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Home My WebLink AboutMiscellaneous - 62 WILLOW RIDGE ROAD 4/30/2018N 1-1 F, c� INNS DEOTAM ENVIRONMENTAL SERVICES June 28, 2016 Board of Health 1600 Osgood Street, B1d.20, Unit 2035 North Andover, MA. 01845 Dear Sirs: Re: Dow Chemical Company -60 Willow Street -Lab Fume Hoods RECEIVED JUL U 5 2016 TOWN OF NORTH ANDOVER HSALTH DEPARTMENT Please be advised that Dec -Tam Corporation will be performing an asbestos abatement project at the above referenced location. This work has been scheduled for July 27, 2016 through July 29, 2016. All applicable local, state and federal agencies have been notified of this work. Please let me know if you have any questions. Sincerest regards, a Dan Michaud Sales Estimator DM/bb Enclosure 50 Concord Street, North Reading, MA 01864 - P: 978.470.2860 F: 978.470.1017 • www.dectam.com Commonwealth of Massachusetts �' Asbestos Notification Form ANF -001 Instructions 1. All sections of this form must be completed in order to comply with MassDEP notification requirements of 310 CMR 7.15 and Department of Labor Standards (DLS) notification requirements of 453 CMR 612 A. Asbestos Abatement Description 1. Facility Location: DOW CHEMICAL COMPANY 60 WILLOW STREET 100246115 Asbestos Project # F- Project Revision F Project Cancellation Name of Facility Street Address NORTH ANDOVER MA 01845 9786891507 City/Town State Zip Code Telephone JOHN BRISTOL ENVIRONMENTAL H & S MANAGER Facility Contact Person Name Worksite Location: 2. Is the facility occupied? r Yes F No Facility Contact Person Title LAB FUME HOODS Building Name, Wing, Floor, Room, etc. 3. Is this a fee exempt notification (city, town, district, municipal housing authority, state facility, or owner -occupied residential property of four units or less)? F Yes F No MassDEP Use Only 4. Blanket Permit Project Approval, if applicable: Date Received Approval ID # 5. Non -Traditional Asbestos Abatement Work Practice Approval, 2Submit Original if applicable: Approval ID # . Form To: Commonwealth of 6. Asbestos Contractor: Massachusetts DEC -TAM CORPORATION P.O. Box 4062 Boston, MA 02211 Name NORTH READING City/Town AC000035 DLS License # %. GEORGE APAGE Name of Contractor's On -Site Supervisor/Foreman 8. ENVIRONMENTAL HEALTH INC Name of Project Monitor 9, ENVIRONMENTAL HEALTH INC Name of Asbestos Analytical Lab 10. 7/27/2016 MA State 50 CONCORD ST Address 01864 9784702860 Zip Code Telephone Contract Type: F Written (-verbal AS071933 DLS Certification # AA000044 DLS Certification # AA000044 DLS Certification # 7/29/2016 Project Start Date (MM/DD/YYYY) End Date (MM/DD/YYYY) 7.00AM - 4.00PM N/A Work Hours - Monday Through Friday Work Hours - Saturday & Sunday 11. What type of project is this? r Demolition rr Renovation r- Repair r' Other - Please Specify: Revised: 11/13/2013 /6 6/04t-/6 Page 1 of 4 Commonwealth of Massachusetts 100246115 Asbestos Notification Form ANF -001 Asbestos Project # r-- Project Revision f- Project Cancellation A. Asbestos Abatement Description: (cont.) 12. Abatement procedures (check all that apply): r Glove Bag r Encapsulation r Enclosure f- Disposal Only r Cleanup r Full Containment r Other - Please Specify: 13. Job is being conducted: F Indoors r Outdoors 14. Total amount of each type of asbestos Containing materials (ACM) to be removed, enclosed, or encapsulated: 1400 Linear Feet (Lin. Ft.) Square Feet (Sq. Ft) Boiler, Breaching, Duct, Transite Pipe Tank Surface Coatings Lin. Ft. Sq. Ft. Lin. Ft Sq. Ft. Pipe Insulation Transite Shingles Lin. Ft Sq. Ft. Lin. Ft Sq. Ft. Spray -On Fireproofing Transite Panels 1400 Lin. Ft Sq. Ft. Lin. Ft. Sq. Ft. Cloths, Woven Fabrics Other - Please Specify: Lin. Ft Sq. Ft. Insulating Cement Lin. Ft Sq. Ft Lin. Ft Sq. Ft. 15. Describe the decontamination system(s) to be used: POLY ENCLOSURPNEGATIVE AIR/DECON FACILITY/PPENVEf METHODS 16. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2)(g): 2X6 MIL POLY BAGS WITH ASBESTOS AND WASTE GENERATOR LABELS 17. For Emergency Asbestos Operations, the MassDEP and DLS officials who evaluated the emergency: Name of MassDEP Official Title of MassDEP Official Date of Authorization (MM/DD/YYYY) Waiver # Name of DLS Official Title of DLS Official Date of Authorization (MM/DD/YYYY) Waiver # 18. Do prevailing wage rates as per M.G.L. c. 149, § 26, 27 or 27A—F apply to this r—, yes F No project? Revised: 11/13/2013 Page 2 of 4 Commonwealth of Massachusetts 100246115 —� - Asbestos Notification Form ANF -001 Asbestos Project # '1 j— Project Revision l r—. Project Cancellation B. Facility Description 1. Current or prior use of facility: R & D/M/WUFACTURING 2. Is the facility owner -occupied residential with 4 units or less? r— Yes r No 3. DOW CHEMICAL COMPANY 60 WILLOW STREET Facility Owner Name Address NORTH ANDOVER MA 01845 9786891507 City/Town State Zip Code Telephone 4. JOHN BRISTOL 60 WILLOW STREET Name of Facility Owner's On -Site Manager NORTHANDOVER Address MA 01845 9786891507 City/TownState Zip Code Telephone 5. DEC -TAM CORPORATION 50 CONCORD STREET Name of General Contractor Address NORTH READING MA 01864 9784702860 Note: Temporary storage of Asbestos City/Town State Zip Code Telephone containing waste THE HARTFORD INSURANCE COMPANY material is only allowed at the place Contractor's Workers Compensation Insurer of business of a DLS UB -2E618043-15 12/28/2016 licensed Asbestos Policy # Expiration Date (MM/DD/YYYY) contractor or a transfer station that is 6. What is the size of this facility? 30000 1 permitted by MassDEP and operated in Square Feet # of Floors compliance with Solid Waste Regulations p C. P Asbestos Transportation & Disposal 310 CMR 19.000 1. Transporter of asbestos -containing waste material from site of generation: r— Directly to Landfill or r7, To Temporary Storage Location/Transfer Station DEC -TAM CORPORATION Name of Transporter NORTH READING City/Town Address MA 01864 9784702860 State Zip Code Telephone 2. If a temporary storage location/transfer station is used, list name of transporter of asbestos containing waste material from temporary storage location/transfer station to final disposal site: SERVICE TRANSPORTATION GROUP Name of Transporter NEW CASTLE City/Town 58 PYLES LANE Address CE 19720 8779999559 State Zip Code Telephone Note: Contractor must sign this for, for DLS Revised: 11/13/2013 Page 3 of 4 Commonwealth of Massachusetts 100246115 Asbestos Notification Form ANF -001 f Asbestos Project # Project Revision r Project Cancellation uuuuceuun puJpu5eb C. Asbestos Transportation & Disposal: (cont.) 3. Name and address of temporary storage location/transfer station for the asbestos containing waste material: DEC -TAM CORPORATION 50 CONCORD STREET Temporary Storage Location Name Address NORTH READING MA 01864 9784702860 City/Town State Zip Code Telephone 4. Name and location of final disposal site (asbestos landfill): MINERVA LANDFILL C/O RANDY BRIDGES Final Disposal Site Name Final Disposal Site Owner Name 9000 MINERVA ROAD Address WAYNESBURG CH 44688 3308663435 City/Town State Zip Code Telephone A Certification "I certify that I have personally examined the foregoing and am DAN MICHAUD DAN MICHAUD familiar with the information Name Authorized Signature contained in this document and SALES 6/28/2016 all attachments and that, based Position/Tide my inquiry those Date (MM/DD/YYYY) 9784702860 n individuals immediately DEC -TAM CORPORATION responsible for obtaining the Telephone Representing information, I believe that the 50 CONCORD STREET NORTH READING information is true, accurate, and Address City/Town complete. I am aware that there MA 01864 are significant penalties for State submitting false information, Zip ode including