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HomeMy WebLinkAboutMiscellaneous - 39 SPRING HILL ROAD 4/30/20185667 Town of North Andover HEALTH DEPARTMENT CHU CHECK#: D A T E: / 04 LOCATION: H/O NAME: CONTRACTOR N 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 $ 0 Swimming Pool $ 11 Tobacco $ 0 TrashlSolid Waste Hauler $ 0 Well Construction $ SEPTIC Systems 0 Septic - Soil Testing $ 0 Septic -Design Approval $ 13 Septic Disposal Works Construction (DWC) $ 13 Septic Disposal Works Installers (DWI) $ VT' 1 5 Inspector t Ti e 5 Report t;e $ 0 Other (Indicate) $ Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. VQ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 39 Spring Hill Road Property Address Paul J. Churinske Owner's Name North Andover MA 01.845 October 22, 2011 City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information 1. Inspector: Peter F. Reilly Name of Inspector Peter F. Reilly Company Name 136 Andover Street Company Address Andover City/Town 978-375-3750 Telephone Number B. Certification OCT 27 ZU11 TOWN OF NORTH ANDOVER MA 01810 State Zip Code S11955 License Number 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 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority October 22, 2011 Insp or's Signature Date The system inspector shall submit a copy of this inspection 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. ****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. t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 Owner information is required for every page. n Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 39 Spring Hill Road Property Address Paul J. Churinske Owner's Name North Andover City/Town B. Certification (cont.) MA 01845 State Zip Code October 22, 2011 Date of Inspection Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 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. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old' or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ® N ❑ ND (Explain below): t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 39 Spring Hill Road Property Address Paul J. Churinske Owner's Name North Andover MA 01845 October 22, 2011 CitylTown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 3 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 39 Spring Hill Road Property Address Paul J. Churinske Owner's Name North Andover MA 01845 October 22, 2011 City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent 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. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" 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 ❑ ❑ 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 '/ day flow t5ins - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 4 of 17 ' Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments sl -39 Spring Hill Road Property Address Paul J. Churinske Owner Owner's Name nformation is required for North Andover MA 01845 October 22, 2011 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® 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 e El El Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. El Any portion of a cesspool or privy is within a Zone 1 of a public well. El Any portion of a cesspool or privy is within 50 feet of a private water supply w [I El Any portion of a cesspool or privy is less than 100 feet but greater than 50 fee from a private water supply well with no acceptable water quality analysis. [Th system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent 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 analys and chain of custody must be attached to this form.] r-1 El The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. El El 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. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area - IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 i II. t is is 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. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area - IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 Copnmonwealth of Massachusetts RUM W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 39 Spring Hill Road Property Address Paul J. Churinske Owner Owner's Name information is North Andover MA 01845 October 22 2011 required for , every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® 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? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were 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? ® ❑ 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? ® ❑ 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: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 600 gpd t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 39 Spring Hill Road Property Address Paul J. Churinske Owner information is required for every page. Owner's Name North Andover MA 01845 October 22, 2011 City/Town State Zip Code Date of Inspection D. System Information Description: 1,500 gallon septic tank / d -box / SAS (4 trenches). Original system installed in 1986. Number of current residents: Does residence have a garbage grinder? Is laundry on a separate sewage system? [if yes separate inspection required] Laundry system inspected? Seasonal use? Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? Last date of occupancy: Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: Gallons per day (gpd) ® Yes ❑ No ❑ Yes ® No ❑ Yes ❑ No ❑ Yes ® No 100 gpd avg. ❑ Yes ® No current Date ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °qM 39 Spring Hill Road Property Address Paul J. Churinske Owner information is required for every page. Owner's Name North Andover MA 01845 October 22, 2011 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Other (describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: currently occupied Date BOH (last pumped 11/9/2010) gallons Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Yes ® No ❑ 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) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 39 Spring Hill Road Property Address Paul J. Churinske Owner information is required for every page. Owner's Name North Andover CitylTown D. System Information (cont.) State Zip Code October 22, 2011 Date of Inspection Approximate age of all components, date installed (if known) and source of information: original system installed in 1986. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer (locate on site plan): Depth below grade: 12" - 18"feet Material of construction: ® cast iron ❑ 40 PVC ❑ other (explain): Distance from private water supply well or suction line: N/A feet Comments (on condition of joints, venting, evidence of leakage, etc.): Building sewer was watertight and appeared sound at the foundation. Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal 6" - 10" feet ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: rectangular approx. 6' x 12' Sludge depth: 1"-2'• t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 39 Spring Hill Road Property Address Paul J. Churinske Owner Owner's Name information is required for North Andover MA 01845 October 22, 2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness 0"-1" Distance from top of scum to top of outlet tee or baffle 4"-5.. Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? measurement Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tank was watertight and appears to be functioning properly. Grease Trap (locate on site plan): Depth below grade: N/A feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): 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: t5ins - 11/10 Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 39 Spring Hill Road Property Address Paul J. Churinske Owner Owner's Name information is required for North Andover MA 01845 October 22, 2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: N/A Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Capacity: Design Flow: gallons gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: Date of last pumping: Date Comments (condition of alarm and float switches, etc.): ❑ Yes ❑ No * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Insp Subsurface Sewage Disposal System For 39 Spring Hill Road D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert W1 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.): Four lines leading to SAS were accepting effluent fairly evenly. Some solids carryover evident. The box cover was 14" - 16" below the surface (to the riser). The d -box itself was about 48" below the surface. Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 17 ection Form m - Not for Voluntary Assessments Property Address Paul J. Churinske Owner Owner's Name information is required for North Andover MA 01845 October 22, 2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert W1 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.): Four lines leading to SAS were accepting effluent fairly evenly. Some solids carryover evident. The box cover was 14" - 16" below the surface (to the riser). The d -box itself was about 48" below the surface. Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 17 Owner information is required for every page. t5ins • 11/10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 39 Spring Hill Road Property Address Paul J. Churinske Owner's Name North Andover City/Town D. System Information (cont.) Type: ❑ leaching pits ❑ leaching chambers ❑ leaching galleries ® leaching trenches ❑ leaching fields ❑ overflow cesspool ❑ innovative/alternative system MA 01845 October 22, 2011 State Zip Code Date of Inspection number: number: number: number, length: number, dimensions: number: 4 trenches about 20' long each Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soils in the area of the SAS appeared normal, no signs of breakout. SAS dimensions based on information from 1986 "as -built' plan on file at BOH. It is noted that the system is 25 years old and observations made at the time of inspection provide no indication as to how the system will perform in the future. Cesspools (cesspool must be pumped as part of inspection) (locate 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 ❑ No Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 17 ` Commonwealth of Massachusetts W Title 5 Official Insp Subsurface Sewage Disposal System For 39 Spring Hill Road D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (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.): t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 ection Form m - Not for Voluntary Assessments Property Address Paul J. Churinske Owner Owner's Name information is required for North Andover MA 01845 October 22, 2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (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.): t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 ' Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 39 Spring Hill Road Property Address Paul J. Churinske Owner information is required for every page. Owner's Name North Andover MA 01845 October 22, 2011 City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view 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. Check one of the boxes below: ❑ hand -sketch in the area below ® drawing attached separately t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17 C�- Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 39 Spring Hill Road Property Address Paul J. Churinske Owner's Name North Andover City/Town D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: MA 01845 State Zip Code October 22, 2011 Date of Inspection <1" below bottom of SAS feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 1984 Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health - explain: information on file. ® Checked with local excavators, installers - (attach documentation) ® Accessed USGS database - explain: USGS data not specific to site. You must describe how you established the high ground water elevation: Soils, grade changes, and lack of sump pump indicates adequate groundwater separation. Howwever, the precise ground water elevation cannot be determined for certain without a soil evaulation test. NOTE: Soil evaulation is the recognized method for determining or establishing the high groundwater elevation. Since I am not a licensed or certified soil evaulator, I am not qualified to determine or establish the high groundwater elevation beyond the public information available, such as recent design plans of the site or the nearby area. My estimation of the high groundwater elevation is based on a due diligence effort to obtain all available information both on and off the site and my experience as a certified septics stem inspector. (see attached Discliamer) Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17 r Commonwealth of Massachusetts N W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 39 Spring Hill Road Property Address Paul J. Churinske Owner information is required for every page. Owner's Name North Andover MA 01845 October 22, 2011 City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART D - SYSTEM INFORMATION (continued) Property Address: 39 Spring Hill Road, North Andover Owner's Name: Paul Churinske Date of Inspection: 10/22/2011 SKETCH OF SEWAGE DISPOSAL SYSTEM: Provide a sketch of the sewerage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100'. N/A Locate where public water supply enters the building. HOUSE 15010 GAL SEPTIC TANK FRONT YARD SEPTIC TANK TIES: A to Center (C) 16.5' B to Center (C) 27.0' D -BOX TIES: A to Box 38.0' B to Box 34.0' NOTE: The system is in the front yard. D -box cover is about 14"-16" below the surface (to the riser). SAS size is based on 1986 "As Built" plan on file at BOH. V DISCLAIMER This passing septic inspection under Massachusetts Title V is in no way a guaranty or warranty of the inspected septic system. The inspection is a "snapshot in time" and does not constitute a complete assessment of the quality or potential longevity of the septic system. The pass/fail criteria are specific and outlined in detail in this report. Under the