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Miscellaneous - 49 MEADOWVIEW ROAD 4/30/2018
_ 49 MEADOwVItvv rcvHo--'\� 210/103._ 0-0095'0000.0 r ` / r! � C/o cu U 1 Location No. U J Date NORTH TOWN OF NORTH AN-DOVER 16. 9 " Certificate of Occupancy $ Building/Frame Permit Fee $ a S { JACHUS Foundation Permit Fee $ Other Permit Fee $ TOTAL $ o2S Check # 15546 �` Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING hyy -..fit i ,x' �. r,` r�„ 1 ..:� :.t •zE Y" ".4s^a�` °`r' S '` ��s,"� a BUILDING PERMIT NUIvIDER. / DATE ISSUED: �j SIGNATURE: icic Building Commissioner/Inspiktor of Buildings Date Z SECTION 1-SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: O P3 II /) /� `�,(5 Map Number Parcel Number �V� f( f l,� B iOC k- q5 L f 1 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area s1) Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided R red Provided Q 1.7 Water Supply M.G.LC.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑ SECTION 2-PROPERTY OWNERSHW/AUTHORIZED AGENT 4 2.1 Owner of Record + KGc2ecry P/Ic 140'S Name(Print) �i n� E� �!n� Address for Service Signature Telephone 2.2 Owner of Record: Name Print Address for Service: o Z Signature Telephone Aw SECTION 3-CONSTRUCTION SERVICES R" 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Constnrction Supervisor: License Number mn Address Expiration Date iC Signature Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number M Address Expiration Date z —Signature Telephone 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 buildingpermit. —Signed affidavit Attached Yes.......❑ No.......❑ SECTION 5 Description of Proposed Work check all applicable) New Construction 0 Existing Building ❑ Repair(s) ❑ Alterations(s) 0-7i-,ion ❑ Accessory Bldg. 0 Demolition 0 Other 0 Specify Brief Description of Proposed Work: SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be a >?FIGxI L 'Alt .Y MIN,�'R �f. Completed by permit applicant 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(a)X (b) 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 BUILDING PERMIT I, y �/`�y n� as Owner/Authorized Agent of subject property Hereby authorizeL, to act on My behalf, ' aff matters relative to work authorized by this building permit application. I 7��.'M/-'(ell)ro --Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 1, 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 Si ature of Owner/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 sr 2ND 3ko SPAN DIMENSIONS OF SILLS DM ENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHININEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE f-UKIVI U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary a Boards and Departments having jurisdiction have been obtain . This does no ermpprovals/ Irs ieVE the applicant and/or landowner from compliance with any applicable or .requirements nts *****************************APPLICANT FILLS OUT THIS SECTION APPLICANT K�A - OC(001, S PHONE 1,�, FS- f qq LOCATION: Assessor's Map Number PARCEL S SUBDIVISION LOT(S) STREET ��OI�U�+�� �� . � . �jCP�Vim- ST. NUMBER *****************************************OFFICIAL USE . REC MMENDATIONS OF TOWN AGENTS: CONSERVATION ADMINI RATOR . DATE APPROVED b DATE REJECTED COMMENTS LOC414w eIS ct,r e. I Dp -- �rc a60 ( -- O TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD INSPECTOR-HEALTH DATE APPROVED DATE REJECTED SEPTIC INSPECTOR-HEALTH DATE APPROVED DATE REJECTED COMMENTS PUBLIC WORKS - SEWER/WATER CONNECTIONS I DRIVEWAY PERMIT FIRE DEPARTMENT ' RECEIVED BY BUILDING INSPECTOR DATE_ Revised 9\97 jm Qt H *A Town of North Andover -� .. Building Department a. . 