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TOWN OF NORTH A-N]C�OVERSEWAGE DISPOSAL SYSTEM
INSTALLATION CERTIFICATION
if� tha, the Se,,,;age Dspcsal Syste- M �--Ons-,;-Ucte6
The under--gried hertby cert
bv C I on =K,-T�
located at 1—,>-F o r— T --A (L 0
was installed In confcrmance with the North Air-Ic T- 2oard of Hea�th a:;orove--' nlan-
System Desian P--,-,njt - '14 � . -
dated q /9 -with, az acproved zesian
-]-;Is 1 - V.P.
flow of pwlors per day. The mate us(��, vere in con�brmance ihcse
specified on the app�o,�ed plan- the sys-zem was ins:3iled �n accuriance the -Irovi!ions
of 0 C2vjR 15.000, Title 5 and local reguiat;cns, and the final grading a a-re2s
s-ubstantially,with the approved plan. All work- is accurately represemed on the Ass-builh-
w�uch has teen to the Board of
Bed :r-spe-c-ion da'e: /VO7-
Fina.1 :AnsT
installer:
Desizn E
zn2ineer Represserniative
SEC, 4"T -Th` 0�_Melr_
Atlantic Engineering &
Survey Consultants, Inc.
97 Tenney Street — Suite 5
Georgetown, MA 01833
(978)352-7870 — Fax(978)352-9940
SEWAGE DISPOSAL SYSTEM
CERTIFICATE OF COMPLIANCE ADDENDUM
DATE: OC -7- 13 / 2 2 9
SITE LOCATION- ��T c,- ;B (Lbc, r- T-_ A Q__M N A ND>D ) -r--. I -,-
Commonwealth of Massachusetts Form 1255, last revised May 1996, requires that the system
designer for this "Sewage Disposal System" certify that the above system has been installed in
accordance with the provisions of 3 10 CMR 15. 00 (Title 5) and the approved design plans.
Atlantic Engineering & Survey Consultants, Inc. (Atlantic) was not been retained to provide any
construction supervision, inspections, soils analysis or layout relating to the sewage disposal system
and as such has no responsibility express or implied relating to said construction supervision.
Atlantic was hired to perform the following services during the construction phase of this project
and limits certifications to the scope of these services.
1 . Stakeout the comers of the proposed system structures.
2. Provide a project bench mark.
Stakeout any lot lines less than 10 feet from the system.
4. Field locate the as -built septic components and prepare a system as -built showing
the horizontal and vertical locations of the as -built system structures.
5.
31
Atlantic Engineering and Survey Consultants, Inc. and its officers, directors, employees and agents
assumes no professional or financial liability for any erroneous or unsuitable construction related to
the installation of this system for which Atlantic was not providing service.
The issuance of a certificate of compliance by the approving authority shall not be construed as a
w"nty or guaWtee that the system will function as designed.
M. Ralleran, P.E.
DAFi1es-WP\Septic Fonns\SEPTC0MF.)&TD
TOWN OF NORTH ANDOVER
BOARD OF HEALTH
CERTIFICATE OF COMPLIANCE
DATE OF COMPLIANCE:
11/10/99
This is to certify that
the individual subsurface disposal system
constructed (X) or repaired ( )
by
Hutton Construction
at
Lot 5 Brook Farm
has been installed in accordance with the provisions of Title V of the State Sanitary Code
and with the North Andover Board of Health regulations as described in the Design
Approval Site System Permit # 1039 dated 9/9/99.
The Issuance of this certificate shall not be construed as a guarantee that the system will
function satisfactorily.
Board of Health Inspector
AS -BUILT CHECKLIST
LOT NUNMER, STREET NAME
ASSESSORS MAP
& PARCEL NUMBER
LOT LINES & LOCATION OF DWELLENGS
LOCATION & DElvfENS!ONS OF SYSTEM,
INCLUDING RESERVE
TIES TO LOT LINES & DWELLENG, WELLS
a. FROM SEPTIC TANK
b. FROM LEACH AREA
LOCATIONS OF DEEP HOLES & PERC
TESTS
I
ELEVA'TIONS OF DI SPOSAL SYSTEM
TOP OF FDN ELEVATION
LOCATIONS OF WELLS, DRAINS, WATERCOURSES
W/TIN 150' OF SYSTEM
LOCATION OF WATER, -GAS, ELECTRIC LINES, CABLE
DISTANCES FROM CORNERS OF HOUSE TO CENTER OF
TANK & D -BOX
STANT & SIGNATURE
2vfPERVIOUSl AREAS - DRIVEWAYS, ETC.
t1l
NORTH ARRO, W
FINAL CONTO U-RS
LOCATION & ELEVATION OF BENICHI�� USED
LOCUS PLAIN
Applicant , Qm'-6 Test No
Site L ocation Lo 1— --; Sy -m)
Reference Plans and Specs. � -\ r)-'V"—� /Az
ENGINEER DESIGN DATE
Permission is granted for an individual soil absorption sewage disposal system to be installed
in accordance with regulations of Board of Health.
4'
Fee - 1
la-'4�
CHAIRMAN, BOARD OF HEALTH
Site System Permit No. �Q '-� 9
Town of North Andover, Massachusetts Form No. 2
I&OWNt
BOARD OF HEALTH
///-19
0
#-
DESIGN APPROVAL FOR
A.
CHU
SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM
Applicant , Qm'-6 Test No
Site L ocation Lo 1— --; Sy -m)
Reference Plans and Specs. � -\ r)-'V"—� /Az
ENGINEER DESIGN DATE
Permission is granted for an individual soil absorption sewage disposal system to be installed
in accordance with regulations of Board of Health.
4'
Fee - 1
la-'4�
CHAIRMAN, BOARD OF HEALTH
Site System Permit No. �Q '-� 9
SEPTIC PLAN SUBMITTAL FORM
LOCATION: Z_07j- �m&e25/0
NEW PLANS: YES
REVISED PLANS: (��S
$125.00/Plan
$ 60.00/Plan
SITE EVALUATION FORMS INCLUDED: YES
DATE:.
19
DESIGN ENGINEER. 19')a/lIr? 1z1a111e1455L1?
DATE TO CONSULTANT:
*If you want your plans expedited, please submit four plans and included a stamped
envelope with the correct amount of postage to mail plans to Port Engineering.
When the submission is all in place, route to the Health Secretary.
FORM 3A - CERTMCATE OF COMPLIANCE
No. Fse
COMMONWEALTH OF MASSACHUSETTS
Board of Health, VA � (1 N)__C) a a MA.
CERTIFICATE OF COMPLIANCE
Description of Work: 0 -Individual Component(s) - XCornplete- System.
Th6.undersigned hereby certify jhat the Sewage Disposal Systevn;
Constructed Repaired Upgraded (),Abandoned 0.
b�:
at- G -x C - -
.has been installed in accordance with the provisions of 3 1 a CMR 15.00 (rill, 5) and the
approved design planslas-built plans relating to application No.
dated-,_ 9 A 121 Approved Design Flow_Z:��6. (gpd)
Designer: �L —inspectbr
Date— OC'7�c+_�3i
The Issuance of this permit shall not be construed as a g6arantee that the system -will,
function -as designed.
DIP APPROVED FORM $196 ,
I
[Click here and type address]
facsfinile trammittal
To: Martin Halleran
From: Susan Ford, N. Andover Insl
352-9940
Date: 10/27/99
Re: Lots 5 + 7 Christian way Pages: 5
CC:
0 Urgent x For Review 0 Please Comment 0 Pleas Reply 0 Please Recycle
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Town of North Andover
OFFICE OF
COMMUNITY DEVELOPMENT AND SERVICES
27 Charles Street
North Andover, Massachusetts 0 1845
WILLL4LM J. SCOT7
Director
(978) 688-9531
October 19, 1999
Martin Halleran, P.E.
Atlantic Engineering
& Survey Consultants
97 Tenney Street — suite 5
Georgetown, MA 0 183 3
Re: Lot 5 Christian Way +Lot 7
Dear Mr. Halleran,
ID j
Fax (978) 688-9542
The Health Department has reviewed your submitted septic system As -Built,
Certification form and the attached addendum concerning Lot 5 Christian Way, North
Andover. The following is a list of outstanding issues that resulted from the review of
these documents.
1) The As- Built is incomplete. Please see the attached check list for missing items
* Submit completed as -built
2) The system certification form is not the form that was issued to the installer upon
permit issuance.
* See attached form. The original, signed by all parties, must be submitted
3) The addendum needs clarification of item # 4. Please describe in detail the
procedure followed by you to "prepare" the system as -built.
o Submit detailed letter of clarification
These issues must be addressed before this office can perform a final inspection
of the property, sign off on the building permit or issue a Certificate of Compliance.
Please call if you have any additional questions. Thank you for your anticipated
cooperation in this matter.
Sincerel
vo
ZsanForcd
Health Inspector
Cc: Mitsu Realty Trust, Owner
BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535
L'-1- C-/� k " f '-, .1, . , - LA.) �
AS -BUILT CHECKLIST
LOT NUMBER, STREET NAIVE
ASSESSORS MAP & PARCEL NUMBER
LOT LINES & LOCATION OF DWELLINGS
LOCATION & DEIVIENISTONS OF SYSTF-i'vt,
INCLUDING RESERVE
TIES TO LOT LrNES & DWELL NIG, WELLS
a. FROM SEPTIC TANK
b. FROM LEACH AREA
LOCATIONS OF DEEP HOLES & PERC
TESTS
ELEV�TIONS OF DISPOSAL SYSTEM
TOP OF FDN ELEVATION
LOCATIONS OF WELLS, DR-AZiNS, WATERCOURSES
W/TIN 150' OF SYSTEM
LOCATION OF WATEF,--CAS, ELECTRIC LENES, CABLE
DISTANCES FROM CORNERS OF HOUSE TO CENTER OF
TANK & D -BOX
STAIv[P & SIGNATURE
Ev[PERVIOUS, AREAS - DRIVEWAYS, ETC.
NORTH ARROW
FINAL CONTOURS
LOCATION & ELEVATION OF BENICHIMARK USED
LOCUS PLAiN
Atlantic Engineefing &
Survey Consultants, Inc.
97 Tenney Street - Suite 5
Georgetown, MA 01833
(978)352-7870 - Fax(978)352-9940
SEWAGE DISPOSAL SYSTEM
CERTUICATE OF COMPLIANCE ADDENDUM
J,-2
DATE: (D cr
SITE LOCATION: �—OT S e_�+ V_ I STI (A-�) (A) A Y 14,
Commonwealth of Massachusetts Form 1255, last revised May 1996, requires that the system
designer for this "Sewage Disposal System" certify that the above system has been installed in
accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans.
Atlantic Engineering & Survey Consultants, Inc. (Atlantic) was not been retained to provide any
construction supervision, inspections, soils analysis or layout relating to the sewage disposal
system and as such has no responsibility express or implied relating to said construction
supervision.
Atlantic was hired to perform the following services during the construction phase of this project
and limits certifications to the scope of these services.
1. Stakeout the corners of the proposed system structures.
2. Provide a project bench mark.
3. Stakeout any lot lines less than 10 feet from the system.
4. Prepare a system as -built showing the horizontal and vertical locations of the
as -built system structures.
Atlantic Engineering and Survey Consultants, Inc. and its officers, directors, employees and
agents assumes no professional or fitiancial liability for any erroneous or unsuitable construction
related to the installation of this system for which Atlantic was not providing service.
The issuance of a Ortificate of compliance by the approving authority shall not be construed as
a warratyty or gu#antee that the system will function as designed.
P.E.
MMES-WASEPTCOMP.WD
20
No.
FORM 3A - CERTMECATE OF COMPLLANCE
IF" * � —
COMMONWEALTH OF MASSACHUSETTS
Board of Health, Pt MA.
CERTIFICATE OF COMPLIANCE
Desaiption of Work 0 - Individual Component(s) Complete System.
Th6.undersigned hereby certify.that the Sewage Disposal System;
Constru Repaired 1, Upgraded Abandoned 0.,
C�4
Y'.
at-'
has been installed in accordance with the provisions of 3 1 1Y CMR 15.00 (rille 5) and the
approved design plans/��built plans relating to application t4o.
dated 9 /9 Approved Design Flow_Z:Z6. (gpd)
Installer ---i-T—.1-1111
Designer: --)L- intpectbr
Date—
The issuance of this permit shall not be construed as a g6arantee that the system' lwill_
function as designed.
