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HomeMy WebLinkAboutMiscellaneous - 2211 SALEM STREET 4/30/2018 2211 SALEM STREET ' Y 210/090-B 0046"0000.0 - L! i I i I I i, Location No. Date tet_/lv zz- 40RT#, TOWN OF NORTH ANDOVER F 9 • ; ; Certificate of Occupancy $ 9 Buildin /Frame Permit Fee $ - s�cHusE Foundation Permit Fee $ j Other Permit Fee $ TOTAL $ rq Check # ` G 15437 �uilding Inspe-o TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING 4" BUILDING PERMIT NUMBER: DATE ISSUED: M ic SIGNATURE: �— Building Commissioner/1 of Buildinp Date SECTION 1-SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: b' Q Map Number Parcel Number 1.3 Zoning Information: h 1.4 Property Dimensions: Zoning District Proposed Use Lot Area Frontage ft 1.6 BUILDING SETBACKS ft k Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided 1.7 Water Supply M.CxL.CAO. 34) 1•5. Flood Zone Infomntion: 1.8 Sewerage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑ SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record May Go L)-6 y 1"4/yX211 tS��tc M sT, Name(Print) Address for Service Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ •`�f}V �,�� CJ�STI�� C,O/Y � /���lT �-- SSG , Licensed Construction Supervisor: C !O Q S {,�7~TD/1� S�. /l l " p V R License Number Wn 69 3 Expiration Date ic P � tgnature Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ ARE , * S;QG Company Name �� Registration Number a o S Lx-rTo z! S T , At 410 U E 4. M A s tA 4 3 — .>� Expiration Date Signature- Telephone r SECTION 4-WORKERS COMPENSATION(M"G.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 permit. Signed affidavit Attached Yes.......0 No.......0 SECTION 5 Description of Proposed Work check all a livable New Construction ❑ Existing Building e Repair(s) ❑ Jterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: ' w, I - x.00 SECTION 6-ESTIMATED CONSTRUCTION COSTS t Item Estimated Cost(Dollar) o be �C�rt d�F'XIAL USE O�'r g Completed b ermit ap Ilcant 1. Building a ( ) Building Permit Fee `T Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(e)X (b) 4 Mechanical(HVAC) 5 Fire 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 1, as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf,in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 1, " AV 1-2 CA-S T,- 1 Cas Owner uthorized Agen of subject property Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief C Print Si attire of Owner/Agent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1S7 2 NU 3 SPAN DIMENSIONS OF SILLS DIMENSIONS 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 Town of North Andover a4 NORTH qti 0 , Building Department o p 27 Charles Street North Andover Massachusetts 01845 (978) 688-9545— Fax (978)688-9542 04^°q�reo`o.11Zw " �•9 �Pa,�gS SSAGHUS� DEBRIS DISPOSAL FORM In accordance with the provisions of MGL c 40 s 54, and a condition of Building permit # the debris resulting from the work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL cl 1, sl 50a. The debris will be disposed of in/at: Facility location • i r Signature of Applicant Date 4 NOTE: A demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector. �.r e I I I I Board tef.Ruildha � ��ar�ua ' g Regufatrons,arid.StaNi7arils HOME IMPROVE"RENT CO NTRACTOi2 '' Regwir�tton • , 104669 . �t TV?ate PrZI.VA T E Cd:"'ORA rON 4 deo CAS 1 c;ICONE nOOFrNl; 7A' nco ie. + a h �e Road N $r ytatzl AJIA d 92.'. G - jt k Z RECEIVE-0 Commonwealth of Massachusetts JUNkI VCity/Town of T nl �r"?"INOOVER . System Pumping Record NORTH ANDOVbz111.1„it-ir�ENT Form 4 DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form,check with your local Board of Health to determine the form they use.The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility information Important: When fitting out 1. System Location: r forms on the computer,use only the tab key Addre /���,l to move your _ i./�t►�N.d V✓' 1 1 _ . 