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Miscellaneous - 728 FOREST STREET 4/30/2018
Liberty Mutual® Liberty Mutual Insurance New England Region Central Property Unit INSURANCE 75 sylvan street Danvers, MA 01923 Tel: (800)566-0323 April 8, 2014 Town of North Andover Attn: Building Inspector 120 Main Street North Andover, MA 01845 Re: Property Address: 728 Forest St, North Andover, Ma 01845 Policy Number: H3221219837411 Underwriting Company: Liberty Mutual Fire Insurance Company Claim Number: 029325024-0001 Date of Loss: 3/17/2014 Attn: Town/City Official Pursuant to M.G.L. c. 139, � 3B, please be aware that a homeowners insurance claim has been made. involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or causes the condition of a building or other structure to render Mass. General Laws, Ch. 143, § 6 applicable. You are required to notify Liberty Mutual by certified mail in accordance with Mass. General Laws Ch. 175, §99, if you intend to initiate proceedings designed to perfect a lien Pursuant to Mass. General Laws, Ch. 139, § 3A & B, or Mass. General Laws, Ch. 143, 5 9, or Mass. General Laws, Ch. 111, 5 127B. This letter should not be construed as a waiver or estoppel of any of the terms, conditions or defenses afforded by the policy or applicable law. . Please direct your notice to the attention of the undersigned and include a reference to the above captioned property address, policy number, claim number, and date of loss. Sincerely, Liberty Mutual Support Liberty Mutual Insurance New England Region Central Property Unit 1-800-566-0323 Date... n NOR71{ °.°° TOWN OF NORTH ANDOVER �• °c p PERMIT FOR WIRING SACl/us This certifies that I.O. y, ..... ....�'+ �— + ............................ ............... has permission to perform . l.1` 'L , �,... . .. wiring in the building of ...... !-%=..... f ....................... at.......................................................................... , Nort Andover, Mass. / / Fee ...4 S ....... Lic. No. A �A �. ELECTRI L SPECTOR Check # 61 48 Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. U Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 9/051 leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT 1N INK OR TYPE ALL INFORMATION) City or Town of: /C%U rrA n Al d Q By this application the undersigned gives7�4 ofs or her inti Location (Street & Number) 9 akf; a . Owner or Tenant I 1D M J Owner's Address —72k . uric 0'GOr)v7wr Date: To the Inspector of Wires: to perform the electrical work described below. Telephone No. Is this permit in conjunction with a building permit? Yes L No ❑ (Check Appropriate Boa) Purpose of Building 1?e 5 j ,0en/C e Utility Authorization No. Existing Service 20CI Amps /20'/ ,2YO Volts Overhead ET Undgrd ❑ No. of Meters New Service ZaV Amps 124 / 2 YO Volts Overhead d Undgrd ❑ No. of Meters Number of Feeders and Ampacity / Location and Nature of Proposed Electrical Work: � / fid ( A1 -1Y 77,ld ,fONL a wv Gf 1 /2,q rA ,/-U r//4-� Completion of the following table may be waived by the Incnertnr of Wire_e No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans o. of ota Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above El ❑ d. d. o. o Emergency Lighting Bagga Units No. of Receptacle Outlets g No. of Oil Burners FIRE ALARMS No. of Zones No. of SwitchesNo. % of Gas Burners o. o Detection an Initiating Devices No. of Ranges No. of Air Cond. Total Z /Z 1 Tons No. of Alerting Devices No. of Waste Disposers eat P Totals: ..... er ons o. of e -Contained Detection/Alertin Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances' KW Security Systems: / No. of Devices or E uivai.. No. of ater Heaters KW No. of o. of Signs allasts Data Wiring: V No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP a ecommunications►ring• No. of Devices or E uivalent OTHER: Attach additional detail ifdesired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: l C) (When required by municipal policy.) 1 Work to Start: //7 —00" Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under the p ins andpenalties ofpedstry, that the information on this application is true and complete. FIRMNAME: C' %r tt U en/ 01'd' r- 16 -C f"! C LIC. NO.: Licensee: /�erP� CcyC>N�G%'iT— Signature LIC. NO.: O g� (If applicable, enter "exempt " ' the licensember li OFBus. Tel. No.: 7 el 7 Address: ! eC? rc- d (^n 0 / ?r5 Alt. Tel. No.: 7 8/ J;.L*01 *Security System Contractor License required for this work; ' applicable, enter the license number here: 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)FJ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE. $ ��— Date ... �� ..1-3.-.4-1.7. - . O a 0 TOWN OF NORTH ANDOVER t s PERMIT F/OOR' S INSTALLATION �9 �,SSAC'HUSE�t r This certifies that :. ...� ......i?