limited criteria of a Title V inspection, it is impossible to determine how long any septic system will last. The inspector made a diligent effort to certify the septic system based on the criteria required under Title V. Under Massachusetts Title V, soil evaluation is the accepted method of determining the high groundwater elevation. This inspector is not a certified soil evaluator and is therefore not qualified underTitle V to determine or establish the high groundwater elevation. The method used to estimate the high groundwater for this inspection was based on the public records and methods of observation described on the previous page. Groundwater levels can vary greatly from season to season, year to year and soil evaluation is considered the most reliable method of groundwater determination under Title V. -0 P ter F. Reilly Inspector October 22, 2011 �' (In 0 0 " 2 w a p d = E _ 0 00 0 y G a d d aC'l o E a SD c � 4 r w w th w m p a � O ID rn O m i m v °' Fa 1► E U Uco '� y m c co al 0 0 O L O O N > > L Ir m W W N y a' m 0 0 � -9 J Z Z Z d 0)� W- c V � w p a y�� m c 0 > c c m Q H 0 co O = Q m rn w U y U vj o � O COO O Z N Z H fn Ui d N k N a LO O W N rn rn F- C) � a N h c a a d� m *D Q p o f `oma E vi c V o E dN 0 p CO) a o 0 3 _ m =oU a o i-�UU c ca c 0 Date ..... /./. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ......... 7��6.4 ....... .............. ............................. has permission to perform ...... ee!� 271 41e— wiring in the building of ............ 7 .W.1 .............................. i at.. v. 1.4. lIek. C . ........... orth Andover, M s. Fee -4 5 Lic. .............. . LECTRICAL INSPE Check# 5'5�;� 10446 4 Commonwealth ®f MassachusettsF0ccupaN11,cy Official Use Only Department ®f F'il'e Services 'C46 BOARD OF FIRE PREVENTION REGULATIONS nd Fee Checked (1PavP hlankl APPLICATION FOR PERMIT TO PERF RM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code C), 5 7 CMR 12.00 (PLEASE PRINT WINK OR TYPE ALL INFO TION) Date: City or Town of: To the Inspe for of Wires: By this application the undersi ed gives not' e of his or her intentiono perform the electrical work described below. Location (Street & Number) K _ �� 1 hr- In i 1,1 Owner or Tenant Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No XJ BLDG PERMIT # Purpose of Building Utility Authorization No. Existing Service Amps / Volts New Service Amps / Volts U iZl Iq Is r— j Telephone No. Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: No. of Recessed Luminaires No. of Luminaire Outlets No. of Luminaires No. of Receptacle Outlets No. of Switches No. of Ranges F of Waste Disposers f Dishwashers .of Dryers No. of Water KW Heaters No. Hydromassage Bathtubs �_. Overhead ❑ Undgrd ❑ Overhead ❑ Undgrd ❑ Completion of the No. of Ceil. Susp. (Paddle) Fans No. of Hot Tubs Swimming Pool Above ❑ InT arnA o. of Oil Burners No. of Gas Burners o. of Air Cond. Space/Area Heating KW Heating Appliances KW Signs Ballasts of Motors Total HP No, of Meters No. of Meters wing table may be waived by the Inspector of Wires. No. of Total. Transformers KVA, Generators KVA Nu. of Emergency Lighting ❑ R.1+o,.., rr..u.,. ALARMS INo. of Zones of Alerting Devices Local ❑ lvlu COL Security Syst No. of Dei Data Wiring: No. of Dei i Devices al ion ❑ Other or Equivalent No. of Devices or Attach additional detail if desired, oras required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same the e - issuing office. CHECK ONE: INSURANCE [� BOND ❑ OTHER ❑ (Specify:) i cert, under the pains and pe alties. of rjury, that the information on this app icatcon rs true and complet FIRM NAMES ) 0 C G j LIC. NO. Licensee: Signature LIC. NO.: (If applicable, enter "exempt" in the license number line) Address: Bus. Tel. No.: Alt. Tel. No.: *Per M.G.L. c.147, s. 57-61, security work requires Department of Public Safety "S" Licen LIC. NO.: OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ ELECTRICAL PERNIIT NO. INSPECTION REPORT: ELECTRICAL INSPECTOR - DOUG SMALL 4. INSPECTION —SERVICE: DATE CALLED NATIONAL GRID: NAME: Passed — [ j Failed — [ ] Re -inspection required ($50.00) - [ j Inspectors' comments: (Inspectors' Signature - no initials) Date k5INSPECTION -OTHER: ed — [ ] Failed — [ ] Re -inspection required ($50.00) - [ectors' comments: (Inspectors' Signature - no initials) Date DOOR TAGS ARE TO BE FILLED OUT AND LEFT ON SITE IF THE AREA TO BE INSPECTED IS NOT ACCESSIBLE AND A RE -INSPECTION OF $50.00 IS TO BE CHARGED. 4 0 2 Date ...... TOWN OF NORTH ANDOVER PERMIT FOR WIRING /),? t w (' 6- -/A - Thisicertifiesthat .......... ......................................................................... has permission to perform ........ / .......... ................................ wiring in the building of ....... at ............ 37 .... 15XX�t orth Andov Mas Lic. ELECTRICAL NSPECTOR Check # Official Use Onl c Permit No. _ a -Age .. e 4 Pum- S400 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:.0 (Please Print in ink or type all information) Date Z To the Ins o of wires: Town of North Andover The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number Owner or Tenant Owner's Address is this permit in conjunction with a building permit Yes No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service.;2�_AmPs Voits Overhead ❑ Undgmd ❑ No. of Meters New Servicq Amps Voits Number of Feeders and Ampacity Location and Nature of Proposed Electrical /,c/ Overhead ❑ Undgmd ❑ No. of Meters No. of Lightin-q Outlets No. of Hot fuse Total No. of Transformers KVA Above ❑ In ❑ No. of Lighting Fixtures Swimming Pool grnd ❑ grnd ❑ Generators KVA No. of Emergency Lighting No. of Rke tacles Outlets No. of Oil Burners Battery Units No. of liwitch Outlets No of Gas Burners FIRE ALARMS No. of Zone No. of Detection and Initiating Devices i No. of Xan es Total No of Air Cond Tons Heat Total Total No. of Di osal No. Pumps Tons KW No. of Sounding Devices No./ of Self Contained No. of Dishwashers Space/Area Heating KW Detection/Sounding Devices ❑ Municipal ❑ Other No. of Dryers Heating Devices KW Local Connection No. of No. of Low Voltage No. of Water Heaters KW Signs Bailases Wiring No. Hvdro Massage Tuds No. of Motors Total HP INSURANCE COVERAGE. Pursuant to the Ca current Li b lity Insurance Policy in( ubmval' proof of same to the 01 ANCE , OND = OTHER (I Estima a Value of Electrical VVorkb , f Massachusetts General Laws J Operations Coverage or its substantial equivalent E5)NO = = If you have checked YES please indicate the type o overage by checking the appropriate box Work to Start X/g-' /6 Z ' Inspection Date (Expiration Date). , Signed under the Pengttiepof perjury: / LIC. NO. FIRM NAME Licensee C /� Signature NO Cs LIC. . Bus. Tel No. Addres4Aft Tel. No. r OWNER'S INSURANCE WAIVER: 1 am aware that the Licenses not have the insurance coverage or its substant al wvalent ss r6quIrea by Massachusetts General Laws. And that my signature on this permit application waives this requirement Owner Agent (Please Check one) r Telephone No. PERMIT`FEE $ (Signature of Owner or Agent) 'A 5, /'? a Z., Date..................... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ............ ............... has permission for gas installation -,,fF.Z in the buildings of . C- �-" .................. at . a?. . . North Andover, Mass. Fw:�. . Lic. No ............ ........ Check# 2-4�:& 4130 M Installin Address MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING '(PPrin�1t or Type) QV'g1'04cJ,i0C , Mass. Date/m 20 Permit # Building Location f /�,;U�owners Name 011v�i,�s�� Type of occupancyl' New❑ Renovation ❑ Replacement❑ Plans Submitted: Yes ❑ _No ❑ Business Telephone / Qldc-, Z 44 Name of Licensed Plumber or Gas Fitter ❑ Corporation ❑ Partnership ><"Fi rm/C o. INSURANCE COVERAGE: If have a current lability insurance policy or Its substantial equivalent, which meets the requirements of MGL Ch. 142. Yes No ❑ If you have checked yes, please indicate the type of coverage by checking the appropriate box. A liability Insurance policy ❑ Other type of Indemnity ❑ Bond ❑ OWNER'S INSURNACE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement Signature of Owner or Owners Agent Check one: Owner ❑ Agent ❑ i nereuy cernty mat an of me aetatis and information I have submitted (or entered) in above application are true d accura to the best of my knowledge and that all plumbing work and installations performed under the permit is r app 11 be compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Ge ral La Type of License: By ❑ Plumber S g e u of Llcens d ber or Gas Fitter Title ❑ G fitter APPROVED ter License Number `� a APPROVED (OFFICE USE ONLY) ❑ ourneyman Cn YW 'v) co Ix 0 Nul r4 I - a J to w Q -Q � m Z � M (n W W p O Z 1- 0 C9 W U Q = 2 H N a. M W Q LU LU W W F' Z W W O O � O W U Z X o J 0 H F- Cnm Z O Z W 0 Cn W x U. > 3 0 vO � > o a LU o SUB-8sMr SASEiVENT 151 FLOOR 2"u FLOOR FLOOR g ompany amL- 01 Mrp ec one:re—ftca Business Telephone / Qldc-, Z 44 Name of Licensed Plumber or Gas Fitter ❑ Corporation ❑ Partnership ><"Fi rm/C o. INSURANCE COVERAGE: If have a current lability insurance policy or Its substantial equivalent, which meets the requirements of MGL Ch. 142. Yes No ❑ If you have checked yes, please indicate the type of coverage by checking the appropriate box. A liability Insurance policy ❑ Other type of Indemnity ❑ Bond ❑ OWNER'S INSURNACE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement Signature of Owner or