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Miscellaneous - 808 JOHNSON STREET 4/30/2018
r 1. f N � o O 4 r Z 8' z �cn �� o m o -I rt 174 co t� �1*i 44� • v U 01 01 Lo _ N Q N 0. W UU a) co C) Z Q ) U Q co N V O L PUBLIC HEALTH DEPARTMENT Community & Economic Development TOWN OF NORTH ANDOVER SEPTIC DISPOSAL SYSTEM — INSTALLATION CERTIFICATION The undersigned hereby certify that the Sewage Disposal System { ) constructed; () repaired; By: Rob Daigle (Print Name) Located at: 808 Johnson Street (Installation Address) Was installed in conformance with the North Andover Board of Health approved plan, originally dated 11/10/16 and last revised on 11/30/16. , with a design flow of 330 gallons per day. The materials used were in conformance with those specified on the approved plan; the system was installed in accordance with the provisions of 310. CMR 15.000, Title 5 and local regulations, and the final grading agrees substantially with the approved plan. All work is accurately represented on the As -built which has been submitted to the Board of Health. Bottom of Bed Inspection Date: 3/22/17 James Melvin, P.E. And — Print Name Final Construction Inspection Date: 4/11/17 James Melvin, P.E. And — Print Name Installer: (Signature) (Signature) n eer Representative (Signature) Cn 'eer Representative (Signature) Date: s' I And — Print Name Date: Phil Christiansen, P.E. And — Print Name 120 Main Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.9542 Web http://www.northandoverma.gov North Andover Health Department Community and Economic Development Division December 8, 2016 BJF Realty Trust 808 Johnson Street North Andover, MA 01845 Re: 808 Johnson Street (Map 38, Lot 60) Dear BJF Realty Trust: The proposed wastewater system design plan for the above site dated November 10, 2016 with a final revision date of November 30, 2016 and received on November 30, 2016 has been approved. Your Local Upgrade Approval request for a 1' reduction in the groundwater offset from 5' to 4' from the estimated seasonal high water table has also been approved. The design has been approved for use in the construction of a new on-site septic system for a 3 - bedroom (maximum of 7 total rooms) home utilizing a gravity leach field system. This design plan approval is valid until December 8, 2019. During this time, a licensed septic system installer must obtain a permit and complete this work, and a Certificate of Compliance be endorsed by the installer, designer and the Town of North Andover. This approval is also subject to the following conditions: If site conditions are found in the field to be different from those indicated on the design plan and/or soil evaluation, the originally issued Disposal System Construction Permit is void, installation shall stop, and the applicant shall reapply for a new Disposal Systems Construction Permit (3 10 CMR 15.020(1)). 2. The installer of the septic system shall provide a swale along the northern property line to prevent runoff onto the adjacent property. Page 1 of 2 North Andover Health Department, 120 Main Street, North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688.8476 f a 3. It is the responsibility of the applicant and/or the applicant's septic system designer, septic system installer or other representative to ensure that all other state and municipal requirements are met. These may include review by the Conservation Commission, Zoning Board, Planning Board, Building Inspector, Plumbing Inspector and/or Electrical Inspector. The issuance of a Disposal System Construction Permit shall not construe and/or imply compliance with any of the aforementioned requirements. Please feel free to contact the office with any questions you may have. We look forward to working with you to obtain a wastewater treatment and dispersal system which will be in compliance with all regulations and assure protection of public health and the environment of North Andover. Brian J,,aGrasse, CEHT Director of Public Health Encl. Installers list cc: Philip Christiansen File Page 2 of 2 North Andover Health Department, 120 Main Street, North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688.8476 PUBLIC HEALTH DEPARTMENT Town of North Andover Community and Economic Development Division CERTIFICATE OF COMPLIANCE As of: September 7, 2017 a o, This is to certify that the individual subsurface disposal system received a . SATISFACTORY INSPECTION of the: New Construction of an On -Site Sewage Disposal System By: Robert K. Daigle At: 808 Johnson Street Map 38 Lot 60 North Andover, MA 01845 suance of this certific n construed as a guarantee that the system will function satisfactorily. Mibhehe Grant Public Health Agent 120 Main St., North Andover, Massachusetts 01845 Phone 918.688.9540 Fax 918.688.9542 Web www.northandoverma.gov nos Town of North Andover — Septic System - AS -BUILT CHECKLIST 1) /All changes to the design plan have been reflected and noted on the as -built plan 2) As -built plan has a suitable scale; (1 inch = 40 feet or fewer for plot plans) 3) ,.,/Street Address, Assessor's Map and Lot Number 4) voLot Lines and Location of Dwellings served by the system 5) Locations, Elevations and Dimensions of As -built system components, including reserve (if applicable) 6) "Ties to all tank openings, d -box, and leach area from dwelling or Permanent Structure Setback distances are shown on the as -built plan from system components to: Subsurface, interceptor & foundation drains Catch basins '1✓ Property lines Dwellings or other structures Private water supply or irrigation wells Watercourses or wetlands 8) Locations of Wet s; 14 ;el North Andover Health Department (ommunity and Economic Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 808 Johnson Street MAP: 38 LOT: 60 INSTALLER: Robert K. Daigle DESIGNER: Christiansen PLAN DATE: 11/2016 BOH APPROVAL DATE ON PLAN: 12/08/2016 INSPECTIONS TANK INSPECTION: 03/06/2017 DATE OF BED BOTTOM INSPECTION: 03/23/2017 DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: 8/26/2017 SITE CONDITIONS ❑ Contractor reports any changes to design plan ® Existing septic tank properly abandoned ® Internal plumbing all to one building sewer (existing) ❑ Topography not appreciably altered Comments: Tank crushed / removed new tank in same location SEPTIC TANK ❑ Building sewer in continuous grade, on compacted firm base ❑ Cleanouts per plan ® Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon tank has been installed H-10 loading ❑ Monolithic tank construction ❑ Water tightness of tank has been achieved by visual testing ❑ Inlet tee installed, centered under access port ❑ Outlet tee installed, centered under access port (gas baffle/effluent filter) ❑ inch cover to within 6" of finish grade installed over one access port ❑ Hydraulic cement around inlet & outlet Comments: PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon Pump Chamber installed ❑ H-10 loading ❑ Monolithic tank construction ❑ Inlet tee installed, centered under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off floats working ❑ Separate on/off floats ❑ Drain hole in pressure line ❑ cover at final grade installed over pump access port ❑ Water tightness of tank has been achieved by testing ❑ Hydraulic cement around inlet & outlet Comments: CONTROL PANEL ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: basement ❑ Alarm signal located inside: basement Comments: DISTRIBUTION -BOX ❑ Installed on stable stone base ❑ H-20 D -Box ❑ Inlet tee (if pumped or >0.08'/foot) ❑ Hydraulic cement around inlet & outlets ❑ Observed even distribution ❑ Speed levelers provided (not required) ❑ Schedule 40 PVC Pipe Comments: Ilk r SOIL ABSORPTION SYSTEM (General) ® Bottom of SAS excavated down to C soil layer, as provided on plan ® Size of SAS excavated as per plan ® Title 5 sand installed, if specified on plan (one load of sand was there) ❑ 40 Mil HDPE barrier installed ❑ Laterals installed and ends connected to header (and vented if impervious material above) ❑ Elevations of laterals and chambers installed as on approved plan ❑ Retaining wall (boulder / concrete / timber/ block) ❑ Final cover as per plan Comments: With over dig. 43 L x 25 w — need another bed bottom next week. Sand was not on sight and hole was not excavated on one end properly. Cease working due to rain for the next'4 days. 3/29/2017 re -inspected: Rob pulled a bolder out of I end of the field SOIL ABSORPTION SYSTEM (Gravel -less Chambers) ❑ Brand and Model of Chamber: Standard Quick 4 Infiltrator Chambers ❑ Number of chambers per row: ❑ Number of rows (trenches): Comments: Total Chambers = FINAL GRADE ® Loamed ® Seeded ❑ Cover per plan Comments: Final Grade — Michele Grant 8/22/2017 DOCUMENTS NEEDED i ❑ Certification of Installation Form submitted By engineer and signed and dated by Engineer and installer ❑ As -Built Plan BM = HR= HI = SYSTEM ELEVATIONS ROD AS -BLT INVERT DESIGN INVERT ELEVATION ELEV ELEV Benchmark Building Sewer OUT Septic Tank IN Septic Tank OUT Pump Chamber IN Pump Chamber OUT Distribution Box IN Distribution Box OUT Lateral 1 TOP Lateral 1 INVERT Lateral 2 TOP Lateral 2 INVERT Lateral 3 TOP Lateral 3 INVERT Lateral 4 TOP Lateral 4 INVERT Lateral 5 TOP Lateral 5 INVERT Lateral 6 TOP Lateral 6 INVERT Top of Chamber Bottom of Bed/Chamber SKETCH PLAN to CRITICAL SETBACK DISTANCES Mark those distances checked in the field against the design plan and regulatory setback ' Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance (NA 5.02). 3 As defined in 310 CMR 10.55, 10.32, 10.54, and 10.30, respectively, pursuant to 15.211(3), also by NA wetland bylaws Tank SAS Sewer ® Property line 10 10 -- ® Cellar wall 10 20 -- ® Inground pool 10 20 -- ® Slab foundation 10 10 -- ® Deck, on footings, etc 5 10 -- Waterline 10 10 101 ® Private drinking well 75 1002 50 ® Irrigation well 75 100 ® Surface Water 25 50 ® Bordering Vegetated Wetland , Salt Marsh, Inland / Coastal Banka 75 100 ® Wetlands bordering surface water supply or trib. (in Watershed) 150 150 ® Trib. to surface water supply 325 325 ® Public well 400 400 ® Interim Wellhead Prot. Area ® Reservoirs 400 400 ® Drains (wat. supply/trib.) 50 100 ® Drains (intercept g.w.) 25 50 ® Drains (Other) Foundation 10 (5) 20 (10) ® Drywells 20 25 ' Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance (NA 5.02). 3 As defined in 310 CMR 10.55, 10.32, 10.54, and 10.30, respectively, pursuant to 15.211(3), also by NA wetland bylaws • ss' , Commonwealth of Massachusetts Map -Block -Lot 038.00060 BOARD OF HEALTH ---------------------- Permit No North Andover BHP -2016-0496 ----------------------- FEE -----------350.00 DISPOSAL WORKS CONSTRUCTION PERMIT���"' C Permission is hereby granted Robert K. -Daigle to (Upgrade) an Individual Sewage Disposal System. at No 808 JOHNSON STREET b as shown on the application for Disposal Works Construction Permit No. BHP -2016-049 Dated December 28, 2016 ---------------------- ----------------------------- ------------- -�--- �' r Issued On: Dec -28-2016 - - BOARD OF�HnA `� y .•. Application for Septic Disposal System Construction Permit -TOWN OF NORTH ANDOVER, MA 01845 Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. _Q ISI Application is hereby made for a permit to: ❑ Construct a new on-site sewage disposal system* -[pr6epair or replace an existing on-site sewage disposal system* ❑ Repair or replace an existing system component —What? A. Facility Information Address or Lot # City/Town WAA 2.- *TYPE OF SEPTIC SYSTEM*: ➢ ❑ Pump ❑ Gravity (choose one) ***If pumps tem, attach copy of electrical permit to application*** ➢ ff Conventional System (pipe and stone system) ta-� ll TODAY'S ATE $350.00 Full Repair $1 . 0 - Component UL l � , ➢ El Infiltrator or Biodiffuser (Gravel -Less) (Attach a copy of your certification to install this type of system.) ➢ ❑ Pressure Distribution S.A.S. (No D -Box) ➢ ❑ Pressure Dosed (D -Box Present) S.A.S. ➢ ❑ Does the system require an effluent filter? Yes No If yes, does plan specify make and model of filter? YES = (no further info. needed) NO = (installer must specify brand of filter before DWC issuance) What is the Make? Address (if d erent from above) City/Town Email address 3. Installer Information gn k Name _ U ue_ City/Town 4. Designer Information pi -I Name What is the Model. Y06- State Zip Code 41 ? 0 �.6 Telephone Number r)e- /P Cz S Name of Company 10-44 .40/ rho State Zip Code �2y'97 3 X33 Telephone Number (Cell Phone # if possible please) Name of Company Q .5 Lm6tly- S Adpless Il gqmrk City/Town State 13'T Zip l Telephone Number (Best # to Reach Application for Disposal System Construction Permit • Page 1 of 2 Cl AM .'. • Application for Septic Disposal System .. Construction Permit - TOWN OF TODAY'S DATE NORTH ANDOVER MA 01845 $ -Full Repair $1775.5.00 00 -Component PAGE 2OF2 A. Facility Information continued.... 5. Type of Building: Residential Dwelling or ❑Commercial B. Agreement The undersigned agrees to ensure the construction and maintenance of the afore -described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of North Andover. I understan that until a final Certificate of Compliance has been issued by this Board ofHealt , e in tailed system is not approved. A/,�10C) 1,6 Na a 0 Date Applip o By: oard of Health Representative) IZ zg 6 Nam(1catio/Disapproved Date App for the following reasons: For Office Use Only: 1. Fee Attached? Yes V No 2. Project Manager Obligation Form Attached? Yes No 3. Pump Sys tem? If so, Attach copy of Electrical it Applicantreceived copy of Yes No "Electrical Inspection Notes for Septic Systems" Yes No Handout? 4. Reviewed approval letter, all paperwork received. Yes No Mlssing: 5. Foundation As -Built? (new construction only): Yes No (Same scale as approved plan) 6. Floor Plans? (new construction only): Yes Application for Disposal System Construction Permit - Page 2 of 2 v i SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction for the septic system for the property at: 'glUf ;S-4 V, (Address of septic system) For plans by (Engineer) Relative to the application of J (Installer's name) And dated Dated I-0?1t6 o ay s ate With revisions dated I understand the following obligations for management of this project: (Original ate (Last revised date) 1. As the installer, I am obligated to obtain all permits and Board of Health approved plans prior to performing any work on a site. I must have the approved plans and the permit on site when any work is being done. 2. As the installer, I must call for any and all inspections. If homeowner, contractor, project manager, or any other person not associated with my company schedules an inspection and the system is not ready, then item three shall be applicable. 