HomeMy WebLinkAboutMiscellaneous - 33 EAST PASTURE CIRCLE 4/30/2018 (3)NEW ENGLAND ENGINEERING SERVICES
lk INC
June 1'7, 2003
North Andover Beard of Health
Town Hall Annex
27 Charles Street -
North Andover, MA 01845 _ -
,< <'a 9 2003
RE: TITLE V REPORT: 33 East Pasture Circle, North Andover, MA
Dear Sirs:
Enclosed is a copy of the Title V report for the above referenced property. The system PASSED
our inspection.
If there are any questions please call me at my office, 686-1768.
Sincerely
Benjamin C. Osgo/Jr.
60 BEECHWOOD DRIVE - NORTH ANDOVER, MA 01845 - (978) 686-1768 - (888) 359-7645 - FAX (978) 685-1099
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
--- PART A
CERTIFICATION
Property Address: 33 [--y}sT ?As i u,? Cr �Zc G
iUo a -W /t•-� 7 0.�� 2 ,,,ert
Owner's Name: - g,42 R y
Owner's Address: _ 33 rAsT CRs i�/LL c�2c_t
Date of Inspection: 0/[r a 3
Name of Inspector: (please print) Benjamin C. Osgood, Jr.
CompanyName:New England Engineering Services Inc. 9 2C�'3
Mailing Address: 60 Beechwood Drive.
liorth Andover, MA 01845
Telephone Number: 978-686-1768
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15340 of Title 5 (310 CMR 15.000). The system:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: 6 �� o
The system inspector shall submit a copy of this inspb tion report to the Approving Authority (Board of Health or
DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Page 2 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 3.3 f---Fi�+` )->f+s T,/ IL L-1 C
10o
Owner: X1-,2 tz
Date of Inspection: Lit
Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D
:Vor
Syste Passes:
have not found any information which indicates that any of the failure criteria described in 310 CMR
1in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
_ One or more system components as described in the "Conditional Pass" section need to be replaced or
repaired The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass.
Answer s, no or not determined (Y,N,ND) in the for the following .statements. If "not determined" please
explain.
The septic s metal and over 20 years old* or the septic tank (whether metal or not) is structurally
unsound, exhibits sub -, I infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced wit complying septic tank as approved by the Board of Health.
*A metal septic tank will pass m$pection if it is structurally sound, not leaking and if a Certificate of Compliance
indicating that the tank is less than 0.years old is available.
ND explain:
Observation of sewage backup or break-out 0 �0 static water level in the distribution box due to broken or
obstructed pipe(s) or due to a broken, settles or uneven distribution box. System will pass inspection if (with
approval of Board of Health): a,f I\
broken pipe(s) are replaced,..,
obstruction is removed
distribution box is leveled or
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if (with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
ND explain:
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 33 . FA--sT i'/ -1s i ,�,2& C,,O CL
njfF
Owner: - Bp 2�tY �� e'
Date of Inspection: - C9 / «la -s
C. Further Evaluation is Required by the Board of Health:
Con d itions exist which require Earths evaluation by the Board of Health in order to determine if the system
is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(l)(b) that the
system is not functioning in a manner which will protect public health, safety and the environment:
— Cesspool or privy is within 50 feet of a surface water r
_ Cesspool`or privy is within 50 feet of a bordering vegetated wetland or a salt m"
r-�
2. System will fail unless the oard of Health (and Public Water Supplier, if any) determines that the
system is functioning in a man r that protects the'public health, safety and environment:
_ The system has a septic tank lad soil absorption system (SAS) and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
_ The system has a septic tank. and SASS d theSAS is within a Zone 1 of a public water supply.
— The system has aseptic, tank and SAS an e SAS is within 50 feet of a private water supply well.
_ The system has aseptic tank and SAS and theS is less than 100 feet but 50 feet or more from a
private water supply -,:well". Method used to determine istance
"This system. -passes if the well water analysis, performed aVa DEP certified laboratory, for coliform
bacteria and'volatile organic compounds indicates that the wellis,free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to &Jess than 5 ppm, provided that no other
failure-�riteria are triggered. A copy of the analysis must be attached `to this form.