DIP APPROVED FORM 5196
20
Atlantic Engineefing &
Survey Consuftants, Inc.
97 Temy Stred '� Suite 5
Georgetown, MA 01833
(978)352-7870 - Pax(978)352-9940
SEWAGE D1SPOSAL SYSTEM
CERTTHCATE OF COMTLL4,NCE ADDENDUM
DATE: (D C7— 1 —_21, 19 2 �
SITE LOCATION: e_[4 i?- tcS-t I (A -,j Lt) A',' E>,T, q. A,:N�6 V C- 10
Commonwealth of Massachusetts Form 1255, last revised May 1996, requires that the system
designer for this "Sewage Disposal System" certify that the above system has been installed in
accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans.
Atlantic Engineering & Survey Consultants, Inc. (Atlantic) was not been retained to provide any
construction supervision, inspections, soils analysis or layout relating to the sewage disposal
system and as such has no responsibility express or implied relating to said construction
supervision.
Atlantic was hired to perform the following services during the construction phase of this project
and limits certifications to the scope of these services.
1. Stakeout the corners of the proposed system structures.
2. Provide a project bench mark.
3. Stakeout any lot lines less than 10 feet from the system.
4. Prepare a system as -built showing the horizontal and vertical locations of the
as -built system structures.
Atlantic Engineering and Survey Consultants, Inc. and its officers, directors, employees and
agents assumes no professional or fitiancial liability for any erroneous or unsuitable construction
related to the installation of this system for which Atlantic was not providing service.
The issuance of a ?6rtificate of compliance by the approving authority shall not be construed as
a warra
,�ty or guqantee that the system will function as designed.
M. Ralleran. P.E.
20 - )
DAFELES-WASEPTCOMP.WD
Jul OG 00 06:29a Randtj Butt 508 -G98 -G883 P.1
%1:
FAX COVER SHEET
11 Service Electrician
COMMERCIAL RESPOENTIAL
Iz
PC
TO: -5-6-"eS
FROM: Rctm-�-
COMMMNTS:
Vo L) 4ILL e- A"
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( .44
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FAX #: ct 7
PAGIES: L-(
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Jul 06 00 06:29a Rand�j Butt
508-698-13883 p.2
(9VUtM6UfV9a1t4 of fflazaarhusetts OFFICE USE ONLY
Department of Public Safety Permit No.
BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 Udfty Authoriz9on No.
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to bip performed in accordance with the Massachusetts Electrical Code, 527 CMR 12:00
& Date: 75-,D460
City or Town of: A )D
TO the InSPOCtOr Of WIr". The
Location (Street & Number): —
Owner or Tenant:---G.-'-C%A—
a Permit to perform the electrical work described below
Owner's Address: 5c,�-e– Phone:
Is this permit in conjunction with a.building permit? Yes 0 No (check appropriate box)
0 11 !X-
UJIP-M 01 bullding:— (A-) el L
Existing Service:_ Amps
Now Service: - Amns I
Number of Feeders and Ampacity-
Location and Nature of Proposed Electrical Work:
Volts Overhead 0 Undgrd 0 No. of Meters._
Volts Overhead 0 Undgrd 0 No. of Meters:
No. Lighting Outlets
No. of Hot Tubs
No. Lighting Fixtures I ;I_
Swimming pool Above r -i
amd.
No. Receptacle Outlets 0
No. Oil Burners
No. Switch Outlets
No. Gas Burners
No. Ranges
TOW
No. Air Cond Tons
No. Disposals
No. of Total Total
ftnrs Tons KW
No. Dishwashers
Space/Area Heating 6 KW
No. Dryers
Heating Devices KW
No. Water Heate KW
Now a No. of
sign Ballaaft
No. Hydro Massage Tubs
No. of Motors Total HP
No. of Transformers
0 Generators
Id. — KVA
yo�- of EmOWncy Lighting
lff�� No. of Zones
------------------------
No. of Debalon and
lnitMN Devk*s
No. of souncling Dowe"
Wo -0-f-S-e-ff-C-0-n-t9-jn-6-d1 -------- *
DOtection/Souncling D"cus
ER:
LOW VOL -go VArbv
OTHER:
INSURANCE COVERAGE: Pursuant to the requirements at Massachusetts General ws I have a current Liability
Insurance Policy including Completed Operations Coverage or its substantial equivat La
I have submitted valid proof of same to this office. YES NO 0 ent YES NO 13
If you have checked 'YES', please indicate th - - rage by checking the appropriate box.
INSURANCE� BONDC3 OTHER 13 (please specify):Clt�4t 71 �041,�JLIUI c140-61
Estimated Value of Electrical Work: $ ) 5-0 () — T— (expiration dub)
Work to Start:_ & Q-7 — Inspection Date Requested: Rough—I-L�-- Final
Signed Under the ftnaftles Perjury* 1
FIRM NAME: c
Lie. No:
Licensee: A 'R 0 Sign ute: -Lie. No:
Address: Ji"JL C—T A Phone: -�r,09- G9 S��-S Alt it:
OWNER'S INSURA14CE WAIVER: I am aware that the Licensee DOES NOT HAVE the insurance coverage or its
substantial equivalent as required by Massachusetts General Laws, and that my signature on this permit application
waives this requirement. OWNER AGENT (please circle one)
m
Jul OG 00 OG:30a Rand�j Butt 508-GSB-GB83 p.4
COMMUMV080 OfAftsawhumft
Dlvbkn Of PAO*Vftn
60" of EMOAM E=mkmm
IOIBHO NA 42035
USTIR ILWMCIU
RAIDT 109"
154 MfI STRUT
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Jul 06 00 06:29a Rand�j Butt 508-698-6883 p.3
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APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT
DATE: 7-c;2 7- CURRENT INSTALLER'S LICENSE#
LOCATION: Z�P-7_ A:71'
LICENSED INSTALLER: An--lh" 1q,) 1-1
SIGNTATTIRE TELEPHONE9
CHECK ONE:
REPAIR: NEW CONSTRUCTION:
IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS-BUMT.
A�rninistrative Use Only
$75.00 Fee Attached? Yes L_� No
Foundation As -Built? Yes No
Floor Plans? Yes No
Approval :z
Date:
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Atlantic Engineering &
Survey Consultants, Inc.
Land Surveyors - Civil Engineers - Planners
97 Tenney Street — Suite 5
Georgetown, MA 01833
(978)352-7870 — Fax(978)352-9940
LETTER OF TRANSMITTAL
Transmittal To:
North Andover Board of Health
Date:
27 Charles Street
Ref.
N. Andover, MA 0 1845
IAttention: I Sandy Starr
WE ARE SENDING YOU X Attached
Reports
X Prints
Letter
Specifications
Job No:
9701-02
Date:
9/10/99
Ref.
Lot 5 Brook Farm
Under Separate Cover
Original Plans - Forms
13 19/10/99 1 Plan of Proposed Sewage System at lot 5 Brook F��Lpm I
THESE ARE TRANSMITTED as checked below:
For your use Approved as submitted Resubmit copies for approval
For Approval Approved as noted Subunt
___,As Requested Returned for corrections Return corrected prints
x For Review and comment Other
1'6'.
Notes:
Sandy, these plans are to replace the plans sent yesterday. There was some incorrect information
on the title block as well as a dimension missing from the house to the tank. Thank you - Tom
Mannetta.
Initial
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 Z_,4Me_� _AQR�4C(00 PHONE
%J
LOCATION: Assessor's Map Number PARCEL
SUBDIVISION &00k FQeM E-21"376 LOT (S)
STREET tk)ctu 4'u'z. ST. NUMBER /50'
I
'""'OFFICIAL USE
RECOMMEfD�PONS OF TOWN AGENTP: -
—1000 a It & A I I A
R_ - - — (I I
_COJN��RVATIOWADMWINISTRATW DATE APPROVED
DATE REJECTED
COMMENTS- 1if,1d9*VNt Ix
L . a
(A A,
I A104C
TOWN PLAMIff y , DATE APPROVED
DATE REJECTED
COMMENTS
FOOD INSPECTOR -HEALTH DATE APPROVED
DATE REJECTED
SEPTIC INSPECTOR -HEALTH DATE APPROVED
DATE REJECTED
COMMENTS
PUBLIC WORKS - SEWERIWATER CONNECTIONS 7—
DRIVEWAY PERMIT
7-e
FIREDEPARTMENT
RECEIVED BY BUILDING INSPECTOR
Revised 9\97 jm
DATE
0
0
SEPTIC PLAN SUBMITTAL FORM
LOCATION
NEW PLANS:
REVISED PLANS
/-c' -/- �q
YES
di)
$125.00/Plan
$ 60.00/Plan L --
SITE EVALUATION FORMS INCLUDED: YES NO
DATE:
DESIGN ENGINEER:—
DATE TO CONSULTANT:
*If you want your plans expedited, please submit four plans and included a stamped
envelope with the correct amount of postage to mail plans to Port Engineering.
When the submission is all in place, route to the Health Secretary.
I
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Town of North Andover
OFFICE OF
COMMUNITY DEVELOPMENT AND SERVICES
27 Charles Street
North Andover, Massachusetts 0 1845
WILLIAM J. SCOTT
Director
(978) 688-9531
November 16,1998
Atlantic Engineering & Survey
97 Tenney Street Suite 5
Georgetown, MA 01833
RE: Christian Way Extension/ Brook Farm subdivision
Dear Mr. Halloran:
This is to notify you that the proposed septic plan for Lot 5 Christian Way
Extension/Brook Farm has been disapproved for the following reasons:
1. Septic tank manhole to within 6" of finish grade missing. (310 CMR 15.228(2))
2. Both septic tank and D -box missing 6" stone bases. (310 CMR 15.221(2))
3. In "General Notes" section there needs to be a statement that "No garbage grinder is
allowed."
4. Missing elevation of the garage floor and driveway grading. (NA 8.02t)
5. Please change note in leaching area to define proposed leaching field.
6. Please justify use of field. Trenches are to be used whenever possible. (310 CMR 15.240(6))
If you have any questions, feel free to call the office.
Sincerely,
Sandra Starr, R.S.
Health Administrator
Cc: File
to I
10
Fax (978) 688-9542
BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535
SEPTIC PLAN SUBMITTAL FORM
LOCATION:
NEW PLANS:
REVISED PLANS
F -
YES
"d�
SITE EVALUATION FORMS INCLUDED
DATE: 1--PZ2-1 , LC7,r_
DESIGN ENGINEER:
DATE TO CONSULTANT: Av-
$125.00/Plan
$ 60.00/Plan
YES NO
When the submission is all in place, route to the Health Secretary.
Nov -.09-98 12:50P Paul D. Turbide, PE/PLS
November 9, 1998
Sandra Starr
North Andover Board of Health Administrator
Office of Community Development and Services
120 Main Street
North Andover� MA 01845
508-465-0313 P.08
RE: Title V review for Christian Way Extension, Lot 5
Dear Sandra,
Enclosed find the "Checklist for North Andover Septic System Plans" for the above-
mentioned site. The following is a list of all the 'Problem" areas and deficiencies Port
Engineering has found.
* One of the three access covers of the septic tank must be raised to within 6" of
finish grade by riser sections of 24" minimum diameter (310 CMR 15. 229(2))
o D -box must have 6" stone base. 3 10 CUR 15.221(2)
o Septic tank must have 6" stone base 3 10 CMR 15.221(2)
# In the "General, Notes" section of the plan should be added the requirement that:
"No garbage grinder shall be installed". (It is stated in the "Calculations" section in
the calculation of flow that the system was designed for no garbage grinder, but I
feel it should be stressed elsewhere on the plan in an area that the future owner of
the property can plainly see that no garbage grinder can ever be installed.)
* The proposed elevation of the garage floor, as well as grading on the driveway is
required. NA 8.02T
Mnor comment: On sheet one, within the leaching bed shown on the plan, is the
statement: "PROP. SEPTIC". To be more accurate and descriptive, this should be
changed to "PROP. 1EACHING FIELD".
If you have any questions or comments please feel free to contact us.
Pown
R1 Si
Civil Engineers & CArlton A. Brown, PFRLS
LAnd Surveyors
One Harrit Street
Newburyport, MA
01950
(978) 46S-8594
j,,ORM 1-1 SOIL EVALUATOR FORM
Pa.ge I of 3
Date:.: 8/5196
No.