3. As the installer, I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection, without completion of the items in accordance with Title 5 and the Board of Health Regulations may result in a $50.00 fine being levied against me and/or my compaDX. a. Bottom of Bed — Generally, this is the first (1'� inspection unless there is a retaining wall, which should be done first. The installer must request the inspection but does not have to be present. b. Final Construction Inspection — Engineer must first do their inspection for elevations, ties, etc. As -built of verbal OK (or e-mail to: healthdept@northandoverma.gov) from the engineer must be submitted to the Board of Health, after which installer calls for an inspection time. Installer must be present for this inspection. With a pump system, all electrical work must be ready and able to cause pump to work and alarm to function. c. Final Grade — Installer must request inspection when all grading is complete. Installer does not have to be on-site. 4. As the installer, I understand that only I may perform the work (other than simple excavation) and I am required to complete the installation of the system identified in the attached application for installation. I further understand that work done by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the system and/or revocation or suspension of my license to operate in the Town of North Andover, significant fines to all persons involved are also possible. 5. As the installer, I understand that I must be on-site during the performance of the following construction steps: a. Determination that the proper elevation of the excavation has been reached. b. Inspection of the sand and stone to be used. c. Final inspection by Board of Health staff or consultant. d. Installation of tank, D -Box, pipes, stone, vent, pump chamber, retaining wall and other components. 6. As the installer. I understand that I am solely responsible for the installation of the system as per the me of this obligation. Undersigned Licensed Septic Installer: (NameA _�� � — not (Today's Date) I aj,� � 16 (Name —Signed) • ;•. Application for Septic Disposal S stem; l Construction Permit — TOWN OF TODAY'S ATE NORTH ANDOVER, MA 01845 $350.00 Full Repair __- $1 0 -Component Important: Application is hereby made for a permit to: When filling out ❑ Construct a new on-site sewage disposal system* forms on the computer, use -24epair or replace an existing on-site sewage disposal system* only the tab key "'""'�' to move your El Repair Repair or replace an existing system component – What?r3c cursor - do notSVCED use the return A. Facility Information key. Address or Lot # 6 `kS fzolh 1 .IWw"I AP N DCK EPARTMENT City/Town � ecle�✓ 2.- *TYPE OF SEPTIC SYSTEM*: ➢ ❑ Pump ❑ Gravity (choose one) ***If pumps tem, attach copy of electrical permit to application— ➢ LKConventional System (pipe and stone system) ➢ ❑ Infiltrator or Biodiffuser (Gravel -Less) (Attach a copy of your certification to install this type of system.) ➢ ❑ Pressure Distribution S.A.S. (No D -Box) ➢ ❑ Pressure Dosed (D -Box Present) S.A.S. ➢ ❑ Does the system require an effluent filter? Yes No If yes, does plan specify make and model of filter? YES = (no further info. needed) NO = (installer must specify brand of filter before DWC issuance) What is the Make? What is the Model. 2. Owner Inform tion a J en NapQ �K.�Crr `S Address (if d' erent from above) City/Town Email address 3. Installer Information Name Li t✓ City/Town 4. Designer Information IBJ G_ State Zip Code 4,1 1? ?? 6 j i6� Telephone Number ee ame of Company rtlj .01 r� b State Zip Code Telephone Number (Cell Phone # if possible please) Name Name of Company 10 --' S/ Adpless City/Town State Zip cok Telephone Number (Best # to Reach Application for Disposal System Construction Permit - Page 1 of 2 r TOWN OF NORTH ANDOVER Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT 1600 OSGOOD STREET; SUITE 2035 NORTH ANDOVER, MASSACHUSETTS 01845 APPLICATION FOR SOIL TESTS DATE: 464 /Z( LOCATION OF SOIL TESTS: °� NORry q, �O 9SSACHU, 978.688.9540 - Phone 978.688.8476 - FAX V healthde t northandoverma. �•. www.northandoverma.gov SEP 2 6 2616 TOWN OF NORTH ANDOVER MAP & PARCEL: HEALTH DEPART .SENT OWNER: -jD`l h Le 6 1&44, Contact #: 6 l 7 — 2-16 "s16 APPLICANT: 6 &W -a— ADDRESS: 908 ./ OAYlS (/Yt S--Jf— Contact #: ENGINEER: C 11 ✓ (S CtNCS P/Vl � S9,,4 Contact #: 91k-,373-6 3l L CERTIFIED SOIL EVALUATOR: -PA 1' P C� I -I Intended Use of Land: Residential Subdivision(--Singleamily Ho Commercial Is This: Repair Testing: Undeveloped Lot Testing: Upgrade for Addition:_ In the Lake Cochichewick Watershed? Yes No THE FOLLOWING MUST BE INCLUDED WITH THIS FORM ➢ Proof of land ownership (Tax bill, or letter from owner permitting test) ➢ 8.5"x 11 " Plot plan & Location of Testing (please indicate test pit sites on the plan) ➢ Fee of $585.00 per lot for new construction. This covers the minimum two deep holes and two percolation tests required for each disposal area. Fee of $440.00 per lot for repairs or upgrades. GENERAL INFORMATION ➢ Only Certified Soil Evaluators may perform deep hole inspections. ➢ Only Mass. Registered Sanitarians and Professional Engineers can design septic plans. ➢ At least two deep holes and two percolation tests are required for each septic system disposal area. ➢ Repairs require at least two deep holes and at least one percolation test, at the discretion of the BOH representative. ➢ Full payment will be required for all additional tests within two weeks of testing. ➢ Within 45 days of testing, a scaled plan (no smaller than 1"-100') shall be submitted to the Board of Health showing the location of all tests (including aborted tests). ➢ Within 60 days of testing soil evaluation forms shall be submitted. Please Do Not Write Below This Line N.A. Conservation Commission Approval Date: Q Signature of Conservation Agent: Date back to Health Department: (stamp in): r"Q(�ppq �� 1� ?�'.� 50 i /�ra'� b�. �... I ► � � vti. �� �`� P X4.1. Uk� I �r ICA - 1 • � t F �dF1 I b Yf u6 I zz 55 Ali A/ 5 hog. 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O rt' 3 m mE CD w CD Y c > c z a10i = m w L� O ++U U) C 0 O 0 0 L O N C C 'c �i N U 0I Fn Ua W, � aa) o U ,o t acu E p w in aH Tz Z O Commonwealth of Massachusetts City/Town of North Andover u Percolation Test ° Form 12 M SV 9 e Vercolatlon test results must be submitted with the Soil Suitability Assessment for On-site Sewage Disposal. DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with the local Board of Health to determine the form they use. Important: When filling out forms A. Site Information on the computer, use only the tab BJF Realty Trust key to move your Owner Name cursor - do not 808 Johnson Street use the return key. Street Address or Lot # North Andover MA 01845 r� City/Town State Zip Code Philip Christiansen 978.373.0310 n---- Contact Person (if different from Owner) Telephone Number B. Test Results vvitnessea by: Comments: t5form12.doc• 06/03 Perc Test • Page 1 of 1 10/5/2016 10:53 Date Time Date Time Observation Hole # 1 Depth of Perc 31 + 16 = 47 Start Pre -Soak 10:53 End Pre -Soak 11:08 Time at 12" 11:08 Time at 9" 11:13 Time at 6" 11:19 Time (9"-6") 6 Rate (Min./Inch) 2 min/inch Test Passed: ® Test Passed: ❑ Test Failed: ❑ Test Failed: ❑ Philip Christiansen Test Performed By: Isaac Rowe vvitnessea by: Comments: t5form12.doc• 06/03 Perc Test • Page 1 of 1 r Commonwealth of Massachusetts City/Town of NORTH ANDOVER a Form 9A - Application for Local Upgrade Approval M DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. 