Owners Agent Check one: Owner ❑ Agent ❑ i nereuy cernty mat an of me aetatis and information I have submitted (or entered) in above application are true d accura to the best of my knowledge and that all plumbing work and installations performed under the permit is r app 11 be compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Ge ral La Type of License: By ❑ Plumber S g e u of Llcens d ber or Gas Fitter Title ❑ G fitter APPROVED ter License Number `� a APPROVED (OFFICE USE ONLY) ❑ ourneyman Location No. Date 3-0?6-6c�, TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ CHUS Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 15 3 9' 3 'Building inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING Ift BUILDING PERMIT NUMBER: .-7 DATE ISSUED: SIGNATURE: lAu kt� Building Commission /I for of Buildin Date SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: S9 Slar-I.Ve 14al /07 Map Number Parcel Num er 1.3 Zoning Information: 1.4 Property Dimensions: Zoning Distrid Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Re "red Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zane Information: 1.8 Sewerage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHM/AUTHORIZED AGENT 2.1 Owner of Record VbWd C VW 12A A S K S 3'� 9r -1 y Na mint) Address for Service: S'qfiature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Lic� te Construction Supern'sor: License Number Mp �esbGuty 4t� V /4h�1 � Address ei -w -7 !604"4�— o o-3 1j-(41 Ea�h'on Date Signature Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ !^ A -M `E Company Name Registration Number j-9 -03 S Address --t7 Expiration Date C�1 5-4r - `Q Si nature Telephone z M go 0 WTI M G) SECTION 4 - WORKERS COMPENSATION (M G.L C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes .......❑ No ....... ❑ SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) Addition Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: r) ^.P Z /C lS ✓� I CO r K TJI ' iyLl C._ SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit applicant {IC1LS;fiNLY 1. Building !l --V (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction �J �� / 3 Plumbina Building Permit fee (a) x (b) v' 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5) Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUR DING PERMIT I, tom' / Crnc��1 C l ✓1 S' k � as Owner/Authorized Agent of subject property Hereby authorize�iLirPG[cl,G� If -77 to act on My Vi 11 mattiveto ork authorized by this building permit application. Si i e of weer Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief Print Name Signature of Owner/Agent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TRVIBERS 1 2 ND 3 RD SPAN DIMENSIONS OF SII LS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL, OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE ,/✓ _ :2 - G/ . , 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 'FAZi C j fATe 1A_,t�_ PHONE Z ,5-,90 573'5 3 LOCATION: Assessor's Map Number__L0___?__ PARCEL b ZV SUBDIVISION LOT (S) STREET ST. NUMBER *****************************************OFFICIAL USE ONLY*********************************** AGENTS: iJ xeZ TOWN PLANNER COMMENTS FOOD INSPECTOR -HEALTH SEPTIC INSPECTOR -HEALTH COMMENTS DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED PUBLIC WORKS - SEWER/WATER CONNECTIO DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTO Revised 9\97 jm TE ij A[6 North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision 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 c11,S150A. The debris will be disposed of in: TP ckri,-J©j�m " S&n S (Location of Facility) Signature of Permit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector Department of Industrial Accidents Olfceoilnn -- esbgations _ 600 Washington Street Boston, Mass. 02111 Workers' Compensation Insurance Affidavit name: location: city phone # [j I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity I am an employer providing workers' compensation for my employees working on this job. city: Phone #: insurance co. noliev # :x .kart -v aR,.rr: Failure to secure coverage as required under Section 25A ol'MGL 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/oi one years' imprisonment as well as civil penalties in the forni of a STOP WORK ORDER and a fine of 5100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the'DiA for coverage verification. do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. signature i Date Cth CO 0 Print name Phone # official use only do not write in this area to be completed by city or town official . city or town 0 check if immediate response is required contact person: 1rc—M jrn rJ.y permit/license # nBuilding Department C]Licensing Board oScicetmen's Office Health