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Home My WebLink AboutMiscellaneous - 178 OLD CART WAY 4/30/2018n 0 \�l IT r N_ O z H o00 7,4 o J n D O � tr1 r tzi� In �-3 1 WATER SUPPLY: ' TOWNS. WELL WELL PERMIT DRILLER WELL TESTS: CHEMICAL DATE APPROVED _ BAC-ERIA I DATE APPROVED____,___.______. COMMENTS: J BACTEN�IA II DATE APPROVED FORM U APPROVAL: APPROVAL TO ISSUE YES NO DATE ISSUED �330�� BY _—_---- CONDLTIONS: FINAL APPROVAL: ALL PERMITS PAID WELL CONSTRUCTION APPROVAL SEPTIC SYSTEM CONSTRUCTION APPROVAL OTHER ANY VARIANCE NEEDED FINAL BOARD OF HEALTH APPROVAL: NO _ NO NO YES NO YES NO DATE:o/- ETMQ S)aTEM-.N.9184L .i3_t1Q IS THE INSTALLER LICENSED? ;`YES . NO TYPE OF CONSTRUCTION: "-NEW-,, REPAIR NEW CONSTRUCTION: CERTIFIED PLOT PLAN REVIEW NO CONDITIONS OF.APPROVAL YES NO (FROM FORM U) ' ISSUANCE OF DWC PERMIT _ _YES NO —r DWC PERMIT N0. ��' i� _ INSTALLER: Ff c%E!' ;:rcd ��'I) BEGIN .INSPECTION YES NO: _ ' EXCAVATION.INSRECTION: :NEEDED: • . PASSED %� ��1. �f' BY " L CONSTRUCTION INSPECTIONS NEEDEDs AS BUILT PLAN SATISFACTORY: YESs„� APPROVAL. TO BACKFILL: DATE: G^v E BY _ FINAL GRADING APPROVAL: DATE FINAL CONSTRUCTION APPROVAL: DATE: I';' •� '" BY �_ r i AS Sui L77 F.LEy,,,- l.o&iS: &D6, COR , A B_ _ G _ TOP Fl_j DTA , = I e134 S.T Zq, Z' I, 3' 14 "o CCN, yo P.vd. 1mv, D- 60 X, 33.3 3o. g -- �, ,, ,., !u Lv S.T, IE�IuD TR Air ¢- 81. Z -?6.q -- OUTGaS.T 8 0uTe D-R)X clss.3(1 SCH ,140 PlF2F; P.v c- I uv. e, IJJtr-7_TW* =105.20 5"I l ,5 ' --x- cAg ' AS BUILT PLAN OF SUBSURFACE DISPOSAL ,SYSTEM LOCATED IN NO (STH ANDOVER , MR A3 PREPARED FOR.. R. S: RIC -HARD Co12P. DATE: oeiosER 2s, X995 SCALE: I "='-lo' MERRIMACK ENGINEERING SERVICES, INC. PROFESSIONAL ENGINEERS • LAND SURVEYORS • PLANNERS: 66 PARK STREET 0 ANDOVER, MASSACHUSETTS 01810 0 TEL. (5a9) 475-3555. 373-5721 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. — I ISI t5ins - 09/08 Commonwealth of Massachusetts Title 5 Official Inspection Fo Subsurface Sewage Disposal System Form - Not for Voluntary) 178 Old Cart V Property Address Kim Maclnnis Owner's Name North Andover Cityrrown MA 01845 State Zip Code y ents ECFIVED ciCd 0 CT aIRTH ANDOVER HEALTH TH DEPARTMENT 10/2 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 1. Inspector: Neil J. Bateson Name of Inspector Bateson Enterprises Inc. Company Name 111 Argilla Road Company Address Andover City/Town 978-475-4786 Telephone Number B. Certification Ma State SI15 License Number 01810 Zip Code I certify that I have personally inspected the sewage disposal system at this address and that the ,4, 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 ❑ e Further Ev ation by the Local Approving Authority 10/23/2009 Inspector' Signatur Date ��i<' tOFaills L S•�►i 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 ortily 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. Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 Owner information is required for every page. t5ins - 09/08 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 178 Old Cart Way Property Address Kim Macinnis Owner's Name North Andover MA 01845 10/23/2009 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: ® I 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): Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 2 of 17 _tel_ Owner information is required for every page. t5ins • 09/08 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 178 Old Cart \ Property Address Kim Macinnis Owner's Name North Andover MA 01845 10/23/2009 City/Town 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 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 178 Old Cart \ Property Address Kim Maclnnis Owner Owner information is North required for every page. City/Tc Name B. Certification (cont.) MA 01845 State Zip Code 10/23/2009 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 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 '/ day flow t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 4 of 17 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 II 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 178 Old Cart Way Property Address Kim Maclnnis Owner information is Owner's Name required for North Andover MA 01845 10/23/2009 every page. Cityrrown 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 II 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 178 Old Cart Way Property Address Kim Maclnnis Owner Owner's Name information is required for North Andover every page. City/Town MA 01845 10/23/2009 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 bedroomsdesi n : 4 4 ( 9) Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 660 t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 178 Old Cart Way Property Address Kim Maclnnis Owner information is required for every page. t5ins - 09/08 Owner's Name North Andover Cityrrown D. System Information Description: 10/23/2009 State Zip Code Date of Inspection Number of current residents: Does residence have a garbage grinder? Is laundry on a separate sewage system? [if yes separate inspection required] Laundry system inspected? Seasonaluse? 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) ❑ Yes ® No ❑ Yes ® No ❑ Yes ❑ No ❑ Yes ® No Yes ❑ Yes ® No Current Date ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w y 178 Old Cart Way Property Address Kim Maclnnis Owner Owners Name information is required for North Andover MA 01845 10/23/2009 every page. City/Town D. System Information (cont.) Last date of occupancy/use: Other (describe below): Pumping Records: State Zip Code General Information Source of information: Pum Was system pumped as part of the inspection? If yes, volume pumped: 1500 gallons How was quantity pumped determined? Measured tank Reason for pumping: Inspect tank & tees Type of System: 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): Date 2008, owner Date of Inspection ® Yes ❑ No t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 178 Old Cart Way Property Address Kim Maclnnis Owner Owner's Name information is required for North Andover MA 01845 10/23/2009 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 12 Years old, 10/23/1995, as built plan t5ins • 09/08 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer (locate on site plan): Depth below grade: 1.5 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" PCV thru wall to tank, 3" PVC in house. Finished cellar has access door for clean out Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal feet ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Dimensions: 10'x 5'x 4' Sludge depth: 3 ❑ Yes ❑ No 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 M 178 Old Cart Way Property Address Kim Maclnnis Owner Owner's Name information is North Andover MA 01845 10/23/2009 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 29„ Scum thickness 3 Distance from top of scum to top of outlet tee or baffle 81- Distance "Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? 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 invert. No evidence of leakage Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass 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: t5ins - 09/08 feet ❑ polyethylene ❑ other (explain): Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 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 178 Old Cart Way Property Address Kim Maclnnis Owner's Name North Andover MA 01845 10/23/2009 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 ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Capacity: gallons Design Flow: 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 - 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 178 Old Cart Way Property Address Kim Maclnnis Owner Owner's Name information is required for North Andover MA 01845 10/23/2009 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 0 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 & distribution equal. No evidence of leakage. Evidence of light carryover 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: t5ins - 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 12 of 17 Commonwealth of Massachusetts F W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 178 Old Cart Way Property Address Kim Maclnnis Owner information is required for every page. t5ins • 09/08 Owner's Name North Andover Cityrrown State D. System Information (cont.) 01845 Zip Code 10/23/2009 Date of Inspection Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 2 trenches 51' long ❑ leaching fields number, dimensions: ❑ 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.): Soil ok. Vegetation ok. 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 Title 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 178 Old Cart Way Property Address Kim Maclnnis Owner information is required for every page. Owner's Name North Andover MA 01845 10/23/2009 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 • 09/08 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 178 Old Cart V Property Address Kim Maclnnis Owner's Name North Andover Citylrown MA 01845 10/23/2009 State Zip Code Date of Inspection 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 ❑ drawing attached separately l5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17 e>0Y �e/ l5ins • 09/08 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 178 Old Cart Way Property Address Kim Maclnnis Owner Owner's Name information is required for North Andover MA 01845 10/23/2009 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: 5 feet Please indicate all methods used to determine the high ground water elevation: ►/ FN -1 C Obtained from system design plans on record If checked date of desi n Ian reviewed 4/27/1987 g F, 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: As per test pit on design plan Before filing this Inspection Report, please see Report Completeness Checklist on�next page. t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 178 Old Cart Way Property Address Kim Maclnnis Owner Owner's Name information is required for North Andover MA 01845 every page. Cityrrown State Zip Code E. Report Completeness Checklist 10/23/2009 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 t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 17 of 17 Summary Record Card generated on 10/23/2009 10:57:12 AM by Karen Hanlon ' Town of North Andover Tax Map # 210-1073-0119-0000.0 Parcel Id 18229 178 OLD CART WAY ROBERT & KIM MACINNIS 178 OLD CART WAY NORTH ANDOVER, MA 01845 Page 1 Class 101 Single Family Property Type 1 Residential Size Total 1.1 Acres FY 2010 UB Mailing Index Name/Address Type Loan Number Active/Inact. From Until ROBERT & KIM MACINNIS Owner 178 OLD CART WAY NORTH ANDOVER, MA 01845 R.J. RICHARDS CORP. Previous Customer Inactive 5/26/2004 178 OLD CART WAY NO.ANDOVER,MA 01845 CHERYL A COLETTI Previous Customer Inactive 12/27/2005 178 OLD CART WAY NORTH ANDOVER, MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 13760.0 - 178 OLD CART WAY Last Billing Date 8/5/2009 1090437 01 Cycle 01 Active UB Services Maint. Account No. 1090437 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 464.50 /1 UB Meter Maintenance Account No. 1090437 Serial No Status Location Brand Type Size YTD Cons 40746488 a Active 00 METE METE w Water 0.63 0.63 304 Date Reading Code Consumption Posted Date Variance 7/24/2009 4378 m Manual estimate 90 8/12/2009 260% 4/24/2009 4288 m Manual estimate 25 5/13/2009 2% MSG 1/23/2009 4263 m Manual estimate 25 2/10/2009 -65% MSG 10/22/2008 4238 a Actual 71 11/12/2008 -25% 7/22/2008 4167 a Actual 93 8/15/2008 304% 4/23/2008 4074 a Actual 22 5/19/2008 -4% 1/28/2008 4052 a Actual 26 2/19/2008 -88% 10/22/2007 4026 a Actual 202 11/16/2007 62% 7/20/2007 3824 a Actual 117 8/15/2007 520% 4/23/2007 3707 aActual 18 5/21/2007 -11% 1/29/2007 3689 aActual 23 2/20/2007 -74% 10/25/2006 3666 a Actual 83 11/16/2006 -7% 7/28/2006 3583 a Actual 87 8/18/2006 411% 5/2/2006 3496 a Actual 18 5/16/2006 27% Trouble Code:03 1/30/2006 3478 a Actual 6 2/13/2006 23% Trouble Code:03 12/22/2005 3472 f Final Bill 7 12/22/2005 -93% OMHONWFAtTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENTmoNN'Zb M*AL AFFAIRS DEPARTMENT OF ENVIROMIENTAX, PROTECTION TITLE 5 OFFICIAL INSPECTION FORM -!- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART CERTIFICATION Property Addra&-. 1 7 9 (310 CAlz_rA,)Ar' owsces K- Kkc_�Oeo& OwmesAd&um 1-7tr n1f)erVJA-f- Mc.—YiN flL.!Aov.7AL A4 Date a( lupecdoaJ 3 —ALI -()q Name of Inspector; Ir =e k,.S T-A� Company Karat M&MxgAddrc=*_fj5- CAA TdcPhous Number: "E 41 -7�� 3 "i a37 e ljc� - 1. , lc;ds.a 0nYiOr PA4." ? CERTIFICATION STATEMENT 1 =7* tba I hm M=Lily inspaded the W*w dbpoW ot= ax this address and tial the infccmxdw rqaW bdaw is eve, R=rae and 0=00W as of the time ofthe famewoo The fa*adca Ww'Pafb=0d WW 00 my U=mj and cqwicwc in the propw fLmctica and rn frumm of ca* sits wwage dLipcW rlacms. I am a DEP a pprvetd rfgtt= WSPOCtOr P7 0.3 0 arms 5 (310Psystem: 1&000� The jPassq caawwjypwm Noeds'Furthw Evahadca by the Local Approving Audwrity 7— Feit Inspector's Signature: Date: 3 � L1— 0 L/ The syucm kLspo= sha xUballt j'6Wy of thLs4=tlm rcpcd to the ApSw&j Authority aW" ofHa Ith cr DEF) widilm 30 day: of c=pjcdmStbb inspapdom If dw.qstcm is gshared system orbasadesign Bar of 10000 9Pd or wean, the inspector aad the rju= owner shill xubmh the report to the WWWvTc&cW amm of the DEF. The angina] should be ww to the rfjt= Ow= sad copies W to the UW, ifaWH;&U;, and the amoving Luthcriry. I Nous and Commc= "wwrlb report ocly dcscriba .1 gitioaa attine time of&gKdm MW =4a tUmMou atom apt that d=c- Ilds inspectsoo does ma address haw the BY49M WID Putwu in the fhture wLdw the same or diffu=f cocdkiom of me. hge2ofII OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMEN Is SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (coatinuod) Property Address: 1 7F d) D e A eT W 4;o/ Ny '� � .. A Ai i•Y7 � t(Z 1.1 A � Owmzr: Daae of Inspection: laspocdoa Snmmary: Check A,B,C,D or E / j',� complete all of Section D A. m Passes: I haemo not found any inEamatioa which indicates that any of the &Ilure aitaris described in 310 CUR 15.303 or in 310 CMR 15.304 exist. Any Whav crkaia not evaluated are indicated below. Coaimeao: SyS�rri c9P'cRA� & Symm Cooditioasl2y Passes: One or more system ocmponents as descnbod is the "Coaditional Pass" section need to be replaced or r7Azrd The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer ycs, no or not determined (Y,N,ND) in the for the following stat=cntz If `bot detammod" please oKPla.m. The septic tank is metal and over 20 years old* or the septic tank (whether metal or act) is structurm2y =i-%cxmd, exhibits substantial infiltration or exdltradon a taak failure is t�'m;ntme�t. System will pass iaspcction if the ocisrmg avtic is rzplaeod with a complying septic tank as approved by the.Board of Iiealth. 'A meal scpcic tank will pass kUpectioa if it is st:ucttaally sound, not leaking and If a Certificate of Compliance m6caring ttut the tank is less thea 20 years old is available. 06a-vatioa of sawage backup or break out.or hlgb static ware: level in the distributiea boot due to broken or otsauacd pt*s) or due to a brokca, sealod or uneven dist *utioa boa. System will pass inspocdca if (with LpprovaJ of Board of Healt4 brolkea pipc(s) are replseed obatructioa is removed dLuribWoo box is leveled or replaced The rysum required pumping more dim 4 times a year due to broken or obsuzxded.pipe(s} The system will pan mspoaion if (with approval of the Board ofHeahhk broken pipe(s) are replaced obstruaioa is rtmoved = Pngc 3 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 17 `i (51c) C la 2-T- LJ A . Oh►nej- K%C4Rftlis Da is of Inspection: 3 -,XLj —6 -L/ C. Furter Evaluation is Required by the Board of Health: Cmdidoas acist which roquire further evaluation by the Board of Health is order to dd=3jne if the rystcm is £tiling to protea public health, safety or the aovk=em I. SY-stem will pan Mika Board of Health detumines In accordance with 310 Chl$13.303(l)(b) that the FYrum is not functioning In a mannerwhich Will proted public health, safety and the enviroan=t: _ Cesspool or privy is within SO feet of a s zhce water _ Cesspool or privy is within SO fed of a bordering vgctatcd wetland or a salt marsh S, s, m w-lD fill unless the Board of Health (and Palle Water Supplier, if any) determines that the rrrtrm U fuactloaing in a manner that protects the public health, ufety and environment: _ The system his a 3eptic tank and soil abaarptim rysicm (SAS) and the SAS is within 100 foci of s:utLce water supply or trilut ary to a =t ce water supply. The system has a septic tank and SAS and the SAS is within a Zane 1 of a public avatar supply. — The system has a septic tank and SAS and the SAS is within$ foot of aprivate water supply wail. The system hu a sec tank and SAS and the SAS is less than 100 fed bat SO fod or more him a pn rate water supply well••. Method used to determine distance •'Th ns sysum POS3= if tae MAlj water s=b* porfnrmed at a DEP artifiod laboratory, for coliform baaeria and voiaWe or&&= oompouads iadicstaa thst the wall is free from pollution from that ficility and the presmoc of ammonia nitrogca and nitrate aitrNea is equal to or less than 5 ppm, provided that no other 5LjJtsc cnL ris arc triggered. A oopy of the analysis must be attachod to this farm. 3. Oth er: ,. Page 4 of 11 OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Addrm: 17q ( CA QT (,U AY p 11 �� w.. v erL MA Owner. ki hA2il5 Ds to of Inspection: D. S ucm Failan Criteria applicablc to all sym= You mwT indican `yes" or `bo" to each of the fnUowing for inspections: Yes No Backup of sewage into facility or system cotapooeat due to overloaded or clogged SAS a cesspool Dischzrgc or ponding of a®u cut to the vzfwc of the groLmd or surface waters due to an overloaded or logged SAS or cesspool Static liquid level in the distribution box above outld invert due to as overloaded or clogged SAS or oesspool Liquid depth in cesspool is less than 6" below invert or available volume is less than :i day flow Rc9uircd Pumping more than 4 times to the last year bQZduc to clogged or obstructed pipe(s� . dumber of times pumped . 1/ �Y Peron of the SAS, cesspool or privy is Wow high ground water elevation. MY Peron of cesspool or privy is within 100 feet of a sur5soe water supply or tributary to a surface yuter suPP1Y• .�/ y portion of a cesspool or privy is within a Zone 1 of a public well. _ ,/ Any portion of a cesspool or privy is within SO fat of a private water supply well. Any portion of a cess pool or privy is less than 100 fee' but greater than 50 feat from a private Water supply weU with no acceptable water gttLk analysj& 1n1S' VWm Passes if the wcU water anatyais, performed at a DEF tertised laboratory, for coliform bacteria and volatile organic compoands indicates that the well is b" from poilatlon &= that facility and the presence of ammoala aitroge n and nitrate nitrogen is egmd to or less than S ppm, provided that no other fallars criteria are aluvred. A copy of the analyals taut be attached to tills form.] U (Ycs/No) The system kb I have determined that one or more of the above failure criteria exist as dcsrnbod in 3 10 CMR 15.303, therefore the system &UThe system owner should contact the Board of Health to determine what will be necessary to correct the failure. F- Isrge Sysacros: To be considered a large syaCm`the system mast serve a facility with a design flow of 10,000 gpd to 15,000 tK You mus' indicate either `Yes" or "DO" to each of the following: (Tbc following criteria apply to large systems in additioa to the criteria above) w yes 00 the system is within 400 feet of a surface drinking water supply dic system is within 200 Rex of a tributary to a surface drinking water supply tfi c sysum is located in a nitrogen sensitive arca (Interim Wellhead Procc tion Ara — IWFA) or a mapped ZCCC li of a public Water supply well If you h ave answered "yet" to any question is Sextico E the cyst® is coasidered a signi5csut tl jca4 or answered f-cs" m Somon D above the large system bas fuzed The owner or operator of any large system considered a s gni5cant threat under Section E or fLilod tinder Section D shall upgrade the sysicm in accordance with 310 CMR ' 5.344. The system owner should contact the appropriate regional office of the Dcparunmt:. Page 5 of I 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: OBJ C ARI- WAY TK M �'" Owner t R- S Date of Inspection: 3 —.-). c-1 — O y Check if the following have been done. You must indicate `yes" or "no" as to each of the following: Y No Pumping information was provided by the owner, occupant, or Board of Health -Z,-Wcre any of the system components pumped out in the previous two weeks ? ZHas the system received normal flows in the previous two week period ? Z-Hve 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) NoQTV\ Ar40a c2 a 0 4 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: Yo Existing information. Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [3 10 CMR 15.302(3)(b)] Page 6ofiI OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION property Address: 1 7 013 CA 2T L) ;.. Y Or.vcr: c,c h A(Z QS Da cc of Inspection: FLOW CONDMONS l�Es>D1?rrnAl N=be of bodrooms (design): Numberof bodrooma (actual): 3 " DESIGN How basad on 310 CW 15.203 (for cxsrmpJe: 110 gpd x 0 ofbedrooms): Num be of current residents: 3 Does r=dcnoc have a gsriaage grinder (yam or no): t'.5 Is [sundry an a sep vue sewage system (yes or no): U-0 (tf'yq SCP&nac injon rcqub'cd) L-&LzdrY sYst= inspcctcd (yes or no): �J91< Scasoaal usc: (ycs or no): NO Wada mac rcadings, if available (last 2 years usage (gpd)): See ATTTAAe,-) S=P Pump (yrs or no): — Lj_v dacc of occupanry: • �; ; ` ,� CO MMFR CIAI A ND USI'RUL Type of csmblishmenr- Dcugn Bow (based oa 310 CMX,15.203): gpd. Buis of design bow (xats/paacxt $/Recto,): Grnsc 71P Prat (yes or no): — LncDzsuiil waste holding ank pm=t (yes or no): _ Non -sanitary waste di�cd to the Tide S system (yes or no): W ate mac readings, if available: Lase duc of ocaipu cy/use: OTBER (describe): GENERAL INFORMATION �P�t; Records Source of information: M_ Was , Y� pumpod as part of ttic. Uispoctioa (Yd or no): _1 o If yes, volume pmnpod _�1� _ How was quantityPumpod determined? Rnson for pumping: YecO Y STEM YS Spnc rank, distribution box, soil abuxpoW system — S ingl c cesspool — oyatow cesspool — Pri vy — Shared syszcm (yrs or no) (if yes, attach previous kLp=don rococds, if any) _ tnnorati VdAltemativc technology. Attach a copy of the current operation and maintenance coatraot (to be obca.mad fTom systan owner) — Tigbt tarlk _ Attach a copy of the DEP approval — Omer (dcsaibc): 1,oprox=atc age of al Ponrnu, dale insraIlod (if known) and source of information: `1/cc scwagc odors cheered whoa arriving at the site (yes or no): NG Pagc 7 of l l OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (oontinucd) PrOPCMY Address: 7 IF. -I � CAr`r WAX Dais of Inspection: '3 --,19 B UII.DING SEWER (locate on site plan) Depth below grade: n% Mua'iils of consaucrion: _cast iron PVC other (cgkin): Dumoc c from private water supply well or autcdon lima 100 r Ccmm am (oo omdition of joints, vrutin& evidence of (akage, etc,): SEP'T'IC TANK: _ locate en site plan) Depcb below grade: I �f MszmsJ of nru: �000a etc _metal _fibaglas: __potydhyicne —oCbC*xp'&m) If auk is to nal list age: _ I, ago confirmed by a Catificate of Compliance (yw or no): _ (atttach a copy of cru 5cata) D=ausiau: sludge dtpcb: Distanc c from top of sludge to bottom of outlet toe or baS]e: t Scum thickocds: 'y rN Duz=cc from top of scum to top of outlet toe or kffle: �i N Disa=ce llnm bottom of sarin to bottom of o�d tm or baffle:.;L How were dimensions ddamined,_ i N c e C'm (en P=Piag recemmendations, inlet and outlet toe a baffle condition, structural integrity, liquid levels u rtlaz.od to outlet invert, evidcaee of leakage, etc, : p 1 Pry IL 1,e,j eFy (�( C Tres f GREASE TRAP: _(locate on sitz plan) Depch below grades _ titan ial of construction: _oc]narte _metal _ffbc ghw _polyethylene other Dim atsi ons: Set= cbjckncm: DL=CC from top of satin to top of outlet too or baffle: DLS=cc from bottom of scum to bottom of outlet toe or baffle: Dcc of list pumpIIx C"' cm (m PumP'mg rooaarmardatiom% mlet amd outlet tee or bale eoaditioa, structural tutcgrit), liquid levels Ls rrJrcd to outlet invet, evid ace of