41 Form 9A is to be submitted to the Local Board of Health for the upgrade of a failed or nonconforming septic system with a design flow of less than 10,000 gpd, where full compliance, as defined in 310 CMR 15.404(1), is not feasible. System upgrades that cannot be performed in accordance with 310 CMR 15.404 and 15.405, or in full compliance with the requirements of 310 CMR 15.000, require a variance pursuant to 310 CMR 15.410 through 15.415. NOTE: Local upgrade approval shall not be granted for an upgrade proposal that includes the addition of a new design flow to a cesspool or privy, or the addition of a new design flow above the existing approved capacity of an on-site system constructed in accordance with either the 1978 Code or 310 CMR 15.000. A. Facility Information 1. Facility Name and Address: BJF Realty Trust Name 808 JOHNSON STREET Street Address NORTH ANDOVER MA City/Town State 2. Owner Name and Address (if different from above): BJF REALTY TRUST 808 JOHNSON Name Street Address NORTH ANDOVER MA City/Town State 01845 617-216-5164 Zip Code 3. Type of Facility (check all that apply): ® Residential ❑ Institutional 4. Describe Facility: SINGLE FAMILY HOME 5. Type of Existing System: Telephone Number ❑ Commercial ❑ School 01845 Zip Code ❑ Privy ❑ Cesspool(s) ® Conventional ❑ Other (describe below): 6. Type of soil absorption system (trenches, chambers, leach field, pits, etc): LEACH FIELD . t5form9a (1) • rev. 7/06 Application for Local Upgrade Approval• Page 1 of 4 I Commonwealth of Massachusetts City/Town of NORTH ANDOVER a a Form 9A — Application for Local Upgrade Approval ^M , • DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. A. Facility Information (continued) 7. Design Flow per 310 CMR 15.203: Design flow of existing system: Design flow of proposed upgraded system Design flow of facility: B. Proposed Upgrade of System unknown gpd 330 GAL/DAY gpd 330 gal/day gpd 1. Proposed upgrade is (check one): ❑ Voluntary ❑ Required by order, letter, etc. (attach copy) ❑ Required following inspection pursuant to 310 CMR 15.301: date of inspection 2. Describe the proposed upgrade to the system: REMOVE EXISTING SEPTIC TANK AND SYSTEM, INSTALL NEW SYSTEM 3. Local Upgrade Approval is requested for (check all that apply): t5form9a (1) • rev. 7/06 ❑ Reduction in setback(s) — describe reductions: ❑ Reduction in SAS area of up to 25%' sas size, sq. ft. %reduction ® Reduction in separation between the SAS and high groundwater: Separation reduction ft Percolation rate 2 MINUTES PER INCH min./inch Depth to groundwater 2 MINUTER PER INCH ft. Application for Local Upgrade Approval• Page 2 of 4 Commonwealth of Massachusetts City/Town of NORTH ANDOVER i , F a Form 9A — Application for Local Upgrade Approval -..M , •' DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. B. Proposed Upgrade of System (continued) ❑ Relocation of water supply well (explain): ❑ Reduction of 12 -inch separation between inlet and outlet tees and high groundwater ❑ Use of only one deep hole in proposed disposal area ❑ Use of a sieve analysis as a substitute for a perc test ❑ Other requirements of 310 CMR 15.000 that cannot be met— describe and specify sections of the Code: If the proposed upgrade involves a reduction in the required separation between the bottom of the soil absorption system and the high groundwater elevation, an Approved Soil Evaluator must determine the high groundwater elevation pursuant to 310 CMR 15.405(1)(h)(1). The soil evaluator must be a member or agent of the local approving authority. High groundwater evaluation determin Philip Christiansen 10/5/2016 Evaluator's Name (type or print)%Signat a Date of evaluation C. Explanation Explain why full compliance, as defined in 310 CMR 15.404(1), is not feasible. (Each section must be completed) 1. An upgraded system in full compliance with 310 CMR 15.000 is not feasible: Limited conditions on site 2. An alternative system approved pursuant to 310 CMR 15.283 to 15.288 is not feasible: repair/ limited space t5form9a (1) • rev. 7/06 Application for Local Upgrade Approval, Page 3 of 4 Commonwealth of Massachusetts City/Town of NORTH ANDOVER H o Form 9A — Application for Local Upgrade Approval DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. C. Explanation (continued) 3. A shared system is not feasible: none available 4. Connection to a public sewer is not feasible: not available 5. The Application for Local Upgrade Approval must be accompanied by all of the following (check the appropriate boxes): E Application for Disposal System Construction Permit E Complete plans and specifications E Site evaluation forms ❑ A list of abutters affected by reduced setbacks to private water supply wells or property lines. Provide proof that affected abutters have been notified pursuant to 310 CMR 15.405(2). ❑ Other (List): D. Certification "I, the facility owner, certify under penalty of law that this document and all attachments, to the best of my knowledge and belief, are true, accurate, and complete. I am aware that there may be significant consequences for submitting false information, including, but not limited to, penalties or fine and/or imprisonmen,jeftr del iberpteyiolations_' ageXt for BJF Realtv Trust Pririt Name Philip Christiansen Name of Preparer 160 Summer Street Preparer's address MA State/ZIP Code t5form9a (1) • rev. 7/06 11/15/16 Date 11/15/2016 Date Haverhhill City/Town 978.373.0310 Telephone Application for Local Upgrade Approval* Page 4 of 4 ` � V Commonwealth of Massachusetts City/Town of North Andover a Form 9A — Application for Local Upgrade Approval �M DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. Form 9A is to be submitted to the Local Board of Health for the upgrade of a failed or nonconforming septic system with a design flow of less than 10,000 gpd, where full compliance, as defined in 310 CMR 15.404(1), is not feasible. System upgrades that cannot be performed in accordance with 310 CMR 15.404 and 15.405, or in full compliance with the requirements of 310 CMR 15.000, require a variance pursuant to 310 CMR 15.410 through 15.415. NOTE: Local upgrade approval shall not be granted for an upgrade proposal that includes the addition of a new design flow to a cesspool or privy, or the addition of a new design flow above the existing approved capacity of an on-site system constructed in accordance with either the 1978 Code or 310 CMR 15.000. Important: When filling out forms on the computer, use only the tab A. Facility Information 1. Facility Name and Address: BJF Realty Trust key to move your Name cursor - do not 808 Johnson Street use the return key. Street Address North Andover MA 01845 _Q City/Town State Zip Code 2. Owner Name and Address (if different from above): same Name Street Address City/Town State Zip Code Telephone Number 3. Type of Facility (check all that apply): ® Residential ❑ Institutional ❑ Commercial ❑ School 4. Describe Facility: Single Familv home 5. Type of Existing System: ❑ Privy ❑ Cesspool(s) ® Conventional ❑ Other (describe below): 6. Type of soil absorption system (trenches, chambers, leach field, pits, etc): LEACH FIELD t5form9a (1) • rev. 7/06 Application for Local Upgrade Approval* Page 1 of 4 Commonwealth of Massachusetts City/Town of North Andover W Form 9A - Application for Local Upgrade Approval 0 �,M s , •" DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. A. Facility Information (continued) 7. Design Flow per 310 CMR 15.203: Design flow of existing system: Design flow of proposed upgraded system Design flow of facility: B. Proposed Upgrade of System 1. Proposed upgrade is (check one): UNKNOWN gpd 330 GAL/DAY gpd 330 GAL/DAY gpd ® Voluntary ❑ Required by order, letter, etc. (attach copy) ❑ Required following inspection pursuant to 310 CMR 15.301: date of inspection 2. Describe the proposed upgrade to the system: REMOVE EXISTING SEPTIC TANK AND SYSTEM, INSTALL NEW SYSTEM 3. Local Upgrade Approval is requested for (check all that apply): ❑ Reduction in setback(s) — describe reductions: ❑ Reduction in SAS area of up to 25%: SAS size, sq. ft. % reduction ® Reduction in separation between the SAS and high groundwater: Separation reduction 1 FOOT ft. Percolation rate 2 MINUTES PER INCh min./inch Depth to groundwater FOUR FEET ft. t5form9a (1) • rev. 7/06 Application for Local