0 i cursor-do not CitylTown State Zip Code use the return key. 2. System Owr)er: Name Address(if different from location) ” City/Town State Zip Code Telephone Number — B. Pumping Record tllovo 1. Date of Pumping —- -- - 2. Quantity Pumped: talions Date 3. Type of system: ❑ Cesspool(s) tic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): _ - -- _. .. -----. _. .... . _ _.. 4. Effluent Tee Filter present? ❑ Yes [4-N6— If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: Wind River Environmental Name 163 WestcrnAYC. V icteLicense Number _ Company 7. Location where contents were disposed: V ® PJB ....— ---- - A Signature of Hauler Date Signature of Receiving Facility Date I5form4.doc•03106 System Pumping Record•Page t of 1 Commonwealth of Massachusetts RECEIVED City/Town of System Pumping Record NORTH ANDOVER �3 2Q14 - Y TOWN OF NORTH ANDOVER .ti Form 4 HEATH DEPARTMENT DEP has provided this form for use by local Boards of Health. Other forms may be used,but the information must be substantially the same as that provided here. Before using this form,check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility information Important: When fining out 1. System Location: forms on the ^I � ) / { computer,use _.__. o a� ( 1_ . ._eonly the tab key Address to move your � A o v e-r _ C)tv 5 - ' - ------ _. cursor-do not ------ — - — - - � - � Stafe Zip Code use the return CitylTown key- 2. System Owner: Address(if different from location) Cit frown State Zip Co/de j— ?2—- b Telephone Number B. Pumping Record �_���/ - Z. Quantity Pumped: —IS 00, 1. Date of Pumping -- - -- - Y p Gauo s Date 3. Type of system: ❑ Cesspool(s) F�S eptic Tank ❑ Tight Tank ❑ Grease Trap El Other(describe): 4. Effluent Tee Filter present? ❑ Yes 0"No if yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 4 r� 6. System Pl��\mped y: Name Vehicle License Number — Company -- 7. Location where contents were disposed: --- GIL D- 1 Torah •J Signature of Hauler Oate Signature of Receiving Facility Date 15form4.doc•03/06 System Pumping Record•Page 1 of t KEGEIVED ,per 9 2013 \ Commonwealth of Massachusetts TOWN OF NORTH ANDOVER HEALTH DEPARTMENT City/Town of system Pumping Record NORTH ANDOVER Form a y DEP has provided this form for use by local Boards of Health. Other forms may be used,but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important: 1 When filling out � System Location: forms onthe 4�N111_ _. computer,use only the tab key Add r ss �}� to move your J""���r�j `'`.4 - _ o l gqs - f�VV.r-4--- cursor-do not CState Zip Code use the return itylTown key. 2. System Owne Name —.. .-- �^ Address(if different from location) — --- —Zip ---------- -- --- _ _ State _.. o e CitylTown ' ti, mber _. B. Pumping Record 01 ASO®_._._ . 1. Date of Pumping 8 - 2. Quantity Pumped: Canons 3. Type of system: ❑ Cesspool(s)at Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): - _ --- 4. Effluent Tee Filter present? ❑ Yes V4 No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: ! 6. System Pumped By: vehicle License umber Name i _._..------._._._.163 `1lWOM Ave.._... Company Gloucester, MA 01930 7. Location where contents were disposed: �ignatureuler Date o_rth_ A_n_ do__ve_r_._M_ A. Si_gnature_ of Receiving Facility Date System Pumping Record•Page 1 of 1 t5form4.doc 03106 i I Location No. — © DateOf HOR11='+ TOWN OF NORTH ANDOVER F D ` Certificate of Occupancy $ Building/Frame Permit Fee $ "� S sACMus j Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 15 ll 49 / Building Inspector r III TOWN OF NORTH ANDOVER r BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,REN®VAT-, OR DEMOLISH A ONE OR TWO FAMILY DWELLING s BUILDING PERMIT NUNIBER. DATE ISSUED: SIGNATURE: Building CommissionerAnsr5ektor of Buildings Date SECTION 1-SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: Map Number Par ]Number 1.3 Zoning Information: VVV 1.4 Property Dimensions: O Zonin District Proposed Use Lot Area Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided red Provided 1.7 water Supply M.G.LC.40. 