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HomeMy WebLinkAboutMiscellaneous - 59 JOHNNY CAKE STREET 4/30/2018 Mi 59 JOHNNY CAKE STREET _ 210/107.A-0180-0000.0 r59JOHNNY CAKE STREET 21O110.71A 01$0-0000.0 a r North Andover Board of Assessors Public Access f Page 1 of 1 r t pORTM ®rth Andover Board of Assessors Of jr�eo �,ti0 CHUU1 roperty Record Card Parcel ID:210/107.A-0180-0000.0 FY:2012 Community:North Andover Click on Sketch to Enlarge Click on Photo to Enlar e ?r ..y' 1 � 58 JOHNNY CAKE STREET Location: 59 JOHNNY CAKE STREET i Owner Name: MICELI,TODD E MARIANNE E MICELI Owner Address: 59 JOHNNY CAKE STREET City: NORTH ANDOVER State: MA Zip: 01845 Neighborhood:8-8 Land Area: 1.00 acres Use Code: 101-SNGL-FAM-RES Total Finished Area: 2974 sqft CURRENT VEAR Total Value: 578,700 578,700 Building Value: 348,600 348,600 Land Value: 230,100 230,100 Market Land Value: 230,100 Chapter Land Value: LATEST SALEI Sale Price: 555,000 Sale Date: 09/08/2000 Arms Length Sale Code: Y-YES-VALID Grantor: DAVID PERRY Cert Doc: Book: 05857 Page: 0002 http://csc-ma.us/PROPAPP/display.do?linkId=1896170&town=NandoverPubAcc 5/22/2012 Residential Property Record Card PARCEL ID:210/107.A-0180-0000.0 MAP:107.A BLOCK:0180 LOT:0000.0 PARCEL ADDRESS:59 JOHNNY CAKE STREET FY:2012 PARCEL INFORMATION Use-Code: 101 Sale Price: 555,000 Book: 05857 Road Type: T Inspect Date: 04/07/2008 Tax Class: T Sale Date: 09/08/00 Page: 0002 Rd Condition: P Meas Date: 04/07/2008 Owner: Tot Fin Area: 2974 Sale Type: P Cert/Doc: Traffic: M Entrance: X MICELI,TODD E Tot Land Area: 1.00 Sale Valid: Y Water: Collect Id: RRC MARIANNE E MICELI Address: Grantor: DAVID PERRY Sewer: Inspect Reas: C 59 JOHNNY CAKE STREET NORTH ANDOVER MA 01845 Exempt-B/L% / Resid-B/L% 100/100 Comm-B/LP/o Indust-B/L% / Open Sp-B/L% / RESIDENCE INFORMATION LAND INFORMATION Style: CL Tot Rooms: 7 Main Fn Area: 1814 Attic: NBHD CODE: 8 NBHD CLASS: 8 ZONE: R2 Story Height: 2.00 Bedrooms: 4 Up Fn Area: 1160 Bsmt Area: 1796 Seg Type Code Method Sq-Ft Acres Influ-Y/N Value Class Roof: G Full Baths: 2 Add Fn Area: Fn Bsmt Area: 1 P 101 S 43571 1.000 230,054 Ext Wall: FB Half Baths: 1 Unfin Area: Bsmt Grade: DETACHED STRUCTURE INFORMATION Masonry Trim: Ext Bath Fix: 0 Tot Fin Area: 2974 Foundation: CN Bath Qual: T RCNLD: 329495 Str Unit Msr-1 Msr-2 E-YR-BIt Grade Cond%Good P/F/E/R Cost Class Kitch Qual: T Eff Yr Built: 1987 Mkt Adj: PG S 800 0.00 2005 G G /50//49 19,100 1 Heat Type: HW Ext Kitch: Year Built: 1985 Sound Value: VALUATION INFORMATION Fuel Type: G Grade: GV Cost Bldg: 329,500 Current Total: 578,700 Bldg: 348,600 Land: 230,100 MktLnd: 230,100 Fireplace: 2 Bsmt Gar Cap: 2 Condition: G Att Str Val 1: Prior Total: 578,700 Bldg: 348,600 Land: 230,100 MktLnd: 230,100 Central AC: N Bsmt Gar SF: Pct Complete: Aft Str Va12: Att Gar SF: %Good P/F/E/R: /100/100/90 Porch Type Porch Area Porch Grade Factor W 256 SKETCH PHOTO 16 256 SgFt 16 16 ' j, 16 FU/FM/B FM/B ; 1120 SgFt 676 SgFt 28 26 1 40 SgFt 59 JOHNNY CAKE STREET Parcel ID:210/107.A-0180-0000.0 as of 5/22/12 Page 1 of 1 TOWN OF NORTH ANDOVER OORTH BUILDING DEPARTMENT 1600 Osgood Street, Suite 2-36, North Andover Ma 01845 0 �, NOTICE OF VIOLATION SSACHU`�E Date: Address: 0 CA is-G._ \� 1 Building Zoning Bylaw StolS Work Order ❑ Certificate of Inspections C Electrical Plumbing Gas Violation observed: �� w+ p T G M—I S'/ a uc TV n z UO-1 Failure on your part to comply with this notice within 10 days may subject you to penalties prescribed by Massachusetts Law 780C MR7or North Andover's Zoning By law. Please contact the Building Department for further information at 978-688-9545 Inspector�- Home Owner Contractor Commonwealth of Massachusetts = City/Town of lVo. 14tid Q v-&K a System Pumping Record Form 4 M DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. k A. Facility Information �� t 'Lu14 lgiImportant:When filling out forms 1. System ocationJOhnnu UT, ; , on the computer, L�use only the tab � .' L � key to move your Address ` cursor-do not Nd w�r"� m • use the return key. City/Town State Zip Code 2. System Owner: ttD oW 'i�nA (3 Name renes Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record Aih 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 ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. stem Pumped By: C, Name Vehicle License Number Stewart's Set Service Company 7. Location where contents were disposed: Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 Signat of Hauler Date ignature of Receiving Facili y Date t5form4.doc•03106 System Pumping Record•Page 1 of 1 . Sw ZY • PUBLIC HEALTH DEPARTMENT Town of North Andover (ommunity Development Division Cenificate o f Compliance As of.• 96-y 14, 2012 This is to cert that a S3TIS FACTORT IMPECTIO5V Was completed for the: Instalration o f an 91-20 Distri6ution Box {or an On Site Wastewater DisposalSystem (By: Lames xelrett at: 59 16hnny Cake Street Parcel ID :210/107.A-0180-0000.0 alorth Andover, WA 01845 The Issuance of this certificate shaff not 6e construed as a guarantee that the On Site Sewage 1DisposafSystem wifffunction satisfactorily. 18i�a&Sa er, 1REXS/YJ------- Pu6fcYfeafth Director 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofoorthandover.com • Stiq'f CED'�� . • PUBLIC HEALTH DEPARTMENT Town of North Andover (ommunity Development Division Cenificate o f Compfiance As of.• Kay 14, 2012 This is to cert that a SA`IIS FAC`IORT INSTECT[ON Was completedfor the: Instalration o f an 0-20 Distri6ution BK for an On Site Wastewatir DisposaCSystem By: Lames nffett at: 59 Johnny Cake Street Parcel ID :210/107.A-0180-0000.0 Noi rthAndover, SNA 01845 The Issuance of this certificate shaft not be construed as a guarantee that the On Site Sewage 1DisposaCSystem wiff function satisfactorily. -XIxtl, a Sar, RAS/ (Public 9fealth Director 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com • s�.rc�u,�6 • PUBLIC HEALTH DEPARTMENT Town of North Andover (ommunity Development Division Celtificate o f Compliance As of.• Kay 14, 2012 This is to cert that a SATISFAC`IOR,T ISVSTEC 109V Was completed for the: Installation of an Yf-20 Ustri6ution Box f„ or an On Site Wastewater0isposalSystem By: games xellett at: 59 lohnny CakeStreet Parcel ID :210/107.A-0180-0000.0 North Andover, 91A 01845 The Issuance of this certificate shaff not be construed as a guarantee that the On Site Sewage lnisposafSystem wifffunction satisfactorily. 18i�an Sa er, R&S/1 (Pu6fic Yfeafth Director 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com S�TTLEDt�s • North Andover Health Department �Q9 a Community Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: S7 © MAP: LOT: INSTALLER: ;�� DESIGNER:�� PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS TANK INSPECTION: DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS ❑ Contractor reports any changes to design plan ❑ Existing septic tank properly abandoned ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered Comments: SEPTIC TANK ❑ Building sewer in continuous grade, on compacted firm base ❑ Cleanouts per plan ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ gallon tank has been installed loading ❑ Monolithic tank construction ❑ Watertightness of tank has been achieved by testing ❑ Inlet tee installed, centered under access port ❑ Outlet tee installed, centered under access port (gas baffle/effluent filter) ❑ inch cover to within 6" of final grade installed over one access port ❑ Hydraulic cement around inlet & outlet Comments: PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ gallon Pump Chamber installed ❑ loading ❑ Monolithic tank construction ❑ Inlet tee installed, centered under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off floats working ❑ Separate on/off floats ❑ Drain hole in pressure line ❑ cover at final grade installed over pump access port ❑ Water tightness of tank has been achieved by testing ❑ Hydraulic cement around inlet & outlet Comments: CONTROLPANEL ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: basement ❑ Alarm signal located inside: basement Comments: DISTRIBUTION-BOX Installed on stable stone base H-20 D-Box [Inlet tee (if pumped or >0.08'/foot) Hydraulic cement around inlet & outlets Observed even distribution Speed levelers provided (not required) ) Comments: f NOIttN '� 6097 3r OL N 9 Town of North Andover HEALTH DEPARTMENT ,SSACNU5�4 CHECK#: 14/� DATE: LOCATION: H/O NAME: CONTRACTOR NAME: Type of Permit or Licens Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $ ❑ S -Design Approval "�-1Q $ Septic Disposal Works Construction D C) $/ 54� ❑ Septic Disposal Works Instalier� ) $ ❑ Title 5 Inspector $ ❑ Title 5 Report $ ❑ Other. (Indicate) $ Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer i✓ 1 A �10R7M Application for Septic Disposal System [Li- Of 3:•��'' '-�''�°c ` pConstruction Permit — TOWN OF TODA 'S 6ATE $250.00—Full Repair . o+ ORTH ANDOVER, MA 01845 p 3 s+,.•� '`'` S.00�On'1pa11Ent-� SACHUSEt Important: Application is hereby made for a permit to: When filling out ❑ Construct a new on-site sewage disposal system* forms on the computer, use ❑ Repair or replace an existing on-site sewage disposal syste only the tab key �_��� to move your Repair or replace an existing system component—Wha . cursor-do not use the return key. A. Facility Information _ � 0 .�d1 S �J �n r� C 4 kf- VAI Address or Lot# . City/Town ANDOVER 2.- TYKE OF SEPTIC SYSTEM : HEALTH ❑ Pump ❑ Gravity (choose one) ***If pump system,attach copy of electrical permit to application*** ,gConventional System (pipe and stone system) ❑ Infiltrator or Biodiffuser(Gravel-Less) (Attach a copy of your certification to install this type of system. ❑ Pressure Distribution S.A.S. (No D-Box) (Attach Draft Maintenance Agreement) ❑ Pressure Dosed (D-Box Present)S.A.S. 2. Owner Information Name 59 V O G"%l CAI"— P-A Address(if different from above) N . A AJN-D oJ-c City/Town State Zip Code 97K— kV7- 57/ i Telephone Number 3. Installer Information / ,J �rhe-j re//,e4 ffelaoff reel'1it/Rr Name Name of Company yob Sa Address q City o/T wn State Zip Code `'lk/-- 553- 7/V4 Telephone Number(Cell Phone#if possible please) 4. Designer Information Name Name of Company Address City/Town State Zip Code Telephone Number(Best#to Reach) Application for Disposal System Construction Permit•Page 1 of 2 I lJ � NOR7N Apblication for Septic Disposal System TODAY'S DATE AConstruction Permit - TOWN OF , MA 01845 $ 250.00-Full Repair ORTH ANDOVER r ".�•;•;„p;e�,�,* $125.00 -Component 1SS�cNustt PAGE 2 OF 2 A. Facility Information continued.... 5. Type of Building: Residential Dwelling or❑Commercial B. Agreement The undersigned agrees to ensure the construction and maintenance of the afore-described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of North Andover, and not to place he system in operation until a Certificate of Compliance has been issued by this Board of He e Date �ii► Application proved By: (B d of Health Representative) Name Date A ication Disapproved for the following reasons: For Office Use Only: L Fee Attached? Yes No 2. Project Manager Obligation Form Attached. Yes v No 3. Pump System? If so,Attach cop-v ofElectrical Permit Yes No 4. Foundation As-Built?(new construction ronly): Yes No (Same scale as approved plan) 5. Floor Plans?(new construction only): Yes No J)/0N I'' Application for Disposal System Construction Permit•Page 2 of 2 A� SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction for the septic system for the property at: �rl J,o 4r,776a 1-,e /tel. /✓ A (Address of septic system) For plans by - / / � (Engineer) Relative to theapplication of✓y�le3 Il{C1 (Installer's name) And dated 1 4 �/� gena ate Dated 5/V 1?j —t o ay s ate With revisions dated (Last revise date) I understand the following obligations for management of this project: 1. As the installer, I am obligated to obtain all permits and Board of Health approved plans prior to performing any work on a site. I must have the a1212roved plans and the permit on site when any work is being done. 2. As the installer, I must call for any and all inspections. If homeowner, contractor,project manager, or any other person not associated with my company schedules an inspection and the system is not ready, then item three shall be applicable. 