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Miscellaneous - 575 WINTER STREET 4/30/2018
r 10275 Date ... Ph. 2. A,3 ....... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that �Ve— �Cj W ... . ..... f ....... ............ ....................... ........ . .. .................................................. has permission to perform ..... ...... 4 ..... k . ................... plumbing in the buildings of .......... L ......... ..) ...... A .................................................................... at .................... 5.15 ..... ......... :45k.-, North Andover, Mass. Fee.5T. .... Lic. No.n. ?.... tl.)�� ............................................................... PLUMBING INSPECTOR Check# �r9ll MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Print or Type) r - -_-- -= r o 21 ,Mass. Date A,6y / j 20 /3 Permit # ` Building Location 4--,/y �y �7� Owners Name Owner Tel# Type of Occupancy I� New ❑ Renovation ❑ Replacementx FIXTURES Plan Submitted: Yes ❑ No ❑ Installing Company Name d? ,5 P/ Address P, 0 13sX �� Y Business Telephone # ,�?-7R-r- R 6 - oDa� Name of Licensed Plumber 5y<0 4-eL.-, /,,.) f / Check one: Certificate ,Corporation 3 3 y ❑ Partnership ❑ Finn/Co. INSURANCE COVERAGE: I have a current liability 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 ❑ 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 intormation 1 have submitted (or entered) in above appncanon are true ana accurate to me oest or my xnowieage and that all plumbing work and installations performed under t e permit 1 sued for this application will be ' complian with all pertinent provisions of the Massachusetts State Plumbing Code and Chapter 142 of e G_ aws. ® 11 7 By Title City/Town APPROVED (OFFICE USE ONLY) Plumber Type of License: Master t` Journeyman El License Number vJS LJ S !_.� 10. : Installing Company Name d? ,5 P/ Address P, 0 13sX �� Y Business Telephone # ,�?-7R-r- R 6 - oDa� Name of Licensed Plumber 5y<0 4-eL.-, /,,.) f / Check one: Certificate ,Corporation 3 3 y ❑ Partnership ❑ Finn/Co. INSURANCE COVERAGE: I have a current liability 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 ❑ 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 intormation 1 have submitted (or entered) in above appncanon are true ana accurate to me oest or my xnowieage and that all plumbing work and installations performed under t e permit 1 sued for this application will be ' complian with all pertinent provisions of the Massachusetts State Plumbing Code and Chapter 142 of e G_ aws. ® 11 7 By Title City/Town APPROVED (OFFICE USE ONLY) Plumber Type of License: Master t` Journeyman El License Number vJS LJ S !_.� 10. i� r - r W cn r t (} In t Q co . l N C��^�N/'U U. :0 ;O tj> > >- to �' • ZQ �� > Lri CD tF- '• W. W co o7 LA • W F- :` O 1• • �� . _ 'r .. UL N U W 1(o �i This certifies that .. 7Tk.(N-Y,. has permission to perform..Nj ............................ , I L' plumbing in the buildings of ........................ at ... 5.-1,:) ... � r,) *� P— e ........... North Andover, Mass. Fee F '3 4- PLUMBING INSPECTOR Check # _FS -3W2 TOILET WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING I i OTHER INSURANCE COVERAGE: I have a current liabilily insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES 2-110 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY BOND OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance cove rage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER M-1 AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in com fiance with all Pe inen ovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME SIGNATURE COMPANY NAME IADDRESS CITY !IISTATE TEL ZIP FAX CELL EMAIL � � MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY MA DATE ]PERMIT# JOBSITE ADDRESS POWNER ADDRESS TEL=__..__IIFAX TYPE OR OCCUPANCYTYPE COMMERCIAL Eq EDUCATIONAL Ell RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: EP--' PLANS SUBMITTED: YES 0 NOE] BATHTUB I CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OILISAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM _j DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR /AREA DRAIN INTERCEPTOR (INTERIORT KITCHEN SINK LAVATORY ROOF DRAIN -A —1 1 SHOWER STALL _j i TOILET WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING I i OTHER INSURANCE COVERAGE: I have a current liabilily insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES 2-110 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY BOND OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance cove rage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER M-1 AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in com fiance with all Pe inen ovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME SIGNATURE COMPANY NAME IADDRESS CITY !IISTATE TEL ZIP FAX CELL EMAIL � � H z° 0 H U a w O z N o F- w p w O W IL Z u LUx W F- W ® a w IL W o > fx w L 3 L' a p z w a C.) J a M a � � w x w LL Z z ' 0 H U W a M a a p� PAr •• c7 The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations UIP 600 Washington Street Boston, MA 02111 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leizibly Name (Business/Organization/Individual): AI 0 Address: yir &,d,A) 5' ";7— City/State/Zip: .) City/State/Zip:.)torleg, cf tit�Z Phone #: A aF 29 r 9�219 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).* 2. �am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. �• E] 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 10.❑Electrical repairs or additions required.] officers have exercised their 3111 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.E] Roof repairs insurance required.] t 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. I 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 joh site information. Insurance Company 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. Ido hereby cert der [tiesrjury that the information provided above is true and correct Riunnfi�-7;= bate. 9%J j�C3�®/ Phone #: 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 #: 0` Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract ofhire,- 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 whoresides 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, §25C(6) 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 not producedacceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "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 out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit 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. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials 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 permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Invesfigatlons 604 Washington Street Boston} MA 02111 Tel, # 617-727-4900 ext 406 or 1-877:MASSA.BB Revised 5-26-05 Fax # 617-727-7749 www.mass,govfdla Division of Professional Licensure: License Search Page 1 of 1 I The Official Website of the Office of Consumer Affairs and Business Regulation (OCABR) Division of Professional Licensure Mass.Gov Home State Agencies A -Z Topics Home > Division of Professional Licensure > Check A Professional License By the Division of Professional Licensure I LICENSEE Name:THOMAS S. FARHADIAN HAMPSTEAD, NH fitEVf', Licensing Board: PLUMBERS li GASFITTERS License Type: JOURNEYMAN PLUMBER License Number: 19420 Status: CURRENT Expiration Date: 5/1/2014 Issue Date: 5/6/1996 Exam Date: School: This web site displays disciplinary actions dating back to 1993. This license has had no disciplinary actions taken during this time. The page above has been generated by the Division of Professional Licensure web server on Thursday, March 07, 2013 at 9:11:21 AM. © 2007-2011 Commonwealth of Massachusetts Mass.Gov ONLINE SERVICES Check a License Locate a Licensed Professional Online Address Change Contact the Agency More... REFERENCES & RELATED INFO Disclaimer Regarding Website License Searches Enforcement Process Glossary Glossary of License Status Codes More Site Policies Contact Us http://license.reg. state.ma.uslpubLiclpubLicenseQ. asp?board_code=PL&type_class=_J&Iic... 3/7/2013 This certifies that .. Date .... ...' J . ............. q..... TOWN OF NORTH ANDOVER PERMIT FOR WIRING ..................... ........ has p6rmission to perform .......................................................... wiring in the building of ........ ............................................................................ at 2-5 ............ North Andover, Mass. FeeZ� .. ..... Lic. No. lu ............ ........ ............ ELECTRICAL INSP R Check #,, 8723 Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No.� BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRIC //�� All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 C ,12 OOwORK (PLEASE PRINTININK OR TYPE ALL INFORMATION) Date: 'Ld V'1-11 City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) Owner or Tenant 1 �A / fA Telephone (a hone No. Owner's Address Is this permit in conjunction wit ait? er building pmYes No � ❑ (Check Appropriate Box) Purpose of Building bUtility Authorization No.—&a a// S . Existing Service /0-) Amps /ad / gci> Volts Overhead ❑' Und rd g ❑ Na. of Meters New Service `� Amps 1,2-L 13 +�� Volts Overhead Q- Und rd g ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: No. of Recessed Luminaires I-om tenon o the o[lowtn No. of Ceil: Susp. (Paddle) Fans ------------- No. of Luminaire Outlets No. of Hot Tubs No. of Luminaires Swimming Pool Above ❑ In- ❑ d. nd. No. of Receptacle Outlets No. of OR Burners No. of Switches No. of Gas Burners No. of Ranges No. of Air Cond. Total Tons No. of Waste Disposers Heat Pump Number Tons KW Totals: __._.......... .... _.... _._. No. of Dishwashers Space/Area Heating KW No. of Dryers Heating Appliances KW 1 No. of WaterKW Heaters No. of No. of Si Zrn s Ballasts . No. Hydromassage Bathtubs No. of Motors Total HP OTHER: table may be waived by the i ranstormers KVA Generators KVA No. o mer57encv .,Q na FIRE ALARMS No. of hones No..of Detection and No. of Alerting Devices Local ❑ mint-nnnrtpalfinn ❑ Other n No. of Devices or Data Wiring: No. of Devices or No. of Devices or Wires. 'Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start —a 3_ �� 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 to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that Ile information on this application is true and complete. FIRM NAME: LIC. NO.: Licensee: �J�� ��//_ `� Signature LIC. NO.: (If applicable, a ter "exempt " 'n1he license number line.) Address: 42Z2 Bus. TeL No.: 11h, *Per M.G.L c. 147, s. 57-61, securi work re uires „� Alt. Tel. No.: tY q epartrnent f Public Safety S License: 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: $ if t a k, r Mir i The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 tr i www.mass.gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/tndividctal):_P(�_� Address:� . 7 �n I 4L- , *-r f City/State/Zip: `L (" i , i �el- � Phone #: l Type of project (required): 6. ❑ New construction 7. Q Remodeling 8. Q Demolition 9. Building addition I0.❑ Electrical repair or additions I I.❑ Plumbing repairs or additions 12.[] Roof repairs 13.[Q.Other ing arwo ars compensation policy mtormation. Homeowners who submit this affidavit indicating they art; daring 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 ininmtation. I artt an employer that is. proWing:workerscompensation insurance for my employees: Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lie. #:_ /�r / V- Expiration Date: ' Sob Site Address:_ City/State/Zip:`�k"-� 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 DCA for insurance coverage verification. I do hereby certify under the pains and penalties of perjwy that the information provided above is true and correct Signature: D Phone #: ficial use only. Do not write in tfris 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 S. Plumbing Inspector 6. Other Contact Person: Phone #• Are you an employer? Check.the appropriate box: I X I am a employer with / 4. ❑ 1 am a general contractor and I employees (full and/or part-time).* 2. Q I am a:sole proprietor or have hired the sub -contractors listed x partner_ on the attached sheet ship and have no employees These sub -contractors have working for me .in any capacity. [No worker' comp. insurance workers' comp. insurance. 5. ❑ We are a corporation and its required-] 3. ❑ I am a homeowner doing officers have exercised their all work right of exemption per MGL myself. [No -worker' comp, c. 152, § I (4), and we have no insurance required.] f employees. [No workers' comp, insurance required..] •Any applicant dist checks bort f€ I must also fill out the section below show' Type of project (required): 6. ❑ New construction 7. Q Remodeling 8. Q Demolition 9. Building addition I0.❑ Electrical repair or additions I I.❑ Plumbing repairs or additions 12.[] Roof repairs 13.