HomeMy WebLinkAboutMiscellaneous - 75 FOREST STREET 4/30/2018 (4)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: ' ' 1-4•
NIL v4 �
Owner's Name: a /VI ,
Owner's Address:
Date of Inspection: j-� % /
Name of Inspector:please riot) SO��
Company Name:
Mailing Address:
}
Telephone Number.
SEP 2 2 2008
TOWN OF 1\10RT'- t ,\!nOVER
HEALTH
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the infonnation 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 an maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to S on 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: Date: y f�
The system inspector shall submi copy of this i specti report to the Approving Au iorityZoard of Health or
DEP) within 30 days of comple ' ge this inspectio . 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 Comment ,,��%
i4iV4 it (k
****This report only describes con tions 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 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
—_ - CERTI ICATIGN �,;entinued)
Property Address: '75— F r,�,s Ci
Owner: St'91
Date of Inspection: t`2
Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D
z
stem Passes:
I have not found any information which indicates that any of the failure criteria described in 310 CMR
1.5.303 or in 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 if a 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):
broken pipe(s) are replaced
obstruction is removed
ND explain:
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
_ - CERTIFICATION � vntinued)
Property Address: c�S
Owner: N{;IAAPte/
Date of Inspectio f3
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 15.303(1)(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 a septic 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:
Page 4 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICA T'10� ;° Ptinued)
Property Address: 55— - veS_J�_y� �` _% 5✓
Owner:
Date of inspection
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 '/z day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped
'Any portion of the SAS, cesspool or privy is below high ground water elevation.
XAny 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 1 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
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 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: �A/
To be considered a large/Y!;ii 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 sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped
Zone II 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
15.304. The system owner should contact the appropriate regional office of the Department.
Page 5 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
- CHEChLyk T
Property Address: /
A
owner: `. al
Date of Inspecti /
Check if the following have been done. You must indicate `yes" or "no" as to each of the following:
Yes No
— Pumping information was provided by the owner, occupant, or Board of Health
YWere any of the system components pumped out in the previous two weeks ?
Y_ 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)
_ Was the facility or dwelling inspected for signs of sewage back up ?
_ Was the site inspected for signs of break out ?
JC _ Were all system components, excluding the SAS, located on site ?
_ Were the septic tank manholes uncovered, opened, and the interior 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 ?
_ 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:
T
no
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) [310 CMR 15.302(3)(b)J
Page 6 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
= --- SYSTET I INFO � ?'ION
Property Address: r76— For ,44 (94
Owner: t1ri4goti
Date of Inspection G
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms (design): Number of bedrooms (actual):
DESIGN flow based on 310 C 15.203 (for example: 110 gpd x # of bedrooms): Z qc>
Number of current residents:
Does residence have a garbage grinder (yes or no): `ee00 e- a44V
Is laundry on a separate sewage system (yes or no): IV [if yes separate inspection required]
Laundry system inspected (yes or no): jn
Seasonal use: (yes or no):
Water meter readings, if available (last 2 years usage (gpd)): SVAf4—r"x
Sump pump (yes or no):
Last date of occupancy: �r �-
COMMERCIALANDUSTRUL
Type of establishment:
_ 4�LA—
Design flow (based on 310 CMR 15.203): gpd
Basis of design flow (seats/persons/sgft,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 readings,. if available:
Last date of occupancy/use:
OTHER (describe):
GENERAL INFORMATION
Pumping Records
Source of information: 0 A�'COr
Was system pumped as part of the inspection (yes or no): _)YQ
If yes, volume pumped: gallons -- How was quantity pumped determined? &l al
Reason for pumping: c -0— Olt -Cl tom, nC4
TSot1cF SYSTEM
eptank, distribution box, soil absorption system
_ Single cesspool
Overflow cesspool
_— Privy
_ Shared system (yes or no) (if yes, allach 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):
all components, date installed (if known) and source of information:
Were sewage odors detected when arriving at the site (yes or no): IJD
Page 7 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM I1vFORMATION (continued)
Property Address: 75� ere
Len Mj:a�SP
Owner: ed vi, jv WA "
Date of Inspection 1-5
9.