leakage, etc,): T J'sgc8ofII 0 FFICIAL INSPECTION FORM — NOT FOR VOLUNTARY A'NTS SSESSr SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: I"IS CG1 � CA P-7 —P 'V� kvAy Owocr:%, P R %— NA c• + c 2 Da tit of rwpccd ; _ -� -- ;t y -- v 9 TIGHT or HOLDING TANK ` (teak must be primped at time of inspoction)(locate on site plan) Depth below Vadc: MLUTW of construction: =crcte metal fibaglass _polyUhylcne other(explaiak Dim m dons: C"citY caloos Design Flow 041loas/dmy Al::m preset (yes or. no): Alarm level: Alarm in working order (yes or no): Dgic of last Contmants ( of m `md goat switches, d4- DLYMMLMON BOX: _ ('dp v3ent must be open* locaia onsite plea) Depcb of Liquid level above outlet inv=..Q_ Comm wts (note if bar is level and distribution to outlets equal, any evidence of solids carryover, any evidence of I=JaP into or out of boa, etc,): IUMP CHA IMUL (locate in site pym) Pumps in wcxiciag order (Ya or oro): Alarms m woddng order (yes or oro): Ccc=c= (note 000dkion ofpump chsmba, condition ofpumps and appurtamces„ VtQ): Page 9 of I 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Addneas: 1.71' 3Q C �QT Lu Py v^Th.. ANC)dvY own cr. Q PS Date of Inspoetioa: N —G L% SOLL ABSORPTION SYSTEM (SAS): (locate oa site plan, euavation not required) if SAS not Iocatcd ocplain. why: Type _ leaching pits, numbs: _ _ Icachmg ch=bers, number: leaching galleries, numbs — Icacttmg trenches, number, length: I- . s� T leaching fields, number, dimensions: _ overflow ccsspo*nttmber: _ ®ovuivrlaltanative ryatem Typdnamc of txhnology: Commem (note coaditioo of soil,"signs of hydraulic &Burt, level of ponding, damp soil, condition of vegdatim CESSPOOLS: _ (cesspool must.be pumpod as part of inspocxioaXlocate on site plan) Number and configutatioa: / Dcptb - top of liquid to inlet invert: Depth of solids layer: Depch of == layer D=casions of cesspool: Matvials of construction: indication of grotmdwater inflaw (yes or no): Comments (vote condition of sail, signs of hydraulic &iJure, level of ponding, condition of vegetatioa. etc.): PR V' : _ (locate on site plan) 1.1 a als of construction: Dim Ceras: Dcpcb of solids: C.ocamants (nae condition of soil, signs of hydraulic Mort, love] ofpooding. eondidoa ofvegastiea, etc.): Pig- 10 of 11 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (ooati=4 Property Address• j 7 h v I C A P -T tic) c- T )l A0 -0,.r. R'AAar7s 0-0,.r.R'AA2rs Date of Iarpo doa: 3 —"19 — 0 y SX2-rCE OF SEWAGE DERIMAL SY57XM Prwidc a ska.cb of the sewage dispose systam including tics to at least two parmaamt ra£ormco landmarks or bmchmx*.& Locate all wells within foo fat Loate whav public wale supply enters the building. S��TTA CJ\eL) Vl_ _ _ -r - r,7 � p )>. D � n O Lp -o •2 2 CSJ W W C N WGo (� r (� T.1 e* Z: z x � < Vl_ _ _ -r - - -,� )>. -V Lp -o aDc Z: z < � C6 ><, "' — O. d%F - ' m � • • m j� 0 w -r NNS D, m� � .•y'` TZ ''fj -�� Z� C p:. oa Q UD . zO zirn 70 b0,> D 8 Z N mm ANz - b m 5 • A > vi - r" c� � N =N C < m v 0 rn <� . N r � . vr. rZn u .N v 4Arn9, Page 11 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (coctinuod) Property Address: l`l� 01� GA Q -r way . L7 r'�'►� n:, nn a �-rZ.. . Owner. i P2A5 eats of raspeafon: y - v 4i SM EXAM Slope Swtwc water Chock cel I& Shallow wc113 E.samuod depth to ground water S fon Picric mdicnc (chock) all methods usod to ddermine the high ground water elevation: -ZObamod from sysaem design plans ca record . If chodcod, date of design plan reviewed 6 t-Tk Ob=vcd site (abutting property/observation hole within 150 fed of SAS) R o-► =Checked with local Board otlial>h-explain: pI a hZ DRl-t I �{ �{ S�=Checked Checked with loiral cxavatarz, installer- (attach doatmeutsiioc) Accmsed MS daubwo-Wlain: You man darnbc how you cstablishod the high pv=d water clevatioa: . �IANNS 0 NJ 1Ie- +49!�, �v- Commonwealth of Massachusetts City/Town of RECEIVES a System Pumping Record Form 4 r SEP 27 'LU11 �M DEP has provided this form for use by local Boards of Health. Oth r'f, gJAWILUROY681the information must be substantially the same as that provided here. ck 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. eft front of house)right front of house, left side of house, right side'of house, Left rear of house, right rear o ouse, left side of building, right rear of building, under deck. City/Town State Zip Code 2. System Owner: D A— _ _ _ ,'I, (1) Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ Sta� Telephone Number 1�—� -- ` c Date 2. Quantity Pumped: Cesspool(s) eptic Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes No 1 � ®U Gallons ❑ Tight Tank If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System:1U.C t jAIA 6. System Pumped By: Neil J. Bateson Name Bateson Enterprises Inc. Company 7. LSpatitw4�where contents were disposed: G. L. S. D: F5821 Vehicle License Number Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts IRP -100 -ft -0 City/Town of System Pumping Record �� 01Q ! Form 4 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 tQ, 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 Loca i n: Left �of fight side of house, Left front of house, Right front of house, Left rear of ho Left rear of building. Right rear of building. Address r!) Cityrrown State Zip Code 2. System Owner: Name Address (if different from location) CitylTown . B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): Sta ode !7 Telephone Number Co -Cf- ccs . Date 2. Quantity Pumped. Cesspool(s) eptic Tank Gallons ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes (] If yes, was it cleaned? ❑ Yes ❑ No 5. Conditjpn��S�ystem: � � � 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Location where contents were disposed: L.S.D A n Lowell Waste Water of F5821 Vehicle License Number Date L -r' f �ro t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts lg �1V'.®� RuCity/Town of System Pumping Record OCT 3 © �U09 Form 4 TOWN OF NORTH ANUUVER 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 tQ 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 effside of hous ight side of house, Left front of house, Right front of house, Left rear of house,—Rlg—ff rear of house. Left rear of building. Right rear of building. Address City/ Town State Zip Code 2. System Owner:( Name Address (if different from location) Cityrrown B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe). - Dat( State Code �- a Telephone Number 2. Quantity Pumped: l's -c -IL-) Gallons Cesspool(s) 2--5ptic Tank ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes [2-11q_o'� If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: `N0, (- d-". ac- cA 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Location here contents were disposed: =G. Lowell Waste Water Signature of Hauler F5821 Vehicle License Number to Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Af o. 1 Cl 1 retts:,,l . ER MASSACHUSETTS'.` ' .,:',{�:,, ,- �ay��@��•�mp1n'g.3°record' -- ri ,., .� yYi fir° ' rir•;,,'..,, ..:1...,,{r;...., �'v';<'�y.� :�P1k;'KJj�;�1;iC�i�s;•:n:•r;•. , .M n:;�''..14:y,:;r: l:P.has provided this form for usa by I B �iF��i�, ,cal be submitted to the t3oard of He Th System Pumping Record m s .loca! alt or other approving auth A ..Facllity Info,rritptlon OLL, 2W . ... •' ' . , TC;rvURTH • `J�TINh4n (illin� �out'� ;1.. YSt8�T1 L S OCatlon:' ANDOVER Ht,1LrH DEPARTMENT only the tab key Address to move your:; a� cursor • do not `Ua the mtum'•% :: ,' ', ', -t . '•�. �i.,.i;;,.•: State 1., r4 ;: :.; •. System Owner;" ZIP code '' °;�•..;, „ dress (If different fr,,,; om bcatlon) V%�7%� ;:, Cttyliown. Telephone Number ".r:: :;.,'�;;iY: j�. (�>:yrit:Cc�f�ii.! .al�,;.:a1;C'/l�{�if.(•,1.,.�, �./l , , r { '•� '1 / Date of Ptirnpino n r Date Quantity Pumped: TYp.9 pf.system;, .:: ' ❑ cesspool(�eptic Tank L� (Other (descrfbe)1 � ' •:�,::';:�;,;:: fir,::;:.;: ;::^"'+`�Yf+' �`•�` . . Effl.uen Tee Fllter • resent? ..E) ,":Cnn"iilllrin`nl:QveFer„i''7:'_ *•.. . �jy :.ii�:� 'vi j:i�: w4 JY'�(.,:f�J 14r,f•�7 ��//sl. �1��S ;<�r�• ///�',/ o �/• I w;, J.'.. .', .�11r�r�'r..'1 ,fy+�:•n1��p.,V.X' �:lX' KNV'•�/ '.'�'•,.^, :r. `�' • ; ^•. 't •'�ti;in•+visa,. ' I r,u ',�;. ,}�tt�'�,. 1.�(e', h� ('�,,'• ,%�, ' �'►'Y`Yl+;.;•..'•�k4:::..• ,,•d ,; y.�!' H•avjfr,,((•+�'t�!•4 p.�: ifs°��.';'�,.Irljy.'�..,.,,, • �' r''�.T'�r:,� .4 Hfl�•1 � �W'.:.�i•..Vi:l+lyy <�i`', �I :;'::I:f.�'•;;; ;". 7r',A I l.ocaflon.wfiere contents yrere dlAposed: `..;:`, `•::,;:,`:,i j'':',,;;;.,rr..,;.; Siena a of httpJ/tivww.mass.8ov/dep/water/approvsjsJt5forms,htm#inspect t5foMA.doa.-0NQ3 If yes, was It cleaned? Gallons I )VehlGe Ucen#e Number ,12T�`rrtQ. , Syslam Pumping Record • Page 1 c! i TOWN OF SYST] DATE: SYSTEM OWNER & ADDRESS L PUMPING RECORD F1� Old cof+ W11j SYSTEM LOCATION (example: left front of house) -i�ovA of 6usf DATE OF PUMPING: QUANTITY PUMPED: I GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) SYSTEM PUMPED BY: - Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED TO: G.L.S.D 'J Lowell Waste System Owner Roaur RICHARD 1"8 CID CART k" Commonwealth of Mossachusetss : Massachusetts System Pumoira Record system Location Yoke ,r 178 OLD CA17 WY Form 4 -- System Pumping Record OCT 2 5 2001 N,nTlN VWVER. MA 018-..,-6361 NORTH ANDOVER. HA 0164'+ (978) 669-0453 (14781 OV) -04.53 R, jr_r PC Ir Type: Emergency Routine Cesspool: No Yes Septic tank: W Yes Date of Pumping: '111Quantity Pumped:(J/ U 6 Gallons System Pumped By: Wind River Environmental, U -C Permit #: Contents transferred to: Date: Disposed at: of System/Other Comments Pumper Dep Appnved from - 12/07/95 f FORM 4 - SYSTEM PUMPING RECORD CURRIER SEPTIC & DRAIN SERVICE 107 FOREST STREET; MIDDLgTON, MA 01949 (978) 774-2772 COMMONWEALTH OF MASSACHUSETTS AL'I doll c- , MASSACHUSETTS SYSTEM PUMPING RECORD SYSTEM OWNER: 1 P old c1qA L. jd,/c SYSTEM LOCATION: L14 DATE OF PUMPING: �� QUANTITY PUMPED: CESSPOOL: NO Eq-�ES F7 SEPTIC TANK: SYSTEM PUMPED BY: CURRIER SEPTIC & DRAIN SERVICE CONTENTS TRANSFERRED TO: DATE: �N O INSPECTOR: f� U, IS -66 GALLONS NO 0 YES � CURRIE SEPTIC & 107 FOREST STREET; (978) 774-2772 IN FORM 4 - SYSTEM PUMPING RECORD SERVICE 'ON, MA 01949 COMMONWTH OF MASSACHUSETTS �/l c�✓_ , MASSACHUSETTS SYSTEM PUMPING RECORD SYSTEM OWNER: n tc C W/91 SYSTEM LOCATION: •� �� V,0'ts:--e Gam e 0 ba�f DATE OF PUMPING: "� QUANTITY PUMPED:DCS GALLONS CESSPOOL: NO YES 0 SEPTIC TANK: NO a YES SYSTEM PUMPED BY: CURRIER SEPTIC & DRAIN SERVICE CONTENTS TRANSFERRED TO: -DATE: ! INSPECTOR: c� Form 4 -- System Pumping Record Commonwealth of Mossachusetss : Massachusetts System Pumping Record System Owner System Location t�;i ci R:�t1.,r. 'r itnar: y fiottt,� L? C,)I i f„ t 4?::y 78 cttd cart W:.y 1,)r to .nc,vvr t!3 11•.i, nrth Ando—r. '9A. 01a1y (97x11 o89 U7`+s 117th -689 0453 x Type: Emergency Routine Cesspool: No Yes Septic tank: W Yes ©� Date of Pumping: Quantity Pumped: jJCe,) Gallons System Pumped By: Wind River Environmental, LLC Permit #: Contents transferred to: Contents Disposed at: ----------- -- Date: Pumper Signature: 110 Condition of Systen✓Other Comments Dep Approved From - 12/07/95 Ft /v c v FORM U - LOT 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 or requirements. ****"'APPLICANT FILLS OUT THIS SECTION*********************** APPLICANT-0.IP !y Z C�,caL,e- 'Z I�j� PHONE 6- 9 3 60 3 LOCATION: Assessor's Map Number. SUBDIVISION STREET I_ "**""'*********************OFFICIAL USE ONLY RECOMMENDATIONS OF TOWN AGENTS: UVN*CKVAi 1UN AUMIN15TRATUR DATE APPROVED DATE REJECTED COMMENTS 1 UVVN rLANNtK COMMENTS DATE APPROVED DATE REJECTED FOODPECTOR-HEALTH W DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED COMME PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT PARCEL LOT (S) ST. NUMBER 0 RECEIVED BY BUILDING INSPECTOR DATE Revised 9197 jm m C m z � z z m C tr- � � CZ D O z = r- r = � n� -a .p o OCD p CL CD c') CD o �o 0 mCDrn Do Cl D y �O m Cp CD = z � y CD 'gym v co .o d �C d O y C'f O G y -v d n CD Cm CD v CD y, CD CA O CD a O CD 0 rn Cl 'Tf �D a m C h� Cr1 .