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HomeMy WebLinkAboutMiscellaneous - 25 MILL ROAD 4/30/2018Owner 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. Commonwealth of Massar-husetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Asses: 25 Mill Road Property Address George Russo I Owner's Name North Andover City/Town Inspection results n' way. Please see con A. General lnfc Inspector: Neil James Bates( Name of Inspector Bateson Enterpris( Company Name 111 Argilla Road Company Address Andover City/Town 978-475-4786 Telephone Number B. Certification MA State SI -15 License Number RECE JUN 19 2012 HEALTH DEPARTMENT 6/8/2012 Date of Inspection ms may not be altered in any 01810 Zip Code I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority W - j 6�k� 6/8/2012 Inspectors Si nature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins • 11110 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. ®V� Commonwealth of Massar-.hus tts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Asses! 25 Mill Road Property Address George Russo Owners Name North Andover City/Town MA 01845 State Zip Code RECEI JUN 19 ?0Q HEALTH DEPARTMENT 6/8/2012 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 Inspector: Neil James 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 SI -15 License Number 01810 Zip Code I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 6/8/2012 Inspector's Si nature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins • 11/10 Title 5 Official Inspection Fonn: Subsurface Sewage Disposal System • Page 1 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 25 Mill Road Property Address George Russo Owner's Name North Andover MA 01845 6/8/2012 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 El N ❑ ND (Explain below): t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 25 Mill Road Property Address George Russo Owners Name North Andover MA 01845 6/8/2012 Cityrrown B. Certification (cont.) B) System Conditionally Passes (cont.): State Zip Code Date of Inspection ❑ 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 ❑ obstruction is removed ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ Y ❑ N ❑ ND (Explain below): ❑ 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 F1 Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further lEvaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins • 11110 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 25 Mill Road Property Address George Russo Owner's Name North Andover City/Town B. Certification (cont.) MA 01845 6/8/2012 State Zip Code Date of Inspection 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than % day flow t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 25 Mill Road Property Address George Russo Owner Owner's Name information is required for every North Andover MA 01845 6/8/2012 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 the system is within 200 feet of a tributary to a surface drinking water supply tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® 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 ❑ El 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 • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 25 Mill Road Property Address George Russo Owner's Name North Andover MA 01845 6/8/2012 Cityrrown C. Checklist State Zip Code Date of Inspection 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 G is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 4 440 t5ins • 11110 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 ,M 25 Mill Road Property Address George Russo Owner Owner's Name information is required for every North Andover MA 01845 6/8/2012 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 9 ( Y 9 (gP ))� Yes Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Cu terent Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day (gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non -sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 25 Mill Road Property Address George Russo Owner Owner's Name information is required for every North Andover MA 01845 6/8/2012 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Other (describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Type of System: Date Pumped April 2012, owner gallons ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins • 11110 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 25 Mill Road Property Address George Russo Owner Owner's Name information is required for every North Andover MA 01845 6/8/2012 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) t5ins • 11110 Approximate age of all components, date installed (if known) and source of information: 15 vears old, 3/13/1997, as built plan Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): Depth below grade: Material of construction: ® cast iron ® 40 PVC ❑ other (explain): 1.8 feet Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): 4 " Cast Iron thru wall, 3" PVC in house, Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal ❑ Yes ® No .8 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: N1 ❑ Yes ❑ No Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 9 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments D. System Information (cont.) Septic Tank (cont.) MA 01845 State Zip Code Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 27" 0" 8" 15" 6/8/2012 Date of Inspection 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.): Inlet tee ok. Outlet tee ok. Depth of liquid at outlet invert. No evidence of leakage. Center cover has riser 3" deep. Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal Dimensions: Scum thickness ❑ fiberglass 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 • 11110 feet ❑ polyethylene ❑ other (explain): Date Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 10 of 17 25 Mill Road Property Address George Russo Owner Owner's Name information is required for every North Andover page. Cityrrown D. System Information (cont.) Septic Tank (cont.) MA 01845 State Zip Code Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 27" 0" 8" 15" 6/8/2012 Date of Inspection 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.): Inlet tee ok. Outlet tee ok. Depth of liquid at outlet invert. No evidence of leakage. Center cover has riser 3" deep. Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal Dimensions: Scum thickness ❑ fiberglass 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 • 11110 feet ❑ polyethylene ❑ other (explain): Date Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments "r 25 Mill Road Property Address George Russo Owner Owner's Name information is required for every North Andover MA 01845 page. Cityrrown State Zip Code 6/8/2012 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: Design Flow: Alarm present: Alarm level: gallons gallons per day ❑ Yes ❑ No 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 • 11110 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 17 _tel - Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 25 Mill Road Property Address George Russo Owner's Name North Andover Cityrrown D. System Information (cont.) MA 01845 State Zip Code Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 6/8/2012 Date of Inspection 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. No evidence of carryover. Pump Chamber (locate on site plan): Pumps in working order: Alarms in working order: ❑ Yes ❑ No ❑ 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 • 11110 Tide 5 Official inspection Form: Subsurface Sewage Dispose! System • Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 25 Mill Road Property Address George Russo Owner Owner's Name information is North Andover MA required for every page. City/Town State D. System Information (cont.) Type: El El leaching pits leaching