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HomeMy WebLinkAboutMiscellaneous - 46 WHITE BIRCH LANE 4/30/2018kq Commonwealth of Massachusetts ---- City/Town of North Andover .,System Pumping Record Form 4 DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information REGENED Important When filling out forms 1 on the computer, use only the tab key to move your cursor - do not use the return k�e.,y. V �=V 2 System Location- JUL '13 2015 JCk0FIt TH ' NDOVER Address North Andover Cityrrown State System Owner: 4 - Name �_.. Address (if different from location) CityfTown State ---------- Telephone Number Zip Code Zip Code . Pumping Record co1cc� � 1. Date of Pumping dJ __ -- 2. Quantity Pumped: --- - — Date Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6` System Pumped Bv' Name Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 Signature of Hauler Date Signature of Receiving Facility Date t5forrn4.doc• 03106 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts W City/Town of North Andover REC a W° System Pumping Record OCT I zotl ,M Form 4 TOWN OF NORTH ANDOVER Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. rertun DEP has provided this form for use by local Boards of Health.' " ut the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information 1. System Location Address No.Andover City/Town 2. System Owner: Name Address (if different from location) City/Town ma 01845 State Zip Code State Telephone Number Zip Code B. Pumping Record qR , 1. Date of Pumping 2. Quantity Pumped: Date Gallons 3. Type of system: ❑ Cesspool(s)ptic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No 5. Condition of System: 6. Sy, t Pumped B Name Stewart's Septic Service Company 7. Location where contents were disposed: t5form4.doc- 03/06 If yes, was it cleaned? ❑ Yes ❑ No C Vehicle License Number Pre-treatment Plant, 20Ss-Mill Bradford,. Ma 01835 Signature of Rec9ving Facility Date CH Date System Pumping Record • Page 1 of 1 Location --4(O ly-� ��r , No, 2 � Date � /22 M°"T" TOWN OF NORTH ANDOVER O G L A Certificate of Occupancy $ * �° ; ," Building/Frame Permit Fee $ o� ...___. ssAMus cmu E<� Foundation Permit Fee $ r; Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL $ �L t r. r.. 1 U j Building Inspector 8672 Div. Public Works Location � No. Date "NORTH TOWN OF NORTH ANDOVER p Certificate of Occupancy $ Building/Frame Permit Fee $ _ Foundation Permit Fee $ sACHU Other Permit Fee $ Sewer Connection Fee $r X370 Water Connection Fee $ . 7 l D• TOTAL $ U �� Y Build' g Ins ect r 7007 Div u is works 5 W w W < Z m W Z < Z O < N Z 0 N 4 N m W r N C W U Z WW 40 = U O < N O 0, < m O $r O L) L) x cm o Phi Q C LLJ uiLA- r W J O W F 0 N J 3 0 0 0 Z < 4 LL 0 t7 t7 W W J Z Z U U 4 O O Z Z 0 m m r r O O < N N mg m dO W r 0 'u U U a LY � D D O L m m m {V. W �c C) C6 P cq Q cf � Q a pC uj O pQ„ iWJ. 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(n P71 �AG7 G r d :- O � a y CA m M x H O 0 �z O 9 y 0 O C CD K 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 local or state law, regulations or requirements. ****************Applicant fills outthissection***************** APPLICANT: Scams Coil UhJ 1 C Phone 17 V — O 03 LOCATION: Assessor's Map Number Subdivisionaid 2r Street Parcel Lots) St. Number ************************Official Use Only************************ RECOMMENDA ONS OF TOWN AGENTS: Conservation Administrator Comments - �cz (.