27 Charles-Street North Andover, MA. 01845 D. Robert Nicetta 's {' Building Commissioner ' (978) 688-9545 •°-9.78 588-9542 Fax HOMEOWNER LICENSE EXEMPTION Please print n , DATE 5- 7 D (��j '/ - •/vl r�f..P X03, 8/rz/�qs JOB LOCATION ! t l�/lX_GLr/1 V�C(A� �I dQI/�� Number Street Address c Map/lot "HOMEOWNER Nt I G�� l' �G/�.i✓t�. �C ����S ��Q ��S I%� Name. 'Home Phone Work Phone PRESENT MAILING ADDRESS City Town Siate Tip Code The currentexemption for"homeowners"was extended to include.owner-occupied dvC igs of two units or.less and to allow such homeowners to.engage an individual.,W'hire.who,dolps. not possess a°license,.provided that the,owner acts as supervisor. (Slate Be aiding,Code S. ecbon 1.08.3.5.1) .DEFINITION OF HOMEWOWNER. Persons)who owns a parcel of land on which he/she resides or intends.to.reside;on which there is, or is intended to be,a one or two family dwelling.allached or detached sbuch►res ac_ cessory to such use and/or far />;perms constructs more that one home-in a two-year period shag-not bw onsidered a homeowner The undersigned"horneownee'ass ' 9 assumes responsibility for complia<uce with Slate Buikling Code and other Applicable Bodes, by-laws, rules and regions, ; The undersigned"homeowner"certifies that helshe understands the Towci of No.Andover Building Depaftent minimum inspection procedures and requirements and that heJshe wiH ' comply with said procedures and requirements. HOMEOWNER'S SIGNATURE G (,o,.n 0' APPROVAL OF BUILDING OFFICIAL Sr' own of over No. 100� `- - L A y h dover, Mass., COC MICMEWICK ADRATED IC3 S BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT C .. T*AO� hasp r......... buildings on ........ fill permission to erect.... ...................... ... .....................................................................�.. Rough to be occupied as paste005 D�C Chimney provided that the person accepting this permit shall In every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the. Town of North Andover. O PLUMBING INSPECTOR sop VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION ST " TS Rough 1: M111................................................. Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To BeDone FIRE DEPARTMENT Until Inspected and Approved by the Budding Inspector. Burner Street No. " SEE REVERSE SIDE Smoke Det. / /� CEOl�.P,4L �4/t/O TEC.yN/CAG .S'T.4it/O.•�PQ�'�O•� �� FO,E� 4it/y OT,�/E,E� /�C/.P`12�•E /.S �.��f//�/7�0. 2 �•E�O�•E.P/'Y G/�t/.E.,.S' Gl/E.PE i!/OT .E.S�8•�./.3�EO � GU,4.e4NTEE.3' -4.�E�.4GTE.�s To Tir.�E oe' 5-1 Ac L/�C/E.�� .�iC/O O.�,r3.E'T,��,S'�'+/O!/LO ,t/OT :�a ��c� BE tl3Eo rte G�E'r.E.P.r-yiwE �o�E.Pry .c%v.E3' T/TZE ,PEF� �SSE� ,eEG,CST.eY of OEEL2S� x ` B,Q.SEO Oit/ �,vJy .E�NO`s/G EOGE, BE.G/EF, .4it/O Q /•c/Ft�.E�il-1.4T/O�l/, I ,4�E,PEBS/ �'E.P1JFy Tfs�.4T T.�,/E .�E.�iY�4�t/E�t%T�"T•Pl��'7r/•P�'�' .4.E�E (� ' � m- `�� �JCCO.E�O/�/G TZ7 T.yE .�'-E.y1.,•4. .y�.4.o FO.e THE �7.e�'EG F.4,C„GS' /tet/ .4iC/.4.PE/J CG.4�.S/F%E•O `v �1 714� Th/E �� O O/A�1E.t/.,�'/CLt/.4L .�EQU/.EE•HE.t/7,�' �/�YE�t/�t/,�7'.eIJCT,Ep• 7W.Q.c/o .cis-firEo /2-2o Oo �O.E'TG.4GE" L4.4i1/ ele 14 OF ®e� THEODORE, �yG cSCAGE•' / �- �4 ,dEGE��BE.� �!/ 2pp4 2v.' o,��•v DEER / � 9�ENIcyT NO. 748 �y �o• Bax z'.33 -di.�S 4/90� suc °�`� c/GB it/D. cop Date. . . . A � . �TTTXL,T�v TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that . :`� ? . . .5. .!�.�. �. . . . . . . . . . . . . . . . . has permission for gas installation . . . S t q(J.--e . . . . . . . . . . . . . . . . . in the buildings of. .a) 12w ! C.e . . . . . . . . . . . . . . . . . . . . . . . . at . . y. . . ."??". �U w ✓1"e w L-:'�^ orth ndover, Mass. Feega j.Q©. . . Lic. No. . i GAS INSPECTOR Check# ii 0 8535 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK rG CITY v ^/d ay.