possible fines and imprisonment. The undersigned hereby states that I have read the Commonwealth of Massachusetts regulations governing asbestos abatement (453 CMR 6.00 promulgated by the Department of Labor Standards and 310 CMR 7.15 promulgated by the Department of Environmental Protection), and that I am aware that this permit application or notification shall not be deemed valid unless payment of the applicable fee is made." Revised: 11/13/2013 Page 4 of 4 Commonwealth of Massachusetts MAY 1 1 2015 Cl�®wn ®� l�®rah Andover t TOWN OF NORTH ANDOVER i ° SYS �� ding Record H�LTHG F ` Form 4 w` 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 The System Pumping Record musubmitted to local Board of Health to determine the form they use. date in the local Board of Health or other approving authority within 14 days from the pumping accordance with 310 CMR 15.351. A. Facility Information important When 1. System Location: ailing out forms on the computer, use only the tab key to move your Address cursor- do not North Andover use the return Cty1Town key. 2. System Owner: (, Name Address (if d'rrrerent from location) 0 Ma 01886 Slate Zio Code State Cityrowh Telephone Number B. Pumping Rec® d _ a�)s2 Quantity Pumped: 1. Date of Pumping Date 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank " ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped i2ocation:wh ri'S tIC Service 7. Ls Stewart's Pre-treatment F Signature of Hauler Signature of Receiving Facility t5form4.doc- 03/06 Zip Code "6 0U_ Gallons ❑ Grease Trap If.yes, was it cleaned? ❑ Yes ❑ No Vehicle License Number disposed: 20 So. Mill Bradford, Ma 01835 Date Date System Pumping Record - Page No Andover J&S Development dba 1600 Osgood St Stewart's Septic Building 20 Suite 2-36 Andover Septic No. Andover, Ma 01845 58 South Kimball Street Bradford, MA 01835 Date Name & Address Gallons Comments 1-May'Patter reality 81 Sawmill Rd 1600 Good TOWN OF NOR-rH ANDOVCR 2-May'Mulcahy 350 Sharpners Pond Rd 1500 Good icALf'Fi DEPARTMNT Gieene 62 Willow Ridge Rd 1000 Good 3-Maylacross"259 Grandville 2500 Good 4 -May`.. R jncon 115 Sherwood Dr 1500 Xsolids HG 9 -May .Callahn`940 Foster St 1500 Good ay"� 10-MMelerim�1444 Salem St 1500 Xsolids 15-May:0iraffel 3 Brenkin ridge Rd 1500 Good .Depari,175 Stone Cleave Rd 1500 Good 16 -May Martin 701 Forest St 1500 Good YMurphy.16 Carleton Lane 1500 Good 18 -.May Varidergraaf 267 Old Cart Way 1500 Good , 8olano'2198 Tnok St 1000 Rh 21 -May �omicho"115 Laconia Cir 1500 Good Reti 42 Cross Bow 1500 Good 24May,Carbonell 1560 Salem St 1000 Good 29 -May Thurber 210 Farnum St 1500 Good ,31-May'Cleary .105 Winter green Dr i 1000 Good M N rtt � rt�wt W' NUK1,M SY87EX-1 PUMPINU RRCOKI T1 OF p ry':r � .�;�!*•ftx�t py'�1�1 tte'k• � ! i t0SPOOL CX300GONt�!TiUN t�v�, rvLuvtx CLO KVNf)A�j, 4LipCA14,iSYC'.Y�'3t' EXPLAIN r A. y s wryf3i-n.'k, KulY I t ' rri fly^ u ti i.+-• ,,, �^ r- n t;.ws} rl*f}F v :e.+ 4 J6Fx• s^kkw - { • b t €�."'4t�+laY�st!(� ( rnnsFJ� T _ Commonwealth of Massachusetts W City/Town of No Andover System Pumping Record Form 4 '4M DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important: When filling out forms 1. System Location: on the computer, use only the tab 62 Willow Ridge Rd key to move your Address cursor - do not No Andover use the return City/Town key. 2. System Owner: reNm Name Address (if different from location) CitylTown B. Pumping Record Date y , 2. Quantity Pumped: ❑ Cesspool(s) j /Septic Tank ❑ Tight Tank 1. Date of Pumping 3. Type of system: ❑ Other (describe) Ma State zip, kl,�Plq 1 ,y(� TOWN OF NORTH ANDOVER HEALTH DEPARTMENT State Telephone Number 4. Effluent Tee Filter present? ❑ Yes /(No 5. Condition of System: Vft� ca�� 6. System Pumped By: Zip Code Gallons ❑ Grease Trap If yes, was it cleaned? ❑ Yes ❑ No Name Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: Stewart's Pre-treatment Plant. 