HomeMy WebLinkAboutMiscellaneous - 2050 SALEM STREET 4/30/2018 (2)i
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Commonwealth of Massachusetts
City/Town of
system Pumping Record NORTH ANDOVER
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this fort, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Wo -at
System Location:
Address �
ate e
System owner:
Name -
Address {Ef dirent tornlocation)
Zip Code
—., ,..., - • r -.
State Zip rade—
"
Telepnorte Numt)er —
B. Pumping Record
1_ Data of Pumping 6j 2. Quantity Pumped: Gallons� RC2...
Oa1e
3. Type of system: 0 Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ other (describe);
4. Effluent Tee Filter present? ❑ Yes [] No if yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6 System Pumped By:
Nanfe veride License Number
Cornpany
7. Location where contents were disposed:
Sign ure o a r
S riature'of
Dale. ......,..._.._..---•-----.�.......----...._..._ .
1510MAdoc• 03106 System ftmpirg Record • Page I of 1
� Commonwealth of Massachusetts -
City/ i own of AUG ' 3 'L0 1
System Pumping Record N4F2TH ANDOVER
Form 4 TOWN OF NORTH ANDOVER
DEP has provided this form for use by local Boards of Health. Other forms may be ed,lq@a1eTH DEPA
information must be substantially the same as that provided here. Before using this
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 within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important:
1 S
When filling out stem Location:
Y
forms on the ST
computer. use
only the tab key Address
to move your Cy�j('Th --�
cursor - do not City/Town — State Zip Code
use the return
key- --�� 2. System Owner:
Name
Address (udifferent from location)
City/Town — - — State y -- Zip Code— — -
b1 -7 S0.__.
Telephone Number
B. Pumping Record
1000
1. Date of Pumping -da-1 e 2. Quantity Pumped: 6 ons
3. Type of system: E]Gesspool(s) [0/ Septic Tank ❑ Tight Tank ❑ Grease Trap
[-j Other (describe):_/ --- -. _.
/. .
4- Effluent Tee Filter present? E] Yes [j No If yes, was it cleaned? ❑ Yes 5 No
5. Condition of System:
6. System Pumped By:
_,m U1}Gn -76'b7`�
`1,')
a Vehicle License Number
- Lnd.3,,Ve( _Ft�VtcoYlrn_�n.i�l
Company
7. Location where cfq e���� e disposed:
--11-55 Water
plant
Signature of Ha' ie a -:V1r
Signature of Receiving Facility Date
15form4,doc• 03106
System Pumping Record • nage 9 of t
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GILIETT �!
GOODWIN
EZ CE t�l�("�aL. SY CES T ��suR�'A
otsv
Location S 7
No. 1,Date V171(11/
I
NORT#t TOWN OF NORTH ANDOVER
O:�t�ao ,a,h0
p Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
s�CHU
i
Other Permit Fee $ /
Sewer Connection Fee $
qpR
�Oiv r Connection Fee $
4,1
('0//
1 1 ctr
Building Inspector --
Div. Public Works
PERJLIT NO.., /3 1
r .
e
APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS.
PAGE 1
MAP KVO.
LOT NO.
2 RECORD OF OWNERSHIP IDATE
BOOK "PAGE
BONE
SUB DIV. LOT NO.
LOCATI
PURPOSE OF BUILDING
OWNER AME ��X jf
f
NO. OF STORIES SIZE
s'�f
OWNER'S ADDRESS P /GAO S""®/J't°'!7
v '
BASEMENT OR SLAB
ARCHITECT'S NAME
SIZE OF FLOOR TIMBERS IST 2ND 3RD
BUILDER'S NAME v111,R1ti r,�qel,
C•! G �y
SPAN
DISTANCE TO NEAREST BUILDING
DIMENSIONS OF SILLS
DISTANCE FROM STREET /
'" POSTS
DISTANCE FROM LOT LINES - SIDES REAR
"" "' GIRDERS
AREA OF LOT FRONTAGE
HEIGHT OF FOUNDATION THICKNESS
IS BUILDING NEW- - .e-5'
SIZE OF FOOTING X
IS BUILDING ADDITION
MATERIAL OF CHIMNEY
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 NATURAL GAS LINE
INSTRUCTIONS
SEE BOTH SIDES
PAGE 1 FILL OUT SECTIONS 1 - 3
PAGE 2 FILL OUT SECTIONS 1 - 12
ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING
ATTACH€D GARAGES MUST CONFORM TO STATE FIRE REGULATIONS
PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR
DATE FILED
SIGNATURE OF OWNER OR AUTHORIZED AGENT
OWNER TEL. #
CONIN. ILL.
CONTR. LIC. #
PERMIT
19 l C�
�F�tlPi TF�
6 APR 22DE
3 PROPERTY INFORMATION
LAND COST
EST. BLDG. COST O, p
EST. BLDG. ,COST PER SQ. FT.
EST. BLDG. COST PER ROOM
SEPTIC PERMIT NO.
4 APPROVED BY
BOARD OF HEALTH
PLANNING BOARD
BOARD OF SELECTMEN
BUILDING RECORD
1 OCCUPANCY 12
SINGLE FAMILY
STORIES
MULTI. FAMILY
OFFICES
APARTMENTS
_
CONSTRUCTION
2 FOUNDATION
—I
8 INTERIOR FINISH
CONCRETE
3
1
2
13
CONCRETE BL'K.
PINE
BRICK OR STONE
HARDWD
PIERS
PLASTER
_ DRY WALL
UNFIN.
3 BASEMENT
AREA FULL
FIN. B'M'T' AREA
'/. 1/1 '/.
FIN. ATTIC AREA
_
NO BMT
FIRE PLACES
_
HEAD ROOM
MODERN KITCHEN
_
4WALLS I 9 FLOORS
CLAPBOARDS
B
_
1
2
�_
_
—{I_
3
_
DROP SIDING
WOOD SHINGLES
CONCRETE
EARTH
ASPHALT SIDING
ASBESTOS SIDING
HARD\!J'D
COMMGN
VERT. SIDING
_
ASPH. TILE
STUCCO ON MASONRY
STUCCO ON FRAME
_
BRICK ON MASONRY
BRICK ON FRAME
ATTIC STRS. & FLOOR _
CONC. OR CINDER BILK.
WIRING
STONE ON MASONRY
STONE ON FRAME
SUPERIOR I� POOR
ADEQUATE NONE
5 ROOF
10 PLUMBING
GABLE
I
HIP
BATH (3 FIX.)
GAMBREL
MANSARD
TOILET RM. (2 FIX.)
_
FLAT
SHED
WATER 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 I
11 HEATING
WOOD JOIST
PIPELESS FURNACE
FORCED HOT AIR FURN.
TIMBER BMS. & COLS.
STEAM
STEEL BMS. & COLS.
HOT W'T'R OR VAPOR
WOOD RAFTERS
_
AIR CONDITIONING
RADIANT H'T'G
UNIT HEATERS
7 NO. OF ROOMS
GAS
OIL
B'M'T 2nd _
1st 13rd 11
ELECTRIC
NO HEATING
THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM
LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES, GA-
RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN.
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