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Miscellaneous - 251 GRANVILLE LANE 4/30/2018
Location No. Date TOWN OF NORTH ANDOVER o a Certificate of Occupancy $ ��s'"•°''t�' Building/Frame /Frame Permit Fee $ /0• <<' s�CHust 9 r Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # • rt / ( ;C— L' Building Inspecto( . TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: l" DATE ISSUED: (p SIGNATURE: rcv—�� Building Commissioner/12ffor of Buildin Date SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: P-- I Map Number Parcel Number Jt It t N c l 11 1.3 Zoning Information: Zoning Dis rk—t Proposed Use 1.4 Property Dimensions: Lot Area (so Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: Public ❑ Private 0 Zone Outside Flood Zone 0 1.8 Sewerage Disposal System: Municipal 0 On Site Disposal System 0 SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record est e- ame (Print) Address for Service: �J 7 0' 2 Signature Telephone V10 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Licensed Construction Supervisor: Address Signature Telephone Not Applicable ❑ License Number Expiration Date 3.2 Registered Home Improvement Contractor Not Applicable 0 Company Name Registration Number Address Expiration Date Signature Telephone 00 rn X Z O I 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 .......❑ No ....... ❑ SECTION 5 Description of Proposed Work check all applicable) ' New Construction ❑ 1 Existing Building Repair(s) ❑ Alterations(s) Addition ❑ Accessory Bldg. ❑ I Demolition ❑ ( Other ❑ Specify j3rief Description of Proposed Work: �u x 1'k k -e' 4 I SECTION 6 - ESTIMATED CONSTRUCTION COSTS I Item Estimated Cost (Dollar) to be Completed by permit applicant OFFICIAL US Y 1. Building A°as (a) Building Permit Fee Multiplier /69 Y60 = 3 4 D a x 2 Co > rla ©o, — 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) 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 I .2 0 y a 0 = '100 k Ja S,4 = �� f d t) e7 , as Owner/Authorized Agent of subject property 73 _ Hereby authorize /oZ Y 80 .3`O � � &� � sa1.5" a a _ 0 0 �' �0 � ` r to ,act on t2 g My behalf, in all matters relative to work authorized by this bidding permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, ��'rJ 31ia 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 of I/" Date ' NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 ST 2 3 RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DtIvIENSIONS 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 1 FORM U - LOT RELEASE FORM N la.y3o �(Visk A` • INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. PLICANT FILLS OUT THIS SECTION v v APPLICANT_ 41 PHONE_q— LOCATION: Assessor's Map Number PARCEL SUBDIVISION LOT (S) STREET 4o'Ga v• 1/% I—ea ST. NUMBER 2 *****************************************OFFICIAL USE ONLY*********************************** I RE99MMENDATW OF TOWN AGENTS: . —4 CONSERVATION COMM COMM FOOD INSPECTOR -HEALTH EPTIC INSPECTOR - TOR DATE APPROVED f DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED COMMENTS s re PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTO Revised 9\97 jm +-V 01., L,( &,tzj�, 11a-lt 0 DATE � /I 6ewl&- T 2x, Tl� - s. 'W*V N,e'Lt� aN d- 0 Lm0 �, - -r----- -- - -- -- {'' - ---- .. ..- -- - FORM U LOT RELEASE FORM IaV3o � ,5k iaffcL � ao�.a� RAwRN1 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. t *****************************APPLICANT FILLS OUT THIS SECTION***********************`a� Z APPLICANT A LOCATION: Assessor's Map Number. PHONE q" PARCEL SUBDIVISION LOT (S) STREET �5�''�s. v• �I� L-�e�. ST. NUMBER_Z *****************************************OFFICIAL USE RECOMMENDATIONS OF TOWN AGENTS: CONSERVATION ADMINISTRATOR DATE APPROVED DATE REJECTED COMMENTS TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD INSPECTOR -HEALTH DATE APPROVED DATE REJECTED §EPTIC INSPECTOR -HEALTH DATE APPROVED DATE REJECTED COMMENTS PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTO Revised 9\97 jm DATE o v, 0 e") 02 wI, /23/99 04:28 FAX 978 521 0951 ✓� 8orrmw FRW CR1I37IAt1 DotlONTY _ ._—_-•— P�?Pprrypoy°°t 251-CRANVILL!-LAW Qty KORTII ANDWEA ..— .•.._.__ .._ .... _... RBLO PORT APPRSL ['t. ose� . U' wuJi4.u'.�6 wry' ^.'•� . Lj;-at—� �i�p11G Z 1 r'.rat.rJdt (``r{ rJatXNlw---- AOPCt�'S5 = r: Ati . dOtJ0.GE , f`, • �.