� Town Planner Comments Food Inspect�or-Health Septic Inspector -Health Date Approved Date Rejected Date Approved Date Rejected Date Approved Date Rejected / Date Approved Date Rejected Comments C— A).0 G/Z-- /Z lOR '3 0 C(5A)S72g0C T/o/J Public Works - sewer/water connections - driveway permit Fire Department //" ,_, �G%�lllDl�t�,f �G,L ,�ZGGfi/ Re? eyed b)Building Inspector Date IN 2 3 �Iv � s r I ,. . T–n T :\ — i location.- 4'"j t city —b OV, is phone # 37 / UU SL ❑ 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 iob. company name . address. _. city. phone #. On io Failure to secure coverage as required under Section 25A of NIGL 152 can lead to the imposition of criminal penalties of a fine up to 51.500.00 and/or one years' imprisonment as well as civil penalties in the form 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. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Signature 10- Date Print name Phone # official use oniv do not write in this area to be completed by city or town official city or town: permittlicense;V ` VI uilding Department C3 Licensing Board C3 check if immediate response is required [3Selectmen's Office C]Health Department contact person: phone #: rjOther (inroad 3/95 P1A) sE, ngs, WHITE BIRCH LANE . CLIENT: FOUNDATION LOCATION PLAN JPD DEVELOPMENT THIS CERTIFICATION IS MADE AND LIMITED TO THE ABOVE CLIENT. LOCATION: NORTH ANDOVERNA. SCALE. I" = 40' DATE: AUG.29, 1995 CHRISTIANSEN &SERGI PRO LANDISAL ENGI URVEYORS RS 160 SUMMER ST. HAVERHUMA. 01830 TEL 508-373-0310 ©1995 BY CHRISTIANSEN & SERGI INC. I CERTIFY THAT THE PRIMARY STRUCTURE SHOWN CONFORMS TO THE HORIZONTAL SETBACK REQUIREMENTS OF THE LOCAL APPLICABLE ZONING BY-LAWS IN EFFECT WHEN CONSTRUCTED. (THIS CERTIFICATION DOES NOT CONSIDER ANY OTHER RESTRICTIONS SUCH AS COVENANTS, WETLANDS,EASEMENTS, ORDERS OF CONDITIONS,ETC.) THIS DRAWING SHALL NOT BE USED BY THE CLIENT FOR ANY PURPOSE OTHER THAN THAT OUTLINED ABOVE.£XCEPT WITH THE WRITTEN PERMISSION OF CHRISTIANSEN & SERGI INC. FURTHERMORE THIS DRAWING IS THE COPYRIGHTED PROPERTY OF CHRISTIANSEN & SERGI INC. AND ANY UNAUTHORIZED USE IS PROHIBITED.CHRISTTANSEN & SERGI TAKES NO RESPONSIBILITY FOR THE UNAUTHORIZED USE OF THIS DRAWING OR ANY INFOR- MATION CONTAINED HEREON. BASED ON SCALED DATA ONLY THE PRIMARY STRUCTURE SHOWN IS NOT LOCATED IN A FLOOD HAZARD ZONE AS SHOWN ON FEMA FLOOD INSURANCE RATE MAP. COMMUNITY NO.: 250098 0005C DA TE. . m OF ,u._' MICHAEL 11--% o V pq N� S DRAWING No. 93067016 n T1 ;n w � w Crl r G '� '°5. Z z v IMil z £ CO) O CO) C") -v o D n Z CO) D CL r 0 O dF y >Cc o n CD O p C � O s Q O CD n CD o CD n z C C CD y. < �; v CD H z o �C z _ CA v O � 0 z �. Do CD z D C CD r v rn C CO. o Z M a CD rn y? N M n MZ c m m h y o OZ � y 'lo 0 bd n� T M M a �. Olt' u.] of c =r m =_ �. y O Q' y d Om .0 y mC m Cl) ySwc �. w 0) r y T =r CL C'0CD =r 0 rn �OOyC y � �m �- _ f, C) c m ov;n :. d aH :. = -..Co C.�.. O ?? oif 06 H 9 .0 d y C Q CID C'O. C CCD /�... y CA y10 CD 0 : ✓ .+ y V l .o o� moo. m0N� CO) m O�` RM m v-Im 0. CD d: • cnrn 1 7' A M ., ;n w � w Crl r G '� -? c) :� w � a G7 co OCD cn a n IMil £ y 0 O C w..#ERTIFICATE OF USE & OCCUPANC Town of North Andover I Building Permit Number a, 7 o,> - THIS CERTIFIES THAT THE BUILDING LOCATED ON MAY BE OCCUPIED AS Date /--Z- `i- 9 WITH THE PROVISIONS OF THE MASSACHUS; SUCH OTHER REGULATIONS AS MAY APPLY. 