3. Other:
Page 4 of 11
OFFICIAL INSPECTION FORM -- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 33 DIST 11(L& C , 2CLC-
N`- Q-TH A.u9 c, -e✓- . AA
Owner:
Date of Inspection:
D. System Failure Criteria applicable to all systems:
--- ----------- ----- -- --- -
ou must indicate "gess' or `Sno" to each of the following for all inspections:
Yes No
Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
i/ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
_✓ Liquid depth in cesspool is less than 6" below invert or available volume is less than V2 day flow
,/Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped
Any portion of the SAS, cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
_✓Any portion of a cesspool or privy is within a Zone 1 of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool orprivy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
(Yes/No) The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicatl�,either "yes" or `no" to each of the following:
(The following crit&, apply to large systems in addition to the criteria above)
yes no
— _ the system is within ft feet of a surface drinking water supply
—
the system is within 200 feet of1"%butary to a surface drinking water supply
— _ the system is located *in a nitrogen sensitise, area (Interim Wellhead Protection Area - IWPA) or a mapped
Zone II o . a public water supply well
If you have ered "yes" to any question in Section E the stem is considered a significant threat, or answered
"yes" in Section D above the large system has failed. The own or operator of any large system considered a
significant threat under Section E or failed under Section D sh pgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
Page 5 of 11
OFFICIAL INSPECTION FORM -- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 3 3 Ea s j�, F-s7-u,2r c .2( L
N.Z.- alw A V DQu` �Z
Owner: _ 6A2l2Y
Date of Inspection: (o % I
Check if the following have been done. You must indicate "y�io" asto-each_of the -following•
Yes No
--Z — Pumping information was provided by the owner, occupant, or Board of Health
f Were any of the system components pumped out in the previous two weeks ?
Has the system received normal flows in the previous two week period ?
_ZHave large volumes of water been introduced to the system recently or as part of this inspection 7
fWere as built plans of the system obtained and examined? (If they were not available note as N/A)
_ Was the facility or dwelling inspected for signs of sewage back up ?
— Was the site inspected for signs of break out ?
.,Z-- Were all system components, excluding the SAS, located on site ?
,,— Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition
of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum ?
,Z'— Was the facility owner (and occupants if different from owner) provided with information on the proper
maintenance of Subsurface sewage disposal systems ?
The size and location of the Soil Absorption System (SAS) on the site has been determined based on:
Yes no
✓`_ Existing information. For example, a plan at the Board of Health.
_ V -"Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [3 10 CMR 15.302(3)(b)]
Page 6 of 11
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: S 2 P iq 5 T� r c c 2 c t E
D C7utr 1%L .vl✓o}
Owner: Y �E
Date of Inspection: !o f o3.
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms (desiiZ : jt- Numberof-bedrooms-(actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): L (a 0
Number of current residents: e
Does residence have a garbage grinder (yes or no): _W
Is laundry on a separate sewage system (yes or no):Ajo [if yes separate inspection required]
Laundry system inspected (yes or no):—
Seasonal
o):—Seasonal use: (yes or no): _lam
Water meter readings, if available (last 2 years usage (gpd)):
Sump pump (yes or no): —NO
Last date of occupancy:
COMMERCIALMiDUSTRIAL
Type of establishment:
Design flow (based on 310 CMR 15.203): gpd
Basis of design flow (seats/persons/sgft,etc.):
Grease trap present (yes or no): _
Industrial waste holding tank present (yes or no): —
Non -sanitary waste discharged to the Title 5 system (yes or no): _
Water meter readings, if available:
Last date of occupancy/use:
OTHER (describe):
GENERAL INFORMATION
Pumping Records
Source of information: j_/9_s7- FHu. p6A- ow ,tl� Q
Was system pumped as part of the inspection (yes or no): _O
If yes, volume pumped: gallons -- How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
�( Septic tank, distribution box, soil absorption system
_ Single cesspool
_ Overflow cesspool
_ Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
_ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be
obtained from system owner)
Tight tank _ Attach a copy of the DEP approval
Other (describe):
Approximate age of all components, date installed (if known) and source of information:
A) ( L:y i ,N i `Tq :7
Were sewage odors detected when arriving at the site (yes or no): /t/0
Page 7 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: -3 3 C= /+sT ? Af l u p C , ac..l, C