BUILDING SEWER (locate on site plan)
<j'
Depth below grade: � V
Materials of construction: _cast iron PVC _other(explain):
Distance from private water supply well or suction line:
Comments (on condition of joints, venting, evidence of leakage, etc.):
SEPTIC TANK: V (locate on site plan)
Depth below grade:
Material of construction: _concrete —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:
Sludge depth:
Distance from top of s ledge to bottom of outlet tee or baffle:
Scum thickness: !�L `f
Distance from top of scum to top of outlet tee or baffle: �y
Distance from bottom of scum to bottom of outlet tee ora I
How were dimensions determined: '[A a- ` Tt'o 4(_'
Comments (on pumping recommendation , inlet and outlet te"ts or bale condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
GREASE TRAP.44ocate 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 8 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM -INFORMATION (continued)
Property Address: - 67Gres
Owner: io4�
Date of Inspection / 6
TIGHT or HOLDING TANK: 0 ank 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):
Alann 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)
r/
Depth of liquid level above outlet invert: -A
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.): f S_ k( _ A, 'In / t
a _%_-
PUMP CHAMBER: AAt Aocate on site plan)
Pumps in working order (yes or no):
Alanns in working order (yes or no):
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Page 9 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION.(continued)
Property Address:'' S
qtr > tat �S'wJ
Owner: e-j1,4SVA
Date of Inspection: 0&' --
SOIL ABSORPTION SYSTEM (SAS):pocate on site plan, excavation not required)
If SAS not located explain why:
Type
leaching pits, number: _
1 chmg chambers, number:
eaclung galleries, number: /
leaching trenches, number, length:
leaching fields, number, dimensions
overflow cesspool, number:
innovative/alternative system Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,
CESSPOOLS- *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:A�/I'-lTocate on site plan) Ir
Materials of construction:
Dimensions:
Depth of solids:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
Page 10 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM WI-ORMATION (continued)
Property Address: 75 Forest Street
North Andover, MA 01845
Owner's Name: Jennifer Melson
Date of Inspection: 08-JI16;2008
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.
-11-OP46 r
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OUT OF lvv.5E
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Page 11 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
-SYSTEM INFORMATION (continued)
Property Address:r ✓�'
Owner: o ( - c;
Date of Inspecti : /
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water S--!S-feet
Please indicate (check) all methods used to determine the high ground water elevation:
tamed from system design plans on record - If checked, date of design plan reviewed:
served 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 descriifb/Je how you established the high ground water elevation:
Jul 28 08 03:26p
Summary Recerd Lard generated on 7/28/2008 12:51:42 PM by Karen Hanlon
Town of North Andover
Tax Map # 210-106.A-0170-0000.0
Parcel Id 17313
75 FOREST STREET
MELSON, DONALD
75 FOREST STREET
--_ STH ANDOVER, MA -
01845
Class 101 Single Family Property Type
Size Total 1.02 Acres
FY 2008
UB Mailing Index
Name/Address Type Loan Number Activellnact. From
MELSON, DONALD Payor
75 FOREST STREET
NORTH ANDOVER, MA
01845
UB Account Maint.
Account No Cycle
Bldg Id. 17608.0 - 75 FOREST STREET
3170279 03 Cycle 03
UB Services Maint-
Service Code
MISCFEE ADMIN FEE
WTR WATER
UB Meter Maintenance
Occupant Name Active/Inactive
Last Billing Date 7/8/2008
Active
Rate Charge Multiplier/Users
0.635/8 7.82 1/
01 ALL METER SIZE 116.04 /1
Serial No
Status
Location
32634806
a Active
ERT HH
Date
Reading
Code
6/5/2008
720
a Actual
3/11/2008
692
a Actual
12/10/2007
673
a Actual
9/5/2007
623
a Actual
6/18/2007
499.
a Actual
3/13/2007
445
a Actual
12/12/2006
419
a Actual
9/18/2006
370
a Actual
6/14/2006
146
a Actual
3/8/2006
78
a Actual
12/22/2005
62
a Actual
9/7/2005
0
n New Meter
9/7/2005
3299
r Replacement
6/27/2005
3215
a Actual
3/23/2005
3164
a Actual
12/14/2004
3135
a Actual
9/23/2004
3100
a Actual
6/11/2004
2995
a Actual
4/15/2004
2953
a Actual
12/19/2003
2915
n New Meter
-Pee+
C)
;14 � j G 1 1 vvN-�
Brand
b Badc
Type
w Water
tion , Posted Date
28 7116!20 18
194111 /2008
50 1/22/2008
12410/12/2007
54 /20/2007
26 /16/2007
49 /19/2007
224 0/20/2006
68 /10/2006
16 4117/2006
62 1/17/2006
0 10/14/2005
84 10/14/2005
51 7/15/2005
29 /5/2005
35 1114/2005
105 10/8/2004
42 7/30/2004
38 5/17/2004
0 12/19/2003
Size
0.63 0.63
p.
