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Commonwealth of Massachusetts
City/Town of NORTH ANDOVER, MASSACHUSETTS
System Pumping Record
Form 4 R 15- 1 V D
DEP has provided this form for use by local Boards of Health. he S�Wrn-FP$i4U'11111114 Rec rd must
be submitted to the local Board of Health or other approving a thority.
TaAIN OF NORTH ANDOVER"I
A. Facility Information HEALTH DEPARTMENT
1.
J] L/
Alress . A
I Inv(
Cityrrown
2. System OWner:
0
Name
AA0 - -
State
Address (if different from location)
City/Town State
Telephone Number
B. Pumping Record
1. - Date of Pumping Date 2. Quantity Pumped
3. Jype of system: El Cesspool(s) [T Septic Tank
Other (describe),
4. Effluent Tee Filter present? Yes [] No
5. Condition of System:
Zip Code
Zip Code
Gallons
Tight Tank
If ye's','Was it cleaned? [I Yes [I No
6. System Pumped B -
#? /A r
"e Vehicle License Number
Company
7. Loption where contents were disposed:
Q CAJ (t r-15' dU ,,So(
tl`gnifure of Hauldr- bate
http:/twww.mass.gov/dep/water/approvalstt5forms.htm#inspect
t5form4.doc- 06/03
System Pumping Record - Page 1 of 1
89.74
I
Date. 5 /.;, 0 / /!
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING.
..............
This certifies that ..... P it. . % (—
has permission to perform ... /3". 1 1, e4,7 ..........
plumbing in the buildings of .... 1—C. �1 ..............
at I-) - (I - �-) ...... S. -7c ..... ...... North Andover, Mass.
4d 5 --CP . . Lie. No. JPI.�.�— . ... . .
PLUMBING INSPECTOR
Check # R �3 3,,2 -
MASSACHUSETTS UNIFORM APPLICAT]ON FOR PERMIT TO DO PLUMBING
% J, JVrW, Us 11 5 &US)
Bunftg Lvc�tion_ Ftmh #
L a ^�a
-a ownm NaMe CL -
New 0 A�enovzflon 0 Rcpbcemtnt Plaw SAmitted 0
A P*
Flxnjjzts oA
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Nam_iLl i a4l-d P Q 4 t,.-) C- Qgp.
ingauing compaw
L a 0
Addmss
11 0 [3 rom/co
Businm WeDboat
Ron,3, i
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�isty bw m -m p-wiq [)A)tba Vp of bxkms*
Insurajoct Walver. =&miviA bm b= ma& swm tW ft liceinm of tbb appUcation does not bm my one of
the above dree man= cove'83M
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ingauing compaw
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Businm WeDboat
Ron,3, i
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lmsprsiDct,CQ_ycr2rCi WcOlt thc'I)W Of hswm= cOvmgt bY cbtddn %c mWW'�k*W
�isty bw m -m p-wiq [)A)tba Vp of bxkms*
Insurajoct Walver. =&miviA bm b= ma& swm tW ft liceinm of tbb appUcation does not bm my one of
the above dree man= cove'83M
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sismat= Qf.0wm&&w of isap"
jf.,.bjwVytmlsldtw*A*%wWblb-wb , i btakoddeNlow big, pvd.tiddpbdftwkwdl a
s0.*wWOm*lQdtmGwwdLm.m
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APPROVED (a�yJCE USE.ONLY)
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TlieCoiiiFizoiiiieelitizofillassetclitisetts
Department ofIndristrialAccidents
Office of Investigations
600 T-Vashington Sh-eel
-�7
Boston, M4 02111
IM111knuiss-govIdia
Workers' Compensation Insulance Affidavit: Builders/Coiitractors/Electriciaiis/Plumbers
Applicant Information
Please Pri it Legibly
Name (Business.;'Orp
,anizadonandixidual):
Address:
City/Statolzip:
gMrLi Pholie 9: M
z"�-`
T-Scs-
Are you an employee. Check- the appropriate box: I .