54) 1:5. Flood Zone Infomration: 1.8 Sewerage Disposal System: Public ❑ private 0 Zone Outside Flood Zone 0 Municipal 0 On Site Disposal System.0 SECTION 2-PROPERTY OW NERSIIIP/AUTHORIZED AGENT 2.1 Owner of Record 0 LIC ,Ame(Print) Address for Service Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Si nature Tel hone SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensyd Constructiop Supervisor: 11� License Number Add e s .mese 5,/ V 62f'_S't; 9/0 Expiration Date signat4je Telephone Z!L Y,x", 33 Registered Horde Improve ent Contractor Not Applicable ❑ ��ompany Name Registration Number address amu= Expiration Date mature Telephone SECTION 4-WORKERS COMPENSATION(N.G.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 permit. Signed affidavit Attached Yes.......0 No.......❑ SECTION 5 Descnlitionof Proposed Work check all a Hcable New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition 0 Accessory Bldg. ❑- Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: Lcze C7 SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to Completed by permit applicant 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of - Construction 3 Plumbipg, Building Permit fee(8)X.(b) 4 Mechanical(HVAC) 5 Fire Protection 6 Total 1+2+3+4+5 Check Nufibei 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,in all matters relative to work authorized by this building permit application. Signature of Owner .Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION h ,as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true,and accurate,to the best of my knowledge and belief Print Name Signature of Own er/A ent Date NO. OF.STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMERS 1 2 RD 3 SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS ~,SIZE OF FOOTING X lyIATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND 'SIS BUILDING CONNECTED TO NATURAL GAS LINE 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 A C-u 0,1, PHONE LOCATION: Assessor's Map Number D PARCEL SUBDIVISION 1 LOT(S) STREET ST.NUMBER a ) I ***** OFFICIAL USE ONLY **** RECOMMENDATIONS OF TOWN AGENTS: ONSERVATION ADMINISTRATOR' DATE APPROVED 12 16 I DATE REJECTED I COMMENTS / lA) A," I I DD t DATE APPROVED DATE REJECTED COMMENTS /W0�et'►'t '7` °' (�. c IC s. FOOD INSPECTOR-HEALTH DATE APPROVED DATE REJECTED i SEPTIC INSPECTOR-HEALTH DATE APPROVED COMMENTS v� �� vA4 r) CSS 70 C3 / PUBLIC WORKS -SEWERIWATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9197 jm tNORTH Town of North Andover -.'+ Building Department A 27 Charles Street r North Andover, MA. 01845 o • '• D. Robert Nicetta �,SSgCHUS t j9 Building Commissioner (978) 688-9545 978 688-9542 Fax HOMEOWNER LICENSE EXEMPTION Please print DATE JOB LOCATION G Number Street Address Map/lot "HOMEOWNER Sot-)1_ ( fl i Mc (; . 171e_6t?3.776, �03-0-01(p � Name Home Phone Work Phone PRESENT MAILING ADDRESS City Town State Zip Code The current exemption for"homeowners"was extended to include owner-occupied dwellings of two units or less and to allow such homeowners to engage an individual for hire who does. not possess a license, provided that the owner acts as supervisor. (State Building Code Section 108.3.5.1) DEFINITION OF HOMEWOWNER: Persons)who owns a parcel of land on which he/she resides or intends to reside,on which there is, or is intended to be, a one or two family dwelling,attached or detached structures ac- cessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other Applicable codes, by-laws, rules and regulations, The undersigned"homeowner"certifies that he/she understands the Town of No.Andover Building Department minimum inspection procedures and requirements and that he/she will ! comply with said procedures and requirements. HOMEOWNER'S SIGNATURE APPROVAL OF BUILDING OFFICIAL II � 3 r – i.