►va (=M-( b4A
Owner: 2d' 11� EFe
Date of Inspection: f, (i % I (;3
BUMDING SEWER (locate on site plan)
r•
Depth below grade: 2
Materials of construction: cast iron40 PVC other (explain):
Distance from private water supply well or suction line:
Comments (on condition of joints, venting, evidence of leakage, etc.):
SEPTIC TANK: _ (locate on site plan)
Depth below grade: 2 y
Material of construction: concrete metal _fiberglass _polyethylene
_other(explain)
If tank is metal list age: _ Is age confirmed by a Certificate of Compliance (yes or no): _ (attach a copy of
certificate)
Dimensions: 15'vQ L-ALLa.Aj $,
Sludge depth: < V1 „
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness; .4l ' `
Distance from top of scum to top of outlet tee or baffle: r7
Distance from bottom of scum to bottom of outlet tee or—baffle:
How were dimensions determined: cAs v 2 c 5'r< <
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
ITA.)►/ in/ G-e»p CON.D ►"17oN ?,)c , S tN 6-o oz:'
MrN'J i'S7-4t- AJ r-kSCrZS 1� r u �tlt►.tf �.. Ut' �YtD
GREASE TRAP:,(,}'j, (locate on site plan)
Depth below grade: _
Material of construction: concrete metal _fiberglass _polyethylene other
(explain): _polyethylene
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
Page 8 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 33 Figs , ��gsti,2� C*(ZC C--
v4
Owner: BA -22Y k9 FF
Date of Inspection:
TIGHT or HOLDING TANK -.A,;+ (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass _polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present (yes or no):
Alarm level: Alarm in working order (yes or no):
Date of last pumping:
Comments (condition of alarm and float switches, etc.):
DISTRIBUTION BOX: (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: O 4
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of
leakage into or out of box, etc.):
_I;Dx i,v a (--5.v> (-n 3.&-. tvc) CFV ,ac"...cc OF s L,Zks CA-✓LAX6';Zt
C) /I- 6.. Ei' ,K tG-E` 1 0 2 0 .ice
PUMP CHAMBER: 44t (locate on site plan)
Pumps in working order (yes or no):
Alarms in working order (yes or no):
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Page 9 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 33 k'A57 29s-.,-zi2Ec �,✓lt�c =
1ti o 2i7 -e A -AJ J
Owner: yAfzRY KCEG�'
Date of Inspection: &A-Ia3
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required)
If SAS not located explain why:
Type
leaching pits, number: _
leaching chambers, number:
leaching galleries, number:
✓ leaching trenches, number, length: 3 t.c r �re vac L f
leaching fields, number, dimensions:
overflow cesspool, number:
innovativelalternative system Type(name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,
etc.):
�� 0 F o S DEA& 1,,;, V- S &V E- t p P .y ( r
FU_,UZ5%N C DA -AA P Sn1L 012 U,OU AL V6%C F7 -19-DOA-A
CESSPOOLS: 4,f - (cesspool must be pumped as part of inspectionxlocate on site plan)
Number and configuration:
Depth - top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow (yes or no):
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
PRIVY:N&(locate on site plan)
Materials of construction: _
Dimensions:
Depth of solids:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
Page 10 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: _3 3�drs i �Aj i 2 _,It
1�`o2�i sF�✓O ���2
Owner: 6
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
Page 11 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: .3 3 E A-5-,
Owner:
Date of Inspection:
SITE EXAM
Slope
urface water
Check cellar
Shallow wells
Estimated depth to ground water & feet
Please indicate (check) all methods used to determine the high ground water elevation:
Obtained from system design plans on record - If checked, date of design plan reviewed:
Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health -explain:
Checked with local excavators, installers- (attach documentation)
_ Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
sTerr� lleSi�..v� 4i A 6� ✓C A-�'�/L '��4C� ut
— _ l� 5 �i--S /h.4+�S 1 N,? r C .4-''� w A-'� /1.- � (o � � Lc .�C �J w �T✓Lc1J✓r
Location
No. �'� 3 Date
TOWN OF NORTH ANDOVER
pt�ao a.,�0
3: a p
L
amwlA S Certificate of Occupancy $
ROW•
Building/Frame Permit Fee $
1i •%�'`�
,SIACK USE� Foundation Permit Fee $
Other Permit Fee $
Sewer Connection Fee $
Water Connection Fee $
TOTAL $
t. 031'
Building Inspector
Div. Public Works
Location 1.I i, -We,
No. Date
TOWN OF NORTH ANDOVER
p Certificate of Occupancy $
o Building/Frame Permit Fee $
; ,,• .
Foundation Permit Fee $
Other Permit Fee $
Sewer Connection Fee $
Water Connection Fee $ «��•
TOTAL $
{
Bu' d' Inspe-1 X'j
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Div. Public Works
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Growth Management Bylaw Exemption Statement
Town of North Andover Building Department
This form shall be used to assist the Building Department in their determination of exemptions under section 8.7.6 of the
Town of North Andover Growth Management Bylaw. The building applicant shall provide all of the necessary information
as requested below.