-2/t— MA DATE l PERMIT# JOBSITE ADDRESSIM�, w i.!� t-I_ __ OWNER'S NAME OWNER ADDRESS ji TEL —_ FAX TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL ElEDUCATIONAL RESIDENTIAL CLEARLY NEW:1:1 RENOVATION:Ej REPLACEMENT:[R- PLANS SUBMITTED: YES F-11 OEJI APPLIANCES Z FLOORS- BSM 1 2 3 4 5 6 7 8 9 ,10 11 12 13 14 BOILERf - BOOSTER CONVERSION BURNER COOK STOVE Tr � ) . l DIRECT VENT HEATER L_ -- J �J.h -_ 1 .- ^ .,_ T- .. -- DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR ) GRILLED_ t FRARED HEATER -T( LABORATORY COCKS (_�f �{-yJ I � (I � -_ �I— — I �_ ���.-y l!� MAKEUP AIR UNIT I_ _. I-- I � - I - . _ _..1-.. � - r-z� =� I -f OVEN I �..---� L-- -1. POOL HEATER [^._ r� r_ -.� . _:.� n_I � . -- _ �� I(- I i i ROOM/SPACE HEATER ROOF TOP UNIT J I� TEST UNIT HEATER UNVENTED ROOM HEATER I_ —J, WATER HEATER OTHER F I F_ 11 MI-� INSURANCE COVERAGE 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES [3140 D__I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICYOTHER TYPE INDEMNITY BOND OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER E] AGENT SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information 1 have submitted or entered regarding this application are true and pccurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in co i nc with all Pertinent ,rovisi n of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. LICENSE# � SIGNATURE PLUMBER-GASFITTER NAME �1� �oyH_{ (,� IMP Ell MGF El JP D JGF LPG]�_-.I CORPORATION( # 3,y� _ � PARTNERSHIP 0#=LLC 0# COMPANY NAME: `�_�.. 1� t2irru... ' ADDRESS CITY 1,i U _ '�_vim t STATE ?% ZIP U� `1. TEL cF Cr _-_- 4 c�L v FAX 2v'� CdL b &/ i EMAIL _.- The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 'Y www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate box: 1.❑ I am a employer with 4. EJI am a general contractor and I Type of project(required): employees(full and/orpart-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 1 7• ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. [No workers' comp.insurance 5. F-1Weare a corporation and its 9 ❑Building addition required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself o y [N workers comp. c. 152 1 4 and we have p § ( )� no 12.E]Roof repairs insurance required.]t employees. [No workers' comp.insurance required.] 13.❑Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. t am an employer that is providing workers'compensation insurance for my employees. Below is the policy and ob site information. j Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: lob Site Address: City/State/Zip: attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). ,ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine )f up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of nvestigations of the DIA for insurance coverage verification. do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. ,nature: Date• 'hone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Date —! �/. Z. . • . TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that j. S was permission for gas installation . v r . . . . . . . . . . . in the buildings of. Z/.? . . • • • • • • • • • • • • • at . . . . . . . . . . . . . . . . . . . . . . . . . . ,North Andover, Mass. Few . . . Lic. No G/ . . . . . . . . GAS INSPEOT.OR Check# 8497 C4- I-C'Ljts L409i MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY '1 ,✓ �z UL- _: MA DATE PERMIT#��`7 JOBSITE ADDRESS �^ G y 1J.k.