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HomeMy WebLinkAboutMiscellaneous - 75 CROSSBOW LANE 4/30/2018 (3)"'Ooew I Si/.3� �G�'�° n �` �� � �� � y� P r �� �� -�-_ Date ......73..':. � -3..'. 1.� TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that.............................�i16, 7— has permission to perform ............. �l ��,¢i/tul/.�t........... .......................... wiring in the building of ..............J.. 4141 C.... ............................................................... gat......../....SC v � ®C( .......... �.1................. . orth Andover, Mass. -o Fee../..Z, .." ....�... Lic. No...``'.�..,,.......................�.,CCll...................,..... ELFT TRICAL INSPECTOR Check # 2-(2 le ,�\- - Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. Occupancy and Fee Checked [Rev. 1/07] (leave blank) APPLICATION FOR PERMIT TO PERFORM .ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (ME ), 52 CMR 12.00 (PLEASE PRINT I7V. fl VK OR TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVER To the Inspeclor of Wires: By this application the undersigned gives notice of his or her intentipn to perform the electrical work described below. Location (Street & Number) Owner or Tenant Owner's Address SS 19c)w 4 1., �q 2 Telephone No. Is this permit in conjunction with a building permit? Yes ❑ No Purpose of Building .51 h G )-f Utility, Existing Service Amps / Volts Overhead ❑ New Service Amps / Volts Overhead ❑ Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: ; ,/1 A r � 0 (Check Appropriate Box) Luthorization No. Undgrd ❑ No. of Meters Undgrd ❑ No. of Meters No. of Recessed Luminaires -111 ---- —.... the uttuwin No. of Ceil: Susp. (Paddle) Fans tante may oe watvea Dy the inspector oy Wires. No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- ElIN o -Emergency ig mg rnd. rnd. Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No, of Switches No. of Gas Burners No. of Detection and Initiating Devices ' No. of Ranges No. of Air Cond. TonsTota No. of Alerting Devices No. of Waste Disposers Heat Pump Number .Tons...._... KW No. of Self -Contained Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems:* - No. of Water 0.0 No. of Devices or E uivalent Heaters KW Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or E uivalent OTHER: �� Attach aaamonat aerau y aestrea, or as required by the Inspector of Wires. Estimated Value o lectrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE C GE: Unless waived by the owner, no permit for tlie 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 p t issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) ljd. I certify, under the ai penalti per'ury, that th info, , . 'non tlii _ a licati n E; true and tori rete FIRM NAME: Beet C C pp LIC. NO.: 6 Licensee: Signature LIC. NO.: (If applicable, a `exemp the li' nse number lin . Bus. Tel. No.' Address: ,QC n Ih (f Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security wor equires Department of Public Safety "S" License: Lie. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No.PERMIT FEE: $ -- ELECTRICAL PERLYJJ..I. NO. )WFy.0 ECRONJL�iJ.J' PORT: `� • . . -FJ1 AL!MS AC,TIOIii , - Passed' C ] . Failed j ] � Re-luspection required ($50.00) -• [ � Jnspectors' comments: (.inspectors' Signature •• no ixiitials) Date U 3, UMER GROUND ]NURCTIO': Passed •- [ ] Failed — [) Re -inspection required ($50.00) - [ ] Inspectors' comments: Cbspectors} Signature -no initials) Date D O OR TA.GN AM TO BE ED Off` AND LEFT ON SITE IF THE :AP. A TO BE INSPE CTUDISNOT ACCESSIBLE AND A RE WSPECTION• OF $50.0 0 IN TO BE CMGED. t a - � I. . -FJ1 AL!MS AC,TIOIii , - Passed' C ] . Failed j ] � Re-luspection required ($50.00) -• [ � Jnspectors' comments: (.inspectors' Signature •• no ixiitials) Date U 3, UMER GROUND ]NURCTIO': Passed •- [ ] Failed — [) Re -inspection required ($50.00) - [ ] Inspectors' comments: Cbspectors} Signature -no initials) Date D O OR TA.GN AM TO BE ED Off` AND LEFT ON SITE IF THE :AP. A TO BE INSPE CTUDISNOT ACCESSIBLE AND A RE WSPECTION• OF $50.0 0 IN TO BE CMGED. The Commonwealth of Nlassachusetts - ____�_ De,Oartment of Xndifshi.l A.ccid&fs Office of Ifivesfigaflons 600 Wffshington. Street Boston, M'A. 02.11.1 U1 www mass goMdia Worke& Compensation bsurance Affidavit: Buffders/Contractors/Elect] iciansIPlwmbers Please Print LedbX� Name (Businesslorganization/lndividual): Cxiv/State/Zip: Phone #: Are you an. employer? Check the appropriate box: d'• El I am a general contractor and 1 1. ❑ 1 am a employer with _____-_... employees full. and/or art tame).* p have hiredthe sub -contractors 2, [] I am a sole proprietor or Partner- listed on the attached sheet. esub-contractors have ship and have no employees working for me in any capacity. -workers' comp. insurance. [No workers' comp. Insurance 5. El are a corporation and. itsOfffGerg ofi7cers have exercis ed their required.] 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers comp. c. 152, § 1(4), and we have no employees. LNO workers' j insurancerequixed.] i comp. insurancexequired_I Type ofproject (required): d. [] New construction 7. [] Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.[1 Electrical repairs or additions 11. F1 Plumbing, rep aim or additions M EI. Roof repairs 13.[1 Other Any applicant fhat checks box#k1 must also fill out the section below showing their workers' compensation policy information. Homeowners who submit flus affidavit indicating they ifro doing all work and then hire outside contractors must submit a new affidavit indicating such. !Contractors that checkthis box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. Y am an employer that is providing workers' compensation insurance for my employees: Belo>v is the policy anti job site information. Insurance Company Name:. Policy # ox Self --ins. LIG. #: Expiration Date: sob Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration. page (showing the policy number and expiration date). 25A of MG Failure to secure coverage as required under Section L 0.152 can lead to the imposition of criminal penalties of a fine up to $1,500!00 and/or one-year Imprisonment, as well as civilpenalties in the form of a STOP WORD ORDER and a fine of p to $250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office" of Indestigations of tiro D7A for insurance coverage verification. Ilk 11 Y go riereby certo under tree pains and venalties ofpeyjury that the informationprovided above is true and correct. nate* Si aiure: Phone #- Official use only. Do not write in triis area, to he completed by city or town official. City or Town Permit/License Issuing Authority (circle one): 1. Board of health 2. Building Department 3. CitylTown Clerk d. Electrical Inspector 5. Plumbing Inspector° fi. Other - y PhoneContact Person: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,- express hire,-express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two ormore of the foregoing engaged in a joint enterprise, and including the legal representatives of a•deceased employer, or to receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be. deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or p ermit to op erate a business or to construct buildings in the commonwealth for any applicant who has not produced -acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political. subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the cgntracting authority." Applicants Please fill, out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phonenumber(s) alongwiththeir certificates) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, apolicy is required. Be advised that this affidavit maybe submitted to the Department of Tndustrial Accidents fog confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain. a workers' compensation policy, please call the Department at the number listed below. Self insured companies should enter their self-insurance license number on the appropriate line. ` City or Town Officials Please be sure that the affidavit is complete andprinted legibly. The Departmenthas provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy infommtion (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town.)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as pro of that a valid affidavit is on file for future p ermits or licenses. A new affidavit must be filled out each year. 