Commonwealth of ' Massachusetts
Massachusetts
N -41.v VO . e DiSQOSal
ent for on-site Sewa
AsseSsin
Datc: -51-±) se�
Pcrformcd By:
Witncsscd By:
oww's Num. MAR(;,&.P�ET ANIOWELL4
jAcalion Addfcis or ig p. DoYC 15A P. M Ad&cjs. and
NORTA AN1po%J5R Tdcphom 1 1111 CIATEWOCO DR
ALExAqPRA, YA
New constructio n E]'Re'p�lr
orrice Reviely
Published Soil Survey Available: No EJ Yes,
Year Published . Publication S . calc 15&10 Soil Map Unit
C
Drainage Class Soil Limitat . ions
Surficial.,Gcologic Report Available: No [2"* Yes
Year Published Publication Scale
Geologic Material (Map Unit)
Landform
Flood Insurance Rate Map:
Above 500 year flood boundary No D Yes
Within 500 year flood boundary No zlycs
Yes
Within 100 year flood boundary No
Wctland Area:
National Wetiand'Invcntory Map (map unit)
Wctlands Conservancy Program Map (map unit)
Currcnt-Water Resource Co d . itions (USGS): Month
Normal D 13c1cw Normal 0
Rangc:Abovc Normal
Other References Reviewed:
DEP APPRO I V -ED FOMI - 12/07/OS
7 %4'
'ORM
FOR.M 11 SOIL EVALUATOR 1,
Page 2 of 3
Location Addrcss or Lot No. EWM4� FARM &4;7
On-site Review
Weather
Deep Hole Number
Location (identify on site plan)
Land Use W0c:'DE;D Slope 7 Surface Stones
Vegetation FORREST
Landform .. Ok->TWAStA RLAitj-
Position on landscape (sketch onthc back)
Distances from:
Open Water Body -4-16o' feet Drainage'way -5; 1.0 0 feet
Possible Wet Area 4 100 feet Property Line 4 10 feet
Drinking Water Well 4 too feet Other
DEEP OBSERVATION HOLE LOG*
Depth fro m
Surface (Inches)
Sail Horizon
Soil Texture
(USD
Soil Color
(Munsell)
Soil
mouling
Other
(Structure, Stones, Boulders, Consistency, %
Gravel)
A
10 YK
10 YR
7/b
M DTQ-0s'
1Zr7
S.L.
MINIMUM Ul- Z HULLb MLUUIHLLJ A I LV
Parent Material (geologic) PWO-61 LA -CI -AL OUTI&I A '-H DopthtoBodrock:
Depth to Groundwater: Standing Watcrin the Hole: Weeping from Pit Face:
Estimated Seasonal High Ground Water:
M FORAI - 12107/9S
DEP APPRIO
F01zM 11 - SOIL EVALUATOR F01ZM
Page 3 of.3
Location Address or Lot No. —1.0 . _r -5
ennination fo Seam�j
,I �J-Ji �IiW�ater�Tdh
Me.thodUsed*
3 ---Depth observed standing in observation hole ... e� inches
El Depth wee . ping from side of observation hole . ......... .... inches
�Depth to soil mottles,-�..._..._ inches
El Ground water adjustment ................... feet,
Index well level ..... . ...... ...
Index Well Number .................. Reading Date ...................
Adjustment factor,.* ................. Adjusted ground water level ........................................ ............
Depth OfAaturally �Occu�rrin �Pervio�usM�ateria�l
Does at least four feet of naturally occurring pervious material exist in all areas
observed throughout the area proposed for the soil I absorption system? L& -S
If not, what is the depth of naturally,- occurring pervious material?
Certification
I certify that on (date) I have passed the soil evaluator examination
n and that the above analysis
approved by the Depa ment of Enviropinental Protectio
v�4 . . kA ertise and experience
m �� W1
was performed by me on t e required training, exp
?sisVt wi
described in 310 CIVIR 7 'J
Date tO
Signature
—7Z
iiDLp APPRONLD FOWN1 - 12107/95
j,,ORM I'l SOIL EVALUATOR FORM
P,age I of
Date:
No.
Commonwealth of Massachusetts
Massachusetts
/V
Assessunent for On-site. SeEgg!�_���
Date: Es 12S.1 9 1�)
Performed By:
Witnessed By:
_,5' .0wM(*SjqA(=. N�ARC-,AWET AN10W E: LLA
L=atjon Ad&css Or jagooV� VAR M Addruz. and 11111 clATzwooD r,>R
NORI" ANDIVCR Tdcphonr I
-2
Aj_EXA�J pr>RiA YA
NewConstructlon [1'Re'Pa'ir
Ofrlc,� JR-tevicliv
Published Soil Survey Available: No Yes
VIM Publication S . c ale Soil Map Unit
Year Published P
. ; Soil Limitations 4,FC \4
Drainage Class
Surficial.,Gcologic Report Available: No Yes
Year Published Publication Scale
Geologic Material (Map Unit)
Landform
Flood Insurance Rate Map:
Above 500 year flood boundary No Elycs
Within 500 year flood boundary -No Z`Ycs
No Zlycs
Within 100 year flood boundary
Wctland Area:
National Wetland'Inventory Map (map unit)
Wctlands Conservancy Program Map (map unit)
Currcnt'Watcr Resource Roditions (USGS): Month
I rmal [113c1cw Normal
Range :Above Nor--- No
Other References Reviewed:
DEP APPROVED FORM 121076S
FOR.M 11 SOIL EVALUATOR FORM
Page 2 of 3
Location Addrcss or Lot No. &RQC�9 FA120 — 4-07-5
On-site Review
Deep Hole NumberV-5-7-9B Date;..-.8J.5/'?8 Time:... Weather
Location (identify on site plan)
Soil Horizon.
Soil Texture
(USDA)
Soil Color
(Munsell)
Land Use W CO P—E�P-
Slope
Surface Stones
Vegetation
loyr?
Landform OuTwA-SH j?jj-.A-ic-1
Ap
Position on landscape (sketch on the back)
Distances from:
Open Water Body 4 too'
feet
Dr.ainagc�way 4 too feet
Possible Wet Area ::� too
feet
Property Line feet
Drinking Water Well 4-1 Do
feet
Other
DEEP OBSEBVATION HOLE LOG*
Depth from
Surface (Inches)
Soil Horizon.
Soil Texture
(USDA)
Soil Color
(Munsell)
Soil
Mottling
Other
(Structure, Stones, Boulders, Consistency, %
Gravel)
loyr?
Ap
IDYR
3'9
;W
-5. L.
-7/8
10 yg
o),1Z
138
A
MINIMUM W- 2 HULLb hLLLU1hLU A I LV Ln I
Parent Material (geologic) &.QCqLA6lA L- QUI-WA.S14 Depthto Bedrock*.
Depth to Groundwater: Standing Watcrin the Hole: I Weeping from Pit Face:
Estimated Seasonal High Ground Water: -Z!�(- 2N, 0-lrrff-15�,
DEP APPROV'ED FORM - 12/0719S
FOJ�M 11 -SOIL EVALUATOR FORM
-Page 3 of 3
Location Addrcss or Lot No. m � -! LOT . S
Det �easonal High W
- aferTable
Method Used:
E��Depth observed standing in observation hole .... 1.,34!.. inches
F� Depth weeping from side of observation hole . ...... .. .... inches
�epth to soil mottles inches
M Ground water adjustment ................... feet,
Index Well Number .................. Reading Date ................... Index well level ...................
Adjustment factor ................... Adjusted gro und water level .....................................................
Depth of Naturally occurring Pervious Material
Does at least four feet of naturally occurring pervious material exist in all areas
observed throughout the area proposed for the soil absorption system?
I
If not, what is the depth of nat'urally. occurring pervious material?
Certification
I certify that on (date)
approved by the D4epK!e_nt of Envir(
was performed by me consis ent wl/
described in 310 CMR 15.0
F_
Signature
DEP APPRM,1D F0101 - 12107195
have passed the soil evaluator examination
mental Protection and that the above analysis
,ie required training, expertise and experience
Date
Atlantic Engineering &
Survey Consultants, Inc.
Land Surveyors - Civil Engineers - Planners
97 Tenney Street – Suite 5
Georgetown, MA 01833
(978)352-7870 – Fax(978)352-9940
LETTER OF TRANSMITTAL
Transmittal To: North Andover Board of Health Date: 10/22/98
Job No: 9701-02
Ref Lot 5 - Brook Farm
Attention:
WE ARE SENDING YOU X Attached —Under Separate Cover
Reports Letter Original Plans X Forms
X Prints Specifications Shop Drawings
COPIES DATE
DESCRIPTION
3 10/2/98
Plan of Proposed Sewage System
1 10/2/98
Application for Disposal System Construction Permit
THESE ARE TRANSMITTED as checked below:
For your use
X For Approval
As Requested
For Review and comment
* Remarks:
Approved as submitted
Approved as noted
Returned for corrections
Other
Resubmit copies for approval
Submit
Return corrected prints
CAWINDOWSOESKTOMoleerfs BriefcaseUransmittals\Brook Fann Lot 5 Septic - BOH.wpd
No
FEE
COMMONWEALT14 OF MASSACHUSETTS
Board of Health, Atl
01/0 , MA.
APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct (% Repair ( ) Upgrade ( ) Abandon ( ) - Ll Complete System Ll Individual Components
Location Y12,jolf r -,VM— C1ffl1jj7AA1 IV4-K
e-Xt:
Owner's Name
A , A AfTeAr &U /
Map/Parcel# I P
Address 1// 7 (,4-Tt WOW W 410 4410,6A yA
Lot# 5-
Telephone#
13YZ
Installer's Name
Designer's Name
47 5#1114y'
Address
Address
(-04C Mir 0V - A .4
Telephone#
Telephone#
170 —3"o- 7S'70
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
No. of persons
Lot Size YY4 if —sq. ft.
r
Garbage grinder(
Showers ( ), Cafeteria
Other Fixtures
Design Flow (min. required) gpd Calculated design flow 149 010A Design flow provided Ptj gpd
Plan: Date jp4l -�/j ed Number of sheets Revision Date
Title Zat Y_ -� F -As �f
Description of Soil (s) WS 9
Soil Evaluator Form No. Name of Soil Evaluator N Y.Wir0ki, Date of Evaluation sh/11
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed
Inspections
Date
No. COMMONWLALT14 OF MASSAC14USETTS FEE
Board of Health, , MA.
CERTIFICATE OF COMPLIANCE
Description of Work: Ll Individual Component(s) Ll Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed Repaired Upgraded Abandoned
by:
at
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. , dated . Approved Design Flow _(gpd)
Installer
Designer: Inspector: Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No.
COMMONWEALTH OF MASSACHUSETTS
Board of Health,
"A
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEE
Permission is hereby granted to; Construct( ) Repair( ) Upgrade Abandon an individual sewage disposal system
at - as described in the application for
Disposal System Construction Permit No. dated
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date Board of Health
Town of North Andover I "ORTN
0
OMCE OF 41
0
COMMUNITY DEVELOPMENT AND SERVICES 0
30 School Street
1 J. SCOTT North Andover, Massachusetts 0 1845 o Argo
1AM SACH st
Director
OUTSIDE CONSULTANT ESCROW AGREEIMENT FILE
NORTH ANDOVER BOARD OF HEALTH 8
Agreement is made thisn o--�- q, �, i q q 7 between the
Town of North Andover and QJ A4,1�L
o f —YAt I i Lnj LA -L-A n Mt
for Soil Tests- Plan Revi
KNOW ALL men by these present that the Applicant hereby
provides the Town of North Andover with a check in the sum
of $ ?15- 61)-., to be deposited in an escrow account for the
Town of North Andover and has deposited in an interest-
bearing account as designated by the Town Treasurer to be
expended by the North Andover Board of Health to insure
payment to any outside consultant (s) for Soil Tests, Plan
Review for the above referenced project.
This agreement shall remain in full force and effect
until the specified project has reached completion,
V)
-56-ard of Health Chairman
or Agent
Nk.