�cl OWNER'S NAME. GOWNER ADDRESS S w' TEL[^��FAX TYPE OR OCCUPANCY TYPE COMMERCIAL D-j EDUCATIONAL ® RESIDENTIAL PRINT CLEARLY NEW:Q RENOVATION:Ej REPLACEMENT:®' PLANS SUBMITTED: YES Q NO R APPLIANCES'l FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE _- I _ DIRECT VENT HEATER DRYER J FIREPLACE _ _1 I - . �I —� - ---- 1 J FRYOLATOR .FURNACE GENERATOR GRfLLE INFRARED HEATER LABORATORY COCKS 1. _J MAKEUP AIR UNIT OVEN J _ POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER (_ VV.J�ER HEATER O'. R INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ONO Q IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 3 OTHER TYPE INDEMNITY Ej( BOND F] OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER E AGENT �]Q SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are trugapda accurate to the best f my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in com- is ce w I P rtinent p visi of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. r PLUMBER-GASFITTER NAMES ` b c� _CLICENSE# 3(-I SIGNATURE MP 0 MGF JP 0 JGF LPGI CORPORATION[y]# 3 __ __.- , PARTNERSHIP D# LLC #� _ COMPANY NAME: ADDRESS CITY `?�l N_40 V� Lti _ ?7�STATE ZIP _ FAX CELL �.—�f �MAIL The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): L❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction "'employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet.t 7• ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.El Electrical repairs or additions 3.[:11 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.[No workers'comp. c. 152, §1(4),and we have no 12.❑Roof repairs insurance required.]f employees. [No workers' 13.❑Other comp.insurance required.] Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 'ontractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site !formation. isurance Company Name: olicy#or Self-ins.Lic.#: Expiration Date: ib Site Address: City/State/Zip: Itach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ne up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of westigations of the DIA for insurance coverage verification. do hereby certtfy under the pains and penalties of perjury that the information provided above is trace and correct. Ignature: Date: .lone#: Official use only. Do not write in this area,to be completed by city or town offacial, City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other iContact Person: Phone#: Date. 9452 { pf.apRTM,gyp TOWN OF NORTH ANDOVERee . - PERMIT-:FOR PLUMBING SSAC04US� This certifies that . . . . . . . . . . . j has permission to perform plumbing in the build.'ngs of . . . . .. . . . . . . . . . . . . . at. . . �74'� . yJeA/. . . . . . . ., North Andover, Mass. /f Fee.,fQel.�. .Lic. No.. PLUMBING INSPECTOR i Check # //lam MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING City/Town: , MA. Dat G `2 4crmit# Ll°/✓ Building L ca ion: //�� �` Owners Name: NL(moi'[ e o t �7 � /.[>U P.�tJ Type of Occupancy: Commercial ❑ Educational❑ Industrial ❑ Institutional❑ Residential New:❑ Alteration:❑ Renovation:❑ Replacement: [✓1 Plans Submitted: Yes❑ No❑ FIXTURES DEDICATED z SYSTEMS Uj o LU cn °C o: Z a of u l7 C �Q Z 0. H Y V1 a W Z 3 H S H W Z f' W Z ~ N 0 a� O ca Q W DU. ao QYm =Qm =o c o x Y > Q ro Z oC vxai ►Wwa- a `' xCu o LU Zv p30 0 Q x 0. > a z = Q 4A io � gp 3 0 SUB BSMT. BASEMENT F FLOOR 2ND FLOOR 3"D FLOOR ; 4TN FLOOR STN FLOOR e FLOOR 7 FLOOR 8TH FLOOR L Check One Only Certificate# Installing Company Name: 4 L [P-e rporation 1. Address: JUP MW /� Fax:City/Town: State: ❑ Partnership Business Te1100 J 2 03761" ❑Firm/Company Name of Licensed Plumber: INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes VA10❑ If you have checked Yes,please indicate the type of coverage by checking the appropriate box below. 