2 Nage i
1 Residential
Until
YTD Cons
28
Variance
58%
-60%
-67%
182%
95%
-50%
-75%
236%
230%
-64%
-100%
-100%
120%
81%
-31%
-58%
37%
129%
0%
0%
,Cr
1
Date ...C.a.%%jG �.. .
f
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that ..............
G
has permission for gas installation ......IZ
n !.lr'..... .
in the buildings of .......�L!? ......................... .
at �.... t .gip . ... .... ,North Andover, Mass.
Fee . Lic. No.e�t� f�.L�. �%'....... .
/ r GAS INSPECTOR
Check #
6032
MAS.SACHUSETIS UNIFY
(Type or print)
NORTH ANDOVER, MASSACH
OR PUMU TO DO GAS FITTING
Date
Building Locations (� I— Permit #
Owner's Name Amount $
New Renovation Replacement 11 Plans Submitted 11 1
(Print or type) � pp n one: Certificate Installing Company
Name 44'- rh 2ir,,; "�9 P�� C k
Corp.
0 Partner.
ri
Firm/Co.
Name of Licensed Plumber or Gas Fitter_ yl ��
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes NoO
If you have checked ves. please indicate the type coverage by checking theappropriate box. D
Liability insurance policy ED 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:
Signature of Owner or Owner's Agent Owner Agent
hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the
ri
best of my knowledge and that all plumbing work apd installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the MassachusettiSkate Gas "g and Chapter 142 of the General Laws.
IC
y:
itle
ity/Town
APPROVED (OFFICE USE ONLY)
Slpatpre of Licensed Plumber Or Gas Fitter /
?lumber
Gas Fitter Licenseum erum er
Master
Journeyman
loe
C1 NO oTM
0
s ;�-
Date. � .. .
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that .f.�.'"` v� ... f it . • • • • • •
has permission to perform
plumbing in the buildings of ..... e-. .. ................
at ... . ..71 j. ............. . orth Andover, Mass.
. . ............. .... `Fee '. Lic. ..... .
^ O ) q � %� PLUMBING INSPECTOR
Check # r
7342
t i
Frit "'J
01'Fhn� cn 7Pyp,,-.) o.
I.A
--Z
T(t
Y
X�
3�
IWO
99 0 U,
0 0
Cc
0
0 0 0
0 <
gn 0
BASEMENT
IST FLOOR
2ND FLOOR
3RDFLOOR
4TU FLOOR
GTH FLOOR
. . . . . . . . . . . .
77'2� F LC, 0 ft
t
CLIMATE DESIGN HEATING and AIR CONDITIONING, LLC
Installing Company Name 5 South Summer Street Check one: (-ertificate
Address Bradford, MA 0 183 5
978-372-9999 (phone) FLCorporation C) o
978-372-0882 (fax)
_ Partnership
Business Telephone Lic. plumber. r-7
Name of Licensed Plumber
IRS.URANCE COVERAGE-
-
I have ales
urrent No 0
liability insurance policy or its substantial cquk-alent Which Meets the requirements of 9,AGL Ch. 142.
YOU have checked es, ease MIcate the type COver2ge by checking the appropriate 1),Ox
A fiabiIi6( Insurance policy Other type of Indemnity 0
Bond
OWNER'S INSURANCE WAFVER: I am aware alat thr.
__6 en, _ licensee does
Ch2pter 142 of the Mass. General Laws, and tha AOM� _E'Othave the Insurance coverage required by
My �_.jgnature on this permtt &ppj_
Ication Walves this requirement.
Check one:
of Orter or Agent 0
t —r Owner D
L�;o n
or, 05�wwn e r's —Age n t
I J)ereby Certify that all of the details and information I have submitterd (or entered) in above pplicau
.uGd for this knaeAedge and that all plurntning work and installations P-Srforroied under410 Nrmit iss On Ere twe and accurate to the best of my
pertinent provisions of the mas.—Chusetts- State Plumbi is appiicationLVAII be in CoMPIi&rC,3 W;