20 So. Mill Bradford. Ma 01835 t5form4.doc• 03/06 Date Date System Pumping Record • Page 1 of 1 Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. Goimmonwealth Massachusetts i.ty/T6wn of NORTH ANDOVER, MASSAC stem Pumping Record -1-Form 4 USET IL OCT CT T Ij 1 2 ' TOWN C� ' j' DEP has provided this form for use by local Boards of Health. The i-iF tem"'Pum— be submitted to the local Board of Health or other approving authority,yS A. Facility Information 1. System Location: ng Record mu., Address, Cityfro wn State Zip Code 2. System Owner: Name Address (If different from location) City own State Zip Code - Telephone Number B. Pumping Record 1. ecord 1. Date of. Pumping Type of system: ❑ D -Qther (describe): DateU --- 2. Quantity Pumped: 3 Ions Cesspool(s)Septic Tank M Tight Tank 4. Effluent Tee Filter present? El Yes [I No If yes, was it cleaned? [I Yes [] No 5. Condition of System: 6. Sy em Pumped By: ame Vehicle License Number (9 -- -Company 7. Location where contents were disposed: Si .atureof Hain' htp://www.maskgov/dp/water/ pro�Val$/t5for m s.htm#inspect 7 - Date 15form4.doc- 06/03 System Pumping Record - Page I of i WEST 7!�e ENVIRONMENTAL ,NC. 122 Mast Road, Suite 6, Lee, NH 03824 603-659-0416 ♦ Fax 603-659-0418 ♦ westenv@empire.net V MEMORANDUM Date: October 16, 2002 To: Julie Parrino, Conservation Administrator Q North Andover Conservation Commission From: Mark C. West, West Environmental, Inc. Re: Kathy Green Residence/62 Willow Ridge Road, N. Andover Subject: Site Inspection for Wetland Determination West Environmental, Inc. conducted a site inspection at the above referenced property on September 23, 2002 to determine if wetland resources areas were present. Our inspection found that there were no resources areas under the jurisdiction of State of Massachusetts or the North Andover wetlands Bylaw. We found a stone and piped drainage area that did not support wetland vegetation or hydric soils and that was not connected to any down stream wetland resource area. RECEIVED OCT 2 8 2002 1) O THAWoVE, MK&q"—�rt0fvcomm Lasm Location No. Datejnia7- TOWN OF NORTH ANDOVER "'- 9 ' Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee TOTAL Check # 15;64 Building lnspt�cor ' TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVAT OR DEMOLISH A ONE OR TWO FAMILY DWELLING P ,T BUILDING PERMIT NUMBER: / DATE ISSUED: l a 1l _ D SIGNATURE: A/H C Building Commissioner/InEeEtor of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: & 2 c,J ( L �.,, 12 �c (� . 1.2 Assessors Map and Parcel Number: 4q- 9� Map Number Parcel Number1.3 �A � UIZoning Information: Zoning District Prbposed Use 1.4 Property Dimensions: /5b Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided 1! 30'1 ?3' Da ' 1.7 Water Supply M.GL.C.40. 54) 1.5. Flood Zone Information: Public ❑ private >0 Zone Outside Flood Zone ❑ 1.8 Sewerage Disposal System: Municipal ❑ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record Name (FA -1 Address for Service: Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTI N 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Licensed Construction Supervisor: Addres '0 Signature -F Telephone Not Applicable 0 License Number Expiration Date 3.2 Registered Home Improvement Contractor CyvbC-Lk mCW24 WtV- Not Applicable ❑ ►1i Company Name ( S� • �Q^"F) Y/ Registration Number (2,� d-? Address CQ(� &3(,,- t/5 -t Expiration Date Signature Telephone Ma rn X Z O SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 § 2! Workers Compensation Insurance affidavit must be completed and submitted in the denial of the issuance of the building permit. Signed affidavit Attached Yes ...... No ....... 