[Q.Other ing arwo ars compensation policy mtormation. Homeowners who submit this affidavit indicating they art; daring 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 ininmtation. I artt an employer that is. proWing:workerscompensation insurance for my employees: Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lie. #:_ /�r / V- Expiration Date: ' Sob Site Address:_ City/State/Zip:`�k"-� 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 DCA for insurance coverage verification. I do hereby certify under the pains and penalties of perjwy that the information provided above is true and correct Signature: D Phone #: ficial use only. Do not write in tfris 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 S. Plumbing Inspector 6. Other Contact Person: Phone #• Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, 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 individuals, 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, §25C(6) 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 not produced acceptable evidence..of compliance with the insurance 'covemge required." Additionally, MGL chapter 152, §25C(7) states "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 out the workers' compensation. affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) aind phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not requiredto carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit 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, notthe 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 numberlisted below. Self-insured companies should enter their self insurance license number on the appropriate line. City or Town Officials 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 permidlicense number which will be used as a reference number. In addition, an applicant that must submit multiple permitilicense applications in any given year, need only submit one affidavit indicating -current policy information (.if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give as a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Stieet Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-8.77-MASSAFE Revised 5-26-05 Fax # 617-727-7744 www.mass.govldia Date .4�3' °9 . TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING '3 SSACMusE� f� This certifies that�'�..............:. !?! ............. . has permission to perform ......P .�. ..... `... ................. . plumbing in the buildings of ..:.................... . at ..... l'��-� •^ .... , North Andover, Mass. Fee ��� ..... Lic. No... `?�9../. ......... �!............ . PLUMBING INSPECTOR Check # 8052 f MASSACHUSETTS UNIFORN4 A-PPLICATION FOR (Type or print) PERMIT TO DO PLUM ] NG NORTH ANDOVER, MASSACHUSETTS Building New Renovation ald , l >In n 1 c2 of Replacement ,M M'1'UT ES EMMA ®/nnnnn vn//v�� I' • B .. • -//MINE �SIIIIi� . r: a • to • �������� as • �-- M Date Permit # U Amount od Plans Submitted Yes .13 x`11 No ❑' (Punt or type) R 'nstallirtg Company Name I onJ c l "AA Check one: Certificate Address Q u Q Corp s � NK e? �ti n usutess. elephone b �--+ Pier' Name of Licensed Plumber;r� Fmn/Co. Cr Insurance Coverage: Indicate��ne a of insurance covers e b e Liability insurance policy K g Y heckmg the appropriate box: 84 Other type of indetnttity ❑ er. Bond Insurance Waiva I the undersigned have been made aware three insurance that the licensee of this application does not have any one of the above 'agnat ire Owner ❑ ❑ I hereby certifyAgent that all of the details and information I have submi best of m plumbing tted (Or entered) in above application are true and accurate to the } knowledge and that all lumbin work and installations performed under P compliance with all pertinent provisions of the Massae efts State Permit Issued for this application will be in P�jbmg�and Chapter ] 42 of the General Lays, By a2gnaiure o� .,•'..,�,.., is -i -VT own APPROVED rotcE USE ONLY Type of Plumbirig License License lvumuer Master Journeyrrlan ❑ ,;;6-- e -v, l,K l jt>J i :ii ,,,, r 'he (-ommonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 x'�'.n?ass.; ov/din Workers' Compensation Insurance Affidavit: guilders/Contractors/Eleetricians DIieant Iafornzation /Plumbers Name (Business/Organization/Individual) (.) r Address:- I t„ t �In , . (A t) City/State/Zip: ,� ,x)y KM oS I Phone #: 9%g Are you an empioyer? Check the appropriate box: I . ❑ I an a employer with 4. ❑ IML a eneal em pto ees (fill and/orpart-time).* 2. U11 -lam a sole proprietor or partner. ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3.❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t contractor and I have hired the sub -contractors listed oxi the attached sheet I These sul- contractors have workers' comp. insurance. 5.. ❑ We are a corporation and its of"iic= have eyercised.their right of exemption per MGL c. 152, § 1(4) and we have no empioyees. [No .workers' comp. inset $0t -19)C Type of project (required): .6• ❑ New construction 7• ❑ RemodeIing . 8• ❑ Demolition 9• ❑ Building addib.on 10:0 .Electrical repairs or additions I l.❑ Plimtbing repairs or additions 12:❑'Roof repairs ranee required ] I 13 ❑Other *Any appli ant,that chec(cs box #I .must also fill out the section below showing their N orkers .compensation poiicy iniomsation. t. riumeowners who subtnit.thic esdavit indicering titej- eft duin� eErc ,,. etrei � hi ou iae convat rues '"us x MfOrbmii a YContractots that check this box mu si attached an additional sheet showing the name of the s :b ; c ncm, afdavir irdi�rt seen. r „ - Zmctors and their wnrY..... Ll[f011nati0/j wvcr IMUL Ls pro.'Lsi[ne workers' compensation insurance for ny, employe s. B -- r. Y • �y eu1urmmauon. elow LS the pO&Y and job size Insurance Company Name: Policy # or Self -.ins. Lic. #: Expiration Date: Job Site Address: Attach a copy of the workers' compensation otic deela City/State/Zip: P y . t'ation page (showictg the on date). poiicy number and expirati .Failure to secure coverage as required under Section 25A of fine up to $1,500.00 and/or one-year imprisonment; as well MGL C. as 152 can lead to the imposition of criminal penalties of a of up to .5250.00 a day against the violator. Be advised that a ccivil penalties in the form of a STOP WORK ORDER and a fine op}� of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. 