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HomeMy WebLinkAboutMiscellaneous - 60 RALEIGH TAVERN LANE 4/30/2018 (3) D /C'� Leic � T��� ��� - � � .. i R�.Ptxeutw�+fi - FORM U - LOT RELEASE FORM 1 !�rI INSTRUCTIONS: This form is used to verify that all necessary approvals ermits 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*********************** APPLICANTit A��k k Anna, t( \(.Cv-Ae--e—, PHONE - %,k. ` LOCATION: Assessor's Map Number 1071A PARCEL C3� SUBDIVISION LOT(S) STREEb T YST. NUMBER Coo ************************************OFFICIAL USE ONLY*********************************** E MMENDATIONS OF TOWN AGENTS: CONSERVATION ADMINI RATOR DATE APPROVED DATE REJECTED P/7 lo�- COMMENTS {_ 98/ a oc) 4-- AppLca„4 !nLALf F le. ar WDA TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD INSPECTOR-HEALTH DATE APPROVED DATE REJECTED - 5 SEPTIC INSPECTOR-HEALTH DATE APPROVED O 0 DATE REJECTED nn COMMENTS l�/rlf PUBLIC WORKS-SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9\97 Jim 04/19/99 MON 08:34 FAX CARLSON N.ANDOVER 10006 MORTGAGE PLOT PLAN EK SURVEY 17 ROYAL STREET, LA NI`,E, SMA. 01841 Tet. 508--975-1413 1AORTGAGOR �44�N�AIL, ►�r 'P'�.7.wT`I -EO REF. r;t; PG. 1;.36 ADDRESS OF PRINCIPLE BUILDING PLAN REF. 6180 60 RALEIGH TAVERN IN. DATE OF INSPECTION AUGUST 24 , 1992 N . ANDOVER, 101A. - SCAI.E: 1' 100' rq� IAT 16A r ryAtl LOT 15 30' DRAIN EASEMENT �A, PONLOT POND �.:� ,-' 'TRAVEL EA.%-MF-NT �- T. SHED 1 � � so! ; — COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PEON ONE WINTER STREET, BOSTON MA 02108 (617)292-5500 TRUDY CO? Secreta ARGEO PAUL CELLUCCI DAVID B.STRUI Governor Commiss or SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A __. ._.... CERTIFICATION n� Prapertl►Addr.ae k6kA �TA A(: .. " -. - Address of Owner sAtAl, Date at Inspection:t(azzm #�tAOnveW Nainie at Inspect= I am a DEP apprawed yste inspector ptrsuanrt to Section 15.340 of Title 5(310 CMR 15.000) ConlipenM yAddnes:Mom: s� CTJ `J� a2`�i Z Telephone Number: . CERTIFICATION STATEMENT 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 inspection. The inspection was performed based on my training and experience In the proper function and maintenance of on-sitesewage disposal systems. The system: V Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fells l&g# inspectors Sign ahme: Date: 'Z ` The System Inspector shall submit a copy of this Inspection report to the Approving Authority(Board of Health or DEP)within thirty 130)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 owns shall submit the report to the appropriate regional office of the Department ofrEnvkenmental Protection. The original should,be sent toVw system owner and copies sent to the buyer,if applicable, and the approving authority. NOTES AND COMMENTS revised 9/2/98 page 1ortt i~, Printed on Recycled Paper . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Go LWI;,-- k4oitf4 Pi"OO AFIR , -A oke-45 Owner: ���� + �n� Data of tiapwdoL INSPECTION SUMMARY: Cledt A, e, c, or A A,V7 PASSES: �// I have not found any information which indicates that any of the failure conditions described in 310 CMR 1-6.303 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. Indicate yes, no,or not determined IY, N,or ND). Describe basis of determination in all instances. H"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 pip is) or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). broken pipes)are replaced obstruction is removed distribution box is levelled or replaced _ - The system required pumping-more than four times a yeardue to broken or obstracted pipe(s►. Theystem will pave inspection if(with approval of the Board of Health): -- broken pips(s)are replaced obstruction is removed revised 9/2/98 Page 2of11 1 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(con*%" M-A o t 04 5 Property Address: fit' s M O,wnw: A-R�c.