3. As the installer, I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection,without completion of the items in accordance with Title 5 and the Board of Health Regulations may result in a $50.00 fine being levied against me and/or my company. a. Bottom of Bed—Generally, this is the first (ls� inspection unless there is a retaining wall,which should be done first. The installer must request the inspection but does not have to be present. b. Final Construction Inspection—Engineer must first do their inspection for elevations, ties, etc. As-built of verbal OK (or e-mail to: healthdept@townofnorthandover.com) from the engineer must be submitted to the Board of Health, after which installer calls for an inspection time. Installer must be present for this inspection. With a pump system, all electrical work must be ready and able to cause pump to work and alarm to function. c. Final Grade—Installer must request inspection when all grading is complete. Installer does not have to be on-site. 4. As the installer, I understand that only I may perform the work (other than simple excavation)and I am required to complete the installation of the system identified in the attached application for installation. I further understand that work done by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the system and/or revocation or suspension of my license to operate in the Town of North Andover, significant fines to all persons involved are also possible. 5. As the installer, I understand that I must be on-site during the performance of the following construction steps: a. Determination that the proper elevation of the excavation has been reached. b. Inspection of the sand and stone to be used. c. Final inspection by Board ofHealth staff or consultant. d. Installation of tank,D-Box,pipes, stone, vent,pump chamber, retaining wall and other components. 6. As the installer, I understand that I am solely responsible for the installation of the system as per the appr�plans. No instructions by the homeowner, general contractor, or any other persons shall absolve me of this obligation. Undersigned Licensed Septic Installer: �� `� / (Today's Date) (Name—Print) a e—Signed) 6098 Of HOR7'y�h d F -Z - Town of North Andover ���'• '+ HEALTH DEPARTMENT ,SSACMUSES CHECK#: a�� ATE: LOCATION: 3 H/O NAME: CONTRACTOR NAME: Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ 0 Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ;;t*'tl-e tle Spector 5 Report $ ❑ Other:(Indicate) $ C',A//V. Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer Commonwealth sof Massachusetts 10, Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '< 59 Johnnycake Street Property Address Todd Micieli Owner owner's Name information is North Andover MA 01845 4/30/2012 !v required for every page. Cityrrown State Zip Code Date of Inspection ,, v Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of th o EC IM Important' A. General Information MAY When filling out ti t forms on the computer,use 1. Inspector: only the tab key TOWN OF ANDOVER HEALTH DEPARTMENT to move your Neil James Bateson cursor-do not use the return Name of Inspector key. Bateson Enterprises Inc. Company Name .. 111 Argilla Road Company Address Andover MA 01810 City/Town State Zip Code 9784754786 S115 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ❑ Passes ® Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 4/30/2012 Inspecto s Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•11/10 Title 5 Official Inspection Form:Subsurfaos Sewage Disposal System-Page 1 of 17 ` Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 59 Johnnycake Street Property Address Todd Micieli Owner Owner's Name information is required for North Andover MA 01845 4/30/2012 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ® one or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exMtration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ® N ❑ ND (Explain below): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts a Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 59 Johnnycake Street Property Address Todd Micieli Owner Owner's Name information is required for North Andover MA 01845 4/30/2012 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or.high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ® N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ® N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ® N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipes)are replaced ❑ Y ® N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ® N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 59 Johnnycake Street Property Address Todd Micieli Owner Owner's Name information is required for North Andover MA 01845 4/30/2012 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D-Box needs to be replaced. D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts M Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ..''� 59 Johnnycake Street Property Address Todd Micieli Owner Owner's Name information is required for North Andover MA 01845 4/30/2012 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. El Z Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ E3 the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question.in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 59 Johnnycake Street Property Address Todd Micieli Owner Owner's Name information is required for North Andover MA 01845 4/30/2012 every page. Cityfrown State Zip Code Date of Inspection C. Checklist Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 600 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 59 Johnnycake Street Property Address Todd Micieli Owner Owner's Name information is required for North Andover MA 01845 4/30/2012 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 5 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage Yes 9 ( Y 9 (gPd))� Detail: Sump pump? ® Yes ❑ No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(teased on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? _ ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Tale 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M , 59 Johnnycake Street Property Address Todd Micieli Owner Owner's Name information is required for North Andover MA 01845 4/30/2012 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Pumped 2010, owner Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? Measured tank. Reason for pumping: Inspect tank&tees Type of System: ® Septic tank distribution box soil absorption stem P P Y ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ d Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 59 Johnnycake Street Property Address Todd Micieli Owner Owner's Name information is required for North Andover MA 01845 4/30/2012 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Tank original, D-box&trenches 20 years old, 7/1/1992, as built plan. Were sewage odors detected when arriving at the site? ❑ Yes' O No Building Sewer(locate on site plan): Depth below grade: 2.6 feet Material of construction: ® cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): 4"Cast iron wall to septic tank. 3" PVC in house, no leaks visible Septic Tank(locate on site plan): Depth below grade: 1.6 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age', years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 10'x 5'x4' Sludge depth: 5" t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 59 Johnnycake Street Property Address Todd Micieli Owner Owners Name information is required for North Andover MA 01845 4/30/2012 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 22" Scum thickness 6" Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? Tape Measure Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumped septic tank. Inlet tee ok.inlet baffle ok. Outlet tee ok. Depth of liquid at outlet invert. No evidence of leakage. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 59 Johnnycake Street Property Address Todd Micieli Owner Owner's Name information is required for North Andover MA 01845 4/30/2012 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 59 Johnnycake Street Property Address Todd Micieli Owner Owner's Name information is required for North Andover MA 01845 4/30/2012 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box has bad corrosion, needs to be replaced. D-Box level &distribution equal. Depth of liquid at outlet inverts. No evidence of leakage. Evidence of carryover, pumped d-box to clean. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber, condition of pumps and appurtenances, Ptc.): Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form Not for Voluntary Assessments 59 Johnnycake Street Property Address Todd Micieli Owner Owner's Name information is required for North Andover MA 01845 4/30/2012 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching.chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 3 trenches, one40'two 42' ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soil ok.Vegetation ok. No sign of ponding to surface. Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction , Indication of groundwater inflow ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 59 Johnnycake Street Property Address Todd Micieli Owner Owner's Name information is required for North Andover MA 01845 4/30/2012 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions :Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 59 Johnnycake Street Property Address Todd Micieli Owner Owner's Name information is required for North Andover MA 01 845 4/30/2012 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters:the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately Dr,LIQ/ g ° -3.5'4' 64V ` �IDt c prt t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 't 59 Johnnycake Street 'Property Address Todd Micieli Owner Owner's Name information is required for North Andover MA 01845 4/30/2012 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 4 feet Please indicate all methods used to determinethehigh ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 5/10/1984 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Design plan info ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: As per test pit data on design plan Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Fonn:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 59 Johnnycake Street Property Address Todd Micieli Owner Owner's Name information is required for North Andover MA 01845 4/30/2012 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems) completed ® System Information.—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file l5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 ar �- N °e ;� � r ^ 0 ', M1ee 69, a w(., ;a Date �ieadiig, nsµu, trr1 iat�i3�r.. ske"_dater ,(" °; 1 2!2!2012 1492 30 0.3 -76 a 3!14/2012 77 11/1!2011 1462 122 1.3 -20 a 12/15/2011 77 8/1/2011 1340 151 1.7 502 a 9/14/2011 k � 4 502011 1189 24 0.3 5 a 6/13/2011 2/4!2011 1165 25 0.3 76 a 3!15/2011 11/V20 10 1140 100 1.1 20 a 12!13!2010 8/3!2010 10401 127 1.41 471 a 9/13/2010 5!3!2010 913 22 0.2 15 a 6!9/2010 LE 2!1!2010 891 26 0.3 -46 a 3!11!2010 A, Dailyggp sagehrt ymi,� �az�i;.`-' }' •'�'' �aw:..{,x a���a'��a��{s'�1� �+ `' a �`-�`$-�xnsF .. ��F r 1 � r '� m'` i. z £ r � � 5�kt. �€.�,, �,€ �,>p w-,., � � ,. ,w ..., Y � ;:°���r{ "--� '`�+'d,�a���'".,,�r-dry�,rS '�•�3 . : Editing Existing Record(111J e z' _e • Commonwealth of Massachusetts City/Town of System Pumping Record Form 4 DEP has provided this form'for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form,.check with your local Board of.Health to determine the form they use.The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Rig vont of hou Left/Right rear of house, Left/right side of house, Left/ Right side of building, Left/Right front of building, Left/Right rear of building, Under deck Address v c� ` �� �� �� oo r� cityrrown 1/` State Zip Code 2. System Owner. e Name Address(if different from location) City/rown State Zip Code —fir-►'7 i Telephone Number B. Pumping Record L - Bo-t =,- 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) eptic Tank El Tight Tank ❑ Other(describe): . 