� O t�.y � {�.. —'- =�( I ,1,x•,1 a 1 GfTt Lt�.'i fj, PL 114... 6G 27 s ze i 1ULLET FT --fit 42 i , AKIDOVE A1AIt, JU1 414 ele 4D 142 i .o�..:..�..wr�......:...`.....•..,.:..-......,.�...�.w•.,�..�v.....,�+.a.««wr..nem..+.w..,.�_..w.:..............W..x.�.-.�ea.Qaw..___.._ ,... ....asm.:ea.vow.w+....w:,..,....-.-..s».......w.........:._,.:w.........:.-... A uo�t S as Jx 44, IT + loll ..4. i I ! 41 Al 071/ ivj� 3 i N 75°32— 5 89� 334 05,w �8 W ,..29."10•. 54.90 O d Z04.80 0 LOT 4A 443 23-7S.F. . .. J� ,s% ,.- 2� �� o Land of Lam pros � ��M Qom. ✓ ��� .s:`\` :1 O' g, 39 E N ,L3 , ..: - I36.•8r O 0 0.00 DUE EAST LOTS �! o vh. o_ 44; 26"7 S.F Z° Land of Cordella #Costa o � O� ,9 * alk, € o \17- ... ''• t5'WIDE �• l4z 120.00' DU -EST ACCE55.1.`CASEM-ENT � q 47 O, , U t ' lie'�a�n�,aan,c�utra� ' a•�` � HOME IMPROVEMENT CONTRACTOR:. .= s Registration ;11899 a: :TYe DBA Ezp�raton� 05/03/9Y ,a.„_u HARRINGTON CONSTRUCTION x�N �Af �� xKE+JIN J HARRIN.GTONh �: $oCRESCENT-CIR. IN 'ADMISTRATOR a - _ ur r i -'own of North Andover � NORTH • Building Departmento - 27 Charles Street North Andover, Massachusetts 01845' z (978) 688-9545 Fax.(978) 688-9542 M �.Y °A�reo rP�y�S s SAC"Lis i DEBRIS DISPOSAL FORM In accordance with the provisions of MGL c 40 s 54, anda condition of Building permit.# the debris resulting from the work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 11, posed be dis The debris will be disposed of in/at: Z,/v 4�A . LA/It Facility location Signature of Applican 0 Date NOTE: A demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector. a The Commonwealth of Massachusetts Department of Industrial Accidents Office of investigations Boston, Mass. 02111 Workers'Compensation Insurance Affidavit { Name 77-7 Please Print a is V �I Name: tlr r�Ayht n �17 ' I Location: h, City ry . 4 n d O v 4 v- IWA, S Phone # I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity I am an employer providing workers'compensation for my employees working on this job_ Company name: l Address City- Phone - Insurance Co.. Policy:# Cornpany name-. I Address CitX Phone..#: - Insorando.co. : _ Rolicy.# Fadute to .secure coverage as required under Section ZSA°or MGL Y52 can lead tothe imposfion of enminal penalties of Bl:fine up to$1,501)00 and/or one years'irnpnsonment-as well_as_ciW-Pena[ttesjn3haloan-d-a-$IQP W. P"RE)EP-mtl-aline o�$IjQO.�� -dayAgainstme. I I I i of Investigations of the DIA for covers a verification. forwarded'to the Office9 ent may be understand that a copy of this statem y I do hereby certify under the pains and penalties of pequry that the information provided above is true and correct. j Signature_ Date j Print name Rhone# Official use only do not write in this area to tie completed by city or town official' City or Town Permit/Licensing Building Dept i ❑Check if immediate response is required .0 Licensing Board El Selectman's Office Contact person: Phone#: lj Health Department t Other El IIS l Town of Forth. Andover p°RTH 0 IV Office of the Health Department Community Development and Services Division . 