1. CAI am a employer -,-.itli +
4. El I iim a general contractor and I
Type of project (required):
employees (full audfor part-time).*
2. 1 am a sole proprietor or partner-
have hired the sub -contractors
listed on the attached sheet-
6. El Nle--%, consta-uction.
7. CJ Remodeliniz
ship and have no employees
These sub-contractois have
8. E] Demolition
working for me in any capacity.
employees and have xvorkers�
Nfo Avorkers' comp. insurance
comp. insurance.*+
9. n Building addition
required-]
I am a homeowner doing
5. EJ We are a corporation and its
officers have
10.[] Electrical repairs or additions
all work
myself (No workers' comp.
exercised their
right Of exemption per1MGL
I I n Plumbing repairs or additions
insurance requ ired.]
c. 152, §1(4), and we have no
12.F] Roof repairs
employees- Filo workers'
13.E] Other
surance renpi--,j I
*Any applicant that checks box #1 t
-1 must also fill out the section below showing their WOrkeW compensation policy infonnation.
Homeowners who submit this affidavit indiaging they are doing all Work and then hire
�Contractors that check- this bo.-, aua I an a
outside contractors must submit a new affidavill. indicating such.
employees. If the sub ,, -1 stat %vhether or not those entities have,
must Cl ed dditional sheet showing the name or the subcontMctor, nd e
-contractors Iraxre ernPfoyees� they must provide their workers' cOmP. Poliev number.
A 'alli
all ej"Ploy" t1lat is PrOvilUng morkets' conipeitsaliolt 111silrallcefor, Illy
inforlization. ellzPloveem Belon, is the PONT andiob site
Insumce Company Name: 7�-/-& .
-7 -D,
Policy # or Self-ins._LLc_
46�
Expiration Date- z
/15 , -12
Job Site Address:
Attach a copy of the -,vorlters. compensation pol, City/State/Zip: -
Failure to secure coverage as required under cy declaration page (showing the policy number and expirauuiLL
-year imprisomn
fine up to $1,500.00 and/or one Section 25A Of M-fGL c. 152 can lead to the imposition of criminal penalties of a
of up to $250.00 a day against the violator ent' as X't'ell as Civil Penalties in the form of a STOP WORK ORDER and a ne
Investigations of the DIA for insurance coverage verification. of fi
Be advised that a copy of this statement may be fonvarded to the'Office
I do hereby cerd-fY Under the pahis tuidpen allies ofpeoFirry that the i"f0l"I'aflon pro vided above is trite and correct.
cl:--- _0 . ,, f, I I - - a - — —
Official use only. Do 'lot '"ite ill this area, to he completedby city 0)- tti, * , , -
1,1Z official
City or Town:
Permitfr;� U
Issuing Authorfty (circle one): exase
1. Board of Health ;k., B41
h01I!9-,JDJeA-4r-tAent..3, City/Tolyn cje,4!.7 4.zF!eC.t1.jC,1l
6. (Ai�e'r InTeCtOr 5. Plumbing Inspector
r -
Contact Person:
Phone #:
17 -------------
IN PLUMBERS AND GASFITTERS
LICENSED AS A MASTER PLUM
BER.
�.RQNALD L HILLARD
.-..147 FARLEY RD
HOLLIS NH 03049-591 8
11485, 05/01/12 776008'
c" 0., tv! F
ll� ;LUMBERS-A-ND'-GASFITTEkS
REGISTERED AS A PLUMBING CORF!'
ISSUES THIS LICENSE TO -
-RONALD L HILLARD
I L LARD PLB & HTG 1KC
25 STEDMAN ST
N I T 17
LOWELL MA 01-851-2792:
05/01/12 754086-"
�0'1 0 1 0 3
.7&
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ................................. .............................
has permission to perform ...... ........
.... ..................
wiring in the building of .... ........ . ........................................
at .......... ................. . North Andover s.
Fee .... .......... . ..... ..........