� V n O c V J n� rn O � v N Z m �= v 47k z ^� O CD z =R o a� 7' o w O -• N G Q' a O C CD N .O CA CD n d CD m C N C7 Z ^ x a7 N rt CrD �=� CI, GO) plo tz -•� a m „ _ CD W O CD N C CA CD -� •a � n o f �m CD ca m > C CD p f%N• W D N :t4 CL ca O g ' = CD OCD N to7 /cam O CD c c - .dr• CCD d N N ads :l c J WCL v O . G. N CD N CD N CD N CD O ' CD � CD . CD o (� CD o CD m � CD c CD O r•F aCD C dam• 0Z c O 002, ��: •Cn0 C2 cn :A • nC2 L z ^� O CD z =R o a� 7' o w o w G '� o w G G °° Q.. G! C o ti O a"1 d O � ^ x a7 N rt CrD 'o GO) plo n to N n JT- \vv� I&A old I►1 G .AtiON 4 I&l 0 c Z07- 47 OO 20 4 7 7/2 S. ,=- f Z Tf= /99.39 r Alefe.MY e-eA7-1,7b T.YE rirGE /,vsaenr.gvo 7Tj 7WS- 04.oVt- 7.7147 /S GGC'ATEO ON r114C GoT As . hvoowA,1 ANO T.WT?OUES GGWFGI�iJ! IY/TN 7.S/6 TV WW O/ 0' 40 AMOV w&[ ZGW/.v6 �E6�/LAT•ISLNS A112rr/.CO/.W0 rfrA4CorX FXGLN STREETS f GOT G/•vES. r S Flj,�.yEC CE.�T/fY T.yIT Ti✓/s GAr'rS'GC/N6 /sA/oT 44044r4W IA/ T.vE WZAW.4.pEA. 6WOOVK O/V FEiN•4' COM,o/4/N/TY P.tNGL '* eszvv OGl7PC 6/ZI?,3 PLO T PG,4-t/ /N O.PA/✓/V FO.P PSstm,/tlFP.P//l1.4Gt' E',ti6•Gt/EE.P/.(/6 SE.P/�/lES .t/oOYE.� /f�AS,�oGf/vSE1TS oi8io 4" a n� N PSstm,/tlFP.P//l1.4Gt' E',ti6•Gt/EE.P/.(/6 SE.P/�/lES .t/oOYE.� /f�AS,�oGf/vSE1TS oi8io 4" Town of North Andover , 40 RT" OFFICE OF COMMUNITY DEVELOPMENT AND SERVICES ° 146 Main Street KENNETH R. MAHONY North Andover, Massachusetts 01845 9SsAcmus Director (508) 688-9533 TOWN OF NORTH ANDOVER BOARD OF HEALTH CERTIFICATE OF COMPLIANCE This is to certify that the individual subsurface disposal system constructed (X) or repaired ( ) by Roger Richard installer at Lot #20 Old Cart Wa has been installed in accordance with the provisions of TITLE 5 of the State Sanitary Code and with Board of Health regulations as described in the Design Approval Permit #589 dated 11/20/92 THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY. Board of Health Inspector BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 Julie Parrino D. Robert Nicetta Michael Howard Sandra Start Kathleen Bradley Colwell Town of North Andover, Massachusetts Form NO' 3 BOARD OF HEALTH NORTH 3? � O /�"`' f`^ �19 L ..... DISPOSAL WORKS CONSTRUCTION PERMIT ,Sg/ICMUSEt Applicant k()0/ ( NAME I ADDRESS TELEPHONE Site Location �T 04--j— te"� Permission is hereby granted to Constructor Repair ( ) an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. Fee r CHAIRMAN, BOARD OF HEALTH D.W.C. No. MERRIMACK ENGINEERING SERVICES, INC. PROFESSIONAL ENGINEERS • LAND SURVEYORS • PLANNERS PW 66 PARK STREET • ANDOVER, MASSACHUSETTS 01810 • TEL. (508) 475-3555, 373-5721 FAX (508) 475-1448 Apri124, 1995 TOWN OF N0M ANDQ�VE BOARD OF HEALTH %51995 Town of North Andover Board of Health Town Hall - 120 Main Street North Andover, MA 01845 RE: Lot 20 Old Cart Way Wagon Wheel Estates Dear Board Members: On behalf or our client, R.J. Richard Construction Co., we herein request a Variance to Town of North Andover Board of Health Minimum Requirements for the Subsurface Disposal of Sanitary Sewage, Reg. 4.18 "Distances" so that a subsurface disposal system may be constructed 25 feet distant from foundation drains as opposed to 35 feet, as required, for the subject lot. The installation of foundation drains is a general requirement of the Town of North Andover Building Department, however, please note that the cellar floor elevation is above the seasonal high water table in this case, therefore, no sewage infiltration into the foundation drains should occur. Please schedule this item for the next available meeting of the Board of Health and feel free to contact me at this office should you have any questions or comments. Very truly yours, MERRIMACK ENGINEERING SERVICES Les Godin Project Manager cd O �= CS N -I A 0 _ s N w r r I N w ibz z BOARD OF HEALTH 120 MAIN STREET NORTH ANDOVER, MASS. 01845 Les Godin Merrimack Engineering 66 Park Street Andover, MA 01810 Dear Les: TEL. 682-6483 Ext23 April 28, 1995 This is to confirm that on April 27, 1995 the North Andover Board of Health granted a variance to North Andover regulation 4.18 of the Minimum Requirements for the Subsurface Disposal of Sanitary Sewage to allow the construction of a leaching area 25 feet from a foundation drain instead of 35 feet for Lots 1 and 20 Old Cart Way. If you have any questions, please call the Board of Health office at 688-9540. Sincerely, Sandra Starr, R.S. Health Administrator cc: R. J. Richard File FORM U - IAT R=ASH 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. ****************Ann1icant fills out this section***************** APPLICANT: je.I ( , E`;Z2er,,��,a- _ I Phone LOCATION: Assessor's Map Number /L1Parcel �l Subdivision Lot (s) Street ��✓c7 %��i St. Number 17 �_ ************************Official Use Only************************ RECOMMENDATI NS 0 TOWN AGENTS: Date ADnroved Conservation Administrator Dat/e Rejeted .^ Coments - ;) ilr �P��', �L��- (�//� 6u Town Planner Comments Food Inspector- e; lth Seotic Insnec=zr-Health Com' -ner.ts Date Approved Date Rejected Date Approved Date Reieczed Date Apnrcved Date Rejec=ed Pub? is Wcrks - seaer; water connections _`-1 --3 -Z ! ° r s - driveway permit /'-j -0 3.-2.'3 - �� Fire Decart:aent Received by Building Inspector Date PLAN REVIEW CHECKLIST ADDRESS,-/ 20 6e-�A,P�- ,q�_ _ ENGINEER IVC=rr'iP//yl/; 3 COPIES STAMP LOCUS `"� NORTH ARROW SCALE T� �c CONTOURS PROFILE SECTION BENCHMARK SOIL & PERC INFO ELEVATIONS L' WETS. DISCLAIMER WELLS & WETLANDS -/ WATERSHED?/yD DRIVEWAY t/(Elev) WATER LINE L/J FDN DRAIN SCH40 ✓ TESTS CURRENT? /987961M SEPTIC TANK MIN 1500G. tri .17 INVERT DROP L/ GARB. GRINDER(+200% EDF) 25' TO CELLAR ✓ MANHOLE TO GRADE C/ ELEV Oft" GW D -BOX SIZE �rr -3 # LINES FIRST 2' LEVEL STATEMENT INLET OUTLET ( 2" OR .17 FT) TEE REQ' D?� LEACHING RESERVE AREA ,L, -X 4' FROM PRIMARY? C,-" 100' TO WETLANDS_ 2% SLOPE�� 100' TO WELLS ^/ 35' TO FND & INTRCPTR DRAINS/ 4' TO S.H.GWt_-- 325' TO SURFACE H2O SUPP c/ 4' PERM. SOIL BELOW FACILITY MIN 12" COVER L,,--- FILL? x(25' if above natural elev; 101if below) BREAKOUT MET? TRENCHES MIN 660 gpd (/ SLOPE (min .005 or 6"/1001) >3' COVER? - VENTA SIDEWALL DIST. 2X EFF. W OR D (MIN 6')1/ IS RESERVE BETWEEN TRENCHES? '% IN FILL?✓ MUST BE 10' MIN.Z_ " 4" PEA STONE? , BOT5O X LDNG_Lbq + SIDE a'10"I X LDNG ��g = TOT (L x W x #) (G/ft2) (DxLx2x#) TOWN OF NORTH ANDOVER SEWAGE DISPOSAL SYSTEM INSTALLATION CERTIFICATION The undersigned hereby certify that the Sewage Disposal System ( ) constructed; ( �) repaired; by_ L 10 if%9 QQGy located at 2�5 e -Epp): , was installed in conformance with the North Andover Board of Health approved plan, System Design Permit # , plan dated , with a design flow of gallons per day. The materials used were in conformance with those specified on the approved plan; the system was installed in accordance with the provisions of 310 CMR 15.000, Title 5 and local regulations, and the final grading agrees substantially with the approved plan. All work is accurately represented on the As -built which has been submitted to the Board of Health. Bed inspection date: �j �. t (0 3 Final inspection dater& a� Installer: Engineer: G L c> /L. Engineer Representative --?;-. cC-) Engineer Representative Date: Date: Reference Plans and Specs Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. Fee b CHAIRMAN, BOARD OF HEALTHRMAN, BOARD OF HEALTH Site System Permit No --15-6 9 Town of North Andover, Massachusetts Form No. 2 MORTh BOARD OF HEALT f o P `;•b;;-='�;,.,'" DESIGN APPROVAL FOR �SSACHUSEt� SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant Ui'�� A-) VYLb, Test No. � Site Location � (C-46 /t;L UJB Reference Plans and Specs Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. Fee b CHAIRMAN, BOARD OF HEALTHRMAN, BOARD OF HEALTH Site System Permit No --15-6 9 DATE.. // /Z-oh,z- Sheet of BOARD OF HEALTH TOWN OF NORTH ANDOVER APPLICANT ADDRESS ENGINEER ADDRESS ASSESSOR'S MAP 1,07-,6 PARCEL # oz 7 LOT # 196 STREET oe- T L�,i PLAN DATE -�(��REVISION DATE CONDITIONS OF APPROVAL: APPROVED 4 ---- DISAPPROVED SUBSURFACE DISPOSAL DESIGN REVIEW FEE PERMIT # ��'9 DATE RECEIVED APPLICANT ADDRESS ENGINEER ADDRESS ASSESSOR'S MAP 1,07-,6 PARCEL # oz 7 LOT # 196 STREET oe- T L�,i PLAN DATE -�(��REVISION DATE CONDITIONS OF APPROVAL: APPROVED 4 ---- DISAPPROVED io ' oco C) 0 J n (�i� D V �c 0 C 0 40 _ +l 0 location t �o. tii - C Date c,f W TOWN OF NORTH ANDOVER Lto I co I "I Water Connection Fee $ TOTAL n)I- $ ZcS� l� 3 627- Building Inspector 8707 Div. Public Works p Certificate of Occupancy $ Building/Frame Permit Fee $ S�cMus Foundation Permit Fee $ o Other Permit Fe/IL KIM L $ Sewer Connection Fee $ Lto I co I "I Water Connection Fee $ TOTAL n)I- $ ZcS� l� 3 627- Building Inspector 8707 Div. Public Works a .4 i 0 ICARE H.P. XET=O` aim BUILDING CONSERVATION HEL:'. ii 0ATv- i t .... - - - _ -_ 120 01345 >• NORTH AN-' VER PLANK. - ti G &- COtiL UNNITY DEVELOP -N NT AP?T+TG-XTTON AND LCCy _vV - -�- CvV,,,ZR, S Nn:1� r !e, G! ![ IV -AEON'S Nliiz pElzmIT T -117 ' C- /1 OF -err•--__ C�� ••�i:.. V _ t-_�al�� C le cr C, TM LIC C'•�:+IC i �t,;CT_vij �._... _ \..�i� � �:...- _ ZlL.�. r.: - . R�'•L�tiU D-: nL-=_2 T:-T_S p=-t~�= ='n-=- -= DiSPLAY=D ON T:_= PR�fTS�= 0-2 O F=4 LI ►j LU*�1 z co elk, O C, CW. cy Oe!' 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O io .g,z • ` N N O o CD N U O � o M w is cn • O 2v ,n M U •O,L .0,9 .9,£ AL .6,6 .£,Ol .O,S .0,9 „0,£l .9,Z .9,01 AN .O,OL .O,9Z .0,0£ .O,L / 0 8 0 (A w OE tD O 1 30'0" 4' 10'8" 11'0° g'p' - 1 4- 1 1 � � 1 1 1 _ 1 w 160" �. c -------------- CA ---------- w or 0 ' 3 2 6 0 6'0" 6'0' 3'2' , N , I , I , -- - TI71 n-__ r--- -- ---- --0 ' � _' I I I I I I I I o' I- , I I w ' I ' 111111 • O i I � -OI N-- ----- _1____ I _1_ r T' Itil 1•.1---- --- ---------------a 1 , 4'2• 4'2" , • 1 1 , 1 , I� 1 1 , 1 , 1 , 1 , 1 , 1 , 1 , 1 , --------- • r--------- ------------ ' I ------------------------------------ __--_----_---_----:-------_-+-------------------------------------- I 1 - - - - - , - - - - - - - - - - - - - - - - - - - - - - - - - - - 1 , 1 I' o 1 i .. 1 1 1 O+N , " 1 1 I' -�► 1 BEAM ROCKET 1 1 i 1 1 6' W x 6' Dp x 9" H (5 req'd) ; 1 1 I� w I, 1 Slim beam with Steel Shins ' , ' a (n � vp or Hard Brick , n 1 O ] • C7 O i I� o ----_----------------------------------- -i CD O O - 1 4- 1 1 � � 1 1 1 _ 1 w 160" �. c -------------- CA ---------- w or 0 ' 3 2 6 0 6'0" 6'0' 3'2' , N , I , I , -- - TI71 n-__ r--- -- ---- --0 ' � _' I I I I I I I I o' I- , I I w ' I ' 111111 • O i I � -OI N-- ----- _1____ I _1_ r T' Itil 1•.1---- --- ---------------a 1 , 4'2• 4'2" , • 1 1 , 1 , I� 1 1 , 1 , 1 , 1 , 1 , 1 , 1 , 1 , --------- • r--------- ------------ r------------------------------- i�• �ti1 I 1 1 , 1 1 , 1 I' o 1 i .. 1 1 -0 O� O+N , C7 1 1 I' -�► 1 1 ' 1 (� a 1 i 1 1 1 1 1 I� w I, 1 a. , ' a (n � vp se , 1 1 O ] • C7 O i I� o ' CD O O C�p) 1 1 � 1 1 O ry v i I� 1 � t0 O 1 1 1 1 1 1 - 1 4- 1 1 � � 1 1 1 _ 1 w 160" �. c -------------- CA ---------- w or 0 ' 3 2 6 0 6'0" 6'0' 3'2' , N , I , I , -- - TI71 n-__ r--- -- ---- --0 ' � _' I I I I I I I I o' I- , I I w ' I ' 111111 • O i I � -OI N-- ----- _1____ I _1_ r T' Itil 1•.1---- --- ---------------a 1 , 4'2• 4'2" , • 1 1 , 1 , I� 1 1 , 1 , 1 , 1 , 1 , 1 , 1 , 1 , --------- • r--------- ------------ 1 ' 1 1 1 1 , 1 I , 1 I' o 1 i 1 1 , I 1 1 I' -�► 1 1 ' 1 (� a 1 i 1 1 1 1 1 I� w I, 1 a. 1 1 se , I 1 1 1 i I� o I , 1 1 I' 3 1 1 � � i I' ' 1 i i I� 1 � II � 1 ',_,----------------------T--------- 1 1 10. 12'6' 6 1 • 2 x 12 Center_ Beam (typ.) 1 8 — 3 1/2' DkL Lally Columns �1 o With 2'6" W. x 1'0' Dp. , 1 , Strip Footing 1 --- c r Cp c R•M O d rL 8'6' 26.0' 4'6' • 4 1 1 I 1 .1 1 1 1 1 1 1 1 � 1 1 1 1 I 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 I 1 1 1 1 1 12'6' 6 1 • 2 x 12 Center_ Beam (typ.) 1 8 — 3 1/2' DkL Lally Columns �1 o With 2'6" W. x 1'0' Dp. , 1 , Strip Footing 1 --- c r Cp c R•M O d rL 8'6' 26.0' 4'6' • 4 1 I C N -� ° N I 1 � U I I II II N IJo � m 0 0 & \ o ca t O ( o U 3 = x •- U r 33 n� 2 0 ®m N Y Q I �xo � m d m Q V). v♦ 42 �! 0-0 ' t x Co .j r- ,c c' x 0- ` v o v m N > o 1- cn � E CI- O U r� oo v+ Q oOo I CD O O o �, Q' c— QL v) x <j co 3 O O >` m J 43 O= x oma` O p 0 r- or J a� .Q H > O Q . 