4. Effluent Tee Filter present? ❑ Yes 9<0 If yes,was it cleaned? ❑ Yes�❑ No 5. Condition of System: 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location where.contents were disposed: S. Lowell Waste Water INAA S; IgnAtufe Haule Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts City/Town of � System Pumping Record Form 4 M DEP has provided this form'for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Righ rout of house eft/Right rear of house, Left/right side of house, Left/ Right side of building, Left/Right front of building, Left/Right rear of building, Under deck Address City/Town State Zip Code 2. System Owner. Name Address(if different from location) Cityrrown State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping .I ' l 2. Qo uantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) ESJ/Septic Tank ❑ Tight Tank [I Other(describe): 4. Effluent Tee Filter present? E] Yes No If yes,was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location-Where contents were disposed: G.L S Lowell Waste Water SignA a I Haule Date t5forrn4.doc•06/03 System Pumping Record•Page 1 of 1 OVE 'Record ' TTS 'ter.. , ,,�`�r�•� ;I�YI•�1;',�,ifq,� '.y`. + '' �iar'::, NOV 13 2008 CEP91 p(ovldod jhl; loan Icr eo y ;o'a, Boar rr or 00 1':^(T?Ii�Od !0 lh9 �OC91 E3"fc C'I rlY ' oar{n or clue Tpf�lQFQT1 gTHA,� '''ty Facilif� EALTH DEPARTIt�civT A. ty Infor�l�flon kJ6 vm `; System Owner ' � �', `J Nuns �:,, ,•.. ,�,,,�,R, ,,. .,o � ��'' /�drµ� (IL4V(Ir'1nl,.r•Pm1bcaUon) U,c�ille - 17 H,m01, B1' P,umPing.Regord ,� 3. ,Type of eyslam:., � Ca99�ooi(y) apOc Tens , } r "t Tens 4. Ehluonl Tea Fula 'Pr�aenr? [' ro9 ',:: ;'•;pl'�, ��.,. ,,'., (. l:T+�V If y69. 189 i: Veano0? ', Y .. . _ � �'�1�;�;'''J'i�r�((�k,, ���t "��i��� �� '•'.y��J.ii'd,)�1' n I �O�IC10 �.1Cd1111 rt'' -. 7ko,n.whara co lent'' d T�n0lW0 olh'1v4 Z��d .+,1,ti✓rl.rT18ppr0Y8f V/Norm 3,P,,.m;In909C1 s-&v L;r Trams: B/-pG. core. �; „B' b-Box Z7,o' 1,►4.g, 43.571 ?'g.F N cA � N s .9 �xisT !sa�Gn(„_ A u8 Cour.sEPf� Tl+u(G .-JEW 6-auz oune" ° eamc, A 1 STS Box 40_— • . 42' ' 14z- 1,ld'f'�: SEL` I EGSd P�oPoSE� � hs•�u►�T Puiu� �� THiS ,,��„G�ACH►uG T�UCNES ��{'w�nE� 4►TE @\/ -rHowa MuP, HY Al Du Fic.a_, 1004 7 e '11OW9 OF mom 4mtwE2 goJ1m oFtf0c { . --�I S1�f 1 �•C�cs7BuL�D (,-30-RZ AS BUILT PLAN OF SUBSURFACE DISPOSAL SYSTEM LOCATED IN KJORT14 AuI)DV5R , MASS - AS PREPARED FOR DATE : �-L1Ly 1 , 199Z SCALE: . 1����ia MERRIMACK ENGINEERING SERVICES, INC. PROFESSIONAL ENGINEERS • LAND SURVEYORS • PLANNERS: 66 PARK STREET 0 ANDOVER, MASSACHUSETTS 01810 0 TESL. (sae) 475-3555, 373.5721 TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: ' SYSTEM OWNER &ADDRESS SYSTEM LOCATION (example: left front of house) V 3JAOV00- DATE OF PUMPING: —D QUANTITY PUMPED 156-0 GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER (EXPLAIN) SYSTEM PUMPED BY: R COMMENTS: If N CO TENTS TRANSFERRED TO: �c TOWN OF FytGloQtC SYSTEM PUMPING RECORD DATE: IrC� h SYSTEM OWNER& ADDRESS SYSTEM LOCATION (example: left front of house) cc-c� e L9 n 6vsc tAnc aDATE OF PUMPING: -02.1" b QUANTITY PUMPED : fl _ GALLONS CESSPOOL: NO V YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER(EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED TO: e ('on nonw alth of Massachusetts Massachusetts System Pumping Record System Owner System Location Date of Pumping: ����m--��/ui Quantity Pumped: `- gallons Cesspool: No t-,� Yes LI Septic Tank: No U Yes System Pumped by: t5at`ejea gffrEvw' dP,a License# Contents transferrred to': Greater Lawrence Sanitary District Date: _ Inspector: I - "t Com mon weal tIt of Massachusetts _�44�-�4. assachusetts System Pumying Record System Owner System Location D(-I Date of Pumping: �C�-� Quantity Pumped: C,62,�4allons Cesspool: No H/ Yes Septic Tank: No I] Yes [4--' System Pumped by: Sdt`edoo Sie&M,41ded License # Contents transrerrred to : Greater Lawrence Sanitary District Date: _ Inspector- MERRIMACK ENGINEERING SERVICES, INC. PROFESSIONAL ENGINEERS • LAND SURVEYORS • PLANNERS 66 PARK STREET • ANDOVER, MASSACHUSETTS 01810 • TEL.(508)475-3555, 373-5721 FAX(508)475-1448 June 26 , 1992 Ms . Sandy Star Board of Health Town of North Andover Town Hall North Andover, MA O1845 RE: Septic Failure - #59 Johnnycake Street (Lot #5 ) Dear Ms . Star: On June 24 , 1992 , our firm performed a site inspection at the subject location in order to determine the most feasible method of repair of the existing subsurface sewage disposal system. Deep observation holes were excavated using a backhoe to confirm existing soil conditions . Portions of the existing leaching trenches were exposed so that the condition of the leaching trenches could be evaluated . Proposed and as-built plans of the existing system as obtained from the Board of Health files were examined . In this case , we recommend that new leaching trenches be constructed in the reserve area as shown in the proposed construction plans for this site as drawn by Thomas Murphy R. S. (on file with the Board of Health ) . However , we also suggest that an additional ( third ) leaching trench be constructed on the uphill (building ) side of the existing trenches to provide some additional leaching area . All pertinent construction details as shown on the proposed construction plans should be complied with . Please review these recommendations and feel free to contact me should you have questions or comments or require any additional information . Thank you for your consideration in this matter. Very truly yours , MERRIMACK ENGINEERING SERVICES 1_7WF'�A 11—, Les Godin Project Manager sh TO" OF NORTH ANDOVER UA 11 SYSTEM PUMPING UCopD SYST,eM OWNER& ADDRESS SYSTEM LOCATION ST Ohio 41dov%y /�q. 10,eO 4o DATE OF PUMP1Nq;_� _QUANTITY PUMPED:_ /,j DD s VWPOOL: NO Y. sn r�k: NU YES P� / . .,.V NA rVRU OF SBRYICB. KOUTINE,.,_ _ bMEROENCY RECEIVED ObSBRVA'rION& / 0000 CONDITIONFULL 'm coVER MAY 0 6 2005 I�A �. KUYY OS8 �.w BAFFLES IN PLACE•. . ROOTS _ LBACHP1Ei,p RUNBACKTOWN OF NORTH ANDOVER 5 C8 S3 7YE SOLIDS ,,,,_.. FL04DBD HEALTH DEPARTMENT .10LID CAKRYOYER OTHER EXPLAIN Sy.Lnm PurrtpcJ by VUMMENTS. t.:vN 'ewr� rKANSFeRKED rc, l I . • 07- zs� �z t SCALE.= LL EVAI-IDY-s Kx AT TSN K IAA . • /�'�"L AT TN K 001L�T. . . AT bl Si,Q©Y 14il bI.ST/.30)CvUrzf, • . • . 1 � Ai f41p OF 7- OC14 / 5 0 5EPTICYSZM__ NS.79.4.L..f�L�..QN ..;, ' IS THE INSTALLER LICENSED? AYES NO TYPE. OF CONSTRUCTION: NEW fZEE�A I R NEW CONSTRUCTION: CERTIFIED PLOT PLnN REVIEW YES 1\10 CONDITIONS OF APPROVAL YL:S NO (FROM FORM U) ISSUANCE OF DWC PERMIT YES NO DWC PERMIT NO. INSTALLER:;__ BEGIN .INSPECTION �1IE N0: : EXCAVATION . INSPECTION: NEEDED: PASSED /Z ig BY ------- --- CONSTRUCTION INSPECTION: NEEDED: AS BUILT PLAN SATISFACTORY: YES• ___ __.—_ APPROVAL- TO BACKFILL: DATE: 71 BY FINAL GRADING APPROVAL: DATE BY FINAL CONSTRUCTION APPROVAL: DATE:__?/��LDY_ C � Town of North Andover, Massachusetts Form No.3 t kCRTH BOARD OF HEALT • 3?�!s•. .'e O 19 Z. • O R F- 9 °��•.o�""� DISPOSAL WORKS CONSTRUCTION PERMIT ,SSACMUSEt Applicant NAME ADDRESS TELEPHONE Site Location Permission is hereby granted to Construct ( ) or Repair ( an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. "CHAIBO OF HEALTH I \ A Fee V D.W.C. No. Board of Realth - 5EMC SnTEH North An(!O!. iN.aaa. IN STALLATICK CHECK LIST LOT CNED DATE DI SUPROTJiMEXCAVATION OK FAIL ea ins t OK 1. Distance Tos a. Wetlands b. Drains c.. Well --- 2. Water Line Location 3'. No PPC Pipe 4. Septic Tank a. Tees --Length & To Clean Out Cowers __-- -- b. Cement Pipe to Tank - On Both Sides of Tank 5. Distribution Box a. Covers & Box - No Cracks b. All Lines F1 o-Ang Equal Amounts c. No Back Flow I 6. Leach Field or Trench a. Dimensions b. Stone Depth. c. Capped Ends d. Clean Double Washed Stone 7. Leach Pits a. Dimensions b. Stone Depth c. Splash Pads d. Tees e. Ceant Pipe to Pit - Both Sides f. Clean Double Washed Stone 8. No Garbage Disposal 9. Yinal Grading Inspection 10. Barricading Covered System 11. As Built Submitted a. Lot Location b. Dimensions of System c. Location with Regard-to Pere Test d. Elevations e; Water Table Health ,... .,bdoger,Mass SUBSURFACE DISPOSAL DESIGN CHECK LI:e i' tt LOT J J6WUy�'IOK�/ APPROVED DATE DISAPPROVED DATE Provided: Reasons: SS Title V FAIL 09 Reg 2.5 The submitted plan must show as a minimums a) the lot to be served-area dimensions lot #,abutters lblocation and log deep observation hoes-distance to ties c location and results percolation tests-distance to ties d design calculations & calculations showing required leaching area (e) location and dimensions of system-including reserve area f) existing and proposed contours (g) location any wet areas within 1001 of sewage disposal system or disclaimer-check wetlands mapping (h) surface and subsurface drains within 1009 of sewage disposal system or disclaimer (i) location any drainage easements within 1)0' of sewap disposal system or disclaimer-Planning Board files (J) known sources of water supply within 20C of sewage disposal e system or disclaimer (k) location of any proposed well to serve 1 )t-100I from leaching facility (1) location of water lines on property-101 .rom leaching facility (m) location of benchmark (n) driveways (o) garbage disposals (p) no PVC to be used in construction _ (q) profile of system-elevations of basement, plumb, pipe, septic tank, distribution box inlets and outlets, distribution field piping and Other elevations (r) maximum ground water elevation in area sewage disposal system (s) plan must be prepared by a Professional Engineer or other professional authorized by law to prepare such plans Reg 6 Septic Tanks (a) capacities-150% of flow, water table, tees, depth of tees, access, pumping (b) cleanout (c) lot from cellar wall or inground suimming pool (d) 25+ from subsurface drains Reg 10.2 Distribution Boxes (a) 'ape greater than 0.08 Reg 10.4 b) saw FORM U. TOWN OF NORTH ANDOVER LOT RELEASE FORM s SUBDIVISION ASSESSORS MAP E; ti• SUBDIVISION LOT(S) PERMANENT ADDRESS (ASSIGNED BY D.P.W. ) STREET / ✓UAlN_V 4: 7 APPLICANT 4.�,�€ � .�/ PHONE i DATE OF APPLICATION Z� f TOWN USE BELOW THIS LINE PLANNING BOARD W DATE APPROVED TOWN PLANNER DATE REJECTED CONSERVATION COMMISSION DATE APPROVED CONSERVATION ADMIN. DATE REJECTED BOARD OF HEALTH DATE APPROVED 7 ZS HEAL Tt NI IAN DA'Z'E REJECTED DEPARTMENT OF PUBLIC WORKS DRIVEWAY PERMIT SEWER/WATER CONNECTIONS A AA TIRE DEPT. ' RECEIVED BY BUILDING INSPECTION DATE This form shall be signed by the agents of the Planning and Health Boards, the Conservation Commission prior to the issuance of any building permits for the subject lot. 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''� 5 ,t ..: . .nt ,I5 5' •'{'i't ��. fna �� rr�.� r ") , �,' +1♦ a ,ti` •' :,,:.*� ` ,t, ••.,;r_ a ',n fit; '�•t.�<' ��,1 t�;,y.. �y, .C'r. �:t i '� t }� t v ,r!'J rc ,1.I f• •''� Jr ••} Gy,• .r7✓. �•ti''.'•'tir• -.i .�; ' ��.., � '•�'t�'�r., ; ' T {' ;"f ;,''dv{� ?ate :`,•i 5_ �j;y a µ,��r•'t '' ,'t," .:i� ,r A ,G�t '+ tF'.. .,srsyt-•�,;.:�� •r..�t•�ti }y''t' t ' a+;!.• - - ' .. fi r •f�,., •t , ;, ,yam - Commonwealth of Massachusetts Massachusetts r` System Nurnping Record System Owner System Location hm Date of Pumping: �'� Qua(itity Pumped: t � gallons Cesspool: No Yes L) Septic Tank: No U Yes L� System Pumped by: Fctt`ed4rt 45ilteo� ,W License# r Contents transferrred to : Greater Lawrence Sanitary District Date: Inspector: Commonwealth of Massachusetts Massachusetts System Pumping Record System Owner System Location Date of Pumping: l.