'l fin 4—A., Pte' . penai6es of perjaf�' that the "forn-60,' provided above is true and correct #: Official use only. DO not write in this area, to be completed by city or town offciaL City or Town: Issuing Authority (circle one): Permit/License # 1. Board of health 2. Building Department 3. City/sown 6. Other Clerk 4. Electrical Inspector 5. Piumbina Inspector Contact Person: Phone ;r f r Location No. po' Date MORTM TOWN OF NORTH ANDOVER k. • Certificate of Occupancy $ s•^°' EtBuilding/Frame Permit Fee $ �cMus # Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # �G 18557 Building Inspec , r. 0 APPLICATION TO CONSTRUCT RE.] BUILDING PERMIT NUMBER: TOWN OF NORTH ANDOVER ]BUILDING DEPARTMENT 1;, RENOVATE,- OR DEMOLISH A ONE OR TWO FAMILY DWELLING '0 DATE ISSUED: SIGNATURE: //I Building CommissionerAns=tor of B SECTION I- SITE INFORMATION I. I Property Address: 5 5- M-ake &)0, Akooyak — 1.3 Zoning Imonnation: ctnlmg rJrsrna Pron,lq-i Use BUILDING SETBACKS ft Front Yard Required Fro—vide Date 1.2 Assessors Map and 16y. 04 Map Number 1.4 Lot Area (sf) Tide Yard — I Provided -Tarcal N41111ber Rear Yard Provided 1.7 Water Supply NiG.L.C.40. S 34) 1A Flood Zone information: Zone 1.8 Sewerage Disposal Sysjm: Public 0 Private 0 I — Outside Flood Zone 0 OWNERSHIP/AUTHORIZEDMunicipal ❑0 On Site Disposal System 0 SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED—AGENT 2.1 Owner of Record vid Name (Print) Address for Service Signature G, -7 Z) V Zz A, Telephone 2.2 Owner of Record: N Name Print Address for Service: 0 z Signature Telephone M SECTION 3 - CONSTRUCTION ES 3.1 Licensed Construction Supervisor: Licensed Construction Supervisor: Not Applicable 0 0 License Number Address n Signature Telephone Expiration Date 3.2 Registered Home Improvement Contractor ------ A V-- VAVLP Not Applicable ❑ 0 Cry axje-o Company Name -W, ,1 /� 2 Registration NU111beF M Ad s Signature Telephone Expiration Date SECTION 4 - WORIURS COMPENSATION (NLG.L. C 152 6 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 ....... 0 SECTION 5 Description of Proposed Work check atl applicable) New Construction 0 Existing Building Repair(s) ❑ Alterations(s) ❑ Addition 0 Accessory Bldg. ❑ Demolition 0 Other ❑ Specify Brief Description of Proposed Work: Re. r0c�- CIOJ�e SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit applicant UFFiCIALUSE t?NL3t 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) X (b) Oz. 4 Mechanical (HVAC) 5 Fire Protection 6 Total 1+2+3+4+5) dV Check Niunber SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf, nr all matters relative to work authorized by this building permit application. Signahue of Ovnier Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 1, T)4 V / 7) C— U A2 E 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 N e �.. Signature of Owner/Agent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TINMERS 1ST2ND 3PD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DRAFNSIONS 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 L, The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street t Boston, MA 02111 °,M SV•�� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): D dY1 d `^ Address: S VqAtr S�(tc_v City/State/Zip Ko NA mg Phone #: 9 � � � � 7 99 ?--' Are you an employer? Check the appropriate box: t. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* 2. ❑ I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t have hired the sub -contractors listed on the attached sheet. These sub -contractors have workers' comp. insurance. ❑ We are a corporation and its officers have exercised their right of exemption per MGL C. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. El Electrical repairs or additions 11.❑ Plumbing repairs or additions 12. 0a'Roof repairs 13.❑ Other sAny applicant that checks box #I 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 ;Contractors that check this box must attached an additional sheet showing the name of the subcontractors and their workers' comp. policy information. J am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Q Insurance Company Name: Policy# or Self -ins. Lic. #: V VV C 6 D O/ 7 6 0 0/ d CU 7 ) Expiration Date: �/,�.3 Job Site Address: 6 -? S �) i ► 4.l' 5\h&_4 06 . Ai0 %Vek,,- City/State/Zip: HA 61 `F r 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 nTrisonment, 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 certify under tjie pains and penalties of perjury that the information provided above is true and correct Phone #: % 7 � 6 [f 3 3VAO 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 #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, 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 ari 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, §25C(6) 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 not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "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 out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit 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. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials 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 permittlicense number which will be used as a reference number. In addition, an applicant that must submit multiple permittlicense applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would hike to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 5-26-05 www.mass.gov/dia DAVID CASTRICONE q -q —oS ROOFING, SIDING & REMODELING REPLACEMENT WINDOWS HOME IMPROVEMENT CONTRACTOR REGISTRATION NUMBER 104569 200 SUTTON STREET, SUITE 226, NO. ANDOVER, MA 01845 7 HILLSIDE ROAD, BOXFORD, MA 01921D M P M 91FM jj In North Andover 978-683-3420 In Boxford 978-887-6147 IUI In Haver/0 9 78-3 74- 7314AUG �31 2005 I/we the owner(s) of the premises mentioned below, hereby contract with and authorize you as contractor, to "ish all necessary----- materials, labor and workmanship, to install, construct and place the improvements according to the following speciftcations, terms and conditions, on premises below described: Owner's Name ..... D -Q-- !.d....t....�. R.ez.rl. ...L !!?..........................................dn4.P...,.-. Telephone #.... a.U.--e'.i.! oa.................... Job Address.. 5-15 ......:...................................... city ... .�!�Q.:.�. yti.'.:....................... State... MA ............... Specifications: ..i....................................................................................................................................................... ................. ........................ I............. trp existing shingles. 4(pply new drip edge to all edges. .vt; ti �tn;s n or hrow„ l. ✓apply �_ feet ice and water shield membrane to bottom edges of house. 3 feet ice and water shield membrane in valleys and bottom edges of any unheated areas of house. ................................................................................................................................................................................................................. ✓hpply felt paper underlayment. +'Install ridge vent to :k rPd e a y?42 r n pprn r Y S' .................... r6..