'Where a home owner or citizen is obtaining a license ox permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and shpuld you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: Tho CQUUA0xWwe41th of Vfusa ohwev ts� Depat1.eul: ofh?dwWax ,A,ccidolits, Offloe of fAvestigAtims. • 60 Wa &a SKoet 13wtoni. 02111 Tel, # 617-7.2,7-490 ext 406 ox- I-877-MASSAFE Revised 5-26-05 Fax# 617"727-7 749 RA�.._: x +f f/%/ ryt:llil Vie �..• 4. 19 WNW,/ -ff 75 Crossbow Lane North Andover, MA 01845 March 19, 2015 Juba Electric Company 589 Chickering Road North Andover, MA 01845 Dear Stephen, Thank y'ou very much for your quick service to replace the meter socket after it was damaged. I understand that we have paid for that work, in full, including the work remaining to be done on that project, such as installing the ground rods. We understand that you will complete that work and at the conclusion of that work, the electrical permit for that work should be closed out. Please don't forget to send us a copy of the completed permit. As my husband indicated to you at the town office, we are electing at this time to not proceed with the circuit panel move until we can properly prepare for that and set aside the appropriate space for that. Again your help was appreciated. Give my regards to Cheryl. Sincerely Nancy Flant Juba Electric Company, Inc. Electrical Contractors 589 Chickering Road. North Andover, MA 01845 (978) 683-8831 . (978) 689-8784 smjuba@aol.com P Pt I Nancy Flanz 75 Crossbow Lane No. Andover Ma. 01845 Invoice Invoice # 3/13/2015 B15-3-22 Terms Due on rec... Job Description 3/11/2015—Emergency service - Checked out damage to 200 amp meter socket, wait for National Grid to shut down power. ( Power not disconnected that day) Picked up proper UG 200 amp meter socket, inter bonding bar, and material needed to complete job. 3/12/2015 Replaced meter socket, installed interbonding system and wire for two future ground rods to be installed. 'Town of No. Andover electrical permit. # 13155 Labor Mike/Brett-Steve--Labor 855.00 Material & Tax 138.30 Permit Fees Town of No. Andover electrical permit # 13155 125.00 Credit Card Payments Accepted: Name on card: Check One: MC Visa — Discover — Expiration Date: Cavi #: 3 -digit security code Please include e-mail address with payment: Payments/Credits $-1,118.30 "No Job Too Small, Give Us A Call" Est. 1923 Total Due: $0.00 (1HN:S:URANCE OMPANY July 31, 2013 Building Commissioner or Inspector of Buildings 120 Main St North Andover, MA,01845 RE: Insured: Jacob B Flanz Property Address: 75 Crossbow Ln Claim Number: 2013072402901 Policy Number: 5A268831-11 Date of Loss: 07/18/2013 Form of Notice of Casualty Loss to Building Under Massachusetts General Laws Chapter 139, Sec. 3B Claim has been made involving loss, damage or destruction to the above captioned property, which may equal or exceed $1,000 or cause Massachusetts General Laws, Chapter 143, Section 6 to be applicable. If any notice under Massachusetts General Laws, Chapter 139, Section 3B is appropriate, please direct to the attention of the undersigned and include a reference to the captioned insured, location, policy number, date of loss and claim or file number. On July 31, 2013, copies of this notice were sent by first class mail to the entities and addresses noted herein. Sean Pedersen Claims Specialist 75 Sam Fonzo Drive Beverly, MA 01915 800.227.2757 www. Electricinsurance.com 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance-with the provisions of M.G.L. c. 143, § 3L, the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed on the prescribed form. Atter a permit application has been accepted by an Inspector of Wires appointed pursuant to M. GI c. 166, § 32, an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shall-be limited as to the time ofongoing construction activity, and maybe—deemed—by the .Inspector_of_Wires abandoned_and_invalid.ifhe—_.. _ or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. f The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections.74 and 75 of Chapter 238 of J the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With i limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending'through August 15, 2012. ule — Permit/Date Closed: Note: Reapply for new permit 0 Permit Extension Act — Permit/Date Closed: Date...../.Z--- /-5-- // ...................... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ..... ......... ........................................ has permission to perform ......... kv.cl ...................................... wiring in the building of ............ .... .. %'/.7..,. ........................................ at ...... North Andoveip Mass. ........ 1101 Fee :,5 Lic. No. 914o' - ICA. -iMP" Check # 10535 elmr=nweaflh o` Maijachajelb 2eparinrenl of Jim �erviced BOARD OF FIRE PREVENTION REGULATIONS official Use ot;ly Permit No. /2�7 Occupancy and Fee Checked Rev. 11/991 APPLICIATIOwork tohN�eFORt accordance JS PERMIT TOPERFORM ELECTRICAL WORK s Electrical Code (NIEQ) 527 CNIR 12.00 (PL C.1SC PRINT 1N INK OR TYPE AL1.1NT'ORM 17.70M llatc:_1 / ra City or "Town 0�+�) To the Inspector of FYires: By this application the undersigned gives notice of his or her intention to per rm the elecrrical work described below. Location (Street ,& Number)' �_�' � .0 s S 4�d �� � � t\J 0 A 1 � /j v Owner or Tenant N r� N C Y /' Z r1 n3 Owner's Address <n im f Telephone No. Is this permit in conjunction with a buildinb permit? Yes ©''� No I ❑ (Check Appropriate Box) Purpose of BuildingPJ �� UJ 1 n 1 N G Utility Authorization No. Existing Scrvicc l / O Amps Volts Overhead' l ► Q ndgrd ❑ 1\0. of Alctcrs New Service Anips / Volts Overhead Q Undgrd ❑ No. of Meters of Feeders and Ampacity Location and Nature of Proposed Electrical Rork:r<frii 2 �, � Completion ofiIle falli,u•inn !nh/o .,..... 1......_:.._., No. of Recessed Fixtures •------- ....�•� No. of coil: Susp. (Paddle) Fans ••+••roc .urvcu VYl1lC/ll Otal r O/ Wires. 1 0. of Transformers KVA No. of Lighting Outlets No. of Ilot Tubs Generators KVA No. of Lighting Fixtures Sivimming Pool Above ❑ Lt- ❑ o. o mergency Lighting find. rnd. Batte Units ZFIRE ALARMS No. of Zones No. of Receptacle Outlets No. of Oil Burners No. of Switches No. of Gas Burners f Detection and Initiatin Devices No, of Ranges No. of Air Cond. rota! Tons No. of Alerting Devices No. of Waste Disposers Heat Pum umber Tons KW No. of Sclf-Contained Totals Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW ical Local Q IV untp Connection Other No. of Dryers Heating Appliances K�V Security Systems: No. o water No. of No. of No. of Devices or Equivalent Heaters KNV Signs Ballasts , Data 1� iring: No. of Devices or E uivalent No. Hydromassage Bathtubs No. of illotors Total I1P Telecommunications Wiring: No. of Devices or Equivalent OTHER: ntlaca additional detail 1i desired, or as required by the Inspector of {Vires. INSURANCE COVEILIGE: 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 0 -'(Specify:) I l''t (t L/ Estimated Value of Electrical Work: (When required by municipal policy.) (EFpiration Date) Work to Start: I certifj•, under the Inspections to be requested in accordance with IVIEC Rule 10, and upon completion. and penalties of perjury, that he it formation on this application is true and complete. FI101 NAA E:1 -1a C4 -r— 7rr1 / LIC. NO... Liccnsee:'e_—r Sj�,,,Abs,_Tj_� Signature 0/%% LIC. (If applicable, enter "e.r. nlpt " in the license number hlre.) Bus. Tel. i\o.: j7h-- dw Address: A.� % M&: �i/ All. Tel. No.: Wl O NER'S 1NSUIIANCE �tiAIVEII: I am aware that the Licensec does not have the babilily insurance coverage normally required by law. By my signalttte below, I hereby waive this requi Owucrrement. 1 am the (check one) E]�� oncr ❑ o�� ner'S agent. /r'l c Siguatw',c Telephone No.— Pj-R/111T F- E- S A The Commonwealth of Massachusetts ` Department of IndustrialAccidents " Office of Investigations I Congress Stree4 Suite 100 r Boston, MA 02114-2017 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers A>pnlicant Information Please Print Legibly Name (Business/Organization/individual): &{ W jc)�S /i ce _ �, �%fcr Address:_ i t( r K A v z l City/State/Zip: ` C0 I MIS,• 01 k -Q- 6 Phone #: 7 t�� wl oZ'dZ'7 J Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I Type of project (required): employees (full and/or part-time).* have hired the sub -contractors 6. E] New construction 2.0I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling fship and have no employees These sub -contractors have g, ❑ Demolition working for me in any capacity. employees and have workers' 9 ❑Building addition [No workers' comp. insurance required.] comp. insurance.