� �``� Quantity Pumped: /Soe--/gallons Cesspool: No H__� Yes [] Septic Tank: No [] Yes [-}— System Pumped by: 64&4" License# Contents transferred to: Greater Lawrence Sanitary District Date: Inspector: 53 1 , . f 0, V COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENmNmENTAL AFFAms DEPARTMENT OF ENVIRONMENTAL P.R.OTECTION ONE VMMR STREET,BOSTON MA 02108 (617)M5500 TRUDY COXE S812*11127 ARGEO PAUL CELLUCCI DAVID B.STRUHS Governoroma' . SUBSURFACE SEWAGE DISPOSAL SYSTEM NSPECTION FSAConmimi PART A tCAT10N Property Address:59 Johnnycake,North Andover Name of Owner: David Perry Address of Owner:59 Johnnycake,North Andover,MA. 01845 Date of Inspection:7/20/2000 Name of Inspector: Neil J.Bateson I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name:Bateson Enterprises Inc. Mailing Address:111 Argilla Road Andover,MA 01810 Telephone Number:(978)475-4786 CERTIFICATION STATEMENT certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.The system: _X Passes Conditionally Passes NeedsFurt r Evaluation By the Local Approving Authority F Inspector's Signature: Date:7/20/2000 The System Inspector sCsmit c of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS revised 9/2/98 Page I of 11 Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:59 Johnnycake,North Andover Owner:Perry Data of Inspection:7/20/2000 INSPECTION SUMMARY: Check A, B, C,or D: A.SYSTEM PASSES: _X I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. COMMENTS:Replaced outlet tee with gas baffle In septic tank&D-box cover. B.SYSTEM CONDITIONALLY PASSES: One or move system components as described in the'Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Indicate yes,no,or not determined(Y,N,or NO).Describe basis of determination in all instances.If"not determined",explain why not. _ The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health). broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed revised 9/2198 Page 2 of 11 C e SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:59 Johnnycake,North Andover Owner:Perry Date of Inspection:7/20/2000 C.FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water. Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and sal absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm.Method used to determine distance (approximation not valid). 3) OTHER revised 9/2/98 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:59 Johnnycake,North Andover Owner.Perry Date of Inspection:7/20/2000 D.SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E.LARGE SYSTEM FAILS- You must indicate either"Yes"or"No"to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area @ IWPA)or a mapped Zone 11 of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2).Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4 of 11 ` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:59 Johnnycake,North Andover Owner.Perry Date of Inspection:7/20/2000 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No _X Pumping information was provided by the owner,occupant,or Board of Health. X None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. _X_ As built plans have been obtained and examined.Note if they are not available with NIA _X The facility or dwelling was inspected for signs of sewage back-up. _X The system does not receive non-sanitary or industrial waste flow.The site was inspected for signs of breakout. _X All system components,excluding the Soil Absorption System,have been located on the site. _X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees, material of construction,dimensions,depth of liquid,depth of sludge,depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: _X Existing information.For example,Plan at B.O.H. _X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) [I 5.302(3)(b)] _X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 9/2/98 Page 5 of 11 ` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:59 Johnnycake,North Andover Owner:Perry Date of Inspection: 7/20/2000 FLOW CONDITIONS RESIDENTIAL: Design flow_150_ .g.p.d./bedroom. Number of bedrooms(design):-4_ Number of bedrooms(actual)_4_ Total DESIGN flow_600_ Number of current residents:_3_ Garbage grinder(yes or no):_No_ Laundry(separate system)(yes or no):_No_If yes,separate inspection required Laundry system inspected(yes or no) Seasonal use(yes or no):_No_ Water meter readings.30,500 W x 7.5=228,750 Gals./730 Days=313 Gals./Day Sump Pump(yes or no):_Yes_ Last date of occupancy:_Current COMMERCIALII NDUSTRIAL: Type of establishment: Design flow: gpd(Based on 15.203) Basis of design flow Grease trap present:(yes or no) Industrial Waste Holding Tank present:(yes or no) Non-sanitary waste discharged to the Title 5 system:(yes or no) Water meter readings,if available: Last date of occupancy: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: Pumped two months ago,owner System pumped as part of inspection:(yes or no)_Yes_ If yes,volume pumped:_1500_gallons Reason for pumping:To replace outlet tee in septic tank. TYPE OF SYSTEM _X Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components,date installed(if known)and source of information:Tank original-14 years old.D-box&leach area 8 years old.As built plan 7/1/1992 Sewage odors detected when arriving at the site:(yes or no)— No-revised 9/2/98 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 59 Johnnycake,North Andover Owner:Perry Date of Inspection:7/20/2000 BUILDING SEWER:X (Locate on site plan) Depth below grade:30" Material of construction:_X cast iron_X 40 PVC _ other(explain) Distance from private water supply well or suction line: Diameter:4" Comments:4"cast iron thru wall to septic tank.3"PVC in house. SEPTIC TANK:X (locate on site plan) Depth below grade: 18" Material of construction:_X_concrete_metal_Fiberglass_Polyethylene_other(explain) If tank is metal,list age_Is age confirmed by Certificate of Compliance_(Yes/No) Dimensions: 10'x 5'x 4' x 7.5=1500 gallons. Sludge depth:1" Distance from top of sludge to bottom of outlet tee or baffle:N/A Scum thickness:1" Distance from top of scum to top of outlet tee or baffle:N/A N/A=outlet tee corroded off. Distance from bottom of scum to bottom of outlet tee or baffle:N/A How dimensions were determined:Measured scum&sludge depths. Comments:Pumped septic tank,inlet tee&baffle ok.Outlet tee corroded off,replaced with plastic tee with gas baffle.Depth of liquid at outlet invert.No evidence of leakage. GREASE TRAP:None (locate on site plan) Depth below grade: Material of construction: concrete_metal_Fiberglass_Polyethylene_other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: revised 9/2/98 Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:59 Johnnycake,North Andover Owner:Perry Date of Inspection:7/2012000 TIGHT OR HOLDING TANK:_None_ (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: Material of construction: concrete_metal_Fiberglass Polyethylene_other(explain) Dimensions: Capacity:_gallons Design flow: gallons/day Alarm present Alarm level: Alarm in working order:Yes_No Date of previous pumping: Comments: DISTRIBUTION BOX.:_X_ (locate on site plan) Depth of liquid level above outlet invert:0 Comments:D-box level&distribution equal.Heavy carryover-outlet tee corroded off in septic tank.Pumped D-Box to clean.No evidence of leakage.Replaced broken d-box cover. PUMP CHAMBER:_None,gravity system_ (locate on site plan) Pumps in working order:(Yes or No) Alarms in working order(Yes or No) Comments: Revised 9/2/98 Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued)) Property Address:59 Johnnycake,North Andover Owner: Perry Date of Inspection:7/20/2000 SOIL ABSORPTION SYSTEM(SAS):X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: Type: leaching pits,number: leaching chambers,number: leaching galleries,number: leaching trenches,number,length:3 trenches,one 40'long,two 42'long. leaching fields,number,dimensions: overflow cesspool,number: Alternative system: Name of Technology: Comments:Soil ok.Vegetation ok.No sign of ponding to surface. CESSPOOLS:None (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow(cesspool must be pumped as part of inspection) Comments: PRIVY:None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: revised 9/2/98 Page 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:59 Johnnycake,North Andover Owner: Perry Date of Inspection:7/20/2000 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) House Family Room& Driveway Garage B Water Meter A 1 A to 1 =35'4" 2 Ato2=37' 3 Ato3=38'10" A to D-Box=41' Bto1 = 16'10" Bto2=20' B to 3=23'9" 1 40' B to D-Box=27' D- Box 42' revised 9/2/98 Page 10 of 11 Tel: (978)475-4786 Fax: (978) 475-5451 BATESON ENTERPRISES, INC. Excavating-Water.& Sewer Lines-Septic Systems&Pumping Service 11 I Argilla Road Andover, Mass. 01810 Title 5 Inspection Report Property Address: 59 Johnnycake , North Andover Owner: Perry Date of Inspection: 7/20/2000 My report contained herein does not constitute a guarantee of future usage and the functionality of the existing septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further operation of your current septic system. 4Bason eil Bateson Enterprises, Inc. TOWN OF NORTH ANDOVER pORT►y BUILDING DEPARTMENT O'r a 0 1600 Osgood Street, Suite 2-36, North Andover Ma 01845 _ � Y NOTICE OF VIOLATION 10L q°gArco SSACHUS� Date: Address: 0 k n 6A /C-e ... Building Zoning ByTaw ❑Stoo Work Order Certificate of Inspections BlectricaI Plumbin Gas Violation observed: _-10 OAR ( tM'-I - 5 1 rL�/C-7V t7i UM b n, Failure on your part to comply with this notice within 10 days may subject you to penalties prescribed by Massachusetts Law 780CM mor o h Andover's Zoning By law. Please contact the Building Department for further information at 978-688-9545 inspeVeto' r— Home Owner Contractor 59 JOHNNY CAKE STREET JS-2005-0158 Proiect Detail Report Printed On:Mon Aug 30,2004 t' Project Name: - - - - - - - - - - - - - - - - - GIS#: 17488 (Project No: �JS-2005-0158 Owner of Record MICELI, TODD E&MARIANNE E Map: {l07.A tDate Submitted: Aug-18-2004 59 JOHNNY CAKE STREET Block: 0180 Status: (Open NORTH ANDOVER,MA 01845 Lot: Work Category: Work Location: X59 JOHNNY CAKE STREET T District: -- p - - - - and Use: 1161 Pro osed Use Detail { Subdivisiont. Description �INGROUND VINYL POOL - -- - mments• of Work: Department Status GeoTMS Module: Status File No. Comments: LCDate: Board of Health GREEN FLAG BHJ-2004-0125 Building,Electrical&Mechanical Permits GREEN FLAG BEM-2005-0133 Permit History Type: Permit No: Issue Date Status Work Category Contractor Project No: Description of Work: Building BP-2005-0132 Aug-17-2004 OPEN Pool JS-2005-0158 INGROUND VINYL POOL Form U Signoff-construct BHP-2004-0617 Aug-16-2004 SIGNED OFF JS-2005-0158 Inground Pool-21 x 41 &Shed GeoTMS®2004 Des Lauriers Municipal Solutions,Inc. Page I of 1 / yl r - FORM - U - LOT RELEASE FORM tr S CJ INSTRUCTIONS: This form is used to verify that all-necessary approval/permits from e� D Boards and Departments having jurisdiction have been obtained. This does not relieve the 161 applicant and or landowner from compliance with any applicable requirements. APPLICANT--1-L d !j riaf1w ml '(2 ( HONE Ga� ASSESSORS MAP NUMBER 16ALOT NUMBER 19 O SUBDIVISION LOT NUMBER �) N STREET /I,� -t -�ihe, A �2 �TREET NUMBER OFFICIAL USE ONLY RECONVvffiNDATIONS OF TOWN AGENTS leavesi DATE APPROVED CONSERVATION ADMIMSTRAT DATE REJECTED COMMENTS TOWN PLANNER DATE APPROVED DATE REJECTED COMMENT'S DATE APPROVED /FOOD INFECTOR-HEALTH DATE REJECTED / DATE APPROVED G b C INSPECTOR- ', - DATE REJECTED COMMENTS l.�� O T ter,^•� S n�i r PUBLIC WORKS-SEWER/WATER CONNECTIONS DRIVEWAY PERMIT DATE APPROVED FIRE DEPARTMENT DATE REJECTED COMMENTS RECEIVED BY BUILDING INSPECTOR DATE ct,`1,/, r� !�2 . ` f LO �-o a �{3.S71 T 9.F civ 31 Is y1 Tal'�`'`'`� N cp .c N c� tf�fE, Oft SZ? , W 5X,O ISA GAL. A �g COMIC. sEPfe- Tiimv— ufrtJ G-Nott ounce' __- 60mc, r 1ST BOX 40 t{2 4z, rj�S: 0>5r- AGSD PP-�PosE� ieb_Qr,jiT QLA ur FvP TN IS L TI a b2 � p x F �►. _ e1a Sid P TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: S-a3-0I SYSTEM OWNER &ADDRESS SYSTEM LOCATION ` (example: left front of house) 0.� DATE OF PUMPING: QUANTITY PUMPED i 5 GALLONS CESSPOOL: NO J YES SEPTIC TANK: NO YES —Z NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER (EXPLAIN) SYSTEM PUMPED BY: COMMENTS: CONTENTS TRANSFERRED TO: 'Location ������• ct No. � `; Date •- , TOWN OF NORTH ANDOVER. ;$ HORTMr f 1 Certificate of Occupancy $ buil,' ing/Frame Permit Fee $ 0.7s Foundation Permit Fee $ b,. Other Permit Fee? $ z t �S&& Connection Fee $ `,;,�ter Water Connection Fee $ . -,TOTAL.