(�O:r4.!avl...........................e,,k;'Jg......... shingles with a � r) year warranty. .....................................................................................:................................. vil�eroof using Tawt k o �� rr rz rr. " few_ g ........................................................................................................................................... .......................................................................... ounterflash chimney. Kew vent pipe flashing. gal disposal of all debris. ................................................................X..........,............................................................................................I........... Area(s) to be worked on:. """"""""" .. a� ...re.�pla>., �t�✓l i.... ..x►�c�s >,r ....r .......�ao� h:ct....ar......1+/Et.:.......................... .............. .................................................................................................................................................................. One Year Workmanship Warranty (Not Transferable) Manufacturer's Warranty effi!%"bX Manufacturer Materials and Labor to cos ........ :5"-47 ?......... Payable .......foo ............ on .... ,5xr +........ Payable ........ :77= ............. on .................................. eBalance payable on completion of job Owner or Owners are not responsible for Property Damage or Liability while job is in operation. Contractor is not responsible for any damage to the interior of property, including pre-existing conditions (i.e. water stains, crumbling plaster, exposed nails) or conditions resulting from application of materials specified above (i.e. objects coming loose from walls, crumbling plaster, exposed nails, dust in attic or other living spaces, water stains when roofing shingles have not had adequate time to cure). Upon completion of above work, all undersigned agree to execute and deliver to contractor, their joint note in accordance with his (their) above obligation as requested by contractor. Upon refusal to do so, contractor may at its option declare the entire contract price or so much as then remains unpaid, immediately due and payable. It is agreed that, if permitted by law, contractor shall be paid by the owner(s) all reasonable costs, attorney fees and expenses, in addition to the amount due and unpaid, that shall be incurred in enforcing the terms and conditions of the contract and/or any lien in connection herewith. It is further agreed that this contract may be assigned by contractor, and also that the obligations hereof shall bind and apply to their heirs, successors or estates. The undersigned warrant(s) that he is (they are) the owners(s) of the above mentioned premises and that legal title thereto stands of record in his (their) names(s). There are no representations, guaranties or warranties, except such as may be herein incorporated, if any, nor any agreements collateral hereto, nor is the contract dependent upon or subject to any conditions not herein stated. Any subsequent agreement in reference hereto shall be binding only if in writing and signed by all parties. All Home Improvement Contractors shall be registered and any inquiries about a contractor or subcontractor relating to a registration should be directed to: Director, Home Improvement Contractor Registration One Ashburton Place Room 1301, Boston, MA 02108 Tel: 617-727-8598 Any and all necessary construction -related permits shall be obtained by the Contractor. Any Owner who secures his own construction -related permit or deals with unregistered contractors shall be excluded from access to the Guaran Fund Approximate starting date of work...��........� Completion date.............................................................. Receipt of a copy of this contract is hereby acknowledged, and it is further acknowledged by the undersigned that the foregoing provisions have been read and the contents thereof understood and that no representation or agreement not herein contained shall be binding upon the parties and that all of the agreements and understandings of said parties are contained herein. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. Owner has three business days to cancel this contract and incur no penalty. IN WITNESS WHEREOF, the parties have hereunto signed their names this .........10...N..., day of ......... 20.1...... Accepted: Signed..K......// �V...................................................................... Owner /� .(. ti Sigtied ........ 1(�,1(.�....(Lld........................................ Owner Per................................................................. Representative 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 at: 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. Also, note Permits are required under Fire Prevention laws Chapter 148 Section 10A. The debris will be disposed of in: VF -6 k L S 7-6 Z I- Y--5 _.1.1VC,�) SA -1 -EM A)tl (Location of Facility) Signature of Permit Applicant Fire Department Sign off: Dumpster Permit Date w O C% o Ec o0 R r� E ?•JCA 91 O O v CDE O Z v. O h cm p � I � C O•� caCD p y di �O 'FE m m CD 0 CD Z O� •� 3 co CD p O� evv o L �Q Cos o � c ec =.50 0 CD CO3 Z m 0 CL V N3 O C C_ ■ C Cos p 0 vI W W oC W C9 W U) a a AG 3 W 0 I Qu W .�� •1 ' Y U W W C/) 0 C/) w O C% o Ec o0 R r� E ?•JCA 91 O O v CDE O Z v. O h cm p � I � C O•� caCD p y di �O 'FE m m CD 0 CD Z O� •� 3 co CD p O� evv o L �Q Cos o � c ec =.50 0 CD CO3 Z m 0 CL V N3 O C C_ ■ C Cos p 0 vI W W oC W C9 W U) 3 W 0 I Qu W .�� •1 ' Y w O C% o Ec o0 R r� E ?•JCA 91 O O v CDE O Z v. O h cm p � I � C O•� caCD p y di �O 'FE m m CD 0 CD Z O� •� 3 co CD p O� evv o L �Q Cos o � c ec =.50 0 CD CO3 Z m 0 CL V N3 O C C_ ■ C Cos p 0 vI W W oC W C9 W U) Date .. - 7• •' '� N2 4264 O".o�Ttio TOWN OF NORTH ANDOVER ° : a PERMIT FOR PLUMBING This certifies that .?� ..�!r......_..:,.-....r.�-:............ has permission to perform • • • • • • • • plumbing in the buildings of � ., .- - _.-�.-� .................. • • • at• • . • • • • • • • • • , North Andover, Mass. Fee:2---- Lic. No. ..../ 'i �,,.-�. ........... /` PLUMBfiVSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Print or Type) ' iJ . N p ID (,( Q42 , Mass. Date c9 7 c9� .-Iermit # IN Building Location 5 N-1 67?- S Owner's Name ! "S -Do Pi Ii nI-�0✓l-N A Type of Occupancy ':2t S + D E w ll 4 t✓_ New ❑ Renovation ❑ Replacement 1' Plans Submitted: Yes ❑ No ❑ FIXTURES k1stalling Company Name PSOtMel i0i - ,S,4erM14'TA,e-0 Check one: Certificate Address Ct: Rt /4 (nf4n) s- Pi Corporation IY) E TW � ' ' Al f4 • y IT V� ❑Partnership Business Telephone ��f Z -i97 1 �rrn/Co. Name of Licensed Plumber 'EL r3 F?- T fry 5,4MMt4 rK O -O ,' 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 v s, please indicate the type coverage by checking the appropriate box. A liability insurance policy tied 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 and apter of the oral laws. By. visL Title re of Licensed Plumber Type of License: Master Joumeymah ❑ City/Town APPROVED(OFFICE USE ONL License Number z z Y O U< z z W W W N 1L z N J .4 N> Q ~ N z O O O z N a .J N N N= a a Q x Q m d < z O Z Q a O U. W F� h' W N D J N CL C Q J c W C k W S f U> F- O x a H z O O O N z= W F' O x V W X 3 it m vi c o ai 3 s x H a 's m o SUB—BSMT. BASEMENT IST FLOOR f 2ND FLOOR 3RD FLOOR 4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR 8TH FLOOR k1stalling Company Name PSOtMel i0i - ,S,4erM14'TA,e-0 Check one: Certificate Address Ct: Rt /4 (nf4n) s- Pi Corporation IY) E TW � ' ' Al f4 • y IT V� ❑Partnership Business Telephone ��f Z -i97 1 �rrn/Co. Name of Licensed Plumber 'EL r3 F?- T fry 5,4MMt4 rK O -O ,' 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 v s, please indicate the type coverage by checking the appropriate box. A liability insurance policy tied 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 and apter of the oral laws. By. visL Title re of Licensed Plumber Type of License: Master Joumeymah ❑ City/Town APPROVED(OFFICE USE ONL License Number m m co m r O In O z O �n A ' m c N m v' O Z r r p v n O � m z � C O O O m C � � m = � 0 O O r C a m m co m r O In O z O �n A ' m c N m v' O Z r N2 21 3 7 Date ........ h... .... p' ao- TOWN OF NORTH ANDOVER p PERMIT FOR WIRING This certifies that ............ °C ( . R. `,�.... .I ....... r -t ................................... has permission to perform ..... .!'a.. .....�— ��.z..WZ................................... wiring in the building of ........ nl.k l .......................................................... i S %......1, a �? rZ S ( �, North Andover, -Mass. at ................................................ FeelWA.. Lic. Jll ..' 'l G>'z ............. ELECTRICAL INSPECTOR Check # 7 ✓ WHITE: Applicant CANARY: Building Dept. PINK: Treasurer It 1f4?m tonwaa& of I!/a�Jjj BOARD OF FIRE PREVENTION REGULATIONS For Office Use Only (Rev. 11/99) Permit Number. Occupancy & Fee ALKICATION FOR PERMIT TO PERFORM ELECTRICAL WORK (ALL WORK TO BE PERFORMED WITH THE MASSACHUSEM MXMICAL CODE 527 CMR 12.00) PLEASE PRINT IN iNK OR TYPE ALI; INFORMATION Date: �3 1-0 /. City or Town of: • ANDOVER To the inspector of Wires: By this application the undersignec l gives notice of his or her intention to perform the electrical work described below. Location: (Street & Number)�� IU//V T&A Owner or Tenant: h Owner's Address: Is this permit in conjunction with a .3uilding Permit? Yes D/ No o (Check Appropriate Box) Purpose of Building: SLAG /E 62t / Utility Authorization #: / Q / / .3 T Existing Service: /uv Amps D/e volts Overhead>� Underground.❑ #of Meters„_ New Service: /U Amps1�� --LZ-VQ Volts Overhead Cl,-" Underground.0 # of Meters:_� Number of Feeders and Ampacity:-j,Q£ Location and Nature of Proposed Electrical Work:_,���R DIIC (/ 14?E"04//2 No. of Transformers Generators '-f/s e�c Total KVA KVA # of Emergency Lighting Battery units Fire Alarms # of Zones # of Detection & Initiating Devices # of Sounding Devices: # of Self Contained DetectiordSounding Devices Security systems: No, of Devices or Equivalent Data Wiring, No. of Devices or Equivalent: Telecommunications Wiring: No of Devices or Equivalent: No. of Water Heaters KW.— 1 No, of Signs; # of Ballasts:— _ OTHER; # of Hydro Massage Tubs I -No. of Motors Tota( HP INSURANCE CbVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue ulicense nless the e including *completed operation' coverage or It i substantial equivalent The undersigned certifies that such coverage is in force, and (las erzh(! proof ofusame W the Penni( issuing office. CHECK ONE: IN; URANCE 0 BOND 0 OTHER 0 PleaSe Specify: Estimated Value of Electrical Work3 (When required by municipal policy) Work to start -LLdPiz i ZO c3 — 7- I certify, under the pains and inspections to be requested in accordance with MEC Rule 10, and upon completion. `� penalties of per/ury, that the Information on this application Is true and complete. Finn Name: �C21 Licensee: -F Signature: (If applieabls enter "exe pt` in the ficansa numb r lin LIC. #_/ 3 4 00 !T Address: (q p�1�� �S-r'• _.�5� � �-� ' l�� • �� Q��3 L4G_-- Bus. T.I. # AIL Tel. # J�~ OWNER'S INSURANCE WARIER: HIM aware that the Licensee does nnr h.- t" No. of Recessed Fixtures No. of Cell.-Buap. (Paddle) Fens No. Of Lighting O.uttets No. of Hot Tubs No. of Lighting Fixtures Swimming Pooh Above ground o in Ground o No. of Receptede Outlets - No. of Oil Sumers No. of switch" . No. of Gas Burners e No. of Ranges No. of Air Conditioners TOTAL TONS: ' No. of Waste Disposals Heat Pump Totals: Number. TONS: KW: No. of Dishwashers Space /Area Heating: Kyy No. of Dryers _: . Heating Appliances KW No. of Transformers Generators '-f/s e�c Total KVA KVA # of Emergency Lighting Battery units Fire Alarms # of Zones # of Detection & Initiating Devices # of Sounding Devices: # of Self Contained DetectiordSounding Devices Security systems: No, of Devices or Equivalent Data Wiring, No. of Devices or Equivalent: Telecommunications Wiring: No of Devices or Equivalent: No. of Water Heaters KW.— 1 No, of Signs; # of Ballasts:— _ OTHER; # of Hydro Massage Tubs I -No. of Motors Tota( HP INSURANCE CbVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue ulicense nless the e including *completed operation' coverage or It i substantial equivalent The undersigned certifies that such coverage is in force, and (las erzh(! proof ofusame W the Penni( issuing office. CHECK ONE: IN; URANCE 0 BOND 0 OTHER 0 PleaSe Specify: Estimated Value of Electrical Work3 (When required by municipal policy) Work to start -LLdPiz i ZO c3 — 7- I certify, under the pains and inspections to be requested in accordance with MEC Rule 10, and upon completion. `� penalties of per/ury, that the Information on this application Is true and complete. Finn Name: �C21 Licensee: -F Signature: (If applieabls enter "exe pt` in the ficansa numb r lin LIC. #_/ 3 4 00 !T Address: (q p�1�� �S-r'• _.�5� � �-� ' l�� • �� Q��3 L4G_-- Bus. T.I. # AIL Tel. # J�~ OWNER'S INSURANCE WARIER: HIM aware that the Licensee does nnr h.- t" Town of North Andover � � �10RT1� OFFICE OF o `.