chambers leaching galleries leaching trenches leaching fields overflow cesspool innovative/alternative system 01845 6/8/2012 Zip Code Date of Inspection number: number: number: number, length: number, dimensions: number: 3 trenches 50' lonq 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 t5ins - 11/10 Title 5 official Inspection Form: Subsurface Sewage Disposal System - Page 13 of 17 Commonwealth of Massachusetts Title -5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 'L 25 Mill Road Property Address George Russo Owner Owner's Name information is required for every North Andover MA 01845 6/8/2012 page. City[Town 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 - 11110 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 25 Mill Road Property Address George Russo Owner's Name North Andover MA 01845 6/8/2012 Cityrrown 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 n drawina attached separately r � (3 r a =a5�� ?r 73 %SCG Cv it t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 15 of 17 n Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 25 Mill Road Property Address George Russo Owner Owner's Name information is required for every North Andover MA 01845 6/8/2012 page. Cityrrown 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: 4 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: Date 996 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health - explain: Design plan ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: As per design plan test pit data Before filing this Inspection Report, please see Report Completeness Checklist on next page. l5ins • 11110 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17 0 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 25 Mill Road Property Address George Russo Owner Owner's Name information is required for every North Andover MA 01845 6/8/2012 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 Summary Record Card generated on 6/7/2012 2:45:28 PM by Karen Hanlon Town of North Andover Tax Map # 210-107.C-0111-0000.0 Parcel Id 18391 25 MILL ROAD GEORGE RUSSO 400 CHARTER WAY NORTH BILLERICA, MA 01862 Page 1 Class 101 Single Family Zoning2 1 Residential Size Total 1 Acres FY 2012 Property Type Zoning3 1 Residential 1 Residential UB Mailing Index Name/Address Type Loan Number Active/Inact. From Until GEORGE RUSSO Owner 400 CHARTER WAY NORTH BILLERICA, MA 01862 DILLEA, DAVID & JANET Previous Customer Inactive 5/4/2006 25 MILL ROAD NORTH ANDOVER, MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 13621.0 - 25 MILL ROAD Last Billing Date 5/2/2012 1090298 01 Cycle 01 Active UB Services Maint.. Account No. 1090298 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 41.80 /1 UB Meter Maintenance Account No. 1090298 Serial No Status Location Brand Type Size YTD Cons 32707609 a Active 00 b Badger w Water 0.63 0.63 556 Date Reading Code Consumption Posted Date Variance 4/23/2012 729 a Actual 11 5/9/2012 -23% 1/23/2012 718 a Actual 15 2/13/2012 -85% 10/20/2011 703 a Actual 95 11/14/2011 74% 7/21/2011 608 a Actual 54 8/15/2011 560% 4/22/2011 554 a Actual 8 5/16/2011 -61% 1/24/2011 546 a Actual 22 2/11/2011 -79% 10/22/2010 524 aActual 105 11/12/2010 188% 7/22/2010 419 a Actual 36 8/16/2010 256% 4/22/2010 383 a Actual 10 5/12/2010 -22% 1/22/2010 373 a Actual 13 2/12/2010 -66% 10/23/2009 360 a Actual 38 11/11/2009 3% 7/24/2009 322 a Actual 37 8/12/2009 517% 4/24/2009 285 a Actual 6 5/13/2009 -70% 1/23/2009 279 a Actual 20 2/10/2009 36% 10/23/2008 259 a Actual 15 11/12/2008 -16% 7/21/2008 244 a Actual 17 8/15/2008 39% 4)22/2008 227 a Actual 12 5/19/2008 8% 1/25/2008 215 a Actual 12 2/19/2008 -80% 10/22/2007 203 a Actual 60 11/16/2007 44% 7/19/2007 143 a Actual 40 8/15/2007 170% 4/19/2007 103 a Actual 13 5/21/2007 -8% 1/29/2007 90 a Actual 17 2/20/2007 -41% 10/25/2006 73 a Actual 27 11/16/2006 2% 7/27/2006 46 a Actual 25 8/18/2006 23% 5/3/2006 21 f Final Bill 21 5/3/2006 -100% 2/4/2006 0 n New Meter 0 5/3/2006 -100% 2/4/2006 1372 r Replacement 1 5/3/2006 -17% THERl0P81f00.11(fd�fE0C-0ARflGR0UP@ v September 12, 2015 FORM OF NOTICE OF CASUALTY LOSS TO BUILDING UNDER MASS. GEN. LAWS, CH. 139, SEC. 3B Building Commissioner, or Inspector of Buildings c/o City or Town Hall 1600 Osgood Street North Andover, MA 01845 Board of Health or Board of Selectmen c/o City or Town Hall 1600 Osgood Street North Andover, MA 01845 Fire Department or Arson Squad c/o City or Town Hall 1600 Osgood Street North Andover, MA 01845 RE: Our File No.: P1500413 Insured: GEORGE T RUSSO Address: 25 MILL ROAD, NORTH ANDOVER, MA Policy No.: H0702566A Loss Date: 09/09/2015 Loss Type: Building or Other Structure Damage A claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or cause Mass. Gen. Laws, Ch. 143, Sec. 6 to be applicable. If any notice under Mass. Gen. Laws, Ch. 139,, Sec. 3B is appropriate, please direct it to my attention and include a reference to the captioned insured, location, policy number, loss date and claim or file number. If no reply is received from your office within ten days, we will assume you have no liens of any type against this property, and the claim will be paid in our customary manner. Sincerely, Linda E. Babineau Property Claim Examiner 1-800-688-1825 x1253 NORFOLK & DEDHAM MUTUAL FIRE INSURANCE CO.222 Ames Street, P.O. Box 9109, Dedham, MA 02027-9109 DORCHESTER MUTUAL INSURANCE CO.[W@ Telephone: (800) 688-1825 FITCHBURG MUTUAL INSURANCE CO. Fax: (781) 329-1818 THER9OQ81FOd06eD1ED6ARAGROUN September 21, 2013 FORM OF NOTICE OF CASUALTY LOSS TO BUILDING UNDER MASS. GEN. LAWS, CH. 139, SEC. 3B Building Commissioner, or Inspector of Buildings c/o City or Town Hall 1600 Osgood Street North Andover, MA 01845 Board of Health or Board of Selectmen c/o City or Town Hall 1600 Osgood Street North Andover, MA 01845 Fire Department or Arson Squad c/o City or Town Hall 1600 Osgood Street North Andover, MA 01845 RE: Our File No.: P1364288 Insured: GEORGE T RUSSO Address: 25 MILL ROAD, NORTH ANDOVER, MA Policy No.: H0702566A Loss Date: 09/18/2013 Loss Type: Building or Other Structure Damage A claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or cause Mass. Gen. Laws, Ch. 143, Sec. 6 to be applicable. If any notice under Mass. Gen. Laws, Ch. 139, Sec. 3B is appropriate, please direct it to my attention and include a reference to the captioned insured, location, policy number, loss date and claim or file number. If no reply is received from your office within ten days, we will assume you have no liens of any type against this property, and the claim will be paid in our customary manner. Sincerely, Lorraine A. Peirce Sr. Property Claims Examiner 1-800-688-1825 x1139 NORFOLK & DEDHAM MUTUAL FIRE INSURANCE CO. 222 Ames Street, P.O. Box 9109, Dedham, MA 02027-9109 DORCHESTER MUTUAL INSURANCE CO. Telephone: (800) 688-1825 FITCHBURG MUTUAL INSURANCE CO. Fax: (781) 329-1818 Of NORTH , 6161 F S ti Town of North Andover HEALTH DEPARTMENT $�CNUSt CHECK #: DATE: LOCATION: H/O NAME: CONTRACTOR NAME: :. Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service - Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑ TitleInspector $ Ty' .t 5 Report $ ❑ Other: (Indicate')" $ Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer Office Use Only Lgammuntut# of :Ma90ar4U9rft9 Permit No. R _ 13epartment rf VUhiit _TfXtq Occupancy &Fee Checked 3190 (leave blank) OL BOARD OF FIRE PREVENTION REGULATIONS 521 CMR 12.00�i� APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code, 527 CM 12 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date v" %* or Town of NORTH ANDOVER To the I specto of Wires: The udersigned applies for a permit to perform the elxtncal wescribed below. Location (Street &Numb � Owner or Tenant Owner's Address Is this permit in conjunction wit a buil 'ng permit: Yes No ❑ (Check Ap r Purpose of Building / Utility Authcrizatio o. Existing Service Amps _J Vol S Overhead ❑ Undgrnd❑ /No. of Meters New Service Amps �VOlts Overhead ❑ Undgrnd Lim No. of Meters �— Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work Total No. of Lighting Outlets No. of Hot Tubs No. of Transformers KVA No. of Lighting Fixtures I Swimming Pool Above In- grnd. [I grnd. [IGenerators KVA No. Hydro Massage Tubs OTHER: No. of Motors Total HP INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts general Laws I have a current Liability Insurance Policy including Comolet perations Coverage or its substantial equivalent. YES _ O have submitted valid proof of same to the Office. YES — If you have checked YES, please indicate the type of coverage by checking the ap rop to box. INSURANCE BOND OTHER :: (Please Specify) (Expiration Date) Estimated Value o 1 trical Work S Work to Start Inspection Date Requested: .Rough Final Signed under the en Itis of erlury: LIC. NO. FIRM NAME C. NO. Licensee ---Signature Bus. Tel. No. ..- Alt. Tel. No. fe Address OWNER'S INSURANCE WAIVER: I am aware that the Li a see does not have the insurance coverage or its substantial equivalent as entre quired by Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owne 9 (Please check one) Telephone No. PERMIT FEE S (Signature of Owner or Agent) x•5565 No. of Emergency Lighting No. of Receptacle Outlets I No. of Oil Burners Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Detection and Initiating Devices No. of Sounding Devices No. of Ranges Total No. of Air Cond. tons —T— No. of Disposals No.of Heat Total Total Pumps Tons KW No. of Self Contained No. of Dishwashers Space/Area Heating KW Detection/Sounding Devices Municipal ❑ Other Local ❑ Connection No. of Dryers Heating Devices KW No. of No. of I Signs Ballasts Low Voltage Wiring No. of Water Heaters KW No. Hydro Massage Tubs OTHER: No. of Motors Total HP INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts general Laws I have a current Liability Insurance Policy including Comolet perations Coverage or its substantial equivalent. YES _ O have submitted valid proof of same to the Office. YES — If you have checked YES, please indicate the type of coverage by checking the ap rop to box. INSURANCE BOND OTHER :: (Please Specify) (Expiration Date) Estimated Value o 1 trical Work S Work to Start Inspection Date Requested: .Rough Final Signed under the en Itis of erlury: LIC. NO. FIRM NAME C. NO. Licensee ---Signature Bus. Tel. No. ..- Alt. Tel. No. fe Address OWNER'S INSURANCE WAIVER: I am aware that the Li a see does not have the insurance coverage or its substantial equivalent as entre quired by Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owne 9 (Please check one) Telephone No. PERMIT FEE S (Signature of Owner or Agent) x•5565 Date.................................. 12 i , A 914 4, NORTH TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING cis SACHU This certifies that .....cl-? ... ............. . .. ................................ has permission to perform ............................... .... ......... wiring in the building of .. ... ..................... at ...... * .............................. . North Andover, MasF FeeS.L�..-�',/.v... Lic. N4-1-9�Z'7.� ........................................... I ................ Ael aj/. ELE RICAL INSPECTOR /jj� 14L Y11TE: Applicant CANARY: Building Dept. asurer L# nvs rv.Jc! (Punt or Types NORTH ANDOVER, ,MAIL Building Location —9 S A t wfv rJrt rtrtivlt i 1U uu c� �/S �� o^ Date gCj �.��to 77 Permit * - 3 3 d Owner's Name D IYAh New t" Renovation ❑ Replacement ❑ Pians Submitted: Yea ❑ No ❑ FIXTURES Check one: Cadwicate Installing Company Name _ Sc-' VLA; Le-- r L (3 C"P. Address_ ❑ Partnership w7'6 n/ ❑ Firm/Co. Business Telephone . 6 0 3 3 dna 7 9a g Name of Ucensed Plumber. n vle INSURANCE COVERAGE:ecx e I have a current Ilabillty Insurance policy or Ra substantial equtMenL Yes No ❑ It you have checked y", please Indicate the type coverage by checking the appropriate box A ilabilty Insurance policy . tither type of Indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee dm not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on thia permit application waives this requirement. Check one: SlonOwner ❑ Agent ❑ ature o Owner a Owner a ent I hereby cwUty that ail of the detaAa and information i have subnttted lot entered) In above appikation as true and axwate to the best of my knowledge and that aA plumbing work and instaAatlons performed under the pem-A luued toe this application nn7 be in LK pertinent provisions of the Massachusetts State Pkrmbing Code trod Chapter 142 Ganwai ta. compliance � 0l wsSig ey - nature of UcQrsed Humber This License Number /%Sol 6 CitylTown Type of Plumbing License: Master t� lum M 110VED (OfFlCE USE ONLY) Journeyman 0 ori M » Z Z • Ill r 11 J • V < M d M ! e/ M = = 1' V M • : ; • t t it N U r 0 �. r S N s O 1<� y w 0 S < 11 2 o• a ' • 11- V> a a M '' IS •O < O >s H a •O U x >s�1« to «oo3j°s►�.�i`' pO M iso if°s iis - a`ao sua-GssrT. GAGa1aaNT IGT FLOOR / / :NO FLOOR 300 FLOOR ITHFLOOR aTH FLOOR aTHFLOOR YTH FLOOR aTHFLOOR — Check one: Cadwicate Installing Company Name _ Sc-' VLA; Le-- r L (3 C"P. Address_ ❑ Partnership w7'6 n/ ❑ Firm/Co. Business Telephone . 6 0 3 3 dna 7 9a g Name of Ucensed Plumber. n vle INSURANCE COVERAGE:ecx e I have a current Ilabillty Insurance policy or Ra substantial equtMenL Yes No ❑ It you have checked y", please Indicate the type coverage by checking the appropriate box A ilabilty Insurance policy . tither type of Indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee dm not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on thia permit application waives this requirement. Check one: SlonOwner ❑ Agent ❑ ature o Owner a Owner a ent I hereby cwUty that ail of the detaAa and information i have subnttted lot entered) In above appikation as true and axwate to the best of my knowledge and that aA plumbing work and instaAatlons performed under the pem-A luued toe this application nn7 be in LK pertinent provisions of the Massachusetts State Pkrmbing Code trod Chapter 142 Ganwai ta. compliance � 0l wsSig ey - nature of UcQrsed Humber This License Number /%Sol 6 CitylTown Type of Plumbing License: Master t� lum M 110VED (OfFlCE USE ONLY) Journeyman 0 7 Date ...' 11- .... . 330-6 Hoar„ TOWN OF NORTH ANDOVER Of ac .,ti0 PERMIT FOR PLUMBING This certifies that ..t!3 ... ���' `% , .......... . has permission to perform f::7?; 1)tpn/°�rr-�gS�o!� plumbing in the buildings of ...D. n 6V1 ?9 ...... , . . at. t -z?. .� (-L ..1�c��,�.t7 ... . ...... . . . . . .. . North Andover, Mass. Fee.12 t Q _ Lic_ Nn 1 58 eK-1:1/5 53 WHITE: Applicant PLUMBING INSPECTOR D4/14/97 10:52 CANARY: Building Dept 125.00 PAID PINK: Treasurer Location It No. 9t5� Date �aRTh TOWN OF NORTH ANDOVER + Certificate of Occupancy $ CHU Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ /lam Check # c:14L3 z _ 15675 /. -Building Inspector J i',%_ 1IV1\ 1- J1 1 r, ll`tr VKIYiA 11V1V 1.1 Property Address: ,2�-�/,, 4 -09/ 1.3 Zoning Information: A� Zoning Disuicx Proposed Use 1.6 BUILDING SETBACKS ft Front Yard Reou.ired I Provide 1.2 Assessors Map and Parcel Number: . /� D/// Map Number Parcel Number 1.4 Property Dimen s: � s Lot Ar (sf) Side Yard Provided 1.7 Water —Supply M.G.L.C.4D. � 34) 1.3. Flood Zone Information: Public 7 Private 0 Zone Outside Flood Zone SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record Name (Print Sf n re 2.2 O'l ner of Record: Name Print 7,R Telephone Signature T SECTION 3 - CONSTRUCTION SERVICES ado% Rear Y. V X O Required Provided 1.8 Sewerage Disposal System: D Municipal 0 On Site Disposal System �11_ J M Address for Service Address for Service: 3.1 Licensed Construction Supervisor: ' Licensed Constru ton Supervisor: .2 Registered Home Improvement ompany