and we have no 12.[] Roof repairs insurance required.] t .employees. [No workers' comp. insurance required_] 13.[] -other -e : • — ••• •• o• w.w�e ��x ff must also nu out tt►e section below showing their wotkerc' ootnpensatioe policy information. t Homeowners who submit this affidavit indicating they are doing all wotIkI and then hire outside contractors must submit a new affidavit indicatinsuc lContractors that check this box mustattaehed an additional sheet showing, the name of the sub-conUschors and their workers, comh p, policy infg omu<I I ant an emlployer that rs providing:workers' compensation insurance for my employees: Below is the policy and job site information. Insurance Company Name: ' LA�p ke'lz Y �.vSve,QNGF� /y'r91VII-1warelel All/ Policy # or Self -ins. Lie. #: Expiration Date: ✓Urt/E 4� Job Site Address: 175'acv . Eq T u.9 �, ����, City/State/Zip: /V. f!i✓pOvc�i M�% 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains an�d �penaUks. of perjury that the information provided above is true and correct Sitmature - •�� Date •Z�. D? 76Y • 3&73 - Official use only. Do not write in this area, to be completed by city or town— City or Town: Permit/License # Issuing Authority (circle one): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. 6. Other Plumbing Inspector Contact Person Phone #: 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 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 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 Accid=ts for confirmation of insurance coverage.. Atso *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 worker&' compensation policy, please call the Department at the numberlisted below. Self-insured companies should enter their self insurancelicense 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 (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 bum 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 of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7744 Revised 5-26-05 www.ma.ss.gov/dia � Safety Insurance - - - --- -PO Box 55098 _ Boston, MA 02205 Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS, Ch. 139, Sec. 3B To: Building Commissioner or Board of Health or Inspector of Buildings Board of Selectman City Hall City Hall NORTH ANDOVER, MA 01845 NORTH ANDOVER, MA 01845 RE: Insured: BHAVISHA P PATEL and PUSHPAK M PATEL Property Address: 175 OLD CART WAY, NORTH ANDOVER, MA Policy Number: HMA 0335898 Claim Number: BOS00066000 Date of Loss: 11/15/2015 Company: Safety Indemnity Insurance Company Claim has been made involving loss, damage or destruction of the above -captioned property, which may either exceed $1,000.00 or cause Mass. Gen. Laws, Chapter 143, Section 6 to be applicable. If any notice under Mass. Gen. Laws, Chapter 139, Section 3B is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim number. Bryan Savosik Claim Examiner Safety Insurance Company Homeowners Claims Unit P. O. Box 55098 Boston, MA 02205-5098 Phone: (617) 951-0600 EXT 2070 Fax: (617) 535-5841 Email: BryanSavosik@Safetylnsurance.com 11/19/2015