«f c '6 �tio COMMUNITY DEVELOPMENT AND SERVICES ° 27 Charles Street L �o , North Andover, Massachusetts 01845 `°`'""'" 41 WII,LIAM J. SCOTT q�gATFD°"`y (`� Director 9SSACNUSE� (978)688-9531 Fax (978) 688-9542 MEMORANDUM TO: Mark Rees, Town Manager FROM: Heidi Griffin, Town Planner Michael McGuire, Building Inspector William Scott, Community Development Directo RE: 575 Winter Street — Culvert/Flooding DATE: April 6, 2001 The following is a compilation of studies and/or issues relative to the culvert and flooding situation at 575 Winter Street. The issues have been listed by departmental findings: • Planning/DPW Coordination: 575 Winter Street is a house lot that is not within a subdivision or a Form A Lot. Per conversation today with Jim Rand, Director of Engineering from the Department of Public Works, the culvert is town -owned. The culvert was designed to handle a flow capacity for a 25 -year storm. However, the recent storm/rainfall was significantly greater than a 25 - year storm. The Lind property is lower than Winter Street, hence the great amount of flooding on their property. I have no drainage calculations as the lot is not part of a subdivision. • Building/Health: The Health Department file provides a septic inspection report in 1998. The report indicates that the depth to groundwater is 4 feet; this is taking into consideration that the area was filled for the septic system and home construction. The Soil Conservation service shows that groundwater is 1.5 to 3 feet below grade typically for this area. The possibility is that groundwater is close to the foundation elevation. The attached photos were taken upon a site inspection at 575 Winter Street on 4/3/01 by Mike McGuire. The homeowners are taking precautions from future damage by lifting the heating system and laundry facilities. There is some new flood damage as well as old flood damage evidence. There are no other issues with the building department in regards to this site. BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 • Community Development: The Conservation file, 242-142, shows that this rt property was granted an Orders of Conditions bruary 1983. In,1982. The the Engmeersoreport was granted a Certificate of Complianceon June 29 of June 20, 1983 a cast iron pipe was mentioned as being installed under the driveway "to maintain existing flow of waAccording of the areathe of thectul eic rt lies, is which were in the Conservation File the elevation 94 feet; the elevation of the home is 100 feet, for a difference of 6 feet. The horizontal distance, culvert to the home, is 140 feet. ix4.2 percent: elevations the slope to the home from the culverts approximately This slope is minimal. Further information shows that the home could be within a floodplain area. The attached portion of the Flood Insurance Rate Map panel 250098 0007 C shows that the estimated location of the property is close to or within a flood plain area. Attachments: • Flood Insurance Rate Map panel 250098 0007 C • Parcel Map 104A showing parcel 91 -subject parcel. • Air Photo 1995 • Septic Plan 1981 • Building Inspector Photos f40Ac _ - 42 / 85 Q 1.04Ac. a, 28 55 67 • /' ' 0j 88 1.of AC 90 1W 0 J` 1 16ew 4 � co a O 34 y x 1-�' f 10.50 AC. IV \a ob a 2. O 98 100Z s« plan21 2.q7, ° 4 23 Y 22 Q. df 101 o W s.00 24 f W C/i L 97 : 102 e. 2.01 fc 30 S �i 310 K. t-2 32 y,5 81 82 9 4 � 75 m�J3 78 80 79 N .Q R $ g ,r R Iso .�5 # `�.,.� �..�• 4 N 79 77 75 1W 3� 1° 19e 1N 95 Ia N7ER u'r IV 74 93 94 20 1 Y O o 7211 � 12 1.a% �4 ,� �0 ,pec 8.2 at 71 f ,a 83 f p1 p ,.r17 � 12 ,?1 19 la , 04 Ir 84 :A a 73 1e 0 27 2� 14 18 TNO. 1 ",a 104 A 575 Winter Street —1995 Photo If/ 4 Q 40T A ., QYl' IV x (30' �i n S•i, ', �� ttt + ; jA of 10 '-�` v % N .� A OF 'u'FAC E I , SPOSAL SYSI I N ,41V M�), FOR, A:yo'sl'rc NORTH, � A'NDOVE-R,'M,ASc' 0 AS PREPARED FOR /A ROBERT AHERN I APACH E A V E,. ANDOVER, MASS. 01810 SCALE: 1 '20' DECO 1981 C NI MERRIMACK ENGINEERIG SERVIC E S, 1 C PROFESSIONAL ENGINEERS tAh SURVEYORS PLANNERS 66 PAPK. STkr--ET. iNDOVER. MASSACH)ETTS 01810 TIH: (617) 475.3555, 3173-5721 NOTES: I- ALL FILL TO BE BANK R U IN GRAVEL 2 -ALL STONE TO BE DOUBLE WASHED. ..3 -NO GARSAGE GRINDER TO BE INSTALLED. 4 -REMOVE ALL TOPSOIL, ROOTS, AND SUBSOIL AND REPLACE ,WITH CLEAN GRAVEL WITHIN 25' AROUND DISPOSAL SYSTEM. .5- COVER MATERIAL OVER THE SYSTEM SH -AL! B E FREE OF LG, STONES, MASONRY, STUNI'PS OR' WASTE CONST. MATERIAL.THE TOP 4 SHALL BE LOAMED SURFACE SEEDED, MACHINERY WHICH MAY CRUSH OR DISTURB, THE ALIGNMENT OF THE PIPE IN: THE DISPOSAL AREA SHALL NOT• BE ALLOWED. "F led illy or Sfr*d# '6 7 ,lp�0ellp E -------------- 7-? volirs uel)elklljvj cwi t*lght t, of *tope .9 aria steepness of iresulfinq grode of tot Q1 grlwrid' 1,0 W pl 2 x x 3 SID kes eoch be to To bt Vfed ihl�focatlons Where 'b be uted where pusti-ic the cl � . 11 . w - ;xi'st , ing groond slopo5 in around slopes ioiay . tr(,-)j the towurd the. t6e OU the 4tinbonkmoof i0e of the embcnkme BALED HAY, QR STRAW EROSION CpFECj<$ Photos 575 Winter Location sgs WthtYl� S� No. Date 7 .:- 8557 TOWN OF NORTH ANDOVER Certificate of Occupancy $ — Building/Frame Permit Fee $ 0 Foundation Permit Fee $ o Other Permit Feeq* $ Sewer Connection Fee $ Water Connection Fee $ TOTAL $ S Building Inspector o Div. Public Works s 631IT NO. i APPLICATION FOR PERMIT TO BUILD -NORTH ANDOVER, MASS. 09 PAGE 1 MAP K -4O. LOT NO. I 2 RECORD OF OWNERSHIP IDATE BOOK 'PAGE ZONE SUB DIV. LOT NO. � 7 � � 11n �p(- S77 'LOCATION 577'9' �J POSE OF BUILDING f. CJ , dWNER'S NAME �T' ��� NO. OF STORIES SIZEC GWNER'S ADDRESS ` -', n.L,e� S C` BASEMENT OR SLAB ARCHITECT'S NAME SIZE OF FLOOR TIMBERS IST 2ND 3RD ?OILDER'S NAME C\n� SPAN DISTANCE TO NEAREST BUILDING DIMENSIONS OF SILLS POSTS 1075TANCE FROM STREET I-A� STANCE FROM LOT LINES -SIDES ,1"t REAR-icY7 't GIRDERS AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS BUILDING NEW Y625 11// �..7 SIZE OF FOOTING X IS BUILDING ADDITION MATERIAL OF CHIMNEY IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION, IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE SEE BOTH SIDES PAGE 1 FILL OUT SECTIONS 1 - 3 PAGE 2 FILL OUT SECTIONS 1 - 12 INSTRUCTIONS ELECTRIC METERS MUST BE ON OUTSIDE OF BUILDING ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND �APPROVED QBY BUILDING INSPECTOR DATE F V SIGNA RE OWNER OR AUTHORIZED AGENT F E E I s, -- PERMIT GRANTED 19 3 PROPERTY INFORMATION LAND COST ST. BLDG. COST Ar - EST. BLDG. COST PER SQ. FT. /. EST. BLDG. COST PER ROOM F SEPTIC PERMIT NO. 4 APPROVED BY UILDIN INtP6CTOR OWNER TEL. # T7 CONTR. TEL. N CONTR. LIC. N H.LC.l1 o altsb3� CGJLcLll1 BUILDING RECORD 1 OCCUPANCY 12 w SINGLE FAMILY I I STONES THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM MULTI. FAMILY OFFICES LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA - APARTMENTS I I RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. 