$ P• 5. ❑ We are a corporation and its 10. ❑ Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their 11. ❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12. ❑ Roof repairs insurance required.] t c. 152, § 1(4), and we have no 13. ❑ Other employees. [No workers' comp. insurance reouired.l *Any applicant that checks box #1 must also 511 out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new'affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lib. #: (� is G S Expiration Date: 0 4 Job Site Address: City/State/Zip:_(�/1_ Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cern under the pains and penalties of perju that the information provided above is true and correct. Official use only. Do, not ivrite in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): 1. Board of health 2.' Building Department 3. City/Town Clerk 6. Other 4. Electrical Inspector 5. Plumbing Inspector Contact Person: Phone #: Location No. Z� Date 13 _p TOWN OF NORTH ANDOVER r•.o Certificate of Occupancy $ 4 Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee TOTAL Check # c)-,3 18560 �'---Building Ins for TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT RE PAI RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: 196 DATE ISSUED: SIGNATURE:04a4ze-f Building Coniinissioner/IEEESWrofBuildin Date SECTION 1- SITE INFORMATION 1.1 Propedy Address: c � J � SS 61c, 1.2 Assessors Map and Parcel Number: p L"A� .. ��j(i p Map Number Parcel Number 1.3 Zoning Information:' Zoning Distrid Proposed Use 1.4 Property Dimensions: Lot Area (so Frontage ft 1.6 BUILDING SETBACKS (ft) Front Yard Side Yard Rear Yard Regaired Provide Required Provided Required Provided 1.7 Water Supply M.G.L.C.40. 34) 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 77.rict: Yid J �:!n 2.1 Owner of Record ,Z 5 G �� S Name (Print) Address for Service /76 Signature Telephone 2.2 Owner of Record: Name Print Address for Service: y Signature Telephone SECTJQ* 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Licensed Construction Supervisor: Address _ 7 Z G 5 '% 2,!; S e Telephone Not Applicable ❑ License Number Expiration Date 3.2 Registered Home Improvement Contractor Company Name Not Applicable ❑ Registration Number Address 1 7�' ZCS Z ' S Expiration Date _91nature Telephone T M z 0 0 z M 90 0 M SHOWNz 0 SECTION 4 - WORKERS COMPENSATION (KG.L C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes .......0 No ....... 0 SECTION 5 Description of Proposed Work check alta cable New Construction ❑ Existing Building 0 Repair(s) Alterations(s) 0 T ddition ❑ Accessory Bldg. 0 Demolition 0 Other 0 Specify Brief Description of Proposed Work: ��j� _ - �/-r'� �� C KIK SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit applicant OFFICIAL USE ONLY 1. Building <-2 `7 . (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) x (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 2, Do Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, .—,.as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION as Owner/Authorized Agent of subject r property Hereby declare that the state nts and information on the foregoing application are Lrue and accurate, to the best of my knowledge and b w -Print 'Name Se,& L (�� Signature of Owner/Agent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 15 2` 3RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIMERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY 1S BUILDING ON SOLID OR FILLED LAND IS BUII.DING CONNECTED TO NATURAL GAS LINE I w O O FM4 I o O C� VV .n C A s� y O �> E Q :mac 3 m O A �ti .l Qu 111 ++ CL .€ .110 E c Ip ** ts CD mi vai �v E 0 Ag .mo � m3 MM C m W N W O ca ID ro mo CD CLC.) m m amc w o ci '0 c co c oa m r CL O C H HnC C _ m o 3 1V e.0 C W m r WCOL. OCt O C Z L .E ar O'o U O O o h a . �� g z ���=o z $aim' 5 W U) W W LU 19 W U) a a a Ju p Q. U A p o a: u W w G w" W W rs: w o a G w a cA o cn o cn o O C� VV .n C A s� y O �> E Q :mac 3 m O A �ti .l Qu 111 ++ CL .€ .110 E c Ip ** ts CD mi vai �v E 0 Ag .mo � m3 MM C m W N W O ca ID ro mo CD CLC.) m m amc w o ci '0 c co c oa m r CL O C H HnC C _ m o 3 1V e.0 C W m r WCOL. OCt O C Z L .E ar O'o U O O o h a . �� g z ���=o z $aim' 5 W U) W W LU 19 W U) y Sold To: ►V Au HIC Registration #129774 Federal ID #04-3277886 Pella Windows & Doors of Bo "Viewed to be the Be Boston St" DOOR CONTRACT Pella Windows & 1 45 Fondi Road Haverhill, MA 018, PH: (800) 866-988 Service: Ext. 124 Fax: (978) 556-03£ Sales: (866) PellaO PELLA IS NOT RESPONSIBLE FOR ANY EXISTING SECURITY SYSTEMS. SALESMAN HAS NO AUTHORIZATION TO CHANGE ANY ITEMS OR MAKE PLEASE REMOVE ALL SHADES, VERTICALS, BLINDS, CURTAINS, DRAPES ANY REPRESENTATIONS OTHERTHAN CONTAINED INTHIS AGREEMENT OR WINDOW MOUNTED AIR CONDITIONERS, PRIORTOTHE INSTALLATION AND "OWNER" REPRESENTS THAT NONE HAVE BEEN MADE TO OR OF YOUR NEW DOORS. INSTALLERS ARE NOT RESPONSIBLE FOR THE RELIED UPON BY "OWNER". YOU ARE ENTITLED TO A COMPLETELY REMOVAL OR INSTALLATION OF THESE TYPES OF ITEMS. FILLED IN CONTRACT SUBJECTTO FINAL INSPECTION BY PELLA CONSTRUCTION DEPARTMENT.DUPLICATE OF THIS AGREEMENT. TERMS AND CONDITIONS THAT GOVERN THIS CONTRACT ARE PRINTED ON THE REVERSE SIDE. This contract Is a legal document. your Pella products will be specially made-to-order for you. UNDER NO CIRCUiutSTe CA CELLATION BE POSSIBLE BEYOND THE THIRD BUSINESS DAY AFTER THE NCES WILL REVISIONS OR 9 LOw YOt] ARF At VK1 %1A11 or%^ . CONTRecT wec occ�� Pella Rep. Signature: i Date: Dustomer Signature: Date: 0'— White - Original Yellow - Customer' Pink -Store City: Jt1 �.�. '� Date: `b 115 State _ Job site Address (If different).- �.« `�`- Zip'(�� Phone (Home) (9h t Phone (Work) 1 ) Phone (Cell) ( ) YES NO Pella Boston Will Furnish and Install: E-mail: 32. 33. 0 ❑ 'a' tu"NMadu "" ""'^"" 'afuri diu u domny insurance maintainea Warranty mailed to customer on completion when full payment is received. Total Project Amount $ Z- 34. 35. ❑ •$ $ ❑ Financed If Yes: Amount Financed $ Deposit Received $ (Reference # ) 36. 37. $ ❑ ❑ 8' Balance on Substantial Completion $ _ 4 42:K2G_ Additional Comments: (Payment is payable to installer at completion of job) 5200LO t q� :. PELLA IS NOT RESPONSIBLE FOR ANY EXISTING SECURITY SYSTEMS. SALESMAN HAS NO AUTHORIZATION TO CHANGE ANY ITEMS OR MAKE PLEASE REMOVE ALL SHADES, VERTICALS, BLINDS, CURTAINS, DRAPES ANY REPRESENTATIONS OTHERTHAN CONTAINED INTHIS AGREEMENT OR WINDOW MOUNTED AIR CONDITIONERS, PRIORTOTHE INSTALLATION AND "OWNER" REPRESENTS THAT NONE HAVE BEEN MADE TO OR OF YOUR NEW DOORS. INSTALLERS ARE NOT RESPONSIBLE FOR THE RELIED UPON BY "OWNER". YOU ARE ENTITLED TO A COMPLETELY REMOVAL OR INSTALLATION OF THESE TYPES OF ITEMS. FILLED IN CONTRACT SUBJECTTO FINAL INSPECTION BY PELLA CONSTRUCTION DEPARTMENT.DUPLICATE OF THIS AGREEMENT. TERMS AND CONDITIONS THAT GOVERN THIS CONTRACT ARE PRINTED ON THE REVERSE SIDE. This contract Is a legal document. your Pella products will be specially made-to-order for you. UNDER NO CIRCUiutSTe CA CELLATION BE POSSIBLE BEYOND THE THIRD BUSINESS DAY AFTER THE NCES WILL REVISIONS OR 9 LOw YOt] ARF At VK1 %1A11 or%^ . CONTRecT wec occ�� Pella Rep. Signature: i Date: Dustomer Signature: Date: 0'— White - Original Yellow - Customer' Pink -Store t 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 at: Iis that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 11, S BO A. Also, note Permits are required under Fire Prevention laws Chapter 148 Section I 0A. The debris will be disposed of in: (Location of Facility) Fire Depdrtment Sign off. Dumpster Permit Signature of Permit Applicant Date a ✓/ze �am�nanui� a�.. `iaaaaclu�aeka BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 089839 Birthdate: 06/19/1972 Expires: 06/19/2008 Tr. no: 89839 Restricted: 00 SCOTT P HOUSE BROADWAY HA 0 _ HAVERHILL, MA 01832 Commissioner ✓/ze �omvinoouuea� a�.��.Czaaac/ivaP,l1L Board of Building Regulo:ions and Standards HOME IMPROVEMENT CONTRACTOR Registration: 129774 Expiration: 11/2/2005 Type: Supplement Card 1 PELLA WINDOWS AND DOORS SCOTT HOUSE 45 FONDI RD. _ HAVERHILL, MA 01832 Administrator m s Location No. Date ? iB Date -2 /.7 e1 ?.