Upgrade Approval• Page 2 of 4 - 'r • Commonwealth of Massachusetts City/Town of North Andover a Form 9A — Application for Local Upgrade Approval ;M , , •` DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. B. Proposed Upgrade of System (continued) ❑ Relocation of water supply well (explain): ❑ Reduction of 12 -inch separation between inlet and outlet tees and high groundwater ❑ Use of only one deep hole in proposed disposal area ❑ Use of a sieve analysis as a substitute for a perc. test ❑ Other requirements of 310 CMR 15.000 that cannot be met— describe and specify sections of the Code: If the proposed upgrade involves a reduction in the required separation between the bottom of the soil absorption system and the high groundwater elevation, an Approved Soil Evaluator must determine the high groundwater elevation pursuant to 310 CMR 15.405(1)(h)(1). The soil evaluator must be a member or agent of the local approving authority. High groundwater evaluation determined by: Isaac Rowe 10/50/2016 Evaluator's Name (type or print) Signature Date of evaluation C. Explanation Explain why full compliance, as defined in 310 CMR 15.404(1), is not feasible. (Each section must be completed) 1. An upgraded system in full compliance with 310 CMR 15.000 is not feasible: Limited conditions on site. 2. An alternative system approved pursuant to 310 CMR 15.283 to 15.288 is not feasible: An alternative optiion will add expense to construction and operation without any added benefit t5form9a (1) • rev. 7/06 Application for Local Upgrade Approval• Page 3 of 4 o � Commonwealth of Massachusetts City/Town of North Andover a o Form 9A — Application for Local Upgrade Approval DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. C. Explanation (continued) 3. A shared system is not feasible: none availaable 4. Connection to a public sewer is not feasible: not available 5. The Application for Local Upgrade Approval must be accompanied by all of the following (check the appropriate boxes): ® Application for Disposal System Construction Permit ® Complete plans and specifications ® Site evaluation forms ❑ A list of abutters affected by reduced setbacks to private water supply wells or property lines. Provide proof that affected abutters have been notified pursuant to 310 CMR 15.405(2). ❑ Other (List): D. Certification "I, the facility owner, certify under penalty of law that this document and all attachments, to the best of my knowledge and belief, are true, accurate, and complete. I am aware that there may be significant consequences for submitting false information, including, but not limited to, penalties or fine and/or imorisonmentJor deliberateViinlatinns " Print Name Philip Christiansen Name of Preparer 160 Summer Street Preparer's address MA 01830 State/ZIP Code t5form9a (1) • rev. 7/06 11/15/2016, revised 11/30/2016 Date 11/30/2016 Date Haverhill City/Town 978.373.0310 Telephone Application for Local Upgrade Approval* Page 4 of 4 North Andover Health Department Community and Economic Development Division November 28, 2016 Philip Christiansen, P.E. Christiansen and Sergi, Inc. 160 Summer Street Haverhill, MA 01830 Re: 808 Johnson Street (Map 38, Lot 60) Dear Mr. Christiansen, The proposed wastewater system design plan for the above site dated November 10, 2016 and received on November 15, 2016 has been reviewed. Unfortunately, the plan cannot be approved until the following items are corrected. The specific section in Title 5: 310 CMR 15.000, or North Andover regulation that is not met by this design follows each item. 1. The toe of the slope should be a minimum of 5 feet from the property line or a swale or other drainage system is required to prevent runoff to the adjacent property (3 10 CMR 15.255(2)). 2. On sheet 1 of 2, the LTAR used in the "CALCULATIONS" section is incorrect. 3. Since no elevation of the existing building sewer pipe is indicated on the design plan the minimum slope requirement in 310 CMR 15. 222(6) cannot be confirmed. Provide a note on the design plan to indicate the minimum slope of the existing building sewer shall be confirmed during construction and prior to installing the proposed septic tank. 4. On Form 9A the following sections need to be revised: - B(1) was not checked off - B(3) is missing the proposed groundwater separation distance and has the incorrect depth to groundwater - B(3) should list the soil evaluator acting as the agent for the local approving authority instead of the soil evaluator currently listed - C(2) indicates "repair/limited space" as the reason an alternative system is not feasible. This should be revised to provide a more detailed and practicable reason such as being an excessive cost to the overall project. Page 1 of 2 North Andover Health Department, 120 Main Street, North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688.8476 - D is not signed and dated by the owner 5. Please provide an explanation to justify the Board of Health variance request to locate the leach field within 100' to the wetland resource area. There is an area northwest of the proposed leach field which is beyond the 100' wetland buffer zone. Although not a reason for disapproval you may want to consider the following: 6. Moving the inspection port between the active perforated leach pipes instead of at the most northeastern corner of the leach field. 7. The use of an impervious barrier on the north, south and east sides of the leach field to reduce the amount of finish grading needed to meet the breakout requirement. It appears by using an impervious barrier the toe of the slope would end more than 5 feet from the property line and end the grading approximately before the existing 92 contour on the eastern side. Please feel free to contact the office or Mill River Consulting at 978-282-0014 with any questions you may have. We look forward to working with you to obtain a wastewater treatment and dispersal system which will be in compliance with all regulations and assure protection of public health and the environment of North Andover. incerely, i Michele Grant Health Inspector cc: BE Realty Trust File Page 2 of 2 North Andover Health Department, 120 Main Street, North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688.8476 12/5/2016 Town of North Andover Mail - RE: 808 Johnson St. NOR^Flif1i.OVER Massachus ��ts�.,... Lisa Hadge <Ihadge@northandoverma.gov> .ter RE: 808 Johnson St. 1 message Isaac Rowe <irowe@millriverconsulting.com> Fri, Dec 2, 2016 at 12:41 PM To: Lisa Hadge <Ihadge@northandoverma.gov>, Pam Lally <plally@millriverconsulting.com> Cc: Brian LaGrasse <blagrasse@northandoverma.gov>, Michele Grant <mgrant@northandoverma.gov>, Isaac Rowe <irowe@millriverconsulting.com> Brian, I have reviewed the revised plan and offer the following comments: 1. The swale provided on the revised plan is represented incorrectly but not a deal breaker. I would add an item of condition to the approval, "The installer of the septic system shall provide a Swale along the north property line to prevent runoff to the adjacent property" 2. The designer's reasons for the variance request do not seem very strong but if you/BOH are comfortable then approval could be granted. It seems like he is trying to avoid a pump system and additional soil testing beyond the 100' buffer zone. Let me know if you have any questions. Thanks, Isaac Rowe Project Manager .. LL RIVER CONSULTING t:fr!I]AV S"AAAi0t1%R)I iIn! it] D4-%1r-h4)J[Iit719t 6 Sargent Street Gloucester, MA 01930-2719 Phone: 978-282-0014 ext.804 https://mail.goog le.com/mail/ca/u/0/?ui=2&ik=46857787dO&view=pt&search=inbox&th=158cOaObf8579348&siml=158cOaObf8579348 1/3 