$ 2 r h Building Inspector Div. Public Works 77 PERJtIT NO. 1XD a APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. PAGE 1 MAP 4-40. LOT NO. 2 RECORD OF OWNERSHIP IDATE BOOK iPAGE (ZONE I SUB DIV. LOT NO. -L OCATION PURPOSE OF BUILDING ,6WNER'S NAME NO. OF STORIES SIZE OWNER'S ADDRESS irk OV BASEMENT OR SLAB ARCHITECT'S NAME V �K• �{/ �/� SIZE OF FLOOR TIMBERS IST 2ND 3RD BUILDER'S NAME SPAN -- DISTANCE TO NEAREST BUILDING DIMENSIONS OF SILLS DISTANCE FROM STREET POSTS DISTANCE FROM LOT LINES -SIDES REAR GIRDERS AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW 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 INSTRUCTIONS 3 PROPERTY INFORMATION LAND COST SEE BOTH SIDES EST. BLDG. COST Q PAGE 1 FILL OUT SECTIONS 1 - 3 EST. BLDG. COST PER SQ. FT. PAGE 2 FILL OUT SECTIONS 1 - 12 EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE JF�ILED AND APPROVED BY BUILDING INSPECTOR DATE FILED SUILDING INSPECTOR IGNATURE OF OWNER OR THORIZ D GENT ,,F E E OWNER TEL.N PERMIT GRANTED CONTR.TEL.# O ` 9 CONTR.LIC.# od`l H.I.C.k 16 s33 / 7 BUILDING RECORD Lrc 1 OCCUPANCY 12 SINGLE FAMILY S-ORIES 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 RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. CONSTRUCTION 2 FOUNDATION 8 INTERIOR FINISH CONCRETE d 112 to CONCRETE BIL K. PINE BRICK OR STONE HARDW D PIERS PLASTER _ V"LL UNFIN 3 BASEMENT AREA FULL FIN. 8 M AREA _ Y, 1/1 FIN. ATTIC AREA _ NO 8 MT FIRE PLACES HEAD ROOM MODERN KITCHEN 4 WALLS 9 FLOORS CLAPBOARDS B 1 1 2 1 3 DROP SIDING CONCRETE WOOD SHINGLES EARTH ASPHALT SIDING HARD"/D _ ASBESTOS SIDING _ COMMCN_ VERT. SIDING ASPH. TILE _ STUCCO ON MASONRY STUCCO ON FRAME l BRICK N MASONRY ATTIC STRS. 8 FLOOR BRICK ON FRAME CONC. OR CINDER ELK. STONE ON MASONRY WIRING STONE ON FRAME _ SUPERIORADEQUI� POOR ATE NONE 5 ROOF 10 PLUMBING GABLEHIP BATH 13BATH FIXE GAMBREL MANSARD TOILET RM 12 FIX.I _ FLAT I SHED WATER CLOSET _ ASPHALT SHINGLES LAVATORY WOOD SHINGES KITCHEN SINK _ SLATE NO PLUMBING _ TAR d GRAVEL STALL SHOWER _ ROLL ROOFING MODERN FIXTURES _ r TILE FLOOR TILE DADO I 6 FRAMING I 11 HEATING L� WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. TIMBER BMS. &COLS. STEAM STEEL BMS. 3 COLS _ HOT W T R OR VAPOR WOOD RAFTERS _ AIR CONDITIONING RADIANT H T G UNIT HEATERS 7 NO. OF ROOMS GAS IL sT 13 d I NO ItELECTRIC HEATING '140' 140NNM ot IN"s.ortft' ctover �V� , Nort AF ndover, Mass., 194 n nc i '+ BOARD OF HEALTH IT TO IBUILD Food/Kitchen Septic System PERM BUILDING INSPECTOR 1 THIS CERTIFIES THAT..... . ��� .� ............................... .................................................. has permission to erect... ........F'.Ne. ... buildings on ... Foundation .... o u ... Y .... N.�R.......... Rough to be occupied as ...c—em.......A.�.RM....(P...4Q.......AsP.V ,4X.....9'rk ,lr+!. .................... 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. PERMIT FOR FRAME/BUILDING PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough DATE: d Z-1 FEE PAID: Final PERTAIrh [I'll,I :IS ELECTRICAL INSPECTOR UNLESS COI\,I,' RlT-::• . .[� , ,1 I-f'�I7 Rough ... Service BUILDI G INSPECTOR Final I'errnit ReyLcircd to Occ-ttjry Bi -g GAS INSPECTOR Occlspur>cy Display in a Conspicuous Place on the Premises — Do Not Remove FinaRou�h No Lathing or Dry Wall To Be Done Inspected and Approved by the Building Inspector. FIRE DEPARTMENT Until Ins p p p Burner PLANNING FINAL CONSERVATION FINAL street No. Smoke Det. SEWER/WATER FINAL DRIVEWAY ENTRY PERMIT � r 3560 Date%..... . ...... NORTN TOWN OF NORTH ANDOVER 's O PERMIT FOR'GAS INSTALLATION 6. ~ �,SSACMUSEt This certifies that • has permission for gas installation . . . . • . . . • • • 6 ' in the buildings of . .% 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . at North Andover, Mass. Fee./,/-5. !. Lien�` ?. . . . . . . . . . . . �• �� J ✓ �� GAS INSPECT6 WHITE:Applicant CANARY: Building Dept. PINK:Treasurer t � 0 ,C MASSACHUSETTS, UNIFORM APPUCATION FOR PERMIT TO DO GASFITTING (Print "or Type) v IA+J w✓'vim - , Mass. Date 44 Permit # Building Location 5 N^f A V-, -S Owners Name 1h 4I/1 D AI J� ,2-j /V A AJ p JIM w O f `�S Type of Occupancy_ R E:5I -D N T! r4 New ❑ Renovation ❑ Replacement 2 Plans bmitted: Yes[] No ❑ y y ¢ W y Y = ¢ y tr1 frl V y ¢ C! ¢ O y S !- WJ N W 0 0 1, O V < O W < m y 1- < C O O f. ¢ W < :L W_ILI N d C W < dl ¢ W d V W 0 < ¢ O C W 01 L7 F' = J < C ~ H � M m Z O Z W O a S Y < W < W > ¢ W 2. < ¢ < < O O W O SUB-8SMT. BASEMENT 1 ST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR STH FLOOR Installing Company NaCheck one: Certificate Address 3 LOA[H/V%,4 nJ `q C3 Corporation Me 7 H U e fJ 01 r1 U ( ❑ Partnership Business Telephone /n 92 -9 9- ( 2-'firm/Co. Name of Licensed Plumber or Gas Fitter '�Rr�OE F T A- '�)AjAM 14 r4 L� INSURANCE COVERAGE: I have a current (}'ability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes ltd" No ❑ If you have checked ye, 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: Signature of Owner or Owner's Agent Owner❑ Agent C1 I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the pe for this application be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of t, laws. BY T of License: G� Plumber n ure o u _ or Fitter Title � City/City/TownJy/Tournyman License Number X333 . BELOW FOR OFFICE USE ONLY FINAL INSPECTION SKETCHES PROGRESS INSPECTION FEE NO, APPLICATION FOR PERMIT TO DO GASFITTING I NAME A TYPE OF BUILDING LOCATION OF BUILDING PLUMBER OR GASFITTER LIG NO, PERMIT GRANTED DATE 10 GASINSPECTOR pro 26-49 Date�.... .. ...1/U NORTN . TOWN OF NORTH ANDOVER k PERMIT FOR WIRING e ♦ i • ;�Ss�cMusE� 1. i This certifies that ...... ...�..aJ�.!...5(�..... .5 .............Y.S ..... ... ................ has permission to perform AJ.a k.! P wiring in the building of ........... .......................! . .... .......................................... rr `�......., t�>.....��<J. ..(G.�� ... �.. ,North Andov r�Mass. Fee..... Lic.No. y ........ ...%:?^ ! -7 LECTRICALINSPECTOR Check # WHITEN Applicant CANARY: Building Dept. PINK:Treasurer M• • '- "` .► ,,, J' ,Y, 11;f �, may,, r 6�,��,,�� '✓' . !_!3, . Ali'. � ., a aRD OF F'RE FREV9MON REtUL,4MO S. ��'Y and Fez~Qz •- - A'P LICAi IO 10 R P t I�91 All work to be pmt-oma � O PERFORM ELECTRICAL _ (PLlSL PRIN"1'ININKOR TYPE. dict Cade(lw[�.sz7 a IwO qty or To Ott GYFORILlT70��7 Det r►a or. �C�oVerh .�j _ By this an I- thetmd=kCc va nouct:oflus r�hcr���cTQ drelizrPecrorof Location(Street S Yumber) �q 'n a to gcrfcrru the efccIIic„�"'Mt bdm Osvae.�or Teaaat + �1 Owners Atidr= Tciepaoae 1.0.Is this pc-mit;it: �a caizluaesia¢With a btuldinb rrmit? PuYesrpose of I3cu7diag Q i`io (Cltcc't:f1 UtzT:t Autho ' PProP�.:teBa=) meting Sen-ice T riz..tion Yo. Amps / Vohs Orerii�d Q U Newsicrricci`{v.af�Ici.- Amps ��:Yaits Or��d Q LIIId�t•If Yumfie. of Femiers and NO.of ampacity • Location 311d ;iaturic of Proposed EIc:trici+Yorft: Cvmaietio.rot'theralralvinzrablemavGe.t�.. � tlrc! "'swcro�IY,rQ of Reecss� Fiaturrs No.of C21-S�.(F=ddIe) .•,= tyo.of No- of L-4-211dng Outlets ITr•-nsfor-,n Iti Na.of Hot Ttu�s INo.uf Liaiiti,-tQ `Generators ;�/A 5 `=tures ISlvimmi g?aoi ° e Q fid. Q 1 0. at r.mern�._^.c-i,;yIIttII; INO-of Re-_atuc a Outlets IBare.^r Units INN.of Oil Burners NO- of Sy it es �F=RE AI.ARi1iS iYo.ofZ=es IYo.of G:s Burners I1 0. at-Detez-son aau INLO. of R=Cres li`(o.of.�it-CoacL Tot:.t Lidaalnz Dcvtcs - �'o. O[W- Disposers Tori INv- of Aler ncr Devices pert P3Inp C u-MCer I T OILS I Z Y 1 Tots=! I IiV0. ai Sc:f-�aIIt;,;�tca (.;ti`o. of Dir,'iir:slie:•s I I?eter:ioniAleM �Spac• Are:Semina :fit n-Q Devlc 5 _.l I j tYiutucJm 1,14 o. o f D r:c-s ILarCanaeon I_ Otho- Fe=�.�Dpll�aCeS ILN0 . of tiYcte_ ISecc;.[yJv_re�s. r l'ta.01 NO of Device or V I`to. ai -^*�•eIIr Std B aiI:S2S I D 1 i: I'- No.H}ti.'o t,^.:sszoA Yo.ai Deti cs ar'^ -:leaf y_Bathtubs �iVo.ai ltators Tot:i�„'p 1'�e-omrlluntc too`s l II`+Su-R.i�i duals ecaitianai detcit ijde-ire:,ori;r �i ;yrite:rrs• roj;YuYs COti-ERAGc.: Unicom:.r••.ive by t"-o'vr:e;ao P=.:.it far the oe:totr.-.:Ic_of ei =Gf vera�f is�Ie uakss the iicc:sc_ c� Pmof of liability insure=irzrr,;ciII unde;r'o� c �cO=ic—^d oaer•tica"cover_-or:s s�:cr,"tial e...^,-;r•,r fes tl�tt such=wage is in f=-,red has eiiibitri proof of satt:e to the BOND I i OMMi L7o(�,r- Estiur`ted e o't:=ricl Wa rfi J C (Whet :r uat>zl b -.i Dol1C;t-� tivan to s�:,� 6 500 I=c_tions to be ticr is rrsuWed is=arm:tvitii 1tEC R 1e I0,zIId upon=rc; ,. I ccrrif}•, rrncter tlrrFairrs acrd persalli¢s ofP01�1 drat o FIRINI NAZti IE� f�orz ars tYr't application is tyre and complde Y Lic=sce: S Lien_ (!/'appticact . Qr[er"tr 'ur 4w 1" am ratr ) !!,, LIC.irO-9 l " Address_ •, Z� dt7e /Vl� �Z�S�Ba=Tel:iio- OtiY�fER'S RNSLRANCE W.UVER: I ams tftst ttte �L Tet.` - 1- - g wed by Izty_ By msLiceas�doer no hast the li ability i Y rcgmix lmv mY. p==below,I hceby arrive this = . I the(ch, vete=Q== Silnss�tr•e Q Tefephouc o- .. ,. .. _ IZ o X000000000000000000000 ULJIAAa1 l:+lr w.h=AJ�.N.1W � � 0 i �CIy�CLiL�LJ «•••(�����,y000000000�00000�00000000000000000000000000000 ® ••••r• ca�/J �. Vi1:f.'i:iti.72.►iL1 0.000000000000000000000000000 0"00006i;6OOp000000o00000o00000o000o00000o o�00000eoob000000000000000000000000pBlItAin � Ni'"' T3360b000000 9&M6000000000 00000000000000000000000000 rr�// .�p��� fi/yr., M �+ 7w:�mm L7.3AWJ1iJD fh(f ft�' ma Rb MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GA ING"� (Print or Type) 2 L�( �i , Mass. Date 5_/a r 99_� Permit # Building Location_�`� _Owner's Name JJJJJJ Type of Occupancf i/ New ❑ Renovation ❑ Replacement Plans Submitted: Yes[] Nom N W W to N N U Y (L 5 N Q N D: � O � N = J N W O U p� F- Z Vf z p ►- a >- z z o >✓ a m ,n r a ¢ 0 0 Uj 0 ►- W Q W W H U) �t 0: O W W W N j z a S 0: cc W Q W H W F S cc 0 f- z J H z W W O O > U. f- J H 1' Q W Q C >. N O a W > X w z Q ¢ a Q o ow = [m 010 z U. n 3 a 0 _j U � > o 00 Fes- O SUB-BSMT. , BASEMENT ! ISTFLOOR ` 2ND FLOOR I 3RD FLOOR 4TH FLOOR I STH FLOOR 6TH FLOOR 7TH FLOOR 8TH FLOOR Installing Company Name Check one: Certificate Address Corporation ❑ Partnership Business Telephone — ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter 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 rtes, please indicate the type coverage by checking the appropriate box. A liability Insurance policy P_ 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: Signature of Owner or Owner's Agent 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 performed under the permit issued for this a plication will be in compliance with all pertinent provisions-of4he Massachusetts State Gas Code and Chapter 142 of the eneral Laws :Type of License: Plumber Title �°i I ' Gasfitter Signatur of ceased Plume or Gas Fitter City/Town ;' `+ (Un` aster Ucense Number APPROVED OFFICE US _ONLY) Journeyman i BELOW FOR OFFICE USE ONLY FINAL INSPECTION SKETCHES PROGRESS INSPECTION FEE NO. _ APPLICATION FOR PERMIT TO DO GASFITTING NAME & TYPE OF BUILDING S) / LOCATION OF BUILDING ,Irh71J-h ( �l gyp_ K!J PLUMBER OR GASFITTER 1�✓C'�r.�I� 1!/1���/� LIC. NO. Q/ Q---l? PERMIT GRANTED DATE 19 GAS INSPECTOR �� Location v No. 4 '7 / Date UL NORTH TOWN OF NORTH ANDOVER Certificate of Occupancy $ • s ; , Building/Frame Permit Fee $ Area Foundation Permit Fee $ s�cMust Other Permit Fee $ SewerrConnection Fee $ Water Connection Fee $ JOT1►�g1 $ ��/> Building Inspector Div. Public Works ; f 0i1��0.1 A.- .00 R3•:1'� � �R':.E� I� Hr110k 1 i t w gftW aIIQu9 vtC. PER'lfll NO. ✓ APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. PAGE 1 1t� MAP KJO. LOT NO. 2 RECORD OF OWNERSHIP ]DATE BOOK PAGE ZONE SUB DIV. LOT NO. �-1-1 LOCATION PURPOSE OF BUILDING OWNER'S N E TOAWV pe)?;e NO. OF STORIES SIZE OWNER'S DDRESS /�l OIy N ClgG BASEMENT OR SLAB ARCHIT T'S NAME L&V >J,.` SIZE OF FLOOR TIMBERS 1Sj,, 2ND 3RD BUIL 'S NAME / e�{�tI�AtCe, SPAN DISTANCE TO NEAREST BUILDING DIMENSIONS /OF SILLS DISTANCE FROM STREET POSTS DISTANCE FROM LOT LINES-SIDES REAR GIRDERS AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW 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 - 1 BOARD OF APPEALS ACTION. IF ANY 1\,/ �J IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS 3 PROPERTY INFORMATION LAND COST SEE BOTH SIDES EST. BLDG. COST rrra ,,- PAGE 1 FILL OUT SECTIONS 1 - 3 EST. BLDG. COST PER SQ. FT. EST. BLDG. COST PER ROOM PAGE 2 FILL OUT SECTIONS 1 - 12 SEPTIC PERMIT NO. ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR DATE FILED BOARD OF HEALTH SIGNATURE OF OWNER OR AUTHORIZED AGENT OWNER TEL.M -<"c-'03S FEE �� GUN ^ z)jb7 rONTR.IT.�-��,�o. —J PLANNING BOARD PERMIT GRANTE t 19 _ BOARD OF SELECTMEN BUILDING INSPECTOR BUILDING RECORD 1 OCCUPANCY 12 SINGLE FAMILYSTORIES 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 RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. CONSTRUCTION 2 FOUNDATI(4N 8 INTERIOR FINISH CONCRETE a 1 12 I— CONCRETE BIL K. _ _PINE BRICK OR STONE HARDW D PIERS PLASTER _ DRY WALL UNFIN 3 BASEMENT AREA FULL FIN, B M T- AREA _ '/. Yjj/./. FIN. ATTIC AREA _ NO BMT -FIRE PLACES _ HEAD ROOM MODERN KITCHEN 4 WALLS I 9 FLOORS CLAPBOARDS B 1 2 1 3 DROP SIDING CONCRETE ��_ WOOD SHINGLES EARTH__ _ ASPHALT SIDING HARD"J D ASBESTOS SIDING COM t.1C;N VERT. SIDING ASPH. TILE _ STUCCO ON MASONRY STUCCO ON FRAME BRICK N MASONRY ATTIC STIRS. 8 FLOOR _ BRICK ON FRAME CONC. OR UNDER BLK. STONE ON MASONRY WIRING STONE ON FRAME _ SUPERIOR I I POOR ADEQUATE NONE 5 ROOF 10 PLUMBING GABLE I HIP BATH (3 FIX.) GAMBRELMANSARD TOILET RM (2 FIX.) FL _ AT 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 LINIT HEATERS 7 NO. OF ROOMS GAS OIL B'M'T 2nd _ ELECTRIC 1st 13rd NO HE A � • NORTH Town of ndover NO. ° � N er, Mass., &F W - Z 19 C ni HEWICK V C11 aoR Q�� SS BOARD OF HEALTH PER IT T 0 THIS CERTIFIES THAT........ .. ... .. ......... ...... .. .. ............. .... BUILDING INSPECTOR , has permission to erect ... ....... build' .. f...... .... ... p f� � Rough Chimney tobe occupied as.......... 4W.... �......C�. .. � .... ............. Final provided that the person accepting this permit shall in every respect conform to the terms of the application on file in PLUMBING INSPECTOR this office,and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Rough 9 Buildings in the Town of North Andover. Final VIOLATION of the Zoning or Building Regulations Voids this Permit. PERMIT _EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTR TIO TARTS Rough Service Final 4 BUlLDI G INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Final Display in a Conspicuous Place on the Premises Do Not Remove Burner FIRE DEPT. No Lathing to Be Done Until Inspected and Approved by Smoke Det. Building Inspector r FORM U � j `TOWN OF NORTH ANDOVER `LOT RELEASE FORM,, ' f: SUBDIVISION ASSESSORS MAP r SUBDIVISION LOT(S) ►, PERMANENT A- DRESS (ASSIGNED BY D.P.W. STREET ✓oA Il APPLICANT j ,c%u€ PHONE DATE OF APPLICATION Z� w TOWN USE BELOW THIS LINE PLANNING BOARD w DATE APPROVED TOWN PLANNER DATE REJECTED CONSERVATION COr1M SSIN (✓ DATE APPROVED 7 CONSERMTION ADMIN. V DATE REJECTED BOARD OF HEALTH DATE APPROVED 7 ZS HEALTIr 8XNIYAAIAN DATE REJECTED DEPARTMENT OF PUBLIC WORKS DRIVEWAY PERMIT i�J/dQ SEWER/WATER CONNECTIONS z FIRE DEPT. Af RECEIVED BY BUILDING INSPECTION DATE This form shall be signed by the agents of the Planning and health Boards, the Conservation Commission prior to the issuance of any building permits for the subject lot. This form shall not releive the applicant from the compliance of any applicable Town requirement or Bylaw. r � t1t� r' 1 .1 t11 - a• � x � 6. + b1 f[y�•� J�yy�^S. � .fj xL :r7i� t� S,I rt•t� ;fT tr \ r•r !r ` ^ *•fitt � �+ h �J.a ; , i „t•+ \ k.'�'• �MY,r\l.ta�(e,T �.'4•}. '.r„i'e I �. �+' x.• •'r`N\tr j,`,r ;`^h ,y • ,r, J ,,t; 7 T 'yt:L� y'y`.. ,t'j'tC �`•.y:'':�• r� ><,'�t1'•: 't.,., y '' ,� V r, ; rJ. t'•i j'rt ars 4 T`' 5;fi ra,'b'i•r.M k.fi Lip ....c>. 1 ., i • y��l^a`, t'^,!'.'�f'r 'i•a �,t+_ lZir :4�"..r tom ,,�•., �:fZ: .0 lel l y�}.t gAa ,t:•�:i1 rl..�==.� ,r qi.t! 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U Date O• "CRT" TOWN OF NORTH ANDOVER ,•,�Ow 41 9 Certificate of Occupancy $ �'�s'•"°''<�' Building/Frame/Frame Permit Fee $ sncM,sa 9 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ �- Check # 17147 —Building Inspector I� TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAI RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERK 1T NUMBER: DATE ISSUED: ic C _ SIGNATURE: Building Commissioner for of Buildings Dates—O Z SECTION 1-SITE INFORMATION IO 1.1 Property Address: 1.2 Assessors Map and Parcel Number: Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(so Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard R ired Provide ReqWred Provided Required Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: v Public ❑ Private 0 Zone Outside Flood Zone ❑ Municipal 0 On Site Disposal System 0 SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT M 2.1 Owner of R , Name(Print) Address forervice: 6J-6 /003 Signature Telephone 2.2 Owner of Record: Name Print Address for Service: — _ 0 Z m Signature Telephone SECTION 3-CONSTRUCTION SERVICES 3.1 Licen onstruction Supervisor: Not Applicable 0 Licensed Construction Supervisor: �`'" O �� LAY D� ��J� �� 030 7� License Number mn Addres-- (l� /� - [ALI(� � `(•( 6 Expiration Date --- ic — — Sig ature- Telephone r 3.2 Registered Home Improvement Contractor Not Applicable G 0 ACG (6 ��6° 3 Comp ny Name � m "Wes ,W 63,117S Registration Number Addr s `7/Z Y &CIU 3"'q/4 y�� Expiration Date 7 ^ Signature Telephone V I SECTION 4-WORKERS COMPENSATION(M.G.L C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. -Signed affidavit Attached Yes.......0 No.......0 SECTION 5 Description of Proposed Work check alf a cable New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: alp Anci r) r SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be `'OFFICIAL USE,'ON3:Y Completed by perrriit 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 v, 6 Total 1+2+3+4+5 m Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER GENT OR CON CTOR APPLIES FOR BUILDING PERMIT 11 �Ja�d ,as Owner/Authorized Agent of subject property HVy2 uthorize iCl VTujc to act on Mll;in all mane ers elative to work authorized by this building pennit application. 312�/bU , SigAature 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 e C..�z r nti Print e 3 1 6 I e Si tune of Owner/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 ST2 ND 3 SPAN DfNIENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE :JJCP focqnwso^wAqaM Of..-ff4dj�W400 Board of Building Regulations and Standards 1icease or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Re9istratIcn: 106603 Board of Building Regulations and Standards Expiration: 7/242004 One Ashburton PIM Rm 1301 Type: DBA Boston,Ma.02108 I WOOD CONSTRUCTION Chat d Smith - Shore Drive G.G......��,4,, n dem,NH 03079 C ___tu Administrator - Not valid out signare `^ ✓,F6�icvxonuraa�o�'✓t�aoaaa��e�a o' r:t BOARD OF SUILDING-REGULATIONS �t UceriseCONSTRUCTION SUPERVISOR Number.-CS 070882 F` `i: <� �t3itthda6e:-0773871956 ,V Epio-.._�.-. .. Tr.rto: 1474 Restrictedi OO RICHARD J SMITH _ ^- 5-7 DELAWARE DR (, ,w,t—,-ri'..• ✓ /J SALEM, NH 03079 Administrator COMMOnwealth of Af"sschusettts Dmskn of oca4vatkW1 Surety RobW J.Praaicso,OB*aiedor r� Deader-Contracts S, RICHARD S.SMITH Eft.Date 06710!03 EW Date 06711704 D0001721 Member d C.OXE.S.T. 0,4 BO BMO"E W North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11, S150A. The d n will be disposed fin: � Aj (Loc of Facility) Signature of Permit Applicant *3(2c, (4 Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector The Commonwealth of Massachusetts d Department of Industrial Accidents Office of Investigations sr Boston, Mass. 02111 Workers'Compensation Insurance Affidavit Name Please Print Name: Location: City Phone # EDI am a homeowner performing all work myself. I am a sole proprietor and have no one woridng in any capacity' . I am an employer providing workers compensation for my employees working on this job. Company name. Address r Cib[ &4n &d b-o ? ecr (-1616zq Insurance Co. Pogg# U bel-ty xAu-tur.4 Comvanv name: Address fes: #k Msurance Co. Poky S Faikireto secure coverage as requi►ednnder Seebon 25A or MGL 152 carrleatttathe imposition cfall.—atp es era rkw dptD, a"or one yews'Imprisorrneotas�aeelLas�ngl peoaklesblbeSam��f� fioa�f ]tom L��arl a9atastme urKierstand that a copy of this staternent may be forwarded to the OfBoe of h e tigabons d the NA for coverage verwiicsion. /do hereby cerWP and p��ofpeomy bw the z0 rmatlanr pounded above a eve and correct Signature Date _,j912-(0 16 Print name 0S PbWel 6, Official use only do not write in this area to be completed by city or town dficiar Cdy at Town Pem>fi/Licer�sirw. . iJUNv� q []Check ff#mnediahe response is required U 01 ift Ba [j selechrnarr'S i contact persar: Phone# Q Health Depar Q Other XAOR ® Of Andover 0 No. 43 C, dover, Mass.,— 0 LAKE COC HICHEWICK 0"?ATED P"? U BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System &000 BUILDING INSPECTOR THIS CERTIFIES THAT ......... .. ................... .. Foundation cation on file in Final has permission to erect........................................ buildings on ..... . ... ... Rough -4&41*-�l "W"W-01-------------- to be occupied as ........... ... . .. ... ....... .... Chimney provided that the perso ccepting this permitlse�;inn every respect confor othe term of the appIi -0 so I this office, and to the po visions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings In the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS UNLESS CONSTRUCTION4ZW)g.. ELECTRICAL INSPECTOR Rough ................................................................................................................. Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove Rough Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and .Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. ,\ '•` -,'.'thy, � �:� y Date N2 - 10 4 6 4 ��,<"0T ,rho TOWN OF NORTH ANDOVER L o PERMITFyOR P,LU.MBING . t- SSAC"us N This certifies that . . . . /w. 1I has permission to perform . . . . plumbing in the buildings of . . . .!. J ' v rd. ��.�. 9.ri.. . . . . -'No, rtndover, Mass - Mass`.. FeeP. Lic. No.. MBING INSPECTOR PLU WHITE:4NU$80 14:52CANARY: 9 D IQ=, PINK:Treasurer - S-o '� t•� n ,r pp Y MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Pri nt or Type) Mass. Dat 19Permit # 4eO YG Building Location( T C. kc L Owner's NamaL, t ,/V 1"7YI/�Jfilz ZA2 Type of Occupancy New ❑ Renovation ❑ Replacement t?" Plans Submitted: Yes ❑ No ❑ FIXTURES N Z Y H N of 0 0 Z +" H W Y J N Y V < N O Q LU Us ¢ O Z N < ¢ Q = ~ N Z O Z h a o = O O ¢ W ¢ 2 < W O < W Z ¢ a ¢ 0 < i0 N ¢ J O O W = < _ x O Z = Y d C F- < z < W W X W !- V > F- O = d O W f- Z O O w W �- O v S < F- < < = H H 4 < 0 -C J j < ¢ ¢ a < O < 3 Y J m SUB—BSMT. BASEMENT IST FLOOR 2N0 FLOOR 3RD FLOOR 4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR 8THFLOOR ,± Installing Company Name /'AOMle-r Q SP(rm,4TAe0 Check one: Certificate Address J(� ct," q(H mt4 k) s Pi ❑ Corporation 1Y) If TI-4 1,F_ A Al A U rias ❑ Partnership Business Telephone �Iff Z-i97 1 a<rm/Co. . Name of licensed Plumber ,(`r3r f'T h� SAm�ylr4 tr4/�r INSURANCE COVERAGE: I have a current ' bility insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes No ❑ ' If you have checked yes, please indicate the type coverage by checking the appropriate box A liability insurance policy 21 Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAVER: 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: Signature of Owner or Owner's Agent Owner ❑ Agent C1 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 Wormed under the permit issu for this application will be in compliance with all pertinent provisions of the Massachusetts State Plum ' g Oode and CDapter of the ral Laws. BY L Title S(Pmre of Uoensedum ber Type of license: Master % Joumeymah ❑ City/Town APPFKNED(OFFICE USE NL License Number q33 ; BELOW FOR OFFICE USE ONLY FINAL INSPECTIONS SKETCHES 1 PROGRESS INSPECTIONS _ FEE NO APPLICATION FOR PERMIT TO DO PLUMBING NAME &TYPE OF BUILDING LOCATION OF BUILDING PLUMBER PERMIT GRANTED DATE 19 PLUMBING INSPECTOR r Location v No. ,/� l v Date v i . NORTH , TOWN OF NORTH ANDOVER k_ FP ` Certificate of Occupancy $ ►H,s9 t�'a Buildin /Frame Permit Fee $ e Foundation Permit Fee $ Other Permit Fee $ t TOTAL $ f t Check # Z) 17574 lie, O Building InsOator 'S. y� JI i, r� 5 �. 