—' NaRTol TOWN OF NORTH ANDOVER 3? J o JL • ; ; Certificate of Occupancy $ baa',••°'�t�' Building/Frame Permit Fee $ sACMust Foundation Permit Fee $ ti Other Permit Fee $ jj TOTAL $ Check # �J j53'19 3'+i / Building Inspect 1.1 Property Address: 1.2 Assessors Map and Parcel Number: ?5 Cmss bow Lav) 2 re U [O b [3 zo$ 2.2 Owner of Record: NofnC u F A 0'7�- Name Print °7 75 C V?DSS bmw 1 ovvt o Address for Service: 97C-69 H-76 6 Signature Map Number Parcel Number SECTION 3 - CONSTRUCTION SERVICES 1.3 Zoning Information: Z A ©(L 1.4 Property Dimensions: Not Applicable A License Number Expiration Date 3.2 Registered Home Improvement Contractor Zoning Dial c ­t Proposed Use —01 Lot Area Frontage ft 1.6 BUILDING SETBACKS ft Registration Number Front Yard . Side Yard Rear Yard Required Provide Required— I Provided R red Provided 30 302-30 7.q O x-30 1.7 Water Supply M.G.L.C.40. 54) 1.5. Zone Flood Zone Information: Outside Flood Zone [( 1.8 Municipal Sewerage Disposal System: ❑ On Site Disposal System Public X Private ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record �R cnt3 F&A/,j z- Name (Print) la-CO8 Q ' 75 0,2)ssbow Liv, +P - Address for Service Q79-1991 re U Telephone 2.2 Owner of Record: NofnC u F A 0'7�- Name Print °7 75 C V?DSS bmw 1 ovvt o Address for Service: 97C-69 H-76 6 Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Licensed Construction Supervisor: s Address Signature Telephone Not Applicable A License Number Expiration Date 3.2 Registered Home Improvement Contractor Not Applicable Company Name Registration Number Address Expiration Date Signature Telephone SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes ...... K No ....... 0 SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ 1 Addition Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: )\dd1figr vvscJ Bg,&emP,4 , 14brgQ aoid, Att' r1los-e SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit applicant !:""OFFICIAL USE ONLY I. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing 6VV Building Permit fee (a) X (b) q 4 Mechanical HVAC 1 6zn7 5 Fire Protection 6 Total 1+2+3+4+5 D I &V -D Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, , as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION Col3 /) 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 JACO/- FLAN Print Name Signature erg /Agent! 9/0 Z -Date NO. OF STORIES o'Z SIZE ti 1000 s >F T BASEMENT OR SLAB f5a Se rnP„� SIZE OF FLOOR TIMBERS 1 6C1 l2 ' 2 ND BC -T- 12 3 SPAN /h 12-2-1 DIMENSIONS OF SILLS a)((, DIMENSIONS OF POSTS '/X ''-/ DIMENSIONS OF GIRDERS ,v /A HEIGHT OF FOUNDATION yL — 7 THICKNESS SIZE OF FOOTING /211 X MATERIAL OF CHININEY AJ /A IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE 0 0 2 FORM U .- LOT RELEASE FORM I 5,q 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_ as Cy PHONE ?6 LOCATION: Assessor's Map Number_((9 (o PARCEL & 0 SUBDIVISION LOT (S) STREET (2�\og5 ST. NUMBER S *****************************************OFFICIAL USE ONLY*********************************** CONSE ATION ADMiklir COMMENTS -2&4L TOWN PLANNER COMMENTS Fr INSPECT -HEALTH SEPTIC INSPECTOR-HEALTh COMMENTS Q e - TOWN AGENTS: n i,,., ,, — 77 TOR — DATE APPROVED 2 Z DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED d N,\,J5 A- .-T,(-qA -9,,v c Q` PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT �-C RECEIVED BY BUILDING INSPECTO Revised 9\97 im DATE 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 LOCATION: Assessor's Map Number �4/? DIVISION STREET_' 0�1 DSS J i� w PHONE f �8-bk/-1 7(, [ PARCEL 00 '9 ST. NUMBER �� *****************************************OFFICIAL USE ONLY*********************************** RECOMMENDATIONS OF TOWN AGENTS: CONSERVATION ADMINISTRATOR DATE APPROVED DATE REJECTED COMMENTS TOWN PLANNER COMMENTS, FOOD INSPECTOR -HEALTH PTIC INSPECTOR -H rh COMMENTS 1, AAA &�c ( e i � 5 DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED PUBLIC WORKS - SEWERIWATER CONNECTIO DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTO Revised 9\97 jm ,)10 �-- pt) -f- di".) -e DATE t c00% s ilk 00 EXISTING LEACH FIELD EXISTING ' 0 SEPTIC TANK ao1 o �F<<11V6 ADDITION PROPOSED C) 0C o� �o' C cV ^ LOT 7 = 48,553 S.F. tN 1.115 Ac. ��o �N 72 0 8.9 30 , V This is to certify that Benjamin C. Osgood, jr, Certified Title 5 Septic System Inspector has located the existing septic system as shown on this plan. f, name date PLAN%500 DRAWN BY. S.B. CHECKED y.S & B.C.O.jr SEPTIC SYSTEM LOCATION PLAN 75 CROSSBOW LANE NORTH ANDOVER, MASSACHUSETTS SCALE: 1 " = 50' FEB. 11, 2002 NEW ENGLAND ENGINEERING SERVICES, INC. 60 BEECHWOOD DRIVE NORTH ANDOVER, MASSACHUSETTS (978) 686-1768 NEW ENGLAND ENGINEERING SERVICES INC February 11, 2002 North Andover Board of Health Town Hall Annex 27 Charles Street North Andover, MA 01845 RE: TITLE V REPORT: 75 Crossbow Lane, North Andover, MA Dear Sirs: Enclosed is a copy of the Title V report for the above referenced property. The system PASSED our inspection. If there are any questions please call me at my office, 686-1768. Sincerely BenJa2m C. Osgoo, Jr. 60 BEECHWOOD DRIVE - NORTH ANDOVER, MA 01845 - (978) 686-1768 - (888) 359-7645 - FAX (978) 685-1099 is North Andover Building Department DEBRIS DISPOSAL FORM Tel: 978-688-9545 In accordance with the provision of MGL c 40 S 54, a condition of Building Permi Number is that the debris resulting from this work shall be t disposed of in a properly licensed solid waste disposal facility as defined by MGL c 11, S 150 A. The debris will be disposed of in: (Location of Facility) ignature of Permi Applicant 1402 Date NOTE: Demolition, permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector D. Robert Nimtta Building Commissioner (978) 688-9545 •1978) 688-9542 Fax Town of North Andover Building Department 27 Charles Street North Andover, MA. 01845 HOMEOWNER LICENSE EXEMPTION Please print. DATE 0291D Z JOB LOCATION 75— Number "HOMEOWNER _ �/' V I� FLA N Name -rvss bow G I1 Street Address 1669 �2o9 Map / lot Home Phone Work PRESENT MAILING ADDRESS 75- CIvi-s-bocu L ti City Town rT State Dl e415 Zip Cc The current exemption for "homeowners" was extended to include owner -occupied: dwellings of two units or less 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 there is, or is intended to be, a one or two family dwelling, attached or detached structures ac- cessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be 'considered a homeowner. 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 requirements. HOMEOWNER'S SIGNATURE 6c 4X lY APPROVAL OF BUILDING OFFICIAL it The Commonwealth of Massachusetts Department of industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Please Print ACa8 ��RN� Location: 75 Cross bow 4Q n e orTh oUer- am a homeowner performing all work myself. 01 am a sole proprietor and have no one working in any capacity mel -1 7�4 I am an employer providing workers' compensation for my employees working on this job. Company name: Address City: Phone # Insurance Co. Policy # Comony name: Address City: Phone #• 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 well as civil penalties in the form of a STOP WORK ORDER and a fine of ($100.00) a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do herby certiry under the pains and penalties of perjury that the information provkkd above is true and correct S 112-R 10.2- Print name u �>g �C> g FLA N �7 Phone #�i� Official use only do not write in this area to be completed by city or town official' ❑Check frimmediate response is required Building Dept Contact person: Phone #: FORM WORKMAN'S COMPENSATION E] Building Dept El Licensing Board p Selectman's Office n Health Department ❑ Other U) m m U) U m y C � — d 'O O CD n Z CA CD o CL r,7� C CL = CO) CD o p CDCL o cr d CD CD o vv ov C O CO) CLop y CD y O 1 Z CD o CD 0 CD %-,) N :5 cw?,!�a W -i 0—y O Q y = no5m .cCL m cn d �y o cl _ ?.0 ti C2, to sa••c m •� CD ., m y .-► y CD O --I I CO y m n 0 a. CD :CE-� O p n W pCD C =rO C!7 c a =r VJ m CCD H C O C9 n Ofl1y:�: FA to ^ 1 CW ` m O dmcmi�J'V. O 0 Cc" 1 o z 0 w s� SCA to moCD LA C' C �o tTJ Co te cn p X- o cn , 0 ° w C w g; G 9 w tom"° w C r- w z G o rt CJ7 � r g )Nq 0 9 0 c all � o M p w o Mn CL M Z oaj -06ty W ��� M mo N Do-MO M m In 3 C:3 2. ;1 -0x H' o� �Q•zdo C� m 0 c1 � M�CD'O.. O > o cr c 3 _ a. 2. 0) CL 3 o H 2: --� g i < La n M= 3c Ln , a M� n O O �Oc ♦ '� O c rr > > C N O G O C E 5a To ?� ?. D r� D a CID � o N-' :ir Ix OM Q. m a" 3 c� ,� C➢ f m _ O ..A J►� < / a O M s r M r �� y o� Z M v o St y M C letc� o --I CD r a� H � i O O Cl, COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 7S- CeosSgpw 6•A�VL At o "? AAj D of m Owner's Name:, c� k 4Aj2 Owner's Address: -7 ; G R o 6513 p w j -q vk A/69,771 kub o u erg. A Date of Inspection: 2 (1 & - 2 Name of Inspector: (please print) e r; a,,,.,.,' � 4 ' 05 oofl J q- CompanyName.