Nam 2 ddress 0 Z M Not Applicable ❑ 0 7, 3 p License Number Expiration 46ate Not Applicable ❑ �_�% �0 / civ O' Telephone/ Registration Number r - r Expiration ate ^ TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING Th;ts; Se�choafor 4#i>i�ai Use` OaI -_. _ .. BUILDING PERMIT NUMBER: DATE ISSUED:_C) a SIGNATURE: C Building Cornmissioner/I for of Buildings Date J i',%_ 1IV1\ 1- J1 1 r, ll`tr VKIYiA 11V1V 1.1 Property Address: ,2�-�/,, 4 -09/ 1.3 Zoning Information: A� Zoning Disuicx Proposed Use 1.6 BUILDING SETBACKS ft Front Yard Reou.ired I Provide 1.2 Assessors Map and Parcel Number: . /� D/// Map Number Parcel Number 1.4 Property Dimen s: � s Lot Ar (sf) Side Yard Provided 1.7 Water —Supply M.G.L.C.4D. � 34) 1.3. Flood Zone Information: Public 7 Private 0 Zone Outside Flood Zone SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record Name (Print Sf n re 2.2 O'l ner of Record: Name Print 7,R Telephone Signature T SECTION 3 - CONSTRUCTION SERVICES ado% Rear Y. V X O Required Provided 1.8 Sewerage Disposal System: D Municipal 0 On Site Disposal System �11_ J M Address for Service Address for Service: 3.1 Licensed Construction Supervisor: ' Licensed Constru ton Supervisor: .2 Registered Home Improvement ompany Nam 2 ddress 0 Z M Not Applicable ❑ 0 7, 3 p License Number Expiration 46ate Not Applicable ❑ �_�% �0 / civ O' Telephone/ Registration Number r - r Expiration ate ^ 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 buil4g permit. t Signed affidavit Attached Yes ....... IV No ....... 0 6LB' SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ 1 Existing Building ❑ 1 Repair(s) ❑ Alterations(s) 0 Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other Pr Specify Brief Description of Proposed Work: '."moi/ SECTION 6 - ESTIMATED CONSTRUCTION COSTS Print a e Si ure of Oent NO. OF STORIES Item Estimated Cost (Dollar) to be ` cOF1[+I.ISETQ1+iLY SIZE OF FLOOR TIIviBERS 1 Completed by permit applicant SPAN 1. Building DIMENSIONS OF SILLS (a) Building Permit Fee DIIvv1ENSIONS OF POSTS Multiplier 2 Electrical HEIGHT OF FOUNDATION (b) Estimated Total Cost of SIZE OF FOOTING X Construction 3 Plumbing IS BUILDING ON SOLID OR FILLED LAND Building Permit fee (a) x (b) l 4 Mechanical HVAC 5 Fire Protection 6 Total (1+2+3+4+5) Check Number SECTION 7a OWNER AUTHORTZATIOK TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, Own A thorize gent subject property Hereby /i -v;' to act on &nnia�ttters relative o work authorized by this building Wnil appli on. ..<6wr ire of Owner Date (/ SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, V�Y�1� ee!sG lfi✓ 4$ as Own uthorized A nt 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 a e Si ure of Oent NO. OF STORIES Date OF SIZE BASEMENT OR SLAB SIZE OF FLOOR TIIviBERS 1 ND 2 3 SPAN DIMENSIONS OF SILLS DIIvv1ENSIONS OF POSTS DD,4ENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHININEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE FORM - U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all -necessary approval / permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and or landowner from compliance with any applicable requirements. APPLICANT ��= % i�TS ''� j IJi ��r/i.�2� PHONE r ASSESSORS MAP NUMBER LOT NUMBER %// SUBDIVISION LOT NUMBER STREET........ .............. "' ............... STREET SNUMBER ........ —.;�s . ........................... OFFICIAL USE ONLY........................... RECOMMENDATIONS OF TOWN AGENTS DATE APPROVED (fo-2 0 O Z CONSERVATION ADMINISTRA DATE REJECTED CONRVIENTS DATE APPROVED TOWN PLANNER DATE REJECTED COMMENTS DATE APPROVED AF D INSPECTOR -HEALTH DATE REJECTED (V ^��, `^S V- DATE APPROVED O IC INSPECTOR - HEALTH DATE REJECTED I COMMENTS iV\� e S �i 2j� �,Vl \ e,,, S �Oo� MJS� VLO- fi JC)' -C/DN- lei �.-�� ��J ��� - to PUBLIC WORKS - SEWER / WATER CONNECTIONS DRIVEWAY PERMIT DATE APPROVED FIRE DEPARTNIENT DATE REJECTED COMMENTS RECEIVED BY BUILDING INSPECTOR DATF F C/) m C m U) 0 m ) CA m �q o f� ° 3 °'- PCI 0 o�c � CO) d Cl) CD n Z CO) CD O A O r � C. _• O CO) acm � o ~ o p CD CD o CLQ H d CD CD CD mm y. CD a O CO)CD C CD R- TP � CO) v O mo co Cl) Z O CD Z is Z z O y CCD m �q o f� ° 3 °'- PCI 0 o�c C40 -x w �p"t 7 n: 0 arc A O r y = O ~ 2i C S. H O Q d 4c H f + -i p OO p O m 1-" R- TP o y Cj _n m Z is Z z ?'C• y _I CD.. m d y �7i O IE =r O C9 7 m y '� m NcjCD :O �\ A t-+ a a N C 0 m n,rt...� C Com; CD O N Fly UV�^J V / m O m : � CD O Q rf N\ n O CL N <D :� to N ^� VJ y ` -4 8 2 O `� = U U� Z m o 0 (r) C/) �G •-!n CD st r^ D Cy ^l oc� ro: C7 a C2 m �q o f� ° ~ ro °'- PCI 0 o�c C40 -x w �p"t 7 n: 0 arc MPO O r ��"tIo O ~ �-p ~ V p ro 9 rA IN 0 z 0 4, 0 c Location a� Mal Fbaw r No. O ( Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ b� Foundation Permit Fee $ Other Permit Fee $ TOTAL $ a 0 Check # �� 17887 Building Inspector 4 i TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING s x ����V,� .:"' r ., +7• i .%?>..'1' "'i..g € +r, vC wx �-n.`Yf -9ax �`: LYRA AZfi .'{? BUILDING PERMIT NUMBER: c /� DATE ISSUED: SIGNATURE: Building Commissioner for of buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address; 2-5 Md 1.2 Assessors Map and Parcel Number: o Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area Frontage ft 1.6 BUILDING SETBACKS 00 Front Yard Side Yard Rear Yard RegWred Provide Required Provided Re red Provided 1.7 Water Supply M.G.L.C.40. 34) 1.5. Flood Zone Information: Zone Outside Flood Zone 0 1.8 Sewerage Disposal System: Municipal 0 On Site Disposal System 0 Public ❑ Private ❑ SECTION 2 -PROPERTY OWNERSHIP/AUTHORIZED AGENT sIUVIC istrict: YES PJo 2.1 weer of R rd �— av r �GdV e�t e l X00. �� Name (Print) Address for Service Signature Telephone 2.2 Owner of Record: Name Print Address for Service: 4 Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Lic nsed nstruction Su rvisor: Not Applicable ❑ (� j�LGN Licensed Constru tion Supervisor: E XY, 3O 3�` License Number C� li 3 �a3 3 �� Expiration Date p Signature Telephone 3.2 RegisteredHome Imp r vement Contract/tor Not Applicable ❑ ' v Company Name J >fl�vn /V JG / Registration Number Addr s Expiration Date Signature � Tele hone MU m a SECTION 4 - WORKERS COMPENSATION (NLG.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 buildine hermit. Signed affidavit Attached Yes .......0 No ....... 0 SECTION 5 Description of Proposed Work check an appHcable New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition 41/' Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Wor : k a.Ndx r 5 r ry 6"J 10 . 4 1 X 1 �' E1ycl6sea� ocG� Ck '8' K 2 2_ OOC,6U V0 e c L W-1 _16 I?- SECTION Z SECTION 6 - ESTIMATED CONSTRUCTION COSTS t Item Estimated Cost (Dollar) to be ' OF'1F`ICIAt:'USE ONLY Completed by permit applicant 1. Building(a) Building Permit Fee 3-7 ,00 Multiplier 2 Electrical (b) Estimated Total Cost of fg� .3. Construction 3 Plumbing Building Permit fee (a) X (b) 4 Mechanical HVAC U 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 I r dellst".' , as Owner/Authorized Agent of subject property 14 Hereby Mithor'-e to act on [My lffi n 1 n tters re a to work authorized by this building permit application. Si `ia ure of Owtter Date SECTION 7bn OWNER/AUTHORIZED AGENT DECLARATION IV ,as Owner/Authorized Agent of subject property Hereby decIpre that the state ents anq information on the foregoing application are Ln:e and accurate, to the best of my knowledge and behm � v Fruit t/`^�y Signature of Owner/Agent NO. OF STORIES /z ` 071 Date SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 15 2' 3RD SPAN _ DINIENSIONS OF SILLS DM ENSIONS OF POSTS DIMENSIONS OF G.MDERS 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 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 f(f�-' I k U& LOCATION: Assessors Map Number SUBDIVISION /�� ] _ STREET�1 r L I' l **********OFFICIAL USE ONLY OF TOWN AGENTS: PHONE PARCEL LOT (S) ST. NUMBER CONSERVATION ADMINISTRATOR DATE APPROVED I G DATE REJECTED COMMENTS E121 v)L , S i TOWN PLANNER DATE APPROVED DATE'REJECTED COMMENTS FOOD INSPECTOR -HEALTH DATE APPROVED DATE REJECTED SEPTIC INSPECTOR -HEALTH DATE APPROVED DATE REJECTED COMMENTS PUBLIC WORKS - SEWERIWATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9197 jm 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: s 0oSa _ocaflon ol Facility) Signature of Permit Applicant 12- 2 - o 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 Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Name Please Print Name: Location: CriyPhone # I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity aI am an emer providing workers' compensation for my employees eking on this job. Com n name:plo s® C`3 f;tl (,o;✓� Comaanv name: Address Cit . Phone # 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 andfor one years' imprisonment_as well.as _civil.penalties in the imn dA .ST.OP YVORK ORDER..and_a .fine of.