0 SECTION 5 Description of P o osed Work check all a Ucable New Construction ❑ Existing Building ❑ Repair(s) ❑ application. Failure to provide this affidavit will result Alterations(s) ❑ 1 Addition Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: e C o�k) c� cvi fir, d c k I SECTTON 6 - FSTTMATETI C0NQTR1TrTT0N Cne.TC I Item Estimated Cost (Dollar) to be Completed bV permit applicant OFFICIAL USE ONLY 1. Building / / Orb (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) X (b) / ^O y 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 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 SECTIIOpN�7b OWNER/AUT/HORRIZED AGENT DECLARATION as Owner/ uthorized Agent subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief Print 9 Date NO. OF STORIES ► SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS Isr2 ND 3 RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS 27/6 HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING 2 X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE /a).;zcf aEc1C FORM U - LOT RELEASE FORM 9 , Ll` G z 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*********************** APPLICANT v/ IIr�ElPHONE &(7 'SYS -2'►a? LOCATION: Assessor's Map Number IU -7 PARCEL /Q SUBDIVISION n • LOT (S) STREET 671 �JiUC U (L" Cf a-9. ST. NUMBER ************************************OFFICIAL USE ONLY*********************************** ��f • •� •- COMMENTS TOWN PLANNER COMMENT INSPECTOR -HEALTH (c. ,, �`(. [ k IC INSPECTOR -HEALTH COMMENTS AGENTS: DATE APPROVED DATE REJECTED ,�,Av 12401T, DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED- , .a /'.l J2d 3-J PUBLIC WORKS - SEWER/WATER CONNECTIO CA DRIVEWAY PERMIT IRE DEPARTMENT V" �u RECEIVED BY BUILDING INSPECTOR_ `4Revi.ed 9\97 jm TE l ��,40 --------------- �_ I lereby certify Olt She afloat !lartgi9t .Iaspectzan Pilo +dis�ptepartd for Ulf tonnectior vita a AN Martgalt ad is rat Intended or represented to bw a property line or lu►d Sauey. It cannot be used tar tstabiisbinq fexce, kedge I Will$ or Inii.diag lirex. Mt raePonxibility it. extended. herein to the land Orner or Occupant. tht Iocat19A of the origlari kullding(s) as shows Sent 8y: WEST ENVIRONMENTAL; 603 679 8232; Oct -16-02 5:29PM; WEST 7!�Ae ENVIRONMENTAL INC. 122 Mast Road, Suite 6, Lee, NH 03824 603-659-0416 • Fax 603-659-0418 ♦ westenv@empire.net MEMORANDUM Date: October 16, 2002 To: Julie Parrino, Conservation Administrator North Andover Conservation Commission From: Mark C. West, West F..nvironmental, Inc. Re: Kathy Green Residence/62 Willow Ridge Road, N. Andover Subject. Site Inspection for Wetland Determination West Environmental, Inc. conducted a site inspection at the above referenced property on September 23, 2002 to determine if wetland resources areas were present. Our inspection found that there were no resources areas under the jurisdiction of State of Massachusetts or the North Andover wetlands Bylaw. We found a stone and piped drainage area that did not support wetland vegetation or hydric soils and that was not connected to any down stream wetland resource area_ Page 1/1 �TM CERTIFICATE OF LIABILITY INSURANCE YI DATE01/03/200 01/03//2002 PRODUCER Lockton Risk Services, Inc. PO BOX 410679 Kansas City, MO 64141-0679 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE INSURED Archadeck of Metro West 48 Mechanic Street Newton, MA 02464 INSURERA: Legion Insurance Company INSURER B: INSURER C: INSURER D: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE ATE (MMIDDNYI POLICY EXPIRATION DATEM LIMITS A GENERAL LIABILITY CP11933420 01/01/2002 1/01/2003 EACH OCCURRENCE 6 1,000,000 X COMMERCIAL GENERAL LIABILITY CLAIMS MADE a OCCUR FIRE DAMAGE (Any one tire) 6 300,000 MED EXP (Any one person) 6 10,000 PERSONAL d ADV INJURY 6 1,000,000 GENERAL AGGREGATE 6 2,000,000 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG 6 2,000,000 X POLICY PRO- LOC AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT 6 (Ea accident) ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY 6 (Per person) HIRED