- lVGw "trj,4rjD C -1y& NvG Mailing Address: Coo j3 rZ- c y wovp D izi ul NO 2n -t A,,boo0z -1-4 Telephone Number: 97f3- 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 andcomplete as of the time of the inspection. The inspection was performed based on my training and egpaience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000 The system: ✓ Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: ,.z X4 Date: ;E////VZ 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. Page 2 of l l OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: _ 75 CROSSBOW LANE Owner: — NORTH ANDOVER, MA Date of inspection: NANCY FLANZ • — 2/11/02 Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D A. System Passes: �I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 3 W CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: M e or more system components as described in the "Conditional Pass" section need to be replaced or repaired. system, upon completion of the'replacement or repair, as approved by th/Board alth, will pass. Answer yes, no or not ermined (YNND) in the for the following statements.ined" please explain. The septic tank is metal an ver 20 years old* or the septic tank (wh metal or not) is structurally unsound, exhibits. substantial infiltrati or exfiltration or tank failure is ' ent. System will pass inspection if the existing tank is replaced with a complyin tic tank as approved by theoard of Health. *A metal septic tank will pass inspection if i ' structurally sound, no Baking and if a Certificate of Compliance ' indicating that the tank is less than20 years old available. ND explain: Observation of sewage backup or break out obstructed pipe(s) or due to a broken, settledor approval of Board of Health): ^gyp^�•�(s) are replaced is removed box is leveled or ND explain: igh is water level in the distribution box due to broken or distribu ' n box. System will pass inspection if (with The system req ed pumping more than 4 times a year due to broken or pass inspection if (vfiffi approval of the Board of Health): broken pipe(s) are replaced obstruction is removed ND explain: pipe(s). The system will Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: _ 75 CROSSBOW LANE Owner: — NORTH ANDOVER, MA Date of Inspection: NANCY FLANZ 2/11/02 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. 1 System '11 pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is n functioning in a manner which will protect public health, safety and the environment: _ Cesspool or rivy is within 50 feet of a surface water/ra I _ Cesspool or is within 50 feet of a bordering vegetsh 2. System will fail unless the Board o ealth (and Pablic Wdeterminesthat'the system is functioning in a manner that pr acts the public shement: _ The system has a septic tank and soil absbTtionem (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface watq soply. The system has a septic tank and SAS and e S is within a Zone 1 of a public water supply. _ The system has a septic tank and S and the SAS is in 50 feet of a private water supply well. The system has a septic tank SAS and the SAS is less th 100 feet but 50 feet or more from a private water supply well**. M od used to determine distance **This system passes if th ell water analysis, performed at a DEP certi laboratory, for coliform bacteria and volatile or is compounds indicates that the well is free from llution from that facility and the presence of amm is nitrogen and nitrate nitrogen is equal to or less than m, provided that no other failure criteria are ggered. A copy of the analysis must be attached to this form. 3. r Page 4 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: _ 75 CROSSBOW LANE Owner: - NORTH ANDOVER, MA Date of Inspection: NANCY FLANZ - 2/11/02 - - - -- D. System Failure Criteria applicable to all systems: You must indicate `yes" or "no" to each of the following for all inspections: Yes No ✓' Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool — ' Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6" below invert or available: volume is less than %s day flow _✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped f Any portion of the SAS, cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. _ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water I. supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP.certifed 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.] (Yes/No) The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system mustfF7" h a design flow of ;000 gpd to 15,000 gpd. You must in i e either `yes" or "no" to each of th (The following crit ply to large systems in adboyes nothe system is within 400 f a surfacey _ — the system is within 200 feet of a tri to a surface drinking water supply _ the system is located in a ogen sensitive area terim Wellhead Protection Area - IWPA) or a mapped Zone II of a public er supply well If you have answ 'yes" to any question in Section E the system is co dered a significant threat, or answered "des" in SeoKh D above the large system has failed. The owner or operator any large system considered a significant threat under Section E or failed under Section D shall upgrade the Sys in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Page 5 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: _ 75 CROSSBOW LANE NORTH ANDOVER, MA Owner: NANCY FLANZ Date of Inspection:. 2/11/02 Check if the following have been done. You must indicate "yes" or "no" as to each of the following: i Yes No Pumping information was provided by the owner, occupant, or Board of Health c� Were any of the system components pumped out in the previous two weeks ? ✓ Has the system received normal flows in the previous two week period ? Have large volumes of water been introduced to the system recently or as part of this inspection ? ✓ Were as built plans of the system obtained and examined? (If they were not available note as N/A) i Was the facility or dwelling inspected for signs of sewage back up ? i Was the site inspected for signs of break out ? — Were all system components, excluding the SAS, located on site ? v Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles br tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum ? _vl' Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems ? i The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Yesino 6/ Existing information. For example, a plan at the Board of Health. . / Determined in the field (if any of the failure criteria related to'Part C is at issue approximation of distance is unacceptable) [3 10 CMR 15.302(3)(b)] Page 6 of 11 x ti OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: _ 75 CROSSBOW LANE _ NORTH ANDOVER, MA Owner: NANCY FLANZ Date of Inspection: 2/11/02 _ FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): _�t__ Number of bedrooms (actual): q DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): G a Number of current residents: V_ Does residence have a garbage grinder (yes or no): AID Is laundry on a separate sewage system (yes or no): � [if yes separate inspection required] Laundry system inspected (yes or no): = Seasonal use: (yes or no): &a a• Water meter readings, if available (last 2 years usage (gpd)): Sump pump (yes or no): _a Last date of occupancy: Go r Devic COMMERCIAL/INDUSTRIAL Type of establishment: Design flow (based on 310 CMR 15.203): gpd Basis of design flow (seats/persons/sgft,etd.): Grease trap present (yes or no): _ Industrial waste holding tank present (yes or no): _ Non -sanitary waste discharged to the Title 5 system (yes or no): _ Water meter readings, if available: ' Last date of occupancy/use: OTHER (describe): GENERAL INFORMATION Pumping Records Source of information: l % g Pet 0 , v164 - Was 64 - Was system pumped as part of the inspection (yes or no):.LO If yes, volume pumped: gallons — How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM �( Septic tank, distribution box, soil absorption system _ Single cesspool _ Overflow cesspool _ Privy _ Shared system (yes or no) (if yes, attach previous inspection records, if any) _ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) Tight tank _ Attach a copy of the DEP approval — Other (describe): Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site (yes or no): lL/ Page 7 of 11 " i OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _ 75 CROSSBOW LANE —NORTH ANDOVER, MA Owner: NANCY FLANZ Date of