Applicant
§LE
WILLIAM ANTONELLI 3-96 560 392
JANET M. ANTONELLI 2239 916
5431 FLINT TAVERN PL. 19 fk
BURKE, VA 22015 — jeg
Pay to the
order of
aRIER-M V
Crestar Bank
Alexandria, Virginia
1: 0 S C300 Lo 7 91: a 2 2 3 9 5 qJLF-112 0 3 9 2
$ k,:y- OJ
oo
e1141 -0-- Dollars
688-9535
t46 NIAIN STREET
WN
0 1 WE
Will
-10
ffw-
UAA-Ma
—MP
DATE Sheet of
BOARD OF HEALTH
TOWN OF NORTH ANDOVER
SUBSURFACE DISPOSAL DESIGN REVIEW
FEE—VI ?1 -le -15 PERMIT # DATE RECEIVED /-2
APPLICANT ASSESSOR'S MAP
ADDRESS PARCEL #
LOT #
V ?IT STREET
///V/ / c -
ADDRESS 7,-*,A-1A1,9Y ',�7- 6,u,
PLAN DATE // A /, A 5: REVISION DATE'
CONDITIONS OF APPROVAL:
040,35
APPROVED
DISAPPROVED L---
It444,F. 6Zt,-o�I-IA/46 Oe4) Co A A107- e'OC19
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y
DZA1&' Zy 1A.1
5 7-1 Al I z�-7 IAII�>I-
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7,
%, , 13
PLAN REVIEW CHECKLIST
ADDRESS—/ Z1 -JY z!�-X7- ENGINEER- 1 -q,7; -1, -91V,7 -1c
GENERAL
3 COPIES ST*AMP LOCUS NORTH ARROW SCALE
CONTOURS PROFILE
PERC INFO ELEVATIONS_
WETLANDS WATERSHED?
FDN DRAIN SCH40
SEPTIC TANK
SECTION BENCHMARK SOIL &
WETS. DISCLAIMER 4.,� WELLS &
DRIVEWAY -,y (Elev) WATER LINE
TESTS CURRENT?
MIN 150OG 6,-' .17 INVERT DROP GARB. GRINDER (+200% EDF)
251 TO CELLAR MANHOLE TO GRADE_,y ELEV GW—.
D -BOX
SIZE # LINES FIRST 2' LEVEL STATEMENT
INLET OUTLET = 117 (21' OR .17 FT) TEE REQ I D? A�D
LEACHING
MIN 660 GPD? RESERVE AREA L,`�4' FROM PRIMARY? i,-� 2% SLOPE
1001 TO WETLANDS L-"'-100' TO WELLS e-� 4' TO S.H.GW
35' TO FND & INTRCPTR DRAINS /,-' 325' TO SURFACE H20 SUPP
41 PERM. SOIL BELOW FACILITY,></ MIN 12 " COVER FILL? ---(2 51
if above natural elev elow) BREAKOUT MET?
TRENCHES
MIN 660 gpd_ SLOPE (min .005 or 611/1001) >31COVER?-VENT
SIDEWALL DIST. 2X EFF. W OR D (MIN 6-) IS RESERVE BETWEEN
TRENCHES? IN FILL? MUST BE 101 MIN. 4" PEA STONE?
BOT X LDNG + SIDE X LDNG = TOT
(L x W x #) (G/ft2) (DxLx2x#) (G/ft2)
Copyright Q 1993 by S.L. Starr
PITS
MIN 660 LEACHING MIN 1 (131xl6l) PIT MANHOLE/PIT
GW MIN 41 BELOW BOTTOM EXd 2x EFF W OR D 1211-4811 STONE
BOT + SIDE x LOAD = TOTAL
(L x W x #) (2X(L+W)XD X #) (G/ft2)
CHAMBERS
MIN 660 LEACHING GW MIN 41' BELOW COVER >3 FT - VENT
MANHOLES 1211-48" STONE SPLASH PADS SLOPE .005
BED/TRENCH_(Bed max. 601 X 601) MIN 131 X 161 PIT
BOT + SIDE X LOAD = TOTAL
I (L x W x #) (2 x (L+W)xD x #) (G/ft2)
FIELDS
MIN 660 GPD ft2 BED PERC RATE FASTER THAN 20M/IN
GW MIN 41 BELOW BOTTOM OF FIELD PIPE ENDS JOINED? e—�
411 PEA STONE?,OC-- DIST LINE SLOPE .005? >31COVER-VENT
SCH 40 L-' MIN 12" COVERZ-1----
RATE-E-/q�w LDG 0 X 660
- TOTAL. 961D
ft2/G REQID (ft2) LXW
DOSING TANKS AND PUMPS
DIMENSIONS X X
-W -D Vol.
DISCHARGE SIZE DISCHARGE RATE
MANHOLES TO GRADE
inlet) HWL
OP. SWITCH
Copyright 0 1993 by S.L. Starr
ALARM SEP. CIRC.
LWL CHECK VALVE
PUMP CAPACITY Pm
9pm
DISCHARGE TIME
GW (Min. 11 below
BLEEDER HOLE MANUAL
Lot 4
Test Pit #1
Top and Subsoil
T o o 'VJe t
U1 a t e r T a b I e
Test Pit """
L o t 5
Lot 6
Top and Subsoil
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ATLANTIC ENGINEERING AND SURVEY CONSULTANTS, INC.
33 WEST.MAIN-STREET-, GEORGETOWN, MASSACHUSETTS, 01833
(617) 352-7870 (617) 593-3395
SOIL LQQ�S;-
Lo�c'atloni VIAY 1::YT
no:
Date: M1 Ib
Testi performed by: Ry fi it y //C
observed by: C_ /?A F
Pit # Pit
Elov. Elev.
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1 '5702--0.�___
Time
soak start
end
Average min/inches
Time
Soak start
end
Average —min/inches
Water Depth
Water
Depth
Water Elev.
Water
Elev.
Perculation data/#
Perculation data/#
Datet
Date:
Elevations
Elevations
Top of Pit
Top of
Pit
Depth to test
Depth
to test
Depth of test
Depth
of test
Time
soak start
end
Average min/inches
Time
Soak start
end
Average —min/inches
IN ZWQ.i
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NI
is
Ik M.,
1/8/99
Memo to File RE: Lot 5 Brook Farm
Met with Tom Marietta on 1/7/99. After discussion agreed that Lot 5 should be designed with a
field, since a trench system would require over 1000 yards of extra fill and increase the system cost
significantly.
"'I/ 41�
Town of North Andover
0MCE OF
COMMUNITY DEVELOPMENT AND SERVICES
27 Charles Street
North Andover, Massachusetts 0 1845
WILLIAM J. SCOT7
Director
(978) 688-9531
November 16,1998
Atlantic Engineering & Survey
97 Tenney Street Suite 5
Georgetown, MA 01833
RE: Christian Way Extension/ Brook Farm subdivision
Dear Mr. Halloran:
This is to notify you that the proposed septic plan for Lot 5 Christian Way
Extension/Brook Farm has been disapproved for the following reasons:
1. Septic tank manhole to within 6" of finish grade missing. (310 CMR 15.228(2))
2. Both septic tank and D -box missing 6" stone bases. (310 CMR 15.221(2))
3. In "General Notes" section there needs to be a statement that "No garbage grinder is
allowed."
4. Missing elevation of the garage floor and driveway grading. (NA 8.02t)
5. Please change note in leaching area to define proposed leaching field.
6. Please justify use of field. Trenches are to be used whenever possible. (310 CMR 15.240(6))
If you have any questions, feel free to call the office.
Sincerely,
Sandra Staff, R.S.
Health Administrator
Cc: File
'to ,
,-. L0
-1-00
Fax (978) 688-9542
BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535
Town of North Andover
OMCE OF
COMMUNITY DEVELOPMENT AND SERVICES
27 Charles Street
North Andover, Massachusetts 0 1845
WILLIAM J. SCOTT
Director
(978) 688-9531
February 2, 1999
Atlantic Engineering & Survey
97 Tenney Street
Georgetown, MA 01833
RE: Brook Farm/ Christian Way Extension, Lots 1-7
Dear Mr. Manetta:
Fax (978) 688-9542
This letter is to inform you that the proposed septic plans for Lots 1-7
Brook Farm/ Christian Way Extension have been approved.
Please do not hesitate to call the office at the number below if you have any
questions.
Sincerely,
Sandra Starr, R.S.
Health Administrator
Cc:
M. Antonelli
W. Scott
File
BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535
Jan -13-99 11:38A Paul D. Turbide, PE/PLS 508-465-0313 P.05
January 13, 1999
Sandra Starr
North Andover Board of Health Administrator
Office of Community Development and Services
120 Main Street
North Andover, MA 01845
RE: Title V second review for Christian Way Extension, Lot 5
Dear Sandra,
I have reviewed the revised design plan for the above project with revision date of I I
December 1998. 1 find all my original concerns have been addressed except for the
following. Asper 310 CMR 15.221(2) there must be a 6" stone base beneath the d -box
and the septic tank. The plans correctly have added "3 10 CMR 15.221(2y' and have
added a six inch base beneath the d -box and septic tank on the plans, but they still call
for "gravel" instead of "stone". The word "gravel" should be deleted and the word
44 stone' put in its place. (If this minor change is made, I do not need to review this plan
again.)
If you have any questions of comments please feel free to contact us.
Sincerely/,-,,
,o" a141—
Carlton A. Brown, PE/PLS
PODT
Itt
GINLLn
Civil Engineers &
Land Surveyors
One Harris Street
Newburyport, MA
01950
(978) 465,8594
Location
No.
Date - :2 , -
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check # // /,//"
Building Inspector
I
The Conirnonwealth of Massachusetts
1.2A.Map..dParcell,lumber:
State Board of Building Regulations and
TOWN OF NORTH ANDOVER
Standards
BUILDING DEPARTMENT
Massachusetts State Building code
Lot Area (4 Fromage(ft)
780 CMR
T,gnat,r.
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, CHANGE THE USE OF OCCUPANCY OF, OR DEMOLISH ANY
BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING
Building Permit Number: 0 C� & I Date Issued: / e) - c3� f) --Lq ao 3
Date
1. 1 Property Address &� Q ,4.—
'�7 4�Ij
1.2A.Map..dParcell,lumber:
#P60
Map Number Parcel Number
IJ Zoning Information:
1.4 Property Dimensions:
Zoning District Proposed Use
Lot Area (4 Fromage(ft)
From Yard Side Yard Rear Yard
Required Provided ReTured provides Required Provided
1 107 Water Supply 9M.G.L.C.40.4 %54 1.5. Flood Zone Information: 1.8 D . als
Public Priv Zone outside Mood Zone On Site Disposal System
13 b 1 13 716 'sp" yst":
2.1 Owner of Record
Not Applicable 13
Licensed Construction Supervisor:
License Number
Rt4A,')()q 5 .
05�� y 7
Name (Print)
Addre s:
.27 CXarr.A
Alwolgys'
T,gnat,r.
Telephone
2.2 _Apthorized Agent:
4>b, -J A.1 Lr V la
'4) s- P.Q.
"IT
gcic 19091, Ad
Nami (Print
A
Address
0113
po
Telephone 7-7
60q If
V %-�
3. 1 Licensed Construction Supervisor:
Not Applicable 13
Licensed Construction Supervisor:
License Number
Rt4A,')()q 5 .
05�� y 7
Address
Expiration Date
Sigpn �-���elephotie
3.2 RegisteredvHome Irnprovement Contractor
Not Applicable 13
Company N
Registration Nwnber//-3,.,, 3
7ddress
Expiration Date
21"
�AK,'4:'���elephone?yg
Sif �,u
Revised 1997 'MY
SECTION 6 - DESCRIPTION OF PROPOSED WORK (check all applicable) I
New Construction 13 Existing Building D 1 Repairs Er Alteration(s) Er Addition 0
Accessory Bldg. [3 Demolition I other 0 Specify
Brief Description of Proposed:
SECTION 7 - USE GROUP AND CONSTRUCTION TYPE I
USE GROUP Check as applicable)
A Assembly A-1 A-2 A-3
B Business 13 A-5
E Educational [3
F Factory 13
F-1 F-2
H High Hazard [3
IB
I Institutional C3
1-1 1-2 1-3
M Mercantile 13
2B
R Residential C3
R-1 R-2 R-3
S Storage C3
S-1 S-2
U utility C3
Specify:
M Mixed Use 0
Specify:
S Special a
Specify:
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS.