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 Massachusetts General Laws,and that my signature on this permit application waives this requirement. Check One Only Owner ❑ Agent ❑ Signature of Owner or Owner's Agent I hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Cha ter 142 of the General La yj By Type of License: Title ❑Plumber SkAiture of)LicenseFITurnher city/Town master License Number: 933 APPROVED OFFICE USE ONLY) []Journeyman 1 4qv � ,w Q The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations E! 600 Washington Street V..; Boston, MA 02111 www.mass.gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/individual): fly/, �G, Address: U V1 raLA--.O, City/State/Zip: ,r(�l y► hwn fi*t)36 "*1 hone #: 3 Are you an employer?Check the appropriate box: Type of project(required): 1.[1 I am a employer with_ 4. ❑ I am a general contractor and I 6. �ew construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on.the attached sheet.x [�'�emodeling ship and.have no employees These sub-contractors have $. []Demolition working for me in any capacity, Yorkers' comp. insurance. g, ❑ Building addition [No workers'comp. insurance 5. 21we are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.�umbing repairs or additions myself.[No workers'comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.]t employees. [No workers' 13.0 Other comp. insurance required.] *Any applicant that checks boi#I must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins. Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby c under the airs and pe ties of per'u information provided abo a ' tr a and correct Signature: W Date: a// Phone 9: I-e Q:53 / — 5 42P �� Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: Date.. .�l! ! . ... .. NORTM Of 3? TOWN OF NORTH ANDOVER • - PERMIT FOR GAS INSTALLATION 9SS^CHUSEt This certifies that has permission for gas installation in the buildings of . . . . 1 . . . . . . . . . . . . . . . . . . . . . . . . . at . f �! � . . . ., North Andover, Mass. Fee. O ..t. . . Lic. No. % 3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . GAS INSPECTOR Check# 8203 .r MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING City/Town: A. MA. Dat ' ��t ermlt# Building Location: eQ'�(, d��euJyOwners Name. I el Type of Occupancy: Commercial❑ Educational ❑ Industrial❑ Institutional❑ Residential[� New: ❑ Alteration: ❑ Renovation: ❑ Replacement: Plans Submitted: Yes❑ No❑ FIXTURES I® � LU W ~ U) V 2 N O W 0 rn ~ rn Z F- Z J } � Z O a W t3 O Z Q Ce W W Q 1- M (n W W Z m 0 ~ W 0 x > P/i C3 W C9 a W a Q W W F Q W W W Z a' y 2 W W = U. > W W Z Q J H F O Z J (� LLW = z W W lx 0 a W W m > O Z O to H > z F' _ o o u. c� t7 = = g O a° a� lZ � > > > 3 0 SUB BSMT. BASEMENT 1 FLOOR 2 FLOOR 3 FLOOR 4 FLOOR 5 FLOOR 6 FLOOR 7 FLOOR 8 FLOOR Installing Company Name. Check One Only Certificate# Address: Mnra orporation ity/Town: State: - ljigtt�. Partnership Business Tel Fax: ;A) ❑Firm/Company Name of Licensed Plumber/Gas Fitter: INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes Io❑ If you have checked Yes •please indicate the type of coverage by checking the appropriate box below. A liability insurance policy fid" 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 Massachusetts General Laws,and that my signature on this permit application waives this requirement. Check One Only Si nature of Owner or Owner's A ent Owner ❑ Agent ❑ By checking this box accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for ;I hereby certify that all of the details and information 1 have submitted(or entered)regarding this application are true and this application will be in compliance with all Pertinent provision of the Massachusetts State Plu ing Code and Chapter 142 a General Laws. By Type of License: ❑Plumber Title W❑�GG,�,s Fitter a ure of Licensed lumber/Gas Fitter L�1'Master Ci town ❑Journeyman APPROVED OFFICE USE ON L ❑LP Installer License