27 Charles Street 4�R�rec North Andover,Massachusetts 01845 �Ssnck�s�t� Sandra Starr Telephone(978)688-9540 Health Director Fax(978)688-9542 August 2,2001 Basil J. Coughlin,III 2211 Salem Street North Andover,MA 01845 Re: Application for deck Dear Mr. Coughlin: Your application for a deck at 2211 Salem Street has been reviewed by the Health Department. The application was denied on August 1,2001 for the following reasons: 1. [ Missing information 2. ❑ Passing Title 5 inspection of septic system may be required 3. ❑ Location of structure not acceptable To address the problem(s): If#1 is checked, please supply: a. Floor plan of existing and proposed addition Certified plot plan showing house, septic system,well and proposed project in scale of 1"=40'. Please show dimensions of deck on plan. If#2 is checked: a. Have the septic system inspected by a certified Title 5 inspector to determine the size of the system and whether it is operating properly. b. Tie-in to municipal sewer If#3 is checked: a. Relocate the project Please feel free to call the Health Office at 978-688-9540 with any questions you may have. Sincerely, Sandra Starr,Health Director Cc: Building Department artment File BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 NURSE 688-9543 PLANNING 688-9535 ('fie e... Board of Building Regulations and Standards License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration:.112899 Board of Building Regulations and Standards One Ashburton Place Rm 1301 ii-Expiration: 05/.0.3/2003 Boston,Ma.02108 - w 'TYpe; DBA HARRINGTON CONSTRUCTIONf' KEVIN HARRINGTON 13 CRESCENT CIR �� n r PELHAM,NH 03076 Administrator No id without sign tune _ 0 NORTH 01VM ® - 4 Andover No. o h dower, Mass, CN z n COC �MI CMEWICK ORATED S BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System THIS CERTIFIES THAT... � ...�..y'..m 2.. ....... .�? )A N BUILDING INSPECTOR ............................................. Foundation has permission to erect....Q .. a .......... buildings on .. .a.��.......S a ..................... Rough 1`67 S .............................. to be occupied as.... 0 0.2-10 a .. .A.)....}...r...0.....M.........FC .t_- cs .... _ Chimney ................ ....... 1 provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws lating to the inspection, Alteration and Construction of Buildings in the Town of North Andover. D L/ / c �� PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. T Rough PERMIT EXPMES I V 6 MONTHS Final L�l! ELECTRICAL INSPECTOR UNLESS C®NSTRUC N T TS � Rough ........................................................................................ Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. KOUE, D, 69 C.)i (\j h dz 1174 D d,4 s--e sh2y WELL DATABASE ADDRESS: ' l "Aa AGE OF WELL: ? WELL DRILL WELL PERMIT : ? WELL LOCATIOl�T; � , I J Iv vi WELL PERMIT DATE: DEPTH OF WELL: TYPE OF WELL: a: DRILLED b. DUG c.` ITNKNO WET TYPE OF WATER BEARING ROCK: WATER ANALYSIS DATE: HIGH MANGANESE: Y N HIGH IRON: Y N OTHER CONTAMINANTS: Y N FORM U - LOT RELEASE FORM JCTIONS: This form is used to verify that all necessary approvals/permits from ,,,'ds and Departments having jurisdiction have been obtained. This does not relieve :,e applicant and/or landowner from compliance with any applicable or requirements. *****************************APPLICANT FILLS OUT THIS SECTION*********************** APPLICANT A t:c s f J J: C-i.� G�i, PHONE c1 976 LOCATION: Assessor's Map Number 70 PARCELy SUBDIVISION LOT (S) � 1 STREET ` r,1 evY� S eg f� ST.NUMBER22 ? E * OFFICIAL USE ONLY ***** RECOMMENDATION OF TOWN AGENTS: ONSERVATION ADMINISTRATOR DATE APPROVED DATE REJECTED I t , COMMENTS rt. lob kl_lk TOWN PLANNER DATE APPROVED { DATE REJECTED COMMENTS it f FOOD INSPECTOR-HEALTH DATE APPROVED DATE REJECTED SEPTIC INSPECTOR-HEALTH DATE APPROVED -DATE-REJECTuEi�? f a ' COMMENTS z�5<_ - w`' ; 1 PUBLIC WORKS SEWERIWATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9197 jm i IER�%_ • THE PROFESSIONAL EXPERTS IN THE SEPTIC DRAIN INDUSTRY PLEASE PAY FROM THIS BILL - 7 CUSTOMER NAME: SERVICE LOCATION; 107 FOREST STREET CITY: 'MAIN�(;�lE r,sY- OFFICE MIDDLETON, MA 01949 r j -1 „-3 T (978) 774-7122 • FAX (978) 774-8676 BILLING NAME: BILLING ADDRESS: CITY: ZIP: • RESIDENTIAUCOMMERCIAL BILLING PHONE: DATE OF SERVICE: • SERVICING THE ENTIRE NORTH SHORE I� Zv • CERTIFIED TITLE V INSPECTORS SERVICES RENDERED IoCr ` 0 WATER JETTING FEES O VISUAL INSPECTION $ 0 TITLE V INSPECTION $ O LOCATION/TRANSMIT $ O BACKHOE $ 0 SMALL BACKHOE HRS. $ 3—bIGGING HRS. $ 0 SERVICE C,WAL, HRS.