Department phone #; 0ther h.vi mation an:- ,astructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the "law", an employee is defined as every person in the service of another under any contract of hire, express or implied, oral or written. An employer is defined as an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual , partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance , construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has nui produced acceptable evidence of compiiance wiih the insurance coverage required. Additionally, neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority. Applicants Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and supplying company names, address and phone numbers as all affidavits may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the "law" or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. City or Towns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the pennii/license number which will be used as a reference number. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions, please do not hesitate to give us a call. e Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 IVashington Street Boston, Ma. 02111 fax #: (617) 727-7749 phone #: (617) 727-4900 est. 406, 409 or 375 �z au 7 cnw m D w A Cn V 42'9 O 'a ::r -n —� O O ::r N N in N Ca CL 00 N Vi 27'4 42'9 C s• N C.) 7 N 3a? N 15'5 1'13'2'1172'10 2'972' \T CD \\ fD m o � v o m CL I n o� M _ O ----C — N —�— w W a, CL c" n;p tp n A'O N x,m x3 O N V N CL y. N 7 0 0 0 0 1 — L—I--i--J--J- 0 CD x CD K (D 7 n m CL q 1'9 3' 3'1 2'10 2'10 2' 15'5 q 4 (O v A C6 I : i Ot : I i • : I } i i I i : I N i fIQ , I � i : i � ' d I N r r ; r r N : tTj .+ R I r- ----- - ;. I- -o.a : I b n ID 0 r I : r I I � I Oo , fiQ �. 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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***************** APPLICANT: x e� Phone LOCATION: Assessor's Map Number C d 7 Parcel o) (44 Subdivision Street 3 q Sk,,L,-,.6 /a ********** Lots) St. Number **************Official Use Only************************ RECOMMENDATIONS OF TOWN AGENTS: Conservation Administrator Comments Comments Date Approved Date Rejected Date Approved LO 3 Date Rejected i / Date Approved Health Agent Date Rejected Comments /,21411 S1 j1 Public Worcs - sewer/water connections driveway perm ' t ire Department \;�� v �✓ 7�Gu1 �dC11, Received by Building Inspector '? {` -- ' Date E i W*z ISM 0/- e -a -1-1la-I.."m HOME T MPROV,- �4.,C ' I - Reg ;.Yoe E I CONS IRUCTION 'RIC rE7_Au; - 7 ADMINISTRATOR �l 0 u ivi Jtir Yt5'S L A COMMONWEALTH OF MASSACHUSETTS 0EPARTMENT OF PUBLIC SAFETY ONE ASHBORTON PLACE BOSTON, MA 02108 C"O Is *sea* for foreastloil EXPIRATION DATE I 5"ENSE ofthislisesse. I I i 19 / I q CONSTR� l)UP�_-RVjcJp CAUTION q 5 RESTRICTIONS Its 5 EFFECTIVE DATE LIC -NO. FOR PROTECTION AGAlf )m c 08/1 .1THEFT, PUT RIGHT THU! 0 kl 54643 PRINT IN APPROPRIAT 0 BOX ON LICENSE. Ol z cL T R'fT- 0 z T z D O 0 L lcl m A 0 1 BLASTING OPERATOR,' PHOTO(BLASTING OPR ONLY) FEE. z MUST INCLUDE PHOTC NOT HEIGHT: VALID UNTIL SIGNED 13Y LICENSEE AND OFFICIALLY STAMPED -OR -SIGNATURE 0 E COMMISSIONER F 7PH DOB: THIS DOCUMENT MUST 13E CARRIED ON THE PERSON OF THE SIGN NAME HOLDER WHEN EN- 'TH n OTHt INT GAGED IN THIS OCCUPATION. "ATURE OF LICENSEE J%rs"�IONER IN FULL ABOVE SIGNATURE LINE 0/- e -a -1-1la-I.."m HOME T MPROV,- �4.,C ' I - Reg ;.Yoe E I CONS IRUCTION 'RIC rE7_Au; - 7 ADMINISTRATOR �l 0 u ivi Jtir Yt5'S L A General Construction 20 Birch Road Andover, MA 01810 7-OSAL SUBMITTED TO LtAl d- 61, Y) 14, BEET ] rY, STAT�dZl CODE _ —7 L � � CONSTRUCTION JOB LOCATION PLANS Page of Estimates Free . Ray 508-474-0186 We hereby submit estimates for: L]/�� 'W 0-1A O -A PJA R x a%' r ,G C4-.aL ' ,. -o we Propose hereby to furnish material and lEbor -- complete In accordance with above specifications, for the sum of: dollars ($ 9 92 Payment to be made as follows: O o-- V All material Is guaranteed to be as spectfled. All work to be completed in a workmanlike manner according to standard practices. Any alteration or deviation from above specifications 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 or delays beyond our control. Owner to carry fire, tornado and other necessary Insurance. Yi y Aaoe#u +e of. ft —The above prices, specifics Ions and conditions -are satisfactory and are .hereby accepted. You are authorized to do the work as specified. Payment will be made as outlined above. (J Date of Acceptance: o q� J 0 0 6 .. Authorized rT /� Signature__�(�. NOTE: This proposal may be withdrawn by us If not accepted within days. Signature Q r 0 •F)�; ��� 0 Z In 00 to z La LU z tf to z z tf vo iw to z 0 0 0 0 E o°'c i 0 o Q CD Z y, 0 D I CO CM C C CA co p '0 y 0 �E m m CD 0 co CL O i CD CD C O M 0 CL CM< ca o l." cc cccc CJ J -0 CO zts �..