3n i' J � '.f g.. TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING '1'1&Seed66 for OE *dd Use Oil BUILDING PERT NUMBER: / i DATE ISSUED: /�/D X MI �/ Cp SIGNATURE- Building IGNATURE Buildin Commissioner/1for of Buildings Date z SECTION I-SITE INFORMATION O I.1 Property address: 1:2 Assessors Map and Parcel Number Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions. 3 ,? I -v VNt Zoning District Proposed Use Lot Areas Frontage(fi) 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Reqwred Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: D Public 0 Private Zone Outside Flood Zoae 0 Municipal 0 On Site Disposal System SECTION 2 -PROPERTY OWNERSHIP/AUTHORIZED AGENT M 2.1 Owner of Record yanan innst Ca CD lT ame(Print) Address for Service: \ lig'n4rure Telephone 2.2 Owner of Record: Name Print Address for Service: O Z M Signature Telephone SECTION 3-CONSTRUCTION SERVICES 3.1 LicenConstruction S !rvtsor: Not Applicable r a rk nsed Construction Supervisor:� n � d /• � /)/)� �/�S—y License Number ' Add s ` � > �� �1n3-�� 7 7 Expiration Date jSf Tele nature phone Jr 3.registered Home Improvemen ontractor Not Applicable 0 v ( r,e L.I 1 FJ mpany Name �3 M S- .e-r 414 Registration Number k7dr, I-10 q . /�f J _/ Expiration Date "re 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 building permit. Signed affidavit Attached Yes......scNo.......❑ SECTION 5 Description of Pro osed Work checkapplicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) 0 Addition ❑ Accessory Bldg. 0 Demolition 0 Other Specify �✓k,Jk/ f+e7 Brief Description of Proposed Work: � f Sri f.�:Yc,�( Cc'YtCI�Tl •� -- � SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be Completed by permit applicant 1. Building i (a) Building Permit Fee '6270OU Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(+) 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 1, ��Lt�h Q 1'c as Owner/Authorized Agent of subject property Hereby authorize Ce�r) 0- n Yl to act on a t, in all matters relative to work authorized by this bui ding permit application. Q SignattirJ of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 1, as Owner/Authorized Agent of subject property Herebv declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief Print Name Signature of Oxvner/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TINMERS iST 2 NU 3 RD SPAN DIN ENSIONS OF SILLS DIMENSIONS OF POSTS DDAENSIONS OF GIRDERS DIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHUANEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE FORM - U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all-necessary approval/permits from + � D Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and or landowner from compliance with any applicable requirements. APPLICANT 1W !t man,moe M I Ce I( '"PHONEqw-b&--1063 � ASSESSORS MAP NUMBER LOT NUMBER I F) Q S I SUBDIVISION LOT NUMBER <� � �STREET Jit 11 rl r'tt,� e446e— � 4TR ET NUMBER aJ' 9 ................... ........................................................ OFFICIAL USE ONLY RECO nD TIONS OF TOWN AGENTS DATE APPROVED CONSERVATION ADMWISTRAT DATE REJECTED CONBAENTS DATE APPROVED TOWN PLANNER DATE REJECTED CONIIVIENTS DATE APPROVED FOOD IN ECTOR-HEALTH DATE REJECTED / DATE APPROVED b t/ C INSPECTOR- DATE REJECTED COIVQVIENTS i ��� 2 47n2,- Sc ro 7L C PUBLIC WORKS-SEWER/WATER CONNECTIONS DRIVEWAY PERMIT DATE APPROVED FIRE DEPART'MEN'T DATE REJECTED CONIIyIENTS RECEIVED BY BUILDING INSPECTOR DATE -----D- 9 - -- T 9.r X13,S71 y� i � � N � 9 1 �XisT ISa�Gni. _ A ,8 Our, sEPf o Tltuv_ . o ' _ IUEW 6-NocE ouTLz _ CpuC, h sT Box �o • . �{2 - 4 Z' f>✓: SFaE Al-go pp-oPosED AS-BWLT PtAus Fie THiS "pw lae"14. TI d9f-S 64,w�nE� S Ry -rHOMR� MGfonY Al Fit,_ W r)4 731E Towu o F .VW A} jtgVM got M aFNEACTR . �S1�t1 V,E•G�k 47p,�c7�D G•3D-qZ o >yUVCAE E. AS BUILT PLAN OF SUBSURFACE DISPOSAL SYSTEI LOCATED IN ._-_. . L. . .- L ,fir. ► n n f Rams Boom go m eggs vousumvi Imperials 3000/3050 SERIES MOUNTAIN LAKE As 21' x 40'SBUrtm t 21'x 40'3000 SERIES 21'x 40'3000 SERIES Wl 6'R x 12'W STEEL STAIR A.'• 21'x 40'3060 SERIES W1 RADIUS PLASTIC STEP STANDARD VIEW PART NO. DESCRIPTION 5 5 4 04162 8'RAOIUS PANEL 63' 16' I 1 1 04476 8'RAD.SKIMMER PANEL 6'3' r30'-r r 1 1 2 D4167 IT RAD.RETURN PANEL 6'3' Y-4 'Locellen (P ml®mea weer 3•�• erwelope pw AN6VN9PFe 2003 2 04437 6'RADIUS PANEL 8'3' adn°ir0e- -""� e' e• Y MINIMUM 1 04438 6'RAD.RETURN PANEL 8'3' PREPARED BOTTOM � 2 04485 6'RADIUS PANEL 5'3' 2 04474 VRADIUS PANEL I'11' 14' e•-1-8-6-J L3'-e' 91--1-T-6'J 1 1 1 04116 7 RADIUS PANEL SLOPE BOTTOM BACK SIDE BOTTOM SIDE PAD WALL WALL PAD WALL 5 6 5 04165 8'REV.RADIUS PANEL 6'3' 1 1 1 04488 2'1 112'PLAIN PANEL 1 1 1 04119 V PLAIN PANEL 111111113104223 ADJUSTABLE A-FRAME 1 04495 8'R x 12'W STEEL STAIR 1 0741SRSNR S'RADIUS STEP-N-REST 1 1 1 04255 NUT 8 BOLT PAK REVERSE VIEW 04134 8'RAD.LIGHT PANEL 81' 16' I � r3D', 04133 8'RADIUS PANEL 3'1 112' 3•-4. I 'London M Pain/®on yr wear 3•y ��. snwebpe pM ANSdNSPF62003 s e su a.lm. L Y MINIMUM PREPARED BOTTOM DIVING PERMITTED ONLY FROM I GALLONS- 17950 L3'-8•J—e•—L3'a•J L3'.8•J-6• 1 W DESIGNATED DIVING AREA PERIMETER-100'-8' SIDE BOTTOM SIDE BACK BOTTOM SLOPE WALL PAD WALL WALL PAD 1.Pod Is designed for use below grade end Only In areas where the ground watar table 4 a m W mum of 4'8'below grade. 2.BackNI vrtth dean earth,free of roots and debne.Do not allow Ma Want of ec bk fix to exceed the hoight of the water In the Pod by more Man B'nor the water to".ad the bark NI by more Men 6'. 3.Pow2eoo P.S.I.PMcrea fooWtg around antlre p.mnsler,MMmum S*deep. 4�.S ALL DIMENSIONS ARE FINISH DIMENSIONS 4.S wide cdnaeb deck 4 tobe poured al Wal 3'thkkne6a and■sloped•'/.•to 1•away hem the Pod. PANELTTOM 5.Aa beide pool dbnenalorw are to M ndahed dmanalons. TEP 6.FatlNed b000m is to beY mldmum of sulable matanal or undt3turbed eaM.T.A salary line.with buoys.le m be permanently attached 1'0'to Me shallow saeof the point of first elope flange. 8.StM:For ag staff layout.,refer to Imperial Inaleeetldn manual.9.Construction Drawing:DMlerent methods and precatNon.may be dicatad bywanous ground a..Oxlens.Tole Is to be delemMned by and la iM POOL responslEgly dthe contractor who 16 nal an spent d Me manufacturer of the WALLFREE FORM TAIR FILLER component Pana. LEFT 7 10.Insta bon Is to be done in eccordwoe with all federal,vat*and local Wading RIGHT-05489 codas,sawalles N.S.P.I.Suggested Wandarda. The twddm oonapxW ehawa lonfnme wan au—t N.S.P.I.slrotesu°minlnum alaaerae FEBRUARY s� bo'Poeppn wed for use wM r.ufacn d d-9 pWut pnM-If dlvng epuiluMnt M wteded,fo9ow aro saulPawn nud.rt w�v.iawteuan.uw aro wiry wevur,Pae. 2004 -eommonawaAt O/C--, Jho L,( tions and Standards - a Board of Building � g Re f` One Ashburton Place - Room 1301 Boston. Massachusetts 02108 Home Improvement Contractor Registration Registration: 136940 Type: DBA Expiration: 9/16/2004 PRECISION POOL CONSTRUCTION ----- SEAN CANNIN 21 WOODLAND ST. --_ NEWBURYPORT, MA 01950 Update Address and return card.Mark reason for change. Address '-1 Renewal -i Employment 1 Lost Card ✓�ie �o��v�naruaeall� o�✓L� c�a Board of Building Regulations and Staadards License or registration valid for individul use on ly . before the expiration date. U found return to: HOME IMPROVEMENT CONTRACTOR � Board of Building Regulations and Standards Registration: 136940 One Ashburton Place Rm 1301 Expiration: 9/1612004 Boston,Ms.02108 Type: DBA PRECISION POOL CONSTRUCTI %&N CANNIN 21 WOODLAND ST. G!.-.• �✓r _...--- ---- — - ---- NEWBURYPORT,MA 01950 Administrator Not valid without signature cense: CONSTRUCTION SUPERVISOR Number: CS Ir 084006 �. Birthdate:1127/1968 Exjiires: 11/27/2006 Tr.no: 84006 Restricted- 00 SEAKA CANNING 21 WOODLAND ST NEWBURYPORT, MA 01950 Administrator +� .The Commonwealth of Alassachusetts • _ Department of Industrial Accidents ' •� � 01B1d0// d� 600 Washington Street Boston,Mass. 0211 d Workers'Compensation Insurance Affidavit NNW It t . n work myself. ^ t an a homeowner pertormins all in acity 0 1 am a sole proprietor and have no one working Y Cap to er roviding workers'co on for my employees working on'this job. I am an emp y P �C Z;c- . c v a e add . Z city Qo 0 01 ' a eneral contractor,or homeowner(circle one)and have hired the contractors listed below who have FIMa sole proprietor,g the following workers' compensation polices: v ame• nhtkn ad ess• e=• insuranc co nv na nhn ad r s• ne T: i an Wn,i. r .� NIGL IF-can-ie2d to the imposition of criminal penalties of Failure to secure coverage as required fine nadnaf es nnth f rm of a STOP FORK ORDER and a line of S100.00 2 daagainst-mc.up understand that a one years'imprisonment as well as civil pe �t mac , copy of this statement may be forwardedi5a the C'c!of Investigations of:he .....r:o •.»z•""' I do hereby c under the Pal yand penaUies of perjury that the utformation provided above is true and cotre� Date Sip-nature Print name �•tcs.a'► �4st.. ,tw Phone - official use only do not write in this area to be completed by city or town oMCiat permitllicease#_ 11Bailding Departn►ent j city or town• pLicensing Board pgeiecnaen's Otfice 0 check if immediate response is required C3Health Department phone rIOther { contact person: Imperial 3000/3050 SERIES MOUNTAIN LAKE STANDARD VIEW - LN murom 21 x 40 y39b' B 8R `}• 8R 6'Y 6'3• A 4• 8RR Q 8RR BR9Y 1S'S' CENTER LIGHT B'3' B3' 4i 71-12' 8R PANEL OPTION 1; SR P RI' 3'11? Rs 6R P 2X7 �v� x� b 69 21.1 - �< e3 ti 2a ti. 2 �` T.- 2- E Rs-6sR LIGHT R � 3,�, T PANEL 8R 8R N1 83' 3.6 87 8RR "g 8RR IRR /R1 IR 8'3' 0'3' 8'3' 3912' 2R D 8R 8R 67' 6'3' C' 39.6• FR0.N i0: 12'-2j 28.9• PROM TO: B 13 -0y' WAY' R20' A N1 111-9%' 11'-9%• A-FRAME BRACE U O R 20.x,. Rt 23'-4\ P1S 33'-toy 23'-$- 3.•6. T 1s-11#, `\, u 33'6 21'1}• 14'-8' 23'd \RVNp 3-9' 71'6}• 34'-7 `\` FROM Tv R•S 10'-0yi `\E 17-1�• mOu7 To: N14r.0+:• T-81' P 3Z.OY' T N 375' Pt 34•-$3;' YS R 1Y•1• P 18'•2;5- 0 Z7-'31" $ Pi 18'i' R 27'Sy* O 17-7• R7 25'-11'/.' R1 28' R tY-9• T 39'-6 y' u 7r-1 o• C r s5 R12' U 3T•1 A43 BC 44'-103:' �N1 FEBRUARY 6T 2004 NORTH Town of � _ 19Andover Adover, Mass., A ICV 7 4DRCOCHE D A-rA'HEWICK 5 '9S _4� BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System 07. ' a BUILDING INSPECTOR THIS CERTIFIES THAT...... '.410/47.,0004f.1.10 An....... h� � , I#J.Apy �............`.....�........ Foundation 0 has permission to erect... .................. ....... buildings on .. f.