• � ' S7AYrr C�D9�t I i�FF+• �_�k Lf 3 ? xo%fi` ,y wy1nM \Y�4 Yycl Crl � .t .• ..-. ,ter � ;rte.: .: � • .. "–. � •:: \kn Cor: �„� • . X43=•-. • `';'•- v i rpt "w • - .., : .moi � .. .._ �,. _ . _ tl,a _.j-rn! CEII4IYIC g r.;;• �• r.YGi`!BY 7 cs�l � I CYIKIPY sSscthfiTAI. i 98tH: 5K. L t6� ?.49 a t4at t i Gwti�trJ� Wttu_rt�E • �roiitnt GLBT. 0.r+ tltL': • —�— ri. QN bt lRoberc G. Gwdwia •sh. 7rs-oo[ eopt¢s[ead Laad 6iuww not u. rlthsarrw5'looa n"orderlrJC4�nIPEL+sbj`.7w..Cr�::_. -,� �7fi"•+' Ardnvrr,MA01810 ••• • •^ "'• •a te• (5031 '1040 _--J.•---� . woo OOtA 0? -22-1999 04:17PM 9?8 521 0931 P.06 1' a�.l�A.a1A.A. 1_2. -■ A� ��■ ^ A-a�—��w�� dpi TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMy�OLISH A ONE OR TWO FAMILY 1 _w BUILDING PERMIT NUMBER:� DATE ISSUED: SIGNATURE: Building Commissioner/Inspector of Buildings Date 1 -.AWT J1N,C.11V1V 1-J11G ll�i`va�t�at�aavi. 1.2 Assessors Map and Parcel Number: 1.1 Property Address: C) Map Number Parcel Number J ��� asI cr�z�„ 11� . 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided R aired Provided 1.5. Flood Zone Infomntion: 1.7 Water Supply M.G.L.C.40. 5 54) Zone outside Flood Zone 0 1.8 Sewerage Disposal System: Municipal 0 On Site Disposal System 0 Public 0 Private 0 SECTION 2 - PROPERTY OWNERSHIPIAUTHORIZED AGENT 2.1 Owner of Record �/ 7®k 2s-/ ���� ►,� ii 4,t� ame (Print) Address for Service 7 �, 6/12 —f^C / Signature Telephone .2 Owner of Record: gig Name Print Address for Service: Signature Tele hone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: License Number Address Expiration Date Signature Telephone 3.2 Registered Home Improvement Contractor Not Applicable 0 Company Name Registration Number Address Expiration Date c:,..,. fi— Telephone T M X Z O D. Robert Nicetta Building Commissioner (978) 688-9545 (978) 688-9542 Fax Town of North Andover Building Department 27 Charles Street North Andover, MA. 01845 HOMEOWNER LICENSE EXEMPTION Please print / DATE 4//;? JOB LOCATION Number Street Address HOMEOWNER Name - U &Rome Phone 4612--sC�/ RESENT MAILING ADDRESS Map / lot Work Phone & /e �✓ ' it d,.G� ��- D ! �.J� 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 -W.. 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: Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is irrtended 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 homeawner. 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 ( A&--- " — . Ifr"Mfifi I I --I AT r%r"l rl A ^r' r-O%r%s A Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the;retum key. Commonwealth of Massachusetts City/Town of System Pumping Record Form 4 RECEIVED OCT 2 4 2006 . TOWN OF NORTH ANDOVER HEALTH DEPARTMENT DEP has provided this form for use by local Boards of Health. The System Pumping Record must be submitted to the local Board of Health or other approving authority. . A. Facility Information 1. System ovation: '0' Address City/Town State 2. System Owner: Name Address (if different from location) City/Town Zip Code ware ) Zi ,ode a -r Telephone Number B. Pumping Record 1. Date of Pumping Date - 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes 04.0 Ifes w y as It cleaned? ❑ Yes ❑ No 5. Condition Elys c 6. System Pu pe By. r"1 ! :Name �`e^^Vehicle License Number Company��— .7. Locatioq^ere coP!nts w jadispo^ Date h.ftp://www.mass-gov/dep/`witer�/appr'ovals/t5forms.htm#inspect t5form4.doc• 06103 System Pumping Record • Page 1 of 1 TOWN OF P- SYSTEM Pl DATE: `, SYSTEM OWNER & ADDRESS Do'�kt a� n�c,/Au� (A, -- L1/1111/ L1/111-✓ ING RECORD SYSTEM LOCATION (example: left front of house) 0 V - 2 2004 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT DATE OF PUMPING: C- y QUANTITY PUMPED: C - V GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: coNTENTs TRANsFERRED To: G.L.S.D Lowell Waste ARGEO PAUL CELLUCCI Governor COMMOINWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET. BOSTON biA 02108 (617) 292-5500 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION -V�' '7.7 IC -1 r ED JN I 1 R) EA LTH Property Address: 2 S Name of Owner A �V t✓ �'� h a v l �� N (l/� (I ��Address of Owner: fl v Date of Inspection: �j(� �� j �, v -Do V C 1� , � M 9 SS, o Name of Inspector: (Please Print) v 2'+' I am a DEP approved system inspector pursuant to Section 15.340 of Tide 5 (310 CMR 15.000) Company Name: fl 0 U !