(3100.00)-aJey .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 hereby Print andevslyes ofperj�iy that the information provided above is true and correct. Official use only do not write in this area to be completed by city or town official - City or Town Perm' 'censi na 1'2- -r/loy Y,3 43 7 6(3�-. ❑ Building Dept []Check rf immediate response is required Licensing Board C] Selectman's OfficeContact person: Phone #: ❑ Health Department ❑ Other t .k ;u o m z0� J ocn D _. -Z-ri o> tWl2 0 3 Z " ot, o �izo Cl)� X C rn rn o. n C) 1 d D . OD c m' N 00 CA) M z 1 m m x m C m X m y mm _?� co m S 0 ca y d0Sm y SI m do m m v y O a Z H =r= H' o� m " In CL a o m C o -4 0 S -� m eo S �. Amo —ai d m o CO) : V O c � CO) WZ CA x a a a o = A' CCD � � CL C m am O c 71 0 • ? ^ m .�. Co0.0 � ll � o ���� OC'. H O d 7 C z o cc o cD H n m �ma ti CD CLCD CD cr CCDAt .. -� o 0 0 0 0o Z ,. C CD CO) C/) �. 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Public Works 11 1 Location � ' (r (t No. Date Z 7 N°*Th TOWN OF NORTH ANDOVER O0� . -'6 n Certificate of Occupancy $ ; # Building/Frame Permit Fee $ ° s�CHUS Foundation Permit Fee $ ' Other Permit Fee $ Sewer Connection Fee $ lo. fj l Water Connection Fee $ US�•� TOTAL � $ /Ca �/ing Ins f02/18/97 1 i,d&?.00 PflID A 55 :.- E` Div. ubltc Works PER311T NO. d S� J APPLICATION FOR PERMIT TO BUILD —NORTH ANDOVER, MASS. gPAGE 1 MAP h40. JO -7_ I LOT NO. L�- 2 ' RECORD OF OWNERSHIP IDATE BOOK 'PAGE ZONE SUB DIV. LOT NO. I I 32let LOCATION25 MJ9 r�C11. �6i'� PURPOSE OF BUILDING Si 1w�St` OWNER'S NAME 1 � NO. OF STORIES 2 G Slz nd ��� OWNER'S ADDRESS �/ �' J 1 S1 BASEMENT OR SLAB-e,%6r11.. ARCHITECT'S NAME SIZE OF FLOOR TIMBERS 1ST`® 2ND?x BUILDER'S NAME •M� •;'G, �,y, SPAN DISTANCE TO NEAREST BUILDING �kk��/J�L�.i�✓t s DIMENSIONS OF SILLS ye�x 11 POSTS DISTANCE FROM STREET ® DISTANCE FROM LOT LINES - SIDES3r} �/JJ1`� REAR L. ,4jFRONTAGE1�9 a + GIRDERS .7 A� 3 )t j%/2 m /� �,s xp`9 Z �vL J J Q �i � AREA OF LOT Lf� J �3� S�• �L�iL HEIGHT OF FOUNDATION 9Z4G7��I THICKNESS ' %I JN IS BUILDING NEW t/�'� ll�� SIZE OF FOOTING /iA L•• x Id, X 404 jt4oL)� IS BUILDING ADDITION MATERIAL OF CHIMNEY w L IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND�,p1 WILL BUILDING CONFORM TO REQUIREMENTS OF CODE ` IS BUILDING CONNECTED TO TOWN WATER 4{ BOARD OF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWN SEWER 4' IS BUILDING CONNECTED TO NATURAL GAS LINE NQ INS RU 0 T S 3 PROPERTY INFORMATION _ii I F R FOUNDATION ONLY LAND COST i tiG4 1 SEE BOTH BIDES REGULATED BY PARA. 114.0-S. O.C,0 EST. BLDG. COST 1 � 212/ O 3 -�� PAGE 1 FILL OUT SECTIONS 1 - 3 EST. BLS. COST P Sq. FT, PAGE 2 FILL OUT SECTIONS 1-I'{¢.Ti7 ' OD EST. BLDG. C ST PER ROOM 4W 0rnoc Ib /r l L � � I � ---- FSE PAID /od — ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING SEPTIC PERMIT NO. ( 4 APPROVED BY ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS 4t��lAl� * S tie. PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR Pezr--,ir �o /( DATE FIL ��1Gi l' BUILDING INSPECTOR SIGNATURE OF OWNER OR F E E P► ._375 w ww%m v w•••••• ••� w _ PERMIT GRANTED �+ii.3 �t•�..5�� _� • 19 9_ iCi�/�27 vt4 FRAME/BUILDING :-I P fT. FEE PAID:12:1i ?.: OWNER TEL. # S05 -721-i2-36'36) COONTNT R. TEL. # e09 72-5 3CPBc� CONTR.LIC.# 059321 H.I.C. # 1 OCCUPANCY SINGLE FAMILY Si OR IES % PIPELESS FURNACE FORCED HOT AIR FURN ..SINGLE FAMILY • OFFICES _ `APARTMENTS HOT W'T'R OR VAPOR AIR CONDITIONING CONSTRUCTION ' 2 FOUNDATION UNIT HEATERS 8 INTERIOR FINISH CONCRETE OIL B'M'T 2nd la 13rd ELECTRIC 3 1 2 3 CONCRETE BL'K. PINE BRICK OR STONE HARDW'D _ PIERS PLASTER DRY WALL _ _ 3 BASEMENT _ UNFIN. I Z -cut, u40 - AREA FULL FIN. B'M'T' AREA _ 1/1 1/7 �/. FIN. ATTIC AREA N_O B M -T. FIRE PLACES HEAD ROOM MODERN KITCHEN 4 WALLS I 9 FLOORS CLAPBOARDS B 1 2 3 DROP SIDING CONCRETE _ WOOD SHINGLES EARTH ASPHALT SIDING HARDH,'D ASBESTOS SIDING COMRACN VERT. SIDING ASPH. TILE STUCCO ON MASONRY STUCCO ON FRAME BUILDING RECORD 12 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. BRICK ON MASONRY ATTIC STRS. 8 FLOOR BRICK ON FRAME CONC. OR CINDER BLK. STONE ON MASONRY WIRING STONE ON FRAME SUPERIOR 010 POO -11 R ADEQUATE I NONE 5 ROOF 10 PLUMBING GABLE HIP BATH 13 FIX.)NO ; • �� t GAMBREL MANSARD TOILET RM. 12 FIX.) FLAT SHED WATER CLOSET ASPHALT SHINGLES LAVATORY WOOD SHINGES .. KITCHEN SINK SLATE NO PLUMBING TAR & GRAVEL STALL SHOWER 6 FRAMING I 11 HEATING °. WOOD JOIST.- PIPELESS FURNACE FORCED HOT AIR FURN TIMBER BMS. 6 COLS. STEAM STEEL BMS. & COLS. WOOD RAFTERS HOT W'T'R OR VAPOR AIR CONDITIONING RADIANT H'T'G UNIT HEATERS 7 NO. OF ROOMS GAS OIL B'M'T 2nd la 13rd ELECTRIC I NO HEATING p¢q.ww..iiY +any r' w — H d CO) 10 CD n Z 0 NA 'a 0 0 a„ c =r fl. _. C y >cc � o PO oGc o v � CD CD O .r* n w CD Coo � �C � CD w z •'1 �TT 5)0 �j -O~ ;LID � .P � �I Mo V7 �.izn 1. Vo a•RO cn t C n cn �� z0 J• ir �' C c ?= o m = p• y O C N Oymdc Z a� N -4 logoO� .► _ m O TI Fn - CD CD O 5 m OCD n 1 •7 0 • CA o Z�•n : Dom H . a = o m eo o ?� CD m N ; co 0CD CD rt :R H O o C :L C& a col C tC 5 !Em 'N 0 CD CP � N� a =m cm 2N 5 J� � 3 c� WiCD 0 m. oCD C nCD_ cn 0� 0 D y. IV °� CDa y O CO) PO oGc CL7 CD �� °'- oCa CA O n CD Z d z t � �C � CD w I CD z •'1 �TT 5)0 �j -O~ ;LID � .P � �I Mo V7 �.izn 1. Vo a•RO cn t C n cn �� z0 J• ir �' C c ?= o m = p• y O C N Oymdc Z a� N -4 logoO� .► _ m O TI Fn - CD CD O 5 m OCD n 1 •7 0 • CA o Z�•n : Dom H . a = o m eo o ?� CD m N ; co 0CD CD rt :R H O o C :L C& a col C tC 5 !Em 'N 0 CD CP � N� a =m cm 2N 5 J� � 3 c� WiCD 0 m. oCD C nCD_ cn 0� 0 cn 0 w IV °� 9 oCa y °� 7n A. PO oGc tz b �� °'- oCa rd r b z °� n ora CL ^� d z t � �C � a Q x w z O A 0 c CD ol FORM U - VERIVICA'TION 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. ****************Applicant fills out this section***************** APPLICANT: pAy�� � tw('E�-S"t'Et� Phone !. 72rp 3Co30 LOCATION: Assessor's Map Number D1 'G Parcel 4 Subdivision 'Lot(s) ,- Street ?'N04C> St. Number ************************Official Use Only************************ RECOMMENDAT VONS9TOWN AGENTS: Date Approved Conservation Administrator �jDate Rejected Comments►/��Kc� ICS �/.if qv/�ia�fts �'IYK'h1 Wt Town Planner Comments Food Inspector -Health /2;74— Septic Inspector -Health Comments Date Approved Date Rejected Date Approved Date Rejected Date Approved _ Date Rejected Public Works - sewer/water connections driveway permit I:7 -k/ l 7 Fire Department I Jar G{;, � �� c�.E�� i An& -"(t `t° abs 6jaft 1ee,fZ.