� $ 3'-LABOR $ O SYSTEM TREATMENT HRS _L�_t• $ 13.0 O EQUIPMENT RENTAL $ 3-'STOCK LIST 10, HRS Z- $ 0 OTHER $ ! ---- S TOTAL $ -3"9 _ RECOMMENDATIONS: VL TOTALS: TAX $ DISCOUNT/COUPON $ 'TOTAL _ $ 3 449 TERMS l CONDITIONS • NOT RESPONSIBLE FOR DAMAGE BEYOND THE CURB UNE TERMS OF PAYMENT: �Q • ALL COMPLMNTS SHALL BE REPORTED WITHIN 48 HOURS ,.qSH DIGGING CHARGE IS PER DRIVER'S DISCRETION T y • t5%PER MONTH WILL BE CHARGED TO ACCOUNTS PAST DUE CHECK# �,G �� l� /_s �!I • THE PURCHASER AGREES 70 PAy ALL COSTS OF COLLECTIONS v NOT RESPONSIBLE FOR ANY UNDERGROUND LRTLRTES,SPRINKLER SYSTEMS,ELECTRIC DOG FENCES,ETC 0 ��•,�'��....._-- -- EXP. I THE UNDERSIGNED AGREE TO ALL THE TERMS AND CONDITIONS. CUSTOMER SIGNATURE TECHNICIAN r. FORM U - LOT RELEASE FORM JCTIONS: This form is used to verify that all necessary approvals/permits from As and Departments having jurisdiction have been obtained. This does not relieve , e applicant and/or landowner from compliance with any applicable or requirements. *****************************APPLICANT FILLS OUT THIS SECTION*********************** APPLICANT r� s t J C'�LLc Gv i,, PHONE LOCATION: Assessor's Map Number C C? PARCEL SUBDIVISION LOT (S) STREET �a'�� 'H(et l ST.NUMBER a l 6 ****** OFFICIAL USE ONLY 'i a RECOMMENDATION , OF TOWN AGENTS: ONSERVATION ADMINISTRATOR DATE APPROVED DATE REJECTED COMMENTS ',. opt . TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD INSPECTOR-HEALTH DATE APPROVED 3s- DATE REJECTED SEPTIC INSPECTOR-HEALTH DATE APPROVED COMMENTS i PUBLIC WORKS -SEWERMATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9197 jm gf f. •,� or r=< fo �t F}, ���-Fry• � � "f c s<-� �_� ���• a 'r" ,,� �;'�. g ''y9 as+, pp*""�� i` icy O•�l�y . ..,. GtT{LFA."( i _.�- 6 FL.=IM,(—,t. �6'^ 27 s l_ I,ULt�"I" _ �t E.L.=114,O, +E L. 14%, LC 1' -40' �l1AlL u!4 7}F C%k'yt"�{il ��, / JUMP .\ BUDSl f /N' 7h'1`1� �t ' R?� �.. % ; _ .n/ TES �� d ( -Tel NAL, NG\ k �• 30' y too Cri 1 r y a . ie A Fri aT . ;} + ar a r - H t ' 1 r � e . s:! � �! f •� �"� � �Eta PL io 11.0 • L E�' 1 + �s t aft ;S" a#c v - •_ - ..''.f F�.� { Gr )a p 4 'aro" �' .Y r� < c , - - - .. M '{g,��Y � -v .: ate+• $; _ ,:it t ,� '� L_E V • S K y PERCOLATION -TEST t _6 �rov ;v) ) N O GA t 'Pa n J tsl�s DEEP TEST PVT E x 15 TI tit G CoN,ToQv+tA. FROFo5F- 0 Ct ..N T c;=+-Q V %-C-. .f•- .0# h ff' { `g { .. .....e.�...._. _.( .�,.1.! .. .`�.{ tL f1( -i:. �s� q + t \V Farm:A-- &(Own PLW994 Algid ... .... Cq:rtr"Wealth of AAsn"hussto aAas r�eestt� f?i ,'r OF Hr. L APR*2 j•<.�..i'.1� ,,,"t.i .� :C' �41�•, i1;. .. �� �NV�� ...��' .. ....- ..:1: `+dn•, I.��. .,d' , 4' i Sop*tank: K6 Yan be%of 3'(PIA-05 Q-M"Pvmw fpr folk*, &prh m Pw ood&y: !Nerd fhw fnr:v^"wd* LLC P it w. CoPoents fled to, CM"W Ns pond at- 1' of sya?ew*ow Cowan" Mn Amwmev} Frnrn !2109/98 �0 3�Jt7d Hl6ON 3aM 698VTBZBLG Z9:90 6OOZ/9Z/c© Form 4 -- System Pumpirg Record Commonwealth of Massachusetss Massachusetts System Pumang Record :'. n}OF I NOR""P MAR 3 1 2003 syxftm 0~ system Location 1 Coutjlt1in ttiry Pto ik Hint- A°idu\,.Hr MA. 01845 t;n�t t F.n 1•v, i MA 0 1 A 4", 97 0 ti C Coughlin Type: Emergency Routine Cesspool: No X Yes septic tank: No ®Ycs Date of Pumping: -01LA-C Quantity Pumped: Gallons System Pumped By: Wind River awwAmntal, LLC Permit#: Contents transferred to: Contents Disposed at: a-L-5zl;l 1 Date: 3 � CY'j Pumper Signature: 9-VA Condition of system/0ther Comments Y k r J Dep Approved Form - 12/07/95 Town of North .Andover c�NORTpr N Office of the Health Department