/_ PteSc- 0 —rI C_ Mailing Address: L,/ "J A/L.. 12,0W)o 5 W - Telephone Number: TRUDY C0XE Secretary DAVID B. STRUHS Commissioner CERTIFICATION STATEMENT 1 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 ' e tion. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sew disposal systems. The system: _ Passes _ Conditionally Passes 1 _ Needs Furth i valuation By the Local Approving Authority _ fails J� Inspector's Signature: Date: 7— The The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty (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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. . NOTES AND COMMENTS revised 9/2/98 Page 1 of 11 40 Prmied or Recycird Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A �''i CERTIFICATION (continued) 'roperty A dress,: ' 51l�- l� l N (/I l/ e 4 1i Al C A& lid l !P v V e r , Jwner: �f Vh14 W Date of Inspecrnon: 6 „ ll r 9 ! INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: ✓ �S I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. SYSTEM CONDITIONALLY PASSES: �/ A 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. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not. _ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Board of Health). broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four 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 obstruction is removed revised 9/2/98 Page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A „ CERTIFICATION (contirwed) {` Property Address: 2 L_—rl R K/ V/ I c /J tJ C Ivo P0 fl A/ D o v e 2 (fit Owner: F4M 4 W T Date of Inspectiony, y 7— Q C� C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: / Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and 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 THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER revised 9/2/98 Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) i Property Address: S'/ 9 F q nl t) l l % NC No I? 4 fi tv D o u t Owner: I Date of Inspection: r 9 p D. SYSTEM FAILS: P( ,A You must indicate either "Yes" or "No" to each of the following: 1 have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility- or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or' available volume is less than 1l2 day flow. 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: H.A. You must indicate either "Yes" or "No" to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400'feet of .a surface drinking, Water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area - IWPA) or a mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 2 -5 W ✓ 1 d 'f N/ D G CL, Owner: Date of Inspectio�i Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: YVIII, No Pumping information was provided by the owner, occupant, or Board of Health. _ None of the system components have been pumped for at least two weeks and -the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. _ — As built plans have been obtained and examined. Note if they are not available with N/A. TheJacility or dwelling was inspected for signs of sewage back-up. _ The system does not receive non -sanitary or industrial waste flow. The site was inspected for signs of breakout. All system components, excluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: _ Existing information. For example, Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) / [15.302(3)(b)1 The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance -of SubSurface Disposal s p Systems. s. ,, revised 9/2/98 Page 5 of 11 O .y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION 'roperty Address: -2 3'1 CFh "V Owner: f�' /} 1/ 114 A Al Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: g.p.d.lbedroo Number of bedrooms (design): G¢ Number of bedrooms (actual):_ Total DESIGN flow Number of current residents: kt- Garbage grinder (yes or no):_Y" Laundry (separate system) lyes or no):,h/-; If yes, separate inspection required Laundry system inspected (e or no) Seasonal use (yes or noir• Water meter readings, ifavai able (last two year's usage (gpd): Sump Pump (yes or no):V Last date of occupancy:_) ON Pie COMMERCIAL/INDUSTRIALc- 14 Type of establishment: fir' Design flow: gpd ( Based on 15.203) Basis of design flow Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non -sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: `� A c System pumped as part of inspection: (yes or no) �( P3 If yes, volume pumped: a0 gallons T Reason for pumping: TYPE OF STEM 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) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site: (yes or no) 2'Z�- revised 9/2/98 Page 6ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C .