-% or . FO �16Q. 72% 1 P sr^ ✓ &%z 217/9'7 Received by Building Inspector Date r #'1 �' I Growth Management Bylaw Exemption Statement Town of North Andover Building Department This form shall be used to assist the Building Department in their determination of exemptions under section 8.7.6 of the Town of North Andover Growth Management Bylaw. The building applicant shall provide all of the necessary information as requested below. Name of Applicant on Building Permit (below) Address of Property for Permit (below) -0N\Ar_> MSR"e�_ezi-ie1 til z1b M1 LL_ Map and Parcel: Purpose of Application (check below) Phone Number of Applicant:'*-'Single Family _ Two Family =C6'125 36&?06 I the undersigned applicant for the above property attest that the attached building permit for which this form is completed does comply with the EXEMPTION section 8.7.6 of the North Andover Growth Management Bylaw. I also understand providing this form does not absolve me or any party to this permit from the requirements of obtaining other permits required prior to the issuance of the Building Permit. Further I understand that my interpretation of the EXEMPTION status is subject to review by the Building Department and is only officially accepted when the Building Permit is issued. Based on section 8.7.6 of the North Andover Growth Bylaw the above lot and the work as applied for on the above lot, in the building permit application and associated attachments, complies with one or more of the following sections as indicated by a check mark. This is an application for a building permit for the enlargement, restoration, or reconstruction of a dwelling in existence as of the effective date of this by-law, provided that no additional residential unit is created. The lot(s) were/was created prior to May 6, 1996 are exempt from the provisions of this Section 8.7 of the Zoning Bylaw. This application is for dwelling units for low and/or moderate income families or individuals, where all of the conditions of 8.7.6.c are met and/or represents Dwelling units for senior residents, where occupancy of the units is restricted to senior persons through a properly executed and recorded deed restriction running with the land. For purposes of this Section "senior" shall mean persons over the age of 55. This application is a part of a development project which voluntarily agreed to a minimum 40% permanent reduction in density, (buildable lots), below the density, (buildable lots), permitted under zoning and feasible given the environmental conditions of the tract, with the surplus land equal to at least ten buildable acres and permanently designated as open space and/or farmland. The land to be preserved shall be protected from development by an Agricultural Preservation Restriction, Conservation Restriction, dedication to the Town, or other similar mechanism approved by the Planning Board that will ensure its protection. This application represents a tract of land existing and not held by a Developer in common ownership with an adjacent parcel on the effective date of this Section 8.7 shall receive a one-time exemption from the Planned Growth Rate and Development Scheduling provisions for the purpose of constructing one single family dwelling unit on the parcel. This application represents a lot which is ready for building permits,(i.e. all other permits from all other boards and ommissions have been received and the project is in compliance with those permits), and the Development Schedule does not accommodate issuing a building permit in that Year, one building permit will be issued per Year per Development until such time as the Development Schedule accommodates issuing building permits. Applicant must supply approved form U with this EXEMPTION. Please provide any and all information that would assist the Building Department in making a determination that your application is allowed one or more of the above EXEMPTIONS. By signing below 1 attest to the accuracy of the information provided and that the attached building permit is allowed an EXEMPTION as cited above. Further I understand that the submittal of misleading and or inaccurate information, or the checking off of an above item which does not comply, whether done to my knowledge or not is grounds for refusal by the Building Department to issue a Building Permit. Signature 'oT Owtrizetl Agent who signed the Attached Building Permit Date This form must be attached to the Building Permit upon application for such permit. BK 45: PG 320 i•:•}ji,Y•i:::+i?.v:y::{n:?:,?•:{•;xMf;+:,F}:ii:?^'�?i:•finy.;}v:::{?{.;xvxx:{.'n:•::r:. �yv,:: x}'l hrrmn•:::.vv» t... ,r?{C : .. i..^?:?{!?i'SMr� :};n;{::{:.}: M..;Ciq,{.• :• n:yy,?r{{{rp;:{4:•'ri.{{?M?:.•ii:?.}???Y.?i??{?{?+F.?i ..:rx, .';�'<L:•i:{ix:Y.i:•i::h:.: i::•:Y•.}:•::::::{yryviiiiYLii rii:.:n.::::............::::::.�:r:x�:::::::::�:.::::.::ii.:::�x..�:::::::�`:.:�:.i.::i.:i�:::.;::...;.::.... �3..�...:.:,..•,�.,...:.....��:::::xr..�..:..:.:::.n.. ...:..::::: x• �/r...':x:...vn.rxr.r..nnx.:M•x.rru:::::r:r:::x•: nvvrl:li✓.:if.?:rv: is-jr% •'•iiiYiJ�iYiii�i:Li:%i% Town of North Andover Planning Board This form represents the schedule for allowing the following lots to be considered as eligible for building permits under the Town of North Andover Growth Management by-law Section 8.7 of the Zoning by-law. Pursuant to 8.7.5 this Development Schedule must be filed in the Registry of Deeds and be referenced on the deed of each of the lots below and be filed with the Planning Board prior to the issuance of any building permit or permit for construction. Name and Address of Applicant for Lots: Name of Development: Helen M. Kellner 920 Turnpike Street North Andover, MA 01845 Not Applicable Map and Parcel of Original Lot: Date of Application for Lots Division: August 7, 1996 Lots Covered by this Schedule: Lot 4 Mill Road 09 The Planning Board by their signature below, or a signature of a duly authorized representative, do hereby establish for the 3,5ovc named development the following Development Schedule for the purpose of Section 8.7 of the Growth management By -Law. The applicant, their assignees, successors and or subsequent property owners shall conform to the following schedule that limits the eligibility of the following lots for building permits. This form must be filed in the Registry of Deeds by the property owner or representative and be referenced on each deed for each of the following lots. Such deed reference for the deed of each lot shall at a minimum reference the book and page in which this Development Schedule is filed and contain the language : " This lot is subject to a Development Schedule pursuant to the Town of North Andover Zoning By -Law all owners, representatives, and future purchasers should avail themselves of said restriction by reviewing the approved Development Schedule as filed in Book insert here and Page insert here. The fact that a lot is eligible for a building permit is subject to the limitation of the number of building permits per year pursuant to section 8.7.2.d of the Zoning By -Law." The Planning Board hereby schedule the lot(s) for the above development as follows: Year Eligible Number of Building Office Use Building Office Use Lots Eligible Date Lot Eligibility Notes Completely Utilized 1996 one Signature of Planning Board member or Authorized Representative R_ Date Sign ture of Property Owner or Authorized Representative Date FEB 1 0 P97 O ICL -2L NG'M - 2 S kA: LL -e/.4i,-P Crvc= P. 4 x 2 Z. a?G 2 4� J - Mace:, 1(.xZ/ z 334 3RX225 1064— 06¢= r16 xa,I -63C i=rzvuv as - rv;N1 & y/MID . ?.:Z7 de4;6J---)ir-j6- AG74hPP Zosm7 o 5ti,- #,alb m� Al ✓fze �a»��zairur�a�fi�- r.`�-l�la:lJac�icJe/,l� DEPARTMENT OF PUBLIC SAFETY CONSTRUCTION SUPERVISOR LICENSE Number: Expires: Birthdate: CS 059321 08/23/1998 08/23/1962 Restricted To: 00 DAVID M MERMELSTEIN 41 CHESTNUT ST N ANDOVER, MA 01845 CERTIFICATE OF USE & OCCUPANCY Town of North Andover Building Pen It Number Date 9 THIS CERTIFIES THAT THE BUILDING LOCATED ON Z �� pyt C ( - 'f MAY BE OCCUPIED AS60zIN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. 