ADDITIONS AND/OR CHANGE IN USE
Existing Use Group:
Proposed Use Group:
Existing Hazard Index (780 CUR 34)
SECTION 8 - Building Height and Area
BUILDING AREA
Number of Floors or stories include
basement levels
Floor Area per Floor (sf)
Total Area (sf)
Total Height (ft)
CONSTRUCTION TYPE
IA
0
IB
C1
2A
E3
2B
0
2C
13
3A
0
3B
0
4
0
5A
C)
5B
C3
Proposed Hazard Index (780 CUR 34)
Existing (if applicable)
SECTION 9 -STRUCTURAL PEER REVIEW (780 CUR 110.11) 1
Independent Structural Engineering Structural Peer Review Required
SECTION 10a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,
hereby auth&ize 10��A-WV/4r_ -2;u
my behalf, in all matters relative to work authorized by this building permit application.
r.
revised bldgform/state JMC
/V -
Date
Proposed
Yes C3 No 0
As Owner of subject property
to act on
- OWNER/AUTHORIZED AGENT DECLARATION
1, 1 as Owner/Authorized Agent hereby declare
that the stat=44 and information on the foregoing application are true and accurate, to the best of my knowledge and belief
Signed under the pains and penalties of pe�ury.
SECTION I I - ESTIMATED CONSTRUCTION COSTS I
Item Estimated Cost (Dollars) to
be completed b permit
applicant
Date
27/ b 13
Official Use Only
(a) Building Permit Fee
Multiplier
(b) Estimated Total Cost of
Construction from (6)
Building Permit Fee (a)x(b)x 300—
Check Nurnber
I .
Building a o
2.
Electrical 57
3.
Plumbing 'S'
4.
Mechanical (HVAC)
5.
Fire Protection
6.
Total = (1+2+3+4+5)
Date
27/ b 13
Official Use Only
(a) Building Permit Fee
Multiplier
(b) Estimated Total Cost of
Construction from (6)
Building Permit Fee (a)x(b)x 300—
Check Nurnber
SECTION 4 WORICERS, CONYENSA17ION INSURANCE AFFIDAVIT JKGJ� e. 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.
0: A Afr.A-4 Aft -t -A V.. rl M. 0
SECTION5- PROFFESSIONAL DESIGNANI) CONSTRUCTION SERVICES - FORBUILDINGA141) STRUCTURES SUBJECT TO CONSTRUCTION
CONTROL PURSUANT TO 780 CMR 116 (CONTAINING MORE THAN 35,000 CIROF ENCLOSED SPACE)
5.1 Registered Architect:
90 b JA-�509-) ( (d (500
No Applicable
Name (Registrant):
Address
/6)
4
Y
Registration r
Signature
Telephone
Expiration Date
5.2 Registered Professional Engincer(s)
Name
Area of Responsibility
Address
Registration Number
Signature
Telephone
Expiration Date
Name):
Area of Responsibility
Address
Registration Number
Signature
Telephone
Expiration Dale
Name
Area of Responsibility
Address
Registration Number
Signature
Telephone
Expiration Date
Name
Area of Responsibility
Address
Registration Number
Signature
Telephone
Expiration Date
5.3 General Contractor
Not Applicable (3
Company Name:
Ca 4n4i�,—
Responsible in Charge ofConstruction
Address P.
6LA �,, IVA �y 3
Signatme (A�A TelMho
V 1-nf f f1j
6�10 C7
Oct -24-03 11:37A Daniel Hurley
AtQ-80-
978-777-3306
CERTIFICATE OF LIABILITY INSU-RANCE
ban Hurley insurance Agency
Chestnut Green, Suite 24
Seven federal street
Dahvers Nh 01923-3620
Phone. -978-777-9394 Fax. -979-777-3306
Fm iUR 9 6 — — -- I— — - —
Sonnevie Constt"Ution
I'" Sonnevi* b
14 CUJALr Street
Amffibury MA 01913
ALTER
INSIURERS AFFORDING COVERAGE
INSURER A:
rugamm ce
Gua.zd Insurance GESLip
±!!UR�RC
.
P. 01
DATE IMMOMMI
--IV24/03
DF INFORMA—TIOt
CERTIFICATE
NO, EXTEND OR
POLICIES RELOVY
NAIC 0
THE POLICIES OF INSURAME LISTED 13ELOW HAVE BEEN ISSUED - 0 THE INSURED NAL4FO
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR )THEN O=Uh*NT ABOVE FOR THE POLICY KRIOD INDICATED. NOTWITHSTANDING
WITH RESPECT TO WHICH THIS C911TIFICATF jAy BE ISSUED OR
WAY PERTAIN. THE 1NSL9W4CE AFFORDED By THE POLICIES bESC MEO WRCIN IS SUBJECT TO ALL THE TERM, EXCLUSIONS AND CONDITI13W OF SUCH
POLICIES. AGOREGATE LUTS SHOWN MAY HAVE BEEN REDUCfD ly PAID CLAW.
TYPE OF INSURANCE POUCY NUNN I 7701� MITIi �(Wf LIMIT3
( GVMCRAL LIABILITY ;ACAOCCUR%j;NQ: %Soo 000
it,
A COMMERCIALMNERALL."PLITY CPP0l705l9&qS
X. 06/22/03 06/22/04 —500, 0 0 —
LAWS MADE "c~00) —
C OCCUR MED Ex'P (Any ?R* peltan) & 5001c�
PERSONAI A AOV INJURY S50
GENERAL A*GRCGATr 6 00
GEN'L AGGREGATE LIW� A� K-11- ROLWTS C� �1011 AGG 51000000
PULCY PR" -
I JFCI'
AUTOMOBILE LIABILITY
ANY AUTO
ALL OWNFO AvTO5
5CNCDULFO AUTOS
"MCD AUTOS
NON -OWNED AUTOS
Q"AGG LIAtULITY
I ANY A1.110
EXCEAWNBRELLA CIABILITY
IOewn 0 CLANS MAI JE
RETENTION S
VIWKERS COMPIENSAVION AND
EMPLOYER& MAIMLI"
ANYPROPAIF1OWPAA1WR/EXECU'nVr ROWC423693
0FFCER#AEMbER EXCI.Lk)ED?
If yas. (19wibe undst
a
COM2110*0 &NGLE LIMIt
SC60ont)
RODILY INJURl
(Per pamon)
ENXXY INJURY
owideno
PROPERTY OAMA06
AVrOOkLY-EAACC1r*NT 15
OTHERTHAN _�-A Al:�� S
C
Amoow-y
r-AGHOCCURACK.E
AGOREGATE
-6000--0
02/03/03 ' 02/03/04 E. L EACH ACC0jNT --W,
C.L. WtASC - CA F.mpLoypq S 100DOO
INIRINrO &'*UAV AMY OF THE ABOVE DISCRIBE0 POIXIES W MAINCELLIEV fwFcft TP#E EXPIRATN
ror informtion purposes only. OA19 THEREOF, THE IMUM INSURER 4411.1, ENDEAVOR TO MAIL I0 DAYS WItITTEN
Please contact agency for W&M To f"E CERTIFICATE MXM NAMED 4TO THE LEFT, OUT 04
individual certificate. IMPOW NO OBLIGATION opt LIABILr" OF ANY ktko UPON VNE IN&U14ER' ITS AQENTS OR
I WRIMEWATIves.
Balrd of 81tildft Replatafts w3d Stnn&rdl
HOME IMPROVEMENT CONTRACTOR
RegWmlion: 113663
Fxplradon: DTI=005
Type: Irdividual
SONNEVIE CONSTRUCTION CO.
KANDY BONNEVIE
14 CEDAR ST
AMESBURY. MA 01913 Administrawr I
BOARD OF BRUILIDIN' EGULATIONS
License: CONSTRUCTION SUPERVISOR
Number: CS 052472
Birthdate: 02/0211959
Expires: 02/0212005
Tr- no: 10993
Restricted: A G
RANDYS BONNEVIE
2 PALMER DR
KENSINGTON, NH -03833
Administri-tor
North Andover Building Department
Tel: 978-688-9545
DEBRIS DISPOSAL FORM
In accordance with the provision of IVIGL 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 IVIGL
c 11, S 150A.
The debris will be disposed of in:
(Location of Faciffty)
- C44�,X'1�
41 Signature of Permit Applicant
7 /03
Dfite
NOTE: Demolition permit from the Town of North Andover must be obtained for
this project through the Office of the Building Inspector
$04
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Location
No.
Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check# -3 V/ ��,
C9 11) ()
C >1 -) U
�7, Li -In9pa-6tor
Building
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
M& Sm" hw goeb
Jump*
BUU,DING PERMIT NUMBER: n, DATE ISSUED:
SIGNATURE: C
Building Commi—ssioner/12Wtor of Buildings Date
- a A �LN I- �1 ALF, IVA^ I IWIN
1.1 Property Address:
Z
—7—
1.2 Assessors Map and Parcel
I q,;�, —
Map Num
Number:
—
Parcel Number
—
P/Pt/ 5
1.3 ZoninT1-nfmmafion:
Zoning District Proposed Use
—7
/ CIIZ�,62,�Z
1.4 Property Dimensions:
Lot Area (SO
Frontage �t-t)
1.6 BURDING SETBACKS (ft)
�9112
I
Front Yard
Side Yard
Rear Yard
Required Provide
Reqwred ReqWred
—+
Provided
-
4
1.7 Water Supply M.G.L.C.40. 54)
Public 0 Private 0
—
1.5. Flood Zone Information: 1.9
zone Outside Flood Zone D Municipal
Sewerage Disposal System:
0 On Site Disposal System 0
am%- 11%J11 A - rMurILIKIL X UWfNzlK5nW/AU1n0V AGENT
1�1 LjiZJL1 kA. 1(7,z, 1,41 U
2.1 Owner of Record
P/Pt/ 5
—7
/ CIIZ�,62,�Z
Name (Print)
Address for Service:
�9112
Signature Telephone
2.2 Owner of Record:
--4
V;.tme Print
Address for Service:
Signature Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Not Applicable 0
Licensed Construction Supervisor:
License Number
Address
Expiration Date
Signature Telephone
3.2 Regist Home Improvement Contractor
7�
Not Applicable 0
1
mmlo�:—
Corn ny Name
Registration Number
r
Address
;;� —f,7&�
xpirafion Date
STignatu;i- Telephone I
SECTION 4 - WORKERS COMEPENSATION (XG.L C 152 § 25c(6) I A*
Workers Compensation Insurance affidavit plust be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the buil�Aperrnit.
Signed affidavit Attached Yes ..... -�K No ....... r,
SECTION 5 Description o Proposed Work (check appHcitble)
New Construction 0 Existing Building 0 Repair(s) 0 Alterations(s) Addition 0
Accessory Bldg. 0 Demolition 0 Other 11 Specif�
Brief Description of Proposed Work:
57�
I/A / 1/1
I SECTION 6 - ESTIMATED CONSTRUCTION COSTS I
item
Estimated Cost (Dollar) to be
Completed by permit applicant
OMCIAL USE ONLY
I .
Building
of oQ 78
(a) Building Permit Fee
Multipl er
2
Electrical
(b) Estimated Total Cost of
Construction
Plumbing
Building Permit fee (a) x (b)
.3
Mechanical (HVAC)
.4
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, 014�p� S , as O,�Amer/Authorized Agent of subject property
Hereby authorize —to act on
My behalf, in al vork authorized by this building permit application.
e'lY-7 C61L,7-,e,* 0777
Signature of Owner Date
SECTION 7b OWNERIAUTHORIZED AGENT DECLARATION
I — I - — J
property
Hereby declare that the statements and
and belief
Print Name
as Owner/Authorized Agent of subject
on the foregoing application are true and accurate, to the best of my knowledge
, F/ .2
Date I
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TIMBERS Isl 2 ND 3 RD
SPAN
DIMENSIONS OF SILLS
DIMENSIONS OF POSTS
DIMENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CHRvINEY
IS BUILDING ON SOLID OR FELLED LAND
IS BUILDING CONNECTED TO NAIURAL GAS LINE
HOME IMPROVEMENT CONTRACT
Sold, Furnished and Installed by:
Branch Date: THD At -Home Services, Inc.
Naml7i7a d/b/a The Home Depot At -Home Services
345A Greenwood Street, Worcester, MA 0 1607
Branch Number: Job#: Toll Free (800) 657-5182� Fax: 508-756-2859
Federal ID# 75-2698460 ME Lic # C 02439 RI Cont. Lic# 16427
CTLic#565522; MA Home Improvement Contractor Reg. #126893
Installation Address: N_N4WVe1/_ Mp 0VT5<
City State Zip
Purchaser(s): Driver's Lic. # & EXQ. Date:
Work Phone: Home Phone:
N TIMM Z. I %1M, 1 -2 a = IS 3 M �] I a F TO 11 Wffl_ a RTFI 117, C 0 M,
Home Address:
(If different from Installation Address)
city
State Zip
Prooect Information: I[We/You ("Purchaser"), the owners of the property located at the above installation address, offer to
contract with Home Depot U.S.A., Inc. ("Home Depot") to furnish, deliver and arrange for the installation of all materials as
described on the attached Spec Sheet #: �AA!03 , incorporated herein by reference and made a part hereof
Home Depot reserves the right to cancel this contract if, upon re -inspection of the job, Home Depot determines that it
cannot perform its obligations due to a structural problem with the home or because work required to complete the job
was not included in the contract.