AUTOS NON -OWNED AUTOS BODILY INJURY 6 (Per accident) PROPERTY DAMAGE 6 (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT 6 OTHER THAN EA ACC 6 ANY AUTO AUTO ONLY: AGG 6 A EXCESS LIABILITY X1 OCCUR F] CLAIMS MADE UM11943139 01/01/2002 01/01/2003 EACHOCCURRENCE 6 1,000,000 AGGREGATE 6 1,000,000 6 6 DEDUCTIBLE X RETENTION $10, 000 6 A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY WC11933421 03/23/2002 03 /23/2 003 X T CSTATURY S OER E.L. EACH ACCIDENT 6 500,000 E.L. DISEASE - EA EMPLOYEE 6 500,000 E.L. DISEASE -POLICY LIMIT 6 500,000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONSIVEHICLESIEXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Proof of coverage ♦.ten r rr ra. r� r r wr.v�n Auu11 IUNAL INSURED; INSURER LETTER: V AIYLCLL.A 1 IUIV F_ Archadek of Metro West SHOUANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE EREOF, THE ISSUI�! G4NSURER WILL ENDEAVOR TO MAIL 1 0 DAYS WRITTEN NAMED TO THE LEFT. BUT FAILURE TO DO SO SHALL NGiANY KIND UPON THE INSURER, ITS AGENTS OR AUTHORIZED REPRESENTA A".vnv ca -v t i is i I a ACORD CORPORATION 1988 V /l� VV'//Z!I/W/wciri.VVN L• 0/ 1 /✓:/(AMV(.4/C/f/LV BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 066851 Birthdate: 08/21/1946 Expires: 08/21/2003 Tr. no: 1004 Restricted: 00 JAMES R FINLAY 2 WATERTOWN ST...e.rr 4TAvt-J LEXINGTON, MA 02421 Administrator /fie �a�t�no�rcue�l� a�1. ��.a�:1��,r�tc�:ieCZs Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration: 111975 Expiration: 01/28/2003 Type: DBA METRO WEST RES.CONT.INC/AR JAMES FINLAY 48 MECHANIC ST«�' NEWTON, MA 02464 Administrator m � I i i m n a Z: 0 H 0 Jrn H r0 x n x 0 9p �E C/1 O C- CD ✓ A_ CD _ 3c (7Z l 1 df p A a � _ — n .� o—o = m d ^- m O ' � 0 1 O .•� r0 x n x O C- ✓ v mp CD SN O X 3c (7Z 0 03 df p A a � m Z p H C13 = m d ^- m O ' � T rj x co CD 0 x x N .— C7 ' n N I I m < Q 3 A ' x ^' N N J1 f�N Q C) 'a o co x x X : x x a X -s .� 0 m �' �► O N a X a 'f . ca O w cn n 'II ]� a� m m Q T _ — o- _ = w 3 O Q_ c IL � 01=3 1 N � � o� _ O _^-� NNS N o' _ = n C. m r0 x n x O C- v mp CD SN O X cc 3 _ 0 03 df p A a � m Z p H C13 = m d ' � T 11 Cl) 3D M C/) 0 m C r� CO) CD.p cl) Z O O ar Ck) Q �. n� -00 o p CL Q CCD O .. .. CD CD CO) CD 0 O C• O C CO) Er C) CD 0 �f CD CCD y. CD CO) _C W ? *0 c= -1 C• H O Q' N = _a 0 5.0 "0 :*cc, to — Cl)0m Cl) Z N m nC �' �-w N -0.w .d+ m N T �d�►CL O. C CD H O Cm/d N o m m o a > > H o c O "O~ to O o z 5. -) O W mom CL n CO) _. CL a: coCD N a O C G m O N H 0. d Q J� - D to .rt N 1 C cCA l, `� c cc',, 0 o L v oCD ci 1 �. CD ?: omco ` W H =r :C CD o 0C C. 0 o. CD �o cn 77.. l--1 (n p tp 7 rD r• -i ?7 w GQ o w cnpo O Cz7 � M w 0 UQ Z w � OQ G n C ,., z U Cn p %� aj O A) O C CD TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: SYSTEM OWNER & ADDRESS sr SYSTEM LOCATION (example: left front of house) DATE OF PUMPING:. `� /g -O/ QUANTITY PUMPED /Sac> 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: COMMENTS: CONTENTS TRANSFERRED TO: U.0 �'� _ 4 0 /Q °,r;r 2 01 4 a FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards'and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. APPLICANT FILLS OUT THIS SECTION APPLICANT 9&t/IAM 6& mi"4L5 PHONE_022-_432,0 LOCATION: Assessors Map Number 17 PARCEL SUBDIVISION LOT (S) A9A STREET t'hhIlG Q&/ P�L�� Po,�,r, ST. NUMBER OFFICIAL USE ONLY*** COO'S RECIINJMENDATIONP OF TOWN AGENTS: . Q F CONSERVATION ADMINISTRATOR DATE APPROVED DATE -REJECTED TOWN PLANNER �r l� COMMENTS DATE APPROVED DATE REJECTED FOOD INSPECTOR -HEALTH DATE APPROVED DATE REJECTED 7 ►1� _ TH DATE APPROVED /-,9 DATE REJECTED /C --, PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT D L� �� •,GU i 2 - --��j FIRE DEPARTMENT ct !� �4'. RECEIVED BY BUILDING INSPECTOR DATE `-M 12/17/1999 12:20 9786886008 v GREENE 6 PAGE 01 12/17/1999 12:23 9786886008 V GREENE PAGE 01 c a 4 "' � 11% �lj np�. Z 3 � N w a GREENE PAGE 01 c a 4 "' � 11% �lj it, �r R'If'j SS •S• i 1 t +1 ' 1.