0 � NN J JI N'�� I CONoO Etl o Ncn �— (Z 0 2� a cn I - I E I I I I -I �- ON p Jr`CO n o� C� Z \�- , J $ M Ci v n- o c -J y CDacv 0 X.0o 0"L W CDODu –. . . . � QmN , d d l 4 4 d. c 4 v � U o O N v G • os`z0� C'N v s® Z ®(®m3 O cn� `o. W x O a.N �X U N Of > LL I') N J000 n MOPUIM 11819 I �I I 1 I C N -� ° N � U I I II II ® IJo QI 0 0 110,E ,IO,OL c ° iv $ ® 0 0 _ O NC \o OJ �x o U v L� MN Z 33 N O —'00 � m d m Q _ U x Uc O U CD O O I I II II I�� Etl (Z cn I - I E I I I I -I �- 1123 II" I ` U* i� 4" 718" 113" 1010"1'0" 810" 91/4" II I I I I I I IITT I N 11 0 1 1,-+- 3 r-+- I I Q I I Ci (ICD CD I I I I� • • • • • • • • • • 4" 718" 113" 1010"1'0" 810" 91/4" II I I I I I I IITT I N 11 0 1 1,-+- 3 r-+- I I Q I I Ci (ICD CD I I I I� • • • • • • • • • • O CO r' o -Ui:p A -T, moo _ oo O O O -00 Z � -9 n X n O P N �CD ccr 1 CD D 0< N CO 1D N G'lD 0 a O 0 N W 4N oo-P �P o O ua \ x N p LA 0 o Q' ® S CDO N 0 U N Off+ t0 C c b O '. 0 to 6'8" J Window & Door Header Height NW <mNn x O 'o r ®� 70 go ®GJ .• p o C lam- in O y O 15* 1 co O `O N n c 0 a - • o � ^, o 0 < a- s 0 0 0 La n. tq • O • f H co N AE N n ^0G1NlZ91n n T (n Ln (n O CO r' o -Ui:p A -T, moo _ N r O II o P, 0 � -9 f C: X w P N —� "O 0< N CO G'lD 0 a O 0 4N oo-P �P o co ® , ua x rn v CD o Q' o N c b 0 co N AE N n ^0G1NlZ91n ZO v SA. -•Nam O CO r' o -Ui:p A -T, moo o a,ov N a Q. q �7 r (D r N G'lD 0 a O 0 4N oo-P CO •. �, ua Q N v CD N rn .c 0 N N O U, rn o a� o O Z o a- _T C) 0 M N X �Q m�N C > o rn p O co o 7- v m � � m ~ N rn `v 0 Occ C 04 s=� C0 C O X X U N N rn .G 0 0 �+ N N o Lj ` O O OO O T 0 0+ 00 � -g o N X �Q mN � U c o HU C Q C O V � 7 O CDL- G -3 C V U O to L --a a� = �0 s = p 01. li = v o v oo \+ c �m (Dcn N N CD C14V) _ O z v U o XoaNO�X O�rX 0 cai �> � PO N Li I"7 CV ~ t a� 00 n> "! Q UX u m 32 L Is CIL U 0 U U m � O �O OO. m Cl N-JAUUMQUESO . . . . . . . . . m a) i oo iC C C14 t0 I I I 1 I I C I I F— O C-) X 04 X 1 I I I OI 1 _ID I 1 CI (n 1 Q �I u�i6�I1E t -1 b ..0.8 .IY�E „O,OI -I- a -1.0„8,L JapuaH PauJDJJ 4SNJ J9PDOH PawoJJ 4MIJ Cyd S n W 0 � 00 D 3 � v II o H 4 A ^' x Flush Framed Beam t 0 Ci 0 ti 2 I 0 cm N I CA I�_ low=% In I low Ism Ism INN WW -am I i � ' i I - ■NONNI NEI Location � � � C3 �-O �6 2r LO! No. l `1`� Date TOWN OF NORTH AN DOVER $ p Certificate of Occupancy $J. Building/Frame Permit Fee $ IA CNuBEt� Foundation Permit Fee $ 4 Other Permit Fee $ s Sewer Connection Fee $ Water Connection Fee $ r TOTAL $ uildTng Inspector 'S Div. Public Works Location I -1 b Q-4-6 No. Date 4 NpRT„ TOWN OF NORTH ANDOVER x Certificate of Occupancy $ _ Building/Frame Permit Fee $' s^CMUs <� Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL $� J f� Building Inspector 7 Div. Public Works Location I 7S C-)//� No. �y A N°RTh TOWN OF NORTH ANDOVER Certificate of Occupancy $ ,# Building/Frame Permit Fee $ o Foundation Permit Fee $ �cHusE z ' Other Permit Fee $FdM .� Sewer Connection Fee $ "~' 19 rt�`J Water Connection Fee $ w 7Z - 5L6:-; TOTAL $ Buildin ?Inspe or j 8494 biv. FAbg6 Works PERMIT NO. I �� APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. PAGE 1 MAP K40.L07rJ IJ LOT NO. s I 2 tlECORD OF OWNERSHIP DATE BOOK ;PAGE ZONE SUB DIV. LOT NO. �I PURPOSE OF BUILDING O E S AME NO. OF STORIES SIZE SbC OWNER'S ADDRESS fK �( AAs G� a/A�f�� BASEMENT OR SLAB �l/J�F 'A ��y�.� 1 � a0,09—tom^ w 1�A ARCHITECT'S NAME �J O�L�i/, 2ND SIZE OF FLOOR TIMBERS 1STax )((2- .L ZV r)_ 3`IR+D BUILDER'S NAME C� SPAN /7� r°��ri�C N DISTANCE TO NEAREST BUILDING loo I- DIMENSIONS OF SILLS "Y �j� POSTS V DISTANCE FROM STREET "'T"Q ,T. DISTANCE FROM LOT LINES FROM LOT LINES - SIDES REAR��iREAR�� '1 ��/ rrv/1 " GIRDERS - AREA OF LOT OF LOT 0��FRONTAGEFRONTAGE HEIGHT OF FOUNDATION 4 to ° THICKNESS `S IS BUILDING BUILDING NEWW SIZE OF FOOTING L 1 r X IS BUILDING ADDITION MATERIAL OF CHIMNEY 6�fc IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION, IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATU4VL GAS LINE INSTRUCTIONS 3 PROPERTY INFORMATION SEE BOTH SIDES PERMIT FOR FOUNDATION ONLY -LAND `CBT REGULATED BY PARA. 114.8-S. B.C. EST. BLDG. C66T zSzT PAGE 1 FILL OUT SECTIONS 1 - 3 EST. BLDG. COST PER AQ. FT. EST. BLDG. COST PER ROOM PAGE 2 FILL OUT SECTIONS 1 - 12 4SIcIS- DATE FEE PAID SEPTIC PERMIT NO. ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECURMIT FOR FRAME/BUILDING OATS ILED DATE: "7 zO ` FEE PAID* BUILDING IN=PKCTOR SIGN AT F OWNER OR AUTHORIZED AGENT ~F E E` � «CO ~ OWNER TEL.# �'R�� PERMIT GRANTED CONTR. TEL. k ' 19 ti CONTR. LIC. a NO Q/4 8.4 o H.I.C. # . PERMIT FEE MAT "" 2 1995 LESS FDA �El � DUE FRAME PERM9 s .� � o-c'b 2:3. * Sir) 1. � r BUILDING RECORD 1 OCCUPANCY 12 SINGLE FAMILY STORIES THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM „ MULTI. FAMILY _OFFICES _ LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA - APARTMENTS RAGES, ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. V • 1 t�' .,n ,'I , '1 ,. a .... .. . •i...l1.1..J• `i • F. I satyr61. B'M'T 2nd ELECTRIC 't' " 1st 13rd I NO HEATING mus - TAN RM o CONSTRUCTION 2 FOUNDATION $ INTERIOR FINISH CONCRETE PINE B t 2 J3 CONCRETE 81. K. BRICK OR STONE HARDWD _ PIERS PLASTER DRY WALL _ UNFIN. 3 BASEMENT AREA FULL FIN. B'M'TAREA _ '/. 1/1 1/. FIN. ATTIC AREA _ N_O B M T FIRE PLACES _ HEAD ROOM MODERN KITCHEN 4 WALLS 9 FLOORS CLAPBOARDS de B 1 VOL_ 2 �— 3 _ DROP SIDING CONCRETE WOOD SHINGLES ASPHALT SIDING ASBESTOS SIDING VERT. SIDING STUCCO ON MASONRY EARTH HARDVJ'D COMMCN ASPH. TILE STUCCO ON FRAME BRICK ON MASONRY ATTIC STRS. & FLOOR _ BRICK ON FRAME CONC. OR CINDER BLK. _ WIRING STONE ON MASONRY STONE ON FRAME SUPERIOR POOR _ ADEQUATE NONE 5 "F 10 PLUMBING GABLE I HIP BATH 13 FIX.) GAMBREL MANSARD TOILET RM. (2 FIX.) " FLAT SHED opWATER CLOSET ASPHALT SHINGLES LAVATORY WOOD SHINGES KITCHEN SINK SLATE NO PLUMBING TAR & GRAVEL STALL SHOWER ROLL ROOFING MODERN FIXTURES TILE FLOOR TILE DADO 6 FRAMING IL 11 HEATING WOOD JOIST I PIPELESS FURNACE FORCED HOT AIR URN. TIMBER BMS. & COLS. STEAM STEEL BMS. & COLS. HOT W'T'R OR VAPOR WOOD RAFTERS AIR CONDITIONING _ RADIANT H'T'G UNIT HEATERS GAS OIL 7 NO. OF ROOMS • 1 t�' .,n ,'I , '1 ,. a .... .. . •i...l1.1..J• `i • F. I satyr61. B'M'T 2nd ELECTRIC 't' " 1st 13rd I NO HEATING mus - TAN RM o 14 Or r� cis w y� 00 ci :a 0 y� 00 ci :a o Z C) C-? zCR CL C�p C41C co :o Cc Cc l EQ z J A � m C W Z c Qaco c7 LFoCL. ECO2 d s v Q m a , o A � m y m M -� c w .a m w 0 3 O ca C=M C w cn w w U w ix. u:o v) o0 0 cn y� 00 ci :a o Z C) C-? zCR CL C�p C41C co :o Cc Cc l EQ z J � m C W CIE c Qaco c7 LFoCL. ECO2 LLJ Dm , o � m m E � CC V m m G. = d1 0 3 ca C=M C _� _ =CO= c o0 0 to ea acoa o w m � QII cm o � U W-�rZ Cl, � C C o Q _ ,m ii m=., --Co CD m t:5 N vJ C33c o E'. m W CO r cc jz 'O t � df ;azcr- CL a y _ m -.= C) CL m y� 00 �6 O CO 0 E C) o v z CD C_ O H � C c I o 'a EwCD CD m m m OL _C.3 O C co � � Q C�cc C C3ca ts J 'O M C2 co Cco CD CL V y cc CL CO2 0 J Q z z 0 Q LU Cf) z 0 U ._ LU F- 21-1 z LU :a o CIE c7 LLJ � eo m � C Q QII � U � •�' vJ Cf) Z O Lir c f) Q �6 O CO 0 E C) o v z CD C_ O H � C c I o 'a EwCD CD m m m OL _C.3 O C co � � Q C�cc C C3ca ts J 'O M C2 co Cco CD CL V y cc CL CO2 0 J Q z z 0 Q LU Cf) z 0 U ._ LU F- 21-1 z LU . r r FORM U — IAT RELPME FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Hoards 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. ****************Ap icant fills out this section***************** APPLICANT:il, 9,Phone �37Y - Z2 LOCATION: Assessor's Map Number /d 7W Parcel Subdivision 116-6Lots) Street WSt. Number ************************Official Use Only************************ RECOMMENDATI NS O TOWN AGENTS: ~ `� Date Approved 313b1)T Conservation Adminis raator Dat Rejected Com:^,entsvG' y�-1' �1(� ,�, Pub? is Wcr:;s - se*.aer/water. connections / 3—,>- - �-;-i5, - dr'-vpdav permit Fire Department Received by Building Inspector 1995 3-2,5� - ?�4 Date Date Approved Town Planner Date Rejectad Comm en4s Date Approved Food Inspector-::ealth Date Rejected Date Approved Sept_c Inspector -Health Date Rejected Comments Pub? is Wcr:;s - se*.aer/water. connections / 3—,>- - �-;-i5, - dr'-vpdav permit Fire Department Received by Building Inspector 1995 3-2,5� - ?�4 Date 1 BOARD OF HEALTH 120 MAIN STREET NORTH ANDOVER, MASS. 01845 TEL. 682-6483 Ext23 April 28, 1995 Les Godin / Merrimack Engineering 66 Park Street Andover, MA 01810 Dear Les: This is to confirm that on ril 27, 1995 the North Andover Board of Health granted a varian to North Andover regulation 4.18 of the Minimum Requirements for he Subsurface Disposal of Sanitary Sewage to allow the construc 'on of a leaching area 25 feet from a foundation drain instead of 5 feet for'.Lots- 1 and 20 Old. Cart Way. If you have any qu stions, please call the Board of Health office at 688-9540. Sincerely, Sandra Starr, S. Health Admin'strator cc: R. J. Richard File a TEL. 682-6483 Ext23 April 28, 1995 Les Godin / Merrimack Engineering 66 Park Street Andover, MA 01810 Dear Les: This is to confirm that on ril 27, 1995 the North Andover Board of Health granted a varian to North Andover regulation 4.18 of the Minimum Requirements for he Subsurface Disposal of Sanitary Sewage to allow the construc 'on of a leaching area 25 feet from a foundation drain instead of 5 feet for'.Lots- 1 and 20 Old. Cart Way. If you have any qu stions, please call the Board of Health office at 688-9540. Sincerely, Sandra Starr, S. Health Admin'strator cc: R. J. Richard File 1 1 t r z� ��• 7S Z07 - 47, 71,E s /, 09.5-2 .4C. a S .yEPEBY CE.�T/Fy Tp TyE T/TGE' /,�/SU.�O.� A,VO TT% Tf/E Bq.Ve 7W47 LOC.4729-.0 O,c/ MiC LOr Af S.4biy'.t/ ANO T.�G4T?OGEES eawA;Giew IY/TN ANAv k4C ZON/.vG c�E6vLAT.b,NS A'W4&4.00/.W SETdGIC.t'S FE0�1 STPE�TS f LOT L/•vES. " 'r ,l!X-TyC.W 7WI-f O.Y'ELL/N6 /S�t/OT LOG47E0 /i(/ r1lEFEGIE.P.4G F[ONJO WZWe. o APE.4. SryOIvN 0,41 FEM�t' COMMt/NiTy P.fNGL '� 2S 0098 OG�JS' C oW 7-6-o -41-03 s, 1v f S,0 V/ PL or RG.4.,,v O.P/iril�iV fO.P /1le,eelifl.9Gt' E'.t/61wee-/WSE.P -/SES 6G �-4•P.E� .ST.rEET A.t/OOI�E.� �J.4S.S.4GfU/SE7?S O/8/O Date...�.d . TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that zm.. � %:.r... . .........has permission to pe�,-+•-�- r! ............. . a plumbing in the buildings of ..��— .................... at . �7...« . ..... , North Andover, Mass. Fee./.�...Lic. No..... :.: .. ............ PLUM 1 _ INSPECTOR Check # --' � MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBP (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Location New 0 Renovation ED Date Owners me'e k 4-►-) t %�� Permit r Amount _ JJ,3_ Plans Submitted Yes 0 No ❑ A_ (Print or type) Check one: Installing Company Name C'pm'r-- -/Z-CA T-oJL, Corp. DPartner. Lj Finfn/Co. Certificate a� acs Name of Licensed Plumber: KA t t C.L Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Ej Other type of indemnity 0 Bond ❑ 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 N_,A' L,1 tgnature Owner E Agent I hereby certify that all of the details and information I 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 Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. By Signature or Licenseaum er Type of Plumbing License Title Cit/Town l 13.E Y cense NumDer Master Journeyman ❑ APPROVED (OFFICE USE ONLY. El Q N Mo0 o n 7° c� a a N n to m r- Wo --q --qoX OX m O, X-4 m 3 me Z M3 Xn= v vm �; CD xa Cl) cn = i vai 0 3 2 DZ o 'Ti _r • � �i zrGl _ y Ca in CIO O N' N W -n a. Hy 01. 7� 3:1 {J1 G) -I c 1 CD c m C-) eo (n M t �a Y Signature � Location No. Date i NORTH TOWN OF NORTH ANDOVER � 9 i - y Certificate Occupancy $ of 3A MU Building/Frame Permit Fee $ Foundation Permit Fee $ All Other Permit Fee $'� TOTAL Check # Building Inspector F i J TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING ��.� �, ,$ x ?- t yz°�S„-�ofz z�.' `-.'t .�.. b.� 5. J ,��y3 '�Y'�l '�`�..x�f�lf� ';`�' •a'� $t.��' ”. �' ....'• . ;:`. € v _; . .ry m%;in� .` .�� .. _ Isi�,i i' ;� 4 '+i s ,x` s t..; �Z, s%a MR BUILDING PERMIT NUMBER: rY DATE ISSUED: oZ _ SIGNATURE: Building Commissioner/Inspector of Buildings Date SECTION 1- SITE INFORMATION i 1.1 Property Address: / 7p G40 C. *R r U,,:,4 -Y 1.2 Assessors Map and Parcel Map Number Number: Parcel Number /: Address for Service 1.3 Zoning itiformationZoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Name Print Front Yard . Side Yard Telephone Rear Yard Required Provide Required 7 Provided Required Provided 1.7 Water Supply M.G L.C.40. 