Number: The Commonwealth of Massachusetts Department of Industrial Accidents �. Office of Investigations f 600 Washington Street Boston, MA 02111 www.mass.gov/dia . r3 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information y A Please Print Legibl Name(Business/Organization/individual): (W0 Q if rk A S—a a t ZVI U Address: h City/State/Zip: h tTy'3 rhone #: 0 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with__ 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors ,., - 2.E3i am a sole proprietor or partner- listed on.the attached sheet.# �. i emodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. _ wprkers' comp. insurance. 9. ❑ Building addition [No workers'comp.insurance 5. a are a corporation and its 10.❑Electrical repairs or additions required.] officers have exercised their 3.❑ 1 am a homeowner doing all work right of exemption per MGL l l.[ lumbing repairs or additions myself,[No workers'comp. c. 152, §1(4),and we have no 12.❑Roof repairs insurance required.]t .employees. [No workers' 13❑Other comp. insurance required.] 'Any applicant that checks boX tl l must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. ;Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp,policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins. Lie.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required.under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. 1 do hereby ce 'y under the pa' and pen !ties o erjury that the information provided ab ve is true and correct. Si afore: AL��I) Date: Phone 4: d�_ !_,_ Official use only. Do not write in this area,to he completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#• rOR7,y p� to , ,ti0 BOARD OF HEALTH a '�i. • ' • 120 MAIN STREET TEL. 681-6483 NORTH ANDOVER, MASS. 01845 Exr23 APPLICATION FOR ABANDONMENT OF SUBSURFACE DISPOSAL SYSTEM (SEPTIC SYSTEM) PURSUANT TO SECTION 310 CMR 15 . 354 OF THE STATE ENVIRONMENTAL CODE, TITLE V This form must be submitted to the Board of Health no less than five (5) days prior to date of abandonment and be accompanied with a copy of the sewer connection permit. Name Phone Address 41 �L:: Contractor hired for work: e-2 Name /'-,n Phone Address3-��rR �,��-7�' ✓ =� Date for scheduled abandonment 4 Method of septic tank abandonment (check one) . ( ) removal ( ) sandfill crush ( ) other (describe below) Other PLEASE DO NOT WRITE IN THE SPACE BELOW FOR HEALTH AGENT ' S USE ONLY I_pect ng ent Date Comments N-' N° 1130 APPLICATION FOR SEWER SERVICE CONNECTION North Andover, Mass. �l) "" 19 Application by the undersigned is hereby made to connect with the town sewer main ini�Street, subject to the rules and regulations of the Division of Public Works. The premises are known as No. ( / `` 11 10I,1111) Street or subdivision lot no. Owner Address �f L2 54 1� Contractor Address Applica s Signature G �4 C -10A� ,c�0 C� PERMIT TO CONNECT WITH SEWER MAIN The Division of Public Works hereby grants permission to to make a connection with the sewer main at Street subject to the rules and regulations of the Division of Public Works.. Division of Public Works By Inspected by Date See back for rules and regulations Town of North Andover NORT1y OFFICE OF �? ,�' °' COMMUNITY DEVELOPMENT AND SERVICES ° 27 Charles Street ► o yro<. ....