.... ......... Lic. No# X'11Z .......
ELECTRICAL NSPECTOR
Check #
d,
(fllmmonwealth -/ VaddacAudeltj Official Use Only
Permit No. It, ;;K
Apartment -I Jim serviced r1it
Occupancy and Fee Checked
fRev. 1/07
BOARD OF FIRE PREVENTION REGULATIONS F) (Leave bla.k)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00
(PLE'4SE PPJNT IN INK OR TYPE ALL INFORAM TIoN) Date: 6-
CityorTownof- Alo"�i-), I�Aldkoelelz
By this application the undersig To the Inspector of Wires:
ned gives notice or his or her intention to perform the electrical work described below.
6 tz e
Location (Street &,Number) 1?, 63 �z -
Owner or Tenant S o /V Telephone
Owner's Address No. 9 7- -Z S? b - (,S& 7
Is. this permit in conjunction with a building permit? Yes El No (Check Appropriate Box)
Purpose of Building_ LJ c. /'/V Utility Authorization No.
Existing Service Am s
p Volts OverheadEl UndgrdE] No. of �Mefers
aew M.Service Amps —Volts OverheadEl UndgrdE] No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: (ol
Com leti n o theJ6116win table may be waived b the Ins ector ol"Wires.
!No. of Recessed Luminaires No. of �Ceitl.-Susp. IP�addlel F�ams ------ . No. of Total
V ' "c
'-Su'p* Transformers KVA
No. of Luminaire Outlets No. of 110 Tubs lGenerators KVA----, I
1101tTubs
INo. of Luminaires
No. of Receptacle Outlets
No. of Switches
No. of Ranges
No. of Waste Disposers
No. of Dishwashers
No. of Dryers
'IV. UX Water
Heaters KW
No. Hydromassage Bathtubs
OTHER:
Swimming Pool Al
gr
No. of Oil Burners
No. of Gas Burners
No. of Air Cond.
ffe-aTPu`m`pT.—Numb,
Space/Area Heating KW�
Heating Appliances
Mattery Units
- r
FIRE ALARMS No. of Zones
No. of "Detection Tand
Initiatin Devices
No. of Alerting Devices
No. OFSelf-Contained
Detection/Alerting Devices
E] Municipal
Local Cnnnorfin. Elpeei
No. of Del
Data Wiring.
No. of Dei
0. of Motors cI2!2Lup ITelecoi
No.
or
or
ins
or
— '7
Estimated Value of Electrical Work: 4 ttach additional detail y desired, or as required by the i7,pecto, of �Ir
Work to Start: - (When required by municipal policy.)
Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE C6VERAGE. Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "Completed operation" coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force, and has exhibited proof of same to the pen -nit issuing office.
CHECK ONE: INSURANCE P9 BONDE] OTHER
I certify, under thepains andpenalties ofperjury, that the 2nf,,r'm'per-4-:' -h' ation is true
FIRM N AME: -Castle Electric, Inc.
y
r ha
I
t t e n
f
or
m
p
a
ec hi i 'io ru
'K
t ap, t c
N
g 26
n 0 f
Licensee: c NO.: AT 6191
IC No..
0 - 1
Str rill s L el. . �8
1. o..
James R. Prescott Si gnatur LIC.NO.. 26186E
(Yapplicable, enter "exempt " in the license number line) Bu -T
Address: B"J1daCr.#21, Eadigott ' r Buy. Tel. No.:- 7 8 1 - 7 6 2 -9-8 9 1
'treet r ood,MA 02062 Alt. Tel. No.:.
re p f ic S f " ' - �i No.
*Per M.G.L. c. 147, s. 57-6 1, security work requires Depa t of Public Safety "S" License: Lic. No.
OWNER'S INSURANCE WAIVER: I am aware that t icensee does not have the Iliability insurance coverage normally
required by law. BY my signature below, I hereby waive this requirement. I am the (check one) -
Owner/Agent Elowner [lowner'sagent.