�F D 1`K Deb of Mpectiort: 2 .zj5.9 4 C. FURTHER EVALUATION 1S 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 1101 THAT THE SYSTEM IS NOT FUNCTIONING N A MANNER WHICK WILL.PRQIECT THE PUBLIC HEALTH:AND SAFETY AND THE ENWRONMENL• Cesspool or privy is within 50 fest of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or s salt marsh. 21 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 ENVBIONMENT: - The system has a septic tank and soil absorption system(SASI and the SAS is within 100 fast 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 weg. _ The system has a septic tank and soil absorption system and the SAS is within 60 feet of a private water supply wag. _ The system has a septic tank and soil 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 immonis nitrogen and nitrate nitrogen is equal to or less then 5 ppm. Method used to determine distance (approximation not valid).- 3) OTHER revised 9/2/98 Page 3or11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: � 'r� L l� ,t-(o R ( 4 Owner. CZ��2D �- C�fl�R.� 1�s�j M•vrt5'tf��C�•t�Q2 Das,cf inspection: 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 ofeewsge imo4ocilii"spew componor&due1to en overloaded a. ggedSAS•oreesspool. 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 1 of a public wall. 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 analysed to be acceptable,attach copy of well water analysis for -coliform bacteria,volatile organiacompounds,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-ie-vitii)n200 feet wowr-ouplWy - --- -- - the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area=1WPA)or a mapped tone 11 of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412). Please consult the local regional office of the Department for further inforination. revised 9/2/98 Page 4of11 ` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner. Dab of intp.ction: Check if the following have been done:You must Indicate either"Yes" or"No" as to each of the following: Ye_ sNo — /� Pumping information was provided by the owner, occupant,or Board of Health. (�S _ None of the systemsompownts hemabeen pumped4sratJeast two weeks aml4be-srystem Sow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with NIA. _ The facility or dwelling was inspected for signs of sewage back-up. _ The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of brbakout. _ AN system components,excluding the Soil Absorption System,have been located on the site. C�p _ 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 off the site has been determined based on:• M6%vt ew _ Existing information. For example, Plan at B.O.H. _ Determined in the field(if any of the failure criteria related to Part C Is at issue,approximation of distance is unacceptable) 115.302(3)lb)) The facility owner land.^^^—P—tt- If differma fraimowner).wets.providad witb fofcrmatiom on t1w pgaperf SubSurface Disposal Systems. revised 9/2/98 Page 5of11 • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Coo 4Lke'r, tA �►4ufttR�( -A�(c'� l (Nowak (�N�Oov( (Z l�(� Q 1 Qj45 Owner: � NIA Date of k%spection: Cr FLOW CONDITIONS RESIDENTIAL: Design flow:4140 g.p.d./bedroom. Number of bedrooms(design): Number of bedrooms(actual) Total DESIGN flow Number of current residents: �- Garbage grinder(yes or no):—Wo Laundry(separate system) lyes or no): 0,, If yes, separateanspection.required _ Laundry system inspected (yes or no) Seasonal use(yes or no): 't 1 S E)E:, At"Aci, Water meter readings,if available(last two year's usage(gpd): _ �a ` Sump Pump lyes or o►:�0 D Last deco of occupancy:��7(>Lev ��� COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: ocd (Based on 15.203) Basis of design flow Grease trap