+.� .'�rj`,1.�r��'i''`.r1r,rF.C'" ,{t t."� .i'f�r'T�rv�•..r . t:x,i�.l f,.;.. • RAoz � . •up� ' �r r+R r• � tl ,� , . ,w , r ;hie „ ,lr� ;�,}M+� � ��i !. 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Yl i; TOWN OF N RTH ANDOVE,k j SYSTEM PU PINQ RECORD UA 1'k ?4ellol- I RECEIVED OCT 0 5 2004 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT I SYSTEM WNER & ADDRESS IS STEM LOCATION do DATE OF PLJMPING:_.... -7— CLSSf'WL: NO SOPUCTank: NO_ YES N,ArUREOF SERVICE: K0U'UINE..._,.L---,rmERGEN('Y 0138F,RVA I"IONS: GOOD CONDITION FULL TO COVER HEAVY OREASEBAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIJDS'-- FLOODED SOLID CARRYOVER-.-.--..-- OTHER EXPLAIN SYstvm Pumped by �:UMMENTN. CON FEN FS rKAN3.FhRKEL) 1-c) I MR-W*Record' F0 DEPr,hai prcMd4d this form for use by local boards be Subinl4id to the-10cal'Board of Health or other a� MASSA �H U �SE T �T87.'. Health. The System Pumping Record mus, oving authority. -7 � U -�Ai. Fpcilityin -tion V 5 UU'[ "N OF NORTH ANDOVER" .99 .'SYstemL6cdon:ATH DEPART%: r-'4 T only the tab key Address A41 to move your:; "I (VtU zip Code Owner " tem 0 Address If different from location) .7- Telephone Number por F. rpin0:Rk' d' V "I %''i . 1.....Dat P u Q.0 nflty Pumped: o!ot umping"-.�., Date/ 2 Gallons 'T' yple 9 Cesspool(s) ...... . ...... Septic Tank ❑ Tight Tank Effluent Ye -s If yes, was it cleaned? Yes E] No Iq • umped By W.. h Awe Ucen ........... .Umb......... or Ina Qrl.w ere contents e 7. .......... ........... -N- 'k '... at Date hUPYAM. mass. gov ep/w er apprQV8js/t5f0*r'ms.htm#lnspect SWOM Pumping Record - Pap 1 of I �ETTs A' Faclllty infor�i�clon 5 location; 62 �"� • 00 f1Ql �M n Vim'. Clq/Tvwn 1: IJ.y �. `,f(�,%. rfi ,ri 'I VYVIa •., o nVf,.. �� ,,. �'� ,:+1.1'x'•' r,. ',:,' ., 1 ,'•.1 t, l�drµ� (114Uf4r4nl rc�n I�uUpn) • C4^�,.n 'P,umping'Ragord �. Oa;o o! Pumpinp. 04.. DQ 2 �'.ar:�f r• . TYPO of eyslon, C053P001(9) Sepl•C Tens IS^t Tar" EMuonl Too Fllle(P(q�onr? it es _ .:•.I`r/. •'''I1'.Colidl�lon'Q(:9yf,�m;'.1..• , .. -------------— 7777777777 P�'mPed 8y: _ :'WIll �f,i�� !' `�1��i11'' •�I, �. mer •1 �m ' ; r .4•'�':,�� .• .;,• ..'1,1:A li'1'a! "t; � orf'",t�- iai.. . Louon. Who(Q 000jon a'yvara dly osev: P • �' •, ,,• �l;C �{• '• gilt;,. . , 'j '' ,��r.. ;\:,,'�'.`l;,l,♦l�i,... .•... I/lY �� SIJ, .. .�� // � %/p -- 'n, w.mass.poY/dep!welOr/epprOYeJa/lblorm�.r:naln9�eC1 041, 'y Wj • ,1�/.p1�illY i�'t ��/! �G��' ! „ I !rt . '', lop p(Qy dod Wo rolrn r-?, of 1'•%0/I11110d 10 1111 10611 Bot,{; r A. Faclllty In(orm��lon E• ED^ SACS{ SET- , N O V 1 0 2009 W:a.-I1 ; .. -.;: �.• .i',4.' 5)T-rn CPU Nn:. �. W%''i�.�j�.�l��';'��,�'2 �'i,'l��+lil'1.�!•��„'1'� '��.'.�,' �IIII----_�__.. iml ` f w' 1'''t�' �''•(r; .,,, �'•,, '•' •,• , tz S�El' �C' „ (4 {rrnl rcvn buVvn) �;�'rVdr�41--------------------- zr f1:l�npnl n•m01r� ,!81:Pumping; ord • 'r " ',! {y; .'•�"ll L' - Ill, , ;.. / ). Oelo of Pv'm91n9 • •� "'. ' ', ,,. oral riPl ? ^•.a�'.�, �.. 'e^ ��.�;�� ,� •' 0� iy�110n1,„ l..' CB77p001(�) rre Fllle(. r,0„aont? t yo o0 �'i'•,,;X1 ''I^ Oil I;VQ��I�I ._. Y S �''�i : ; ,011'QI ,VY%uIl�,rr'.�•,' • .. 'Y O.G . ' 1 °,..�i 'i;�.�!v'r (.r 1'1 ''i'I �•r II'� I',�u�)�•l� r i jll+;( ;11� • r • .... ! '•. � ,:! ooe on. h (ilenl.i,y,�,o'ro d(� • .t,,. r,,, ., w er�,00 posey: �' '_.:.;•.,n�,•r.me�,' S�n�,k'', 1�'iv4(�y�l�y,f,l,.'r,,.,�, ^ 1 porldep el'eilepPr4Ye��lwQ i j rm�,r,:ma n Foci Commonwealth of Massachusetts W City/Town of No.Andover a System Pumping Record ` Form 4 M OR -7 U11 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT 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. t5form4.doc• 03/06 System Pumping Record • Page 1 of 1 A. Facility Information Important: When filling out 1. System Location: forms on the computer, use 62 Willow Rd only the tab key Address to move