1 • CONSTRUCTION 2 FOUNDATION 8 INTERIOR FINISH 3 1 2 13 PINE CONCRETE CONCRETE BL'K. BRICK OR STONE HARDW D PIERS PLASTER DRY WALL _ UNFIN. 3 BASEMENT AREA FULL 1/1 1/2 1/1 FIN. BMT' AREA FIN. ATTIC AREA _ _ N_O B M'T HEAD ROOM FIRE PLACES MODERN KITCHEN _ 4 WAILS I 9 FLOORS CLAPBOARDS B _ ll�STUCCO 1 2 3 — _ _ _ DROP SIDING WOOD SHINGLES CONCRETE EARTH ASPHALT SIDING ASBESTOS SIDING VERT. SIDING HARMWD COMMON ASPH. TILE STUCCO ON MASONRY ON FRAME BRICK ON MASONRY ATTIC STRS. & FLOOR _ BRICK ON FRAME CONC. OR CINDER $LK. WIRING STONE ON MASONRY _ STONE ON FRAME SUPERIOR I� POOR _ ADEQUATE NONE 5 ROOF 10 PLUMBING GABLE HIP BATH 13 FIX.) GAMBREL MANSARD TOILET RM. 12 FIX.) FLAT SHED WATER CLOSET _ _ ASPHALT SHINGLES LAVATORY WOOD SHINGES KITCHEN SINK SLATE NO PLUMBING' TAR & GRAVEL STALL SHOWER _ _ ROLL ROOFING MODERN FIXTURES _ TILE FLOOR TILE DADO 6 FRAMING I 11 HEATING WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. TIMBER BMS. & COLS. STEAM STEEL BMS. & COLS. HOT W'T'R OR VAPOR WOOD RAFTERS _ AIR CONDITIONING _ RADIANT H'T'G UNIT HEATERS 7 NO. OF ROOMS GAS OI l B'M'T 2nd _ to 13rd ELECTRIC NO HEATING 1 • w ' G z W W cd O as o v a 0 O 0 z o U c w x O U O bo o w c w" a O W w O M1 o a; cn c w � � tw aG c w 1-4 W w w y rA cis cn uj om c � O M L C +r O h 0 C.)v C3. c c t o 0 � c m C m r �: • t v : r :oa 3' 16— E So . o m • c 0 0 3 r a m c E a O�L m CO �y N CM co m 3 Cm 7 A h /`—•� c� A y w o U a cn mo cn r „" c oa� W o,cs m M r^ V�+ wo ccja �'y o L co c F- a Q ID .o = m :moo N :a M- O O H m r H m r = LJJ O 'O r 'O :5 .� �N m W R O 2 'at c Z ac E 0.0 o vLm mom c a y a m O.0 J aim 6 O O "TZ3 .t a O E 0 o v Z CD CL O y C C W CM I Q ._ y O O 'CD E m m 0 CD CL �.+ O O i O 00. CL a�Q ca C -p O = C O C O O .c Z CD 0 CL �..± CO) C .0 cc a CO2 J Q z Z 0 F-- 5 5 w z 0 U i I z j Po •it" rand fax nsmittalmemo7O I IT* Ur FAX NO. 508 851 7LM P. o? 0`:ryD rWW 2-11%ZC 1A1fP,,aVW,44W V rAWdAdAW r4Wr ",ea�norwp 0,,v AV "r -w *Wwwqwo yxw"no.." eta ,ww "r geWLIM W4r4W IW J-Ad..-W4CoW j -W AtAACA a* ooaz or I IT FAX NO, 1508 851 72-10 P. 0? yE eabddo'4rC 'ff�fl )P7 aye= 7A 4, r 1� LVI foo - 4%" a �OW 0 4 WAP OAoO' "Zvz ,Vo ^W:,~ eAr 4441Z.Y. Cd4fr 4W,OW roild-, I IIAIP t X/Y 4j 1,4v El 4- '571 E jo-Z 1!� A, MERRIMACK ENGINEERING SERVICES, INC. i A - I......_.. fpiFfsf�:'•r"^z''�r�"'7�'���(Ci'•SJi'%j5;'"1* i J• i• �� 1ria� �,o.,�.,c�i::.y',%,'�L�, '�jr�,•'la(,in1r{r','jgr�a !1 �? 'rh' �5;:.� �•; t.l'•:, �•! ,..}rlf•:i4:,e.'1,1;%{� y,S 1' >> 1:r;r��� R - s�'�'�'ly�� rl� 1��'>:.('t:i,l�':{;t'..r.. � n, 1 • �' A - _ `Cyt � • 'Gi• � � r pT provided 01i'form for use by local Boards of H be subtttltted to�the.local'Board o/ Haalth or other a e Ith, The qt, pin Recor'- rn :r•s< ;;;, '::I:1, :.. PPro r��ta ,t� rlry • ,��A Facility .lnforri��tf on N�A� �oRT . . ARTMFNTER LmRortant: ' 'Ping ,out : `:1; . System Location; ' .;•'computer, tuer•�L'ir' � � � .,•! � t oNy the tab key q' ' ` (37 ddress to move your I do ' uz+'lh.rotum<t ; ,CItvfrQwn U ':'i'• ll,p�y 4` lyl 4J'L'�•1'' r!' .:r:', 1,t'';,';rli l; lv r.J :'' r,.r r', .:' :(:r ' •. ' it i.y .• -I 1�. JI,i'(i:�;fl�:,�.',Il,','.i. )(:. ?I•' •.,' ,! ��.l i,' � , .�� p Coda ,;•.System Nun' :.•F�:'' ' ' r ,i, �•. :r•�l y' '� :J�.'I �w.ti:° fr1•y: ,3 1. U1�'�1. .l Nn+l Y�: it',Q ' ����1;•''i,':,�'f�,/,r:.\Jf,.;�}`1�•rN�e"�J,it�r1•I"',�,'i'.'j`Irr;ijr.,.r:vy,.\..:, ..•' � �tL •L�.' •; .fh.. V.,.:/ ,,��'i;r;'i•Pr,r,,i•li ri .v,p'� r:•.rLJ:: � �^ �p' ' ... ALA ,•:r. � .a +•1 -'-�� �t. y:.• . . •/W A i dress t Owerent rom bcatlon) ; . ... ,,;'. .r .iii. ,,:.,, •,. lop �"Pur pjg:.R.eq:ord ' '1' �•' ri5, F ,1ir••.i: f ,r:'17iL/t�,'{I1tit,l. ,•t : is ': i r .. DAte`'of Stale 9 yam- OZID code �Z Telephone e e ephone Number6 QuandtyPumped: '.:: • , , �7yP,e pt,aystem; , [] Cesspools) j$eptic Tank ❑ ht ', Tight Tank '. �] (Other (describe • ' �• '! � � �•�;' i'(f'Tq':;il!'i 1 �'!i: ii'.'.,�.T;+1'r�''i'Y�fp`' �' ;lf a:d '4';;EMU'Ont Tee Fllte resent? Yes ,;;., +,i?, �;;:,1;,. r�,...'�i" ;,�,p:t i •1, ❑ ° If yes, was It cleaned? ....i,'''' 4p ,14 rp .• . ,; ❑Yes �%. No rrq',.y�.''.,;; 4Gs�r •J'7;�(fb�� i.r.. Lrr\ / •:vr.:. , ,. •ia��l ,, •7 v, f fi b.' ,`'; T;..r t )off r.ifl.'•'�.. v.••, ... . �"`';• •.�,';�i;?f '1.Ji �11}}t l�hmiIi,'�''j.li:fiily'f f,'•'t.j. ..,, . y,y ,..�i, .+ Y•''•.lti'tY:i�+uJ_i:o: ;r.ti ;'{i'r'!t/taiga}.:?;' P.umped �i ,'. i.{'J �i"• ::�i); ,� SI ;,'?+G. l�•. i��l��'d�rl:l� q�rr'l:r Jr�rry '.•.� ., p. ''u ''�''1!•,�' lYrh (r r(,, 1ti,Ga+ t .�I%'•i/t�'.�:'rt :Vr ' 4!'r::! �Y'r:..: J � i•"%;V� r `'�� �y �• �SF- -WO ' .Ow ;�Y!X' • tl� ii+ f � : r . ,• ;,, ''•i: � 1/3%;lir. Ytr �/ `,r, �:%,\. 1 i.� ,}.i; • 'i.'�r`.�',j°' r?:;., +'fN'�'i tti i� yid 'lf t' ���lt•.�"•, vt��i +.I I jN �1r:.11'�,Ii't<lh•a,;.r:C ; ':T L'ocontests 1. :;; , •t:'F,;,,. , :,:,7;'.. on.wfiere ere:dl�: '' i�.:r+:. ;:: •,,;,:;<i'f.'.:;: r � ,:.. .W., posed; .•1�� :J : :� I r,/;^ :. •}-'.'t0', � •.,.., . ..r, l.r�. � � Mi,j'r4 L fii i.V)' � t. ��J:. � :y r.ii .: 1.1: •.If','i�,'.:; is t'., •�. ' � ,,,��.,,,.:���� • moi' ;t•.'•�>':;i r ' ; �ij"',^ ...r. •i.•.tir.:,':;'}''': ''iw i r':.. :\'• :i}'., �;}:.''.:�!�`:;•..,,, r.�.•. it" Ir gip.,','; �.�.::•+ u,t`.f"W `If.kSi 'J.'"' . "• f >N„ S .,;. ', .'%•,•/•.,�i•;.:,r�y•3,f: ,.;�:l,.SJGnetWe oilleu+V��S,/•`i,.rrp;.y..'�.;:r.l:. • \'. .t . r'.:' 'r + .. r . .. , 1. ��'� : titt�://wtivw,mass.gov/dep!viate�/apprGvaJs%t6foims.htm#Inspect t5torm4,doa10drQ3,I: • •:� �,t,, •... ;�• . � Vehicle Uceni}e Number , Sy:lem Pumping Record ' Paye 1 Commonwealth of Massachusetts _ Xr1 EW W City/Town of No Andover System Pumping RecordY 18 2012 Form 4TOWN OF NORTH ANDOVER I HEALTH DEPAR MENT Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. r� xenon DEP has provided this form for use by local Boards of Health. Other formss ;bat-tte-----1 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: 575 Winter St Address No Andover City/Town 2. System Owner: Lind Name Address (if different from location) City/Town MA State Zip Code State Telephone Number Zip Code B. Pumping Record cflo- f, 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes [U/No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System:�d�Vl x 6. y tem Pumped By: ame Stewart's Septic Service Company Vehicle License Number 7. o kation where contents were disposed: Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 of Hauler of Receiving Facility Date i Date t5form4.doc• 03/06 t I System Pumping Record • Page 1 of 1