present: lyes or no)_ Industrial Waste Holding Tank present:(yes or nol_ 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 info�atioon: WTI,' -jR -i a System pumped as part of inspection: (yes or no)_bLO If yes, volume pumped: gallons Reason for pumping: TYPE OF SYSTEM ✓ Septic tank/distribution box/soil absorption System Single cesspool , Overflow cesspool Privy Shored system(yea or no) (if yes,attach previous inspection records,if any) IIA Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other �. lticSCf4u .fl . APPROXIMATE AGE of all components, date InStaNed4if known)-and source a#�irrferrr�ation: -•--�- •Z`d - 10.1 . Sawege odors detected when arriving at the site:(yes or no) revised 9/2/98 Page 6of11 • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM WFORMATION(continued) Property Address: Go �� 4 �(AMJCt •Q � � 1`(4 E A -t&UQhQ Owner- Date of kupection: BUILDING SEWER: (Locate on site pian) Depth below grads: C�1 Material of construction: cast iron_40 PVC_other(explain) Distance from private water supply well or auction line 100 Diameter_4.0 t.0 Comments:(condition of joints, venting,evidence of ieakage,♦tc.) SEPTIC TANK:_ (locate on site pian) Depth below grade:22 Material of construction: uconcroto_metal_Fiberglass _Polyethylene_other(explain) B tank is(natal,list age_ 1s.age-confirmed by Certificate of Compliance_(Yes/No) Dimensions: 8�,10 L X, j o W Sludge depth:. © ti Distance from top Sffsluddgge to bottom of outlet tae orbaffie:- 2 Scum thickness: erf at Distance from top_ u . to top of outlet tee or baffle: Distance from bottom cum to bottom of outlet tee or baffle: \-2� How dimensions were determined: M#A:59khfi2kLlr Comments: (recommendation for pumping,condition of inlet and outlet tees or-baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,etc.) �]�U k k- -C_�/� '� 00t \ GREASE TRAP: (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: (recommendation for pumping,condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) revised 9/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION(FORM PART C SYSTEM INFORMATION(continued) Pmperty Address: Cao ( cast -'�Avew-) I UW4k,, No12t-�i 1t�d�R,�� M 0 m&45 Owner: 0�ckkaez -t- Dame of inspection: Z- q�l 71GHT OR HOLDING TANK: (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: (condition of inlet tee,condition of alarm and float switches,etc.) DlSTR9UJT1ON BOX. (locate on site plan) Depth of liquid level above outlet invert: Comments: (note-if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box, etc.) - -— F�t 4 c0tlLo �l F — O '770 C_K-1-eAQ_�r1 V t3_RP_. PUMP CHAMBER:_ (locate on site plan) Pumps in working order:(Yes or No) Alarms in working order(Yes or No) Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) revised 9/2/98 Page 8of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Pfopsity Address: CoO J � t, �tC� M4 o t 84 Ownw: Date of(sapecoort: -z- SOIL SOIL ABSORPTION SYSTEM(SAS): C/ (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_ t T leaching trenches,number,length:_4_� teaching fields,number, dimensions: overflow cesspool,number:_ Alternative system: Name of Technology: Comments: (note condition of soil, signs of hyifraulic failure,level of ponding, damp soil,condition of vegetation, etc.) So L. to�-L., Tl oxoor�c a CESSPOOLS-_ (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: (note condition of soil, signs of hydraulic failure,level of pending,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.) revised 9/2/98 Page 9of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(condmad) Property Address: (oo R�t� Owrwr: (��crlt2►tJ M�k(z`( K Mvt�tStR.6�Cf�- Dete of inspection: Z •2�-`1`� 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) Z2�� Che or, ik lkse- Tqt tt-o � 9 (43 Q 1R) - C- u, H