` ...... has permission for gas installation A............................ in the buildings of . , ..................................... at ?' .... . , North Andover, Mass. Fee `�* .I' . Lic. NoAi6 'O... . GAS IN E OR Check # l 5276 'MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING ftnt or Type) Z0 O N orAN\ R A a O V -� . Mass. Date 0 C* Permit s Building Location }2492 �O�'eg� Sir ee� Owners Name L Type of Occupancy, 9-SLs k de,� New Renovation O Replacement ❑ Plans Submitted: Yes ❑ No M FIXTURES Installing Company 6-1 0r �1- Check one:. ❑ Corporation .❑ Partnership y Business telephone ` a - .� � 1 - �-�- �(o O Fin voc. Name of Ucensed Plumber T�\ow\D c, 4' C-0Y\v\ 0 - Cemliate INSURANCE COVERAGE: I have a 11abRily insurance policy or its substantial equivalent which metes the requirements of MGL Ch 142: Yes is No ❑ If you have checked 10. please Indicate the type coverage by checking the appropriate book. A liability Insurance Policy d Other bpe Of Mdemnily ❑ - Bond O OWNER'S INSURANCE WAIVER: I am aware thd the licensee does not have the insurance coverage required by Chapter 142 Of the MasL General Laws, and that my Signature On this pemtit appllntion walm this requirement. Check One: Owner O Agent ❑ I hereby CW* that all of the det"s and infomratim I have wbmilted (or entered) in above appiiaetim are true and amtrate to the best of my bmwledge and that al! pknnbmg work and installations parfomsd under the permit arced for this apprzalm willl be in compfimos with a1 per inent provisions of the Massadameps Shite AumbUQ Code and Chapter 142 of tlw General Laws. Title urnberle_ ? Type of License: gaster 61 .bun ""M ❑ Ucense Number M P 14 t O\(0 O v d-`57 z x z a kc F a v t w h O u z m a Z= = a Z to s C US <'~ Q . � 6 el z O 06 Z x w °' Z: ar � J W= a w 6 s O a s el x W �' Y < a !� a q z a d K a a< C d< 4 C 3 0 x Yom. C O f O< el C O 44 J a C C J x O C6. F- u> IF O= d O A F z O p M x= ;! O v Y < a e) q<< O< J J < C C ,Z G< O < F- SUBB S MT. BASEMENT IST FLOOR 2ND FLOOR 3RD FLOOR Z 1 4TH FLOOR STN FLOOR eTH FLOOR 7TH FLOOR STU FLOOR Installing Company 6-1 0r �1- Check one:. ❑ Corporation .❑ Partnership y Business telephone ` a - .� � 1 - �-�- �(o O Fin voc. Name of Ucensed Plumber T�\ow\D c, 4' C-0Y\v\ 0 - Cemliate INSURANCE COVERAGE: I have a 11abRily insurance policy or its substantial equivalent which metes the requirements of MGL Ch 142: Yes is No ❑ If you have checked 10. please Indicate the type coverage by checking the appropriate book. A liability Insurance Policy d Other bpe Of Mdemnily ❑ - Bond O OWNER'S INSURANCE WAIVER: I am aware thd the licensee does not have the insurance coverage required by Chapter 142 Of the MasL General Laws, and that my Signature On this pemtit appllntion walm this requirement. Check One: Owner O Agent ❑ I hereby CW* that all of the det"s and infomratim I have wbmilted (or entered) in above appiiaetim are true and amtrate to the best of my bmwledge and that al! pknnbmg work and installations parfomsd under the permit arced for this apprzalm willl be in compfimos with a1 per inent provisions of the Massadameps Shite AumbUQ Code and Chapter 142 of tlw General Laws. Title urnberle_ ? Type of License: gaster 61 .bun ""M ❑ Ucense Number M P 14 t O\(0 O v d-`57 . - �, f _' •, � - _ , � .T..r. .� _ 3 ' i 1 i r . - (Print or Type) • i i�s?>t.l�' v'Cate, �V�y �O. 19 b y l:h•'s:' `'; : . ,. Mass ZJ©BuIldino t�@^J=i.,- owners 4 ...: `i�I4 _Name New Ge Renovation O Replacement C3 Plans Submitted; -Yes. O ti G( No f f• Check one CertiflC<� Installing Company Name ' \rN0MQL-% CO Cc�1�V�e�t— L7 Corp. Address ? F©,rQcA S*4-ee,�K d Partnerthip, (\Jc --�W �oole� i �. 0 k SLks O Firm/Co.. Business Telephone 509,-695\-J39 , Name of Ucensed Plumber or Gas Fitter 'f M©vyn4.S 6 Ccs, N=c- .. INSURANCE COVERAGE: Check one I have a current liability Insurance policy or its substantial equivalent. Yes O No IV' 111 you have chocked yo, please Indicate the type coverage by checking the appropriate box. A liability Insurance policy O Other type of Indemnity O .:. bond. O. 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. C ock one: Owner Agent 0, Signature of Owner or r s Agent I hereby certify that all of the details and information I have submitted (or entered) in above application are We and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General taws. I � Title City/Town APPROVED (OFFICE USE ONLY) Type,of license: tuber slitter Master -'Journeyman ga urs n �um r or Uas titter license Number % 0 % L C7 k JSEEM No f f• Check one CertiflC<� Installing Company Name ' \rN0MQL-% CO Cc�1�V�e�t— L7 Corp. Address ? F©,rQcA S*4-ee,�K d Partnerthip, (\Jc --�W �oole� i �. 0 k SLks O Firm/Co.. Business Telephone 509,-695\-J39 , Name of Ucensed Plumber or Gas Fitter 'f M©vyn4.S 6 Ccs, N=c- .. INSURANCE COVERAGE: Check one I have a current liability Insurance policy or its substantial equivalent. Yes O No IV' 111 you have chocked yo, please Indicate the type coverage by checking the appropriate box. A liability Insurance policy O Other type of Indemnity O .:. bond. O. 