CONTRACT AMOUNT $
*LESS DEPOSIT $
BALANCE DUE
ONCOMPLETION S
*Minimum 25"'. of Contract Amount due upon execution
if this contract.
Indicate Payment Method For
BALANCE DUE ON COMPLETION:
bVI l6l,601�
DEPOSIT PAYMENT OPTIONS
(Subject to find verification and/or credit aporoval.)
1. (;C�hcc�kashicrs Check or US Postal Service Money Order
pa
payable to The Home Depoo.
2. Credit Card- and/or other payment options - Circle One Below
Visa MasterCard Discover American Express
The Home Depot Home Improvement Loan The Home Depot Credit Card
Available Credit: $
Acct#:
Name as it appears on card:
(HIL & HDCC ONLY)
Exp. Date:
*By my/our signature below, I/we agree to allow Home Depot to charge the above
referenced credit card for the deposit indicated.
Cardholder's Signature
Date
HIL or HDCC Authorization Codes
Depos Final Pavment
Purchaser agrees that, immediately upon satisfactory completion of the work, Purchaser will execute a Completion Certificate
and pay any balance due. Purchaser also agrees to be jointly and severally obligated and liable hereunder.
Entire A ement: This agreement and its attachments, including any financing agreement, contain the complete agreement
F___ -t_
etween tfr
e parties and can not be amended or modified unless in writing in a separate agreement signed by both parties.
NOTICE TO PURCHASER
Do not sign this contract before you read it. You are entitled to a completely fliled-in cop of the contract at the time you sign. Keep
it to protect your rights. Do not sign ay Completion Certificate or agreement stating at you are satisfied with the entire project
before this project is complete. Law pro ibits home repair contractors from reyesting or accepting a Completion Certificate signed
by the owner prior to the actual completion of the work to be performed under I e co tract.
You ma
,,Ytcancel this transaction at any time prior to midnight ofthe third business day after the date ofthis contract. See Notice of
Cancel ion for an explanation of t1iis right. There will -be a service charge equal'to 25% of the contract amount if the job is
cancelled by Purchaser AFTER the third business day.
BY MY/OUR SIGNATURE BELOW, UWE AGREE TO BE BOUND BY THE TERMS OF THIS CONTRACT. I/WE ACKNOWLEDGE
RECEIPT OF A COPY OF THIS CONTRACT AND TWO COMPLETED COPIES OF THE NOTICE OF CANCELLATION.
BY MY/OUR SIGNATURE BELOW, IfWE UNDERSTAND THAT THE AGREEMENT IS SUBJECT TO REVIEW OF MY/OUR
CREDIT HISTORY AND UWE AUTHORIZE HOME DEPOT AUTHORIZED CONTRACTOR, TO VERIFY AND REVIEW MY/OUR
CREDIT RECORD WITH AN INDEPENDENT CREDIT REPORTING AGENCY AND RELEASE THEM FROM ALL LIABILITY
INCURRED FROM INADVERTENT OMISSIONS OR ERRORS,
SUBMITTEDBY: �'W Date: _4 I:kl
XWes onsultajnt�
ACCEPTED BY: Date:
Homeowner Date:
Homeowner
NOTICE: ADDITIONAL TERMS, CONDITIONS AND WARRANTIES ARE STATED ON THE REVERSE SIDE AND ARE PART OF THIS CONTRACT
VAite — Branch File Yellow — Customer Pink — Sales Consultant
5-18-04 C -SC
North Andover Building Department
Tel: 978-688-9545
DEBRIS DISPOSAL FORM
In accordance with the provision of IVIGL 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 IVIGL
c 11, S 150 A.
The debris will be disposed of in:
7(Location of Facility)
Permit A
Signature o ermit A icant
at�
NOTE: Demolition permit from the Town of North Andover must be obtained for
this project through the Office of the Building Inspector
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The Commonwealth ofMassachusetts
Department of Industrial Accidents
600 Washington Street
Boston, Mass. 02111
Workers' Compensation insurance Affidavit - General Businesses
1-7" 1--t7l
citV 7--y2 - __�4
=:,:? state A — zi]2: 0 phone 7
I am a sole proprietor and have no one
working in any capacity.
I am an ernployer with eniDlovee
Business Type:
(full & part tim6
I am an eniployer providing workers, com
Eompariv name: i I I
address: :� V,5-,S—
c.. H -M e -,I -,l
Retail Lj Restaurant/Bar/Eating Establis-hment
Office E] Sales (including Real Estate, Autos etc.)
Other
sa ion Ifoor my employees working on __ t. - h . i . s jo I b
4 AIC,
7 ,gx / C>
one 00: Ro 0 6,5_�'
liev # 441 �,O/ ?7,2cz,
LJ I arn a sole proprietor and have hired the independent contract'or"s listed below who have the following workers'
compensation polices:
c21n2nnv name:
address:
citv:
urance co.
c(sunpanv name:
uddress:
insurance ro.
I -allure to secure coverage as required -un r d , c , r , S , ect , i , on 25A of NIGL 152 -can lead to the imposition of e'riminal penalties of a rme up to $1,500.00 and/or
one years' iniprisonment as nell as civil Penalties in the form ofs STOP NVORK ORDER and a fine ofSI00.00 a day against me. I understand that a
vop� uf this 3taternent may be Forwarded to the office of Investigations of the DIA for coverage verification,
I do hereby certib, und-er-4k s andpenal
that the information provided above is true and c rrect.
Date —2
Print name
—Phone # 7(1
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Date . ..........
TOWN OF NORTH ANDOVER
0 PERMIT FOR PLUMBING
This certifies that . . �� �-? .... P.�. 3 ....................
has permission to perform ... ...............
plumbing in the buildings of . Arl.', .........................
at. d.?. .............. North Andover, Mass.
7 ) (' I
Fee. Lic. No.. ( ... ......... ......
PCUMBING INSPECTOR
Check# 3 1 '?
5 k k- I
U ��./
a
.1
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER, MASSACHUSEITS
Date
Buildina Location Z, Owners Name Permit #
Type of Occupancy Amount
New ri Renovation IT Replacement 1:1 Plans Submitted Yes 1:1 No
FIXTURES
F VTOMM: I
[01,110re-111-1
F 7IRTITM
F. -I 1 -1 11 (11 I'm
�j I a, I a f -cf, all
1.1111IFFIF8
(Print or type)
Installing Company Name
0 Pj
U
Check one: Certificate
Corp.
Address
Partner.
[ErFirm/co.
Business Telephone
Cl'
Name of Licensed Plumber:
Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box:
Liability insurance policy F111*1 Other type of indemnity F1 Bond F-1
Insurance Waiver: 1, the undersigned, have been made aware that the licensee of this application does not have any one of the above
three insurance
Signature Owner 11 Agent El
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 an install ti rf rider Permit Issued for this application will be in
a
s �ions )e ormed u
compliance with all pertinent provisions of the Ma6c ett ' t e Plumbin
,*Co,d4hd Chapter 142 of the General Laws.
By: Signature or yAensea Flumoer
Type of.Plumbing License
Title 2—"?3
City/Town 1-Mense NumDer Master El Journeyman 9-11"
APPROVED (OFFICE USE ONLY
Datel,//,;7�,
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ... . ........................
has permission to perform &J.� ..... �.a� ... 4
wiring in the building of
............
at ...... J .. 7... .............................. . North Andover, Mass.
Fee,:5.—C). I (A)... Lic. No. .................
EacrRicAi!INSPECTOR
Check #
I ' r
1 1, J
Official Use Only
Permit No.
V0 -4--a 4 POO& S*0 Occupancy & Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code 527 CMR 12:00
(Please Print in ink or type all information) Date Noil- 9-17"wy
To the Inspector of Wi(es:
Town of North Andover
The undersigned applies for a permit to perform the electrical work described below.
Location (Street & Number 6�
Owner or
Owners Address 7 L j,(y W/
Is this permit in conjunction with a building permit (Y� :0) No 9 (Check Appropriate Box)
Purpose of Building A-�C, 4 -1e -A Utility Authorizzation No.
Existing Service Amps.
New Service Amps Voits
Voits Overhead 0
Undgmd 9 No. of Meters
Overhead 0 Undgmd 0 No. of Meters
Number of Feeders and Ampacity .4 ; I g-- 4 Q g.1 1 /9 a A
Location and Nature of Proposed Electrical Work e�E 1— OL Z),Z74 12,7zJ 12 ,L.HCe, &—re-cz.
INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws
I have a current Liability Irmur2nce Policy including Completed Operations Coverage or its substantial equivalent YES = NO
have submitted valid proof of same to the Office YES = NO - If you have checked YES please indicate the type of coverage by checking the appropriate box.
INSURANCE - BOND - OTHER - (Please Specify)
(Expiration Date)
Estimated Value of Electrical Work$
Work to Start Inspection Date Resquested —Rough Final
Signed under the/Renatties Of PF"ju
FIRM NAME_fe-4-r—/O� T�-L4110—letl LIC. NO. P 76 Yl
Licensee 7_ _______,Signature 1z LIC. NO.__,,j-,76,31
(/ 671 f74Y
Bus. Tel No.
e
'r, )// /4L./
Address e,.c_ -- - Att Tel. No.
OWNER'S INSURANCE WAIVER: Vfim aware that the Licenses does not have the insurance coverage or its substantial equivalent as required by Massachusel
General Laws. And that my signature on this permit application waives this requirement. Owner Agent (Please Check one)
Telephone No. PERMIT FEE $
(Signature of Owner or Agent)
Total
No. of Lighting Outlets
No. of Hot fuse
No. of Transformers KVA
Above 9
In 9
No. of Lighting Mixtures
Swimming Pool gmd 9
gmd 9
Generators KVA
No. of Emergency Lighting
No. of Receptacles Outlets
No. of Oil Burners
Battery Units
No. of Switch Outlets
No of Gas Burners
FIRE ALARMS No. of Zone
No. of Detection and
Total
No. of Ranges
No of Air Cond
Tons
Initiating Devices
Heat Total Total
No. of Diposal
No. Pumps
Tons
KVV
No. of Sounding Devices
NoJ of Self Contained
No. of Dishwashers
SpacetArea Heating
KW
Detection/Sounding Devices
9 Municipal a Other
No. of Dryers
Heating Devices
KVV
Local Connection
No. of
No. of
Low Voltage
No. of Water Heaters KW
Signs
Bailases
Wiring
No. Hydro Massage Tuds
No. of Motors
Total HP
I
INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws
I have a current Liability Irmur2nce Policy including Completed Operations Coverage or its substantial equivalent YES = NO
have submitted valid proof of same to the Office YES = NO - If you have checked YES please indicate the type of coverage by checking the appropriate box.
INSURANCE - BOND - OTHER - (Please Specify)
(Expiration Date)
Estimated Value of Electrical Work$
Work to Start Inspection Date Resquested —Rough Final
Signed under the/Renatties Of PF"ju
FIRM NAME_fe-4-r—/O� T�-L4110—letl LIC. NO. P 76 Yl
Licensee 7_ _______,Signature 1z LIC. NO.__,,j-,76,31
(/ 671 f74Y
Bus. Tel No.
e
'r, )// /4L./
Address e,.c_ -- - Att Tel. No.
OWNER'S INSURANCE WAIVER: Vfim aware that the Licenses does not have the insurance coverage or its substantial equivalent as required by Massachusel
General Laws. And that my signature on this permit application waives this requirement. Owner Agent (Please Check one)
Telephone No. PERMIT FEE $
(Signature of Owner or Agent)
The Commonwealth of Massachusetts
Department of Industrial Accidents
F
Office of Investigations
Boston, Mass. 02111
Workers' Compensatm Insurance A ffida vit
FNa�me Please Print
Name:
Location:
city Phone #
I am a homeowner perfon-ning all work myself
I am a sole proprietor and have no one worldng in any capacity'
F-1 I am an employer providing workers! compensation for nTy employees working on this jc)b.