<. . North Andover, Massachusetts 01845 �9` °•°°°`�ch WILLIAM J. SCOTT SSACHUS� Director (978)688-9531 Fax(978)688-9542 March 24, 2000 Ms. Mary Finn 49 Meadowview Road No. Andover, MA 01845 Re: Sewer Tie-in Dear Ms. Finn: The Health Department has been supplied with a list of all residences, currently on septic, which have access to the municipal sewer system. As previously published at a Public Hearing on March 17, 1994, the Board of Health has adopted regulations concerning the required sewer tie-in. The following timetable concerning your property status was adopted: 4.1 All establishments that currently do not have municipal sewer available to them must connect to the sewer as soon as it becomes available, with a maximum time limit of six months. The purpose of these regulations is to safeguard North Andover's drinking water, surface waters, groundwater and surrounding environment. Sanitary sewer is believed to be the most effective form of wastewater treatment. A copy of the entire regulation can be obtained at our office. Your property is in violation of this Board of Health regulation. Please contact the Health Department regarding this matter immediately. If we do not hear from you by May 10, 2000 your name will be placed on the regularly scheduled Board of Health meeting agenda and placed on public notice. The meeting will be held on May 25, 2000 for discussion of legal action including court hearings. BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 Sewer Tie-In 49 Meadowview Road Page 2 Any questions concerning this regulation should be directed to the Board of Health at (978) 688-9540. Additional inquiries regarding the physical tie-in and permitting process should be directed to the Department of Public Works at (978) 685-0950. Please be advised this Board intends to persevere in this regulation. Yours truly, Gayton Osgood, C airman Francis P. MacMillan, M.D., Member J J Rizza, D.M.D., Ember--_' SF/smc Town of North Andover, MA L Watershed Septic System servici:nq,Fepor p Date: f Homeowner: r Pumper Street Address: / ZZ, Phone �� �a�Phcn TS� Nature of Service: Routine Emergency Observations. Good condition � Full to Cover Baffles in Place Leachfield Runback Excessive solid$ Heavy . Grease Roots Other (Explain) r Description of Work: Comments: 1 e k A �h APPLICATION FOR SEWAGE DISPOSAL INSTALLATION HEALTH DEPARTMENT. - NORTH ANDOVER, MASS. hereb make application for a permit for a sewage disposal installation at tl ( /� %, .,,(ez „ /lee I will install this system in ac- cordance with all the laws of the Commonwealth of Massachusetts and regulations of the Board of Health of the Town of North Andover. Further, I will construct the house sewer of bell and spigot pipe, the minimum diameter being 4 inches, and will maintain a minimum grade of 1% until 10 feet pre- ceding the septic tank, where the grade shall not exceed 2%. I will install a con- crete septic tank of in size. A manhole (s) permitting easy cleaning will be provided with7 removable cover (s) of iron or concrete within 12 inches of the ground surface. I will provide subsurface disposal field with 4 inch perforated or open jointed pipe and laid in a series of trenches, the bottom of which will pro- vide a minimum of ;/ 0 lineal (square) feet of effective absorption area. The pipes will be laid on a 6 inch layer of washed gravel or crushed stone ranging in size from 3/4 to 1-1/2 inches (dia.) and the pipes will be surrounded by similar material to a height of 2 inches above the crown of the pipe. The joints of these pipes will be protected from clogging and before filling the trench, 2 inches of gravel or stone 1/8" to 1/4" (dia.) will be placed over the course gravel or stone. The disposal field will be installed at a grade of 4 to 6 inches/100 feet. No single the line will exceed 100 feet in length and in any case, two lines of tile will be installed. A minimum of 6 feet will be maintained between the center lines of the disposal field trenches and the average depth of trench shall not exceed 36 inches. No part of the installation will be less than 100 feet from any private