A9 Cor:16 arid of Y,2c f tha'Genoral Lavfs. Ith all
LAP.6 3�y A, h-
T&I atuf- U-11,5 .0 dumber/_1
T
O,t_
Tipe
f 0%'n Journe man
Apt' 0 N 57 LicenselNumberr
35:,,�
Location �`
No. 4 0"J, Date
Check # /
15598
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Q",2 -
�—Building Insp r
0
TOWN OF NORTH ANDOVER
1.2 Assessors Map and Parcel Number:
Y R, l'70
Map Number Parcel Number
BUILDING DEPARTMENT
7rW,A)tFF-?, IM Ls ons
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
1.3 Zoning Information: .
Zoning District Proposed Use
Name (Print)
1.4 Property Dimensions:
Lot Area (sf) Frontage ft
BUILDING PERMIT NUMBER:/ e� DATE ISSUED:'
dod�
Front Yard
�I
•
Required Provide
RegWred. Provided
Re uired Provided
Signature Telephone
SIGNATURE:
1.7 Water Supply M&1.5.
'C.4Q,,4� Zone
Public 0 Private ❑
Building Commissioner/I ctor of Buildin Date
1.8 Sewerage Disposal System
Municipal 0 On Site Disposal System ❑
3.1 Licensed Construction Supervisor:
SECTION 1- SITE INFORMATION
1.1 Property Address:
7s- r'oKFS-r sr
1.2 Assessors Map and Parcel Number:
Y R, l'70
Map Number Parcel Number
�\
r "Q0 P
AIDVF
7rW,A)tFF-?, IM Ls ons
?s'
1.3 Zoning Information: .
Zoning District Proposed Use
Name (Print)
1.4 Property Dimensions:
Lot Area (sf) Frontage ft
1.6 WELDING SETBACKS ft
Front Yard
Side Yard
Rear Yard
Required Provide
RegWred. Provided
Re uired Provided
Signature Telephone
1.7 Water Supply M&1.5.
'C.4Q,,4� Zone
Public 0 Private ❑
Flood Zone Information:
Outside Flood Zone 0
1.8 Sewerage Disposal System
Municipal 0 On Site Disposal System ❑
SECTION 2 - PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record
7rW,A)tFF-?, IM Ls ons
?s'
Foes 7r
Name (Print)
Address for Service:
Signature Telephone
2.2 Owner of Record:
Name Print
Address for Service:
Signature Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Not Applicable ❑
Licensed Construction Supervisor:
License Number
U DV
D U�Ta ) �7 I`np, AVPo VER- Vh
Ad s
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5��. C
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Expiration Date
Signature Telephone
3 . 2 Registered Home Improvement Contractor
Not Applicable ❑
AV ).D C%}51r;q1C-,6A) E KE6,
* SL)G,
6
Company Name
An w,
fj o' �
Registration Number
nA3�
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fj1l!0.2
Expiration Date
Signature "fele hone
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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.
Si ned affidavit Attached Yes .......0 No ....... 0
SECTION 5 Description of Proposed Work checkall applicable)
New Construction ❑ Existing Building Repair(s) ❑ 4ter tion s ❑ Addition ❑
Accessory Bldg. `❑ '94" l De*1ti6r sit El I Other ❑ Specify "
I
Brief Description of Proposed Work: . ::..R " F,t �„ : �• ,a y '�
ILJ 5 1 ZA)
I SFCTTON 6 - )F.CTTMATIM r nNQTurrr--rTnw 4-nc,rr
Item Estimated Cost (Dollar) to be
U CME
Completed by permit applicant
r .arg
' a .E't .:'��� G eR.-,• r J-d�i.iD``4i; �ii.�.F:: � Yr.,.
1. Building
(a) Building Permit Fee
,,,+
/J-0 d O
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 ;SO 0
Check Number
CVA/ ril1TT-7.. /L]XTi ATTmTTATT/'T .......�. ...
Illi v V 171r LL` 1 r." VV KIP1114
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.
3i nature of owner Date J
SECTION 7b OWNER/AUTC�HORIZEDAGENT DECLARATION
"-� A
1, V 1P CA -5 T_,R I 0A?E ,as Oivner�a4uthoriz�� ed g �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
Signature of Owrier/went Date
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TIMBERS 1 ST 2 ND 3 KD
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
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Board of Building Regulations and Standards
,i HOME IMPROVEMENT CONTRACTOR
Registration: 104569
Expiration: 7/14/02
Type: PRIVATE CORPORATION
DAVID CASTRICONE ROOFING, S
L9 01P O.,astricone
7 Hillside Road
Boxford, MA 0192'. Admin;strmor
License or regktratio n valid for individul use only
before the expiration date. If found return to:
Board of Building Regulations and SG^ndards
One Ashburton Place Rm 1301
Boston, Ma. 02105
zllz-C—Z,�
Not valid without signature
Town of North Andover
Building Department
27 Charles Street
North Andover, Massachusetts 01845
(978)688-9545 Fax(978)688-9542
DEBRIS DISPOSAL FORM
In accordance with the provisions of MGL c 40 s 54, and a condition of
Building permit # the debris resulting from the 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 /at:
S7 7-E -1 -L 0-aW - a F -k
Facility location
Signature of Applicant
Date
NOTE: A demolition permit from the Town of North Andover must be obtained for this
project through the Office of the Building Inspector.