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Date tuilding Location oZ "S� A;I-( �� Permit # 2-G76a Owners Name 1;tA?X)4-(- `i%eSigx: ell New '_Renovation II Replacement Lj Plans Submitted II FIXTI ro.c (Print or Type) Installing Company Check one: Certificate Corp. Address /off Partner: _ et�� �% /U 1•J� ��� Firm/Co. Business Telephone: Lp,53 ;7 j` Name of Licensed -Plumber or._Cas Fitter /jJQ} AII� AA of B._c )6L/� Insurance Coverage: tndica:e n` t•�pe of insurance coverage by checking the appropriate- box: LiabiIit insurance. policy.I . Ot^er tvpe of indemnity,. Bond Insurance Waiver: 1, the undersicneJ, have been made aware that.-the.licensee.of this appiication.does not have any one of the above three insurance -coverages.__ Signature of owner/agent of property Owner Agent I 1 hc:cby certify that all of the details and information I time suhmitted (cr entered) in above appiidtion are tree and aocwzte to the best of my SrloWcdCa and that ILL plumbing work and lnftadatioms ;criorzzc: and :'trmit iz=td re: this appiicat:aa wiU be in compliurce with all pertlactt frorisions of tlso Stassar_4useCIS State Cas GJda and Qapter 14-' ct t:a Ccic:i LawL ._ By Tile Cit-_,r/Town: APPROVED (OFFICE USE 011LY1 2yP= LICZNSEE P, u.TLzer Gasf�ie Master Journeyman Signature of License< u.r be- r Gasfi.tter License Dumber ca as c LUus ci Y - __... w - us Gt O C us -C < r � Q O t G w _. t<s 0 w ` L _ t- C C C > us C w W . 2 _Q1 to� tct a 'C C G w f' =s _ C3- ..- - - - — - - ui us a > u_ w 1 - - _ _ G C O .__.f BASEMEXT I ZS'. FLOOR � iu FLOOR j 3Rn FLOOR I I I -i _I I I I ( �tt I I I I Iy I I- -4__-�--lr-----(---- 4TH. FLOOR j_ .,I .i ,j I... I II STK FLOOR 6TH FLOOR I I I I 1 I I t M I 1 I I I I( I I I I I I ( I(( f 11 7TH FLOOR STN FLOOR.. (Print or Type) Installing Company Check one: Certificate Corp. Address /off Partner: _ et�� �% /U 1•J� ��� Firm/Co. Business Telephone: Lp,53 ;7 j` Name of Licensed -Plumber or._Cas Fitter /jJQ} AII� AA of B._c )6L/� Insurance Coverage: tndica:e n` t•�pe of insurance coverage by checking the appropriate- box: LiabiIit insurance. policy.I . Ot^er tvpe of indemnity,. Bond Insurance Waiver: 1, the undersicneJ, have been made aware that.-the.licensee.of this appiication.does not have any one of the above three insurance -coverages.__ Signature of owner/agent of property Owner Agent I 1 hc:cby certify that all of the details and information I time suhmitted (cr entered) in above appiidtion are tree and aocwzte to the best of my SrloWcdCa and that ILL plumbing work and lnftadatioms ;criorzzc: and :'trmit iz=td re: this appiicat:aa wiU be in compliurce with all pertlactt frorisions of tlso Stassar_4useCIS State Cas GJda and Qapter 14-' ct t:a Ccic:i LawL ._ By Tile Cit-_,r/Town: APPROVED (OFFICE USE 011LY1 2yP= LICZNSEE P, u.TLzer Gasf�ie Master Journeyman Signature of License< u.r be- r Gasfi.tter License Dumber -.`-r�-s T- 2508 Date Of"TI, TOWN OF NORTH ANDOVER: -. ,,cD ,^1ti0 0? '�.. op PERMIT FOR GAS INSTALLATION., s � r O •^ i �9SSACNUSEt This certifies that .. t`�? !'� .. ...... has permission for gas installation .+? ' ' .. C.�...... it in the buildings of.... .... ..:.. .......... , at .... �'�?'. L t..��?A !�....... North Andover, Mass. Fe4Sv °-�.. Lic. No. 14 EWO .. ........ ....... G+ f\:L+ ,G'r S a GAS INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File x 100 Date.����.. ........ TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ....-.................................................. has permission to perform ............................................ wiring in the building of.....!`z.'`.".:..'..................................................... at ?....... ...... ..... r' , North Andover, Mass. Fee? ........ Lic.No! � lb�„...... ELECTRICAL INikCT Check # U U 5535 s DF.PARTARMOFPUB, BOARDOFFIREPREVE TON APPLICATTONFOR PERMIT TO P ALL WORK TO BE PERFORMED IN ACCORDANCE W; (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Town of North Andover The undersigned applies for a permit to perform the electrical Location (Street Owner or Tenant Owner's Address Permit No. .— C11maw � —I fv� . Occupancy & Fees Checked RMELECMCAL WO ELECTRICAL CODE, 527 CMR 12:00 ` Q� Date / To the Inspector of Wires: below. Is this permit in conjunction with a building permit: Yes ErNo (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps�Volts Overhead M Underground No. of Meters New Service Amps_ Volts Overhead M Underground No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work i.r� -�kvt t $Lmvn Mom No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures Swimming Pool Above Below Generators KVA round 0 ground No. of Receptacle Outlets / No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Ranges No. of Air Cond. Total Tons No. of Detection and No. of Disposals No. of Heat Total Total _ Pumps Tons KW Initiating Devices No. of Sounding Devices �Io. of Dishwashers Space Area Heating KW No. of Self Contained Detection/Sounding Devices Local Municipal Other No. of Dryers Heating Devices KW ID Connections No. of Water Heaters KW No. of No. of Signs Bailasis No. Hydro Massage Tubs No. of Motors Total HP OTHER• Corers Rus�an[todletagmanatts�GalaalLaws IatnerttLiab>1rtYhtsur�rrePblicyirtdgCorrtple� Covaageaitssttbsiasrialegttivalatt YES NO Iha validprobox ofofSMrlDtheOffM YES Ifyouhareclted�,BYES, plemirtd *diegpeofeovt ageby . 6 , >N� BOND p 0114ER p ft=sp�) Ll , WorkloStatt h>spectimD&RecVested SignedurrirTieFtrralbesofpc jU7.. HRMNAME Li== f,/t ►� 1�a �P' w c�w sign Etrn*d Vale dE1Xt cal Wdk $ �SnlP3� Lio=No Busk=TeL Na Alt. Tel Na -E—.3/693- 7 �3 1- �y doesmthavetheinsttrameoowaFarilsa>bsUlUeWivalentasmglwdbyMasmdxm,-mCtna lLaws andthatmysigtahnecnthispemtRapplitxt mwai%esthisrequicerrtatt (Please check one) Owner a Agent signature of Owner or Agent Telephone No. PERMIT FEE4--30 10 3915 Date ..... .......... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ......... ....... ........ has permission to perform .................... � .c .. . ..... .................... wiring in the building of ......... X�'/Ifc( ....................................................... at ...... ...5...... . &�.8 .... 5T........................... North do ass. 1�37... .............................. �Fee ..33.��. Lic. No./�,7 7 ELECTRICAL INSPECTOR Check #- A I "••••� WIL11 w Massachusetts — Otlicial l Ise Only Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONSPermit No. Occupancy and I ec Checked q A R APPLICATION FOR PERMIT PERFORM r eV. 11/99] (1�,,�� blank) All work to be performed in accordance with the®assach, ® ELECTRICAL R1�AL WORK (PLEASE PRINT WINK OR TYPEALL INFORM TION) Date: rical ode (I\q :c) 527 12.00 City or Town of ) t. ? By this application the undersi -�����To the gn gt� notice f h r her intention top form the electrical (work described Location (Street & Num ber) e� ork described below. Owner or Tenant Owner's Address Is this permit in conjunction with a building permit? Yes ❑ Purpose of Building Existing Service Amps / _____ Volts Nei Ce _ Amps / _Volts Number of Feeders and Ampacity� Location and Nature of Proposed Electrical Work: _. and LIGHT _ No. of Recessed Fixtures No, of Lighting Outlets No. of Lighting Fixtures No. of Receptacle Outlets No. of Switches No. of Ranges rs No. of Waste Dispose No. of Dishwashers No, of Dryers o. o ate r Y Heaters KW "t No. of Bathtubs 0 .v t No ❑ (Check Appropriate Box) Utility Authorization No. Overhead ❑ Undgrd ❑ Overhead ❑ Undgrd ❑ INGROUND POOL: BONDING No. of Meters No. of Meters I'VC, GFI, FILTER, PUMP Com letion o the ollowin No. Qf Ccil.