� N2 �C C _cc Q Z O Q w U) z 0 U J a z z z z d p w cn p v) o U p u. p w v C U G w p c�: it G w O w z V v C x p w p Q: -co X z w a w O Q O V) 0 0 0 0 E o°'c i 0 o Q CD Z y, 0 D I CO CM C C CA co p '0 y 0 �E m m CD 0 co CL O i CD CD C O M 0 CL CM< ca o l." cc cccc CJ J -0 CO zts �..� N2 �C C _cc Q Z O Q w U) z 0 U J a z z z z d c� o �asc : o � C H C C :=o y o co COEE- Ea _ts w o c. V! C E CD C3 CD C c ca.m IE G y y v, > 3 .O m _O � :=C y y C O 0 o.C, L m s = -�O �cm C! oa ya.�.� S V y O L �•�Z O cmCL x C p y O C c C N � o,, -o w0+ CO Or=...�Z L Ly LL •y .0� C�•+ O O O O � • y •d= C 0 •a COi •y Z CC C.3 4D C3 CD F- cc t a. -m 0 0 0 0 E o°'c i 0 o Q CD Z y, 0 D I CO CM C C CA co p '0 y 0 �E m m CD 0 co CL O i CD CD C O M 0 CL CM< ca o l." cc cccc CJ J -0 CO zts �..� N2 �C C _cc Q Z O Q w U) z 0 U J a z z z z d MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING Od� (Print or Type) /J 1 V U l^� /f_?AOUeN , Mass. Dat ►/ /!17 19 Permit # 3 Building Location CJS % Sir%tom9 l�X Owner's NameY/��S C—y iGT ci(elrllljk, Type of Occupancy, 2 51 D E N tI A t✓_ New ❑ Renovation ❑ Replacement R" Plans Submitted: Yes ❑ No ❑ FIXTURES N Z Z O � Y Z 4 = W W Y_ J 4C N cc(` V N Z 2 4 O O J N W y f. dl W = y = = F = < Z W N N Y Q H d Z `N'- a t7 Q < 3 X C1 cc Z Q 0 m 7 = N Q W N y ¢> F. N Q W = N p < rt N Z .S a= J p p Q U. W = < S 3 0 Y= Y �" d 0 1 < Y Q W k Z Z Y W 3 m H c N O d1 3 Z Y O p0 N a e 's e m o Y o- (A U. SUB—BSMT. BASEMENT i 1ST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR STH FLOOR Installing Company Name jAmtIA14TAe0 Check one: Certificate Addressr �'t: RC H /Y)A�) P) ❑ Corporation /r E% N4 o_ AJ Al A U I NL/ Partnership Business Telephone ���Z - i97 1 �❑, L�Fltm/Co. Name of Licensed Plumber •:�f,r3Fe r ,'SArylmA req�e ` INSURANCE COVERAGE: I have a current fiability insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142. Yes No ❑ If you have checked Les, please /Indicate the type coverage by checking the appropriate box A liability insurance policy 1d Other type of Indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner ❑ Agent ❑ 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 and installations ormed under the permit issu for this application will be in compliance with all pertinent provisions of the Massachusetts State Plum g e andapter of the eral Laws. By vl. L re of Uoensedum rTitle Type of License: Master % Joumeymah ❑ CitAP Rowe O IC ON License Number �l3 31 m 2 Q O r p A� O � Z r � � Z � � � m O C v m O O C � m 2 Q p, Date.. 1326 14OR 4, TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING CH, Th is. certifies that a M -:?W 41�z.�14 e�_ has permission to perform .... 041 plumbing in -the buildinp of.... (.:.w ....... North Andover, Mass.s_ at 3 Fee.'O� . Lic. qo..93 $3 ............ PLUMBING INSPECTOR WHITE: Applicant CANARY-.' Bqilcling Dept, PINK: Treasurer MASSACHUSETTS UNIFORM APPLICA (Print or Type) JVD / AGe(JU�/ , Mass. Date Le New ❑ FOR PERMIT TO DO GASFITTING Permit #�c Owner's Nam ' (ice Type of Occupancy Renovation ❑ Replacement Plans Submitted: Yes❑ No ❑ Installing Company Name �e-�,;e Z T A elm mP� Tr1.2c:' Check one: Certificate Address 30 Oo A C H i" A ry Kf . ❑ Corporation M E 7 H U E tj r }1 ❑ Partnership Business Telephone /o 12- —5 (7 7 ( 2--Firm/Co. Name of Licensed Plumber or Gas Fitter ii c (� E T A • f> A M r11 d ; A fir) -- INSURANCE COVERAGE: I have a current I' bility insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142. Yes No ❑ If you have checked yes, please indicate the type coverage by checking the appropriate box A liability insurance policy ' Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws. and that my signature on this permit application waives this requirement. Check one: owner[] Agent ❑ Signature of Owner or Owner's Agent 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 and installations performed under the pe i ed for this application be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of ner laws. By T of License: 6� Plumber nature of Licensed PlurriMror Gas itter Title tter er License Number 333 City/Town 0 IC Journeyman z 0 W M N Z N'. N W O S a n r d z• H W N Q O O O O H 1- ¢ O Z Z d ¢ O W m Z O w O W Q 9L U J 4 CL. Q W •� W la U. Z O J d Z J J '2529 Date..................... ,,ORTH TOWN OF NORTH ANDOVER 6 4, 0 PERMIT FOR GAS INSTALLATION S u S This certifies that has permission for gas s allation ;I t .... ...... in the buildings of . I ... ... aj�� ............................. a t North Andover, Mass. Fee ... Lic. No.Y ...................... GASINSPECTOR 6�-4— Liiu(, IV, WHITE: Applicant Ci—NARY: Building Dept. PINK: Treasurer GOLD: File