Inspection: 2/11/02 BUILDING SEWER (locate on site plan) Depth below grade: 1$` Materials of construction: cast iron _40 PVC _other (explain): Distance from private water supply well or suction line: — Comments (on condition of joints, venting, evidence of leakage, etc.): t'� 4 L,00A S 6-009 gU e r, t SEPTIC TANK: _ (locate on site plan) Depth below grade: Material of construction: A�' amc rete _metal _fiberglass ___polyethylene _other(explain) If tank is metal list age: _ Is age confirmed by a Certificate of Compliance (yes or no): _ (attach a copy of certificate) Dimensions: J_v"00 Lo N 5 - Sludge Sludge depth: e " Distance from top of sludge to bottom of outlet tee or baffle: Z 8x Scum thickness: 0_ Distance from top of scum to top of outlet tee or baffle: (a Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: ,-n c n s o t�ts •n -cis Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): i R A) )1. I .y L) l k r ern D, C ©rjc /`C �C `iGc,> 1 ✓1 p ►I� ern �% GREASE TRAP: LirAocate on site plan) Depth below grade: _ Material of construction: concrete metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Page $ of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _ 75 CROSS80W LANE Owner: — NORTH ANDOVER, MA NANCY FLANZ Date of Inspection: _ 2/11/02 TIGHT or HOLDING TANK: kfi (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass _polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day 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: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): rJa:x�oa IA's (roti i2.__ 1% �5 i n��� 8n q ence uk,- l 14Dm2 110-Ao t, G- C o ., <4- C.^c PUMP CHAMBER: A14 (locate on site plan) i 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.): Page 9 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _ 75 CROSSBOW LANE — NORTH ANDOVER, MA Owner: NANCY FLANZ Date of Inspection:2/11/02 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required) If SASInot located explain why: Type ,. leaching pits, number: _ leaching chambers, number: leaching galleries, number: leaching tranches, number, length: beaching fields, number, dimensions: ! r<<E4 -9 Z�2' XV Z ` overflow cesspool, number: innovativelalternative system Typetname of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): I}-0, + or- rt C- i. --z, A,> ,uhltrh qL /V -Z:' �IDA/4 p s 6) t- d 2 .9,.!yay A- L' V a-G_C -IW-C7 D N i CESSPOOLS: 10 (cesspool must be pumped as part of inspectionxlocate 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: (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.): VJ.t">w Page 10 of 11 ; OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _ 75 CROSSBOW LANE NORTH ANDOVER, MA Owner: NANCY FLANZ Date of Inspection: _ 2/11/02 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 feet. Locate where public water supply enters the building.' II . Page 11 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:_ 75 CROSSBOW LANE - NORTH ANDOVER, MA Owner: NANCY FLANZ Date of Inspection: _ 2/11/02 SITE EXAM Slope Surface water_ Check cellar yo sv� Shallow wells Estimated depth to ground water feet Please indicate (check) all methods used to determine the high ground water elevation: 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 with local excavators, installers- (attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: �F2[A v� s sT�i+t R+tsrp 3 A.Oo � �G�vn CLC✓A7'+�N __OF Al2JAGLA/T' R6N p, �J A� P.d. n W.. 12 ow Iom• �D W. � � N x o O O N ¢' Owe O b O O Im+ o o+ P+ Oe mo Z 00 o2l qo 7w -J CD CDCD �l 9 L CD t� .ac -6K F7� ti q� w Q s 12'-7' O Owe � N O Ow'Owe N �Q O � �D P* �+ we O We follL x Oe O CD 0 iA, 26-11' il.01-.1 'R It -1111111111 -------------i - .-8 — .�.Si i 4 iA, 26-11' il.01-.1 'R It -1111111111 -------------i - .-8 — .�.Si Y N0 TFF� :SZk KAV R'00 •6 Oy QL vj10 M dy,9 4'gnr.nW�R"qq sSACNUs�� Zoning Bylaw Review Form Town: Of North Andover Building Department 27 Charles St. North Andover, MA. 01845 Phone 978-688-9545 Fax 978-688-9542 Street: Zoning Ma /Lot: Applicant: /ob /3 o 8 I 5�,fc 4Filibi6�F .i a e 0 6 F/,4A-J z Request: Item Notes Date: Dln�en No �.1........LSL....a . c__ yV11 mppi ration ana runs your Application is DENIED for the following Zoning Bylaw reasons: Zoning Item Notes Item Notes A Lot Area F Frontage 1 Lot area. Insufficient -T--Frontage Insufficient 2 Lot Area Preexisting ties 2 Frontage Com lies 3 1 Lot Area Complies 3 Preexisting frontage cl e- g 4 Insufficient Information :,4. Insufficient Information B Use 5 No access over Frontage 1 Allowed G Contiguous Building Area N A 2 Not Allowed 1 Insufficient Area 3 Use Preexisting 2 Complies 4 Special Permit Required _ 3 Preexisting CBA 5 Insufficient Information 4 Insufficient Information C Setback H Building Height 1 All setbacks comply 1 Height Exceeds Maximum 2 Front Insufficient 2 Complies 3 Left Side Insufficient 3 Preexistin Height 4 Right Side Insufficient Insufficient Information e S 5 Rear Insufficient � Building Coverage �A 6 Preexisting setback(s) 1 Coverage exceeds maximum 7 Insufficient Information 2 Coverage Complies D Watershed 3 Coverage Preexisting 1 Not in Watershed e. � 4 Insufficient Information 2 In Watershed j Sign 3 - Lot prior to 10/24!94 1 N/A Sign not allowed 4 Zone to be Determined 2 Sign Complies 5 Insufficient information 3 Insufficient Information E Historic District K Parking 1 In District review required 1 N More Parking Required 2 Not in district e S 2 Parking Com lies 3 Insufficient Information RemedY for the above is checked below. Item # Special fermis Plannin Board. item # Variance Site Plan Review Special Permit Access other than Fronta e S ecia! Permit C- Setback Variance Fronta a Exception- Lot S ecia! Permit Parkin Variance Common Drivevva Special Permit Lot Area Variance Hei ht Variance Con re ate Mous{n . S ecia! Permit Continuing Care Retirement Special Permit.1111Variance fo.r Si n Independent Elder! Housih S ecia! Permit Large Estate Condo Special Permit ------------------ .ecia) Permits Zonin Board S 1C, IJ Permit Non-Conformin Use MA Planned Develo meet Dist,{ct S. ecial..P.ecmit Earth Removal Special Permit ZBA Planned Residential Special Permit S ecia) Permit Use not Listed but Similar R-6 Densi S ecia! Permit S eciai Permit for Sign Watershed Special Permit Other The above review and attached explanation of such Is based on the plans, request for or Information submitted. No definitive review and or advice shall be based on verbal explanations by the applicant nor shall such verbal explanations by the applicant serve to provide definitive answers to the above reasons for this action. Any inaccuracies, misleading information, or other subsequent changes to the information submitted by the.applicant shall be grounds for this review to be voided at the discretion of the Building Department. The attached document titled "Plan. Review Narrative" shall be attached hereto and incorporated herein by reference. The building department will retain all..plans and documentation for the above file. Z'��r wilding Department Official Signature�`�� —a5 ��/ Application Received Application Deniwi Denial Sent: If Faxed Phone Number/Date: Plan Review Narrative The following narrative is provided to further explain the reasons for the action on the Property indicated on the reverse side; y ---------------- Conservation Zonin Board Plannin De artment of Public V Other Historical Commission Z4nin9BylawDenia12000 BUILDING DEPT N r Co .h . :�7 6S �� Se�6A�Ks O 00 Dc LOT 7 1,114 a 48,553 S.F. 1.115 Ac. 6000,� 13' S PROPOSED ADDITION This plan is the result of a survey performed by New England Engineering Services, Inc. based upon the approved subdivision plan recorded in the Registry of Deeds. '018 BY. SB & JE 'BY-EDBCOjr & JEF PROPOSED ADDITION 75 CROSSBOW LANE NORTH ANDOVER, MASSACHUSETTS SCALE: 1 " = 50' MAY 24, 2001 NEW ENGLAND ENGINEERING SERVICES, INC. 60 BEECHWOOD DRIVE lk NORTH ANDOVER, MASSACHUSETTS (978) 686-1768 I t p�0 31.2'± 43.2'± �kST. F<<�tic O ww'� ' w b M _ /` v N N� PLAN' 018 0sy SB & JE H � BCOjr & JEF LOT 7 48,553 S.F. 1.115 Ac. 156 60 56$�1$ 00 36.0'± 35.2'± This plan is for the use of the Building Inspector of the Town of North Andover, for the purpose of determination of zoning compliance. It is my opinion that the location of the foundation complies with the requirements of the Zoning Bylaws of the Town of North Andover. This plan is the result of a survey performed by New England Engineering Services, Inc., based upon the approved subdivision plan recorded in the Registry of Deeds. EXISTING CONDITIONS PLAN 75 CROSSBOW LANE NORTH ANDOVER, MASSACHUSETTS SCALE: 1 " = 50' MAY 24, 2001 NEW ENGLAND ENGINEERING SERVICES, INC. 60 BEECHWOOD DRIVE NORTH ANDOVER, MASSACHUSETTS (978) 686-1768 TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING A BUILDING PERMIT NUMBER: DATE ISSUED: SIGNATURE: Building Commissioner/lEEpector of Buildings Date I NEU IUIN I- SITE I.NP'0KrKA'1'IU1N { 1.1 Property Address: iwss 1�o w tAA) 1.2 Assessors Map and Parcel Number: Map Number Parcel Number 2.1 Owner of Record Name (Print) J�S5(�,�I —AQD,K� , Address for Service 1 -7i0(Q 1.3 Zoning Information: �>2 �� ��'1/a . I Zoning District 0ioposed Use 1.4 Property Dimensions, 1 � tir=1 0� t� � I � `Z- � � S� �'� � 12•e4 `� Lot Area Frontage fl1 1.6 BUILDING SETBACKS ft 2.2 Owner of Recor : Name ,Print / Address for Service: Front Yard Side Yard Rear Yard Required Provide Required Provided 1 Required Provided 3a 30 3.1 Licensed Construction Supervisor: Licensed Construction Supervisor: Address Signature Telephone J d 1.7 Water Supply M.G.L.C.40. 