12/5/2016 www.millriverconsulting.com Town of North Andover Mail - RE: 808 Johnson St. From: Isaac Rowe[mai Ito: irowe@millriverconsulting.com] Sent: Wednesday, November 23, 2016 2:28 PM To: 'Lisa Hadge'; 'Pam Lally' Cc: 'Brian LaGrasse'; 'Michele Grant'; Isaac Rowe Subject: RE: 808 Johnson St. Brian/Lisa, Attached is the disapproval letter for the initial plan review for the above referenced property. The LUA request for the 1' groundwater separation seems appropriate but the LUA form needs some edits before the BOH or your office should act on the request. Also the BOH variance request seems appropriate if there are no other options on site. The designer should provide an explanation to justify the request (#5) instead of simply requesting the variance. We can assist in the review of the explanation by the designer if you would like. Let me know if you have any questions. Thanks, Isaac Rowe Project Manager ; WIWI— qt,q WEIR +rONSULTIN `.avmitr solli{ioHN16C 9.r3it3 iM tkyiiiiaiii 6 Sargent Street Gloucester, MA 01930-2719 Phone: 978-282-0014 ext.804 www.millriverconsulting.com https:Hmail.google.com/mail/ca/u/0/?ui=2&ik=46857787dO&view=pt&search=inbox&th=l 58cOaObf8579348&siml=158cOaObf8579348 2/3 TOWN OF NORTH ANDOVER Community & Economic Development HEALTH DEPARTMENT 120 Main Street NORTH ANDOVER, MASSACHUSETTS 01845 978.688.9540 — Phone 978.688.9542— FAX E-MAIL: healthdept@northandoverma.gov _WEBSITE: http://www.northandoverma.gov SEPTIC PLAN SUBMITTAL FORM Date of Submission: 1 2.01 Site Location: yo'z JOA yd e4 _1'2hR!k Engineer: rhi1 J New Plans? Yes I" $275/Plan Check #_�(includes 1St submission and one re- review only) 0-W Revised Plans?Yes $125/Plan Check # Site Evaluation Forms Included? Yes Ll_� No Local Upgrade Form Included? Yes No Telephone #: 7 3 7 3• b 3 Fax #:_ E-mail: C 5 (, — f Yl q r, alYl 1 Homeowner J Name: _ J O k n Le - P6 OFFICE USE ONLY When the submission is complete (including check): >Date stamp plans and letter > V Complete and attach Receipt ➢ ✓ Copy File; Forward to Consultant Enter on Log Sheet and Database RECEIVED NOV 15 2016 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT IUV4 MOM I *_ -1 'M l��� a�ru r j November 15, 2016 Board of Health Town of North Andover 120 Main Street North Andover, MA 01845 Dear Members: CHRISTIANSEN & SERGI, INC PROFESSIONAL ENGINEERS AND LAND SURVEYORS 160 SUMMER STREET, HAVERHILL, MA 01830 tel: 978-373-0310 www.csi-engr.com fax 978-372-3960 On behalf of my client, BJF Realty Trust, I hereby request a waiver for setback for the repair system design for his property at 808 Johnson Street. The proposed system is 64' from the wetland line, rather than the 100' required. In addition, I am enclosing an Application for Local Upgrade approval. The proposed system, with a 2 min/inch perc rate is designed to be 4' from estimated high groundwater level. y CHRISTIANSEN & SERGI, INC PROFESSIONAL ENGINEERS AND LAND SURVEYORS 160 SUMMER STREET, HAVERHILL, MA 01830 tel: 978-373-0310 www.csi-engr.com fax 978-372-3960 November 29, 2016 Mr. Brian LaGrasse CEHT Director of Public Health North Andover Health Department 120 Main Street North Andover MA 01845 Re: 808 Johnson Street Dear Mr. LaGrasse: RECEIVED NOV 3 0 2016 TOoVER WN OF DEPARTMENR T Thank you for your review letter of November 28, 2016. We have made the following changes to the plan as a result of your comments: 1. A swale has been added at the base of the fill 2. The correct LTAR has been placed in the CALCULATIONS 3 A note has been added regarding the existing building sewer 4.The changes requested for Form 9A have been made S.If the system were moved to beyond the 100 ft. buffer line it would be at an elevation approximately 3 feet higher than designed. This would require the addition of a pump to the design. This increases the system cost and increases the potential for problems during operation. The system would be closer to the property line than the submitted design and would require an impervious barrier and most probably a retaining wall which will also add to the cost. 6.The inspection port has been moved as suggested 7. 1 have not added the impervious barrier The septic system is located where it is because of elevation concerns, space for the system, for grading and soils. If moved outside the 100 ft. buffer zone line the system would be at an elevation at least 3 feet higher than the proposed design. That would require a pump and pump chamber be added to the design at increased cost and increasing the probability of failure of the system. It has been my experienced that septic systems that include a pump fail more frequently than those that are fed by gravity. The space between the house and the northerly property line is limited. If a system were located there we would need an impervious barrier or perhaps a retaining wall to provide proper grading for the system. Again, it is increased cost to the owner as well as a design challenge. You will note that the trees in the area of the system are oak and pine. As you move to the north and west the trees are all ash. Ash trees most often grow in areas of high ground water with soils having a slow percolation rate. My experience told me that pits in the area we dug them would provide better results than digging them in a forest of ash. Slower peres and higher water table add to the cost of the system. With all of that information in mind and knowing that the work we are proposing complies with Title 5, it is the best interest of the home owner to locate the system where it is proposed. Very PhilidChristiansen P.E. Ar North Andover Health Department [ommunity and Economic Development Division November 28, 2016 Philip Christiansen, P.E. Christiansen and Sergi, Inc. 160 Summer Street Haverhill, MA 01830 Re: 808 Johnson Street (Map 38, Lot 60) Dear Mr. Christiansen, The proposed wastewater system design plan for the above site dated November 10, 2016 and received on November 15, 2016 has been reviewed. Unfortunately, the plan cannot be approved until the following items are corrected. The specific section in Title 5: 310 CMR 15.000, or North Andover regulation that is not met by this design follows each item. 1. The toe of the slope should be a minimum of 5 feet from the property line or a swale or other drainage system is required to prevent runoff to the adjacent property (3 10 CMR 15.255(2)). 2. On sheet 1 of 2, the LTAR used in the "CALCULATIONS" section is incorrect. 3. Since no elevation of the existing building sewer pipe is indicated on the design plan the minimum slope requirement in 310 CMR 15. 222(6) cannot be confirmed. Provide a note on the design plan to indicate the minimum slope of the existing building sewer shall be confirmed during construction and prior to installing the proposed septic tank. 4. On Form 9A the following sections need to be revised: - B(1) was not checked off - B(3) is missing the proposed groundwater separation distance and has the incorrect depth to groundwater - B(3) should list the soil evaluator acting as the agent for the local approving authority instead of the soil evaluator currently listed - C(2) indicates "repair/limited space" as the reason an alternative system is not feasible. This should be revised to provide a more detailed and practicable reason such as being an excessive cost to the overall project. Page 1 of 2 North Andover Health Department, 120 Main Street, North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688.8476 - D is not signed and dated by the owner Please provide an explanation to justify the Board of Health variance request to locate the leach field within 100' to the wetland resource area. There is an area northwest of the proposed leach field which is beyond the 100' wetland buffer zone. Although not a reason for disapproval you may want to consider the following: 6. Moving the inspection port between the active perforated leach pipes instead of at the most northeastern corner of the leach field. 