� ... ........./�..... ... Rough to be occupied as 1.NA^ 0 v obw V t � PI• / I A& 0%! , M � / 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 rel Ing to the Ins ction, Alteration and Construction of Buildings in the Town of North Andover. /40 7D a a owm- PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Kermit. Rough PERMIT EXPIRES IN 6 MONTHS Final ELECTRICAL INSPECTORUNLESS CONSTRUCTIO S S 4% Rough .. ... .. .. ...... ..... .......... Service .. . ................................... ...... .... ....... UILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove RoughFinal No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. =SEE REVERSE SIDE Smoke Det. N�Rrh Zoning Bylaw Review Form . o Town Of North Andover Building Department °• -=°'- 27 Charles St. North Andover, MA. 01845 4 +O•�no✓' 49 WU Phone 978488-9545 Fax 978488-9542 Street: .S -�� �vv 4°�;t�e Ma /Lot: /o l4 /8 D Applicant: o of-4 ce • Request: 'Xi y' S /a r a t S ti PC/ Date: y a V Please be-advised that after review of your Application and Plans that your Application is DENIED for the following Zoning Bylaw reasons: Zoning — 02 Item Notes Item Notes A Lot Area F Frontage 1 Lot area Insufficient 1 Frontage Insufficient 2 Lot Area Preexisting e 2 Frontage Complies 3 Lot Area Complies 3 Preexisting frontage Ve 5 4 Insufficient Information 4 Insufficient Information B Use 5 No access over Frontage 1 Allowed G Contiguous Building Area 2 Not Allowed 1 Insufficient Area 3 Use Preexisting 2 Complies 4 Special Permit Required 3 Preexisting CBA S 5 Insufficient Information 4 Insufficient Information C Setback H Building Height 1 All setbacks comply 1 Height Exceeds Maximum 2 Front Insufficient 2 Complies r63 Insufficient Left Side Insucient 3 Preexisting Height y S 4 Right Side Insufficient +e S 4 Insufficient Information 5 Rear Insufficient l Building Coverage Preexisting setbacks 1 I Coverage exceeds maximum 7 Insufficient Information 2 Coverage Complies D Watershed 3 Coverage Preexisting y Y� 1 Not in Watershed S 4 Insufficient Information 2 In Watershed j Sign 3 Lot prior to 10/24/94 1 Sign not allowed 4 Zone to be Determined 2 Sign Complies 5 Insufficient Information 3 Insufficient Information E Historic District K Parking a. 1 In District review required 1 More Parking Required 2 Not in district tj-eS 2 Parking Complies 3 Insufficient Information 3 Insufficient Information 4 Pre-existin Parkin - Remedy for the above is checked below. Item # Special Permits Planning Board Item # Variance Site Plan Review Special Permit Setback Variance Access other than Frontage Special Permit Parking Variance Frontage Exception Lot Special Permit Lot Area Variance Common Ddveway Special Permit Height Variance Congregate Housing Special Permit Variance for Sign Continuing Care Retirement Special Permit Special Permits Zoning Board Independent Eldedy Housing Special Permit Special Permit Non-Conforming Use ZBA Large Estate Condo Special Permit Earth Removal Special Permit ZBA Planned Development District Special Permit Special Permit Use not Listed but Similar Planned Residential Special Permit Special Permit for Sign R-6 Density Special Permit Special permit for preexisting nonconforming Watershed Special Permit The above review and attached a pwotion of such is based on the plans and information submitted. No definitive review and or advice shall be based on verbal eq)lanations by the applicant nor shall such verbal eVianations by the applicant serve to provide definitive answers to the above reasons for Any inaccuracies;misleading information,or other subsequent changes to the information submitted by the applicant shall be grounds for this review to be voided at the discretion of the Building Department.The attached document titled"plan Review Narrative'shall be attached hereto and incorporated herein by reference. The building department will retain all plans and documentation for the above file.You must file a new permit application form and begin the permitting process. C//,/ y uilding Department Official Signatyrre Application Received Appl io Denied Plan Review Narrative The following nan*ative is provided to further explain the reasons for DENIAL for the APPLICATION for the property indicated on the reverse side: M f k / . t :✓1 b.t KS S .fF C V �Y y' TTl'`Y H � 3F y� (l yN{" fy . ��,�, �..c.F?y �.;}�.��k.nz,3���T... � zr s s �k-n�''• ,�'yC 1:'x,7-•t�ye��i c S e ,4,+�..�V4 .,4 ...1 � `'• 4.,,•. .,-'r. �. 1 .,v�-{s�.tAlS t)-T r � ! -_N•'i'��,K+`+r,ai N4ik 4�tj'� ,4 Plb f� l S .� s ,m ' S .� b C k , s 7 a y. S- S `e A [ /� ! S r p o S �o Referred To: Fire 4ieafth Police _2�-Zoning Board Conservation Department of Public works Planning Historical Commission Other Building Department • TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMa^ ING rn BUILDING PERMIT NUMBER: DATE ISSUED: X ic SIGNATURE: Building Commissioned) or of Buildings Date Z SECTION 1-SITE INFORMATION Z"f 1.1 Ptoru tent Address: 1.2 Assessors Map and Parcel Number: _ O Jb6 n y d-b S+- Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimension: Zoning District Proposed Use Let Area Fronts ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide ReTuired Provided R red Provided v 1.7 Water Supply M.G.L.C.40. 34) 1.5. Flood Zone Infomution: 1.8 Sewerage Disposal System: D Public 0 Private 0 zoneOutside Flood Zone ❑ Municipal 0 On Site Disposal System J SECTION 2-PROPERTY OWNERSEMAUTHOREED AGENT J t e rn 2.1 Owner of Record n D '" IC�ric�nn� ��i�P (► J��1' J� h I�ny �e Sf . _ Name(Print) Address for Service Signatqre Telephone 2.2 Owner of Record: Name PrintAddress for Service: O Z rn Signature Tel hone SECTION 3-CONSTRUCTION SERVICES 90 3.1 Licensed Construction Supervisor: Not Applicable Licensed Construction Supervisor. _ O License Number on Address a Expiration Date ic Signature Telephone r 3.2 Registered Home Improvement Contractor Not Applicable 0 v Company Name Registration Number r Address r ^� Signature Tel Expiration Date hone V r SECTION 4-WORKERS COMPENSATION(NLG.L C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building it. Signed affidavit Attached Yes.......❑ No.......0 SECTION 5 Description of Prosed Work(check all a ble New Construction ❑ Existing Building 0 Repair(s) ❑ Alterations(s) ❑ Addition 0 Accessory Bldg. 0. Demolition 0 Other ❑ Specify Brief Description`of Proposed Work: Pre-- u/ 2 Shad a c`C a�� � / SECTION 6-ESTIMATED CONSTRUCTION COSTS ItemEsLt Amated Cost(Dollar)to be OMCLAL USE ONLY 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 tb> 4 Mechanical HVAC 5 Fre Protection Q 6 Total 1+2+3+4+5 00 1 Check Number 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,in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTI�O/Nj 7b OWNER/AUTHORIZ ��ED /�AGENT DECLARATION I, ►v (alp I v-) r I I C e I ,as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief M r Print Signaturelof Owner/Agent Date J NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TRABERS 1' 2 NU 3KD SPAN DIMENSIONS OF SILLS DM ENSIONS OF POSTS DN ENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHRANEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE i 1 FORM U - LOT RELEASE FORM • r' INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. ***"`*******APPLICANT FILLS OUT THIS SECTION ` / r APPLICANT Marf'Gz-f7 A4/C&— I I PHONE ?�V/X LOCATION: Assessors Map Number d PARCEL SUBDIVISION LOT (S) STREET 5q JD A h n V ST. NUMBER *OFFICIAL USE ONLY ** RECOMMENDATIONS OF TOWN AGENTS: /CONSERVATION ADMINISTRATOR DATE APPROVED DATE REJECTED COMMENTS TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD INSPECTOR-HEALTH DATE APPROVED DATE REJECTED SEPTIC INSPECTOR-HEALTH DATE APPROVED DATE REJECTED COMMENTS PUBLIC WORKS -SEWERIWATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9197 jm TOWN OF NORTH ANDOVER AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application MGL c. 142 A requires that the"reconstruction, alteration, renovation, repair, modernization, conversion, improvement, removal, demolition, or construction of an addition to any pre-existing owner occupied building containing at least one but not more than four dwelling units...or to structures which are adjacent to such residence or building" be done by registered contractors, with certain exception, along with other requirements. Type of Work: Est. Costo 0 Address of Work D =,a KT— Owner Name: I Cf� Date of Permit Application: I hereby certify that: Registration is not required for the following reason(s): For office Use Only Work excluded by law Pemit No. Job under $1,000 Date Building not owner-occupied Owner pulling own permit s Other (specify) Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FIND LINER MGL c. 142A. Signed under penalties of perjury: I hereby apply for a permit as the agent of the owner: Date Contractor Name Registration No. OR: Notwithstanding the above notice, I hereby apply for a permit as the owner of the above property: Dae 06ner Name f v' �.� S 1 . 4� vt J_ r C/11� N 1 � N �rlsff: ISS GAL. ._ A "g C UC. sprier Wjv- t �1UEIJ 6-Raaf Sox 40' 4 z' r�: s� /kGSl> �oPosE1� AS-�u►t,T PLAuQ fvZ jaeow4 {.R40c S 64,,WI�E) rF Lzy TNomt& MvPYHy Al : FILF- wam Tie Towu of - M giJt)&VM ZMftD oftl"t7R . - ISD "J AS BUILT PLAN °FSYSTEM SUBSURFACE DISPOSAL LOCATED IN Date.. 'a. . �. .. . . t NORTH o� ° TOWN OF NORTH ANDOVER • PERMIT FOR GAS INSTALLATION v Sg CHUSEt This certifies that . . . . . .f . . . . . . . . . . . .� has permission for gas insulation in the buildings of . .. . . . . . . . . . . . . . . . . . . . . . . . . at -�,1". -�,. . , North Andover, Mass. Fee.,-.-. N .v!i �. ;�!. . . . . . . . . . . . . . Li c. o Q?,1. . / GASINSPE69 Check# 30 X0,3 4823 t .,_^':�`."�IRC?^._ i'��'Last;�.ypw�.a:zx-...mow--• �•� F �� '. '},"T 1 C!'= S i.. p 1 MASSACHUSETTS UNIFORM APPLICATI01 R PERMIT TO DQ GASFITTING (Print or Type) / . / w d . Mass Date t City, Town 1 Permit Building 91 „ � owner ! s AT: Location /�/�j1/� ���ame .r w.���`�jy �� M/Ze,�r� Type of Occupancy . SJ)6k New Renovation ❑ Replacement ❑ Plans Submitted Yes ❑ ' Nn�� N W In N y 0 Z a y, ct N x 0 ' N x f. U to 1,- J_ N W 5 to 0 W 1 � cc 0 a Q z W m H o r W < N d x z }. a 00 � < W W V) Z < ec W W f' W x c7U. N < w > W O X .< < < .0 OW x O c7 x u. 7 O O J U > 0 0. H. O SUB—BSMT. ; BASEUEN7 %rr 1ST FLOOR _ 2ND FLOOR 3130 FLOOR 4TH FLOOR 5TH'FLOOR 6TH FLOOR 7TH FLOOR STH FLOOR — (Print or Type) ,Check One, Certificatt Installing Company Name ` ' ❑ Corp Address 209Middleton Rn^d ❑:Partnership:` Boxford; Massachusetts 01921 Firm/Company Business Telephone Namc of Ltocrtsed Plulnber or.Gasritler 6� e I hereby certify that all or the details and information.1 have submitted(or entered)in above application are true and accurate to the best u(my knowledge and that•all plumbing work and installations performed under hrmit issued for this apphcalion will be incompliance with all pertinent provisions of the Massachusctu State Gas Code and Chapter 142 of the General Laws,';; I have informed the owner or his agent that I do..not have Gability.insurance including completed operations coverage Siputun or OWncl AFri I have a current liability insurance policy to include completed operations coverage BY TYPE LICENSE: Title Xplumber Signature of Lice d Plumber or Gasrmcr City/Town Gasfitter APPROVED (OFFICE USE ONLY) ❑ Journeyman License Number O' Frau 19L'T Nnoa•a Waoocu lur 16A0 - - ”' •--• �/ *� � - 1 i. �; �. .}t •� i �� Date.!O-//0 7......... F joRTM TOWN OF NORTH ANDOVER ' PERMIT FOR WIRING j ,SSACow E � � t Thiscertifies that..... ............. : ................................................................... F has permission to perform wiring in the building of....................y: ?-6". ............................................. at.. ..... ...... .......... .. .. . ..........................,North Andover,Mass. F&-..S................ Lic.No. ............. ................................ ............................ i ELECTR�C d�ISPEMR Check // '7%SY 7450 Commonwealth o/M,33,W1W,UJ Permit No. Official Use Only _ cc�� 2,Part.,d o/Dire Service! y t, Occupancy and Fee Checked 5 BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527/"// MR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMA TION) Date: 7 City or Town of: To the Inspector o Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) S-0 --70-AA / Cr, 44P— Owner or Tenant ,�Y?c C//Gy Telephone No. Owner's Address -SCC h',"o- Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building Slh Sle- /12�^ / ,04/c///h J Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: / Ztjy A �"�, ✓),S� S/�h gIle Completion of the following,table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total 3 Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Arnd bove❑ In- ❑ Batte Units Lighting No.of Receptacle Outlets Z No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices g Tons No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained po Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KSecurity Systems: ''y ey No.of Devices or Equivalent No.of Water No.o o.o Data Wiring: Heaters KW Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent 1 OTHER: 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: 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 0 BOND ❑ OTHER ❑ (Specify:) I certify,under the ains and pen ties of perjury,that the information on this application is true and complete FIRM NAME: 16alci! t�Ci�/ LIC.NO.:. Licensee: t C K >Cir(/� Signature LIC.NO.:3 9C). (Ifapplicable, ter "e pt"in the ligense number line.) Bus.Tel.No.: 1-1 7� Address: 7P UrZ% X r'P !2—o Alt.Tel.No.: ?k/ *Per M.G.L.c. 147,s.57-61,security work requires Department of 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 a ent. Owner/Agent PERMIT FEE: - Signature Telephone No. I toxic, `t