ops ti . / 33 6 - 24 •i AY 2-51 F �W P— of 4+ 1 revised 9/2/98 Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: (Z A L*,,-G-1-i l AV Y-,,4 IANC 14 0(z jC A Atj 00 V%)r-_ Owner: (Z<A4k" -i- Dad of Inspection: Z� LS-Ct c( NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep _ SITE EXAM Slope Surface water Check Collar Shallow wells Estimated Depth to Groundwater 4+Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed.Sito(Abutting property,observation hole,basement sump etc.) � Determined from local conditions � Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators,installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) (01 �AC�iC,v{ 14i�CJa2 `.fA KO( � �Q` Jvl `MA F �S•4�� �t�N 8 �2� `t-1 Gklk \Z'q•q1 S�' CS-w;C - 38" CQO ( �I.a�tc 4 1Aut t2kQ , ',62"tH 4a-u00vC&K_ , —�,�kAt`f C \0(� Ari C ' ICLO (3���c 2a Y�kS A GO LS Peev revised 9/2/98 Page 11 of 11 stems,113 KVS Information S ::nsp-r::::;- . .. :v.- ul SMUUB04A/CS/UOS/LO05 TOWN OF NORTH ANDO `'I 2/24/ TERMINAL NO: 000 CONSUMER METER F/M TIME: 13:38:'lil! Acct: 01-2439000-0 MUNSTERTEIGER RICHARD C 60 RALEIGH TAVERN Meter No: 001 Reu Mtr/#: N 000 Book: 10 Page: 24390.0000o Meter Flg: 0 [ Connector: ] Digits: 4] Dim Cd: A] Multiplier: ] Arb #: Manf Cd: ] Units: Pipe Size: ] Len: ] Type- Req: 00/00/0000 Inst: 00/00/0000 Cnct: 00/00/0000 Disc: 0o/oo/0000 Cd: Not s:5 T EAL] Mt Code: ] Met Loc: S ria! ©© In/Out: 2©5906M e9n= Cur: 2535 A Preu: 2517 E 2nd Prev: 2502 A [2 ' From: 11/30/1998 To: 01/29/1999 Cur2: Preu2: Next: 0o/00/0 Cns Cr: Nth Bill: 03 User: ------------------------ Consumption Information ------------------- --- First 12 Billing Months ------[3 ] ------ Last 12 Billing Months ------- 03/1999 18A 09/1997 23C 03/1996 18C 09/1994 2; 12/1998 15E 06/1997 _9C 12/1995 18C 06!1994 09/1998 14A 03/1997 16C 09/1995 21C 03/1994 3 06/1998 8A 12/1996 16C 06/1995 24C 12/1993 3 ; 03/1998 20C 09/1996 16CI 03/1995 17C 09/1993 12/1997 16C 06/1996 11CI 12/1994 20C 06/1993 1' First 12 Total- 182 1 Last 12 Total 251 <ESC> to Enter New Meter Number <M>odif.9, <D>elete or <N>ext _ _0 i1HE id lill i!Ill lililil 111 111`11`1'1h.1 illif min "HO im mill ° K�IfS [ttlnttrtattt S 1 lliIW 16 APPLICATION FOR SEWAGE DISPOSAL INSTALLATION HEALTH DEPARTMENT - NORTH ANDOVER, MASS. , hereby a application for a permit for a sewage disposal installation at . I will install this system in ac- cordance with all the awe of the Commonwealth of Massachusetts and regulations of the Board of Health of the Town of North Andover. Further, I will construct the house sewer of bell and spigot pipe, the minimum diameter being 4 inches, and will maintain a minimum grade of 1% until 10 feet pre- ceding the septic tank, where the grade shall not exceed 2%. I will install a con- crete septic tank of _ l—ra--G in size. A manhole (s) permitting easy cleaning will be provided with removable cover (s) of iron or concrete within 12 inches of the ground surface. I will provide subsurface disposal field with 4 inch perforated or open Jointed pipe and laid in a series of trenches, the bottom of which will pro- vide a minimum of ?-d O—inch (square) feet of effective absorption area. T;The pipes will be laid on 6 inch layer of washed gravel or crushed stone ranging in size from 3/4 to 1-1/2 inches (dia.) and the pipes will be surrounded by sioilar material to a height of 2 inches above the crown of the pipe. The points of these Pipes will be protected from clogging and before filling the trench, 2 inches of gravel or stone 1/8" to 1/41, (dia.) will be placed over the course gravel or stone. The disposal field will be installed at a grade of 4 to 6 inches/100 feet. No single tile line will exceed 100 feet in length and in any case, two lines of tile will -be installed. A minimum of 6 feet