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. C ock one: Owner Agent 0, Signature of Owner or r s Agent I hereby certify that all of the details and information I have submitted (or entered) in above application are We and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General taws. I � Title City/Town APPROVED (OFFICE USE ONLY) Type,of license: tuber slitter Master -'Journeyman ga urs n �um r or Uas titter license Number % 0 % L C7 k 3 COMMONWEALTH OF MASSACHUSETTS IN PLUMBERS §kL#§TAISgkg&RT L LTERS ICENS UMBER THOMAS P OCONNOR 728 FOREST ST N ANDOVER MA 01845-3321 Q �411042 MAIM CONTROL # 1160799 IMPORTANT If this license is lost or destroyed, notify your Board at the Division of Registration, 100 Cambridge St., 15th FI., Boston, Mass. 02202. If name or address shown hereon is changed notify your Board of correct name or address to insure proper mailing of next Renewal Application. Always refer to your license number. License is subject to the provisions of the General Laws as amended. It is a personal privilege, and must not be loaned or assigned to any other person. Keep this license on your person or posted as required by law. �N 0p No 4� S •'l to Tti Ak - f 'Z k n < �S9C�USETT5s +•+ A°�I� ate• .w�' Thf R,y�� o,t- hasAe certjfes ��R pRry . - K` -t at the 6U�lss1Oo that , gs,'NS,4NOo f°r S Feet or iv qpA/ !c ICON Av° t Qq NgRy e`i/ •' ��C� 1 asp�CrO er Ail G`p<O. //e N0RY p� V; o r f 9 �. o ••�"t9 SSACNUS� Date ..L).,. (2-v� TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that . �`1 � `i � 4� V`A � ! �................. has permission to perform .. �^ �' u `�. hY �o.c?. v ............ plumbing in the buildings of' 0\0 at .... na ..... ...s4` c'S..' .... , North And ver, Mass. Fee .. 31 ... Lic. No....A.. �, t .6 .. Check # 3 PLUMBING INSPECTOR 5199 ,� MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Print or Type)' IN i o-rA'h -AYE AoVe,<" . Mass. Date R ,r1- Permit # �Bluilding Location -+I?, �C7��S� ��7ee,e 1 � Owner's Namb,'h F l-aUY�> i` ©� ,Cov\Or- 1�© v mai o er. / V \,A Ol g4Gj Type -of Occupancy New ❑ Renovation 5� Replacement ❑ Plans Submitted: Yes ❑ No FIXTURES Installing Company NameI CA rel, "�� p ti�� Check one: Certificate Address �2 h FOO- .S � J��(C`2 �2, t ❑ Corporation N c9r'+� A v\a o va�a )&/\A c\(?� Lk S ❑ Partnership Business Telephone _ �c ❑ Firm/Co. Name of Licensed PlumberC C-0 Y-\y\e <- INSURANCE COVERAGE:. I have ayes current/liability insour❑ance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. If you have checked _yes `-tlease indicate the type coverage by checiang the appropriate box. A liability insurance policy Sr Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws. and that my signature on this permit application waives this requirement. Check one: Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above' application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. B Title Signature of licensed Plumber City/Town Type of License: Master [� Journeyman ❑ APPROVED (OFFICE US NLY) License Numbers�- EM MENOMONEE ME MEMEMENIMEM Installing Company NameI CA rel, "�� p ti�� Check one: Certificate Address �2 h FOO- .S � J��(C`2 �2, t ❑ Corporation N c9r'+� A v\a o va�a )&/\A c\(?� Lk S ❑ Partnership Business Telephone _ �c ❑ Firm/Co. Name of Licensed PlumberC C-0 Y-\y\e <- INSURANCE COVERAGE:. I have ayes current/liability insour❑ance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. If you have checked _yes `-tlease indicate the type coverage by checiang the appropriate box. A liability insurance policy Sr Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws. and that my signature on this permit application waives this requirement. Check one: Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above' application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. B Title Signature of licensed Plumber City/Town Type of License: Master [� Journeyman ❑ APPROVED (OFFICE US NLY) License Numbers�- Date. G/. .l. a... . 'Z— o TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION 9 ' This certifies that . N Y kp C.N � ! P.i . �+ . has permission for gas installation ... �.�.. �. ........... . in the buildings of ... N9�! S a C ca ► 3 U i— at ............... . Jc �..... , North Andover, Mass. . 2 / r Fee.5.. Lic. NoAlA/PJ GAS INSPECTOR Check # 3:°9? 0 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) G \�"" /AYA(A O-1 E'(- , Mass. Date % Oi Z 2a0 3 L �c�["�y\ /'� c�.�' �' 1 � Permit # Building tl`L_oca/tiion-9-'L9, FOS �S �� �'��- \ Owner's Name Orn i..o�V T\ Q- �` Coy\v-N of- NQS T r\ !' n \s©l4eX ► \ O L $ 4-S Type of Occupancy 9, S New ❑ Renovation [ Replacement ❑ `Plans Submitted: Yes❑ No V/ Installing Company Name co C�o.