Company name.
Address
citw, Phon�
insurance Go. Policy #
CornpM name
A_ddres—s
Ph=w:*
Failure to secure cowevage as required urider Seeftn 25A or UGL 152 can hwd tothe krVasOm of crkrawe penaMes c)r.aVrMft t—V
andfor am years'
understand that a copy of this statement may belormarded to the Office of fly kg�. cif the DIA for coverag& ver�on.
1 do hereby cerMy w ?dqr 09 pabs aod penaMes Of P9 WANY hW Me anbrnm Ow pn Dvided abaoe is &w and e o rrect
Signature —Date
Print name
Oftial use only do not write, in t1is area tD be cmVkAed by city or town dficiar'
CAy ot Town
ElCheck I kmnecUate response is requked boansilh
&Nectrn
Contact person. Ptxxm Health L
Other
VkORT#1
0
CH
.? -,,-21) - 0 3 -
Date..................................
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
Thi� certifies that ....... ......... ............................................
has permission to perform ...... .......
. : . (� !,\ A � 11 -
wiring in the building of ...................................................................................
at ...... ....... .................... . NorthA,"dover, Mass.
Fee .... ... ..... Lic. No.�'.51J3 ......
.. .. ... ... ................... .............................
ELECIRICAL INSPECrOR
Check# -�3 to kf
,(. j j ,
TRECOMWONWEALTHoFMAMCHUSEM Office Use oni
DEPAXM1ZAT0FPUBMCS4FE7Y -IV
Permit No. �A 5 , _�
BOAROOFF)REPREVEMONREGUL4TIOMS27aRlz.00 cupancy & Fees Checked -7
Lol
APPLICITIONFORPERA41TTOPERFORMELECTRIC4LWi
ALL WORK TO BE PERFORMED
(PLEASE PRINT IN INK OR TYPE ALL I IN ACCORDANCE WITH THE MASSACHUSSTS ELEC-MCAL CODE, 527 CMR 12:00
Town o NFORMATION) ZM�2 �72z�2,5)
f6� To the Inspector of Wires:
The undersigned applies for a permit to perform the electrical work described below.
Location (Street & Number) 2-7 C_ 4 U VIC S—r -
Owner or Tenant JA TAk7d IvLa=
Owner's Address
Is this permit in conjunction with a building permit: Yes M NO (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
4 -
No. of Lighting Outlets
No. of Hot Tubs
--------- L____�
No. of Transformers
Total
No. of Lighting Fixtures
Swimming Pool
Above
Bel -w
Generators
No. of Receptacle Ou dets
No. o Oil Burners
ground U-- I
aroow
nd
No.
KVA
OfEmergency Lighting Bat—ter—yUn—its
No. of Switch Outlets
__—f
No. of Ranges
No. of Gas Burners
No. of Air Cond.
Total
FIRE ALARMS
Tons
No. Of
Zones
No. of Disposals
No. of Heat
Total
Total
No. of Detection and
No. of Dishwashers
_[�_ Pumps
Space Area Heating
Tons
KW
Initiating Devices
KW
No. Of Sounding Devices
No- Of Self Contained
No. of Dryers
eati
Heating Devices
s
4
KW
Detection/Sounding Devices
�vic
Local Municipal
Other
No. of Water Heaters
EEE
KW
No. of
0�of
No. of
Connections
No. Hydro Massage Tubs
Signs
No. of Motors
Bailasis
Total HP
OTFIER-
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LicamNo.— /TO 53
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WNER'SKSURANCEWAIVER- lam awaie46the I imwdoesnothav��MarMWODWrdg�crils-qtsWrtdeqwvakuasmgmedbyMa%adugE�ZGffiedLays
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lease check one) Owner Agent
Signature or Uwn—eror Agent Telephone No. PERMIT FEE
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ACOR - CERTIFICATE OF
LIABILITY
-1
INSURANCE
DATE (MM/DDNY)
05/lt/99
PRODUCER
I TYPE OF INSURANCE
THIS CERTIFICATE
IS ISSUED AS A MATTER OF INFORMATIOW'V--
Bechard Insurance Agency, Inc.
PO Box 884
211 Main Street
LIMITS
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
GENERAL LIABILITY
1680808W1377COF
Nashua, NH 03060
06/12/99
EACH OCCURRENCE $1, 000, 000
INSURERS AFFORDING COVERAGE
INSURED
.A.J. Wood Construction
.86 Shore Rd.
Salem, NH 03079
X COMMERCIAL GENERAL LIABILITY
INSURER&
Travelers Insurance Cc -Comm. Lines
INSURER B:
INSURER C:
INSURER D:
INSURER E:
PERSONAL & ADV INJURY $1, 000, 000
I
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
IISR
LTR
I TYPE OF INSURANCE
POLICY NUMBER—
POLICY EFFECTIVE
DATE (MM/DDNY)
IPOLI EXPIRATION
DATCEY(MM/DDNY)
LIMITS
A
GENERAL LIABILITY
1680808W1377COF
06/12/98
06/12/99
EACH OCCURRENCE $1, 000, 000
FIRE DAMAGE (Any one fire) $300,000
X COMMERCIAL GENERAL LIABILITY
CLAIMS MADE ERJOCCUR
MED EXP (Any one person) s5, 000
PERSONAL & ADV INJURY $1, 000, 000
—7
GENERALAGGREGATE s2, 000, 000
GEN'L AGGREGATE LIM ITAPPLIES PER:
PRODUCTS - COMP/OP AGG s2, 000, 000
POLICY 7 PRO- F7 LOC
JECT
—7
AUTOMOBILE
LIABILITY
COMBINED SINGLE LIMIT $
ANY AUTO
(Ea accident)
BODILY INJURY $
ALL OWNED AUTOS
SCHEDULED AUTOS
(Per person)
BODILY INJURY $
HIRED AUTOS
NON -OWNED AUTOS
(Per accident)
PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY
AUTO ONLY - EA ACCIDENT $
OTHER THAN EA ACC $
ANY AUTO
AUTO ONLY: AGG $
EXCESS LIABILITY
EACH OCCURRENCE $
AGGREGATE $
7 OCCUR F_� CLAIMS MADE
$
RDEDUCTIBLE
$
RETENTION $
A
WORKERS COMPENSATION AND
IUB744Y470299
02/21/99
02/21/00
'WC STATU
S I JOTH
IT R ER
Y LIMIf
E.L. EACH ACCIDENT $100, 000
EMPLOYERS' LIABILITY
E.L. DISEASE - EA EMPLOYEE $100, 000
E.L. DISEASE - POLICY LIMIT $500,000
OTHER
I
DESCRIPTION 0.1 OPE,9ATIO%IVLOCATIONSIVEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
** Workers Comp Information
Other States Coverage
RE: Different Jobs through out the year
ADD
Shirley Community Development
Program
Shirley Town Hall
Shirley MA
— - __ - \., - , _, 1_1 I- Tr , � � �
LETTER:
SHOULD ANYOFTHE ABOVE DESCRIBED POLICIESSE CANCELLED BEFORETHE EXPIRA71ON
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 1 0 DAYSWRITTEN
NOTICETOTHE CERTIFICATE HOLDERNAMED TOTHE LEFT, BUTFAILURE TODOSOSHALL
IM POSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON TH E INSURER,ITS AGENTS OR
REPRESENTATIVES.
AUTHORIZED REPRE ENTATIVE
.r,
Town of North Andover
OFFICE OF
COMMUNITY DEVELOPMENT AND SERVICES
27 Charles Street
North Andover. Massachusetts 01845
WILLIAM J. SCOTT
Director
(978) 688-95 3 1
0 T -T I
.:� 1 16, 0 0
0
1K
"�ACHU�-�
Fax (978) 688-95,112
in accordance with the provisions 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 c 11, S
15 0 A.
The debris will be disposed of in: 1.
-(S
�illqlye(,u 6ro/)
(Location of Faciflity)
Signature of Pehnit Applicant
q116 ( �y
Date
NOTE: Demolition permit from the Town of Ncr-th Andover must be obtained for
this project through the Cffice of the Building Inspector
M
8
BOA -RD 0FAPPE,1_LS 638-954, BUILDING 68S-9545 CONSERVATION 683-9530 HE.,tLTH 688-9540 Pl_�_NRNING 68V)J35
4
07.
DEPARTMENT OF PU8LIC SAFETY
CONSTRUCTION SUPERVISOR LICENSE
Number: - Expires: Birthdate:
CS 07@882 0712812001 07/28/1956
MUNRO 10: vu
RICHARD. 3 SMITH
86 SHORE DRIVE
SA L E M, NH 030 79
q,
ANE IMPROVEMENT -CONTRACT'
OR
RegiWation 106603
Type - 08A
-Expiration .07124100
AJ WOOD COMRUCTION
Richard j, smith
h o r e D r i v e
ADMINISTRATOR
Salem.Ng 030,79
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Date. � ........... f ......
14oftTk TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
I , I -, I —
This certifies that .............................................
has permission for gas installation
........... ............
in the buildings of
at
..................... ...... North Andover, Mass.
Fee�� . Lic. NO.5;1?z ... ...... ......
GAS INSPECTOR,
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
MASSACtiUSETTS UNIFORM APPLICATION FOR PERMIT T ASFITTING
(Print or Type)
NORTH ANDOVER Mass. Datel 21-�j /99'
�uilding 'Location 27 CHURCH STREET 77;
Permit #
Owners Name CHRISTOPHrR LATHROP
New Plans Submitted
Renovation El Replacement uf 0
FIXTUPICIZ - - -
a
(Print or Type) Check one: Certificate
Installing Company Name ANDOVER PLBG.
& HTG. CO. INC.EE
Corp. 2122
Address 20 AEGEAN DR.
UNIT 1 10
Partner.
METHUEN, MA.
01844
Firm/Co.
UUM-01 I
=ME=
ES1
SEE
MEALM14
(Print or Type) Check one: Certificate
Installing Company Name ANDOVER PLBG.
& HTG. CO. INC.EE
Corp. 2122
Address 20 AEGEAN DR.
UNIT 1 10
Partner.
METHUEN, MA.
01844
Firm/Co.
Business Telephone: 978-685-8383
Name of Licensed Plumber or Gas Fitter (.,-FogrF I Ago_SF
Insurance Coverag In dicate the type of insurance coverage by checking the
appropriate box:
Liability insurance policy Other type of indemnity = Bond
Insurance Waiver: 1, the undersigned, have been made aware that the licensee of
this application does not have, any one of the above three insurance coverages.
Signature of owner/agent of property Owner 0 Agent El
I hczeby cerdry that all of (he dcuils and information I have submitted (or entered) In above application are true " accurate to the best Of rnY
knowtcdge and that &U p(umbing work and InstAtUtions paforrnc�d under'Ptcralt iuLtd [oz this *ppLication will-bc in complianca with au Pertinent
provisions or tho Wssachusetts State Cis Cade and (lipter 142 of the General Laws.
By
Title
City/Town:
APPROVED (OFFICE USE ONLY)
,TYPE LICENSE:
Plumber
Gasfitter- Siql�ature of Licensed
I Master Plumber or Gasfitter
Journeyman 9983
License Number
r
Date .............
N2 .. j -
,AORTM
TOWN OF NORTH ANDOVER
0
PERMIT FOR PLUMBING
11 'Low—
S" CHUS
This certifies that ..................
has permission to perform .................
plumbing in the buildings of ........ ...................
at ....... ........................ North Andover, Mass.
Fee .......... Lic. No/ �—� .... .................... �( ...........
PLUMBING INSPECTOR
WHITE: Applicant CANARY: Building Dept PINK: Treasurer
NORTH ANDOVER, MASS. Daie DEC. 21—...Ig_j9
Building Pe A#.
Location 27 CHtJRCH STRFFT 7.
Name CHRISTOPHER LATHROP
New 0 Renovation 0 Re erA PlansSubmKied: YesCj No.C]
F1 e-Tr;.nMF1ES
Check cm: Cert)(I"te
Installing Company Name ANDOVFR PI G, &- HTQ. CQ-. INC. gCorp. 2122
Address 26 AEGEAN DR. --UNIT # 10 13 Partners hip
MFTHIJFN, MA- 01844 0 Firm/Co.