7. The use of an impervious barrier on the north, south and east sides of the leach field to reduce the amount of finish grading needed to meet the breakout requirement. It appears by using an impervious barrier the toe of the slope would end more than 5 feet from the property line and end the grading approximately before the existing 92 contour on the eastern side. Please feel free to contact the office or Mill River Consulting at 978-282-0014 with any questions you may have. We look forward to working with you to obtain a wastewater treatment and dispersal system which will be in compliance with all regulations and assure protection of public health and the environment of North Andover. erely, Michele Grant Health Inspector cc: BE Realty Trust File Page 2 of 2 North Andover Health Department, 120 Main Street, North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688.8476 11/28/2016 Town of North Andover Mail - RE: 808 Johnson St. NORTH ANDOVER Massachus�s Lisa Hadge <Ihadge@northandoverma.gov> RE: 808 Johnson St. 1 message Isaac Rowe <irowe@millriverconsulting.com> Wed, Nov 23, 2016 at 2:28 PM To: Lisa Hadge <Ihadge@northandoverma.gov>, Pam Lally<plally@millriverconsulting.com> Cc: Brian LaGrasse <blagrasse@northandoverma.gov>, Michele Grant <mgrant@northandoverma.gov>, Isaac Rowe <irowe@millriverconsulting.com> Brian/Lisa, Attached is the disapproval letter for the initial plan review for the above referenced property. The LUA request for the 1' groundwater separation seems appropriate but the LUA form needs some edits before the BOH or your office should act on the request. Also the BOH variance request seems appropriate if there are no other options on site. The designer should provide an explanation to justify the request (#5) instead of simply requesting the variance. We can assist in the review of the explanation by the designer if you would like. Let me know if you have any questions. Thanks, Isaac Rowe Project Manager llkMILL RIVER CONSULTING C A-VolLkV Mc4111fiot1%4'61 Lind D4-%4.61111[vm 6 Sargent Street Gloucester, MA 01930-2719 Phone: 978-282-0014 ext.804 www.millriverconsulting.com https:Hmail.goog le.com/mail/ca/u/0/?ui=2&ik=46857787dO&view=pt&search=inbox&th= l 5892a8e 14f5e7d3&siml=15892a8e14f5e7d3 1/2 9 t,46� /0/(7 0 4 r Location No. -"`:r G Date 2z�J &ORT#q TOWN OF NORTH ANDOVER F w a +'a Certificate of Occupancy $ Building/Frame /Frame Permit Fee $ s+cMU 9 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ /?!;Sf Check # 1%3 i 'I 675 -t' f ;��8uilding Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE,OR DEMj OLISH OR TWO FAMILY DWELLING yAONE se MI BUILDING PERT NUMBER: - DATE ISSUED: c22 �Z SIGNATURE: Oil Building Commissioner/1for of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: %ap Number Parcel Number 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Provided -Required 1.7 Water Supply M.GL.C.40. 54) 1.5. Flood Zone Information: Public ❑ Private ❑ Zone Outside Flood Zone ❑ 1.8 Sewerage Disposal System: Municipal ❑ On Site Disposal System 0 SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record Name'(Pri Address Service 1 6 c `7 Zk 5 — Signature TRephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES Sr,:, / ,, �,�, 3.1' Lice/ named Constru9-�t/1O-uts a`Y -JV Liconsed C nstru ion Supervisor: �-�. �61 Address(� O -4i -Q3 Signature Telephone Not Applicable ❑ ��^ 2,041 � License Number a — O — ©, / /�1 Expiration Dat7e 3.2 Registered Home Improvement Contractor Not Applicable ❑ Com��it �/ 0 Registration Number Addre Expiration Date Signature Telephone T M X Z O 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 applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: I SECTION 6 - F.STIMATFD CONSTRUCTTON V0Q.Tc I Item Estimated Cost (Dollar) to be Completed by permit applicant OFFICIAL USE ONLY = ' ; 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (e) X (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number a�� 11vi� is vW1'4JV1(AU1n%JK1,LA114K4 1V 15h lUNWLElED 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 I SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 1, 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 14�r�u�Z of 9-��_®� I Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS IST 2 ND 3 SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHM/INEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE i 10 M4 14 04 0 O z rn M w A o .rya z o o � � u Fr w a z m Aa V .Q w C o 30 ' as b COD W wED ro °' a U w H �° w aw w Ev-w OJ r.° Ea t u: ro c w v a ° cq z cn ° cn E a M S N y C O 75 m cm m it cm c C N ID t O Z 0 O •� O E _ O O cs co C. O y D C I Ctm O •— ca p 'C H CO �E m co 0 CD CD O O cc O d cmQ ca SC O O d O ♦3 C Z 03 0 CL LD y O C C C ey Q. _03 LLJ _0 Cn LLJ U) W w W LU U) o .rya as c o o � O N 1— m Aa V .Q Z C o 30 ' eo COD W t m C O=+O' m +r fl t w O CAW R w H a) O Ev-w v.v� C.) Ea CJ a 'D o D .9 Z :... co a0y'� o c. C Ca Co +, «' CD m c co leo :mm O �y CO cm � CD C : C CO y m CV ` E a M S N y C O 75 m cm m it cm c C N ID t O Z 0 O •� O E _ O O cs co C. O y D C I Ctm O •— ca p 'C H CO �E m co 0 CD CD O O cc O d cmQ ca SC O O d O ♦3 C Z 03 0 CL LD y O C C C ey Q. _03 LLJ _0 Cn LLJ U) W w W LU U) .rya `a' s r cm 1— m O cCDo vJ C Z m o 30 H D. COD W ~ O=+O' m +r fl t CAW R w H a L&j Ev-w v.v� C.) o CJ a VD m� Oca� Z CC a0y'� F- C 0.= m E a M S N y C O 75 m cm m it cm c C N ID t O Z 0 O •� O E _ O O cs co C. O y D C I Ctm O •— ca p 'C H CO �E m co 0 CD CD O O cc O d cmQ ca SC O O d O ♦3 C Z 03 0 CL LD y O C C C ey Q. _03 LLJ _0 Cn LLJ U) W w W LU U) A,J, Walsh & Sons Inc. 55 Plcasanl Siren( Not -Ili Andover, MA 01845 Nl ass. LICENSE' n 022690 1I,'Iss RIX;ISTRATION n 10.3.3.59 RESIDENTIAL CONTRACTING AGREEMENT Read this agreement and make sure you understand it before signing it. This agreement has legal force and effect and binds those who sign it. Notice: All home Improvement contractors and subcontractors engaged in home improvement contracting, unless specifically exempt from registration by provisionsof Chapter 142a of the general laws, must be registered with the Commonwealth of Massachusetts. Inquiries about registration and status should be made to the Director, Home Improvement Contract Registration, One Ashburton Place, Room 1301, Boston, MA 02108. This agreement is made on Designated Registrant's Name: Registration Number: Salesperson's Name: C/ (CONTRACTOR) of 3-7 hereinafter called "Contractor" and of 6�_O hereinafter called "Owner". ACT (ADDRESS) (PHONE NUMBER) of U/ rJ.�J�/. (DAT (PHONE NUMBER) ' DETAILED DESCRIPTION OF WORK 7'0 BE PERFORMED Contractor agrees to perform in a gml and woikmanlik inner all work detailed heiow. ;uch work consists of the follow, �^.,.