� \ p Check one: Certificate Address'-42-Qa Fo<'2S4 Corporation Ua,rkh %Y\a over MA O i cr� Lt 5 ❑ Partnership Business Telephone TIll-16 ^ (0 S k- :�-" G to ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter T\--�Ow',0,S 0`C-0,nY\0,(— INSURANCE COVERAGE: I have a currenVability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes S1 No ❑ If you have checked Les, please indicate the type coverage by checking the appropriate box. A liability insurance policy 15d Other type of indemndy ❑ Bond D 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 Owners Agent Owner❑ Agent El 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 application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. ^� By T of License �� Vt cz,� . Plumber Signature of Licensed Plumber or Gas Fitter Title 4,Gastitter 1 p A* t O`(0Q Master cense Number t-\ City/Town Journeyman APPROVED O IC US NLY —5 ,�— N ¢ Y = ¢ N W J N W Oo 2 !1 a a ¢ m N C7 w a y W Z 0 n a o ¢ F Q W N W ¢ W :!7 W = V Q W N W a ¢ ¢ W 1`-W F- 2 (A C C b 11. I-' a' J W 4 ¢ W 2 > ¢ W O 2 O W Z a ¢ # Q a J O U O e W > a o W f- SUB-BSMT, BASEMENT 1ST FLOOR 2ND FLOOR 3RD FLOOR LIL I -"I 4TH FLOOR I STH FLOOR 6TH FLOOR 7TH FLOOR STH FLOOR Installing Company Name co C�o.� \ p Check one: Certificate Address'-42-Qa Fo<'2S4 Corporation Ua,rkh %Y\a over MA O i cr� Lt 5 ❑ Partnership Business Telephone TIll-16 ^ (0 S k- :�-" G to ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter T\--�Ow',0,S 0`C-0,nY\0,(— INSURANCE COVERAGE: I have a currenVability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes S1 No ❑ If you have checked Les, please indicate the type coverage by checking the appropriate box. A liability insurance policy 15d Other type of indemndy ❑ Bond D 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 Owners Agent Owner❑ Agent El 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 application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. ^� By T of License �� Vt cz,� . Plumber Signature of Licensed Plumber or Gas Fitter Title 4,Gastitter 1 p A* t O`(0Q Master cense Number t-\ City/Town Journeyman APPROVED O IC US NLY —5 ,�— Date .... .: a.9.: �'....... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that . +-2...... j has permission to perform ......................................... wiring in the building of ............... . ^ -�� ............................................................................ at ......... ........................... . North Andover, Mass. n � Feer'........ Lic. No�t.�b��iS �'... .. L .:..::...........................:.................. 6' ELECTRICAL INSPECTOR Check # 4480 Commonwealth of Massachusetts Official Use Only Permit No. y y go Department of Fire Services Occupancy and Fee CheckedS—' BOARD OF FIRE PREVENTION REGULATIONS [Rev. 11/99] leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: tZ % 7 -(ice j City or Town of: A/or%A &IN®n rjlalr— To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) 7 �2 5,? J=Q res 7— Owner or Tenant Jr/i e),At 6't S 0 C Q A1A1 a P" Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building R es 1yea Cts Utility Authorization No. Existing Service�C® Amps 6/ 6 Volts Overhead Undgrd ❑ No. of Meters / New Service 206 Amps 119-L2 f 6Volts Overhead [j?"' Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work. Service (J/' lctye Gi /,o Retaai INS UAI QC ' ro SeC n,N D /-/Q 0 r - Completion ofthe followinz table may be waived bn the Inspector of Wires. No. of Recessed Fixtures No. of Ceil.-Susp. (Paddle) Fans Tr o Total Transformers KVA No. of Lighting Outlets No. of Hot Tubs Generators KVA No. of Lighting Fixtures Swimming Pool and Above Elrnd. ❑ tg g Batte uniol ts No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners o Detection and No. Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Beat Pump Number Tons KW No. of Self -Contained Detection/AlertingDetection/Alerting Devices No. of Dishwashers SpacelArea Heating KW Local ❑ Mumcipal ❑ Other Connection of Dryers Beating Appliances KW SecurNo. No of De Stems: or Equivalent No. of Water KW o. of No. of Data Wiring• Beaters signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. 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 cove a is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE [BOND ❑ OTHER ❑ (Specify.) (Expiration Date) Estimated Value of Electrical Work10 4 � 0' (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. I certify, under thepains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: rMof - " T/' LIC. NO.: A /O Licensee: A-'% er nrA t,+C,JA r' T— Signature LIC. NO.: (If applicable, enter "exempt " in the licece ser line.) Bus. Tel. No.. 7 97 7S�6 Address: / 7 9! Peco-t- S7— i?Pu Ot w✓ j ..til Gt G/ 6Y2 Alt. TeL No.: 7 036 7 OWNER'S INSURANCE WAIVER: 1 am aware thatIfte Licensee d6es not have the liability insurance coverage normally required by law. By my signature below, l hereby waive this requirement. 