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O F0 LO Go 1.4- (9) x x N LLJF— pp N x I I z N N N U N 0 SII , N \ L- 0 O � s c to Q N ,VIC-4 E C, qXC -5 U- d0 c cx c o = o N t=.= o U c Cc ; L' Office Use Only __ �ullt Lfiammuniuralth If fflaggar4u5P1t5 Permit No. 2S"L!$ r = i9ep tltI int of Vub11t $IIfPtg Occupancy A Fee Checked Z BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 390 (leave blank) 26 APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code, 527 CMR 12:00 /'�/ (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date (X1* or Town of NORTH ANDOVER To the Inspector of Wires: The udersigned applies fora permit tq perform the electric/all work described below. Location (Street & Number) ��� — vibe Owner or Tenant 'Yb DC[Jezoyo IM.OiJ 'Tj' Owner's Address To 60X Y3 93 W ARIA 911- L Is this permit in conjunction with a building permit: Yes 7L!:f� No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. S06 0131"1 Existing Service Amps _J Volts Overhead ! Undgrnd ❑ No. of Meters New Service Dov Amps QO-J'C2_ Volts / Overhead f' Unndgrnd No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Workf^�iYJ If Total No. of Lighting Outlets No. of Hot Tubs No. of Transformers KVA Above.—, In- �V No. of Lighting Fixtures Swimming Pool grno _ , grnd r I Generators KVA U�No. of Emergency Lighting p No. of Receotacie Outlets � No. of Oil Burners , I Battery Units O 0. No. of Switch Outlets I No. of Gas Burners FIRE ALARMS No. of Zones Total No. of Detection and /No. of Ranges I No. of Air Cond. tons initiating Devices L J No. of Disposals NO'°f Heat Total Total Pumos Tons KW No. of Sounding Devices No. of Seif Contained / No. of Dishwashers I ScaceiArea Heating KW Detec::onlSounding Devices s 2 ��;':o MunicipalOther Heating Devices KW Local ! ConnectionNo. of No. of Low Voitage �. of Water Heaters 1 KW Signs Sailasts Wiring Lil- No. Hydro Massage Tubs I No. of Motors Total HP OTHER: INSURANCE COVERAGE: Pursuant to the requirements of 'Massachusetts general Laws _ I have a current Liability Insurance Policy including Ccmcietec Operations Coverage or its substantial equivalent. YES = NO 1 have submitted valid proof of same to the Office. YES e NO = If you have checked YES. please indicate the type of coverage by checking the appropriate box. INSURANCE _ BOND - OTHE _ (Please Soec:ty) y 10 0 (Expiration Date) Estimated Value of Electrical Work f Work to Start Insoectton Date Requested: Rough Final Signed under the Penalties of perjury: ME LIC. NO, FIRM NA ? Licensee /e : Signature LIC. NO. c47� ��✓ _ Bus. :el. No. LfVCr- i�i� 3?fol Address _ /2 3 •i�.�itih,Z.0.t/D_/�D mow/// h9/� — Alt. -el. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its substantial equivalent as re - OWNER'S by Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner Agent (Please checK one) Teleonone No. PERMIT FEE S (Signature of Owner or Agent) x-5565 5 14 NORTI{ FO A ,SSAOMUSES Date...... I ...I. LA........... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that.,..+......:..'..F........>>.........1 t C- has permission to perform .....t.,:....... ... . A wiring in the building of ............ :...........%............................................... ate... ... �..........�........... '.!.. �..Y....l.............. �...... I ....... , North Andover, Mass. F1.:..... z; ....... Lic. No =. . :--.�................ ... ELECTRICAL INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File 0he LIII1tImuniuralth IIf fflagsar4use1t5 i9epartmient of Publlt _'Elfin- BOARD OF FIRE PREVENTION REGULATIONS 521 CMR 12:00 Office Use Onl Permit No. Occupancy & Fee Checked 3/90 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL All work to be performed in accordance with the Massachusetts Electrical Code, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) (MY,, or Town of NORTH ANDOVER The udersigned applies for a permit Location (Street & Nu WORK Date To the Inspector of Wires: perform the electrical work described below. e Owner or Tenant nVy I Aec+ ric ^ yr i►ic IF LO Owner's Address T O C8 OX Is this permit in - —it with a building permit: Yes '�� No C (Check Appropriate Box) Purpose of Building Utility Authorization No. ='1 c- 0 Sy Existing Service r Amps Volts Overhead Undgrnd ❑ No. of Meters New Service 0 0 Amps _629i C9 00 Volts Overhead ❑ Undgrnd No. No. of Meters Number of Feeders and Ampacity -/,,-°7 A�4 U -` Location and Nature of Proposed Electrical Work / C /-wP &g -Ude r Total No. of Liqhtinq Outlets No. of Hot Tucs No. of Transformers KVA No. i of Lighting Fixtures bover—, Swimming Pool Arno. — In - n- r I Generators KVA No. of Emergency Lighting No. of Receptacle Outlets No. of Oil Burners Battery Units No. of Switch Outlets ( No. of Gas Burners FIRE ALARMS No. of Zones No. of Detection and Total No. of Ranges I No. of Air Conc. tons Initiating Devices Heat Total Total No. of Disposals No.of Pumos Tons KW No. of Sounding Devices of Seif Contained No. of Dishwashers iNo. ScaceiArea Heating KW DetectioniSounding Devices Local Municipal Other ! Connection i No. of Dryers I Heating Devices KW i No. of No. of Low Voltage No. of Water Heaters KW I Signs Ba:lasts Wiring . u..- ..__,.___ r..ti� I No. of Motors Total HP OTHER: J INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws _ I have a current Liability Insurance Policy inc!ucing Comc:eted Operations Coverage or its substantial equivalent. YES = NO I have suomitteo valid proof of same to the Office. YES �NO Z: if yo,& havt checked YES. please indicate the type of coverage by checking the appropriate box. / /6 INSURANCE = BONO = OTHER Z (Please Soec:ty) /� T (Expiration Date) Estimated Value of Electrical Urk S 2 6 14 Final Work to Start I'a ' g Insoec::on Date Recuested: Rough Signed under the Penalties of perjury: LIC. NO. FIRM NAME Licensee Ge2AL A ��R� Sicnature t.[--yy�� LIC. NO. c (/�� Bus. �774INo. Address _ 1a'3 -F-Aif �A/V40 I o Gi Alt. Tel. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee goes not have the insurance coverage or its substantial equivalent as re- cu:rea by Massachusetts General Laws, and that my signature on this permit aop:icat:on waives this requirement. Own�Amgernix(P!ease check one) Telephone No. PERMIT FEE3 (Signature of Owner or Agent) X-5565 r NORTH{ O 9 s o a ��SSACNus r � � Date.................. Y......I...a TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that..........`...................:..............::...............................:../ ......... has permission to perform ........../..,�. t, c,.....,`.L�................................ wiring in. the building of. . L)..../..........z.:.....:......:...............................:` :�..:. at - n... , .. ....!?f ....... ....... r , North Andover, Mass. Fee....... ...... Lic. Nom ..... :�. .............................................................. - ELECTRICAL INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File