54) 1.5. Flood Zone Information: Public t]/ Private ❑ Zone Outside Flood Zoae O, 1.8 Municipal Sewerage Disposal System: 0 On Site Disposal System SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record ,Ro� Fl? 4- �lti-� /� �Icowf'p o�d � T Name (TWint Address for Service Sigeftffe Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ License Construction Supervisor: C-5 012f 941F License Number Ad ss Expiration Date Sign#ure v Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Address Expiration Date Signature Telephone La is W V N 0 r L R SECTION 4 - WORKERS COMPENSATION (M.G.I Workers Compensation Insurance affidavit must be completed in the denial of the issuance of the building permit Signed affidavit Attached Yes ......0 No 0 SECTION 5 Doerrintinn ..f A.. a w a. I C 152 § 25c(6) id submitted with this application. Failure to provide this affidavit will result New Construction 0 Existing Building ❑ o ... Repair(s) ❑ Alterations(s) ❑ Addition I c Print e Accessory -Bldg. ❑ ' " Demolition ❑ Other 0 Specify BASEMENT OR SLAB r SIZE OF FLOOR TIMBERS 1sT x /0 2 3 SPAN �, Brief Description of proposed Work: 3X (o DRVIENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION = Q ' THICKNESS /o " SIZE OF FOOTING X „ MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND Sd�/,� `• IS BUILDING CONNECTED TO NATURAL GAS LINE SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be tp OFF I+ IAA% USE O LY Completed by permit a licant r 1. Building a � () Building Permit Fee J._ q X 6-'-00 Multi lier ctrical i S� 2iiFire (b) Estimated Total Cost of `� �7" 6 �� Construction s'! 3mbin �- Building Permit fee (a) x (b) �- 4chanical AC 5 Protection 6 Total 1+2+3+4+5% Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT /7 n I I n Hereby authorize as Owner/Authorized Agent of subject property to work authorized by this building permit application. to act on ( Signature 6f Owner Date l SF.CTTSDN7hnWNTi7?/A7rTiI/%D771V7%.�.,.,.,.,,ter . Fa�ndd'belief as Owner/Authorized Agent of subject declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge I c Print e Si tur of caner/A ent Date NO. OF STORIES SIZE /g xo2 BASEMENT OR SLAB r SIZE OF FLOOR TIMBERS 1sT x /0 2 3 SPAN �, DRVIENSIONS OF SILLS 3X (o DRVIENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION = Q ' THICKNESS /o " SIZE OF FOOTING X „ MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND Sd�/,� `• IS BUILDING CONNECTED TO NATURAL GAS LINE I I Y FORM U - LOT RELEASE FORM 1--3d ©a INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. ****************************APPLICANT FILLS OUT THIS SECTION / APPLICANT - - R �C<'��K t c� %a PHONEf5� LOCATION: Assessor's Map Number �� PARCEL �/% SUBDIVISION LOT (S) STREET. ST. NUMBER *****************************************OFFICIAL USE ONLY*********************************** RECOMM DATIONS TOWN AGENTS: CONSE V 'fiON AftfpfISTRATOR DATE APPROVI5D 7` DATE REJECTED COMMENTS ! V G' M&si/ p ( C TOWN PLANNER COMMENTS FOOD INSP-APTQR-HEALTH §0PT16 I SPECTOR- COMMENTS DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED 'EALTH DATE APPROVED 'Z DATE REJECTED P 0 MS PUBLIC WORKS - SEWERNVATER CONNECTIONS DRIVEWAY PERMIT V/ FIRE DEPARTMENT_ I RECEIVED BY BUILDING INSPECT6 Revised 9\97 jm //3-0/oz ATE__ _ A SZoe•75— Z(97- 7/0 --7/0 M � N • � v�'n i 3S � I I � � cam, Z 11ERE0,V Tb T,yE 74V Tf/E BR.V,r 7wr /S LOc.4TEG ON T.S/E Gor.lS .S.S4 WV A.VO ;W47 -17 -PACs CaA/FGtPA/ lY/TN r11-- ra&.IW ao-, 7. A-OokcC ZOw/w6 eE6vLArWAIV Al --X I.f I,W FWOPW Sreed7S f " 1' A&leTp VC.0 GE.PT/fY ;;0fr TiVXf A01MeeL/�V6 /SNdT LOG4rE0 /N T.YE Ae4WP.44 oxe' 4WP f/AT4•r0 APEA. S�lQ/vN OiS/ FEMA' CO,aAMt/iviTy PANCL '� 25Oo98 Opp ^ . Of E 7 G J _ $,_ _• • .� • RL. S. GATE /L or Rz 4,41 AA // /N O.P.9i�iV FO,P ✓. �/C�/A�2D �o.E'P � °�rsst°�� i' �fIE.P.P/�l.4Gt' E.fi6•cvEE.Pi.!/6 SE.Pi�/CES ''��r�v� 6G f'-4•P.E� .ST.�EET A.ti00YE.� �1.4S.S,vC,�//SETTS O/8/O AS Bvl[.T TiEs i Bt DG, CoR. A d G S.T.r�. H. D -BOX 33.3' 30. B' r:: -W[) T2.4*� I tit- 81. Z' -76.y' N W 1500 GAL SEPn G TA N119 AS SVIL.T r✓LEUATIoi.1S: Top F"DT lj. If 14"0 SCH�yo P.VC.I)JV, E 81 -DG „ Wrd S. -r �It �, ". "� O�Te D -max •if 1I"41 SCN.)Io PTF P.v.6.1JJV.0 I1JW--rTflPt =Ir G .75 Zo 1`1 --))-7 C' C a r\ CA AS BUILT PLAN OF SUBSURFACE DISPOSAL SYSTEM LOCATEDIN MO RTS ANDOVER , MA . AS PREPARED FOR R.I RICHARD 625RP, DATE: ocTosER Z3, ►a9S SCALE: I "= 440" i North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11,S150A. The debris will be disposed of in: Y (Location of Facility) Sibnature of Permit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector The Commonwealth of Massachusetts Department of Industrial Accidents t Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Please Print Name: Location: i" % a G� %� C - T tA11111-Y City XZ, 41V JJQC V A,- am a homeowner performing work myself. =I am a sole proprietor and have no one working in any capacity zPg V5-, �am an employer providing workers' compensation for my employees working on this job. Company name �. J� �C ��>T/� ccyee Address / % 040 C2R % Gt/i9l City: �/ /fi'tirJot/�'2 Phone I-fnsura ce Co ri (iG/c7 /1Cr5 7`e fZ -T&S(/OIuC'g cc Policy* Wc-: Company name � � i'S yr � L ui0 %t' CC'S %£_A �,vsvgAe� -C�E Address 1 Insurance Co. Policy # 30 Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of ($100.00) a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do herby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature /� Date Print name !/1c � �1C Hag Phone # Official use only do not write in this area. to be completed by city or town official' ❑ Building Dept ❑Check /f immediate response is required Building Dept ❑ Licensing Board ❑ Selectman's Office Contact person: Phone #: ❑ Health Department ❑ Other FORM WORKMAN'S COMPENSATION ✓1ze Coanamzoruuea,�i �✓�iCi°°aciivaelta BOARD OF BUILD,;( REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 014848 Birthdate: 05131/1955 Expires: 05/31/2002 Tr. no: 23217 Restricted To: 00 ROGER J RICHARD 178 OLD CART WAY N ANDOVER, MA 01845 Administrator C/) m m m m m m Cf) m (n 0 m F -W --.-m 0. ] Q co CD CO) "0 CD 5zCD 7 L�. CO) C-) O CO) O CO) -0 CD Cl) CD CD CD CO) CD CO) CD O CD = 2:- 0 w —0 CO) '0 cr 0 r .L CrD a O L % m COP w a z a- ;r --4 2L LA. :F =r rL 'O'C36 O= =r CD =r 0) CAO) CD -.4 a.: r 0 N 0 rr 0 IE CD CA CD 0 0 o0 * CS as• CD -N, C2 P -j ff Er 2b %cot cm A 9 a CD C/) co Cl)= 0 kit CD n Cr1 Or mn; - cn 5: V.CD cn Q 0 N. TZ, CL CD cnRr C* -O. . CD ED, 0 cn cn C2 V 00 CD 0 ---rj 0 CA CD 0ES3 mmi C/) 0 (n z t7l -x C) tz CA 0 GO m n 0 C/) Z� 0 N LN y 0 0 ez� a Multi -Loaded Beam( 99 BOCA National Building Code (97 NDS) 1 Ver. V5010215 By: charles tanzi , architecture plus on: 01-28-2002: 11:36:39 AM Prosect: - Location: 178 Old Cart Way Summary: ( 2 ) 1.75 IN x 7.25 IN x 10.5 FT / Versa -Lam 2800 Fb DF - Boise Cascade Section Adequate By: 8.8% Controlling Factor: Moment of Inertia / Depth Required 7.05 In * Laminations are to be fully connected to provide uniform transfer of loads to all members Center Span Deflections: Dead Load: DLD-Center= 0.18 IN Live Load: LLD -Center= 0.31 IN = U411 Total Load: TLD -Center= 0.48 IN = U261 Center Span Left End Reactions (Support A): Live Load: LL-Rxn-A= 720 LB Dead Load: DL-Rxn-A= 432 LB Total Load: TL-Rxn-A= 1152 LB Bearing Length Required (Beam only, Support capacity not checked): BL -A= 0.37 IN Center Span Right End Reactions (Support B): Live Load: LL-Rxn-B= 960 LB Dead Load: DL-Rxn-B= 562 LB Total Load: TL-Rxn-B= 1522 LB Bearing Length Required (Beam only, Support capacity not checked): BL -B= 0.48 IN Beam Data: Center Span Length: L2= 10.5 FT Center Span Unbraced Lenqth-Top of Beam: Lu2-Top= 0.0 FT Center Span Unbraced Length -Bottom of Beam: Lu2-Bottom= 10.5 FT Live Load Duration Factor: Cd= 1.00 Live Load Deflect. Criteria: U 360 Total Load Deflect. Criteria: U 240 Center Span Loading: Uniform Load: Live Load: wL-2= 0 PLF Dead Load: wD-2= 0 PLF Beam Self Weight: BSW= 8 PLF Total Load: wT-2= 8 PLF Point Load 1 Live Load: PL1-2= 1680 LB Dead Load: PD1 -2= 911 LB Location (From left end of span): X1-2= 6.0 FT Properties For: Versa -Lam 2800 Fb DF- Boise Cascade Bending Stress: Fb= 2800 PSI Shear Stress: Fv= 285 PSI Modulus of Elasticity: E= 2000000 PSI Stress Perpendicular to Grain: Fc_perp= 900 PSI Adjusted Properties Fb' (Tension): Fb'= 2961 PSI Adjustment Factors: Cd=1.00 Cf=1.06 Fv': Fv'= 285 PSI Adjustment Factors: Cd=1.00 Design Requirements: Controlling Moment: M= 6753 FT -LB 5.985 Ft from Left Support of Span 2 (Center Span) Critical moment created by combining all dead loads and live loads on span(s) 2 Maximum Shear: V= 1522 LB At Right Support of Span 2 (Center Span) Critical shear created by combining all dead loads and live loads on span(s) 2 Comparisons With Required Sections: Section Modulus: Sreq= 27.4 IN3 S= 30.6 IN3 Area: Areq= 8.1 IN2 A= 25.3 IN2 Moment of Inertia: Ireq= 102.2 IN4 1= 111.1 IN4 Multi -Loaded Beam[ 99 BOCA National Building Code (97 NDS) ]Ver. V5010215 By: chanes tanzi , architecture plus on: 01-28-2002 Project: - Location: 178 Old Cart Way Summary: ( 2 ) 1.75 IN x 7.25 IN x 10.5 FT / Versa -Lam 2800 Fb DF - Boise Cascade Section Adequate By: 8.8% Controlling Factor: Moment of Inertia / Depth Required 7.05 In LOADING DIAGRAM P1 Center Span = 10.5 ft Reactions Live Load Dead Load Total Load Uplift Load A 720 Lb 432 Lb 1152 Lb 0 Lb B 960 Lb 562 Lb 1522 Lb 0 Lb Center Span Uniform Loading Live Load Dead Load Self Weight Total Load W 0 Plf 0 Plf 8 Plf 8 Plf Point Loading Live Load Dead Load Location P1 1680 Lb 911 Lb 6 Ft Multi -Loaded Beamf 99 BOCA National Buildinq Code (97 NDS) ) Ver. V5010215 Bv: charles tanzi , architecture plus on: 01-28-2002 : 11:33:54 AM Protect: - Location: 178 Old Cart Way Summary: ( 2 ) 1.75 IN x 11.25 IN x 16.0 FT / Versa -Lam 2800 Fb DF - Boise Cascade Section Adequate By: 64.5% Controllinq Factor: Section Modulus / Depth Required 9.44 In * Laminations are to be fully connected to provide uniform transfer of loads to all members Center Span Deflections: Dead Load: DLD-Center- 0.18 IN Live Load: LLD -Center= 0.29 IN = U657 Total Load: TLD -Center= 0.47 IN = U407 Center Span Left End Reactions (Support A): Live Load: LL-Rxn-A= 735 LB Dead Load: DL-Rxn-A= 497 LB Total Load: TL-Rxn-A= 1232 LB Bearinq Lenqth Required (Beam only, Support capacity not checked): BL -A= 0.39 IN Center Span Riqht End Reactions (Support B): Live Load: LL-Rxn-B= 945 LB Dead Load: DL-Rxn-B= 611 LB Total Load: TL-Rxn-B= 1556 LB Bearing Length Required (Beam only, Support capacity not checked): BL -B= 0.49 IN Beam Data: Center Span Lenqth: L2= 16.0 FT Center Span Unbraced Lenqth-Top of Beam: Lu2-Top= 0.0 FT Center Span Unbraced Length -Bottom of Beam: Lu2-Bottom= 16.0 FT Live Load Duration Factor: Cd= 1.00 Live Load Deflect. Criteria: U 360 Total Load Deflect. Criteria: U 240 Center Span Loading: Uniform Load: Live Load: wL-2= 0 PLF Dead Load: wD-2= 0 PLF Beam Self Weight: BSW= 12 PLF Total Load: wT-2= 12 PLF Point Load 1 Live Load: PL1-2= 1680 LB Dead Load: PD1 -2= 911 LB Location (From left end of span): X1-2= 9.0 FT Properties For: Versa -Lam 2800 Fb DF- Boise Cascade Bendinq Stress: Fb= 2800 PSI Shear Stress: Fv= 285 PSI Modulus of Elasticity: E= 2000000 PSI Stress Perpendicular to Grain: Fc_perp= 900 PSI Adjusted Properties Fb' (Tension): Fb'= 2820 PSI Adjustment Factors: Cd=1.00 Cf=1.01 Fv': Fv'= 285 PSI Adiustment Factors: Cd=1.00 Design Requirements: Controllinq Moment: M= 10545 FT -LB 8.96 Ft from Left Support of Span 2 (Center Span) Critical moment created by combining all dead loads and live loads on span(s) 2 Maximum Shear: V= 1556 LB At Riqht Support of Span 2 (Center Span) Critical shear created by combining all dead loads and live loads on span(s) 2 Comparisons With Required Sections: Section Modulus: Sreq= 44.9 IN3 S= 73.8 IN3 Area: Areq= 8.2 IN2 A= 39.3 IN2 Moment of Inertia: Ireq= 245.2 IN4 1= 415.2 IN4 Multi -Loaded Beam[ 99 BOCA National Building Code (97 NDS) ]Ver. V5010215 By: chanes tanzi , architecture plus on: 01-28-2002 Project: - Location: 178 Old Cart Way Summary: (2 ) 1.75 IN x 11.25 IN x 16.0 FT / Versa -Lam 2800 Fb DF - Boise Cascade Section Adequate By: 64.5% Controlling Factor: Section Modulus / Depth Required 9.44 In LOADING DIAGRAM P1 Center Span = 16 ft Reactions Live Load Dead Load Total Load Uplift Load A 735 Lb 497 Lb 1232 Lb 0 Lb B 945 Lb 611 Lb 1556 Lb 0 Lb Center Span Uniform Loading Live Load Dead Load Self Weight Total Load W 0 Plf 0 Plf 12 Plf 12 Plf Point Loading Live Load Dead Load Location P1 1680 Lb 911 Lb 9 Ft tiREU ARCliv n 'No. 4351 � � O TEWKSBURY, MA �Fql TH OF 0PS�� Uniformly Loaded Floor Beam[ 99 BOCA National Buildinq Code (97 NDS) ) Ver. V5010215 By: charles tanzi , architecture plus on: 01-28-2002 : 11:51:11 AM Prosect: - Location: 178 Old Cart Way Summary: ( 2 ) 1.75 IN x 11.25 IN x 12.5 FT / Versa -Lam 2800 Fb DF - Boise Cascade 11666 Section Adequate By: 48.7% Controllinq Factor: Section Modulus / Depth Required 9.65 In Laminations are to be fully connected to provide uniform transfer of loads to all members Deflections: LB Dead Load: DLD= Live Load: LLD= Total Load: TLD= Reactions (Each End): 19.7 Live Load: LL-Rxn= Dead Load: DL-Rxn= Total Load: TL-Rxn= Bearing Length Required (Beam only, Support capacity not checked): BL= Beam Data: IN4 Span: L= Unbraced Lenqth-Top of Beam: Lu= Live Load Deflect. Criteria: U Total Load Deflect. Criteria: U Floor Loadinq: Floor Live Load -Side One: LL1= Floor Dead Load -Side One: DL1= Tributary Width -Side One: TW1= Floor Live Load -Side Two: LL2= Floor Dead Load -Side Two: DL2= Tributary Width -Side Two: TW2= Live Load Duration Factor: Cd= Wall Load: WALL= Beam Loadinq: Beam Total Live Load: wL= Beam Self Weiqht: BSW= Beam Total Dead Load: wD= Total Maximum Load: WT= Properties For: Versa -Lam 2800 Fb DF- Boise Cascade Bendinq Stress: Fb= Shear Stress: Fv= Modulus of Elasticity: E_ Stress Perpendicular to Grain: Fc perp= Adjusted Properties Fb' (Tension): Fb'= Adjustment Factors: Cd=1.00 Cf=1.01 Fv': Adiustment Factors: Cd=1.00 Design Requirements: Controllinq Moment.