Community Development and Services Division 27 Charles Street North Andover,Massachusetts 01845 .Us�4 Sandra Starr Telephone(978)688-9540 Health Director Fax(978)688-9542 August 2,2001 Basil J. Coughlin,III 2211 Salem Street North Andover,MA 01845 Re: Application for deck Dear Mr. Coughlin: Your application for a deck at 2211 Salem Street has been reviewed by the Health Department. The application was denied on August 1,2001 for the following reasons: 1. [lY Missing information 2. ❑ Passing Title 5 inspection of septic system may be required 3. ❑ Location of structure not acceptable To address the problem(s): If#1 is checked, please supply: a. Floor plan of existing and proposed addition Certified plot plan showing house,septic system,well and proposed project in scale of 1"=40'. Please show dimensions of deck on plan. If#2 is checked: a. Have the septic system inspected by a certified Title 5 inspector to determine the size of the system and whether it is operating properly: b. Tie-in to municipal sewer If#3 is checked: a. Relocate the project Please feel free to call the Health Office at 978-688-9540 with any questions you may have. Sincerely, Sandra Starr,Health Director Cc: Building Department File BOARD OF APPEALS 688-9541 BIJILDING 688-9545 CONSERVATION 688-9530 NURSE 688-9543 PLANNING 688-9535 Form 4 -- System Pumping Record Commonwealth of Massachusetss Massachusetts System Pumoirw Record System Owner �V vL L4✓� System Location Type: Emergency Routine Cesspool: W Yes Septic tank: hb =Yes ®� Date of Pumping: �—/(1 / Quantity Pumped: /,c jGallons System Pumped By: Wind River Environmental, LLC Permit#: Contents transferred to: Contents Disposed at: Date: Pumper signature: Condition of System/Other Comments i Dep Approved from - 12/07/95 of Nol�TH �tiI�VEI�, NIA. � y4.PP�� Ct�ti I Po eKk 55 -— W—ri c SIr STFc.1 �PPi�ovr="v DArt' APR�OVPJ6 AuTI-joi? ry PLAAJ DES+ GwC-K 4 . R�4SoNS a D� SCPT"I� SYSTEM t N STA t.(.,,QT+o�..1 CX- 4U4T(ON io&j p �rG 2, ( :54' q l.A S q F41L PIN,AL I'V5P61--rlon) INS%�OI.�GL1i ,/.�, j-�N�✓ +4�DIT�p1J,QL In�Sz i joti DIS,�P�'�dvi:D DArC. FkAL APPizpvAL APpi3alcA)6 16U i HoRl ;y BOARD„OF HEALTH No.Andover, Mass . SUBSURFACE DISPOSAL DESIGN CHECK LIST LOr by APPROVED - DATE_-7-10- DISAPPROV DATE - Provid6d: Reasons: r Title V FAIL Og Reg 2.5 The submitted plan must show as a minira m. a) the lot to be served-area,dimensions lot #,abutters b location and log deep observation hoiss-distance to ties c location and resultspercolation tests-distance to ties d design calculations & calculations showing required leaching area (e) location and dimensions of system-including reserve area f) existing and proposed contours (g) location any Bret areas vithin 1001 of sewage disposal system or disclaimer-check wetlands mapping (h) surface and subsurface drains within 1001 of sewage disposal system or disclaimer (i) location any drainage easements within 1001 of sewage disposal system or disclaimer-Planning Board files (J) known sources of water supply within ?)01 of sewage disposal d system or disclaimer — - --- (k) location of any., proposed well to serve lot-1001 from leaching facility (1) location of water lines on property-1C , from leaching facility (m) location of benchmark (n) driveways (o) garbage disposals (p) no PVC to be used in construction - (q) profile of system-elevations of ba smEa. t, plumb, pipe, septic tank, distribution box inlets and outlets, di.1,ribution field piping and Omer elevations (r) maximum ground water elevation in area aewage disposal system (s) plan mast be prepared by a Professional Engineer or other professional authorized by law to prepare such plans Reg 6 Septic Tanks (a) capacities-150,% of flow, water table, tees, depth of tees, access, pumping (b) cleanout (c) 101 from cellar wall or inground swimming pool (d) 251 from subsurface drains Reg 10.2 Distribution Boxes (a) s pe greater than 0.08 Reg 10.4 b) ,sumo N IVN C-M O{a C Z Q r Is a �vl � aryarr j ' c� y �yJ ld o 3� !i -7 Nti:i r� r o�ry �".ta,�:�&"i� '�?