� aur A Y, - / i w-0 . /J A _ n _ i DETAILED DESCRIPTION OF MATERIA L'i TO BE USED u. rxit L Contractor agrees to do all work described in Section I for the total price of S_ ill. PAYMENT Payment will be made as follows: 133133 1/31 % (s 14WU, r) upon signing Contract; 53' fro (S t 1006, upon completion of ; upon completion of and the remaining A % (s c(a oo ) upon verification of the work by Owner and Contractor as having been satisfactorily completed, which verification shall take Place, promptly after completion. Notice: No agreement for home Improvement contracting work shall require a down payment (advance deposit) of more than one-third of the total contract price or the total amount of all deposits or payments which the contractor must make, in advance, to order and/or otherwise obtain delivery of special order materials and equipment, whichever amount Is ere. et r. IV. COMMENCEMENT AND COMPLETION OF WORK Contractor will not begin the work or order the materials before the third day following the signing of this Agreement, unless specified here in writing. Contractor will begin the work on (y about "a;5 6 3 (date). Barring delay caused by circumstances beyond Contractor's control, the work will be completed by I O v`ZJ b (date). The Owner hereby acknowledges and agrees that the scheduling dates are approximate and that such. delays that are not avoidable by the Contractor shall not be considered as violations of this Agreement. V. KO ACCELERATION OF 1'AYNIEN'1 S Ill; I' 1 tic:k(►��'1.\(; ALLOWED The Contractor may not require psymertts to he nta le in advan�:c of the times slxx: ific(1 to Sri tion III (Payment ► shove for the reaum that he deems himself or the payments to be insecure. If, however. he det:ms htmsclf u) he insecure, he may require, as a prerequisite to continuing the work described herein, tim the halance of the l)aymcnl� urulrr Utis comsat 111,41 jilt. ni Ihr ( onIto I of Ihr Owner. shall Ia• placr<I in" inial rsLros. account that rc(luirci Itte sig iature of both the Contractor and the Owner for withdrawal. VI. INSURANCE Contractor will be. responsible to Owner or any third part y for any property damage or NXIi ly injury catised by himself, his employees or his suhcontractors in the performance of, or as a result of, the work under this Agreement. Contractor agrees to cavy insurance to cover such damage or injury. VU. SUBCONTRACTING Contractor agrees that, notwithstantlutg any agreement for materials andlor labor between Contractor and a third parry. Contractor is responsible to Owner for completion of all work described in a timely and workmanlike manner. VIII. CONSTRUCTION -RELATED PERMITS The following construction -related permits will be necessary in order In complete the %cote of work includ(:(1 in this Agreement: /r _ , n The Contractor under provisions of Chapter 142A of the General Laws is required to apply for and obtain all construction -related permits. The Contractor shall not be deemed responsible for delays in the work described in this Agreement caused by regulatory, permit granting or inspectional agencies, authorities or individuals. Notice: If the homeowner obtains his own construction -related permits for the work described under this agreement, the homeowner is hereby advised that in the event of a dispute, Judgment and nonpayment of the contractor, the homeowner will not be entitled to make a claim to or collect from the guaranty fund established by Chapter 142A, M.C.L. IX. MODIFICATION This Agreement, including the provisions relating to price (Section l l) and payment schedule (Section III) cannot be changed except by a written statement signed by both Contractor and Owner. However, cancellation by Owner is allowed in accordance with the Notice of Cancellation (annexed). X. WARRANTIES The Contractor warrants that Ute work Iurniahed hereunder shall be It cc from defects tit mala rah. and workmam%hip for a period of following completion and shall comply with the requirements of this Agreement. In the event any defect in workmanship or materials, or damage caused by the Contractor. Ills sut>contracuors, employees or agents, is duu(vcred wiUtin one year after urmpleuon of any job, including cleanup, the Contractor shall. at his own expense, forthwith remedy, repair, correct replace, or (:.lure to he remedial. repairect or replaced• such damage or such defect in materials or workman hip. the forceoinr warranties shalt survive any imsprctwr. ;,•••formed in cor•net•((on with t1,ework. All warranties for equipment supplied by the Contractor under this Agreement shall he those given by the manufacturers of such equipment, which shall hr nrul me hereby 1 as�cd through directly to Ihr Ownrt. l In,Irr su h nuuntlacIll crs' war tendo•:. Ute. Owner may be required to register or mail tit a warranty card or other evidence of ownership and use of such equipment in order to activate such warranties. The Owner's failure to mail in or register such documentation, which failure voids the manufacturer's warranty, shall not aeatc any responsibility for the Contractor to warranty such equipment. This warranty gives the owner specific legal rights, and owner may also have other rights which vary from state to state. Under Massachusetts law, sales of goods carry an implied warranty of merchantability and fitness for a particular purpose. XI. COMPLETENESS OF AGREEMENT FOR EXECUTION The Owner is hereby advised that he should not sign this Agreement unless and until all blank- sections have been Filled in or marked as void, deleted or not applicable, Iiad until all exhibits and related or referenced documents that are incorlxir ivA herein are attached hereto. XII. COPY OF AGREEMENT TO BE GIVEN TO OWNER This Agreement is govemed by Ute Laws of Niassachuscus. It roust be executed in duplicate, and an original signed copy hereof given to the Owner at thr tine of execution. No work under the Agrernu•nt shall begin prior uo the signing of 1ie Agreement anti transmittal to the owner of a copy thereof. ^— --- RIGHTS TO CANCEL The owner may cancel this agreement if it has been signed by the owner at a place other than an address of the contractor which may be his main office or branch thereof, provided that the owner notifies the contractor in writing at his main office or branch by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the third business day following the signing of this agreement. See attached Notice of Cancellation. HOMEOWNER: DO NOT SIGN TIIIS CONTRACT IF THEREARE ANY BLANK SPACES. s Signa Contractor's Sign:u a4X Date Signed U yc'i;y The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Please Print eye Aly am a homeowner performing all work myself. 01 am a sole proprietor and have no one working in any capacity >7,k— lodaeX7,3' I am an employer providing workers' compensation for my employees working on this job. company name Address -,!5'2 Al-e/o<,4 w i S/ Phone #- i suraanoe ca. r # /Valel?-7t3z.., rdmoany name: Address Com'- Phone # Failure to secure coverage as r�ufr ed under §action 25A or MGL 152 can lead to the i(nposition of criminal penaities.of a fine up to $1,5)0.00 and/or one years, bmprisonrnent as wve0 as civil penalties in the form of a STOP WORK ORDER and a fine of ($100.00) a day against roe. I understand that a copy of this statement may be forwarded to the Office of investigations of the DIA for coverage verifica bon I do herby certify under the pains and 'peenaf Ass of perjury that the kftmatlon provided above is true and correct Signature a4w-l4Lw 19�al � Date �1— S Print name Official use only do not wrote in this area to be completed by city or town official' El Check if immediate response is regui d Building Dept Contact person: Phone #: VORKMAN's COMPENSATION Phone # WA"f --0 7S 7 C] Building Dept El Licensing Board El Selectman's ice t] Health Department 0 Ohher NORTH ANDOVER BUILDING DEPARTMENT Tel: 978-688-9! DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in properly licensed solid waste disposal facility as defined by MGL Chapter 111, S 150 A. The debris will be disposed of in: (Location of Facility) � J Signature If Permit Applic t q,3 Date NOTE: Demolition permit from the Town of North Andover must be obtained for this projec through the Office of the Building Inspector