will be maintained between the center lines of the disposal field trenches and the average depth of trench shall. not exceed 36 inches. No part of the installation will be leas than 100 feet from any private water supply; 25 feet from any stream, 20 feet from any dwelll.rg nr 10 foot free al-.y p;,oFerty line. I further agree not to cover any portion of this installation until approved by the inspection officer, as provided below, and to incorporate any additional requirements that may be attached to the permit. Plot Plans must be pub tted with application. DATE `fl`-�-c a - W . Signature of Applicant I hereby issue the above permit for the Board of Health of the Town of North Andover, Massachusetts. DATE 171 Signature of Health Agent I have inspected the uncovered system indicated above and find everything done as describ d. DATE lG c 1 7 / 7 7 Y Signature of I e ecting Officer Percolation Teat_ �7 Garbage Grinder s tir✓ i BOARD OF HEALTH OF NORTH ANDOVERt MASSACHUSETTS . SEWAGE DISPOSAL � NAME OF APPLICANT DATE L?1 LOCATION Lot 16 Ralei h Tavern Address of it no. BUILDING: Dwelling JC Other SYSTEM: New X Repair GENERAL DESCRIPTION OF LAND hi h SUBSOIL: Clay_ Gravel Sand _ PERCOLATION TEST minutes per inch. MINIMUM INSTALLATION RECOMMENDATIONS CONCRETE SEPTIC TANK LEACH FIELD_ aaa Ann —gallon capacity. lineal feet of drain pipe. 116"! gravel under bed William �J� t ~ . ' r scolly Engine Board of Health BOARD OF HEALTH TOWN OF NORTH ANDOVER, MASS. fi r ` 1 flq � ry S , 4 �- DATE ( ` 1. NAME �. . Y- .a t , ` .i���•. �. 'LOT NO. ! TEL. - 2. ADDRESS k 3. NO. OF BEDROOMS_L DEN YES „ NO___„--- 4. GARBAGE GRINDER YES NO 5. SHOW DIMENSIONS OF HOUSE . 6, SHOW DISTANCES OF HOUSE TO ALL PROPERTY LINES C7 7. SHOW DIMENSIONS OF LOT f.-0 / 3 i3 U $. SHOW LOCATION AND SIZE OF SEPTIC TANK OR CESSFOOL 9. NOTE LOCATION AND DISTANCE OF WELL FROM SEWERAGE SYSTEM 10. SHOW LOCATION OF BROOKS, STREAMS, DITCHES9 LEDGE OUTCROP, ETC. 11. SHOW DISTANCE OF SEPTIC TANK OR CESSPOOL FROM HOUSE NOTE: LOCAL REGULATIONS SHOULD BE READ CAREFULLY- TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING w ' S for Mew Se Oil BUILDING PERMIT NUMBER. DATE ISSUED: m ic SIGNATURE: Building Commissioner/Inspector of Buildings Date Z SECTION 1-SITE INFORMATION I 0 1.1 Property Address: 1.2 Assessors Map and Parcel Number: Ca O (la\6 NL. 'a►,1 eoh l�-7 p� —13� Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Via. I . 69L L"-4- �L ZoningDistrict Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required r54) iovde Required Provided Required Provided 1.7 Water Supply M.G.L.C.40. 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: D Public :W Private ❑ Zone Outside Flood Zone Municipal ❑ On Site Disposal System SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT M 2.1 Owner of Record ��'►��C ���L�.�-ec. �� L) Na�PrNam int) Address for Service Signature Telephone 2.2 Owner of Record: Name Print Address for Service: z 0A,,/k - 4u, ON r M Signature Telephone 90 SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: o 5-3 O License Number mn re 33 JJ Lt2 10-3 D Expiration Date Sign a Telephone r 3.2 Registered Home Improvement Contractor Not Applicable ❑ v Company Name m S4 Registration Number r Cd—dr-e'sN ) T � Expiration Date Si natu G1 Tele hone 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 bui ing permit. Signed affidavit Attached Yes..... No.......