Signature Telephone No._ PERMITFEE. $-?0,.00
The Commonwealth, ofMassachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov1dia.
WorkeW Compensation Insurance Affidavit: ]3uilders/Contractors/Electricians/Plumbers
Applicant Iliforination Please Print Leaffily
7- o c
Name (BusiTiess/c)rganiza�on4ndividual): If'C-7ZI'l
Address: Ic
_Y/
C
city/state/zip:
LP d 6—,A Phone 4:
--;76F1 - 7 4 _;� — �7'(ff j
Are you an employer? dheck the appropriate box:
1 - I am a employer with
4.7 1 am a general contractor and I
employees (full and/or part-time).
2. E] I am a sole proprietor or trier-
have hired the sub -contractors
listed t
pal
on the attached sheet
ship and bave no employees.,
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. El We are a corporation and its
required.] N
3. 1 -am a homeowner
officers have exercised their
doing- 01 work
right of exemption per 1\4GL
myself [No workers' comp.
c. 152, § 1(4), and we have no
insurancerequired,] t
employees. [No workers'
W A Z
comp. insurance required.]
Type of project (required):
6. New construction
7. Remodeling
8. F1 Demolition
9. F� Building addition
.10. 7 Electrical repairs or additions
I l.* F� Plumbing repairs or add itions
12.E] Ro of repairs
13.7 Other
uUA �L MUSL also I", out Me section below showing their workers' compensation policy information.
t Homeowners who submitthir affidavit indicating they art doing all work and then hire outside contractors must submit a new affidavit indicating such.
lContraefors that check this box must attached, an additional sheet showing the name of the sub -contractors and their workers' comp, policy informatun.
Iam an employer that isproviding workers' compensation insurancefor my employees. Below is thepol!Q7 andjohgite
information.
Insurance Company Name.. Guard Insurance Grou p
Policy # or Self-ins.Lic.#: CAWC033404
*R1 iration Date: 6/7/2011
ob Site Address: -2- �3 0_R e- s J. -e/Zip
City/Stat 19A)dayee 1'119
Attach a copy of tne workers' compensation po*Hcy declaration page (iihowing the policy numher and expiration datel.
Failure to secure.coverage as required under Section 25A 'of MGL c. 152 ran lead to the imposition of criminal penalties of'a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the Form of a STOP WORK, ORDER and a fine
of up to $250.0.0 a day against the violator, Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for misurancr, coveragq verification.
I do hereby
and penalto yfperjury that the information provided above is true and correct.
Off Icial Wse o n ly. 1) o n o t write in th is a rea, to b e eom� lete d by city o r to wn offi cia I
City or Town:
Permit/License #
Issuing Authority (circle one):
I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone#:
NORTH ANDOVER
SYSTEM P
UMPING RECORD
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QUAMW
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GALL
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TANIC: NO
YES
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40
7 Wmi EMERGENCY
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T.
OD,
CONDITION
HEAVY GREASE, FULL'TO COVER
13AFFLES IN PLACE
ROOTS
LUCHFIELD RUNBACK
SWE SOLIDS
FLOODED
S. CARRYOVER
""NNE -WNW. OTHER (EXPLAIN)
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Commonwealth of Massachusetts EIVED
ri:CEIVED
5 1]
4
City/Town of Nm+
o440OVER
System Pumping Record OVER
m T
ENW
DU�,"'RTME
Facility Information:
System Location:
J1 0.
Address
aw 0
q
City/Town State Zip Code
System Owner:
Name:
Adress (if different from location of pump)
City/Town State Zip Code
OFX_ 556 - 6
Telephone Number
Pumping Record
Date of Pumping A �(t) -Quantity Pumped /I M6 Prallons
Type of System_)�_Septic Tank____Grease Trap_Other (what)
System Pumped by: In
J K /U0
Company: ROOTER -MAN 46 Portland Street Lawrence, MA 0 1843
Location where contents were disposed:
A 4
Signature of Hauler -O - -D, Alk"Le Date A&W