your No.Andover Ma 01845 cursor - do not use the return City/Town State Zip Code key. 2. System Owner: Green Name �hO Address (if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) []tic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: Name Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 Signature of Hauler Date Signature of Receiving Facility Date t5form4.doc• 03/06 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts! MAY 19 2014 " Andover w City/Town of No Andover 6 TOWN OF Hi=A► TH EP AN COV"? ' w 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 Bumping Record must be submitted to the local Board of hiealth or other approving authority within 14 days from the pumping date in accordance with 310 C:MR 16.351. A. Facility Informations ---- �� Important: When filling out forms 1. System Location: on the computer, use only the tab 62 Willow Rid"gq Rd, key to move your Address cursor - do not No Andover iifiA_ " use the return /iotvn -�� key. Cit �, State--------� Zip Code V QW 2. System Owner: _Green Name reran Address (if different from lccetion) City/Town Mate "---- — zip Code— Telephone Number ^—�--- S. Pumping Record 1. Date of Pumpingo t 1. I --- 2. Quantity Pumped: Gallons`010IQ 3. Type of system: [] Cesspool(s) rV Septic Tank L! Tight Tank [a Grease Trap [j Other (describe): 4. Effluent Tee Filter present-? C j Yes [:1 No 5. Condition of System: 6. System Pumped By: If yes, was it cleaned? 0 Yes ❑ No Name - - Vehicle Lir enc•e Number Stewart's Septic Company 7. Location where contents were disposed: Stewart's Pre-treatment Plant, 2Q So. -fill Bradford, Ma 0 Signature of Signature of Receiving Facility Date Datta t5form4.doc• 03/06 System Pumping Record • Fuge 1 of 1 Commonwealth of Massachusetts W City/Town of NO ANDOVER 14 System Pumping Record f� 23 } Form 4 L HZALTH, M Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. rab DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information 1. System Location: 62 WILLOW RIDGE RD Address NO ANDOVEF City/Town 2. System Owner: e e) Name Ma State Zip Code Address (if different from location) City/Town State Zip Code Telephone Number B. Pumping Record �f 1. Date of Pumping Date 2. Quantity Pumped. Gallons ons 3. Type of system: ❑ Cesspool(s) E eptic 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: G 6 6. System Pumped By:2 '41-11 /V/- 7 �/// Name Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: Stewart's Pre-treatmentff9an�-�O So. Mill Bradford, Ma 01835 Signature of Hauler Signature of Receiving Facility Date Date t5form4.doc• 03/06 System Pumping Record • Page 1 of 1 w TO: FROM: NORTH ANDOVER, MASS BOARD OF HEALTH DESIGN ENGINEER 19 7e Re: Soil Absorption Sewage System Inspection This is to certify that I have inspected the construction of the said disposal system at Z e' "� %�+ W1110 Ui /-P I'D Ge North Andover, Mass. SITE LOCATION The grades and construction are as specified in my plans and specifications dated 9 `f3 19.1 O F MAssq��' JOSEPH 0 J. a eg. r pE rb6r/Reg. ;Sa4itarian n A�o� ST �SSIOi AL �Il / SOIL PROFILE & PERCOLATION TEST DATA /VLrliU�- - Lot No. Town/City No.&Street -- Loc. /Subdiv. 60"maw 1�C qc Plan _ Owner rU�. Investigator //S ��-9��U Observer O SOIL PROFILES -DATE 3' Elev. 3' Elev. 3. Elev.ev•______ 0 0 0 0 �V Benchmark Elevation 2 3 4 5 6 7 8 9 10 2 3 4 5 6 7 8 9 10 2 3 4 5 6 7 8 9 10 Location Datum Percolation Tests -Date 9 /U Pit Number 1 2 3 4 S Start Saturation 3•Z Soak -Mins. 10 Start Test -Time Drop of 3" -Time 3 Drop of 6" -Time 'D Ci Mlns.lst 3"Dro � Mir' 0-A Z11nr� V7 L_ Notes &`Sketches on Back Frank C. Gelinas & Associates, North And. cI rr� �myL>ytii rj '; b m m u Ao 1-b LAp d o Zrn ik 0 ,�\ , N th 3 u A �oe�oyn�j�' luf N. ;w - ZO' s 1 ry �o c m e to �rh o \ 4 j o � -5; 77 C C� o° i.v /31 oo 1 l !� . N n • � �oe�oyn�j�' luf N. ;w - ZO' s 1 �s ry �o c m to �rh o j �s