�7 s3i�7C� ,O�_,.► :9'7'V�S y �� �""�' �ZJ'�1.��TY�d d0 Xt 0'-3.Lv'70'7 -LoI 8Z'i�i►:.� —� l�^►f1'1 B�.L:s�►.1� � - a�7rr�► fC_ d OL ci.:7" a.1.1� I jp sr Commonwealth of Massachusetts City/Town of System Pumping Record NORTH ANDOVER ti Form 4 DEP has provided this form for use by local Boards of Health. Other forms may be used,but the information must be substantially the same as that provided here. Before using this form,check with your local Board of Health to determine the form they use.The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days fro the ump_ gda accordance with 310 CMR 15.351. PSCEIVED A. Facility Information j f { it Important: When filling out 1. System Location: `GOWN OF,WORTH ANDOV5R forms on the ATM ` computer.use only the tab key Address to move your cursor-do not use the return City/Town State Zip Code key. 2 System Owner: Name Address(if different from location) City/Town i State Zip Code q?e` � ~ ------- ----- Telephone Number B. Pumping Record 1. Date of Pumping Dat 5 -- 2. Quantity Pumped: Gallons ` -- ---1 3. Type of system: ❑ Cesspool(s) R;-'S—eptic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): ------ -- —_�- -- --- -- -- --- 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition System: ----- ---- — - --------- - - -- -- ----.�__� --- - 6. System Pumped By: Name —' Vehicle License Number Company 7. Location where contents were disposed: Signature of Hauler Date Signature of Receiving Facility Date t5form4.doc•03106 System Pumping Record Page 1 of 1 ,�C\ Commonwealth of Massachusetts E City/Town of NC)KW A�lt��oN System Pumping Record KAY o 6 20og r` Form 4 TOWN-OF NORTH ANDOVER HEALTH DEPARTMENT DEP has provided this form for use by local Boards of Health. Other form information must be substantially the same as that provided here. Before using this form,check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important: When filling out 1. System Location: forms on the computer,use ax( only the tab key Ad re to move your %isA, cursor-do not CitylTown State Zip Code use the return key. 2. System Owner: VQ t"'l �r Name ea Address(if different from location) /VUR t rn f�V>�c�Uef 14 City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes 2--N'o If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: , r-Lt r�88-G�7 Name Vehicle License Number Comp ny 7. Location where contents were disposed: Signature of Hauler Treatment Plant Date Ipswich, MA 0193.3 Signature of Receiving Facility Date r t5form4.doc•03/06 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts City/Town of NORTH ANDOVER, MASSACHUSETTS System Pumping Record ,\ o Form 4 DEP has provided this form for use by local Boards of Health. he S r�'t�rYi" Q109 Re rd must be submitted to the local Board of Health or other approving a hority. TOWN OR NORTH ANDOVER A. Facility Information Important: When filling out 1. System Location: forms on the ` / computer,use 2 Z I l �c L2 only the tab key Addr ss to move your t4 s cursor-do not WAOMW use the return City/Tow State Zip Code key. 2. System Owner: Name Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record �Soy . _ 1. Date of Pumping Date7' 2. Quantity Pumped: Gallons .; 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes /No If yes, was it cleaned? ❑ Yes ❑ No rK< 5. Condition of System: 6. System Pumpe : Na e Vehicle License Number Company 7. Location where cont t we '�'�`�� re disposed: Lawrence, I!/!A. Signature of Hauler Date �r http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect t5form4.doc•06/03 System Pumping Record•Page 1 of 1