1 am the (check one) ❑ owner ❑ owner's a ent. Owner/Agent Signature Telephone No. PERMIT FEE. $ 'Dlf _r w4 Location No. 4 Date Z 1673 ~��TN TOWN OF NORTH ANDOVER F ` Certificate of Occupancy $ Building/Frame Permit Fee $ ARD►� Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # /0 6, 16 i 7 8 Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAI RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: `/a DATE ISSUED: SIGNATURE: Building Commissioner/InEeEtor of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: U& �ore�i SI �2ee,� 1.2 Assessors Map and Parcel Number: ✓rev �d i� 9 Map Number Parcel Number 1.3 Zoning Information: 'Zoning District Proposed Use 1.4 Property Dimensions: Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide R 'red Provided R red Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: Public ❑ Private ❑ - Zone Outside Flood Zone ❑ 1.8 Sewerage Disposal System: Municipal ❑ On Site Disposal System ❑ SECTION 2 -PROPERTY OWNERSHIP/AUTHORIZED AGENT Historic District: Yes NO 2.1 Owner of Record tlh�y�nas OV -O l-Gtuy�e Q`Co1�t�b� 'lZr� orP�} v N�Y�1G� o �Y Mfg Name (Print) Address for Service rA r-- 1 Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Licensed Construction Supervisor: Address'. Signature Telephone Not Applicable License Number Expiration Date 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Address - Expiration Date Si nature Telephone ou M Z O J� i r 0� O z M 90 ic r M r z G) SECTION 4 - WORKERS COMPENSATION (M.G.L C 152 6 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building it. Signed affidavit Attached Yes .......❑ No ....... ❑ SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building 3. Repair(s) ❑ Alterations(s) Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: 616h SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed b t a licitr' x ^ ° i C 'U t 1 k W; 'U.0 � r ' 1. Building(a) 0 C�O(� , Building Permit Fee Multiplier 2 Electrical 2-000, 00 (b) Estimated Total Cost of Construction 3 plumbing frraf—' , OQ Building Permit fee tel x tnl 4 Mechanical HVAC ^D 000. DQ 5 Fire Protection DO OD 6 Total 1+2+3+4+5) Ob 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, iq all matters relative to wor authorized by this building permit application. �t 1 � .�-- �) blue 1��✓' � 2bb3 Si Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 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 Print Name Signature of Owner/Agent Date NO. OF STORIES ' r6 iS Y1►aiK SIZE `l �6 y BASEMENT OR SLAB RD SIZE OF FLOOR TRVMERS 1 x 2 n 3 SPAN DIN ENSIONS OF SILLS A v, i x DIMENSIONS OF POSTS ; 't1 DMIENSIONS OF GIRDERS { x 10 °5 rf HEIGHT OF FOUNDATION THICKNESS I i Ye H LYlLel SIZE OF FOOTING n. rrn { • ? _ E Y -?t X MATERIAL OF CHININEY V� 0 IS BUILDING ON SOLID OR FILLED LAND Soca IS BUILDING CONNECTED TO NATURAL GAS LINE no FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits fri Boards and Departments having jurisdiction have been obtained. This does not relie the applicant and/or landowner from compliance with any applicable or requirements. *****************************APPLICANT FILLS OUT THIS SECTION ****: APPLICANT 0!1'1 —and I n u6e, PHONE LOCATION: Assessor's Map Number 1a`S Q PARCEL 42119 SUBDIVISION LOT (S) STREET Tn rP 51 51 Peej ST. NUMBER % Z ***'►`'`k****`***************'�**"`OFFICIAL USE RECOMMENDATIONS OF TOWN AGENTS: CONSERVATION ADMINISTRATOR DATE APPROVED DATE REJECTED COMMENTS s� TOWN PLANNER COMMENTS DATE APPROVED DATE REJECTED FOOD INSPECTOR -HEALTH DATE APPROVED { /'1 _ _ ,. DATE REJECTED INSPECTOR -HEALTH DATE APPROVED. DATE -REJECTED PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9197 jm 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: IIXI of Facility) 11 7, Signature of Permit Applicant 5, 2t)Do-- Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector i� Fireplace o a F; c� N iv 0" N �I —.P— Q � r -9 O � O o 0 0 a N �I —.P— Q = ++ ❑ � o O ym o N O down up Q. mn 0 � o 0 ❑ W = c. C1 3 A• 1 M p O O O n n � 2 O m t�OL n p O a1 CXN N O C .�. O a CL a O Q + m aigel �, o 6uiplol z �1 O JI A CL a fp N � obi �D �D CL a 'O o =r O O 3 w w p ic C W �D m � IL7 _ ic �\ =r0) O 090 3 , 0, = ++ ❑ � o O ym o N O down up Q. mn 0 � o 0 ❑ W = c. C1 3 A• 1 M p O O O n n � 2 O m t�OL n p O a1 CXN N O C .�. O a CL a O Q + m aigel �, o 6uiplol z �1 O JI A CL a fp N C �D �D CL a 'O o O O 3 11 3 Landmark Insurance 97EI9753987 11/12/03 03:SOpm P. 002 AcORID CERTIFICATE OF LIABILITY INSURANCE mF bATE,MMIDDTYn Ex 1 11/12/03 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Landmark Insurance Agency, Inc HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 198 Mas achuaettC Avenue ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW - North Andover MA 01845-4190 Phone:978-688-8829 Pax:978-975-3987 INSURED Sheehan Co. 8 Merrimack Meadows Lane Tewksbury MA 01876 I COVERAGES INSURERS AFFORDING COVERAGE INSLIRFRA: A.I.M. Mutual Ins Company INSURFR B National Grange Mutual _ ....._..._.......... — -- IINSURER G: 1 INSURER D i INGQRER G --_-- TME 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 WITM RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INGURANCF AFFORnF0 nY TI tr FOI IC:If nI7!,f,:RInrn I IfRCIN Y_S 3UBJECT TO ALL THE TERN", EXCLUSIONS AND CONDITIONS OF SUCH POLICIEG. AGGRCGATC LMITO 01 ]OWN MAY 1 UVC DEEN RCDUCCD 13Y PAID CLAId13. I00LTR TYPE OF INSURANCE POLICY NUMBER OATE MM/DDIYY DATE MMtDDfA- _- " -- LIMITS GENERAL LIABILITY EACHOCCURRENCE 1—$1000000 $ X COMME-RCIALGENERALLIABILrtv MPI17025 12/04/02 12/04/04 FIRE DAMAGE (Anyamfire) S 500000 CLAIM.; MAO,- X OCCUR MM' F_XP (Any one pmon) 12 X Business-OwnerB MPI17025 12/09/02 12/04/04 PERRONALAADV INJURY 151000000 _..