❑ SECTION 5 Description of Pro osed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: A6u Ib e-- s S.. SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OFFICIAL USE ONLY Completed by permit applicant 1. Building (a) Building Permit Fee 57 Le 1/0 Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(a)X (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO Bt COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, Ay4, , y�c� �Gt� ,as Owner/Authorized Agent of subject property Hereby authorized ,N /"L•nom p to act on My behalf;in all matte relative to work authorized by this tilding permit application. Sign re of Owner Date SECTION 7b OWNER/AUT (H �ORIZED AGENT DECLARATION 1, y�"� ` �- ,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 �f Pri me Si a tiro of wner/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB �p SIZE OF FLOOR TIlvIBERS 1 2 SPAN DIMENSIONS OF SILLS L DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X ) MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND V IS BUILDING CONNECTED TO NATURAL GAS LINE North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11, S150A. The debris will be disposed of in: (Location of Facility) ( . 4,- �. Signature of Permit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector z a The Commonwealth of Massachusetts d Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers'Compensation Insurance Affidavit Name Please Print Name: 04.04-04 c Location: A* City /+ Phone # LEI 01 I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity I am an employer providing workers'compensation for my employees working on this job. Company name �,P Address City N-i- Phone# Insurance Co. li,A w�l Policy# /Ll U Ug,4— 10 '� ! 3 Company name: -- Address City Phone#: Insurance Co. Policv# Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of.a fine up to$1,500.00 and/or one years'imprisonment.as_yell_as-cival.penattiesinlhefoundAETOP WORK ORDER..and..afire of.($1_0_0M)_a�day.againstme, 1 understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. D i do hereby'c ify un <jains and naltie f pe ' e information provided above is true and correct. Signature Date Print name Phone.# Official use only do not write in this area to be completed by city or town official' City or Town Permit/Licensing Building Dept ❑Check if immediate response is required n licensing Board E] Selectman's Office Contact person: Phone#: E] Health Department Other Town of North Andover Building Department 27 Charles Street _� w North Andover, MA. 41845 n r D. Robert Nicetta - -=� - .• .Building Commissioner ��`�'4ct-ttJs t�ti (978) 688-9545 978 688-9542 Fax HOMEOWNER UCENSE EXEMPTION Please print DATE �I a � I C> 109 LOCATIONA J ber \ ��`^��`'` , ee Address Map/lot IOMEOWNER _�� Name �Pone� �!Home Work Phone ESENT MAILING ADDRESS o City Town State Zp Code The current exemption for"homeowners"was extended to include of two units or less and to allow such hane4wners to engage an individ -occupied dwelfirigs not possess a license gag uWf0rhire who does Provided that the owneracts as supervksor (Std Buffing Code Section► 108.3.5.1) DEFIN1770N OF HOMEWOWNER: Person(s)who owns a pante, of land on which he/she resides or intends to there is, oris intended to be, a one or two fie. °►�which es cessorac- y to such use and/or fart» ha dwelling. attached or detached sfrere two-year period shall not be'considered a Peen ysfio t1>an one homeovrr►er. a The undersigned*homeowner"assumes responsibility for co Applicable codes, by-laws. rules and regulations, mpliance with the State Building Code and other The undersigned "homeowner" certifies that he/she and Building Departmentminirnurn ins ectiori understands the Town dNo_Andover P procedures and requirements and that he/she will empty with said procedures and requirements_ HOMEOWNER'S SIGNATURE 'PROv,AL OF BUILDING OFFICIAL ' r.d. ��o�✓ W i L�v��-�v AL� 3 n { D L fry��- ' s � Z � t I FAMILY DOOM I � I 6Ap�� I � I I PININCA p00M I I I KlfCNFN El 1%IV5f FOR PLAN c�xisnr�� SUNI?OOM n�CK t'M5 XR McNl�F P,,�51PNCS 60 MN6H TAMN �AN NOpTN A POMC \ ,MA, 5C&N/4" - I'-0" PATE; 9114102 CL. 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