54) Public ❑ Private ❑ 1.5. Flood Zone Information: 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 (Print) J�S5(�,�I —AQD,K� , Address for Service 1 -7i0(Q Si ture. Telephone �lc�✓�c��i F 1 g✓► z- 2.2 Owner of Recor : Name ,Print / Address for Service: Signature V Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Licensed Construction Supervisor: Address Signature Telephone Not Applicable a' License Number Expiration Date 3.2 Registered Home Improvement Contractor Not Applicable QY Company Name Registration Number Address Expiration Date Signature Telephone SECTION 4 - WORKERS COMPENSATION (M.G.L C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes .......❑ No ....... ❑ SECTION 5 Description of Proposed Work check all a h'cable New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) TT ddition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) tobe Completed b ermit a lilt 4FFJC AL USS :- 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) x (b) 4 Mechanical HVAC 5 Fire Protection 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 ;his building permit application. Signature of 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 SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1ST2ND 3 SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE All -37 7 A TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .......... )- .�.6 ....... Ela.o..: ...................................... has permission to perform ....... Arid.,.Ik .. ..................................... wiring in the building of .... 0 �.. (1/ ... Q ......................................................... at .......... �75 . ...... /I North Andover, MM s. ... X�El �Zf !2' .... Lic. No.. ... ............ ELECTRICAL i�; /ER Check # Official Use Only (j THE COMMONWEALTH OF MASSACHUSETTS Permit No.sey 7,Z Department of Public Safety BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 Occupancy & Fee Checked APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK I All work to be performed In accordance with the Massachusetts Electrical Code 527 CMR 12:00 (Please Print In ink or type all information) [lateYS l (g'© 2' To the Inspector of Wires: Town of North Andover _ The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number 75CYDsSb©u-) Owner or Tenant�� i ,_ _ - . [� _ , I Owner's Address 7� gwgs bow '—�►�L NO • r \�' love r Is this permit in conjunction with a/ building permit Yes No • (Check Appropriate Box) Purpose of Building r / lam{ Utility Authorization No. Existing Service '? 00 Amps j1 D 122.0 Volts Overhead Und and No. of Meters New Service Amps Voits Overhead Undgmd No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Workl1 OTHER: INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES = NO = have submitted valid proof of same to the Office YES = NO = If you have checked YES please indicate the type of coverage by checking the appropriate box. INSURANCE = BOND c' OTHER = (Please Specify) (Expiration Date) — Estimated Value of Electrical Work$ Work to Star _ Inspection Date Resquested Rough Final Signed under the Penalties of perjury: FIRM NAME _ _ -— LIC. NO. Licensee SignatureLIC. NO. Bus. Tel No. Address Alt Tel. No. OWNER'S INSURANCE WAIVER: I am aware that the Licenses does not have the insurance coverage or its substantial equivalent as required by Massachusetts General Laws. And that rX signature on this permit application waives this requirement. Owner Agent (Please Check one) IN ` '� " " 0A PERMIT FEE $ 't� 0 of Owner or Total No. of Lighting Outlets No. of Hot fuse No. of Transformers KVA Above In No. of Lighting Fixtures Swimmin Pool and Generators KVA r/1104 l� No. of Emergency Lighting Outlets No. of ReceptaclesrT An No. of Oil Burners N Battery Units AI IA No. of Switch Outlets No of Gas Bumers FIRE ALARMS No. of Zone No. of Detection and No. of Ranges � A ll%Total No of AirCond t—tUlN/ijlTons Initiating Devices _ k A Heat Total Total No. of Di sal / v No. /V A Pumps Tons KW No. of Sounding Devices Nol of Sell Contained Detection/Sounding Devices Municipal • Other No. of Dishwashers f V i� S ace/Area Heating fLks 4 SP KW n�A� ///� Dryers / v,1A No. of D Heating Devices KW Local Connection ilVo/RELY No. of No. of Low Voltage No. of Water Heaters KW Signs Bailases Wirin J es , No. Hydro Massage Tuds No. of Motors Total HP OTHER: INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES = NO = have submitted valid proof of same to the Office YES = NO = If you have checked YES please indicate the type of coverage by checking the appropriate box. INSURANCE = BOND c' OTHER = (Please Specify) (Expiration Date) — Estimated Value of Electrical Work$ Work to Star _ Inspection Date Resquested Rough Final Signed under the Penalties of perjury: FIRM NAME _ _ -— LIC. NO. Licensee SignatureLIC. NO. Bus. Tel No. Address Alt Tel. No. OWNER'S INSURANCE WAIVER: I am aware that the Licenses does not have the insurance coverage or its substantial equivalent as required by Massachusetts General Laws. And that rX signature on this permit application waives this requirement. Owner Agent (Please Check one) IN ` '� " " 0A PERMIT FEE $ 't� 0 of Owner or t � TO: FROM: NORTH ANDOVER, MASS BOARD OF HEALTH DESIGN ENGINEER — -7 19 8", Re: Soil Absorption Sewage System Inspection This is to certify that I have inspected the construction of the said disposal system at LD �/Q (3&� / G (3 LV /—AA),t North Andover, Mass. SITE LOCATION The grades and construction are as specified in my plans and specifications dated M. lor a-6 19 D. by �,eg'C`I2f�glZt r � Pd3SOr Q) anliarlan Board of Health SD'MC SISTEM North An ver ?ia". INSTALLATICEQ CHECK LIST LOTI� eagnnst 1. Instance Tot a. WetIands b. Drains c.. Well 2. - -Water- -Line Location w 3. No -PPC Pipe 4. Septic . Tank a.. _Tees -_Length & To Clean Ont Covers. . b.. -.Cement Pipe to Tank on Both Sides of Tank 5. Distribution Box a. Covers & Box - No Cracks b. All Lines FloAmg Equal Amounts c. No Back Flow .A -�„�A;�n.�'TnanAtS �f1nY-�- 6. Leach Field or Trench a. Dimensions _ --- b. Stone Depth- _ c: Capped ids- . _ d. Clean Double Washed Stone- _ .Pits -a* Dimensions b. Stone Depth. _ c. Splash Pads d. Teas e. Garment Pipe to Pit - Both Sides f. Clean -Double Washed Stone - - 8. No Garbage Disposal - - - - -- -�„�A;�n.