�y (( ,/ /SfYSTEM INFORMATION (continued) u ,,/ �`� 'roperty Address: G (;"R 17 Al V (/ 4 lV C /1/A �� 1 /V ✓ G V Owner: Y Date of Inspection: ds p &— ( / TIGHT OR HOLDING TANK (Tank must be pumped prior to, or at time of, inspection) (locate on site plan) ` Depth below grade:_ Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm present Alarm level: Alarm in working order: Yes _ No_ Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches`, etcT DISTRIBUTION BOX: (locate on site plan) T / Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) PUMP CHAMBER:_ (locate on site plan) Pumps in working order: (Yes or No) Alarms in working order (Yes or No) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) revised 9/2/98 Page 8ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) `'v erty Address: .2-jif �C t✓C /�D + Al O VC tc Date of Inspection: � Ij' 7 - SOIL ABSORPTION SYSTEM (SAS): l/p S (locate on site plan, if possible; excavation not required, location may be approximated by non -intrusive methods) If not located, explain: Type: leaching pits, number:_ leaching chambers, number:_ leaching galleries, number:_ leaching trenches, number, length: leaching fields, number, dimensions: L Nr' DV X 1 overflow cesspool, number:_ Alternative system: r \ Name of Tephnology:•:r { r Comments: (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.) ,*-' 1-/ C /'e wl f,Jl-� CESSPOOLS: (locate on site plan) 7{// Number and configuration: Depth -top of liquid to inlet invert: ipth of solids layer: epth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: _ (locate on site plan) 4; Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) revised 9/2/98 Page 9oftt Li SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM] INFORMATION (continued) 'roperty Address: 5/ (;'/ N V lwner: Date of Inspection: ' , j � / M�,� SKETCH OF SEWAGE DISPOSAL SYSTEM: ti include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) revised 9/2/98 Page 10 of 11 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) operty Address: ,' L..1� 1 0,?,y qj /? N /� -� �f f1,�s'1�, U Vc ��- Jwner: k a 41 p N Date of Inspection: NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth td; Groundwater Please indicate all the methods used to determine High Groundwater Elevation: 1 Obtained from Design Plans on record Observed Site (Abutting property, observation hole, basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators, installers Used USGS Data r Describe how you established the High Groundwater Elevation. (Must be completed) 6 �o At vy revised 9/2/98 Page 11 of 11 d;7/23/99 04:28 FAX 978 821 0931 RBLO MORT APPRSL 1006 oDUG Pmparyr�ress s� vntE -• •---•--..--------._.... caway-Est ._... CityNORtN �►m0Yk7i ... -- ZIP! •01845_—...... _...------- ---- stus MA .------•--_...- -•-- -- _.._ LwWK/Cfiard - ARAN J+��� • �N/+h►•• �, . MOSLTG;1.64R` ILI, wa! atn I ! C jet in •� -7LY E5;S) �a •.t'tnl ,1 CEf1429lC.� - .• .... .? _ i. '• .'�G"ngy_�cc, V �.ibl"AtSsc�O t ahem jser6ad ,•'.-�•�.'•: that tAs E E ltu C•r j Y�:7: WLT�t r E }TdaMt Unit, I CS!iT. C? •FITL�:,r,___— T,•,,_,�, .OT D� Am V Ta•: _.. _ Robert G. Gtsgdwiri nnc l;e vithla�tB Ps¢suredlsadSvnrWc a Cea=gne6ed ? \1t:� �tA7 - l Flood ►lizard A- ti olv:ersc • Et-lwx 9it a616'L, I•A r !last=�- 07-22-1999 04:17PM 978 521 0931 P.06 t t Noteyk Town of North Andover ��°.�+��-ao Building Department &- 27 27 Charles Street North Andover, MA. 01845 D. Robert Nicetta Building Commissioner , (978) 688-9545 °(978) 688-9542 Fax Please print / DATE JOB LOCATION 2� Number "HOMEOWNER Name HOMEOWNER LICENSE EXEMPTION d6-e't..1-7,49-C Go.