water supply, 25 feet from any stream, 20 feet from any dwelling or 10 feet from any property line. I further agree not to cover any portion of this installation until approved by the inspection officer, as provided below, and to incorporate any additional requirements that may be attac ed to the permit. Plot Plans must be submitted with application. DATE Sign ,pef. ure of Applicant I hereby issue the above permit for the Board of Health of the Town of North Andover, Massa husetts. DATE �i 7 Sign tune o Health Agent I have inspected the uncovered system indicated above and find everything done as described. DATE Signaturo Inspecting Offic Percolation Test Z W44ZZL`� Garbage Grinder BOARD OF HEA r TOWN OF NORTH MASS �-5 1 INV .sa /-5o 1. NAME,& -- DATE �Q-.28-6 LT :f/ ✓/&)�<&G /fC7 LOT NO. /� 2. ADDRESS, TEL. 3. NO. OF BEDROOMS DEN YES NO�, 4. GARBAGE GRINDER YES _ NO 5. SHOW DIMENSIONS OF HOUSE 6. SHOW DISTANCES OF HOUSE TO ALL PROPERTY LINES 7. SHOW DIMENSIONS OF LOT 8. SHOW LOCATION.AND SIZE OF SEPTIC TANK OR CESSPOOL ,' / 9. NOTE LOCATION AND DISTANCE OF WELL FROM SEWERAGE SYSTEM A,16Ute ALL 10. SHOW LOCATION OF BROOKS, STREAMS, DITCHES, LEDGE OUTCROP, ETC. 11. SHOW DISTANCE OF SEPTIC TANK OR CESSPOOL FROM HOUSE NOTE: LOCAL REGULATIONS SHOULD BE READ CAREFULLY. BOARD OF HEALTH OF NORTH ANDOVER , MASSACHUSETTS SEWAGE DISPOSAL DATE NAME OF APPLICANT LOCATION Address of lot no, BUILDING: Dwelling X Other SYSTEM: New Repair GENERAL DESCRIPTION OF LAND r SUBSOIL: Clay--L— Gravel Sand PERCOLATION TEST �- minutes per inch. MINIMUM INSTALLATION RECOMMENDATIONS CONCRETE SEPTIC TANK4 0 69 0 gallon capacity. LEACH FIELD _ ,,�/O lineal feet of drain pipe. Oil 'William J. D iscoll, Engin r Board of H th WATERSHED RESIDENTS QUESTIONNAIRE 1. Name s?/v sty Z_I P64y 2. Street Address -ft /f4^06qJ614W /60 3. How many members are in your household? 4. What type of sewage disposal system do you have? ❑ cesspool septic tank and leaching area ❑ connection to municipal sewer ❑ other (describe) ❑ do not know S. Are the plans (drawings) for your sewage disposal system on file with the Board of Health? ❑ yes ❑ no ❑ do not know 6. How old is your sewage disposal system? ❑ 0-5 years ❑ 6-10 years 11-20 years El over 20 years ❑ do not know - 7. Has your se wa a disposal system been rebuilt or repaired? El yes no ❑ do not know If yes, approximately how long ago? years. What was done? i - 8. How frequently is your sewage disposal system pumped out? ❑ annually - every 2-4 years ❑ every 5-10 years ❑ over 10 years ❑ never 9. Have you had any problems with your sewage disposal system? ❑ yes no If yes, what problems? - ❑ repeated pump-outs needed ❑ system clogs, backs up, or drains slowly ❑ odors ❑ sewage surfaces through ground 10. How many of each appliance are connected t0 your sewage disposal system? J washing machine X dishwasher X / garbage disposal dehumidifier drain sump pump toilet roof/pavement drains shower/bathtub 1 11. Please state the brand and type (liquid or powder) of detergent you use for: dishwasher clotheswasher AJAK 12. Does your property have a lawn? yes ❑ no If yes, approximately what size? - ❑ less than 1/4 acre ❑ 1/4 acre ❑ 1/z acre ❑ % acre acre ❑ more than 1 acre (Specify) acres 13. How often do you fertilize your lawn? No. of applications per year d Season(s) of the year 14. Please state the brand and type (liquid or granular) of lawn fertilizer you use: ❑ Check here if your lawn is maintained by a professional landscape contractor. SEPTIC SYSTEM INSPECTION FORM ADDRESS4 {ry'L�ac� � lei DATE INSPECTED ' PROPERLY FUNCTIONING? 6 N WEATHER CONDITIONS COMMENTS : a WA i ER aVALI i Y TES 1 Et, n hESO,-TS? DYE TEST PERFORMED? Y N DATE? SKETCH: