HomeMy WebLinkAboutMiscellaneous - 282 BLUE RIDGE ROAD 4/30/2018 (5)�P
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Date.,�.)A.114 .............
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
4 F
This certifies that .... E.6.k ...... [1.6k-
...... .. . ... . ....
has permission to perform-ul'-"'..."', . . .......................................................................
plumbing in the buildings of ............................................................
12 1 k�L e
__,� j ..........
at ..... ............................ 2�. ......... , North Andover, Mass.
Fee ... N . . ...... Lic. No. 610 ....... MtN�
...............................................................................
PLUMBING INSPECTOR
7 r -
Check # 5 2-S
"- '41,
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY AArIL 4,nJjXK-21 MA DATE PERMIT#
ki1W
& d )OWNERSNAME AJ61.4C
JOBSITE ADDRESS jc'
V
POWNER
d
ADDRESS TEL FAX
TYPE OR
OCCUPANCYTYPE COMMERCIAL E:1 EDUCATIONAL RESIDENTIAk;K
PRINT
CLEARLY
NEW: RENOVATION: F1 REPLACEMENT -Ar PLANS SUBMITTED: YES F] NO El
FIXTURES -1 FLOOR— BSM 1 2 3 4 5 6 7 8 9 10 11 '12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIUSAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR / AREA DRAIN
INTERCEPTOR (INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN
.SHOWER STALL
SERVICE / MOP SINK
�OILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES �2 , " 2
WATER PIPING V
OTHER
INSURANCE COVERAGE:
I have a current liabilibf nsurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Y NO E]
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICYP' OTHER TYPE OF INDEMNITY [I BOND El
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER 0 AGENT R
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in coFmplia ce with all Pertinent provision ofthe
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBERS NAME LICENSE # 61UNA I LIKI:
MPZ JP EJ CORPORATION [-] # PARTNERSHIP [I # LLC #
COMPANY NAMEAA&L-�- &05. Pjj.1tA6 / /-)t ADDRESS AO s�
CITY STAT/ t-�8 ZIP TEL
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FAX CELL EMAIL VA U .
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Date ....... . ..... ...
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that ...........................
has permission for gas installa ion ......................................
inthe buildings of ....... ................................................................................
at ..... ...... North Andover, Mass.
Fee..W� ..... Lic. No. �.5)%P ......... .......................................................
GASINSPECTOR
Check # 12
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MASSACHUSETTS UNIFORM APPLICATION FOR A PERJIT TO PERFORM GAS FITTING WORK
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CITY MA DATE PERMIT#
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JOBSITE ADDRESS LtZ /()WNFR"q NAME
(JIFAX
GOWNER
ADDRESS TEL
TYPE OR
OCCUPANCYTYPE COMMERCIAL EDUCATIONAL Ej RESIDENTIAO--
PRE14T
CLEARLY
NEW: Ej RENOVATION: Ej REPLACEMENTA PLANS SUBMITTED: YES E] NO[]
APPLIANCES -1 FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE Apo
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM/ SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER "0
OTHER
INSURANCE COVERAGE
I have a current liabili!y nsurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YESA6 NO
I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY X OTHER TYPE INDEMNITY E] BOND F]
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER [] AGENT
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliancq with all Pertinent provision ofthe
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASATTER NAME IA- 3 LICENSE# (go SIGNATURE
MP 0, MGF E] JP Ej JGF [:1 LPGI Ej CORPORATION [:1 # PARTNERSHIP El # LLC E:1 #
RQ&Lk,9 &2g.061"ML I 1A A t4tJ V- —
COMPANY NAME ADDRESS?
MC6"-' -76 7 - 0 -T -V
CITY S.". ZIP - TEL
FAX CELL EMAIL
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The Commonwealth ofMassachusetis
Depadmint ofinduadglAccidints
Office of Investigations
600 Washington Street
Boston., MA 02111
wwwmassgoMfla
Workers' Compensation Insurance Affidavit: Buflders/Contractors/ElectriciansfPlumbers
Applicant Information Please Print Legib
Name (Businesstorganization&dividual): Q r 0 P)
Address: -23 4-(14
City/State/Zip: b S 4e Phone
6 / n
XA you an employer? Check the appropriate box: Type of project (required):
I am a employer with 4. El I am a general contractor and 1 6. E] New construction
employees (full and/or part-time).* have hired the sub -contractors
2. Ell am a sole proprietor or partner- listed on the attached sheet 7. El Remodeling
ship and'have no employees These sub -contractors have 8. E] Demolition
working for me in any capacity. workers' comp. insurance. 9. F1 Building addition
[No workers' comp. insurance 5.El We are a corporation and its 10-0131ectrical repairs or additions
required-] officers have exercised their
3.0 1 am a homeowner doing all work right of exemption per MGL I 1.P9 Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4), and we have no 12.[] Roofrepairs
insurance required.] t employees. [No workers' 13.[j Other
comp. insurance required.]
*Any applicant that checks box #1 mustalso fill out the section below showing their workers' compensation policy information.
I Homeowners who submit this affidavit indicating they fti-e doing all work and then hire outside contractors must submit a new affidavit indicating such.
k'Antractors that check this box must attached an additional sheet showing the name ofthe sub -contractors and their workers' comp. policy information.
I am an employer that Isproviding workers'compensadon insurancefor my employea. Below is thepoUcy andjob site
informatiom
Insurance Company
PORGY # or Self -ins. Lic. M 14 -W (_44 637 t6 Expiration Date:— >
10LUMMMW& "I'S rV0
Job Site AddressW�—Oww )51Lepid�e-eh-,.,—Pitylst-tezip: AZld /
Attach a copy of the workers' compensation -policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as requirectunder Section 25A of MGL o. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or ono -year imprisonment, as well as civil penalties in the form of a STOP. WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations ofthe DIA for insurance coverage verification.
I do hereby certify under fliepains andpenalfies ofperfury that the information provided above is true and correct.
Official use onoi. Do not write in this area, to he completed by city or town official
City or Town:
PermittLicense #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. CitylTown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
COMMONWEALTH OF MASSACHUSETTS
North Andover
Board of Health
--------------------- SKOWRON-E-K,--CHRISTO-PHE-R --------------------------
NAME
281 BLUE RIDGE ROAD
-------------------------------------------------------------------------------------------------------
ADDRESS
IS HEREBY GRANTED A PERMIT
Well Construction
Well Construction
NUMBER
BHP -2010-0713
FEE
This permit is granted in conformity with the Statutes and ordinances relating thereto, and
expires ----------- December -1-02-201-0 ----------- unless sooner suspended or revoked.
September 10, 2010
Board of Health Chairman
$135.00 1
------------------------------------------------------ Board of
------- C0113 ---------- Health
_,__y ----------
------------------------------------------------------
--- -- --------------
Town of North Andover
HEALTH DEPARTMENT
CHUS
CHECK #: DATE:
LOCATION: "4, xz,,�
H/O NAME:
CONTRACTOR NAME:
486�
WO/O
Type
of Permit or License: (Check box)
0
Animal
$
0
Body Art Establishment
$
0
Body Art Practitioner
$
0
Dumpster
$
11
Food Service - Type.
$
11
Funeral Directors
$
0
Massage Establishment
$
0
Massage Practice
$
0
Offal (Septic) Hauler
$
0
Recreational Camp
$
0
Sun tanning
$
0
Swimming Pool
$
0
Tobacco
$
0
TrashlSolid Waste Hauler
$-
0
Well Construction
$
SEP77C Systems:
0
Septic - Soil Testing
$
0
Septic - Design Approval
$
0
Septic Disposal Works Construction (DWC)
$
0
Septic Disposal Works Installers (DWl)
$-
0
Title 5 Inspector
$
11
Title 5 Report
$
I
Health Agent Initials
White - Applicant Yellow - Health Pink - Treasurer I
0 �— -�L6 -155 -
TOWN OF NORTH ANDOVER
Office Of COMMUNITY DEVELOPMENT AND SERVICES
HEALTH DEPARTMENT
1600 OSGOOD STREET; BUILDING 20; SUITE 2-36
NORTH ANDOVER, MASSACHUSETTS 0 1845
Susan Y. Sawyer. RERQ/DQ
Public Health Director
Well and/or Pum lication
(Pleatin .
978.688-9540 - Phone
978.688.8476 - FAX
ealthde t townofn
orthandover co
www.townofnorthandover.com
t'. lit)
DATE: to
LOCATION to Drill Well or install a pump:
L
Licensed Well COntracto Name and Company Name: A/t 0/-L &14 ec, rpc
�6 L L
I Ontact Phone Numbers -
t 3
----------
Romeowner:
PLLS-m
q,/L
K 1
0 1.4 60R.0 N e
Address: l?)
hue–
A06 -e,
kA. P - A *fDQjeA
Contact Phone Numbers:
WEL" (to be completed at time of pump test)
Type of well: V (x.3 r— K,
Use:
Diameter of well: ------- a ------�Size of Casing:
Depth Of bedrock:
Depth of casing into bedrock:___.
Sea] been tested? Yes No Date of test:
Depth of well: Water -bearing rock:
Depth of water:_ Delivers:— GPM for:
Drawdown:_
Date of Completion:
feet after pumping:_ (how long)
hours at: r-plu
PUMPS (To be filled in before installation)
Name & size of Pump:
Size of Tank:
Pipe used in well:
Sleeve used to protect pipe?
Cast lron—
UJ,
Type:
Pump delivers: —GPM
Galvanized— Plastic
Yes No-- -Typeofwell seal:
Date:
Signature of � �jnpjnsta�jler�
Date wafty analysis report sobinitted to Health Department,
Plumbing
Wiring Inspector
C:\DOCUME—I\bcurran\LOCALS—I\Temp\WelI Application.doc
Health Department Representative
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41.9
pi! �Al 7.29' 67.08'
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57.1'
...........
S
100'BUFFE:
EXISTING STONE WALL
PROPOSED 44, '0� To BE REMOVED
FENCE
6'x6'FIREPLACE
...........
281 BLUE
PATIO
RIDGI
AREA
ASSESSORS
DECK.
43,588
sy
CK
000 t
/E
EXISTING SMNGSET
EXISTING
BUILDING C
GFE. 84.10 TRIDGE FILTER
#281 8 POOL EQUIPMENT
PRO pris'e
NTROL 72.91 w (-:- Lf'-
LlbC AT jo
L=165.14' 23-0(
R=617 -23t
TE7
3675
0 0 Aidm&k 0
0 "O"'w - Town
-of North Andover
HEALTH DEPARTMENT
Its
CHECK#: + DATE:
LOCATION: 3 r'A PS-I-u� R I b�C- N, A-
H/O NAME:
CONTRACTORNAME: 0-4figW- W��010-fvS
TyRe
of Permit or License: (Check box)
$
0
Animal
$
0
Body Art Establishment
$
0
Body Art Practitioner
$
0
Dumpster
$-
0
Food Service - Type.
$
0
Funeral Directors
$
0
Massage Establishment
$
0
Massage Practice
$
0
Offal (Septic) Hauler
$
0
Recreational Camp
$-
0
Sun tanning
$
•
Swimming Pool
$
•
Tobacco
$
•
TrasIVSolid Waste Hauler
)3
Well Construction
SEP77C Sustems:
•
Septic - Soil Testing
$
•
Septic - Design Approval
0
Septic Disposal Works Construction (DWC)
0
Septic Disposal Works Installers (DWI)
0
Title 5 Inspector
$
0
Title 5 Report
$
0 Other (Indicate) $
�/6/
lleahh)A�ent Initials
White - Applicant Yellow - Health Pink - Treasurer
"ORTh COMMONWEALTH OF MASSACHUSETTS
North Andover
Board of Health
------------------------------ Ch-a-rles-M-.--R-oll-i-ns-Co.,--I-nc -----------------
NAME
282 BLUE RIDGE ROAD
----------------------------------------------------------------------------------------------
ADDRESS
IS HEREBY GRANTED A PERMIT
Well Construction
Bedrock Irrigation Well
NUMBER
BHP -2008-0223
FEE
$135.00
-----------
This permit is granted in conformity with the Statutes and ordinances relating thereto, and
expires --------------- March 091-2009 --------------- unless sooner suspended or revoked.
December 09, 2008 -------------------- ----- I ---------------------------------------- Board of
------------------------------- - -------------- ----- ------ Health
----- - ---------- -- ------
-------------------------------- - -----
-----------------------------------------------------------------
-v
COMMONWEALTH OF MASSACHUSETTS
North Andover
Board of Health
------------------------------ Ch-arles-M-.--Roll-i-n-s-Co.,--I-n-c -----------------
NAME
282 BLUE RIDGE ROAD
----------------------------------------------------------------------------------------------
ADDRESS
IS HEREBY GRANTED A PERMIT
Well Construction
Bedrock Irrigation Well
NUMBER
BHP -2008-0223
FEE
This permit is granted in conformity with the Statutes and ordinances relating thereto, and
expires --------------- March 0912009 --------------- unless sooner suspended or revoked.
$135.00 1
December 09, 2008 ----------------------------------------------------------------- Board of
----------------------------------------------------------------- Health
-----------------------------------------------------------------
-----------------------------------------------------------------
-----------------------------------------------------------------
Town of North Andover
HEALTH DEPARTMENT
Cow
CHECK#: DATE:
LOCATION: �-ui R I tj'\'f C- r,
H/O NAME:
CONTRACTOR NAME: C t4k 97 &,� W.�' 4 4 1 k S -
Type of Permit or License: (Check box)
0 Animal $
0 Body Art Establishment $
0 Body Art Practitioner $
0
Dumpster
$
0
Food Service - Type.
$
0
Funeral Directors
$
0
Massage Establishment
$
0
Massage Practice
$
0
Offal (Septic) Hauler
$
0
Recreational Camp
$
0
Sun tanning,.-,
$
0
Swimming Pool
$
0
Tobacco
$
0
TrashlSolid Waste Hauler
$-
13
Well Construction
$ —) —3 —'� - �)
SEP77C Systems:
0
Septic - Soil Testing
$
0
Septic - Design Approval
$
[3
Septic Disposal Works Construction (DWC)
0
Septic Disposal Works Installers (DWI)
$
0
Title 5 Inspector
$
13
Title 5 Report
$
0
Other (Indicate)
$
&aIih1Aj'e'nt In itia Is
White - Applicant Yellow - Health Pink - Treasurer
I-
P — C, 7 'E-: D
TOWN OF NORTH ANDOVER
Office of COMMUNITY DEVELOPMENT AND SERVI ES 4 008
HEALTH DEPARTMENT
1600 OSGOOD STREET; BUILDING 20; SUITE 2-36 TOM, /-u\JD0VER
NORTH ANDOVER, MASSACHUSETTS 01845 HEALTH RTMENT
Susan Y. Sawyer, REHS/RS 978.688.9540 — Phone
Public Health Director 978.688.8476 — FAX
healthdept@townofnorthandover.com
www.townofnorthandover.com
Well and/or Pump Application
(Please print)
DATE: I - OL
LOCATION to Drifl Well or install a pump: �Lm " .
Licensed Well Contractor Name and Company Name: C �A*gXe5, ,AA. P-0 k-L�' rj 'S ca tj
L 12% t> -?'Q -r- -9-A' , 60 X C-0 V4 -D. f-4 � 0"4Ge- Uj'
Contact Phone Numbe
k-151M�A -7 8
Homeowner:
Address:- �J. Ar avo ve-�
Contact Phone Numbers:
WELLS (to be completed at time of pump test)
Type of well: Ae -1) izo C– Use:
Diameter of well: (.0 —Size of Casing-
X-�r
Depth of bedrock: Depth of casing into bedrock -
Seal been tested? Yes( No( Date of test:
Depth of well: Water -bearing rock:
Depth of water: Delivers:—
Drawdown: feet after pumping:
Date of Completion:
PUMPS (To be filled in before installation)
GPM for.
(how long)
hours at. GPM
Gk-�o L'45'—Ak"
Signature eell Contractor
Name & size of Pump: Type:
Size of Tank: Pump delivers: —GPM
Pipe used in well: Cast Iron— Galvanized Plastic
Sleeve used to protect pipe? Yes No_ Type of well seal:
Date:
Date water analysis report submitted to Health Department:
Plumbing
Wiring Inspector
Signature of Pump Installer
C:\DOCUNE-I\bcurran\LOCALS-I\Temp\WelI Application.doc
Health,Departinent Represe tive
Town of North Andover RE: Applications for a permit to drill a well:
Before a permit can be issued, you must have your contractor submit the following:
1. Submit to the Health Department a site plan showing the house and or lot
footprint
2. Indicate any wetlands within 200 feet of the proposed location for the well
3. Indicate the well location
4. Submit a check for $135.00 with the application
Note: All submittals must be drawn to scale. Please note that you may also be
required tofile with the Conservation Commission ifwetlands are near to the
proposed well, and to the Planning Board ifyou are located in the Watershed
District.
Hwrican burvelj 781 893 6477 P,01/01
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AMERICAN SURVEYING COMPANY
OF BOSTON, INC.
1204 NM 3?p'WL 'WALTffW' KU& OMI
PHONZ (781) OS -6477 FAX (78i) 093-7091
A REGISTERED LAND SURVEYOR. PREPARED. FOR INTEGRATED MORTGAGE SERVICES, INC.
DO HEREey CERTIFY THAT TME
ABOVE MORTGAGE INSPECTION rLAGE INS
Of AN WAC COOCCAOM C^o I MORT. PPYMON PTAW I