— oLreeI Accress ome Phone PRESENT MAILING ADDRESS %!5�,-Z liYrtw Le., Z,e— City Town State L — .S' -C F, Map / lot Work apvjl-- i Tip 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 Budding Code Section 108.3.5.1) DEFINITION OF HOMEWOWNER: Person(s) 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 I a N 0 z w. O u o O w v a v o 04 w z cz O w azo O 02 v C U C w 94 w O w -ct C w 9 o a W O u: v J)w" m C a p U w O n: m C w z w x w G co V) o cn am O c c c H n c 13 6 I e�r itm I N - rioa� m S E N m m O mil- L N cm 1 C 1 N A: :yO `C O cm CLU (D ; N m m ♦: C. JZ 0 cm r C I L o N ; m V N O r. I '0 Z . .:coo c yn m c c = m : m 3 N I f- o y mFo- m W C -0 t ui _.s .y = :5 Z LU •b- V co) c 0 V2 = 0--0 O� F- = 0n=m > z 0 w W CD O co z O 0 w CD .y d L CD c 0 CD 0 CL CL CO) 0 V C. CO) c CLO c ev CA 5 LLJ 0 ui CO W w W VJ Location'>) No. Date TOWN OF NORTH ANDOVER F p Certificate of Occupancy $ sCMUs Building/Frame Permit Fee $ 3 Foundation Permit Fee $ Other Permit Fee $ !- TOTAL $ (9 Check # i `} Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVAT OR DEMOLISH A ONE OR TWO FAMILY DWELLING lis ' - BUILDING PERMIT N1 MI3ER:�6�' 7, DATE ISSUED: SIGNATURE: /fi/q /K Building Commissioner/I for of But din Date SECTION 1-SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: 0 C A- J �v Map Number Parcel Number A-N a 1.3 Zoning Information: Zoning DiAric—t Proposed Use 1.4 Property Dimensions: Lot Area (so Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide ReTfired Provided ReqWred Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: Public ❑ Private ❑ Zone Outside Flood Zone ❑ 1.8 Sewerage Disposal System: Municipal ❑ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner ofRecord (� �(.crrS �dl fi�'L/J 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: Licensed Construction Supervisor: t Address Signature Telephone Not Applicable ❑ License Number Expir7�� 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name. Registration Number Address Expiration Date Signature Telephone O Z M 90 O mn r v M r r z G) 0 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 .......❑ No ....... ❑ SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: ClIe SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit applicant OFFICIAL USE ONLY 1. Building (a) Building Permit Fee Multiplier 2 Electrical V (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) 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 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 AGENT DECLARATION Ox I, Ox �� l -Jd 6� ClasOwner/ orized 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 4 7Pp ,,-41r Print Signature of Owner/A ent NO. OF STORIES Date SIZE BASEMENT OR SLAB SIZE OF FLOOR TINIBERS 1ST2 ND 3 RD SPAN DIWNSIONS OF SILLS DIMENSIONS OF POSTS DIIv1Fl.NSIONS 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 of NOK7N, r. Town of North Andover "a Building Department 27 Charles Street North Andover, MA. 01845 �,,°•.,.°.»�{g D. Robert Nicetta Building Commissioner (978) 688-9545 .'(978) 688-9542 Fax HOMEOWNER LICENSE EXEMPTION Plea not DATE JOB LOCATION oLt� l L Number "HOMEOWNE L:�l fsd Name PRESENT MAILING ADDRESS 2 � ( ,.jVvl\e— Street Address LN. "??F-- 6 -1'2 - Home -1'2 - Home Phone 6v -o. ✓ � //, 4-1-1— Map / lot Work Phone City Town State Zip Code The current exemption for "homeowners" was extended to include owner-0ccupied 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: Person(s) 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 OFFIC �;D co M I � ca _I m i N - � -- --- b" � 00 00 "\ A i co w Wo YW <~ � Q Z J LL LU JOCK ~ LL Ll U) LJJ Z J LU cow O Q F- M U IL w O LL LU O n. O F- LU LU J a Q N t t4— 1 eL O c m 3 D 00 0 I "32 LO O � I .. I c liL ,� I I E Y 7 U E `y N c m m L E N m Y_ rn E LO co C O O R CL E cos_ LLErn•>> U- _r C e O o 0 am Im M CN N = m O C U N c N .0 O U) O E ro 0 � c a _ `63a c -0 a CD U 9 c � s (u a) o m w a) c � N U rn m a� U Q (n' a� o a F c m o O m W wp F W O 2 N 0 W W a GO a o w V) � z °z o1G w o w va U w O � a o �: a w a w cii rw U w z c4 c r3. z w a m ° z(U cn Qvn cn LN 0 0 TITv w P4 0 co E 0 Zcr- cm y CD h E O CO)CL O C. COD O C CO2 r�1 L C CO)is02 C CM C G '2 W co 0 co 3� 0D L CLC J � 40 co Z CD CLCA C 0 U) W W W U) • L = N Cm :=o �om D o a y1jr E5 O m �_,¢-t� mS 1 wry PQI441 �c CD V y L O � Z O CM H O O. y = C = o o 3 m. wO IVR r •H O .m CLSO C O O yCD C 0 COD a 0*9 ��=� s o aA*--.mS. LN 0 0 TITv w P4 0 co E 0 Zcr- cm y CD h E O CO)CL O C. COD O C CO2 r�1 L C CO)is02 C CM C G '2 W co 0 co 3� 0D L CLC J � 40 co Z CD CLCA C 0 U) W W W U)