- 6.25 oment:6.25 ft from left support Critical moment created by combining all dead and live loads. Maximum Shear: At support. Critical shear created by combining all dead and live loads. Comparisons With Required Sections: Section Modulus: Area: Moment of Inertia: Fv'= 0.14 IN 0.26 IN = U582 0.39 IN = U380 2438 LB 1296 LB 3733 LB 1.19 IN 12.5 FT 0.0 FT 360 240 30 PSF 15 PSF 6.5 FT 30 PSF 15 PSF 6.5 FT 1.00 0 PLF 390 PLF 12 PLF 207 PLF 597 PLF 2800 PSI 285 PSI 2000000 PSI 900 PSI 2820 PSI 285 PSI M= 11666 FT -LB V= 3733 LB Sreq= 49.7 IN3 S= 73.8 IN3 Areq= 19.7 IN2 A= 39.3 IN2 Ireq= 262.5 IN4 1= 415.2 IN4 0. . Uniformly Loaded Floor Beam[ 99 BOCA National Building Code (97 NDS) ]Ver. V5010215 By: charles tanzi , architecture plus on: 01-28-2002 Project: - Location: 178 Old Cart Way 3 Seasons Rm. Summary: (2) 1.75 IN x 11.25 IN x 14.0 FT /Versa -Lam 2800 Fb DF - Boise Cascade Section Adequate By: 12.6% Controlling Factor: Moment of Inertia / Depth Required 10.81 In LOADING DIAGRAM A Span = 14 ft Reactions Live Load Dead Load Total Load Uplift Load A 2730 Lb 1451 Lb 4181 Lb 0 Lb B 2730 Lb 1451 Lb 4181 Lb 0 Lb Span Uniform Loading Live Load Dead Load Self Weight Total Load W 30 Pf 195 Plf 12 Plf 597 Plf B Roof Beamf 99 BOCA National Building Code (97 NDS) 1 Ver. V5010215 By: charles tanzi , architecture plus on: 01-28-2002 : 11:28:22 AM Project: - Location: 178 Old Cart Way V= Summary: LB ( 2 ) 1.75 IN x 9.25 IN x 14.0 FT / Versa -Lam 2800 Fb DF - Boise Cascade 32.9 Section Adequate By: 34.7% Controlling Factor: Moment of Inertia / Depth Required 8.38 In * Laminations are to be fully connected to provide uniform transfer of loads to all members Deflections: IN3 Dead Load: DLD= Live Load: LLD= Total Load: TLD= Reactions (Each End): 171.4 Live Load: LL-Rxn= Dead Load: DL-Rxn= Total Load: TL-Rxn= Bearing Length Required (Beam only, Support capacity not checked): BL= Beam Data: Span: L= Maximum Unbraced Span: Lu= Pitch Of Roof: RP= Live Load Deflect. Criteria: U Total Load Deflect. Criteria: U Roof Loading: Roof Live Load -Side One: LL1= Roof Dead Load -Side One: DL1= Tributary Width -Side One: TW1= Roof Live Load -Side Two: LL2= Roof Dead Load -Side Two: DL2= Tributary Width -Side Two: TW2= Roof Duration Factor: Cd= Beam Self Weight: BSW= Slope Adjusted Beam Loading: Beam Uniform Live Load: wL= Beam Uniform Dead Load Adjusted for Rafter Pitch: wD_adj= Total Uniform Load: WT= Properties For: Versa -Lam 2800 Fb DF- Boise Cascade Bending Stress: Fb= Shear Stress: Fv= Modulus of Elasticity: E_ Stress Perpendicular to Grain: Fc perp= Adjusted Properties Fb' (Tension): Fb'= Adjustment Factors: Cd=1.15 Cf=1.03 Fv': Fv'= Adjustment Factors: Cd=1.15 Design Requirements: Controlling Moment: 7.0 ft from left support Critical moment created by combining all dead and live loads. Maximum Shear: At support. Critical shear created by combining all dead and live loads. Comp4risofesWith Required Sections: �Sktiol'iUodulus: A `r&. Mori1k°of Inertia: 0.24 IN 0.45 IN = U374 0.69 IN = U242 1680 LB 911 LB 2591 LB 0.82 IN 14.0 FT 0.0 FT 0 : 12 240 180 30 PSF 15 PSF 4.0 FT 30 PSF 15 PSF 4.0 FT 1.15 10 PLF 240 PLF 130 PLF 370 PLF 2800 PSI 285 PSI 2000000 PSI 900 PSI 3314 PSI 328 PSI M= 9068 FT -LB V= 2591 LB Sreq= 32.9 IN3 S= 49.9 IN3 Areq= 11.9 IN2 A= 32.3 IN2 Ireq= 171.4 IN4 1= 230.8 IN4 e - No 3 :SBU RY, MA rH of �?� Roof Beam[ 99 BOCA National Building Code (97 NDS) ]Ver. V5010215 By: chanes tanzi , architecture plus on: 01-28-2002 Project: - Location: 178 Old Cart Way Summary: ( 2 ) 1.75 IN x 9.25 IN x 14.0 FT / Versa -Lam 2800 Fb DF - Boise Cascade Section Adequate By: 34.7% Controlling Factor: Moment of Inertia / Depth Required 8.38 In LOADING DIAGRAM A [3 Span = 14 ft Reactions Live Load Dead Load Total Load Uplift Load A 1680 Lb 911 Lb 2591 Lb 0 Lb B 1680 Lb 911 Lb 2591 Lb 0 Lb Span Uniform Loading Live Load Dead Load Self Weight Total Load W 240 Plf 120 Plf 10 Plf 370 Plf Location J r) Z O k c� CA R I c&A q- t( No. -5- Date /70� T NORTN TOWN OF NORTH ANDOVER s Certificate of Occupancy $ asNus Eta' �c Building/Frame Permit Fee $ 3 Foundation Permit Fee $ Other Permit Fee $ TOTAL $.--- Check # v 17495 Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING TWr sectim fiW officid use ola BUILDING PERMIT NUMBER: DATE ISSUED: SIGNATURE: A Ay r Building Co missioner/Inspector of Buildings Date I SECTION 1- SITE INFORMATION I r -j ) _2__,7_ 1.1 Property Address: 1.2 Assessors Map and Parcel Map Numbd Number: Parcel Number " 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Recluired Provide Required Provided R red Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: Public ❑ Private ❑ Zone Outside Rood Zone ❑ 1.8 Municipal Sewerage Disposal System: ❑ On Site Disposal System ❑ SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT I, i L v 1 1 U v 1 a L i I t. r c: s i N U 2.1 Own 'of Record n Ccs Name (Print) Address for Service l CoD3--d 3[ -_3V -oz -(t) Signatur Telephone V 2.2 Owner of Record: Name Print Address for Service: Signature e ep,one SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable Licensed Construction Supervisor: _ License Number Address Expiration Date Signature Telephone 1� Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Address Expiration Date Signature Telephone A SECTION 4 - WORKERS COMPENSATION (MG.L C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building it. Signed affidavit Attached Yes .......0 No ....... 0 SECTION 5 Description of Proposed Work(check all a Ucable New Construction 0 Existing Building Repair(s) ❑ Alterations(s) ❑Tddi tion 11 Accessory Bldg. 0 Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: l 1C,_�tN�t � � � ( C�—`��✓l "t- �C1.--�S \ `►'�LS�� z'r—� dN I SECTION 6 - ESTIMATED CONSTRUCTION COSTS I Item Estimated Cost (Dollar) to be Completed by permit applicant OFFICIAL USE ONLY 1. Building �U Lei (a) Building Permit Fee Multiplier 2 Electrical �. (b) Estimated Total Cost of Construction 3 Plumbin Building Permit fee (a) x (b) 4 Mechanical (HVAC 5 Fire Protection h 6 Total 1+2+3+4+5 3i eTII�-D Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf matters relat orized by this building permit application. Zi ':' w: Signature of e e SECTION b OWNER/AUTHORIZED AGENT DECLARATION i I, as Owner/Authorized Agent of subject property Herebv declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief Print Name Si ature of Owner/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TDABERS i;T 2 ND 3 RD SPAN DIMENSIONS OF SILLS DM ENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE =i/V Zay. FORM U - LOT RELEASE FORM q - �L "o_ wo `-( INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. *****************************APPLICANT FILLS OUT THIS SECTION*********************** APPLICANT/ , -1117/?!y / 6-) `,2 Ae PHONE '�X�? u 3 3 3 LOCATION: Assessor's Map Number PARCEL SUBDIVISION LOT (S) n STREET ST. NUMBER / `****************OFFICIAL USE ONLY *********** RECOMMENDATIONS OF TOWN AGENTS: CONSERVATION ADMINISTRATOR DATE APPROVED DATE REJECTED COMMENTS TOWN PLANNER COMMENTS DATE APPROVED DATE REJECTED FOOD�PECTOR-HEALTHD DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED COMMENTS�,,,�-► f , �- r r —� -c5 �' m /1 -L- PUBLIC PUBLIC WORKS - SEWERIWATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR o DATE Revised 9197 jm r TOWN OF NORTH ANDOVER AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application MGL c. 142 A requires that the "reconstruction, alteration, renovation, repair, modernization, conversion, improvement, removal, demolition, or construction of an addition to any pre-existing owner occupied building containing at least one but not more than four dwelling units ... or to . structures which are adjacent to such residence or building" be done by registered contractors, with certain exception, along with other requirements. Vuv�-o Type of Work: C `� 1 , MEst. Cost Zo VC, Address of Wo Owner Name: O kcl ( Date of Permit Application: ` Z -Z _ c-) `t I hereby certify that: Registration is not required for the following reason(s): For office Use Only Work excluded by law Pemit No. Job under $1,000 Date Building not owner -occupied Owner pulling own permit Other (specify) Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FIND LINER MGL c. 142A. Signed under penalties of perjury: I hereby apply for a permit as the agent of the owner: Date Contractor Name Registration No. OR: Notwithstanding the above notice, I hereby apply for a permit as the owner of the above property: 1;;V� Date ame r North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 11, S 150 A. The debris will be disposed of in: LL a S Wow (L ation of Facil ignature of Permit Applicant D to NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector i m m X m m m CO) 10 CD az CDCL O �cc � O o p CD Cr d =� CD O -- CA .p CD 0 CA O CO) 0 C CO) Er C) co O CD CD CO) CD CO) O CD 0 c CD o O -• H O Q N La aoCa m ti m o n m m 0 O NmaCC3 Im O CO). T =r m = Im y O -1 O m N O -� > > m C ._ a O N• O A W � O 'O C N :t a C3 CDCD S - m n� c c3_ m O N co N N d d Q C � o n N CL tog CDIp .. !cm N �� C, 0 /i a'ak CA " • 0 o CD 0 m m � itO �.�• N ; � I o CD �d d ♦W=4 �2 CD Cn N � wc cw z O OOr- x r "ti r n r �. OT o* C7 9) a,w a H 0 0 O C (D 101 c C� E (ED'xYl[murnft1'calt4 of fflaSS C4nortts OFFICE USE ONLY Department of Public Saf ty Permit No. v S It I Utility Authorization No. BOARD OF FIRE PREVENTION REGULATIOaS 527 CMR 12:00 APPLI ATION FOR PERMIT T PERFORM ELECTRICAL WORK C All work to be performed in accordance with /he Massachusetts Electrical Code, 527 CMR 12:00 please print in Ink or type all information Date: 2�kzc City or Town of: r'' V To the Inspector of Wires: The undersigned ap liesfor a permit to perform the electrical work described below. Location (Street & Number): 8 0 c -*R -r 1-!o Owner or Tenant: C/ e, I (I -a N f Owner's Address: �1 0 C.t'- IT W 161 Phone: Is this permit in conjunction with a building permit? ,�I�Yes ❑ No (check ppropriate box) 4 Purpose of Building: _ 6 -em / - 6�0►�, Rind 0 rtJ' Exist�ngt$ervice: �OAm'ps ' -12-0 /�'a f� h Volts Overhead ❑ Undgrd B�No. of'Meter's: New Service: Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters: Number of Feeders and Ampacity- Location and Nature of Proposed Electrical Work: IFI ►^`S VL �t �1akpL,R K1 +CiV, No. Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No. Lighting Fixtures oZp Swimming Pool 9mde ❑ gmd: ❑ Generators KVA No. Receptacle OutletsNo. Oil Burners No. of Emergency Lighting Battery Units No. Switch Outlets No. Gas Burners No. of Zones --------------------------- No. of Detection and Initiating Devices ------------------------- No. of Sounding Devices --------------------------- DeteNo. c Self Contained ction/Sounding Devices ------------------------- Local❑ Municipal❑ OTHER: Connection No. Ranges g No. Air Conti Total Tons No. Disposals Heat Total Total No. of Pumps Tons KW No. Dishwashers Space/Area Heating KW - No. Dryers Heating Devices KW No. Water Heaters KW No. of Ballasts Low Voltage Wiring No. Hydi;,o Massage Tubs No. of Motors Total HP OTHER: INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent. YES ❑ NO ❑ I have submitted vaild proof of same to this office. YES NO ❑ If you have checked 'YES', please indicate the type of coverage by checking the appropriate box. INSURANCE 0" BOND ❑ OTHER 0 (please specify): Estimated Value of Electrical Work: $ % �6d (expiration date Work to Start: 7 a4 Inspection Date Requested: Rough Final I Signed Under the Penalties of _Perjury: _ FIRM NAME: left h ZSCa 77 ----�"l�fi"1C4,- Lic. No: 46 So 626 Licensee: K"t yy�� ` 4-c act %Signature:/ - Lic. No: Address: Phone: 776' S(acI 583 Alt #: `l?8 f��f X783 OWNER'S INSURANCE WAIVER: I am aware that the Licensee DOES NOT HAVE the insurance coverage or its substantial equivalent as required by Massachusetts General Laws, and that my signature on this permit application waives this requirement. OWNER AGENT (please circle one) . Signed: Telephone No. Permit Feer WHITE - OFFICE COPY • YELLOW - CONTRACTOR'S COPY • PINK - POSTED COPY r, �14 6:9 /Q- 3 - 2 </-, e S- A77�\ R ly(4, 0`t��ao -3v ,0C-/ Date.............................. TOWN OF NORTH ANDOVER CC12KA1T =n= WIDIMM '„ This certifies that .... e.v I S U. ......................................... �. :................ has permission to perform ......�'O.`.`.. .. °% % /....................................................... wiring in the building of ...L. P r'.`.,%. / Cb /t"/. ryl ....... ......... ........................ d f C4.0. .WA y......... , North dover, Mass. Fee..... Lic. No. ..................... ..................::.................... ELECTRICALINSPECTOR Check # a 0J5 5375 Z4e (fomraoniuealt4 of Mao Department of Public Sc e BOARD OF FIRE PREVENTION REGULATION APPLICATION FOR PERMIT T All work to be performed in accordance with he please print in ink or type all information City or Town of: -,Car-ft, lom To the Inspector of Wires: The undersigned Location (Street & Number): 178 Owner or Tenant: setts ty 527 CMR 12:00 OFFICE USE ONLY Permit No. Utility Authorization No. ' PERFORM ELECTRICAL WORK Massachusetts Electrical Code, 527 CMR 12:00 Date: ]v a permit to perform the electrical work described below Owner's Address: 11 1� r Gib CO` T W *I Phone: Is this permit in conjunction with a building permit? L�Yes 1 ❑ No (check �tpprc Purpose of Building: (51M `!V Existing Service: �OAmps 12-0 l New Service: _/J Amps / n,, riate box//),, ? 4,0 Vag A0 ni, Volts Overhead ❑ Undgrd E1**'- No. of Meters: Volts Overhead ❑ Undgrd ❑ No. of Meters: _ Number of Feeders and Ampacity• l Location and Nature of Proposed Electrical Work: ►niS 1L -OC-%rv�-' 1,(,+a� 'Mril No. Lighting Outlets No. of Hot Tubs No. of Transformers Tot No. Lighting Fixtures a Swimming Pool 9md. ❑ gr d. ❑ Generators KVA No. Receptacle Outlets No. Oil Burners No. of Emergency LightingBatterV Units No. Switch Outlets No. Gas Burners No. of Zones ------------------------- Noof Detection and Initiating Devices ------------------------- No. of Sounding Devices ------------------------- No.o Det c Self Contained Detection/Sounding Devices Local❑ Municipal❑ Connection OTHER: No. Ranges g No. Air Cond Total Tons No. Disposals Heat Total Total No. of Pumps Tons KW No. Dishwashers Space/Area Heating KW No. Dryers Heating Devices KW No. Water Heaters KW No. oNo. S gnsf of Ballasts Low Voltage Wiring No. Hydro Massage Tubs No. of Motors Total HP OTHER: INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent. YES ❑ NO ❑ 1 have submitted vaild proof of same to this office. YES NO ❑ If you have checked 'YES', please indicate the type of coverage by checking the appropriate box. INSURANCE 0"' BOND ❑ OTHER ❑ (please specify): Estimated Value of Electrical Work: $ V.86o (expiration date) Work to Start: 7Ld Inspection Date Requested: Rough Final Signed Under the Penalties of _/-7Perjury: _ p FIRM NAME: Kw -I h ZSCa --�l� t �! Lic. No: _�_ so Licensee: K"► f I ^co e/Signature: - Lic. No: Address: Ga C��l/ L r (/iti4V ��'"� Phone: 978 Alt #: 4719 foY-5' '3178,� OWNER'S INSURANCE WAIVER: I am aware that the Licensee DOES NOT HAVE the insurance coverage or its substantial equivalent as required by Massachusetts General Laws, and that my signature on this permit application waives this requirement. OWNER AGENT (please circle one) Signed: Telephone No. Permit Feer WHITE - OFFICE COPY • YELLOW - CONTRACTOR'S COPY • PINK - POSTED COPY Date a) �I.� ... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ... I ' P �- `- ......... . has permission to perform ... j -P.! ✓�.� F T�Z ? �� wiring in the building of ............ ll at t. t._(� . 0'r.4 . ! ,! , N ver, Mass. Fee,.W/ / . Lic. No. .......... .. . ELECTRICAL INSPECTOR Check # 11392 crd wti k� M j M W b 5 3 cOo N N y� cid �•+ .O. � oa> wQ�a �. Q ca cCa �., ' cGd C N 0 y A o O C_ r�i� d o CL N la O y crd X-1 H .N -i .n Co ti 4-tO N T O Q d7 O yJ o .0 F.O 3 U'ia�� 1,2 *� °' � y •� Y .� � ani � .� °� � •pOo U J UW N U N .!4chi jE N � N ami G c�O O .N cCd �e Lg90 X040. CCN U Fr^ 0 Qv�N �w. O 7 �.' 'd U cd O � ai b rOr�� cC000 � .O a v was om o ❑da G' cq Cy N .�.. N ;0>, = ca 0 0 LtiU� O O .0—t 0. to p2 O O O- m.2 O 12b�0 C N C m o m Co o X O O O O O' 00 eq y �? 0 n �O cn N o on 4-4 o b O x N O �.. ..�., A O 0 V °'Q 3• w°.S 0�'�roa U vOv�� O E1-' +.L•+ p O .2 d o$w o 3 0 @fib10 0 Ca 0. H y w 41 0 ca W I N o 0 O_ 0 N a 0 O O A. 20 wO • h L3 .. p 4. 0 � "-0 � co "a l Q� U O P� " 0 N•Lw y abi Q : cr N 0 O cq ti E- 0 '� H� M; Q Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. I X17/ Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (ME ), 5 7 CMR 12.00 (PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date: ' , P /3 City or Town of. NORTH ANDOVER To the Inspeltorlof Wires: By this application the undersigned gives notice of his or he ' te�n7ti—on to perform the electrical work described below. Location (Street & Number) l Owner or Tenantffi"WfTelephone No. Owner's Address 36-M-? Is this permit in conjunction witha b ilding permit? Yes L Purpose of Building �'e Existing Service Amps / Volts Overhead ❑ Overhead ❑ No LX (Check Appropriate Box) Utility Authorization No. New Service Amps _ ,Number of Feeders and Ampacity Volts Undgrd ❑ Undgrd ❑ No. of Meters No. of Meters Location and Nature of Proposed Electrical Work: A10V11 &-X ; &Rm_ T,P.rn r?j)g C'mmnletinn nfthe fnllnwina table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans V No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Above ❑ In - Swimming Pool ❑ rnd. rnd. o. of Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices 1�o. of Ranges No. of Air Cond. Tons Tot No. of Alerting Devices Ido. of Waste Dis posers p Heat Pump Totals: Number Tons I.KW No. of Self -Contained Detection/Alerting Devices No. of Dishwashers S ace/Area Heating KW p g Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW SecuritySystems:* : or Equivalent No. of Water KW 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: Estimated Value of Electrical Work: Attach additional detail tf desired, or as required by the.Inspector oJ wires. (When required by municipal policy.) Work to Start: �� 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 cove is in force, and has exhibited proof o a e e permit issuing office. CHECK ONE: INSURANCE BOND El OTHER F1(Specify:)/6qj d I certify, tinder the pains andpe altie ofper,�ry, that �Jie in nation on this application is true and complete FIRM NAME:. /��2 <( (�. 4 11 LIC. NO. Licensee:, /JP4#11e4? �-J610J Signature LIC. NO.: (If applicable, a er 'e 'in Z ceps limber line.) us. Tel. No.: Address: /L� l Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work r uires Department bf Public Safety "S" License: Lic. No. 4&5�: 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. k� d ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shall.be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic foul -year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012. ❑ Rule 8 — Permit/Date Closed: *** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass M Failed Re- Inspection Required ($.) ❑ Inspectors Comments: r Inspectors Signature: Date: SERVICE INSPECTION: Pass M Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass 0 Failed'❑ Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTION: Pass 0 Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: CiEB WEINHOLD ...TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com The Commonwealth of Massachusetts Department of IndustrialAccidints Office of Investigations 600 Washington Street Boston, MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name Address: �7 W /C! City/State/Zip: /Up ZA Phone #: 2k Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction employees (full and/or part-time).* 2. ❑ I am a sole proprietor or partner- have Hired the sub -contractors listed on the attached sheet. # E] Remodeling ship and'have no employees These sub -contractors have 8. ❑ Demolition 1' working for me in any capacity. workers' comp. insurance. 9, E] Building addition [No workers' comp. insurance 5. El We are a corporation and its 10. F1 Electrical repairs or additions required.] 3. ❑ I am a homeowner doing all work officers have exercised their right of exemption per MGL 11. [J Plumbing repairs or additions myself. [No workers' comp. c. 152, § 1(4), and we have no 12. ❑ Roof repairs insurance required.] t employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. % Homeowners who submit this affidavit indicating they aie doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing orkers' compensation insurance for my employees. Below is thepolicy and job site information. � , 7/1 Insurance Company Name:. Pollcy # or Self -ins. Lie. Expiration Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder 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 may be forwarded to the Office of Investigations of the DTA for insurance coverage verification. I do hereby cert' y fl pains a*l penaltles ofperjury that the information provided aboto is !Iue and correct. Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other 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 a 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 f 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 certificate(s) 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 Accidents for confirmation of insurance coverage. Also 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 workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license 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 Off -ice of Investigations has to contact you regarding the applicant. Please be sure to fill in the permittlicense 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 ofIuvestigations 600 Washington Street Boston., MA. 02111 Tel. # 617-727-4900 ext 406 or 1-877,7MASSAFI Revised 5-26-05 Fax # 617-727-7749 ww.mass.gov1dia r1---- 1 1 1 I LJ 1 I 1 I 1 I I 1 1 1 1 1 I 1 1 I I I I 1 1 1 1 I I I I 1 1 cc m w O O AN MA 1 1 1 1 1 I I s c L v� Q) O - �- o� O 0 p � U N X � z S O O oo (Q M LL „Qo Y�� 061 9 op 1 9 'Zi NT 1 ,• p 0= sU0 "� (L � x Q� � 1 L M► �.. � Q _ 3 F- C4 C4 0� a�(N L 610 ZI E ti( - � F%, Q) v Q� s Z3 W L v� Q) O - �- -� O 0 p � U N X � z S O O oo (Q M LL In u- op 1 9 N X NT 1 ,• p 0= sU0 "� (L sz:_ x W L v� '1-4 qu (L 0000 p Q U r► X � 0 S O O o0 (Q M LL In W L v� '1-4 (L 0000 p Q U r► X � 0 S O O o0 In u- op 1 9 �- NT 1 T- 00 o(L� "� (L x (Q Z ►- tQ — U -, ts Q N 3 F- C4 C4 N x � cn N N d) 715� moo >~ Lu Q� Ob '1-4 0000 � O O o0 In op 1 0� 4-4 00 ts Q - 3 V) � cn N Ob v O z�H O a to r =----------------- :, -!--------- -------r{----------{---;, f' -f'----=-- -' l--------- ------ ------ W 1 ' -r----- ------- ;- 1 ' Iv ------ O r7 Lj_ - -- - - - x 118eam above I t t 1... 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