-Susp. (Paddle) table ma,, he wai,,ed by the Ins ecta o- Fans o Transformers eta No. of Hot Tubs KVA Generators KVA Swimming Pool Ove e ❑ rod. 110. ° :mergency tg tug Battery Units No. of Oil Burners FIRE ALARMS No. of Zones NO. of Gas Burners o. o . ctectton an Vo. of Air Cond, eta dnitiatin Devices eat Tons limp um er No. of Alerting Devices Totak. ..._......... ons o. o Space/Area Heating KW Heating Appliances KW o. o n. o Signs Ballast' Vo. of Motors Total HP Detection/A lertin Devices nto a Local Cuonnection ❑ Other No: of [)evices or E uivt Data Wiring: No. of Devices or Euiva e ccornmuntcations tang No. of Devices or Fniv;va Wires. INSURANCE COVERAGE: /!/loch additional detail ifdesired or as re aired b the licensee provides proof of liability b lily insurance in ludinthe ner, no fermited for operation" fcoverage 4 v the /izry issuclore of Wires, Performance of electrical work may issue unless undersigned certifies that such coverage is in force, and has exhibited er its substantiae equivalent. The CHECK ONE: INSURANCE x Proof of same to the permit issuing office. ❑ BOND E] OTHER ❑ (Specify:) Estimated Value of Electric9l Work: 20 Work to Start: (When required by municipal policy.) (Expon Date) 1 cerci Inspections to be requested in accordance with MEC Rule 10, and upon completion. fy, under the palas and penalties, off'edilrY, that the information on !Iris app/fcation it tate and complete. FIRM NAME: Village Electric. Inc p Licensee: AnthonP DeIPa a LIC. NO.: 9163 (ligpplicab/e, enter ."exempt" in the license number line.) Signature Address: 4 Kidder Rd. Chelmsford MA 01824 LIC. NO.: -- -861 OWNER'S INS Bus• Tel. No.:1 _ URANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normall required by law. By my Signature below, I hereby waive this requirement. I am the check one Alt Tel. No.: rage n rmall Owner/Agent ( ) ❑owner Y Signature ❑ owner s a ent. Telephone No. PERMIT FEE. $ S�� ., lrlc c,um�rluNwr.�h ur DF.PAWNWOFPUB, BOARDOFFIREPREVF1 ON APPUCA77ONFOR PERMIT TO ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE 1 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) \ Town of North Andover The undersigned annlies for a vermit to perform the electrical Location (Street B Owner or Tenant Owner's Address 1113 vunx use u�wy'` Permit No. CMR12iD 57,77 Occupancy & Fees Checked r RFORMELE=CAL WO :HUSSTS ELECTRICAL CODE, 527 CMR 12:00 Dat / Q To the Inspector of Wires: below. Is this permit in conjunction with a building permit: Yes Iallo [D (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps�Volts Overhead Underground a No. of Meters New Service Amps Volts Overhead Underground No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work WWirt- f'ltni r- Stmy,\ Mom No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total y . KVA No. of Lighting Fixtures Swimming Pool Above ^ . Below ^ Generators KVA vmnnd 1 1 omnnd , 1 No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting Batte ' . of Switch Outlets No. of Gas Burners FIRE ALARMS of Ranges No. of Air Cond. Total Tons No. of Detection and of Disposals No. of Heat Total Total Plumps . Tons KW Initiating Devices No. of Sounding Devices of Dishwashers Space Area Heating KW No. of Self Contained Detection/Sounding Devices tof Dryers Heating Devices KW Local Municipal Connections of Water Heaters KW No. of No. of Signs Bailasis Hydro Massage Tubs No. of Motors Total HP SSW hq"mD*Rgle&d underTr cfpeduT.. • No. of Zones M Other 31st . YES r-1 NO 71 ff3auhmdmd1odYfN,Omirldr*theWofa mWlyy Etit mWV"cfDe=a4Wolk $ Rao I aw VNSCSINS ff ANaWAIVE; ;larnmmd attheLicffwdoesnothm anddatmyagramcnthispem tffhcalialwanestt>lclegtmernat (Please check one) Owner Agent Signature of Owner or Agen Lio=Na 6 9T LioaiseNo 3 Dtouless Tel Na - 3 AlTdNa - � y tatltriledbvNfa�sad>t�llsGenetalLaws Telephone No. PERMIT FEE4-7 Iii% CULiMUNVVrAI.l h UP lila DEPAMMENPOMMIK BOARDOFFIREPREVEM ONPA 13 viiu:c�u^seC U11122y���� Permit No.c / �IR12OID r✓ Occupancy & Fees Checked A PPLICATION FOR PERMIT' Vt,THE ERFORMELECTRICALWODIV ALL WORK TO BE PERFORMED IN ACCORDANCE WITM SSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 ` Q (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Dat / Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical wor escribed below. Location (Street & Number) Owner or Tenant Owner's Address S O, Is this permit in conjunction with a building permit: Yes [EINo (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps /Volts Overhead Underground No. of Meters New Service Amps Volts Overhead Underground No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work W irl- An -r- S Asvh mo^ No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total No. of Lighting Fixtures Swimming Pool Above 1 1 Below ^ I Generators KVA omnnd o Ilnd 1 1 No. of Receptacle Outlets L I No. of Oil Burners I No. of Emergency Lighting Battery Units of Ranges of Disposs of Dishwa of Dryers of Water Heaters KW Hydro Massage ag No. of Air Cond. No. of Heat Total Pumps . Tons Space Area Heating Total FIRE ALARMS No. of Zones Tons No. of Detection and Tew KW Initiating Devices No. of Sounding Devices KW No. of Self Contained Detection/Sounding Devices Local Municipal Other KW Connections . of alat . YES NO 0 ffycuhavec rdkedYES,pleaseindraI drtypeofeo%wVby EkpimfimD* Es1im*dV"ofEhWcdWak $ Final .�S� // l%rfts. �1P3� WNER'SINS[,DRANCEWAIV T IanawmdxttheLiaemedoesmthm and that my 4natilte on this peunR ffbcatim waives dis requirement (Please check one) Owner M Agent signature of Owner Of Agent Uc=Na Limm?,o E-- 3 DUNII]M'ICL AU I L- 3 AkTdNa y rearmedbvMassadwMtxn WLaws Telephone No. PERMrr FEE,&-� r 0 Date... 4k....a; - ..... 7 .....2oo..p_....... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that Al ............. has permission for gas installation ...... in the buildings of ........................... at ......... North Andover, Mass. Feie2n.*. Lic. No........... ......... GAS INS, OR Check # =*9 MASSACHUSETTS UNIFORM APPUCATON FOR PERN Ur TO DO GAS FTWING (Type or print) NORTH ANDOVER, MASSACHUSETTS - v 2 Building Locations ©Z 5 ��91 �-� Q f Permit # �� V Amount $ . Owners Name T y) i j New Renovation Replacement [:] Plans Submitted (Print ortype j CA* one: Certificate Installing Company Name k ! LJ Corp. Address 35 -e o 1,_ 0 `l J 14ycf D (LA Cc,k,;h a Partner. .v1iA- GId-24 Business Telephone _ CT �° s / j� Firm/CO. Name of Licensed Plumber or Gas Fitter 2 rA JAJ K Pot V. ) kLi INSURANCE COVERAGE Check one: I have a current liability 19surance policy or it's substantial equivalent. Yes No If you have checked yes,rle the type coverage by checking the appropriate box Liability insurance policyOther type of indemnity 13 13 13 Passer's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the . General Laws, and that my signature on this permit application waives this requirement. ICheck one: ❑ � Bignature of Owner or Owner's Agent Owner ❑ 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 Gas CoqOe-sand Chapter 142 of the General Laws. ICity/Town (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter ® Plumber $94 i �l 0 Gas Fitter License Number ® Master rl Journeyman — (Print ortype j CA* one: Certificate Installing Company Name k ! LJ Corp. Address 35 -e o 1,_ 0 `l J 14ycf D (LA Cc,k,;h a Partner. .v1iA- GId-24 Business Telephone _ CT �° s / j� Firm/CO. Name of Licensed Plumber or Gas Fitter 2 rA JAJ K Pot V. ) kLi INSURANCE COVERAGE Check one: I have a current liability 19surance policy or it's substantial equivalent. Yes No If you have checked yes,rle the type coverage by checking the appropriate box Liability insurance policyOther type of indemnity 13 13 13 Passer's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the . General Laws, and that my signature on this permit application waives this requirement. ICheck one: ❑ � Bignature of Owner or Owner's Agent Owner ❑ 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 Gas CoqOe-sand Chapter 142 of the General Laws. ICity/Town (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter ® Plumber $94 i �l 0 Gas Fitter License Number ® Master rl Journeyman