Name of Applicant on Building Perit (below) Address of Property for Permit (below)
_'5A
Q��3Papand Parcel : urpose of lication (check below)
Ph b� j Applicant: gle Family _Two Family
I the undersigned applicant for the above property attest that the attached building permit for which this
form is completed does comply with the EXEMPTION section 8.7.6 of the North Andover Growth
Management Bylaw. I also understand providing this form does not absolve me or any party to this permit
from the requirements of obtaining other permits required prior to the issuance of the Building Permit.
Further I understand that my interpretation 6f the EXEMPTION status is subject to review by the Building
Department and is only officially accepted when the Building Permit is issued.
Based on section 8.7.6 of the North Andover Growth Bylaw the above lot and the work as applied for on the
above lot, in the building permit application and associated attachments, complies with one or more of the
following sections as indicated by a check mark.
existThis is an application for a building permit for the enlargement, restoration, or reconstruction of a dwelling in
ence as of the effective date of this by-law, provided that no additional residential unit is created.
The lot(s) were/was created prior to May 6, 1996 are exempt from the provisions of this Section 8.7 of the Zoning
This application is for dwelling units for low and/or moderate income families or individuals, where all of the
conditions of 8.7.6.c are met and/or represents Dwelling units for senior residents, where occupancy of the units is
restricted to senior persons through a properly executed and recorded deed restriction running with the land. For
purposes of this Section "senior" shall mean persons over the age of 55.
This application is a part of a development project which voluntarily agreed to a minimum 40% permanent
Fe—duction in density, (buildable lots), below the density, (buildable lots), permitted under zoning and feasible given the
environmental conditions of the tract, with the surplus land equal to at least ten buildable acres and permanently
designated as open space and/or farmland. The land to be preserved shall be protected from development by an
Agricultural Preservation Restriction, Conservation Restriction, dedication to the Town, or other similar mechanism
approved by the Planning Board that will ensure its protection.
adjacThis application represents a tract of land existing and not held by a Developer in common ownership with an
ent parcel on the effective date of this Section 8.7 shall receive a one-time exemption from the Planned Growth
Rate and Development Scheduling provisions for the purpose of constructing one single family dwelling unit on the
parcel.
This application represents a lot which is ready for building permits,(i.e. all other permits from all other boards and
commissions have been received and the project is in compliance with those permits), and the Development Schedule
does not accommodate issuing a building permit in that Year, one building permit will be issued per Year per
Development until such time as the Development Schedule accommodates issuing building permits. Applicant must
supply approved form U with this EXEMPTION.
Please provide any and all information that would assist the Building Department in making a determination
that your application is allowed one or more of the above EXEMPTIONS.
By signing below I attest to the accuracy of the information provided and that the attached building permit is
allowed an EXEMPTION as cited above. Further I understand that the submittal of misleading and or
inaccurate information, or the checking off of an above item which does not comply, whether done to my
knowledge or not, is grounds for refusal by the Building Department to issue a Building Permit.
rture of Owner or Authorized Agent o sign�thepAtached Building Permit pe
form must be attached to the B ing Pern application for such permit.
FORM U - IAT 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 local or state law,
regulations or requirements.
****************Applicant fills out this section*******�*�*
****r*;**
APPLICANT: Phone ( D9� Ao 19
LOCATION: Assessor's Map Number� b
i �-L3 Parcel 8 �15( i sal
Subdivision 11 Qtdii Q La % Lot (s) 3
Street �� & L A. -C ci ,t r_ � St. Number
************************O ficial use Only************************
RECOMMENDATION OF AGENTS:
Date Approved
Conservation Administ_ator Date Rejected
Comments
�Qa �✓� �� Date Approved 1 a o
Town Planner Date Rejected
Comments
Food Inspec or -Health
'd"JA le�,; —,/�
Septic Inspector -Health
Comments
Public Works --s
- d
Fire Department
Date Approved
Date Rejected G
Date Approved
Date Rejected
Received by Building Inspector Date
C'� k/ 5- Vic
sc
JUL 0 1996
Ix.
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CERTIFICATE OF USE &OCCUPANCY
Town of North Andover
Building Permit Number---YA Date
THIS CERTIFIES THAT
THE BUILDING LOCATED ON 306 4,4 4 Q `fiU hf til S IS
MAYBE OCCUPIED AS -T IN ACCORDANCE
WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND
SUCH OTHER REGULATIONS AS MAY APPLY.
CERTIFICATE ISSUED TOd NSI /�A4
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CERTIFICATE OF USE &OCCUPANCY
Town of North Andover
Building Permit Number :/-I-
THIS CERTIFIES THAT
THE BUILDING LOCATED ON 3 —
Date C?-
MAY BE OCCUPIED AS S' N
IN ACCORDANCE
WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND
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