HomeMy WebLinkAboutMiscellaneous - 64 WHITE BIRCH LANE 4/30/2018 (2)S
Town of North Andover
Community Development and Services Division
Office of the Health Department
400 OSGOOD STREET
North Andover, Massachusetts 01845
Susan Y. Sawyer, REHS/RS
Public Health Director
(978) 688-9540 - Phone
(978) 688-9542 - Fax
Date: I
Address: (py �F.t�r; t,l,�jLt'�� North Andover, MA 01845
Re: Application for: �ii(�I t'i�1') bv'
Dear:��-�-
Your application for at �� Ce. has been reviewed by the Health
Department. The application was denied on, �/', 2004 for the following reasons:
1. &/ Missing information
2. ❑ Passing Title 5 inspection of septic system required
3. ❑ Location of structure not acceptable
4. ❑ Undersized septic system
To address the problem(s):�
If #1 is checked, please supply:
a. Floor plan of existing and proposed addition - all rooms
Certified plot plan showing house, septic system and proposed project in scale
If #21s checked:
a. Have the septic system inspected by a certified Title 5 inspector to determine the size of the system -and
whether it is operating properly: OR
b. Tie-in to municipal sewer
If #3 is checked:
a. Relocate the project
If #4 is checked:
a. Provide additional information proving that the existing septic system meets current capacity
requirements. Please consult an engineer to determine the flow capacity of the septic system.
Please feel free to call the Health Office at 978-688-9540 with any questions you may have.
Sincerely,
1'(
eviewer
Cc: Building Department
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Bf)ARI) OF :\NPL:f\La ti88-9141 BUILDING 688-9545 CONSI{RV I'iON 8 -95 N R. 8- . PLANNING 688-9535
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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 .W C � CA 1 _IP ' C tr�►S�
LOCATION: Assessors Map Number
UBDIVISION /
STREET �' ��' [� t Vcl L4ke
b
OFFICIAL USE ONLY**
TION ADMINISTRATOR DATE APPROVED
I A . DATE REJECTED_
COMMENTS
1 UWN F'LANNEK
COMMENTS
S
DATE APPROVED
DATE REJECTED
PHONE[ 7�'6h r�16 F
PARCEL
LOT (S)
ST. NUMBER�Ckht
FOOD INSPECTOR -HEALTH DATE APPROVED
���, / � G/��✓� DATE REJECTED
SEPPCPECT H LTH DATE APPROVED
DATE REJECTED L� 5
C`
PUBLIC WORKS - SEWER/WATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTMENT
RECEIVED BY BUILDING INSPECTOR DATE
Revised 9197 jm
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REP RENOVATF2 OR DEMOLISH A ONE OR TWO FAMILY DWELLING
77777
BUILDING PERMIT NUMBER: DATE ISSUED:
SIGNATURE:
Building Commissioner/12EREtor of Buildings Date
arl llVty 1-Jl1r W UKiVIA1ION
1.1 Property Ad& 1.2 Assessors Map and Parcel Number:
64 W L I'�
Novt ' J t� `V ✓er PiA O f r f;- Map Number Parcel Number
1.3 Zoning Information: "a �I i �1 �1 7 1.4 Property Dimensions:
L 1,'780 21L4 33
Zoning District Proposed Use I Lot Areas Fronts ft
1.6 BIJU DING SETBACKS ft
Front Yard Side Yard Rear Yard
Required Provide ReqWred Provided Required__ Provided
4
1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System:
Public ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT ric is rlCt: Yes No
2.1 Owner of Record
c6Y6 C. c7 r,M s 6y wL,' ?-v-cQ Lathe
Name (Print) Address for Service:
tgnature Telephone
2.2 Owner of Record:
Name Print Address for Service:
Signature Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor: Not Applicable Pa
tA P� !' ccrf- yr r
Licensed Construction Supervisor: C 5 Q $ 7 72
D % License Number
Address / /�C
L�����
Expiration Date
Signature Telephone
3.2 Registered Home Improvement Contractor Not Applicable ❑
PVC V t'JV (0Company ame
/ Registration Number
Address �� ( ) r `/,Sl /Z O 66
�A � y ( Expiration Date
Signature Telephone
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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:
I
(Location of Facility)
ignature 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
11
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
Name Please Print
Name: e G In P. PQ N S`
Location:
city L �' k �^ I� c � � Phone # 7,r/ C,. �'2 rT
I am a homeowner performing all work myself.
F�7 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:
Address
City'
Phone #
Insurance Co. Policy #
Company name:
Address
Phone #
Insurance Co. __ Policy #
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 -weU_as_axiLQenaWmin ft form dA..STOP WORK..ORDER..and..a.fine.of (.$100M) -achy agair�st.me. I
understand that a copy of this statement may be forwarded to the Ofrroa of Investigations of the DIA for coverage verification.
i do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signatur Date d �'
Printname �..� .� �c�r-�y., �, Phone #
official use only do not write in this area to be completed by city or town official'
City or Town PermWUcensina
Building Dept
❑Check if immediate response is required I] Licensing Board
❑ Selectman's Office
Contact person: Phone #: E] Health Department
Other
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TOWN OF
SYSTEM P
DATE:
SYSTEM OWNER & ADDRESS
G RECO
RECEIVED
MAY 2 5 2005
TOHEAOLTH D PARTM TER
SYSTEM LOCATION
(example: left front of house)
��- b0 -c -v e 10 us�-'
DATE OF PUMPING: 4 - S- Q J QUANTITY PUMPED : 'Soo _ GALLONS
CESSPOOL: NO YES PTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
FULL TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
OTHER (EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TO: G.L.S.D ✓ Lowell Waste