------._... .. CtNERAL AGCJiECATE -......,... ,. .. z2000000 ., CEN'L AGGRECATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG .,...._.....-. $ 2000000 POLICYECT LOC AUTOMOBILE LIABILITY COMBINED.$INGLE.LIMIT $ ANY AUTO (Ee ACCWe4 ALL OWNED AlIT03 900ILv INJURY S RCHEDULEO ALrTOS (Per person) HIRED AUTOS GODLY IN.Il)RY 5 NON -OWNED AU110S (Pet weidem) PROPERTY DAMAGE 5 (Prr arn;&A GARAGE LIABILITY AUTO ONLY - EA ACCIDENT S OTHER THAN EA ACC Z ANY AUTO — AUTOONLY: AA0 S EXCESS LIABILITY EACH OCCURRENCE $ OCCUR P AIMS MADE ACCRFGATF S S .. DEDUCTIBLEE ( i_ _ RETF_NTION 2 �- 3 WORKERS COMPENSATION AND X TORY LIMITSER A EMPLOYE .7 LIABILITY AWC7011776012D03 01/09/03 01/09/09 E.L. EACH ACCIDENT 8100000 Fl.OISEASE-EAEMPLOYE f 100000 E.L. DISEASE - POLICY LIMIT 5 500000 OTI/ER 1--1-1-1 -11IVIWI♦GfIIVLC.I.UVLVOW001-1C Ol LPIW 1111 111111111 MU1111VIII CERTIFICATE HOLDER N I ADDITIONAL INGRIED. INSURER LETTER: CANCELLATION 0000000 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TME EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL -Q-- DAYS WRITTEN Tom O'Connor NOTICE TO THE CERTIFICATE MOLDER NAMED TO THE LEFT- BUT FAILURE TO 00 30 SHALL 729 Forest St IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER. ITS AGENTS OR North Andover MA 01845 REPRESENTATIVES. AU ! REPR/SENTATIVE ACORD 25S (W) 0 Town of North Andover Building Department 27 Charles Street North Andover MA 01845 Tel: 978-688-9545 HOMEOWNER LICENSE EXEMPTION Please print. DATE NMYY)�W ly, Zen 3 JOB LOCATION �Z ✓Ps} Nt)Y-" A 11p1bV-er Number Street Address Section of Tc "HOMEOWNER 7R� �OYesi- 64. 9%-&Sj-Sfs,57D 9-) dl'gjS-0 Number r� Home Phone , , ,n Work Pho PRESENT MAILING ADDRESS I Z� YPS S') ND)Lik/' n d b" Al plays City Town State Zip Code The current exemption for "homeowners" was extended to include owner -occupied dwellings of 1 or 2 units and to allow such homeowners to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor. (State Building Code Section (108.3.5.1) DEFINITION OF HOMEWOWNER: Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which of two there is, or is intended to be, a one family dwelling, attached or detached structures accessory to such use and and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner" shall submit to the Building Official, a form acceptable to the Building Official, that he/she shall be responsible for all such work performed under the building permit. (Section 108.3.5.1) The undersigned "homeowner" assumes responsibility for compliance with the State Building Code and other Applicable codes, by-laws, rules and regulations, The undersigned "homeowner" certifies that he/she understands the Town of No. Andover Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and retirements. HOMEOWNER'S SIGNATURE(/l, J AA_t __1 t APPROVAL OF BUILDING OFFI Note: Three family dwelling 35,000 cubic feet, or larger, will be required to comply with State Building Code Section 127.0 Construction Control. Revised 4.30.03 Home owner Exemptions Form Dec 15 03 09:25a D.F. Clark Inc. 978 356 5500 p.l TITTLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSL SYSTEM FORM PART A CERTIFICATION Property Address: 728 Forest Street North Andover, MA 01845 Owner's Name: Thomas & Laurie O'Connor Owner's Address: 728 Forest Street North Andover, MA 01845 Date of Inspection: December 9, 2003 Name of Inspector: (please print) George Norris Company Name: D.F. Clark, Inc. Mailing Address: P.O. Box 265, Ipswich, MA 01938 Telephone Number: (978)356-5638 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 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: X Passes Conditionally Passes Needs Further Evaluation by the Local Approval Authority Fails Inspector's Signature:--E"r�` IJP4, LJ Date: X% Q 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. Notes and Comments ****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. Title 5 Inspection Form 6115100 page 1 Dec 15 03 09:25a D.F. Clark Inc. 978 356 5500 p.2 Page 2 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 728 Forest Street North Andover, MA 01845 Owner: Thomas & Laurie O'Connor Bate of Inspection: December 9, 2003 Inspection Summary: Check A, B, C, D or E I ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure conditions described in 310 CMR 15303 or m 