Business Telephone 978-685"8383
Name of Ucensed Plumber _r, F 0 g r, F i A g o s F
INSURANCE COVERAGE! U-necK ope
I have a current Ilablifty Insurance policy or As substantial equivalent. Yes 13, No 0
It you have checked jM. please Indicate the type coverage by checking the appropriate box
A liability insurance policy Other type c( Indemnity 13 Bond 0
OWNER'S INSURANCE WAIVER: I am aware that the licenses does not have the Insurance coverage requIred by
ChaMer 142 of the Mass. General Laws, and that my slgn&tLff a an tWa permit application waives this requirement.
Check one:
slonahns of Own9t or 0,vnef I a Aeon( Owner 0 Agent 0
I hateby ewilty that an of the details and Informailon I have vibntted lor entsteo in &bay* application we bue and &=mate to the bast of my
know4d9a "that all pfurnbingwock and hutafialloneWornwd txWw the rrnitluuod lortMeappikationwill be in oonvRance with afl
Winent provisions of the Massachusetts State PkffnbkV Cod* arxi Chapter r42 of tM Gumal Laws.
This
Ctty/'Town
AlTrKMD (OFFICE USE ONLY)
,-,/81gnattx* of Ucensed Plumbler
Ucens* Numbee -9 9 8 3
Type of Pknbing Uosnse: Master
Joutneyman 0
z
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MAGRUNNT
ISTFLOOR
INDFLOOR
$11115 FLOOR
4TH FLOOR
ITH FLOOR
I A
6TH FLOOR.
ITH FLOOR
TH FLOOR
I
V .
--
V .1
-
Check cm: Cert)(I"te
Installing Company Name ANDOVFR PI G, &- HTQ. CQ-. INC. gCorp. 2122
Address 26 AEGEAN DR. --UNIT # 10 13 Partners hip
MFTHIJFN, MA- 01844 0 Firm/Co.
Business Telephone 978-685"8383
Name of Ucensed Plumber _r, F 0 g r, F i A g o s F
INSURANCE COVERAGE! U-necK ope
I have a current Ilablifty Insurance policy or As substantial equivalent. Yes 13, No 0
It you have checked jM. please Indicate the type coverage by checking the appropriate box
A liability insurance policy Other type c( Indemnity 13 Bond 0
OWNER'S INSURANCE WAIVER: I am aware that the licenses does not have the Insurance coverage requIred by
ChaMer 142 of the Mass. General Laws, and that my slgn&tLff a an tWa permit application waives this requirement.
Check one:
slonahns of Own9t or 0,vnef I a Aeon( Owner 0 Agent 0
I hateby ewilty that an of the details and Informailon I have vibntted lor entsteo in &bay* application we bue and &=mate to the bast of my
know4d9a "that all pfurnbingwock and hutafialloneWornwd txWw the rrnitluuod lortMeappikationwill be in oonvRance with afl
Winent provisions of the Massachusetts State PkffnbkV Cod* arxi Chapter r42 of tM Gumal Laws.
This
Ctty/'Town
AlTrKMD (OFFICE USE ONLY)
,-,/81gnattx* of Ucensed Plumbler
Ucens* Numbee -9 9 8 3
Type of Pknbing Uosnse: Master
Joutneyman 0
Permit NO:
Date Issued:
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
I TYPE OF IMPROVEMENT I PROPOSED USE I I
Non- Residential
0 New Building tTOne family
11 Addition 11 Two or more family 0 Industrial
0 Alteration No. of units: 11 Commercial
El Repair, replacement El Assessory Bldg 11 Others:
0 Demolition 0 Other
�D 866tic" " 0 Well, C P1 n 1:.7ti, -at 'District
-ershed
DESCRIPTION OF WORK TO BE PREFORMED:
'Q /Nv 4 /F-" /1 6 1, /`� �2-- 5Z.
ARCHITECT/ENG I NEER Phone:
Address: Reg. No.
FEE SCHEDULE: BULDING PERMIT., $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ f p Z) FEE: $ / IZ';r�
Check No.: 43 %2 � T5-- Receipt No.: 0� 0 57 (:�
NOTE: Persons contracting ith nre . tered contractors do not have access to th Ityfund
Signature of Agent/OwnerM7.-11- Signature of contractozMrA
0 — 0 \1 I � I--,
Plans Submitted El Plans Waived 11 Certified Plot Plan D
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT
COMMENTS
Stamped Plans F1
DATE REJECTED DATE APPROVED
DATE REJECTED DATE APPROVED
CONSERVATION El F1
COMMENTS
HEALTH
COMMENTS
a
DATE REJECTED DATE APPROVED
TYPE OF SEWER -AGE DISPOSAL
Public Sewer
Tanning/Massage/Body Art
Swimming Pools
Well
Tobacco Sales
Food Packaging/Sales [I
Private (septic tank, etc.
Permanent Dumpster on Site El
Zori'ag Board of Appeals: Variance, Petition No: -_____Zoning Decision/receipt submitted yes
Planning Board Decision:
Conservation Decision:
Water & Sewer Connectio
Located at 384 Osgood Street
Comments
Comments
FIRE DEPARTMEN'T . T6mn -D
pl, urapster,Qn site' nb
y
Located at 424 Main Street,,
00, M M E NTT S.
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
ELECTRICAL: Movement of Meter location, mast or service drop requires approval of
Electrical Inspector Yes No
DANGER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21 A —F and G min.$100-$l 000 fine
Building Department
The following is a list of the required forms to be filled out for the appropriate permit to be
obtained.
Roofing, Siding, Interior Rehabilitation Permits
• Building Permit Application
• Workers Comp Affidavit
• Photo Copy Of H.I.C. And/Or C.S.L. Licenses
• Copy of Contract
• Floor Plan Or Proposed Interior Work
L3 Engineering Affidavits for Engineered products
Addition Or Decks
L3 Building Permit Application
• Certified Surveyed Plot Plan
• Workers Comp Affidavit
• Photo Copy of H.I.C. And C.S.L. Licenses
• Copy Of Contract
• Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan
And Hydraulic Calculations (if Applicable)
• Mass check Energy Compliance Report (If Applicable)
• Engineering Affidavits for Engineered products
New Construction (Single and Two Family)
u Building Permit Application
c3 Certified Proposed Plot Plan
u Photo of H.I.C. And C.S.L. Licenses
Li Workers Comp Affidavit
• Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan
And Hydraulic Calculations (if Applicable)
• Copy of Contract
c3 Mass check Energy Compliance Report
u Engineering Affidavits for Engineered products
In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the
Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds.
One copy and proof of recording must be submitted with the building application
Doc- INSPECTIONAL SERVICES DEPARTMENT:BPFORM07
Revised 2.2007
Locatio,PQ-4 (Wiveld', 5 -1 -
No. Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
Building Inspector
i —
.-IJ17
Te
z
s and Standards
.1cense
5
Tr# 4731
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The Coiitinoitwealth ofWassachiliselis
Mparitneia of'Itiditstrial Accidews
Ofjice of M vest�gatiolls
600 11"asliiiigtoti Street
Bostoli,.AIA 02111
wjt,w.tnass.gov1dia
wol-kers, Coil) pellsati Oil 111suralice Affidavit:
Applicapt hifoi-matiol, Neise Print Legibly
Nmile (Business/Orgaiiiz,,itioii/Iii(tividiial): AL 1,_ j n-12 —,1 6 " /7 a's ;,--
Address: .1"', 494
City/State/Zip: H A'j `\ ft_/�L Pholic il
e7?,l Y - 4t -y )---7j-j /
A u all employer? Check the appropriate box:
1.)Y10ain demployer with 4. [:11 ani a gencral contractor in(] I
employees (full and/or I)art-tiiiic).* havc hircol flic sub -contractors
2. n I aina sole pioprictor or partncr-
ship and have no cinployccs
working for nic in any capacity.
[No workus'comp. insurance
rcqu4cd.]
3.0 1 ania honicowner doing all work
inyscif [No workers' comp.
insurance tcAluircd] t
listed on thc attachcol shcct i
These sub-contiactors have
workcis' coinp. insmancc.
5. n We -,lie a corporation and its
officers have excrciscd their
right of excniption per MGL
c. 152, § 1(4), and we have no
cniployces. [No Nvorlocts'
conip. insuiance required.]
Type of project (required):
6. F] New constructioii
7. Reniodcling
8. Dcniolition
9.0 Building addition
10.0 Electrical rcpairs or additions
I LEI Plumbing rcpairs or- additions
12.Fj Roof rcpairs
13.0 Other
*Any applicant that checks lyox I/ I n Ili st also fill out tile Sect ion below sill Milig tilcir wolke Is' co I 111-1-tioll r-licy inromint ion
t lionveownen who submit this affi(Invit indicating they rut dohig nil work and then hite outside COIAMOOTS, Iml-st sulmnit a new*nflidavit indicilthig SUCIL
lContractors that clieck thisbox most atinclied air additional shect showing tile 11allic oftlic sub-conit actors and their wotkm' con)p. policy inrorillatic)II.
I am all employer that is providing ii,orkers'compellsatioll ills urall cc for nly eltililoyces. Below is file policy andioll site
Mfortitati011.
Insurance Company Nanic: M j TV-yv (
Policy fl or Self -ins.
Lie. H: 0
C-:4 A — t -T-
Expiration Date: I(
Job Site Address:
2,
33—
City/Statc/Zip:-.
Attach a copy of the workers' compensation policy -declaration page (sholving the policy number and expiratioii date).
Failure to secure coverage as required under Scction 25A ofMGL c. 152 can lead to tile il"position of criminal petialtics of a
fine up to $1,500.00 and/or one-year impris011ilicill, as well as civil peliallics in die Form of a STOP WORK ORDER arld a fine
of up to $250.00 -a day against die violator. Be adviscd that a col)y of this statcnient ifiay be rorwarded to die Office of
Investigations of die DIA for insurance coverage verification.
i lwita ies , It I C t.
I do hereby certify under f� Imins all I ofpcijuij, that the infi),-litatioti Itrovided above is it -lie a d co -t- c
% ip,
Signature: Date-.
Phone ct 7
Official use only. Do not irrite in this area, to be coinl4eted kv city of' lowli offici . al.
City or Town: Perinit/License H
Issuing Authority (circle one) -
1. Board of Health 2. Building Departmetit 3. cityrrown, Clerk 4. Eller-trical Inspector 5. Plumbing Itispector
6. Other
Contact Person: I'llone H:
.1 V
CORD—
L'nsu=ca Av=y
MA, 1 C-45
JOHN L4uNzAFAa_AlIC_
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Chimneys Kesidentiall & Gorninnerciall Kooting All Types Of
Siding CIHIMNEYS POINTED -REBUILT -CAPPED Expert Masonry Work
Mass Toll Free I * Roof Leaks Experts * Licensed & Insured
I -800-WAIT-4-US r-ocally Owned & Operated Since J 9 76 ........ t License #034200
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(924-8487) IKO Cz&' *Norm cc 9ohv We Work Year Round
978-794-3883 Ejlfle�ele4l 978-975-7531
70jeffersonSt., North Andover, MA01845 &4ccz�W&el, 4�;Fec-" 30 Temple Dr., Methuen, MA 01844
Ph Date
Proposal Submit V 12
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City, State & Zip Code Job Location
41411 —To,
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Phone
We Propose hereby to furnish and labor in accordance with specifications below, for the sum of:
41�1.�3AJ 9"S-oo' 6 6
4121-rtIT J12.511 C"�'2�0 Dollars ($
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All material is guaranteed to be as specified. All work to be completed in a workmanlike Authorized
manner according to standard practices. Any alteration or deviation from specifications be- Signature:
low involving extra costs will be executed only upon written orders, and will become an
extra charge over and above the estimate. All agreements contingent upon strikes� accidents NOTE: This propouma—ybe
or delays beyond our control, Owner to carry fire, tornado and other necessary insurance.
Our workers are fully covered by Workmen's Compensation Insurance. withdrawn by us if not accepted within days.
We hereby submit specifications and estimates for-'all
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QK'n"s'ta_Ha'J!4�� barrier bottom
ater prot—ectio-n-a—long all edges of roof
and top to bottom in each valley. l0roof is stripped, we will appjy conventional ice and water shield
ft. high in ' the same locati-o'ns—previously described and tar paper will cover the
remaining bare wood. Any rotted or damaged boards will be replaced at per linear ft.
or per sheet of plywood.
P'lln/stall heavy gauge aluminum drip edges along every edge surface of each roofline.
Cover entire roof (S�) with lK0 ��t-,non-fiberglass, premium grade shingles
(Color of choice). _F� Lj, i oc� q11 C1141kn
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