�'TnanAtS �f1nY-�- -Boart of Health Nar+-h Ando erlMass APPROVED DATE_ Provided: �! //'M A SUBSURFACE DISPOSAL DESIGN CHECK LIST DISAPPROVED DATE Reasons: LCT # 7 Title V FALL OK Reg 2.5 The submitted plan mrast show ss a minim=: a) a lot to be served-area,dimensions lot #,abutters location and log deep observation hoes -distance to ties 1 cation and results percolation tests -distance to ties design calcnlations & calculations shm*ing required leaching area location and dimensions of system -including ►reserve area f - existing and proposed contours g) location any vat areas within 100' of sewage disposal system or disclaimer -check watlands mapping surface and subsurface drains within 1001 of se- --ge dispflsal. system or disclaimer (i location any drainaga ease, eats -ithin 100' of serge disposal system or disclairer-Planning Board files (j) kno:.a sources of water simply within 2001 of se -.j -age disposal 8 system or disclaimer (k) cation of any Proposed --ell. to serve lot -100 from leaching facilf cation of kater lines on property -101 from leaching facility m to pa of benchmark iveways • garbage disposals ,,,ano PDC to be used in construction Profile of system- elevations of basement, plumb, pipe, septic tank, distribution box inlets and outlets, distribution field piping and Otter elevations ra)dm> am ground j.ater- elevation in area sewage disposal system (s) plan must be prepared by a Professional R gineer or other pro es 0 authorized by law to prepare such playas Reg 6 Septic Tanks a) capacities -150 of flow, water table, tees, depth of tees, access, pu=ping (b) cleanout c) 10' from cellar u*.11 or inground sing pool ,(d) 251 from subsurface grains Reg 10.2 ( Distribution Foxes I ) s ope g, -eater than 0.08 Reg 10.4 I b) stmt/ i 1 subk]r ce Denis FAIL Reg 15.1 15.4 15.8 3.7 Reg 14.1 14.3 14.4 14.6 14.7 IL. .10 Check- List 0K 03 Leaching Pits Leaching pits are preferred where the installation is possible a) calculations of leaching area -minim m 500 eq ft b) spacing c) surfacerbow 2% d) cover tr e) 2 � x21 xish pad f) tee a g) no dpe fromd-box to pipe / Leaching Fields a) no greater than 20 Wnutes/inch b) arca-r;i ni.rax 900 sq ft 0 construction of field �) surface drainage 2 % e) 20t from cellar w�7.1 or inground s-sirming pool Leachi_n�g �—_T_r_ Inches a) ccvation8 0I thing area -min 5� sq ft b) spacing -4 ft 6 ft with reserve bet;,,eea c) dim--isicns d.) constrac on e) stone f) su acs drainage 2% Do-,,mhi 11 Slop e w) s opey x=�to be s�on b y/x x 150 = (to be shown) Ftry Reg 9.1 a) roval 9.6 kb) wand -by power SOIL PROFILE & PERCOLATION TEST DATA North Andover, Mass. Street No CeoSSBo••J Lot No / Loc/Subd.iv. TN 4�kk 5 Pland Owner Investigator 3 8� y�L�83 Observer f-ts"� 5�i) 63 SOIL PROFILE DATES 1.Elev 2.Elev 3.Elev 4.Elev T p/ T.P. Z 7R 0 _573"/60 1 2 3 5 B0We�— 6 7 8 9 la Benchmark Elevation 0 1 2 3 5 6 7 8 9 10 DATES 0 1 2 3 4 5 6 7 8 11 Location Datum_ PERCO TION TESTS 2 3 Tiles tc� Test Pi s 9 10 10Ats Pit Number 1 2 3 5 Start Saturation Z• ¢� 3 : 0 7 Z_ Soak -Minutes Start •1 e QAC E V Drop of 3" -Time, Drop of 6" -Time M ns.lst 3" drop 8 Mins.2nd " Drop 9 10 10Ats Pit Number 1 2 3 Start Saturation Z• ¢� 3 : 0 7 Soak -Minutes Start •1 e Drop of 3" -Time, Drop of 6" -Time M ns.lst 3" drop Mins.2nd " Drop Percolation G Y�y -L3— Oz 4 0' C G a J Location �" US S � �'� )..) No. !�'` Date Check # r.ft S P TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee TOTAL c� S J 3 7 2 2 � Building Inspector 1;1%" Property Address: �AnZ 1.2 Assessors Map and Parcel 11-� Map Number Number: o a 05� Parcel Number 1.3 Zoning Information: ,/ ✓ PRIVATE Zoning District Proposed Use `15 C''vys 1.4 Property Dimensions: c, H 41 000 Lot Areas f t 5 Fronta e ft 1.6 BUILDING SETBACKS ft ,^ Front Yard Side Yard Rear Yard Required Provide Required Provided Reqttired Provided 757 Crmss Liztn Name Print Address for Service: 1.7 Water Supply M.G.L.C.40. 34) Public ❑ Private ❑ Zone 1.5. Flood Zone Information: Outside Flood Zone ❑ 1.8 Municipal Sewerage Disposal System: ❑ On Site Disposal System ah'U11VIv Z - r-KUPER1 Y VWNERNMMAUTMOR"JED AGENT 2.1 Owner of Record a c—q a n z `15 C''vys 6 b o w Lane Name (Print) I - Address for Service: ,^ Signature I Telephone 2.2 Owner of Record: ,IJ-AD.3 AJV 757 Crmss Liztn Name Print Address for Service: Si na r Telephone SECTMN 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: License Number 'Address i Expiration Date Signature Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Address Expiration Date Signature Telephone SECTION SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit in the denial of the issuance of the building permit. Signed affidavit Attached Yes ....... No ....... ❑ SECTION 5 Description of Proposed Work check an a 6cable New Construction ❑ 1 Existing Building ❑ 1 Repair(s) ❑ Alterations(s) ❑ 1 Addition ❑ Accessory Bldg. ❑ 1 Demolition ❑ 1 Other ❑ Specify Brief Description of Proposed Work: /. Deck EXheAS/o-X a, FRONT PPSCH- A6' -Y '' I SECTION 6 - ESTIMATED CONSTRUCTION COSTS 1 Jn('o wilres 3-7 s� Item Estimated Cost (Dollar) to be Completed by permit applicant OFFICIAL USE ONLY 1.. Building $Do (a) Building Permit Fee Multiplier (9 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing it Building Permit fee (a) X (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 D 0 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 SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 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 of Date NO. OF STORIES SIZE BASEMENT OR SLAB ST ND RD SIZE OF FLOOR TIMBERS 1 2 3 SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS DIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE s • �� �� 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. i APPLICANT FILLS OUT THIS SFC T ION -k ' APPLIGANTt-4"(3 ne / b 10 Vl. 21- LOCATION: sLOCATION: Assessors Map Number IND SUBDIVISION TN&ALL S CR.O,Ss (O G- LOT (S) 4 STREET -15 C4t566, -A) l a. he- ST. NUMEER OFFICIAL USE ONLY REC,OMMENDAT�ONS_OF TOWN AGENTS: 9,jo7a Rear _�)?G4 -L 9 )Ct )e O ERVATION ADMINISTRATOR DATE APPROVED COMMENTS Lt• e� i TOWN PLANT ER DATE APPROVED DATE REJECTED COMMENTS FOOD INSPECTOR -HEALTH DATE. APPROVED DATE REJECTED S . TIC INSPECTOR -HEALTH DATE APPROVED I J DATE REJECTED COMM i S "ti, •' cr1. / e.. S PUELIC WORKS - SEWERIWATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED EY BUILDING i,i"ISPECTCR Revised 919; im DATE MORTGAGE PLOT; PLAN LOT 0 7 CROSSBOW -LANE `N09111 ANVOVtRo MASSACHUSETTS ZUALtl 1 60 SUYM SAMUEL M. 8 ANN MARIE 8. PERRUCCIO 1 JUNE 13 1984 u # < I _t_384 NOTE. THIS IS NOT A SURVEY AND IS To ONLY, BE USLV FOR MORTGAGE PURPOSES N.B.- DO NOT USE OFFSETS FOR ESTABLISHING LOT LINES FOR THE ERECTIOA OF FENCES, WALLS, f(EDGES, ETC." IL HEREBY CERTIFY THAT tiff BUILOINC, ON THIS PROPrRTV IS LOCAM AS -"OWN ON PLAN AND COMPLIES WITH Tilt LOCAL ZONINO Stt me K RtQU?Rr- CYR ENGINEERING SERVICES, 1K I FURTHER CERTIFY THAT THE ABOVE DWELLING IS NOT 300 CANAL STREET LOCATED IN A FLOOD HAZARD ZONE. LAWRENCE, MASSACHUSETTS. • t3 0 f r ,i HOMEOWNER LICENSE EXEMPTION Please print DATE APRIL 31 2000 JOB LOCATION Cgo 5SBOW L jkNe Number Street Address Map / lot "HOMEOWNER TA C 0R FLAN 2- q7 PB — 68 ( — I � 6 78 -b 61 ( � 6 is Name Home Phone Work Phone PRESENT MAILING ADDRESS SAME As Aboy e- UOPT4 ANMvek MA OSB 4.5 City Town State Zip Code The current exemption for "homeowners" was extended to include owner -occupied dwellings of two units or less 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 there is, or is intended to be, a one or two family dwelling, attached or detached structures ac- cessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. 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 requirements. HOMEOWNER'S SIGNATU APPROVAL OF BUILDING OFFICIAL Town of North Andover q`�° °'`• 4 Building Department F� r 27 Charles Street► North Andover, MA. 01845 D. Robert Nicetta Building Commissioner (978) 688-9545 -l- -°(978) 688-9542 Fax HOMEOWNER LICENSE EXEMPTION Please print DATE APRIL 31 2000 JOB LOCATION Cgo 5SBOW L jkNe Number Street Address Map / lot "HOMEOWNER TA C 0R FLAN 2- q7 PB — 68 ( — I � 6 78 -b 61 ( � 6 is Name Home Phone Work Phone PRESENT MAILING ADDRESS SAME As Aboy e- UOPT4 ANMvek MA OSB 4.5 City Town State Zip Code The current exemption for "homeowners" was extended to include owner -occupied dwellings of two units or less 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 there is, or is intended to be, a one or two family dwelling, attached or detached structures ac- cessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. 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 requirements. HOMEOWNER'S SIGNATU APPROVAL OF BUILDING OFFICIAL In accordance with the pmvisions of MGL c 40 S 54, a condition of Building Permit Number Is that the debris resulting form this work shall be disposed of in a properiy licensed solid waste disposal facility as defined by MGL c 11, S 150A The debris will be disposed of in: Location of Facility Signature of P Applicant APR I L- 3, CUW Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector 0 k \ f. » © » «» ƒ�I ; Back Deck Extension — 7§ Crossbow C. 1IN1 r�o h iz N .... LL 1IN1 r�o h Cl) 7) C/) 0 m v CA d C CD CO) Cl) CD Ca Z y CD 0 O "0.� , r C O =r d a y 0 CD CD O •rt CL Q� =r CD c=r o C CD y. �a v y Cc CD F v CA O '= Z CD OCD 0CD i� FO C C? O d 2 O -• VJ OQ y G O dc m y S 3m n m n H c7 0. C') m O_ Im w m N CL CL mT m �Sa) y CD .40 m H p � m O = N O > > o: a E, IG �• p O : � � 0 oy�:V o CD 00 7 a � CA m c'! 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