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. Answer yes, no or not determined (Y, N, ND) in the 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 exfiltration 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 ifa Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: 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 _ obstruction is removed distribution box is leveled or replaced ND explain: 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): ND explain: broken pipe(s) are replaced obstruction is removed 2 Dec 15 03 09:25a D.F. Clark Inc. 978 356 5500 p.3 Page 3 of l I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 728 Forest Street North Andover. MA 01845 Owner: Thomas & Laurie O'Connor Date of Inspection: December 9 2003 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 15303(l)(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 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 aseptic 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 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, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Dec 15 03 09:25a D.F. Clark Inc. 978 356 5500 p.4 Page 4 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 728 Forest Street North Andover, MA 01845 Owner: Thomas & Laurie O'Connor Date of Inspection: December 9, 2003 D. System Failure Criteria applicable to all systems: You must indicate either `yes" or "no" to each of the following for all inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert duc to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6" below invert or available volume is less than '/Z day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s) Number oftimes pumped X Any portion of the SAS, cesspool or privy is below the high ground water elevation X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply X Any portion of a cesspool or privy is within a Zone 1 of a public well X Any portion of a cesspool or privy is within 50 feet of a private water supply well X 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from the facility 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 he attached to this form.] No (YeWNo) The system AUL i have determined that one or more ofthe 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, large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. 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) 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 scnsitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone 11 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 15304. The system owner should contact the appropriate regional office of the Department. Dec 15 03 09:25a D.F. Clark Inc. 978 356 5500 p.5 Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPEC'T'ION FORM PART B CHECKLIST Property Address: 728 Forest Street North Andover, MA 01845 Owner: Thomas & Laurie O'Connor Date of Inspection: December 9.2003 Check if the following have been date: You must indicate gees' or "no" as to each of the following: Yes No X — Pumping information was provided by the owner, occupant, or Board of Health X Were any of the system components pumped out in the previous two weeks? X _ Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? X _ Were as built plans of the Nysten obtained and examined? (If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out? X _ Were all system components, excluding the SAS, located on site? X _ Were the septic tank manholes uncovered, opened, and the interim 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? X _ 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: Yes No X — Existing information. For example, a plan at the Board of Health - X ____ Determined in the field (if any of the failure criteria related to Part Cis at issue approximation of distance is unacceptable) [3 10 CMR 15.302(3)(6)] 5 Dec 15 03 OS:26a D.F. Clark Inc. S78 356 5500 p.6 Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 728 Forest Street North Andover, MA 01845 Owner: Thomas & Laurie O'Connor Date of Inspection: December 9 2003 FLOW CONDITIONS RESIDENTIAL 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 Number of current residents: 7 Does residence have a garbage grinder (yes or no): No Is laundry on a separate sewage 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, if available (last 2 years usage (gpd)): Well Water Sump Pump (yes or no): No Last date of occupancy: Currently Occupied COMMERCIA WINDUSTRIAL Type of establishment: Design flow (based on 310 CMR 15.203): gpd Basis of design flow (seats/persons/sglt, etc.): 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 reading, if available: Last date of occupancy/use: OTHER: (Describe) GENERAL INFORMATION Pumping Records Source of information: Svstem was last pumped SprinatSummer 2003 accordine to owner Was system pumped as part of inspection (yes or no): No If yes, volume pumped: _gallons — How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM X Scptic tank, distribution box, soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Innovative/Altemative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) Tight Tank Attach a copy ofthe DEP approval Other (describe): Approximate age of all components, date installcd (if known) and source of information: System was installed in 1984 according to homeowner Were sewage odors detected when arriving at the site (yes or no): No Dec 15 03 09:26a D.F. Clark Inc. 978 356 5500 p.7 Page7ofII OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 728 Forest Street North Andover. MA 01845 Owner: Thomas & Laurie O'Connor Date of Inspection: December 9, 2003 BUILDING SEWER (locate on site plan) Depth below grade: 25" Material of construction: X cast iron 40 PVC _ other (explain): Distance from private water supply well or suction line: 18' Comments: (on condition of joints, venting, evidence of leakage, etc.): Building sewer pipe is in god condition no evidence of leakage. SEPTIC TANK: _ es (locate on site plan) Depth below grade: 16" Material of construction: X concrete _metal _ fiberglass polyethylene other (explain) If tank is metal list age_ Is agc confirmed by a Certificate of Compliance (yes or no): (attach a copy of certificate) Dimensions: 5' W x 8'L x 4' D Sludge depth: I" Distance from top of sludge to bottom of outlet tee or baffle: 33" Scum thickness: 0" Distance from top of scum to top of outlet tee or baffle: N/A Distance from bottom of scum to bottom of outlet tee or baffle: NIA blow were dimensions determined. Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet and outlet bathes are in olaoe, liquid level is normal, tank is in good condition with no sign of leakage. GREASE TRAP: No (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 ofoutlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Dec 15 03 09:26a D.F. Clark Inc. 978 356 5500 P.8 Page 8 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 728 Forest Street North Andover. MA 01845 Owner. Thomas & Laurie O'Connor Date of Inspection: December 9.2003 TIGHT or HOLDING TANK: No (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: eallonstday Alarm present (yes or no): Alarm level: Alarm in working order (yes or no): Date of last pumping: Comments (condition of alarm and float switches, etc.): DISTRIBUTION BOX: Yes (if present must be opened)(locate on site plan) (Depth below grade = 25") Depth of liquid level above outlet invert: _" 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.): Distribution is eflual, no evidence of solid carryover, d -box is in good condition. PUMP CHAMBER No (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): Dec 15 03 09:26a D.F. Clark Inc. 978 356 5500 p.9 Page 9 of 1 I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 728 Forest Street North Andover, MA 01845 Owner: Thomas & Laurie O'Connor Date of Inspection: December 9, 2003 SOIL ABSORPTION SYSTEM (SAS): Yes (locate on site plan, excavation not required) If SAS not located explain why: Type _leaching pits, number: _leaching chambers, number _leaching galleries, number. X leaching trenches, number, length: 7 leach trenches — 50' lone _leaching fields, number, dimensions: _overflow cesspool, number: _innovativetaltemative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): SAS is under side yard and under snow, inspected SAS with a vides inspection camera and found no sign of hydraulic failure. CESSPOOLS: No (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 or no): Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): PRIVY: No (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.): Dec 15 03 09:26a D.F. Clark Inc. 978 356 5500 p.10 Page 10 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 728 forest street North Andover, MA 01945 Owner: Thomas & Laurie O'Connor Date of Inspection: December 9, 2003 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 fleet. Locate where public water supply enters the building. r 5 Forest Street 10 Dec 15 03 09:27a D.F. Clark Inc. 978 356 5500 p.11 Page 11 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 728 Forest Street North Andover, MA 01845 Owner: Thomas & Laurie O'Connor Date of Inspection: December 9. 2003 SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated depth to ground water _feet Please indicate (check) all methods used to determine the high ground water elevation: X Obtained from system design plans on record — If checked, date of design plan reviewed: _ Observed Site (abutting property/observation hole within 150 feet of SAS) _ Checked with local Board of Health -explain: _ Checked local excavators, installers— (attach documentation) Accessed USGS database -explain: You must describe how you established the high ground water elevation_ Bottom of SAS is 41" below grade. 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